Elevated tumour marker CA19-9: clinical interpretation and influence of obstructive jaundice

AIMS

The tumour marker CA19-9 has been promoted as a reliable test for the detection of pancreatobiliary malignancy, yet its diagnostic role remains poorly defined. In this study the clinical interpretation of a raised serum CA19-9 level has been evaluated, with particular reference to obstructive jaundice.

METHODS

One hundred and sixty-four patients with a CA19-9 level above 33 U/ml were studied. Serum CA19-9 was compared with clinical diagnosis and correlated with serum bilirubin level. In a subgroup of jaundiced patients (16 benign and 15 malignant cases), follow-up CA19-9 levels were determined 2 weeks after biliary drainage.

RESULTS

The median CA19-9 level was lower in benign cases (102 (IQR 50-264) U/ml) than those with pancreatobiliary tumours (910 (IQR 263-6170) U/ml; P<0.01), although the overlap was substantial. In benign jaundiced cases, a positive correlation was observed between bilirubin and CA19-9 elevation (R=0.41, P<0.01). Relief of jaundice was associated with a fall in CA19-9 level in all benign cases and in nine of the 15 with malignancy.

CONCLUSION

Confident discrimination between benign and malignant disease could not be made on the basis of a solitary elevated CA19-9 measurement. Hyperbilirubinaemia was associated with a further deterioration in specificity and caution is warranted when interpreting the results in jaundiced patients. Overall, only one half of patients with an elevated CA19-9 level ultimately proved to harbour a malignancy.

A GDP-fucose-protected, pyridoxal-5'-Phosphate/NaBH(4)-sensitive lys residue common to human alpha1-->3Fucosyltransferases corresponds to Lys(300) in FucT-IV

Human alpha1-->3/4fucosyltransferases (FucTs) contain a common essential pyridoxal-5'-phosphate(PLP)/NaBH(4) reactive, GDP-fucose-protectable Lys. For identification, site-directed mutants at lysines of FucT-IV and -VII were prepared and tested. Non conserved lysine mutants K119Y and K394Q were similar to wild-type FucT-IV. However, mutants of conserved lysines K228R and K300R were distinct. The specific activity of K228R was 2- to 3-fold lower but retained K(m) values for donor and acceptor substrates as wild-type FucT-IV. The specific activity of K300R was reduced over 400-fold with an apparent K(m) for GDP-fucose over 200 microM. FucT-VII mutants K169R and K240R (equivalent to K228R and K300R for FucT-IV, respectively) were inactive. No change in PLP/NaBH(4) sensitivity occurred with K119Y, K228R, and K394Q compared to wild-type FucT-IV. These and previous results (A. L. Sherwood, A. T. Nguyen, J. M. Whitaker, B. A. Macher, M. R. Stroud, and E. H. Holmes, J. Biol. Chem. 273, 25256-25260, 1998) demonstrate that of three conserved lysines in FucT-IV, two (Lys(228) and Lys(283)) are not involved in substrate binding but perhaps in catalysis. The third site, Lys(300), is involved in GDP-fucose binding and PLP/NaBH(4) inactivation.

Impact of a diagnostic cerebrospinal fluid enterovirus polymerase chain reaction test on patient management

CONTEXT

Enterovirus (EV) infection, the most common cause of aseptic meningitis, can be rapidly diagnosed with an EV-specific reverse transcriptase polymerase chain reaction (EV-PCR) test. However, no studies have examined EV-PCR in a clinical context in which it is routinely used.

OBJECTIVE

To determine the impact of EV-PCR testing on diagnosis and clinical management of suspected aseptic meningitis cases.

DESIGN AND SETTING

Retrospective review of electronic medical records from a 220-bed tertiary care pediatric medical center in San Diego, Calif.

PATIENTS

A total of 276 pediatric patients for whom a diagnostic EV-PCR test was performed during the calendar year 1998.

MAIN OUTCOME MEASURES

Clinical parameters such as length of stay, medication use, and ancillary test use.

RESULTS

One hundred thirty-seven patients (49.6%) had a positive cerebrospinal fluid EV-PCR result. Enterovirus-positive patients with results available before hospital discharge (n=95) had significantly fewer ancillary tests performed (26% vs 72% with at least 1 test performed; P<.001), received intravenous antibiotics for less time (median, 2.0 vs 3.5 days; P<.001), and had shorter hospital stays (median, 42 vs 71.5 hours; P<.001) than EV-negative patients (n=92). A positive EV-PCR result was associated with more rapid hospital discharge (median EV-PCR-to-discharge time, 5.2 hours) compared with a negative result (median EV-PCR-to-discharge time, 27.4 hours; P<.001).

CONCLUSIONS

Our results suggest that a positive EV-PCR result may affect clinical decision making and can promote rapid discharge of patients, and that unnecessary diagnostic and therapeutic interventions can be reduced by use of EV-PCR testing. JAMA. 2000;283:2680-2685.

Joint position during anterior-posterior glide mobilization: its effect on glenohumeral abduction range of motion

OBJECTIVE

To investigate the effect of joint position during an anterior-posterior glide (APG) procedure on the range of motion (ROM) of glenohumeral abduction in cadaver specimens.

DESIGN

Mechanical simulation of APG mobilization and abduction torque ROM measurement of the glenohumeral joint with a material testing system. The immediate mechanical efficacy of APG was compared in two groups of specimens at two different joint positions: midrange (n = 5) and end range (n = 6) of glenohumeral abduction.

SETTING

Biomechanics laboratory.

SPECIMENS

Eleven fresh cadaver shoulder specimens (mean age, 66.9+/-2.5 yrs).

MAIN OUTCOME MEASURE

Improvement in glenohumeral abduction torque ROM obtained before and after APG procedure.

RESULTS

Glenohumeral abduction improved significantly, as indicated by a significant increase (Kruskal-Wallis statistics, chi2 = 7.50, p = .006) in the torque ROM of the end range group (mean +/- standard error of the mean, 2.02 degrees +/- .20 degrees) over the midrange group (.64 degrees +/- .08 degrees). A significant difference in the magnitude of peak displacement of the humeral head between midrange (14.44+/-3.56 mm) and end range (3.19+/-.81 mm) groups was also found (Mann-Whitney test, p < .030).

CONCLUSION

This study demonstrated that APG technique performed at close to the end of the range of abduction is more effective in improving glenohumeral abduction ROM than that performed at the middle of the range of abduction.

Mucin gene expression in the rat middle ear: an improved method for RNA harvest

Mucins are heavily glycosylated proteins characterized by high molecular weight and heterogeneous structure. Mucin genes are expressed in a tissue- or epithelium-specific manner. Although mucins are known to be important structural components of the mucociliary transport system that protects epithelium against invading microorganisms, very little is known about mucin gene expression unique to the middle ear. This study demonstrated that middle ear messenger RNA specifically hybridized with rat MUC2 and human MUC2 (SMUC-41) complementary DNA probes. MUC3 and MUC5AC mucin genes, dominantly expressed in rodent intestine and trachea, were not detected in the rat middle ears in this study. The middle ear MUC2 messenger RNA harvested by lavage was characterized by a single transcript--unlike its counterpart in intestine and airways, which is characterized by polydispersity--suggestive of a better method for RNA analysis. It was concluded that rat middle ears possess a MUC2 mucin gene or homologue of human MUC2 (SMUC-41).

Phase II studies with DaunoXome in patients with nonresectable hepatocellular carcinoma: clinical and pharmacokinetic outcomes

A total of 14 Chinese patients with inoperable hepatocellular carcinoma received a liposomal formulation of daunorubicin (DaunoXome) at a dose equivalent to 100 mg/m2 of the free drug every 3 weeks. Altogether, 12 patients were assessable for response; 2 patients had stable disease for 8 weeks, but all eventually developed progressive disease and there was no responder. The drug was well tolerated, with no evidence of cardiac toxicity being observed. Deterioration of liver-function tests was attributed to progressive tumors in the terminal stage of the disease. Pharmacokinetics studies revealed a biexponential decay for daunorubicin in association with mean initial and terminal half-lives of 1.8 and 7.4 h, respectively, and a mean total clearance of 15.0+/-5.5 ml/min. The AUC ratio between the metabolite daunorubicinol and daunorubicin was 0.07. These data differ markedly from the pharmacokinetics of the free drug.

The role of Bcl-2 expression in EGF inhibition of TNF-alpha/IFN-gamma-induced villous trophoblast apoptosis

The inflammatory cytokines tumour necrosis factor alpha (TNF-alpha) and immune interferon gamma (IFN-gamma) stimulate villous cytotrophoblast apoptosis while epidermal growth factor (EGF) protects. We hypothesize that TNF-alpha, IFN-gamma and EGF regulate apoptosis in part by modulating cellular expression levels of the anti-death gene bcl-2. While Bcl-2 is reported to be strongly expressed in villous syncytiotrophoblasts, it is not known whether the protein is expressed in cultured villous cytotrophoblasts (CT) and, if so, whether it is functional. We show by Northern blot analysis that bcl-2 mRNA is expressed in cultured CT and by immunoblot analysis that the protein is strongly expressed in highly purified first trimester and term villous cytotrophoblasts. The expression levels of Bcl-2 protein were the same in first trimester and term cytotrophoblasts. Culture with TNF-alpha/IFN-gamma and EGF did not alter expression of either Bcl-2 protein or of the pro-apoptotic Bcl-2 family member Bak. Double label flow cytometric analysis that measured apoptosis and Bcl-2 content simultaneously showed that cells expressing low levels of Bcl-2 underwent TNF-alpha/IFN-gamma-induced apoptosis at a higher frequency than cells expressing lower levels. We conclude that Bcl-2 is expressed in cytotrophoblasts, that its expression is constitutive and that modulation of its expression levels does not mediate cytokine and growth factor regulation of apoptosis in these cells.

The nature of the principal type 1 interferon-producing cells in human blood

Interferons (IFNs) are the most important cytokines in antiviral immune responses. "Natural IFN-producing cells" (IPCs) in human blood express CD4 and major histocompatibility complex class II proteins, but have not been isolated and further characterized because of their rarity, rapid apoptosis, and lack of lineage markers. Purified IPCs are here shown to be the CD4(+)CD11c- type 2 dendritic cell precursors (pDC2s), which produce 200 to 1000 times more IFN than other blood cells after microbial challenge. pDC2s are thus an effector cell type of the immune system, critical for antiviral and antitumor immune responses.

Intraarticular anterior cruciate ligament graft placement on the average most isometric line on the femur. Does it reproducibly restore knee kinematics?

In the past, there has been a plausible hypothesis that anterior cruciate ligament graft placement at isometric sites, such that the tibial and femoral attachment sites remain equidistant from each other throughout knee range of motion, would increase the likelihood of a satisfactory outcome. For a given tibial placement we wanted to determine whether placing the graft on the average of the most isometric femoral line, a fixed distance from the outlet of the intercondylar notch, would return normal laxity to all knees. The three-dimensional kinematics of seven cadaveric knees were measured for angles from full extension to 90 degrees of flexion at 15 degrees increments. Physiologic levels of quadriceps muscle forces were applied to the intact knee, after transection of the anterior cruciate ligament, and after ligament reconstruction with a patellar tendon graft. On average, the reconstruction was found to return anterior-posterior translation, internal-external rotation, and varus-valgus rotation to levels not significantly different from those of the intact knee. However, the ranges of the translation and rotations were large. Placing the graft on the average most isometric femoral line did not restore knee laxity to normal in all knees. This supports the need to customize graft placement in each knee at the time of surgery.

Activity patterns and synaptic organization of ventrally located interneurons in the embryonic chick spinal cord

To investigate the origin of spontaneous activity in developing spinal networks, we examined the activity patterns and synaptic organization of ventrally located lumbosacral interneurons, including those whose axons project into the ventrolateral funiculus (VLF), in embryonic day 9 (E9)-E12 chick embryos. During spontaneous episodes, rhythmic synaptic potentials were recorded from the VLF and from spinal interneurons that were synchronized, cycle by cycle, with rhythmic ventral root potentials. At the beginning of an episode, ventral root potentials started before the VLF discharge and the firing of individual interneurons. However, pharmacological blockade of recurrent motoneuron collaterals did not prevent or substantially delay interneuron recruitment during spontaneous episodes. The synaptic connections of interneurons were examined by stimulating the VLF and recording the potentials evoked in the ventral roots, in the VLF, or in individual interneurons. Low-intensity stimulation of the VLF evoked a short-latency depolarizing potential in the ventral roots, or in interneurons, that was probably mediated mono- or disynaptically. At higher intensities, long-latency responses were recruited in a highly nonlinear manner, eventually culminating in the activation of an episode. VLF-evoked potentials were reversibly blocked by extracellular Co2+, indicating that they were mediated by chemical synaptic transmission. Collectively, these findings indicate that ventral interneurons are rhythmically active, project to motoneurons, and are likely to be interconnected by recurrent excitatory synaptic connections. This pattern of organization may explain the synchronous activation of spinal neurons and the regenerative activation of spinal networks when provided with a suprathreshold stimulus.

Spontaneous network activity transiently depresses synaptic transmission in the embryonic chick spinal cord

We examined the effects of spontaneous or evoked episodes of rhythmic activity on synaptic transmission in several spinal pathways of embryonic day 9-12 chick embryos. We compared the amplitude of synaptic potentials evoked by stimulation of the ventrolateral funiculus (VLF), the dorsal or ventral roots, before and after episodes of activity. With the exception of the short-latency responses evoked by dorsal root stimulation, the potentials were briefly potentiated and then reduced for several minutes after an episode of rhythmic activity. Their amplitude progressively recovered in the interval between successive episodes. The lack of post-episode depression in the short-latency component of the dorsal root evoked responses is probably attributable to the absence of firing in cut muscle afferents during an episode of activity. The post-episode depression of VLF-evoked potentials was mimicked by prolonged stimulation of the VLF, subthreshold for an episode of activity. By contrast, antidromically induced motoneuron firing and the accompanying calcium entry did not depress VLF-evoked potentials recorded from the stimulated ventral root. In addition, post-episode depression of VLF-evoked synaptic currents was observed in voltage-clamped spinal neurons. Collectively, these findings suggest that somatic postsynaptic activity and calcium entry are not required for the depression. We propose instead that the mechanism may involve a form of long-lasting activity-induced synaptic depression, possibly a combination of transmitter depletion and ligand-induced changes in the postsynaptic current accompanying transmitter release. This activity-dependent depression appears to be an important mechanism underlying the occurrence of spontaneous activity in developing spinal networks.

Cognitive effects of topiramate, gabapentin, and lamotrigine in healthy young adults

OBJECTIVE

To study the acute and steady-state cognitive effects of three new antiepileptic drugs (AEDs): gabapentin, lamotrigine, and topiramate.

BACKGROUND

Several newer antiepileptic medications approved recently by the Food and Drug Administration are gaining attention as efficacious alternatives to established AEDs. Greater tolerability with fewer side effects are reported in some. However, the potential cognitive effects of these newer AEDs have received limited attention.

METHODS

Healthy young adults randomized to either of the three drugs were administered tests of attention, psychomotor speed, language, memory, and mood at baseline (predrug), acute single-dose period, and after 2 and 4 weeks on the drug.

RESULTS

Compared with baseline, the topiramate group had selective, statistically significant declines on measures of attention and word fluency at acute doses, whereas the other two AED groups had no performance changes. At the 2- and 4-week test periods, only the topiramate subjects continued to display neurocognitive effects from drug administration.

CONCLUSIONS

Results demonstrate potential acute and steady-state adverse cognitive effects for topiramate, whereas minimal effects were displayed for either gabapentin or lamotrigine in young healthy adults.

Combating hepatocellular carcinoma with an integrated approach

This short review summarizes an integrated approach to new methods of managing hepatocellular carcinoma (HCC) developed at our centre. HCC-specific isoforms of alpha-fetoprotein were detected by isoelectric focusing and their value in the differential diagnosis of early HCC on a background of chronic liver disease has been shown. Selective internal radiation therapy using yttrium-90 (90 Y) microspheres has been shown to be an effective treatment for inoperable HCC in a phase I and II study. A partition model for estimating the radiation doses from the 90 Y microspheres to the tumour and the non-tumorous liver during the therapy was then formulated, verified by correlating with intraoperative dosimetry, and evaluated in clinical settings. This permits 90 Y microspheres to be administered safely without the need of an open surgery and a randomized therapeutic controlled trial is in progress. Another randomized controlled trial using iodine-131 Lipiodol as a post-operative adjuvant therapy, aiming at reducing the recurrence rate is also on-going. HCC may be more effectively combated with a better understanding of its pathogenesis from chronic liver disease.

Internal radiation therapy for patients with primary or metastatic hepatic cancer: a review

BACKGROUND

The limited efficacy of current approaches to the treatment of patients with hepatic cancer, including external beam radiation therapy and cytotoxic chemotherapy, has reawakened interest in the use of internal radiation therapy.

METHODS

The authors reviewed series of patients with liver metastases or hepatocellular carcinoma (HCC) treated with 1) interstitial irradiation and direct intratumoral injection of 90Y microspheres, 2) intraarterial infusion of (131)I-Lipiodol, 3) intraarterial infusion of 90Y microspheres, or 4) parenteral administration of radiolabeled monoclonal antibodies.

RESULTS

High dose rate interstitial irradiation with afterloading of (192)Ir resulted in local control of hepatic metastases for a median of 8 months and complete tumor eradication in 2 patients. Direct intratumoral injection of 90Y microspheres reduced the size of 90.6% of tumors and completely destroyed them in 8 patients. Treatment with arterial (131)I-Lipiodol resulted in a 17-92% response rate as well as a case of complete remission of unresectable HCC. It was found to be most effective against small tumors. No response was observed with liver metastases from colorectal carcinoma. Partial response was commonly achieved when patients with unresectable liver metastases or HCC were treated with intraarterial 9OY microspheres. Among four patients whose HCC became resectable following treatment with 90Y microspheres, two cases of complete remission were documented. In a prospective randomized trial, (131)I-antiferritin combined with chemotherapy was no more effective than chemotherapy alone.

CONCLUSIONS

The different approaches to internal radiation therapy that are reviewed in this article represent several ways in which radiation can be selectively targeted to hepatic tumors without undue radiation to the nontumorous liver. However, the efficacy of each of these therapies still needs to be evaluated in randomized controlled trials.

Should doctors practise resuscitation skills on newly deceased patients? A survey of public opinion

Trainee doctors must acquire skills in resuscitation, but opportunities for learning on real patients are limited. One option is to practise these skills in newly deceased patients. We sought opinions from 400 multiethnic guests at an open-access dinner dance for members of a local community. The questionnaire could elicit the responses strongly agree, agree, unsure, disagree or strongly disagree. 332 (83%) guests responded. For non-invasive techniques, 32% of responders supported practice without consent, 74% with consent. Support diminished with increasing invasiveness of procedure. 91% of the sample were uncomfortable about the procedures, the commonest reason being 'respect for the body' (264/302). 86% of responders felt that practice should last for no more than 5 minutes. The most popular solutions were for people to carry a personal card giving consent (89%) and establishment of a central register of individuals consenting to be practised upon after death (79%).

Staging and IgA VCA titre in patients with nasopharyngeal carcinoma: changes over a 12-year period

The distributions of 2093 patients with nasopharyngeal carcinoma (NPC), by stage, over a 12-year-period did not show any evidence of a shift towards early stages despite growing awareness of this prevalent malignancy. The IgA VCA titre was determined for 1880 of these patients. The median titre increased from 40 in stage I to 80 in stages II, III, and IV, before rising to 160 in stage V. The percentage of patients with a titre > or = 320 increased steadily with advancing stages. Within the same disease stage, the percentage of patients having a particular titre value and the median titre varied considerably from year to year. Better education of the general population and a better serological marker for screening are needed for the early detection of NPC.

Apoptosis of JHMV-specific CTL in the CNS in the absence of CD4+ T cells

The role of CD4+ T cells in altering the activity of cytotoxic T lymphocytes (CTL) during infection of the central nervous system (CNS) by the neuroptropic JHMV strain of mouse hepatitis virus was examined. Adoptive transfer of in vitro activated CTL into CD4-depleted and control recipients showed that CTL were not effective in reducing JHMV replication within the CNS. The distribution of CD4+ and CD8+ T cells within the CNS during JHMV infection showed that the CD4+ T cells remained in perivascular and subarachnoid spaces and few entered the parenchyma. By contrast approximately half of the CD8+ T cells entered the parenchyma. In CD4-depleted mice the trafficking of CD8+ T cells was not inhibited; however, the majority of the cells were found to be apoptotic. These data suggested that CD4+ T cells were not required for CTL induction but were required for the maintenance of CTL viability. The limited role of CD4+ T cells in CTL induction was confirmed by comparison of CTL activity from CD4-depleted and control mice.

New development of laparoscopic ultrasound and laparoscopic pelvic lymphadenectomy in the management of patients with cervical carcinoma

OBJECTIVES

The objectives of this study were to evaluate the use of laparoscopic ultrasonography (USG) in combination with laparoscopic pelvic lymphadenectomy in the management of patients with cervical carcinoma.

METHODS

A technique for detecting pelvic and para-aortic lymph node metastases through laparoscopic USG was developed. Laparoscopic USG was done prior to pelvic lymphadenectomy performed either laparoscopically or by laparotomy. Laparoscopic USG findings were compared with pathologic findings.

RESULTS

The sensitivity and specificity of laparoscopic USG in detecting pelvic lymph node metastases were 91 and 100%, respectively. Metastatic pelvic lymph nodes could be completely removed through laparoscopes in 7 of 11 patients, with no complications.

CONCLUSION

Laparoscopic USG is highly sensitive in detecting metastatic pelvic lymph nodes. Detection and removal of metastatic pelvic lymph nodes laparoscopically allow quick recovery from the operation and early commencement of radiotherapy.