Differential potentiative effects of GABA receptor agonists in the production of antinociception induced by morphine and beta-endorphin administered intrathecally in the mouse

The effect of muscimol or baclofen injected intrathecally (i.t.) on the inhibition of the tail-flick response induced by morphine and beta-endorphin administered i.t. was studied in ICR mice. The i.t. injection of muscimol (100 ng) or baclofen (10 ng) alone did not affect the basal inhibition of the tail-flick response. Morphine (0.2 microg) and beta-endorphin (0.1 microg) caused only slight inhibition of the tail-flick response. Baclofen, but not muscimol, injected i.t. enhanced the inhibition of the tail-flick response induced by i.t. administered morphine. Both muscimol and baclofen injected i.t. significantly enhanced i.t. injected beta-endorphin-induced inhibition of the tail-flick response. Our results suggest that the GABA(B), but not GABA(A), receptors located in the spinal cord appear to be involved in enhancing the inhibition of the tail-flick response induced by morphine administered spinally. In addition, both GABA(A) and GABA(B) receptors are involved in enhancing the inhibition of the tail-flick response induced by beta-endorphin administered i.t.

A glass compensator filter to improve breast image quality in radiation therapy simulation

PURPOSE

To improve the image quality of simulation films in tangential radiotherapy for breast cancer, we have designed a new compensator filter for the variation of breast contour using high-density-glass material.

METHODS AND MATERIALS

The measurements and analyses of the body contour were done using CT scans, taken in the treatment position, of 20 breast cancer patients. The maximum tissue deficit that needed to be compensated for was 8 cm, and the authors fabricated the compensator system using high-density-glass material to maintain transparency. The glass compensator can be attached to the accessory mount of the simulator head and its position can be easily adjusted according to breast shape and position. The image qualities of simulation films taken with and without the glass compensator in tangential breast radiotherapy field were compared and the film densitometry was performed using the humanoid phantom.

RESULTS

Using this compensator system, the overall image quality improved, resulting in enhanced contrast and resolution of the breast simulation image. The delineator wires for the beam margins were also well depicted, and the surgical clips within the breast tissue can be easily demonstrated. The film densitometry resulted in much less saturation over the breast tissue when using the glass compensator.

CONCLUSION

Using the glass compensator system, the geographical miss may be reduced with the virtue of the improved image quality.

Subcutaneous nodules attributed to nocardiosis in a renal transplant recipient on tacrolimus therapy

We report a renal transplant patient who suffered from disseminated nocardiosis after empirical tacrolimus rescue therapy for chronic allograft rejection. The nocardiosis presented initially as only mildly tender subcutaneous calf nodules without any other signs of inflammation nor constitutional upset, which later spread to the lung and brain causing bronchopneumonia and brain abscesses. The risk factors for nocardial infection in our patient include the use of potent immunosuppressive agents such as tacrolimus, poorly controlled diabetes mellitus and kidney dysfunction. She responded well to combination antibiotic therapy comprising parenteral meropenem, cefotaxime and oral minocycline. We conclude that in transplant recipients, especially those receiving newer and more potent immunosuppressive agents like tacrolimus, nocardial infection can present as apparently 'cold' subcutaneous nodules without any systemic upset. An associated brain lesion should be excluded even in patients without neurological symptoms.

Nontraumatic nasal septal abscesses in the immunocompromised: etiology, recognition, treatment, and sequelae

Proper management of a nasal septal abscess requires prompt diagnosis, adequate surgical drainage, and antibiotics to prevent the potentially dangerous spread of infection and the development of severe functional and cosmetic sequelae. Most septal abscesses are the result of trauma to the nose with septal hematoma and subsequent infection. We present our experience with nasal septal abscesses in five immunocompromised patients without history of nasal trauma. All patients were treated with surgical drainage and antibiotics. The infections in four patients resolved, whereas in the fifth, the infection led to death. We report these cases to depict alternate etiologies of nasal septal abscess, particularly in the immunocompromised patient. Our review illustrates the wide spectrum of disease presentation, provides treatment strategies, and emphasizes the potentially catastrophic sequelae of this disease when unrecognized. With the growing number of immunocompromised individuals, it is important to recognize the potential for immunocompromise to influence the development of septal abscess.

Giant cisterna chyli: MRI depiction with gadolinium-DTPA enhancement

AIM

To demonstrate the use of MRI with Gadolinium-DTPA enhancement in the diagnosis of giant cisterna chyli.

MATERIALS AND METHODS

The study consisted of contrast enhanced MRI with ultrasound and CT correlation in three patients with a giant cisterna chyli. An analysis of the morphology, location and post-contrast MR signal characteristics in relation to time was performed.

RESULTS

Cisterna chyli has a characteristic lobulated morphology and location but the unenhanced MRI appearances are not specific. The post-Gadolinium-DTPA MRI appearances are critically dependent on the time elapsed after injection of contrast medium. Within the first 5 min, there is no enhancement at all, but by 10 min there is early layering of contrast medium evident, which by 30 min produces a clear fluid-fluid level. Delayed images at 4-5 h demonstrate a uniform enhancement of the cisternal contents producing a homogeneous intermediate signal. All of these features are best visualized on T1 fast saturation sequences.

CONCLUSION

MRI with Gadolinium-DTPA enhancement is valuable in confirming the nature of the lymphatic ducts in the retroperitoneal space and helps to differentiate these normal structures from alternative lesions such as lymphadenopathy and tumour recurrence.

Trucut needle biopsy through superior orbital fissure for the diagnosis of rabies

Necropsy diagnosis of rabies can be done by taking a brain biopsy specimen with a trucut needle inserted through the superior orbital fissure into the cranial cavity. This technique reduces the number of personnel who require post-exposure prophylaxis and avoids full necropsy if the deceased's relatives are opposed.

Comparison of incidence of gastroesophageal reflux and regurgitation associated with timing of removal of the laryngeal mask airway: on appearance of signs of rejection versus after recovery of consciousness

STUDY OBJECTIVES

To compare the incidence of gastroesophageal reflux and regurgitation associated with laryngeal mask airway (LMA) removal when signs of rejecting the LMA, such as swallowing, struggling, and restlessness, were observed and when the patient could open his or her mouth on command.

DESIGN

Randomized clinical trial.

SETTING

Operating room and recovery room of a tertiary care referral hospital.

PATIENTS

63 ASA physical status I and II adult patients scheduled for elective orthopedic surgery.

INTERVENTIONS

Using a standardized general anesthetic technique, patients were allocated randomly to Group A (n = 34; LMA removed when signs of rejection, such as swallowing, struggling, and restlessness, were observed) or Group B (n = 29; LMA removed when the patient could open his or her mouth on command).

MEASUREMENTS AND MAIN RESULTS

To detect gastroesophageal reflux throughout anesthesia, a pH monitoring probe was positioned in the lower esophagus on the day before surgery. To assess regurgitation during emergence, a gelatin capsule of methylene blue (50 mg) was swallowed prior to induction. At the end of anesthesia, episodes of reflux and regurgitation of gastric contents were analyzed/determined by pH below 4 and bluish staining of the pharynx and/or LMA, respectively. Physical events such as bucking, straining, and coughing during the arousal phase were recorded in both groups by an independent observer. The incidence of reflux (pH < 4) from the time of the appearance of rejection signs to LMA removal and the total incidence of reflux in Group B were significantly higher than in Group A (p < 0.05). Staining of the LMA and the pharynx by methylene blue was not observed in patients from either experimental group. The number of physical events in Group B during the arousal phase was significantly increased compared to Group A (p < 0.05). Considering all patients in Group A and Group B, physical events were associated with the occurrence of reflux (p < 0.05). Desaturation (SpO2 < 95%) and clinical evidence of aspiration of gastric contents did not occur in either group.

CONCLUSION

Maintenance of the LMA until the patient can open his or her mouth on command increases the incidence of gastroesophageal reflux.

Increased bioavailability of clomipramine after sublingual administration in rats

This study examined the absorption and disposition of clomipramine in rats after sublingual (5 and 50 mg/kg), oral (50 mg/kg), and iv (5 mg/kg) administration. The mean oral bioavailability of clomipramine was 24.8% and 29.7%, respectively, in conscious rats and in rats anesthetized with ketamine/xylazine (30/3 mg/kg). When given sublingually in isotonic saline at a dose of 50 mg/kg, clomipramine was rapidly absorbed, and the mean absolute bioavailability (36.2%) was increased over oral dosing. The mean AUC values of clomipramine were 2258 +/- 1762 ng.h/mL and 1891 +/- 867 ng.h/mL after oral administration to conscious and anesthetized rats, respectively, and 3303 +/- 1576 ng.h/mL after sublingual administration to anesthetized rats. Sublingual administration (5 mg/kg doses) of clomipramine formulated with a permeation enhancer, 2-hydroxypropyl beta-cyclodextrin, further increased the sublingual bioavailability to 57.1%. The sublingual route may be an alternative route of administration of clomipramine, providing enhanced bioavailability.

Variability of P1 protein of zucchini yellow mosaic virus for strain differentiation and phylogenetic analysis with other potyviruses

The complete nucleotide sequence of a Singapore isolate of zucchini yellow mosaic potyvirus (ZYMV-S) was determined from viral cDNA clones. The complete genome is 9603 nucleotides in length excluding the poly (A) tail. Computer analysis of the sequence revealed a single large open reading frame (ORF) that presumably encodes a polyprotein of 3082 amino acids with a calculated molecular weight of 350 kDa. Analysis of the helper component (HC) protein showed that the highly conserved motif K-I-T-C which is involved in aphid transmission appeared as K-L-S-C. There is also a change of D-A-G to G-A-G triplet near the N-terminal of the coat protein (CP). Amino acid sequence identity comparison of ZYMV-S gene products with the California and Reunion Island isolates of ZYMV revealed a minimum range of 65-75% to a maximum range of 95-98%. Comparison with other distinct potyviruses showed a low degree of identity from 19-74%. The 5' untranslated region (UTR) of ZYMV-S showed 67% and 72% identity when compared with the California and Reunion Island isolates, respectively. The sequence variability in the 5' UTR of ZYMV can be exploited for strain differentiation and phylogenetic analysis. ZYMV-S shared 94% and 82% identity in the 3' UTR as compared to the California and Reunion Island isolates, respectively. The P1 protein of ZYMV-S shared moderate sequence variability among ZYMV isolates but high sequence variability among all potyviruses. In addition, phylogenetic analysis using the P1 protein indicated that highly variable proteins in the viral genome could also be employed in the study of potyvirus taxonomy and used for strain differentiation.

Stability and cytotoxicity of Fab-ricin A immunotoxins prepared with water soluble long chain heterobifunctional crosslinking agents

The effects of the hindered and non-hindered water soluble long-chain disulfide bonds on the stability and cytotoxicity of the ricin A chain (RTA) immunotoxin were examined. The RTA immunotoxins were prepared with the Fab fragments of anti-common acute lymphoblastic leukemia antigen (CALLA) monoclonal antibody (Fab-RTA) using sulfosuccinimidyl-6-[(-methyl-(-(2-pyridyldithio)toluamido]hexanoate (S-LC-SMPT) and sulfosuccinimidyl-6-[3-(2-pyridyldithio)-propionamido]hexanoate (S-LC-SPDP). The prepared Fab-RTA immunotoxins were evaluated for their conjugation yield, immunoreactivity, thermal and disulfide bond stability and cytotoxicity. The conjugation yield of the Fab-RTA immunotoxin from the water soluble long chain crosslinking agents, S-LC-SMPT and S-LC-SPDP, were comparable. Both Fab-RTA immunotoxins exhibited a similar immunoreactivity and thermal stability in aqueous solution. However, S-LC-SMPT -mediated Fab-RTA, sterically hindered, showed an enhanced disulfide bond stability in vitro over S-LC-SPDP mediated one. In the cytotoxicity against antigenic cell Daudi, the S-LC-SMPT -mediated RTA immunotoxin maintained a comparable cytotoxicity, compared with S-LC-SPDP mediated Fab-RTA immunotoxin.

Presence of donor- and recipient-derived DNA in cell-free urine samples of renal transplantation recipients: urinary DNA chimerism

BACKGROUND

Previous studies have indicated that microchimerism is present in body tissues, peripheral blood, and plasma of recipients after organ transplantation. We hypothesize that donor-derived DNA may also be present in cell-free urine of renal transplant recipients and that the concentrations of urine DNA may be correlated with graft rejection.

METHODS

Thirty-one female patients who had renal transplantation were enrolled in the study. In women with male organ donors, the SRY gene on the Y chromosome was used as a marker for donor-derived DNA. Real-time quantitative PCR for the SRY and beta-globin genes was carried out on cell-free urinary DNA from these patients. Serial urine samples from a female renal transplant recipient undergoing an acute rejection episode were also collected and analyzed with the beta-globin quantitative PCR system.

RESULTS

SRY sequences were detected in the urine of 14 of 17 female patients with male organ donors. None of the 14 patients with female organ donors had detectable SRY sequences in urinary DNA. The median fractional concentration of donor-derived DNA was 8.7% (interquartile range, 1.9-26.4%). During the acute rejection episode, urinary concentrations of the beta-globin gene were markedly increased, with the concentrations returning rapidly to normal following antirejection treatment.

CONCLUSIONS

Our results demonstrate that urinary DNA chimerism is present following renal transplantation. The measurement of urinary DNA using quantitative PCR may be useful for the diagnosis and monitoring of graft rejection.

Primary non-Hodgkin's lymphoma of the breast: breast conservation therapy in two patients

We report two patients with primary non-Hodgkin's lymphoma of the breast who were treated with breast conservation therapy. These two patients were diagnosed with primary breast lymphoma by fine-needle aspiration cytology and underwent tumorectomy followed by adjuvant chemoradiation therapy. Follow-up studies showed that the two patients were free of disease for two and three years, respectively. To date, there exists no therapeutic standard for this disease and there is no survival advantage for patients who undergo radical mastectomy. Despite the rarity of lymphoma in the breast, a preoperative accurate diagnosis is essential so that unnecessary, extended breast ablation or delayed treatment is avoided. Cytologic diagnosis of breast lymphoma is an easy procedure and provides guidance for appropriate preoperative management. Early diagnosis combined with breast conservation therapy and systemic adjuvant therapy results in a favorable outcome for patients with breast lymphoma.

Hepatocyte nuclear factor 3 relieves chromatin-mediated repression of the alpha-fetoprotein gene

The alpha-fetoprotein gene (AFP) is tightly regulated at the tissue-specific level, with expression confined to endoderm-derived cells. We have reconstituted AFP transcription on chromatin-assembled DNA templates in vitro. Our studies show that chromatin assembly is essential for hepatic-specific expression of the AFP gene. While nucleosome-free AFP DNA is robustly transcribed in vitro by both cervical (HeLa) and hepatocellular (HepG2) carcinoma extracts, the general transcription factors and transactivators present in HeLa extract cannot relieve chromatin-mediated repression of AFP. In contrast, preincubation with either HepG2 extract or HeLa extract supplemented with recombinant hepatocyte nuclear factor 3 alpha (HNF3alpha), a hepatic-enriched factor expressed very early during liver development, is sufficient to confer transcriptional activation on a chromatin-repressed AFP template. Transient transfection studies illustrate that HNF3alpha can activate AFP expression in a non-liver cellular environment, confirming a pivotal role for HNF3alpha in establishing hepatic-specific gene expression. Restriction enzyme accessibility assays reveal that HNF3alpha promotes the assembly of an open chromatin structure at the AFP promoter. Combined, these functional and structural data suggest that chromatin assembly establishes a barrier to block inappropriate expression of AFP in non-hepatic tissues and that tissue-specific factors, such as HNF3alpha, are required to alleviate the chromatin-mediated repression.

Spontaneous renal allograft rupture attributed to acute tubular necrosis

A renal allograft recipient receiving triple immunosuppressive therapy developed spontaneous allograft rupture 5 days after her second cadaveric renal transplantation. Renal biopsy showed interstitial edema with severe acute tubular necrosis (ATN). There was no evidence of acute rejection or renal vein thrombosis. The ruptured renal graft was salvaged by an aggressive fluid resuscitation therapy and surgical hemostasis. The renal function was satisfactory on discharge. We conclude that renal allograft rupture can be the result of interstitial edema solely attributed to ATN in the absence of graft rejection. The ruptured graft kidney is potentially salvageable for those patients whose hemodynamic status can be stabilized by appropriate supportive therapy.

Tentorial meningioma encroaching the transverse sinuses and sigmoid sinus junction area associated with dural arteriovenous fistulous malformation: a case report

A 62-year-old woman was evaluated for tinnitis and headache. Magnetic resonance imaging and angiography revealed the coexistence of a tentorial tumor encroaching the junction of the right transverse-sigmoid sinuses, and dural arteriovenous fistulous malformation (AVFM) of the right transverse sinus. AVFM was not manipulated at all during the surgery. The pathology was fibroblastic meningioma. Postoperatively, the dural AVFM completely disappeared on follow-up angiography. The fistulas were occluded also after surgery, even though there was no manipulation of the AVFM. It is suggested that the right dominant transverse-sigmoid sinuses are partially occluded by tentorial meningioma, developing the dural arteriovenous fistula of the right transverse sinus. An acquired origin of the dural AVFM was suggested in this case.

Analysis of correlation between rectal complications and rectal dose following high dose rate intracavitary radiotherapy in patients with uterine cervix cancer: in vivo dosimetric analysis

PURPOSE

To investigate the correlation between late rectal complications and rectal dose in uterine cervix cancer patients treated with high dose rate intracavitary radiotherapy (HDR ICR) and to analyze dose factors reducing complications.

METHODS

A retrospective analysis was done of 74 patients treated with external beam RT and HDR ICR between 1995 and 1997. Radiotherapy (RT) consisted of a median 50.4 Gy external beam plus six fractions of HDR ICR given two times per week, concurrent with the last three weeks of external beam therapy, to a total dose of median 24 Gy to point A or the reference point. Rectal doses were calculated at rectal reference points using barium contrast criteria. In vivo measurement of rectal dose was performed with thermoluminescent dosimeters (TLD) immediately prior to the first fraction of HDR ICR.

RESULTS

Eight patients developed rectal complications (11%). There was a significant difference between measured rectal doses for patients with rectal complications and those without (p < 0.05), and the doses were higher in complicated patients. A significant increase in the probability of development of complications was found for patients receiving measured rectal doses of ICR fractional dose 320 cGy or more, ICR total dose 2000 cGy or more, and ICR% to point A 80% or more.

CONCLUSIONS

This study showed that in vivo dosimetry using TLD during HDR ICR could have a useful role as a predictor of late rectal complications. Dose limitation to the rectum could possibly be achieved by thorough vaginal packing or use of an applicator with proper shielding while maintaining a high dose to the tumor.

Isolation, characterization, and stability of positional isomers of mono-PEGylated salmon calcitonins

PURPOSE

To separate and characterize the different positional isomers of mono-PEGylated salmon calcitonins (mono-PEG-sCTs) and to evaluate the effects of the PEGylation site on the stability of different mono-PEG-sCTs in rat kidney homogenate.

METHODS

Mono-PEG-sCTs were prepared using succinimidyl carbonate monomethoxy polyethylene glycol (5,000 Da) and separated by gel-filtration HPLC followed by reversed-phase HPLC. To characterize PEGylated sCTs, matrix-assisted laser desorption ionization time of flight mass spectrometry (MALDI-TOF MS) and reversed-phase HPLC of the trypsin digested samples were performed. Mono-PEG-sCTs and sCT in rat kidney homogenates were measured by column-switching reversed-phase HPLC with on-line detection of the radioiodinated samples using a flow-through radioisotope detector.

RESULTS

Three different mono-PEGylated sCTs were separated by reversed-phase gradient HPLC. From the MALDI-TOF MS analysis, the average molecular weight of mono-PEG-sCTs was confirmed as around 8650 Da. The presence of PEG moiety in the mono-PEG-sCTs was also manifested by the fact that the distance between two adjacent mass spectum lines was 44 Da which corresponds to PEG monomer unit. Tryptic digestion analysis demonstrated that these mono-PEG-sCTs are 3 positional isomers of N-terminus, Lys18- and Lys11-residue modified mono-PEGylated sCTs. The degradation half-life of these 3 positional isomers in rat kidney homogenates significantly increased in order of the N-terminus (125.5 min), Lys11- (157.3 min), and Lys18 residue modified mono-PEGylated sCT (281.5 min) over the native sCT (4.8 min).

CONCLUSION

Three positional isomers of mono-PEGylated sCTs were purified and characterized. Of these, the resistance to proteolytic degradation was highest for the Lys18-residue modified mono-PEG-sCT. These studies demonstrate that the in vivo stability of PEGylated sCTs is highly dependent on the site of PEG molecule attachment.

Cytomegalovirus colitis in individuals without apparent cause of immunodeficiency

Cytomegalovirus infection is usually reported in immunocompromised patients. In this study, apparently immunocompetent patients with cytomegaloviral colitis were reviewed. Records with a diagnosis of cytomegaloviral colitis from January 1989 to June 1996 were retrieved for analysis. Ten patients were included (median age 70 yr). The major presenting symptoms were diarrhea and hematochezia. Ulceration was the main macroscopic finding. Rectal bleeding was mostly self-limiting. Three patients developed local complications (rectovaginal fistula in two; rectal stricture in one). In the two patients with rectovaginal fistula, lymphocytes subsets and proliferative response were entirely normal. In the other patient, low B lymphocyte count and low response to mitogen were demonstrated. However, the immunoglobulins were not suppressed and rectal biopsies revealed noncaseating granulomas, suggesting activated cell-mediated immunity. In conclusion, a high index of suspicion is crucial for early diagnosis of cytomegaloviral colitis in patients with bloody diarrhea, even though obvious evidence of immunodeficiency is lacking.

Preparation and characterization of polyethylene-glycol-modified salmon calcitonins

The conjugation of salmon calcitonin (sCT) by covalent linkage of polyethylene glycol (PEG) was attempted to overcome several disadvantages of sCT as a therapeutic drug, namely its rapid clearance from blood circulation and enzymatic degradation. The polymer employed was succinimidyl carbonate monomethoxypolyethylene glycol (12 kDa). Superose HR size-exclusion chromatography was applied to separate the PEGylated sCTs (mono-PEG-sCT and di-PEG-sCT) from the unmodified sCT. The PEGylation of sCT was verified by an electrophoresis gel stained with iodine and by MALDI-TOF mass spectrometry. The molecular weights of mono-PEG-sCT and di-PEG-sCT were determined to be 16,094 and 29,077 Da, respectively. PEGylated sCTs showed a substantially improved stability in rat liver homogenates as compared to the intact sCT, indicating that PEG molecules protected sCT from various degrading enzymes. These PEGylated sCTs exhibited similar biological activity to the intact sCT by adenosine cyclic 3',5'-phosphate (cAMP) assay. In clearance studies in the rat, PEGylated sCTs had significantly longer circulating half-lives than the intact sCT (11.2 min for mono-PEG-sCT and 54.0 min for di-PEG-sCT versus 4.7 min for intact sCT).

Three Hong Kong Chinese cases of pretibial epidermolysis bullosa: a genodermatosis that can masquerade as an acquired inflammatory disease

Three patients in two families presented with many years' history of fragile skin, blisters, erosions and scars affecting almost exclusively the shin areas, accompanied by a variable degree of itching. Two of the patients also had toenail dystrophy. Skin biopsy revealed dermal-epidermal blister formation and milia but no immunohistochemical evidence of immunoglobulin or complement deposition. Electron microscopic study of the lesional and perilesional skin showed very sparse or absent anchoring fibrils. Immunolabelling for type VII collagen using LH 7.2 monoclonal antibody revealed a bright, linear staining pattern at the dermal-epidermal junction. The clinicopathological features were thus compatible with pretibial epidermolysis bullosa, a subtype of dystrophic epidermolysis bullosa. Of note, the inflammatory nature of the skin lesions, and their resemblance to nodular prurigo and hypertrophic lichen planus, had caused diagnostic difficulties in all cases in the past. A high degree of awareness of this rare subtype of epidermolysis bullosa is important to establish the correct diagnosis, to allow for genetic counselling and to plan clinical management.

Microbore high-performance liquid chromatographic determination of cisapride in rat serum samples using column switching

For the determination of cisapride from serum samples, an automated microbore high-performance liquid chromatographic method with column switching has been developed. After serum samples (100 microl) were directly injected onto a Capcell Pak MF Ph-1 pre-column (10 x 4 mm I.D.), the deproteinization and concentration were carried out by acetonitrile-phosphate buffer (20 mM, pH 7.0) (2:8, v/v) at valve position A. At 2.6 min, the valve was switched to position B and the concentrated analytes were transferred from MF Ph-1 pre-column to a C18 intermediate column (35x2 mm I.D.) using washing solvent. By valve switching to position A at 4.3 min, the analytes were separated on a Capcell Pak C18 UG 120 column (250 x 1.5 mm I.D.) with acetonitrile-phosphate buffer (20 mM, pH 7.0) (5:5, v/v) at a flow-rate of 0.1 ml/min. Total analysis time per sample was 18 min. The linearity of response was good (r=0.999) over the concentration range of 5-200 ng/ml. The within-day and day-to-day precision (CV) and inaccuracy were less than 3.7% and 3.8%, respectively. The mean recovery was 96.5+/-2.4% with the detection limit of 2 ng/ml.

Isolation and characterization of biologically active lectin from Korean mistletoe, Viscum album var. Coloratum

A mistletoe lectin was isolated from water extracts of Korean mistletoe, a subspecies of Viscum album, grown on Quercus mongolica using CM-Sepharose chromatography followed by an affinity chromatography on a concanavalin A-Sepharose column. The compound proved to be a mistletoe lectin II with D-galactose and N-acetyl-D-galactosamine specificity. Matrix-assisted laser desorption time-of-flight mass spectroscopy showed it to have an average molecular mass of 62.7 kDa and to consist of two subunits of 30.6 kDa and 32.5 kDa. It was a basic protein with isoelectric points of 9.4 and 9.6 by capillary isoelectric focusing and was cytotoxic to Molt4 cell.

Screening for the Gly40Ser mutation in the glucagon receptor gene among patients with type 2 diabetes or essential hypertension in Taiwan

As a major counterregulatory hormone of insulin, glucagon plays an important role in regulating glucose homeostasis through its binding to the glucagon receptor. Recently a missense mutation in the glucagon-receptor gene (Gly40Ser) was found to be associated with type 2 diabetes in France and Sardinia, with a frequency as high as 4.6% and 8.3%, respectively. This mutation was also found to be associated with essential hypertension in the white population with a frequency of 5.4%. To investigate the role of this mutation in the pathogenesis of type 2 diabetes and essential hypertension in Taiwanese population, we screened 121 normal controls, 213 unrelated subjects with type 2 diabetes, and 107 unrelated subjects with essential hypertension by use of polymerase chain reaction/restriction fragment length polymorphism (PCR-RFLP). None of the Taiwanese subjects recruited in the study had this receptor mutation. Our results demonstrate a strong genetic heterogeneity among the ethnic group and suggest that the Gly40Ser mutation of the glucagon receptor gene plays little role, if any, in the pathogenesis of type 2 diabetes and essential hypertension in the Taiwanese population.

Quantitative analysis of derivatized proteins prepared with pyridyl disulfide-containing cross-linkers by high-performance liquid chromatography

Determination of the introduced moieties into derivatized proteins is an essential step in the preparation and quality control of chemically defined immunoconjugates. For the derivatized proteins using pyridyl disulfide-containing cross-linkers such as N-succinimidyl 3-(2-pyridyldithio)propionate (SPDP) and 4-succinimidyloxycarbonyl-alpha-methyl-alpha-(2-pyridyldithio)tolu ene (SMPT), the derivatization degree (ratio of pyridyl disulfide moieties to protein) has been traditionally determined by measuring the absorbance of both the derivatized protein and 2-thiopyridone (2-TP) released from the dithiothreitol (DTT) treatment (spectrophotometric method). This method, however, causes several problems including false high and low determinations of the protein and 2-TP, respectively, low selectivity, poor reproducibility, and relatively large amounts of sample consumption. A quantitative determination method of the derivatization ratios using bovine serum albumin derivatized with SPDP and SMPT as the model system has been developed. The concentration of protein and 2-TP released from the DTT treatment of derivatized proteins was determined directly without consideration of different reagents used and their concentrations. The present HPLC method was proved to be better in terms of accuracy, selectivity, and reproducibility with micro sample consumption. Moreover, this HPLC method can be directly applied to all derivatized proteins prepared with pyridyl disulfide-containing cross-linkers.

p53-mediated repression of alpha-fetoprotein gene expression by specific DNA binding

Aberrant expression of the alpha-fetoprotein (AFP) gene is characteristic of a majority of hepatocellular carcinoma cases and serves as a diagnostic tumor-specific marker. By dissecting regulatory mechanisms through electromobility gel shift, transient-transfection, Western blot, and in vitro transcription analyses, we find that AFP gene expression is controlled in part by mutually exclusive binding of two trans-acting factors, p53 and hepatic nuclear factor 3 (HNF-3). HNF-3 protein activates while p53 represses AFP transcription through sequence-specific binding within the previously identified AFP developmental repressor domain. A single mutation within the DNA binding domain of p53 protein or a mutation of the p53 DNA binding element within the AFP developmental repressor eliminates p53-repressive effects in both transient-transfection and cell-free expression systems. Coexpression of p300 histone acetyltransferase, which has been shown to acetylate p53 and increase specific DNA binding, amplifies the p53-mediated repression. Western blot analysis of proteins present in developmentally staged, liver nuclear extracts reveal a one-to-one correlation between activation of p53 protein and repression of AFP during hepatic development. Induction of p53 in response to actinomycin D or hypoxic stress decreases AFP expression. Studies in fibroblast cells lacking HNF-3 further support a model for p53-mediated repression that is both passive through displacement of a tissue-specific activating factor and active in the presence of tissue-specific corepressors. This mechanism for p53-mediated repression of AFP gene expression may be active during hepatic differentiation and lost in the process of tumorigenesis.

Laryngeal pathology in the acquired immunodeficiency syndrome: diagnostic and therapeutic dilemmas

The acquired immunodeficiency syndrome has produced a growing population of patients who, because of their associated immune system compromise, are prone to opportunistic infections and neoplastic diseases. The larynx, with its relatively inaccessible yet critical anatomic location, is a site in which these processes can produce clinical dilemmas, with respect to diagnosis as well as to therapy. By presenting 4 cases involving unusual laryngeal problems in patients infected with the human immunodeficiency virus (HIV), we emphasize these inherent diagnostic and therapeutic problems. Otolaryngologists must be familiar with the many diagnostic possibilities and therapeutic alternatives when HIV-infected patients present with laryngeal complaints.

Limited joint mobility in diabetes

Cheiroarthropathy is a syndrome usually associated with diabetes mellitus that involves mainly the small joints of the hand. It is generally painless and seldom treated until hand deformity is severe enough to interfere with daily life. Because cheiroarthropathy is correlated with microvascular complications of diabetes, patients with hand symptoms should be carefully investigated for neuropathy, retinopathy, and nephropathy. Improved control of diabetes is the cornerstone of management, but surgery and corticosteroid injection may alleviate severe symptoms in some patients.

A frequent activated smoothened mutation in sporadic basal cell carcinomas

Basal-cell carcinomas (BCCs) are the most common cancer in Caucasians. It has been reported that the patched gene is inactivated in 30-40% sporadic BCCs and 20% sporadic medulloblastomas via loss of heterozygosity and nonsense mutations. Recently, two activating smoothened mutations have been found in the sporadic basal cell carcinomas. One, at base pair 1604 (G-to-T transversion) of exon 9, changes codon 535 from tryptophan to leucine, and the other, at base pair 1685 (G-to-A transition) of exon 10, changes codon 562 from arginine to glutamine (Xie et al., 1998). In our study, 1604G-->T was found in 20 out of 97 (20.6%) sporadic BCCs. The high prevalence indicates that 1604G is the mutation hot spot in our tumor samples. This mutation was detected in all three histological subtypes of BCCs, suggesting that smoothened mutation is an early event during the development of the tumor. Our finding of a high smoothened mutation rate, together with high frequent patched gene mutations reported recently, indicates that activation of the hedgehog signal transduction pathway is the most common and early event in the development of sporadic BCCs. Additionally, to determine whether smoothened, like patched, is also involved in the carcinogenesis of medulloblastomas, we screened medulloblastoma samples for these two mutations by restriction analysis. We have found the 1604G-->T mutation in 1 out of 21 medulloblastomas. This result confirmed smoothened gene involvement in the carcinogenesis of medulloblastoma.

Recanalization of completely thrombosed giant aneurysm: case report

BACKGROUND

Spontaneous recanalization in a completely thrombosed giant aneurysm is a very rare condition.

CASE DESCRIPTION

An 18-year-old woman presented with a serpentine variety giant aneurysm of the posterior cerebral artery, in which spontaneous recanalization of a completely thrombosed lumen was demonstrated on magnetic resonance imaging and angiography. The patient was treated by trapping of the parent artery and aneurysmectomy.

CONCLUSION

This case will provide insight into the potential for spontaneous recanalization in completely thrombosed giant aneurysms.

Gastro-intestinal cytomegalovirus infection and extensive colonic ulceration in a renal transplant recipient

Cytomegalic inclusion disease is a common complication in recipients of organ transplants. In renal transplant recipients, the disease involves the lungs more often than it does the gastrointestinal tract. We report on a recipient of a cadaveric kidney who had cytomegalic inclusion disease that involved both the upper and lower gastro-intestinal tract, and massive gastro-intestinal bleeding that was caused by a large colonic ulcer. Despite treatment with ganciclovir and cytomegalovirus-specific immunoglobulin, the patient died from subsequent complications.

Guidelines for using insulin lispro

OBJECTIVE

To review the best evidence-based literature on the insulin analogue, lispro insulin, and to provide guidelines for its use.

QUALITY OF EVIDENCE

Using the MeSH terms, lispro and insulin analogues, we searched PubMed, Current Contents, MEDLINE, and EMBASE from January 1986 to July 1998 and selected 42 articles out of 97 for high quality and relevance to family medicine. Twenty-eight were randomized controlled trials, but only two studies were blinded because lispro and regular insulin have different optimal times of administration.

MAIN MESSAGE

The new insulin analogue, lispro, produces a much more rapid, higher, and shorter-lasting peak level of insulin than regular human insulin, thus mimicking physiologic secretion of insulin more closely. This allows insulin administration just before or just after meals and means patients can manage with fewer snacks. Lispro controls postprandial blood glucose levels better and does not cause hypoglycemia. Although most older studies showed no change in glycosylated hemoglobin (HbA1c) levels, a few recent studies involving refinements, such as continuous subcutaneous insulin infusion or basal insulin to reduce preprandial glucose levels, have found small but significant improvements. Insulin lispro has also been used successfully in cases of insulin resistance and insulin allergy.

CONCLUSIONS

Lispro is a useful addition for motivated diabetic patients who like to achieve better control of HbA1c without increased hypoglycemia and to match mealtime insulin injections with diet, exercise, and various lifestyles.

Calculating the Effects of Longitudinal Resistance in Multi-Series-Connected Quantum Hall Effect Devices

Many ac quantized Hall resistance experiments have measured significant values of ac longitudinal resistances under temperature and magnetic field conditions in which the dc longitudinal resistance values were negligible. We investigate the effect of non-vanishing ac longitudinal resistances on measurements of the quantized Hall resistances by analyzing equivalent circuits of quantized Hall effect resistors. These circuits are based on ones reported previously for dc quantized Hall resistors, but use additional resistors to represent longitudinal resistances. For simplification, no capacitances or inductances are included in the circuits. The analysis is performed for many combinations of multi-series connections to quantum Hall effect devices. The exact algebraic solutions for the quantized Hall resistances under these conditions of finite ac longitudinal resistances provide corrections to the measured quantized Hall resistances, but these corrections do not account for the frequency dependences of the ac quantized Hall resistances reported in the literature.

Do clinical breast examination skills improve during medical school?

PURPOSE

To assess the effects of stage of training, gender, and specialty interest on medical students' breast cancer knowledge, attitudes, and clinical breast examination (CBE) skills as a case study of the progression of physical examination skills during medical education.

METHOD

In 1996, questionnaires assessing breast cancer knowledge and attitudes were administered to 493 premedical and first-, second-, and third-year medical students at Northwestern University Medical School. Silicone breast models were used to evaluate the CBE proficiency of a subset of 151 students.

RESULTS

Breast cancer knowledge was positively correlated with stage of training (r = .62), with significant differences between all levels (p < .001). In contrast, first-year medical students attained the highest mean lump-detection sensitivity (61.5%), followed by second-year (53.9%) and third-year (43.5%) students (p < .001, first- vs third-year students; p < .10, second- vs third-year students). There was no significant difference in specificity among the four stages.

CONCLUSIONS

The results suggest that breast cancer knowledge and attitudes are not related to CBE proficiency, which is a practiced tactile skill. The decline in lump-detection sensitivity with increased stage of training may demonstrate the need for increased attention to palpation skills during the clinical years. These findings are consistent with those of earlier reports that suggest the need for the reinforcement of physical examination skills during clinical education.

Doxycycline sclerosis of benign lymphoepithelial cysts in patients infected with HIV

Benign lymphoepithelial cysts (BLCs) are a widely recognized cause of parotid gland swelling in HIV-infected patients. Although they are neither invasive nor associated with malignant degeneration, BLCs can become large and disfiguring. Multiple modalities have been used to control these cysts, but no ideal treatment has been identified. The current study examines the efficacy of doxycycline as a BLC sclerosant in eight patients, and nine BLCs (bilateral BLC in one patient). Follow-up ranged from 12 to 17 months in all cases. Doxycycline sclerosis controlled further cyst growth in 100% of cases with no serious complications. The BLCs became negligible or unnoticeable in two patients, and in six patients (seven BLCs) the cyst became fibrosed and showed no evidence of further growth over the follow-up period. Although further studies are needed to determine the long-term efficacy of this treatment modality, doxycycline sclerosis appears to offer a simple, safe, cost-effective, office-based therapeutic option for the treatment of BLCs in patients infected with HIV.

Purification of Sepharose-unbinding ricin from castor beans (Ricinus communis) by hydroxyapatite chromatography

Sepharose-unbinding ricin was one-step separated and purified from a crude extract of castor beans (Ricinus communis) by affinity chromatography on hydroxyapatite. This purification method does not require the time-consuming and complicated steps, such as gel filtration and ion-exchange chromatography, that have been essential in the separation of Sepharose-unbinding toxins. Using this method, approximately 180 mg of ricin was obtained from 100 g of castor beans using a bed volume of 80 ml on a hydroxyapatite column. Weak affinity of the ricin on Sepharose was confirmed and compared with Sepharose-binding ricin (ricin D), using radioiodinated ricins. The molecular mass of the ricin was estimated to be 62 kDa by 10% SDS-PAGE under nonreducing conditions. Under reducing conditions, the purified ricin appeared to be two subunits, corresponding to the molecular masses of 30 and 32 kDa. The pI value was determined to be approximately 8.9 for the ricin. Uptake of the ricin by HeLa cells was measured as almost half of ricin D uptake. Similar results were observed on CEM cells as well. In vitro cytotoxicity of ricins on different cell lines was measured by the MTT method. When compared with ricin D, the purified ricin showed approximately 10-fold less cytotoxicity to HUT78 or K562 cells and 30-fold less toxicity to CEM cells. This lower cytotoxicity of the ricin may be due to its lower cell-binding properties as evidenced by its low affinity for the cell surfaces. From these results, the purified ricin was considered to be ricin E.

Contemporary presentation and management of a spectrum of mastoid abscesses

BACKGROUND

The incidence of complications resulting from suppurative otitis media has significantly decreased since the introduction of antibiotics. At the start of the 20th century 50% of all cases of otitis media developed a coalescent mastoiditis. By 1959, the incidence had fallen to 0.4%. Recent studies suggest a current incidence of only 0.24%. Additionally, during the time of Friedrich Bezold (1824-1908), 20% of patients with mastoiditis developed subperiosteal abscess. Interestingly, this has incidence increased; today nearly 50% of patients diagnosed with coalescent mastoiditis have subperiosteal abscess.

OBJECTIVE

To review the contemporary presentation, diagnosis, and management of a spectrum of mastoid abscesses.

DESIGN

Retrospective case series.

SETTING

Hospitals associated with the Department of Otolaryngology/Head and Neck Surgery at the University of California, San Francisco.

PATIENTS

Three patients with mastoid abscesses are reported. One patient displayed "classic" Bezold's abscess, with pus escaping the mastoid near the incisura digastrica and tracking along the digastric and sternocleidomastoid muscles into the neck. The second and third patients exhibited temporoparietal swelling secondary to mastoid abscess eroding the root of the zygomatic process, a complication noted by Bezold in 1908 as occurring "in only very rare cases."

RESULTS AND CONCLUSIONS

Since only one third of patients show pathologic tympanic membrane changes, and since complaints of otalgia, fever, and tenderness are inconstant, subperiosteal mastoid abscess is frequently a delayed diagnosis. The clinical presentation, pathogenesis, and routes of abscess spread are presented with photographic and radiographic illustration. Medical and surgical management is reviewed, and methods for accurate diagnosis are emphasized.

Formation of high axial ratio microstructures from peptides modified with glutamic acid dialkyl amides

A growing number of amphiphiles are known to form high axial ratio microstructures (HARMs) such as the hollow cylindrical microstructures called lipid tubules. As a prelude to exploring the potential of HARMs formed from lipopeptides in controlled release drug delivery, several microstructure formation conditions were investigated. We report the preparation of several glutamic acid dialkyl amides with varying alkyl chain lengths bearing a verity of peptides (1-4 amino acids) [peptide-Glu-(NHCnH2n+1)2, n=12, 14, 16]. These surfactants have been rapidly and efficiently converted into HARMs in aqueous buffer at physiological pH and ionic strength, or in buffer containing MeOH or EtOH. Helical ribbons and tubular HARMs were produced that were stable for as long as 6 months below the phase transition temperatures of the compounds. To estimate the stability of HARMs in vivo, HARMs formed from (Pro)3-Glu(NHC16H33)2 were incubated with DOPC liposomes or fetal calf serum at 40 degreesC. HARM size and shape did not change significantly, suggesting that such lipopeptide particles can retain their morphology long enough in vivo to be useful as drug delivery vehicles.

Intraperitoneal pulse calcitriol in the treatment of secondary hyperparathyroidism in patients on continuous ambulatory peritoneal dialysis

OBJECTIVE

To determine whether it is practicable to use intraperitoneal calcitriol to treat continuous ambulatory peritoneal dialysis (CAPD) patients with secondary hyperparathyroidism and whether this form of therapy is effective and safe.

DESIGN

A prospective, nonrandomized study.

SETTING

Division of Nephrology, Tertiary Hospital.

METHOD

Eight patients from our CAPD population were recruited (5 F, 3 M), aged 24 to 63 years (mean 38.9 +/- 7.6 yr). They had been on CAPD for 8 to 84 months (mean 47.6 +/- 24.6 months). All the patients had bone biopsy-proven secondary hyperparathyroidism with 2 patients showing mixed lesions. The CAPD system was changed to the twin-bag system (Ultrabag, Baxter Healthcare, McGaw Park, IL, U.S.A.) in all 8 patients, who were taught to inject the calcitriol directly through the short transfer set and the Tenckhoff catheter into the peritoneal cavity, twice per week before bedtime. Calcium carbonate or calcium acetate was used as the main phosphate binder. Intact parathyroid hormone level (iPTH), serum ionized calcium (iCa), serum phosphate, and serum total alkaline phosphatase (alk. phos.) levels were measured at baseline and then every 4 weeks. The mean duration of follow-up was 10.5 months +/- 1.9 months.

RESULTS

There was a significant drop of iPTH level from the pretreatment level of 100.6 +/- 35.8 pmol/L to a level of 63.8 +/- 48.7 pmol/L at 24 weeks (p = 0.036). The lowest level of iPTH attained was 43.4 +/- 27.0 pmol/L at 48 weeks. Serum total alk. phos. also dropped from 232.4 +/- 83.3 IU/L pretreatment to 147.9 +/- 52.0 IU/L at 24 weeks (p = 0.017). The decrease in alk. phos. level paralleled the decrease in iPTH level. The mean serum iCa level did not show any significant rise throughout the study period. The maximum dose of calcitriol used was 6.6 +/- 1.5 microg/week and the average dose of calcitriol was 5.4 +/- 1.2 microg/week. One patient did not respond satisfactorily and she subsequently had a parathyroidectomy. Two episodes of peritonitis occurred during the study period, giving a peritonitis rate of one episode per 42 patient-months. There was no significant change in the urea clearance tests or the peritoneal equilibration tests before and after the study.

CONCLUSION

Intraperitoneal calcitriol is practicable, effective, and safe in the treatment of secondary hyperparathyroidism in CAPD patients.

Phylogenetic analysis of triple gene block viruses based on the TGB 1 homolog gene indicates a convergent evolution

The complete nucleotide sequence of the triple gene block one (TGB 1) of cymbidium mosaic potexvirus (CymMV) was compared to those from other potex-, carla-, furo- and hordeiviruses. Seven conserved motifs in the TGB 1, including the ATP-GTP binding domain (P-Loop) consensus GXXGKTSTS, were found in all four virus genera. We propose that all TGBV can be classified into phylogenetic clusters based on their TGB 1 homolog genes. These clusters can be further delineated to form subgroups. The first cluster comprises the potexviruses which are further subdivided into three subgroups; BaMV, FMV, PlaMV and PapMV (subgroup Ia); CymMV, PAMV, NMV, SMYEaV and WC1MV (subgroup Ib) and PVX (subgroup Ic). The second cluster comprises carlaviruses with a dual subgrouping; CVB, LSV, PVM, PMV and ASPV (subgroup IIa) and LVX (subgroup IIb). The third cluster carries the most diverse of TGBV comprising furoviruses PCV, PMTV and BSBV (subgroup IIIa) and hordeiviruses PSLV, BSMV and LRSV (subgroup IIIb). The phylogenetic relationships of triple gene block viruses (TGBV) based on the TGB 1 homolog gene indicates a convergent evolution.

Stability of Octastatin, a somatostatin analog cyclic octapeptide, in aqueous solution

In this study, the degradation of Octastatin, a cyclic octapeptide analog of somatostatin, was examined as a function of pH, temperature, buffer, and ionic strength by reversed-phase gradient high-performance liquid chromatography. Degradation of Octastatin followed a first-order kinetics. Various buffer species such as acetate, ammonium acetate, citrate, glutamate, phosphate, and borate showed differing effects on the degradation of the octapeptide. Good stability was found in glutamate and acetate buffer of pH 4.0. Degradation of Octastatin was greater in citrate- or phosphate-containing buffers than in glutamate or acetate buffers. With phosphate buffer, higher buffer concentration caused greater degradation, while in acetate buffer, the effect of buffer concentration and ionic strength was negligible. In addition, the degradation of Octastatin was markedly inhibited by increasing the concentration of glutamate buffer. This study allows the prediction of good stability in acetate buffer (0.01 M, pH 4.0) with a t90% of 84.1 days at 20 degrees C.

Mirizzi syndrome caused by xanthogranulomatous cholecystitis: report of a case

Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory disease of the gallbladder. In severe cases, inflammation extends to adjacent structures, and XGC is sometimes confused with a malignant neoplasm. We recently diagnosed XGC as the preoperative cause of Mirizzi syndrome in a patient based on the clinical course. The patient was admitted because of obstructive jaundice, with gallbladder carcinoma as the suspected cause. The gallbladder was swollen with gallstones and the serum level of carbohydrate antigen 19-9 (CA19-9) was 3070 U/ml at admission. A percutaneous transhepatic cholangiodrainage (PTCD) was done, and the common hepatic duct as well as the right and left hepatic ducts were found to be obstructed. Later, the CA19-9 level and swelling of the gallbladder decreased and the obstruction of the bile ducts disappeared. A cholecystectomy was performed and the intraoperative pathohistological diagnosis of chronic cholecystitis was made from frozen sections. The pathohistological diagnosis of XGC was made from paraffin-embedded sections. Mirizzi syndrome such as that seen in our patient is a rare complication of XGC. XGC occasionally causes extensive inflammation; thus, performing a conventional cholecystectomy can be unsafe. However, in our opinion, a total, not subtotal, cholecystectomy should be done whenever possible because the incidence of gallbladder carcinoma accompanied with XGC is higher than that with ordinary cholecystitis or gallstones.