Ndel1 disfavors dynein-dynactin-adaptor complex formation in two distinct ways

Dynein is the primary minus-end-directed microtubule motor protein. To achieve activation, dynein binds to the dynactin complex and an adaptor to form the "activated dynein complex." The protein Lis1 aids activation by binding to dynein and promoting its association with dynactin and the adaptor. Ndel1 and its paralog Nde1 are dynein- and Lis1-binding proteins that help control dynein localization within the cell. Cell-based assays suggest that Ndel1-Nde1 also work with Lis1 to promote dynein activation, although the underlying mechanism is unclear. Using purified proteins and quantitative binding assays, here we found that the C-terminal region of Ndel1 contributes to dynein binding and negatively regulates binding to Lis1. Using single-molecule imaging and protein biochemistry, we observed that Ndel1 inhibits dynein activation in two distinct ways. First, Ndel1 disfavors the formation of the activated dynein complex. We found that phosphomimetic mutations in the C-terminal domain of Ndel1 increase its ability to inhibit dynein-dynactin-adaptor complex formation. Second, we observed that Ndel1 interacts with dynein and Lis1 simultaneously and sequesters Lis1 away from its dynein-binding site. In doing this, Ndel1 prevents Lis1-mediated dynein activation. Together, our work suggests that in vitro, Ndel1 is a negative regulator of dynein activation, which contrasts with cellular studies where Ndel1 promotes dynein activity. To reconcile our findings with previous work, we posit that Ndel1 functions to scaffold dynein and Lis1 together while keeping dynein in an inhibited state. We speculate that Ndel1 release can be triggered in cellular settings to allow for timed dynein activation.

Ndel1 modulates dynein activation in two distinct ways

Dynein is the primary minus-end-directed microtubule motor [1]. To achieve activation, dynein binds to the dynactin complex and an adaptor to form the "activated dynein complex" [2, 3]. The protein Lis1 aids activation by binding to dynein and promoting its association with dynactin and adaptor [4, 5]. Ndel1 and its orthologue Nde1 are dynein and Lis1 binding proteins that help control where dynein localizes within the cell [6]. Cell-based assays suggest that Ndel1/Nde1 also work with Lis1 to promote dynein activation, although the underlying mechanism is unclear [6]. Using purified proteins and quantitative binding assays, we found that Ndel1's C-terminal region contributes to binding to dynein and negatively regulates binding to Lis1. Using single-molecule imaging and protein biochemistry, we observed that Ndel1 inhibits dynein activation in two distinct ways. First, Ndel1 disfavors the formation of the activated dynein complex. We found that phosphomimetic mutations in Ndel1's C-terminal domain increase its ability to inhibit dynein-dynactin-adaptor complex formation. Second, we observed that Ndel1 interacts with dynein and Lis1 simultaneously and sequesters Lis1 away from its dynein binding site. In doing this, Ndel1 prevents Lis1-mediated dynein activation. Our work suggests that in vitro, Ndel1 is a negative regulator of dynein activation, which contrasts with cellular studies where Ndel1 promotes dynein activity. To reconcile our findings with previous work, we posit that Ndel1 functions to scaffold dynein and Lis1 together while keeping dynein in an inhibited state. We speculate that Ndel1 release can be triggered in cellular settings to allow for timed dynein activation.

POS0816 DRUG SURVIVAL OF INFLIXIMAB IN BEHÇET’S SYNDROME PATIENTS WITH DIFFERENT TYPES OF INVOLVEMENT

Background

Infliximab (IFX) is an effective therapeutic option in the management of severe and refractory manifestations of Behçet’s syndrome (BS).

Objectives

We aimed to evaluate long term drug survival of IFX in a large cohort of BS patients.

Methods

We reviewed the charts of BS patients who received IFX between 2004 and June 2021 and noted demographic features, reasons for IFX use, IFX duration, and reasons for discontinuation.

Results

371 patients (290 men, mean age at IFX initiation: 35.5 ± 10 years) received IFX for uveitis (n=164), vascular involvement (n=114), central nervous system (CNS) involvement (n=55), arthritis (n=19), gastrointestinal (GI) involvement (n=15), mucocutaneous involvement (n=10), venous ulcers (n=13), and secondary amyloidosis (n=1). Twenty patients had more than one type of involvement requiring IFX.

During a median follow-up of 30 months (IQR: 13-52), 175 (47%) patients were still receiving IFX for a median period of 40 months (IQR: 22-66) while 196 (53%) patients had discontinued IFX after a median follow-up of 19 months (IQR: 8-34).

IFX retention rate was 50% for mucocutaneous involvement, 43% for uveitis, 49% for vascular involvement, 58% for CNS involvement, 37% for arthritis, 53% for GI involvement, and 31% for venous ulcer (Table 1).

Table 1.

Drug survival of infliximab and reasons for infliximab discontinuation

Mucocutaneous involvement (n=10)Uveitis (n=164)Vascular (n=114)CNS (n=55)Arthritis (n=19)GIS (n=15)Venous ulcer (n=13)Male (n, %)3 (30)127 (77)89 (78)49 (89)14 (74)9 (60)12 (92)Age at infliximab initiation (mean ± SD years)35.8 ± 9.334 ± 9.936 ± 9.136.2 ± 10.439.6 ± 10.743 ± 14.137.4 ± 8.2Number of patients who used concomitant immunosuppressives (n, %)5 (50)108 (66)86 (75)38 (69)5 (26)11 (73)7 (54)Duration of infliximab use (mean ± SD months)33 ± 3845 ± 3828 ± 2337 ± 2837 ± 3526 ± 2625 ± 25Number of patients who discontinued infliximab (n, %)5 (50)93 (57)58 (51)23 (42)12 (63)7 (47)9 (69)Due to remission-30212121Due to primary inefficacy157---5Due to secondary inefficacy212545--Due to adverse event1231211541Due to noncompliance11113--2Due to other reasons-1212311-

Reasons for discontinuation were adverse events in 56 (15%), remission in 54 (15%) patients, inefficacy in 45 (12%) (secondary inefficacy in 26 (7%), primary inefficacy in 19 (5%)), and lack of patient compliance in 18 (5%). Other reasons were preparation for surgical operation (n=4), pregnancy (n=4), lack of health insurance (n=4), preferring subcutaneous administration during the pandemic (n=3), due to prison sentence (n=3), willing to get pregnant (n=1), rejecting the treatment (n=1), and death (n=3).

Adverse events (n=56) leading to the cessation of IFX were infusion reactions (n=22), infections (n=7), tuberculosis (n=6), malignancy (n=6), palmoplantar psoriasis (n=5), hepatotoxicity (n=4), lichen planus (n=1), drug induced lupus (n=1), auricular chondritis (n=1), macrophage activation syndrome (n=1), splenic infarction (n=1) and a decrease in left ventricular ejection fraction (n=1).

At the end of the follow-up, 2 patients had died due to lung adenocarcinoma, 1 patient had died due to pneumosepsis, 1 due to severe parenchymal neurologic involvement and 1 with pulmonary artery involvement due to massive hemorrhage during IFX treatment. Additionally, 7 patients had died 9, 10 months, 3, 3, 4, 7 and 9 years after IFX discontinuation. The causes of death were severe nervous system involvement in 2 patients, right heart failure due to pulmonary hypertension, laryngeal adenocarcinoma, lung adenocarcinoma, sepsis and gastrointestinal bleeding in 1 patient each.

Conclusion

IFX seems to be effective for the treatment of organ and life-threatening manifestations in the majority of the patients. However, drug retention rate was not optimal, mainly due to adverse events, inefficacy and patient non-compliance.

Disclosure of Interests

Sinem Nihal Esatoglu Speakers bureau: Sinem Nihal Esatoglu has received honorariums for presentations from UCB Pharma, Roche, Pfizer, and Merck Sharp Dohme, Beyza Tukek: None declared, Sitki Safa Taflan: None declared, Yilmaz Ozyazgan: None declared, Didar Ucar: None declared, Vedat Hamuryudan Speakers bureau: Vedat Hamuryudan has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma, Grant/research support from: Vedat Hamuryudan has received grant/research support from Celgene., Yesim Ozguler Speakers bureau: Yesim Ozguler has received honorariums for presentations from UCB Pharma, Novartis, and Pfizer., Emire Seyahi Speakers bureau: Emire Seyahi has received honorariums for presentations from Novartis, Pfizer, AbbVie, and Gliead, Melike Melikoglu: None declared, Ugur Uygunoglu Speakers bureau: Ugur Uygunoglu has received speaker fees from F Hoffmann La-Roche, F Hoffmann La-Roche, Bayer, Merck-Serono, Novartis, Teva, and Biogen Idec/Gen Pharma of Turkey, Consultant of: Ugur Uygunoglu has received advisory board honorariums from F Hoffmann La-Roche, F Hoffmann La-Roche, Bayer, Merck-Serono, Novartis, Teva, and Biogen Idec/Gen Pharma of Turkey, Aksel Siva Speakers bureau: Aksel Siva received honorariums from Teva for speaking engagements., Consultant of: Aksel Siva received honorariums from Bayer-Schering AG, Biogen/Gen Ilac of Turkey, Genzyme, Merck-Serono, and Roche for consulting, fees from Novartis as a consultant and advisory committee member,., Grant/research support from: Aksel Siva received travel and registration reimbursements from Genzyme., Zekayi Kutlubay: None declared, Izzet Fresko: None declared, Sebahattin Yurdakul: None declared, Hasan Yazici: None declared, Gulen Hatemi Speakers bureau: Gulen Hatemi has served as a speaker for AbbVie, Celgene, Novartis, and UCB Pharma., Grant/research support from: Gulen Hatemi has received grant/research support from Celgene.

POS0819 EMERGENCE OF DE NOVO MANIFESTATIONS DURING INFLIXIMAB TREATMENT IN BEHÇET SYNDROME

Background:

Infliximab (IFX) is increasingly used in the management of severe, relapsing or refractory manifestations of Behçet Syndrome (BS). Emergence of de novo manifestations have been reported during IFX treatment, despite efficacy for the initial manifestation that required IFX use1.

Objectives:

We aimed to survey a sizeable cohort of BS patients treated with IFX for the development of de novo manifestations during treatment.

Methods:

A chart review was conducted to identify all BS patients who were given IFX in our Behçet Disease Research Center between 2004 and 2020. Demographic data, indications for IFX initiation, concomitant drugs, prior treatments, and outcomes were recorded. De novo manifestations were defined as new BS manifestations that had not occurred before IFX treatment.

Results:

A total of 252 patients used IFX with the main indications being uveitis in 122, vascular involvement in 82, parenchymal central nervous system involvement in 32, gastrointestinal involvement in 11, arthritis in 10, mucocutaneous involvement in 4, and secondary amyloidosis in 1. Of these patients, 17 (6%) had developed a total of 21 de-novo manifestations during a mean follow-up of 38.4 ± 92 (SD) months (Table 1). Vascular involvement was the main indication for IFX in the majority (n=12; 71%) of these 17 patients followed by eye involvement (n=3; 18%), central nervous system involvement (n=1), and joint involvement (n=1). Concomitant medications were prednisolone in 14 patients, azathioprine in 6 patients, mycophenolate mofetil, cyclosporine-A and methotrexate in 1 patient each. Thirteen patients (76%) were in remission for the main indication when de-novo manifestations emerged. In 10 patients IFX treatment was intensified either by increasing the dose to 10 mg/kg (2 patients) or by shortening the infusion intervals to 4 weeks (2 patients) along with the addition of corticosteroids or immunosuppressives. In the remaining 7 patients IFX was switched to another agent (cyclophosphamide in 5, adalimumab in 1 and anakinra in 1). At the time of this survey 8/17 patients were still on IFX for a mean follow-up of 32.5 ± 24.6 (SD) months, with concomitant low dose prednisolone in 5, azathioprine in 3 and mycophenolate mofetil in 3. In addition to the 7 patients who discontinued IFX at the time of de-novo manifestations, 2 more patients had discontinued IFX due to allergic reactions.

Conclusion:

De novo manifestations developed during IFX treatment in 6% of BS patients, despite efficacy for the initial manifestation. Appearance of de novo manifestations mostly in patients with vascular involvement is noteworthy. Intensification of IFX treatment was efficacious in managing de novo manifestations in more than half of these patients.

References:

[1]Hamuryudan V et al. Semin Arthritis Rheum. 2015;45(3):369-73.

Table 1.

Distribution of de novo manifestations that have emerged in 17 patients

De-novo manifestations21Pulmonary artery aneurysm1Pulmonary artery thrombosis2Coronary artery involvement3Superficial thrombophlebitis5Arthritis5Erythema nodosum3Gastrointestinal involvement1Central nervous system involvement1

Disclosure of Interests:

None declared

POS0814 DRUG RETENTION RATE, REASONS FOR DISCONTINUATION AND OUTCOME OF INFLIXIMAB USE IN BEHÇET SYNDROME

Background:

Infliximab (IFX) plays a key role in the management of severe and refractory manifestations of Behçet syndrome (BS). However we had previously shown that its sustained use may be limited due to adverse events and lack of patient compliance (1).

Objectives:

To assess the retention rate of IFX, adverse events, causes of discontinuation and outcome after cessation of IFX in a larger group of BS patients who were followed in a tertiary center.

Methods:

The charts of BS patients who were prescribed IFX between 2004 and 2020 were reviewed to determine demographic features, reasons for IFX use, previous and concomitant drugs, IFX duration, reasons for cessation of IFX and time to flare following cessation of IFX. Follow-up was censored on March 2020.

Results:

A total of 252 patients (195 men, mean age 40±10 years) received IFX for uveitis (n=122), vascular involvement (n=82), parenchymal neurologic involvement (n=32), gastrointestinal involvement (n=11), arthritis (n=10), mucocutaneous involvement (n=4), and secondary amyloidosis (n=1). Ten patients had more than 1 involvement requiring IFX.

During a median follow-up of 52 (IQR: 30-88) months, 122 (48%) patients were still receiving IFX for a median period of 33 (IQR: 15-56) months while 130 (52%) patients had discontinued IFX after a median follow-up of 17 (IQR: 7-31) months. Reasons for discontinuation were remission in 25 (19%) patients, adverse events in 39 (30%), lack of efficacy in 23 (18%) (4 primary and 19 secondary), lack of patient compliance in 36 (28%), pregnancy in 4, and preparation for surgery in 3 patients.

Adverse events (n=39) that required the cessation of IFX were infusion reaction (n=17), infection (n=7), hepatotoxicity (n=4), malignancy (n=4), palmoplantar psoriasis (n=3), lichen planus (n=1), drug induced lupus (n=1), splenic infarction (n=1), and a decrease in left ventricular ejection fraction (n=1).

Among the 25 patients who discontinued IFX due to remission, 5 (20%) had a relapse after 4, 21, 26, 29, 38 and 46 months. The remaining patients did not experience a relapse during a median follow-up of 35 (IQR: 24-68) months.

At the end of the follow-up, 2 patients had died due to lung adenocarcinoma during IFX treatment and 3 patients had died 1 year, 3 and 8 years after IFX discontinuation. The causes of death were with right heart failure due to pulmonary hypertension in 1, and severe nervous system involvement in 2 of the patients.

Conclusion:

Despite its successful use for the management of potentially organ and life-threatening manifestations in more than half of our patients with BS, long term maintenance was not possible in 42%, mainly due to adverse events, lack of patient compliance and inefficacy.

Reference:

[1]Esatoglu SN, Tukek B, Taflan SS, et al. SAT0258 Drug Retention Rate and Prognosis After Discontinuation of Infliximab in Patients with Behçet Syndrome. Annals of the Rheumatic Diseases 2020;79: 1071-1072.

Reasons for infliximab treatmentNo of patientsNo (%) of patients who were still receiving infliximabNumber (%) of patients who discontinued infliximabReasons for discontinuationDuration of infliximab use(median (IQR) months)Eye involvement12259 (48)63 (52)Remission (n=17)Inefficacy (n=10)Lack of patient compliance (n=19)Adverse event (n=12)Others (n)=5)28 (12.5-52)Vascular involvement8240 (49)42 (51)Remission (n=10)Inefficacy (n=7)Lack of patient compliance (n=12)Adverse event (n=12)Others (n=4)18.5 (9-33.5)Parenchymal neurologic involvement3221 (66)11 (34)Adverse event (n=8)Inefficacy (n=2)Lack of patient compliance (n=1)25 (14.5-50)Gastrointestinal involvement114 (36)7 (64)Remission (n=1)Inefficacy (n=1)Adverse event (n=2)Lack of patient compliance (n=4)7 (2-17)Joint involvement102 (20)8 (80)Inefficacy (n=1)Adverse event (n=5)Lack of patient compliance (n=2)20 (4-35)Mucocutaneous involvement431Inefficacy (n=1)6, 10, 12, 104 monthsAA amyloidosis101Inefficacy (n=1)6 years

Disclosure of Interests:

None declared

FRI0202 WHAT IS NOT NERVOUS SYSTEM INVOLVEMENT IN BEHÇET SYNDROME: A SURVEY OF PATIENTS WITH BEHÇET SYNDROME REFERRED TO NEUROLOGY

Background:

Nervous system involvement of Behçet syndrome (neuroBS) is a serious, but infrequent manifestation of Behçet syndrome (BS). Although many BS patients present with signs and symptoms related to the nervous system, several of these are diagnosed with conditions other than neuroBS. The differential diagnosis may be difficult in such patients.

Objectives:

To identify conditions mimicking neuroBS among patients with BS and to determine clinical, laboratory and imaging findings that may help the differential diagnosis.

Methods:

We retrospectively screened the charts of 500 BS patients who were registered to our clinic between February 2012 and April 2015, to identify those who were referred to neurology at any time during their follow-up. We follow our BS patients in a multidisciplinary clinic and all patients with a sign or symptom related to the nervous system are seen by one of the neurologist members of the clinic. The final diagnoses, as well as presenting signs and symptoms, laboratory and imaging results and results of any other diagnostic modalities were retrieved from patient charts. Patients who did not have a follow-up visit during the last 3 months were invited to the clinic for their final condition. Those who were not able to come, or one of their family members if they were not able to talk, were interviewed on the phone.

Results:

Among the 500 BS patients who were screened, 116 (23%) were referred to neurology (53 men, 63 women, mean age 32.8 (±9.8), 98 (84%) fulfilled ISG criteria). Among these, 29 (5.8%) were diagnosed with neuroBS, 30 (6%) had other conditions related to the nervous system, 46 (9.2%) were not diagnosed with a nervous system disorder and their symptoms disappeared and 11 (2.2%) were inconclusive and lost to follow-up. Of the 29 patients with neuroBS, 20 had parenchymal involvement, 7 had cerebral venous sinus thrombosis, 1 had concurrent parenchymal involvement and cerebral venous sinus thrombosis and 1 had atypical neuroBS. Of the 30 BS patients who were diagnosed with another nervous system condition, 14 (2.8%) had primary headache syndromes including tension type headache (n=5) and migraine (n=9), 6 (1.2%) had psychiatric disorders including psychotic disorder (n=1), depression (n=4) and somatization disorder (n=1), the remaining patients had other diagnoses which were entrapment neuropathy (n=2), epilepsy, glial tumor, multiple sclerosis, Meniere’s disease, optic neuritis, neuroretinitis, steroid myopathy and polyneuropathy in one patient each. Presentation features such as cerebellar symptoms, motor symptoms, visual problems, altered consciousness, seizure, fever and facial palsy were more common among patients with neuroBS, whereas sensory symptoms and isolated headache were more common among BS patients with other nervous system conditions (Table).

Table.

Clinical characteristics of patients with neuroBS versus other diagnoses

Clinical findings at presentationBS patients with nervous system involvement (neuroBS) (n=29)BS patients with other nervous system conditions (n=30)Only headache2 (7%)17 (56%)Cerebellar symptoms*8 (27%)4 (13%)Motor symptoms*4 (14%)2 (7%)Sensory symptoms*3 (10%)5 (17%)Visual problems*(diplopia, blurred vision)9 (31%)1 (3%)Cognitive symptoms*2 (7%)2 (7%)Other* (Alteration of consciousness, seizure, fever, facial palsy)9 (31%)1 (3%)

* Accompanying more than 1 symptom/sign

Conclusion:

Nervous system conditions other than neuroBS are common in patients with BS who present with nervous system findings. Caution is required to avoid misdiagnosis of these patients as neuroBS.

Disclosure of Interests:

Elif Dincses: None declared, E. Buse Caliskan: None declared, Z. Ece Kaya: None declared, Ugur Uygunoglu: None declared, Melih Tutuncu: None declared, Sabahattin Saip: None declared, Aksel Siva: None declared, Melike Melikoglu: None declared, Vedat Hamuryudan Speakers bureau: Pfizer, AbbVie, Amgen, MSD, Novartis, UCB, Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker

SAT0258 DRUG RETENTION RATE AND PROGNOSIS AFTER DISCONTINUATION OF INFLIXIMAB IN PATIENTS WITH BEHÇET SYNDROME

Background:

Infliximab (IFX) has become an important treatment option for all manifestations of Behçet syndrome (BS). Adverse events, loss of efficacy, lack of patient compliance and cost may limit its sustained use in patients with BS.

Objectives:

We aimed to evaluate the drug retention rates, causes of discontinuation and outcome after cessation of IFX.

Methods:

We reviewed the charts of 850 patients with BS who were registered in our clinic between 2009 and 2013 and identified those who had used IFX. The charts of these patients were surveyed for demographic features, the reasons for IFX use, previous and concomitant drugs, IFX duration, reasons for discontinuation and time to flare after discontinuation of IFX. We defined flare as disease activity in the organ involvement that necessitated IFX use. New major organ involvement that developed during or after discontinuation of IFX were also be noted.

Results:

A total of 50/850 patients were treated with IFX (40 men, mean age 40±9.5 years), for uveitis (n=29), vascular involvement (n=11), parenchymal neurologic involvement (n=8), arthritis (n=1) and venous ulcer (n=1). Of these 50 patients, 22 (43%) are still receiving IFX for a median duration of 40 (IQR: 25-83) months. The remaining 28 (47%) patients had discontinued IFX after a median follow-up of 12 (IQR: 7-30) months. Reasons for discontinuation were remission in 7 patients, adverse events in 10, primary lack of efficacy in 2, and lack of patient compliance in 9 patients. Among the 7 patients who discontinued IFX due to remission, only 1 patient with uveitis had a flare, 11 months after discontinuation, while on azathioprine. The remaining 6 did not experience any flares during a median follow-up of 29.5 (IQR: 4-24) months. Five of these patients used azathioprine and 1 used mycophenolate mofetil for maintenance. Among the 10 patients who discontinued due to adverse events, IFX was switched to adalimumab in 3 patients and none experienced flares under adalimumab. The remaining 7 patients continued to receive azathioprine or mycophenolate mofetil without a biologic. Among these, 1 patient with uveitis 1 with arthritis experienced flares 6 months after discontinuing IFX. Among the 9 patients who discontinued IFX due to lack of patient compliance, 3 patients (2 with uveitis and 1 with arthritis) had flares after 5 months, 1 year and 1.5 years. IFX was re-initiated in all. The remaining 6 patients did not experience any flares after a mean follow up of 5±1.5 years. Two with uveitis and 2 with venous thrombosis used azathioprine for maintenance, while 2 patients did not receive further treatment. New major organ involvement was not observed. New BS manifestations developed in 2 patients under IFX, arthritis in one patient and both epididymitis and erythema nodosum in the other.

Conclusion:

Almost half of our patients with BS remained on IFX during a median follow-up of 5.4 years (IQR:2.4-7). Main reasons for discontinuation were adverse events, remission and lack of patient compliance. Our observations further support the efficiency of IFX in managing patients with BS.

Disclosure of Interests:

Sinem Nihal Esatoglu: None declared, Beyza Tukek: None declared, Sitki Safa Taflan: None declared, Yilmaz Ozyazgan: None declared, Didar Ucar: None declared, Emire Seyahi: None declared, Melike Melikoglu: None declared, Vedat Hamuryudan Speakers bureau: Pfizer, AbbVie, Amgen, MSD, Novartis, UCB, Ugur Uygunoglu: None declared, Aksel Siva: None declared, Izzet Fresko: None declared, Sebahattin Yurdakul: None declared, Hasan Yazici: None declared, Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker

Live-cell imaging of lipid droplets using solvatochromic coumarin derivatives

Lipid droplets (LDs), the lipid-rich intracellular organelles were selectively detected using simple coumarin containing fluorophores.

Reduced inhibition in brainstem circuits in classical trigeminal neuralgia

OBJECTIVE

We hypothesized that prepulse modulation (PPM) would be altered in trigeminal neuralgia (TN) if suprasegmental inhibitory network involvement was present and tested our hypothesis in a group of patients with classical TN.

METHODS

The study enrolled nine consecutive patients with classical TN and 14 healthy subjects. Diagnosis and classification followed the International Classification of Headache Disorders-third edition (beta version). The blink reflex (BR) and BR-PPM were recorded. Ipsilateral recordings were made after stimulating each trigeminal nerve in the patient group whereas right-sided recordings were performed after stimulating the right trigeminal nerve in the healthy subjects. A conditioning electrical stimulus was applied to the ipsilateral median nerve at interstimulus intervals (ISIs) of 50 and 100 ms before the test stimulus to the supraorbital nerve.

RESULTS

The unconditioned BR recordings were similar in all groups. In the healthy subjects, the prepulse stimulus resulted in a reduced R2 magnitude (p = 0.000, Friedman's test) and longer R2 latency (p = 0.008, Friedman's test) at ISIs of 50 and 100 ms in comparison with unconditioned recordings. The R2 latency differed significantly between the unconditioned recordings and the ISI of 100 ms. In the patients with TN, no significant change was observed on either the symptomatic or asymptomatic sides.

CONCLUSIONS

There is a bilateral prepulse inhibition deficit in TN, even on the asymptomatic side. Our findings provide electrophysiological evidence for suprasegmental changes and loss of filtering activity at the brainstem in level TN.

Crystal structures of 2'-benzoyl-1'-(4-methyl-phenyl)-1,1',2,2',5',6',7',7a'-octa-hydro-spiro-[indole-3,3'-pyrrolizin]-2-one and 2'-(4-bromo-benzoyl)-1'-(2-chloro-phen-yl)-1,1',2,2',5',6',7',7a'-octa-hydro-spiro-[indole-3,3'-pyrrolizin]-2-one

The two title compounds, C28H26N2O2, (I), and C27H22BrClN2O2, (II), differ in their substituents, viz.4-methyl-phenyl and benzoyl rings in (I) replaced by 2-chloro-phenyl and 4- bromo-benzoyl, respectively, in (II). A significant difference between the two mol-ecules is found in the deviation of the benzoyl O atom from the least-squares plane of the ring to which it is attached [0.593 (4) and 0.131 (3) Å, respectively], a fact which may be attributed to the different participation of the benzoyl O atoms as acceptors in their inter-molecular C-H⋯O inter-actions. The chemical modifications in (I) and (II) do not seem to affect the type nor strength of the inter-molecular N-H⋯N and C-H⋯O hydrogen bonds responsible for the two crystal structures, such that the aggregation of mol-ecules appears similar in spite of the mol-ecular changes.

European Headache Federation consensus on technical investigation for primary headache disorders

The diagnosis of primary headache disorders is clinical and based on the diagnostic criteria of the International Headache Society (ICHD-3-beta). However several brain conditions may mimic primary headache disorders and laboratory investigation may be needed. This necessity occurs when the treating physician doubts for the primary origin of headache. Features that represent a warning for a possible underlying disorder causing the headache are new onset headache, change in previously stable headache pattern, headache that abruptly reaches the peak level, headache that changes with posture, headache awakening the patient, or precipitated by physical activity or Valsalva manoeuvre, first onset of headache ≥50 years of age, neurological symptoms or signs, trauma, fever, seizures, history of malignancy, history of HIV or active infections, and prior history of stroke or intracranial bleeding. All national headache societies and the European Headache Alliance invited to review and comment the consensus before the final draft. The consensus recommends brain MRI for the case of migraine with aura that persists on one side or in brainstem aura. Persistent aura without infarction and migrainous infarction require brain MRI, MRA and MRV. Brain MRI with detailed study of the pituitary area and cavernous sinus, is recommended for all TACs. For primary cough headache, exercise headache, headache associated with sexual activity, thunderclap headache and hypnic headache apart from brain MRI additional tests may be required. Because there is little and no good evidence the committee constructed a consensus based on the opinion of experts, and should be treated as imperfect.

Conversion from clinically isolated syndrome to multiple sclerosis: A large multicentre study

Background and objective:

We explored which clinical and biochemical variables predict conversion from clinically isolated syndrome (CIS) to clinically definite multiple sclerosis (CDMS) in a large international cohort.

Methods:

Thirty-three centres provided serum samples from 1047 CIS cases with at least two years’ follow-up. Age, sex, clinical presentation, T2-hyperintense lesions, cerebrospinal fluid (CSF) oligoclonal bands (OCBs), CSF IgG index, CSF cell count, serum 25-hydroxyvitamin D3 (25-OH-D), cotinine and IgG titres against Epstein-Barr nuclear antigen 1 (EBNA-1) and cytomegalovirus were tested for association with risk of CDMS.

Results:

At median follow-up of 4.31 years, 623 CIS cases converted to CDMS. Predictors of conversion in multivariable analyses were OCB (HR = 2.18, 95% CI = 1.71–2.77, p < 0.001), number of T2 lesions (two to nine lesions vs 0/1 lesions: HR = 1.97, 95% CI = 1.52–2.55, p < 0.001; >9 lesions vs 0/1 lesions: HR = 2.74, 95% CI = 2.04–3.68, p < 0.001) and age at CIS (HR per year inversely increase = 0.98, 95% CI = 0.98–0.99, p < 0.001). Lower 25-OH-D levels were associated with CDMS in univariable analysis, but this was attenuated in the multivariable model. OCB positivity was associated with higher EBNA-1 IgG titres.

Conclusions:

We validated MRI lesion load, OCB and age at CIS as the strongest independent predictors of conversion to CDMS in this multicentre setting. A role for vitamin D is suggested but requires further investigation.

Characterization of neuromyelitis optica and neuromyelitis optica spectrum disorder patients with a late onset

BACKGROUND

Few data are available for patients with a late onset (≥ 50 years) of neuromyelitis optica (LONMO) or neuromyelitis optica spectrum disease (LONMOSD), defined by an optic neuritis/longitudinally extensive transverse myelitis with aquaporin-4 antibodies (AQP4-Ab).

OBJECTIVE

To characterize LONMO and LONMOSD, and to analyze their predictive factors of disability and death.

METHODS

We identified 430 patients from four cohorts of NMO/NMOSD in France, Germany, Turkey and UK. We extracted the late onset patients and analyzed them for predictive factors of disability and death, using the Cox proportional model.

RESULTS

We followed up on 63 patients with LONMO and 45 with LONMOSD during a mean of 4.6 years. This LONMO/LONMOSD cohort was mainly of Caucasian origin (93%), women (80%), seropositive for AQP4-Ab (85%) and from 50 to 82.5 years of age at onset. No progressive course was noted. At last follow-up, the median Expanded Disability Status Scale (EDSS) scores were 5.5 and 6 in the LONMO and LONMOSD groups, respectively. Outcome was mainly characterized by motor disability and relatively good visual function. At last follow-up, 14 patients had died, including seven (50%) due to acute myelitis and six (43%) because of opportunistic infections. The EDSS 4 score was independently predicted by an older age at onset, as a continuous variable after 50 years of age. Death was predicted by two independent factors: an older age at onset and a high annualized relapse rate.

CONCLUSION

LONMO/LONMOSD is particularly severe, with a high rate of motor impairment and death.

Clinical and radiological characteristics of tumefactive demyelinating lesions: follow-up study

BACKGROUND

Demyelinating lesions over 20 mm in size, referred to as tumefactive demyelinating lesions, can be misdiagnosed as being either a tumor or an abscess. Although some radiological characteristics can help make a differential diagnosis easier, a cerebral biopsy may still be necessary.

OBJECTIVE

Our objective was to assess the clinical characteristics of tumefactive lesions, with or without a diagnosis of multiple sclerosis (MS), and present follow-up data for 54 patients with tumefactive lesions.

METHODS

Demographic, clinical, radiological and laboratory data were gathered and treatment responses were evaluated in a total of 54 patients from five medical centers.

RESULT

Twenty-nine patients were diagnosed with tumefactive lesions at the onset, whereas 25 patients were diagnosed with tumefactive lesions after a diagnosis of MS. Median follow-up was 38.12 months. At final examination, 19 of the patients with a tumefactive lesion diagnosis at the onset eventually developed relapsing-remitting MS, while 10 remained with the condition as a clinically isolated syndrome. The tumefactive lesions studied were mostly focal, with closed-ring enhancement. We found that oligoclonal band positivity was less frequent in the patients with tumefactive onset.

CONCLUSION

Although our demographic data were similar to formerly collected Turkish MS data, we found that the distribution of the patients' clinical course differed if there was an absence of primary progressive MS and that there was a lower frequency of secondary progressive MS cases in our group of patients. We believe that less frequent oligoclonal band positivity and the difference we witnessed in the clinical course of disease in our study groups suggest that there is a need for further studies to compare all the biological and immunological differences between MS and tumefactive lesion cases, in order to reveal whether there are different pathogenetic mechanisms involved.

Impact of pregnancy on conversion to clinically isolated syndrome in a radiologically isolated syndrome cohort

Background:

In multiple sclerosis (MS), the relapse rate declines during pregnancy and increases during the first three months post-partum before returning to the pre-pregnancy rate. It is unknown whether pregnancy impacts the risk of clinical conversion in those within the presymptomatic period.

Objectives:

We investigate the impact of pregnancy on developing a clinical event in women diagnosed with radiologically isolated syndrome (RIS).

Methods:

All women with RIS underwent clinical and radiological assessments as part of an observational, prospective, longitudinal study. Clinical and MRI outcomes were analyzed during and after pregnancy. Subjects who became pregnant were compared with an age-matched female RIS group who did not become pregnant during the same follow-up period.

Results:

A total of 60 women with RIS were followed for up to seven years. Among them, seven became pregnant and were compared with 53 age-matched control women with RIS who did not become pregnant during the observation period. A significantly shorter time of conversion to the first neurological event was observed in the pregnant group [15.3 months (10–18)] compared with the non-pregnant controls [35.7 months (8–76)], yielding an absolute difference of 20.4 months ( p<0.05). The mean (SD) number of active lesions on a subsequent brain MRI scan was significantly higher in the pregnant group [3.2 (±1.7)] compared with the control group [1.8 (±0.6)].

Conclusions:

The risk for clinical conversion from RIS to a clinical event and new MRI disease activity seems to be influenced by pregnancy. Pregnancy related physiological changes could operate as early as the presymptomatic period in patients with MS.

Evaluation of parenchymal neuro-behçet disease by using susceptibility-weighted imaging

BACKGROUND AND PURPOSE

Neurologic involvement in Behçet disease, also known as NBD, is one of the most devastating manifestations of the disease. The precise pathologic mechanism of parenchymal NBD lesions has not been established. We evaluated lesion characteristics and probable venous hemorrhage in parenchymal NBD by using SWI, and we compared the imaging results with conventional MR imaging sequences.

MATERIALS AND METHODS

We performed cranial MR imaging by using a 1.5T scanner in 23 patients with a definitive diagnosis of parenchymal NBD. We compared the proportion of lesion detection and the performance of hemorrhagic detection with the T2 FSE, T2*GE, and SWI magnitude, and SWI mIP by using the χ(2) test.

RESULTS

The proportion of lesion detection with both SWI magnitude and SWI MinMIP was significantly larger than that with T2*GE. The proportions of lesion detection among all other pairs of methods were not significantly different according to the corresponding P value (χ(2) = 17.4929, df = 3, P = .0006). Proportions of hypointense hemorrhagic lesions with T2 FSE and T2*GE were not significantly different, and likewise for the proportions of hypointense hemorrhagic lesions with SWI magnitude and SWI mIP. In contrast, the proportions of hypointense hemorrhagic lesions with SWI magnitude and SWI mIP were significantly larger than that with T2 FSE and T2*GE (χ(2) = 108.5396, df = 3, P < .0001).

CONCLUSIONS

Most of the lesions in parenchymal NBD were found to be hemorrhagic with SWI, supporting the proposed venous theory in pathology. In addition, compared with T2 FSE and T2*GE sequences, SWI was more successful in the determination of widespread involvement of the disease, particularly in nonchronic cases.

Multiple sclerosis risk in radiologically uncovered asymptomatic possible inflammatory-demyelinating disease

BACKGROUND

Natural history of patients with incidentally discovered lesions that fulfill magnetic resonance imaging (MRI) criteria for multiple sclerosis (MS) in the absence of objective clinical symptoms suggestive of central nervous system (CNS) inflammatory-demyelinating disease is not well defined.

OBJECTIVE

We evaluated the risk of developing symptomatic MS in patients with radiologically uncovered asymptomatic possible inflammatory-demyelinating disease (RAPIDD).

METHODS

We identified and longitudinally followed a cohort of 22 patients from two tertiary care MS centers: Istanbul University, Cerrahpasa School of Medicine, Istanbul, Turkey, and Mayo Clinic, Rochester, Minnesota, after an initial MRI study fulfilling the Barkhof-Tintore MRI criteria completed for other reasons unrelated to MS.

RESULTS

Eight of 22 patients developed an objective clinical symptom consistent with a CNS inflammatory-demyelinating syndrome and fulfilled dissemination in space and time criteria for definite MS. Median age at the time of diagnosis of MS was 44.8 years (range 28.3-71.4 years). Time taken for the development of definite MS was studied by survival analysis. Cumulative event rates were; 12 months: 9%, 24 months: 15%, 36 months: 30.4%, and 60 months: 44.6%. Six of 22 patients were followed beyond 60 months. Two of these six patients developed MS later (at 66 and 112 months, respectively). Three patients remained asymptomatic despite follow-up of 10 years.

CONCLUSIONS

PATIENTS

with RAPIDD develop MS at a similar rate to treated patients (and less frequently than placebo groups) with clinically isolated syndromes from prior randomized controlled studies. Some patients with RAPIDD continue to have radiological evolution of subclinical disease without MS symptoms despite long follow-up periods.

A comparative ID migraine screener study in ophthalmology, ENT and neurology out-patient clinics

Migraine is more likely to be misdiagnosed in patients with comorbid diseases. Not only primary care physicians, but also specialists might misdiagnose it due to the lack of diagnostic criteria awareness. The ID migraine test is a reliable screening instrument that may facilitate and accelerate migraine recognition. This study aimed to compare the prevalence and characteristics of migraine in a large sample of patients admitted to clinics of ophthalmology (OC), ear, nose and throat diseases (ENTC) and neurology (NC), as well as to validate the use of the ID migraine test in OC and ENTC settings. This was a multicentre (11 cites) study of out-patients admitting either to NC, ENTC or OC of the study sites during five consecutive working days within 1 week. From each of the clinics, 100 patients were planned to be recruited. All recruited patients were interviewed and those having a headache complaint received an ID migraine test and were examined for headache diagnosis by a neurologist, blinded to the ID migraine test result. A total of 2625 subjects were recruited. Only 1.3% of OC patients and 5.4% of ENTC patients have been admitted with a primary complaint of headache, whereas the percentage of NC patients suffering from headache was 37.6%. Whereas 138 patients (19.3%) in OC, 154 (17.3%) in ENTC and 347 (34%) in NC were found to be ID migraine test positive, 149 patients (20.8%) in OC, 142 (16%) in ENTC and 338 (33.1%) in NC were diagnosed with migraine. The sensitivity, specificity, and positive and negative predictive ratios of the ID migraine test were found to be similar in all clinics. An important fraction of the patients admitted to NC, as well as to OC and ENTC, for headache and/or other complaints were found out to have migraine by means of a simple screening test. This study validated the ID migraine test as a sensitive and specific tool in OC and ENTC, encouraging its use as a screening instrument.

Immune modulation by melanoma and ovarian tumor cells through expression of the immunosuppressive molecule CD200

BACKGROUND AND OBJECTIVE

Immune escape by tumors can occur by multiple mechanisms, each a significant barrier to immunotherapy. We previously demonstrated that upregulation of the immunosuppressive molecule CD200 on chronic lymphocytic leukemia cells inhibits Th1 cytokine production required for an effective cytotoxic T cell response. CD200 expression on human tumor cells in animal models prevents human lymphocytes from rejecting the tumor; treatment with an antagonistic anti-CD200 antibody restored lymphocyte-mediated tumor growth inhibition. The current study evaluated CD200 expression on solid cancers, and its effect on immune response in vitro.

METHODS AND RESULTS

CD200 protein was expressed on the surface of 5/8 ovarian cancer, 2/4 melanoma, 2/2 neuroblastoma and 2/3 renal carcinoma cell lines tested, but CD200 was absent on prostate, lung, breast, astrocytoma, or glioblastoma cell lines. Evaluation of patient samples by immunohistochemistry showed strong, membrane-associated CD200 staining on malignant cells of melanoma (4/4), ovarian cancer (3/3) and clear cell renal cell carcinoma (ccRCC) (2/3), but also on normal ovary and kidney. CD200 expression on melanoma metastases was determined by RT-QPCR, and was found to be significantly higher in jejunum metastases (2/2) and lung metastases (2/6) than in normal samples. Addition of CD200-expressing, but not CD200-negative solid tumor cell lines to mixed lymphocyte reactions downregulated the production of Th1 cytokines. Inclusion of antagonistic anti-CD200 antibody restored Th1 cytokine responses.

CONCLUSION

These data suggest that melanoma, ccRCC and ovarian tumor cells can express CD200, thereby potentially suppressing anti-tumor immune responses. CD200 blockade with an antagonistic antibody may permit an effective anti-tumor immune response in these solid tumor types.

Validity of the ID-Migraine screener in the workplace

OBJECTIVE

The impact of migraine on physical, social, and emotional performance is considerable, yet it remains an underdiagnosed disorder. ID-Migraine is a validated migraine-screening tool developed to facilitate diagnosis. This study evaluated the validity and use of the Turkish version of the ID-Migraine screener (ID-Ms) in the workplace, and measured the impact of headache on disability, productivity, and quality of life among the workforce.

METHODS

A total of 465 employees from four companies were interviewed for screening with the ID-Ms. Subjects were included in the study if they reported two or more headaches in the past 3 months and gave a positive answer to one of the two ID-Ms prescreening questions. Eligible subjects completed the ID-Ms, the Migraine Disability Assessment Questionnaire, and the Medical Outcomes Study 36-Item Short Form Health Survey. Subjects were then evaluated for confirmation of their diagnosis according to the International Classification of Headache Disorders, 2nd edition (ICHD-2) criteria.

RESULTS

A total of 227 subjects (mean age 31.9 +/- 5.9 years; 65.6% women) completed the study. Migraine was diagnosed in 106 of the 227 subjects (46.7%) according to the ID-Ms and in 117 of the 227 subjects (51.5%) according to ICHD-2 criteria. The sensitivity of the ID-Ms was 70.9%, specificity was 79.1% and Cohen kappa value was 0.50. Workdays lost over the previous 3 months due to headache amounted to 8.7 +/- 9.5 days for migraine-positive and 4.9 +/- 6.6 days for migraine-negative subjects.

CONCLUSION

The Turkish version of the ID-Migraine screener is a valid tool for identifying subjects with migraine in the workplace.

Management of Behçet disease: a systematic literature review for the European League Against Rheumatism evidence-based recommendations for the management of Behçet disease

OBJECTIVES

To present and analyse the literature sources regarding the management of Behçet disease (BD) identified during the systematic literature research, which formed the basis for the European League Against Rheumatism (EULAR) evidence-based recommendations for the management of BD.

METHODS

Problem areas and related keywords regarding the management of BD were determined by the multidisciplinary expert committee commissioned by EULAR for developing the recommendations. A systematic literature research was performed using MedLine and Cochrane Library resources through to December 2006. Meta-analyses, systematic reviews, randomised controlled trials (RCTs), open studies, observational studies, case control studies and case series' involving > or = 5 patients were included. For each intervention the effect size and number needed to treat were calculated for efficacy. Odds ratios and numbers needed to harm were calculated for safety issues of different treatment modalities where possible.

RESULTS

The literature research yielded 137 articles that met the inclusion criteria; 20 of these were RCTs. There was good evidence supporting the use of azathioprine and cyclosporin A in eye involvement and interferon (IFN)alpha in mucocutaneous involvement. There were no RCTs with IFNalpha or tumour necrosis factor (TNF)alpha antagonists in eye involvement. Similarly controlled data for the management of vascular, gastrointestinal and neurological involvement is lacking.

CONCLUSION

Properly designed, controlled studies (new and confirmatory) are still needed to guide us in managing BD.

The heritability of plasma homocysteine, and the influence of genetic variation in the homocysteine methylation pathway

BACKGROUND

The extent of genetic influence on plasma homocysteine, a risk factor for ischaemic heart disease, is uncertain. Many association studies have investigated common polymorphisms and their role in hyperhomocysteinaemia, but only the thermolabile variant of methylene tetrahydrofolate reductase (MTHFR) has shown an association (small but robust).

AIM

To estimate the heritability of plasma homocysteine and the contributions of well-studied common SNPs in the three main candidate genes in the homocysteine methylation pathway.

DESIGN

Twin study.

METHODS

We studied 216 monozygotic and 790 dizygotic pairs of twins; all were women. Blood was collected after overnight fasting for measurement of homocysteine, folate, vitamin B12, and extraction of DNA. Heritability was estimated by structural modelling, including correction for known environmental influences, particularly serum folate. The frequency of a common coding SNP in MTHFR and methionine synthase (MTR), and two coding SNPs in methionine synthase reductase (MTRR) were measured in dizygotic twins by ABI 7700 Sequence Detection, and the contribution of each to homocysteine variance was determined.

RESULTS

The heritability of homocysteine was 57% (95%CI 51-63%). The highest contribution to homocysteine was serum folate, accounting for 10.13% of variance. This was twice the total genetic contribution of 4.56%, and only the C1763T SNP of MTRR showed significant association with homocysteine.

DISCUSSION

Homocysteine has one of the highest heritabilities of common risk factors for ischaemic heart disease. This is not accounted for by the commonly studied SNPs in MTHFR, MTR and MTRR.

Fatigue and sleep disturbance in multiple sclerosis

Considering the association of sleep disturbance and fatigue in multiple sclerosis (MS), we investigated the presence of sleep disturbances that may be related to fatigue by using objective and subjective measures. We included 27 MS patients with fatigue, 10 MS patients without fatigue and 13 controls. The Pittsburgh sleep quality index score showed significant differences between patient groups and controls. Beck depression inventory scores were significantly higher in fatigued than non-fatigued patients. Comparison of patient groups and controls revealed significant differences for time in bed, sleep efficiency index, sleep continuity index, wake time after sleep onset, total arousal index and periodic limb movement arousal index. Our study confirms that MS causes sleep fragmentation in terms of both macro and microstructure. Fatigue in MS could be partially explained by disruption of sleep microstructure, poor subjective sleep quality and depression.

The R110C mutation in Notch3 causes variable clinical features in two Turkish families with CADASIL syndrome

Mutations in Notch3 gene are responsible for the cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). It is a late onset neurological disorder recognized by recurrent strokes and dementia. We describe here the clinical and molecular findings of three unrelated Turkish families with CADASIL syndrome. Two of the families were identified to have the same mutation, p.R110C (c.C328T), located in exon 3 of the Notch3 gene. Interestingly, the phenotypic expression of the disease in these two families was markedly different in severity and age of onset implicating additional genetic and/or non-genetic modulating factors involved in the pathogenesis. In addition, we identified the novel p.C201R (c.T601C) mutation in exon 4 of the Notch3 gene in a proband of the third family with two consecutive stroke-like episodes and typical MRI findings. Mutations described here cause an odd number of cysteines in the N-terminal of the EGF domain of Notch3 protein, which seems to have an important functional effect in the pathophysiology of CADASIL. The phenotypic variability in families carrying the same molecular defect as presented here makes the prediction of prognosis inconceivable. Although DNA analysis is effective and valuable in diagnosing approximately 90% of the CADASIL patients, lack of genotype-phenotype correlation and prognostic parameters makes the presymptomatic genetic counseling very difficult.

Immune evasion by melanoma and ovarian tumor cells through upregulation of the immunosuppressive molecule CD200

2545

Background: Immune escape by tumors can occur by multiple mechanisms, each a significant barrier to immunotherapy. Upregulation of the immunosuppressive molecule CD200 on chronic lymphocytic leukemia cells inhibits Th1 cytokine production required for an effective cytotoxic T cell response. CD200 expression on human tumor cells in animal models prevents human lymphocytes from rejecting the tumor; treatment with an antagonistic anti-CD200 antibody restored lymphocyte-mediated tumor growth inhibition. This study evaluated CD200 expression on other cancers, and its effect on immune response. Methods: CD200 levels in ovarian adenocarcinoma and metastatic melanoma samples were evaluated by RT-QPCR and immunohistochemistry. Cell-surface CD200 on melanoma and ovarian cancer cell lines was assessed by flow cytometry. The effect of CD200 on cytokine production in mixed lymphocyte reactions (MLR) was assessed by adding the cells to cultures containing human monocyte-derived dendritic cells and allogeneic T cells. Th1 and Th2 cytokines in culture supernatants were detected by ELISA. Results: RT-QPCR showed CD200 expression levels upregulated in serous ovarian adenocarcinoma compared to normal samples. In malignant melanoma, CD200 expression in jejunum metastases was significantly higher than in normal samples, and 2 of 6 lung metastases showed CD200 upregulation. IHC showed strong, membrane-associated CD200 staining on malignant cells of two melanoma patients. Three ovarian cancer patients showed varying levels of CD200 tumor staining; all showed strong stromal staining. CD200 was highly expressed on the cell surface of SK-MEL-24 and SK-MEL-28 melanoma and OV-CAR-3 ovarian cancer cell lines and moderately expressed on the melanoma cell line SK-MEL-5. Addition of these cell lines to MLRs downregulated the production of Th1 cytokines; addition of CD200-negative cell lines did not. Inclusion of an antagonistic anti-CD200 antibody during the culture restored Th1 cytokine responses. Conclusion: Melanoma and ovarian tumor cells can upregulate CD200, thereby potentially suppressing anti-tumor immune responses. Therapy with an antagonistic anti-CD200 antibody may permit an effective cytotoxic immune response against the tumor cells.

[Table: see text]

Real-Time Three-Dimensional Echocardiography

Background— Left ventricular (LV) mechanical dyssynchrony (LVMD) has emerged as a therapeutic target using cardiac resynchronization therapy (CRT) in selected patients with chronic heart failure. Current methods used to evaluate LVMD are technically difficult and do not assess LVMD of the whole LV simultaneously. We developed and validated real-time 3D echocardiography (RT3DE) as a novel method to assess global LVMD.

Methods and Results— Eighty-nine healthy volunteers and 174 unselected patients referred for routine echocardiography underwent 2D echocardiography and RT3DE. RT3DE data sets provided time-volume analysis for global and segmental LV volumes. A systolic dyssynchrony index (SDI) was derived from the dispersion of time to minimum regional volume for all 16 LV segments. Healthy subjects and patients with normal LV systolic function had highly synchronized segmental function (SDI, 3.5±1.8% and 4.5±2.4%; P =0.7). SDI increased with worsening LV systolic function regardless of QRS duration (mild, 5.4±0.83%; moderate, 10.0±2%; severe LV dysfunction, 15.6±1%; P for trend <0.001). We found that 37% of patients with moderate to severe LV systolic dysfunction had significant dyssynchrony with normal QRS durations (SDI, 14.7±1.2%). Twenty-six patients underwent CRT. At long-term follow-up, responders demonstrated reverse remodeling after CRT with a significant reduction in SDI (16.9±1.1% to 6.9±1%; P <0.0001) and end-diastolic volume (196.6±17.3 to 132.1±13.5 mL; P <0.0001) associated with an increase in LV ejection fraction (17±2.2% to 31.6±2.9%; P <0.0001).

Conclusions— RT3DE can quantify global LVMD in patients with and without QRS prolongation. RT3DE represents a novel technique to identify chronic heart failure patients who may otherwise not be considered for CRT.

Moderate mitral stenosis in pregnancy: the haemodynamic impact of diuresis

A case of asymptomatic, newly diagnosed, moderate mitral stenosis in a 27 year old pregnant woman is described. A conservative management strategy with regular cardiac assessment was adopted and the patient remained well. Routine transthoracic echocardiography at 36 weeks' gestation showed the development of severe pulmonary hypertension with right ventricular pressure overload, which was successfully treated with oral diuretics resulting in rapid normalisation of pulmonary pressure. Mitral stenosis in pregnancy and its management in pregnancy are briefly discussed.