Sperm characteristics and teratology in rats following vas deferens occlusion with RISUG and its reversal

The functional success of the reversal of vas occlusion by styrene maleic anhydride (RISUG), using the solvent vehicle, Dimethyl Sulphoxide (DMSO), has been investigated. Reversal with DMSO was carried out in Wistar albino rats 90 days after bilateral vas occlusion. The body weight, organ weight, sperm characteristics, fertility test and teratology, including skeletal morphology were evaluated in vas occlusion and reversal animals and in F(1) progenies to assess the functional success of the occlusion and reversal. Body weight, organ weight and the cauda epididymal sperm characteristics of vas occlusion and reversal animals and of F(1) progenies were comparable to control. Ejaculated spermatozoa in the vaginal smear showed detached head/tail, acrosomal damage, bent midpiece, bent tail and morphological aberrations in sperm head after vas occlusion, which returned to normal, 90 days after reversal. Monthly fertility test, post-injection showed 0% fertility, which improved gradually and 100% fertility was achieved 90 days after reversal. The fertility/pregnancy/implantation record and skeletal morphology of the offspring were comparable to control. The results suggest functional success and safety of vas occlusion reversal by DMSO.

Breast cancer in young women (YBC): prevalence of BRCA1/2 mutations and risk of secondary malignancies across diverse racial groups

BACKGROUND

Despite significant differences in age of onset and incidence of breast cancer between Caucasian (CA), African-American (AA) and Korean (KO) women, little is known about differences in BRCA1/2 mutations in these populations. The purpose of this study is to evaluate the prevalence of BRCA1/2 mutations and the association between BRCA1/2 mutation status and secondary malignancies among young women with breast cancer in these three racially diverse groups.

METHODS

Patients presenting to our breast cancer follow-up clinics selected solely on having a known breast cancer diagnosis at a young age (YBC defined as age <45 years at diagnosis) were invited to participate in this study. A total of 333 eligible women, 166 CA, 66 AA and 101 KO underwent complete sequencing of BRCA1/2 genes. Family history (FH) was classified as negative, moderate or strong. BRCA1/2 status was classified as wild type (WT), variant of uncertain significance (VUS) or deleterious (DEL).

RESULTS

DEL across these three racially diverse populations of YBC were nearly identical: CA 17%, AA 14% and KO 14%. The type of DEL differed with AA having more frequent mutations in BRCA2, compared with CA and KO. VUS were predominantly in BRCA2 and AA had markedly higher frequency of VUS (38%) compared with CA (10%) and KO (12%). At 10-year follow-up from the time of initial diagnosis of breast cancer, the risk of secondary malignancies was similar among WT (14%) and VUS (16%), but markedly higher among DEL (39%).

CONCLUSIONS

In these YBC, the frequency of DEL in BRCA1/2 is remarkably similar among the racially diverse groups at 14%-17%. VUS is more common in AA, but aligns closely with WT in risk of second cancers, age of onset and FH.

Effects of riluzole (RZ) and ionizing radiation (IR) in metabotropic glutamate receptor-1 (GRM1) positive human melanoma

9083

Background: Melanoma has long been known to be relatively radio-resistant. GRM1 is a metabotropic glutamate receptor that has been detected in human melanoma cell lines and biopsies. Riluzole (RZ), a glutamate release inhibitor, has been shown to arrest GRM1 positive human melanoma cells in G2/M and sub-G1 phases of the cell cycle. The purpose of this study was to determine if RZ enhances the lethal effects of IR in human melanoma. Methods: ATP luminescence assays were performed. Clonogenic assays were performed and cell survival curves generated. Cell cycle analysis was performed utilizing flow cytometry. Western blot analysis was performed utilizing cleaved PARP and caspase-3 antibodies as markers of apoptosis. Results: Luminescence assays revealed 25uM Riluzole to be the necessary concentration for clonogenic assays. At 2Gy, there was a 48% reduction (p≤0.05) in cell survival in RZ-treated cells. At 4 Gy, there was a 19% reduction (p≤0.05) in cell survival in RZ-treated cells. No differences were seen at 6 and 8 Gy. Cell cycle analysis showed that the combination of IR and RZ was superior to IR alone in increasing the number of cells in sub-G1, which represents apoptotic death. Western blot analysis showed that the combination of IR and RZ showed yielded increased cleaved PARP and caspase-3 activity when compared to IR alone. Conclusions: Riluzole is a FDA approved drug that has long been used in ALS. It is relatively non-toxic and crosses the blood brain barrier. Our data shows that Riluzole in combination with radiation eliminates the radio-resistant shoulder of the C8161 survival curve. RZ and IR, as combination therapy are more lethal than IR or RZ alone in human melanoma, as demonstrated by flow cytometry and WB analysis. This data has promising implications for melanoma patients with brain metastases.

No significant financial relationships to disclose.

Lymphedema following irradiation in breast cancer: A cross-sectional study

e11569

Background: Nearly 15–30% of breast cancer patients (pts) face lymphedema (LE) following locoregional therapy, incidence being higher with surgery (Sx) & radiotherapy (RT) combination than with Sx alone. We intended to study the incidence of post-RT LE and associated symptoms. Method: We evaluated 104 unilateral breast cancer pts who had completed curative therapy (Sx + RT + chemotherapy ± hormone therapy HT), with a minimum follow up of 6 months. Besides demographic & treatment details, symptoms associated with LE and objective measurements of upper limb circumference were recorded using an indigenous questionnaire. Results: Median age was 45 years (range 28–65). Chest wall or breast RT was delivered using medial & lateral tangential portals (Cobalt-60 unit) in 88 pts & with 12 MeV electrons in 18 pts. Of all pts, 77 were given supraclavicular & axillary RT. HT was given to 72 pts. Pathological stages were: T1/2- 73, T3/4- 27, Tx-4; N0–44, N1–25, N2/3–33, Nx-2. Arm swelling was reported by 68 pts (mild-40, moderate-28). Other symptoms included reduced range of motion (mild-52, moderate-24), fatigue (48), pain (28), numbness (20), infections (12), shoulder droop (12) and local tenderness (8). Forty-four pts reported having psychological stress (mild-40, moderate-4). Nearly 60% had symptoms mandating change in physical activity (mild-56, moderate-8). Dominant hand was involved in 57 pts. Shoulder exercises were advised in 84 pts; compliance was poor in 16, average in 32, & good in 36. Only 36 pts were advised compression garments, compliance being poor in 28, average in 4 & good in 4. Objective measurements revealed a difference of ≥3 cm in 27 pts in mid-arm circumference (MAC) (median 5.5 cm, maximum 8 cm) & 34 pts in forearm circumference (FAC) (median 3.5, maximum 7 cm). There was no significant association between MAC or FAC with age, stage, body surface area, basal metabolic index, Sx type, chemotherapy or HT. Perceived LE and objective measurements correlated well. MAC difference >3 cm was seen in 28.5% (22/77) pts who received axillary RT and in 18.5% (5/27) of those who received only local RT. Conclusions: LE, with its associated complications, is often understudied in breast cancer survivors. Revision of Sx and RT policies (e.g., omission of axillary dissection & RT in selected pts) may help minimise LE.

No significant financial relationships to disclose.

A retrospective analysis of the potential impact of IgG antibodies to agalsidase beta on efficacy during enzyme replacement therapy for Fabry disease

Fabry disease results from a genetic deficiency of alpha-galactosidase A (alpha GAL) and the impaired catabolism of globotriasoylceramide (GL-3) and other glycosphingolipid substrates, which then accumulate pathogenically within most cells. Enzyme replacement therapy (ERT) with agalsidase beta (Fabrazyme), one of two available forms of recombinant human alpha GAL, involves regular intravenous infusions of the therapeutic protein. Immunoglobulin G (IgG) antibodies to recombinant alpha GAL develop in the majority of patients upon repeated infusion. To explore whether anti-alpha GAL IgG interferes with therapeutic efficacy, retrospective analyses were conducted using data obtained from a total of 134 adult male and female patients with Fabry disease who were treated with agalsidase beta at 1mg/kg every 2 weeks for up to 5 years during placebo-controlled trials and the corresponding open-label extension studies. The analyses did not reveal a correlation between anti-alpha GAL IgG titers and the onset of clinical events or the rate of change in estimated GFR during treatment, and no statistically significant association was found between anti-alpha GAL IgG titers and abnormal elevations in plasma GL-3 during treatment. However, a statistically significant association was found between anti-alpha GAL IgG titers and observation of some GL-3 deposition in the dermal capillary endothelial cells of skin during treatment, suggesting that GL-3 clearance may be partially impaired in some patients with high antibody titers. Determination of the long-term impact of circulating anti-alpha GAL IgG antibodies on clinical outcomes will require continued monitoring, and serology testing is recommended as part of the routine care of Fabry disease patients during ERT.

Heat-treatment of bovine colostrum. II: effects of heating duration on pathogen viability and immunoglobulin G

Batches (30-L) of first-milking bovine colostrum, inoculated with Mycoplasma bovis (10(8) cfu/mL), Listeria monocytogenes (10(6) cfu/mL), Escherichia coli O157:H7 (10(6) cfu/mL), Salmonella enteritidis (10(6) cfu/mL), and Mycobacterium avium subsp. paratuberculosis (Map; 10(3) cfu/mL), were heat-treated at 60 degrees C for 120 min in a commercial on-farm batch pasteurizer system. Duplicate 50-mL subsamples of colostrum were collected at 15-min intervals throughout the heat-treatment process for the purpose of bacterial culture and for measurement of IgG concentration (mg/mL) and antibody activity [log2(bovine viral diarrhea virus type 1 serum neutralization titer)]. Four replicate batches of colostrum were run for each of the 5 pathogens studied. There was no effect of heating moderate- to high-quality colostrum at 60 degrees C for at least 120 min on mean IgG concentration (pre = 60.5 mg/mL; post = 59.1 mg/mL). Similarly, there was no effect of heat-treatment on the mean log2 bovine viral diarrhea virus type 1 serum neutralization titer (pre = 12.3; post = 12.0). Viable M. bovis, L. monocytogenes, E. coli O157:H7, and S. enteritidis added to colostrum could not be detected after the colostrum was heat-treated at 60 degrees C for 30 min. Average bacteria counts showed that Map was not detected when batches were heated at 60 degrees C for 60 min. Although the authors believe that heat-treating colostrum at 60 degrees C for 60 min should be sufficient to eliminate Map from colostrum in most situations, further research is needed to determine whether these findings may be replicated, given that variability was observed in Map culture results.

NOD2-expressing bone marrow-derived cells appear to regulate epithelial innate immunity of the transplanted human small intestine

BACKGROUND

Intestinal allograft rejection resembles Crohn's disease clinically and pathologically. An understanding of its mechanism could impact this life-saving procedure, as well as provide insight into the pathophysiology of inflammatory bowel disease. The NOD2 protein has been implicated as a key player in intestinal immune health, as a consequence of the discovery of three polymorphisms linked with Crohn's disease. An investigation was carried out to determine whether epithelial immune function and graft survival were influenced by NOD2 mutations in an intestinal transplant population.

METHODS

The NOD2 genotypes of 34 transplants performed consecutively over the past 3 years were determined. The NOD2 genotypes were related to clinical outcomes and the expression of certain intestinal antimicrobial peptides (AMPs) believed to protect the epithelium.

RESULTS

An unexpectedly high percentage of recipients, 35%, possessed NOD2 polymorphisms, while 8.6% of donors had comparable mutations. The likelihood of allograft failure was about 100-fold higher in recipients with mutant NOD2 alleles compared with recipients with wild-type NOD2 loci. Rejection in NOD2 mutant recipients was characterised by decreased expression of certain Paneth cell and enterocyte AMPs, prior to the onset of epithelial injury and inflammation.

CONCLUSIONS

Crohn's disease-associated polymorphisms in the NOD2 gene in the recipient represent a critical immunological risk factor for intestinal allograft rejection. Compromised epithelial defences precede visible epithelial injury and inflammatory infiltration. The association of impaired epithelial immunity with the recipient's genotype suggests that certain NOD2-expressing cells of haematopoietic origin play a role in the process, perhaps by regulating expression of certain epithelial AMPs within the allograft.

Effect of oral pilocarpine on xerostomia and quality of life in patients receiving curative radiotherapy for head and neck cancers

6088

Background: Xerostomia is the most debilitating condition following irradiation (RT) in patients with head and neck cancers. The present study intended to evaluate the effect of salivary stimulants such as pilocarpine given concurrent with RT on xerostomia and quality of life in these patients. Methods: In a prospective study conducted between July 2004 and May 2006, 60 patients receiving curative (radical or postoperative) RT for squamous cell head and neck carcinoma were randomized into two groups; group A (n=30) received concurrent pilocarpine 5 mg thrice daily for 12 weeks starting on day 1 of RT while group B (n=30) did not receive pilocarpine. Xerostomia was assessed using RTOG/EORTC criteria, and Quality of life (QOL) using EORTC QLQ-C30 version 3.0 and QLQ-H&N35 questionnaires in phases I-V: preradiation, week 4 of RT, and at 1, 3 and 6 months following completion of RT. Results: Oral dryness was the commonest toxicity, its incidence in phase II being 80% in group A and 89% in group B. By phase V, 13% patients in group A and none in group B had recovered to their pretreatment status. When compared with group B, group A had a significantly lower incidence of oral dryness in phases III (p=0.001), IV (p=0.014) and V (p=0.009) and lesser speech difficulty in phase V (p=0.021). QOL evaluation showed a decline in functional scores and rise in symptom scores during radiation with subsequent improvement to pretreatment levels in phase V. Group A had a significantly higher physical functioning score than group B in phases III (p=0.037) and IV (p=0.027), a better emotional functioning score in phases III (p=0.046) and IV (p=0.008), and a higher global health score, especially in phases II (p=0.012) and III (p=0.001). QLQ-C30 symptom scores were comparable between the 2 groups while H&N35 symptom scores were higher in group B with higher painkiller use in phase II (p=0.043) and IV (p=0.011), and higher dryness (p=0.025), sticky saliva (p=0.021) and constipation (p=0.011) in phase IV. Conclusions: Concurrent pilocarpine during head and neck RT helps maintain salivary function, reduces xerostomia and improves the quality of life in these patients, both during and after RT, especially in terms of parameters related directly to xerostomia.

No significant financial relationships to disclose.

Characterization of Na+/H+ exchanger NHE8 in cultured renal epithelial cells

NHE8 is expressed in the apical membrane of the proximal tubule and is predicted to be a Na+/H+ exchanger on the basis of its primary amino acid sequence. Functional characterization of native NHE8 in mammalian cells has not been possible to date. We screened a number of polarized renal cell lines for the plasma membrane Na+/H+ exchangers (NHE1, 2, 3, 4, and 8) and found only NHE1 and NHE8 transcripts in NRK cells by RT-PCR. NHE8 protein is expressed in the apical membrane of NRK cells as demonstrated by immunoblots, confocal fluorescent immunocytochemistry, and immunoelectron microscopy. NHE1, on the other hand, is expressed primarily in the basolateral membrane. Bilateral perfusion of NRK cells grown on permeable supports shows Na+/H+ exchange activity on both the apical and basolateral membranes. NHE8-specific small interfering RNA knocks down NHE8 protein expression but does not affect NHE1 protein levels. Knockdown of NHE8 protein is accompanied by a commensurate reduction in apical NHE activity, without altered basolateral NHE activity. Conversely, transfection of NHE1-specific small interfering RNA knocks down NHE1 protein expression without affecting NHE8 protein levels and reduces basolateral NHE activity without affecting apical NHE activity. NHE8 is the only apical membrane Na+/H+ exchanger in NRK cells. NHE8 activity is Na+ dependent, displaying a cooperative sigmoidal relationship, and is highly sensitive to 5-(N-ethyl-n-isopropyl)-amiloride (EIPA). NRK cells provide a useful system where NHE8 can be studied in its native environment.

Ontogeny of NHE8 in the rat proximal tubule

Proximal tubule bicarbonate reabsorption is primarily mediated via the Na(+)/H(+) exchanger, identified as NHE3 in adults. Previous studies have demonstrated a maturational increase in rat proximal tubule NHE3 expression, with a paucity of NHE3 expression in neonates, despite significant Na(+)-dependent proton secretion. Recently, a novel Na(+)/H(+) antiporter (NHE8) was identified and found to be expressed on the apical membrane of the proximal tubule. To determine whether NHE8 may be the antiporter responsible for proton secretion in neonates, the present study characterized the developmental expression of NHE8 in rat proximal tubules. RNA blots and real-time RT-PCR demonstrated no developmental difference in the mRNA of renal NHE8. Immunoblots, however, demonstrated peak protein abundance of NHE8 in brush border membrane vesicles of 7- and 14-day-old compared with adult rats. In contrast, the level of NHE8 expression in total cortical membrane protein was higher in adults than in neonates. Immunohistochemistry confirmed the presence of NHE8 on the apical membrane of the proximal tubules of neonatal and adult rats. These data demonstrate that NHE8 does undergo maturational changes on the apical membrane of the rat proximal tubule and may account for the Na(+)-dependent proton flux in neonatal proximal tubules.

Aneurysmal bone cyst of the coronoid process of the mandible

A rare case of aneurysmal bone cyst (ABC) located in the coronoid process of the mandible in a 12-year-old girl is presented. Treatment consisted of excision of the lesion through preauricular, submandibular and intraoral approach. An access osteotomy distal to second molar region was required to gain access to medial side of the coronoid process. To our knowledge, this is the third case of an aneurysmal bone cyst of the coronoid process of mandible. While examining a patient with a large expansile intrabony jaw cavity with thin peripheral bone, which is filled with blood without presence of bruit, thrills and pulse pressure, the diagnosis of aneurysmal bone cyst should be on top of the differential diagnosis list. Seventy-four to eighty-five percent of aneurysmal bone cysts of jaws occur in 10-20 years age group. Therefore, a pediatric dentist may be the first person to see such a lesion.

Comparative evaluation of hand wrist radiographs with cervical vertebrae for skeletal maturation in 10-12 years old children

A comparative evaluation of hand wrist and cervical vertebrae was done to know the validity of cervical vertebrae as maturity indicators. A sample of 50 subjects (25 females and 25 males) in the age group of 10-12 years were selected on criteria of normal occlusion and the result showed that cervical vertebrae can be used with the same confidence as hand wrist radiographs to evaluate skeletal maturity, thus avoiding the need for an additional radiograph.

Heat treatment of bovine colostrum. I: effects of temperature on viscosity and immunoglobulin G level

The objective of this study was to identify the critical temperature, at or below which heat-treatment of bovine colostrum would produce no significant changes in viscosity, IgG concentration, or Ig activity. Results of preliminary work, using a Rapid Visco Analyzer (RVA) to heat 50-mL aliquots from 6 unique batches of bovine colostrum at 59, 60, 61, 62, and 63 degrees C, suggested that colostrum could be heated to 60 degrees C for up to 120 min without changing viscosity or IgG concentration. This finding was confirmed by heating 50-mL aliquots from 30 unique batches of colostrum in an RVA for 120 min at 60 and 63 degrees C. Heating colostrum to 63 degrees C resulted in an estimated 34% decrease in IgG concentration and 33% increase in viscosity. However, there was no difference in IgG concentration between preheat-treated (73.4 +/- 26.5 mg/mL) and post-heat-treated (74.5 +/- 24.3 mg/mL) samples after heating colostrum to 60 degrees C in an RVA for 120 min. Similarly, viscosity was unaffected after heating colostrum to 60 degrees C in an RVA for 120 min. High quality colostrum (> or =73.0 mg/mL) suffered greater losses of IgG and greater viscosity changes when heated to 63 degrees C than did moderate quality colostrum (<73.0 mg/mL). However, the effects of colostrum quality were minor if high quality colostrum was only heated to 60 degrees C. The results of a bovine viral diarrhea serum neutralization assay suggested that antibody activity was unchanged after heating colostrum to either 60 or 63 degrees C. However, these results were interpreted as being inconclusive due to a high proportion of missing results because of the congealing of many samples after heat treatment. The results of this study indicate that 50-mL volumes of bovine colostrum can be heat treated at 60 degrees C for up to 120 min in an RVA without affecting IgG concentration or viscosity.

Cytomegalovirus retinitis in chronic lymphocytic leukaemia

PURPOSE

To describe a rare association of cytomegalovirus (CMV) retinitis.

PATIENTS AND METHODS

Report of three patients with chronic lymphocytic leukaemia (CLL) who developed CMV retinitis.

RESULTS

The diagnosis was established by the detection of CMV DNA by polymerase chain reaction analysis of aqueous and/or vitreous humour. CD4+ T-lymphocyte count was reduced in two patients and normal in the third one. There was bilateral involvement in two of the three patients. There was delay of 8-10 months in diagnosis. The visual outcome was poor in four out of the five eyes involved owing to optic atrophy or total retinal detachment with proliferative vitreoretinopathy.

CONCLUSION

Increased awareness of CMV retinitis in patients who have received immunosuppression for haematological malignancies, such as CLL, could lead to earlier diagnosis and possibly better visual outcome.

Cornelia de-Lange syndrome

Cornelia De Lange syndrome is a relatively uncommon, multiple congenital anomaly / mental retardation disorder of unknown etiology. Its incidence has been reported to vary from 1 : 30,000 to 1 : 50,000 of live births, without any known racial predilection. However, it has been considered to be due to a new dominant mutation. Main clinical features of this syndrome include growth retardation, developmental delay, hirsutism, structural limb abnormalities, mental retardation and facial growth discrepancies. Main causes of death in such patients include pneumonia along with cardiac, respiratory and GI abnormalities.

Microbial keratitis in ITU staff: an occupational hazard?

Microbial keratitis is a potentially blinding corneal infection; the infection may progress rapidly if untreated and result in corneal perforation. The breakdown of the innate ocular defences is known to predispose to corneal infection. We present three cases of microbial keratitis in intensive therapy unit (ITU) staff each of whom had compromised corneal immunity. Anaesthetists and nurses regularly perform high-risk procedures, such as tracheal suctioning, which have been known to cause ocular infections by aerosol inoculation. We suggest that although the absolute risk of infection is low, susceptible individuals may be at increased risk of corneal infection from exposure to potentially pathogenic organisms in such environments. We stress the need for ITU staff, particularly those who wear contact lenses, to wear eye protection when performing procedures likely to cause infected aerosols.

Immunolocalization of NHE8 in rat kidney

In situ hybridization studies demonstrated that Na+/H+ exchanger NHE8 is expressed in kidney proximal tubules. Although membrane fractionation studies suggested apical brush-border localization, precise membrane localization could not be definitively established. The goal of the present study was to develop isoform-specific NHE8 antibodies as a tool to directly establish the localization of NHE8 protein in the kidney by immunocytochemistry. Toward this goal, two sets of antibodies that label different NHE8 epitopes were developed. Monoclonal antibody 7A11 and polyclonal antibody Rab65 both specifically labeled NHE8 by Western blotting as well as by immunofluorescence microscopy. The immunolocalization pattern in the kidney seen with both antibodies was the same, thereby validating NHE8 specificity. In particular, NHE8 expression was observed on the apical brush-border membrane of all proximal tubules from S1 to S3. The most intense staining was evident in proximal tubules in the deeper cortex and medulla with a significant but somewhat weaker staining in superficial proximal tubules. Colocalization studies with gamma-glutamyltranspeptidase and megalin indicated expression of NHE8 on both the microvillar surface membrane and the coated-pit region of proximal tubule cells, suggesting that NHE8 may be subject to endocytic retrieval and recycling. Although colocalizing in the proximal tubule with NHE3, no significant alteration in NHE8 protein expression was evident in NHE3-null mice. We conclude that NHE8 is expressed on the apical brush-border membrane of proximal tubule cells, where it may play a role in mediating or regulating ion transport in this nephron segment.

Symptom interval in young people with bone cancer

Symptom interval (SI), the time from first symptom/sign to diagnosis and initiation of treatment, appears to be principally influenced by tumour biology. Whether the age of the patient, patient delay, professional delay and access to health professionals influences the SI in bone tumours was investigated in this study. 115 patients with newly diagnosed osteosarcoma and Ewing's sarcoma were retrospectively reviewed. The median total SI for all bone tumours was 3.8 months (range 1-46 months). Patients older than 12 years had a longer SI (P = 0.05) and more patient delays (P = 0.02). Total SI and professional delays were longer if the General Practitioner was first seen compared with an Accident and Emergency Consultant (P = 0.02 and 0.02, respectively). However, SI did not influence overall and event-free survival in this series. Bone tumour patients have long SIs that are significantly affected by age and local health-care support systems. Early referral to specialists would help to alleviate anxiety and distress to the patient and family, even if currently delay does not influence outcome.

Gastrointestinal stromal tumour in an inguinal hernial sac: an unusual presentation

Malignancy involving hernial sacs is rare. A 72 year old man is reported who had a right inguinal irreducible mass as an initial presentation of gastrointestinal stromal tumour mimicking irreducible inguinal hernia. The diagnosis was missed at the time of surgery and was revealed only by the histology results of the excised sac.

Gastrointestinal stromal tumour in an inguinal hernial sac: an unusual presentation

Malignancy involving hernial sacs is rare. A 72 year old man is reported who had a right inguinal irreducible mass as an initial presentation of gastrointestinal stromal tumour mimicking irreducible inguinal hernia. The diagnosis was missed at the time of surgery and was revealed only by the histology results of the excised sac.

Thalidomide after allogeneic haematopoietic stem cell transplantation: activity in chronic but not in acute graft-versus-host disease

Thalidomide was used to treat acute (n=21) or chronic (n=59) graft-vs-host disease (GVHD) in 80 haematopoietic stem cell allograft recipients after failure to respond to the combination of cyclosporine and corticosteroids with or without other agents. The median time to onset of acute GVHD was 11 days, and thalidomide was started at a median of 48 days post transplant. In addition to corticosteroids and cyclosporine, 13 patients had also received other agents before thalidomide. None of the patients responded and all died of acute GVHD. For chronic GVHD (limited in 13, extensive in 46), thalidomide was started at a median of 385 days post transplant. In addition to corticosteroids and cyclosporine, 34 patients received azathioprine concomitantly. In all patients, thalidomide was added to the ongoing immunosuppressive regimen. The median duration of therapy with thalidomide was 60 days (range, 11-1210; <2 weeks in 11). In total, 13 patients (22%) had complete response, eight (14%) partial response and 38 (64%) no response. Response rates were comparable for limited (39%) and extensive (33%) chronic GVHD. At a median of 53 months, 19 patients are alive, 13 without evidence of chronic GVHD. Survival was significantly better in patients who responded to thalidomide. The principal causes of death were progressive chronic GVHD (n=29) and relapsed leukaemia (n=7). In conclusion, thalidomide has no activity in acute GVHD, but has some activity in chronic GVHD in combination with other agents.

Renal expression of novel Na+/H+ exchanger isoform NHE8

Although Na(+)/H(+) exchanger isoform 3 (NHE3) mediates most Na(+)/H(+) exchange in the proximal tubule, studies of NHE3/NHE2 null mice suggest residual Na(+)-dependent proton secretion (Choi JY, Shah M, Lee MG, Schultheis PJ, Shull GE, Muallem S, and Baum M. J Clin Invest 105: 1141-1146, 2000). To characterize additional NHE isoforms that might be expressed in the kidney, we identified the partial sequence of a novel NHE. PCR was used to define the 5'- and 3'-ends, and a cDNA encoding the complete open reading frame was amplified from mouse kidney. The predicted protein of 576 amino acids, which we have named NHE8, has 30-35% amino acid identity to known mammalian isoforms (NHE1-7) but has >50% identity to Drosophila melanogaster "NHE1," suggesting it is the mammalian ortholog of this ancient invertebrate isoform. Northern blot of mouse tissues revealed ubiquitous expression. Western blot using anti-NHE8 antibodies demonstrated protein expression in apical membranes purified from rat renal cortex by divalent cation precipitation. In situ hybridization revealed that NHE8 message was present in both cortex and medulla. In the cortex, NHE8 was present in the majority of cortical tubules, consistent with proximal tubule (S1 and S2) localization. In the medulla, NHE8 message was most highly expressed in the proximal tubules (S3) of the outer stripe of the outer medulla. Thus NHE8 is expressed in the proximal tubule, where it may contribute to apical membrane ion transport.

Exercise systolic blood pressures are of questionable value in the assessment of the adult with a previous coarctation repair

BACKGROUND

The role of exercise testing in the follow up of adults with a coarctation repair is unclear. Exercise induced systolic hypertension has been advocated as an indication for further investigation; however, the value of exercise testing in this role has been questioned, especially in paediatric populations.

OBJECTIVE

To assess the value of resting and exercise blood pressure measurements in a cohort of adults with repaired coarctation.

SETTING

Tertiary referral centre for adult congenital cardiac disease.

PATIENTS

56 patients (33 male, 23 female) with a previous coarctation repair, and 33 age matched controls.

MAIN OUTCOME MEASURES

Resting and exercise blood pressures, including arm-leg systolic blood pressure gradients; standard echocardiographic measurements of left ventricular mass, aortic root diameter, and repair site gradient.

RESULTS

The coarctation cohort had higher resting upper limb blood pressures than the controls (systolic: 129.7 v 120.7 mm Hg, p = 0.014; diastolic: 76.8 v 72.2 mm Hg, p = 0.02). Mean resting arm-leg systolic blood pressure gradient was also higher, at 3.6 v -2.2 mm Hg, p = 0.027. However, there were no differences between the peak exercise systolic blood pressures of the two groups. Peak exercise systolic blood pressure did not correlate with resting arm-leg blood pressure gradient (r = 0.24, p = 0.13) or with repair site gradient (r = 0.14, p = 0.39). Resting upper limb systolic blood pressure and resting arm-leg systolic blood pressure gradient were related to repair site gradient (r = 0.33, p = 0.03, and r = 0.47, p = 0.002).

CONCLUSIONS

Measurements of upper limb blood pressure during exercise are of limited value in the assessment of the post-repair coarctation patient. If routine exercise testing is to be advocated in this population it must be for another indication.