Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective

Diabetes and obesity are both increasing at a fast pace and giving rise to a new epidemic called diabesity. Lifestyle interventions including diet play a major role in the treatment of diabetes, obesity and diabesity. There are many guidelines on dietary management of diabetes or obesity globally and also from South Asia. However, there are no global or South Asian guidelines on the non-pharmacological management of diabesity. South Asia differs from the rest of the world as South Asians have different phenotype, cooking practices, food resources and exposure, medical nutrition therapy (MNT) practices, and availability of trained specialists. Therefore, South Asia needs its own guidelines for non-pharmacological management of diabesity in adults. The aim of the Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective is to recommend therapeutic and preventive MNT in the South-Asians with diabesity.

Development of genome wide transposable elements based repeat junction markers in Jatropha (Jatropha curcas L.)

Jatropha curcas is a potential biodiesel crop and a highly adaptable species to various agro-climatic conditions. In this study, we have utilized transposable elements' (TE) repeat junctions (RJs) which are an important constituent of the genome, used to form a genome-wide molecular marker platform owing to its use in genomic studies of plants. We screened our previously generated Jatropha hybrid genome assembly of size 265 Mbp using RJPrimers pipeline software and identified a total of 1274 TE junctions. For the predicted RJs, we designed 2868 polymerase chain reaction (PCR) based RJ markers (RJMs) flanking the junction regions. In addition to marker design, the identified RJs were utilized to detect 225,517 TEs across the genome. The different types of transposable repeat elements mainly were scattered into Retro, LTR, Copia and Gypsy categories. The efficacy of the designed markers was tested by utilizing a subset of RJMs selected randomly. We have validated 96 randomly selected RJ primers in a group of 32 J. curcas genotypes and more than 90% of the markers effectively intensified as amplicons. Of these, 10 primers were shown to be polymorphic in estimating genetic diversity among the 32 Jatropha lines. UPGMA cluster analysis revealed the formation of two clusters such as A and B exhibiting 85.5% and 87% similarity coefficient respectively. The various RJMs identified in this study could be utilized as a significant asset in Jatropha functional genomics including genome determination, mapping and marker-assisted selection.

Factors influencing patency of Brescia-Cimino arteriovenous fistulas in hemodialysis patients

Autologous arteriovenous fistula is gold standard to maintain vascular access for hemodialysis patients. As per the Kidney Disease Outcomes Quality Initiative guidelines, distal veins are preferred as the first choice. In this study, a total of 134 patients and 138 fistulas were evaluated from April 2015 to March 2016. Demographic factors and clinical factors were taken into consideration. Our study showed that age, sex, diabetes, and type of construction (end-to-side vs. side-to-side) had no influence over fistula patency rates. Intradialytic hypotension was one of the risk factors for loss of fistula patency. Smoking and history of hypertension were associated with reduced patency rates (P<0.001). Primary failure was more with distal fistulas (15.2%).

Plant cysteine proteases that evoke itch activate protease-activated receptors

BACKGROUND

Bromelain, ficin and papain are cysteine proteases from plants that produce itch upon injection into skin. Their mechanism of action has not been considered previously.

OBJECTIVES

To determine the mechanism by which these proteases function.

METHODS

The ability of these proteases to activate protease-activated receptors was determined by ratiometric calcium imaging.

RESULTS

We show here that bromelain, ficin and papain activate protease-activated receptors 2 and 4.

CONCLUSIONS

Bromelain, ficin and papain function as signalling molecules and activate protease-activated receptors. Activation of these receptors is the likely mechanism by which these proteases evoke itch.

Catalytic properties and structural components of lysyl oxidase

Key aspects of the biosynthesis and catalytic specificity of lysyl oxidase (LO) have been explored. Oxidation of peptidyl lysine in synthetic oligopeptides is markedly sensitive to the presence of vicinal dicarboxylic ami/no acid residues. Optimal activity is obtained with the -Glu-Lys- sequence within a polyglycine 11-mer, whereas the -Lys-Glu- sequence is much less efficiently oxidized. The -Asp-Glu-Lys- sequence is a very poor substrate, although this sequence is oxidized in type I collagen fibrils. These results are considered in the light of a model requiring collagen to be assembled as fibrils prior to oxidation by LO. An in vitro system for the expression of catalytically active LO has been devised. Deletion or inclusion of the cDNA coding for the propeptide region in the expressed construct results in apparently identical, catalytically active enzyme products, indicating the lack of essentiality of this region for active enzyme production. These effects are considered with respect to the conservation of the amino acid sequence of LO produced by different species.

Fine-needle aspiration biopsy of the liver: a multicenter study of 602 radiologically guided FNA

With improved radiologic techniques fine-needle aspiration (FNA) is becoming a rapid, effective diagnostic method in evaluating a wide range of liver masses. Review of six hundred two radiologically guided liver aspirates performed over a ten-year period forms the basis of this report.

Fine-needle aspiration biopsy of the liver: a multicenter study of 602 radiologically guided FNA

With improved radiologic techniques fine-needle aspiration (FNA) is becoming a rapid, effective diagnostic method in evaluating a wide range of liver masses. Review of six hundred two radiologically guided liver aspirates performed over a ten-year period forms the basis of this report.

Fine-needle aspiration of extranodal and extramedullary hematopoietic malignancies

There is relatively little information concerning the use of fine-needle aspiration (FNA) to diagnose extranodal and extramedullary hematopoietic malignancies. Seventy-one such cases diagnosed by FNA form the basis of this study. Seventy-one cases of FNAs performed between 1988 and 1998 on extranodal and extramedullary hematopoietic malignancies were reviewed in order to evaluate the usefulness of this technique in diagnosing these entities as well as to assess patterns of relapse. There were 45 male and 26 female patients ranging in age from 29-86 years (mean, 68 years). Sixty-six patients had a previous history of a hematopoietic malignancy. Aspirates from 65 of these patients were consistent with the patient's known primary. One aspirate of a paravertebral mass from a multiple myeloma patient showed extramedullary hematopoiesis. The remaining five aspirates were cases of multiple myeloma that first presented as soft tissue masses. The most common malignancies were lymphoma: 52 cases (73%), 48 large cell lymphomas, four mixed small and large cell lymphoma; followed by multiple myeloma: 12 cases (17%); leukemia: four cases (5.4%); Hodgkin disease: two cases (2.8%); and one case of extramedullary hematopoiesis. The aspirate sites were soft tissue: 23 cases (32%); bone: 17 cases (24%); kidney: 14 cases (20%); liver: 11 cases (15%); lung: three cases (4%); adrenal: two cases (3%); and eye: one case. The interval between primary diagnosis and FNA was 1-36 months (mean, 13 months). In conclusion, 98% of the aspirates were neoplastic in patients with a known history of hematopoietic malignancies. The most common site of involvement was soft tissue in 23 (32%) cases. In five patients with multiple myeloma, the FNA diagnosis prompted a work-up to find the primary site of involvement. FNA is a useful technique in assessing extranodal and extramedullary hematopoietic malignancies.

Chrysoptin is a potent glycoprotein IIb/IIIa fibrinogen receptor antagonist present in salivary gland extracts of the deerfly

Salivary gland lysates of the deerfly (genus Chrysops) contain chrysoptin, an inhibitor of ADP-induced platelet aggregation, which presumably assists the fly in obtaining a blood meal. Chrysoptin has now been isolated, and its cDNA has been cloned and expressed. Chrysoptin was purified to homogeneity using anion exchange and hydrophobic interaction chromatography and found to be a protein with a molecular mass of 65 kDa as determined by gel electrophoresis. N-terminal amino acid sequencing allowed for the synthesis of degenerate oligonucleotides that led to cloning, from salivary gland specific mRNA, of the cDNA encoding this platelet inhibitor. No RGD sites are present in the predicted sequence. A search of GenBank(TM) did not reveal significant sequence homology between chrysoptin and other proteins. The molecular mass predicted from the cDNA was 59 kDa. Predicted glycosylation and phosphorylation sites may account for this difference in molecular mass, as recombinant chrysoptin expressed in Sf21 cells had a molecular mass of 65 kDa, matching that of the natural protein. Chrysoptin functions by inhibiting the binding of fibrinogen to the fibrinogen/glycoprotein IIb/IIIa receptor on platelets with an IC(50) of 95 pmol. These results reveal that insect salivary glands are a source of fibrinogen receptor antagonists.

Role of fine-needle aspiration in the clinical management of solid organ transplant recipients: a review

BACKGROUND

We evaluated the clinical course of the solid-organ transplant population at our institutions to determine the role of fine-needle aspiration (FNA) in the clinical management of this subgroup of patients.

METHODS

1196 allograft recipients (522 liver, 288 cardiac, 250 renal, 131 lung, 5 heart and lung) were reviewed. A total of 62 (5.2%) (32 liver, 23 heart, 6 lung, and 1 renal) transplant patients underwent an FNA procedure. Thirty-seven males and 25 females were included, ranging in age from 18 to 71 years (mean 50 years).

RESULTS

Of the 62 fine-needle aspirates, 29 (47%) were neoplastic. The most common malignancies aspirated were malignant solid tumors (15 cases)-including 8 epithelial malignancies, 5 hepatocellular carcinomas, and 2 mesenchymal neoplasms-followed by posttransplant lymphoproliferative disorders (14 cases). Thirteen (21%) aspirates were inflammatory. The remaining 20 (32%) cases were benign aspirates from various sites (9 liver, 3 breast, 2 thyroid, 2 soft tissue, 2 lung, and 2 vertebral body). Surgical and/or autopsy material was available in 34 cases (55%). There was agreement between the tissue diagnosis and FNA material in 33 cases (97%). One case (3%) was a false negative. No false-positive cases were recorded.

CONCLUSIONS

This study showed that over 50% of the aspirates were benign, justifying a conservative approach in the clinical management of these patients. Histologic correlation was available in 54% of the cases with an overall specificity of 100% and a sensitivity of 97%. We conclude that FNA is a highly sensitive and specific technique in the evaluation of lesions occurring in posttransplant patients. Cancer (Cancer Cytopathol)

Utilization of fine-needle aspiration in the diagnosis of metastatic tumors to the kidney

Renal masses secondary to metastases are not common. Few comprehensive reviews exist, which consist primarily of autopsy and radiologic reports. The purpose of this study was to review the types and incidences of various neoplasms which metastasize to the kidney and to determine the usefulness of fine-needle aspiration (FNA) in diagnosing them. Two hundred and sixty-one radiologically guided FNAs of renal lesions over a 9-yr period were reviewed. The diagnoses of the 261 renal FNAs were as follows: 136 (52%) were malignant, 111 (43%) were benign, and 14 (5%) were unsatisfactory. Of the 136 positive FNAs, 28 (21%) revealed metastatic tumors. The overall incidence of renal FNAs displaying metastatic tumors was 11%. Among the 28 patients with metastases to the kidney, 23 patients were men and 5 were women, with the mean age being 58 yr. Twenty-five patients (89%) had prior history of a primary malignancy, including lung carcinoma (11 cases, 39%), lymphoma (8 cases, 29%), hepatocellular carcinoma (3 cases, 11%), and one case each of breast, pancreatic, and cervical cancer. In the remaining 3 patients (11%), with metastatic adenocarcinoma (2 cases) and squamous-cell carcinoma (1 case), the primary tumor site remained unknown despite an extensive clinical workup. Overall survival after FNA was poor, with a mean of 9.8 mo. FNA is useful in the diagnosis of masses in the kidney secondary to metastatic disease. This information is of clinical importance, principally in the exclusion of a primary malignancy, but also to avoid unnecessary surgery and to plan for subsequent patient care.

Low-stage carcinoma of the male breast. A histologic, immunohistochemical, and flow cytometric comparison with localized female breast carcinoma

Male breast carcinoma (MBC) accounts for only 1% of total mammary carcinomas. Controversy exists about whether MBC differs clinically and pathologically from female breast carcinoma (FBC). We compared 10 archival cases with 75 stage-matched FBCs. Clinical data, histologic details, immunostains for mammary lineage markers, and results of several putative "prognostic" analyses were addressed, including DNA ploidy and expression of c-erbB-2 (neu) oncoprotein and p53 protein. Cumulative literature data on 2,530 MBCs were contrasted with information from 135 institutional cases of FBC. A statistically significant difference in grade 3 lesions at low stage persisted when MBCs of all stages were compared with similar FBCs. For stages I and IIA, 5-year survival was 60% and 86% for MBCs and FBCs, respectively (also statistically significant). This difference disappeared when all stages were compared. A similar number of MBCs and FBCs, regardless of stage, demonstrated DNA aneuploidy with or without synthesis of S-100 protein, gross cystic disease fluid protein-15, c-erbB-2 protein, and p53 protein. Hormone receptor positivity was more common in MBC than in FBC at high tumor stages. Low-stage MBC and FBC differ biologically; MBCs tend to manifest at a higher grade with lessened 5-year survival. However, aside from distinctions in hormone receptor proteins, broader comparison of MBC and FBC at stages IIB and higher shows no significant differences in 5-year survival or expression of breast cancer-associated gene products.

Utilization of core wash material in the diagnosis of breast lesions by stereotactic needle biopsy

BACKGROUND

Several reports have compared the results of fine-needle aspiration and stereotactic core needle biopsy in nonpalpable breast lesions. In this study the authors describe a simple method to retrieve cytologic material from a core breast biopsy sample that provides the diagnosis within 1 hour of the procedure.

METHODS

Two hundred and eleven nonpalpable breast lesions were biopsied. Each core needle biopsy sample was placed in a mesh bag, and the bag and needle notch were washed in Cytolyt solution to obtain a monolayer using a commercial ThinPrep processor. The cytologic diagnoses were divided into four categories: benign, suspicious, malignant, and unsatisfactory, which then were compared with core needle biopsy results.

RESULTS

Cytology reports of 211 lesions were as follows: 169 lesions (80%) were benign, 16 lesions (7.6%) were suspicious, 11 lesions (5.2%) were malignant, and 15 lesions (7.1%) were unsatisfactory. Core needle biopsy showed 165 of 169 samples (98%) to be benign and 4 to be malignant. Of the 16 suspicious smears, 10 were invasive carcinoma, 2 were in situ lesions, 3 were hyperplasias, and 1 was fibrosis. Of the 11 malignant smears, 10 were confirmed on core needle biopsy and 1 was read as atypia on the first core needle biopsy sample and malignant on a second, separate, follow-up core needle biopsy. Of the 15 unsatisfactory samples, 14 were found to be benign and 1 was found to be malignant on a separate, follow-up core needle biopsy.

CONCLUSIONS

The core wash technique was 85% sensitive and 98% specific for malignancy. Only 7% of specimens were insufficient for diagnosis, and 93% of these were proven to be benign. This technique is useful for immediate (within 1 hour) diagnosis of breast lesions, alleviating patient anxiety and supplementing the diagnostic yield of the core biopsy.

The yield of bone marrow biopsy and culture compared with blood culture in the evaluation of HIV-infected patients for mycobacterial and fungal infections

PURPOSE

To compare the clinical utility of bone marrow biopsy and culture specimens with blood cultures for mycobacterial and fungal infections among human immunodeficiency virus (HIV)-infected patients.

PATIENTS AND METHODS

All bone marrow biopsies obtained from HIV-infected patients at the University of Alabama at Birmingham (UAB) Medical Center during 1993 to 1995 were blindly reviewed in a standardized format. Bone marrow culture results and blood culture results obtained within 6 weeks of each bone marrow study were compiled. Medical records were reviewed to determine indications for performing bone marrow biopsies, empiric or prophylactic antimicrobial therapies preceding the biopsy, and CD4 counts.

RESULTS

Eighty-two bone marrow studies were obtained from 76 patients. Most were performed during the evaluation of fever, cytopenia, or weight loss. Of 55 bone marrow mycobacterial cultures, 13 yielded Mycobacterium avium complex (MAC) and 2 yielded M tuberculosis (MTB). Of 51 bone marrow fungal cultures performed, 2 yielded Cryptococcus neoformans and 1 Histoplasma capsulatum. All patients with a bone marrow culture positive for MAC had a CD4 count of 20 cells/mm3 or less. The mean CD4 count in this group (+/-95% confidence interval) (8+/-3 cells/mm3) was lower than that of culture-negative cases (41+/-25 cells/mm3); P <0.015). When bone marrow cultures and mycobacterial blood cultures were concurrently obtained, results were usually in agreement between the two sites. The mean time until the report of positive mycobacterial bone marrow cultures (22+/-5 days) was similar to that for blood cultures (24+/-3 days). Most (84%) patients with multiple mycobacterial cultures had completely concordant results (all positive or all negative). When blood or bone marrow culture yielded mycobacteria, only 29% of the corresponding bone marrow examinations revealed stainable acid-fast bacilli (AFB). In contrast, all 3 cases with positive fungal bone marrow cultures also had stainable organisms on histologic examination.

CONCLUSIONS

The combined use of bone marrow biopsy and culture as well as blood cultures provide the maximum diagnostic yield when evaluating patients with AIDS for mycobacterial or fungal infections. However, when mycobacterial infections were diagnosed, bone marrow results seldom provided more immediate or specific information than lysis centrifugation blood cultures. A single lysis centrifugation blood culture should be the first step in the routine evaluation of HIV-infected patients when disseminated MAC infection is suspected.

Role of fine-needle aspiration in clinical management of transplant patients

Fine-needle aspiration (FNA) of superficial and deep seated lesions has been used with high sensitivity and specificity in the diagnosis of neoplastic and non-neoplastic entities. However, studies of FNA in post-transplant patients are virtually absent. Six hundred and seventy-four allograft recipients (cardiac 288, renal 250, lung 131 and heart-lung 5) were reviewed. A total of 30 (25 heart, 4 lungs and 1 renal transplant) patients underwent an FNA procedure. There were 26 males and 4 females. Ages ranged from 18-63 yr (mean 48 yr). The most common entity aspirated was post-transplant lymphoproliferative disorder (PTLD) in 12 cases, followed by inflammatory lesions in 10 cases, malignant epithelial neoplasms in 3 cases, and 1 case each of malignant mesenchymal tumor, pulmonary infarction, hamartoma of liver, fatty changes of liver, and a benign vascular lesion. Surgical or autopsy tissue was available in 19 cases (63.3%). There was an agreement between tissue diagnosis and FNA material in 18 cases (94.7%). One (5.2%) false negative case was recorded. This was a liver aspirate showing benign liver elements, which a surgical biopsy proved to be a bile duct hamartoma. No false positive cases were recorded. FNA is a highly sensitive and specific diagnostic tool in the management of post-transplant patients.

Posttransplant lymphoproliferative disorders: a fine-needle aspiration biopsy study

Fine-needle aspiration biopsy (FNAB) has been used with high sensitivity and specificity in the diagnosis of both Hodgkin's and non-Hodgkin's lymphoma. However, studies of FNAB of posttransplant lymphoproliferative disorders (PTLDs) are rare. The clinical course of 593 allograft recipients (cardiac, 288; renal, 250; lung, 50; and heart/lung, 5) was reviewed. Twenty-six patients developed PTLD with an overall incidence of 4.4%. Of these patients, 12 underwent FNAB. Their age ranged from 33-67 yr (mean, 55 yr). The interval between transplantation and FNAB ranged between 2-14 mo (average, 8.4 mo). The lungs were the most common site aspirated (7 cases), followed by lymph nodes (3 cases) and other extranodal sites (2 cases, liver and paraspinal mass). The cytologic features of these aspirates could be classified into two categories: a polymorphous smear composed of a spectrum of mature and immature lymphocytes with scattered plasma cells and histiocytes; and a monotonous population of large lymphoid cells consistent with malignant lymphoma, large-cell type. Surgical biopsies were available in 10 (83.3%) cases and confirmed the FNAB diagnosis. In summary, FNAB appears to be a highly sensitive and specific diagnostic tool in patients with PTLD.

Humoral (antibody-mediated) rejection in lung transplantation

To confirm the existence and characterize the pathologic features of humoral (antibody-mediated) lung rejection, we prospectively studied 55 lung transplant recipients (24 male [44%] and 31 female [56%], age range 14 to 69 years [mean 45]). The time between transplantation and biopsy ranged from 2 to 1546 days (mean 274). We performed direct immunofluorescence with C3, immunoglobulin M, and immunoglobulin G antibodies on frozen sections of 106 transbronchial biopsies and one wedge biopsy and compared the results with 13 explanted lungs, one donor lung, and two controls. The histologic diagnoses of these 107 biopsies included acute cellular rejection (62, 58% [minimal 23, mild 33, moderate 5, and severe 1]), chronic rejection (eight, 7%), chronic vascular rejection (two, 2%), acute vasculitis (five, 5%), cytomegalovirus pneumonitis (two, 2%), acute pneumonia (two, 2%), acute organizing pneumonia (two, 2%), diffuse alveolar damage (one, 1%), no evidence of rejection or infection (30, 28%), lipoid pneumonia (one, 1%), and inadequate for histologic diagnosis (one, 1%). Eighty-nine of 106 (84%) transbronchial biopsies, the wedge biopsy, and control lungs were satisfactory for direct immunofluorescence, because each contained alveolate lung parenchyma and arterioles or venules. There was no demonstrable immunofluorescence in the wall of the blood vessels or in the lung parenchyma in any case. We conclude that (1) transbronchial biopsies and wedge biopsies provide adequate material to evaluate humoral rejection, and (2) in spite of the large population studied, the satisfactory material obtained, and the wide range of histologic diagnoses, we could not demonstrate the occurrence of humoral rejection in the lung.

Pulmonary alveolar proteinosis: an unusual association with Mycobacterium avium-intracellulare infection and lymphocytic interstitial pneumonia

Pulmonary alveolar proteinosis is a nonspecific alveolar response to various forms of injuries. Many cases have been associated with hematologic malignancies. The most commonly reported complication of pulmonary alveolar proteinosis is superinfection with fungal, bacterial, and viral infections. We report a case of a 33-year-old man with alveolar proteinosis complicated by Mycobacterium avium-intracellulare complex infection. The additional presence of diffuse lymphocytic interstitial pneumonitis is an association that has not been previously reported.

Postmortem findings in lung transplant recipients

Lung transplantation is now an accepted modality for treating end-stage lung disease. To better understand the factors limiting the survival of these patients, we reviewed the autopsy findings in 37 patients who received lung transplants. Between 1986 and 1995, 131 patients have undergone lung transplantation at our institution, including 4 patients with repeat transplantations. Of these, 48 (36.6%) died, 37 (77%) of whom had an autopsy. The autopsied patients were divided into three groups on the basis of post-transplantation interval: early (< 30 d), intermediate (31-365 d), and late (> 365 d). Of the 12 patients in the early group, 6 died of intra- and postoperative complications and 6 of bacterial infection with pneumonia in the transplanted lung. There were 18 patients in the intermediate group, of whom 11 died of infection (5 of cytomegalovirus, 5 of nonviral infections of the transplanted lung, and 1 of encephalomyelitis), 3 of post-transplantation lymphoproliferative disorder, 3 of chronic airway rejection, and one of unrelated cause. Of the seven patients in the late group, four died of chronic airway rejection, two of unrelated causes, and one of bacterial infection. Native lungs examined in 23 patients showed, in addition to the primary disease, bacterial pneumonia in 5, post-transplantation lymphoproliferative disorder in 3, cytomegalovirus in 2, and aspergillosis in 1. In this series of 37 autopsied patients, chronic rejection was the cause of death in 7 and was concomitantly seen in 3 patients (27%). In summary, the most common cause of death was infection (48%), followed by chronic rejection (19%), surgical complications (19%), post-transplantation lymphoproliferative disorder (7%), and unrelated causes (7%); rejection was not a major cause of death in the early and intermediate post-transplantation periods; in 30% of native lungs, significant pathologic findings were present in addition to the primary disease; and in the intermediate post-transplantation period, significant left ventricular hypertrophy occurred, which may be attributable to cyclosporine-induced hypertension but which needs to be further studied.

Atypical cutaneous changes after topical treatment with nitrogen mustard in patients with mycosis fungoides

Side effects in the treatment of mycosis fungoides with topical nitrogen mustard include allergic contact dermatitis, hyperpigmentation, urticaria, and erythema multiforme-like dermatitis. We reviewed biopsy specimens from 10 patients with mycosis fungoides who were treated with topical nitrogen mustard for 10-76 months. There was no history of oral psoralen with long-wave UV radiation treatment, radiotherapy, or systemic chemotherapy. Control biopsies taken from erythematous or poikilodermatous patches on the trunk or proximal extremities showed epidermal and dermal changes associated with cytologic atypia that were not present before treatment. These changes included slight epidermal hyperplasia with foci of flat rete ridges, atypical keratinocytes with large nuclei, mostly in the lower portion of the epidermis; suprabasal mitotic figures; a few dyskeratotic cells, focal vacuolar alteration of the epidermal basal layer; increased number of slightly enlarged junctional melanocytes; melanophages in the papillary dermis; dilated blood vessels lined by plump, atypical endothelial cells; and large fibroblasts with atypical nuclei. These atypical histologic changes resemble, in part, those described in association with systemic chemotherapeutic agents, such as etoposide, busulfan, and bleomycin. We conclude that topical nitrogen mustard should be added to the list of chemotherapeutic agents that can produce atypical histologic changes in the skin.

Expression of lysyl oxidase from cDNA constructs in mammalian cells: the propeptide region is not essential to the folding and secretion of the functional enzyme

Rat aortic lysyl oxidase cDNA was expressed under a metallothionein promoter in Chinese hamster ovary cells using a dihydrofolate reductase selection marker. One methotrexate-resistant cell line, LOD-06, generated by transfecting with full-length cDNA, yielded lysyl oxidase proteins consistent with the 50 kDa proenzyme and a 29 kDa mature catalyst. A second cell line, LOD32-2, was generated by transfection with a truncated cDNA lacking sequences which code for the bulk of the propeptide region. Both cell lines secreted apparently identical, 29 kDa forms of mature lysyl oxidase each of which catalyzed the deamination of human recombinant tropoelastin and alkylamines, consistent with the known specificity of lysyl oxidase. The secreted enzyme forms were inhibited by chemical inhibitors of lysyl oxidase activity, including beta-aminopropionitrile, phenylhydrazine, ethylenediamine, alpha, alpha'-dipyridyl, and diethyldithiocarbamate. Sensitivity to these agents is consistent with the presence of copper and carbonyl cofactors in the expressed enzymes, characteristic of lysyl oxidase from connective tissues. These results indicate the lack of essentiality of the deleted proprotein sequence for the proper folding, generation of catalytic function, and secretion of lysyl oxidase.

Cell proliferation markers in predicting metastases in malignant melanoma

It is often difficult to predict the outcome of melanoma in patients with Clark level III-IV disease. We sought to identify markers of cell proliferation which may be useful in predicting prognosis. Patients with Clark's level III-IV malignant melanoma who had no local recurrences or metastases were matched with patients of comparable level and thickness who did experience recurrences of metastases. Cell proliferation markers p53, proliferating cell nuclear antigen (PCNA), and Ki-67 were assessed by immunohistochemistry. DNA ploidy was determined by flow cytometry. There was no difference in the expression of p53, PCNA, and Ki-67 between patients with metastases and patients without metastases. However, patients with metastases were more likely to have an aneuploid tumor cell population than were patients without metastases (p < 0.03). Expression of cell proliferation markers do not appear to help predict prognosis in advanced level melanoma; however, aneuploidy may be associated with a greater probability of metastasis.

Cytologic patterns of metastatic thymoma: diagnosis by fine-needle aspiration biopsy

Thymomas are the most frequent primary tumors of the anterior mediastinum. These lesions are slow growing and can be locally invasive, but extrathoracic metastases are rare, occurring in less than 2% of cases. Fine-needle aspiration biopsy (FNAB) may be helpful in making the diagnosis of metastatic thymoma, with or without a clinical history of primary mediastinal thymoma. We report three cases of metastatic thymoma diagnosed by FNAB. Each case illustrates a distinctive cytologic pattern. While two of the patients had a history of histologically confirmed thymoma 11 and 13 years previously, a third patient presented with an enlarged supraclavicular lymph node and pulmonary nodules, and no prior diagnosis of thymoma. These cases demonstrate that based on distinctive cytologic patterns and features, a diagnosis of metastatic thymoma can be made with FNAB. Ancillary studies will often confirm the diagnosis.

Treatment of scleromalacia perforans with dura mater grafting

We describe, to our knowledge for the first time in the English literature, the successful use of cadaveric dura mater in reinforcing the sclera in a rheumatoid arthritis patient with scleromalacia perforans.

Prognostic significance of DNA ploidy in male breast carcinoma. A retrospective analysis of 32 cases

BACKGROUND

DNA aneuploidy has been prognostically significant in female breast carcinoma of low stage, but its value in male breast carcinoma remains undetermined.

METHODS

Flow cytometric DNA analyses were performed retrospectively on paraffin-embedded tissue from 32 men with breast carcinoma (mean follow-up time, 5.97 years [standard deviation +/- 4.63]; range, 1 to 18 years).

RESULTS

Multivariate discriminant function analysis showed only tumor size less than 2 cm to be independently predictive of better disease-free survival (P less than 0.05). DNA ploidy (aneuploid, 25 patients; diploid, 7 patients) and lymph node status (positive, 22 patients; negative, 10 patients) were not predictive of survival, regardless of tumor size.

CONCLUSIONS

The authors concluded that DNA ploidy may not significantly predict survival in male breast carcinoma.

Dermatomyofibroma. A benign cutaneous, plaque-like proliferation of fibroblasts and myofibroblasts in young adults

We report nine examples of a distinct cutaneous plaque-like proliferation of fibroblasts and myofibroblasts. Eight of nine lesions were located in or around the shoulder, including axilla and upper arm. There was a predominance of women to men of 8:1. The lesions measured from 1 to 2 cm in greatest diameter. All patients were young adults (mean age 29.8 yr). All lesions involved the reticular dermis in a plaque-like fashion and extended to the upper part of the subcutaneous septa in seven cases. The lesions consisted of a proliferation of very uniform slender spindle-shaped cells arranged as well-defined elongated and intersecting fascicles with a predominantly parallel arrangement to the skin surface. There was no evidence of cytologic atypia and mitotic figures were infrequent. The spindle-shaped cells were separated by thin collagen fibers. Elastic fibers were preserved and some of them appeared thicker than normal. All adnexal structures were spared. Immunohistochemistry revealed that the cells stained positively for vimentin and muscle actin, but lacked smooth-muscle specific actin, desmin, and S-100 protein. Some dermal dendrocytes stained positively for Factor XIIIa, but the spindle-shaped cells were negative. Electron microscopy studies revealed a mixture of fibroblasts, myofibroblasts, and undifferentiated mesenchymal cells. All lesions were treated by conservative excision; follow-up information revealed no evidence of recurrence. We name this distinct lesion dermatomyofibroma. To the best of our knowledge, this entity has not been previously described in the literature.

Unusual benign fibrous and fibrohistiocytic tumors of the skin

This article reviews recently reported unusual benign fibrous and fibrohistiocytic tumors of the skin. Some of these lesions are variants of common and well-known entities. Because some of these variants have cytologic atypia, they could be confused with malignant neoplasms.

Lectin histochemistry of sex cord-stromal tumors and small cell carcinoma of the ovaries

Binding sites of peanut agglutinin (PNA), Ulex europaeus (UEA-1), concanavalin A (Con A), and wheat germ agglutinin (WGA) were localized in 10 granulosa cell tumors, 10 Sertoli-Leydig cell tumors, 4 theca cell tumors, and 5 small cell carcinomas. Con A and WGA reacted positively with the majority of the studied neoplasms. PNA and UEA-1 were persistently negative in the sex cord-stromal tumors (SCST) but showed focal positivity in small cell carcinomas. Negative reactions of SCST with PNA and UEA-1 may serve for differentiation between them and common epithelial tumors that are usually PNA and UEA-1 positive.

Computed tomography-guided fine needle aspiration biopsy of deep-seated lesions. A four-year experience

With the increased sophistication of radiologic imaging techniques, the sensitivity of detecting nonpalpable, deep-seated lesions has greatly improved. Coupling these techniques with fine needle aspiration biopsy (FNAB) provides a cost-effective, minimum-risk, highly sensitive and specific method of diagnostically evaluating the lesions. Over a four-year period (1985-1989) a total of 2,229 FNABs were performed at Loyola University Medical Center, Chicago; 539 of these biopsies were computed tomographically guided. The geographic computed tomographic biopsy sites were: thorax, 267 (49.54%); abdomen, 175 (32.47%); and retroperitoneum, 97 (18%). Four hundred eighty FNAB cases were diagnostic, with subsequent histologic follow-up in 284 (58%) cases. Fifty-nine (10.9%) FNABs were unsatisfactory; of them, 31 had subsequent diagnostic histology, and 9 remained unsatisfactory. A good correlation between FNAB and histology was observed, with an overall sensitivity of 93.2%, specificity of 98.8%, false-negative rate of 6.8% and false-positive rate of 1.2%. Diagnostic pitfalls and biopsy adequacy in computed tomographically guided FNABs are discussed.

A synthetic DNA encoding a modified human urokinase resistant to inhibition by serum plasminogen activator inhibitor

Using DNA synthesis technology we constructed two synthetic DNAs, designated syn-uPA-DNA and mut-uPA-DNA. Syn-uPA-DNA contains the complete coding sequence of human presecretion form of single-chain u-PA. Mut-uPA-DNA was derived from syn-uPA-DNA by deleting 18 base pairs coding for amino acids Arg179-Ser184. Each synthetic DNA was inserted into a bovine papilloma viral genome-based expression vector to obtain expression in mouse cells. The results indicate that both syn-uPA and mut-uPA proteins are secreted predominantly in single-chain form. The single-chain form of both enzymes can be completely converted to two-chain form by treatment with plasmin. Both enzymes are as active as natural urokinase (std-uPA) isolated from urine. Analysis of enzymatic activity indicates that under conditions where syn-uPA and std-uPA are completely inhibited by endothelial-type plasminogen activator inhibitor (PAI-1), mut-uPA retains 90% activity. In identical experiments with placental-type PAI (PAI-2), mut-uPA retains 80% activity. Syn-uPA is capable of forming a approximately 100-kDa complex with PAI, whereas mut-uPA can not. PAI-treated mut-uPA has kinetic properties similar to untreated syn-uPA or std-uPA. Overall, the data indicate that amino acids Arg179-Ser184 function at least in part as a binding site for PAI. Resistance to PAI inhibition may increase the potency of mut-uPA as a thrombolytic agent.

Lectin binding to common epithelial tumors of the ovaries

Binding sites of peanut agglutinin (PNA), Ulex europaeus (UEA-1), wheat germ agglutinin, concanavalin A, and Ricinus communis were localized in 46 common epithelial ovarian tumors. Binding pattern of serous cystadenomas showed significant similarity with the pattern seen in the epithelium of fallopian tubes. Lectin affinity of endometriosis and endometrioid tumors was similar to normal endometrium in secretory phase. Binding pattern of clear cell carcinomas was similar to gestational endometrium, with PNA and UEA-1 showing strong affinity. This pattern is in contrast to clear cell carcinomas of the kidney, that do not bind PNA and UEA-1. Mucinous cystadenomas exhibited binding patterns identical with cervical epithelium. Malignant counterparts of the described tumors were characterized by the partial loss of lectin binding and uneven distribution of the binding reaction.

Global and molecular hemostatic markers in acute myeloid leukemia

Patients with acute myeloid leukemia have multiple hemostatic and thrombotic complications, which may or may not result from disseminated intravascular coagulation. Previous studies incorporating routine coagulation analyses failed to detect any clinically useful information in most of these patients. In this study, the first comprehensive evaluation of the various aspects of the hemostatic system in a population of patients with acute myeloid leukemia was performed. Eighteen patients (23-71 years of age) were studied at either diagnosis or relapse. Hemostatic studies were performed at onset and on days 3, 7, and 30 after initiation of therapy. The bone marrow blast counts ranged from 8% to 98%; prothrombin time and activated partial thromboplastin time showed only minor prolongations in a few of these patients. However, in all patients measurement of platelet-associated markers revealed elevated platelet factor 4 and thromboxane B2 and normal 6-keto-prostaglandin F1 alpha levels. Fibrinolytic markers showed an increase in D-dimer and tissue plasminogen activator and a decrease in alpha 2-antiplasmin levels. Plasminogen, plasminogen activator inhibitor, and fibrinogen levels were normal. Coagulation markers demonstrated a decrease in protein C and antithrombin III levels and an elevation of the thrombin-antithrombin complex. The pretreatment values for all hemostatic markers studied were similar to the values obtained on days 3, 7, and 30 during treatment. This investigation demonstrated a subclinical activation of the components of the hemostatic system possibly leading to a hypercoagulable state. Although only six patients (33%) experienced hemorrhagic complications, the risk of bleeding and/or thrombosis was strongly evident in all patients. The significance of finding abnormal levels of specific molecular markers of hemostasis will be established in the future application of such markers in clinical evaluations of leukemic patients known to be at risk for coagulation disorders.

Synchronous adenocarcinomas of jejunum and cecum following transverse colon carcinoma. A case study

A case of synchronous primary adenocarcinomas of the small and large bowel in a patient previously treated by transverse colectomy for cancerous polyps is presented. These new primaries were incidental findings during surgery for suspected recurrence of colonic carcinoma. Primary tumors of the small bowel are rare, and the diagnosis of primary adenocarcinoma of small bowel in the presence of primary adenocarcinoma of large bowel requires a high degree of suspicion and may well modify the prognostic outcome if detected early.

Inflammatory myopathy and acquired immunodeficiency syndrome

A 33-year-old black woman with advanced acquired immunodeficiency syndrome (AIDS) presented with rapidly progressive muscle weakness and serologic and radiologic evidence of central nervous system Toxoplasma infection. Muscle biopsy revealed an inflammatory infiltrate predominantly composed of macrophages and T suppressor/cytotoxic cells. Human immunodeficiency virus major core protein (p24) was also detected in macrophages and damaged muscle cells around the inflammatory infiltrates. The patient improved clinically with glucocorticoid therapy for polymyositis and pyrimethamine and clindamycin therapy for toxoplasmosis.

Plasma cell granuloma of the heart

A case of plasma cell granuloma arising in the free ventricular wall and involving the coronary arteries of a 10-month-old female infant is presented. Morphologic characteristics were comparable with those of plasma cell granulomas arising elsewhere. The histologic, immunohistochemical, and ultrastructural observations, and in particular the quiescent clinical course of the disease and its control with anti-inflammatory medication, favor a nonneoplastic nature of the lesion. This report documents the presence of an intracardiac plasma cell granuloma for the second time in the medical literature.

Expression of human uterine tissue-type plasminogen activator in mouse cells using BPV vectors

Human tissue-type plasminogen activator (t-PA) cDNA was cloned from uterine tissue and engineered in expression vectors for production in mouse C127 cells. The vectors consisted of the bovine papilloma virus-1 (BPV-1) genome and t-PA transcriptional unit with a mouse metallothionein (MT-1) promoter at the 5' end and MT-1 genomic sequences or SV40 early introns and polyadenylation signals at the 3' end. Analysis of the expression vectors transfected into cells revealed that t-PA is expressed 100- to 200-fold more with an intronless vector utilizing the SV40 polyadenylation signal than with other, intron-containing vectors. RNA analysis of stable cell lines indicated that t-PA expression levels correlated with mRNA abundance. DNA copy number and transcriptional rate of the MT-1 promoter remained constant in cell lines transformed by different BPV expression vectors. Uterine t-PA produced by recombinant DNA means was enzymatically active and similar in properties to Bowes melanoma t-PA.

Fungal endocarditis caused by Pseudallescheria (Petriellidium) boydii in an intravenous drug abuser

We present a case of fungal endocarditis in a 42-year-old man with a history of intravenous drug abuse who required aortic valve replacement for severe aortic insufficiency. Cultures of the resected valve grew Pseudallescheria boydii. The patient subsequently developed persistent endocarditis of the prosthetic valve with systemic embolism. At autopsy, cultures of the prosthetic valve grew Monosporium apiospermum, an anamorph of Pseudallescheria boydii. Although fungal endocarditis is not uncommon in intravenous drug abusers, endocarditis caused by Pseudallescheria boydii is rare. It has been reported in only three other instances, and under circumstances that were different from ours.

Kaposi's sarcoma of the bone marrow

We report a case of Kaposi's sarcoma of the bone marrow presenting as a myelophthisic anemia with bone marrow necrosis. The patient did not fit into any of the current clinical patterns described for Kaposi's sarcoma. This case illustrates the need for including Kaposi's sarcoma in the differential diagnosis of myelophthisic anemia.

Biology of simian virus 40 (SV40) transplantation antigen (TrAg). IX. Analysis of TrAg in mouse cells synthesizing truncated SV40 large T antigen

Mouse LTK- cells (H-2k) were transfected with a series of recombinant plasmids consisting of the herpes simplex virus type 1 thymidine kinase (TK) gene linked to fragments of SV40 DNA coding for portions of SV40 T antigen in pBR322, and TK+ transformants (LTK+) were selected in HAT medium. The TK+ transformants were analyzed for SV40 transplantation rejection antigen (TrAg) at the cell surface by reacting them with cytotoxic lymphocytes (CTL) generated to SV40 TrAg in C3H/HeJ (H-2k) mice. The results indicated that the cells transformed by pVBETK-1 and synthesizing full size SV40 large T antigen were efficiently lysed by SV40 CTL. In addition, cells transformed by the plasmid pVBt1TK-1 and synthesizing a truncated 33 K T antigen were also found to be susceptible to lysis by the CTL. However, LTK+ cells that were transformed with the plasmid pVBt2TK-1 and which synthesized a truncated T antigen of 12.3 K did not provide a target for SV40 CTL nor did pVBETK-1-transformed cells that did not express any of the SV40 tumor antigens. Only the pVBETK-1-transformed cells that express 94 K T antigen were able to immunize mice against a challenge of syngeneic SV40-transformed cells. These results suggest that the TrAg expression at the cell membranes of transformed cells may be associated with the proximal half of SV40 T antigen.

Nonselective expression of simian virus 40 large tumor antigen fragments in mouse cells

To understand the role of various functional domains of simian virus 40 early tumor antigens, we have cloned and introduced into mouse cells portions of early simian virus 40 DNA. Two types of truncated large tumor antigen (33 and 12.3 kilodaltons), as well as small tumor antigen, were identified by immunoprecipitation. Both truncated large tumor antigens have been found to be overproduced with respect to the small tumor antigen, although the 12.3-kilodalton truncated large tumor antigen was more stable than the 33-kilodalton one. Nonviral 53-kilodalton protein was not found associated with either truncated large tumor antigen in immunoprecipitations.

Abnormally spliced messenger RNA in erythroid cells from patients with beta+ thalassemia and monkey cells expressing a cloned beta+-thalassemic gene

The reduced beta-globin synthesis characterizing the beta+ thalassemia phenotype has been shown to be caused by anomalous processing within the small intervening sequence (IVS1) of the beta-globin mRNA precursor. The beta-globin gene from such patients contains a single base substitution within IVS1, located 22 bp from the 3' junction between IVS1 and exon 2, creating an alternative splice site within IVS1 and resulting in retention of the 3'-terminal 19 bases of IVS1. We have identified this abnormally spliced mRNA in the reticulocyte RNA of two patients with beta+ thalassemia, by S1 nuclease mapping and primer-extension analysis. Moreover, a cloned beta+-thalassemic gene preferentially generated the anomalously spliced RNA when expressed in monkey kidney cells. The anomalously spliced RNA constituted approximately 80%--90%, and normal beta RNA approximately 10%--20%, of the total beta mRNA. In contrast, the small amount of beta mRNA present in reticulocytes from such patients consisted predominantly of normal beta mRNA. These results suggest that the reduced amount of normally functioning beta mRNA present in such patients results from preferential processing at the alternative splice site, with subsequent instability, reduced nuclear processing and/or inadequate cytoplasmic transport of the abnormal RNA species.