[Autoimmune hepatitis with prolonged IGM antibodies to HAV. Are serological markers reliable in ruling out a diagnosis of autoimmune hepatitis?]

We present the case of a 44-year-old woman who was referred to us for jaundice, choluria and acholia. Review of the patient's clinical history revealed that tests for hepatitis A virus (HAV) IgM antibody had been positive 4 and 2 years previously and continued to be so. The patient showed a score of 16 in the International Autoimmune Hepatitis Group's system when the HAV marker was not taken into account and a score of 13 when this marker was taken into account. The persistence of this viral marker for so many years in such patients is probably associated with polyclonal hypergammaglobulinemia. Consequently, we believe that the inclusion of this antibody as a negative datum in the diagnosis of autoimmune virus should be viewed with caution.

[Acute iron poisoning. A case report]

The ingestion of iron-containing products is a potential toxicological emergency. It is a leading cause of pediatric unintentional ingestion fatalities because some iron-containing compounds are readily available (vitamin mixtures, iron pills). Among adults, it has been described as accidental overdoses (mainly in pregnancy) and as suicidal attempts. We report a 42 years old woman, admitted due to the intentional ingestion of iron pills with suicidal purposes. A plain abdominal X ray showed at least 20 pills in the gastric fundus and antrum. She was successfully treated with intravenous desferroxamine chelation. Plain abdominal X ray examination can be very useful in the diagnosis of acute iron poisoning.

[Qualitative approach to the attitudes and expectations of doctors during the process of computerising primary care]

OBJECTIVE

To find the attitudes and expectations of doctors during the process of computerising primary care (PC).

DESIGN

Qualitative investigation through discussion groups.

PARTICIPANTS

Thirty-one doctors from the two PC regions of Gipuzkoa.

METHOD

Intentional stratified sampling by regions and by experience in using a computer in the consulting-room. Five discussion groups with recording and transcription of the contents with prior authorisation and guarantee of confidentiality. Qualitative analysis of the notes and transcriptions with the help of computer back-up. Validation through sending of results to participants and discussion between the authors.

RESULTS

Introducing computers into PC consulting-rooms had repercussions both on the ordering and contents of the information recorded. The effort <> was not accompanied by subsequent evaluation. Notable deficiencies in management of the computerising process were perceived. Computer use created additional symbolic effects for both patients and doctors.

CONCLUSIONS

Computerising PC is a process whose repercussions on medical care are far from neutral and so require rigorous discussion and evaluation. Defining step-by-step and measurable objectives, transparency in management and the promotion of evaluative research would all favour the effective development of projects to computerise PC.

Fusion of the human gene for the polyubiquitination coeffector UEV1 with Kua, a newly identified gene

UEV proteins are enzymatically inactive variants of the E2 ubiquitin-conjugating enzymes that regulate noncanonical elongation of ubiquitin chains. In Saccharomyces cerevisiae, UEV is part of the RAD6-mediated error-free DNA repair pathway. In mammalian cells, UEV proteins can modulate c-FOS transcription and the G2-M transition of the cell cycle. Here we show that the UEV genes from phylogenetically distant organisms present a remarkable conservation in their exon-intron structure. We also show that the human UEV1 gene is fused with the previously unknown gene Kua. In Caenorhabditis elegans and Drosophila melanogaster, Kua and UEV are in separated loci, and are expressed as independent transcripts and proteins. In humans, Kua and UEV1 are adjacent genes, expressed either as separate transcripts encoding independent Kua and UEV1 proteins, or as a hybrid Kua-UEV transcript, encoding a two-domain protein. Kua proteins represent a novel class of conserved proteins with juxtamembrane histidine-rich motifs. Experiments with epitope-tagged proteins show that UEV1A is a nuclear protein, whereas both Kua and Kua-UEV localize to cytoplasmic structures, indicating that the Kua domain determines the cytoplasmic localization of Kua-UEV. Therefore, the addition of a Kua domain to UEV in the fused Kua-UEV protein confers new biological properties to this regulator of variant polyubiquitination.

[Validity of clinical tests to confirm or exclude the diagnosis of acute myocardial infarction]

BACKGROUND

To know the clinical usefulness of the diagnostic tests habitually used to diagnose an acute myocardial infarction (MI), in a group of patients in which this diagnosis is clinically highly suspected.

PATIENTS AND METHODS

A cross sectional study was designed. The sample (n = 114) was randomized and selected by term and specific of days from the patients attending the Emergency Service at Elda General Hospital (Alicante, Spain) in a year period. The method we used was is a validity study, making 2 x 2 tables. The clinical outcome was the gold standard and was cross matched with some of the clinical criteria habitually used to diagnose acute myocardial infarction: thoracic pain character, irradiation, ECG findings and CK-MB levels.

RESULTS

Clinical suspicion of MI was confirmed in only 27.8% (IC--95%: 19.3-36.3). The best validity indexes of clinical usefulness to confirm the MI diagnosis were obtained from ECG findings (CP+ = infinity) and CK-MB (CP+ = 24.2 at the end of the observational period and CP = 17.9 at the beginning). The best negative clinical validity indexes were CK values obtained at the end of the observational period (CP- = 0.07) and the ECT findings obtained at the end of the observational period (CP- = 0.10).

CONCLUSION

Clinical carefulness is essential to avoid a diagnostic mistakes in MI patients, since the symptoms we used as a diagnostic guide do not offer good validity indexes. Changes in ECG or CK-MB levels could confirm the MI diagnosis but normal findings in both tests did not discard this diagnosis. We should keep the possibility of a mistake till the end of the observational period.

[Validity of clinical tests to confirm or to exclude the diagnosis of acute appendicitis]

AIMS

The clinical usefulness of the diagnostic tests (usually employed to diagnose an acute appendicitis in a group of patients in which this diagnosis is clinically highly suspected).

PATIENTS AND METHODS

A cross sectional study was designed. The sample (n = 116) was randomly selected by term and specific days from the patients attending the Emergency Service at Elda General Hospital in a year period. The method used was is a validity study making 2 x 2 tables. We have cross matched the habitual routine tests with: a) the clinical outcome if the patient was not surgically treated, or b) the result of the biopsy for those operated. Being these the gold standard. The validity indexes studied were sensibility (S), specificity (E). The 95% confidence index of the CF were calculated.

RESULTS

Acute appendicitis clinical suspicion was confirmed in 29.4% (IC 95%: 20.8-38). The best validity indexes were: a) kind of pain (S = 81.3; E = 33.8); b) peritoneal inflammatory signs (S = 78.5%, E = 45.9%); c) presence of leucocytosis in blood exam (S = 100%, E = 54.5%), and d) a greater difference in axillary-rectum temperature (S = 13.6%, E = 96.6%). Only leucocytosis reached 0 for PP- and CP-; the blood leucocytosis (PP+ = 47.8%, CP+ = 2.20) and the axillary-rectum temperature (PP+ = 60%, CP+ = 4.0) dissociation were the test with most valuable indexes.

CONCLUSIONS

Clinical suspicion of acute appendicitis in a group of patients having a great probability of suffering it over estimates this diagnosis. The symptoms or signs routinely used in the diagnosis did not reach high validity indexes in these patients. They are a poor help to stress or reject the diagnosis of acute appendicitis. To be careful is the main tool the doctors have. Blood leucocytosis is the test that has the best agreement indexes of clinical usefulness and it has the best countence with the gold standard.

The increase of IFN-gamma production through aging correlates with the expanded CD8(+high)CD28(-)CD57(+) subpopulation

The use of flow cytometry to detect intracellular cytokines at the single cell level has the potential to quantify cytokine production together with the possibility of phenotypic identification of the cell population concerned. The unbalanced presence of intracellular cytokines produced by T cells has been recognized in some pathological conditions. To better address this issue, we studied the production of IFN-gamma and IL-4 in CD4(+) and CD8(+high) T cells in healthy donors of a broad range of age (17-62 years). Given that an increase of IFN-gamma and IL-4 with aging had been reported by some authors in healthy controls, we have performed a multivariate analysis to assess the intrinsic role of aging or of other external factors, such as chronic antigenic exposures (i.e., viruses), over the cytokine production of phenotypically characterized T cells. In this respect we show that, mainly in CD8(+high) T cells, the production of IFN-gamma is directly correlated with age. Besides, the cytokine production correlates with the CD8(+high)CD28(-)CD57(+) T-cell population, which we have recently reported elevated in aged individuals. Perhaps this T-cell subpopulation plays a regulatory role as a Tc1 response in aging individuals.

The mouse SHIP2 (Inppl1) gene: complementary DNA, genomic structure, promoter analysis, and gene expression in the embryo and adult mouse

SHIP2 is a new member of the inositol polyphosphate 5-phosphatase family showing homology to SHIP1. The structure of both enzymes is characterized by the presence of a 5' SH2 domain, a central catalytic domain, and a 3' proline-rich region. Recent results suggest that SHIP2 and SHIP1 act downstream of various receptors by removing a phosphate from the 5' position of the phosphatidylinositol 3'-kinase phosphatidylinositol 3,4, 5-triphosphate product and of inositol 1,3,4,5-tetrakisphosphate. Human SHIP2 is highly expressed in adult heart, skeletal muscle, and placenta, whereas SHIP1 expression is limited to the hematopoietic system. We report here the molecular analysis of the mouse SHIP2 cDNA and the corresponding protein, the structure of the gene, and the identification of its promoter. SHIP2 mRNA expression was analyzed in embryonic and adult mouse tissues by reverse transcription-polymerase chain reaction and in situ hybridization. In embryonic day 15.5 mice, SHIP2 was strongly expressed in the liver, specific regions of the central nervous system, the thymus, the lung, and the cartilage perichondrium. In adult mice, SHIP2 mRNA was markedly present in the brain and the thymus and at different stages of spermatozoa maturation in the seminiferous tubules. The subtle differences in the protein structure of SHIP2 and SHIP1 as well as their different patterns of expression are discussed.

Different roles for LFA-1 and VLA-4 integrins in T-B-cell interactions in vivo

Adhesion molecules are critical in the cellular interactions involved in specific immune responses. They are used for homing, cell migration, cell-cell contact and, in some cases, for the delivery of costimulatory signals. Since the host-versus-graft (HVG) reaction represents a particular form of T-B-cell interaction, we have explored whether the inhibition of lymphocyte function-associated antigen-1/intracellular adhesion molecule-1 (LFA-1/ICAM-1) interactions and the signalling through very late activation antigen-4 (VLA-4) have any effect on the development of a lupus-like disease in BALB/c mice injected at birth with (BALB/cxC57BL/6)F1 spleen cells. In close association with the development of tolerance to donor allografts, these mice show a polyclonal activation of F1 donor B cells by alloreactive host CD4+ T cells, manifested by the production of autoantibodies (autoAbs) and the development of a mild glomerulonephritis. The dose of the monoclonal antibody (mAb) employed has been adjusted to block completely the molecule on the surface of peripheral lymphocytes without interfering with the induction of neonatal tolerance. Injection of saturating doses (100 microg/2 days) of either anti-LFA-1alpha or anti-ICAM-1 mAbs, but not anti-VLA-4alpha or anti-LFA-1beta mAbs, blocks the production of anti-ssDNA autoAbs and the thrombocytopenia characteristic of this HVG disease (HVGD). However, anti-VLA-4alpha treatment is only able to delay the production of autoAbs and the anti-LFA-1beta treatment, not to modify the evolution of the HVGD. These results point to the relevance of LFA-1/ICAM-1 interactions, but not of the VLA-4-mediated signal, in the polyclonal B-cell activation occurring during the allogeneic interactions between host T helper type 2 cells and donor B cells in HVGD.

[Non-compliance of the treatment with antibiotics in non-severe acute infections]

BACKGROUND

To determine the nonfulfillment of antiinfectious therapy in clinical practice.

MATERIAL AND METHODS

Fulfillment was quantified by tablet counting (TC) in the homes of 366 patients undergoing antibiotic treatment and the motives and predictive factors were identified.

RESULTS

Nonfulfillment was of 61% (95% confidence interval [CI] 55.4-66.6%). Patient improvement was the main reason for discontinuation (54.5%). The predictive factors were greater length of treatment (p = 0.000004), dose (p = 0.0019) and number of tablets (p = 0.0000).

CONCLUSIONS

Nonfulfillment of antiinfectious treatment in clinical practice is high, mainly due to clinical improvement and to the greater complexity and length of treatment.

Nod1, an Apaf-1-like activator of caspase-9 and nuclear factor-kappaB

Ced-4 and Apaf-1 belong to a major class of apoptosis regulators that contain caspase-recruitment (CARD) and nucleotide-binding oligomerization domains. Nod1, a protein with an NH2-terminal CARD-linked to a nucleotide-binding domain and a COOH-terminal segment with multiple leucine-rich repeats, was identified. Nod-1 was found to bind to multiple caspases with long prodomains, but specifically activated caspase-9 and promoted caspase-9-induced apoptosis. As reported for Apaf-1, Nod1 required both the CARD and P-loop for function. Unlike Apaf-1, Nod1 induced activation of nuclear factor-kappa-B (NF-kappaB) and bound RICK, a CARD-containing kinase that also induces NF-kappaB activation. Nod1 mutants inhibited NF-kappaB activity induced by RICK, but not that resulting from tumor necrosis factor-alpha stimulation. Thus, Nod1 is a leucine-rich repeat-containing Apaf-1-like molecule that can regulate both apoptosis and NF-kappaB activation pathways.

CIPER, a novel NF kappaB-activating protein containing a caspase recruitment domain with homology to Herpesvirus-2 protein E10

We have identified and characterized CIPER, a novel protein containing a caspase recruitment domain (CARD) in its N terminus and a C-terminal region rich in serine and threonine residues. The CARD of CIPER showed striking similarity to E10, a product of the equine herpesvirus-2. CIPER formed homodimers via its CARD and interacted with viral E10 but not with several apoptosis regulators containing CARDs including ARC, RAIDD, RICK, caspase-2, caspase-9, or Apaf-1. Expression of CIPER induced NF-kappaB activation, which was inhibited by dominant-negative NIK and a nonphosphorylable IkappaB-alpha mutant but not by dominant-negative RIP. Mutational analysis revealed that the N-terminal region of CIPER containing the CARD was sufficient and necessary for NF-kappaB-inducing activity. Point mutations in highly conserved residues in the CARD of CIPER disrupted the ability of CIPER to activate NF-kappaB and to form homodimers, indicating that the CARD is essential for NF-kappaB activation and dimerization. We propose that CIPER acts in a NIK-dependent pathway of NF-kappaB activation.

Cytokine flow cytometry differentiates the clinical status of multiple sclerosis (MS) patients

In this study we have examined intracellular cytokines in peripheral blood mononuclear cells (PBMC) of MS patients by flow cytometry (cytokine flow cytometry). MS progressive patients showed an increased number of cells producing interferon-gamma (IFN-gamma) after activation with phorbol 12-myristate 13-acetate and ionomycin, compared with patients with clinically inactive forms (P < 0001) and with healthy controls (P = 0001). These cells belonged to the CD4+ and CD8+ subsets in similar proportions. Clinically inactive patients showed a lower level of cells producing IL-2 than controls (P = 0.03) and active MS patients (P = 0.03). Most IL-2-producing cells were CD4+ lymphocytes, although a small part of the IL-2 was also produced by CD8+ cells. The percentage of cells producing simultaneously IL-2 and IFN-gamma was increased in active MS and they were mainly CD4+ lymphocytes. No differences in the production of IL-4 were observed between groups. However, we found an increased IL-10 production in clinically active MS patients (P = 0.03). Treatment with IFN-beta of active MS patients showed lower levels of cytokines when compared with untreated MS patients. This methodological approach could help in the follow up and therapeutic monitoring of MS patients.

Diva, a Bcl-2 homologue that binds directly to Apaf-1 and induces BH3-independent cell death

We have identified and characterized Diva, which is a novel regulator of apoptosis. Sequence analysis revealed that Diva is a member of the Bcl-2 family of proteins containing Bcl-2 homology domain 1, 2, 3, and 4 (BH1, BH2, BH3, and BH4) regions and a carboxyl-terminal hydrophobic domain. The expression of Diva mRNA was detected in multiple embryonic tissues but was restricted to the ovary and testis in adult mice. The expression of Diva promoted the death of 293T, Ramsey, and T47D cells as well as that of primary sensory neurons, indicating that Diva is a proapoptotic protein. Significantly, Diva lacks critical residues in the conserved BH3 region that mediate the interaction between BH3-containing proapoptotic Bcl-2 homologues and their prosurvival binding partners. Consistent with this, Diva did not bind to cellular Bcl-2 family members including Bcl-2, Bcl-XL, Bcl-w, Mcl-1, and A1/Bfl-1. Furthermore, mutants of Diva lacking the BH3 region fully retained their proapoptotic activity, confirming that Diva promotes apoptosis in a BH3-independent manner. Significantly, Diva interacted with a viral Bcl-2 homologue (vBcl-2) encoded by the Kaposi's sarcoma-associated herpesvirus. Consistent with these associations, apoptosis induced by Diva was inhibited by vBcl-2 but not by Bcl-XL. Importantly, Diva interacted with Apaf-1, an adapter molecule that activates caspase-9, a central death protease of the apoptotic pathway. The expression of Diva inhibited the binding of Bcl-XL to Apaf-1, as determined by immunoprecipitation assays. Thus, Diva represents a novel type of proapoptotic Bcl-2 homologue that promotes apoptosis independently of the BH3 region through direct binding to Apaf-1, thus preventing Bcl-XL from binding to the caspase-9 regulator Apaf-1.

[Relationship between medical treatment compliance and the degree of control in patients with high blood pressure, non-insulin dependent diabetes mellitus and dyslipidemia]

BACKGROUND

To study the relationship between therapeutic compliance and the control of arterial hypertension, non insulin dependent diabetes mellitus and hyperlipidemia.

PATIENTS AND METHODS

Prospective study performed on 174 hypertensive patients, 107 with diabetes and 107 with hyperlipidemia evaluating compliance by counting of tablets in two home visits.

RESULTS

34% hypertensive patients, 20% diabetics and 37% hyperlipidemics that took medication as instructed or more than they should were badly controlled.

CONCLUSIONS

The control grade of high blood pressure, non insulin dependent diabetes mellitus and hyperlipidemia not only depends on improving compliance but also in adapting pharmacologic prescriptions.