Expression of apoptosis-regulating proteins in chronic lymphocytic leukemia: correlations with In vitro and In vivo chemoresponses

B-cell chronic lymphocytic leukemia (B-CLL) represents a neoplastic disorder caused primarily by defective programmed cell death (PCD), as opposed to increased cell proliferation. Defects in the PCD pathway also contribute to chemoresistance. The expression of several apoptosis-regulating proteins, including the Bcl-2 family proteins Bcl-2, Bcl-XL, Mcl-1, Bax, Bak, and BAD; the Bcl-2-binding protein BAG-1; and the cell death protease Caspase-3 (CPP32), was evaluated by immunoblotting using 58 peripheral blood B-CLL specimens from previously untreated patients. Expression of Bcl-2, Mcl-1, BAG-1, Bax, Bak, and Caspase-3 was commonly found in circulating B-CLL cells, whereas the Bcl-XL and BAD proteins were not present. Higher levels of the anti-apoptotic protein Mcl-1 were strongly correlated with failure to achieve complete remission (CR) after single-agent therapy (fludarabine or chlorambucil) (P = .001), but the presence of only seven CRs among the 42 patients for whom follow-up data were available necessitates cautious interpretation of these observations. Higher levels of the anti-apoptotic protein BAG-1 were also marginally associated with failure to achieve CR (P = .04). Apoptosis-regulating proteins were not associated with patient age, sex, Rai stage, platelet count, hemoglobin (Hb) concentration, or lymph node involvement, although higher levels of Bcl-2 and a high Bcl-2:Bax ratio were correlated with high numbers (>10(5)/microL) of white blood cells (WBC) (P = .01; .007) and higher levels of Bak were weakly associated with loss of allelic heterozygosity at 13q14 (P = .04). On the basis of measurements of apoptosis induction by fludarabine using cultured B-CLL specimens, in vitro chemosensitivity data failed to correlate with in vivo clinical response rates (n = 42) and expression of the various apoptosis-regulating proteins. Although larger prospective studies are required before firm conclusions can be reached, these studies show the expression in B-CLLs of multiple apoptosis-regulating proteins and suggest that the relative levels of some of these, such as Mcl-1, may provide information about in vivo responses to chemotherapy. In vitro chemosensitivity data, however, do not appear to be particularly useful in predicting responses in B-CLL.

Analysis of the value of empiric vancomycin administration in febrile neutropenia occurring after autologous peripheral blood stem cell transplants

We conducted a retrospective review of 125 patients undergoing high-dose therapy and stem cell rescue in order to evaluate the incidence of documented infection and the utility of the administration of vancomycin empirically. All patients received prophylactic oral quinolone therapy. Because neutropenia in this setting is relatively brief, 21 patients never manifested fever, and no patient died of infection. Of the remaining 104 patients, positive blood cultures were obtained in only 10, nine with a gram stain positive and one with a gram stain negative organism. Sixty-two patients without any evidence of gram positive infection received vancomycin according to the existing algorithm for care of neutropenic fevers. In this population of patients, empiric administration of vancomycin for neutropenic fevers without culture documentation appears to be unnecessary, could be discontinued safely and at substantial cost savings, and might slow the appearance of vancomycin-resistant organisms.

Kinetic and mass spectrometric analyses of the interactions between plant acetohydroxy acid isomeroreductase and thiadiazole derivatives

Plant acetohydroxy acid isomeroreductase (EC 1.1.1.86), the second enzyme of the branched chain amino acid biosynthetic pathway, has been submitted to high-throughput screening for herbicide discovery. We report here the discovery of a new class of compounds belonging to the thiadiazole family, which exhibit a strong inhibitory effect on this plant enzyme. Kinetic analyses revealed that these compounds act as either reversible or irreversible noncompetitive inhibitors of the plant enzyme. Reversibility or irreversibility of these compounds can be attributed to the nature of the additional groups of the thiadiazole ring favoring or not favoring the formation of a covalent adduct. Mass spectrometric experiments on the complex between an irreversible compound belonging to the thiadiazole family and the plant enzyme identified Cys498 as the binding site of the inhibitor.

Elevated connexin-43 expression in term human myometrium correlates with elevated c-Jun expression and is independent of myometrial estrogen receptors

Just previous to the onset of parturition, a number of genes such as the one that codes for connexin-43 (Cx43) gap junction protein are induced in the myometrium. We have shown previously that activation of protein kinase C in human myometrial cultured cells leads to an up-regulation of cx43 transcription through an activating protein-1 element in the 5'-flanking promoter. Analyses were now performed on extracts of term myometrial tissue to test for an association between the up-regulation of cx43 expression and the expression of transcription factors and steroid hormone receptors that might regulate cx43 expression at term. Immunoblot analyses were performed on extracts of term myometrial tissue from women receiving elective or indicated cesarean sections to test for an association between the up-regulation of cx43 expression and the up-regulation of expression of the transcription factors c-Jun, c-Fos, and Sp1, which have cognate binding elements in the cx43 5'-flanking promoter. Immunoblot analysis, immunohistochemistry, and receptor binding assays were also performed to analyze the levels of progesterone receptors (PR) and estrogen receptors (ER) in the same term myometrial tissue, and these were compared to the levels in nonpregnancy myometrial tissue. The levels of PR were consistently 2- to 3-fold higher in term myometrial tissue than in nonpregnancy values and did not fluctuate during the menstrual cycle as did ER levels. Surprisingly, in term myometrium, ER was barely detectable by immunoblot and had whole cell diffuse staining by immunohistochemistry. In addition, very low levels of estrogen binding were observed in the term myometrial tissue. Treatment of primary myometrial cultures containing ER with estrogen for 3 or 48 h did not result in up-regulation of c-Jun or c-Fos proteins or in trans-activation from the proximal cx43 promoter with the activating protein-1 element. In contrast, an activated form of c-Jun protein was 10- to 18-fold higher in term myometrial tissue that also had elevated cx43 expression compared to c-Jun levels in term myometrial tissue with low cx43 expression. Likewise, c-Fos and Sp1 levels were 2-4 fold higher in term myometrial tissue with elevated cx43 expression. Although c-Fos and Sp1 proteins could be detected by immunoblot in myometrial tissue from nonpregnant women, c-Jun and Cx43 proteins could not. In summary, these results suggest that up-regulation of human myometrial cx43 gene expression at term involves induction of primarily c-jun expression through a mechanism that does not directly involve myometrial ER or the loss of PR. Peptide hormones that activate protein kinase cascades, such as the protein kinase C cascade, may be important to signal the onset of labor in humans.

Oral SIV, SHIV, and HIV type 1 infection

Several strains of simian immunodeficiency virus (SIV), including uncloned and molecularly cloned SIV strains, can cross intact mucosal surfaces after oral exposure in both adult and neonatal rhesus macaques, resulting in viremia and disease. Cell-free SIV strains as well as infected whole blood have resulted in systemic infection after oral inoculation. Neonatal macaques, exposed orally to the chimeric SHIV-vpu+, a derivative of SIVmac239 that encodes the env gene of the T cell-tropic HIV-IIIB, have also become persistently infected. These data indicate that oral exposure to various virus strains, including T cell-tropic variants, leads to infection. After nontraumatic inoculation, the oral route was more efficient than the rectal route in permitting SIV entry in adult macaques. Infection and AIDS resulting from oral exposure of adult macaques have implications for the transmission of the human immunodeficiency virus type 1 (HIV-1) during oral-genital contact.

Molecular genetic analysis of easily accessible breast tumour DNA, purified from tissue left over from hormone receptor measurement

In order to establish a large panel of normal and tumour DNA from primary breast cancer patients, we looked for a source of easily accessible, good quality breast tumour DNA. Following routine hormone receptor analysis at the hospital the leftover pellets contained the nuclei from the tumour tissue. We collected 670 pellets over a period of 2 1/4 years and isolated a large amount of DNA (on average 400 microg per pellet). To control the quality of this tumour DNA, we analysed 41 pellets and matching normal DNA for loss of heterozygosity (LOH), with 11 microsatellite markers along chromosome 17. This chromosome is well described for breast cancer. LOH is a sensitive method, requiring good quality and pure tumour DNA. Contamination with normal DNA will blur the results. We found a high rate of LOH, ranging from 33 to 74%, which is in agreement with other reports, and therefore recommend this rich source of breast tumour DNA for molecular biological analysis.

Perspective: human immunodeficiency virus type 1 (HIV-1) RNA end points in HIV clinical trials: issues in interim monitoring and early stopping

Due to the desire to both shorten the length and reduce the size of clinical trials in human immunodeficiency virus (HIV) disease, the use of surrogate end points such as HIV-1 RNA is becoming increasingly standard. While these end points may be reasonable surrogates for the clinical effectiveness of drugs, a key point in their use as trial end points is the definition of a relevant duration of antiviral response. This definition is often complicated by the desire to perform interim reviews of ongoing laboratory end point trials. Unlike clinical end point trials, in which early clinical response is generally indicative of longer-term follow-up, it is yet to be determined whether short-term viral response adequately predicts the long-term durability of that response.

Prognostic significance of urokinase-type plasminogen activator and plasminogen activator inhibitor-1 in primary breast cancer

The uPA-mediated pathway of plasminogen activation is central to cancer metastasis. Whether uPA and PAI-1 are related to local recurrence, metastatic spread or both is not clear. We present a retrospective study of 429 primary breast cancer patients with a median follow-up of 5.1 years, in which the levels of uPA and PAI-1 in tumour extracts were analysed by means of an enzyme-linked immunosorbent assay. The median values of uPA and PAI-1, which were used as cut-off points, were 4.5 and 11.1 ng mg(-1) protein respectively. The levels of uPA and PAI-1 were correlated with tumour size, degree of anaplasia, steroid receptor status and number of positive nodes. Patients with high content of either uPA or PAI-1 had increased risk of relapse and death. We demonstrated an independent ability of PAI-1 to predict distant metastasis (relative risk 1.7, confidence limits 1.22 and 2.46) and that neither uPA nor PAI-1 provided any information regarding local recurrence.

BCL-2 expression correlates with lower proliferative activity in the intermediate- and high-grade non-Hodgkin's lymphomas: an Eastern Cooperative Oncology Group and Southwest Oncology Group cooperative laboratory study

An inverse relationship between BCL-2 expression and cell cycle transition has been suggested by recent studies in murine models. To investigate the clinical relevance of these laboratory studies, a group of 116 paraffin-embedded non-Hodgkin's lymphoma (NHL) biopsy specimens (Working Formulation Groups D-H, and J) from a cooperative group study of cellular DNA content were analyzed for the 14;18 translocation using polymerase chain reaction (PCR)-based methods and, if sufficient tissue remained, for BCL-2 and BAX expression by immunohistochemistry. The results of these studies were then compared with the results of the previously performed flow cytometric analysis of ploidy and proliferative activity (S-phase-fraction). BCL-2 expression was inversely associated with proliferative activity (P = .001; n = 41), but there was no association between staining for Bax and %S-phase. Ploidy was not associated with either BCL-2 or BAX expression. The t(14;18) was detected in 21 of the 54 cases in which PCR-amplifiable DNA was recovered; 20 of these occurred at the major breakpoint region and 1 at the minor breakpoint region. High levels of BCL-2 or BAX expression occurred independently of t(14;18). There was no association between t(14;18) and either ploidy or proliferative activity. The inverse relationship between BCL-2 expression and proliferative activity in the intermediate- and high-grade NHLs is consistent with recent studies suggesting that Bcl-2 both retards entry into the cell cycle and inhibits apoptosis.

[Organization and results of ambulatory surgery for inguinal hernia]

The results of a reorganization of surgery for inguinal hernias within a department of surgical gastroenterology were assessed concerning staff simplifications, feasibility, patient satisfaction, safety, complications and resources. Five hundred consecutive, elective, open operations for unilateral reducible inguinal hernias were performed in 466 patients under local anaesthesia in an ambulatory setup. One hundred and fourteen of the operations were for a recurrent hernia. The median age was 60 years (44-74 years as 25% and 75% quartiles). Two of the operations were converted to general anaesthesia. The patients were discharged 85 min (median) post-operatively, but 12 patients were not discharged on the same day. Bleeding or wound infections in need of treatment were seen postoperatively in 1.6% and 1.6%, respectively. All patients were given a postoperative questionnaires with a response rate of 95%, 89% of the respondents were satisfied with the whole procedure, 11% were dissatisfied. A reorganization of surgery for inguinal hernias to a standardized ambulatory setup induced staff simplifications and saved resources with a preserved high patient satisfaction, safety and a low complication rate.

Acute myeloid leukaemia expressing the leucocyte integrin CD11b-a new leukaemic syndrome with poor prognosis: result of an ECOG database analysis. Eastern Cooperative Oncology Group

While assessing the prognostic implications of immunophenotyping in 382 patients enrolled in treatment protocols of the Eastern Cooperative Oncology Group (ECOG) for de novo adult acute myeloid leukaemia, we identified 95 patients with a unique antigen profile characterized by high expression of the leucocyte integrin CD11b (CD11b+ AML). High expression of CD11b was defined as > or = 32% positive blasts based on the retrospectively established prognostic cut-off point for this antigen. Although CD11b is normally expressed by mature monocytes, natural killer cells and granulocytes, leukaemic blasts in CD11b+ AML lacked other immunologic monocytic features (e.g. CD14 and CD122, the interleukin-2 receptor beta chain) and demonstrated a high degree of immaturity, as reflected by a high incidence of blasts expressing the stem cell factor receptor, CD117, and few blasts positive for the myeloid differentiation antigen CD15. Furthermore, by FAB criteria, only 41% of CD11b+ AML cases were classified as M4/M5. Patients with CD11b+ AML had a low response rate (54%) when compared with acute monocytic leukaemia (AMOL; 82%, P = 0.006) or AML overall (68%, P = 0.031), independent of age, cytogenetic abnormalities and P-glycoprotein expression. Because of its poor prognosis, recognition of CD11b+ AML is clinically warranted and, given its morphologic and cytogenetic ambiguity, must be based on the unique antigen profile.

Causal probabilistic network and power spectral estimation used in sleep stage classification

A new method for sleep-stage classification using a causal probabilistic network as automatic classifier has been implemented and validated. The system uses features from the primary sleep signals from the brain (EEG) and the eyes (AOG) as input. From the EEG, features are derived containing spectral information which is used to classify power in the classical spectral bands, sleep spindles and K-complexes. From AOG, information on rapid eye movements is derived. Features are extracted every 2 seconds. The CPN-based sleep classifier was implemented using the HUGIN system, an application tool to handle causal probabilistic networks. The results obtained using different training approaches show agreements ranging from 68.7 to 70.7% between the system and the two experts when a pooled agreement is computed over the six subjects. As a comparison, the interrater agreement between the two experts was found to be 71.4%, measured also over the six subjects.

[Ischemic/AMI ECG changes in perforated pyloric ulcer]

A patient without known heart disease developed electrocardiographic changes compatible with myocardial ischemia/infarction because of a perforated pyloric ulcer. The possible mechanisms responsible are discussed.

Prevalence of very mild to severe dementia in Denmark

OBJECTIVES

The prevalence of dementia has been estimated in several countries and a meta-analysis has shown moderate and severe dementia in people aged 65 years and older to be between 4% and 6%. The Odense study is aiming to estimate the prevalence and incidence of dementia and to identify risk factors.

MATERIAL AND METHODS

A total of 3346 persons, equivalent to 64.5% of a random sample of 5237 persons aged 65-84 years living in the municipality of Odense, Denmark, underwent a two phase diagnostic procedure including a screening with CAMCOG, the cognitive section of The Cambridge Examination for Mental Disorders of the Elderly, seven neuropsychological tests, medical examination, and CT scan. The severity of dementia was assessed by the CDR (Clinical Dementia Rating).

RESULTS

The prevalence rate was 7.1%, including the very mildly demented, defined as persons rated questionably demented according to the CDR scale. The prevalence rate of very mild dementia was 2.8%. The proportion of cases with very mild dementia decreased with increasing age while the prevalence rate increased.

CONCLUSION

Inclusion of very mild cases of dementia resulted in a higher prevalence rate than generally reported, and the prevalence rate increased exponentially with age which was mainly due to Alzheimer's disease.

MIB-1 expression in breast carcinomas with medullary features. An immunohistological study including correlations with p53 and bcl-2

Typical medullary carcinoma (TMC) is usually considered to have a more favourable prognosis than other types of infiltrating breast carcinomas. This is a biological paradox, since its clinical behaviour is not in agreement with its anaplastic morphology and high mitotic rate. It should be remembered that neoplastic growth reflects cell production minus cell loss, the latter being achieved by apoptosis. At present, bcl-2 oncogene (apoptosis inhibitor) and p53 gene are assumed to be involved in the regulation of cell death and tumour proliferation. Sixty breast carcinomas, initially indexed as medullary carcinomas, were re-classified using the diagnostic criteria given by Ridolfi. This review yielded 13 typical (TMC), 24 atypical (AMC), and 23 non-medullary carcinomas (NMC). Following antigen retrieval by microwave treatment, immunohistochemical analyses, using MIB-1, p53 and bcl-2 monoclonal antibodies were performed on serial sections from formalin-fixed, paraffin-embedded specimens. TMC revealed the highest incidence of intense p53 positivity, and the highest mean MIB-1 index, and absence of the apoptosis-inhibitor protein bcl-2. These results suggest the presence of a higher overall cell turnover in TMC than in AMC and NMC. Increased apoptosis balancing the increased cell proliferation might be among the possible explanations for the more favourable prognosis in TMC.

RAR alpha1/RAR alpha2-PML mRNA expression in acute promyelocytic leukemia cells: a molecular and laboratory-clinical correlative study

In addition to the major fusion gene PML-RAR alpha, the t(15; 17) in acute promyelocytic leukemia (APL) produces the reciprocal fusion gene RAR alpha-PML. To determine the scope of RAR alpha-containing mRNA expression in APL cells, we tested PML-RAR alpha-positive APL cells for the presence of mRNAs initiated from two distinct RAR alpha gene promoters, alpha1 and alpha2. From the normal allele, both RAR alpha1 and RAR alpha2 mRNAs were expressed in all APL cases (N = 24). From the translocated allele, RAR alpha1-PML mRNA was expressed in 77% and RAR alpha2-PML mRNA in 28% of cases (N = 98). RAR alpha2-PML mRNA was not observed in the absence of RAR alpha1-PML mRNA. There was no association between RAR alpha1-PML or RAR alpha2-PML mRNA expression and the type of PML-RAR alpha mRNA formed by either 5' or 3' breaksites in the PML gene. RAR alpha1-PML mRNAs and RAR alpha2-PML mRNAs from 5' PML breaksite cases coded for full-length RAR alpha-PML proteins but RAR alpha2-PML mRNAs from 3' PML breaksite cases encoded a truncated RAR alpha2 peptide. RAR alpha1/alpha2-PML mRNA expression was not associated with differences in APL cell sensitivity to all-trans retinoic acid(tRA)-induced differentiation in vitro or in clinical outcome after tRA or chemotherapy induction therapy (protocol E2491). Our analysis indicated that RAR alpha1/alpha2-PML mRNA expression markedly differs from normal RAR alpha1/alpha2 mRNA expression, that the difference in RAR alpha1-PML and RAR alpha2-PML mRNA expression frequency is primarily related to the genomic separation of the RAR alpha1 and RAR alpha2 coding exons, and that variations in RAR alpha1/alpha2-PML mRNA expression likely have no clinically relevant function in APL cells.

Prognostic comparison of three classifications for medullary carcinomas of the breast

The aim of this study was to make prognostic comparisons between the modified scheme of Pedersen et al. the definitions of Tavassoli and the Ridolfi criteria for medullary carcinomas. Sixty breast carcinomas primarily diagnosed as medullary carcinomas were reclassified into typical medullary carcinoma (TMC), atypical medullary carcinoma (AMC) and non-medullary carcinoma (NMC) according to the three classifications. The Ridolfi classification proved to be superior to the two other schemes in discriminating survival differences between the three groups TMC, AMC and NMC. All 13 patients with TMC are still alive indicating an excellent prognosis, while 29% and 39% of the 47 patients in the AMC and NMC category, respectively, have died of their disease. In the simplified system of Pedersen et al. the survival at 10 years for TMC patients decreased to 75% and no significant survival difference between the three groups could be demonstrated. As the prognosis for AMC proved to be worse compared to TMC and in fact was similar to NMC with values of 43% at 10 years in the Ridolfi classification, we find no reasons to maintain this category. We conclude that as long as no alternative and more easily applicable diagnostic method exists, pathologists should still apply the Ridolfi criteria on these tumours with medullary features leaving two diagnostic possibilities: TMC or NMC (i.e. poorly differentiated ductal carcinoma). Only lesions that fulfil all six criteria without any doubt should be diagnosed as TMC, thus avoiding overdiagnosis and a resulting risk of undertreatment.

Improvements in survival and clinical benefit with gemcitabine as first-line therapy for patients with advanced pancreas cancer: a randomized trial

PURPOSE

Most patients with advanced pancreas cancer experience pain and must limit their daily activities because of tumor-related symptoms. To date, no treatment has had a significant impact on the disease. In early studies with gemcitabine, patients with pancreas cancer experienced an improvement in disease-related symptoms. Based on those findings, a definitive trial was performed to assess the effectiveness of gemcitabine in patients with newly diagnosed advanced pancreas cancer.

PATIENTS AND METHODS

One hundred twenty-six patients with advanced symptomatic pancreas cancer completed a lead-in period to characterize and stabilize pain and were randomized to receive either gemcitabine 1,000 mg/m2 weekly x 7 followed by 1 week of rest, then weekly x 3 every 4 weeks thereafter (63 patients), or to fluorouracil (5-FU) 600 mg/m2 once weekly (63 patients). The primary efficacy measure was clinical benefit response, which was a composite of measurements of pain (analgesic consumption and pain intensity), Karnofsky performance status, and weight. Clinical benefit required a sustained (> or = 4 weeks) improvement in at least one parameter without worsening in any others. Other measures of efficacy included response rate, time to progressive disease, and survival.

RESULTS

Clinical benefit response was experienced by 23.8% of gemcitabine-treated patients compared with 4.8% of 5-FU-treated patients (P = .0022). The median survival durations were 5.65 and 4.41 months for gemcitabine-treated and 5-FU-treated patients, respectively (P = .0025). The survival rate at 12 months was 18% for gemcitabine patients and 2% for 5-FU patients. Treatment was well tolerated.

CONCLUSION

This study demonstrates that gemcitabine is more effective than 5-FU in alleviation of some disease-related symptoms in patients with advanced, symptomatic pancreas cancer. Gemcitabine also confers a modest survival advantage over treatment with 5-FU.

Acute meningococcal meningitis: analysis of features of the disease according to the age of 255 patients. Copenhagen Meningitis Study Group

Clinical and laboratory features of acute meningococcal meningitis according to age were studied in 255 patients. Whereas males accounted for three out of five patients aged 0-4 years, females accounted for three out of four patients older than 50 years of age. All patients had clinical signs of nuchal rigidity and fever. Patients older than 30 years of age had less frequent petechiae (62%) than younger patients (81%). Furthermore, elderly patients above 50 years of age were prone to an obtunded mental state and a prolonged disease course with fever. Without relation to age, 2/3 had purulent meningitis and 2/3 had marked peripheral leucocytosis (> 15 x 10(9) cells/l); 90% of patients had at least one of these findings. The cellular inflammatory response in peripheral blood indicated a bacterial aetiology in > 95% of the cases. More than 80% of children and adults had abnormal CSF biochemical findings, but the level of protein and the glucose ratio (CSF/serum) were positively and negatively correlated to increasing age of the patient, respectively: thus, in children these biochemical markers may be unreliable in the differentiation between a bacterial and non-bacterial aetiology. Thrombocytopenia (< 100.000 x 10(9)/I) was not associated with age, though the lowest platelet count was found in elderly patients. The case fatality rate was 7.5%, but neither age, sex nor sign of septicaemia was associated with fatality. Thrombocytopenia, a lowered coagulation index (< 0.5, factors II, VII, X), a moderate anaemia (haemoglobin < 11 g/dl), an obtunded mental state and a history of convulsions were poor prognostic factors; only anaemia was independently correlated to fatality so this should be considered as an important prognostic marker in the acute phase of meningococcal meningitis.

Measurement of antibodies against meningococcal capsular polysaccharides B and C in enzyme-linked immunosorbent assays: towards an improved surveillance of meningococcal disease

In order to improve the surveillance of serogroup B and C meningococcal diseases, enzyme-linked immunosorbent assays (ELISAs) specific for anti-B immunoglobulin M (IgM) and anti-C IgM and IgG antibodies were developed. The tests were evaluated by using paired sera from 122 patients with and 101 patients without laboratory evidence of meningococcal disease. Fifty-three of 67 patients (79%) with culture-confirmed serogroup B disease had an anti-B IgM antibody response; anti-B IgM levels waned rapidly in children < or = 4 years of age. Twenty-four of 25 patients (96%) with culture-confirmed serogroup C disease had an anti-C IgM and/or IgG antibody response (IgM, 92%; IgG, 68%). In patients without evidence of meningococcal disease, 19% of children < or = 4 years of age and 69% of those > 4 years of age had intermediate anti-B IgM titers. In contrast, only 1 and 5% of these patients had intermediate titers of anti-C IgM and anti-C IgG, respectively. The ELISAs were shown to be powerful tools for discriminating between serogroup B and C diseases in 96 to 100% of culture-confirmed cases. For 90% of patients with culture-negative meningococcal disease, a serogroup-specific diagnosis could be established by examination of paired sera in the ELISAs. As serogroup B and C meningococci account for practically all cases of meningococcal disease in industrialized countries, the availability of these tests may improve surveillance and prevention.

Report of the European DNA profiling group (EDNAP): an investigation of the complex STR loci D21S11 and HUMFIBRA (FGA)

This paper describes a collaborative exercise which was intended to demonstrate whether uniformity of DNA profiling results could be achieved between European laboratories using two complex short tandem repeat (STR) loci. The loci D21S11 and HUMFIBRA (FGA) were chosen because they are commonly used by different European laboratories. D21S11 has approximately 14 common alleles (f > 0.001), whereas HUMFIBRA has 19 common alleles. Laboratories were asked to test seven blood stains, one of which was a known control, and to report the results to the coordinating laboratory. The exercise demonstrated that complex STRs were amenable to standardisation.

[Posterior rectotomy--a minimally invasive procedure?]

This study included twenty-five consecutive patients, 12 men and 13 women, treated with a posterior approach to the rectum because of diseases in the mid and lower third of the rectum. Surgical indication included rectovaginal fistula in four patients, villous adenoma in 13 patients, villous adenoma containing carcinoma in three patients, primary carcinoma in four old high-risk patients and recurrent cancer in one old high-risk patient. There were only a few minor postoperative surgical complications, one wound infection and one rectal bleeding from the place of the excision. The bleeding was treated transanally. Three patients developed pneumonia. No patients died as a complication of the procedure. The posterior approach provides excellent exposure for complete removal of tumour in the mid- and distal part of the rectum, and the results of this study indicated that the technique has a place in the management of various benign and selected malignant conditions in the mid and lower third of the rectum. The procedure is easy to perform, safe with only a few minor complications and well tolerated even in old high-risk patients.

In vitro interaction of U2 snRNA with cytoplasmic 6S protein complexes

Interactions of U2 snRNA with anti-Sm precipitable proteins in RNA-free cytoplasmic complexes were analyzed. U2 snRNA was found to bind specifically with proteins in the 6S complexes but not in the 20S complexes. The binding activity was preserved using U2 snRNA having a mutated Sm binding site. Label-transfer experiments indicate that snRNA makes direct contact with anti-Sm precipitable proteins in the 6S fraction with apparent molecular mass of about 16 kDa. These data corroborate that proteins in the 6S core particle are the first to interact with snRNA, and suggest that the proteins recognize snRNA structures in addition to the Sm site.

The effects of fingermark enhancement light sources on subsequent PCR-STR DNA analysis of fresh bloodstains

This paper describes a study designed to investigate the effects of light sources used to enhance fingermarks on the subsequent polymerase chain reaction (PCR)-short tandem repeat (STR) analysis of bloodstains. Dried bloodstains on glass were exposed for up to 30 min to five different light sources: Argon ion laser, Polilight UV, Polilight green, Superlite, and shortwave UV. The bloodstains were subsequently analyzed using a quadruplex PCR system. It was found that treating the bloodstains with four of the five light sources had no appreciable effect on the results obtained from subsequent PCR analysis. However, exposure of the bloodstains to shortwave UV light for more than 30 s precluded the acquisition of results from PCR testing. Therefore, under casework conditions, it would be preferable to avoid exposing bloodstains, on which PCR typing is to be performed, to shortwave UV.

Effect of prednisolone on the systemic response and wound healing after colonic surgery

OBJECTIVE

To study the effect of preoperative treatment with a single high-dose glucocorticoid on the systemic and immunologic responses, wound healing, and convalescence after colonic surgery.

DESIGN

Double-blind, placebo-controlled, randomized trial.

SETTING

Department of surgery in a university hospital.

PATIENTS

Thirty patients scheduled for open colonic resection; 6 patients were excluded from the study (N = 24).

INTERVENTIONS

Patients were randomized to either of 2 treatment regimens: methylprednisolone sodium succinate 90 minutes before induction of anesthesia and epidural analgesia (group 1, n = 12), or placebo 90 minutes before anesthesia and epidural analgesia (group 2, n = 12).

MAIN OUTCOME MEASURES

Assessments of pain, pulmonary function, convalescence, and various injury and wound-healing factors were done several times until 10 days after surgery.

RESULTS

Conventional reduction in pulmonary function and mobilization was improved in group 1. Interleukin-6 and C-reactive protein levels increased significantly less in group 1, as delayed-type hypersensitivity was abolished in group 1. Plasma cascade system activations were significantly less pronounced in group 1. Reduction of collagen turnover was observed in group 1, but without detrimental effects on collagen accumulation.

CONCLUSION

Treatment with a single high-dose glucocorticoid before colonic surgery may improve postoperative pulmonary function and mobilization and reduce plasma cascade system activations, the inflammatory response, and immunofunction, but without detrimental effects on wound healing.

[Recurrence of inguinal hernia: ambulatory surgery under local anesthesia]

In order to assess the feasibility of repair of a recurrent inguinal hernia in unmonitored local anaesthesia in an ambulatory set-up pain scores and data on patient satisfaction were obtained from 76 unselected patients after 79 consecutive operations. Median age was 63 years, and 25%- and 75% quartiles were 49 and 72 years respectively. All operations were conducted in local anesthesia. Three patients stayed in hospital overnight after the operation. Pain: After one, six and 28 days 27, 14 og 7% respectively had severe pain during function (cough and/or rising). Satisfaction: 82% were satisfied with ambulatory surgery in local anaesthesia, 82% were satisfied with the analgesic therapy (tenoxicam and methadone), but one third needed supplementary analgesics during the first week (acetaminophen was recommended). It is concluded, that ambulatory repair of a recurrent inguinal hernia in unmonitored local anaesthesia is a safe and cost effective alternative to operation in general or spinal anaesthesia.

The validation of a 7-locus multiplex STR test for use in forensic casework. (II), Artefacts, casework studies and success rates

PCR-based DNA typing of biological evidence is now widely used in forensic analyses due to the obvious advantages of enhanced sensitivity, the ability to distinguish discrete alleles and efficacy with degraded samples. A multiplex short tandem repeat (STR) system has been previously developed which successfully co-amplifies six STR loci HUMTH01, D21S11, D18S51, D8S1179, HUMVWF31/A and HUMFIBRA (FGA) in conjunction with the X-Y homologous gene Amelogenin. This is known as the second generation multiplex system (SGM). Detection of the PCR products is undertaken on ABD 373A or 377 automated sequencers using denaturing polyacrylamide gels coupled with fluorescent-based technology. We have evaluated this system for routine forensic use and demonstrated that the technique is robust and reproducible under conditions consistent with those encountered in a forensic environment. A total of 132 stains from simulated and actual casework were analysed, together with relevant control areas and reference samples. The success rate was high with 76% of stains giving full profiles; we were also able to successfully detect and interpret mixtures. No mistyping was observed. A detailed examination of each of these profiles has assisted in the development of guidelines for casework interpretation. Although artefacts, stutter peaks and undenatured DNA were occasionally observed, these did not interfere with the accuracy of interpretation. In addition 38 samples, previously examined using the quadruplex system, were analysed with the SGM to enable a direct comparison to be made between the systems. The performance of the system with poor quality samples demonstrated its use as a rapid and powerful technique for individual identification.

Prognostic implications of ploidy and proliferative activity in the diffuse, aggressive non-Hodgkin's lymphomas

The International Index is a powerful predictor of outcome in the aggressive non-Hodgkin's lymphomas that is based solely on clinical features. Proliferative activity (% S-phase) measured by flow cytometry has been reported to have prognostic significance in many series and may represent a biologic correlate of clinical behavior that further defines prognosis. Flow cytometric analysis of cellular DNA content and proliferative activity (% S-phase) was performed on fixed paraffin-embedded biopsy specimens from 242 previously untreated patients with diffuse, aggressive non-Hodgkin's lymphomas entered on phase III intergroup clinical trials. The International Index was calculated for each patient based on stage, lactate dehydrogenase, performance status, number of extranodal sites, and age, as previously reported. The International Index consistently predicted response to therapy (P = .027) and survival (P = .007) in this series. DNA aneuploidy was shown in 57% of cases, but was not predictive of clinical outcome. The median % S-phase was 9.9 (median coefficient of variation, 3.6%), which was highly correlated with mitotic index (P = .0001). Although a trend associating low proliferative activity with good early survival and very high S-phase with a shortened survival was shown, International Index risk was the only significant predictor of survival in the multivariate analysis. Although proliferative activity quantitated by flow cytometric analysis of nuclei extracted from paraffin-embedded specimens is probably predictive of survival, it is a less powerful prognostic indicator than clinical parameters represented by the International Index and provides no additional prognostic information.

Phase II trial of interferon-alpha in locally recurrent or metastatic squamous cell carcinoma of the head and neck: immunological and clinical correlates

The objective of this study was to study the antitumor, host toxicity, and immunomodulatory effects of recombinant interferon-alpha 2b (IFN) in patients with recurrent or metastatic squamous cell carcinoma of the head and neck (SCCHN). Seventy-one patients with recurrent or metastatic SCCHN were entered into a phase II noncomparative randomized trial of IFN at two dosage schedules. Eligible patients with histologically proven SCCHN were randomized to receive low-dose IFN, 6 x 10(6) U/m2 daily x 3 every 4 weeks or high-dose IFN, 12 x 10(6) U/m2, 3 x/week. Pretreatment levels of natural killer (NK) activity, CD3, CD4, CD5, CD8, CD16, CD19, CD56, DR, and the CD4/CD8 ratio were evaluated for any relationship with survival. The toxicity encountered in patients receiving low-dose IFN was for the most part mild to moderate. With high-dose IFN, toxicity was greater with significantly more episodes of grade 3 and 4 toxicity encountered. Dosage reduction was required in the majority of patients receiving high-dose IFN. Of the four lethal complications, only one was thought to be possibly associated with therapy. Of the 32 evaluable patients receiving low-dose IFN, there were 1 complete response, 1 stable disease, 24 patients with progressive disease, and 6 unevaluable. Of the 29 evaluable patients taking high-dose IFN, there were 2 complete responses, 7 with stable disease, 16 with progressive disease, and 4 patients were unevaluable. Median survival in the two arms was similar (6.2 months). Because it was postulated that a more prolonged exposure to IFN might be needed for it to be effective, patients receiving > or = 6 weeks of therapy were evaluated. Median survival in that subset was 10 and 12 months for patients receiving low- and high-dose IFN, respectively. None of the immune parameters tested was a significant predictor of survival when evaluated in all cases entered into study regardless of therapy duration. No difference in baseline NK activity was noted between patients who received < 6 or > or = 6 weeks of IFN (p = 0.90). However, among the 35 patients who received > or = 6 weeks of therapy, a high baseline NK activity was a significant predictor of the duration of survival (p = 0.04). IFN was well tolerated in patients with recurrent or metastatic SCCHN. The higher incidence of toxicity encountered in the high-dose arm could be ameliorated by reducing the dose 50%. In patients receiving 6 or more weeks of therapy, elevated baseline NK activity was associated with increases in survival, suggesting that IFN may play an immunomodulatory role. Although the overall response rates were low, disease stabilization was noted, suggesting an antiproliferative, noncytotoxic role of IFN in this group of heavily pretreated patients.

Missing cause of death information in the analysis of survival data

Goetghebeur and Ryan proposed a method for proportional hazards analyses of competing risks failure-time data when the failure type is missing for some cases. This paper evaluates the properties of the method using data from a clinical trial in Hodgkin's disease. We generated several patterns of missingness in the cause of death in 'pseudo-studies' derived from the study database. We found that the proposed method provided regression coefficients and inferences that were less biased than those from other methods over an increasing percentage of missingness in the failure type when missingness is random, when it depends on an important covariate, when it depends on failure type, and when it depends on follow-up time. We present suggestions for study design with planned missingness in the failure type.

[Open surgery of choledochus in Denmark]

For each of the years 1991-1994 400, 209, 170 and 133 open common bile duct stone extraction were performed in Denmark, corresponding to 35%, 17%, 12% and 5% respectively of patients diagnosed with common bile duct stone. There was only little variation between the 16 hospital counties. The expected decrease in open common bile duct surgery corresponds to the introduction of several non-invasive methods for the treatment of common bile duct stones. To achieve further reduction in open surgery, centralization of the treatment of common bile duct stones is necessary.

Activation of protein kinase C in human uterine smooth muscle induces connexin-43 gene transcription through an AP-1 site in the promoter sequence

Myometrial connexin-43 gap junctions are scarce throughout gestation but appear in large numbers at term to facilitate contractions during labor. The mechanisms that regulate this process are incompletely characterized. This report investigates the effects of protein kinase C activation on the regulation of connexin-43 gene transcription in human uterine smooth muscle cells. In primary myometrial cells treated with phorbol ester, transient increases in c-Fos and c-Jun protein levels were observed at 2-4 h, followed by significant increases in connexin-43 protein levels at 6-8 h. Nuclear run-on transcription analysis showed an increase in connexin-43 transcription 3 h after phorbol ester treatment. AP-1 sites were identified in the sequence of the 5'-flanking promoter region of the human connexin-43 gene at 44 and 1000 base pairs upstream of transcription start. Transcription from a reporter plasmid containing the proximal human connexin-43 promoter was increased in transfected primary cultures treated with phorbol ester. Mutation of the proximal AP-1 site in the promoter abolished the phorbol ester-dependent transactivation. This work provides evidence that transcription of the human connexin-43 gene is induced through protein kinase C activation in uterine smooth muscle cells, and that the induction involves up-regulation and activation of c-Jun and c-Fos.

Rate dependence of regional cerebral activation during performance of a repetitive motor task: a PET study

Using repeated positron emission tomography (PET) measures of regional cerebral counts, we investigated the regional cortical activations induced in eight normal subjects performing eight different frequencies of fingertapping (0.5-4 Hz) with the right index finger. The task was auditorially cued and the performance recorded during the scanning procedure. Performance evaluation showed increased error rates, during fingertapping, of high and low frequencies, and the best tapping performance was measured in the midrange of frequencies. Significantly activated areas (p < 0.05) of normalized cerebral counts were located in the left sensorimotor cortex (MISI), right motor cortex, left thalamus, right insula, supplementary motor area (SMA), and bilaterally in the primary auditory cortex and the cerebellum. Statistical evaluation showed a significant (p < 0.01) and positive dependence of cerebral activation upon movement rate in the contralateral MISI. There was no significant rate dependence of cerebral activation in other activated motor areas. The SMA and the right cerebellar hemisphere showed a more uniform activation throughout the tapping frequency range. Furthermore, we found a stimulus rate dependence of cerebral activation in the primary auditory cortex. We believe that the present data provide useful information for the preparation and interpretation of future motor activation studies of normal human subjects and may serve as reference points for studies of pathological conditions.

Clearance of normal and type 2A von Willebrand factor in the rat

A model for the in vivo clearance of normal and mutant forms of human von Willebrand factor (vWF) has been established using catheterized rats. vWF clearance rates in rat plasma were determined by quantitation of reduced vWF subunits on sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), and multimeric vWF was analyzed using nondenaturing SDS-agarose gels. Normal vWF derived from human umbilical vein endothelial cells displayed a biphasic pattern of clearance, with half times of 35 minutes (T 1/2 a; SD 15. min.) and 245 minutes (T 1/2 b; SD 76. min.); metabolic clearance rate = 0.65%/minute. High molecular weight multimers of vWF were cleared more rapidly than dimeric vWF. vWF containing the S1613P mutation found in some type 2A von Willebrand disease (vWD) patients was observed to undergo proteolysis in vivo resulting in a reduction of high molecular weight vWF and concomitant appearance of rapidly-migrating satellite species, although the overall clearance rate of vWF antigen was similar to wild type vWF. These results provide direct in vivo evidence that the S1613P mutation causes the characteristic type 2A vWD phenotype. Full-length recombinant vWF produced from transfected Chinese hamster ovary cells was cleared at a similar rate to endothelial cell-derived vWF, and recombinant vWF devoid of O-linked carbohydrates was cleared significantly faster. vWF devoid of sulfate was cleared at a similar rate as wild type vWF, indicating the sulfate moiety of vWF does not regulate in vivo clearance. This animal model should prove useful in subsequent in vivo analysis of additional forms of vWD and in the development of protease inhibitor therapy for 2A vWD.

Growth factors and cytokines in uterine leiomyomas

Uterine leiomyomas, hard masses of smooth muscle-like tissue embedded in the myometrium, may be the most common tumors among humans. These tumors enlarge in as many as 30% of women over 30 years of age, cause significant morbidity, and are the most frequent indication for hysterectomy. Many researchers and clinicians have recently directed their attentions to understanding the etiology of these benign tumors, the conditions which cause their enlargement, and appropriate therapies which may be used as alternatives to hysterectomy. The ovarian steroid hormones estrogen and progesterone are known to play a central role in the pathology of leiomyomas. Both estrogen and progesterone contribute to the pathology of leiomyomas through gene regulation, but in opposing ways. During the follicular phase, estrogen maintains high expression of several genes which are normally expressed in the differentiated myometrium of pregnancy. During the luteal phase, progesterone can increase the mitotic activity of leiomyomas, particularly in younger women. Progesterone may act by inducing the production of growth factors and/or their respective receptors. This article surveys growth factors which may promote enlargement of susceptible leiomyomas. A potential role for cytokines in leiomyoma pathology is also discussed.

Terminal transferase expression in the differential diagnosis of acute leukemias. Eastern Cooperative Oncology Group

While the clinical significance of terminal transferase (TdT) detection in acute lymphoblastic leukemia (ALL) is uncontested, conflicting evidence exists for the prognostic relevance of this enzyme in blast cells from patients with acute myeloid leukemia (AML). The technical challenge of determining TdT in myeloid blast cells may be primarily responsible for those discrepancies in the literature. We present here the relative values of various standard approaches to the detection of TdT in ALL versus AML, including the slide staining technique, which served as the reference method, flow cytometry, and the biochemical enzyme assay.

10 years of pediatric liver transplantation

PURPOSE

Pediatric liver transplantation is an accepted therapy for end-stage liver disease, but little long-term data exist.

METHODS

From October 1984 to October 1994, 202 patients underwent a total of 225 liver transplantations. There were 98 boys and 104 girls, the average age was 5.1 +/- 4.9 (range, 0.2 to 19.1) years. Thirty (16%) were under 1 year of age. The diseases that required transplantation included biliary atresia (BA) (45%), metabolic liver disease (MLD) (9.9%), acute hepatic failure (6.9%), and Alagille's syndrome (AS) (5.4%). Originally the immunosuppression was cyclosporine- and steroid-based; the later regimens also included azathioprine and antilymphocyte preparations. All reported survival rates were derived from life-table analysis.

RESULTS

The patient survival rates at 1, 5, and 10 years were 76%, 70%, and 61%; the retransplantation rate was 11%. The respective graft survival rates were 71%, 63%, and 59%. There were 60 deaths; 48 (81%) occurred in the first year. These first-year deaths were from sepsis (20; 42%), central nervous system problems (5; 11%), intraoperative complications (4; 8%), lymphoproliferative disease (LPD) (2; 4%), rejection (2; 4%), primary nonfunction (2; 4%), and miscellaneous other causes (7; 15%). There were 12 deaths after the first year, from LPD (3; 25%), sepsis (1; 8%), rejection (2; 18%), cancer (1; 9%), secondary hepatic failure (1; 9%), cerebral vascular accident (1; 9%), or pre- or postoperative complications (3; 25%). Compared with the overall survival rate, patients with MLD had a better chance of survival (83%; P <.012) than did those with AS (45%; P < .001). The 5- and 10-year survival rates for patients with BA were 61% and 58%. Over the past 2 years, the survival rate has increased (87% v 72%; P < .05) as early septic deaths have decreased (from 2.6 to 1.0 per year).

CONCLUSION

Liver transplantation is effective treatment for end-stage liver disease. Decreasing the number of early septic deaths has improved the chance of survival, and better diagnosis and treatment of LPD would improve the late survival rate.

MLL tandem duplication and multiple splicing in adult acute myeloid leukemia with normal karyotype

Rearrangement of the MLL (myeloid-lymphoid or mixed-lineage leukemia) gene through a reciprocal chromosomal translocation is found in 5% of adult acute myeloid (AML) and 10% of pediatric acute lymphoid (ALL) leukemia. More than 25 different reciprocal chromosomal translocations, with an 11q23 breakpoint, fuse the MLL gene (also named ALL-1, HRX and Htrx1) to a second partner gene. These leukemias have poor prognosis and frequently have a monocytic, lymphoid or biphenotypic (myeloid and lymphoid) antigen expression in blast cells. Approximately 20-30% of patients diagnosed as having adult de novo, AML have normal chromosomes by metaphase analysis and the majority of these patients have good prognosis. With the use of reverse transcriptase-polymerase chain reaction (RT-PCR) technique and Southern blot analysis, we found that seven of 34 such patients (21%) had a tandem partial duplication of exons 2 to 6 or 2 to 8 of the MLL gene. These seven patients showed a median survival of 2.7 months, compared to a 6.8 months median survival for all other patients in the study. If confirmed on a large series of patients, our findings may help differentiate AML with normal karyotype and poor prognosis from those with normal karyotype and a more favorable prognosis.

Report on the third EDNAP collaborative STR exercise. European DNA Profiling Group

This report describes an inter-laboratory exercise completed on behalf of the European DNA Profiling (EDNAP) group. The exercise is one in a series designated to identify STR loci which could be used for harmonisation between participating European forensic science laboratories. Participants were asked to identify the alleles present in five bloodstains at the STR loci HUMTHO1 and HUMVWFA31/A. Two of the stains were prepared from mixtures of two different blood samples. There were no special instructions and each laboratory was requested to use the methodology normally employed for crime case investigations. All participating laboratories achieved the same results for both loci. In addition, the laboratories were also requested to report the results obtained from any other loci which would normally be used in crime case investigations. A comparison of these results showed some inter-laboratory variation.

Progestin represses human connexin43 gene expression similarly in primary cultures of myometrial and uterine leiomyoma cells

The mechanism by which progestin represses the expression of the human connexin43 (cx43) gene was analyzed in primary cultures of human myometrial cells, and for comparison, in primary cultures of uterine leiomyoma cells. Within 24 h, the levels of connexin43 (Cx43) protein in primary cells treated with progestin were reduced to about 50% of that in untreated cells, and these levels were maintained for up to 120 h. A plateau in the reduction of Cx43 protein levels was reached at progestin concentrations of 50-100 nM. No significant difference was found in a comparison of progestin-mediated reduction of Cx43 protein in autologous myometrial and leiomyoma primary cultures. Levels of cx43 mRNA levels also decreased to about 50% in myometrial and leiomyoma cells within hours after treatment with progestin, and these new levels were maintained for up to 48 h. Nuclear run-on transcription analysis showed that 100 nM progestin partially repressed transcription of the cx43 gene in both myometrial and leiomyoma primary cultures. The amount of decrease in cx43 transcription in cells treated with progestin was paralleled by a corresponding decrease in cytoplasmic cx43 mRNA levels. Progesterone receptor (PR)-mediated transcription was also determined to be similar in the two types of primary cells as evidenced by transient expression assays. Thus progestin down-regulates the expression of the human cx43 gene primarily by repressing transcription of the gene in myometrial cells, and it acts similarly in leiomyoma cells.

An electron microscopic study of clinical Paget's disease of the nipple

An ultrastructural study of the epidermis from eight patients with clinical Paget's disease of the nipple supports the epidermotropic theory. There was no evidence that the Paget's cells originated from keratinocytes. We propose the hypothesis that Paget's cells represent transformed ductal cells, from the subjacent lactiferous ducts of the nipple, which have migrated into the epidermis, either as neoplastic cells or as normal ductal cells with secondary in situ transformation in the epidermis.

Acute meningitis of unknown aetiology: analysis of 219 cases admitted to hospital between 1977 and 1990

Clinical and biochemical parameters in 219 patients with meningitis of unknown aetiology were analyzed according to their initial CSF leucocyte count. The male/female ratio was 1.1 and the median age 30 years,(males = 22 years/females = 42 years). Pre-admission antibiotic, which may inhibit bacterial growth, was given to 28% patients. On admission symptoms of meningitis were predominant: 96% had fever, 91% neck rigidity and 19% a severely affected mental state. In addition, 10% had a petechial rash. A bacterial aetiology was likely, as 91% had a predominance of polymorphonuclear leucocytes in the CSF and in 50% it was frankly purulent. The CSF leucocyte count correlated positively with age, the period of fever and the length of hospitalization, but did not relate to the 10.1% in-patient mortality rate. Mortality was related to advancing age, but not to the antibiotic regimen chosen. Patients admitted directly from their homes had the least complicated disease course and all survived. A low CSF leucocyte count, mainly found in young patients so admitted, could indicate either a non-bacterial self-limiting aetiology or diagnosis at an early stage of the disease. We found, however, that bacterial meningitis cannot be excluded on the basis of the CSF leucocyte count in combination with any clinical and biochemical parameters. Rapid hospital admission, regardless of age, is of major importance for prognosis. Improvement of non-cultural diagnostics tests and adjunctive therapy regimens are essential.

Abnormal gene expression in uterine leiomyomas

Uterine leiomyomas, benign tumors of myometrial origin, are the most common neoplasms of the uterus and occur in 20-30% of women over 30 years of age. Despite their high prevalence, little is known about the pathophysiology of these tumors. Recently, several studies have compared leiomyoma gene expression with that of normal myometrium. In general, the major differences in leiomyoma and myometrial gene expression are found for estrogen-regulated genes, which have elevated expression in myometrium during pregnancy. The tumors appear to maintain high sensitivity to estrogen during the estrogen-dominated follicular phase of the menstrual cycle, unlike normal myometrium. The abnormal gene expression of leiomyomas suggests that they are tumors of dysregulated differentiation and resemble the myometrium of pregnancy in several aspects.