Serum amyloid A protein concentration in progressive systemic sclerosis (scleroderma)

Serum amyloid A protein (SAA) concentrations were determined in 62 patients with progressive systemic sclerosis (PSS). Forty-seven patients had normal or slightly elevated SAA levels (less than 1000 ng/ml = micrograms/l), while 15 patients had moderately to markedly elevated SAA levels, similar to those observed in active rheumatoid arthritis (RA) (greater than or equal to 1000 ng/ml = micrograms/l). Five patients with PSS had SAA levels corresponding to those observed in amyloidosis secondary to RA. High SAA was associated with more severe skin thickening and diminished cumulative survival at five years. The rarity of amyloidosis secondary to PSS is unlikely to be related to an intrinsic defect in SAA production.

Familial amyloid polyneuropathy: a new kinship of German ancestry

Familial amyloid polyneuropathy (FAP) is an autosomal dominant inherited disorder that primarily affects the peripheral and autonomic nervous systems and usually becomes symptomatic in the third or fourth decade. Because of the confusion with other genetically transmitted neurologic conditions, the diagnosis is often delayed until advanced stages. We describe a new German kinship with FAP in which the disorder was detected in two asymptomatic family members who were seeking genetic counseling.

Localized amyloidosis of the head and neck and upper aerodigestive and lower respiratory tracts

Seven cases of localized amyloidosis limited to structures of the head and neck and upper aerodigestive and lower respiratory tracts evaluated and treated at Boston University Hospitals in a recent 7-year period were reviewed. Negative Congo red staining of abdominal adipose aspiration biopsy or rectal biopsy specimens established that the amyloidosis was not systemic. Localized amyloidosis occurred in discrete masses in a variety of sites in the aerodigestive tract including the orbit, nasopharynx, lips, floor of mouth, tongue, larynx, and tracheobronchial tree. Five patients required surgical excision because of significant airway obstruction or organic dysfunction. Amyloid deposits completely excised with the carbon dioxide laser have not recurred, though other amyloid masses may appear elsewhere within the same organ or region. Amyloidosis may occur primarily or secondarily to other disease states. Localized amyloidosis has not been chemically identified but is usually defined by the absence of systemic features. While rare, amyloidosis must be recognized and understood by the otolaryngologist/head and neck surgeon to allow appropriate diagnostic and therapeutic planning.

Hepatic amyloidosis. A histopathologic analysis of primary (AL) and secondary (AA) forms

The liver is a major site of amyloid deposition. The spectrum of histopathologic changes in the liver was studied in 38 patients with systemic amyloidosis (25 with primary or myeloma-associated amyloidosis [AL] and 13 with secondary, reactive [AA] amyloidosis). Overall architectural distortion, alterations of portal triads, as well as predilection for topographic deposition in the parenchyma and/or blood vessel walls were noted. Significant histopathologic differences in AL or AA amyloid liver involvement included 1) portal fibrosis, seen in 7 of 25 (28%) AL patients and 8 of 13 (62%) AA patients (P = 0.05), 2) parenchymal amyloid deposition in 25 of 25 (100%) AL amyloid and 10 of 13 (77%) AA amyloid patients (P = 0.04), and 3) vascular amyloid deposition found in 17 of 25 (68%) with AL amyloid and 13 of 13 (100%) patients with AA amyloid (P = 0.02). These data vary from the widely held concept that deposition of amyloid is predominantly vascular in the AL form and parenchymal in amyloid AA. Clearly, however, in individual cases significant overlap occurred, and characterization of amyloid types based on morphologic distribution of amyloid deposits may be possible in only a minority of cases. In most cases, differentiation of amyloid AL and amyloid AA forms requires clinical, histochemical, immunochemical, and sometimes more elaborate laboratory amino acid sequence studies for accurate identification.

Measurement of murine serum amyloid P component by rate nephelometry

Murine serum amyloid P component (SAP) is an acute-phase protein that is increased 2-10-fold in concentration following appropriate inflammatory or infectious stimuli. Previous studies of the acute-phase SAP response have employed quantitative immunoelectrophoresis or radioimmunoassay to measure SAP concentration. A rate nephelometric procedure has been developed which measures SAP concentration rapidly and with equivalent or greater precision than the previously applied techniques. This simple method will facilitate experimental and clinical studies of the acute-phase response.

Amyloid goiter: preoperative scintigraphic diagnosis using Tc-99m pyrophosphate

Amyloid goiter is a rare clinical entity. The diagnosis is rarely made preoperatively because clinical and laboratory findings are nonspecific. We report two cases of amyloid goiter in whom the diagnosis was made preoperatively using Tc-99m pyrophosphate scintigraphy.

Behavior modification and the treatment of myopia

Myopia is a highly prevalent disorder of vision that has traditionally been managed by means of corrective lenses. In recent years, however, there has been an upsurge of interest in the use of vision training programs as an alternative form of treatment, and particularly in the application of behavior modification techniques for the improvement of visual acuity. The most impressive experimental work to date has been in the area of operant conditioning methods (principally feedback and fading) on the modification of acuity, and this research is reviewed in depth. Also considered here are a number of relevant studies on the use of hypnosis and biofeedback training of accommodation. Research in this area is particularly timely in view of the increasing interest in the role of learning factors in both the development and maintenance of myopia. Despite a number of methodological problems identified in this review, there appears to be considerable promise in the application of behavior modification to disorders of vision.

Acute-phase proteins or tumour markers: the role of SAA, SAP, CRP and CEA as indicators of metastasis in a broad spectrum of neoplastic diseases

Two hundred and seventy-seven patients with a broad spectrum of neoplastic diseases, including 10 classes of solid tumours and three classes of haematologic malignancies, were retrospectively surveyed, and from the same sample of plasma or serum their concentrations of serum amyloid A (SAA), serum amyloid P component (SAP), C-reactive protein (CRP), and carcinoembryonic antigen (CEA) were measured. SAA levels varied from 105 ng/ml to 105,000 ng/ml, and mean SAA levels were higher in patients with metastatic tumours than in those with limited disease (P less than 0.001). Similarly, CRP levels varied from less than 8 micrograms/ml to 328 micrograms/ml and were significantly higher in the metastatic disease category. In contrast, SAP levels varied from 32 micrograms/ml to 120 micrograms/ml and showed no difference in patients with limited or metastatic disease, although an overall slight elevation was present. CEA levels were available in 150 patients and were significantly higher in patients with advanced lung or breast cancer than in patients with limited disease. The correlation between mean SAA and CRP levels was significant (r = 0.74, P less than 0.001), suggesting that SAA originates as an acute-phase protein rather than as a tumour cell product. However, the consistent elevation of SAA in all tumour types and the more marked elevation in metastatic disease may make its measurement useful in malignancy.

Iatrogenic morbidity accompanying suppression of temporal arteritis by adrenal corticosteroids

The records of 19 patients receiving corticosteroid therapy for temporal arteritis were reviewed. Of 11 patients (58%) who suffered major corticosteroid related complications (group A), four died. Eight patients (group B) remained free of serious corticosteroid related complications. The average daily maintenance prednisone dose was 26.3 mg in group A and 13 mg in group B. Although all disease recrudescenses in both groups were treated by increasing the corticosteroid dose, a slower tapering of the dose to the pre-flare level was observed in group A. These findings emphasize the necessity of keeping the maintenance corticosteroid dose in patients with temporal arteritis at the lowest level consistent with suppression of disease activity.

Immunocytochemical demonstration of prealbumin in the vitreous in heredofamilial amyloidosis

Vitreous material obtained at pars plana vitrectomy from a patient with heredofamilial amyloidosis with vitreous involvement and control vitreous from a patient without amyloidosis were subjected to immunocytochemical studies. P component (AP), a minor constituent of all amyloid deposits, was found in trace amounts in the familial amyloid vitreous, but other amyloid proteins, which occur in secondary amyloidosis or in primary amyloidosis, were not found. The major amyloid protein in the vitreous in heredofamilial amyloidosis (but not control vitreous) was found to be prealbumin.

Familial amyloid polyneuropathy. Demonstration of prealbumin in a kinship of German/English ancestry with onset in the seventh decade

A family with autosomal dominant transmitted familial amyloid polyneuropathy residing in Texas is described. Clinically, the prominent sensory and severe autonomic nervous system involvement resembles the Andrade (Portuguese) type I familial amyloid polyneuropathy but is unique in that the age of onset is in the seventh decade in all family members affected to date. Using an immunoperoxidase technique, prealbumin was demonstrated in the amyloid deposits. This finding suggests that this family shares biochemical as well as clinical characteristics consistent with similar kinships with type I familial amyloid polyneuropathy of diverse geographic origin.

Cardiac arrhythmias in systemic amyloidosis: correlation with echocardiographic abnormalities

To determine the prevalence of cardiac arrhythmias in patients with systemic amyloidosis 24 hour electrocardiographic monitoring was performed in 27 patients with primary amyloidosis and in 6 patients with familial amyloid polyneuropathy. All patients underwent echocardiographic studies. Despite a high prevalence of conduction disturbances on standard electrocardiogram, clinically significant bradyarrhythmias were rare (one patient). Complex ventricular arrhythmias (multiform, paired or repetitive beats) occurred in 14 patients (47%) with primary amyloid and 3 patients (50%) with familial amyloid polyneuropathy. The presence of cardiac arrhythmia correlated with heart failure and, more strongly, with an abnormal echocardiogram. There were four sudden deaths, all in patients with abnormal echocardiograms and complex ventricular arrhythmias. These findings suggest that complex ventricular arrhythmia on Holter monitoring is common in cardiac amyloidosis and may be a harbinger of subsequent sudden cardiac death.

Esophageal manometry in systemic amyloidosis. A study of 30 patients

The motility of the esophagus was studied by esophageal manometry in 24 patients with primary amyloidosis and six with secondary amyloidosis. Resting lower esophageal sphincter pressure was decreased in 12 patients with primary amyloidosis and two with secondary amyloidosis; 12 of these 14 patients complained of heartburn. Abnormalities in the motility of the body of the esophagus were found in nine patients with primary amyloidosis and one with secondary amyloidosis. No abnormality of the upper esophageal sphincter was demonstrated in any of the 30 patients. Six of the nine patients with primary amyloidosis exhibiting the most marked esophageal motor dysfunction had striking evidence of peripheral and/or autonomic nervous system involvement. No consistent pattern of motility disorder was observed in either group. The manometric abnormalities observed are consistent with a random deposition of amyloid in the esophagus involving a myopathic and/or neuropathic component.

Nephelometric measurement of human serum amyloid P component (SAP)

Serum amyloid P component (SAP) is a normal constituent of human serum. A rate nephelometric technique has been developed that can measure this protein more rapidly and reproducibly than previously described methods. Materials required are simple and commercially available. Studies on 30 patients with amyloidosis show no difference in SAP levels from control patients. Rate nephelometry is a simple technique that could expand the ability to measure SAP beyond the research setting.

Use of abdominal fat tissue aspirate in the diagnosis of systemic amyloidosis

The needle aspirate of abdominal fat was investigated for its sensitivity in giving a tissue diagnosis in 32 consecutive patients with systemic amyloidosis. The fat tissue aspirate was stained with Congo red and examined with a polarizing microscope. Positive results were obtained in 95% (18/19) of patients with primary (AL) amyloidosis, 66% (4/6) of patients with secondary (AA) amyloidosis, and 86% (6/7) of patients with the heredofamilial (AF) form. The overall positive yield was 88% (28/32). Abdominal fat tissue aspiration is proposed as a simple, rapid, and effective technique for the diagnosis of amyloidosis. The prevalence of positive results in known amyloid disease are comparable with the rectal biopsy specimen and are more frequent than gingival or skin biopsy specimens.

Amyloidosis of heart and liver: comparison of Tc-99m pyrophosphate and Tc-99m methylene diphosphonate for detection

A prospective, comparative study was made of the efficacy of technetium-99m pyrophosphate (Tc PYP) and technetium-99m methylene diphosphonate (Tc MDP) in detecting soft-tissue amyloidosis. Tc PYP and Tc MDP scans were obtained within ten-day intervals in seven patients with histologically proven amyloidosis. Tc PYP was a better scanning agent for soft-tissue amyloidosis in all patients. Cardiac and hepatic involvement were proved by autopsy in one patient. Involvement of the heart was confirmed by echocardiography in five patients. The potential use of Tc PYP scanning as a screening test for soft-tissue amyloidosis is discussed.

Different regulatory mechanisms for serum amyloid A and serum amyloid P synthesis by cultured mouse hepatocytes

Regulation of the in vitro synthesis of the serum amyloid proteins A and P has been studied with hepatocyte cultures from CBA/J and C3H/HeJ mice. Liver cells were isolated by the collagenase perfusion technique and established for 48 h in the presence of fetal calf serum. Viable cells could then be maintained in the absence of serum for at least 72 h and in the presence of serum for up to 2 weeks. Serum amyloid A synthesis differed from serum amyloid P synthesis in three significant ways. 1) Serum amyloid A production was stimulated in the presence of fetal calf serum, whereas serum amyloid P was not; 2) serum amyloid A synthesis was increased 200% by monokine-rich macrophage supernatants while serum amyloid P was increased only 10 to 20%; 3) serum amyloid A synthesis was strikingly resistant to cycloheximide inhibition as compared with serum amyloid P and other liver proteins. It is concluded that the in vivo asynchrony of the acute phase serum amyloid A and serum amyloid P responses results at least in part from differences in regulatory mechanisms for their synthesis by hepatocytes.

The educational impact of a rheumatology elective

We used a newly developed evaluation strategy to compare the performance of 12 medical residents who received ambulatory care rheumatology training and 12 who received inpatient consultative training. There was no significant difference in the cognitive test scores or the patient examination skills of the 2 groups. The ambulatory care residents saw more patients with common rheumatic diseases and performed more joint aspirations and injections. Both groups performed significantly better in all education impact measurements than did a control group of medical residents who received no formal rheumatology elective training. The control group of residents performed no better than did fourth-year medical students who had no formal rheumatology elective training. The study demonstrated that formal rheumatology training is essential if medical residents are to achieve adequate skills in rheumatology. This training can be provided through ambulatory care or inpatient-oriented electives.

Bleeding manifestations in 100 patients with amyloidosis

Focal or generalized hemorrhage is a commonly encountered clinical problem in patients with amyloidosis. In 100 patients with amyloidosis, 41 patients experienced one or more bleeding episodes: petechiae and ecchymoses (23), gastrointestinal tract bleeding (18), bleeding after a diagnostic procedure (eight), hematuria (three), hemoptysis (two), and miscellaneous (four). Severe hemorrhage was the cause of death in three patients. Bleeding occurred frequently in the absence of abnormalities of clotting tests, suggesting that hemorrhage in amyloidosis is most often due to amyloid infiltration of blood vessels. In this group of patients, an isolated factor X deficiency was not observed.

Sensitivity of technetium-99m-pyrophosphate scintigraphy in diagnosing cardiac amyloidosis

To determine the value of technetium-99m-pyrophosphate myocardial scintigraphy in the diagnosis of amyloid heart disease this procedure was prospectively performed in 20 consecutive patients with biopsy-proven primary amyloidosis. Eleven patients had echocardiographic abnormalities compatible with amyloid cardiomyopathy, 9 of whom had congestive heart failure. Diffuse myocardial pyrophosphate uptake was of equal or greater intensity than that of the ribs in 9 of the 11 patients with echocardiograms suggestive of amyloidosis, but in only 2 of the 9 with normal echocardiograms, despite abnormal electrocardiograms (p less than 0.01). Increased wall thickness measured by M-mode echocardiography correlated with myocardial pyrophosphate uptake (r = 0.68, p less than 0.01). None of 10 control patients with nonamyloid, nonischemic heart disease had a strongly positive myocardial pyrophosphate uptake. Thus, myocardial technetium-99m-pyrophosphate scanning is a sensitive and specific test for the diagnosis of cardiac amyloidosis in patients with congestive heart failure of obscure origin. It does not appear to be of value for the early detection of cardiac involvement in patients with known primary amyloidosis without echocardiographic abnormalities.

Juvenile rheumatoid arthritis with renal amyloidosis: a 23-year survival

A 14-year-old girl with juvenile rheumatoid arthritis developed severe renal amyloidosis and presented with nephrosis and renal failure. Renal function returned to normal in a year and over 23 years, serial biopsies showed remarkable, biopsy-proven regression of amyloid deposits. Amyloid was not found in skin, gum or rectal biopsies. This case demonstrates an improved prognosis and apparent reversibility.

The 1982 revised criteria for the classification of systemic lupus erythematosus

The 1971 preliminary criteria for the classification of systemic lupus erythematosus (SLE) were revised and updated to incorporate new immunologic knowledge and improve disease classification. The 1982 revised criteria include fluorescence antinuclear antibody and antibody to native DNA and Sm antigen. Some criteria involving the same organ systems were aggregated into single criteria. Raynaud's phenomenon and alopecia were not included in the 1982 revised criteria because of low sensitivity and specificity. The new criteria were 96% sensitive and 96% specific when tested with SLE and control patient data gathered from 18 participating clinics. When compared with the 1971 criteria, the 1982 revised criteria showed gains in sensitivity and specificity.

HLA antigens in amyloidosis associated with plasma cell dyscrasias (amyloid AL)

Histocompatibility antigen testing was performed on 55 patients with amyloidosis associated with plasma cell dyscrasias (amyloid AL). When compared with 290 healthy North American Caucasians, no significant increase in frequency of any of the 26 HLA antigens (locus A and B) tested was observed.

The degradation of serum amyloid A protein by activated polymorphonuclear leucocytes: participation of granulocytic elastase

To determine the role of inflammation in amyloidogenesis, we have studied the degradation of human serum amyloid A (SAA) protein by purified preparations of human blood polymorphonuclear leucocytes (PMN) and monocytes. When both PMN and monocytes were incubated in SAA-containing medium, the concentration of SAA as measured by a competitive anti-AA radioimmunoassay decreased over time. The rate of decrease of SAA was similar for both monocytes and PMN and there were no differences between four patients with amyloidosis and three normal controls. Resting PMN from normal volunteers were able to degrade SAA to smaller acid-soluble peptides within 16 hr while zymosan-activated PMN produced significant degradation within 1 hr (31%–50%). The supernatants from zymosan-treated PMN also caused marked SAA degradation within 1 hr.

The following enzyme inhibitors were able to prevent degradation of SAA by PMN supernatants; phenylmethylsulphonyl fluoride, a serine esterase inhibitor; α₁ anti-trypsin and soybean trypsin inhibitor; and acetyl-ala-ala-pro-val-chloromethyl ketone, an elastase inhibitor. The ability of a neutral lysosomal enzyme to degrade SAA was further confirmed by showing that purified PMN elastase significantly degraded ¹²⁵I-SAA.

We conclude that PMN contain one or more lysosomal enzymes capable of degrading SAA, an apoprotein of HDL₃ serum lipoproteins. Alteration in SAA proteolysis by activated PMN may contribute to the deposition of amyloid fibrils in the tissues of patients with chronic inflammatory disease.

The role of interleukin 1 in acute phase serum amyloid A (SAA) and serum amyloid P (SAP) biosynthesis

The acute phase SAA and SAP profiles have been compared for localized and endotoxin induced inflammation in LPS responder and nonresponder strains of mice. The SAP profile can reflect a delay with respect to the start of the increase. Its maximum is on the order of ten times the nonacute phase concentration and elevated concentrations are sustained 24 to 48 hours after SAA concentration is rapidly decreasing to normal. The role of Interleukin 1, known to have an essential role in SAA production, was investigated for SAP production. Purified mouse IL 1 and rabbit IL 1 produced a minimal elevation of SAP concentration above normal values, especially when compared with their effects on SAA concentration. BCG infection was shown to synergistically augment SAA induction by LPS and was shown to enhance IL 1 production by macrophages in response to LPS. Unlike SAA synthesis, BCG-preinfection fails to synergistically augment the LPS-induced SAP response. BCG infection alone produced highly elevated and sustained increases in SAP concentration, whereas, the effect on SAA concentration was minimal. Macrophages appear to play an important role in SAP acute phase elevation, but the mechanism in different from that of SAA elevation.

Immunohistochemical evidence for the lack of amyloid P component in some intracerebral amyloids

Sections of brain tissue from patients with Alzheimer's disease with amyloid deposits in vessels, in plaques, and within nerve cells were studied by means of an immunoperoxidase method using a specific antiamyloid P component (AP) antiserum. Amyloid deposits in vessels were found to be strongly positive for protein AP, whereas the Alzheimer's plaques and the neurofibrillary tangles were negative or only weakly positive. The absence of protein AP in some intracerebral amyloid deposits might be due to an inability of the protein AP in some intracerebral amyloid deposits might be due to an inability of the protein to penetrate the blood-brain barrier. These findings support the theory that protein AP is absorbed to already formed amyloid fibrils, but the possibility that it may participate in the formation of vascular amyloid cannot be dismissed. The findings also indicate that protein AP is not necessary for the formation of amyloid fibrils at least in some forms of cerebral amyloidosis.

Senile cerebral amyloid. Prealbumin as a common constituent in the neuritic plaque, in the neurofibrillary tangle, and in the microangiopathic lesion

Three lesions that characterize the nosologic findings in the brain of Alzheimer's presenile dementia and senile dementia of Alzheimer type, ie, neuritic plaque, neurofibrillary tangle, and microangiopathy, all are frequently associated with amyloid deposition. There has been some question, however, as to whether these lesions share the same etiology. Moreover, the specific chemical nature of amyloid associated with these lesions has not yet been determined. In the present study, formalin-fixed paraffin sections of the affected brains were tested immunocytochemically for their reactivity against antiserum to prealbumin (recently disclosed as the major constituent of amyloid associated with familial amyloidotic polyneuropathy as well as senile cardiac amyloid) and known components of other types of amyloid (AA, AP, etc.). The results demonstrated that amyloid deposits in all three lesions reacted with anti-prealbumin, suggesting that it is a common constituent of these lesions. Indeed, it is likely that prealbumin is the major constituent of amyloid associated with neuritic plaque, neurofibrillary tangle, and microangiopathy.

Inflammatory synovitis in degenerative joint disease

While the cartilage and bone abnormalities in osteoarthritis (OA) have been adequately described there are few prospective reviews of the histopathologic changes in OA synovia. Therefore 15 consecutive patients with OA who underwent hip or knee arthroplasty were evaluated and random samples of the synovial membranes were studied. Synovial membrane histopathologic abnormalities were present in all but 2; 9 demonstrated mild or moderate synovitis whereas 4 synovial membranes were markedly inflamed. Inflammatory synovitis is often present in OA.

The association of amyloid deposits and osteoarthritis

Ten of eighteen consecutive patients who underwent total knee or hip arthroplasty for osteoarthritis had amyloid present in the surgically removed articular tissues. It was found in 6 of 13 cartilage specimens, 4 of 18 articular capsules, and 2 of 16 synovial membranes. In 3 of the cartilage specimens, the amyloid was adjacent to focal deposits of calcium pyrophosphate dihydrate crystals. Therefore, deposits of amyloid are not uncommon in osteoarthritis and may be more than incidental findings.

An evaluation strategy for rheumatology education

The number of professional education programs in rheumatology is increasing at a rapid rate. All efforts to establish such programs should include a formal evaluation plan to assess their value. Clear definitions of program objectives and an understanding of the concepts of education program evaluation should be the basis of planning. We have developed an evaluation approach that focuses on education impact as the key measure of program benefits. Impact is measured in three critical areas: Knowledge, clinical performance, and professional behavior. The tools use in this approach include two questionnaires and a trained patient. Educators may use these measure together to generate an overall estimate of education benefits, or they can use them separately to evaluate specific program objectives. This theory-based strategy can serve as a general model for approaching the evaluation of professional education programs in rheumatology.

The association of amyloid P-component (AP) with the amyloid fibril: an updated method for amyloid fibril protein isolation

An amyloid fibril isolation procedure is proposed which uses citrate as well as saline washes to dissociate the calcium dependent linkage of amyloid P-component (AP) from the amyloid fibril. In two amyloid rich tissues, the amount of AP was quantitated in each saline and citrate wash and totalled 13.8% and 20.8% of the amyloid fibrils isolated. The amount of AP removed from these and 22 additional amyloid rich tissues was greater than had previously been recognized. AP protein was present in tissue only when amyloid fibrils were present. It could not be found in normal non-amyloidotic tissue, nor could it be found in tissue sediment after the fibrils were removed.

Skin involvement in familial amyloidotic polyneuropathy

A 3-mm punch biopsy of clinically normal skin was obtained from the forearm of 11 patients from five kinships with familial amyloid polyneuropathy. Seven of the 11 patients had sensory polyneuropathy in the arms as well as the legs. Abnormalities of the autonomic nervous system (nocturnal diarrhea and sphincter abnormalities) were observed in all patients. Four patients had multiple atrophic scars and poorly healed ulcers on the limb; two had petechiae after gentle stroking of the skin. Histopathology revealed amyloid deposits in all 11 skin biopsies (100%). Amyloid infiltration was noted in blood vessels, sweat glands, dermis, and arrector pili muscles. Intracutaneous neural deposits were not found. Skin biopsies from family members at risk may be an effective method of early diagnosis.

Soft tissue uptake of bone seeking radionuclide in amyloidosis

The diagnosis of amyloidosis is often difficult due to variable clinical manifestations and the need for biopsy confirmation. We evaluated the use of bone scanning radionuclides in an effort to delineate soft tissue amyloidosis. Three of 7 patients with proven amyloid reviewed retrospectively, and 3 of 17 studied prospectively had abnormal soft tissue uptake of radionuclide, most commonly diffuse hepatic uptake. Amyloidosis should be considered in any patient with diffuse hepatic uptake or other soft tissue uptake of bone seeking radionuclides. A mechanism for the abnormal uptake (increased calcium content of the involved tissue) is postulated based on in vitro tissue analysis for calcium.

Arthritis in Whipple's disease

Synovial fluid and membranes were studied in two patients with Whipple's disease. In the first, arthrocentesis revealed 28,350 white blood cells/mm3, 96% of which were polymorphonuclear leukocytes. A dense neutrophilic infiltrate, periodic acid-Schiff, positive macrophages and bacilliform structures were present in the synovial membrane. The synovial fluid and membrane findings in the second case, and during intercritical periods in the first case, showed mild to moderate nonspecific inflammation. Since polyarthritis and other systemic manifestations often precede the gastrointestinal features of Whipple's disease by many years, a closed synovial membrane biopsy should be obtained in the appropriate clinical setting.

Digoxin sensitivity in amyloid cardiomyopathy

Digoxin (5 mg/ml) was added to 10-mg and 20-mg pellets of purified primary and secondary amyloid fibrils, a normal human liver and heart homogenate and a homogenate from the heart of a patient with amyloid cardiomyopathy who had not received digitalis. After centrifugation, the supernatants were recovered and assayed for digoxin concentrations. Aliquots from the sediments were studied for the presence of digoxin, using rabbits antidigoxin antiserum and an indirect immunofluorescent technique. The results showed that 0.11--0.13 ng/ml of digoxin bound per milligram of fibrils and could not be separated by repeated washings. Elution with citrate or changes in the pH of the buffer. Immunofluorescent studies demonstrated diffusely bright immunofluorescence with the fibril preparation and amyloid heart homogenate when reacted with digoxin and digoxin-specific antiserum. These studies demonstrate that isolated amyloid fibrils bind digoxin and suggest that this interaction may play some role in the sensitivity to digitalis that has been observed in some patients with amyloid cardiomyopathy.

Hospital postgraduate training: factors affecting prospective interns' ranking of a municipal hospital program in internal medicine

This study examines the statistical relationship between potential influencing factors and the rank that prospective intern applicants assigned to Boston City Hospital in the National Internship and Residency Matching Program. Types of factors examined include personal considerations, the applicant's experience during the personal interview, hospital attributes, the academic program itself, and perceived house officer experience. A brief questionnaire was mailed to prospective interns ranked by the Department of Medicine. Analysis of questionnaire data indicates that personal reasons and two hospital characteristics, ancillary staff and type of hospital, were predominant influencing factors.

Immunocytochemical identification of amyloid in formalin-fixed paraffin sections

Formalin-fixed paraffin sections of livers, spleens and kidneys from patients with primary, secondary and familial amyloidosis as well as from a casein-induced murine amyloid model were analysed by an immunocytochemical (unlabeled antibody enzyme) method utilizing antisera to amyloid-related proteins. All amyloid deposits of all amyloid types showed positive reactions with anti-AP of the respective species. Positive reaction of anti-human AA to human secondary amyloid deposits and of anti-mouse AA to the deposits of casein-induced murine amyloid was also observed, but there was no species cross reactivity. No significant deposition of the reaction products was produced by anti-immunoglobulin light chains on deposits of any amyloid type, or by anti-AA in the tissues from primary or familial amyloidosis. The results indicate that amyloid proteins AA and AP can survive as antigens through routine histologic preparation, that anti-AP can be a universal marker for deposits of any amyloid type within the same species, and that AA-type amyloid can be identified by this method while there may as yet be no feasible universal marker for the AL-type at present.

Redistribution of amyloid deposits

After 21 daily subcutaneous injections of 0.5 ml 10% casein, CBA/J mice were left untreated and evaluated periodically for 6 months for the development of amyloid in spleens, livers, and kidneys. At the end of the amyloid-inducing regimen, the mice developed moderate to heavy splenic amyloid, trace to light hepatic amyloid, and virtually no renal amyloid. Renal amyloid appeared about 2 months after cessation of the casein and then increased steadily, while splenic and hepatic amyloid gradually diminished. Six months after the cessation of casein, moderate amyloid deposits were observed in the kidneys whereas no, or only traces of, amyloid remained in spleens and livers. This renal amyloid was localized predominantly in the peritubular area and differed from the renal amyloid seen in rapidly induced disease, when it localizes dominantly in glomeruli. This phenomenon is interpreted in the light of possible redistribution of amyloid deposits from organ to organ, and the clinical and investigative significances of this possibility and others are discussed.