Introduction to property management

This document provides an overview of professional real estate management techniques that can be applied to the operations of a health care organization's ancillary outpatient facilities, including medical office buildings. These techniques consolidate and focus real estate operations into a cohesive management structure, permitting the organization to identify areas of cost savings and cost control, identify opportunities for revenue enhancement and providing a higher level of service to physicians and other tenants. The concepts, principles, and techniques presented here can be applied to small, stand-alone hospitals, hospitals that are merging, as well as large multihospital organizations and integrated systems.

High-frequency ultrasound spectral parameter imaging of anterior corneal scars

High frequency (50-MHz) ultrasound allows greater resolution (approximately 30 microns) and improved tissue differentiation of the anterior ocular structures than conventional (8-10 MHz) ultrasonic techniques. Spectral analysis of tissue acoustic backscatter is sensitive to both the concentration and size of tissue inhomogeneities. We studied the healing process of experimentally induced corneal scars using high frequency ultrasound spectral analysis. Scatterer size and concentration parameter images of scarred corneas showed distinctive patterns that were correlated with histology over time. This quantitative technique offers a new, noninvasive, in vivo method for the assessment of the internal microarchitecture of surgically altered corneal tissue and its healing dynamics.

High frequency ultrasound evaluation of radial keratotomy incisions

Radial keratotomy is a surgical procedure to correct myopia that involves placing corneal incisions of precise partial thickness to induce flattening. It has yielded positive but sometimes unpredictable results. Many surgical variables influence the final result. Among them, incision depth is probably the most difficult to control and evaluate. In this study, we used very high frequency (50 MHz) ultrasound (HFU) to image radial keratotomy incisions in post-radial keratotomy human corneas to obtain high definition images of the cornea. The images allowed us to measure the depth of incisions as a percentage of corneal thickness.

Catalytic cleavage of an RNA target by 2-5A antisense and RNase L

2-5A antisense (2-5A-AS) molecules are chimeric oligonucleotides that cause 2-5A-dependent RNase (RNase L) to catalyze the selective cleavage of RNA in human cells. These composite nucleic acids consist of a 5'-monophosphorylated, 2',5'-linked oligoadenylate known as 2-5A (an activator of RNase L) covalently attached to antisense 3',5'-oligodeoxyribonucleotides. Here, we characterize the targeted cleavage of the double-stranded RNA-dependent protein kinase (PKR) mRNA by purified, recombinant human RNase L. A 2-5A-AS chimera, which contains complementary sequence to PKR mRNA, and unmodified 2-5A, which causes general RNA decay, were about 20- and 40-fold more active, respectively, than 2-5A-AS chimeras in which the DNA domains are not complementary to sequences in PKR mRNA. Directed cleavage was efficient because each 2-5A-AS chimera targeted many RNA molecules. Moreover, RNase L caused the catalytic cleavage of the RNA target (kcat of approximately 7 s-1). The precise sites of PKR mRNA cleavage caused by 2-5A-AS were mapped, using a primer extension assay, to phosphodiester bonds adjacent to the 3' terminus of the chimera binding site (5' on the RNA target) as well as within the chimera's oligonucleotide binding site itself. The selectivity of this approach is shown to be provided by the antisense arm of the chimera, which places the RNA target in close proximity to the RNase.

Three-dimensional high-frequency ultrasonic parameter imaging of anterior segment pathology

PURPOSE

High-frequency ultrasound allows high-resolution imaging of anterior segment anatomy and pathology. Acoustic echo data, however, contain information relating to the microanatomic structure of the interrogated tissue which is not evident in B-mode images. The aim of this study is to develop imaging techniques to demonstrate and quantify the distribution of acoustic scattering properties in ocular tissues in three dimensions.

METHODS

A tumor of the iris and a hyphema were scanned using a 50-MHz ultrasound probe mounted on a computer-controlled two-axis positioning system. Scan data from sequential parallel planes were used to make three-dimensional reconstructions. Digital signal processing and a mathematical model of acoustic backscatter then were used to represent the effective size and acoustic concentration of scattering elements using a false color representation superimposed on B-mode images.

RESULTS

Three-dimensional reconstructions improved appreciation of the size and extent of pathology and allowed computation of tissue volumes. Parameter images demonstrated distinctive differences between diffuse and organized blood and allowed quantification of tumor scattering properties.

CONCLUSIONS

Three-dimensional imaging of the anterior segment with high-frequency ultrasound allows construction of perspective images, which adds to the already significant clinical use of individual high-resolution B-mode images. Acoustic backscatter properties determined by tissue microstructure can be computed from echo data and represented in false color in three-dimensional reconstructions.

2-5A-dependent RNase molecules dimerize during activation by 2-5A

2-5A-dependent RNase is an interferon-inducible enzyme that requires 5'-phosphorylated, 2',5'-linked oligoadenylates (2-5A) for its endoribonuclease activity against single-stranded RNAs. We demonstrate here that recombinant, human 2-5A-dependent RNase forms stable homodimers during its stimulation by 2-5A. The protein dimers were observed to form only upon binding to 2-5A, as shown using gel filtration chromatography and chemical cross-linking and after centrifugation in glycerol gradients. A monoclonal antibody to 2-5A-dependent RNase was prepared and used to probe the subunit structure of the enzyme in the presence or absence of 2-5A. Using oligoadenylates of different length, structure, and 5'-phosphorylation states we determined that conversion of 2-5A-dependent RNase from its monomeric, inactive form to its homodimeric, active form required the presence of functional 2-5A. These results demonstrate that the catalytically active form of 2-5A-dependent RNase is a homodimer.

The effect of transducer bandwidth on ultrasonic image characteristics

PURPOSE

This study was conducted to determine the effect of transducer bandwidth on the characteristics of ophthalmic ultrasound images.

METHODS

B-scan images produced using two transducers, one with a narrow bandwidth and the other with a broad bandwidth, both having nominal center frequencies of 10 MHz, were evaluated. Comparative scans were made of a tissue-mimicking phantom, an intraocular tumor, and a vitreous hemorrhage.

RESULTS

Results showed that broadband transducers gave improved resolution and finer speckle texture, but had lower sensitivity. Broadband transducers were most suitable for situations in which resolution was more important than sensitivity, such as imaging of tumors. The greater sensitivity of the narrowband probe made it most useful for evaluation of vitreous complications, such as hemorrhage and membranes.

CONCLUSION

In addition to transducer frequency, bandwidth should be taken into account when choosing a transducer for a specific ophthalmic imaging application. Both broad- and narrowband transducers have relative advantages in particular applications.

HIV-1 TAR RNA has an intrinsic ability to activate interferon-inducible enzymes

The TAR sequence at the 5'-termini of all HIV-1 mRNA species forms a stable structure that is responsible for both transcriptional and translational regulation of HIV-1. Previously we and others reported that purified TAR RNA synthesized by in vitro transcription could activate two interferon-induced enzymes, the protein kinase (PKR) and 2-5A-synthetase. Because the PKR- and 2-5A-systems block protein synthesis initiation and induce RNA decay, respectively, these findings suggested mechanisms for the control of HIV-1 replication by the interferon system. To determine if contaminating dsRNA from in vitro transcription reactions was responsible for this effect, as suggested by Gunnery et al. 1990, (Proc., Natl. Acad. Sci. USA 87, 8687), we have reexamined these findings using chemically synthesized TAR (nucleotides +1 to +57). TAR RNA is shown here to have an intrinsic ability to activate PKR and 2-5A-synthetase. In contrast, a mutant form of TAR designed to have a disrupted secondary structure did not stimulate either enzyme. Chemically synthesized TAR mimicked other dsRNA species in its ability to activate and inhibit PKR at low and high RNA concentrations, respectively. HIV-1 TAT protein inhibited activation of PKR by HIV-1 TAR RNA suggesting an escape mechanism for the virus.

Blockage of NF-kappa B signaling by selective ablation of an mRNA target by 2-5A antisense chimeras

Activation of 2-5A-dependent ribonuclease by 5'-phosphorylated, 2',5'-linked oligoadenylates, known as 2-5A, is one pathway of interferon action. Unaided uptake into HeLa cells of 2-5A linked to an antisense oligonucleotide resulted in the selective ablation of messenger RNA for the double-stranded RNA (dsRNA)-dependent protein kinase PKR. Similarly, purified, recombinant human 2-5A-dependent ribonuclease was induced to selectively cleave PKR messenger RNA. Cells depleted of PKR activity were unresponsive to activation of nuclear factor-kappa B (NF-kappa B) by the dsRNA poly(I):poly(C), which provides direct evidence that PKR is a transducer for the dsRNA signaling of NF-kappa B.

High-frequency ultrasound corneal pachymetry in the assessment of corneal scars for therapeutic planning

We used high-frequency ultrasound B-scanning with digital signal processing for pachymetric analysis of corneal scars to help determine the optimal management strategy. Four patients were selected for this report. By an automated motor system, 12 consecutive, parallel ultrasound B-scans, each 2.5 to 3 mm wide at 0.25 mm intervals, were obtained from the central corneal area of three patients with anterior corneal scarring. In a fourth patient with near complete corneal scarring obscuring the view of the anterior chamber, a set of 15 mm wide B-scans was obtained. Digitized ultrasound signals were used to produce high-resolution images and I-scans enabling a pachymetric precision of +/- 2 microns (SD). Epithelial, scar, and corneal thickness measurements were made along each scan to determine the most significant zone of pathology. Pachymetry of the cornea and the individual layers was used to assess the suitability for either photorefractive or penetrating keratectomy. B-scan imaging of the full anterior segment provided useful information for the preoperative planning of anterior segment reconstruction and the prognostic evaluation of penetrating keratoplasty. This method provides a powerful tool for the corneal surgeon in management planning.

Fascination with 2-5A-dependent RNase: a unique enzyme that functions in interferon action

Interferon (IFN) treatment of cells results in the induction of 2-5A-synthetases, double-stranded RNA-activated enzymes that produce unusual 5'-phosphorylated 2',5'-linked oligoadenylates known as 2-5A. 2.5A activates a unique IFN-induced endoribonuclease, the 2-5A-dependent RNase (RNase L), that is capable of degrading both viral and cellular RNA. The expression cloning of 2-5A-dependent RNase is leading to meaningful analysis of the physiological functions of the 2-5A system. For example, expression in mouse cells of a dominant-negative mutant form of 2-5A-dependent RNase suppressed both the antiencephalomyocarditis virus and anticellular activities of IFN. Future investigations into this intriguing ribonuclease pathway promise to provide an intricate view into a molecular pathway of IFN action.

Intrinsic molecular activities of the interferon-induced 2-5A-dependent RNase

2-5A-dependent RNase (RNase L), a unique endoribonuclease that requires 5'-phosphorylated 2',5'-linked oligoadenylates (2-5A), functions in the molecular mechanism of interferon action. Because this enzyme is present at very low levels in nature, characterization and analysis have been limited. The molecular cloning of human, 2-5A-dependent RNase cDNA has facilitated its expression to high levels in insect cells by infecting with recombinant baculovirus. To determine the properties of the enzyme in the absence of other proteins, the recombinant 2-5A-dependent RNase was purified to homogeneity. The purified enzyme migrated as a monomer upon gel filtration in the absence of activator and showed highly specific, 2-5A-dependent RNase activity. The precise activator requirements were determined by stimulating the purified enzyme with a variety of 2',5'-linked oligonucleotides. The activated enzyme was capable of cleaving poly(rU) and, to a lesser extent, poly(rA), to sets of discrete products ranging from between 4 and 22 nucleotides in length. Reduced rates of 2-5A-dependent RNA cleavage were observed even after removal of ATP and chelation of divalent cations. However, optimal RNA cleavage rates required the presence of either manganese or magnesium and ATP.

Corneal pachymetric topography

PURPOSE

The authors developed a system for producing topographic pachymetric maps of the corneal epithelium and anterior scar tissue.

METHOD

The system uses high-frequency ultrasound scanning enhanced by digital signal processing. Ultrasonic echo data from consecutive parallel B-scans of the cornea spaced at 250-microns intervals are digitized and stored. Using the I-scan (obtained by computing the analytic signal magnitude of the deconvolved ultrasound signal), layer thickness measurements are made with a precision of 2 microns (standard deviation) at 120-microns intervals along each scan plane. The data are stored as an array, z(x,y), mapping thickness, z, onto horizontal and vertical (x,y) spatial coordinates. Pachymetric maps are then constructed by plotting local thickness, represented by a color scale, against measurement point position.

RESULTS

Examples of a normal cornea, a contact lens-wearing cornea, Reis-Bückler dystrophy, and postphotorefractive keratectomy are presented. Areas with significant subepithelial scarring and general epithelial thickening in a subject with Reis-Bückler dystrophy are mapped. Unevenness in the epithelial thickness profile of the cornea in a subject after photorefractive keratectomy is shown, relative to the fellow (untreated) cornea.

CONCLUSION

This technique provides the corneal surgeon with a new tool for the topographic evaluation of the thickness of anterior corneal layers in normal and pathologic corneas with high precision. In addition, the technique is not limited to optically transparent tissue.

Epithelial and corneal thickness measurements by high-frequency ultrasound digital signal processing

PURPOSE

The authors determine the mean central corneal and epithelial thickness in a group of normal human subjects using a new high-frequency ultrasound technique, incorporating digital signal processing.

METHOD

Both eyes of ten volunteers (age range, 23-44 years) were scanned through a normal saline standoff. Digitized ultrasonic echo data were mathematically transformed to produce a plot, the I-scan, which optimally localizes acoustic interfaces to provide improved measurement precision. System precision was determined by analysis of variance of repeated measures. Central epithelial thickness was obtained by averaging multiple measurements. Central corneal thickness was determined by fitting measurements of apparent corneal thickness in consecutive parallel B-scans to a mathematically modeled cornea. A speed of sound of 1640 m/second was used.

RESULTS

Epithelial pachymetric precision using A-scan and I-scan was 4.8 and 2.0 microns (standard deviation), respectively. The mean epithelial thicknesses for the right and left eyes were 50.7 +/- 3.7 microns and 50.3 +/- 3.4 microns, respectively. The mean corneal thicknesses in the right and left eyes were 514.6 +/- 38.4 microns and 516.2 +/- 37.8 microns, respectively. The root mean-square differences in epithelial and corneal thickness between the left and right eyes of each subject were 1.3 and 7.7 microns, respectively (neither was statistically significant).

CONCLUSION

This system provides a pachymetric precision superior to current optical and ultrasound methods. Epithelial and corneal pachymetry is obtained noninvasively by a method that is not limited to optically clear media.

High-frequency ultrasound imaging and spectral analysis in traumatic hyphema

PURPOSE

High-frequency (50-MHz) ultrasound allows high-resolution imaging of anterior ocular structures. Spectrum analysis of acoustic backscatter is sensitive to the concentration, size, and density of tissue inhomogeneities. The authors sought to determine whether acoustic imaging and spectrum analysis of hyphema would allow them to distinguish organized from fluid hyphema and recent from old hemorrhage in the eye.

METHODS

Trauma-induced hyphemas were followed by slit-lamp photography and high-frequency ultrasonography in six New Zealand white rabbits. The blood collections were analyzed using the normalized power spectra of the digitized radio frequency ultrasound data and compared with in vitro references.

RESULTS

The 50-MHz acoustic images permitted differentiation between fluid (diffuse) and clotted (organized) blood. Spectrum analysis allowed quantitative characterization of the degree of blood organization. Significant changes were observed in spectral properties during the time course of absorption both for initial and after-rebleeding hemorrhages. The characteristics of a human postsurgical hyphema also were examined and found to be similar to those seen in the experimental model.

CONCLUSION

Spectrum analysis of high-frequency ultrasound data was able to distinguish organized from recent hemorrhage, which is clinically helpful for planning hyphema therapy.

A dominant negative mutant of 2-5A-dependent RNase suppresses antiproliferative and antiviral effects of interferon

2-5A-dependent RNase is the terminal factor in the interferon-regulated 2-5A system thought to function in both the molecular mechanism of interferon action and in the general control of RNA stability. However, direct evidence for specific functions of 2-5A-dependent RNase has been generally lacking. Therefore, we developed a strategy to block the 2-5A system using a truncated form of 2-5A-dependent RNase which retains 2-5A binding activity while lacking RNase activity. When the truncated RNase was stably expressed to high levels in murine cells, it prevented specific rRNA cleavage in response to 2-5A transfection and the cells were unresponsive to the antiviral activity of interferon alpha/beta for encephalomyocarditis virus. Remarkably, cells expressing the truncated RNase were also resistant to the antiproliferative activity of interferon. The truncated RNase is a dominant negative mutant that binds 2-5A and that may interfere with normal protein-protein interactions through nine ankyrin-like repeats.

High-frequency ultrasound quantitative analyses of corneal scarring following excimer laser keratectomy

OBJECTIVE

To report objective grading and analysis of excimer laser-induced scarring using high-frequency ultrasound.

METHODS

High-frequency ultrasound (50 MHz) corneal examination was performed on eight New Zealand white rabbits at different time points (10, 17, 24, and 74 days following phototherapeutic keratectomy). We used biometry and signal-processing techniques to determine corneal, epithelial, and scar thicknesses and to quantify the acoustic backscatter.

RESULTS

Excimer laser-induced scarring showed an irregularly distributed acoustic hyperreflectivity that decreased through day 74. Corneal thickness remained reduced after ablation (mean, 318 microns compared with 419 microns for controls). Epithelial thickness averaged 62 microns and scar thickness, 87 microns. Scar peak and average anterior stroma acoustic backscatter ratios decreased from day 10 to day 74 (19.65 to 2.76, and 6.42 to 1.32, respectively). Histopathologic study showed increased keratocyte activity at early time points that correlated with acoustic backscatter ratios and imaging pattern.

CONCLUSIONS

High-frequency ultrasound signal processing is a noninvasive method that quantitatively grades excimer laser-induced corneal scarring.

Expression cloning of 2-5A-dependent RNAase: a uniquely regulated mediator of interferon action

2-5A-dependent RNAase, an interferon-induced enzyme that is activated by 5'-phosphorylated, 2',5'-linked oligoadenylates (2-5A), is implicated in both the molecular mechanisms of interferon action and the fundamental control of RNA stability in mammalian cells. Here we report the expression cloning and analysis of murine and human 2-5A-dependent RNAases. The 2-5A binding properties and RNAse activities of recombinant and naturally occurring forms of 2-5A-dependent RNAase were identical. Interferon induction of 2-5A-dependent RNAse expression was demonstrated by measuring the mRNA levels in cells treated with interferon and cycloheximide. Analysis of aligned murine and human 2-5A-dependent RNAse sequences revealed several intriguing features, including similarity to RNAase E, which is implicated in the control of mRNA stability in E. coli. Interestingly, a duplicated phosphate-binding loop motif was determined by deletion analysis and site-directed mutagenesis to function in the binding of 2-5A.

The role of fibronectin in tumor implantation at surgical sites

Fibronectins are a family of glycoproteins with modular functional domains. They mediate cell-cell and cell-matrix interactions which are important in embryogenesis, wound healing, metastasis and other processes. We present data on the influence of fibronectin on wound implantation of a murine mammary carcinoma line, TA3Ha. Fibronectin used in these studies was derived from bovine plasma, human serum, human foreskin fibroblasts, and mouse embryo cultures. TA3Ha cells rarely form tumors in the liver of syngeneic mice when injected intravenously but after hepatic wedge resection, 45% (107/240) of the mice develop tumors in the hepatic wound. Wound implantation is markedly reduced when the cells are pre-exposed to 200 micrograms/ml bovine plasma fibronectin (13%, P = 0.007), human serum fibronectin (0%, P = 0.02), human cellular fibronectin (0%, P = 0.02), or mouse cellular fibronectin (0%, P = 0.04). Lung colonization is also reduced by these fibronectins. These effects are not due to a cytotoxic action of fibronectin, since intraperitoneally injected fibronectin-treated cells form ascites tumor as effectively as do control untreated cells. Local application of a solution containing 0.25 mg/ml mouse cellular fibronectin to the hepatic wound reduces the frequency of tumor implantation from 45% to 5% (1/21, P = 0.001). No tumor implantation inhibition is seen when only suspending medium or albumin in suspending medium is used. The mechanism by which topical application of fibronectin reduces hepatic wound implantation of tumor cells is unclear, but this finding raises an exciting possibility of preventing local recurrence of cancer.

Targeting RNA for degradation with a (2'-5')oligoadenylate-antisense chimera

Antisense oligonucleotides hold considerable promise both as research tools for inhibiting gene expression and as agents for the treatment of a myriad of human diseases. However, targeted destruction of RNA has been difficult to achieve in a versatile, efficient, and reliable manner. We have developed an effective strategy for cleaving unique RNA sequences with 2-5A-dependent RNase, an endoribonuclease that mediates inhibitory effects of interferon on virus infection and is activated by 5'-phosphorylated 2'-5'-linked oligoadenylates known as 2-5A [pn5' A2'(p5' A2')mp5'A], resulting in the cleavage of single-stranded RNA predominantly after UpUp and UpAp sequences. To direct 2-5A-dependent RNase to cleave unique RNA sequences, p5' A2' p5' A2'p5'A was covalently linked to an antisense oligonucleotide to yield a chimeric molecule (2-5A:AS). The antisense oligonucleotide component of 2-5A:AS bound a specific RNA sequence while the accompanying 2-5A component activated 2-5A-dependent RNase, thereby causing the cleavage of the RNA in the targeted sequence. This strategy was demonstrated by inducing specific cleavage within a modified human immunodeficiency virus type 1 vif mRNA in a cell-free system from human lymphoblastoid cells. Because 2-5A-dependent RNase is present in most mammalian cells, the control of gene expression based on this technology--including therapies for cancer, viral infections, and certain genetic diseases--can be envisioned.

Tissue-related and species-specific differences in the 2-5A oligomer size requirement for activation of 2-5A-dependent RNase

2',5'-Oligoadenylate (2-5A)-dependent RNase (L or F) is the final enzyme in the 2-5A pathway and a key component in the molecular mechanism of interferon (IFN) action. Here we demonstrate differences in the 2-5A oligomer size requirement between rabbit 2-5A-dependent RNase from reticulocytes and from cultured kidney cells. The rabbit reticulocyte enzyme was activated by tetramer 2-5A, whereas the ribonuclease from rabbit kidney cells required only trimer 2-5A. Interestingly, in contrast to the 2-5A-dependent RNase from rabbit reticulocytes, that from murine reticulocytes could be activated by trimer 2-5A. Partial proteolysis of affinity-labeled, 80-kD 2-5A-dependent RNase from rabbit reticulocytes and rabbit kidney cells resulted in the same pattern of labeled peptides. However, the affinity labeling reaction with a 32P-labeled 2-5A analog did produce some different labeled polypeptides in rabbit kidney cell extract and rabbit reticulocyte lysate. These results could indicate specialized functions for the 2-5A system in different organ systems.

Using high-frequency ultrasound to characterize intraocular foreign bodies

We scanned uniformly-sized particles of brass, aluminum, glass, and plastic at ultrasonic frequencies of 10 and 50 MHz to determine the effects of material type and transducer frequency on the ultrasonographic appearance of these particles. The particles were scanned in vitro against both anechoic and echoic backgrounds and in vivo, implanted in the angle of rabbit eyes. Both the metals and glass produced reverberations against an anechoic background; the plastic particles appeared as discrete objects, with no reverberations. Against an echoic background, the plastic particles created prominent shadows, while the metal ones did not. When placed in the angle of a rabbit eye, with the exception of the plastic at 10 MHz, all the materials could be differentiated from surrounding tissues at both frequencies. However, the appearance of the foreign body and the surrounding tissues, as well as their exact location and size, were most obvious with the 50-MHz system. In general, the particles produced more reverberations at 10 than at 50 MHz, and more prominent shadowing at 50 than at 10 MHz. In summary, high-frequency imaging enabled superior characterization of all the particles.

Measurement of ocular tumor volumes from serial, cross-sectional ultrasound scans

A system has been developed to determine intraocular tumor volume, a characteristic that has been estimated in previous studies from linear dimensions using a variety of models. Volume was determined by tracing tumor boundaries in sequential, parallel ultrasound scans, adding the areas and multiplying by the interslice interval. The in vitro accuracy of the technique was within +/- 2%. The mean difference between volumes determined from replicate in vivo scans of intraocular tumors was 4.3%. Serial scan volumes were, on average, 19% smaller than volumes computed from an ellipsoidal model and 13% smaller than area-rotational volumes. Differences of as much as 50% were observed between serial scan volumes and volumes computed with these models. The results indicate that methods based on either linear measurements or the tumor area in a single cross-section will tend to both systematically overestimate tumor volume and suffer from unpredictable, nonsystematic errors.

Ophthalmic ultrasonography

Definition and differentiation of ocular structures and abnormalities necessitates the use of high-frequency, high-resolution, and high-definition ultrasound. Frequencies of 10 to 100 MHz are being employed. Color Doppler imaging, tissue characterization, parameter image staining, and three-dimensional volume rendering are new and useful adjuncts to ocular diagnosis.

Ultrasonic tissue characterization of uveal melanoma and prediction of patient survival after enucleation and brachytherapy

We performed survival studies on 136 patients with uveal malignant melanoma who were examined with ultrasonic tissue characterization before treatment with cobalt-60 brachytherapy (74 patients) or enucleation (62 patients). Mean follow-up time was 58.7 months for the brachytherapy group and 59.0 months for the enucleated group. The maximal follow-up time was nearly ten years. Univariate survival analysis showed that patients with small tumors (less than 250 mm3, 49 patients) had a higher five-year survival when treated with brachytherapy than when treated with enucleation. No patients in this study with tumor volumes greater than 1,500 mm3 (13 patients) were treated with brachytherapy. For tumors of intermediate size (74 patients), survival analysis did not indicate appreciable differences between the treatment options. However, multivariate models including two ultrasonic tissue characterization variables, scatterer size and concentration, showed appreciable intergroup differences in the dependence of survival on these factors. Results suggest that tissue properties detectable with ultrasonic techniques are related to differences in patient survival and may be used for treatment planning for tumors of intermediate size.

Histologic effects of contact ultrasound for the treatment of glaucoma

The histologic effects of a contact ultrasound applicator were compared with those of the immersion applicator that is currently used clinically for the treatment of glaucoma. The applicator coupling cone uses a distensible rubber membrane that can be inflated to control stand-off distance relative to the surface of the eye. This feature allows the focal point of the therapeutic beam to be placed at selective depths. Histologic comparisons of lesions in rabbit and pig eyes showed lesions in the sclera and ciliary body that were similar to those produced by the immersion transducer when the same focal position was used. Moving the focal point to a greater depth resulted in less superficial damage, yet still produced ciliodestruction. Damage to the blood supply of the ciliary body, as found in human cadaver eyes, may be an additional mechanism of action of therapeutic ultrasound, and perhaps of other transscleral high-energy modalities.

Therapeutic ultrasound for the treatment of glaucoma

A multicenter clinical trial of therapeutic ultrasound for the treatment of glaucoma included 20 centers in the United States in which 1,117 treatments were performed on 880 eyes. The study was limited to patients with refractory glaucoma who had not benefited from conventional medical and surgical techniques. Approximately 782 of 1,117 treatments (70%) showed an initial decrease in intraocular pressure from a pretreatment mean of 38.1 mm Hg to 22 mm Hg or less. By Kaplan-Meier survival analysis, the single treatment success rate (intraocular pressure between 6 and 22 mm Hg) was 48.7% at six months posttreatment. When retreatment was used subsequent to failure, the one-year multitreatment success rate was 79.3%. The most common complications were an immediate posttreatment intraocular pressure increase lasting a few hours and mild iritis. Other complications included scleral thinning in 28 of 1,117 treatments (2.5%) and phthisis bulbi in 12 of 1,117 treatments (1.1%).

Correlations of acoustic tissue typing of malignant melanoma and histopathologic features as a predictor of death

Forty-six eyes with uveal melanoma were scanned with a computerized diagnostic ultrasound system before enucleation, and light microscope sections were obtained. Tumors were characterized by ultrasonically measured dimensions and power spectrum analysis, which provided information not available in conventional A- or B-scan ultrasonography. Histopathologic features, including cell clustering pattern, cell type, pigmentation, vascularity, and necrosis, were quantified. Statistically significant correlations were found between parameters derived from the power spectrum and histologic characteristics. Patients were followed up for up to ten years with 14 deaths occurring because of metastases. Using a Cox relative risk model with histopathologic data, a risk model comprising pigmentation and cell type (P less than .0001) was obtained. Using ultrasonic characteristics, a model comprising tumor volume and scatterer concentration (P = .0062) was obtained. The results suggest that ultrasonic tissue characterization and three-dimensional biometry may provide improved in vivo prognostic indicators for uveal melanoma.

Direct evidence for translational regulation by leader RNA and Tat protein of human immunodeficiency virus type 1

Translational effects of the RNA leader and Tat protein of human immunodeficiency virus type 1 (HIV-1) were investigated in rabbit reticulocyte lysate. Hybrid RNA species with natural or mutated HIV-1 leader fused to human interferon- gamma mRNA were produced in vitro from recombinant plasmids. HIV-1 leader RNA was found to inhibit translation through two mechanisms. A 3-fold trans-inhibition of translation was demonstrated by mixing hybrid HIV-1 leader RNA with indicator interferon mRNA. By comparison, HIV-1 leader caused a 50-fold cis-inhibition in lysate in which two trans-inhibitory factors, double-stranded RNA-dependent protein kinase and (2'-5')oligoadenylate synthetase, were suppressed. In contrast, purified HIV-1 Tat protein produced in Escherichia coli enhanced by 4-fold translation from HIV-1 leader-interferon mRNA but not from interferon mRNA lacking HIV sequences or from total poly(A)+ RNA. Translation of mRNA containing either a single base substitution in the loop of the "trans-acting responsive" sequence (TAR) or an alternative stem-loop in TAR was nevertheless stimulated by Tat. The enhancement of translation by Tat was largely due to relief of cis-inhibition, since the effect was found even in lysate in which double-stranded RNA-dependent protein kinase was inhibited with 2-aminopurine. These results suggest that translation is an important level of control in the replication cycle of HIV-1.

Photochemical crosslinking in oligonucleotide-protein complexes between a bromine-substituted 2-5A analog and 2-5A-dependent RNase by ultraviolet lamp or laser

2',5'-oligoadenylates known as 2-5A [px(A2'p)nA; chi = 2 or 3, n greater than or equal to 2] are produced in interferon-treated cells in response to double-stranded RNA. 2-5A binds with high affinity to a 2-5A-dependent RNase resulting in the cleavage of single-stranded RNA. An efficient, rapid, and extremely sensitive photoaffinity labeling method was developed to facilitate detection of 2-5A-dependent RNase. A bromine-substituted and radioactive derivative of 2-5A, the 5'-monophosphate, p(A2'p)2(br8A2'p)2A3'-[32P]Cp, was synthesized as probe for 2-5A-dependent RNase. Even though this bromine-substituted analog of 2-5A bore no 5'-terminal triphosphate or diphosphate, it bound to 2-5A-dependent RNase with the same high affinity as did 2-5A per se but it was a less effective activator of the RNase under the present assay conditions. The presence of bromine atoms in the 2-5A analog enhanced by more than 200-fold crosslinking to 2-5A-dependent RNase under a uv lamp; many additional polypeptides were also labeled but at much lower levels. Furthermore, using high-intensity uv laser irradiation (308 nm) covalent attachment of the bromine-substituted 2-5A analog to 2-5A-dependent RNase was readily achieved within 10(-6) s.

Tat trans-activates the human immunodeficiency virus through a nascent RNA target

Expression of the human immunodeficiency virus type 1 (HIV-1) genome is greatly dependent on the viral trans-activator protein Tat. Tat functions through the TAR element, which is represented in both viral DNA and RNA. At present, there is no definitive evidence that determines whether Tat acts through a DNA or RNA form of TAR. We have used an intramolecular mutagenesis approach to change selectively the RNA secondary structure of TAR without affecting its primary sequence. We show that a specific RNA secondary structure for TAR is needed for biological activity. Furthermore, transcripts that only transiently form a native TAR RNA hairpin, which is not maintained in the mature mRNA, are completely trans-activated by Tat, suggesting that TAR is recognized as a nascent RNA.

Cloning of murine gelsolin and its regulation during differentiation of embryonal carcinoma cells

The regulation of gelsolin levels during differentiation of the murine embryonal carcinoma cell line, PC-13, was investigated using nucleic acid and immunological probes. A cDNA clone, Mu-319, which contained the entire coding sequence for the cytoplasmic form of murine gelsolin was isolated using a polyclonal antibody. Gelsolin was detected in several cell lines but was not detectable in three undifferentiated embryonal carcinoma cell lines. Levels of gelsolin mRNA increased 10-fold during the differentiation of the murine embryonal carcinoma cell line, PC-13. Differentiation of PC-13 was accompanied by changes in cell shape, from small indistinct cells to large flat cells. The accumulation of gelsolin mRNA in PC-13 cells began 12-24 h after addition of the differentiation-inducing agents. In comparison, 2-5A-dependent RNase activity showed a 40-fold increase beginning after 24 to 36 h and c-fos mRNA were shown to increase about 9-fold beginning 36 to 60 h after induction of differentiation. The levels of gelsolin per se, as determined by immunoreactivity were also shown to increase with differentiation of PC-13 cells. These results suggest that gelsolin may play a role in the restructuring of actin filaments which accompanies the dramatic changes in cell shape during differentiation.

Activation of interferon-regulated, dsRNA-dependent enzymes by human immunodeficiency virus-1 leader RNA

Human immunodeficiency virus-1 (HIV-1) leader RNA, which contains double-stranded regions due to inverted repeats, was shown to activate the dsRNA-dependent enzymes associated with the interferon system. HIV-1 leader RNA produced in vitro using SP6 RNA polymerase was characterized using probes for antisense and sense-strand RNA. The RNA preparation was free from significant levels of antisense RNA. HIV-1 leader RNA was shown to activate dsRNA-dependent protein kinase in a cell-free system from interferon-treated HeLa cells. Affinity resins, consisting of HIV-1 leader RNA covalently attached to cellulose, immobilized and activated dsRNA-dependent protein kinase and 2-5A-synthetase. HIV-1 leader RNA, therefore, may be a contributing factor in the mechanism by which interferon inhibits HIV replication.

In vivo thickness of the human detached retina by ultrasonic signal processing

Fourier operations on digitized radio-frequency (rf) data can provide the most sensitive measure of the thickness of thin, deterministic structures such as membranes. After deconvolution against the system transfer function, the cepstrum and the analytic signal magnitude can provide measures of membrane thickness on the order of a half-wavelength. A total of 19 patients with rhegmatogenous retinal detachments were scanned using a diagnostic ultrasound system adapted for analog to digital conversion of rf data. Data were analyzed using the signal processing techniques described above to measure retinal thickness. Recent retinal detachments tended to be significantly thicker than normal attached retinas, and thickness decreased with the age of detachment. A statistically significant correlation was found to exist between retinal thickness and the duration of detachment.

Histopathologic effects of ultrasonically induced hyperthermia in intraocular malignant melanoma

Four cases of human intraocular malignant melanoma were treated with ultrasonically induced hyperthermia immediately before enucleation. Tumors were treated in two regimens: 30 minutes at 43 degrees to 45 degrees C and 5 minutes at greater than 50 degrees C. Temperatures were estimated from applied power levels, based on empirical data and mathematical models. Histopathologic changes observed in human tumors were compared with changes seen in malignant melanoma xenografts in athymic nude mice which were treated with ultrasonically induced hyperthermia for 30 minutes at 42 degrees to 46 degrees C. The effects of treatment were similar to changes seen in the animal model treated under analogous conditions: increased intercellular spacing, cytoplasmic vacuole formation, clumping of chromatin, breaks in cell membranes, and swelling and collapse of cells. Perivascular and peripheral zones sometimes showed decreased damage levels. The high temperature (greater than 50 degrees C) technique is presently being used as a means of "sterilizing" tumors before planned enucleation. The moderate temperature (43 degrees-45 degrees C) technique has been used in combination with radiotherapy to treat tumors when vision can be salvaged.

Purification and analysis of murine 2-5A-dependent RNase

2-5A-dependent RNase (RNase L, RNase F) is an enzyme which mediates effects of 2-5A (px(A2'p)nA; x = 2 or 3, n greater than or equal to 2) in cells. 2-5A binding activity present in mouse liver extracts was measured using a 32P-labeled 2-5A derivative. Analysis of Scatchard plots was consistent with a single noninteracting 2-5A binding site with a Ka of 2.5 X 10(10) M-1. Similarly, affinity labeling of proteins with a 32P-labeled 2-5A derivative revealed a single, high-affinity 2-5A-binding protein of Mr 80,000. This 2-5A-binding protein was the only mouse liver protein specifically and consistently eluted by 2-5A from an affinity resin consisting of core(2-5A) covalently attached to cellulose. The 2-5A-eluted protein could degrade polyuridylic acid but not polycytidylic acid. Furthermore, when the 2-5A-eluted protein was electrophoresed into a polyuridylic acid-containing, nondenaturing gel, a band of degraded polyuridylic acid was demonstrated after incubation with 2-5A. There was no band of degraded polyuridylic acid when the elution was performed either in the absence of oligonucleotide or in the presence of low amounts of a closely related analog of 2-5A, p3I2'pA2'pA. Therefore, the Mr 80,000 2-5A-binding protein and the 2-5A-dependent RNase were almost certainly the same protein. Finally, the Mr 80,000 2-5A-binding protein was purified to homogeneity by electroelution from a polyacrylamide gel.

Computerized ultrasonic biometry and imaging of intraocular tumors for the monitoring of therapy

Images

Ultrasonic tissue characterization and histopathology in tumor xenografts following ultrasonically induced hyperthermia

Cells derived from human skin malignant melanoma were implanted subcutaneously in athymic nude mice. Tumors which developed at the implant site were treated with ultrasonically induced hyperthermia at 49 degrees C for 30 min. Tumors were scanned with a computerized diagnostic ultrasound system before and after treatment. Light (LM) and electron (EM) micrographs of tumors were obtained after scanning. Changes in ultrasonic tissue characterization parameters following treatment were well correlated with histopathologic changes observed in tumors. The results are significant in terms of clinical application of ultrasonically induced hyperthermia for treatment of intraocular tumors and the noninvasive monitoring of tumors by use of diagnostic ultrasound.

Ultrasonic hyperthermia and radiation in the management of intraocular malignant melanoma

Hyperthermia and radiation were used in combination to treat four patients with choroidal malignant melanoma. This technique uses ultrasonically induced hyperthermia synergistically with radiation to destroy tumor cells. The lower levels of radiation used should avoid the late vascular and inflammatory complications seen in conventional radiation therapy. Tumors were scanned by a computerized diagnostic ultrasound system before treatment and assigned an acoustic tissue type on the basis of a statistical comparison of their ultrasound backscatter spectrum with spectra of tumors of known pathologic status. During the follow-up period, the longest of which was 15 months, all tumors demonstrated regression patterns consistent with choroidal tumors of the same acoustic tissue types treated with conventional radiation therapy.

Treatment of glaucoma with high-intensity focused ultrasound

This report is a summary of results for 170 eyes of patients with refractory glaucoma treated with high-intensity focused ultrasound. The results are analyzed in terms of the effectiveness of various treatment regimens, complications, and classifications of the patient population according to such factors as age and etiology. The mean pretreatment intraocular pressure (IOP) for the ensemble of patients treated with optimal intensity levels was 38.6 mmHg. Whereas only 10% of these patients had an IOP of 25 mmHg or less prior to treatment, 90% had an IOP of 25 mmHg or less within 3 months of treatment. At 1 year after a single treatment, 65% of patients still maintained intraocular pressures of 25 mmHg or less, and 56% had pressures of 22 mmHg or less. The effectiveness of retreatment of failed or unresponsive cases was also investigated and found to have a degree of success comparable to that of initial treatments.

Activation of 2-5A-dependent RNase by analogs of 2-5A (5'-O-triphosphoryladenylyl(2'----5')adenylyl(2'----5')adenosine ) using 2',5'-tetraadenylate (core)-cellulose

A variety of 2-5A (px(A2'p)nA; x = 2 or 3, n greater than or equal to 2) analogs were assayed for their abilities to activate murine 2-5A-dependent RNase (subsequently "the nuclease") using a recently developed method. This technique consists of immobilizing and partially purifying the nuclease using core-cellulose [A2'p)3A-cellulose) and then monitoring the breakdown of poly(U)-3'-[32P]Cp into acid-soluble fragments. Several 5'-adenosinecapped analogs of 2-5A (containing a tetra-, tri-, or diphosphate) were analyzed, and it was found that reducing the number of phosphoryl groups between the 5' to 5'-diadenosine linkages resulted in a progressive loss of activity. Because A5' pppp(A2'p)3A was a potent activator of the nuclease yet stable during the assay these results suggested that a free 5'-phosphoryl group may not be required for the activation of the nuclease. A number of 8-bromoadenosine-substituted analogs of 2-5A were also studied. Curiously, the brominations decreased the activities of the 5'-di- and triphosphorylated molecules while substantially increasing the activities of the 5'-monophosphorylated species. The results indicated that a tri- or diphosphate moiety on the 5'-end of 2-5A or the presence of ATP is not absolutely required for the nuclease to be active. Furthermore, the ATP analog, beta, gamma-methylene ATP, did not inhibit the activity of the nuclease. Finally, a 3',5'-phosphodiester linkage isomer of 2-5A and a 3'-deoxy (cordycepin) analog of 2-5A were tested, and both were found to be completely without activity.

Interferon-induced 2'-5' oligoadenylate synthetase during interferon-alpha therapy in homosexual men with Kaposi's sarcoma: marked deficiency in biochemical response to interferon in patients with acquired immunodeficiency syndrome

Titers of circulating interferon (IFN) and the activity of 2'-5' oligoadenylate (2-5A) synthetase, an enzyme specifically induced by IFN, were measured in 28 homosexual men with acquired immunodeficiency syndrome (AIDS) who received one- to six-month courses of antineoplastic therapy with IFN-alpha and in homosexual and heterosexual controls. Fifteen of the patients and two of seven healthy homosexual men had high endogenous levels of 2-5A synthetase. IFN therapy induced further increases in this enzyme in only 10 of the 28 patients with AIDS. Furthermore, peripheral blood cells from all but one of the patients with AIDS and homosexual controls tested were markedly deficient in their ability to respond to IFN in vitro, as measured by increased levels of 2-5A synthetase. We did not find a statistical correlation between cytomegalovirus viremia and pretherapy endogenous circulating IFN, nor any apparent correlation between disseminated infection with cytomegalovirus and either basal levels of 2-5A synthetase or changes in enzyme level during therapy. Pretherapy circulating IFN was significantly correlated with progressive Kaposi's sarcoma during therapy, but rises in levels of 2-5A synthetase were not sufficient to predict a good clinical response.