Is Histologic Thrombus Composition in Acute Stroke Linked to Stroke Etiology or to Interventional Parameters?

BACKGROUND AND PURPOSE

Detailed insight into the composition of thrombi retrieved from patients with ischemic stroke by mechanical thrombectomy might improve pathophysiologic understanding and therapy. Thus, this study searched for links between histologic thrombus composition and stroke subtypes and mechanical thrombectomy results.

MATERIALS AND METHODS

Thrombi from 85 patients who had undergone mechanical thrombectomy for acute ischemic stroke between December 2016 and March 2018 were studied retrospectively. Thrombi were examined histologically. Preinterventional imaging features, stroke subtypes, and interventional parameters were re-analyzed. Statistical analysis was performed with the Kruskal-Wallis test, Mann-Whitney U test, or Spearman correlation as appropriate.

RESULTS

Cardioembolic thrombi had a higher percentage of macrophages and a tendency toward more platelets than thrombi of large-artery atherosclerotic stenosis (P = .021 and .003) or the embolic stroke of undetermined source (P = .037 and .099) subtype. Thrombi prone to fragmentation required the combined use of contact aspiration and stent retrieval (P = .021) and were associated with an increased number of retrieving maneuvers (P = .001), longer procedural times (P = .001), and a higher lymphocyte content (P = .035).

CONCLUSIONS

We interpreted the higher macrophage and platelet content in cardioembolic thrombi compared with large-artery atherosclerotic stenosis or embolic stroke of undetermined source thrombi as an indication that the latter type might be derived from an atherosclerotic plaque rather than from an undetermined cardiac source. The extent of thrombus fragmentation was associated with a more challenging mechanical thrombectomy and a higher lymphocyte content of the thrombi. Thus, thrombus fragmentation not only might be caused by the recanalization procedure but also might be a feature of a lymphocyte-rich, difficult-to-retrieve subgroup of thrombi.

P6175Prediction of coronary revascularization by coronary computed tomography angiography derived fractional flow reserve - different algorithms for interpretation

Introduction

Coronary CT angiography (CTA) derived fractional flow reserve (FFRct) is increasingly used for guiding referral to invasive procedures in patients with stable chest pain. However, optimal interpretation of FFRct-analysis in terms of location and threshold of applied FFRct-values is unclear.

Purpose

To evaluate the clinical performance of various vessel-specific physiological FFRct derived measures of ischemia for prediction of standard of care guided coronary revascularization in patients with stable chest pain and coronary artery disease as determined by coronary CTA.

Methods

Retrospective study in patients with stable chest pain referred for coronary angiography based on coronary CTA. Standard acquired coronary CTA data sets were transmitted for core-laboratory analysis at HeartFlow. Any FFRct value in the major coronary arteries ≥1.8 mm in diameter, including side branches, were registered. Lesions were categorized as positive for ischemia using 6 different algorithms: Lowest in vessel FFRct-value (1) ≤0.75 or (2) ≤0.80; 2 cm distal-to-lesion FFRct-value (3) ≤0.75 or (4) ≤0.80; ΔFFRct (5) ≥0.06 or a combination of 2 and 5. The personnel responsible for downstream patient management had no information regarding FFRct test results.

Results

A total of 172 patients were included. Revascularization was performed in 62 (35%) patients. The diagnostic performance of different FFRct algorithms for predicting standard of care guided coronary revascularization is shown in the Table.

Revascularization Predictions by FFRct N=172 Diagnostic performance FFRCT false negative FFRCT false positive Values given as (%) No. of revasc vessels No. of abnormal vessels FFRCT Algorithm Sens Spec PPV NPV Acc 1 2 3 1 2 3 Distal FFRCT ≤0.75 77 68 58 84 72 12 2 0 29 5 1 Distal FFRCT ≤0.80 92 43 48 90 61 5 0 0 40 20 3 Lesion-specific FFRCT ≤0.75 68 86 74 83 80 17 3 0 12 3 0 Lesion-specific FFRCT ≤0.80 82 78 68 89 80 10 2 0 21 3 1 ΔFFRCT ≥0.06 98 36 47 98 59 1 0 0 51 19 0 Combinationa 92 54 53 92 67 5 0 0 39 12 0 aDistal FFRCT ≤0.80 and ΔFFRCT ≥0.06. Sens = sensitivity; Spec = specificity; PPV = positive predictive value; NPV = negative predictive value; Acc = accuracy; FFRCT = fractional flow reserve derived from coronary CTA; ΔFFRCT = difference between FFRCT-value immediately proximal and distal to lesion; Revasc = revascularized.

Conclusion

The diagnostic performance of FFRct in terms of predicting standard of care guided coronary revascularization is dependent on the applied algorithm for interpretation of the FFRct-analysis.

P6186Symptomatic effect of coronary revascularization at 1-year follow-up in stable chest pain - prediction by coronary computed tomography angiography derived fractional flow reserve

Introduction

Coronary CT angiography (CTA) derived fractional flow reserve (FFRct) is increasingly being used for guiding referral to invasive procedures in patients with stable chest pain. However, the ability of FFRct to predict the symptomatic effect of revascularization remains unclear.

Purpose

To evaluate the ability of different vessel-specific physiological FFRct derived measures of ischemia for predicting the occurrence of chest pain one year after coronary revascularization in stable patients.

Methods

Retrospective study in patients with stable chest pain referred for coronary angiography based on coronary CTA. Standard acquired coronary CTA data sets were transmitted for core-laboratory analysis at HeartFlow. Patients were categorized as positive for ischemia using 3 different algorithms: Lowest in vessel FFRct-value ≤0.80; ΔFFRct ≥0.06 or a combination of the two. Personnel responsible for downstream patient management had no information on FFRct test results. Classification of revascularization was performed based on the applied FFRct algorithm: complete if all FFRct positive lesions were revascularized; incomplete if ≥1 FFRct positive lesion was not revascularized. Symptomatic status at 1-year follow-up was obtained by a visit in the outpatient clinic or by telephone.

Results

A total of 172 patients were included. Revascularization was performed in 62 (35%) patients. At 1-year follow-up 48 (28%) patients had chest pain; 15 (24%) revascularized vs 33 (30%) non-vascularized patients, p=0.415. No difference in utilization of anti-anginal medicine for patients with and without chest pain was registered at 1-year follow-up. The association between the chosen FFRct algorithm, revascularization and occurrence of chest pain at 1-year follow-up are shown in the Table.

FFRct, Revascularization and Chest pain FFRCT, Algorithm Revascularizationb Patients with chest pain 1-year risk of chest pain p-valuec N (%) OR (95%-CI) Distal FFRCT ≤0.80 Incomplete 32 (34) Ref. Distal FFRCT ≤0.80 Complete 4 (15) 0.34 (0.11, 1.06) Distal FFRCT >0.80 No 11 (24) 0.61 (0.27, 1.35) 0.097 ΔFFRCT ≥0.06 Incomplete 34 (35) Ref. ΔFFRCT ≥0.06 Complete 7 (21) 0.49 (0.19, 1.24) ΔFFRCT <0.06 No 7 (18) 0.41 (0.16, 1.03) 0.074 Combinationa abnormal Incomplete 30 (40) Ref. Combination abnormal Complete 6 (18) 0.32 (0.12, 0.87) Combination normal No 11 (19) 0.35 (0.16, 0.78) 0.009 aDistal FFRCT ≤0.80 and ΔFFRCT ≥0.06. bIncomplete (≥1 FFRCT positive lesion not revascularized); complete (All FFRCT positive lesions revascularized); No (No FFRCT positive lesions and revascularization not performed). cBetween group comparison performed using logistic regression.

Conclusion

Revascularization based on classification by FFRct is associated with symptomatic relief at 1-year follow-up in patients with stable chest pain.

Wall Contrast Enhancement of Thrombosed Intracranial Aneurysms at 7T MRI

BACKGROUND AND PURPOSE

The pathophysiology of wall contrast enhancement in thrombosed intracranial aneurysms is incompletely understood. This in vivo study aimed to investigate wall microstructures with gadolinium-enhanced 7T MR imaging.

MATERIALS AND METHODS

Thirteen patients with 14 thrombosed intracranial aneurysms were evaluated using a 7T whole-body MR imaging system with nonenhanced and gadolinium-enhanced high-resolution MPRAGE. Tissue samples were available in 5 cases, and histopathologic findings were correlated with 7T MR imaging to identify the gadolinium-enhancing microstructures.

RESULTS

Partial or complete inner wall enhancement correlated with neovascularization of the inner wall layer and the adjacent thrombus. Additional partial or complete outer wall enhancement can be explained by formation of vasa vasorum in the outer aneurysm wall layer. The double-rim enhancement correlated with perifocal edema and wall histologic findings suggestive of instability.

CONCLUSIONS

Two distinct aneurysm wall microstructures responsible for gadolinium enhancement not depictable at lower spatial resolutions can be visualized in vivo using high-resolution gadolinium-enhanced 7T MR imaging.

Axonal damage markers in the cerebrospinal fluid of patients with clinically isolated syndrome improve predicting conversion to definite multiple sclerosis

Clinically isolated syndrome (CIS) represents the earliest phase of multiple sclerosis (MS). This study tested whether biomarkers for axonal degeneration can improve upon sensitivity and specificity of magnetic resonance imaging (MRI) parameters in predicting conversion from CIS to MS. Patients with CIS ( n=52), relapsing-remitting MS (RRMS, n=38) and age-matched controls ( n=25) were included. Cerebrospinal fluid (CSF) levels of tau and neurofilaments (NfHSMI35) were measured using ELISA. The MRI T2-lesion load and the Expanded Disability Status Scale (EDSS) were recorded. CSF tau and NfHSMI35 were elevated in CIS compared to controls (p<0.05). RRMS patients with acute relapse had higher NfHSMI35 levels than stable patients. Tau and NfHSMI35 levels correlated with EDSS in CIS and RRMS. In RRMS, the number of T2-lesions correlated with tau levels ( R=0.53, P=0.01). The sensitivity predicting the conversion from CIS to MS was higher for the combination of CSF markers (either tau or NfHSMI35 elevated) than for MRI (40 versus 34%), but could be further increased to 60% if CSF and MRI criteria were combined. Similarly, the combination of tau and NfHSMI35 showed higher specificity (94%) than MRI (82%). Tau and NfHSMI35 are valuable biomarkers for axonal damage in the CIS patients. Predicting conversion from CIS to MS can be improved if CSF markers are combined with MRI.

Surveillance of Periodic Fever Syndromes in Canada

BACKGROUND: Periodic fever syndromes (PFS) represent a group of rare, inflammatory disorders, which have their onset in childhood, and are associated with significant lifelong morbidity, and at times, increased mortality. The majority of affected children have recurrent, self-limited inflammatory episodes with unprovoked fever. The severe inflammatory state during an attack causes signs and symptoms in one or more organ systems. The Canadian Pediatric Surveillance Program (CPSP) studies relevant conditions of public health importance that are of such low incidence or prevalence that national ascertainment of cases are needed. Conditions that are studied share a high disability, morbidity and economic costs to society, despite the low frequency. More than 2400 pediatricians including relevant subspecialists, have been enrolled as CPSP participants. This program provides an ideal mechanism for surveillance of PFS in Canada.

OBJECTIVES: To estimate the incidence of periodic fever syndromes in the Canadian paediatric population, to describe the patterns of presentation, and to raise awareness in the medical community.

DESIGN/METHODS: This study was initiated through the Canadian Paediatric Surveillance Program (CPSP), and was carried out over a three year period ending in September 2014. The case definition included patients less than 18 years of age presenting with a newly diagnosed periodic fever syndrome (PFS). Conditions under surveillance included Familial Mediterranean fever (FMF), Tumor necrosis factor receptor-associated periodic syndrome (TRAPS), Hyperimmunoglobulin D syndrome (HIDS), cryopyrin-associated periodic syndromes (CAPS), Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA), and Undefined periodic fever syndromes. The study protocol outlined established clinical and/or genetic criteria for diagnosis. Participating pediatricians and pediat-ric subspecialists across the country were sent monthly reporting forms. Detailed questionnaires were completed by physicians who report a recent diagnosis. Submissions were screened for accuracy and confirmed cases then entered into a database.

RESULTS: Between September 2011 and August 2014 a total of 221 cases of PFS were reported. Detailed questionnaires were completed on 194 (88%), from which 13 were excluded. Of the 181 confirmed cases, 85 (47%) were PFAPA, 72 (40%) were undefined PFS, 17 (10%) were FMF, and the remaining 6 cases were CAPS, TRAPS, and HIDS. The mean age at diagnosis was 5.5 years (range 12 months – 16 years). On average symptom onset occurred 2.5 years before diagnosis (range 1-4 years). The majority of reporting physicians were rheumatologists (58%), and paediatricians (36%). Cases were identified in all provinces across Canada with the majority (103, 57%) from Ontario. For the 72 undefined PFS cases the reporting physicians described 36% as PFAPA-like, 10% FMF-like, 5% HIDS-like, 3% CAPS-like, and 1% TRAPS-like. Such cases had features of the specified PFS but either did not meet the full criteria, or confirmatory tests were not available at the time of reporting. Among all cases reported in the study, 58% had genetic testing completed as part of their diagnosis. The majority of cases without any genetic testing had been diagnosed as PFAPA.

CONCLUSION: Periodic fever syndromes represent rare forms of autoin-flammatory disease, which affect many Canadian children. This CPSP study identified that the most common PFS diagnosed was PFAPA followed by undefined PFS and FMF. CAPS, HIDS, and TRAPS were rarely diagnosed. Children with PFS were seen by multiple physicians over an average of two to three years before a diagnosis was made. It is hoped that increased awareness of these rare conditions will facilitate earlier diagnosis and the initiation of effective treatments for these children.

Phenotypic and metabolic responses to drought and salinity of four contrasting lentil accessions

Drought and salinity are among the major abiotic stresses which, often inter-relatedly, adversely affect plant growth and productivity. Plant stress responses depend on the type of stress, on its intensity, on the species, and also on the genotype. Different accessions of a species may have evolved different mechanisms to cope with stress and to complete their life cycles. This study is focused on lentil, an important Mediterranean legume with high quality protein for the human diet. The effects of salinity and drought on germination and early growth of Castelluccio di Norcia (CAST), Pantelleria (PAN), Ustica (UST), and Eston (EST) accessions were evaluated to identify metabolic and phenotypic traits related to drought and/or salinity stress tolerance. The results showed a relationship between imposed stresses and performance of the cultivars. According to germination frequencies, the accession ranking was as follows: NaCl resistant > susceptible, PAN > UST > CAST > EST; polyethylene glycol (PEG) resistant > susceptible, CAST > UST > EST > PAN. Seedling tolerance rankings were: NaCl resistant > susceptible, CAST ≈ UST > PAN ≈ EST; PEG resistant > susceptible, CAST > EST ≈ UST > PAN. Changes in the metabolite profiles, mainly quantitative rather than qualitative, were observed in the same cultivar in respect to the treatments, and among the cultivars under the same treatment. Metabolic differences in the stress tolerance of the different genotypes were related to a reduction in the levels of tricarboxylic acid (TCA) cycle intermediates. The relevant differences, between the most NaCl-tolerant genotype (PAN) and the most sensitive one (EST) were related to the decrease in the threonic acid level. Stress-specific metabolite indicators were also identified: ornithine and asparagine as markers of drought stress and alanine and homoserine as markers of salinity stress.

The consequence of an additional NADH dehydrogenase paralog on the growth of Gluconobacter oxydans DSM3504

Acetic acid bacteria such as Gluconobacter oxydans are used in several biotechnological processes due to their ability to perform rapid incomplete regio- and stereo-selective oxidations of a great variety of carbohydrates, alcohols, and related compounds by their membrane-bound dehydrogenases. In order to understand the growth physiology of industrial strains such as G. oxydans ATCC 621H that has high substrate oxidation rates but poor growth yields, we compared its genome sequence to the genome sequence of strain DSM 3504 that reaches an almost three times higher optical density. Although the genome sequences are very similar, DSM 3504 has additional copies of genes that are absent from ATCC 621H. Most importantly, strain DSM 3504 contains an additional type II NADH dehydrogenase (ndh) gene and an additional triosephosphate isomerase (tpi) gene. We deleted these additional paralogs from DSM 3504, overexpressed NADH dehydrogenase in ATCC 621H, and monitored biomass and the concentration of the representative cell components as well as O2 and CO2 transfer rates in growth experiments on mannitol. The data revealed a clear competition of membrane-bound dehydrogenases and NADH dehydrogenase for channeling electrons in the electron transport chain of Gluconobacter and an important role of the additional NADH dehydrogenase for increased growth yields. The less active the NADH dehydrogenase is, the more active is the membrane-bound polyol dehydrogenase. These results were confirmed by introducing additional ndh genes via plasmid pAJ78 in strain ATCC 621H, which leads to a marked increase of the growth rate.

CCL19 is constitutively expressed in the CNS, up-regulated in neuroinflammation, active and also inactive multiple sclerosis lesions

CCL19 and CCL21 bind to CCR7, which is crucial for both inducing an immune response and establishing immunological tolerance. We report that in the normal human brain CCL19, but not CCL21, is transcribed, and detectable as a protein in tissue lysates and in cerebrospinal fluid. In both active and inactive multiple sclerosis (MS) lesions CCL19 transcripts were elevated. In cerebrospinal fluid from MS and OIND patients CCL19 protein was increased. In relapsing-remitting and secondary progressive MS patients CCL19 correlated with intrathecal IgG production. This study suggests that CCL19 plays a role in both the physiological immunosurveillance of the healthy CNS and the pathological maintenance of immune cells in the CNS of MS patients.

[Aromatase inhibitors of the 3rd generation. What can the "pill against breast cancer" really do?]

Metastatic cancer of the breast in postmenopausal women can be treated with a number of "hormone-active" substances. The drugs of first choice are still anti-estrogens. Today, the three highly selective oral aromatase inhibitors anastrozole, letrozole and exemestane are additionally available for use in continuing progression under anti-estrogen treatment. Roughly one woman in three derives benefit from these new medications as reflected by objective remission or stabilization of the disease for more than 6 months. Neither chemical structure (steroidal/non-steroidal), nor the different nature of inhibition of the active centre of the aromatase, nor whether the inhibition of the enzyme is reversible or irreversible, has any influence on the parameters: response rate, response duration and clinical benefit.

Primary gastrointestinal non-Hodgkin's lymphoma: I. Anatomic and histologic distribution, clinical features, and survival data of 371 patients registered in the German Multicenter Study GIT NHL 01/92

PURPOSE

The study was initiated to obtain epidemiologic data and information on anatomic and histologic distribution, clinical features, and treatment results in patients with primary gastrointestinal non-Hodgkin's lymphomas (PGI NHL).

PATIENTS AND METHODS

Between October 1992 and November 1996, 371 PGI NHL patients were eligible to evaluate clinical features. Radiotherapy and chemotherapy were stratified according to histologic grading, stage, and whether surgery had been carried out or not.

RESULTS

A total of 74.8% patients had gastric NHL (PGL). Within the intestine, the small bowel and the ileocecal region were involved in 8.6% and 7.0% of the cases, respectively. Multiple GI involvement (MGI) was 6.5%. Approximately 90% of the GI NHL were in stages IE/IIE. Aggressive NHL accounted for the majority, with a distinguishable pattern in several sites. Forty percent of PGL were of low-grade mucosa-associated lymphatic tissue type. One third of large-cell lymphomas had low-grade components. Most intestinal NHL were germinal-center lymphomas. The site of origin was prognostic. In gastric and ileocecal lymphoma, event-free (EFS) and overall survival (OS) were significantly higher as compared with the small intestine or MGI (median time of observation, 51 months). In PGL, localized disease was prognostic for EFS and OS. Histologic grade influenced only EFS significantly. Numbers in intestinal lymphomas were too small for subanalyses.

CONCLUSION

PGI NHL are heterogeneous diseases. The number of localized PGL allowed for detailed analyses. Larger studies are needed for stages III and IV and for intestinal NHL. A uniform reporting system for PGI NHL, in terms of definitions and histologic and staging classifications, is needed to facilitate comparison of treatment results.

Primary gastrointestinal non-Hodgkin's lymphoma: II. Combined surgical and conservative or conservative management only in localized gastric lymphoma--results of the prospective German Multicenter Study GIT NHL 01/92

PURPOSE

The aim of the study was to obtain data on anatomic and histologic distribution, clinical features, and treatment results of patients with primary gastrointestinal non-Hodgkin's lymphomas, particularly combined surgical and conservative treatment (CSCT) versus conservative treatment (CT) alone for primary gastric lymphoma (PGL) in localized stages.

PATIENTS AND METHODS

Whether the treatment included surgery was left to the discretion of each participating center. Radiotherapy (Rx) and chemotherapy were stratified according to histologic grading, stage, and the inclusion or omission of surgery as follows: patients with low-grade PGL were treated with extended-field (EF) Rx (30 Gy). In case of residual tumor after surgery or in case of CT only (in stage IIE after six cycles of cyclophosphamide, vincristine, and prednisone), an additional boost of 10 Gy was given. All patients with high-grade PGL were treated with four (stage IE) or six (stage IIE) cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone followed by EF Rx (stage IE) or involved-field (IF) Rx (stage IIE). Rx dosage corresponded to low-grade NHL.

RESULTS

Between October 1992 and November 1996, 106 patients had CT only. The survival rate (SR) after 5 years was 84.4% and was influenced neither by patients' characteristics nor by stage or histologic grade. Seventy-nine patients had CSCT. Their SR was 82.0%. Complete resection of the tumor (R0) was prognostic for the overall survival (P =.0165) as compared with incomplete resection.

CONCLUSION

Although the study was not randomized, a stomach-conserving approach may be favored.

Impact of donor type on outcome of bone marrow transplantation for Wiskott-Aldrich syndrome: collaborative study of the International Bone Marrow Transplant Registry and the National Marrow Donor Program

Human leukocyte antigen (HLA)-identical sibling bone marrow transplantation is an effective treatment for Wiskott-Aldrich syndrome. However, most children with this disease lack such donors and many patients receive transplants from alternative donors. This study compared outcomes of HLA-identical sibling, other related donor, and unrelated donor transplantation for Wiskott-Aldrich syndrome. The outcome of 170 transplantations for Wiskott-Aldrich syndrome, from 1968 to 1996, reported to the International Bone Marrow Transplant Registry and/or National Marrow Donor Program were assessed. Fifty-five were from HLA-identical sibling donors, 48 from other relatives, and 67 from unrelated donors. Multivariate proportional hazards regression was used to compare outcome by donor type and identify other prognostic factors. Most transplant recipients were younger than 5 years (79%), had a pretransplantation performance score greater than or equal to 90% (63%), received pretransplantation preparative regimens without radiation (82%), and had non-T-cell-depleted grafts (77%). Eighty percent received their transplant after 1986. The 5-year probability of survival (95% confidence interval) for all subjects was 70% (63%-77%). Probabilities differed by donor type: 87% (74%-93%) with HLA-identical sibling donors, 52% (37%-65%) with other related donors, and 71% (58%-80%) with unrelated donors (P =.0006). Multivariate analysis indicated significantly lower survival using related donors other than HLA-identical siblings (P =.0004) or unrelated donors in boys older than 5 years (P =.0001), compared to HLA-identical sibling transplants. Boys receiving an unrelated donor transplant before age 5 had survivals similar to those receiving HLA-identical sibling transplants. The best transplantation outcomes in Wiskott-Aldrich syndrome are achieved with HLA-identical sibling donors. Equivalent survivals are possible with unrelated donors in young children.

Lymphocytic vasculitis in X-linked lymphoproliferative disease

Systemic vasculitis is an uncommon manifestation of X-linked lymphoproliferative disease (XLP), a disorder in which there is a selective immune deficiency to Epstein-Barr virus (EBV). The molecular basis for XLP has recently been ascribed to mutations within SLAM-associated protein (SAP), an SH2 domain-containing protein expressed primarily in T cells. The authors describe a patient who died as a result of chronic systemic vasculitis and fulfilled clinical criteria for the diagnosis of XLP. Sequencing of this patient's SAP gene uncovered a novel point mutation affecting the SH2 domain. The patient presented with virus-associated hemophagocytic syndrome (VAHS) and later had chorioretinitis, bronchiectasis, and hypogammaglobulinemia develop. He further developed mononeuritis and fatal respiratory failure. Evidence of widespread small and medium vessel vasculitis was noted at autopsy with involvement of retinal, cerebral, and coronary arteries as well as the segmental vessels of the kidneys, testes, and pancreas. Immunohistochemical analysis using antibodies to CD20, CD45RO, and CD8 revealed that the vessel wall infiltrates consisted primarily of CD8(+) T cells, implying a cytotoxic T-lymphocyte response to antigen. EBV DNA was detected by polymerase chain reaction (PCR) in arterial wall tissue microdissected from infiltrated vessels further suggesting that the CD8(+) T cells were targeting EBV antigens within the endothelium. The authors propose that functional inactivation of the SAP protein can impair the immunologic response to EBV, resulting in systemic vasculitis.

Serial Holter ST-segment monitoring after first acute myocardial infarction. Prevalence, variability, and long-term prognostic importance of transient myocardial ischemia

Based on serial Holter monitoring performed 7 times within 3 years after a first acute myocardial infarction, we assessed the prevalence, variability and long-term clinical importance of transient myocardial ischemia (TMI) defined as episodes of ambulatory ST-segment depression. In all, 121 consecutive male patients <70 years old were studied. The prevalence of TMI on different Holter recordings varied around 20% ranging between 18 and 27%. Fifty-five of the patients (46%) had TMI on at least 1 of the 7 Holter recordings. Considerable variability was found within and between patients for the presence of TMI. No high-risk group for cardiac death, nonfatal reinfarction or coronary revascularization during up to 10 years of follow-up could be identified by the detection of TMI. From these results we conclude that a routine search for TMI on serial Holter monitoring cannot be recommended in male survivors of an uncomplicated first acute myocardial infarction.

Binding of properdin to solid-phase immune complexes: critical role of the classical activation pathway of complement

The capacity of serum to support deposition of C3, properdin and factor B was studied by enzyme-linked immunosorbent assay using solid-phase immune complexes (IC) for activation of complement. Deposition of C3 and properdin occurred in fairly dilute normal human serum (NHS), but factor B uptake was hardly detectable. Alternative pathway-mediated deposition of C3 with slow kinetics was demonstrated in C2-deficient serum and in NHS depleted of C1q, factor D and properdin (C1qDP-depleted serum) after reconstitution with factor D and properdin. Efficient uptake of properdin required a functional classical pathway, in the presence of which C3 and properdin were rapidly deposited onto the IC. Judging from findings in C3-deficient serum, factor I-deficient serum, and C1qDPB-depleted serum, the uptake of properdin was strictly C3-dependent, and did not require the presence of factors B and D. Thus, C3b fixed to IC was the principal ligand for properdin in the assay. The findings could have biological implications relating to complement-mediated modification of immune complexes in disease.

Ataxia-telangiectasia: identification and detection of founder-effect mutations in the ATM gene in ethnic populations

To facilitate the evaluation of ATM heterozygotes for susceptibility to other diseases, such as breast cancer, we have attempted to define the most common mutations and their frequencies in ataxia-telangiectasia (A-T) homozygotes from 10 ethnic populations. Both genomic mutations and their effects on cDNA were characterized. Protein-truncation testing of the entire ATM cDNA detected 92 (66%) truncating mutations in 140 mutant alleles screened. The haplotyping of patients with identical mutations indicates that almost all of these represent common ancestry and that very few spontaneously recurring ATM mutations exist. Assays requiring minimal amounts of genomic DNA were designed to allow rapid screening for common ethnic mutations. These rapid assays detected mutations in 76% of Costa Rican patients (3), 50% of Norwegian patients (1), 25% of Polish patients (4), and 14% of Italian patients (1), as well as in patients of Amish/Mennonite and Irish English backgrounds. Additional mutations were observed in Japanese, Utah Mormon, and African American patients. These assays should facilitate screening for A-T heterozygotes in the populations studied.

The effect of cold stress on lymphocyte proliferation in fetal ethanol-exposed rats

Prenatal ethanol exposure and stress have each been shown to have significant effects on the immune system. This study examined the possible interactive effects of prenatal ethanol exposure and exposure to stress later in life on the immune system. Differential vulnerability to these challenges in female and male offspring was assessed. At 5 to 6 months of age, female and male offspring from prenatal ethanol-exposed (E), pair-red (PF), and ad libitum-fed control (C) conditions were exposed to 0, 1 or 3 days of cold (4 degrees C). At the end of the cold period, the proliferative response of splenic lymphocytes to the mitogens concanavalin A (Con A) and pokeweed mitogen (PWM) was assessed. The data demonstrate a significant interactive effect between prenatal ethanol exposure and cold stress in female offspring. After 1 day of cold stress, E females had significantly increased PWM-induced lymphocyte proliferation compared with PF and C females, and significantly increased Con A-induced lymphocyte proliferation compared with PF females. There were no differences in PWM or Con A-induced lymphocyte proliferation among E, PF, and C females after 0 or 3 days of cold stress, nor among E, PF, and C males on any test day. Regardless of prenatal treatment, females exposed to 1 or 3 days of cold had significantly greater basal plasma corticosterone levels than females not exposed to cold. In contrast, only E males exposed to 1 or 3 days of cold had significantly increased basal plasma corticosterone levels, compared with E males not exposed to cold; PF and C males showed no significant change in basal corticosterone after cold stress. These data demonstrate that, in response to the challenge of cold stress, changes in lymphocyte proliferation to PWM and Con A may occur selectively in E females. Moreover, the interactive effects of prenatal ethanol and cold stress may result in enhanced rather than suppressed immune responsiveness.

Identification of WASP mutations, mutation hotspots and genotype-phenotype disparities in 24 patients with the Wiskott-Aldrich syndrome

The Wiskott-Aldrich syndrome (WAS), an X-linked immunodeficiency disease caused by mutation in the recently isolated gene encoding WAS protein (WASP), is known to be associated with extensive clinical heterogeneity. Cumulative mutation data have revealed that WASP genotypes are also highly variable among WAS patients, but the relationship of phenotype with genotype in this disease remains unclear. To address this issue we characterized WASP mutations in 24 unrelated WAS patients, including 18 boys with severe classical WAS and 6 boys expressing mild forms of the disease, and then examined the degree of correlation of these as well as all previously published WASP mutations with disease severity. By analysis of these compiled mutation data, we demonstrated clustering of WASP mutations within the four most N-terminal exons of the gene and also identified several sites within this region as hotspots for WASP mutation. These characteristics were observed, however, in both severe and mild cases of the disease. Similarly, while the cumulative data revealed a predominance of missense mutations among the WASP gene lesions observed in boys with isolated thrombocytopenia, missense mutations were not exclusively associated with milder WAS phenotypes, but also comprised a substantial portion (38%) of the WASP gene defects found in patients with severe disease. These findings, as well as the detection of identical WASP mutations in patients with disparate phenotypes, reveal a lack of phenotype concordance with genotype in WAS and thus imply that phenotypic outcome in this disease cannot be reliably predicted solely on the basis of WASP genotypes.

The Wiskott-Aldrich syndrome and X-linked congenital thrombocytopenia are caused by mutations of the same gene

The Wiskott-Aldrich syndrome (WAS) is an X-linked recessive disorder characterized by thrombocytopenia, small platelets, eczema, recurrent infections, and immunodeficiency. Besides the classic WAS phenotype, there is a group of patients with congenital X-linked thrombocytopenia (XLT) who have small platelets but only transient eczema, if any, and minimal immune deficiency. Because the gene responsible for WAS has been sequenced, it was possible to correlate the WAS phenotypes with WAS gene mutations. Using a fingerprinting screening technique, we determined the approximate location of the mutation in 13 unrelated WAS patients with mild to severe clinical symptoms. Direct sequence analysis of cDNA and genomic DNA obtained from patient-derived cell lines showed 12 unique mutations distributed throughout the WAS gene, including insertions, deletions, and point mutations resulting in amino acid substitutions, termination, exon skipping, or splicing defects. Of 4 unrelated patients with the XLT phenotype, 3 had missense mutations affecting exon 2 and 1 had a splice-site mutation affecting exon 9. Patients with classic WAS had more complex mutations, resulting in termination codons, frameshift, and early termination. These findings provide direct evidence that XLT and WAS are caused by mutations of the same gene and suggest that severe clinical phenotypes are associated with complex mutations.

Characteristics and prognostic importance of ST-segment elevation on Holter monitoring early after acute myocardial infarction

The correlation between episodes of ST-segment elevation on Holter monitoring, clinical characteristics, left ventricular function, exercise testing, and long-term prognosis was determined in 123 consecutive patients 55 +/- 8 years old (mean +/- SD) with a first acute myocardial infarction (AMI). During 36 hours of Holter recording 11 +/- 5 days after AMI, 11 patients (9%) had 91 episodes of ST-segment elevation (group 1), whereas 112 patients had no such episodes (group 2). Most episodes of ST-segment elevation occurred in leads with pathologic Q waves or small, indistinct R waves. Large, anterior Q-wave AMIs were more prevalent in group 1 than in group 2, and in-hospital heart failure also occurred more frequently in group 1 patients (82% vs 23%; p < 0.0005). Regional and global left ventricular function was reduced in group 1 compared with group 2: ejection fraction 33 +/- 11% vs 50 +/- 11% (p = 0.0001). All episodes of ST-segment elevation were asymptomatic and did not correlate with different indicators of myocardial ischemia. Indeed, exercise-induced ST-segment depression was more prevalent in group 2 than in group 1: 57 vs 18% (p < 0.035). Over a mean of 5 years (range 4 to 6) of follow-up, an association between episodes of ST-segment elevation on Holter monitoring and (1) cardiac death (Kaplan-Meier analysis; p < 0.005), and (2) cardiac death and nonfatal reinfarction (Kaplan-Meier analysis; p < 0.025) was found.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic significance of transient myocardial ischaemia after first acute myocardial infarction: five year follow up study

OBJECTIVE

To assess the five year prognostic significance of transient myocardial ischaemia on ambulatory monitoring after a first acute myocardial infarction, and to compare the diagnostic and long term prognostic value of ambulatory ST segment monitoring, maximal exercise testing, and echocardiography in patients with documented ischaemic heart disease.

DESIGN

Prospective study.

SETTING

Cardiology department of a teaching hospital.

PATIENTS

123 consecutive men aged under 70 who were able to perform predischarge maximal exercise testing.

INTERVENTIONS

Echocardiography two days before discharge (left ventricular ejection fraction), maximal bicycle ergometric testing one day before discharge (ST segment depression, angina, blood pressure, heart rate), and ambulatory ST segment monitoring (transient myocardial ischaemia) started at hospital discharge a mean of 11 (SD 5) days after infarction.

MAIN OUTCOME MEASURES

Relation of ambulatory ST segment depression, exercise test variables, and left ventricular ejection fraction to subsequent objective (cardiac death or myocardial infarction) or subjective (need for coronary revascularisation) events.

RESULTS

23 of the 123 patients had episodes of transient ST segment depression, of which 98% were silent. Over a mean of 5 (range 4 to 6) years of follow up, patients with ambulatory ischaemia were no more likely to have objective end points than patients without ischaemic episodes. If, however, subjective events were included an association between transient ST segment depression and an adverse long term outcome was found (Kaplan-Meier analysis; P = 0.004). The presence of exercise induced angina identified a similar proportion of patients with a poor prognosis (Kaplan-Meier analysis; P < 0.004). Both exertional angina and ambulatory ST segment depression had high specificity but poor sensitivity. The presence of exercise induced ST segment depression was of no value in predicting combined cardiac events. Indeed, patients without exertional ST segment depression were at increased risk of future objective end points (Kaplan-Meier analysis; P < 0.0045). These findings may be explained in part by a higher prevalence of left ventricular dysfunction in patients without ischaemic changes in the exercise electrocardiogram (P < 0.05).

CONCLUSION

There seem to be limited reasons to perform ambulatory ST segment monitoring in survivors of a first myocardial infarction who can perform exercise tests before discharge. Patients at high risk of future myocardial infarction or death from cardiac causes are not identified. Ambulatory monitoring and exertional angina distinguish a small subset of patients who will develop severe angina pectoris demanding coronary revascularisation during follow up. Patients without exercise induced ST segment depression comprise a high risk subgroup in terms of subsequent objective end points. The role of ambulatory ST segment monitoring performed in unselected patients immediately after infarction when risk is maximal remains to be clarified.

[Ambulatory ST-segment monitoring after acute myocardial infarction]

Over the last decade the concept of silent myocardial ischaemia has received considerable attention. Without doubt, the increased use of ambulatory ST-segment monitoring is the most important reason for the growing interest in this field. The prevalence of ambulatory ischaemia after myocardial infarction seems to be lower than in other subgroups with coronary artery disease. In postinfarction patients, however, a greater proportion of ischaemic episodes are silent. At present there is substantial evidence that ambulatory ischaemia provides prognostic information in different subsets of patients with previous myocardial infarction, but there is considerable disagreement about how this is expressed in terms of cardiac events. Patient selection, small patient numbers, and different timing of ambulatory monitoring are proposed as important reasons for the inconsistent findings. The precise role of postinfarction ambulatory ST-segment monitoring in clinical practice has yet to be established.

Activity and activation of the complement system in patients being operated on for cancer of the colon

OBJECTIVE

To find out if there was any local activation of complement in the vicinity of a colonic cancer, and any fluctuation in the function of the complement system during operation.

DESIGN

Prospective study.

SETTING

One university and two district hospitals in Denmark.

SUBJECTS

29 selected patients undergoing emergency and elective operations for colonic cancer.

INTERVENTIONS

Measurements of systemic and local complement fixation capacity and complement activation in samples of serum or plasma taken before, during, and after operation.

MAIN OUTCOME MEASURES

Changes in complement fixation capacity and complement activation during operation.

RESULTS

Haemodilution during operation caused a significant reduction in the complement fixation capacity of serum and in the activation of the complement system as measured by generation of C3c. We were unable to confirm the presence of complement inhibitors during operation. Haemodilution caused a 30% reduction in fixation capacity of C3b (12/29 samples of serum had values more than 2SD below the mean of the reference range compared with 4/29 before operation). The activity of C4 was reduced by 25% during operation and the capacity of the complement system to fix C3b and C4b was restored to baseline nine days postoperatively. Concentration of C3d was significantly higher in serum from tumour venous blood compared with that from peripheral blood during operation.

CONCLUSION

The presence of complement activation products in the general circulation reflects local activation of the complement system in the vicinity of the tumour, but this may have been influenced by tissue necrosis or subclinical infection. Haemodilution causes a significant reduction in the capacity of the complement system during operation, whereas inhibitory factors associated with the cancer or operation and anaesthesia could not be demonstrated. We found no correlation between complement activity and clinical data.

Effect of thrombolytic therapy on postinfarction myocardial ischemia

In patients with acute myocardial infarction a substantial reduction in mortality can be achieved by early intravenous thrombolytic therapy. The beneficial effect of thrombolysis on left ventricular function is relatively small, and it seems unlikely that this minor improvement alone can be responsible for the reduction in cardiac death. So far it has not been clearly established how thrombolytic therapy affects postinfarction myocardial ischemia. From studies evaluating ST segment changes on exercise testing or ambulatory monitoring it is concluded that thrombolysis probably results in a reduction of residual ischemia. The reduced ischemic burden is proposed to be one important pathophysiological mechanism underlying the frequently observed improvement in hemodynamic stress test variables following thrombolytic treatment.

The hemodynamic and prognostic significance of echo-Doppler-proven mitral regurgitation in patients with dilated cardiomyopathy

Data from cardiac catheterization at rest and during exercise in 57 patients with dilated cardiomyopathy (DCM) were analyzed to evaluate the bearing of mitral regurgitation (MR) detected by color Doppler echocardiography (CDE) on prognostically important invasive hemodynamic parameters and survival. The etiology of DCM was coronary artery disease in 21 patients and unproven ('idiopathic') in 36 patients. MR was detected by CDE in 34 patients (60%) with an agreement of 93% compared to left ventriculography. Mean age, etiology of DCM and duration of symptoms were similar in patients with and without MR, while patients with MR were in a higher NYHA class, had lower ejection fraction (LVEF) (25 +/- 13 vs. 35 +/- 17%; p < 0.02), larger left ventricular volumes (356 +/- 138 vs. 268 +/- 61 ml; p < 0.01) and higher left ventricular end-diastolic pressure (LVEDP) (21 +/- 9 vs. 13 +/- 7 mm Hg; p < 0.01). At rest, right-sided pressures were higher in patients with MR compared to patients without MR (pulmonary wedge pressure 20 +/- 9 vs. 10 +/- 3 mm Hg, mean pulmonary arterial pressure 30 +/- 11 vs. 20 +/- 8 mm Hg, mean right atrial pressure 9 +/- 4 vs. 4 +/- 2 mm Hg, all p < 0.001), but no significant differences were found in cardiac index (CI) or stroke index (SI).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of coagulation temperature on measurements of complement function in serum samples from patients with systemic lupus erythematosus

Blood samples from 15 patients with systemic lupus erythematosus (SLE) and 15 healthy blood donors were allowed to coagulate for one hour at room temperature, followed by one hour at 4 or 37 degrees C. The complement activity of the serum samples was assessed by three different functional assays. Serum samples from patients with SLE obtained by coagulation at 37 degrees C had a lower complement activity than serum samples from blood coagulated at 4 degrees C when the capacity of the serum samples to solubilise precipitable immune complexes and to support the attachment of complement factors to solid phase immune complexes was determined. Haemolytic complement activity was not affected by the coagulation temperature. The content of C1q binding immune complexes in paired serum samples obtained after coagulation at 4 and 37 degrees C was similar and the size distribution of the immune complexes, determined by high performance gel permeation chromatography, was also similar. This study shows that the results of functional complement assays, applied to serum samples from patients with SLE cannot be compared unless the conditions for blood coagulation and serum handling are defined and are the same. The data also indicate that assays measuring complement mediated solubilisation of immune complexes and the fixation of complement factors to solid phase immune complexes are more sensitive indicators of complement activity than the haemolytic assay.

Results of fast neutron therapy of adenoidcystic carcinomas of the head and neck at the neutron facility Hamburg-Eppendorf

Between July 1977 and March 1988, 31 patients with an adenoidcystic carcinoma were treated with fast neutrons of a 14 MeV-DT-generator at our department. Primary locations were: parotid gland eight cases, paranasal sinus five cases, submandibular gland five cases, trachea four cases and other locations nine cases. The median follow-up of our patients was 16 months. Most of the patients had advanced tumors. The calculated local control rate is 65% at two years.

Results of fast neutron therapy of adenoid-cystic carcinomas of the head and neck at the neutron therapy facility Hamburg-Eppendorf

Between 1977 and 1987, 30 patients with adenoid-cystic carcinomas of the head and neck region were treated, at the Hamburg-Eppendorf neutron therapy facility, with a 14 MeV-DT-generator. The present review deals with 15 patients treated before October 1986 e.g. with follow up longer than one year. These results, although preliminary, tend to confirm that fast neutrons is the best irradiation modality of adenoid-cystic carcinomas of the head and neck region, especially when surgery is not possible, or cannot be radical.

Evidence from family studies that the gene causing Huntington disease is telomeric to D4S95 and D4S90

A DNA probe (D4S95) that detects a variable number of tandem repeats and a single-site-variation polymorphism after digestion with a single restriction enzyme, AccI, has previously been described. The order of this probe relative to the gene for Huntington disease (HD) and other previously described markers has not been established. Analysis of 24 affected families with HD has shown that D4S95 is in tight linkage with the gene causing HD, with a maximal Lod score of 12.489 at a theta of .03. D4S90 is a probe which maps to 4p16.3, telomeric to D4S95, and detects polymorphisms with HincII and other enzymes. In one affected person, recombination has occurred between D4S10 and HD, between D4S95 and HD, and in all likelihood also between D4S90 and HD, which strongly suggests that the gene for HD is telomeric to all these DNA probes. This suggests that the gene causing HD is located in the most distal region of the short arm of chromosome 4, flanked by D4S90 and the telomere, and supports the locus order D4S10-D4S95-D4S90-HD-telomere. D4S95 is a most useful DNA marker for predictive testing programs, while D4S90 will serve as a useful starting point for identifying DNA fragments closer to the gene for HD.

Determination of telenzepine in human serum by gas chromatography-mass spectrometry

A method for determining telenzepine in human serum is described. Analytes are obtained from alkalinized serum by extraction of the drug using reversed-phase octadecylsilane-bonded silica cartridges. Telenzepine and a desmethyl analogue added to serum as internal standard are retained on the C18 cartridge and recovered by elution with methanol. The gas chromatographic properties of telenzepine and the internal standard are improved by a two-step derivatization involving a benzodiazepinone-benzimidazole rearrangement and simultaneous formation of a methyl ester function. The processed extract is analysed by gas chromatography-mass spectrometry with selected-ion monitoring. Quantification is linear over the range 2-40 ng/ml. Inter-day precision is within 7%, except at the detection limit of 2 ng/ml (16%). Application of this assay to routine analysis is limited by the extensive sample pretreatment essential for derivatization of telenzepine.

[Treatment of Fanconi anemia by bone marrow transplantation]

We report on our experience with allogenic bone marrow transplantation in the treatment of Fanconi anemia. Eight patients were treated, ranging in age from 5 to 17 years. Beside severe hemopoietic insufficiency, all patients exhibited typical cytogenetic abnormalities with an increased rate of chromosomal breaks, while constitutional signs of the disorder were rather variable. Marrow donors were HLA-identical siblings. For conditioning, we used cyclophosphamide at 5 mg/kg on 4 consecutive days followed by thoraco-abdominal irradiation at 5 Gy with full lung shielding. For prophylaxis of graft versus host disease, cyclosporin A was given except in 3 cases who received T-cell depleted marrow. In 2 of the latter cases, graft failure was observed, successfully reversed in one by retransplantation. All others showed prompt and stable engraftment of donor cells. Complications of graft versus host disease developed in 2, requiring prolonged immunosuppressive treatment. Of 8 transplanted patients, 7 survive. With the exception of a recently treated girl, they have normal stable marrow functions. Our results confirm that successful treatment of Fanconi anemia is possible in a majority of patients with HLA-identical donors.

[Development of new positioning and adjustment aids for fractionated whole body irradiation using compensators]

A new system of positioning and adjustment facilities is presented for fractionated total-body irradiation with the use of compensators, consisting of a positioning plate provided with devices for translation and rotation, a lifting device installed in the irradiation room, a transport vehicle, an individually adapted foam bed for the patient, and a fine-adjustment holding device for the compensator. The method as well as the material used are described in detail. The system does not only allow an exact reproduction of patient's position and compensator adjustment, but also reduces the time of preparation.

[Propionic acidemia associated with hypertrophic pyloric stenosis and bouts of severe hyperglycemia (author's transl)]

A newborn is presented with hyperexcitability, drowsiness and later-on with frequent vomiting and muscular hypotonia. Examination of the urine by gas chromatography-mass spectrometry lead to the diagnosis of propionic acidemia which was confirmed enzymatically in fibroblasts. Two unusual features were encountered in this case: There were severe bouts of hyperglycemia with blood glucose values up to 396 and 747 mg/100 ml; furthermore x-ray studies and autopsy revealed a hypertrophic pyloric stenosis.

[2-Methyl-3-oxovaleric acid: a characteristic metabolite in propionic acidemia]

Urine samples from 9 patients with propionic acidemis were analyzed with respect to secondary propionyl-CoA metabolites by means of gas chromatography-mass spectrometry. A wide range of variation was observed. The presence of methylcitric and 2-methyl-3-oxovaleric acids, however, was demonstrable in all urines investigated in considerable amounts. For laboratories analyzing urinary organic acids as their methyl esters, 2-methyl-3-oxovaleric acid is considered to be of diagnostic value. In addition to the usual metabolites, the excretion of N-2-methylbutyrylglycine has been demonstrated in the urine of one patient with propionic acidemia.