Renal relapse in children and adolescents with childhood-onset lupus nephritis: a 20-year study

OBJECTIVES

There is little data on renal relapse in childhood-onset LN (cLN). We investigate the incidence, predictive factors and outcomes related to renal relapse.

METHODS

We conducted a retrospective cohort study of all cLN diagnosed at ≤18 years between 2001-2021 to investigate the incidence and outcomes related to renal relapse.

RESULTS

Ninety-five Chinese cLN patients (91% proliferative LN) were included. Induction immunosuppression was prednisolone and CYC [n = 36 (38%)] or MMF [n = 33 (35%)]. Maintenance immunosuppression was prednisolone and MMF [n = 53 (54%)] or AZA [n = 29 (31%)]. The rates of complete remission/partial remission (CR/PR) at 12 months were 78.9%/7.4%. Seventy renal relapses occurred in 39 patients over a follow-up of 10.2 years (s.d. 5.9) (0.07 episode/patient-year). Relapse-free survival was 94.7, 86.0, 80.1, 71.2, 68.3, 50.3 and 44.5% at 1, 2, 3, 4, 5, 10 and 20 years, respectively. Multivariate analysis showed that LN diagnosis <13.1 years [adjusted hazard ratio (HRadj) 2.59 995% CI 1.27, 5.29), P = 0.01], AZA maintenance [HRadj 2.20 (95% CI 1.01, 4.79), P = 0.05], PR [HRadj 3.9 (95% CI 1.03, 9.19), P = 0.01] and non-remission [HRadj 3.08 (95% CI 1.35, 11.3), P = 0.04] at 12 months were predictive of renal relapse. Renal relapse was significantly associated with advanced chronic kidney disease (stages 3-5) and end-stage kidney disease (17.9% vs 1.8%, P < 0.01). Furthermore, patients with renal relapse showed an increased incidence of infections (30.8% vs 10.7%, P = 0.02), osteopenia (38.5% vs 17.9%, P = 0.04) and hypertension (30.8% vs 7.1%, P < 0.01).

CONCLUSION

Renal relapse is common among cLN, especially among young patients, and is associated with an increased incidence of morbidity and mortality. Attaining CR and the use of MMF appear to decrease the incidence of renal relapse.

Long-term outcomes with rituximab as add-on therapy in severe childhood-onset lupus nephritis

BACKGROUND

Long-term data pertaining to rituximab as add-on therapy in childhood-onset lupus nephritis (cLN) is scarce.

METHODS

A retrospective cohort study was conducted on all patients with proliferative cLN, diagnosed ≤ 18 years and between 2005 and 2021, who received rituximab for LN episodes that were life/organ threatening and/or treatment resistant to standard immunosuppression.

RESULTS

Fourteen patients with cLN (female, n = 10) were included, with median follow-up period of 6.9 years. LN episodes (class III, n = 1; class IV, n = 11; class IV + V, n = 2) requiring rituximab occurred at 15.6 years (IQR 12.8-17.3), urine protein:creatinine ratio was 8.2 mg/mg (IQR 3.4-10.1) and eGFR was 28 mL/min/1.73 m2 (IQR 24-69) prior to rituximab treatment. Ten and four patients received rituximab at 1500 mg/m2 and 750 mg/m2, which were given at 46.5 days (IQR 19-69) after commencement of standard therapies. Treatment with rituximab resulted in improvements in proteinuria (ps < 0.001), eGFR (ps < 0.01) and serological parameters, including haemoglobin levels, complement 3 levels and anti-dsDNA antibodies, compared with baseline. Rates of complete/partial remission at 6-, 12- and 24-month post-rituximab were 28.6/42.8%, 64.2/21.4% and 69.2/15.3%. All three patients who required acute kidney replacement therapy became dialysis-free after rituximab. Relapse rate following rituximab was 0.11 episodes/patient-year. There was no lethal complication or severe infusion reaction. Hypogammaglobulinaemia was the most frequent complication (45%) but was mostly asymptomatic. Neutropenia and infections were observed in 20% and 25% of treatments. Upon last follow-up, three (21%) and two (14%) patients developed chronic kidney disease (stage 2, n = 2; stage 4; n = 1) and kidney failure, respectively.

CONCLUSION

Add-on rituximab is an effective and safe rescue therapy for cLN patients with life-/organ-threatening manifestations or treatment-resistance. A higher resolution version of the Graphical abstract is available as Supplementary information.

Radiomic Phenotypes Distinguish Atypical Teratoid/Rhabdoid Tumors from Medulloblastoma

BACKGROUND AND PURPOSE

Atypical teratoid/rhabdoid tumors and medulloblastomas have similar imaging and histologic features but distinctly different outcomes. We hypothesized that they could be distinguished by MR imaging-based radiomic phenotypes.

MATERIALS AND METHODS

We retrospectively assembled T2-weighted and gadolinium-enhanced T1-weighted images of 48 posterior fossa atypical teratoid/rhabdoid tumors and 96 match-paired medulloblastomas from 7 institutions. Using a holdout test set, we measured the performance of 6 candidate classifier models using 6 imaging features derived by sparse regression of 900 T2WI and 900 T1WI Imaging Biomarker Standardization Initiative-based radiomics features.

RESULTS

From the originally extracted 1800 total Imaging Biomarker Standardization Initiative-based features, sparse regression consistently reduced the feature set to 1 from T1WI and 5 from T2WI. Among classifier models, logistic regression performed with the highest AUC of 0.86, with sensitivity, specificity, accuracy, and F1 scores of 0.80, 0.82, 0.81, and 0.85, respectively. The top 3 important Imaging Biomarker Standardization Initiative features, by decreasing order of relative contribution, included voxel intensity at the 90th percentile, inverse difference moment normalized, and kurtosis-all from T2WI.

CONCLUSIONS

Six quantitative signatures of image intensity, texture, and morphology distinguish atypical teratoid/rhabdoid tumors from medulloblastomas with high prediction performance across different machine learning strategies. Use of this technique for preoperative diagnosis of atypical teratoid/rhabdoid tumors could significantly inform therapeutic strategies and patient care discussions.

Lrp6 Dynamic Expression in Tooth Development and Mutations in Oligodontia

Genes associated with the WNT pathway play an important role in the etiology of tooth agenesis. Low-density lipoprotein receptor-related protein 6 encoding gene (LRP6) is a recently defined gene that is associated with autosomal dominant inherited tooth agenesis. Here, we aimed to identify novel LRP6 mutations in patients with tooth agenesis and investigate the significance of Lrp6 during tooth development. Using whole-exome sequencing, we identified 4 novel LRP6 heterozygous mutations (c.2292G>A, c.195dup, c.1095dup, and c.1681C>T) in 4 of 77 oligodontia patients. Notably, a patient who carried a nonsense LRP6 mutation (c.2292G>A; p.W764*) presented a hypohidrotic ectodermal dysplasia phenotype. Preliminary functional studies, including bioinformatics analysis and TOP-/FOP-flash reporter assays, demonstrated that the activation of WNT/β-catenin signaling was compromised as a consequence of LRP6 mutations. RNAscope in situ hybridization revealed dynamic and special changes of Lrp6 expression during murine tooth development from E11.5 to E16.5. It was noteworthy that Lrp6 was specifically expressed in the epithelium at E11.5 to E13.5 but was expressed in both dental epithelium and dental papilla from E14.5 and persisted in both tissues at later stages. Our study broadens the mutation spectrum of human tooth agenesis and is the first to identify a LRP6 mutation in patients with hypohidrotic ectodermal dysplasia and reveal the dynamic expression pattern of Lrp6 during tooth development. Information from this study is conducive to understanding the functional significance of Lrp6 on the biological process of tooth development.

Epithelial Wnt10a Is Essential for Tooth Root Furcation Morphogenesis

WNT10A (Wingless-type MMTV integration site family, member 10A) plays a crucial role in tooth development, and patients with biallelic WNT10A mutation and mice lacking Wnt10a show taurodontism. However, whether epithelial or mesenchymal WNT10A controls the initiation of the root furcation formation remains unclear, and the functional significance of WNT10A in regulating root morphogenesis has not been clarified. Here, we investigated how Wnt10a affects tooth root development by generating different tissue-specific Wnt10a conditional knockout mice. Wnt10a knockout in the whole tissue (EIIa-Cre;Wnt10a^flox/flox) and in dental epithelium (K14-Cre;Wnt10a^flox/flox) led to an absence of or apically located root furcation in molars of mice, a phenotype that resembled taurodontism. An RNAscope analysis showed that the dynamic epithelial and mesenchymal Wnt10a expression pattern occurred during root development. Immunofluorescent staining of E-cadherin and EdU revealed decreased epithelial cell proliferation at the cervical region of the molar in K14-Cre;Wnt10a^flox/flox mice at postnatal day 0 (PN0), just before the initiation of root morphogenesis. Interestingly, we found increased pulpal mesenchymal cell proliferation in the presumptive root furcating region of the molar in K14-Cre;Wnt10a^flox/flox mice at PN4 and PN7. RNA-seq indicated that among the Wnt ligands with high endogenous expression levels in molars, Wnt4 was increased after epithelial knockout of Wnt10a. The RNAscope assay confirmed that the expression of Wnt4 and Axin2 in the dental papilla of the presumptive root furcating region, where dental pulp overgrowth occurred, was increased in K14-Cre;Wnt10a^flox/flox molars. Furthermore, after suppression of the elevated Wnt4 level in K14-Cre;Wnt10a^flox/flox molars by Wnt4 shRNA adenovirus and kidney capsule grafts, the root furcation defect was partially rescued. Taken together, our study provides the first in vivo evidence that epithelial Wnt10a guides root furcation formation and plays a crucial role in controlling the organized proliferation of adjacent mesenchymal cells by regulating proper Wnt4 expression during root furcation morphogenesis.

Health-related quality of life in paediatric spina bifida

INTRODUCTION

The average incidence of spina bifida (SB) in Malaysia is 0.43 among 1,000 live births. The burden of the disease and its impact on the overall development and health though tremendously improved, remains significant. Therefore, current patient management strategies must include quality of life (QOL) measures.

METHODS

This was a prospective, cross-sectional study on spina bifida children aged 5-20 years, attending the paediatric spina bifida clinics of Universiti Kebangsaan Malaysia Medical Centre Kuala Lumpur and Hospital Tuanku Jaanku Seremban. Scores were obtained using the validated disease specific Parkin QOL questionnaire. Univariate and multivariate analysis were used to investigate factors that were determinants for these outcomes. Results were expressed as beta coefficient and 95% confidence intervals (95%CI).

RESULTS

A total of 54 children and adolescents aged between 5-20 years completed the questionnaires. Presence of neurogenic bowel (p=0.003), neurogenic bladder (p=0.041), shunt (p=0.044), non-ambulators (p=0.007) and being the only child in the family (p=0.037) were associated with lower QOL scores. Multivariate analysis showed presence of neurogenic bowel (β=0.375, 95%CI: 0.00, 0.15) and being the only child in the family (β=0.250, 95%CI: 0.04, 0.17) explained 22.1% of the variance in the QOL mean percentage scores.

CONCLUSION

Being a single child in the family was the only socio-demographic variable associated with lower QOL scores. Although several clinical factors appeared to contribute significantly to QOL in spina bifida children, the presence of neurogenic bowel had the greatest impact.

Transition care readiness among patients in a tertiary paediatric department

INTRODUCTION

A smooth transition of healthcare for young people with chronic illnesses from paediatric to adult healthcare services is important to ensure optimal outcome. At the moment, there are no standard guidelines to assess a patient's readiness to transfer care.

METHODS

A cross-sectional study using a self-administered questionnaire, adapted from UNC (University of North Carolina) TRxANSITION self-assessment tool was conducted to evaluate patients' transition care readiness in paediatric haematology and paediatric diabetes clinic.

RESULTS

A total of 80 patients (37 thalassaemia and 43 diabetes) with the mean age of 21.2 (SD±4.3) years, were recruited during the 3-month study period. Majority of the patients have basic knowledge regarding their medications, and were able to comply with their follow-up. The mean total score obtained by the respondents on this questionnaire was 15.3 (SD±3.59). Self-management skills and knowledge on disease were the two poorly scored section; with mean score of 3.78 (SD±1.38) and 4.28 (SD±1.20) respectively. Overall, only 21 (26.2%) respondents obtained high score (score above 75th percentile). Seventy-five percent of the respondents admitted that they were not ready for transfer to an adult healthcare service yet at the time of the study.

CONCLUSION

We suggest that patients with high score should be prepared for transition to adult facility whereas those with a low score need to be identified to ensure provision of continuous education.

The influence of intensive care unit-acquired central line-associated bloodstream infection on in-hospital mortality: A single-center risk-adjusted analysis

OBJECTIVE

To explore the risk-adjusted association between intensive care unit (ICU)-acquired central line-associated bloodstream infection (CLABSI) and in-hospital mortality.

DESIGN

Retrospective observational study.

SETTING

Forty-five-bed adult ICU.

PATIENTS

All non-extracorporeal membrane oxygenation ICU admissions between July 1, 2008, and April 30, 2014, requiring a central venous catheter (CVC), with a length of stay > 48 hours, were included.

METHODS

Data were extracted from our infection prevention and ICU databases. A multivariable logistic regression model was constructed to identify independent risk factors for ICU-acquired CLABSI. The propensity toward developing CLABSI was then included in a logistic regression of in-hospital mortality.

RESULTS

Six thousand three hundred fifty-three admissions were included. Forty-six cases of ICU-acquired CLABSI were identified. The overall CLABSI rate was 1.12 per 1,000 ICU CVC-days. Significant independent risk factors for ICU-acquired CLABSI included: double lumen catheter insertion (odds ratio [OR], 2.59; 95% confidence interval [CI], 1.16-5.77), CVC exposure > 7 days (OR, 2.07; 95% CI, 1.06-4.04), and CVC insertion before 2011 (OR, 2.20; 95% CI, 1.22-3.97). ICU-acquired CLABSI was crudely associated with greater in-hospital mortality, although this was attenuated once the propensity to develop CLABSI was adjusted for (OR, 1.20; 95% CI, 0.54-2.68).

CONCLUSIONS

A greater propensity toward ICU-acquired CLABSI was independently associated with higher in-hospital mortality, although line infection itself was not. The requirement for prolonged specialized central venous access appears to be a key risk factor for ICU-acquired CLABSI, and likely informs mortality as a marker of persistent organ dysfunction.

Ergonomic port placement in laparoscopic colorectal surgery

AIM

Port placement in laparoscopic surgery has important ergonomic implications. A manipulation angle (MA) of 60° has been shown to maximize task efficiency. We calculated the MA used during various stages of both right hemicolectomy (RH) and high anterior resection (AR).

METHOD

We compared two methods of port placement for each operation. RH-PP1 included ports in the left iliac fossa and left upper quadrant. RH-PP2 included ports suprapubically and in the left iliac fossa. We calculated the MA of each of these methods in mobilizing both the caecum and hepatic flexure. AR-PP1 included ports in the right iliac fossa and right upper quadrant. AR-PP2 included ports suprapubically and in the right iliac fossa. We calculated the MA of each of these methods in mobilizing the splenic flexure, descending-sigmoid junction and the recto-sigmoid junction.

RESULTS

For RH-PP1, the mean MA for mobilizing the caecum and hepatic flexure was 38° and 52°, respectively. For RH-PP2, the mean MA for mobilising the caecum and hepatic flexure was 58° and 44°, respectively. For AR-PP1, the mean MA for mobilizing the splenic flexure, the descending-sigmoid junction and the recto-sigmoid junction was 77°, 41° and 18°, respectively. For AR-PP2, the mean MA for mobilizing the splenic flexure, the descending-sigmoid junction and the recto-sigmoid junction was 40°, 56° and 34°, respectively.

CONCLUSION

There are no two port placements that will allow for an ideal MA at every stage of mobilization for either right- or left-sided resection.

Correlates of physical activity level among hemodialysis patients in Selangor, Malaysia

INTRODUCTION

There is mounting evidence demonstrating the importance of adequate physical activity to promote better well-being among hemodialysis patients. Available data pertaining to the levels of physical activity and its determinants among hemodialysis patients is, however, scarce in Malaysia. The objectives of this study are hence to determine the levels of physical activity and it associated factors among hemodialysis patients.

METHODOLOGY

A total of 70 subjects were recruited from three dialysis centres in Selangor. A face-to-face interview was conducted to obtain socio-demographic data and subjects' knowledge on dietary sources. Medical history, biochemical parameters and weight status were obtained from medical records. Physical activity level (PAL) was assessed using the Global Physical Activity Questionnaire (GPAQ).

RESULTS

A total of 81.4% and 18.6% of the respondents had low and moderate PALs, respectively. Thus, none of the respondents had high PAL. Serum creatinine, education level, personal income and knowledge score on potassium-related medical complications were factors found to correlate significantly with PAL. Multiple linear regression analysis showed that higher PAL was predicted by a lower knowledge score on dietary sodium source, higher education and higher serum creatinine.

CONCLUSION

Despite consistent documentation of the potential positive impact of physical exercise on hemodialysis outcomes, the level of physical activity remains low among these patients. It is hoped that these findings can add to the existing body of knowledge and serve as a supporting document for the formulation of appropriate interventions to improve the status of physical activity among hemodialysis patients in Malaysia.

Lack of association of ABCB1 and PXR polymorphisms with response to treatment in epilepsy

It is proposed that overexpression of P-glycoprotein (P-gp), encoded by the ABC subfamily B member 1 (ABCB1) gene, is involved in resistance to antiepileptic drugs (AEDs) in about 30% of patients with epilepsy. Genetic variation and haplotype patterns are population specific which may cause different phenotypes such as response to AEDs. Although several studies examined the link between the common polymorphisms in the ABCB1 gene with resistance to AEDs, the results have been conflicting. This controversy may be caused by the effect of some confounders such as ethnicity and polytherapy. Moreover, expression of the ABCB1 gene is under the control of pregnane X receptor (PXR). Evidence showed that PXR gene contribute to the response to treatment. The aim of this study was to assess the association of ABCB1 and PXR genetic polymorphisms with response to the carbamazepine (CBZ) or sodium valproate (VPA) monotherapy in epilepsy. Genotypes were assessed in 685 Chinese, Indian, and Malay epilepsy patients for ABCB1 (C1236T, G2677T, C3435T) and PXR (G7635A) polymorphisms. No association between these polymorphisms and their haplotypes, and interaction between them, with response to treatment was observed in the overall group or in the Chinese, Indian, and Malay subgroups. Our data showed that these polymorphisms may not contribute to the response to CBZ or VPA monotherapy treatment in epilepsy.

Viral interleukin-6 encoded by rhesus macaque rhadinovirus is associated with lymphoproliferative disorder (LPD)

BACKGROUND

Rhesus macaques (RM) co-infected with simian immunodeficiency virus (SIV) and rhesus macaque rhadinovirus (RRV) develop abnormal cellular proliferations characterized as extra-nodal lymphoma and retroperitoneal fibromatosis (RF). RRV encodes a viral interleukin-6 (vIL-6), much like Kaposi's sarcoma-associated herpesvirus, and involvement of the viral cytokine was examined in proliferative lesions.

METHODS

Formalin fixed tissue from RM co-infected with SIV and RRV were analyzed for RRV genomes by in situ hybridization and RRV vIL-6 expression by immunofluorescence analysis.

RESULTS

In situ hybridization analysis indicated that RRV is present in both types of lesions. Immunofluorescence analysis of different lymphomas and RF revealed positive staining for vIL-6. Similarly to KS, RF lesion is positive for vimentin, CD117 (c-kit), and smooth muscle actin (SMA) and contains T cell, B cell and monocytes/macrophage infiltrates.

CONCLUSIONS

Our data support the idea that vIL-6 may be critical to the development and progression of lymphoproliferative disorder in RRV/SIV-infected RM.

Scan-directed unilateral neck exploration for primary hyperparathyroidism: eight-year results from a regional hospital

OBJECTIVE

To determine the results of scan-directed unilateral neck exploration for primary hyperparathyroidism.

DESIGN

Retrospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Patients who underwent parathyroid surgery for primary hyperparathyroidism between January 2000 and December 2007 were included.

MAIN OUTCOME MEASURES

The demographic, imaging, biochemical, and pathological data, as well as surgical outcomes were analysed according to the treatment received.

RESULTS

A total of 78 patients were included in this study; 65 underwent unilateral neck exploration with image guidance by ultrasonography or technetium Tc99m sestamibi scan. The scan sensitivity for localising the side of the lesion was 66% for ultrasound scans, 71% for technetium Tc99m sestamibi scans, and 85% for both scans used in combination. Pathological analysis showed that 95% (74/78) of the patients had a single parathyroid adenoma, two had hyperplasia of four glands, one had a double adenoma, and one a parathyroid carcinoma. Among the patients undergoing scan-directed unilateral neck exploration, one defaulted follow-up, while the remaining 64 patients achieved normal calcium levels at a median follow-up of 6 months.

CONCLUSION

Scan-directed unilateral neck exploration is a safe alternative form of treatment for patients with primary hyperparathyroidism, with a cure rate similar to conventional therapy.

Dilated common bile ducts mimicking choledochal cysts in ketamine abusers

Substance abuse is a major health and social problem among Hong Kong youth and ketamine is the drug most commonly abused. Ketamine abuse is associated with a series of side-effects that include hallucination, nausea, vomiting, elevation of blood pressure, and urinary bladder dysfunction. Here we report three cases of ketamine abuse in which the abusers presented with recurrent epigastric pain and dilated common bile ducts that mimicked choledochal cysts on imaging. The dilated biliary tree may occur more frequently than was once assumed.

Malignant hypertension in a child with phakomatosis pigmentovascularis type II b

Phakomatosis pigmentovascularis (PPV) is a rare congenital syndrome characterized predominantly by cutaneous vascular malformations and pigmentary naevi. The most frequently reported form, Type II b, is associated with systemic involvement. Sturge-Weber Syndrome (SWS) with concomitant glaucoma, Klippel-Trenaunay Syndrome (KTS) and naevus of Ota have been frequently described, but there have only been two case reports with asymptomatic renal anomalies.

CONCLUSION

We report the first case of PPV associated with SWS and naevus of Ota presenting with malignant hypertension secondary to bilateral renal artery stenosis. This case raises the possibility that the phakomatoses are not distinct entities but a spectrum of overlapping neurocutaneous, vascular and renal features.

Congenital hepatic fibrosis in a child with autosomal dominant polycystic kidney disease

The association of congenital hepatic fibrosis (CHF) with autosomal recessive polycystic kidney disease (ARPKD) is well known and occurs in approximately 50% of cases. However the association of CHF with autosomal dominant polycystic kidney disease (ADPKD) is less well known and less well documented. We report a child with neonatal onset of hypertension due to ADPKD who later develops portal hypertension due to CHF in childhood. A review of this rare association follows.

Masson's pseudotumour of the ethmoid sinus - a case report

OBJECTIVE

We report a case of Masson's pseudotumour or intravascular papillary endothelial hyperplasia presenting in the ethmoid sinus.

CASE REPORT

We present a diagnostically challenging case of Masson's pseudotumour of the ethmoid sinus presenting with persistent epistaxis and a review of the available literature.

CONCLUSION

Intravascular papillary endothelial hyperplasia is a benign, reactive lesion first described by the French pathologist Pierre Masson in 1923. It can lead to diagnostic uncertainty due to its close resemblance clinically, radiologically and histopathologically to angiosarcoma.

Forebrain regions associated with postexercise differences in autonomic and cardiovascular function during baroreceptor unloading

The cortical regions representing peripheral autonomic reactions in humans are poorly understood. This study examined whether changes in forebrain activity were associated with the altered physiological responses to lower body negative pressure (LBNP) following a single bout of dynamic exercise (POST-EX). We hypothesized that, compared with the nonexercised condition (NO-EX), POST-EX would elicit greater reductions in stroke volume (SV) and larger increases in heart rate (HR) and muscle sympathetic nerve activity (MSNA) during LBNP (5, 15, and 35 mmHg). Forebrain neural activity (n = 11) was measured using blood oxygen level-dependent (BOLD) functional magnetic resonance imaging. HR, SV, arterial blood pressure (ABP), and MSNA were collected separately. Compared with NO-EX, baseline ABP was reduced, whereas HR and total vascular conductance (TVC) were elevated in POST-EX (P < 0.05). In both conditions, 5 mmHg LBNP did not elicit a change (from baseline) in any physiological parameter. Compared with NO-EX, 35 mmHg LBNP-mediated decreases in SV and TVC produced greater increases in HR and MSNA during POST-EX (P < 0.05). The right posterior insula and dorsal anterior cingulate cortex demonstrated a larger decrease in BOLD at 5 mmHg LBNP but greater BOLD increase at 15 and 35 mmHg LBNP POST-EX vs. NO-EX (P < 0.005). Conversely, the thalamus and ventral medial prefrontal cortex displayed the opposite BOLD activity pattern (i.e., larger increase at 5 mmHg LBNP but greater decrease at 15 and 35 mmHg LBNP POST-EX vs. NO-EX). Our findings suggest that discrete forebrain regions may be involved with the generation of baroreflex-mediated sympathetic and cardiovascular responses elicited by moderate LBNP.

Granulocytic sarcoma of the small bowel causing intestinal obstruction

Granulocytic sarcomas of the small bowel are rare. They are discrete tumours of leukaemic myeloblasts and partially matured granulocytes that form in any part of the body. This disease is infrequently seen in patients with acute myeloid leukaemia, and rarely seen in patients without leukaemia. Here we report a case of small bowel obstruction due to granulocytic sarcoma of mid-ileum in a non-leukaemic patient. We also review the literature on treatment and prognosis of this condition.

Comparison of oxidative damage in Malaysian end-stage renal disease patients with or without non-insulin-dependent diabetes mellitus

BACKGROUND

Comparisons of oxidative indices and total antioxidant status between end-stage renal disease (ESRD) patients with or without diabetes is scant, especially in the Asian population.

METHOD

The assays were carried out according to known established protocols.

RESULT

The present study showed that ESRD patients with or without non-insulin-dependent diabetes mellitus (NIDDM) did not have any significant differences in antioxidant enzyme activities, advanced glycated end products (AGE), advanced oxidized protein products (AOPP) and ferric reducing ability of plasma (FRAP), indicating that hyperglycemia does not exacerbate oxidative damage in ESRD. The regulation of catalase and glutathione peroxidase is also altered in ESRD. Elevated FRAP was observed in both ESRD groups (with and without NIDDM). The dialysis process did not alter the antioxidant enzyme activities but decreased AGEs and FRAP and increased AOPP levels.

CONCLUSION

Oxidative stress is present in ESRD but this is not significantly exacerbated by hyperglycemia. The contribution of components in the pathology of renal failure towards oxidative stress exceeds that of hyperglycemia.

Efficacy of enzyme immunoassay for the detection of Helicobacter pylori antigens in frozen stool specimens: local validation

AIM

To investigate the efficacy of measurement of Helicobacter pylori stool antigen (HpSA) using stored frozen stool specimens, and to assess whether there were factors affecting efficacy in Hong Kong.

METHODS

Patients undergoing upper endoscopy at Tuen Mun Hospital were recruited. Stool samples were saved for HpSA testing and questionnaires were completed. Stool samples were frozen immediately upon receipt and stored at -70 degrees C until tested. HpSA results were compared with rapid urease test and histology.

RESULTS

One hundred and eighty-one patients were recruited. One hundred and seventy-eight patients were suitable for analysis. Eighty-three were H. pylori positive and 95 were H. pylori negative. The mean duration of storage of the stool samples was 120 days (range, 40-225 days). The sensitivity, specificity and positive and negative predictive values were 84.3%, 97.9%, 97.2% and 88.6%, respectively. In patients with a false negative HpSA test, there was a significant delay in collecting the stool specimen after endoscopy when compared with those with a true positive HpSA test (4.2 vs. 2.3 days; P < 0.05). However, the duration of storage of the specimens was not longer, and consumption of coffee or tea and smoking habits were similar.

CONCLUSIONS

HpSA testing showed good sensitivity and specificity, even with frozen stool samples stored for up to 225 days. The efficacy was not affected by coffee, tea or smoking.

Levalbuterol hydrochloride

Racemic albuterol, a commonly used bronchodilator, is an exact 50:50 mixture of two enantiomers, R- and S-albuterol. Concern regarding increased mortality associated with the use of this beta-2 (beta 2) agonist triggered the study of both of these enantiomers separately. In vitro studies suggest that the two enantiomers have different binding affinities for beta-adrenoreceptors, may exert opposing effects on inflammation, demonstrate different effects on mucocilary transport, and display differing pharmacokinetics. Clinical studies comparing both enantiomers are few, of short duration, and often in small patient populations, and their results vary. R-albuterol has greater bronchodilatory effects than the racemate and may have anti-inflammatory properties. S-albuterol has markedly less affinity for the beta-adrenoreceptor. It was found to cause bronchoconstriction in animal models, but neither bronchoconstrictive nor pro-inflammatory effects have been conclusively demonstrated in human studies. The data available at present, while suggestive, are insufficient to conclusively recommend R-albuterol over the racemate. Further basic research and investigations in humans comparing both enantiomers at increasing doses over longer time periods are required to clarify the precise roles of R- and S-albuterol.

Identification of the rhesus macaque rhadinovirus lytic origin of DNA replication

We have identified a lytic origin of DNA replication (oriLyt) for rhesus macaque rhadinovirus (RRV), the rhesus macaque homolog of human herpesvirus 8 (HHV-8), also known as Kaposi's sarcoma-associated herpesvirus. RRV oriLyt maps to the region of the genome between open reading frame 69 (ORF69) and ORF71 (vFLIP) and is composed of an upstream A+T-rich region followed by a short (300-bp) downstream G+C-rich DNA sequence. A set of overlapping cosmids corresponding to the entire genome of RRV was capable of complementing oriLyt-dependent DNA replication only when additional ORF50 was supplied as an expression plasmid in the transfection mixture, suggesting that the level of ORF50 protein originating from input cosmid DNA was insufficient. The requirement of RRV ORF50 in the cotransfection replication assay may also suggest a direct role for this protein in DNA replication. RRV oriLyt shares a high degree of nucleotide sequence and G+C base distribution with the corresponding loci in HHV-8.

Maternal or fetal origin of rhesus monkey (Macaca mulatta) amniotic fluid leukocytes can be identified by polymerase chain reaction using the zinc finger Y gene

Leukocytes can be found in substantial numbers within the intrauterine tissues and amniotic fluid of women, and play a central role in the pathophysiology of infection-related preterm labor by their production of proinflammatory mediators. It remains unclear whether these leukocytes represent a fetal immune response, a maternal response, or a combination of the two. The objective of this study was to develop a test in the rhesus monkey (Macaca mulatta) suitable for determining the percentage of male fetal cells present in a population of leukocytes recovered from blood or amniotic fluid. We found inadequate specificity for rhesus monkey cells using commercial human Y-chromosome paint kits (fluorescence in situ hybridization (FISH)). Human-specific primers for the repetitive Y chromosome DYZ-1 locus employed in the polymerase chain reaction (PCR) produced an unacceptable percentage of false positives. However, we successfully developed a PCR-based test using rhesus-specific primers for the zinc finger Y (ZFY) locus. Densitometry of PCR products from known ratios of male and female adult peripheral leukocytes generated a linear standard curve which provided quantitative results and required only 400 cells per sample. The rhesus beta globin (RBG) gene served as an internal control. The PCR test correctly discriminated the sex of peripheral leukocytes in 20 adult males, 20 adult females, two male fetuses, and one female fetus. Serial samples of amniotic fluid from four chronically catheterized rhesus monkeys bearing male fetuses were used to confirm the utility of this assay for quantifying fetal cells in amniotic fluid. In conclusion, we have developed a PCR test which is suitable for distinguishing male from female cells in adult and fetal blood and in amniotic fluid, which lends itself to a variety of diagnostic and biologic applications in the rhesus monkey and potentially in other nonhuman primates.

Modelling variation of lower leg length growth in early life

We consider the estimation of sources of variation for panel data with repeated measurements. With no repeated measurements and known measurement error, models for variation decomposition have been proposed when there are one or more types of measurements. Estimation was performed using the EM algorithm accompanied by model augmentation that demands more computational efforts. In this article we extend previous variation models and modify the estimation methods in order to estimate various variation components after eliminating the unknown effects of measurement error. Specifically, methods that dispense with model augmentation and estimation of time-dependent covariates are considered. A set of lower leg length data from Chinese infants is analysed by using the proposed model. Interestingly, our results are consistent with the well-accepted three-phase (infancy-childhood-puberty) growth transition proposition for human growth. Moreover, gender effect is found to be time-varying.

A simian human immunodeficiency virus with a nonfunctional Vpu (deltavpuSHIV(KU-1bMC33)) isolated from a macaque with neuroAIDS has selected for mutations in env and nef that contributed to its pathogenic phenotype

Previous studies have shown that passage of nonpathogenic SHIV-4 through a series of macaques results in the selection of variants of the virus that are capable of causing rapid subtotal loss of CD4(+) T cells and AIDS within 6-8 months following inoculation into pig-tailed macaques. Using a pathogenic variant of SHIV-4 known as SHIV(KU-1bMC33), we reported that a mutant of this virus with the majority of the vpu deleted was still capable of causing profound CD4(+) T cell loss and neuroAIDS in pig-tailed macaques (McCormick-Davis et al., 2000, Virology 272, 112-116). In this study, we have analyzed the tissue-specific changes in the env and nef in one macaque that developed neuroAIDS (macaque 50 O) and in three macaques that developed only a moderate or no significant loss of CD4(+) T cells and no neurological disease (macaques 50 Y, 20220, 20228) following inoculation with DeltavpuSHIV(KU-1bMC33). Sequence analysis of the gp120 region of env isolated from lymphoid tissues (lymph node and spleen) of macaques 50 Y, 20220, and 20228 revealed no consensus amino acid substitutions. In contrast, analysis of the gp120 sequences isolated from lymphoid and CNS tissues (parietal cortex, basal ganglia, and pons) of macaque 50 O revealed numerous amino acid substitutions. The significance of the amino acid substitutions in gp120 was supported by neutralization assays which showed that the virus isolated from the lymph node of macaque 50 O was neutralization resistant compared to the parental SHIV(KU-1bMC33). Analysis of changes in the nef gene from macaque 50 O revealed in-frame deletions in Nef that ranged from 4 to 13 amino acids in length, whereas the nef genes isolated from the other three macaques revealed no deletions or consensus amino acid substitutions. Inoculation of the virus isolated from the lymph node of the macaque which developed neuroAIDS, SHIV(50OLNV), into four pig-tailed macaques resulted in a severe loss of the circulating CD4(+) T cells within 2 weeks postinoculation, which was maintained for up to 20 weeks postinoculation, confirming that this virus had indeed become more pathogenic in pig-tailed macaques. Taken together, these observations suggest that DeltavpuSHIV(KU-1bMC33) has a low pathogenic phenotype in macaques but that individual pig-tailed macaques can select for additional mutations within the Env and Nef which can compensate for the lack of an intact Vpu and ultimately increase its pathogenicity.

Rapid identification of Pseudomonas aeruginosa from ocular isolates by PCR using exotoxin A-specific primers

The purpose of this research was to evaluate the use of PCR for the identification of ocular isolates of Pseudomonas aeruginosa by using primers specific to the exotoxin A gene of the bacteria. Genomic DNA was obtained from ocular microbial isolates of keratitis patients. Primers were designed based on the published sequence of the exotoxin A gene of P. aeruginosa. Using the primers designed, PCR reactions were performed on the DNA samples. The PCR was also examined for its specificity and sensitivity. In addition, a direct PCR using heating method was attempted on P. aeruginosa with no separate DNA extraction step. ATCC strains of P. aeruginosa were included as positive controls. The rest of the bacteria other than P. aeruginosa served as negative controls. A single band was obtained when analysed on agarose gel electrophoresis only from samples that contained genomic DNA of P. aeruginosa. The direct PCR method was also successful with the same band produced from the amplification. The whole process was completed within 4 h. The direct PCR amplification targeting at the exotoxin A gene of P. aeruginosa is potentially a rapid, specific, sensitive and relatively simple method for the identification of ocular isolates of P. aeruginosa.

Induction of B cell hyperplasia in simian immunodeficiency virus-infected rhesus macaques with the simian homologue of Kaposi's sarcoma-associated herpesvirus

A simian homologue of Kaposi's sarcoma-associated herpesvirus (KSHV), the eighth human herpesvirus (HHV8), was isolated from a simian immunodeficiency virus (SIV)-infected rhesus macaque (Macaca mulatta) that developed a multicentric lymphoproliferative disorder (LPD). This simian rhadinovirus is genetically similar to a recently described rhesus rhadinovirus (RRV) (Desrosiers, R.C., V.G. Sasseville, S.C. Czajak, X. Zhang, K.G. Mansfield, A. Kaur, R.P. Johnson, A.A. Lackner, and J.U. Jung. 1997. J. Virol. 71:9764-9769) and is designated RRV 17577. RRV 17577 was experimentally inoculated into rhesus macaques with and without SIV(mac239) infection to determine if RRV played a role in development of the LPD observed in the index case. In contrast to control animals inoculated with SIV(mac239) or RRV alone, two animals coinfected with SIV(mac239) and RRV 17577 developed hyperplastic LPD resembling the multicentric plasma cell variant of Castleman's disease, characterized by persistent angiofollicular lymphadenopathy, hepatomegaly, splenomegaly, and hypergammaglobulinemia. Hypergammaglobulinemia was associated with severe immune-mediated hemolytic anemia in one RRV/SIV-infected macaque. Both RRV/SIV-infected macaques exhibited persistent RRV viremia with little or no RRV-specific antibody response. The macaques inoculated with RRV alone displayed transient viremia followed by a vigorous anti-RRV antibody response and lacked evidence of LPD in peripheral blood and lymph nodes. Infectious RRV and RRV DNA were present in hyperplastic lymphoid tissues of the RRV/SIV-infected macaques, suggesting that lymphoid hyperplasia is associated with the high levels of replication. Thus, experimental RRV 17577 infection of SIV-infected rhesus macaques induces some of the hyperplastic B cell LPDs manifested in AIDS patients coinfected with KSHV.

Rhesus rhadinovirus establishes a latent infection in B lymphocytes in vivo

Recent DNA sequence analysis indicates that rhesus rhadinovirus (RRV) is a member of the lymphotropic gamma-2 herpesvirus family. To determine if RRV is lymphotropic, peripheral blood mononuclear cells from naturally infected monkeys were separated by immunomagnetic bead depletion and analyzed for the presence of RRV by virus isolation and nested PCR. The recovery and consistent detection of RRV in the CD20(+)-enriched fraction clearly demonstrates that B lymphocytes are a major site of virus persistence.

A rhesus macaque rhadinovirus related to Kaposi's sarcoma-associated herpesvirus/human herpesvirus 8 encodes a functional homologue of interleukin-6

The rhesus rhadinovirus strain 17577 (RRV strain 17577) genome is essentially colinear with human herpesvirus 8 (HHV8)/Kaposi's sarcoma-associated herpesvirus (KSHV) and encodes several analogous open reading frames (ORFs), including the homologue of cellular interleukin-6 (IL-6). To determine if the RRV IL-6-like ORF (RvIL-6) is biologically functional, it was expressed either transiently in COS-1 cells or purified from bacteria as a glutathione S-transferase (GST)-RvIL-6 fusion and analyzed by IL-6 bioassays. Utilizing the IL-6-dependent B9 cell line, we found that both forms of RvIL-6 supported cell proliferation in a dose-dependent manner. Moreover, antibodies specific to the IL-6 receptor (IL-6R) or the gp130 subunit were capable of blocking the stimulatory effects of RvIL-6. Reciprocal titrations of GST-RvIL-6 against human recombinant IL-6 produced a more-than-additive stimulatory effect, suggesting that RvIL-6 does not inhibit but may instead potentiate normal cellular IL-6 signaling to B cells. These results demonstrate that RRV encodes an accessory protein with IL-6-like activity.

The value of S-phase and DNA ploidy analysis as prognostic markers for node-negative breast cancer in the Australian setting

This study aimed to determine the prognostic significance of DNA ploidy and S-phase fraction (SPF) measurements in our laboratory for patients with node-negative breast cancer. Frozen tumors from axillary node-negative breast cancer patients (n = 50) treated at Westmead Hospital, NSW, between 1988 and 1991 were analysed by flow cytometry. The median duration of follow-up for all patients was 8.4 years. Forty-six specimens provided evaluable DNA histograms with 43% (n = 20) diploid and 56% (n = 26) aneuploid tumors identified. Comparisons of DNA ploidy status and SPF were made with traditional prognostic variables, which included age, menopausal status, tumor size, histologic grade and hormone receptor status. Our results showed that there was no significant difference in disease-free or overall survival between patients with diploid and aneuploid tumors. Histologic grade 3 tumors were more likely to be aneuploid and had higher SPF than grade 1 or 2 tumors. Patients with grade 3 tumors and a high SPF were four times more likely to relapse than the rest of the population. These results indicate that DNA flow cytometric analysis in our laboratory provides additional prognostic data that could be utilised alongside traditional clinical and histopathologic indicators for predicting outcome for patients.

Sequence and genomic analysis of a Rhesus macaque rhadinovirus with similarity to Kaposi's sarcoma-associated herpesvirus/human herpesvirus 8

We have sequenced the long unique region (LUR) and characterized the terminal repeats of the genome of a rhesus rhadinovirus (RRV), strain 17577. The LUR as sequenced is 131,364 bp in length, with a G+C content of 52.2% and a CpG ratio of 1.11. The genome codes for 79 open reading frames (ORFs), with 67 of these ORFs similar to genes found in both Kaposi's sarcoma-associated herpesvirus (KSHV) (formal name, human herpesvirus 8) and herpesvirus saimiri. Eight of the 12 unique genes show similarity to genes found in KSHV, including genes for viral interleukin-6, viral macrophage inflammatory protein, and a family of viral interferon regulatory factors (vIRFs). Genomic organization is essentially colinear with KSHV, the primary differences being the number of cytokine and IRF genes and the location of the gene for dihydrofolate reductase. Highly repetitive sequences are located in positions corresponding to repetitive sequences found in KSHV. Phylogenetic analysis of several ORFs supports the similarity between RRV and KSHV. Overall, the sequence, structural, and phylogenetic data combine to provide strong evidence that RRV 17577 is the rhesus macaque homolog of KSHV.

Insurance and the risk of ruptured appendix in the adult

BACKGROUND

Disparities in medical care related to the insurance status of patients have been reported. A retrospective analysis was performed to examine the insurance-related differences in the risk of appendiceal perforation in the Prince of Wales Hospital (POWH), New South Wales.

METHODS

Computerized data of 1179 patient years who had a diagnosis of appendicitis and were admitted to the POWH over the preceding 10 years were examined. The outcome measure was appendiceal perforation. Patient variables examined were insurance status, sex, age, and socio-economic status (SES). Three hundred patients over the same period were identified who had an appendicectomy but not appendicitis. Multiple logistic regression and Fisher's exact test were used for statistical analysis.

RESULTS

The overall perforation rate in 1179 patients was 17%. The only factor that was related to an increased risk of perforation was age over 50 years (odds ratio (OR) 1.57; 95% confidence interval (CI) 1.04-2.53). Sex, insurance status or SES were not associated with a higher risk of perforation. The overall rate of negative appendicectomy was 20% (300 of 1479 patients), and the rate was higher in the uninsured patients (22 vs 17%, P = 0.014, Fisher's exact test).

CONCLUSIONS

Lack of health insurance was not associated with an increased incidence of appendiceal perforation at the POWH. Age over 50 years was identified as the only risk factor for appendiceal perforation. The lower negative appendicectomy rate in the insured group may be because of better diagnostic ability of consultants compared to registrars.

Ulcerative colitis exacerbation associated with cytomegalovirus infection

There is an increasing prevalence of ulcerative colitis in Hong Kong and cytomegalovirus infection is an important factor in the exacerbation of the disease. We report on a 33- year-old Chinese man with ulcerative colitis in remission, who presented with bloody diarrhoea that failed to respond to an intensive regimen of oral and rectal steroid. Colonoscopy was performed and biopsy specimens showed signs of cytomegalic colitis in association with ulcerative colitis. Administration of ganciclovir and the gradual termination of steroid treatment resulted in remission of the colitis. The clinical course suggested an exacerbation of ulcerative colitis due to cytomegalovirus infection. The relationship between ulcerative colitis and cytomegalovirus is discussed.

Halosarpheia heteroguttulata sp.nov. from submerged wood in streams

A new species of Halosarpheia, H. heteroguttulata, is described from wood submerged in streams and lakes in Australia, Brunei, Hong Kong, Mauritius, the Philippines, and South Africa. It differs from other species in the genus in ascospore dimensions, and consistently large guttule(s) in the apical cell, but many smaller guttules in the basal cell. The species is illustrated with light and scanning and transmission electron micrographs and compared with other Halosarpheia species.Key words: appendage ontogeny, freshwater Ascomycete, Halosarpheia, taxonomy, ascospore ultrastructure.

Characterization of rhesus cytomegalovirus genes associated with anti-viral susceptibility

Studies were initiated to determine whether rhesus cytomegalovirus (RhCMV)-infected macaques could serve as an animal model for evaluating anti-CMV compounds, as macaques have a naturally occurring CMV that is similar to human CMV (HCMV). Utilizing plaque reduction assays, RhCMV was tested to anti-viral susceptibility. By these assays. RhCMV displayed anti-viral susceptibility to ganciclovir at a 50% effective dose (ED50) of 0.8 microM, acyclovir at an ED50 of 15 microM, and foscarnet at an ED50 of 250 microM. By Southern blot analysis with HCMV-UL97 (phosphotransferase) and DNA polymerase (pol) genes as probes, we isolated viral DNA fragments that strongly hybridized. DNA sequence analysis of these DNA fragments revealed two open reading frames with homology to HCMV UL97 and DNA polymerase. Steady-state RNA analysis revealed that the RhCMV UL97 homologue and pol genes are transcribed as early late and early genes, respectively. Comparison against HCMV showed the RhCMV UL97 homologue exhibits 54.4% amino acid (aa) sequence identity to HCMV UL97 and the RhCMV DNA polymerase 59.2% aa sequence identity to HCMV DNA polymerase. Results from anti-viral assays and molecular characterization of these two viral genes suggest that RhCMV-infected rhesus macaques should serve as an excellent animal model for evaluating future anti-CMV compounds.

Leg wound infections associated with coronary revascularization

BACKGROUND

Wound infections after saphenous vein harvest for coronary revascularization are common but they are infrequently examined. The aim of the present study was to investigate the risk factors for infection and the possible beneficial effects of saline lavage.

METHODS

From April 1996 to July 1996, 152 consecutive patients who underwent saphenous vein harvest for coronary artery bypass graft were recruited. Factors that may influence infection rates were analysed.

RESULTS

A total of 22 of the 125 (18%) patients included in the present study developed a wound infection. The length of the wound was the only variable found to have a statistically significant association with wound infection. In the analysis of patients with multiple leg wounds, the development of infection correlated with the absence of mechanical wash-out.

CONCLUSION

The use of saline lavage may prevent wound infections by diluting the bacterial population prior to closure. The use of antiseptic or antibiotic lavage may offer an additional benefit.

Explantation of silicone breast implants

Silicone gel-filled breast implants have been employed clinically for decades for aesthetic augmentation or postmastectomy reconstruction. Most patients and surgeons attest to the efficacy and safety of these devices. However, more recently in the medical literature and popular media, silicone gel-filled breast implants have been claimed to incite an array of clinical sequelae such as capsular formation, granulomatous disease, arthritis, arthralgia, fibromyalgia, autoimmune collagen vascular disease, human adjuvant disease, siliconosis, silicone-related disease, and silicone implant-associated syndrome. During a recent 24-month period, 25 referred patients underwent explantation of bilateral silicone gel-filled prostheses at the University of South Alabama. Patient-reported symptoms and signs included mastodynia, arthralgia, fibromyalgia, xerophthalmia, xerostomia, hypesthesia, and amblyopia. Clinical examination and mammography were reliable in diagnosing implant rupture, but only re-exploration reliably detected implant leakage. Most patients underwent concurrent replacement with saline-filled devices. Histopathologic analyses of all tissue samples revealed chronic inflammation. Subjective improvement of patient-reported symptoms and signs occurred over the course of months postoperatively. There was no mortality associated with explantation, with or without replacement, but an overall morbidity incidence of 20 per cent (5 of 25) was observed. Predicated upon review of the available scientific literature and analysis of this modest number of patients, the following perspectives are germane. 1) A small cohort of patients of status postimplantation of silicone gel-filled devices will manifest chronic morbidity. Identifying such patients prospectively remains problematic. 2) Whether or not silicone gel incites adverse systemic phenomena is unproven, although it has been implicated. 3) Symptomatic patients with silicone gel-filled implants in place should be considered for removal, with full knowledge of the morbidity associated with revisional procedures. 4) Patients currently undergoing breast augmentation or reconstruction employing prosthetics are perhaps best served by insertion of saline-filled devices. 5) Patient-physician dialogue regarding the risk-benefit analysis of prosthetic implantation is imperative. Patients consenting to such procedures must be willing to assume risks.

Mesothelioma: a study of 22 gases

Mesothelioma is a rare, asbestos-associated tumor that infrequently metastasizes. We reviewed 22 autopsies (from February 1989 through July 1994) showing mesothelioma. We determined distribution of metastases and staining characteristics of primary mesotheliomas compared to tissue involved by metastases and/or direct extension. Mean patient age was 68 years (range, 38 to 88 years); black:white patient ratio, 4:18; and male:female patient ratio, 2:1. All patients had a history of asbestos exposure. Fifteen autopsies were complete and 7 were limited to the thoracic cavity. Multiple sites were involved by direct extension. Metastases were in multiple sites, including omentum, stomach, intestine, mesentery, adrenal glands, ovary, pancreas, kidneys, liver, spleen, and vertebrae. Results of immunohistochemical staining of primary mesotheliomas and metastases were similar; both were positive for low-molecular-weight keratin and negative for carcinoembryonic antigen, Leu-M1, Ber-EP4, and periodic acid-Schiff reagent with diastase. Results of testing for high-molecular-weight keratin were variable.

Expression of the gibbon ape leukemia virus receptor-1 in rhesus macaque tissues

A cDNA fragment specific for the rhesus macaque gibbon ape leukemia virus (GaLV) receptor (Glvr-1) was isolated by polymerase chain reaction (PCR) amplification and oligonucleotide primers specific for human Glvr-1 and a cDNA library derived from rhesus macaque brain. Sequence analysis of the fragment revealed the polypeptide domain necessary for infection by GaLV. This fragment was utilized to elucidate expression levels of Glvr-1 RNA in rhesus macaque tissues. By Northern blot analysis, Glvr-1 RNA is most abundantly expressed in the thymus and bone marrow, with detectable levels also in the brain and testes of juvenile male macaques. In the developing 70-days gestation fetus, Glvr-1 expression was observed predominately in the liver and spleen. Although additional studies are required, these studies support the notion that cell types involved in hematopoiesis express Glvr-1.

The association of HPV 16 DNA with specific nuclear matrix proteins of normal and cervical carcinoma cell

Human papillomavirus type 16 (HPV 16) has been found to be integrated into the DNA of epithelial cells in most cervical cancers. The HPV16 DNA is bound to different nuclear matrix proteins in normal and cervical carcinoma cells. It has high affinity, for acidic proteins in cancer cells. The molecular weights of the acidic proteins are 200 kD, 186 kD and 67 kD. On the other hand, the viral DNA seemed to bind to higher molecular weight basic nuclear matrix proteins (250 kD, 150 kD) of normal cells. Further investigation of the functional roles of these nuclear matrix proteins may provide insight into the process of carcinogenesis of the cervix.

Autopsy evaluation of asbestos exposure: retrospective study of 135 cases with quantitation of ferruginous bodies in digested lung tissue

In recent years, there has been increased interest in documenting asbestos exposure. The pathologic sine qua non of asbestos exposure has been the presence of "asbestos bodies" in lung parenchyma. In this retrospective study of 135 autopsies done to determine asbestos exposure, ferruginous bodies in digested lung tissue were quantitated by a simplified sodium hypochlorite procedure on fresh or fixed tissue. Of the 131 digested specimens, 26 (20%) showed no ferruginous bodies, 34 (26%) had <5 ferruginous bodies per slide, 7 (5%) had 5 to 10 ferruginous bodies per slide, and 64 (49%) had >10 ferruginous bodies per slide. Ferruginous bodies were identified in hematoxylin-eosin stained sections of lung tissue in only 41 cases (30%). The digestion method described is a simple, reliable, and inexpensive method to assess ferruginous bodies.

Suppression of simian immunodeficiency virus replication by human immunodeficiency virus type 1 trans-dominant negative rev mutants

We demonstrate that trans-dominant negative rev mutants are able to suppress simian immunodeficiency virus provirus replication in both transient cotransfection assays and stably transduced HUT 78 cells. These studies suggest that the efficacy of trans-dominant rev strategies in reducing viral burden may be evaluated in a simian immunodeficiency virus-rhesus macaque animal model.

Assessing genetic-based therapies for AIDS using the simian immunodeficiency virus

A plasmid encoding the full-length infectious molecular proviral clone of SIVmac239 was generated. Virus derived from cells transfected with this clone replicated to high levels and was cytopathic for some transformed human CD4+ cell lines and primary rhesus macaque peripheral blood mononuclear cells. Since replication of SIV requires the functional expression of the viral encoded rev protein, transient co-transfection studies were initiated with the infectious proviral clone and a well-characterized trans-dominant negative HIV-1 rev mutant.

Netherton's syndrome: a syndrome of elevated IgE and characteristic skin and hair findings

Netherton's syndrome is a rare symptom complex characterized by greatly elevated IgE levels with atopic manifestations, an ichthyotic skin disorder (ichthyosis linearis circumflexa and/or congenital lamellar ichthyosis), and the characteristic hair abnormality trichorrhexis invaginata. It may be confused with atopic dermatitis but does not respond to topical corticosteroid treatment. Netherton's syndrome is therefore of considerable importance to allergists. In this article we report the results of the clinical and immunologic evaluation of a previously unreported patient who responded to treatment with 12% ammonium lactate lotion and management of his allergic disease. Furthermore, we have reviewed the English literature and compared the findings in our patient with those of 43 other reported patients. Our patient shared the features of other previously reported patients with this disorder. We conclude that this disease should be included among the other disorders with elevated IgE. Patients may benefit from evaluation and treatment of their allergic symptoms and topical skin treatment with ammonium lactate.

Observations on blood pressure responses to injections of medicinal plant extracts in rats

Aqueous extracts of plant species from different families produced dose dependent decreases in blood pressure in rat within the first minute (immediate hypotensive response) and in duration of this hypotensive response following i.v. injection, while the subsequent response could be either hypotensive or hypertensive depending on plant species. The subsequent response was not dose-related in both magnitude and duration. The immediate hypotensive response was not due to the vehicle (NaCl solution) nor the common cations present in the extracts. It represented probably a reflex response with chemicals in the plant extracts acting on the peripheral chemoreceptors, or in the pacemaker and/or cardiac tissue, leading to a decrease in heart rate and tension. The subsequent hypotensive/hypertensive response was due to the chemicals acting on targets in different parts of various body systems.

Double-cycle high-dose chemotherapy with peripheral blood stem cells and hematopoietic growth factor support in patients with advanced solid tumor. A pilot study by the Hong Kong Biotherapy Group

BACKGROUND

High-dose chemotherapy with autologous bone marrow transplantation has been useful in some patients with advanced breast, lymphoma, or germ cell tumors. Double-cycle high-dose chemotherapy may be able to deliver an even higher total dose within a given time period. It is important to determine whether peripheral blood stem cells and hematopoietic growth factors can diminish the hematopoietic toxicity of such a treatment.

METHODS

From November 1989 to May 1991, 14 patients were enrolled in two cycles of high-dose chemotherapy consisting of cyclophosphamide, 4.5 g/m2; cisplatin, 150 mg/m2; and etoposide, 900 mg/m2 in each cycle. The first five patients received peripheral blood stem cells harvested from 8-10 leukaphereses during steady state. The next nine patients, besides receiving peripheral blood stem cells mobilized by growth factors, also received either granulocyte-macrophage colony-stimulating factor (GM-CSF) at 250 micrograms/m2/day by two subcutaneous (s.c.) injections given 12 hours apart from day 6 until neutrophil recovery or granulocyte colony-stimulating factor (G-CSF) at 200 micrograms/m2 as daily s.c. injections.

RESULTS

For the first five patients, there was a median of 14 days from the first day of absolute marrow suppression to neutrophil count exceeding 500/microliters and a median of 15 days for a platelet count exceeding 20,000/microliters. For the next nine patients, with the use of either G-CSF or GM-CSF, there was a median of 8 days for a neutrophil count exceeding 500/microliters and and a median of 11 days for a platelet count exceeding 20,000/microliters.

CONCLUSION

With the use of peripheral stem cells and growth factors, high-dose chemotherapy could be given safely every 30 days with acceptable toxicity. A high complete response rate was seen in patients with nasopharyngeal carcinoma and in patients with small cell and non-small cell lung cancer who either had not received previous chemotherapy or who had responded to previous chemotherapy.

Epidural hematomas. An unusual complication of minor blunt force injury due to seizures in a patient with sickle cell disease

Multiple subacute epidural hematomas in a patient with sickle cell disease (HbSS) are reported. The patient was a 22-year-old Black man with a history of strokes and seizures, who was unexpectedly found dead at his foster home. Scene investigation disclosed no foul play or any indication of violent activities. Autopsy findings included subgaleal contusions and bilateral epidural hematomas, but no calvarial fractures. The epidural hematomas were subacute and closely patterned to the headboard knots of the bed in which the decedent had slept. The etiology of the hematomas is minor blunt force injury secondary to the head striking against the headboard during seizures. The immediate cause of death was determined to be pneumonia and sepsis secondary to HbSS.