In utero Exposure to Anesthetics Alters Neuronal Migration Pattern in Developing Cerebral Cortex and Causes Postnatal Behavioral Deficits in Rats

During fetal development, cerebral cortical neurons are generated in the proliferative zone along the ventricles and then migrate to their final positions. To examine the impact of in utero exposure to anesthetics on neuronal migration, we injected pregnant rats with bromodeoxyuridine to label fetal neurons generated at embryonic Day (E) 17 and then randomized these rats to 9 different groups receiving 3 different means of anesthesia (oxygen/control, propofol, isoflurane) for 3 exposure durations (20, 50, 120 min). Histological analysis of brains from 54 pups revealed that significant number of neurons in anesthetized animals failed to acquire their correct cortical position and remained dispersed within inappropriate cortical layers and/or adjacent white matter. Behavioral testing of 86 littermates pointed to abnormalities that correspond to the aberrations in the brain areas that are specifically developing during the E17. In the second set of experiments, fetal brains exposed to isoflurane at E16 had diminished expression of the reelin and glutamic acid decarboxylase 67, proteins critical for neuronal migration. Together, these results call for cautious use of anesthetics during the neuronal migration period in pregnancy and more comprehensive investigation of neurodevelopmental consequences for the fetus and possible consequences later in life.

Abstract P1-14-01: Building an experience engine to make cancer treatment decisions using machine learning

Introduction: Experts at tertiary care centers provide solutions to complex cases not addressed by high quality evidence. They intuitively retrieve patterns from years of experience to make treatment decisions. Short of personal consultations, there is no way to access this vast “experience database.” Experience Engine (XE) is a machine learning solution to structure experiential knowledge relevant for decision making, derive a similarity metric for patients who have received similar treatments, and predict treatment decisions that experts are likely to recommend.

Methods: 277 patient histories relating to 743 breast cancer tumor board decisions at two tertiary care centers were abstracted as the training set for machine learning. 161 distinct histories relating to 496 decisions for a separate expert opinion service at one of the centers was the holdout test set. Data was structured into 690 features based on a novel ontology designed specifically for breast cancer decision making.

To uncover nonlinear similarities, (for example, treatments for younger patients with multiple comorbidities and elderly patients may be similar), treatment decisions were grouped by timing and modality into 13 groups, such as primary surgery, 1st line palliative chemotherapy, etc.

Similarity metric was derived using machine learning on the training set. The target for prediction was the specific treatment decision i.e. TAC or another adjuvant regimen. The primary endpoint was percent accuracy of agreement between XE's predicted decision and experts' actual decision in the holdout test set. Multiple similarity distance metrics including Bhattacharya, Eskin, Goodall, etc., and multiclass classification algorithms such as Extreme Gradient Boosted Trees, Support Vector Machines, etc., were systematically evaluated to arrive at the algorithms that best fit each treatment group.

Results: The winning XE algorithms were 71% to 89% accurate for the various treatment groups, in predicting the actual treatment decisions recommended by the experts. The most frequent treatments recommended across all groups were standard evidence based therapies, as are often recommended by experts. For instance, when XE recommended standard adjuvant therapies for Her2- patients, it was 88% to 97% accurate. When XE recommended nonstandard therapies for the same treatment group, it was 72% to 90% accurate, related to larger number of nonstandard therapies within each treatment group and smaller samples of patients who underwent each type of nonstandard therapy. XE learned to weigh features relating to comorbidities and toxicities when recommending nonstandard therapies.

Conclusion: Machine learning on a structured database of past treatment decisions made by experts, can yield a predicted treatment decision that an expert is likely to recommend for a new patient. By including complex decisions that consider toxicities and morbidities, a rich source of knowledge can be created. Despite the limited dataset, XE learned features that experts strongly consider when making decisions. XE has the potential to analyze variations in decision making at expert practices, assess when to recommend nonstandard therapies, and serve as a training tool for new oncologists to make expert grade treatment decisions.

Citation Format: Ramarajan N, Gupta S, Perry P, Srivastava G, Kumbla A, Miller J, Feldman N, Nair N, Badwe RA. Building an experience engine to make cancer treatment decisions using machine learning [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-14-01.

The Pituitary and Prostate: An Endocrine Connection

A 61 year old gentleman presented with polyuria and polydipsia in the absence of diabetes mellitus. This case presentation highlights the diagnostic challenges and surprises in the evaluation of polyuria and polydipsia.

The Emerging Risk Factors Collaboration: analysis of individual data on lipid, inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.

Reprogramming of root epidermal cells in response to nutrient deficiency

Post-embryonic development of the root system is highly plastic to environmental cues, compensating for the sessile lifestyle of plants. The fate of epidermal cells of Arabidopsis roots is particularly responsive to nutritional signals, leading to an increase in the root's surface area in the absence of the essential but immobile minerals iron, phosphate and manganese. The resulting phenotype is characteristic of the respective condition. Growth under nutrient starvation affects the expression of genes involved in cell specification, indicating that environmental signals are perceived at an early stage of cell development. Cell fate decisions are controlled at different levels, probably integrated at the level of chromatin organization.

Functional interaction between E-cadherin and alphav-containing integrins in carcinoma cells

We have demonstrated the possibility of cross-talk between E-cadherin and alphav integrins in breast carcinoma cells. Using the function-blocking anti-alphav monoclonal antibody 17E6, applied to monolayer cultures of breast cancer lines, it was found that treatment of cells possessing detergent-insoluble (implying attachment to the actin cytoskeleton) E-cadherin resulted in the adoption of a spheroid configuration of cell growth. This effect was dependent upon not just alphav occupancy but also receptor aggregation. Thus in vitro alphav-dependent adhesion suppresses E-cadherin-mediated morphological changes. To investigate whether manipulation of E-cadherin would, conversely, modulate integrin activity we introduced a dominant-negative E-cadherin construct into one of the lines, ZR75-1, giving rise to the cell line ZR-E2R1. Surface expression of endogenous E-cadherin was downregulated (by around 25%), whereas beta-catenin levels were increased two- to threefold in ZR-E2R1 cells. There was also a highly significant increase in migration of ZR-E2R1 cells (relative to control cells) toward vitronectin (P<0.001), but not toward collagen type I, fibronectin or laminin. Such increased migration could be abrogated totally by antibody blockade of alphavbeta5 and alphavbeta1 integrins. There was no detectable change in alphav integrin levels. These data suggest that the introduction of a dominant-negative E-cadherin mutant into ZR75-1, in addition to a loss of cohesion, generates a signal (or signals) which increases migration towards vitronectin through increased activity of alphav integrins.

Differences in the localization and morphology of chromosomes in the human nucleus

Using fluorescence in situ hybridization we show striking differences in nuclear position, chromosome morphology, and interactions with nuclear substructure for human chromosomes 18 and 19. Human chromosome 19 is shown to adopt a more internal position in the nucleus than chromosome 18 and to be more extensively associated with the nuclear matrix. The more peripheral localization of chromosome 18 is established early in the cell cycle and is maintained thereafter. We show that the preferential localization of chromosomes 18 and 19 in the nucleus is reflected in the orientation of translocation chromosomes in the nucleus. Lastly, we show that the inhibition of transcription can have gross, but reversible, effects on chromosome architecture. Our data demonstrate that the distribution of genomic sequences between chromosomes has implications for nuclear structure and we discuss our findings in relation to a model of the human nucleus that is functionally compartmentalized.

Identification and characterization of a homozygous deletion found in ovarian ascites by representational difference analysis

We have performed representational difference analysis (RDA) on DNA from tumor cells and normal fibroblasts isolated from the ascites of a patient with ovarian cancer. Five of six products of the RDA were homozygously deleted from the tumor DNA. One of these products has been characterized and identifies a homozygous deletion of approximately 6.9 Mb at chromosome 9p21 in the original ovarian tumor material. This deletion encompasses CDKN2A (p16), CDKN2B (p15), and IFN-alpha. PCR analysis of other tumor cell lines using the novel STS based on the RDA product has shown it to lie between IFN-alpha and p16, and to identify the distal extent of a homozygous deletion in another ovarian cancer cell line. These data provide further evidence for a tumor suppressor locus distinct from, but mapping close to, p16 on 9p21. Cytogenetic analysis using comparative genomic hybridization (CGH) performed on the same primary tumor confirmed a loss of material from chromosome 9p. However, the CGH technique had neither the resolution nor the sensitivity to define a subregion of homozygous loss.

Localization of the 26S proteasome during mitosis and meiosis in fission yeast

The 26S proteasome is a large multisubunit complex involved in degrading both cytoplasmic and nuclear proteins. We have investigated the localization of this complex in the fission yeast, Schizosaccharomyces pombe. Immunofluorescence microscopy shows a striking localization pattern whereby the proteasome is found predominantly at the nuclear periphery, both in interphase and throughout mitosis. Electron microscopic analysis revealed a concentration of label near the inner side of the nuclear envelope. The localization of green fluorescent protein (GFP)-tagged 26S proteasomes was analyzed in live cells during mitosis and meiosis. Throughout mitosis the proteasome remained predominantly at the nuclear periphery. During meiosis the proteasome was found to undergo dramatic changes in its localization. Throughout the first meiotic division, the signal is more dispersed over the nucleus. During meiosis II, there was a dramatic re-localization, and the signal became restricted to the area between the separating DNA until the end of meiosis when the signal dispersed before returning to the nuclear periphery during spore formation. These findings strongly imply that the nuclear periphery is a major site of protein degradation in fission yeast both in interphase and throughout mitosis. Furthermore they raise interesting questions as to the spatial organization of protein degradation during meiosis.

An outcome evaluation of a hospital-based early intervention program

AIM

To determine the effectiveness of the Health Care Intervention Service (HIS), an early intervention program for general hospital patients with alcohol dependence or at risk for alcohol dependence.

DESIGN, SETTING AND PARTICIPANTS

HIS consists of screening, assessment and assignment to either full or risk-reduction intervention. Full intervention includes a referral to treatment. Outcomes were compared across three groups: those who received a full intervention, those who received a risk-reduction intervention, and a comparison group of similar patients from hospitals with no HIS program. Patients were screened for alcohol involvement and interviewed during their hospitalization (prior to the intervention in HIS hospitals) and again 6 months following the intervention.

FINDINGS

Full intervention was effective in increasing the probability of abstinence, reducing the number of heavy drinking days, and encouraging patients to accept the referral to treatment. Risk-reduction intervention was effective in reducing alcohol consumption and consequences, but only for those patients who had some signs of dependence at the first interview.

CONCLUSIONS

HIS has demonstrated its effectiveness in a "real world" bureaucratic and clinical environment.

Scaffold attachments within the human genome

It is generally agreed that, above the level of the 30 nm fibre, eukaryotic chromatin is constrained into loops, but there is disagreement about the nature of the substructure that serves to anchor loops and the DNA sequences that act as the attachment sites. This problem may stem from the very different methods that all purport to separate loop and attached DNAs. We have tested ideas about how the genome is arranged into loops by analysing the average loop size over different cytologically resolvable regions of human chromosomes using fluorescence in situ hybridisation with loop and attached DNA fractions. Variations in average loop size, along and between chromosomes, measurable at this level of resolution were small but significant and were dependent on the extraction method. This emphasises the fundamental differences between the nuclear substructure probed by different protocols. DNA attached to the nuclear ‘scaffold’ or ‘matrix’ hybridises preferentially to gene-poor regions of the genome (G-bands). Conversely, fractions attached to the nuclear ‘skeleton’ hybridise preferentially to gene-rich R-bands and sites of high levels of transcription. The inactive X chromosome has a deficit of associations with the nuclear skeleton but not with the matrix or scaffold. A large excess of attached sequences is found at some sites of constitutive heterochromatin, but not at centromeres.

Committed contracts: what happens after you take the pledge?

For years, hospitals played under shifting rules at the high-stakes purchasing table. Manufacturers, groups and providers all dealt and bluffed. Each made commitments to one another, but afterward the manufacturers would try to go in the back door if a competitor shut them out at the front, and hospitals would join multiple groups and shift loyalties at will to get the lowest price. Sure, all agreed that solid contract commitments would be better for everyone. But when it was time to ante up, what really mattered to each was getting the best deal. And "best" meant something different to each player.

A possible screening test for inherited p53-related defects based on the apoptotic response of peripheral blood lymphocytes to DNA damage

The cellular response, in terms of cell cycle arrest(s) and apoptosis, to radiation-induced DNA damage was studied. Experiments were performed on both mitogen-stimulated and resting peripheral blood lymphocytes (PBLs) from normal and cancer-prone (C-P) individuals. The C-P individuals comprised three patients carrying germline p53 mutations and three members of two families apparently without such mutations, but with an inherited defect which results in p53 deregulation as shown by high levels of stabilised p53 protein in normal tissues. Interestingly, mitogen-stimulated PBL, from both normal and C-P individuals failed to demonstrate a G1 arrest after gamma radiation. However, a clear difference was seen in the apoptotic response to DNA damage, of PBL from normal and C-P individuals; PBLs from C-P individuals with inherited p53-related defects had a reduced apoptotic response (P = 0.0003). There was a wide margin of separation, with no overlap between the two groups, supporting the possibility of using this altered apoptotic response as a screening test. This simple and rapid procedure could be used to identify those individuals in a C-P family who carry germline p53-related defects. The method appears to detect both individuals with p53 mutations and those apparently without mutations but with other p53-related defects.

Unusual chromosome structure of fission yeast DNA in mouse cells

Chromosomes from the fission yeast Schizosaccharomyces pombe have been introduced into mouse cells by protoplast fusion. In most cell lines the yeast DNA integrates into a single site within a mouse chromosome and results in striking chromosome morphology at metaphase. Both light and electron microscopy show that the yeast chromosome region is narrower than the flanking mouse DNA. Regions of the yeast insert stain less intensely with propidium iodide than surrounding DNA and bear a morphological resemblance to fragile sites. We investigate the composition of the yeast transgenomes and the modification and chromatin structure of this yeast DNA in mouse cells. We suggest that the underlying basis for the structure we see lies above the level of DNA modification and nucleosome assembly, and may reflect the attachment of the yeast DNA to the rodent cell nucleoskeleton. The yeast integrant replicates late in S phase at a time when G bands of the mouse chromosomes are being replicated, and participates in sister chromatid exchanges at a high frequency. We discuss the implications of these studies to the understanding of how chromatin folding relates to metaphase chromosome morphology and how large stretches of foreign DNA behave when introduced into mammalian cells.

The frequency of micronuclei in bone-marrow erythroblasts during the treatment of childhood acute lymphoblastic leukaemia

We scored the frequency of micronuclei in bone-marrow erythroblasts from 41 patients with childhood acute lymphoblastic leukaemia (childhood ALL) at diagnosis and during their 2-year treatment cycle in order to see whether there would be any variation in the cytogenetic damage induced by chemotherapy. We found that most patients showed the same trend in micronucleus frequency, with a progressive rise from the diagnostic slide through induction to pre-intensification and completion of treatment. The rise was attributed to damage to the erythroblasts occurring as a result of chemotherapy, and was judged not prognostically significant in this study.

Transactivation of the major capsid protein gene of herpes simplex virus type 1 requires a cellular transcription factor

The purpose of this investigation was to identify and characterize the regulatory elements involved in the transcriptional activation of the beta gamma (leaky-late or gamma 1) genes of herpes simplex virus type 1 (HSV-1) by using the major capsid protein (VP5 or ICP5) gene as model. Gel mobility shift assays with nuclear extracts from uninfected and infected HeLa cells enabled us to identify two major protein-DNA complexes involving the VP5 promoter. The mobilities of these two complexes remained unaltered, and no unique complexes were observed when infected cell nuclear extracts were used. DNase I and orthophenanthroline-Cu+ footprint analyses revealed that the two complexes involve a single binding site, GGCCATCTTGAA, located between -64 and -75 bp relative to the VP5 cap site. To determine the function of this leaky-late binding site (LBS) in VP5 gene activation, we tested the effect of mutations in this region by using transient expression of a cis-linked chloramphenicol acetyltransferase gene. Deletion of the above sequence resulted in a seven- to eightfold reduction in the level of transactivation of the chloramphenicol acetyltransferase gene by superinfection with HSV-1 or by cotransfection of HSV-1 immediate-early genes. From these results, we conclude that the LBS sequence and a cellular factor(s) are involved in the transactivation of the VP5 gene. A search of published gene sequences revealed that sequences related to the LBS exist in a number of other HSV-1, cytomegalovirus, retrovirus, and cellular promoters. Sequence homologies of binding sites and results of unpublished competition binding studies suggest that this leaky-late binding factor may be related to, or the same as, a ubiquitous cellular transcriptional factor called YY1 or common factor-1 (also known as NF-E1, delta, and UCRBP).

Antibodies to defined histone epitopes reveal variations in chromatin conformation and underacetylation of centric heterochromatin in human metaphase chromosomes

Unfixed metaphase chromosome preparations from human lymphocyte cultures were immunofluorescently labelled using antibodies to defined histone epitopes. Both mouse monoclonal antibody HBC-7, raised against the N-terminal region of H2B, and rabbit serum R5/12, which recognizes H4 acetylated at Lys-12, gave non-uniform labelling patterns, whereas control antibodies against total histone fractions H4 and H1 produced homogeneous fluorescence. HBC-7 bound approximately uniformly to the bulk of the chromosomes, but the major heterochromatic domains of chromosomes 1, 9, 15, 16 and the Y showed significantly brighter fluorescence. Serum R5/12 indicated an overall reduction in acetylation of H4 in metaphase chromosomes compared with interphase nuclei, although some specific chromosomal locations had considerably elevated acetylation levels. Acetylation levels in the major heterochromatic domains appeared extremely low. To investigate further the differences noted in heterochromatin labelling, metaphases from cultures grown in the presence of various agents known to induce undercondensation of the major heterochromatic domains were similarly immunolabelled. Decondensed heterochromatin no longer exhibited higher than normal immunofluorescence levels with HBC-7. The higher resolution afforded by "stretching" the centromeric heterochromatin of chromosomes 1, 9 and 16 confirmed the low level of H4 acetylation in these domains. We consider the implications of these observations in relation to chromatin conformation and activity.

Infantile hypertrophic pyloric stenosis

This is a world-wide disease, more common in Caucasians and probably on the increase. The aetiology remains very poorly understood. Presentation is between 2 and 8 weeks with vomiting, classically projectile, in an otherwise well hungry child. The diagnosis can confidently be made in most cases by a careful test feed; ultrasound and barium meal examinations are only required for difficult cases. Intravenous fluid replacement is essential prior to surgery and 24 h or longer may be required to correct acid base disturbances and enable safe general anaesthesia. Pyloromyotomy (Ramstedt's operation) remains the only satisfactory treatment, our mortality rate for this is 0.4%. Occasional vomits occur postoperatively in over half of patients but we are sceptical of the value of graded postoperative feeding regimens. There are no known long-term sequelae to surgery and this remains a most rewarding paediatric surgical condition to treat.

Maintenance treatment with antidepressants in panic disorder

Because panic disorder is a chronic illness, patients may require long-term pharmacologic treatment. Unfortunately, the benefits and risks of such therapy have received little study. At least two classes of antidepressants, the tricyclic antidepressants and the monoamine oxidase inhibitors, are effective for the treatment of panic disorder, but because relapse is common when these drugs are discontinued, many patients require maintenance treatment. However, such long-term use of tricyclic antidepressants and monoamine oxidase inhibitors exposes patients to risks that include potentially fatal overdoses and hypertensive crises. Patients should be aware of the risks involved and should weigh them against the benefits of long-term use. They should reduce the dose to the lowest effective level, from time to time gradually taper medications to assess continuing need, and avail themselves of other therapies rather than rely solely on drug treatment. Above all, more research should be done on the long-term risks and benefits of antidepressant drugs.

Human keratinocytes are a source for tumor necrosis factor alpha: evidence for synthesis and release upon stimulation with endotoxin or ultraviolet light

Tumor necrosis factor alpha (TNF-alpha), in addition to being cytotoxic for certain tumor cells, has turned out as a multifunctional cytokine that is involved in the regulation of immunity and inflammation. Since human keratinocytes have been demonstrated to be a potent source of various cytokines, it was investigated whether epidermal cells synthesize and release TNF-alpha. Supernatants derived from normal human keratinocytes (HNK) and human epidermoid carcinoma cell lines (KB, A431) were tested both in a TNF-alpha-specific ELISA and a bioassay. In supernatants of untreated epidermal cells, no or minimal TNF-alpha activity was found, while after stimulation with lipopolysaccharide (LPS) or ultraviolet (UV) light, significant amounts were detected. Western blot analysis using an antibody directed against human TNF-alpha revealed a molecular mass of 17 kD for keratinocyte-derived TNF-alpha. These biological and biochemical data were also confirmed by Northern blot analysis revealing mRNA specific for TNF-alpha in LPS- or ultraviolet B (UVB)-treated HNK and KB cells. In addition, increased TNF-alpha levels were detected in the serum obtained from human volunteers 12 and 24 h after a single total body UVB exposure, which caused a severe sunburn reaction. These findings indicate that keratinocytes upon stimulation are able to synthesize and release TNF-alpha, which may gain access to the circulation. Thus, TNF-alpha in concert with other epidermal cell-derived cytokines may mediate local and systemic inflammatory reactions during host defense against injurious events caused by microbial agents or UV irradiation.

Instruction on Piagetian concepts for children with mental retardation

Eighteen children with mild mental retardation were pretested on unidimensional classification (oddity), unidimensional seriation, number conservation, Slosson's Intelligence Test, and the Peabody Picture Vocabulary Test (PPVT). The children were instructed on the Piagetian concepts twice per week for 4 months via a learning-set technique. All 315 problems (except 20 verbal classification and 15 verbal seriation items) involved concrete items. When posttested at the semester's end, the children had, with few exceptions, mastered the Piagetian concepts and made significant gains on performance on the PPVT.

Cytokine modulation of keratinocyte cytokines

There is increasing evidence that epidermal cytokines may have an important role in mediating inflammatory and immune responses in the skin. A number of cell types in the epidermis are capable of secreting cytokines including keratinocytes, Langerhans cells, melanocytic cells, and even Merkle cells. Keratinocytes are the major source of cytokines in the epidermis and have been reported to secrete IL-1, IL-3, IL-6, IL-8, CSF, TNF alpha, TGF alpha, TGF beta, and PDGF. Normally these cytokines are not actively secreted by keratinocytes; however, a number of agents are capable of mediating keratinocyte cytokine production, including cytokines themselves. We examined the effect of a number of cytokines on keratinocyte IL-1, IL-6, GM-CSF, and PDGF production. It was found that these keratinocyte cytokines are all modulated by one or more cytokines, including several that keratinocytes themselves secrete. These effects appear to be mediated by high-affinity cytokine receptors on keratinocytes. We are only beginning to understand the molecular mechanisms underlying the production, regulation, and precise role of keratinocyte cytokines in normal and diseased skin; however, recent studies suggest that cytokines secreted by epidermal cells and lymphoid cells may be important modulators of keratinocyte cytokine production.

Recombinant human erythropoietin treatment in pre-dialysis patients. A double-blind placebo-controlled trial

STUDY OBJECTIVE

To determine the efficacy and safety of recombinant human erythropoietin (r-HuEPO) in predialysis renal patients.

DESIGN

Randomized, double-blind, placebo-controlled trial for 8 weeks.

SETTING

Inpatient and outpatient facility in the Clinical Research Center of a university-based hospital.

PATIENTS

Fourteen adult subjects with renal insufficiency (mean serum creatinine, 473 mumol/L +/- 61 [6.2 +/- 0.8 mg/dL]) and anemia (mean hematocrit, 0.27 +/- 0.01).

INTERVENTIONS

Recombinant human erythropoietin, 50, 100, or 150 IU/kg body weight or placebo given intravenously three times per week.

MEASUREMENTS AND MAIN RESULTS

Subjects who received active r-HuEPO showed a dose-dependent rise in hematocrit; mean hematocrit increased 41% from 0.27 +/- 0.01 to 0.38 +/- 0.01. At the same time, erythrocyte mass rose 43% from 13.7 +/- 0.6 mL/kg in the baseline state to 19.6 +/- 1.0 mL/kg after treatment. Maximal oxygen consumption during exercise increased 9% from 16.0 mL/min.kg +/- 1.8 to 17.5 mL/min.kg +/- 1.9.

CONCLUSIONS

Recombinant human erythropoietin is effective and safe in ameliorating the anemia of pre-dialysis patients.

Limited joint mobility in the diabetic foot: relationship to neuropathic ulceration

Limited joint mobility in the hand is a common manifestation of diabetes with the reported prevalence in insulin-dependent diabetes varying between 8 and 43%. Sixty-two subjects were studied in three groups (controls, diabetic patients without foot problems, and diabetic patients with neuropathic ulceration) to determine whether similar changes occur in the joints of the foot and to examine any possible relationship with neuropathic ulceration. There was a significant impairment of mobility in the range of motion of the sub-talar joint in diabetic patients with ulcers when compared with controls (p = 0.0001) or with the other diabetic patients (p = 0.004). There was a significant correlation between sub-talar range of motion and mobility in other joints of the foot such as at the hallux (r = 0.59, p less than 0.001), or with mobility of the 5th finger (r = 0.41, p less than 0.01). There was also a significant association between the clinical presence of limited joint mobility in the hand, Dupuytren's contracture, and mobility of the sub-talar joint (p less than 0.05). Furthermore, impairment of mobility of the sub-talar joint was greatest on the affected side in those diabetic patients with neuropathic ulceration (p = 0.029). We conclude that the syndrome of limited joint mobility also affects the joints of the feet of diabetic patients and may predispose to ulceration in susceptible neuropathic feet.

The expression and modulation of IL-1 alpha in murine keratinocytes

Murine and human keratinocytes produce an IL-1-like factor that appears to be similar if not identical to monocyte-derived IL-1. IL-1 may be an important mediator in cutaneous inflammatory responses, however, little is currently known concerning factors that may modulate IL-1 expression in keratinocytes. To address this issue we examined the effect of LPS, UV, and the cell differentiation state on murine keratinocyte IL-1 mRNA expression. Our results indicated that as with the murine P388D1 monocyte cell line, PAM 212 keratinocytes constitutively express abundant amounts of IL-1 alpha mRNA. On exposure to LPS (100 micrograms/ml) for 8 h there was more than 10 times the increase in PAM 212 IL-1 alpha mRNA which was accompanied by a sixfold increase in supernatant IL-1 activity. Similarly UV irradiation had a significant effect on keratinocyte IL-1 alpha expression. High dose UV (300 mJ/cm2) inhibited PAM 212 IL-1 alpha expression at 4, 8, 24, 48 h post-UV whereas a lower dose of UV (100 mJ/cm2) inhibited UV at 4 and 8 h post-UV, but induced IL-1 expression at 24 and 48 h post-UV. The expression of IL-1 alpha varied with the differentiation state of the keratinocytes. Freshly removed newborn murine keratinocytes were found to constitutively express IL-1 alpha mRNA. Keratinocytes grown in low [Ca2+] tissue culture media (0.05 mM) for 6 days, functionally and phenotypically become undifferentiated and express increased quantities of IL-1 alpha mRNA, whereas cells grown in high [Ca2+] media (1.2 mM) for 6 days become terminally differentiated and IL-1 expression ceased. Keratinocytes cultured for 3 days in low [Ca2+] conditions expressed an intermediate level of IL-1 alpha. In contrast, little or no IL-1 beta mRNA was detected in either the PAM 212 cells or newborn murine keratinocytes. Thus LPS, UV, and cell differentiation state have a significant effect on expression of IL-1 alpha in murine keratinocytes.