Incidence and impact of light chain associated (AL) amyloidosis on the prognosis of patients with multiple myeloma treated with autologous transplantation

Little is known about the incidence of clinically occult AL amyloid in patients with multiple myeloma and its impact on prognosis of these patients. To address these issues, subcutaneous fat pad aspirates (SAFA) and bone marrow biopsies were evaluated for the presence of amyloid in a cohort of newly diagnosed patients with multiple myeloma prior to enrollment on a phase II study including tandem transplants. Organ directed biopsies were performed when clinically indicated. Presence of amyloid at > or = 1 site was noted in 32 patients (38%). SAFA was positive in 25 (31%), bone marrow in 8 patients (10%) and other organ sites in 7 patients. Patients with and without amyloid did not differ in disease characteristics, in particular no lambda predominance was observed in patients with amyloid. Event free survival (59+ vs 52 months; p = .9) and overall survival (59+ vs 66+ months; p = .9) were similar in both groups. Even the seven patients with symptomatic organ involvement with AL amyloid had a median overall survival of 38+ months. In conclusion, AL amyloidosis occurs more often than previously reported, but its presence does not influence the outcome of these patients after transplantation.

M-mode ultrasound: a reliable measure of transversus abdominis thickness?

OBJECTIVE

The purpose of this study was to establish a reliable method for measuring transversus abdominis thickness in asymptomatic human subjects in supine lying, standing and walking.

DESIGN AND METHODS

This was a single operator reliability study using ultrasound imaging to measure 22 subjects on three separate occasions. A purpose built high-density foam reinforced belt was used to house and position the transducer over the mid-point of the transversus abdominis. Each subject was imaged in supine, standing, and treadmill walking at 3 kph. Intraclass correlation coefficients and standard error of measurement analysis were used to measure the data.

RESULTS

The correlation coefficient data analysis resulted in intraclass correlation coefficients of 0.94 (standard error of measurement 0.35) in supine lying, 0.88 (0.66) in standing and 0.88 (0.56) in walking.

CONCLUSION

The method described is a reliable tool for measuring changes in thickness of transversus abdominis in supine lying, standing and walking.

RELEVANCE

This procedure has the potential to detect dysfunctional changes in abdominal muscle activity for patients with low back pain in a functional setting.

Peripheral nerve motion measurement with spectral Doppler sonography: a reliability study

This study evaluates single operator test-retest reliability of spectral Doppler ultrasound measurement of median nerve excursion during wrist extension. Longitudinal motion of the median nerve was measured at the elbow on three occasions in both upper limbs of 16 healthy subjects using a standard colour Doppler ultrasound system. The mean of the three maximum velocity time integrals was calculated from the spectral Doppler sonogram of each test. Analysis of data with intraclass correlation coefficient indicated a high degree of repeatability (0.92). Spectral Doppler ultrasound may provide a valuable method for measurement of peripheral nerve motion and may have a role in the clinical assessment of entrapment syndromes.

A new, comprehensive normative database of lumbar spine ranges of motion

AIMS AND OBJECTIVES

To generate gender-specific and broadly based age-related indices for normative lumbar ranges of motion for all planes of movement.

DESIGN

This was a repeated measures prospective study of spinal range of motion in a sample of volunteer subjects utilizing a portable modified CA6000 Spine Motion Analyzer (Orthopedic Systems Inc., Union City, CA, USA).

SETTING

Data collection was carried out in a variety of community locations including fire, police and ambulance stations, offices and community centres.

SUBJECTS

A total of 405 asymptomatic subjects (196 female, 209 male) were recruited, aged 16-90 years, from sedentary, mixed and physically demanding occupations.

METHODOLOGY

Indices of lumbar spine ranges of motion were measured in standing following a standardized protocol for sagittal flexion/extension, coronal lateral flexion and horizontal axial rotation movements.

RESULTS

Male and female normative flexion ranges declined by approximately 40% (72-40 degrees) across the age spectrum. Extension declined the greatest, by approximately 76% (29-6 degrees) overall. In lateral flexion male and female ranges declined approximately 43% (29-15 degrees) in each direction (total 58-30 degrees). In axial rotation no age-related decline was observed and ranges of motion remained at approximately 7 degrees in each direction (total 14 degrees) across all the ages of the subject group.

CONCLUSIONS

Data have been generated that provide comprehensive, gender-specific, broadly based and age-related indices for normative lumbar ranges of motion in all planes of movement. These are applicable to individuals throughout adult life, from adolescence through to old age.

Pericardial disease in rheumatoid arthritis

Six patients with rheumatoid constrictive pericarditis, five seen in a two and one half year period, are described. All patients were male, all had rheumatoid factor, and all had active arthritis. Diagnosis was suspected from careful physical examination and confirmed in five patients by cardiac catheterization. Pericardiectomy was successful in all five patients on whom it was performed. Rheumatoid constrictive pericarditis should be suspected in any patient with rheumatoid arthritis and unexplained signs of right heart failure.

Brochial stump closure techniques following pneumonectomy: A serial comparative study

Three methods of closing bronchial stumps were evaluated in 90 dogs undergoing left pneumonectomy:interrupted 3-0 silk sutures, interrupted 3-0 nylon sutures, and stapling with an automatic device. The dogs were sacrificed at 24 hours, 3, 5, 7, 10, and 14 days after pneumonectomy. Brochial stump leakage pressures and histological studies were performed on all specimens. Differences in the exudative reaction between silk and staple closures were significant on day 5(238.19+/- 23.28 SD PMN's/HPF in silk closures, 34.95+/- 20.37 SD PMN's/HPF in staple closures) and therafter(P less than 0.001). The reaction to nylon was intermediate between silk and staple. Collagen levels were highest at all periods for staple closures. Staple leakage pressures were greater than silk or nylon(day 5: 145.3 mm Hg +/- 64.9 SD in staple closures, 40.2 mm Hg +/- 15.4 SD in silk closures). These results have clinical relevance to the selection of suture materials for stump closures.

A missense mutation in the non-neural G-protein alpha-subunit isoforms modulates susceptibility to obesity

OBJECTIVE

The Gnas transcription unit located within an imprinting region encodes several proteins, including the G-protein alpha-subunit, Gsalpha, its isoform XLalphas and their variant truncated neural forms GsalphaN1 and XLN1. Gsalpha and GsalphaN1 are expressed predominantly from the maternally derived allele in some tissues, whereas XLalphas and XLN1 are expressed exclusively from the paternally derived allele. The relative contribution of full-length Gsalpha and XLalphas, and truncated forms GsalphaN1 and XLN1 to phenotype is unknown. The edematous-small point mutation (Oed-Sml) in exon 6 of Gnas lies downstream of GsalphaN1 and XLN1, but affects full-length Gsalpha and XLalphas, allowing us to address the role of full-length Gsalpha and XLalphas. The aim of this study was therefore to determine the metabolic phenotypes of Oed and Sml mice, and to correlate phenotypes with affected transcripts.

METHODS

Mice were fed standard or high-fat diets and weighed regularly. Fat mass was determined by DEXA analysis. Indirect calorimetry was used to measure metabolic rate. Glucose was measured in tolerance tests and biochemical parameters in fasted plasma samples. Histological analysis of fat and liver was carried out post mortem.

RESULTS

Oed mice are obese on either diet and have a reduced metabolic rate. Sml mice are lean and are resistant to a high-fat diet and have an increased metabolic rate.

CONCLUSION

Adult Oed and Sml mice have opposite metabolic phenotypes. On maternal inheritance, the obese Oed phenotype can be attributed to non-functional full-length Gsalpha. In contrast, on paternal inheritance, Sml mice were small and resistant to the development of obesity on a high-fat diet, effects that can be attributed to mutant XLalphas. Thus, the neural isoforms, GsalphaN1 and XLN1, do not appear to play a role in these metabolic phenotypes.

Measuring longitudinal nerve motion using ultrasonography

While it is known that peripheral nerves slide longitudinally in response to limb movements, the clinical relevance of this phenomenon remains largely speculative. This technical note introduces a new application for noninvasive measurement of longitudinal movement of peripheral nerves. The rationale for developing the technique is given including a brief overview of nerve motion theories and how these are related to clinical practice. Current ultrasound applications for nerves and tissue motion are outlined and details of the Doppler measurement procedure are described. Limitations of the technique and potential future applications are discussed. Spectral Doppler ultrasound may provide an effective method for noninvasive quantification of longitudinal nerve motion.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Characterization of a beta-adrenergic receptor in porcine trachealis muscle

To establish a model of airway smooth muscle function we studied binding of [3H]dihydroalprenolol [( 3H]DHA), a beta-adrenergic antagonist, to membrane preparations of porcine trachealis muscle and investigated the response of adenylate cyclase to l-isoproterenol in tissue and plasma membranes. [3H]DHA binding was of high affinity (Kd = 1.0 +/- 0.1 nM), was saturable (Bmax = 87.6 +/- 13.2 fmol/mg protein), and was 90% beta 2 and 10% beta 1. Adenylate cyclase activity in the membrane preparation was (in pmol.10 min-1.mg protein-1 +/- SE): basal 420 +/- 74, guanosine 5'-triphosphate (GTP) (10 micron) 600 +/- 45, GTP (10 microM) + l-isoproterenol (100 microM) 660 +/- 63, NaF (10 mM) 1,500 +/- 134, and forskolin (100 microM) 3,000 +/- 410. Guanosine 5'-diphosphate (GDP) and GTP were active cofactors; l-isoproterenol appeared to function as an effector exchanging GTP for GDP on the guanine nucleotide regulatory protein. There was close agreement of the effective dose (ED50) of the l-isoproterenol-induced relaxation (0.95 +/- 0.45 microM) and the inhibitory constant of l-isoproterenol binding (0.39 +/- 0.10 microM). l-Isoproterenol (100 microM) induced a 100% increase in adenosine 3',5'-cyclic monophosphate (cAMP) levels in tissue strips over basal activity. Investigation of the difference in adenylate cyclase activity between tissue and plasma membranes revealed that l-isoproterenol responsive adenylate cyclase was diminished after initial homogenization. Electron microscopy demonstrated disruption of all cells at this early stage of preparation. The decrease in l-isoproterenol responsive adenylate cyclase following cell rupture is different from other tissues and suggests a difference in the actions of beta-agonist in smooth muscle compared with other tissues.

Effects of trimethyltin on the mouse hippocampus and adrenal cortex

The effects of trimethyltin (TMT) on the mouse adrenal histology and its relationship with neuropathology occurrence was studied. Young, male CD-1 mice were divided into three groups: group I, injected on 3 consecutive days with 1.0 mg TMT/kg body weight (b.w.); group II, injected on 2 consecutive days with 1.5 mg TMT/kg b.w.; and group III, injected with a single acute dose of 3.0 mg TMT/kg b.w. Control animals were injected with saline solution. The brain and adrenal glands were sampled for light-microscopic examination. Although all animals received the same total amount of TMT, pathological changes in the granule cells of the fascia dentate appeared to be group III greater than group II greater than group I, suggesting that acute exposures produced a more severe damage to the fascia dentate neurons. Likewise, the adrenal weights of the animals were group III greater than group II greater than group I greater than or equal to control. Significant proliferation and enlargement of the eosinophilic or the "X zone" were observed in the TMT-treated, particularly groups II and III, animals. The expansion of the eosinophilic cell layer (X zone) was accomplished at the expense of the cortical fasciculata cells. Transformation of fasciculata cells into eosinophilic cells could also be demonstrated. As the eosinophilic cells are known to be active in corticosterone production as seen in stress situations, the proliferation of these cells may reflect a feedback response to the hippocampal hyperexcitation.

Somatomedin and analogues of cyclic AMP increase the number of cells synthesizing DNA in cartilage from hypophysectomized rats

The effects of somatomedin and certain nucleotides on nuclear labelling of cartilage cells with [3H]thymidine were determined by autoradiography. Segments of costal cartilage from hypophysectomized rats were incubated for 24 h in a basal medium with or without additions and then pulsed for 2 h with [3H]thymidine in the basal medium. Both somatomedin (0.1 U/ml) and Bt2cAMP (10(-4)M) increased the number of labelled nuclei, and the combined effects were more than additive. A parallelism between the effects of these agents on nuclear labelling and their effects on total thymidine incorporation into DNA was demonstrated. The 8-bromated derivative of cAMP (10(-4)M) also enhanced chondrocyte nuclear labelling, but neither 8-Br-5'-AMP (10(-4)7) nor 8-Br-cGMP (10(-4)M) exhibited actions of the cAMP analogues. It is concluded that in cartilage obtained from hypophysectomized rats and incubated under the specified conditions (1) both somatomedin and cAMP analogues increase the number of cells synthesizing DNA as well as total thymidine incorporation into DNA, (2) the effects of the hormone and cyclic nucleotide in combination are synergistic, and (3) the increased incorporation of labelled thymidine into DNA reflects increased DNA synthesis and not merely an alteration of the specific activity of the intracellular thymidine nucleotide pool.

Impact of postoperative acute kidney injury in patients undergoing major gastrointestinal surgery on 1-year survival and renal outcomes: a national multicentre cohort study

BACKGROUND

The intermediate-term impact of acute kidney injury (AKI) in patients after major gastrointestinal and liver surgery has not been well characterized. This study aimed to evaluate the 1-year mortality rate and renal outcomes associated with postoperative AKI in a national prospective cohort.

METHODS

This prospective multicentre, observational cohort with 1-year postoperative follow-up included adults undergoing major gastrointestinal and liver surgery across the UK and Ireland between 23 September and 18 November 2015. AKI was defined according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. The primary outcome was death at 1-year after surgery, and the secondary outcome was Major Adverse Kidney Events (MAKE-365). Cox proportionate and multilevel logistic regression were used to account for case mix.

RESULTS

Of 5745 patients across 173 centres, 1-year follow-up data was completed for 3504 patients (62.2 per cent, 126 centres), with attrition largely explained by centre non-participation (63.1 per cent). Some 13.6 per cent (475 of 3504) patients developed AKI by 7 days after surgery (stage 1: 9.2 per cent; stage 2/3: 4.3 per cent). At 1 year, 10.8 per cent (378 patients) experienced a MAKE-365 endpoint (303 patients had died, 61 had renal replacement therapy and 78 had renal dysfunction). Patients who experienced AKI by 7 days after surgery had a higher hazard of death at 1 year for KDIGO stage 1 (hazard ratio 1.50 (95 per cent c.i. 1.08 to 2.08), P = 0.016) and KDIGO stage 2/3 (hazard ratio 2.96 (95 per cent c.i. 2.02 to 4.33), P < 0.001). Both KDIGO stage 1 (odds ratio 2.09 (95 per cent c.i. 1.50 to 2.92), P < 0.001) and stage 2/3 (odds ratio 9.26 (95 per cent c.i. 6.31 to 13.59), P < 0.001) AKI were independently associated with MAKE-365.

CONCLUSION

AKI events within 7 days after gastrointestinal or liver surgery are associated with significantly worse survival and renal outcomes at 1 year.

Nuclear magnetic resonance in pathology: I. Principles and general aspects

Nuclear magnetic resonance (NMR) has become established as a powerful diagnostic imaging technique in medicine. The power of NMR as a tool for characterizing molecular structure and for quantitative analysis of complex mixtures in the clinical laboratory or even in vivo is beginning to be exploited. In the clinical laboratory, NMR can analyze the complex mixtures of bodily fluids, intact cells, tissues, and their extracts. Phosphorus-31 or 1H NMR spectroscopy in vivo can provide a noninvasive probe of high-energy compounds, amino acids, and compounds of phospholipid metabolism. The basic principles of NMR spectroscopy are presented here, with emphasis on the various NMR parameters and the information they provide. A companion article presents a survey of applications in pathology.

Effects of aldicarb on the behavior of Heterodera schachtii and Meloidogyne javanica

The toxic effects of sublethal concentrations of aldicarb were studied on eggs and second-stage larvae and males of Heterodera schachtii and second-stage larvae only of Meloidogyne javanica in a quartz sand substrate. Aldicarb was more toxic to eggs of H. schachtii than to those of M. javanica. Complete suppression of hatching occurred between 0.48 and 4.8 microg/ml aldicarb for H. schachtii whereas 100% inhibition of hatch of M. javanica occurred between 4.8 and 48.0 microg/ml. M. javanica hatch was stimulated at 0.48 microg/ml aldicarb. Migration of second-stage larvae of H. schachtii and M. javanica in sand columns was inhibited under continuous exposure to 1 microg/ml aldicarb. Infection of sugarbeet and tomato seedlings by larvae was inhibited at 1 microg/ml. H. schachtii males failed to migrate toward nubile females at 0.01 microg/ml aldicarb. This was partially confirmed in a field study in which adding aldicarb to soil resulted in fewer females being fertilized.

Behavior of aldicarb in soil relative to control of Heterodera schachtii

The adsorption characteristics of two soils for aldicarb sulfoxide were similar to that described by the Freundlich equation, The adsorption constant for the Holtville clay was 3.3, and that of the Buren silt loam, 0.34. Planting beds in a field of Holtville clay and another of Buren silt loam were side-dressed at 25 kg and 50 kg/ha 10% aldicarb (Temik 10G). Comparison of field measurements of aldicarb concentrations with previous laboratory determinations of aldicarb effects on Heterodera schachtii allowed predictions of soil zones in which hatching, infectivity, and orientation of males to females would be affected. Aldicarb in the soil water of Holtville clay sufficient to interfere with male orientation extended through most of the bed profile to a depth of 46 cm 1 week after the first irrigation. Orientation could be affected in only the top 20 cm of the bed 37 days after treatment and application of 712 mm of irrigation water. In Buren silt loam, disorientation of males was estimated to occur throughout the bed 42 days after treatment and 600 mm irrigation water. Aldicarb persisted in extensive areas of the bed at concentrations sufficient to prevent infection. In small areas of the profile, aldicarb sufficient to inhibit hatching persisted. Amounts of aldicarb in soil water samples obtained directly from beds agreed well with those from the analysis of the air dried soil samples.

The role of apoptosis in 2',2'-difluoro-2'-deoxycytidine (gemcitabine)-mediated radiosensitization

The nucleoside analogue Gemcitabine [2',2'-difluoro-2'-deoxycytidine (dFdCyd)] is active against a wide variety of solid tumors and is a potent radiation sensitizer. Because apoptosis has been shown to be an important mechanism of cell death for many cancers, we wished to investigate the role of apoptosis in dFdCyd-mediated radiosensitization. We evaluated HT29 colon cancer cells, UMSCC-6 head and neck cancer cells, and A549 lung cancer cells, which differ substantially in the ability to undergo radiation-induced apoptosis. We hypothesized that if dFdCyd produced radiosensitization by potentiating preexisting death pathways, then only the apoptotic-prone HT29 cells would show a substantial increase in apoptosis when treated with the combination of dFdCyd and radiation and that UMSCC-6 cells and A549 cells would be radiosensitized through nonapoptotic mechanisms. We found that the radiosensitization of HT29 cells (enhancement ratio, 1.81 +/- 0.16) was accompanied by an increase in apoptosis and by caspase activation and that inhibition of this activation by the caspase inhibitor Z-Asp-Glu-Val-Asp-fluoromethylketone (DEVD) significantly decreased radiosensitization (to 1.36 +/- 0.24; P < 0.05). In contrast, UMSCC-6 cells and A549 cells were modestly radiosensitized (enhancement ratio, 1.47 +/- 0.24 and 1.31 +/- 0.04, respectively) via a nonapoptotic mechanism. These findings suggest that although apoptosis can contribute significantly to dFdCyd-mediated radiosensitization, the role of apoptosis in dFdCyd-mediated radiosensitization depends on the cell line rather than representing a general property of the drug.

Changes in bone and bone marrow of rabbits bearing the VX-2 carcinoma. A comparison of local and distant effects

The VX-2 carcinoma in 32 New Zealand white rabbits was studied morphologically with respect to the osseous effects induced by the innoculation and subsequent growth of tumour in the soft tissues over periods ranging from 1 to 5 weeks. Although more severe changes were noted in bones of tumor-bearing than in non-tumor-bearing limbs, effects could be seen in both experimental situations. Severe bone marrow hyperplasia was noted consistently in tumor-bearing animals. A marked increase in numbers of osteoclasts over control rabbit bones was observed along the surface of bones near and distant from the tumor. Resorptive changes were also noted in the cortex of tumor-bearing rabbits. The increase in osteoclast numbers was related chronologically to the development of hypercalcemia and was proportional to the degree of hypercalcemia at the time the animals died. The number of osteoclasts was inversely proportional to the serum creatinine. A diminution of osteoclast numbers was noted in the latter stages of the disease. These changes may be the morphologic expression of humoral hypercalcemia accompanying the VX-2 carcinoma.