Integrated sample collection and handling for drug discovery bioanalysis

An integrated sample handling process for drug discovery bioanalysis is described. The streamlining of study design, sample collection and automatic bioanalytical sample processing is demonstrated. Specific details for the entire procedure regarding the time saved, ease of automation and integration are defined. Details of sample handling involved a sample collection map, sample collection formatting and volume, dilution schemes for high concentration samples, choice of biological fluid and evaluating the capabilities of two liquid-handling workstations. Numerous comparisons were conducted between the new approaches and the conventional sample handling approaches. The precision and accuracy obtained from the new integrated sample handling process were comparable to those obtained from a conventional approach, as were pharmacokinetic profiles and parameters. This new sampling process greatly improved the efficiency of drug discovery bioanalysis. The integration of pre-clinical protocol design, sample collection and bioanalysis processes was also achieved.

Three amino acid residues determine selective binding of FK506-binding protein 12.6 to the cardiac ryanodine receptor

FK506-binding protein (FKBP12) has been found to be associated with the skeletal muscle ryanodine receptor (RyR1) (calcium release channel), whereas FKBP12.6, a novel isoform of FKBP, is selectively associated with the cardiac ryanodine receptor (RyR2). For both RyRs, the stoichiometry is 4 FKBP/RyR. Although FKBP12.6 differs from FKBP12 by only 18 of 108 amino acids, FKBP12.6 selectively binds to RyR2 and exchanges with bound FKBP12.6 of RyR2, whereas both FKBP isoforms bind to RyR1 and exchange with bound FKBP12 of RyR1. To assess the amino acid residues of FKBP12.6 that are critical for selective binding to RyR2, the residues of FKBP12.6 that differ with FKBP12 were mutated to the respective residues of FKBP12. RyR2 of cardiac sarcoplasmic reticulum, prelabeled by exchange with [35S]FKBP12.6, was used as assay system for binding/exchange with the mutants. The triple mutant (Q31E/N32D/F59W) of FKBP12.6 was found to lack selective binding to the cardiac RyR2, comparable with that of FKBP12.0. In complementary studies, mutations of FKBP12 to the three critical amino acids of FKBP12.6, conferred selective binding to RyR2. Each of the FKBP12.6 and FKBP12 mutants retained binding to the skeletal muscle RyR1. We conclude that three amino acid residues (Gln31, Asn32, and Phe59) of human FKBP12.6 account for the selective binding to cardiac RyR2.

An important role for major histocompatibility complex class I-restricted T cells, and a limited role for gamma interferon, in protection of mice against lethal herpes simplex virus infection

Herpes simplex virus (HSV) inhibits major histocompatibility complex (MHC) class I expression in infected cells and does so much more efficiently in human cells than in murine cells. Given this difference, if MHC class I-restricted T cells do not play an important role in protection of mice from HSV, an important role for these cells in humans would be unlikely. However, the contribution of MHC class I-restricted T cells to the control of HSV infection in mice remains unclear. Further, the mechanisms by which these cells may act to control infection, particularly in the nervous system, are not well understood, though a role for gamma interferon (IFN-gamma) has been proposed. To address the roles of MHC class I and of IFN-gamma, C57BL/6 mice deficient in MHC class I expression (beta2 microglobulin knockout [beta2KO] mice), in IFN-gamma expression (IFN-gammaKO mice), or in both (IFN-gammaKO/beta2KO mice) were infected with HSV by footpad inoculation. beta2KO mice were markedly compromised in their ability to control infection, as indicated by increased lethality and higher concentrations of virus in the feet and spinal ganglia. In contrast, IFN-gamma appeared to play at most a limited role in viral clearance. The results suggest that MHC class I-restricted T cells play an important role in protection of mice against neuroinvasive HSV infection and do so largely by mechanisms other than the production of IFN-gamma.

Retrospective report on the effectiveness of a polyurethane football helmet cover on the repeated occurrence of cerebral concussions

This report reviews the literature and unpublished data and presents survey results related to the use of a polyurethane football helmet cover. Two hundred forty-five individuals, identified by the helmet manufacturer as having purchased at least one device, were sent a survey after the 1992, 1993, and 1994 football seasons; 155 (63.3%) of the surveys were returned. The questionnaire, designed to be completed by the athlete, required a detailed history of concussions occurring both prior to and during the period the device was used. Individuals used the device as a result of having incurred at least one concussion. Rates of concussion reoccurrence while the device was worn were grouped by the number of previous concussions (1, 2, 3, or 4+) that occurred over a 4year period prior to use of the device. The rate of concussion reoccurrence was 2.4%, 7.3%, 15.8%, and 33.3%, respectively, over a 4-year period. The range appeared to reflect a parallel relationship between pre- and post-device concussion experiences: the more concussions experienced prior to adopting the device, the higher the rate of concussion reoccurrence while using the device. The natural history of repeated occurrences of concussive events may not be affected by the use of a polyurethane football helmet cover. We suggest that such a device not be routinely used prophylactically, but instead be reserved for individuals with 1 to 2 prior concussion injuries. However, at this time, we neither recommend nor discommend the device.

Efficacy of 24-hour shifts: prepared or impaired? A prospective study

BACKGROUND

The effect of duty duration on performances is unknown. In a prospective cohort study model using repeated measures, we evaluated the effect of shift length on a battery of neuropsychologic performance indicators using our flight program as the test site.

METHODS

Flight nurses completing 24- and 12-hour shifts were tested on memory, attention, reasoning, motor, and speed measures. Ratings of stress, fatigue, sleep quality, and logged amount of work and sleep were evaluated from personal journals kept for this purpose. Data were analyzed by linear regression and repeated measures multivariate analysis of variance (MANOVA) and analysis of variance (ANOVA). Clinical significance was set at P < 0.05.

RESULTS

Fifteen subjects completed the testing and evaluation process. Neuropsychologic testing demonstrated that performance was not predicted by shift length, time of shift (day versus night), amount or quality of sleep before or during shift, or fatigue ratings. Age, gender, and education did not mediate shift length/test performance relationships. Uninterrupted sleep, stress ratings, and number of flights per shift modestly reduced some test scores. Predictably, repeated testings resulted in practice effects that reduced analysis power. We found that 24-hour shifts per se do not result in a cognitive decline compared with 12-hour shifts. Inconsistent sleep, number of flights, and the stressfulness of flights may have greater impact.

Doxorubicin induced expression of P-glycoprotein in a canine osteosarcoma cell line

Canine and human osteosarcoma are very similar with respect to clinical presentation, radiological and histopathological features, metastatic rate and pattern and response to therapy. For these reasons, canine osteosarcoma is a useful intermediate model for the disease in humans. Overexpression of P-glycoprotein, the product of the MDR1 gene, is the most important predictor of an adverse clinical course in human patients with osteosarcoma. Exposure of canine osteosarcoma cells to doxorubicin resulted in overexpression of MDR1 mRNA and P-glycoprotein. Furthermore, these cells failed to accumulate doxorubicin intracellularly and were less sensitive to vincristine-induced cytotoxicity as compared to parental cells.

Identification and localization of extracellular Ca(2+)-sensing receptor in rat intestine

The extracellular calcium (Ca2+o)-sensing receptor (CaR) plays vital roles in Ca2+o homeostasis, but no data are available on its expression in small and large intestine. Polymerase chain reaction products amplified from reverse-transcribed duodenal RNA using CaR-specific primers showed > 99% homology with the rat kidney CaR. Northern analysis with a CaR-specific cRNA probe demonstrated 4.1- and 7.5-kb transcripts in all intestinal segments. Immunohistochemistry with CaR-specific antisera showed clear basal staining of epithelial cells of small intestinal villi and crypts and modest apical staining of the former, whereas there was both basal and apical staining of colonic crypt epithelial cells. In situ hybridization and immunohistochemistry also demonstrated CaR expression in Auerbach's myenteric plexus of small and large intestines and in the submucosa in the region of Meissner's plexus. Our results reveal CaR expression in several cell types of small and large intestine, in which it may modulate absorptive and/or secretomotor functions.

Plexosarcoma of the bladder

Plexosarcomas are rare soft tissue sarcomas, previously reported in association with gastrointestinal autonomic nerve (GAN) plexi. We report the first case arising from the autonomic nerve plexus of the bladder.

Squamous cell carcinoma originating from a cutaneous scar in a llama

A nonhealing wound associated with a laceration in a 12-year-old llama was evaluated. Initial attempts at closure were unsuccessful and biopsy revealed scar tissue. Subsequent biopsies, 18 mo later, revealed squamous cell carcinoma with regional metastasis. This report describes squamous cell carcinoma, secondary to a traumatic wound in a llama.

Skin appendage involvement in anal intraepithelial neoplasia

BACKGROUND

High-grade anal intraepithelial neoplasia (AIN III) may be premalignant. Surgical excision of large areas of anal epithelium carries significant morbidity. Ablation treatments may carry less morbidity; however, the depth of ablation is uncertain and failure to ablate dysplasia in hair shafts and other skin appendages may lead to early recurrence.

METHODS

This study assesses morphometric aspects of skin appendages in perianal skin and anal canal mucosa in tissues from 30 patients with AIN III. Both normal and dysplastic epithelium was assessed in each patient. The depth to which AIN III involved skin appendages was measured using computerized image analysis.

RESULTS

Both the perianal epidermis and anal canal mucosa affected by AIN III were significantly thicker than normal. Nineteen of 30 patients with AIN III had skin appendage involvement. Some 57 per cent of hair follicles (79 of 138), 16 per cent of sebaceous glands (11 of 69) and 25 per cent of sweat glands (24 of 96) observed beneath an abnormal epithelium had evidence of AIN. The median depth of AIN involvement of the hair follicle was 1.14 (range 0.44-1.67) mm, sebaceous glands 1.44 (range 0.96-1.90) mm, and sweat glands 0.94 (range 0.50-2.20) mm. These figures do not take into account tissue shrinkage due to histological processing.

CONCLUSION

AIN III involvement of epithelial appendages is a significant problem. For disease eradication, tissue destruction or removal to a depth of at least 2.2 mm below the adjacent basement membrane is required. Surgical excision of high-grade AIN remains the treatment of choice.

Amyloid-beta proteins activate Ca(2+)-permeable channels through calcium-sensing receptors

The amyloid-beta peptides (A beta) are produced in excess in Alzheimer's disease (AD) and may contribute to neuronal dysfunction and degeneration. This study provides strong evidence for a novel cellular target for the actions of A beta, the phospholipase C-coupled, extracellular Ca(2+)-sensing receptor (CaR). We demonstrate that A beta(s) produce a CaR-mediated activation of a Ca(2+)-permeable, nonselective cation channel (NCC), probably via elevation in cytosolic Ca2+ (Cai), in cultured hippocampal pyramidal neurons from normal rats and from wild type mice but not those from mice with targeted disruption of the CaR gene (CaR -/-). A beta(s) also activate NCC in CaR-transfected but not in nontransfected human embryonic kidney (HEK293) cells. Thus aggregates of A beta deposited on hippocampal neurons in AD could appropriately activate the CaR, stimulating Ca(2+)-permeable channels and causing sustained elevation of Cai with resultant neuronal dysfunction.

Tardive dyskinesia exacerbated after ingestion of phenylalanine by schizophrenic patients

Despite continued research, the influences that promote or exacerbate tardive dyskinesia (TD) symptoms remain incompletely understood. Recent findings (Gardos et al. 1992; Richardson et al. 1989) suggest that ingestion of the dietary constituent, phenylalanine, might exacerbate TD symptoms, but a double-blind, placebo-controlled challenge had not previously been conducted in schizophrenic patients. On two different mornings, in counterbalanced order, 18 male schizophrenic patients with TD were challenged with either 100 mg/kg phenylalanine or placebo. Effects on abnormal involuntary movements, recall memory, and plasma phenylalanine were measured 90 minutes post-challenge. The results supported the hypothesis in that involuntary movements increased to a statistically and clinically meaningful degree after the phenylalanine challenge, but not after placebo. No effects on memory were detected. Significant order effects characterized the plasma findings but not the behavioral data. Results indicate that a dietary constituent, the amino acid phenylalanine, can potentially exacerbate tardive dyskinesia symptoms in schizophrenic patients. The influence of phenylalanine and other ingested substances on clinical symptomatology warrants further investigation.

Knowledge and Attitudes of Certified Athletic Trainers in Pennsylvania Toward HIV/AIDS and Treating HIV-Positive Athletes

OBJECTIVE

As the number of people infected with the Human Immunodeficiency Virus (HIV) continues to increase so does the likelihood that athletic trainers will treat HIV-positive athletes. The purposes of this study were to determine how knowledgeable certified athletic trainers in Pennsylvania are about HIV/ AIDS and their attitudes toward treating the injuries of HIV- positive/AIDS athletes. Another purpose of this study was to determine what effect the athletic trainers' HIV/AIDS attitudes had on their HIV/AIDS knowledge level.

DESIGN AND SETTING

A questionnaire was mailed to 807 NATA-certified athletic trainers who resided in the state of Pennsylvania. A total of 410 (50.8%) athletic trainers participated in the study: 241 (58.8%) males and 169 (41.2%) females.

SUBJECTS

NATA-certified athletic trainers who resided in the state of Pennsylvania as of March 19, 1994.

MEASUREMENTS

A questionnaire was developed by the investigators after reviewing the appropriate literature and in consultation with a panel of experts that consisted of athletic trainers, physicians, and a health educator who specialized in HIV/AIDS education. The questionnaire consisted of three sections: demographic information, HIV/AIDS knowledge, and HIV/AIDS attitude. Returned questionnaires were analyzed via descriptive (frequencies, percentages, and means) and inferential statistics. Univariate analysis consisted of independent t tests to determine what effect the athletic trainers' HIV/AIDS attitudes had on their HIV/AIDS knowledge level.

RESULTS

NATA-certified athletic trainers in Pennsylvania are moderately knowledgeable about HIV/AIDS and have constructive attitudes in treating the athletic injuries of HIV-positive/ AIDS athletes. Their major concern, however, is fear of HIV transmission. It was further determined that differences in HIV/AIDS attitudes had no effect on HIV/ AIDS knowledge level.

CONCLUSIONS

The likelihood that athletic trainers will treat HIV-positive athletes is ever increasing. HIV/AIDS education and appropriate clinical precautions are paramount in protecting the clinician and athlete alike.

Agonists of the Ca(2+)-sensing receptor (CaR) activate nonselective cation channels in HEK293 cells stably transfected with the human CaR

Calcium (Ca2+) ions serve multiple roles both intra- and extracellularly. We recently cloned a cell surface, Cao(2+)-sensing receptor (CaR) that plays a central role in Cao2+ homeostasis by enabling direct regulation by Cao2+ of parathyroid hormone (PTH) secretion and the function of other tissues involved in mineral ion homeostasis. In parathyroid cells, the CaR activates phospholipase C, thereby raising the levels of inositol trisphosphate (IP3) and releasing Ca2+ from intracellular stores. High Cao2+ also activates Ca2+ influx into parathyroid cells through poorly defined mechanisms that may involve Ca(2+)-permeable, nonselective cation channels (NCC). We now show that human embryonic kidney (HEK293) cells also have NCC and, furthermore, that these channels are regulated by the CaR. We have utilized the cell-attached configuration of the patch clamp technique to characterize the properties of these channels as well as their regulation by various CaR agonists added to the external bath solution. The polycationic CaR agonist, neomycin (100 microM), as well as an elevated concentration of Cao2+ (3 mM), both of which activate the cloned CaR, significantly increased the probability of channel opening (Po) in HEK cells stably transfected with the CaR but not in nontransfected HEK cells which do not contain the receptor. Thus, the activation of the CaR enhances the activity of Ca(2+)-permeable NCC in these cells, which could contribute to the sustained increase in Cai2+ in parathyroid cells which is observed in response to elevated Cao2+. The CaR may also regulate the membrane functions of other CaR-expressing cells (e.g., those in the brain), at least in part, by modulating similar channels.

Effect of syringe size on bruising following subcutaneous heparin injection

BACKGROUND: Bruising and induration associated with subcutaneous heparin injection often result in sustained tenderness and severe ecchymosis at the injection site. Research-based practice guidelines for subcutaneous heparin administration are needed to reduce these adverse effects. OBJECTIVES: The purpose of this study was to investigate the effect of syringe size (1-mL vs 3-mL) on postinjection-site bruising and induration following the administration of subcutaneous heparin. METHODS: A convenience sample of 29 subjects receiving 5000 units of subcutaneous heparin at least twice a day was recruited from a large urban hospital. Subjects received their regularly scheduled subcutaneous heparin injections with a 3-mL or a 1-mL syringe in a randomized sequence using a standardized procedure. Injection sites were assessed for bruises and induration at 24, 48, and 72 hours after injection. RESULTS: The incidence of injection site bruising with 1- and 3-mL syringes was 79% and 69%, respectively. The use of a 3-mL vs 1-mL syringe resulted in significantly smaller bruises at 48 and 72 hours after injection. Induration at the injection site occurred in three patients. CONCLUSIONS: Findings suggest that 3-mL syringes are preferable to 1-mL syringes for heparin administration. The effect of other injection-related variables should be studied with the use of the 3-mL syringe, and tested on various populations.

Effect of syringe size on bruising following subcutaneous heparin injection

BACKGROUND

Bruising and induration associated with subcutaneous heparin injection often result in sustained tenderness and severe ecchymosis at the injection site. Research-based practice guidelines for subcutaneous heparin administration are needed to reduce these adverse effects.

OBJECTIVES

The purpose of this study was to investigate the effect of syringe size (1-mL vs 3-mL) on postinjection-site bruising and induration following the administration of subcutaneous heparin.

METHODS

A convenience sample of 29 subjects receiving 5000 units of subcutaneous heparin at least twice a day was recruited from a large urban hospital. Subjects received their regularly scheduled subcutaneous heparin injections with a 3-mL or a 1-mL syringe in a randomized sequence using a standardized procedure. Injection sites were assessed for bruises and induration at 24, 48, and 72 hours after injection.

RESULTS

The incidence of injection site bruising with 1- and 3-mL syringes was 79% and 69%, respectively. The use of a 3-mL vs 1-mL syringe resulted in significantly smaller bruises at 48 and 72 hours after injection. Induration at the injection site occurred in three patients.

CONCLUSIONS

Findings suggest that 3-mL syringes are preferable to 1-mL syringes for heparin administration. The effect of other injection-related variables should be studied with the use of the 3-mL syringe, and tested on various populations.

Escherichia coli tryptophanyl-tRNA synthetase mutants selected for tryptophan auxotrophy implicate the dimer interface in optimizing amino acid binding

Tryptophan auxotrophs of Escherichia coli in which mutations were mapped to the trpS locus (encoding tryptophanyl-tRNA synthetase) have been previously isolated. We have investigated the tryptophanyl-tRNA synthetase (TrpRS) purified from six auxotrophic strains for changes in amino acid activation and aminoacylation. Steady-state kinetic analyses show that these mutant TrpRS proteins have increases in the apparent KM for tryptophan, decreases in turnover number, or both, without significant changes in the apparent KM for ATP or tRNA(Trp). The crystal structure of a highly homologous tryptophanyl-tRNA synthetase from Bacillus stearothermophilus in a complex with the cognate aminoacyl adenylate allowed us to place the mutations in a structural context. The mutations in the enzymes are located in the KMSKS loop (M196I), in or near the active site (D112E, P129S, A133E) or far from the active site. The last three mutants (T60R, L91F, G329S) could not be predicted by examination of the protein structure as they line an interface between the C-terminal alpha-helix of one subunit and the Rossmann folds of both subunits, thus affecting a specific region of the dimer interface. These results support a role for dimerization in properly configuring the two active sites of the dimeric enzymes in the Trp/Tyr subclass of class I aminoacyl-tRNA synthetases in order to achieve optimal catalysis.

The effect of ambient temperature on the shoe-surface interface release coefficient

Previous studies of the shoe-surface interface correlated foot fixation with cleat length, configuration, and material composition as well as turf type and surface conditions. Our study examined the effect of temperature on the rotational torsion resistance of artificial turf football shoes. Five football shoe models, a flat-soled basketball-style turf shoe, a natural grass soccer-style shoe, and three multistudded turf shoes, were studied on dry Astro Turf at five temperatures (range, 52 degrees F to 110 degrees F). An assay device, a prosthetic foot mounted on a loaded stainless steel shaft, was used to determine the force necessary to release a shoe from the turf's surface. We used a torque wrench to apply a rotational force so that each shoe was pivoted counterclockwise through an arc of 60 degrees. Our results indicated that release coefficients differ within and among the shoe models at various turf temperatures. We also found that an increase in turf temperature, in combination with cleat characteristics, affects shoe-surface interface friction and potentially places the athlete's knee and ankle at risk of injury. Based on an established risk criterion, which correlated shoe-surface interface combinations in the laboratory with documented clinical occurrences, only the flat-soled basketball-style turf shoe could be designated "safe" or "probably safe" at all five temperatures.

Pharmacokinetics of pyropheophorbide-a-hexyl ether in the dog

BACKGROUND AND OBJECTIVES

Pyropheophorbide-a-hexyl ether (HPPH) is a new compound being investigated for use as a photosensitizer for photodynamic therapy; however, the pharmacokinetics are not known for any of the target species likely to be treated with this drug. The objective of this study was to determine the pharmacokinetic parameters of this drug prior to institution of a clinical trial in canine patients with various cancers.

STUDY DESIGN, MATERIALS AND METHODS

HPPH (0.3mg/kg i.v.) was administered to 12 dogs and blood samples were drawn at intervals for 24 hours and plasma HPPH concentrations were determined. Pharmacokinetic parameters were calculated for each dog.

RESULTS

No evidence of toxicity was noted in any dog. The mean half-life was calculated to be 26.98 +/- 2.35 hrs. The mean clearance was 5.061 +/- 0.214 ml/hr/kg. The mean volume of distribution of the central compartment was 0.069 +/- 0.003 L/kg, and the mean steady state volume of distribution was 4.47 +/- 0.25 L/kg.

CONCLUSION

The conclusion is that 0.3 mg/kg HPPH injected intravenously resulted in measurable plasma levels for 24 hrs, and resulted in no detectable adverse reactions.

Drugs, poverty, pregnancy, and foster care in Los Angeles, California, 1989 to 1991

To determine the characteristics and childbearing histories of women whose infants entered foster care in Los Angeles County, we examined the cases of 1,155 drug-using women whose infants were removed from them at birth and 236 non-drug-using women whose infants were also removed at birth by court order (July 1989 through March 1991). All of the women were indigent, and less than half had graduated from high school. The drug-using women frequently had criminal records, and more than a quarter were homeless. Many comparison women had mental health problems, and some (16.7%) were teenagers under court custody. Overall, 80% of all the children born to both groups of women were under court jurisdiction. Data obtained after study infants' births on 926 drug-using women observed for 18 months revealed that 22% had borne another infant who was placed in foster care; half of these infants had a positive drug immunoassay. Of the 185 non-drug-using women with 18-month follow-ups, 7.6% had borne another child who was in foster care. The magnitude of the repeated childbearing recorded among both groups of women in this study shows that preventive programs including family planning, mental health services, and drug prevention or rehabilitation programs have not reached this population.

Psychiatric consequences of radical curative surgery for gastric cancer

Radical resection of gastric cancer offers the best hope of cure, but carries the risk of significant psychological morbidity in addition to the well-documented physical complications. In the case presented, recognition of clinical depression after thoracoabdominal gastrectomy enabled successful psychological intervention.

Radical surgery for advanced and recurrent breast cancer

Locally advanced or recurrent breast cancer is commonly seen in breast clinics. One method of palliation for ulcerating tumours is a radical mastectomy with replacement of the chest wall defect with a myocutaneous flap. We report on our experience of this technique in the management of 35 women (21 advanced disease, 14 recurrent disease). The perioperative complications were minimal and there are some longterm survivors. 15 women are alive and well (range 20-96 months postoperatively, mean 55 months). This radical surgery, therefore, has a significant role in the management of selected women with breast cancer.

Determinants of birth weight in Vietnamese detainees in Hong Kong

Five hundred and fifty singleton pregnancies amongst Vietnamese Boat People delivering between January and December 1993 were studied post-natally. Multiple regression analysis showed no direct effect of ethnic origin on birth weight. When analyses were repeated on the two main ethnic subgroups we found that, amongst Anamese patients, both gestation at delivery and birth weight independently increased with longer duration of stay in Hong Kong. This relationship was not seen in Vietnamese patients of Chinese ethnic origin. Possible reasons for these different relationships are discussed.

Treatment of anal intraepithelial neoplasia

The natural history and malignant potential of anal intraepithelial neoplasia (AIN) remain uncertain, making management decisions about such lesions difficult. The management of 70 patients with AIN is described. The majority of lesions encountered were low grade (AIN I and II; 43 of 70) and required no treatment, but eight invasive anal cancers associated with high-grade AIN occurred over the 4-year study period. Three were a result of apparent progression of high-grade lesions; three more invasive lesions were found in areas of AIN III on histological examination. Surgical excision was used to treat 27 patients with AIN III. Treatment of extensive lesions involving the perianal and anal canal epithelium circumferentially in six patients involved excision of the whole of this epithelium and application of split skin grafts.

The effects of hypothermic and normothermic cardiopulmonary bypass on glyceryl trinitrate activity

Glyceryl trinitrate (GTN) is used to control arterial blood pressure during cardiopulmonary bypass (CPB) procedures, but its effects are often decreased during the period of extracorporeal support. The plasma and urine concentrations of GTN and glyceryl-1,2-dinitrate (1,2-GDN) and glyceryl-1,3-dinitrate (1,3-GDN) for male and female patients who received GTN during hypothermic CPB, and male and female patients who were given GTN during normothermic CPB, were measured by gas-liquid chromatography. During hypothermic CPB, the male and female subjects experienced significant decreases in GTN clearance (P < 0.05), 66% and 52%, respectively. Neither the males nor the females who underwent normothermic CPB experienced any significant change in GTN clearance. These results suggest that the lower core temperature during hypothermic CPB may decrease the biotransformation of GTN to GDNs and nitric oxide, thereby resulting in less dilation of blood vessels. Furthermore, the males in the hypothermic CPB group had significantly greater urinary concentrations of 1,3-GDN and 1,2-GDN than the females (P < 0.05), and the normothermic CPB males had a significantly greater urinary concentration of 1,2-GDN than the females in that group. The normothermic CPB males also had significantly higher plasma concentration of GTN at two time points, and 1,3-GDN at one time point, than the females. These data suggest that there may be a gender difference in GTN biotransformation.

Anal colposcopy and the diagnosis of anal intraepithelial neoplasia in high-risk gynecologic patients

The objective of this study was to define the colposcopic features of the normal anal canal and of anal human papillomavirus (HPV)-associated lesions, including anal intraepithelial neoplasia (AIN), and to correlate the colposcopic impression with the final histopathologic diagnosis. A controled colposcopic screening study of women considered at risk for HPV-associated anal epithelial abnormalities was carried out. All colposcopic assessments included a biopsy with matching histopathologic diagnosis. The study group consisted of 213 women who were considered at risk of anal HPV infection and AIN. A further group of 50 women, who had no previous history of ano-genital HPV infection or AIN and whose recent cervical smear was negative were recruited as controls. Informed consent was obtained from all patients, and the study was approved by the local ethical committee. In the control group of 50 women no AIN was detected. Normal histology was obtained in 45/50 (90%) biopsies where normality had been predicted on colposcopy. Histologic diagnosis in the at-risk group was normal in 143 (67%), subclinical papillomarvirus infection (SPI) in 24 (11%), and AIN of all grades (including three cases of early invasive squamous cancer in a field change of AIN III) in 46 (22%) patients. Nineteen of 24 (79%) cases of SPI were incorrectly predicted as normal on colposcopy, and another one (4%) as AIN I-II. Only four (17%) cases of SPI were correctly predicted at colposcopy. Of the 46 cases of histologically proven AIN, 26 (56%) were AIN I-II, and 20 (44%) were AIN III. Some 50% of AIN I-II were incorrectly predicted as SPI on colposcopy. Of the 20 AIN III lesions, 15 (75%) were correctly predicted by colposcopy. Three (20%) of these lesions contained foci of early invasion, of which in only one case (33.3%) was invasive disease suspected at colposcopy. Some 25% (5/20) of AIN III lesions were incorrectly diagnosed as AIN I-II at colposcopy. As is the experience with colposcopic assessment of the cervix, anal colposcopy predictions correlated well with the final histologic diagnosis, at the normal and high-grade AIN ends of the spectrum. The colposcopic predictive distinction between SPI and low-grade AIN (I-II) was less accurate. It was difficult to distinguish early invasive lesions within a field change of AIN III, from pure AIN III. In these studies there were three cases of early anal squamous carcinoma arising in AIN III lesions, two of which were unsuspected clinically.

Prevalence of anal human papillomavirus infection and intraepithelial neoplasia in renal allograft recipients

A study was performed to test the hypothesis that renal allograft recipients are at high risk of developing anal human papillomavirus (HPV) infection and anal intraepithelial neoplasia (AIN). A total of 133 renal allograft recipients and 145 control patients underwent anoscopy and biopsy. A polymerase chain reaction was used to detect HPV16 DNA in biopsy samples. A histological diagnosis of anal HPV infection or AIN was made in 32 allograft recipients (HPV infection, five; AIN I, 20; AIN II, three; AIN III, three; AIN III and anal cancer, one). One subject with AIN was detected in the control group. HPV16 DNA was detected in 47 and 12.4 per cent of anal biopsies in the allograft and control groups respectively. Renal allograft recipients are at high risk of developing anal HPV infection and neoplasia (P < 0.05). Further studies are required to determine whether screening anal examination is required in organ allograft recipients.

Anal human papillomavirus infection and squamous neoplasia in patients with invasive vulvar cancer

OBJECTIVE

To test the hypothesis that women with invasive vulvar cancer are at high risk of developing human papillomavirus (HPV)-associated anal squamous neoplasia.

METHODS

Forty women (median age 54.5 years; range 25-86) who were being treated or had been treated for invasive vulvar cancer and who had not had radiotherapy to the pelvis or anogenital region underwent anal microendoscopy and biopsy. A second group of 80 women who were similar in age to the study group and had no history of anogenital HPV infection or neoplasia formed the control group. The polymerase chain reaction was used to detect HPV 16 DNA in the vulvar and anal tissue samples from 33 patients in the study group and in the anal biopsies of all controls.

RESULTS

A histologic diagnosis of anal HPV infection or squamous neoplasia was made in 19 of 40 biopsies (47.5%) in the study group. These diagnoses consisted of one HPV, two anal squamous intraepithelial lesions (SIL) grade I, 15 and SIL grade III (four of which were associated with invasive anal cancers), and one invasive cancer in the absence of anal SIL. Human papillomavirus 16 DNA was detected in 16 of 33 (48.5%) of anal and 25 of 33 (75%) of vulvar biopsies. In addition, HPV 16 was detected in both the anal and vulvar samples in 13 of 16 cases (81%) of anal SIL III and invasive anal squamous cancer. No evidence of anal SIL was found in the controls, and HPV 16 DNA was identified in only 11 (13.7%) of the anal biopsies in this group.

CONCLUSIONS

This study provides further evidence for the etiologic relation between genital and anal squamous neoplasia. Furthermore, it shows that women with vulvar cancer are at high risk of having or developing HPV-associated anal neoplasia, particularly in younger patients (P = .0006; 95% confidence interval 12-34). Routine anal examination should be performed in patients with invasive vulvar cancer.

Surgery for gastric cancer

Radical dissection for gastric cancer is not widely practiced in the West. This paper reviews the evidence in support of lymphadenectomy and the techniques of radical resection as practiced by Japanese surgeons. We believe the published results support increased use of radical surgery in the treatment of gastric cancer and would recommend further adoption of this technique as there is minimal associated morbidity.

The dynamics of prostaglandin metabolism in human fetal membranes and decidua around the time of parturition

To address whether prostaglandins (PGs) produced in the amnion can gain access to the myometrium, we used three in vitro systems to determine the characteristics of PG secretion, metabolism, and transfer in amnion, chorion, and decidua around the time of parturition. PG metabolism, measured in explant cultures or cytosol preparations, occurs predominantly by the enzyme PG dehydrogenase, which was highest in chorion and was 2- to 3-fold more active for PGE2 than PGF2 alpha. The activity increased significantly around the time of labor onset. The activity of PG-9-ketoreductase, which interconverts the E and F series of PGs, was 2-3 orders of magnitude less than that of PG dehydrogenase. Using a dual chamber perfusion apparatus, we demonstrated that similar amounts of PGE2 were secreted from the fetal (amnion) and maternal (chorio-decidua) surfaces, and this ratio did not change with labor. Using radiolabeled PGE2, radioactivity traversed full thickness membranes at the rate of 4%/h. Only approximately 12% of the transferred radioactivity remained as intact PGE2, and very little conversion to PGF2 alpha was detected. No changes in transfer were detected around the onset of labor. We conclude that it is unlikely that PGE2 produced in the amnion acts directly on the myometrium.

Inflammatory pseudotumour of the liver

Inflammatory pseudotumours of the liver are uncommon, usually mistaken for malignant lesions and resected. This report describes the presentation of an inflammatory pseudotumour of the liver in a 28-year-old male which was demonstrated on C.T. scanning and diagnosed by percutaneous needle biopsy. This case was treated conservatively and spontaneously resolved within four months, emphasising the need to consider this lesion in the differential diagnosis of an intrahepatic mass.

Randomized trial of laser scalpel for modified radical mastectomy

The efficacy of a contact neodymium yttrium-aluminium-garnet laser scalpel was assessed during breast surgery. Forty consecutive women undergoing modified radical mastectomy were randomized to operation performed with a conventional or laser scalpel. The laser scalpel was associated with a significant reduction in mean operative blood loss (149 versus 421 ml; 95 per cent confidence interval of difference 176-368 ml, P < 0.001), but the mean operating time was longer (105 versus 80 min; 95 per cent confidence interval of difference 16-34 min, P < 0.001). No significant differences were found in the volume of postoperative wound drainage, incidence of axillary seroma, postoperative pain score or time to return of shoulder mobility. Use of a laser scalpel in breast surgery cannot be recommended.

Detection of tumour necrosis factor alpha and interleukin-1 beta in the rheumatoid osteoarthritic cartilage-pannus junction by immunohistochemical methods

During inflammation the rheumatoid synovial membrane is invaded by a number of different cell types. When activated most of these cells produce cytokines including tumor necrosis factor alpha (TNF alpha) and interleukin-1 beta (IL-1 beta). These cytokines are believed to stimulate production of degradative enzymes and disturb the equilibrium between such enzymes and their inhibitors resulting in tissue damage. In this study we investigated the localisation of TNF alpha and IL-1 beta at the cartilage-pannus junction (CPJ). Here, cytokines are well placed to influence the integrity of articular cartilage. Tissue was derived from advanced rheumatoid (RA) and, as a comparison, osteoarthritic (OA) joints at the time of replacement surgery (arthroplasty). Antibody staining of fixed serial sections of tissue localised cells that were associated with IL-1 beta and TNF alpha. Cell markers for macrophages and endothelial cells were included to provide positive identification of the cytokine-associated cells. Analysis of these sections revealed that both TNF alpha and IL-1 beta were associated with macrophages, particularly those in the synovium overlying cartilage (pannus) and endothelial cells. Positive staining was seen at the CPJ in RA and in similarly located tissue in OA. The similar distribution of cytokines in OA was unexpected even if the overall numbers of tissue and infiltrating cells in the CPJ were different in the two diseases. This highlights the possible role played by endogenous inhibitors [1, 2] in influencing the degree of cytokine activity necessary to explain the different pathogenic mechanisms in RA and OA.

Immunohistochemical analysis of p53 expression in anal squamous neoplasia

AIMS

To determine the pattern of expression of the p53 tumour suppressor gene product in anal squamous neoplasia, and to determine if this could be used as a marker of disease progression. The association between p53 expression and human papillomavirus (HPV) 16 DNA status of the anal lesions was also investigated.

METHODS

The presence and localisation of the p53 protein in formalin fixed, paraffin wax embedded specimens of anal squamous epithelium (normal and neoplastic) was examined using immunohistochemical staining with a panel of two monoclonal antibodies (DO-1, DO-7) and one polyclonal antibody (CM-1). Thirty nine normal anal epithelia, 14 anal intraepithelial neoplasia (AIN) grade 1, seven AIN 2, and 20 AIN 3 specimens were obtained from patients without demonstrable invasive disease; twelve AIN 3 specimens adjacent to invasive disease and 34 anal squamous cancers were also examined. Genomic DNA from all 126 specimens was extracted and analysed for HPV 16 DNA using the polymerase chain reaction (PCR).

RESULTS

Nuclear p53 was strongly expressed in 67% (23/34) of invasive anal squamous tumours, 75% (9/12) of AIN 3 specimens adjacent to invasive disease, and in 60% (12/20) of AIN 3 specimens obtained from patients without demonstrable invasive disease. Two of the patients in the latter group with positively staining specimens subsequently developed invasive tumours which had staining characteristics similar to those of the AIN 3 specimens. p53 protein was expressed in very low concentrations in low grade AIN and not at all in normal anal squamous epithelium. In those specimens which stained positively for p53, HPV 16 DNA sequences were detected in 69.5% (16/23) of invasive disease, 77.7% (7/9) of AIN 3 adjacent to invasive disease, 75% (9/12) of AIN 3 obtained from patients without demonstrable invasive disease, 33.3% (2/6) of AIN 2, and in 40% (2/5) of AIN 1. There was no significant correlation between p53 immunostaining and HPV 16 DNA status (p < 0.05).

CONCLUSIONS

Aberrant expression of the p53 gene product is probably involved in the pathogenesis of anal squamous neoplasia. Long term follow up studies of all patients with AIN are required to determine if this could be used as a marker of likely disease progression from high grade AIN to invasive disease. There does not seem to be an association between the presence or absence of HPV 16 DNA sequences and mutant p53 proteins in anal squamous neoplasia.

C-myc oncogene expression in anal squamous neoplasia

AIMS

To determine the pattern of c-myc oncogene expression in anal squamous neoplasia and to determine if this could be used as a marker of disease progression.

METHODS

The presence and localisation of the c-myc gene product p62 in archival specimens of anal squamous epithelium, normal and neoplastic, was examined using immunohistochemical staining with the monoclonal antibody Myc1-6E10. Ten normal and epithelia, 10 anal intraepithelial neoplasia (AIN) III, and 31 anal squamous cancers were examined.

RESULTS

There was a noticeable difference between the staining characteristics of invasive tumours, normal anal epithelium, and AIN III. Intense, diffuse, mixed nuclear and cytoplasmic (n = 14) and exclusively nuclear (n = 8) staining in 22 of 31 (71%) of invasive anal tumours was observed. All positively staining tumours were well differentiated histologically, while the negatively staining nine of 31 (29%) were poorly differentiated (n = 7) and moderately well differentiated (n = 2). In six positively staining tumour sections adjacent areas of AIN III and non-dysplastic anal epithelium had staining characteristics similar to those of the invasive component. Staining in both normal anal epithelium (4/10) and AIN III specimens obtained from patients without a history of invasive disease (8/10) was less intense, focal in distribution, and exclusively nuclear. No difference in staining characteristics could be detected in these two groups.

CONCLUSIONS

The results of this study suggest that c-myc oncogene expression is implicated in the pathogenesis of anal squamous neoplasia, and that immunohistochemical staining for c-myc protein may be helpful in identifying those AIN III lesions most likely to progress to invasive tumours.

The identification of informative parameters in the flow cytometric analysis of breast carcinoma

DNA ploidy and the measurement of proliferation or S-phase fraction are both of prognostic significance in breast cancer, yet clinical use is minimal in the U.K. Immunohistochemistry is, however, used to aid diagnosis, so a panel of antibodies were analysed by flow cytometry to assess their predictive value for prognosis, tumour stage and grade. Of 10 parameters tested on 202 breast tumour samples, tumour cell proliferation and DNA ploidy were the two most informative; cytokeratin staining, natural killer and B-cell infiltration also proved to be of value but there was no prognostic value in measuring tumour infiltrating monocytes, helper/suppressor T-cell ratios, tumour cell reactivity with carcinoembryonic antigen or human milk fat globulin antibodies. For each of the informative parameters, scores numerically weighted towards a poorer prognosis were derived which when combined, correlated with tumour grade, stage and prognosis. Such data interpretation is objective, and can be transposed to other human tumours.

Synthetase competition and tRNA context determine the in vivo identify of tRNA discriminator mutants

The discriminator nucleotide (position 73) in tRNA has long been thought to play a role in tRNA identity as it is the only variable single-stranded nucleotide that is found near the site of aminoacylation. For this reason, a complete mutagenic analysis of the discriminator in three Escherichia coli amber suppressor tRNA backgrounds was undertaken; supE and supE-G1C72 glutamine tRNAs, gluA glutamate tRNA and supF tyrosine tRNA. The effect of mutation of the discriminator base on the identity of these tRNAs in vivo was assayed by N-terminal protein sequencing of E. coli dihydrofolate reductase, which is the product of suppression by the mutated amber suppressors, and confirmed by amino acid specific suppression experiments. In addition, suppressor efficiency assays were used to estimate the efficiency of aminoacylation in vivo. Our results indicate that the supE glutamine tRNA context can tolerate multiple mutations (including mutation of the discriminator and first base-pair) and still remain predominantly glutamine-accepting. Discriminator mutants of gluA glutamate tRNA exhibit increased and altered specificity probably due to the reduced ability of other synthetases to compete with glutamyl-tRNA synthetase. In the course of these experiments, a glutamate-specific mutant amber suppressor, gluA-A73, was created. Finally, in the case of supF tyrosine tRNA, the discriminator is an important identity element with partial to complete loss of tyrosine specificity resulting from mutation at this position. It is clear from these experiments that it may not be possible to assign a specific role in tRNA identity to the discriminator. The identity of a tRNA in vivo is determined by competition among aminoacyl-tRNA synthetases, which is in turn modulated by the nucleotide substitution as well as the tRNA context.

Anal intraepithelial neoplasia: part of a multifocal disease process

Invasive carcinomas of the anogenital epithelium share a common aetiological factor--human papillomavirus (HPV) type 16. Although genital intraepithelial neoplasia may be multifocal, there have been no studies of the prevalence of anal intraepithelial neoplasia in women with intraepithelial neoplasia of the genital tract. We tested the hypothesis that women with high-grade cervical intraepithelial neoplasia are at higher risk of disease in the anus than are control women of similar age with no history of anogenital neoplasia. 29 (19%) of 152 women with cervical intraepithelial neoplasia grade III had histological evidence of anal intraepithelial neoplasia. Of the 29 patients, 11 had grade III anal lesions; 2 of those women had concomitant invasive anal squamous-cell carcinomas. Only 7% (8/115) women with high-grade lesions of the cervix alone had evidence of anal intraepithelial neoplasia; by contrast, 57% (21/37) of those with more than one focus of intraepithelial neoplasia (cervix plus vulva, vagina, or both) had anal lesions. HPV 16 DNA was identified in 18 (51%) of 35 anal biopsy samples in the study group. No evidence of anal intraepithelial neoplasia was found in the control group (50 women), although 2 patients had grade I cervical lesions. HPV 16 DNA was identified in 12 (24%) of biopsy samples from the cervix and 7 (14%) from the anus in the control group; all 7 women with anal HPV 16 had concomitant cervical infection. The role of anal examination in the assessment of women with any focus of genital intraepithelial neoplasia requires further investigation.

Comparison of a new pressurized saline canister versus syringe irrigation for laceration cleansing in the emergency department

STUDY OBJECTIVE

Studies have documented the efficacy of normal saline irrigation in decreasing wound infection rates. Wounds traditionally are irrigated using a syringe and needle with manual injection of fluid, a time- and labor-intensive method. We compared irrigation times and infection rates for wounds cleansed with syringe irrigation versus a new, single-use canister of pressurized (8 psi) sterile normal saline.

DESIGN

Prospective, randomized, controlled.

SETTING

Two Level I emergency departments in tertiary care hospitals, both with emergency medicine residency programs.

PARTICIPANTS

Patients with lacerations requiring closure were eligible. Exclusion criteria were wounds above the clavicle more than ten hours old, wounds below the clavicle more than six hours old, insulin-dependent diabetes mellitus, or antibiotic or steroid therapy. Patients (550) were entered between August 1, 1990, and January 31, 1991. Characteristics of the two treatment groups were similar for patient age, age of the wound, size and depth of the laceration, and number of sutures.

INTERVENTIONS

Lacerations were irrigated with 250 mL saline in a syringe or 220 mL saline in a pressurized canister for each 5 cm of laceration. At follow-up or suture removal, patients were evaluated for signs of wound complications (cellulitis, ascending lymphangitis, purulent discharge, or dehiscence).

MAIN RESULTS

The mean irrigation time for the pressurized canister group (281) was 3.9 minutes versus 7.3 minutes in the syringe irrigation group (254) (P < .0001). The complication rate for the pressurized canister group was 5.0% compared with 3.6% for the syringe irrigation group (not significant, P = .50). Only three of the 20 total complications required antibiotics (two in the pressurized canister group, one in the syringe irrigation group).

CONCLUSION

Syringe irrigation times were nearly twice as long as the pressurized canister irrigation times. Use of the pressurized canister facilitates ease of irrigation and markedly decreases the time involved in this traditionally labor-intensive activity. In addition, delivery of the saline is no longer operator dependent, ensuring generation of pressures appropriate for wound cleansing. The pressurized canisters may be useful in standardizing irrigation in wound management research.