Tumor regression grading after neoadjuvant treatment of esophageal and gastroesophageal junction adenocarcinoma: results of an international Delphi consensus survey

Complete histopathologic tumor regression after neoadjuvant treatment is a well-known prognostic factor for survival among patients with adenocarcinomas of the esophagus and gastroesophageal junction. The aim of this international Delphi survey was to reach a consensus regarding the most useful tumor regression grading (TRG) system that could represent an international standard for histopathologic TRG grading of gastroesophageal carcinomas. Fifteen pathologists with special interest in esophageal and gastric pathology participated in the online survey. The initial questionnaire contained of 43 statements that addressed the following topics: (1) specimen processing, (2) gross examination, (3) cross sectioning, (4) staining, (5) Barrett's esophagus, (6) TRG systems, and (7) TRG in lymph node (LN). Participants rated the items using a 5-point Likert style scale and were encouraged to write comments for each statement. The expert panel recommended a 4-tiered TRG system for assessing the primary tumor: grade 1: No residual tumor (complete histopathologic tumor regression), grade 2: less than 10% residual tumor (near-complete regression), grade 3: 10%-50% residual tumor (partial regression), grade 4: greater than 50% residual tumor (minimal/no regression), combined with a 3-tiered system for grading therapeutic response in metastatic LNs: grade a: no residual tumor (complete histopathologic TRG), grade b: partial regression (tumor cells and regression), grade c: no regression (no sign of tumor response). This TRG grading system can be recommended as an international standard for histopathologic TRG grading in esophageal and gastroesophageal junction adenocarcinoma.

The expression of lysyl-oxidase gene family members in myeloproliferative neoplasms

Myeloproliferative neoplasms (MPNs) are malignant disorders originating from clonal expansion of a single neoplastic stem cell and characteristically show an increase in bone marrow reticulin fibers. Lysyl oxidases (LOXs) are copper-dependent amine oxidases that play a critical role in the biogenesis of connective tissue by crosslinking extracellular matrix proteins, collagen and elastin. Expression of LOX gene family members is increased in disorders associated with increased fibrosis. To evaluate involvement of LOX gene family in various MPNs. In-situ hybridization was used to detect Lysyl-Oxidase family members in bone marrow biopsies from patients with different MPNs. We compared normal bone marrows and those from patients with polycythemia vera, essential thrombocythemia, chronic myeloid leukemia, and primary myelofibrosis (PMF). Serum levels of lysyl-oxidase from patients with PMF and healthy controls were also examined. LOX gene family was not detected in normal bone marrows. All members of the LOX gene family were over expressed in PMF. In other MPNs a differential pattern of expression was observed. Differences in gene expression were statistically significant (P < 0.010). The medianserum LOX levels in normal controls was 28.4 ± 2.5 ng\ml and 44.6 ± 9.44 ng\ml in PMF (P = 0.02). The varying pattern of expression of LOX genes may reflect differences in the pathophysiology of bone marrow fibrosis in these MPNs. These observations could be used as the basis for future targeted therapy directed against bone marrow fibrosis.

The involvement of immune semaphorins and neuropilin-1 in lupus nephritis

Background and objectives: Neuropilin-1 (NP-1), a functional vascular endothelial growth factor (VEGF) receptor, is important in the priming of resting T cells and contributes to the development of peripheral tolerance. Semaphorins, a family of axon guidance molecules, has been found to be involved in regulating the immune system.

The aim of this study was to explore the involvement of NP-1 and semaphorins in lupus glomerulonephritis (LGN).

Methods: Twelve kidney biopsies from LGN patients and five normal biopsies were examined in this study. In addition, eight biopsies from patients with primary nephropathy and proteinuria were included serving as a disease control group. Biopsies were stained with anti-VEGF, NP-1, and semaphorins. The Image Pro-Plus software was used to measure the intensity and extent of staining. The correlation with clinico-pathological parameters was evaluated.

Results: VEGF expression was slightly higher in LGN. NP-1 and semaphorins were stained with significantly higher intensity in LGN when compared with both the normal and the disease control groups. NP-1 deposits were found only in damaged glomerulus areas and positively correlated with clinico-pathological parameters of renal disease (a statistical trend). However, the semaphorins were found in inverse correlations.

Discussion: Being present in normal and slightly increased in diseased glomeruli, VEGF is considered protective during inflammation. Increased NP-1 expression in LGN may intensify the possible protective effect of VEGF, thereby preventing endothelial damage. However, one should consider the possibility that increased NP-1 expression is harmful and could play a role in the damage of LGN. NP-1 is suggested to be a reliable marker differentiating focal versus diffuse LGN. Semaphorin 3A can serve as a histological marker for tubular damage. The altered ability of kidneys to secrete semaphorins during advanced renal damage may in part explain its inverse correlation with renal function. Further work is needed in order to better understand the role of NP-1 and semaphorins in LGN.

Glycogen synthase kinase 3beta: a novel marker and modulator of inflammatory injury in chronic renal allograft disease

One key cell-signaling event central to inflammation in kidney diseases, including chronic renal allograft dysfunction or disease (CRAD), is the activation of NF-kappaB, which controls transcription of numerous proinflammatory mediators. Glycogen synthase kinase (GSK) 3beta is an indispensable element of NF-kappaB activation, however, the exact role of GSK3beta in the pathogenesis of inflammatory kidney diseases like CRAD is uncertain and was examined. Immunohistochemistry staining of GSK3beta was weak in normal kidneys, but was markedly induced in inflamed allograft kidneys, with prominent cytoplasmic staining of tubular cells in areas of inflammation. Net GSK3beta activity is regulated by inhibitory phosphorylation of its serine 9 residue, and this occurred in CRAD. Thus, the magnitude of GSK3beta inactivation was inversely correlated with the degree of injury as assessed by Banff criteria. In vitro in cultured human tubular epithelial cells, GSK3beta overexpression augmented, while GSK3beta silencing diminished proinflammatory cellular responses to TNF-alpha stimulation, including NF-kappaB activation and expression of chemokines MCP-1 and RANTES. These inflammatory responses were obliterated by GSK3beta inhibitors. Collectively, GSK3beta plays an important role in mediating proinflammatory NF-kappaB activation and renal inflammation. Suppression of GSK3beta activity might represent a novel therapeutic strategy to treat CRAD.

Minocycline treatment following hypoxic/ischaemic injury attenuates white matter injury in a rodent model of periventricular leucomalacia

AIMS

Periventricular white matter injury in premature infants occurs following hypoxia/ischaemia and systemic infection, and results in hypomyelination, as well as neuromotor and cognitive deficits later in life. Inflammatory infiltrates are seen within human cerebral white matter from periventricular leucomalacia (PVL) cases.

METHODS

In this study, we examine the time course of CD-68+ microglial cell responses relative to cell death within white matter following hypoxia/ischaemia in a rat model of PVL. We also tested the efficacy of the minocycline, an agent that suppresses microglial activation, in this model when administered as a post-insult treatment.

RESULTS

We show that preoligodendrocyte injury in the post-natal day 6 begins within 24 h and continues for 48-96 h after hypoxia/ischaemia, and that microglial responses occur primarily over the first 96 h following hypoxia/ischaemia. Minocycline treatment over this 96 h time window following the insult resulted in significant protection against white matter injury, and this effect was concomitant with a reduction in CD-68+ microglial cell numbers.

CONCLUSIONS

These results suggest that anti-inflammatory treatments may represent a useful strategy in the treatment of PVL, where clinical conditions would favour a post-insult treatment strategy.

Global analysis of the human gastric epithelial transcriptome altered by Helicobacter pylori eradication in vivo

OBJECTIVE

The transcriptional profile of gastric epithelial cell lines cocultured with Helicobacter pylori and the global gene expression of whole gastric mucosa has been described previously. We aimed to overcome limitations of previous studies by determining the effects of H pylori eradication on the transcriptome of purified human gastric epithelium using each patient as their own control.

DESIGN

Laser capture microdissection (LCM) was used to extract mRNA from paraffin-embedded antral epithelium from 10 patients with peptic ulcer disease, before and after H pylori eradication. mRNA was reverse transcribed and applied on to Affymetrix cDNA microarray chips customised for formalin-fixed tissue. Differentially expressed genes were identified and a subset validated by real-time polymerase chain reaction (PCR).

RESULTS

A total of 13 817 transcripts decreased and 9680 increased after H pylori eradication. Applying cut-off criteria (p<0.02, fold-change threshold 2.5) reduced the sample to 98 differentially expressed genes. Genes detected included those previously implicated in H pylori pathophysiology such as interleukin 8, chemokine ligand 3, beta defensin and somatostatin, as well as novel genes such as GDDR (TFIZ1), chemokine receptors 7 and 8, and gastrokine.

CONCLUSIONS

LCM of archival specimens has enabled the identification of gastric epithelial genes whose expression is considerably altered after H pylori eradication. This study has confirmed the presence of genes previously implicated in the pathogenesis of H pylori, as well as highlighted novel candidates for further investigation.

Computerized nuclear morphometry for the prediction of inguinal lymph nodes metastases in squamous cell carcinoma of the vulva

This study evaluated the sensitivity and specificity of computerized morphometry in predicting lymph nodes metastases (LNM) in patients with squamous cell carcinoma (SCC) of the vulva. Histologic samples obtained from 20 consecutive cases of SCC of the vulva with positive inguinal LNM were morphometrically assessed and compared with samples from 20 consecutive cases of vulvar SCC negative for LNM. Computerized morphometry was performed on tumor cells and on adjacent nonneoplastic epithelial cells located 2-4 mm from the tumor margins. Computerized morphometric variables of tumor cell nuclei in patients with negative LNM significantly differed from those in patients with positive LNM. Morphometric differences in nuclear size and contour regularity were detected when comparing the nonneoplastic nuclei adjacent to the tumor of both groups. Multivariate analysis showed that the only independent predictors of LNM were the depth of the invasion (P= 0.005) and the mean nuclear roundness of the nonneoplastic nuclei adjacent to the tumors (P= 0.008). Using these variables, a discriminant score revealed a sensitivity of 90% and a specificity of 86.4% for predicting LNM in SCC of the vulva. Our data suggest that cells from the primary tumors with LNM differ morphometrically from primary tumors with no LNM. In addition, normal epithelial cells adjacent to the tumor express morphometric changes between the two groups. The results of our study justify the need for a prospective study of a larger number of patients to evaluate the reproducibility and the clinical use of the data.

Shc test as a strong prognostic indicator of disease outcome in early stage gastric cancer

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Background: Treatment planning for gastric cancer is primarily based on clinical staging of disease. Markers predicting likelihood of disease outcome would help guide treatment decisions, especially for early stage disease. The Shc proteins, implicated in many aggressive cancers, and measured in tumor specimens by the immunohistochemical (IHC) Shc Test, have shown strong ability to predict disease outcome in breast cancer. We report here that the Shc Test is a strong prognostic indicator of disease outcome in early stage gastric cancer. Methods: Histopathology was examined in one hundred and seventeen (117) primary gastric cancer patient samples from Rhode Island Hospital in tissue microarray format (21 disease recurrences; 63 disease-specific deaths; average follow-up of 2.7 yrs). IHC staining of the Shc proteins was independently scored on a 0–5 scale by two pathologists, blinded to patient information. Results: Stage I or II gastric cancers (n=62) could be clearly separated at a cutpoint of 1.1 on a 0–5 scale, into good prognosis (16% 4yr relapse risk; demonstrating high PY-Shc) and poor prognosis (46% 4yr relapse risk; showing low PY-Shc) (log-rank, P=0.003). p66 Shc showed similar prognostic abilities. High PY-Shc in patients with early stage disease showed a significant protective effect on overall survival (P=0.003) by univariate log rank analysis. As a continuous variable, PY-Shc had a strong predictive ability (HR = 0.09, P=0.055) that approached significance. By univariate Cox proportional hazards, patients with high PY-Shc had a 5-fold reduction in disease specific death (DSD) compared to patients with low PY-Shc (P=0.002). By multivariate Cox proportional hazards, adjusted for grade, stage, chemotherapy and radiation therapy, only PY-Shc (HR = 0.22, P=0.015) and Intestinal tumor type (HR = 0.38, P=0.046) remained as significant predictors of survival. Conclusions: The Shc Test shows a strong prognostic ability to stratify early stage gastric cancer patients by risk, making it a valuable tool in selecting therapy for these patients.

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Increased plasma levels of matrix metalloproteinase-9 are associated with the severity of chronic urticaria

BACKGROUND

Matrix metalloproteinase (MMP)-9 is produced by many inflammatory cells such as macrophages, neutrophils, mast cells, eosinophils and T lymphocytes. Activated T cells are capable, through cell-cell contact, of inducing MMP-9 expression in human mast cells.

OBJECTIVE

To investigate the activation status of peripheral CD4+ T cells and the level of MMP-9 in the plasma of patients with chronic urticaria (CU), and whether MMP-9 levels are in association with CU severity.

METHODS

Study subjects included 29 patients with CU and 30 healthy control subjects. At the time of assessment, patients were divided into subgroups according to urticarial severity. Plasma levels of total MMP-9 (free pro-MMP-9 and free MMP-9) were determined by ELISA. CD4+ lymphocytes were positively selected with magnetic microbeads. After 48 h of activation, CD4+ T cells were assayed for both nuclear factor-kappa B (NF-kappa B) expression and proliferation.

RESULTS

Plasma levels of MMP-9 were found to be significantly higher in 29 CU patients compared with 18 healthy controls (186 +/- 174 vs. 31 +/- 21 ng/mL, P<0.0001). We also found a significant correlation between MMP-9 levels and urticarial severity (r = 0.92, P<0.001). In addition, CD4+ T cells from CU patients expressed higher levels of NF-kappa B than CD4+ T cells from healthy controls (82 +/- 30 vs. 69 +/- 20 optical density, P = 0.007). Finally, as compared with seven healthy individuals, DNA synthesis in CD4+ T cells from seven CU patients was found to be significantly elevated (1000 +/- 240 vs. 751 +/- 166 counts per minute, P = 0.01).

CONCLUSION

Increased levels of MMP-9 are found in CU patients, and particularly among those with severe disease. We also demonstrated that CD4+ T cells from such patients are highly activated.

The role of pleural fluid-serum gradient of tumor necrosis factor-alpha concentration in discrimination between complicated and uncomplicated parapneumonic effusion

In a previous preliminary study an excess of tumor necrosis factor-alpha (TNF) was found in pleural fluid of patients with complicated parapneumonic effusion (CPPE), and its levels in pleural fluid of these patients were shown to be significantly higher than those in patients with uncomplicated parapneumonic effusion (UCPPE). This larger population study was undertaken to investigate, for the first time, the role of pleural fluid-serum gradient of TNF (TNFgradient) in discrimination between UCPPE and CPPE. Using a commercially available high sensitivity ELISA kit, levels of TNF were measured in serum and pleural fluid of 51 patients with UCPPE and 30 patients with nonempyemic CPPE. The mean +/- SEM values of serum TNF (TNFserum), pleural fluid TNF (TNFpf), and TNFgradient in the UCPPE group were 6.65 +/- 0.48 pg/mL, 10.85 +/- 0.74 pg/mL, and 4.2 +/- 0.38 pg/mL respectively, and in the CPPE group they were 7.59 +/- 0.87 pg/mL, 54.02 +/- 5.43 pg/mL, and 46.43 +/- 5.34 pg/mL, respectively. While no significant difference was found between the two groups regarding levels of TNFserum (p = 0.31), a highly significant difference between these two groups was found regarding levels of TNFpf and TNFgradient (p < 0.0001 for both variables). A significant correlation was found between levels of TNFserum and levels of TNFpf in the UCPPE group (r = 0.89, p < 0.0001), but not in the CPPE group (r = 0.18, p < 0.33). TNFgradient at an optimal cut-off level of 9.0 pg/mL was found to be a good marker for discrimination between UCPPE and CPPE (sensitivity, 96.7%, specificity, 98%, accuracy, 97.5%, and p < 0.0001). In conclusion, levels of TNFpf but not TNFserum are significantly higher in CPPEs than those in UCPPEs where TNFgradient at an optimal cut-off level of 9.0 pg/mL is a good marker for discrimination between UCPPE and CPPE.

Correlation between levels of tumour necrosis factor-alpha and levels of pH, glucose, and lactate dehydrogenase in parapneumonic effusions

OBJECTIVES

This study was undertaken to investigate the correlation, which has not been previously investigated, between levels of tumour necrosis factor-alpha (TNF) and levels of pH, glucose, and lactate dehydrogenase (LDH) in pleural fluid of patients with uncomplicated parapneumonic effusion (UCPPE), and patients with complicated parapneumonic effusion (CPPE).

METHODS

Using a commercially-available high sensitivity ELISA kit, levels of TNF were measured in pleural fluid of patients with UCPPE (n = 23), and CPPE (n = 15), and were compared with levels of pH, glucose, and LDH in these two groups.

RESULTS

The mean +/- SD values of pleural fluid TNF, pH, glucose, and LDH in the UCPPE group were 11.05 +/- 7.65 pg/ml, 7.41 +/- 0.08, 125 +/- 48 mg/dl, and 306 +/- 182 IU/l, respectively. In the CPPE group the values were 56.07 +/- 28.5 pg/ml, 6.82 +/- 0.25, 42 +/- 36 mg/dl, and 2096 +/- 1916 IU/l, respectively. The only significant correlation, which was negative, was found between levels of TNF and pH in the CPPE group (r = -0.62, P = 0.01). Levels of pleural fluid TNF and LDH were significantly higher, and levels of glucose were significantly lower in the CPPE group than in the UCPPE group (P < 0.0001).

CONCLUSIONS

This study demonstrates, for the first time that TNF levels correlate inversely with levels of pH in pleural fluid of patients with CPPE but not of patients with UCPPE. This correlation may, in part, explain the pathophysiology of the pleural complications which occur in the presence of CPPE.

Clinical and laboratory parameters in predicting chronic urticaria duration: a prospective study of 139 patients

BACKGROUND

Despite the disabling nature of chronic urticaria (CU), little is known about the disease's duration or the efficacy of adopting aggressive therapeutic regimens such as cyclosporine A.

OBJECTIVES

The aim of this study was to evaluate whether parameters such as angioedema, autologous serum test, anti-thyroid antibodies, and total IgE could predict both CU duration and severity.

PATIENTS AND METHODS

One hundred and thirty-nine patients suffering from CU were prospectively followed over a 5-year period for disease duration, severity and the presence of angioedema. Also investigated was the association between these clinical parameters and the subsequent detection of autologous serum test, anti-thyroid antibodies, and total IgE.

RESULTS

CU lasted over 1 year in more than 70% of cases and in 14% it still existed after 5 years. Angioedema co-existed or appeared during the course of CU in 40% of patients and was associated with disease duration. Autologous serum test and anti-thyroid antibodies were found positive in 28 and 12% of patients, respectively, compared to none of normal individuals, P = 0.001. CU duration was associated with the presence of both autologous serum test and anti-thyroid antibodies; however, autologous serum test and not anti-thyroid antibodies was found in association with CU severity.

CONCLUSION

We demonstrate for the first time that CU duration is associated with clinical parameters such as severity and angioedema, and with laboratory parameters such as autologous serum test and anti-thyroid antibodies. The ability to predict CU duration may facilitate decisions regarding the possible early initiation of cyclosporine A as a means by which to reduce disease severity and duration.

Decreased level of the cell cycle regulator p27 and increased level of its ubiquitin ligase Skp2 in endometrial carcinoma but not in normal secretory or in hyperstimulated endometrium

p27 is a cyclin-dependent kinase (CDK) inhibitor whose specific late G(1) destruction allows progression of the cell across the G(1)/S boundary. The protein is ubiquitinated by S-phase kinase-interacting protein-2 (Skp2) following its specific phosphorylation, and is subsequently degraded by the 26s proteasome. There is a direct relationship between low level of p27 and rapid proliferation occurring in several benign states and in many malignancies. In the glandular cells of the normal endometrium, the level of p27 is exceedingly low during the proliferative phase, whereas it is markedly increased during the secretory phase. The expression of p27 in endometrial carcinoma is very low but has been found to increase following treatment with progesterone. However, estrogen exposure is considered as a major risk factor in developing endometrial cancer. The implications of the high dose of estrogen and progesterone induced during IVF treatment are still unknown. We have examined the expression of p27 and Skp2 as well as of Ki67 proliferation marker by using endometrial extracts and cells from normal endometrium, from ovarian hyperstimulated patients, and from endometrial carcinoma patients. The expression of p27, Skp2 and Ki67 was found to be similar in both normal secretory endometrium and endometrium from ovarian hyperstimulated patients. In striking contrast, p27 is significantly lower while Skp2 and Ki67 are significantly higher in the endometrial carcinoma and in endometrium from the proliferative phase compared with their normal secretory counterpart tissue.

Serum levels of tumor necrosis factor-alpha correlate with severity of hepatic encephalopathy due to chronic liver failure

BACKGROUND

Several studies have shown that serum levels of tumor necrosis factor-alpha (TNF) are significantly elevated in patients with acute and chronic liver diseases, where these elevations are independent of the etiology of the underlying disease. Serum levels of TNF are significantly higher in patients with cirrhosis than in those without cirrhosis, reaching the highest levels in decompensated cirrhosis. It has also been shown that plasma levels of TNF correlate with the severity of hepatic encephalopathy (HE) in fulminant hepatic failure. However, still there are no published data regarding the relationship between blood levels of TNF and the presence or severity of HE in patients with chronic liver failure.

AIM

The aim of this study is to determine the relationship between serum levels of TNF and clinical grades of HE in patients with liver cirrhosis.

METHODS

Using a commercially available high-sensitivity enzyme-linked immunosorbent assay kit, serum levels of TNF were measured in 74 patients with liver cirrhosis in various clinical grades of HE (grades 0-4).

RESULTS

The mean+/-SEM values of serum levels of TNF at presentation in patients with grade 0 of HE (n=23), grade 1 (n=12), grade 2 (n=14), grade 3 (n=16), and grade 4 (n=9) were 4.50+/-0.46, 9.10+/-1.0, 12.98+/-1.22, 21.51+/-2.63, and 58.26+/-19.7 pg/ml, respectively. A significant positive correlation was found between serum levels of TNF and the severity of HE (P<0.0001).

CONCLUSION

Serum levels of TNF correlate positively with the severity of HE in patients with chronic liver failure.

Patterns of cardiovascular reactivity in disease diagnosis

BACKGROUND

Aberrations of cardiovascular reactivity (CVR), an expression of autonomic function, occur in a number of clinical conditions, but lack specificity for a particular disorder. Recently, a CVR pattern particular to chronic fatigue syndrome was observed.

AIM

To assess whether specific CVR patterns can be described for other clinical conditions.

METHODS

Six groups of patients, matched for age and gender, were evaluated with a shortened head-up tilt test: patients with chronic fatigue syndrome (CFS) (n = 20), non-CFS fatigue (F) (n = 15), neurally-mediated syncope (SY) (n = 21), familial Mediterranean fever (FMF) (n = 17), psoriatic arthritis (PSOR) (n = 19) and healthy subjects (H) (n = 20). A 10-min supine phase was followed by recording 600 cardiac cycles on tilt (5-10 min). Beat-to-beat heart rate (HR) and pulse transit time (PTT) were measured. Results were analysed using conventional statistics, recurrence plot analysis and fractal analysis.

RESULTS

Multivariate analysis evaluated independent predictors of the CVR in each patient group vs. all other groups. Based on these predictors, equations were determined for a linear discriminant score (DS) for each group. The best sensitivities and specificities of the DS, consistent with disease-related phenotypes of CVR, were noted in the following groups: CFS, 90.0% and 60%; SY, 93.3% and 62.5%; FMF, 90.1% and 75.4%, respectively.

DISCUSSION

Pathological disturbances may alter cardiovascular reactivity. Our data support the existence of disease-related CVR phenotypes, with implications for pathogenesis and differential diagnosis.

Quinacrine added to ongoing therapeutic regimens attenuates anticardiolipin antibody production in SLE

The benefit of combining quinacrine (Qn) with hydroxychloroquine (HCQ) in the treatment of systemic lupus erythematosus (SLE) was previously re-evaluated by us. In our current study we observed that, in 11 active SLE patients (SLEDAI score 5-12), the addition of Qn (100 mg/day) to their existing ongoing therapeutic regimens resulted in a significant attenuation of their previously persistent anticardiolipin antibody (aCL) response. This was in comparison with a matched non-Qn treated control group composed of 14 randomly chosen aCL-positive SLE patients with a similar SLEDAI score 6-10. Prior to Qn treatment the therapeutic regimens of 12 months' duration, included in all cases HCQ (400 mg/day), in many cases prednisone (P, 10-20 mg/day) and in some additional cases immunosuppressive drugs. SLEDAI scores and aCL levels were monitored during the entire follow-up period which totaled 24 months in the study group and 15-18 months in the controls. Along with the beneficial effect of the added Qn on SLEDAI scores, aCL disappearance was documented in eight of 11 patients and remained negative during 8-12 months of follow-up (P = 0.004), compared with such a change in only three of 14 non-Qn treated aCL-positive patients (P = 0.18). We conclude that the added Qn treatment to former established therapeutic protocols may eliminate aCL response in SLE patients. Whether this agent's effect is permanent needs further elucidation.

Correlation between polymorphonuclear leukocyte counts and levels of tumor necrosis factor-a in pleural fluid of patients with parapneumonic effusion

High concentrations of tumor necrosis factor-a (TNF), as well as excess of polymorphonuclear leukocytes (PMNs), are present in pleural fluid of patients with complicated parapneumonic effusion (CPPE). Several studies have shown that PMNs are capable of secreting TNF. However, the correlation between levels of TNF and PMN counts in pleural fluid of patients with parapneumonic effusion has not been previously evaluated. This study was undertaken to evaluate this correlation. Using a commercially available high sensitivity ELISA kit, levels of TNF were measured in pleural fluid of patients with UCPPE (n = 22), and CPPE (n = 14), and were compared with PMN count in pleural fluid of these patients. The mean +/- SD values of pleural fluid TNF and PMN count in the UCPPE group the group were 10.15 +/- 6.48 pg/mL and 3,452 +/- 2,878 cells/mm3, respectively, and in the CPPE group the values were 55.51 +/- 29.49 pg/mL and 25,261 +/- 11,733 cells/mm3, respectively. Levels of pleural fluid TNF and PMN counts in the CPPE group were significantly higher than in the UCPPE group (p <0.0001). A significant correlation was found between levels of pleural fluid TNF and PMN counts in the CPPE group (r = 0.57, p = 0.03) and also in the UCPPE group (r = 0.44, p = 0.04). The results of this study indicate that in pleural fluid of patients with UCPPE or CPPE, levels of TNF correlate positively with PMN counts, and PMNs might be an important source of TNF production in pleural fluid of these patients, particularly in those with CPPE.

The head-up tilt test with haemodynamic instability score in diagnosing chronic fatigue syndrome

BACKGROUND

Studying patients with chronic fatigue syndrome (CFS), we have developed a method that uses a head-up tilt test (HUTT) to estimate BP and HR instability during tilt, expressed as a 'haemodynamic instability score' (HIS).

AIM

To assess HIS sensitivity and specificity in the diagnosis of CFS.

DESIGN

Prospective controlled study.

METHODS

Patients with CFS (n=40), non-CFS chronic fatigue (n=73), fibromyalgia (n=41), neurally mediated syncope (n=58), generalized anxiety disorder (n=28), familial Mediterranean fever (n=50), arterial hypertension (n=28), and healthy subjects (n=59) were evaluated with a standardized head-up tilt test (HUTT). The HIS was calculated from blood pressure (BP) and heart rate (HR) changes during the HUTT.

RESULTS

The tilt was prematurely terminated in 22% of CFS patients when postural symptoms occurred and the HIS could not be calculated. In the remainder, the median(IQR) HIS values were: CFS +2.14(4.67), non-CFS fatigue -3.98(5.35), fibromyalgia -2.81(2.62), syncope -3.7(4.36), generalized anxiety disorder -0.21(6.05), healthy controls -2.66(3.14), FMF -5.09(6.41), hypertensives -5.35(2.74) (p<0.0001 vs. CFS in all groups, except for anxiety disorder, p=NS). The sensitivity for CFS at HIS >-0.98 cut-off was 90.3% and the overall specificity was 84.5%.

DISCUSSION

There is a particular dysautonomia in CFS that differs from dysautonomia in other disorders, characterized by HIS >-0.98. The HIS can reinforce the clinician's diagnosis by providing objective criteria for the assessment of CFS, which until now, could only be subjectively inferred.

Assessment of cardiovascular reactivity by fractal and recurrence quantification analysis of heart rate and pulse transit time

Methods used for the assessment of cardiovascular reactivity are flawed by nonlinear dynamics of the cardiovascular responses to stimuli. In an attempt to address this issue, we utilized a short postural challenge, recorded beat-to-beat heart rate (HR) and pulse transit time (PTT), assessed the data by fractal and recurrence quantification analysis, and processed the obtained variables by multivariate statistics. A 10-min supine phase of the head-up tilt test was followed by recording 600 cardiac cycles on tilt, that is, 5-10 min. Three groups of patients were studied, each including 20 subjects matched for age and gender--healthy subjects, patients with essential hypertension (HT), and patients with chronic fatigue syndrome (CFS). The latter group was studied on account of the well-known dysautonomia of CFS patients, which served as contrast against the cardiovascular reactivity of the healthy population. A total of 52 variables of the HR and PTT were determined in each subject. The multivariate model identified the best predictors for the assessment of reactivity of healthy subjects vs CFS. Based on these predictors, the "Fractal & Recurrence Analysis-based Score" (FRAS) was calculated: FRAS=76.2+0.04*HR-supine-DET -12.9*HR-tilt-R/L -0.31*HR-tilt-s.d. -19.27*PTT-tilt-R/L -9.42*PTT-tilt-WAVE. The median values and IQR of FRAS in the groups were: healthy=-1.85 (IQR 1.89), hypertensives=+0.52 (IQR 5.78), and CFS=-24.2 (5.34) (HT vs healthy subjects: P=0.0036; HT vs CFS: P<0.0001). Since the FRAS differed significantly between the three groups, it appears likely that the FRAS may recognize phenotypes of cardiovascular reactivity.

Ki67 antigen and PCNA proliferation markers predict survival in anorectal malignant melanoma

AIMS

To find a possible correlation of Ki67 antigen and proliferating cell nuclear antigen (PCNA) with prognosis in anorectal malignant melanoma.

METHODS AND RESULTS

Thirty patients with anorectal malignant melanoma were studied. The percentage of tumour cells stained for Ki67 and PCNA in paraffin sections was assessed. Mode of treatment (local excision or abdominoperineal resection), depth of tumour invasion, attempt at cure as defined by complete tumour excision and absence of distant metastases at presentation, tumour blood vessel invasion, and tumour necrosis, as well as Ki67 and PCNA, were all correlated with survival. By univariate analysis, PCNA, Ki67, attempt at cure, local excision (and not abdominoperineal resection), and depth of invasion were all significantly associated with longer survival. By multivariate analysis, only PCNA was significantly associated with survival, while Ki67 showed a significant positive correlation with PCNA. With a cut-off point of 40%, patients with lower Ki67 scores showed survival advantage over those with higher Ki67 scores (P=0.0004). With a cut-off point of 80%, patients with lower PCNA scores showed survival advantage over those with higher PCNA scores (P=0.0001). The staining for proliferation markers was also associated with depth of tumour invasion.

CONCLUSIONS

Ki67 and PCNA immunostaining in paraffin sections may be useful for the prediction of survival in patients with anorectal malignant melanoma. Larger studies are needed to confirm our results.

Lipopolysaccharide endotoxemia reduces cell proliferation and decreases enterocyte apopotosis during intestinal adaptation in a rat model of short-bowel syndrome

Sepsis is frequently associated with or complicates short-bowel syndrome (SBS). To investigate the effects of lipopolysaccharide (LPS) endotoxemia on enterocyte proliferation and death via apoptosis in a rat model of SBS, adult male Sprague-Dawley rats were divided into three experimental groups: sham rats underwent bowel transection and reanastomosis; SBS rats underwent 75% small-bowel resection; and SBS-LPS rats underwent 75% bowel resection and were given intraperitoneal injections of LPS 10 mg/kg. Parameters of intestinal adaptation (bowel and mucosal weights, mucosal DNA and protein, villus height, and crypt depth), enterocyte proliferation, and death via apoptosis were determined on day 15 after the operation. Statistical analysis was determined by Student's and ANOVA tests with a P less than 0.05 considered significant. SBS-LPS animals demonstrated a significant decrease (vs SBS rats) in duodenal (20%), jejunal (30%), and ileal (15%) overall weight, duodenal (20%), jejunal (27%), and ileal (18%) mucosal weight, jejunal (20%) and ileal (30%) mucosal DNA, jejunal (29%) and ileal (31%) villus height, and jejunal (14%) and ileal (29%) crypt depth. LPS endotoxemia led to reduced cell proliferation and enterocyte apoptosis compared to untreated SBS animals. Thus, in a rat model of SBS, LPS endotoxemia inhibits intestinal adaptation. A possible mechanism may be decreased cell proliferation. Decreased enterocyte loss via apoptosis may reflect a reduced number of enterocytes. Other mechanisms (necrosis) may be mainly responsible for cell death following LPS injection.

Second trimester abortion by laminaria followed by vaginal misoprostol or intrauterine prostaglandin F2alpha: a randomized trial

Intra-amniotic injection, as well as intravaginal application of prostaglandins, have been used to terminate second trimester pregnancies. There is as yet no consensus as to the most efficient protocol of such late abortions. Our goal was to compare the efficacy of intra-amniotic injection of prostaglandin F2 alpha (PGF2alpha) and intravaginal application of misoprostol in terminating second trimester pregnancies after pretreatment with intracervical laminaria. Women with live fetuses and requesting second trimester abortions were randomized into two groups. Eighteen hours following the insertion of intracervical laminaria, women were treated with either intra-amniotic injection of 40 mg PGF2alpha, or 12 hourly doses (to a maximum of 4 doses) of 200 mcg misoprostol. Fifty women were randomly assigned to each group. Failure to abort within 24 h of initiation of treatment occurred in 6 patients (12%) in the misoprostol group and 14 (28%) of the PGF2alpha group (p = 0.04). Mean time of induction of pharmacologic treatment to abortion was 13.6 h in the misoprostol group and 10.7 h in the PGF2alpha group (p = 0.03). The mean number of analgesic injections given were 0.8 in the misoprostol group and 1.6 in the PGF2alpha group (p = 0.0001). Only the method of abortion was predictive of abortion success and not other variables such as patient age, gestational age, gravidity, or parity. Following intracervical laminaria, vaginal misoprostol has been found to be more effective and less painful, compared with intra-amniotic PGF2alpha, for the termination of second trimester pregnancies with live fetuses.

Peripheral B-cell CD5 expansion and CD81 overexpression and their association with disease severity and autoimmune markers in chronic hepatitis C virus infection

Hepatitis C virus (HCV) infection is associated with immune-mediated abnormalities and B-cell lymphoproliferation evolving to an overt lymphoma. Recently, CD81 was identified as an HCV receptor on B-lymphocytes, providing a mechanism by which B cells are infected and activated by the virus. In addition, expansion of CD5+ B lymphocytes was described to be associated with various non-HCV related autoimmune disorders. Therefore, we studied the possible role of peripheral B cells CD81 and CD5 over-expression in the development of HCV-related autoimmunity and their association with disease severity in chronic HCV infection. Peripheral B cells CD5 expression and mean fluorescence intensity (MFI) of CD81 were determined in 30 HCV-infected patients, 30 healthy controls and 15 patients with hepatitis B virus infection using fluorescence-activated cell scan (FACS). We have also investigated the association between peripheral CD5 and CD81 B-cell over-expression and markers of autoimmunity and disease severity in patients chronically infected by HCV. CD5+ B-cells were increased in chronic HCV infection (23.2 +/- 7.2%) compared with those of healthy controls (15 +/- 5.5%) (P < 0.0001) and chronic HBV infection (19 +/- 3.7%) (P = 0.08). CD81 MFI was significantly higher in HCV-infected compared to HBV-infected patients and healthy controls. Both increased CD81 MFI and CD5+ B-cell expansion were associated with the production of rheumatoid factor and mixed cryoglobulins and positively correlated with HCV viral load and histological activity index. The overexpression of CD81 and the expansion of CD5+ peripheral B-cells in HCV-infected patients may possibly play a role in the development of HCV-associated autoimmunity and lymphoproliferation.

The association of serum matrix metalloproteinases and their tissue inhibitor levels with scleroderma disease severity

OBJECTIVE

Matrix metalloproteinase 3 (MMP-3) is reported to play an important role in the pathogenesis of systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). Studies have also investigated the association of different tissue inhibitors of MMPs (TIMPs) with fibrosis in scleroderma (SSc). The aim of this study was to evaluate the correlation of serum MMP-1, 3 and TIMP-1 with severity and disease specific markers of SSc and RA.

METHODS

Serum MMP-1,3 and TIMP-1 were measured in 42 SSc patients (age range 28-68 yr mean 47 yr) and compared to 29 RA and 30 healthy age- and sex-matched individuals. Elevated values of MMPs and TIMP-1 were defined as those greater than 2 SD above the normal mean. All SSc and RA patients were scored for disease severity.

RESULTS

Serum MMP-1 was significantly elevated in 8/42 (19%) SSc patients (p = 0.01) but only in 2/29 (7%) RA patients (p = 0.2). Whereas MMP-3 levels were elevated in 10/29 (34%) RA patients (p = 0.002), it was elevated in only 5/42 (12%) SSc patients (p = 0.03). TIMP-1 was found elevated in 17/42 (40%) SSc patients (p = 0.001) and in only 4/29 RA patients (with a strong trend towards significance, p = 0.052). We found a significant association between the elevation of both MMPs and TIMP-1 levels, with the severity of SSc. Those who had an increase of more than one MMP and/or TIMP, demonstrated life-threatening major organ involvement such as end stage lung fibrosis, GI aperislasis, and severe cardiacfailure. Contrary to that in SSc, the severity of RA showed some trend of association with MMP-3 only.

CONCLUSION

We confirm previous observations that MMPs and TIMPs may play an important role in various rheumatic diseases. Whereas serum increase of MMP-3 correlated with RA severity, SSc severity was more characterized by the increase of both MMP-1 and TIMP-1. This suggests that the MMPs and TIMPs involved in SSc are different than those playing a role in RA, which may indicate that in SSc they are produced in different locations than in RA.

Cytotoxic phenotype of intra-epithelial lymphocytes in normal and cryptorchid human testicular excurrent ducts

BACKGROUND

Most testicular and epididymal lymphocytes express T-cell markers, but their cytotoxic potential and activation status have not been reported. In this study, distribution of the cytotoxic cells was compared between normal and cryptorchid testes stratified into two groups: the first with complete absence of germ cells [Sertoli cell-only (SCO)] and the second with arrested spermatogenesis (SCA).

METHODS

Immunohistochemistry for the T-lymphocyte marker CD3 and cytotoxic markers CD8, TIA-1 and granzyme B was performed on paraffin-embedded sections.

RESULTS

The number of CD8+ and CD3+ intra-epithelial lymphocytes (IELs) increased distally throughout the normal epididymis. TIA-1 immunostaining revealed that a significant proportion of IELs exhibited cytotoxic potential, whereas granzyme B staining disclosed a subpopulation of activated cytotoxic lymphocytes (CTLs). TIA-1/CD8 and granzyme B/CD8 double immunostaining revealed that the vast majority of TIA-1+ and granzyme B+ cells were CD8+. The proportion of activated granzyme B+ lymphocytes increased distally throughout the normal epididymis. The number of TIA-1+ and granzyme B+ intra-epithelial and stromal lymphocytes was significantly increased in the normal as opposed to the SCO cryptorchid epididymis and proximal vas deferens.

CONCLUSIONS

These results suggest that exposure of the testicular excurrent ducts to spermatozoa or immature germ cells triggers the activation and recruitment of CTLs. Cytotoxic granule effector mechanisms may contribute to the immunological barrier preventing the immune response to spermatozoa in testicular ducts.

Enhanced peripheral T-cell apoptosis in chronic hepatitis C virus infection: association with liver disease severity

BACKGROUND/AIMS

It has been suggested that enhanced T-cell apoptosis in hepatitis C virus (HCV) infection may lead to down-regulation of their cellular immune response, thus contributing to the persistency of HCV infection. In the present study we have investigated the role of bcl-2 and nuclear factor kappa B (NFkappaB) in dexamethasone-induced apoptosis of peripheral T cells in chronic HCV infection.

METHODS

The expression of bcl-2 and NFkappaB in peripheral T cells as well as spontaneous and dexamethasone-induced T-cell apoptosis were studied in HCV-infected patients (n=21), hepatitis B virus (HBV)-infected patients (n=14) and healthy individuals (n=19). These parameters were correlated with markers of autoimmunity and disease severity.

RESULTS

NFkappaB, but not bcl-2 expression, was significantly decreased in the HCV-infected patients. This decrease was associated with the presence of mixed cryoglobulins (MC) and rheumatoid factor and was positively correlated with alanine aminotransferase (ALT) levels and histological activity index (HAI). Both spontaneous and dexamethasone-induced T-cell apoptosis were enhanced in HCV-infected patients; however, only the latter was correlated with the presence of MC, ALT levels and HAI.

CONCLUSIONS

We confirm previous reports that enhanced T-cell apoptosis in HCV infection may play an important role in disease severity. Decreased expression of NFkappaB is important in the development of peripheral T-cell apoptosis, thus contributing to viral persistence and autoimmunity in these patients.

Computer-assisted image analysis of the rat postosteonecrotic remodeled femoral head

Osteonecrosis of rat femoral heads was induced by stripping the periosteum of the neck and cutting the ligamentum teres. The epiphyseal marrow and bone were necrotic on the 5th postoperative day. Specimens obtained 18 and 36 days postoperatively showed fibrous and hematopoietic-fatty tissue in the intertrabecular spaces, osteoclastic bone resorption, osteogenesis, and degeneration of the joint cartilage. Morphometrically, the means of the height-to-length ratios of the control, 6-day, 18-day, and 36-day femoral heads were 0.26, 0.28, 0.48, and 0.29, respectively. The shape factor of the femoral heads of the control rats was higher than 0.81 in 80% of the cases, while those of rats killed on the 6th, 18th, and 36th postoperative day were higher than 0.81 in 65, 60, and 50% of cases, respectively. Statistically, the means of the height-to-length ratios and the values of the shape factors of the femoral heads of the rats killed 18 days postoperatively differed significantly from those of the other three groups of rats. The quantitatively gauged data of the remodeled epiphyses negate the authors' subjective impression concerning early flattening of the femoral heads after surgically produced osteonecrosis.

Hemodynamic instability in chronic fatigue syndrome: indices and diagnostic significance

OBJECTIVES

To evaluate the cardiovascular response to postural challenge in patients with chronic fatigue syndrome (CFS) and to determine whether the degree of instability of the cardiovascular response may aid in diagnosing CFS.

METHODS

Patients with CFS (n = 25) and their age- and gender-matched healthy controls (n = 37), patients with fibromyalgia (n = 30), generalized anxiety disorder (n = 15), and essential hypertension (n = 20) were evaluated with the aid of a standardized tilt test. The blood pressure (BP) and heart rate (HR) were recorded during 10 minutes of recumbence and 30 minutes of head-up tilt. We designated BP changes as the differences between successive BP values and the last recumbent BP. The average and standard deviation (SD) were calculated. Time curves of BP differences were loaded into a computerized image analyzer, and their outline ratios and fractal dimensions were measured. HR changes were determined similarly. The average and SD of the parameters were calculated, and intergroup comparisons were performed.

RESULTS

On multivariate analysis, the independent predictors of CFS patients versus healthy controls were the fractal dimension of absolute values of the systolic BP changes (SYST-FD.abs), the standard deviation of the current values of the systolic BP changes (SYST-SD.cur), and the standard deviation of the current values of the heart rate changes (HR-SD.cur). The following equation was deduced to calculate the hemodynamic instability score (HIS) in the individual patient: HIS = 64.3303 + (SYST-FD.abs x -68.0135) + (SYST-SD.cur x 111.3726) + (HR-SD.cur x 60.4164). The best cutoff differentiating CFS from the healthy controls was -0.98. HIS values >-0.98 were associated with CFS (sensitivity 97%, specificity 97%). The HIS differed significantly between CFS and other groups (P <.0001) except for generalized anxiety disorder. Group averages (SD) of HIS were CFS = +3.72 (5.02), healthy = -4.62 (2.26), fibromyalgia = -3.27 (2.63), hypertension = -5.53 (2.24), and generalized anxiety disorder = +1.08 (5.2).

CONCLUSION

The HIS adds objective criteria confirming the diagnosis of CFS.

Acupuncture versus ondansetron in the prevention of postoperative vomiting. A study of children undergoing dental surgery

This study compares the anti-emetic effect of acupuncture with that of ondansetron and a placebo. Ninety children undergoing dental treatment under general anaesthesia were randomly allocated to one of the three equal groups, to receive acupuncture needle insertion, intravenous ondansetron 0.15 mg x kg(-1) or a placebo. Parental satisfaction scores and the incidence of emetic episodes were recorded. A significant difference was found in the number of patients who vomited and the total number of the emetic episodes when comparing the two treatment groups with the placebo group (p < 0.0001). A significant difference was also found between the treatment groups and the placebo group with respect to parental satisfaction score (p < 0.03). We conclude that traditional Chinese acupuncture is a valid non-pharmacological alternative anti-emetic treatment that can be recommended as a prophylactic technique in children undergoing dental surgery under general anaesthesia.

Neuroendocrine cells along the digestive tract express neuropilin-2

Neuropilin-2 (np-2) is a receptor for semaphorin-3F (sema-3F) and semaphorin-3C (sema-3C). These semaphorins repel tips of growing axons that express np-2. In addition, np-2 functions as a receptor for heparin binding forms of the angiogenic factor vascular endothelial growth factor (VEGF) such as VEGF145 and VEGF165. We report that np-2 is strongly expressed in neuroendocrine cells located all along the human digestive tract. Confocal fluorescent microscopy revealed that np-2 is concentrated in vesicle-like structures located near the nucleus at the basolateral side of these cells. In the colon, the np-2-expressing subpopulation of neuroendocrine cell is almost identical with the serotonin-producing subpopulation of neuroendocrine cells. Gastrointestinal carcinoid tumors are digestive tract tumors that develop from neuroendocrine cells. Interestingly, most of the carcinoid tumors derived from the colon and the appendix did not contain np-2-producing cells. However, some carcinoid tumors derived from the small intestine and stomach did express low levels of np-2 in isolated foci of cells. By contrast, strong serotonin and chromogranin-A expression was observed in all of the carcinoid tumors that were examined. These results suggest that loss of np-2 expression may accompany tumor progression in carcinoid tumors.

Cardiovascular response to upright tilt in fibromyalgia differs from that in chronic fatigue syndrome

OBJECTIVE

To compare the cardiovascular response during postural challenge of patients with fibromyalgia (FM) to those with chronic fatigue syndrome (CFS).

METHODS

Age and sex matched patients were studied, 38 with FM, 30 with CFS, and 37 healthy subjects. Blood pressure (BP) and heart rate (HR) were recorded during 10 min of recumbence and 30 min of head-up tilt. Differences between successive BP values and the last recumbent BP, their average, and standard deviation (SD) were calculated. Time curves of BP differences were analyzed by computer and their outline ratios (OR) and fractal dimensions (FD) were measured. HR differences were determined similarly. Based on the latter measurements, each subject's discriminant score (DS) was computed.

RESULTS

For patients and controls average DS values were: FM: -3.68 (SD 2.7), CFS: 3.72 (SD 5.02), and healthy controls: -4.62 (SD 2.24). DS values differed significantly between FM and CFS (p < 0.0001). Subgroups of FM patients with and without fatigue had comparable DS values.

CONCLUSION

The DS confers numerical expression to the cardiovascular response during postural challenge. DS values in FM were significantly different from DS in CFS, suggesting that homeostatic responses in FM and CFS are dissimilar. This observation challenges the hypothesis that FM and CFS share a common derangement of the stress-response system.

The effect of antiviral therapy on t(14;18) translocation and immunoglobulin gene rearrangement in patients with chronic hepatitis C virus infection

The mechanism of lymphomagenesis of hepatitis C virus (HCV)-related B-cell lymphoma is unknown. Recently, it has been suggested that HCV may induce B-cell clonal proliferation and t(14;18) translocation in patients chronically infected with the virus. Thus, this study investigated the effect of antiviral treatment on immunoglobulin heavy-chain gene (IgH) rearrangement and t(14;18) translocation in HCV infected patients. Twenty-nine patients with chronic HCV infection were studied in whom IgH rearrangement and/or t(14;18) translocation were previously detected. The IgH rearrangement (FR3/JH) and t(14;18) translocation (MBR bcl2-JH) were detected in peripheral blood mononuclear cells by polymerase chain reaction. Fifteen of 29 patients (8 with IgH rearrangement, 6 with t(14;18) translocation, and 1 with both) were treated with either interferon-alpha or by combination therapy with interferon and ribavirin for 6 to 12 months. IgH rearrangement became negative in 7 of 9 treated patients compared with only 1 of 8 of nontreated patients (P <.02). The t(14;18) translocation became negative in 6 of 7 treated patients compared with 1 of 6 nontreated patients (P =.03). Disappearance of IgH rearrangement or t(14;18) translocation was strongly associated with virologic response to treatment. Two t(14;18)+ patients developed B-cell lymphoma during follow-up. Antiviral treatment appears to be effective in eliminating the clonal proliferation of B cells in patients with chronic HCV infection and may prevent the subsequent development of lymphoma. The mechanism can be related to a direct effect of interferon-alpha on the proliferating clone or to an indirect effect by eradicating the antigenic stimulus.

Morphologic and morphometric study of patellar resurfacing with woven carbon filamentous pads

Analysis of retrieved woven carbon filamentous pads, used for resurfacing of the patellar joint surface, disclosed a 4-zonal organizational pattern. Zone 1, facing the articular cavity, was devoid of carbon filaments and consisted of fibrous tissue. Foreign body granulation tissue and fibrous tissue occupied about one-third and approximately 50%-60% of the interfilamentous space in zones 2 and 3, respectively. Carbon filaments formed 2%-9% of zone 2 and 14%-16% of zone 3. An interfacial membrane-like zone 4 separated the carbon filamentous pads from a trabecular bony shell. The bone volume within the latter was approximately 25%. Given that the purpose of articular resurfacing with implants is repopulation of the defect by chondrocytes producing a cartilaginous matrix, the woven carbon filamentous pads did not fulfill this expectation. In an environment of an ongoing foreign body-induced granulomatous reaction, the stem cells permeating the interstices of the woven carbon filamentous pad are apparently incapable of maturing into highly differentiated cells (chondrocytes) synthesizing a highly complex (cartilaginous) matrix.

The biomechamcal and surgical solutions for patella implant in total knee arthroplasty

A basic fault in designs of patella implants that calls for a prompt remedy is the inadequate polyethylene thickness in contact areas. The requirement for thickness of patella implants should be similar to the requirement set up by the FDA in 1993 regarding the tibial implants, that is, a minimal thickness of 8 mm. A solution is presented for the optimal design of the patella implant and for the appropriate surgical technique. The implant's undersurface that fixes to bone is concave and has a 1-cm wide but 5 to 6 mm short central peg that does not risk the integrity of the bone. Fixation of the concave aspect to the convex aspect of the bony patella strongly enhances resistance to medio-lateral and supero-inferior shear forces. The circumferential facet of the implant 8 mm thick assures uniform thickness of the entire implant and assures optimal mechanical properties of the polyethylene. The articulating surface is tailored to conform to the corresponding femoral trochlear groove and condyles. It can be made to fit any femoral component of any knee implant.

Microscopic analysis and significance of vascular architectural complexity in renal cell carcinoma

The objective of this study was to evaluate the utility of measuring microvessel fractal dimension (MFD) as a parameter of architectural microvascular complexity in localized renal cell carcinoma (RCC). Forty-nine patients with low-stage clear cell RCC were assessed in a 9-year follow-up retrospective study. Tumor vessels were visualized with the endothelial marker CD34. Tumor microvessel density (MVD) was measured by computerized morphometry. Fractal analysis of the RCC microvascular network was performed and the MFD was computed in each case. Correlation between tumor vascular parameters, histological grade, extent of tumor necrosis and patient survival were tested by uni- and multivariate analyses. A significant correlation was found between tumor grade and decreased survival (P = 0.04). The extent of macroscopic tumor necrosis also significantly correlated with poor prognosis (P = 0.0001). Survival analysis revealed a significantly higher MVD in patients who survived longer than 5 years as compared with those who died before the end of the 5-year follow-up period (MVD = 10.8 +/- 4.7% versus 6.4 +/- 3.7%; P = 0.03). MVD was also inversely associated with the extent of tumor necrosis (P = 0.03). Microvessel fractal dimension was significantly higher in low- as compared with high-grade tumors (1.55 +/- 0.11 versus 1.45 +/- 0.15; P = 0.03). Survival analysis revealed a significantly higher MFD in those who lived >5 years as compared with those who died earlier (1.56 +/- 0.11 versus 1.46 +/- 0.15; P = 0.02). The MFD was inversely associated with the extent of tumor necrosis (P = 0.01). Multivariate analysis revealed that the MFD was the only significant factor to correlate with tumor necrosis, and that tumor necrosis was the only independent predictor of patient survival. These results indicate that the analysis of MFD as a marker of tumor microvascular complexity may provide important prognostic information as well as novel insight into the biology of tumor angiogenesis.

MIB-1 monoclonal antibody to determine proliferative activity of Ki-67 antigen as an adjunct to the histopathologic differential diagnosis of Spitz nevi

BACKGROUND

The histopathologic differential diagnosis of Spitz nevus (SN) from malignant melanoma (MM) may be difficult.

OBJECTIVE

Our purpose was to determine the staining pattern and usefulness of MIB-1 antibody, which recognizes Ki-67 antigen in formalin-fixed, paraffin-embedded tissue, as an adjunct to the histopathologic differential diagnosis of SN.

METHODS

Twenty-five compound SNs, 27 MMs, and 26 compound nondysplastic melanocytic nevi (MNs) were immunostained with the MIB-1 antibody.

RESULTS

The mean counts of MIB-1--stained tumor cells of the epidermal and dermal components, both alone and together, were significantly lower in SNs and MNs than in MMs (P <.0001). The dermal counts showed the best discriminating power. In addition, the mean dermal/epidermal count ratios for MIB-1 in SNs and MNs (0.25 and 0.23, respectively) were significantly lower than the corresponding ratio (0.94) in MMs (P <.0001).

CONCLUSION

MIB-1-stained tumor cell counts, especially of the dermal component, and dermal/epidermal MIB-1 count ratios may be helpful as an adjunct to the histopathologic differential diagnosis of SN.

The Haemodynamic Instability Score (HIS) for assessment of cardiovascular reactivity in hypertensive and normotensive patients

The normal response to postural challenge is characterised by maintenance of relatively stable blood pressure (BP) and heart rate (HR) after 30 sec to 30 min of head-up tilt. The objective of the present study was to determine the degree of instability of cardiovascular responses to postural challenge in normotensive and hypertensive subjects. In the initial phase of the study, two groups of age and sex-matched subjects were assessed: essential hypertension (n = 20) and healthy (n = 37). The BP and HR were recorded at 5-min intervals during the course of the 10-min supine-30-min head-up tilt test (HUTT). We categorised 'BP-change' as the difference between individual BP measurements during HUTT and the last recumbent BP value, divided by latter value. The average and standard deviation (SD) of the recorded BP changes were calculated, and BP changes were plotted along a time curve. A computerised image analyser then calculated the outline ratio (OR) and fractal dimension (FD) values for each of the curves. An identical process evaluated measurements for HR-changes. BP- and HR-changes were then converted into absolute numbers, and the average, SD, OR, and FD were calculated. A multivariate analysis was conducted, evaluating independent predictors of hypertension. Finally, an equation for the calculation of 'haemodynamic instability score' (HIS) was deduced and a cut-off between HIS of hypertensive and normotensive subjects was established. Independent predictors of the cardiovascular response to postural challenge of hypertensives (Group I) vs healthy (Group II) were: a.DIAST-FD, a.HR-AVG, a.HR-SD, a.HR-FD, DIAS-SD and HR-SD and HR-SD. Based on these five predictors, a linear discriminant score was computed and called the Haemodynamic Instability Score (HIS): HIS = 59.4 + (-16.6*a.DIAST-FD) + (-29.0*a.HR-AVG) + (-82.4*a.HR-SD) + (-30.1*a.HR-FD) + (-57.9*DIAS-SD) + (73.4*HR-SD) The HIS values in Group I (hypertensives) were: avg = 3.348, SD = 2.863, and 95% CI for mean = 2.008, 4.688. The HIS values in Group II (healthy) were: avg = -3.394, SD = 2.435, 95% CI for mean = -4.206, -2.582. Values of the HIS > -2.09 were generally observed in hypertensives (sensitivity 95%) and values < or = -2.09 were usually seen in the healthy (specificity 81.1%). The HIS was cross-validated in an additional group of hypertensive patients (n = 73). In the latter group, the HIS values were: avg = -0.456, SD = 4.403, 95% CI for mean = -1.506, 0.593 and 71.4% sensitivity at the proposed cut-off point. In conclusion, the HIS confers numerical expression to the degree of lability of BP and HR during postural challenge. Based on this score, a distinction between the cardiovascular reactivity of hypertensives vs normotensives is drawn. Possible applications of HIS are discussed.

Histomorphometric analysis of the normal adult patella

The patellae of 6 male and 2 female, 40 to 70 year-old individuals, who were healthy at the time of their violent death, were assessed by computer-assisted image analysis. The means of the bone density (percentage of bone in the respective field of interest) ranged from approximately 20% to approximately 30% in the central spongiotic zones, from approximately 40% to approximately 80% in the superior and inferior peripheral zones, and approximately 40% to approximately 60% in the subchondral zone. Bone densities were greatest in the lateral parts of the subchondral and spongiotic territories. The bony trabeculae were haphazardly distributed in the central spongiotic zones. They were commonly oriented vertically or parallel to the surface of the patella in the peripheral and subchondral zones. In conclusion, the histomorphometric data presented validate the rationale of reaming the articular aspect of the patella into a dome-shaped configuration with preservation of a circumferential bony bulwark in the preparation for the implantation of a thick polyethylene-based component with a concave undersurface.

bcl-2 and immunoglobulin gene rearrangement in patients with hepatitis C virus infection

An association between chronic hepatitis C virus (HCV) infection and clonal proliferation of B cells, including B cell lymphoma, has recently been demonstrated. However, the mechanism of malignant transformation is still unknown. It has been shown that B cells from patients with type II mixed cryoglobulinaemia (MC), strongly express the antiapoptotic bcl-2 oncogene product. Therefore, we investigated a possible mechanism of lymphomagenesis, the occurrence of bcl-2 and immunoglobulin gene rearrangement (IgH) in HCV-infected patients. Three groups of patients were studied: (1) 44 patients with HCV and MC (anti-HCV and HCV RNA positive); (2) 59 patients with chronic HCV infection without MC; (3) 50 patients with chronic liver disease (CLD) not related to HCV infection. The t(14;18) translocation (MBR bcl-2-JH) and IgH rearrangement (FR3/JH) were detected by polymerase chain reaction (PCR) in peripheral mononuclear cells. bcl-2 translocation was detected in 17/44 (39%), 7/59 (12%) and in none of the patients of groups 1, 2 and 3 respectively (P < 0.01). Monoclonal IgH rearrangement was detected in 15/44 (34%), 5/59 (8.5%) and 2/50 (4%) patients of groups 1, 2 and 3 respectively (P < 0.05). HCV-infected patients had a higher prevalence of monoclonal IgH rearrangement and bcl-2 translocation than patients with CLD of other aetiologies. These data suggest that HCV may play a role in the multistep mechanism of lymphomagenesis by inducing clonal proliferation of B cells and inhibition of apoptosis.

Prognostic score for patients with localized renal cell carcinoma treated by nephrectomy

OBJECTIVE

To evaluate the feasibility of using combined clinical and histomorphometric features to construct a prognostic score for the individual patient with localized renal cell carcinoma.

PATIENTS AND METHODS

We studied 39 patients with pT1 and pT2 RCC who underwent radical nephrectomy between 1974 and 1983. Univariate and multivariate analyses were used to determine the association between various prognostic features and patient survival.

RESULTS

The most important and independent predictors of survival were tumor angiogenesis (P = 0.009), nuclear DNA ploidy (P = 0.0071), mean nuclear area (P = 0.013), and mean elongation factor (P = 0.0346). Combination of these variables enabled prediction of outcome for the individual patient at a sensitivity and specificity of 78% and 89%, respectively.

CONCLUSION

Our results indicate that no single parameter can accurately predict the outcome for patients with localized RCC. Combination of neovascularity, DNA content and morphometric shape descriptors enabled a more precise stratification of the patients into different risk categories.