The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Transcriptional regulators of the Golli/myelin basic protein locus integrate additive and stealth activities

Myelin is composed of plasma membrane spirally wrapped around axons and compacted into dense sheaths by myelin-associated proteins. Myelin is elaborated by neuroepithelial derived oligodendrocytes in the central nervous system (CNS) and by neural crest derived Schwann cells in the peripheral nervous system (PNS). While some myelin proteins accumulate in only one lineage, myelin basic protein (Mbp) is expressed in both. Overlapping the Mbp gene is Golli, a transcriptional unit that is expressed widely both within and beyond the nervous system. A super-enhancer domain within the Golli/Mbp locus contains multiple enhancers shown previously to drive reporter construct expression specifically in oligodendrocytes or Schwann cells. In order to determine the contribution of each enhancer to the Golli/Mbp expression program, and to reveal if functional interactions occur among them, we derived mouse lines in which they were deleted, either singly or in different combinations, and relative mRNA accumulation was measured at key stages of early development and at maturity. Although super-enhancers have been shown previously to facilitate interaction among their component enhancers, the enhancers investigated here demonstrated largely additive relationships. However, enhancers demonstrating autonomous activity strictly in one lineage, when missing, were found to significantly reduce output in the other, thus revealing cryptic "stealth" activity. Further, in the absence of a key oligodendrocyte enhancer, Golli accumulation was markedly and uniformly attenuated in all cell types investigated. Our observations suggest a model in which enhancer-mediated DNA-looping and potential super-enhancer properties underlie Golli/Mbp regulatory organization.

Pathogenic inflammation in the CNS of mice carrying human PLP1 mutations

Progressive forms of multiple sclerosis lead to chronic disability, substantial decline in quality of life and reduced longevity. It is often suggested that they occur independently of inflammation. Here we investigated the disease progression in mouse models carrying PLP1 point mutations previously found in patients displaying clinical features of multiple sclerosis. These mouse models show loss-of-function of PLP1 associated with neuroinflammation; the latter leading to clinically relevant axonal degeneration, neuronal loss and brain atrophy as demonstrated by inactivation of the recombination activating gene 1. Moreover, these pathological hallmarks were substantially amplified when we attenuated immune regulation by inactivation of the programmed cell death-1 gene. Our observations support the view that primary oligodendroglial abnormalities can evoke pathogenically relevant neuroinflammation that drives neurodegeneration, as observed in some forms of multiple sclerosis but also in other, genetically-mediated neurodegenerative disorders of the human nervous system. As many potent immunomodulatory drugs have emerged during the last years, it is tempting to consider immunomodulation as a treatment option not only for multiple sclerosis, but also for so far non-treatable, genetically-mediated disorders of the nervous system accompanied by pathogenic neuroinflammation.

Abstract P2-07-04: A novel diagnostic androgen receptor gene signature links clinical outcomes and preclinical response to enzalutamide, paclitaxel or the combination in triple-negative breast cancer

Background: The androgen receptor (AR) is expressed in ≈70% of all breast cancers (BCs) and may be necessary for proliferation and survival advantage in AR+ tumors. A novel gene signature associated with AR-signaling biology (PREDICT AR) was developed by sequencing triple-negative BC (TNBC) tumors collected in a phase 2 study evaluating enzalutamide (ENZA) monotherapy1; clinical outcomes were superior in patients (pts) with PREDICT AR+ vs PREDICT AR- tumors.1,2 ENZA blocks nuclear localization and suppresses its activity.3 Paclitaxel (PTX) stabilizes microtubules and may also block AR nuclear localization. Thus we hypothesize that response to PTX-based therapy may be additive in PREDICT AR+ vs PREDICT AR- disease. This study sought to identify independent clinical datasets with PREDICT AR+ gene signature to assess outcomes following PTX-based therapy. Preclinically, we investigated the antitumor activity of ENZA, PTX, or ENZA+PTX in AR-driven TNBC models.

Methods: We probed publicly available TNBC clinical databases from Gene Expression Omnibus datasets to assess PREDICT AR status and clinical outcomes. Similarly, we assessed 21 TNBC lines for PREDICT AR status. BT549, MDA-MB-436, and MDA-MB-453 were treated with ENZA, PTX, or ENZA+PTX to determine activity. Cell signaling and pathway activation were assessed by western blot. ENZA and PTX activity was assessed in PREDICT AR+ xenograft models. Tumor RNA sequencing and immunohistochemistry were used to identify gene signatures, potentially predictive biomarkers, and potential synergistic effects of ENZA+PTX.

Results: The prevalence of PREDICT AR+ tumors in one cohort of 182 pts with primary TNBC4 was 51%. Distant relapse-free survival following PTX-based adjuvant/neoadjuvant therapy was not statistically different between pts with PREDICT AR+ vs PREDICT AR- TNBC (p=0.605). Pathologic complete response rates were 12.5% for PREDICT AR+ vs 21.0% for PREDICT AR- TNBC. Additional sets of pts with primary TNBC are being evaluated. Preclinically, we observed a dose-dependent inhibition of cell viability with either ENZA or PTX in AR+ TNBC cell lines and additive effects from ENZA+PTX. In PREDICT AR+ xenograft models, ENZA or PTX treatment resulted in a dose-dependent antitumor response. Combination studies are underway. Tumor RNA sequencing are being evaluated for gene signature of synergistic antitumor response to ENZA+PTX.

Conclusion: Analyzing publicly available clinical datasets, we found that PREDICT AR+ status was not associated with differential outcomes following PTX-based therapy in primary TNBC, suggesting there is potential to provide additive benefits in PTX-based therapy with ENZA. In preclinical studies, we observed additive effects when combining ENZA+PTX in PREDICT AR+ TNBC lines compared with single agent treatments. Taken together, these data suggest ENZA combined with PTX might provide additive benefits in a clinical setting for pts with PREDICT AR+ TNBC.

References

1. Traina TA et al. J Clin Oncol 2015:33(suppl):abstr 1003.

2. Parker J et al. J Clin Oncol 2015;33(suppl):abstr 1083.

3. Tran C et al. Science 2009;324:787-90.

4. Hatzis C et al. JAMA 2011;305:1873-81.

Citation Format: Phan VT, Protter AA, Peterson AC, Parker JS, Yoon K, Tudor IC, Paton V, Noonberg S, Uppal H. A novel diagnostic androgen receptor gene signature links clinical outcomes and preclinical response to enzalutamide, paclitaxel or the combination in triple-negative breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-07-04.

A tubulin binding peptide targets glioma cells disrupting their microtubules, blocking migration, and inducing apoptosis

Despite aggressive treatment regimes, glioma remains a largely fatal disease. Current treatment limitations are attributed to the precarious locations within the brain where such tumors grow, their highly infiltrative nature precluding complete resection and lack of specificity among agents capable of attenuating their growth. Here, we show that in vitro, glioma cells of diverse origins internalize a peptide encompassing a tubulin-binding site (TBS) on the neurofilament light protein. The internalized peptide disrupts the microtubule network, inhibits migration and proliferation, and leads to apoptosis. Using an intracerebral transplant model, we show that most, if not all, of these responses to peptide exposure also occur in vivo. Notably, a single intratumor injection significantly attenuates tumor growth, while neither peptide uptake nor downstream consequences are observed elsewhere in the host nervous system. Such preferential uptake suggests that the peptide may have potential as a primary or supplementary glioblastoma treatment modality by exploiting its autonomous microtubule-disrupting activity or engaging its capacity to selectively target glioma cells with other cell-disrupting cargos.

Targeted insertion of two Mthfr promoters in mice reveals temporal- and tissue-specific regulation

Methylenetetrahydrofolate reductase (MTHFR), a key enzyme in folate metabolism, synthesizes 5-methyltetrahydrofolate, the main circulatory form of folate which is required for maintaining nontoxic levels of homocysteine and providing one-carbon units for methylation. A common 677C → T variant in MTHFR confers mild MTHFR deficiency and has been associated with a number of human disorders, including neural tube defects and vascular disease. Two promoters of Mthfr, designated as upstream and downstream promoters, are located upstream of a transcription start site cluster and have previously demonstrated cell-specific activities. In this study we used a unique approach for targeted, single-copy transgene insertion to generate transgenic mice carrying a Mthfr upstream or Mthfr downstream promoter-reporter construct located 5' to the endogenous Hprt (hypoxanthine-guanine phosphoribosyltransferase) locus. The Mthfr downstream promoter demonstrated activity in the neural tube, neural crest cells, dorsal root ganglia, heart, and endothelial cells of blood vessels in 10.5-days post coitum embryos and placentas. Upstream promoter activity was absent at this developmental stage. Postnatally, both promoters demonstrated activity in the brain stem, hippocampus, and thalamus of 1-week-old brain that became stronger in the adult. The Mthfr upstream promoter also showed activity in the cerebellum and cerebral cortex. Both promoters were active in male reproductive tissues, including 1-week-old epididymides, and there was upstream promoter-specific activity in the adult testis. Our investigation of Mthfr regulation in an in vivo mouse model revealed temporal- and tissue-specific regulation that supports important roles for MTHFR in the developing embryo, and in postnatal brain and male reproductive tissues.

Towards resolving the transcription factor network controlling myelin gene expression

In the central nervous system (CNS), myelin is produced from spirally-wrapped oligodendrocyte plasma membrane and, as exemplified by the debilitating effects of inherited or acquired myelin abnormalities in diseases such as multiple sclerosis, it plays a critical role in nervous system function. Myelin sheath production coincides with rapid up-regulation of numerous genes. The complexity of their subsequent expression patterns, along with recently recognized heterogeneity within the oligodendrocyte lineage, suggest that the regulatory networks controlling such genes drive multiple context-specific transcriptional programs. Conferring this nuanced level of control likely involves a large repertoire of interacting transcription factors (TFs). Here, we combined novel strategies of computational sequence analyses with in vivo functional analysis to establish a TF network model of coordinate myelin-associated gene transcription. Notably, the network model captures regulatory DNA elements and TFs known to regulate oligodendrocyte myelin gene transcription and/or oligodendrocyte development, thereby validating our approach. Further, it links to numerous TFs with previously unsuspected roles in CNS myelination and suggests collaborative relationships amongst both known and novel TFs, thus providing deeper insight into the myelin gene transcriptional network.

N-WASp is required for Schwann cell cytoskeletal dynamics, normal myelin gene expression and peripheral nerve myelination

Schwann cells elaborate myelin sheaths around axons by spirally wrapping and compacting their plasma membranes. Although actin remodeling plays a crucial role in this process, the effectors that modulate the Schwann cell cytoskeleton are poorly defined. Here, we show that the actin cytoskeletal regulator, neural Wiskott-Aldrich syndrome protein (N-WASp), is upregulated in myelinating Schwann cells coincident with myelin elaboration. When N-WASp is conditionally deleted in Schwann cells at the onset of myelination, the cells continue to ensheath axons but fail to extend processes circumferentially to elaborate myelin. Myelin-related gene expression is also severely reduced in the N-WASp-deficient cells and in vitro process and lamellipodia formation are disrupted. Although affected mice demonstrate obvious motor deficits these do not appear to progress, the mutant animals achieving normal body weights and living to advanced age. Our observations demonstrate that N-WASp plays an essential role in Schwann cell maturation and myelin formation.

Regulatory modules function in a non-autonomous manner to control transcription of the mbp gene

Multiple regulatory modules contribute to the complex expression programs realized by many loci. Although long thought of as isolated components, recent studies demonstrate that such regulatory sequences can physically associate with promoters and with each other and may localize to specific sub-nuclear transcription factories. These associations provide a substrate for putative interactions and have led to the suggested existence of a transcriptional interactome. Here, using a controlled strategy of transgenesis, we analyzed the functional consequences of regulatory sequence interaction within the myelin basic protein (mbp) locus. Interactions were revealed through comparisons of the qualitative and quantitative expression programs conferred by an allelic series of 11 different enhancer/inter-enhancer combinations ligated to a common promoter/reporter gene. In a developmentally contextual manner, the regulatory output of all modules changed markedly in the presence of other sequences. Predicted by transgene expression programs, deletion of one such module from the endogenous locus reduced oligodendrocyte expression levels but unexpectedly, also attenuated expression of the overlapping golli transcriptional unit. These observations support a regulatory architecture that extends beyond a combinatorial model to include frequent interactions capable of significantly modulating the functions conferred through regulatory modules in isolation.

The pace of prostatic intraepithelial neoplasia development is determined by the timing of Pten tumor suppressor gene excision

Loss of the PTEN tumor suppressor is a common occurrence in human prostate cancer, particularly in advanced disease. In keeping with its role as a pivotal upstream regulator of the phosphatidylinositol 3-kinase signaling pathway, experimentally-induced deletion of Pten in the murine prostate invariably results in neoplasia. However, and unlike humans where prostate tumorigenesis likely evolves over decades, disease progression in the constitutively Pten deficient mouse prostate is relatively rapid, culminating in invasive cancer within several weeks post-puberty. Given that the prostate undergoes rapid androgen-dependent growth at puberty, and that Pten excisions during this time might be especially tumorigenic, we hypothesized that delaying prostate-specific Pten deletions until immediately after puberty might alter the pace of tumorigenesis. To this end we generated mice with a tamoxifen-inducible Cre recombinase transgene enabling temporal control over prostate-specific gene alterations. This line was then interbred with mice carrying floxed Pten alleles. Despite evidence of increased Akt/mTOR/S6K axis activity at early time points in Pten-deficient epithelial cells, excisions induced in the post-pubertal (6 wk-old) prostate yielded gradual acquisition of a range of lesions. These progressed from pre-malignant changes (nuclear atypia, focal hyperplasia) and low grade prostatic intraepithelial neoplasia (PIN) at 16-20 wks post-tamoxifen exposure, to overtly malignant lesions by approximately 1 yr of age, characterized by high-grade PIN and microinvasive carcinoma. In contrast, when Pten excisions were triggered in the pre-pubertal (2 week-old) prostate, neoplasia evolved over a more abbreviated time-frame, with a spectrum of premalignant lesions, as well as overt PIN and microinvasive carcinoma by 10-12 wks post-tamoxifen exposure. These results indicate that the developmental stage at which Pten deletions are induced dictates the pace of PIN development.

Temporally controlled prostate epithelium-specific gene alterations

Employing the Hprt locus as the site for targeted transgenesis we have developed mice expressing the tamoxifen-inducible Cre-ER(T2) fusion protein under the control of the ARR2-rat probasin promoter. This system enables external control over the timing of prostate epithelial cell-specific gene alterations. Using both the ROSA26-lacZ and ROSA26-EYFP reporter strains to monitor recombinase activity, Cre-ER(T2) was found to be specifically expressed in the prostatic epithelium and was strictly tamoxifen dependent. This strain thus allows precise control over the timing of gene alterations in the mouse prostate, enabling analyses of the phenotypic consequences of gene alterations in mice of any age. It also provides an ideal platform to study the impact of environmental, hormonal, and age-related factors on prostate tumorigenesis. This latter feature will be of particular value given the paucity of murine models that accurately mimic the late onset and prolonged natural history of human prostate cancer.

Transgenic mice expressing the p75 CCAAT-displacement protein/Cut homeobox isoform develop a myeloproliferative disease-like myeloid leukemia

The p75 CCAAT-displacement protein/Cut homeobox (CDP/Cux) isoform was previously reported to be overexpressed in human breast cancers. To investigate its oncogenic potential, we engineered two transgenic mouse lines expressing p75 CDP/Cux under the control of the mouse mammary tumor virus-long terminal repeat. The FVB strain of mouse is generally used in the generation of mouse models for breast cancer. The transgene was introduced into the hprt locus of 129/Ola embryonic stem cells and, following germ line passage, was backcrossed onto the FVB and C57BL/6 mouse strains. Here, we describe the phenotype of p75 CDP/Cux transgenic virgin female mice of the first backcross generations. We report that after a long latency period, approximately 33% of mice from two independent transgenic lines and from backcrosses into either the FVB or the C57BL/6 strains succumbed to a similar disease characterized by splenomegaly, hepatomegaly, and frequent infiltration of leukocytes into nonhematopoietic organs like the kidneys and lungs. Although an excess of B or T cells was observed in three diseased mice, in 17 other cases, histologic and flow cytometry analyses revealed the expansion of a population of neutrophils in the blood, spleen, and bone marrow. The increase in neutrophils correlated with signs of anemia and thrombocytopenia, whereas there was no indication of a reactive process. Therefore, p75 CDP/Cux transgenic mice displayed heightened susceptibility to a disease defined as a myeloproliferative disease-like myeloid leukemia. These results indicate that the overexpression of p75 CDP/Cux could alter homeostasis in the hematopoietic compartment.

Axonal neurofilaments control multiple fiber properties but do not influence structure or spacing of nodes of Ranvier

In the vertebrate nervous system, axon calibers correlate positively with myelin sheath dimensions and electrophysiological parameters including action potential amplitude and conduction velocity. Neurofilaments, a prominent component of the neuronal cytoskeleton, are required by axons to support their normal radial growth. To distinguish between fiber features that arise in response to absolute axon caliber and those that are under autonomous control, we investigated transgenic mice in which neurofilaments are sequestered in neuronal cell bodies. The neurofilament deficient axons in such mice achieve mature calibers only 50% of normal and have altered conduction properties. We show here that this primary axonal defect also induces multiple changes in myelin sheath composition and radial dimensions. Remarkably, other fundamental fiber features, including internodal spacing and the architecture and composition of nodes of Ranvier, remain unaltered. Thus, many fiber characteristics are controlled through mechanisms operating independently of absolute axon caliber and the neurofilament cytoskeleton.

Axonal degeneration stimulates the formation of NG2+ cells and oligodendrocytes in the mouse

Proliferation of the adult NG2-expressing oligodendrocyte precursor cells has traditionally been viewed as a remyelination response ensuing from destruction of myelin and oligodendrocytes, and not to the axonal pathology that is also a characteristic of demyelinating disease. To better understand the response of the NG2+ cells to the different components of demyelinating pathology, we investigated the response of adult NG2+ cells to axonal degeneration in the absence of primary myelin or oligodendrocyte pathology. Axonal degeneration was induced in the hippocampal dentate gyrus of adult mice by transection of the entorhino-dentate perforant path projection. The acutely induced degeneration of axons and terminals resulted in a prompt response of NG2+ cells, consisting of morphological transformation, cellular proliferation, and upregulation of NG2 expression days 2-3 after surgery. This was followed by a reduction of cellular NG2 expression to subnormal levels from day 5 to 7 and reappearance of normal appearing NG2+ cells from day 10. Mice that had received repeated injections of bromodeoxyuridine from 24 to 72 h after surgery contained significant numbers of bromodeoxyuridine-incorporating oligodendrocytes in the areas with axonal degeneration at day 7. The results suggest that axonal degeneration induces a unique sequence of changes of NG2+ cells and that a subpopulation of the newly generated NG2+ cells differentiate into oligodendrocytes.

A transcriptional role for C/EBP β in the neuronal response to axonal injury

The molecular mechanisms responsible for inducing gene expression following neuronal injury are not well understood. Here, we address this issue by focusing upon C/EBPbeta, a transcription factor implicated in cellular injury and regeneration. We show that C/EBPbeta mRNA is expressed in neurons throughout the mature brain and that levels of both C/EBPbeta mRNA and phosphoprotein are increased in facial motor neurons following axonal injury. To determine the importance of these increases, we examined the regeneration-associated Talpha1 alpha-tubulin gene which contains functional C/EBP binding sites in its promoter. In transgenic mice, expression of a minimal 176 nucleotide Talpha1 alpha-tubulin promoter:nlacZ reporter gene was upregulated in injured facial motor neurons. This injury-induced transcriptional increase was inhibited in C/EBPbeta -/- mice. A similar inhibition was observed in C/EBPbeta -/- mice that carried a larger 1.1-kb promoter Talpha1:nlacZ reporter construct. Moreover, in situ hybridization revealed that the injury-induced upregulation of the endogenous mouse alpha1 alpha-tubulin mRNA, and of a second regeneration-associated mRNA, GAP-43, was inhibited in C/EBPbeta -/- mice. Thus, C/EBPbeta is essential for the neuronal injury response, acting to transcriptionally activate regeneration-associated gene expression.

An 8.5-kb segment of the PMP22 promoter responds to loss of axon signals during Wallerian degeneration, but does not respond to specific axonal signals during nerve regeneration

Altered expression of the PMP22 gene causes Charcot-Marie-Tooth disease type 1A (CMT1A) and hereditary neuropathy with liability to pressure palsies (HNPP). We have examined the promoter activity of 8.5 kb upstream of the first coding exon of the rat peripheral myelin protein-22 (rPmp22) gene in transgenic mice. We found that the -8.5 kb rPmp22/chloramphenicol acetyl transferase (CAT)/beta-galactosidase (lacZ) construct directs reporter gene expression in a weakly developmental and tissue-specific pattern, consistent with the expression pattern of the endogenous Pmp22 gene. The -8.5 kb rPmp22/CAT/lacZ transgene responds to loss of axonal signals during Wallerian degeneration but unlike the endogenous Pmp22 gene, the transgene fails to respond to axonal signals during nerve regeneration after a sciatic nerve crush injury. In conclusion, the function of the -8.5 kb rPmp22/CAT/lacZ transgene suggests that there are separable regulatory elements in the rPmp22 gene that respond differently to axonal signals received by Schwann cells during nerve development, and during remyelination.

Use of oral ketoconazole to prevent postoperative erections following penile surgery

Analgesics and topical agents ineffectively inhibit painful erections after penile and urethral surgery. Oral ketoconazole reversibly inhibits testosterone production and has been used empirically at our institution to decrease postoperative erections. We performed a retrospective review of 38 patients who had undergone penile and urethral reconstructive surgery. In all, 31 patients received 400 mg of ketoconazole three times daily for 10-14 days postoperatively (the study group) and seven patients did not receive ketoconazole (the control group). The incidence of postoperative erections, pain, side effects, surgical outcomes and patient satisfaction in each group were compared. Of the control group, 71% reported erections in the immediate postoperative period, and all these patients reported the erections were painful. Only 23% of the patient taking ketoconazole reported postoperative erections, and only 16% reported the erections were painful. We conclude that ketoconazole effectively prevents painful postoperative erections with minimal side effects.

A combinatorial network of evolutionarily conserved myelin basic protein regulatory sequences confers distinct glial-specific phenotypes

Myelin basic protein (MBP) is required for normal myelin compaction and is implicated in both experimental and human demyelinating diseases. In this study, as an initial step in defining the regulatory network controlling MBP transcription, we located and characterized the function of evolutionarily conserved regulatory sequences. Long-range human-mouse sequence comparison revealed over 1 kb of conserved noncoding MBP 5' flanking sequence distributed into four widely spaced modules ranging from 0.1 to 0.4 kb. We demonstrate first that a controlled strategy of transgenesis provides an effective means to assign and compare qualitative and quantitative in vivo regulatory programs. Using this strategy, single-copy reporter constructs, designed to evaluate the regulatory significance of modular and intermodular sequences, were introduced by homologous recombination into the mouse hprt (hypoxanthine-guanine phosphoribosyltransferase) locus. The proximal modules M1 and M2 confer comparatively low-level oligodendrocyte expression primarily limited to early postnatal development, whereas the upstream M3 confers high-level oligodendrocyte expression extending throughout maturity. Furthermore, constructs devoid of M3 fail to target expression to newly myelinating oligodendrocytes in the mature CNS. Mutation of putative Nkx6.2/Gtx sites within M3, although not eliminating oligodendrocyte targeting, significantly decreases transgene expression levels. High-level and continuous expression is conferred to myelinating or remyelinating Schwann cells by M4. In addition, when isolated from surrounding MBP sequences, M3 confers transient expression to Schwann cells elaborating myelin. These observations define the in vivo regulatory roles played by conserved noncoding MBP sequences and lead to a combinatorial model in which different regulatory modules are engaged during primary myelination, myelin maintenance, and remyelination.

Oligodendrocyte precursor hypercellularity and abnormal retina development in mice overexpressing PDGF-B in myelinating tracts

Platelet-derived growth factor (PDGF) influences the generation of neurons and glia during embryogenesis and in early postnatal life. In an attempt to determine the consequences of an overexpression of PDGF-B during the first weeks of life, we targeted transgenic expression of a human PDGF-B cDNA to myelinating tracts using the promoter region of the myelin basic protein (MBP) gene. Transgenic mRNA and protein were expressed in the brain and the expression profile of the human PDGF-B during early postnatal development closely paralleled that of the endogenous mouse MBP gene. The gross morphological appearance of transgenic brains was normal but at the cellular level several phenotypic alterations could be identified. In white matter tracts such as the corpus callosum and cerebellar medulla, there was a marked hypercellularity. The number of oligodendrocyte precursors was increased and astrocytes were more abundant. In adult mice carrying the MBP-PDGF-B transgene, however, myelination appeared normal and the amount of oligodendrocytes was similar to that of control littermates. In addition to the phenotypic alterations in the brain, investigation of eye structure revealed a striking disorganization of retinal architecture. The retina was folded with cells collected in papillar or follicular-like structures. Retinal whole mount preparations after India ink perfusion revealed capillary disorganization with large-caliber vessels supporting only a few fine branches. Our observations strengthen the notion that PDGF is an important effector molecule in postnatal CNS development.

An essential role for a MEK-C/EBP pathway during growth factor-regulated cortical neurogenesis

Mammalian neurogenesis is determined by an interplay between intrinsic genetic mechanisms and extrinsic cues such as growth factors. Here we have defined a signaling cascade, a MEK-C/EBP pathway, that is essential for cortical progenitor cells to become postmitotic neurons. Inhibition of MEK or of the C/EBP family of transcription factors inhibits neurogenesis while expression of a C/EBPbeta mutant that is a phosphorylation-mimic at a MEK-Rsk site enhances neurogenesis. C/EBP mediates this positive effect by direct transcriptional activation of neuron-specific genes such as Talpha1 alpha-tubulin. Conversely, inhibition of C/EBP-dependent transcription enhances CNTF-mediated generation of astrocytes from the same progenitor cells. Thus, activation of a MEK-C/EBP pathway enhances neurogenesis and inhibits gliogenesis, thereby providing a mechanism whereby growth factors can selectively bias progenitors to become neurons during development.

The prevalence of testicular microlithiasis in an asymptomatic population of men 18 to 35 years old

PURPOSE

Testicular microlithiasis is an imaging entity of the testicle thought to be a marker of testicular cancer. To our knowledge the prevalence of testicular microlithiasis in an asymptomatic population at risk for testicular cancer is unknown. We report an ultrasound screening study done to establish the prevalence of testicular microlithiasis in an asymptomatic population.

MATERIALS AND METHODS

Healthy men 18 to 35 years old from the annual Army Reserve Officer Training Corps training camp volunteered for study. A screening genitourinary history was obtained, and physical examination and screening scrotal ultrasound were performed. We defined testicular microlithiasis as more than 5 high intensity signals on ultrasound with each signal larger than 2 mm. We categorized testicular microlithiasis into microcalcifications that were scant-5 to 25 per side, moderate-greater than 25 per side but no areas of near confluence and too numerous to count. In all subjects with testicular microlithiasis tumor markers were also measured.

RESULTS

Of 1,504 evaluated men with a mean age of 22.4 years, 84 (5.6%) had testicular microlithiasis, including 45 of 1,053 white (4%), 21 of 149 black (14.1%), 6 of 71 Hispanic (8.5%), 3 of 54 Asian or Pacific Island (5.6%) men and 9 of 174 (5.2%) who claimed no race affiliation. Tumor markers were normal in all subjects with testicular microlithiasis.

CONCLUSIONS

Testicular microlithiasis occurs in more than 5% of healthy young men. In contrast, testicular cancer develops in 3/100,000 to 5/100,000 men or 1,000-fold less often. The relative prevalence of testicular microlithiasis with respect to testicular cancer, increased prevalence in minorities, bilateral distribution, and inverse geographic distribution of men with testicular microlithiasis and testicular cancer represent evidence against an association of the 2 conditions. This study indicates that testicular microlithiasis is a common finding in asymptomatic men that may not be related to testicular cancer.

Plastibell template circumcision: a new technique

A novel circumcision technique using the Plastibell as a template is described. This technique is fast and ensures excellent cosmesis compared with the standard sleeve circumcision. It is easy to perform and allows the urologist to achieve consistently excellent cosmetic results. We describe the technique in detail.

Neurofilament cytoskeleton disruption does not modify accumulation of trophic factor mRNA

Previously we described a transgenic mouse model in which neurofilaments are sequestered in neuronal cell bodies and withheld from the axonal compartment. This model and other transgenic models with disrupted neurofilaments are used widely to investigate the role of the neurofilament cytoskeleton in normal neurons and in inherited or acquired diseases. To interpret such studies, it is important to establish whether the maldistribution of neurofilaments has major secondary consequences on the cell biology of the affected neurons. Notably, multiple perturbations of the nervous system simultaneously affect both the neuronal cytoskeleton and neurotrophin expression. To determine whether the expression of neurotrophic factors or their receptors is perturbed by a primary disruption in neurofilaments, we compared the accumulated mRNA levels for ciliary neuroptrophic factor (CNTF), nerve growth factor, neurotrophin 3, and the alpha CNTF receptor in mature transgenic mice and their littermate controls. Consistently with the prolonged survival of neurons expressing atypical or abnormally distributed neurofilaments, no obvious changes were observed for any of the mRNA species examined.

Widespread expression of netrin-1 by neurons and oligodendrocytes in the adult mammalian spinal cord

Netrins are a family of secreted proteins that function as chemotropic axon guidance cues during neural development. Here we demonstrate that netrin-1 continues to be expressed in the adult rat spinal cord at a level similar to that in the embryonic CNS. In contrast, netrin-3, which is also expressed in the embryonic spinal cord, was not detected in the adult. In situ hybridization analysis demonstrated that cells in the white matter and the gray matter of the adult spinal cord express netrin-1. Colocalization studies using the neuronal marker NeuN revealed that netrin-1 is expressed by multiple classes of spinal interneurons and motoneurons. Markers identifying glial cell types indicated that netrin-1 is expressed by most, if not all, oligodendrocytes but not by astrocytes. During neural development, netrin-1 has been proposed to function as a diffusible long-range cue for growing axons. We show that in the adult spinal cord the majority of netrin-1 protein is not freely soluble but is associated with membranes or the extracellular matrix. Fractionation of adult spinal cord white matter demonstrated that netrin-1 was absent from fractions enriched for compact myelin but was enriched in fractions containing periaxonal myelin and axolemma, indicating that netrin-1 protein may be localized to the periaxonal space. These findings suggest that in addition to its role as a long-range guidance cue for developing axons, netrin may have a short-range function associated with the cell surface that contributes to the maintenance of appropriate neuronal and axon-oligodendroglial interactions in the mature nervous system.

A unique role for Fyn in CNS myelination

We analyzed the role of Fyn tyrosine kinase in CNS myelination by using fyn(-/-) null mutant mice, which express no Fyn protein. We found a severe myelin deficit in forebrain at all ages from 14 d to 1 year. The deficit was maximal at 1 month of age and was similar regardless of mouse strain background or whether it was determined by bulk isolation of myelin or by quantitation of myelin basic protein. To determine the cellular basis of the myelin deficit, we counted oligodendrocytes in tissue sections of mice expressing oligodendrocyte-targeted beta-galactosidase, and we used light and electron microscopy to examine the number and morphology of myelinated fibers and size of myelinated CNS structures. All of these parameters were reduced in fyn(-/-) mice. Unexpectedly, there were regional differences in the myelin deficit; in contrast to forebrain, fyn(-/-) cervical spinal cord exhibited no reduction in myelin content, number of oligodendrocytes, or number of myelinated fibers, nor was myelination delayed developmentally. We found that oligodendrocytes express Src, but there was no significant reduction of myelin content in null mutants lacking the Fyn-related kinases Src, Yes, or Lyn. Finally, we investigated the molecular features of Fyn that are required for myelination and found that a single amino acid substitution, which abolishes the tyrosine kinase activity of Fyn, resulted in a myelin deficit as great as that observed in the complete absence of Fyn protein. These results demonstrate that Fyn plays a unique role in myelination, one that requires its kinase activity.

Model for focal demyelination of the spinal dorsal columns of transgenic MBP-LacZ mice by phototargeted ablation of oligodendrocytes

Focal demyelination models provide powerful tools to study demyelination and remyelination in the central nervous system. In this report, we present a novel technique, which selectively targets oligodendrocytes within the spinal cord of transgenic mice to produce focal demyelination. Transgenic mice expressing the E. coli LacZ (beta-galactosidase) gene from the myelin basic protein promotor allowed for oligodendrocyte-specific cleavage of topically applied fluorescein-di-beta-galactopyranoside liberating photoactivatable fluorescein. Subsequent fluorescence illumination generated oxygen radicals that oxidized a second exogenous substrate, 3-amino-9-ethyl carbazole, to form a toxic precipitate within oligodendrocytes. Histochemical staining of the spinal cord dorsal columns 8 days following phototargeting revealed that the treated region no longer contained beta-galactosidase-positive cells. Focal demyelination of the dorsal columns was observed to a depth of 150 microm in transverse semithin plastic sections. Numerous bundles of naked axons interspersed with myelin, debris-laden macrophages, and reactive astrocytes were evident by electron microscopy. Remyelination of axons by both oligodendrocytes and invading Schwann cells was observed within the treated region 14 days after phototargeting. Newly generated oligodendrocytes were identified within the demyelinated region by their incorporation of bromodeoxyuridine. Thus, this novel focal demyelination protocol provides: (1) a method for selective targeted ablation of oligodendrocytes in vivo, (2) control over the extent of the demyelinated region, with (3) an environment that maintains its remyelination capacity. Phototargeted ablation of oligodendrocytes may therefore be a useful model for studying axon-glia interactions, axon regeneration within a demyelinated zone, and remyelination of axons.

Outcomes of varicocele ligation done for pain

PURPOSE

Surgical ligation is an option in the management of patients with painful varicocele. Little objective data exist addressing the effectiveness of this treatment. We reviewed records from 58 patients who underwent varicocele ligation at our institution from January 1985 to May 1996 to establish success of surgical ligation of the painful varicocele.

MATERIALS AND METHODS

ICD-9 billing codes were used to identify all patients who had undergone varicocele ligation for pain since 1985. We documented patient age, grade and location of varicocele, duration and quality of pain, response to conservative therapy and surgical approach to ligation. Telephone interviews and chart reviews were conducted to determine resolution of pain, complications of the procedure and if the patient would choose surgery again.

RESULTS

We obtained followup on 35 of the 58 painful varicocele patients (60%). Average patient age was 25.7 years (range 15 to 65). The varicocele was on the left side in 30 men and bilateral in 5. Of the patients 31 described the pain as a dull throbbing ache, 2 as sharp and 2 as a pulling sensation. Initial conservative therapy failed in all 35 men. Varicocele was grade III in 18 cases, grade II in 16 and grade I in 1. The inguinal or subinguinal approach was used in 24 patients, high ligation in 10 and laparoscopic repair in 1. In 30 patients there was (86%) complete resolution of pain postoperatively and 1 had partial resolution. Only 4 patients (11%) had persistent or worse symptoms.

CONCLUSIONS

This retrospective review supports the conclusion that varicocele ligation is an effective treatment for painful varicocele in properly selected patients.

Pathogenesis of two axonopathies does not require axonal neurofilaments

Neurofilaments are a major component of the axonal cytoskeleton and their abnormal accumulation is a prominent feature of the cytopathology encountered in several neurodegenerative diseases. Thus, an attractive and widely held model of pathogenesis involves the participation of disrupted neurofilaments as a common toxic intermediate. Here, in direct contrast to this hypothesis, we show that two neurodegenerative disease models in the mouse, dystonia musculorum (dt) and a superoxide dismutase 1 (SOD1)-mediated form of human motor neuron disease (amyotrophic lateral sclerosis, ALS), progress with little or no abatement on a transgenic background in which neurofilaments are withheld from the axonal compartment. By specifically excluding a necessary role for axonal neurofilaments, our observations redefine the components of the pathogenic pathway leading to axon disruption in these two degenerative diseases.

Factors contributing to recurrent carotid disease following carotid endarterectomy

BACKGROUND

Retrospective analysis was performed to assess the effect of gender, age, hypertension, diabetes, and smoking upon residual disease, recurrent disease, and progression of disease following carotid endarterectomy (CE). The effect of patch versus primary closure was also studied.

METHODS

Postoperative duplex studies were performed following 323 CEs at months 1, 6, 12, and 24. Residual disease was defined as luminal stenosis >59% at 1 month. Progression of disease was defined as stenosis at any month that was greater than stenosis at month 1. Recurrent disease was nonresidual stenosis >79%.

RESULTS

Correlation was found between age at operation <65 years and cigarette smoking; both also correlated with progression of disease on serial studies, as well as recurrent stenosis <79%. Primary closure of the arteriotomy correlated with residual disease.

CONCLUSION

Primary closure of the arteriotomy following CE increases the likelihood of residual disease. Smokers and those aged <65 years are predisposed to progression of postoperative disease, and to development of recurrent stenosis.

Tissue-specific selection for different mtDNA genotypes in heteroplasmic mice

Mammalian mitochondrial DNA (mtDNA) is a highly polymorphic, high-copy-number genome that is maternally inherited. New mutations in mtDNA segregate rapidly in the female germline due to a genetic bottleneck in early oogenesis and as a result most individuals are homoplasmic for a single species of mtDNA. Sequence variants thus accumulate along maternal lineages without genetic recombination. Most of the extant variation in mtDNA in mammalian populations has been assumed to be neutral with respect to selection; however, comparisons of the ratio of replacement to silent nucleotide substitutions between species suggest that the evolution of mammalian mtDNA is not strictly neutral. To test directly whether polymorphic mtDNAs behave as neutral variants, we examined the segregation of two different mtDNA genotypes in the tissues of heteroplasmic mice. We find evidence for random genetic drift in some tissues, but in others strong, tissue-specific and age-related, directional selection for different mtDNA genotypes in the same animal. These surprising data suggest that the coding sequence of mtDNA may represent a compromise between the competing demands of different tissues and point to the existence of unknown, tissue-specific nuclear genes important in the interaction between the nuclear and mitochondrial genomes.

Increased severity of experimental autoimmune encephalomyelitis, chronic macrophage/microglial reactivity, and demyelination in transgenic mice producing tumor necrosis factor-alpha in the central nervous system

Tumor necrosis factor-alpha (TNF-alpha) is an inflammatory cytokine implicated in a number of autoimmune diseases. Apoptotic cell death is induced by TNF-alpha in vitro, and has been suggested as one cause of autoimmune pathology, including autoimmune demyelinating diseases where oligodendrocytes are a target of immune attack. TNF-alpha also regulates macrophage activity which could contribute to autoimmune inflammation. We have expressed TNF-alpha at disease-equivalent levels in the central nervous system of transgenic mice, using a myelin basic protein (MBP) promoter. These mice were normal and showed no spontaneous pathology, but they developed experimental autoimmune encephalomyelitis (EAE) with greater severity than nontransgenic controls when immunized with MBP in adjuvant. Unlike nontransgenic controls, EAE then progressed to a nonabating demyelinating disease. Macrophage/microglial reactivity was evident in demyelinating lesions in spinal cord, but T cells were not detected during chronic disease. The participation of TNF-alpha in the demyelinating process is thus more probably due to the perpetuation of macrophage/microglial activation than to direct cytotoxicity of myelin or oligodendroglia.

Multipotent CNS stem cells are present in the adult mammalian spinal cord and ventricular neuroaxis

Neural stem cells in the lateral ventricles of the adult mouse CNS participate in repopulation of forebrain structures in vivo and are amenable to in vitro expansion by epidermal growth factor (EGF). There have been no reports of stem cells in more caudal brain regions or in the spinal cord of adult mammals. In this study we found that although ineffective alone, EGF and basic fibroblast growth factor (bFGF) cooperated to induce the proliferation, self-renewal, and expansion of neural stem cells isolated from the adult mouse thoracic spinal cord. The proliferating stem cells, in both primary culture and secondary expanded clones, formed spheres of undifferentiated cells that were induced to differentiate into neurons, astrocytes, and oligodendrocytes. Neural stem cells, whose proliferation was dependent on EGF+bFGF, were also isolated from the lumbar/sacral segment of the spinal cord as well as the third and fourth ventricles (but not adjacent brain parenchyma). Although all of the stem cells examined were similarly multipotent and expandable, quantitative analyses demonstrated that the lateral ventricles (EGF-dependent) and lumbar/sacral spinal cord (EGF+bFGF-dependent) yielded the greatest number of these cells. Thus, the spinal cord and the entire ventricular neuroaxis of the adult mammalian CNS contain multipotent stem cells, present at variable frequency and with unique in vitro activation requirements.

Random genetic drift in the female germline explains the rapid segregation of mammalian mitochondrial DNA

Mitochondrial DNA (mtDNA) is maternally inherited in mammals. Despite the high genome copy number in mature oocytes (10(5)) and the relatively small number of cell divisions in the female germline, mtDNA sequence variants segregate rapidly between generations. To investigate the molecular basis for this apparent paradox we created lines of heteroplasmic mice carrying two mtDNA genotypes. We show that the pattern of segregation can be explained by random genetic drift occurring in early oogenesis, and that the effective number of segregating units for mtDNA is approximately 200 in mice. These results provide the basis for estimating recurrence risks for mitochondrial disease due to pathogenic mtDNA mutations and for predicting the rate of fixation of neutral mtDNA mutations in maternal lineages.

Visualization of slow axonal transport in vivo

In axons, cytoskeletal constituents move by slow transport. However, it remains controversial whether axonal neurofilaments are dynamic structures in which only subunits are transported or whether filaments assemble in the proximal axon and are transported intact as polymers to the axon terminus. To investigate the form neurofilament proteins take during transport, neurons of transgenic mice lacking axonal neurofilaments were infected with a recombinant adenoviral vector encoding epitope-tagged neurofilament M. Confocal and electron microscopy revealed that the virally encoded neurofilament M was transported in unpolymerized form along axonal microtubules. Thus, neurofilament proteins are probably transported as subunits or small oligomers along microtubules, which are major routes for slow axonal transport.

Determination of neuroepithelial cell fate: induction of the oligodendrocyte lineage by ventral midline cells and sonic hedgehog

Near the floor plate of the embryonic neural tube there is a group of neuroepithelial precursor cells that are specialized for production of the oligodendrocyte lineage. We performed experiments to test whether specification of these neuroepithelial oligodendrocyte precursors, like other ventral neural cell types, depends on signals from the notochord and/or floor plate. We analyzed heterozygous Danforth's short tail (Sd/+) mutant mice, which lack a notochord and floor plate in caudal regions of the neural tube, and found that oligodendrocyte precursors did not appear at the ventricular surface where there was no floor plate. Moreover, oligodendrocytes did not develop in explant cultures of Sd/+ spinal cord in the absence of a floor plate. When a second notochord was grafted into an ectopic position dorsolateral to the endogenous notochord of a chicken embryo, an additional floor plate was induced along with an ectopic focus of oligodendrocyte precursors at the ventricular surface. Oligodendrocytes developed in explants of intermediate neural tube only when they were cocultured with fragments of notochord or in the presence of purified Sonic hedgehog (Shh) protein. Thus, signals from the notochord/floor plate, possibly involving Shh, are necessary and sufficient to induce the development of ventrally derived oligodendroglia. These signals appear to act by specifying the future fate(s) of neuroepithelial cells at the ventricular surface rather than by influencing the proliferation or differentiation of prespecified progenitor cells in the parenchyma of the cord.

Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery

STUDY OFJECTIVE: The purpose of this study was to test the effectiveness of oropharyngeal decontamination on nosocomial infections in a comparatively homogeneous population of patients undergoing heart surgery.

DESIGN

This was a prospective, randomized, double-blind, placebo-controlled clinical trial. Experimental and control groups were selected for similar infection risk parameters. SEETTING: Cardiovascular ICU of a tertiary care hospital.

PATIENTS

Three hundred fifty-three consecutive patients undergoing coronary artery bypass grafting, valve, or other open heart surgical procedures were randomized to an experimental (n=173) or control (n=180) group. Heart and lung transplantations were excluded.

INTERVENTIONS

The experimental drug chosen was 0.12% chlorhexidine gluconate (CHX) oral rinse.

MEASUREMENTS AND RESULTS

The overall nosocomial infection rate was decreased in the CHX-treated patients by 65% (24/180 vs 8/173; p<0.01). We also noted a 69% reduction in the incidence of total respiratory tract infections in the CHX-treated group (17/180 vs 5/173; p<0.05). Gram-negative organisms were involved in significantly less (p<0.05) of the nosocomial infections and total respiratory tract infections by 59% and 67%, respectively. No change in bacterial antibiotic resistance patterns in either group was observed. The use of nonprophylactic IV antibiotics was lowered by 43% (42/180 vs 23/173; p<0.05). A reduction in mortality in the CHX-treated group was also noted (1.16% vs 5.56%).

CONCLUSIONS

Inexpensive and easily applied oropharyngeal decontamination with CHX oral rinse reduces the total nosocomial respiratory infection rate and the use of nonprophylactic systemic antibiotics in patients undergoing heart surgery. This results in significant cost savings for those patients who avoid additional antibiotic treatment.

Annexin IV is a marker of roof and floor plate development in the murine CNS

Midline structures, such as the notochord and floor plate, are crucial to the developing central nervous system (CNS). Previously, we demonstrated that annexin IV is an excellent marker of midline structures. In the present study, we explore the possible role of annexin IV in development of the CNS midline. Using immunocytochemistry with an antibody to annexin IV, we have elucidated the temporal and spatial expression of this molecule. Annexin IV is present in the notochord at embryonic day (E) 8.5, prior to its expression in any structures within the neural tube. Subsequently, annexin IV is expressed by floor plate cells at E9.5. Annexin IV is also expressed in the roof plate, but not until E10.5. To determine if normal morphogenesis of these midline structures is essential for annexin IV expression, we analyzed two strains of mutant mice that have defective formation of either the floor or the roof plate. In Danforth's short-tail mice, the floor plate is absent from the caudal spinal cord, and annexin IV immunopositivity disappears at the level where the floor plate is missing. In curly tail mutant mice, there can be a failure of the neural tube to close, and in these regions there is no annexin IV expression in presumptive roof plate cells. Finally, annexin IV immunolabeling is present from the caudal spinal cord, through the brainstem up to the diencephalon and lamina terminalis. Thus, annexin IV is an excellent marker for differentiated midline cells, is temporally and spatially correlated with development of the floor and roof plates, and is expressed in a rostral-caudal manner that supports the hypothesis that the floor plate extends the full length of the original neural tube.

Durability of emergency coronary artery bypass for complications of failed angioplasty

Although emergency coronary artery bypass for complications of percutaneous transluminal coronary angioplasty (PTCA) has proved to be a relatively successful 'bail-out' procedure, little is known about the durability of revascularization under these potentially disastrous circumstances. The authors therefore retrospectively examined their results with this procedure. Emergency coronary artery bypass for complications of PTCA was performed in 112 patients between 1 January 1984 and 19 May 1992. Fifteen patients underwent PTCA for acute myocardial infarction. Eleven patients (9.8%) were stable, and underwent emergency coronary artery bypass after PTCA because of suboptimal angiographic results from percutaneous transluminal coronary angioplasty. None of these stable patients died. The remainder of the patients underwent emergency coronary artery bypass after PTCA because of ongoing documented ischemia, including cardiac arrest requiring cardiopulmonary resuscitation during transit to the operating room in 11 patients (9.8%) and preoperative intra-aortic counterpulsation in 24 (21.4%). The average number of coronary arteries bypassed at emergency coronary artery bypass was 2.2, and 19 patients (17%) received at least one mammary artery conduit. The perioperative incidence of myocardial infarction was 8.9% (10/112), and the operative mortality rate 8% (9/112). During follow-up, which averaged 55 months, the survival rate (including operative mortality) was 85% while 98% of patients experienced freedom from reoperative coronary bypass, 89% experienced freedom from myocardial infarction (including postoperative) and 90% experienced freedom from subsequent catheterization or PTCA. In conclusion, emergency coronary artery bypass for PTCA complications successfully avoids subsequent untoward cardiac events. When compared with published results of PTCA without emergency coronary artery bypass, emergency coronary bypass is more reliable for avoiding subsequent cardiac catheterization (with or without PTCA) than PTCA alone.

Clinical heparin coated cardiopulmonary bypass: reduction of systemic heparin requirements for redo cardiac surgery

The authors compared blood loss, transfusion requirements, and heparin doses for reoperative cardiac surgery using either: a) a Duraflow (Baxter Corporation, Irvine, CA) heparin coated cardiopulmonary bypass (CPB) system or b) standard CPB. Twenty patients underwent redo cardiac surgery while supported with heparin coated CPB, and 17 patients underwent redo cardiac surgery with standard CPB. The following data are presented as mean +/- standard deviation. The heparin coated CPB circuit group received significantly less heparin than the standard CPB group (322 +/- 80 IU/kg versus 448 +/- 80 IU/kg, p < 0.01). There was no difference in blood loss in the first 24 postoperative hrs or mean transfusion requirements for the two groups. Despite the reduced dose of heparin, the mean activated clotting time in the heparin coated group was similar to the mean activated clotting time of the standard CPB group (577 +/- 98 sec versus 612 +/- 117 sec, p = ns). In conclusion, heparin coated CPB without reduced activated clotting time does not reduce transfusion requirements or blood loss in reoperative cardiac surgery. The heparin coated CPB system allows maintenance of the activated clotting time level despite reduced heparin doses.

Dramatically different phenotypes in mouse models of human Tay-Sachs and Sandhoff diseases

We have generated mouse models of human Tay-Sachs and Sandhoff diseases by targeted disruption of the Hexa (alpha subunit) or Hexb (beta subunit) genes, respectively, encoding lysosomal beta-hexosaminidase A (structure, alpha) and B (structure, beta beta). Both mutant mice accumulate GM2 ganglioside in brain, much more so in Hexb -/- mice, and the latter also accumulate glycolipid GA2. Hexa -/- mice suffer no obvious behavioral or neurological deficit, while Hexb -/- mice develop a fatal neurodegenerative disease, with spasticity, muscle weakness, rigidity, tremor and ataxia. The Hexb -/- but not the Hexa -/- mice have massive depletion of spinal cord axons as an apparent consequence of neuronal storage of GM2. We propose that Hexa -/- mice escape disease through partial catabolism of accumulated GM2 via GA2 (asialo-GM2) through the combined action of sialidase and beta-hexosaminidase B.