The Relationship of Transcranial Doppler Ultrasonography with Attention, Motor, and Social-Emotional Functioning in Pediatric Sickle Cell Disease

Objective

Children with sickle cell disease (SCD) are at greater risk for certain neuropsychological deficits due to their medical condition and associated complications. Previous studies have explored the relationship between Transcranial Doppler (TCD) ultrasonography and various domains of neuropsychological functioning in pediatric SCD populations; however, these studies are dated, present variable and inconsistent findings, and are somewhat limited in scope. The goal of this study was to update and expand upon previous research by examining the predictive relationship of TCD results with measures of attention, motor, and social-emotional functioning.

Methods

Thirty-six patients ages 3-19 with SCD with no known history of stroke, with TCD completed within the past 12 months, underwent a brief neuropsychological exam. Attention, motor, and social-emotional functioning were assessed as appropriate for age using the Conners Continuous Performance Test (K-CPT2/CPT3), Purdue Pegboard, and PROMIS, respectively. TCD values were gathered via medical record review, using the highest value of most recent TCD.

Results

TCD significantly predicted certain aspects of attention and motor ability, but not social-emotional functioning. Specifically, TCD significantly predicted Detectability (p = .005), Omissions (p = .001), Commissions (p = .012), Perseverations (p = .035), and HRT SD (p = .046) on K-CPT2/CPT-3 and the non-dominant (p = .009) and bilateral (p = .024) trial scores on the Purdue Pegboard.

Conclusion

This study provides new evidence that TCD may be predictive of motor functioning in pediatric SCD. Results confirm that TCD is predictive of attentional function, though subdomains impacted varied from previous research. While no significant relationship between psychosocial symptoms and TCD were identified, further studies utilizing more comprehensive measurement within this domain is warranted.

Ein System von Zusatznotationen zur Vereinfachung der histologischen Tumordokumentation mittels ICD-O

Es wird eine Zusatznotation zur ICD-0 bei voller Kompatibilität vorgestellt, die eine leichte Auswertung und Codierung patho-histologischer Tumordiagnosen nach Malignität und Ausdehnung sowie nach der geweblichen Herkunft des Tumors zuläßt. Wie am Beispiel der histologischen Diagnosen des Regionalen Krebsregisters Nordbaden für Magen-Darm-Tumoren aufgezeigt wird, ist diese Zusatznotation zur Auswertung übergeordneter Begriffe, z.B. Anzahl der mesenchymalen Tumoren im untersuchten Material, äußerst nützlich.

Logic and Diagnosis

Among the diagnostic algorithms, the statistic syllogism, the Westmeyer model and the confirmative model are discussed. Three methods to eliminate the logical inconsistencies of the statistical syllogism are shown: 1) Substitution of the inductive probability for the objective probability; 2) Replacement of the unconditional probability by the probability limited to the specific antecedents; 3) Proposing a certain distribution of diagnostic rules.

Particularly 2) and 3) are of significance in the construction of a medical thesaurus and point to the separation of identification numbers and search structures. The Westmeyer model can be used to calculate the maximum possible number of diagnoses. The ›static‹ confirmative model can be modified into a dynamic one. This dynamic model allows conclusions regarding. the time-dependence of diagnoses and examination methods.

Thesaurus der Medizin (TdM) - An Internationally Compatible Diagnostic System of Medicine

An internationally compatible medical thesaurus in German, the TdM, is presented. The principle of its structure is based on a documentation language including a complete hierarchic classification as well as a very variable faceted one. The structure items of the thesaurus are marked by abbreviations constructed mnemotechnically by letter corresponding to the hierarchic classification, the digits to the facet division. The organisation of the facets is done in such a way that they can be regarded as additional aspects within the arrangement of the hierarchic classification. The aspect of the meaning of a diagnosis is marked by a string, every item consisting of several strings. The number of strings is unlimited in general. The codification structures of the ICD/E, KDS and SNOP are included in every diagnosis. The thesaurus has a total volume of about 22,000 diagnoses.

Pattern Recognition in Histo-Pathology: Basic Considerations

A basic concept for the automatic diagnosis of histo-pathological specimen is presented. The algorithm is based on tissue structures of the original organ. Low power magnification was used to inspect the specimens. The form of the given tissue structures, e. g. diameter, distance, shape factor and number of neighbours, is measured. Graph theory is applied by using the center of structures as vertices and the shortest connection of neighbours as edges. The algorithm leads to two independent sets of parameters which can be used for diagnostic procedures. First results with colon tissue show significant differences between normal tissue, benign and malignant growth. Polyps form glands that are twice as wide as normal and carcinomatous tissue. Carcinomas can be separated by the minimal distance of the glands formed. First results of pattern recognition using graph theory are discussed.

Formal Considerations on Text Analysis in Anatomic Pathology

The different steps for medical text analysis from the examination of the object to the codification of diagnoses are outlined and formally described. Three types of methods are differentiated according to the point in the procedure at which the computer is used: the manual, the semi-automatic and the fully automatic methods. It is shown that the objective gain in information and the possible control are at maximum in the semi-automatic method when the examining doctor undertakes not only the writing of the summary of findings but also the extraction of the relevant diagnoses. The semi-automatic method is, in this case, as valuable as the fully automatic method with respect to completeness of information when using a thoroughly up-to-date thesaurus.

Indexed Text-Analysis

General conditions for medical text analysis are discussed. By means of formal description the errors which occur during manual codification with the over-cross method are analysed by distribution in different classes of diagnoses. It is pointed out that the largest error arises through incorrect correlation of the diagnoses in the summary of findings with those of the thesaurus and that, furthermore, a thesaurus of 4,500 medical terms is not sufficient for documentation in pathology. The entropy losses were only slightly larger than the losses of diagnoses calculated by percentage. The distribution of the classes of diagnoses follows a general statistical theory. In the over-cross method a loss of information Iμ = 1.532 in a total entropy of HD = 5.789 must be reckoned with as shown in an example.

The galactoside-specific lectin from mistletoe as biological response modifier

Experience with herbal extracts can guide the isolation of substances that effectively amend aspects of the host's defence system against tumor growth and spread. This capacity appears to be conferred to mistletoe (Viscum album) extract by a rather small dose range of the galactoside-specific lectin (VAA). It is a biochemically characterized dimer, consisting of a toxic subunit that acts as a RNA N-glycosidase (depurination of A-4324 in 28S rRNA) and a carbohydrate-binding B-chain. The binding of this subunit to galactose-exposing glycoligands on mononuclear cells elicits cytokine secretion in vitro and antitumoral/antimetastatic capacity in vivo in lymphosarcoma/sarcoma model systems. Increases in NK cell number, the activity of peritoneal macrophages and NK cells as well as the response of splenic T cells to mitogens are detectable. Immunophenotyping of blood samples from lectin-treated patients reveals increases in the number of helper/inducer T cells, NK cells and CD25-positive cells. Since the response to the treatment is assumed to be dependent on the presence of lectin-specific ligands on inflammatory host cells, histopathological monitoring of tumor specimens with labelled lectin is conceivable to be one factor of relevance to predict a response to the treatment in animal models or within clinical trials.

Prognostic relevance of detection of ligands for vertebrate galectins and a Lewis(Y)-specific monoclonal antibody

Tissue sections taken from 157 potentially curatively operated lung carcinoma patients (70 epidermoid carcinomas, 68 adenocarcinomas, 15 large cell anaplastic, and 4 small cell anaplastic carcinomas) were examined by a standardized histochemical protocol in a prospective study evaluating the extent of various types of probes to serve as prognostic indicators in lung cancer. Detailed clinical records and survival data (minimum 56 weeks, maximum 96 weeks) were correlated to the results of the histochemical reactions. The study centres on monitoring the expression of galactoside-containing epitopes in tumor cells by human, animal and plant lectins: and with a monoclonal antibody. In addition, affinity-purified subfractions of natural antibodies from human serum with preferential affinity to alpha- and beta-galactosides, respectively, were employed. Significant contributions to the estimation of the survival of patients are given by clinical parameters (pT, pN stage), number of resected and positive lymph nodes and presence of tumor metastases into specific lymph nodes (No. 5 and No. 6 right and left). With respect to the relevance of subsets of beta-galactosides, the galectin from chicken liver (CL-16) and the Le(y)-specific monoclonal antibody unveiled a negative correlation at a statistically significant level. The predictive value of binding of the animal lectin CL-16 was especially pronounced for patients with advanced tumor stages, pointing to a potential role of such lectin-reactive beta-galactosides in late tumor stages or progression.

MHC class II tetramer guided detection of Mycobacterium tuberculosis-specific CD4+ T cells in peripheral blood from patients with pulmonary tuberculosis

Novel diagnostic tools are needed to diagnose latent infection and to provide biologically meaningful surrogate markers to define cellular immune responses against Mycobacterium tuberculosis (MTB). Interferon gamma-based assays have recently been developed in addition to the more than 100-year-old tuberculin skin test (TST) for the immune diagnosis of MTB in blood. The advent of soluble MHC/peptide tetramer molecules allows to objectively enumerate antigen-specific T cells. We identified novel MHC class II-restricted MTB epitopes and used HLA-DR4 tetrameric complexes to visualize ex vivo CD4(+) T cells directed against the antigens Ag85B and the 19-kDa lipoprotein, shared between MTB and other Mycobacterium species, and CD4(+) T cells which recognize the MTB-associated ESAT-6 antigen. MTB-reactive CD4(+) T cells reside predominantly in the CD45RA(+) CD28(+) and CD45(-) CD28(+) T-cell subset and recognize naturally processed and presented MTB epitopes. HLA-DR4-restricted, Ag85B or ESAT-6-specific CD4(+) T cells show similar dynamics over time in peripheral blood mononuclear cells (PBMC) when compared with CD8(+) T cells directed against the corresponding HLA-A2-presented MTB epitopes in patients with pulmonary MTB infection and subsequent successful therapy. This was not found to be true for T-cell responses directed against the 19-kDa lipoprotein. The dissection of the cellular immune response in M. tuberculosis infection will enable novel strategies for monitoring MTB vaccine candidates and to gauge CD4(+) T cells directed against MTB.

Digitized pathology: theory and experiences in automated tissue-based virtual diagnosis

AIMS

To describe the theory and develop an automated virtual slide screening system. Theoretical considerations. Tissue-based diagnosis separates into (a) sampling procedure to allocate the slide area containing diagnostic information, and (b) evaluation of diagnosis from the selected area. Nyquist's theorem broadly applied in acoustics, serves to presetting the sampling accuracy. Tissue-based diagnosis relies on two different information systems: (a) texture, and (b) object information. Texture information can be derived by recursive formulas without image segmentation. Object information requires image segmentation and feature extraction. Both algorithms complete another to a "self-learning" classification system.

METHODS

Non-overlapping compartments of the original virtual slide (image) are chosen at random with predefined error-rate (Nyquist's theorem). The standardized image compartments are subject for texture and object analysis. The recursive formula of texture analysis computes median gray values and local noise distribution. Object analysis includes automated measurements of immunohistochemically stained slides. The computations performed at different magnifications (x 2, x 4.5, x 10, x 20, x 40) are subject to multivariate statistically analysis and diagnosis classification.

RESULTS

A total of 808 lung cancer cases of diagnoses groups: cohort (1) normal lung (318 cases) - cancer (490 cases); cancer subdivided: cohort (2) small cell lung cancer (10 cases) - non-small cell lung cancer (480 cases); non-small cell lung cancer subdivided: cohort (3) squamous cell carcinoma (318 cases) - adenocarcinoma (194 cases) - large cell carcinoma (70 cases) was analyzed. Cohorts (1) and (2) were classified correctly in 100%, cohort (3) in more than 95%. The selected area can be limited to 10% of the original image without increased error rate. A second approach included 233 breast tissue cases (105 normal, 128 breast carcinomas) and 88 lung tissue cases (58 normal, 38 cancer). Texture analysis revealed a correct classification with only 10 training set cases in >92% for both, breast and lung tissue.

CONCLUSIONS

The developed system is a fast and reliable procedure to fulfill all requirements for an automated "pre-screening" of virtual slides in tissue-based diagnosis.

From telepathology to virtual pathology institution: the new world of digital pathology

Telepathology has left its childhood. Its technical development is mature, and its use for primary (frozen section) and secondary (expert consultation) diagnosis has been expanded to a great amount. This is in contrast to a virtual pathology laboratory, which is still under technical constraints. Similar to telepathology, which can also be used for e-learning and e-training in pathology, as exemplarily is demonstrated on Digital Lung Pathology (Klaus.Kayser@charite.de) at least two kinds of virtual pathology laboratories will be implemented in the near future: a) those with distributed pathologists and distributed (> or = 1) laboratories associated to individual biopsy stations/surgical theatres, and b) distributed pathologists (usually situated in one institution) and a centralized laboratory, which digitizes complete histological slides. Both scenarios are under intensive technical investigations. The features of virtual pathology comprise a virtual pathology institution (mode a) that accepts a complete case with the patient's history, clinical findings, and (pre-selected) images for first diagnosis. The diagnostic responsibility is that of a conventional institution. The Internet serves as platform for information transfer, and an open server such as the iPATH (http://telepath.patho.unibas.ch) for coordination and performance of the diagnostic procedure. The size and number of transferred images have to be limited, and usual different magnifications have to be used. The sender needs to possess experiences in image sampling techniques, which present with the most significant information. A group of pathologists is "on duty", or selects one member for a predefined duty period. The diagnostic statement of the pathologist(s) on duty is retransmitted to the sender with full responsibility. The first experiences of a virtual pathology institution group working with the iPATH server working with a small hospital of the Salomon islands are promising. A centralized virtual pathology institution (mode b) depends upon the digitalization of a complete slide, and the transfer of large sized images to different pathologists working in one institution. The technical performance of complete slide digitalization is still under development. Virtual pathology can be combined with e-learning and e-training, that will serve for a powerful daily-work-integrated pathology system. At present, e-learning systems are "stand-alone" solutions distributed on CD or via Internet. A characteristic example is the Digital Lung Pathology CD, which includes about 60 different rare and common lung diseases with some features of electronic communication. These features include access to scientific library systems (PubMed), distant measurement servers (EuroQuant), automated immunohisto-chemistry measurements, or electronic journals (Elec J Pathol Histol, www.pathology-online.org). It combines e-learning and e-training with some acoustic support. A new and complete database based upon this CD will combine e-learning and e-teaching with the actual workflow in a virtual pathology institution (mode a). The technological problems are solved and do not depend upon technical constraints such as slide scanning systems. At present, telepathology serves as promoter for a complete new landscape in diagnostic pathology, the so-called virtual pathology institution. Industrial and scientific efforts will probably allow an implementation of this technique within the next two years with exciting diagnostic and scientific perspectives.

Bronchioloalveolar carcinoma: a new cancer in Peutz-Jeghers syndrome

Besides gastrointestinal hamartomatous polyposis and melanin spots in the skin and mucosa, patients with the Peutz-Jeghers syndrome (PJS) have repeatedly been observed with a variety of tumours, including lung cancer. Available data indicate an increased cancer risk among PJS patients, which suggests that the gene involved in PJS, STK11 on chromosome 19p13.3, may be a tumour suppressor gene. Herein, bronchioloalveolar carcinoma (BAC) of mucinous type is reported in a 22-year old male PJS patient with a novel germline frameshift insertion in exon 2 at codon 118 of the STK11 gene. Molecular studies of his BAC indicated loss of heterozygosity (LOH) in the region of STK11 on chromosome 19p13.3. This observation supports the hypothesis that STK11 is a tumour suppressor gene which is involved in the development of lung adenocarcinoma.

Phenotype and genotype associations of lung carcinoma with atypical adenomatoid hyperplasia, squamous cell dysplasia, and chromosome alterations in non-neoplastic bronchial mucosa

The frequency of preneoplastic lesions of the lung and bronchial mucosa as well as potential genotype alterations in spatial relationship to pulmonary malignancies still need intensive investigations in order to understand the occurrence and manifestation of lung cancer in detail. To investigate the contemporary manifestation of lung cancer precursor lesions, peripheral (non-neoplastic) lung parenchyma and bronchial mucosa of operated lung carcinomas were analyzed at distinct distances (1, 2, 3, and 4 cm) from the tumor boundary for pre-neoplastic lesions--atypical adenomatoid hyperplasia (AAH) and squamous cell dysplasia (SCD), in 150 surgical specimens. Short-term tissue cultures of additional 55 primary and secondary lung tumors and their surrounding non-neoplastic bronchial mucosa were performed at the same distances in order to search for chromosome alterations, i.e. genotype aberrations. In phenotype observations, atypical adenomatoid hyperplasia was noted in 19/150 (13%) cases, and squamous cell dysplasia in 46/150 (31%) cases. The degree of cellular atypia decreased with increasing distance from the tumor boundary in both AAH and SCM. AAH was observed more frequently in adenocarcinomas, SCQ more frequently in squamous cell carcinomas. In genotype observations, the average number of abnormal metaphases measured 4.5/10 high power fields (HPF) in primary lung carcinomas, and only 2/10 in metastases. Data indicate that the so-called preneoplastic lesions in the lung are not completely tumor-precursor lesions, but, in addition, induced by the tumor itself.

Processes in vertical-flow reed beds: nitrification, oxygen transfer and soil clogging

Vertical-flow reed beds (VF) with intermittent feeding are extremely reliable regarding aerobic processes. For a save operation with high nitrification rates and without soil clogging it is essential to preserve aerobic conditions in the filter. The challenge is to keep aerobic conditions in the filter without oversizing the system (economical aspects). It is very difficult to determine the current oxygen content in the filters because it ultimately results from complex interactions of a large number of different influencing parameters such as loading rate, degree of clogging, temperature, and hydraulic behaviour of the reed bed. To gain better knowledge of this complex system, different tests and examinations were carried out over several years. Focusing on the questions of identification and the description of conversion and transport processes (water/gas), a full-scale treatment plant under clogged and non-clogged conditions was investigated in detail. Additionally soil column test were carried out. The results make it possible to describe some of the processes and their interactions in the filter body. Recommendations for a safe and controlled operation can be derived.

Combined analysis of tumor growth pattern and expression of endogenous lectins as a prognostic tool in primary testicular cancer and its lung metastases

The aim of this study was to glyco- and immunohistochemically analyze expression of distinct growth/adhesion-related markers of primary testicular carcinomas and their lung metastases in relation to the risk of developing lung metastases and survival of patients, and to correlate immunohistochemical staining profile and syntactic structure analysis in order to delineate new prognostic parameters for this tumor type. Clinical features of 50 patients with primary testicular carcinomas and their corresponding lung metastases were evaluated and compared to those of a control cohort of 25 cases. The set of eight probes including labeled galectins-1 and -3, specific non-cross-reactive antibodies against galectins-1, -3, and -8 as well as anti-Ki-67, anti-bcl-2, and anti-p53 was applied to formalin-fixed, paraffin-embedded tumor sections of both primary and metastatic lesions. Syntactic structure analysis computed staining intensities and structural features of the tumor cells. These parameters were set into relation separately and in combination to clinical data including tumor stages, smoking habits, applied cytostatic therapy, disease-free interval, and survival. The risk of testis cancer patients to develop lung metastases depends in descending order on the tumor cell type (non-seminoma versus seminoma), tumor cell heterogeneity (mixed versus monomorphous cell type), age of patients, and pT stage. The extent of differential expression of galectin-related features between primary and secondary lesions was pronounced. Prognostic correlations for distinct galectin-related features were delineated in combination with data from syntactic structure analysis, for example cluster radius of galectin-3-positive tumor cells and post-surgical and total survival. Lengths of disease-free interval and total survival of patients were also correlated to characteristics obtained by syntactic structure analysis and their combination with galectin data in the first place, then to smoking habits, percentage of proliferating cells in the primary and secondary tumors, and finally to expression of certain galectins and of p53. Patients with non-seminoma testicular cancer should be thoroughly controlled for lung metastases. Regarding marker selection, our study underscores that further investigation of the growth-regulatory network of galectins is clearly warranted.

Controlling a combined lagoon/reed bed system using the oxidation-reduction potential (ORP)

Lagoon systems achieve good and stable effluent data in regard to organic pollutants, but they charge the receiving waters with relatively high ammonium loads. Therefore an existing lagoon-plant was extended by a vertical flow reed-bed for the special purpose of nitrification. This paper presents the efficiency of the combination plant as well as the possibility to monitor and control the reed-bed operation by the oxidation-reduction potential (ORP). The results show that the combination plant achieved excellent purification results, the average efficiency degrees were 97% for COD, 77% for N(total) and 94% for the TKN elimination. The ORP in the effluent of the reed bed showed a clear dependence in its characteristic course and its absolute values on the current nitrification performance, the oxygen supply and the hydraulic behaviour of the reed bed. Therefore the ORP is a very good indicator for the state of the reed bed, which ultimately results from the accumulation of a large number of different influencing parameters. As the preservation of aerobic conditions in the reed bed is the crucial prerequisite for a high nitrification performance and for the avoidance of clogging, the ORP thus offers the possibility of immediate operation control.

Nutrient removal from piggery effluent using vertical flow constructed wetlands in southern Brazil

Santa Catarina State, southern Brazil, has the greatest swine breeding activities of Latin America. Generally, the piggery wastewater is treated in pond systems that are able to remove organic material according to local environmental legislation. However, these systems do not remove nitrogen and phosphorus efficiently. This work deals with a post-treatment system, using vertical flow constructed wetlands. The experiment was conducted in a swine production farm which has 45,000 animals. Although the pond system was able to partially remove the content of nutrients, their concentration in the effluent was high for environmental disposal. A four-bed vertical flow constructed wetland pilot plant, using Typha spp., was built. The pilot plant operated for 280 days for beds 2-4 (sand 2). However, the experiments with beds 1-3 (sand 1) were stopped after 111 days of operation, when a reduction in the wastewater drainage was observed. The beds with sand 2 showed a 33% COD removal, and about 49% of nitrification was observed from 111 days until the end of the operation. PO(4)-P removal was 45% with a loading rate of around 1.36 g m(-2) d(-1).

Comparison of multiple DNA adduct types in tumor adjacent human lung tissue: effect of cigarette smoking

Cigarette smokers inhale a broad range of carcinogens derived from tobacco and its pyrolysis products, including free radicals, which induce oxidative stress and subsequent lipid peroxidation (LPO). Miscoding carcinogen-DNA adducts are formed by cigarette smoke constituents and are thought to initiate lung carcinogenesis. The presence of various types of DNA damage was therefore analyzed in tumor adjacent uninvolved lung tissues of 13 smoking and 11 non-smoking operated lung cancer patients. O(4)-ethylthymidine (O(4)etT), 1,N(6)-ethenodeoxyadenosine ( epsilon dA) and 3,N(4)-ethenodeoxycytidine ( epsilon dC) were determined by immuno-enriched (32)P-postlabeling. Polycyclic aromatic hydrocarbon (PAH)-DNA adducts were measured as diagonal radioactive zones after nuclease P1 enriched (32)P-postlabeling. Mean O(4)etT and PAH-DNA adduct levels were higher in lung DNA of smokers than of non-smokers (O(4)etT/10(8) thymidine: 3.8 versus 1.6, P < 0.01; PAH-DNA adducts/10(8) nucleotides: 11.2 versus 2.2, P < 0.01). Pulmonary etheno-DNA adduct levels did not differ between smokers and non-smokers, but large inter-individual variations were observed (80- and 250-fold differences for epsilon dA and epsilon dC, respectively). As all smokers (except one) refrained from smoking at least for 1 week before surgery, our results demonstrate the persistence of O(4)etT and PAH-DNA adducts in human lung. A positive correlation obtained between O(4)etT and PAH-DNA adducts (R = 0.65, P < 0.01) suggests that both adducts are formed from cigarette smoke as the main exposure source. We conclude that in addition to the DNA adducts derived from PAH and tobacco-specific nitrosamines, miscoding O(4)etT lesions are formed by cigarette smoke that contribute to the increased genomic instability and increased lung cancer risk in smokers.

[Telepathology in diagnostic consultations for controversial neoplastic growths in the lung--personal experience]

The authors assessed the diagnostic accuracy of the static telepathology (sTP) for practical consultations in the controversial pulmonary oncology cases. The short characteristics of the diagnostic cases is included. We reported the results of 6 difficult clinico-pathological cases submitted to Dept Quantitative Pathology [DQP] for consultations (5F and 1M, age: 26-68 yrs). Digital images of histological or cytological samples were captured at DQP and transmitted to telepathologist (TPat) in Thoraxklinik, Heidelberg or AFIP, Washington DC. Simultaneously, the same slides (or with a paraffin block) were mailed to TPats for re-evaluation with the conventional microscope (dgn-zwPat). The controversial cases presented 2 types of diagnostic problems: 1/rare entities, 2/common difficulties in the routine work of pathologist, but with indefinitely proved diagnosis. The first group encounters TPat diagnoses as follows: * case A: pulmonary plasma cell granuloma with lymphoidal interstitial infiltrates [LIP]--preleukemia; * case B: microfoci of early metastases of benign uterine leiomyoma; * case D: small cell carcinoma spreading along pleura. The second group included: * case C: invasive epidermoidal carcinoma in bronchus; *case E: probably metastatic adenocarcinoma of colon; *case F: synchronous or metastasising 2 lung tumours sharing NE morphology or NE immunohistochemical features. There was very high concordance between referring pathologist (ref-Pat) diagnoses and TPat diagnoses as well as a consensus in zw-TPat diagnoses. In 2 cases the conceptual problem was solved by TPat. Telepathology offered a support or improved the quality of the final diagnosis. The implementation of sTP remarkably reduced the time of consultations and allowed to present the diagnostic problems to the international group of experts.

Nitrification in reed beds--capacity and potential control methods

Vertical-flow reed beds (VFBs) are known to be very effective regarding nitrification. However, a generally accepted design formula for dimensioning reed beds for a controlled nitrification process has still not been found. Especially for the purpose of nitrification a vertical-flow reed bed (VFB) has been installed following an existing unaerated pond-system. The paper presents the results concerning the limits of the VFB's performance as well as the main factors influencing the nitrification process gained by balancing the conversion rates under different loads. Even under high loads the VFB provides an excellent nitrification performance, which is mainly influenced by the wastewater temperature. The ammonia oxidation rate is about 90% at temperatures over 10 degrees C; at temperatures below 5 degrees C the average nitrification rate is still approximately 50%. The hydraulic load and the TKN load have almost no impact on this efficiency (the maximum load has been: 180 mm/d, 7.1 g TKN/(m2 x d)). The redox potenial, which is continuously measured in the effluent of the reed bed, proved to be dependent on the current nitrification performance and the oxygen supply of the VFB, and therefore appears to be a suitable control parameter for the operation of VFBs.

Small pulmonary lesions--a challenge for thoracic surgery?

We analyzed the diagnosis, the potentially associated external and clinical features, and the surgical procedures of small pulmonary lesions, especially hamartomas (in relation to peripheral T1 lung carcinomas and lymphoid hyperplasia) in 103 patients who experienced enucleation or resection of pulmonary hamartomas between March 1, 1995 and December 31, 2000. The causes of surgical intervention, presurgical diagnoses, surgical procedures, location, size, and histological compartments were analyzed, as well as clinical features potentially associated with the tumors (alcohol, asbestos, smoking, and chronic lung diseases). Follow up of patients lasted for 5.5 years at maximum. For comparison, 36 patients with peripheral T1 lung carcinomas are included as well as 50 patients with lymphoid hyperplasia. The sex and age distribution of the patients with hamartomas was comparable to that of patients with lymphoid hyperplasia. About 75% of men and 55% of women were heavy smokers, with an average history of 30 and 17 pack years, respectively. In 84% of patients, the lesions were incidentally detected in chest radiographs, whereas 12% of patients underwent thoracic surgery suspicious for intrapulmonary metastases of known extrapulmonary malignancies. Enucleation was performed in 21%, and wedge resection in 77% of patients. At average, hamartomas were smaller than T1 lung carcinomas, but considerably larger in comparison to lymphoid hyperplasia. No recurrent tumors or additionally detected hamartomas were noted during the follow up, and both surgical procedures (enucleation or wedge resection) were identical in curative treatment. All patients with peripherally localized T1 tumors underwent lobectomy. The 3/5 year survival rate was calculated to 69/52%. Lymphoid hyperplasia is of clinical importance for the estimation of prognosis in patients with metastatic disease, as the number of radiologically suggestive metastatic nodules can often be significantly changed due to this entity. Pulmonary hamartomas are benign lesions that display certain clinical associations with malignant lung carcinomas in respect to external risk factors, and to lymphoid hyperplasia. Both surgical procedures (enucleation or wedge resection) can be performed, giving identical results in respect to treatment.

Glutathione-S-transferase M1, M3, T1 and P1 polymorphisms and susceptibility to non-small-cell lung cancer subtypes and hamartomas

Polymorphic glutathione-S-transferase (GST) genes causing variations in enzyme activity may influence individual susceptibility to lung cancer. In this case-control study (consisting of 389 Caucasian lung cancer patients, including 151 adenocarcinomas (ACs) and 172 squamous cell carcinomas (SCCs), and 353 hospital control subjects without malignant disease, genotype frequencies for GSTM1, GSTM3, GSTP1 and GSTT1 were determined by polymerase chain reaction (PCR)/ restriction fragment length polymorphism (RFLP)-based methods. While adjusted odds ratios (ORs) indicated no significantly increased risk for lung cancer overall due to any single GST genotype, the risk alleles for GSTM1, GSTM3 and GSTP1 conferring reduced enzyme activity were present at higher frequency in SCC than in AC patients. This is consistent with a reduced detoxification of carcinogenic polycyclic aromatic hydrocarbons (PAHs) from cigarette smoke that are more important for the development of SCC than for AC. An explorative data analysis also identified statistically significantly increased ORs for the combinations GSTT1 non-null and GSTP1 GG or AG for lung cancer overall (OR 2.23, CI 1.11-4.45), and for SCC (OR 2.69, CI 1.03-6.99). For lung cancer overall, and especially among SCC patients, the GSTT1 null genotype was underrepresented (SCC 11.2% v. control subjects 19%, P = 0.026, OR 0.57, CI 0.30-1.06). Additionally, in 28 patients with hamartomas, the GSTT1 null genotype was also protective (P = 0.013), while GSTP1 variant allele carriers were overrepresented (OR 2.48, CI 1.06-6.51). In conclusion, GST genotypes may act differently, either by detoxifying harmful tobacco carcinogens and/or by eliminating lung cancer chemopreventive agents. The latter role for GSTT1 would explain the observed lower risk of SCC and hamartoma associated with GSTT1 null. Further confirmatory studies are required.

Telepathology overview: from concept to implementation

Telepathology is the practice of pathology at a distance by using video imaging and telecommunications. Significant progress has been made in telepathology. To date, 12 classes of telepathology systems have been engineered. Rapid and ultrarapid virtual slide processors may further expand the range of telepathology applications. Next-generation digital imaging light microscopes, such as miniaturized microscope arrays (MMA), may make virtual slide processing a routine laboratory tool. Diagnostic accuracy of telepathology is comparable with that of conventional light microscopy for most diagnoses. Current telepathology applications include intraoperative frozen sections services, routine surgical pathology services, second opinions, and subspecialty consultations. Three telepathology practice models are discussed: the subspecialty practice (SSP) model; the case triage practice (CTP) model; and the virtual group practice (VGP) model. Human factors influence performance with telepathology. Experience with 500 telepathology cases from multiple organs significantly reduces the video viewing time per case (P < .01). Many technology innovations can be represented as S-curves. After long incubation periods, technology use and/or efficiency may accelerate. Telepathology appears to be following an S-curve for a technical innovation.

Reduced T-cell receptor CD3zeta-chain protein and sustained CD3epsilon expression at the site of mycobacterial infection

Control of mycobacterial infection by the cellular immune system relies both on antigen-presenting cells and on T lymphocytes. The quality of an effective cellular immune response is dependent on functional signal transduction residing in the cytoplasmic tails of the T-cell receptor CD3 components. In order to investigate potential effects of mycobacteria on T-cell receptor signalling, we examined the protein expression of T-cell signal transduction molecules (CD3zeta, ZAP-70, p59fyn, p56lck). In Western blots of peripheral blood mononuclear cells of Mycobacterium tuberculosis infected patients, only the CD3zeta-chain showed a marked reduction in protein expression. To investigate the situation in situ, immunoenzymatic and immunofluorescence stainings for CD3epsilon and CD3zeta expression were performed on sections of normal lymphoid tissue, M. leprae infected and sarcoid tissue. CD3epsilon and CD3zeta expression were similar with respect to intensity, localization and the number of cells stained in normal lymphoid tissue and in sarcoid granulomas. In contrast, the granulomas of M. leprae infected tissues showed a significantly reduced expression of CD3zeta compared to CD3epsilon. Using double immunofluorescence analysis, virtually no CD3zeta expression could be detected in comparison to the CD3epsilon expression in the lesions. Apparently, mycobacteria are capable of significantly reducing CD3zeta-chain expression, which may be restored by cytokines. IL-2-enhanced zeta-chain expression and T-cell effector functions, defined by interferon-gamma release, in M. tuberculosis-specific and human leucocyte antigen-DR restricted CD4+ T cells isolated from granuloma lesions from patients with pulmonary tuberculosis. Because CD3zeta is essential for CD3 signalling and for eliciting T-cell effector functions, reduced CD3zeta protein expression could result in altered signal transduction and inefficient T-cell effector functions. Alternatively, reduced CD3zeta-chain expression may protect T cells from repetitive TCR stimulation associated with anergy or apoptosis.

Cathepsin S in tumours, regional lymph nodes and sera of patients with lung cancer: relation to prognosis

Cysteine proteinase cathepsin S (Cat S) is expressed mainly in lymphatic tissues and has been characterised as a key enzyme in major histocompatibility complex class II (MHC-II) mediated antigen presentation. Cat S has been measured in tissue cytosols of lung parenchyma, lung tumours and lymph nodes and in sera of patients with lung tumours and of healthy controls, by specific enzyme-linked immunosorbent assay (ELISA). A difference in Cat S level was found between tumour and adjacent control tissue cytosols of 60 lung cancer patients (median 4.3 vs. 2.8 ng mg(-1) protein). In lymph nodes obtained from 24 patients of the same group, the level of Cat S was significantly higher than in tumours or lung parenchyma (P< 0.001). Additionally, significantly higher levels were found in non-infiltrated than in infiltrated lymph nodes (median 16.6 vs 7.5 ng mg(-1) protein). Patients with low levels of Cat S in tumours and lung parenchyma exhibited a significantly higher risk of death than those with high levels of Cat S (P = 0.025 - tumours; P = 0.02 - parenchyma). Immunohistochemical analysis (IHA) of lung parenchyma revealed a staining reaction in alveolar type II cells, macrophages and bronchial epithelial cells. In regional lymph node tissue, strong staining of Cat S was found in lymphocytes and histiocytes. Nevertheless, Cat S was detected also in tumour cells, independently of their origin. Our results provide evidence that Cat S may be involved in malignant progression. Its role, however, differs from that of the related Cats B and L and could be associated with the immune response rather than with remodelling of extracellular matrix.

[Proliferation rate of small cell lung carcinoma. A cytomorphometric parameter with prognostic significance]

AIM

Evaluation of prognosis-associated parameters in patients with small cell lung carcinoma.

MATERIAL AND METHODS

Biopsies of 46 patients suffering from a non-treated small cell lung carcinoma were stained with Feulgen and immunohistochemically with Ki-67 antibody. The integrated optical density (IOD) and proliferation rate was measured by syntactic structure analysis and correlated with survival.

RESULTS

About 85% of patients had a smoking history (46 pack years on average). The median survival time was 13.5 months, the proliferation rate (Ki-67 positive tumor cell nuclei) 68.2% and S-phase percentage 9.2%. Ot average, 25 proliferating tumor cell nuclei formed clusters (mean diameter 95 microns). The prognosis was associated with the proliferation rate (p < 0.04), tumor stage (stage I versus lib, p < 0.05), at threshold limits with S-phase rate (p < 0.07) and serum levels of LDH and NSE (p < 0.06 and p < 0.07 respectively).

CONCLUSIONS

Immune histochemical determination of the Ki-67 protein is a useful method to estimate the prognosis of patients with small cell lung carcinoma.

Lectin (WGA)-dependent superoxide anion release by neutrophils as a prognostic factor in lung cancer

This study was performed to explore whether lectin-induced generation of superoxide anions by neutrophils, lectin-induced degranulation of these cells and NO-synthase activity in pleural effusions can be used as prognostic factors of primary lung cancer patients. Among the activities tested, increased generation of superoxide by Triticum vulgaris agglutinin (WGA)-activated neutrophils showed prognostic relevance. Thus, this lectin-dependent reactivity of immune cells warrants further investigation in addition to the histochemical analysis.

Survival, disease-free interval, and associated tumor features in patients with colon/rectal carcinomas and their resected intra-pulmonary metastases

OBJECTIVE

Colon/rectum cancer often presents with intrapulmonary metastases. Surgical resection can be performed in a selected group of patients. In this study, the search for possible prognostic factors of patients with primary colon/rectum cancer and lung metastases was performed.

METHODS

Medical records of 110 patients operated on pulmonary metastases of primary colon/rectum cancer were reviewed. The clinical parameters include age, sex, pTNM/UICC stage, grading, localization, surgical and adjuvant therapy of the primary cancer. The number, maximum diameter and total intra-thoracic resected tumor-mass ('load'), the pre-thoracotomy serum carcinoembryonic antigen (CEA) levels, localization of the metastases (uni- vs. bilateral), the presence of hilar/mediastinal tumor-infiltrated lymph nodes, the surgical procedure and performed therapy schemes of lung metastases were recorded.

RESULTS

The cumulated 5- and 10-year total survival after diagnosis of the primary carcinomas was estimated to 71 and 33.7%, respectively. After resection of the pulmonary metastases, the 3- and 5-year post-thoracotomy survival measured 57 and 32.6%, respectively. The median time interval between diagnosis of the primary cancer and thoracotomy (disease free interval (DFI)) was found to be 35 months. A non-negligible percentage of patients (15.4%) displayed limited tumor stages of the primary cancer (pT1/2, pN0). The median diameter of the largest metastasis measured 28 mm, and the median resected intrathoracic tumor-load was calculated to 11.4 cm(3). In only 8 patients hilar or mediastinal tumor-involved lymph nodes were found. A potentially curative resection of lung metastases was recorded in 96 patients. The overall survival was significantly correlated with the DFI and the number of intrapulmonary metastases. The DFI correlated significantly with the tumor load and the number of metastases; the post-thoracotomy survival with the number of metastases, tumor-load and pre-thoracotomy serum CEA level. Treatment, stage and grade of the primary cancer, occurrence of liver metastases and local recurrences, mode of treatment of metastases and postoperative residual stage had no significant correlation with either total nor post-thoracotomy survival.

CONCLUSIONS

Pulmonary metastases occur even in patients with limited tumor-stages of primary colon/rectum cancer. DFI is the major parameter to estimate the total survival of patients with lung metastases. The survival after thoracotomy depends on the number of metastases, the intrapulmonary tumor load and the presence of elevated serum CEA level prior to thoracotomy.