Spinal Stenosis in Familial Transthyretin Amyloidosis

Here we describe a patient with genetically confirmed ATTR, a family history of the disease and histological confirmation following carpal tunnel release surgery but no other manifestations. The first major neurological or systemic manifestation was cauda equina syndrome with ATTR deposits contributing to lumbar spinal stenosis. Recent gene therapy trials showed improvement in the neuropathy in TTR amyloidosis. This case highlights the need for awareness of the heterogeneous neurological phenotype seen in ATTR to aid earlier diagnosis especially now that disease modifying therapies are available.

[Anatomic pathology workflow. IHE: modeling based on current developments in HL7 and DICOM]

AIMS

Consistent and complete information is essential for medical decision making. Anatomic pathology as a diagnostic discipline has a central role in the exchange of information between clinical departments throughout the diagnostic process. The IHE (Integrating the Healthcare Enterprise) has created an integration profile for information systems based on HL7 and DICOM standards.

METHODS

Created by the IHE Anatomic Pathology working group, the integration profile (so-called Technical Framework) ensures the consistent management of data and material in the pathology laboratory information system (PLIS). HL7 and DICOM standards are taken into account. Communication processes both within and outside the institute are modelled using eight actors and 13 transactions.

RESULTS

The IHE's Technical Framework covers basic business processes, provision of diagnostic services and includes requesting examinations, as well as image and report management. In particular, a consistent data model for incoming material, containers, cartridges and slides has been developed and approved by the standards committee.

Organ transplantation in hereditary apolipoprotein AI amyloidosis

Patients with hereditary apolipoprotein AI (apoAI) amyloidosis often have extensive visceral amyloid deposits, and many develop end-stage renal failure as young adults. Solid organ transplantation to replace failing organ function in systemic amyloidosis is controversial due to the multisystem and progressive nature of the disease and the risk of recurrence of amyloid in the graft. We report the outcome of solid organ transplantation, including dual transplants in 4 cases, among 10 patients with apoAI amyloidosis who were followed for a median (range) of 16 (4-28) and 9 (0.2-27) years from diagnosis of amyloidosis and transplantation, respectively. Eight of 10 patients were alive, seven with a functioning graft at censor. Two patients died, one of disseminated cytomegalovirus infection 2 months after renal transplantation and the other of multisystem failure following severe trauma more than 13 years after renal transplantation. The renal transplant of one patient failed due to recurrence of amyloid after 25 years. Amyloid disease progression was very slow and the natural history of the condition was favorably altered in both cases in which the liver was transplanted. Failing organs in hereditary apoAI amyloidosis should be replaced since graft survival is excellent and confers substantial survival benefit.

Microarray data mining using gene ontology

DNA microarray technology allows scientists to study the expression of thousands of genes--potentially entire genomes--simultaneously. However the large number of genes, variety of statistical methods employed and the complexity of biologic systems complicate analysis of microarray results. We have developed a web based environment that simplifies the presentation of microarray results by combining microarray results processed for statistical significance with probe set annotation by Genbank, NCBI RefSeqs, GeneCards and the Gene Ontology. This allows rapid examination and classification of microarray experiments--annotated by NCIBI tools --by Statistical Significance and Gene Oncology Classes. By providing a simple, easily understood interface to large microarray data sets, this tool has been particularly useful for small research groups focused on a small number of related genes and for researchers who want to ask simple questions without the overhead of complex data management and analysis.

mu-Bis(diphenylphosphino)methane-P:P'-octacarbonyldimanganese(Mn-Mn) and its toluene hemisolvate

The Mn-Mn bonds in the two independent molecules of the unsolvated title compound, [Mn(2)(C(25)H(22)P(2))(CO)(8)], (I), are 2.9714 (7) and 2.9746 (7) A. This bond is distinctly shortened in the toluene hemisolvate, [Mn(2)(C(25)H(22)P(2))(CO)(8)] x 0.5C(7)H(8), (II), to 2.9338 (14) A and this shortening is accompanied by an increase in magnitude of the P-Mn-Mn-P torsion angle [26.93 (3) and 28.44 (3) degrees in (I), and 33.25 (7) degrees in (II)], while the P...P 'bite' is much less affected [3.092 (2) and 3.099 (2) A in (I), and 3.091 (3) A in (II)]. The toluene solvate molecule in (II) lies on a twofold axis.

Prototype Web-based continuing medical education using FlashPix images

Continuing Medical Education (CME) is a requirement among practicing physicians to promote continuous enhancement of clinical knowledge to reflect new developments in medical care. Previous research has harnessed the Web to disseminate complete pathology CME case studies including history, images, diagnoses, and discussions to the medical community. Users submit real-time diagnoses and receive instantaneous feedback, eliminating the need for hard copies of case material and case evaluation forms. This project extends the Web-based CME paradigm with the incorporation of multi-resolution FlashPix images and an intuitive, interactive user interface. The FlashPix file format combines a high-resolution version of an image with a hierarchy of several lower resolution copies, providing real-time magnification via a single image file. The Web interface was designed specifically to simulate microscopic analysis, using the latest Javascript, Java and Common Gateway Interface tools. As the project progresses to the evaluation stage, it is hoped that this active learning format will provide a practical and efficacious environment for continuing medical education with additional application potential in classroom demonstrations, proficiency testing, and telepathology. Using Microsoft Internet Explorer 4.0 and above, the working prototype Web-based CME environment is accessible at http://telepathology.upmc.edu/WebInterface/NewInterface/welcome.html.

Pathology imaging on the Web. Extending the role of the pathologist as educator to patients

The increasing role of patients in medical decision making and the growing availability of medical information are changing the physician-patient relationship. One aspect of this change is that patients are searching for medical information on the Internet and are visiting sites, including pathology sites, that were not originally intended for patient use. This article describes evidence for this activity and how the University of Pittsburgh Medical Center Department of Pathology has evolved mechanisms to handle patient use of its web site.

Carotid artery tandem lesions: frequency of angiographic detection and consequences for endarterectomy

BACKGROUND AND PURPOSE

Several prospective trials have shown that ischemic stroke can be prevented by performing an endarterectomy in patients with high-grade carotid stenosis. Our purpose was to ascertain the frequency of carotid artery tandem lesions and to determine whether their presence alters the surgeon's decision to perform an endarterectomy.

METHODS

We retrospectively reviewed the cerebral angiograms obtained between January 1994 and June 1996 in 853 patients with carotid occlusive disease. Studies were analyzed for the presence of internal carotid artery (ICA) stenosis as well as for tandem lesions (defined as > or = 50% diameter stenosis) within the common carotid artery, carotid siphon, or proximal intracranial arteries. The frequency of intracranial saccular aneurysms was determined.

RESULTS

Six hundred seventy-two of the 853 patients had a carotid bifurcation stenosis of 70% or greater or underwent an endarterectomy. Of these, a carotid siphon stenosis of 50% or greater was noted in 65 patients (9.7%) and was ipsilateral to an ICA stenosis in 37 patients (5.5%). A common carotid stenosis was present in 29 patients (4.3%), ipsilateral to an ICA stenosis in 14 patients (2.1%). A stenosis of 50% or greater within the proximal intracranial circulation was present in 28 patients (4.2%), ipsilateral to an ICA stenosis in 15 patients (2.2 %). Four patients had tandem stenoses at more than one site. Tandem stenoses in the siphon or intracranial segments were noted in 13.5% with a bifurcation stenosis and in 8.8% of those with no bifurcation stenosis. Endarterectomy was performed in 48 of the 66 patients with tandem stenotic lesions.

CONCLUSION

The presence of a tandem lesion infrequently alters the surgeon's decision to perform an endarterectomy. However, the importance of detecting tandem stenoses cannot be underestimated, since they may have important implications for long-term medical management in symptomatic patients.

Continuing medical education on the World Wide Web (WWW). Interactive pathology case studies on the Internet

OBJECTIVE

To present interactive online continuing medical education (CME) over the World Wide Web as a more efficient alternative to traditional modes of CME delivery.

DESIGN

A departmental Web site available to those with access to the Internet.

SETTING

A tertiary-care teaching hospital in the United States.

RESULTS

Comprehensive case studies have been developed and are complete with images, text, and questions, including explanations for correct and incorrect responses. The images are linked to pertinent text to maximize their educational value. The cases are easily accessible, user friendly, and fully referenced. The system became operational in January 1996, and the first CME certificate was awarded to a participant shortly thereafter.

CONCLUSIONS

Continuing medical education over the World Wide Web is an efficient means of delivering CME to the community at large; it allows participating physicians the latitude to obtain convenient CME credit at their leisure, in contrast to the regimented experience of formal CME conferences or symposiums. The interactive format of the CME cases allows the participant to submit immediate comments or criticism to case authors and receive instant feedback on their own performance, features unavailable in comparable educational software packages. The dynamic environment of the World Wide Web lends itself to the production and dissemination of such flexible forms of CME for the physician and will continue to expand in this capacity into the foreseeable future.

Expression of heat shock proteins in chronic pancreatitis: protective or pathogenic roles?

The tissue-distributions of heat shock proteins (HSP) identified by monoclonal antibodies ML-30, TB-78, CA-Str7-1, and MAB 72/73 have been examined in formalin-fixed and paraffin wax-embedded tissues from 10 normal pancreatic specimens and 92 cases of chronic pancreatitis. The chronic pancreatitis cases were divided by probable etiology into alcohol-related, postacute pancreatitis, or idiopathic. The HSP identified by ML-30 and CA-Str7-1 were constitutively expressed, with a regional distribution, by duct and ductular epithelial cells in all normal pancreatic tissues. The HSP detected by ML-30 were expressed uniformly throughout the cytoplasm of the majority of ductular epithelial cells in all cases of chronic pancreatitis, irrespective of suspected etiology, and in the ducts of all but two cases of alcohol-associated chronic pancreatitis. The HSP defined by CA-Str7-1 were identified in the majority of duct or ductular epithelial cells in most of the cases of chronic pancreatitis, although possible differential expression was observed with respect to etiology (ie, there seemed to be less HSP in cases of postalcohol pancreatitis). The HSP identified by TB-78 were not constitutively expressed by normal pancreatic tissues but were found in a few scattered epithelial cells in two of these cases. However, significant expression of these HSP were observed in most epithelial cells in a population of cases regarded as either alcohol-associated (0.05 > p > 0.02) or postacute chronic pancreatitis (0.01 > p > 0.001). The HSP identified by monoclonal antibody MAB 72/73 were either not demonstrable or were expressed at very low levels in both the normal and inflamed pancreatic tissues. Expression of the four groups of HSP molecules appeared to be differentially regulated both in normal pancreatic and in chronic pancreatitis tissues. These differences in expression may indicate different functions in normal tissues, with either a protective or a pathogenic role for these proteins in the diseased state. Our current findings support the hypothesis that expression of certain HSP, particularly those identified by TB-78, may be involved in the pathogenesis of distinct subtypes of chronic pancreatitis. Our data do not suggest that HSP are the primary targets of immune-mediated cytotoxic activity; nevertheless, enhanced expression of these molecules by pancreatic ductular epithelial cells does provide an environment in which increased amounts of endogenous intracellular peptides may be transported to the cell surface, thereby becoming potential targets of immune-surveillance and cell-mediated cytotoxicity. Conversely, HSP may play a protective role in such a manner that selected groups of pancreatic ductular epithelial cells withstand cytotoxic damage of chemical, metabolic, or immune origin, and for significantly increased periods of time than they would otherwise; HSP thereby conserve a population of "reserve" epithelial cells from which pancreatic regeneration might occur. Identification of distinct pathogenic groups, defined according to precise immunohistochemical criteria, might provide the basis of a functional assessment and hence allow development of biologically appropriate strategies for managing individual patients with chronic pancreatitis.

The Pittsburgh Reference Laboratory Alliance: a model for laboratory medicine in the 21st century

The Pittsburgh Reference Library Alliance (RLA) represents a successful response by hospital laboratories to the new realities of medical economics and practice. By using informatics technology to integrate the laboratory resources of community hospitals and academic medical centers across western Pennsylvania, the RLA has created a large virtual laboratory that can compete for price with large national referral laboratories. More significantly, the combination of medical expertise, the ties to academic and community centers, and the regional medical database of the RLAs allows laboratory medicine to be practiced in a new proactive way. This should provide better and more cost-effective patient care. The success of the RLA is a model for regional cooperation in pathology and potentially in other medical specialties and demonstrates the importance of informatics in the future of medical practice.

Timing of growth hormone injections and reproduction in gilts

Sixty-eight Yorkshire × Landrace gilts were selected at 85 kg body weight (BW) and exposed to a mature boar for 20 min d−1 to detect puberty. At the onset of puberty, gilts were allocated to receive daily intramuscular injections of porcine growth hormone (pGH, 90 μg kg−1 BW) from either 14 to 17 d (GH17, n = 22) or from 14 to 22 d (GH22 n = 22) after puberty, inclusively. A third group of gilts served as controls (n = 24) and received vehicle buffer. A single blood sample was obtained from each gilt on days 14, 17 and 20. Also, four gilts from each pGH treatment and eight control gilts were sampled at 15-min intervals for 8 h on day 16. Gilts were slaughtered 30 d after puberty at which time their ovaries were recovered for the determination of ovulation rate. Injection of pGH resulted in elevated serum concentrations of triiodothyronine, insulin and glucose (P < 0.01). There was no significant (P > 0.1) treatment effect on mean serum concentrations of LH or FSH. However, pGH treatment tended (P = 0.1) to increase LH pulse frequency and to decrease (P = 0.01) LH pulse amplitude. The incidence of a second estrus was reduced (P < 0.01) in GH22 compared to control gilts, with GH17 being intermediate (72.7 vs. 90.9 vs. 100% for GH22, GH17 and control gilts, respectively). Ovulation rate was not affected by pGH treatment (15.1 vs. 14.3 vs 14 0 for GH22, GH17 and control gilts, respectively). The present data confirm an adverse effect of pGH on ovarian function and suggest that an altered LH pulsatility may be involved. Key words: Gilts, growth hormone, estrus, endocrinology

Multiple K-ras codon 12 mutations in cholangiocarcinomas demonstrated with a sensitive polymerase chain reaction technique

By using a modified polymerase chain reaction strategy, we have devised an approach to detect a K-ras oncogene mutated at codon 12 in the presence of 1000 normal alleles. This is a considerable improvement in sensitivity on previous assays. Application of this assay to 15 cholangiocarcinomas showed that all contained a K-ras mutation to codon 12 and that nine of the tumors contained two or more mutations. In 11 cases, mutations were present in less than 10% of the cells in the sample. In common with pancreatic adenocarcinomas, in which 75 to 95% of cases contain a mutation in K-ras, cholangiocarcinomas show a very high frequency of ras gene mutation, but within a tumor only a fraction of cells contain a ras mutation. The presence of multiple mutations and the low frequency of mutant alleles in the samples argue against K-ras mutations being the initiating genetic lesion in this tumor, but suggest that ras gene mutation is involved in the stepwise progression of neoplastic cells to full malignancy.

Effects of the synthetic glucocorticoid betamethasone on the survival of neurons in fetal rabbit brain cell culture

Dissociated fetal rabbit brain cells were grown on petri dishes coated with collagen. Culture medium consisted of Dulbecco's Modified Eagles Medium plus 10% serum. The mitotic inhibitor 1-beta-D-arabinofuranosylcytosine was added at 6 days for a 2 day period to inhibit over-growth by glial cells and fibroblasts. In some cases cultures were chronically exposed to 0.5, 1.0 or 2.0 microM betamethasone. Examination of cultures by phase microscopy and acetylcholinesterase (AChE) staining demonstrated that cultures incubated with 1.0 and 2.0 microM betamethasone contained 2-2.5 times as many neurons as compared to control cultures. Furthermore, there was an increase in the specific activities of both AChE and choline acetyltransferase (ChAT) which were proportional to the increase in neuronal cell numbers obtained from phase microscopy and AChE staining. These results suggested that betamethasone enhanced survival of cholinergic neurons. Cultures were also examined for neuron specific gamma-aminobutyric acid (GABA) uptake. Again GABA uptake was approximately 2-2.5 times as great in cultures incubated with 1-2 microM betamethasone when compared to controls. Thus, the increase in GABA uptake paralleled the increase in neurons observed by phase microscopy and AChE staining, suggesting that the survival effect of betamethasone was not specific to cholinergic neurons. While betamethasone treated cultures always contained greater numbers of neurons the percentage of neurons lost from all cultures after 2 weeks was the same.(ABSTRACT TRUNCATED AT 250 WORDS)