Proteomic associations with forced expiratory volume - a Mendelian randomisation study

A decline in forced expiratory volume (FEV1) is a hallmark of obstructive respiratory diseases, an important cause of morbidity among the elderly. While some data exist on biomarkers that are related to FEV1, we sought to do a systematic analysis of causal relations of biomarkers with FEV1. Data from the general population-based AGES-Reykjavik study were used. Proteomic measurements were done using 4,782 DNA aptamers (SOMAmers). Data from 1,648 participants with spirometric data were used to assess the association of SOMAmer measurements with FEV1 using linear regression. Bi-directional Mendelian randomisation (MR) analyses were done to assess causal relations of observationally associated SOMAmers with FEV1, using genotype and SOMAmer data from 5,368 AGES-Reykjavik participants and genetic associations with FEV1 from a publicly available GWAS (n = 400,102). In observational analyses, 473 SOMAmers were associated with FEV1 after multiple testing adjustment. The most significant were R-Spondin 4, Alkaline Phosphatase, Placental Like 2 and Retinoic Acid Receptor Responder 2. Of the 235 SOMAmers with genetic data, eight were associated with FEV1 in MR analyses. Three were directionally consistent with the observational estimate, Thrombospondin 2 (THBS2), Endoplasmic Reticulum Oxidoreductase 1 Beta and Apolipoprotein M. THBS2 was further supported by a colocalization analysis. Analyses in the reverse direction, testing whether changes in SOMAmer levels were caused by changes in FEV1, were performed but no significant associations were found after multiple testing adjustments. In summary, this large scale proteogenomic analyses of FEV1 reveals protein markers of FEV1, as well as several proteins with potential causality to lung function.

Treatment of idiopathic pulmonary fibrosis: a position paper from a Nordic expert group

Idiopathic pulmonary fibrosis (IPF) is a fatal progressive lung disease occurring in adults. In the last decade, the results of a number of clinical trials based on the updated disease classification have been published. The registration of pirfenidone and nintedanib, the first two pharmacological treatment options approved for IPF, marks a new chapter in the management of patients with this disease. Other nonpharmacological treatments such as lung transplantation, rehabilitation and palliation have also been shown to be beneficial for these patients. In this review, past and present management is discussed based on a comprehensive literature search. A treatment algorithm is presented based on available evidence and our overall clinical experience. In addition, unmet needs with regard to treatment are highlighted and discussed. We describe the development of various treatment options for IPF from the first consensus to recent guidelines based on evidence from large-scale, multinational, randomized clinical trials, which have led to registration of the first drugs for IPF.

Clinical features in secondary and cryptogenic organising pneumonia

SETTING

The clinical differences between cryptogenic organising pneumonia (COP) and secondary organising pneumonia (OP) have not been studied well.

OBJECTIVE

To compare clinical features in COP and secondary OP.

DESIGN

Causes, clinical features, treatment, radiographic studies and pathology were studied.

RESULTS

After re-evaluation, 104 patients fulfilled the diagnostic criteria, 58 for COP and 46 for secondary OP. The mean age was 68 years. Most of the patients were smokers (79/104). Infections were the most common causes of secondary OP (21/46). Cough was the most common symptom and crackles the most common sign. Crackles were more common in patients with secondary OP (P = 0.02). Transbronchial biopsy was the diagnostic test in 81/104 cases. Most patients had lowered partial oxygen pressure (PO(2)) and mildly restrictive spirometry, with no differences between the two groups. Radiographic features were similar. Corticosteroids were the treatment in 70% of the patients, but 27% received no pharmacological treatment. The average initial dose of steroids was 42 mg prednisolone, and was similar for both groups. Relapses were seen in 20% of cases, with no difference between the two groups.

CONCLUSION

There were no major differences in clinical features of COP and secondary OP, except that crackles were more common in secondary OP.

20 years follow-up after the first microsurgical lumbar discectomies in Iceland

BACKGROUND

Microsurgical discectomies are an established procedure in spinal surgery. This operating technique was first used in the Department of Neurosurgery in Iceland in 1981 and has become standard operative treatment for herniated lumbar discs. There is a great variability in outcome reports regarding recurrence rate and re-operation rate. Few articles are based on follow-up of more than 10 years. This article presents the results of a 20 years follow-up study.

METHODS

A retrospective study of all patients undergoing microsurgical discectomy for herniated lumbar disc, from June 1, 1981 to December 31, 1984. Outcome, based on recurrence rate, return to work and patient satisfaction was determined by a self-evaluation questionnaire, phone interviews and patient medical records.

FINDINGS

Of the 170 patients, 134 (78.8%) were included in the study (M:F, 58:42%). Preoperative symptoms: back pain with sciatica 108 (80.6%), sciatica 20 (14.9%), back pain 2 (1.5%). Mean follow-up time was 20.7 years (19.5-22.8). Recurrence rate was 12.7%. 19 patients (14.2%) underwent a subsequent lumbar operation at a different level or side. A majority of patients 108 (80.6%) returned to previous level of work, 26 (19.4%) lost some or all working capabilities. Patient satisfaction was high, 91.1% reporting excellent (68.7%) or good (22.4%) results. 5.2% of patients rated the outcome fair and 3.7% poor. Women reported worse outcome than men, excellent M:F 74.7:60.7%, and poor 7.1:1.3%. There was no significant difference in patient satisfaction in patients undergoing additional operations or those with recurrence of the herniated disc.

CONCLUSIONS

Outcome was very good with 92.0% return to work and 91.1% patient satisfaction. The recurrence rate was 12.7% with a substantial number of cases occurring 10-20 years after operation. To conclude, microsurgical discectomies maintain a high success rate in the long-term.

Epidemiology of organising pneumonia in Iceland

BACKGROUND

Cryptogenic organising pneumonia (COP) has also been called idiopathic bronchiolitis obliterans organising pneumonia. In secondary organising pneumonia (SOP) the causes can be identified or it occurs in a characteristic clinical context. The aim of this study was to determine the incidence and epidemiological features of COP and SOP nationwide in Iceland over an extended period.

METHODS

A retrospective study of organising pneumonia (OP) in Iceland over 20 years was conducted and the epidemiology and survival were studied. All pathological reports of patients diagnosed with or suspected of having COP or SOP in the period 1984-2003 were identified and the pathology samples were re-evaluated using strict diagnostic criteria.

RESULTS

After re-evaluation, 104 patients fulfilled the diagnostic criteria for OP (58 COP and 46 SOP). The mean annual incidence of OP was 1.97/100 000 population (1.10/100 000 for COP and 0.87/100 000 for SOP). The mean age at diagnosis was 67 years with a wide age range. The most common causes of death were lung diseases other than OP, and only one patient died from OP. Patients with OP had a lower rate of survival than the general population, but there was no statistical difference between COP and SOP.

CONCLUSIONS

The incidence of OP is higher than previously reported, suggesting that OP needs to be considered as a diagnosis more often than has been done in the past.

Risk factors for rehospitalisation in COPD: role of health status, anxiety and depression

The aim of the present study was to analyse the risk of rehospitalisation in patients with chronic obstructive pulmonary disease and associated risk factors. This prospective study included 416 patients from a university hospital in each of the five Nordic countries. Data included demographic information, spirometry, comorbidity and 12 month follow-up for 406 patients. The hospital anxiety and depression scale and St. George's Respiratory Questionnaire (SGRQ) were applied to all patients. The number of patients that had a re-admission within 12 months was 246 (60.6%). Patients that had a re-admission had lower lung function and health status. A low forced expiratory volume in one second (FEV1) and health status were independent predictors for re-admission. Hazard ratio (HR; 95% CI) was 0.82 (0.74-0.90) per 10% increase of the predicted FEV1 and 1.06 (1.02-1.10) per 4 units increase in total SGRQ score. The risk of rehospitalisation was also increased in subjects with anxiety (HR 1.76 (1.16-2.68)) and in subjects with low health status (total SGRQ score >60 units). When comparing the different subscales in the SGRQ, the closest relation between the risk of rehospitalisation was seen with the activity scale (HR 1.07 (1.03-1.11) per 4 unit increase). In patients with low health status, anxiety is an important risk factor for rehospitalisation. This may be important for patient treatment and warrants further studies.

Cause-specific mortality in adults with unprovoked seizures. A population-based incidence cohort study

PURPOSE

To determine the cause-specific mortality relative to that expected in a population-based incidence cohort of people with unprovoked seizures.

METHODS

The cohort comprises 224 inhabitants of Iceland first diagnosed as suffering from unprovoked seizures during a 5-year period from 1960 to 1964. The expected number of deaths was calculated by multiplying person-years of observation within 5-year age categories for each year from diagnosis through 1995 by cause-specific and sex-specific national death rates for those aged 20 years and above. The standardized mortality ratio (SMR) and 95% confidence intervals (95% CI) were calculated.

RESULTS

All-cause mortality was increased among men (SMR 2.25, 95% CI 1.56-3.14) but not women (SMR 0.79, 95% CI 0.38-1.46). Among men, there were 8 deaths from accidents, poisoning and violence observed versus 2.82 expected (SMR 2.84, 95% CI 1.22-5.59) and 4 deaths from suicide versus 0.69 expected (SMR 5.80, 95% CI 1.56-14.84). All-cause mortality for men was still elevated after restriction of analysis to those with seizures of unknown etiology (SMR 1.73, 95% CI 1.05-2.67) with the excess deaths attributable to suicide (SMR 5.26, 95% CI 1.06-15.38). Both males and females with remote symptomatic unprovoked seizures had an increase in all-cause mortality due to excess mortality from all cancers, cerebrovascular disease and accidents.

CONCLUSION

When compared with the age-, time-period- and gender-specific mortality in the general population, there is excess mortality in men but not women. The increased mortality for men is partly attributable to excess mortality from accidents and suicides.

The cerebral hemorrhage-producing cystatin C variant (L68Q) in extracellular fluids

A variant of the normal extracellular cysteine protease inhibitor cystatin C (L68Q-cystatin C), is the amyloid precursor in hereditary cystatin C amyloid angiopathy (HCCAA). It has been suggested that the mutation causes cellular entrapment of L68Q-cystatin C in vivo and that the variant protein is not secreted to extracellular fluids. In order to test this hypothesis, we used matrix-assisted laser desorption ionization time-of-flight mass spectrometry in an effort to demonstrate the presence of L68Q- along with wildtype cystatin C in plasma and cerebrospinal fluid (CSF) of HCCAA-patients. Plasma from all five investigated HCCAA-patients contained both L68Q- and wildtype cystatin C. The presence of approximately equal amounts of cystatin C dimers and monomers was demonstrated in plasma from HCCAA-patients, whereas only monomers could be found in normal plasma. L68Q-wildtype-cystatin C heterodimers seem to be present in the dimeric cystatin C population. CSF from six HCCAA-patients also contained cystatin C-dimers and monomers, but the dimeric fraction was minute. CSF from control patients did not contain dimeric cystatin C. These results suggest that the milieu of L68Q-cystatin C is important for its stability and dimerization status and that certain milieus might hinder its further development into oligomers, amyloid fibrils and other precipitating aggregates.

Downregulation of bactericidal peptides in enteric infections: a novel immune escape mechanism with bacterial DNA as a potential regulator

Antibacterial peptides are active defense components of innate immunity. Several studies confirm their importance at epithelial surfaces as immediate barrier effectors in preventing infection. Here we report that early in Shigella spp. infections, expression of the antibacterial peptides LL-37 and human beta-defensin-1 is reduced or turned off. The downregulation is detected in biopsies from patients with bacillary dysenteries and in Shigella- infected cell cultures of epithelial and monocyte origin. This downregulation of immediate defense effectors might promote bacterial adherence and invasion into host epithelium and could be an important virulence parameter. Analyses of bacterial molecules causing the downregulation indicate Shigella plasmid DNA as one mediator.

Risk of epilepsy in long-term survivors of surgery for aneurysmal subarachnoid hemorrhage: a population-based study in Iceland

PURPOSE

Epilepsy is known to result from aneurysmal subarachnoid hemorrhage (SAH). There are no population-based estimates of the absolute risk or the duration for which this risk is elevated. We have conducted a population-based study in Iceland of the risk of epilepsy after a ruptured cerebral aneurysm to address these questions.

METHODS

The index patients are all of the patients who presented with SAH caused by ruptured cerebral aneurysm in Iceland during an 11-year period (1958 to 1968) and survived more than 6 months. We determined the number of index patients who developed epilepsy. The observed number of cases of epilepsy was compared with that expected based on the incidence of epilepsy in Iceland.

RESULTS

There were 44 index patients; 11 (25%) developed epilepsy, all within 4 years of the insult. Seven (70%) of 10 patients with acute symptomatic seizures (defined as seizures during the first 2 weeks after the hemorrhage) developed epilepsy (relative risk, 7.0; 95% confidence interval, 2.3-21.6). Epilepsy was more frequent in patients with severe neurological residua (48%) compared with patients without (20%) (relative risk, 2.5; 95% confidence interval, 0.9-6.3).

CONCLUSIONS

The risk for epilepsy among survivors of SAH caused by ruptured cerebral aneurysm is substantially increased. Both acute symptomatic seizure and persistent neurological impairment are associated with a further increase in the risk of epilepsy.

Copper, ceruloplasmin and superoxide dismutase (SOD) in amyotrophic lateral sclerosis

In two previous studies we found copper dyshomeostasis in patients with Alzheimer's disease and in patients with Parkinson's disease. In this study, the levels of copper in plasma, of ceruloplasmin in serum, ceruloplasmin oxidative activity, ceruloplasmin specific oxidative activity (activity related to mass) as well as superoxide dismutase (SOD) activity in erythrocytes have been determined in 14 patients with amyotrophic lateral sclerosis and their healthy age- and gender-matched controls. Three of the patients had a familial form of the disease or were suspected of having it. The mean values of all parameters were found not to differ significantly between the patients and their controls (Student's t-test; P>0.05). By testing the equality of variances (F distribution) we found that the variances of individual results for ceruloplasmin specific oxidative activity and SOD activity differed significantly between the patients group and the controls group (P= 0.021 and P=0.003), but the individual results of these two activities were not correlated (P>0.05). We conclude that disturbances in ceruloplasmin specific oxidative activity and SOD activity could contribute to motor neurone death in amyotrophic lateral sclerosis, and since the two enzyme activities are not correlated it is uncertain which one is more closely related to the pathology of the disease.

Viral infection modulates expression of hypersensitivity pneumonitis

Hypersensitivity pneumonitis (HP) is a granulomatous, inflammatory lung disease caused by inhalation of organic Ags, most commonly thermophilic actinomycetes that cause farmer's lung disease. The early response to Ag is an increase in neutrophils in the lung, whereas the late response is a typical Th1-type granulomatous disease. Many patients who develop disease report a recent viral respiratory infection. These studies were undertaken to determine whether viruses can augment the inflammatory responses in HP. C57BL/6 mice were exposed to the thermophilic bacteria Saccharopolyspora rectivirgula (SR) for 3 consecutive days per wk for 3 wk. Some mice were exposed to SR at 2 wk after infection with respiratory syncytial virus (RSV), whereas others were exposed to SR after exposure to saline alone or to heat-inactivated RSV. SR-treated mice developed a typical, early neutrophil response and a late granulomatous inflammatory response. Up-regulation of IFN-gamma and IL-2 gene expression was also found during the late response. These responses were augmented by recent RSV infection but not by heat-inactivated RSV. Mice with a previous RSV infection also had a greater early neutrophil response to SR, with increased macrophage inflammatory protein-2 (MIP-2, murine equivalent of IL-8) release in bronchoalveolar lavage fluid. These studies suggest that viral infection can augment both the early and late inflammatory responses in HP.

Respiratory epithelial cells release interleukin-8 in response to a thermophilic bacteria that causes hypersensitivity pneumonitis

Hypersensitivity pneumonitis (HP) is a granulomatous inflammatory lung disease that is usually triggered by organic antigens. At early time points after inhalation of antigen, neutrophilic inflammation is prominent in the lungs. Interleukin (IL)-8 is a potent chemoattractant for neutrophils and it is known that alveolar macrophages can release IL-8 after exposure to organic antigens. However, the role of respiratory epithelial cells in the production of IL-8 in HP is unknown. We exposed A549 epithelial cells to the thermophilic bacteria Saccharopolyspora rectivirgula (SR), and measured IL-8 release via enzyme-linked immunosorbent assay (ELISA) and IL-8 messenger RNA (mRNA) induction via Northern analysis. We observed a dose- and time-dependent release of IL-8 in response to SR. The maximal release of IL-8 was measured at 24-48 hours after exposure. There was also an increase in release of IL-6 in a time-dependent fashion. SR induced a peak increase in IL-8 mRNA at 12-24 hours. SR also triggered expression of the DNA-binding activity of NF-kappa B, a transcription factor that mediates activation of the IL-8 gene. Both corticosteroids and IL-10 blocked the production of IL-8. The release of IL8 was not mediated through IL-1 beta. These data suggest that SR-induced IL-8 production in airway epithelium may play a role in the initial inflammatory response in HP.

A phosphatidylcholine-specific phospholipase C regulates activation of p42/44 mitogen-activated protein kinases in lipopolysaccharide-stimulated human alveolar macrophages

This study uses human alveolar macrophages to determine whether activation of a phosphatidylcholine (PC)-specific phospholipase C (PC-PLC) is linked to activation of the p42/44 (ERK) kinases by LPS. LPS-induced ERK kinase activation was inhibited by tricyclodecan-9-yl xanthogenate (D609), a relatively specific inhibitor of PC-PLC. LPS also increased amounts of diacylglycerol (DAG), and this increase in DAG was inhibited by D609. LPS induction of DAG was, at least in part, derived from PC hydrolysis. Ceramide was also increased in LPS-treated alveolar macrophages, and this increase in ceramide was inhibited by D609. Addition of exogenous C2 ceramide or bacterial-derived sphingomyelinase to alveolar macrophages increased ERK kinase activity. LPS also activated PKC zeta, and this activation was inhibited by D609. LPS-activated PKC zeta phosphorylated MAP kinase kinase, the kinase directly upstream of the ERK kinases. LPS-induced cytokine production (RNA and protein) was also inhibited by D609. As an aggregate, these studies support the hypothesis that one way by which LPS activates the ERK kinases is via activation of PC-PLC and that activation of a PC-PLC is an important component of macrophage activation by LPS.

Interleukin-10 modulates the severity of hypersensitivity pneumonitis in mice

Hypersensitivity pneumonitis (HP) is an inflammatory lung disease characterized by granuloma formation. We recently showed that interferon-gamma (IFN-gamma) is essential for inflammation and granuloma formation in HP. Interleukin-10 (IL-10) counteracts many of the biologic effects of IFN-gamma, suggesting that IL-10 modulates inflammation and granuloma formation in HP. We compared the expression of HP in C57BL/6 mice that lack IL-10 (IL-10 knockout [KO]) with that in wild-type (WT) littermates. IL-10 KO and WT mice were exposed to the thermophilic bacteria Saccharopolyspora rectivirgula or to saline alone for 3 wk. The IL-10 KO mice had higher cell counts in their bronchoalveolar lavage fluid (2.85 +/- 0. 43 x 10(6)) than did WT mice (1.4 +/- 0.3 x 10(6)/ml; P < 0.03), with a more prominent neutrophil response. They also had greater inflammation after antigen exposure than did the WT mice (P < 0. 0001). There was increased upregulation of IFN-gamma, IL-1, and tumor necrosis factor-alpha (TNF-alpha) mRNAs in the lungs of IL-10 KO mice. Adenovirus-mediated gene transfer of IL-10 to the liver of IL-10 KO mice reduced the inflammation from that seen in WT mice. These studies show that IL-10 has important anti-inflammatory properties in HP, and that lack of this cytokine leads to a more severe granulomatous inflammatory response.

Changes in PKC isoforms in human alveolar macrophages compared with blood monocytes

Alveolar macrophages play an important role in host defense and in other types of inflammatory processes in the lung. These cells exhibit many alterations in function compared with their precursor cells, blood monocytes. To evaluate a potential mechanism for these differences in function, we evaluated expression of protein kinase C (PKC) isoforms. We found an increase in Ca2+-dependent PKC isoforms in monocytes compared with alveolar macrophages. We also found differential expression of the Ca2+-independent isoforms in alveolar macrophages compared with monocytes. One consequence of the activation of PKC can be increased expression of mitogen-activated protein (MAP) kinase pathways. Therefore, we also evaluated activation of the MAP kinase extracellular signal-regulated kinase (ERK) 2 by the phorbol ester phorbol 12-myristate 13-acetate (PMA). PMA activated ERK2 kinase in both alveolar macrophages and monocytes; however, monocytes consistently showed a significantly greater activation of ERK2 kinase by PMA compared with alveolar macrophages. Another known consequence of the activation of PKC and subsequent activation of ERK kinase is activation of the transcription factor activator protein-1 (AP-1). We evaluated the activation of AP-1 by PMA in both monocytes and macrophages. We found very little detectable activation of AP-1, as assessed in a gel shift assay, in alveolar macrophages, whereas monocytes showed a substantial activation of AP-1 by PMA. These studies show that the differential expression of PKC isoforms in alveolar macrophages and blood monocytes is associated with important functional alterations in the cells.

Pregnancies of women with epilepsy: a population-based study in Iceland

PURPOSE

Women with epilepsy who become pregnant are commonly considered to be at high risk for complications during pregnancy or delivery. The offspring are also considered to have increased risk of perinatal mortality, congenital malformations, and maturational delay. Because few of these studies are population based, potential bias exists because of selection.

METHODS

We performed a historical population-based cohort study in Iceland to determine the prevalence of epilepsy among pregnant women, to identify pregnancy and delivery complications in women with epilepsy, and to determine the outcome of their pregnancies as compared with that in the general population of Iceland. We identified all women with active epilepsy who gave birth during a 19-year period in Iceland.

RESULTS

In this population, 3.3 in 1,000 pregnancies involve mothers with active epilepsy. The frequency of adverse events (AE) during pregnancy in the women with epilepsy is similar to that observed among all live births in the population, but cesarean section was performed twice as frequently as in the general population. Perinatal mortality rate and mean birth weight are not significantly different in the offspring of women with epilepsy as compared with rest of the population. The risk of major congenital malformations (MGM) is increased 2.7-fold over that expected when a mother is treated with antiepileptic drugs (AEDs) during a pregnancy.

CONCLUSIONS

Our study indicates that the rate of complications of pregnancy in mothers with active epilepsy is low and similar to that of the general population with epilepsy. Use of AEDs by the mother during pregnancy significantly increases the risk of MGM in the offspring.

IL-12 modulates expression of hypersensitivity pneumonitis

Hypersensitivity pneumonitis (HP) is a granulomatous, inflammatory lung disease caused by inhalation of organic Ags, most commonly thermophilic actinomycetes. Only a minority of individuals exposed to these Ags develops disease, suggesting that host factors are important for the expression of HP. We compared the expression of HP in a sensitive strain of mice, C57BL/6, and in a resistant strain of mice, DBA/2. They were exposed to the thermophilic bacteria Saccharopolyspora rectivirgula (SR) or to saline alone for 3 consecutive days/week for 3 wk. After exposure to Ag, C57BL/6 mice, but not DBA/2 mice, developed granulomatous inflammation with an increase in lung index (lung weight). Both strains had similar amounts of Ag delivered to the lungs after intranasal installation, as determined with 14C-labeled Ag. Both also had similar increases in total bronchoalveolar cells after Ag exposure, but the C57BL/6 mice had more lymphocytes. Compared with the resistant strain, the sensitive strain had a significantly greater Ag-induced increase in IL-12 and IFN-gamma gene expression. DBA/2 mice resembled sensitive, C57BL/6 mice if they received IL-12 augmentation therapy at the time of Ag exposure. These findings were not limited to lung, since both unstimulated and SR-stimulated spleen cells from C57BL/6 mice released significantly more IL-12 than cells from DBA/2 mice. However, spleen cells from DBA/2 mice made more IFN-gamma when exposed to IL-12, than cells from C57BL/6 mice. These results suggest that the IL-12 response to Ag may modulate in part the expression of HP.

Fertility in patients with epilepsy: a population-based study

OBJECTIVE

Several studies have suggested that people with epilepsy have altered fertility, but comparison groups have been imperfect.

METHOD

A retrospective cohort study of all live births to 209 incident patients with epilepsy in Iceland from 1960 to 1964 and live births to 418 age- (to the closest day of birth) and gender-matched residents without epilepsy.

RESULTS

Incident patients with epilepsy had an average of 2.0 children; the controls also had an average of 2.0 children. When people with idiopathic/cryptogenic epilepsy were compared with controls, there was no difference in number of children or number of partners overall, nor were there differences when stratified by seizure type or age at diagnosis. There was a deficit in the number of children among patients with remote symptomatic epilepsy. This was attributed to a reduced number of offspring of patients with mental retardation (MR) or cerebral palsy (CP) when compared with their controls.

CONCLUSION

There is no evidence of altered fertility among people with idiopathic/cryptogenic epilepsy or remote symptomatic epilepsy (other than MR or CP) within this population-based incidence cohort.

Hereditary cystatin C amyloid angiopathy: monitoring the presence of the Leu-68-->Gln cystatin C variant in cerebrospinal fluids and monocyte cultures by MS

Hereditary cystatin C amyloid angiopathy (HCCAA) is an autosomal dominant condition in which the patients suffer at an early age from repeated cerebral haemorrhages. The development of HCCAA is directly linked to a Leu-68-->Gln (L68Q) mutation in the cystatin C protein sequence. The concentration of cystatin C in cerebrospinal fluid (CSF) of HCCAA patients is markedly diminished and cultivated monocytes from affected individuals accumulate cystatin C. The goal of this work was to characterize cystatin C isolated from CSF and monocyte cultures originating from healthy persons and HCCAA patients with respect to the L68Q mutation. Cystatin C was isolated by carboxymethylpapain affinity chromatography. Proteins from CSF and monocyte cultures that bound specifically to the carboxymethylated papain column were resolved by reverse-phase HPLC chromatography and tryptic peptides were subsequently analysed by matrix-assisted laser desorption ionization MS. No evidence for mutated cystatin C protein was found in CSF samples from healthy subjects or HCCAA patients, but approx. 60% of the protein was found to be hydroxylated on Pro-3. No evidence was found for secretion of mutated cystatin C from HCCAA monocytes. However, we obtained evidence for the presence of mutated cystatin C in HCCAA monocytes. These results support the conclusion that the mutated cystatin C is retained in association with the monocytes and not secreted. An increased intracellular concentration would presumably promote the aggregation and denaturation of the mutated cystatin C, leading to the formation of amyloid fibrils and cell death.

Long-term survival of people with unprovoked seizures: a population-based study

PURPOSE

Few population-based studies of long-term survival in people with seizures or epilepsy have been made.

METHODS

Between January 1, 1960 and December 31, 1964, we identified 224 incidence cases of unprovoked seizures in Iceland and determined survivorship status and date of death for the cases as of January 1, 1996. We compared survivorship with that expected based on data from age-/sex-specific life tables from the country for 1961-1990 and calculated the standardized mortality ratio (SMR).

RESULTS

By 30 years after diagnosis, there were 45 deaths among patients with unprovoked seizures as compared with an expected 28 deaths [standardized mortality ratio (SMR) 1.6; 95% confidence interval (CI) 1.2-2.2]. Patients with unprovoked seizures of unknown etiology did not have a significant increase in mortality overall (SMR 1.3, 95% CI 0.8-1.9) or in any time interval. For patients with remote symptomatic unprovoked seizures, mortality was increased (SMR 2.3, 95% CI 1.4-3.5). This increase was attributable to excess mortality for the first 15 years after diagnosis (SMR 4.1, 95% CI 2.4-6.6), and SMR was not different after that time.

CONCLUSIONS

Survivorship was decreased for the population of patients with unprovoked seizures. The increased mortality was primarily due to excess mortality in patients with remote symptomatic seizures, occurring in the first 15 years after diagnosis. Overall mortality for idiopathic unprovoked seizures was not significantly increased.

[Epidemiological study on cognitive abilities in the elderly in two separate rural areas in Iceland.]

OBJECTIVES

This study was undertaken to estimate the cognitive abilities in an elderly population in rural areas in Iceland and to get an idea of the prevalence of dementia. By examining inhabitants in two different areas it was further possible to detect any possible difference in these areas.

MATERIAL AND METHODS

All persons aged 70 and over, living independently in the community and in institutions in two geographically separate areas were contacted. The areas were an agricultural (area A) and a fishing (area F) one. Four simple neuropsychological tests where used, the MMSE (Mini Mental State Examination), WAIS (Wechsler Adult Intelligence Scale)-Similarities, Trail making test A and Trail making test B. Two students in psychology and a teacher were trained in applying the tests but the results were scored and interpreted by the authors.

RESULTS

In area A, 280 of 353 (79.3%) participated and in area F, 190 of 238 (79.8%). Participation was thus similar in both areas. There was a highly significant difference in all the tests with p<0.01 in Trail making test B but p<0.001 in the other three tests. In all the tests the results were better among the population in area A. The prevalence of dementia as estimated by the MMSE showed a prevalence of 14.4% in area A and 35.7% in area F.

CONCLUSION

A significant difference in cognitive abilities was found between the elderly inhabitants of two separate rural areas in Iceland. There is substantial evidence to suggest that this difference is real but it is however not clear if the prevalence of dementia is higher in this study than in others. It is postulated that the difference found is due to cultural differences.

Long-term follow-up after methyl chloride intoxication

In this study, the authors investigated mortality and cancer patterns among a group of individuals accidentally exposed to methyl chloride 32 y earlier. This group of 24 persons had survived the immediate intoxication, which had occurred on a trawler during a fishing trip. The authors selected a reference group, which contained five times as many individuals as the study group, from registers of crews, and they controlled for age, occupation, social class, and lifestyle factors. The authors established a record linkage through personal identification numbers with the national death register and cancer register, thus securing 100% follow-up. The Mantel-Haenszel point estimate (M-H) was 2.2, and the 95% confidence interval (CI) was 1.3-3.1 for all causes of death. There was an excess of deaths from cardiovascular diseases (M-H = 2.1, 95% CI = 1.2-3.8). This excess mortality was more prominent among deckhands who had been subject to higher exposure; risk ratios (RRs) were elevated for all causes of death (RR = 2.5, 95% CI = 1.0-5.7), as well as for cardiovascular diseases (RR = 3.9, 95% CI = 1.0-14.4). In addition, the authors noted elevated risks for all cancers (M-H = 1.5, 95% CI = 0.3-5.6) and for lung cancer (M-H = 2.7, 95% CI = 0.1-52.6). The authors concluded that exposure to methyl chloride may have contributed to the risk of cardiovascular disease. Investigators need to conduct further studies on groups exposed to methyl chloride to refute or confirm this result.

Spirometric values in obese individuals. Effects of body position

Obesity is increasingly prevalent. Earlier studies indicated that there was a significant but small difference in spirometric values between sitting and standing position in the normal population. It is not known if this is true for obese individuals. The recommendations of the American Thoracic Society (ATS) are to document if a spirometry is done in a sitting or standing position. We performed a study in which we compared sitting and standing spirometric values in obese individuals. Patients with a body mass index (BMI) > or = 30 kg/m2 who were referred for spirometry were invited to participate. All tests were done according to American Thoracic Society recommendations. We studied 50 subjects (32 females and 18 males; mean age 45 yr [SD +/- 14.4]). Age range was 20-71 years. Average BMI was 39 (SD +/- 7, range 30 to 65). Twenty-two did the first testing in the sitting position and 28 standing. There was a small but statistically significant difference between forced vital capacity (FVC) in the standing versus sitting position (Wilcoxen test, p < or = 0.05). There was no significant difference in FEV1 between sitting and standing. Our conclusion is that body position is not important when performing spirometry in persons with BMI > or = 30 kg/m2.

Interferon-gamma is necessary for the expression of hypersensitivity pneumonitis

Farmers lung disease is a common form of hypersensitivity pneumonitis (HP) and is characterized by inflammation and granuloma formation in the lung. Interferon-gamma is important for the expression of granulomatous diseases caused by infectious agents; however, the role this mediator in regulating expression of the granulomatous response to inhaled antigen is not known. To evaluate this, we compared the response to inhaled antigen of mice that do not express the gene coding for interferon-gamma (GKO) with that of their normal littermates (WT). GKO and WT mice on a BALB/c background were exposed to 150 microg of the thermophilic bacteria Saccharopolyspora rectivirgula or saline alone, for three consecutive days a week, for 3 wk. After exposure to antigen, WT mice developed a marked granulomatous inflammation associated with an increase in lung weight and numbers of cells in bronchoalveolar lavage fluid (BAL). Although GKO mice also exhibited an increase in lung weight and numbers of cells in BAL fluid, they developed minimal inflammation and no granulomas after a similar exposure to antigen. To further evaluate if the lack of a response to antigen in GKO mice was due to lack of IFN-gamma, we replaced this mediator via intraperitoneal injections. When given replacement IFN-gamma, the GKO mice developed granulomatous inflammation in the lung. These studies show that IFN-gamma is essential for the expression of hypersensitivity pneumonitis.

A population-based study of prognosis of ruptured cerebral aneurysm: mortality and recurrence of subarachnoid hemorrhage

OBJECTIVE

To determine the risk of recurrent subarachnoid hemorrhage (SAH), mortality, and relative survivorship following SAH caused by ruptured cerebral aneurysm (RCA).

DESIGN/METHODS

The 86 individuals with a first diagnosis of SAH caused by RCA in Iceland from 1958 through 1968 were followed a minimum of 24 years (range, 24 to 32.5 years) or until death to determine mortality and to identify those with recurrent SAH.

RESULTS

Thirty-eight patients (44%) died within 30 days of the index event. Two additional (both comatose from onset of ictus) died in the following month. There were no deaths between 3 and 6 months after onset. Based upon the age/gender-specific person years of observation for the population of Iceland, the Standardized Mortality Ratio for the 44 surgically treated patients surviving 6 months was 1.3. Those neurologically normal or with only mild impairment at 6 months had no identified increase in mortality. Excess mortality that was limited to individuals with severe neurologic deficit at 6 months could be identified through the first 10 years after onset. Two 6-month survivors experienced recurrent SAH.

CONCLUSIONS

Early mortality is high (47%) in patients with RCA. In patients operated on for RCA and surviving 6 months, recurrent SAH occurred in 5%. Survivorship among patients surgically treated and neurologically normal or with mild residual neurologic impairment at 6 months following presentation was similar to that expected in the general population. Survivorship among patients surgically treated who had severe residual neurologic impairment at 6 months was significantly reduced.

[Surgery of lumbar disk prolapse in Scandinavia. A questionnaire study in Scandinavian neurosurgical departments in 1993]

This article consists in a review of treatment for lumbar disc prolapse in 1993, as reported by all 22 neurosurgery units in the Nordic countries, serving a total population of 23.5 million. Of surgical operations for the condition, 37 per cent were performed by neurosurgeons-using standard lumbar discectomy in 61.3 per cent of cases, microsurgical techniques in 36 per cent of cases, and percutaneous lumbar discectomy in the remaining 2.7 per cent. Chemonucleolysis is no longer considered a viable therapeutic alternative. In the Nordic countries as a whole, the annual incidence of lumbar disc prolapse surgery is 52.5 per 100,000, though the figure varies from one country to another.

Escherichia coli DNA polymerase II catalyzes chromosomal and episomal DNA synthesis in vivo

We have investigated a role for Escherichia coli DNA polymerase II (Pol II) in copying chromosomal and episomal DNA in dividing cells in vivo. Forward mutation frequencies and rates were measured at two chromosomal loci, rpoB and gyrA, and base substitution and frameshift mutation frequencies were measured on an F'(lacZ) episome. To amplify any differences in polymerase error rates, methyl-directed mismatch repair was inactivated. When wild-type Pol II (polB+) was replaced on the chromosome by a proofreading-defective Pol II exo- (polBex1), there was a significant increase in mutation frequencies to rifampicin resistance (RifR) (rpoB) and nalidixic acid resistance (NalR) (gyrA). This increased mutagenesis occurred in the presence of an antimutator allele of E. coli DNA polymerase III (Pol III) (dnaE915), but not in the presence of wild-type Pol III (dnaE+), suggesting that Pol II can compete effectively with DnaE915 but not with DnaE+. Sequencing the RifR mutants revealed a G --> A hot spot highly specific to Pol II exo-. Pol II exo- caused a significant increase in the frequency of base substitution and frameshift mutations on F' episomes, even in dnaE+ cells, suggesting that Pol II is able to compete with Pol III for DNA synthesis on F episomes.

Whooping cough and Parkinson's disease. The Europarkinson Preparatory Activity Research Group

BACKGROUND

We reported high levodopa use and prevalences of Parkinson's Disease (PD) in periodically, time-clustered, icelandic cohorts born after major whooping cough epidemics (MWCE).

METHODS

In order to quantify a possible relationship between age at first post-birth MWCE and risk of PD we: 1) calculated cumulative incidences of PD during the period 1954-1963 in one-year Icelandic cohorts born between 1869 and 1927, using raw material from a reported survey; 2) identified MWCE from 1869 onwards in Iceland; 3) estimated cohort ages at onset of incidence period and at first MWCE; and 4) combined the above-mentioned information using log-linear models. In addition, we studied the prevalence of levodopa users in Icelandic birth cohorts during a recent period.

RESULTS

The curves of the above-mentioned incidences and prevalences in one-year birth-cohorts showed: 1) a similar, age-related, inverted V profile; and 2) a systematic notchy pattern, with peak values for one or both measurements for cohorts born during or after each of nine MWCE identified during the period 1869-1927. When 13 cohorts born in years with MWCE were excluded from the analysis, the risk of PD rose with age at first defined MWCE, with the linear increase being 8.4% per year (95% CI: -0.1-18.3%).

CONCLUSIONS

These results are consistent with reported effects of age at exposure in animal models of toxic parkinsonism, age-related changes in the dopamine receptor-GPT-binding protein-adenylatecyclase system observed in rats treated with pertussis toxin, and some PD epidemiological features. They suggest that pertussis neurotoxicity could be casually treated to PD worldwide.

Incidence of epilepsy in rural Iceland: a population-based study

PURPOSE

We wished to determine the incidence of epilepsy in the population of rural Iceland.

METHODS

Cases were identified through review of records of primary care facilities for the study population, supplemented by review of referrals to EEG facilities and neurologic specialists.

RESULTS

The incidence of epilepsy (recurrent unprovoked seizures) was 47 in 100,000. Age-specific incidence was bimodal, highest in the youngest and oldest age groups. About one third of the patients had an identifiable etiology, and one third had partial seizures. Integration of imaging and neurophysiologic data did little to modify the distribution of etiology or seizure type.

CONCLUSIONS

The present study confirms findings of other recent studies of incidence in Western Countries.

Progressive dementia and leucoencephalopathy as the initial presentation of late onset hereditary cystatin-C amyloidosis. Clinicopathological presentation of two cases

Hereditary Cystatin-C Amyloidosis (HCCA) is a genetic disorder in Icelandic families in which a defective cystatin-C amyloid protein is deposited in the walls of small and middle sized arteries. Cerebral vessels are most affected, resulting in recurrent cerebral hemorrhages and infarctions, usually with onset of clinical symptoms in the twenties or thirties and a rapidly deteriorating clinical course. The disease can be diagnosed by a skin biopsy in symptomatic patients. We report two patients (father and daughter) who did not have a known family history of the disorder and presented late in life with a progressive dementia, associated with cerebral hemorrhages in the younger patient. Cerebral MRI and CT scans of this patient showed extensive leukoencephalopathic changes. Brain tissue samples from both patients showed immunohistochemical reaction to cystatin-C in small and medium-sized cerebral arteries and extensive cortical and white matter microinfarctions. The amyloid changes were less severe in the older patient and a colocation of beta-amyloid protein and cystatin-C was observed in addition to neurofibrillary tangles and senile plaques. Subcortical and cortical infarctions were also observed. HCCA may present late in life with progressive dementia as the only clinical manifestation, reflecting a multi-infarct syndrome secondary to the amyloidosis. A coexpression of cystatin-C and beta protein may occur as in other cerebral amyloid disorders, probably as age-specific changes.

Middle lobe syndrome

Middle lobe syndrome is defined as recurrent or chronic collapse of the middle lobe of the right lung. It occurs in all age groups and is divided into an obstructive type, with a demonstrable airway occlusion, and a nonobstructive type, with a patent right middle lobe bronchus apparent on bronchoscopy. Middle lobe collapse has specific radiographic findings. Malignancy is the most common cause of the obstructive type, and infections are the second leading etiology. The nonobstructive type is associated with inflammatory conditions and bronchiectasis. In all cases, treatment is directed at the underlying cause.

[MRI of the brain as a diagnostic tool in Wilson's Disease.]

The case history of a young patient with Wilson's disease (WD) is presented. The diagnosis of WD was based on increased urinary copper excretion, the presence of Keyser-Fleisher rings, changes observed on MRI of the brain and a remote family history of WD. The patient's parents were distantly related. The MRI showed symmetrically increased signal in the basal ganglia and in the brain stem on protein density and T2 weighted images. Similar changes were later observed in the thalamic nuclei. Signal changes observed on cerebral MRI in WD and their diagnostic and prognostic significance are discussed. The importance of recognising the symptoms of WD is emphasized, as early treatment may prevent death from hepatic failure or permanent damage of the central nervous system.

Proofreading-defective DNA polymerase II increases adaptive mutation in Escherichia coli

The role of Escherichia coli DNA polymerase (Pol) II in producing or avoiding mutations was investigated by replacing the chromosomal Pol II gene (polB+) by a gene encoding an exonuclease-deficient mutant Pol II (polBex1). The polBex1 allele increased adaptive mutations on an episome in nondividing cells under lactose selection. The presence of a Pol III antimutator allele (dnaE915) reduced adaptive mutations in both polB+ cells and cells deleted for polB (polB delta 1) to below the wild-type level, suggesting that both Pol II and Pol III are synthesizing episomal DNA in nondividing cells but that in wild-type cells Pol III generates the adaptive mutations. The adaptive mutations were mainly -1 frame-shifts occurring in short homopolymeric runs and were similar in wild-type, polB delta 1, and polBex1 strains. Mutations produced by both Pol III and Pol II ex1 were corrected by the mutHLS mismatch repair system.

Wilson disease in Iceland: a clinical and genetic study

A survey of Wilson disease in Iceland has revealed two large kindreds with affected individuals. We have carried out studies of haplotypes of dinucleotide repeat polymorphisms (CA repeats) flanking the Wilson disease gene. The same mutation, a 7-bp deletion, is present in both families, and the clinical features are similar. The haplotype data and nature of the mutation support the existence of a founder chromosome carrying the mutation. This Icelandic mutation was not found in patients of Irish or Scottish origins, who could share some of the Icelandic ancestral genes. Although the protein function is predicted to be completely abolished by the deletion, predicting early-onset liver disease, we find that the patients present with later-onset neurological and psychiatric symptoms. We show that alternative splicing of the transcript in the region of the deletion could contribute to later onset, suggesting that alternative isoforms of the protein might have some functional significance.

Complications to the use of vicryl-collagen dural substitute

The authors describe 3 cases of postoperative infection as a complication after the use of vicryl-collagen dural substitute. The substitute had already partially dissolved 2 weeks after surgery with the remnant so densely adherent to the brain surface that it could not be removed without damaging the cortex. This was confirmed microscopically.

Fatty acids from cod-liver oil as skin penetration enhancers

A fatty acid extract is discharged during the refining of medicinal cod-liver oil. The fatty acid composition of the extract was determined and it was found to contain an vast variety of fatty acids. About 17% of the fatty acids consisted of saturated fatty acids, the rest was unsaturated fatty acids. The extract was an effective transdermal penetration enhancer and this effect was found to be associated with the unsaturated portion of fatty acids.

High levodopa use in periodically time-clustered, Icelandic birth cohorts. A vestige of parkinsonism etiology? Europarkinson Preparatory Activity Research Group

We evaluated levodopa use (LDU) by the Icelandic population focusing on: 1) annual gross levodopa (LD) sales from wholesalers to pharmacies for the period 1978-1990, using a reported method; 2) data from a prescription survey conducted from October 1st, 1990 to March 31st, 1991; and 3)raw and reported data on prevalences of Parkinson's disease (PD) in 1963 in this country. The standard for adjustments and reference population for LDU comparisons was the Swedish in 1984. Crude gross sales of LD in Iceland in 1990 and in Sweden in 1984 amounted to 1.67 and 1.35 DDD/1000 person days respectively. After respective adjustments for age, and for age and the infant mortality rates, taken as an indicator of health care quality, LDU in Iceland in 1990 was found to be 1.82 and 1.63 (95% CI 1.47-1.89) times that for Sweden. Prevalences of LD-prescription recipients in 1990-1991 and of PD in 1963 increased with age; however, those of drug users were higher than those of PD among the elderly. Higher-than-expected prevalences of PD and LD-prescription users (there being a partial overlap between these two categories) were found in periodically-clustered, one-year birth cohorts. These results support the notion that Iceland has a high LDU and suggest that this variation is due to a high prevalence of LD responsive disorders. Cohorts born after registered whooping cough outbreaks in Iceland may account for the magnitude and birth-related pattern of PD prevalences and LDU levels.

Involvement of Escherichia coli DNA polymerase II in response to oxidative damage and adaptive mutation

DNA polymerase II (Pol II) is regulated as part of the SOS response to DNA damage in Escherichia coli. We examined the participation of Pol II in the response to oxidative damage, adaptive mutation, and recombination. Cells lacking Pol II activity (polB delta 1 mutants) exhibited 5- to 10-fold-greater sensitivity to mode 1 killing by H2O2 compared with isogenic polB+ cells. Survival decreased by about 15-fold when polB mutants containing defective superoxide dismutase genes, sodA and sodB, were compared with polB+ sodA sodB mutants. Resistance to peroxide killing was restored following P1 transduction of polB cells to polB+ or by conjugation of polB cells with an F' plasmid carrying a copy of polB+. The rate at which Lac+ mutations arose in Lac- cells subjected to selection for lactose utilization, a phenomenon known as adaptive mutation, was increased threefold in polB backgrounds and returned to wild-type rates when polB cells were transduced to polB+. Following multiple passages of polB cells or prolonged starvation, a progressive loss of sensitivity to killing by peroxide was observed, suggesting that second-site suppressor mutations may be occurring with relatively high frequencies. The presence of suppressor mutations may account for the apparent lack of a mutant phenotype in earlier studies. A well-established polB strain, a dinA Mu d(Apr lac) fusion (GW1010), exhibited wild-type (Pol II+) sensitivity to killing by peroxide, consistent with the accumulation of second-site suppressor mutations. A high titer anti-Pol II polyclonal antibody was used to screen for the presence of Pol II in other bacteria and in the yeast Saccharomyces cerevisiae. Cross-reacting material was found in all gram-negative strains tested but was not detected in gram-positive strains or in S. cerevisiae. Induction of Pol II by nalidixic acid was observed in E. coli K-12, B, and C, in Shigella flexneri, and in Salmonella typhimurium.

On the role of monocytes/macrophages in the pathogenesis of central nervous system lesions in hereditary cystatin C amyloid angiopathy

The pathogenesis of the deposition of a variant cystatin C as amyloid in hereditary cystatin C amyloid angiopathy (HCCAA) is not known. To address this question the synthesis and secretion of cystatin C in cultured monocytes from 9 carriers of the mutated cystatin C gene (5 symptomatic and 4 asymptomatic) was examined. The quantity of cystatin C in cells and supernatants was determined by the ELISA method, Western blots were done and selected samples immunostained for cystatin C. Monocytes from individuals carrying the gene defect synthesized cystatin C that was apparently not truncated, a form found in the cerebral amyloid deposits in HCCAA, but showed a distinctly lower rate of cystatin C synthesis than monocytes from healthy controls. The main difference was that the quantity of cystatin C was significantly lower in the supernatants in monocyte cultures from carriers of the gene defect than from healthy controls, possibly due to a partial block in its secretion. This abnormal processing of the cystatin C could explain the low cerebrospinal fluid levels of cystatin C in HCCAA and might be a part of the pathogenetic pathway of amyloid deposition. Furthermore it could, through a lower extracellular concentration of this inhibitor of cysteine proteinases, contribute to destruction of the amyloidotic blood vessels, leading to the most serious clinical manifestation in HCCAA, intracerebral hemorrhage.

Piroxicam and indomethacin suppositories for painful coxarthrosis

Six orthopaedic clinics in Sweden made a comparison of the effects and side effects of Piroxicam (20 mg) and Indomethacin (100 mg) suppositories in 261 patients with painful coxarthrosis on the waiting list for total hip replacement (THR). The study was designed as a single blind study over 4 weeks. Amount of pain and range of motion was registered before the trial and compared with findings after 4 weeks, including reported side effects. Both drugs gave satisfactory pain relief without any appreciable variation on weightbearing or at rest. On the other hand, the trial showed a significant difference (p = 0.0033, Student's-test) between the two drugs as regards the frequency of side effects from the lower gastrointestinal tract, where piroxicam had a lower rate compared with indomethacin. No serious complications occurred; 16 patients dropped out, 8 in each group.

Primary cytomegalovirus infection and gastric ulcers in normal host

A 42-year-old woman presented with epigastric pain and vomiting. Upper gastrointestinal endoscopy revealed three gastric ulcers. Histologic examination of biopsies from the ulcers showed cytomegalovirus inclusion bodies. The appearance of IgM antibodies to cytomegalovirus indicated a recent and primary infection. Stored serum from her last pregnancy 17 months previously contained no cytomegalovirus antibodies. A thorough evaluation of her immune system revealed no abnormality. We are aware of only two other cases where seroconversion was documented in normal hosts. Cytomegalovirus infections in the gastrointestinal tract of normal hosts are very unusual but a common cause of morbidity in immunocompromised hosts. We believe that cytomegalovirus may have a role in the pathogenesis of gastrointestinal lesions in nonimmunocompromised patients.

Skin deposits in hereditary cystatin C amyloidosis

Clinically normal skin from 47 individuals aged 9-70 years was investigated. Cystatin C amyloid deposits were found in various locations of the skin by light and/or electron microscopy, in all 12 patients with a clinical history of hereditary cystatin C amyloidosis (HCCA). Six asymptomatic individuals, who had the Alu 1 restriction fragment length polymorphism (RFLP) marker reported to cosegregate with the disease, also had cystatin C amyloid deposits in the skin. Three asymptomatic individuals (age 17-46) belonging to the HCCA families were without amyloid in the skin but had Alu 1 RFLP marker. Skin from 12 individuals who served as controls and skin from 14 close relatives of the patients was negative for amyloid. Punch biopsy of the skin is a simple procedure which is of value for the diagnosis of HCCA, even before the appearance of clinical symptoms. This method might also be of use in following progression of the disease.

The amino terminal portion of cerebrospinal fluid cystatin C in hereditary cystatin C amyloid angiopathy is not truncated: direct sequence analysis from agarose gel electropherograms

The isolated amyloid substance in hereditary cystatin C amyloid angiopathy (HCCAA) is mainly composed of a cystatin C variant devoid of the 10 amino terminal amino acid residues of extracellular cystatin C from healthy individuals. We have developed a procedure for protein sequencing directly from agarose gel electropherograms and used this in conjunction with isoelectric focusing to investigate the amino terminal sequence of cerebrospinal fluid (CSF) cystatin C in HCCAA patients. The amino-terminal sequence determined for cystatin C from a HCCAA patient CSF sample, Xaa-Ser-Pro-Gly-Lys-Pro-Pro-Xaa-Leu-Val-Gly-Gly-Pro-Met-Xaa-Ala-Xaa-Val, showed that the protein was not amino-terminally truncated. CSF cystatin C from all nine HCCAA patients investigated was found to have an isoelectric point identical to that of native cystatin C, and the truncated form of cystatin C isolated from amyloid deposits was shown to contribute to less than 1% of the total amount of cystatin C in CSF. The total cysteine proteinase inhibitory capacity of CSF from HCCAA patients was lower than that of CSF from other patients. This decreased CSF inhibitory capacity in HCCAA patients was caused by decreased levels of cystatin C, since the levels of the other two cysteine proteinase inhibitors found in CSF, alpha 2-macroglobulin and kininogen, were significantly higher than in CSF from non-HCCAA patients.