What We Learned about the Feasibility of Gene Electrotransfer for Vaccination on a Model of COVID-19 Vaccine

DNA vaccination is one of the emerging approaches for a wide range of applications, including prophylactic vaccination against infectious diseases and therapeutic vaccination against cancer. The aim of this study was to evaluate the feasibility of our previously optimized protocols for gene electrotransfer (GET)-mediated delivery of plasmid DNA into skin and muscle tissues on a model of COVID-19 vaccine. Plasmids encoding the SARS-CoV-2 proteins spike (S) and nucleocapsid (N) were used as the antigen source, and a plasmid encoding interleukin 12 (IL-12) was used as an adjuvant. Vaccination was performed in the skin or muscle tissue of C57BL/6J mice on days 0 and 14 (boost). Two weeks after the boost, blood, spleen, and transfected tissues were collected to determine the expression of S, N, IL-12, serum interferon-γ, the induction of antigen-specific IgG antibodies, and cytotoxic T-cells. In accordance with prior in vitro experiments that indicated problems with proper expression of the S protein, vaccination with S did not induce S-specific antibodies, whereas significant induction of N-specific antibodies was detected after vaccination with N. Intramuscular vaccination outperformed skin vaccination and resulted in significant induction of humoral and cell-mediated immunity. Moreover, both boost and adjuvant were found to be redundant for the induction of an immune response. Overall, the study confirmed the feasibility of the GET for DNA vaccination and provided valuable insights into this approach.

Non-Clinical In Vitro Evaluation of Antibiotic Resistance Gene-Free Plasmids Encoding Human or Murine IL-12 Intended for First-in-Human Clinical Study

Interleukin 12 (IL-12) is a key cytokine that mediates antitumor activity of immune cells. To fulfill its clinical potential, the development is focused on localized delivery systems, such as gene electrotransfer, which can provide localized delivery of IL-12 to the tumor microenvironment. Gene electrotransfer of the plasmid encoding human IL-12 is already in clinical trials in USA, demonstrating positive results in the treatment of melanoma patients. To comply with EU regulatory requirements for clinical application, which recommend the use of antibiotic resistance gene-free plasmids, we constructed and developed the production process for the clinical grade quality antibiotic resistance gene-free plasmid encoding human IL-12 (p21-hIL-12-ORT) and its ortholog encoding murine IL-12 (p21-mIL-12-ORT). To demonstrate the suitability of the p21-hIL-12-ORT or p21-mIL-12-ORT plasmid for the first-in-human clinical trial, the biological activity of the expressed transgene, its level of expression and plasmid copy number were determined in vitro in the human squamous cell carcinoma cell line FaDu and the murine colon carcinoma cell line CT26. The results of the non-clinical evaluation in vitro set the basis for further in vivo testing and evaluation of antitumor activity of therapeutic molecules in murine models as well as provide crucial data for further clinical trials of the constructed antibiotic resistance gene-free plasmid in humans.

Potentiation of electrochemotherapy effectiveness by immunostimulation with IL-12 gene electrotransfer in mice is dependent on tumor immune status

Electrochemotherapy (ECT) exhibits high therapeutic effectiveness in the clinic, achieving up to 80% local tumor control but without a systemic (abscopal) effect. Therefore, we designed a combination therapy consisting of ECT via intratumoral application of bleomycin, oxaliplatin or cisplatin with peritumoral gene electrotransfer of a plasmid encoding interleukin-12 (p. t. IL-12 GET). Our hypothesis was that p. t. IL-12 GET potentiates the effect of ECT on local and systemic levels and that the potentiation varies depending on tumor immune status. Therefore, the combination therapy was tested in three immunologically different murine tumor models. In poorly immunogenic B16F10 melanoma, IL-12 potentiated the antitumor effect of ECT with biologically equivalent low doses of cisplatin, oxaliplatin or bleomycin. The most pronounced potentiation was observed after ECT using cisplatin, resulting in a complete response rate of 38% and an abscopal effect. Compared to B16F10 melanoma, better responsiveness to ECT was observed in more immunogenic 4 T1 mammary carcinoma and CT26 colorectal carcinoma. In both models, p. t. IL-12 GET did not significantly improve the therapeutic outcome of ECT using any of the chemotherapeutic drugs. Collectively, the effectiveness of the combination therapy depends on tumor immune status. ECT was more effective in more immunogenic tumors, but GET exhibited greater contribution in less immunogenic tumors. Thus, the selection of the therapy, namely, either ECT alone or combination therapy with p. t. IL-12, should be predominantly based on tumor immune status.

Abstract B25: The effect of peritumoral gene electrotransfer of interleukin-12 as an adjuvant immunotherapy to electrochemotherapy varies according to immune status of treated tumors

The aim of the study was to test a new combined therapy including electrochemotherapy (ECT) and gene electrotransfer (GET) of plasmid encoding interleukin-12 (IL-12) in three immunologically different tumors. Therapeutic effectiveness of ECT in the clinics is up to 80% of local tumor control. However, systemic antitumor effect (abscopal effect) has not been observed. We proposed a combined therapy consisting of ECT with intratumoral application of cisplatin, oxaliplatin, or bleomycin with peritumoral GET of plasmid encoding IL-12. In the combination, IL-12 boosts the in situ vaccination effect of ECT and together with immunogenic cell death and danger-associated molecular patterns release recruits effector immune cells. Our hypothesis was that IL-12 potentiates the effect of ECT on a local and systemic level and may vary regarding immunologic profile of the treated tumors. The therapy was tested in three immunologically different primary murine tumor models (malignant melanoma [B16F10], mammary carcinoma [4T1], and colon carcinoma [CT26]) and on dual-flank melanoma model mimicking systemic disease. Tumor growth was followed and blood samples were collected for immunohistochemical and cytometric analysis of the tumor microenvironment and for the detection of IL-12. We demonstrated that GET of IL-12 potentiates the effect of ECT with all three chemotherapeutic drugs on local level. The most pronounced potentiation was with ECT using cisplatin, resulting in 38% of complete responses as well as an abscopal effect. The antitumor effectiveness of this treatment combination could be ascribed to the induction of the local and systemic immune response. Furthermore, the combined therapy was also tested in two other immunologically different tumor models, 4T1 and CT26. The results indicate that peritumoral GET of IL-12 inversely correlates with tumor response to ECT. We observed better responsiveness to ECT in more immunogenic tumors, where the addition of GET led to the lowest potentiation. So far, we have demonstrated an abscopal effect after the combination of ECT with cisplatin and peritumoral IL-12 GET in B16F10 tumor model. Currently, we are also testing the systemic effect of the combined therapy in 4T1 and CT26 tumor models. In conclusion, we showed that peritumoral GET of IL-12 significantly potentiates ECT in treated melanoma tumors and has notable effect on distant untreated tumors, predominantly when cisplatin was used for ECT. Potentiation of this treatment combination depends on the immunologic status of the tumors. ECT was more effective in more immunogenic tumors, but the contribution of peritumoral GET was not as pronounced as in less immunogenic tumors.

Citation Format: Katja Ursic, Spela Kos, Urska Kamensek, Maja Cemazar, Gregor Sersa. The effect of peritumoral gene electrotransfer of interleukin-12 as an adjuvant immunotherapy to electrochemotherapy varies according to immune status of treated tumors [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology and Immunotherapy; 2019 Nov 17-20; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2020;8(3 Suppl):Abstract nr B25.

Measurement of anti-TSH receptor antibodies: what is the correct cut-off value?

BACKGROUND

Autoantibodies against the thyroid stimulating hormone receptor, thyrotropin receptor autoantibodies (TRAb) are diagnostic for Graves' disease and can be measured by different methods. As antibody concentrations are not comparable between methods, appropriate cut-off values need to be established for every single method. For a third-generation TRAb assay (Phadia, Thermofisher), the manufacturer determined the cut-off value in a study population consisting of Graves' disease (both newly diagnosed and patients under treatment) and non-Graves' disease patients. The aim of this study was to verify whether this cut-off value holds true in our population.

METHODS

Retrospective analysis was performed on TRAb measurements collected over a period of six months from all patients referred for TRAb testing. For our study, we included patients that were newly diagnosed with hyperthyroidism including Graves' disease, multinodular goitre, toxic adenoma, and thyroiditis. Furthermore, we included Graves' patients that were under treatment at the time of TRAb measurement.

RESULTS

Whereas all patients with Graves' disease had positive TRAb, few patients with multinodular goitre, toxic adenoma, and thyroiditis scored positive for TRAb. ROC curve analysis revealed a cut-off value of 4.5 IU/l (compared to 3.3 IU/l established by the manufacturer). Newly diagnosed Graves' patients had higher TRAb concentrations compared to patients under treatment.

CONCLUSION

The cut-off value of this immunoassay should probably be set higher in untreated Graves' patients than proposed by the manufacturer as the cut-off value should be determined in a study population excluding Graves' patients under treatment. The overall clinical picture remains crucial in the diagnosis of Graves' disease.

Intradermal DNA vaccination combined with dual CTLA-4 and PD-1 blockade provides robust tumor immunity in murine melanoma

We aimed to explore whether the combination of intradermal DNA vaccination, to boost immune response against melanoma antigens, and immune checkpoint blockade, to alleviate immunosuppression, improves antitumor effectiveness in a murine B16F10 melanoma tumor model. Compared to single treatments, a combination of intradermal DNA vaccination (ovalbumin or gp100 plasmid adjuvanted with IL12 plasmid) and immune checkpoint CTLA-4/PD-1 blockade resulted in a significant delay in tumor growth and prolonged survival of treated mice. Strong activation of the immune response induced by combined treatment resulted in a significant antigen-specific immune response, with elevated production of antigen-specific IgG antibodies and increased intratumoral CD8⁺ infiltration. These results indicate a potential application of the combined DNA vaccination and immune checkpoint blockade, specifically, to enhance the efficacy of DNA vaccines and to overcome the resistance to immune checkpoint inhibitors in certain cancer types.

Optimization of laboratory procedures for intrauterine insemination: survey of methods in relation to clinical outcome

BACKGROUND

There is a wide practice variation of used methods and outcomes in IUI in fertility laboratories. Standardization of the IUI procedure is important for reducing inconsistency among laboratories in counseling infertile couples and in pregnancy results. The aim of the study was to evaluate the currently used laboratory procedures of IUI in Dutch fertility laboratories and their effect on IUI pregnancy results. Additionally, the methods for semen analysis (SA) were evaluated, as SA is related to IUI in terms of inseminated sperm number and IUI counseling.

MATERIAL AND METHODS

This questionnaire survey study was sent to laboratories participating in the Dutch external quality control program for semen analysis (SKML) and consisted of 46 questions concerning laboratory management, methods for semen analysis and IUI, and clinical results. The results were analyzed using univariable and multivariable logistic regression models.

RESULTS

A total of 52 laboratories (out of 99) provided information on used methodologies for SA or laboratory procedures of IUI and the organization of the laboratory. A wide variability was confirmed in used methods for both SA and IUI. Evaluation of pregnancy results obtained during 3 years (2013-2015) showed that specific used laboratory methods have a significant effect on the probability of becoming pregnant.

DISCUSSION AND CONCLUSION

Important to remark is that in this survey study cycle-specific data, including variables of the individual couples (age, stimulation protocol, etc), were not included and may have effects on the results. The reported results provide an overview of the current practice performance; however, the organization of fertility laboratories is changing rapidly. The use of standardized methods in IUI is important for optimizing the performance of care and improving pregnancy results. The knowledge on used procedures, however, is limited, and further research on factors involving SA and the IUI procedure is necessary.

Techniques used for IUI: is it time for a change?

STUDY QUESTION

Are the guidelines for the technical aspects of IUI (WHO, 2010) still in accordance with the current literature?

SUMMARY ANSWER

In general, the laboratory guidelines of the World Health Organization (WHO) are a suitable protocol, although the evidence is not always conclusive and some changes are advisable.

WHAT IS KNOWN ALREADY

Lack of standardization of the technical procedures required for IUI might result in inter-laboratory variation in pregnancy rates. Most centers still use their own materials and methods even though some guidelines are available.

STUDY DESIGN, SIZE, DURATION

A structural review focusing on the association between pregnancy rates and the procedures of semen collection (e.g. ejaculatory abstinence, collection place), semen processing (e.g. preparation method, temperature during centrifugation/storage), insemination (e.g. timing of IUI, bed rest after IUI) and the equipment used.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A literature search was performed in Medline and the Cochrane library. When no adequate studies of the impact of a parameter on pregnancy results were found, its association with sperm parameters was reviewed.

MAIN RESULTS AND THE ROLE OF CHANCE

For most variables, the literature review revealed a low level of evidence, a limited number of studies and/or an inadequate outcome measure. Moreover, the comparison of procedures (i.e. semen preparation technique, time interval between semen, collection, processing and IUI) revealed no consensus about their results. It was not possible to develop an evidence-based, optimal IUI treatment protocol.

LIMITATIONS, REASONS FOR CAUTION

The included studies exhibited a lack of standardization in inclusion criteria and methods used.

WIDER IMPLICATIONS OF THE FINDINGS

This review emphasizes the need for more knowledge about and standardization of assisted reproduction technologies. Our literature search indicates that some of the recommendations in the laboratory guidelines could be adapted to improve standardization, comfort, quality control and to cut costs.

STUDY FUNDING/COMPETING INTEREST(S)

The Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Nijmegen, The Netherlands. S.K. and W.N. have no conflicts of interest to disclose. C.B. and A.W. are members of the board of the SKML. With a grant from SKML, L.L. was paid for her time to perform the research and write the publication. D.B. received grants from Merck Serono, Ferring and MSD, outside the submitted work.

REGISTRATION NUMBER

N/A.

Antitumor effect of antibiotic resistance gene-free plasmids encoding interleukin-12 in canine melanoma model

The electrotransfer of interleukin-12 (IL-12) has been demonstrated as an efficient and safe treatment for tumors in veterinary oncology. However, the plasmids used encode human or feline IL-12 and harbor the gene for antibiotic resistance. Therefore, our aim was to construct plasmids encoding canine IL-12 without the antibiotic resistance genes driven by two different promoters: constitutive and fibroblast-specific. The results obtained in vitro in different cell lines showed that following gene electrotransfer, the newly constructed plasmids had cytotoxicity and expression profiles comparable to plasmids with antibiotic resistance genes. Additionally, in vivo studies showed a statistically significant prolonged tumor growth delay of CMeC-1 tumors compared to control vehicle-treated mice after intratumoral gene electrotransfer. Besides the higher gene expression obtained by plasmids with constitutive promoters, the main difference between both plasmids was in the distribution of the transgene expression. Namely, after gene electrotransfer, plasmids with constitutive promoters showed an increase of serum IL-12, whereas the gene expression of IL-12, encoded by plasmids with fibroblast-specific promoters, was restricted to the tumor. Furthermore, after the gene electrotransfer of plasmids with constitutive promoters, granzyme B-positive cells were detected in the tumor and spleen, indicating a systemic effect of the therapy. Therefore, plasmids with different promoters present valuable tools for focused therapy with local or systemic effects. The results of the present study demonstrated that plasmids encoding canine IL-12 under constitutive and fibroblast-specific promoters without the gene for antibiotic resistance provide feasible tools for controlled gene delivery that could be used for the treatment of client-owned dogs.

Clinical potential of electroporation for gene therapy and DNA vaccine delivery

INTRODUCTION

Electroporation allows efficient delivery of DNA into cells and tissues, thereby improving the expression of therapeutic or immunogenic proteins that are encoded by plasmid DNA. This simple and versatile method holds a great potential and could address unmet medical needs such as the prevention or treatment of many cancers or infectious diseases.

AREAS COVERED

This review explores the electroporation mechanism and the parameters affecting its efficacy. An analysis of past and current clinical trials focused on DNA electroporation is presented. The pathologies addressed, the protocol used, the treatment outcome and the tolerability are highlighted. In addition, several of the possible optimization strategies for improving patient compliance and therapeutic efficacy are discussed such as plasmid design, use of genetic adjuvants for DNA vaccines, choice of appropriate delivery site and electrodes as well as pulse parameters.

EXPERT OPINION

The growing number of clinical trials and the results already available underline the strong potential of DNA electroporation which combines both safety and efficiency. Nevertheless, it remains critical to further increase fundamental knowledge to refine future strategies, to develop concerted and common DNA electroporation protocols and to continue exploring new electroporation-based therapeutic options.

Improved Specificity of Gene Electrotransfer to Skin Using pDNA Under the Control of Collagen Tissue-Specific Promoter

In order to ensure safe, efficient and controlled gene delivery to skin, the improvement of delivery methods together with proper design of DNA is required. Non-viral delivery methods, such as gene electrotransfer, and the design of tissue-specific promoters are promising tools to ensure the safety of gene delivery to the skin. In the scope of our study, we evaluated a novel skin-specific plasmid DNA with collagen (COL) promoter, delivered to skin cells and skin tissue by gene electrotransfer. In vitro, we determined the specificity of the COL promoter in fibroblast cells. The specific expression under the control of COL promoter was obtained for the reporter gene DsRed as well as for therapeutic gene encoding cytokine IL-12. In vivo, the plasmid with COL promoter encoding the reporter gene DsRed was efficiently transfected to mouse skin. It resulted in the notable and controlled manner, however, in lower and shorter expression, compared to that obtained with ubiquitous promoter. The concentration of the IL-12 in the skin after the in vivo transfection of plasmid with COL promoter was in the same range as after the treatment in control conditions (injection of distilled water followed by the application of electric pulses). Furthermore, this gene delivery was local, restricted to the skin, without any evident systemic shedding of IL-12. Such specific targeting of skin cells, observed with tissue-specific COL promoter, would improve the effectiveness and safety of cutaneous gene therapies and DNA vaccines.

Importance of promoter methylation of GATA4 and TP53 genes in endometrioid carcinoma of endometrium

BACKGROUND

Epigenetic changes are considered to be a frequent event during tumor development. Various methylation changes have been identified and show promise as potential cancer biomarkers. The aim of this study was to investigate promoter methylation of GATA4 and TP53 genes in endometrioid carcinoma of endometrium.

METHODS

To search for promoter methylation of GATA4 and TP53 genes we used methylation-specific PCR (MSP) to compare the methylation status of 54 patients with endometrioid carcinoma of endometrium and 18 patients with normal endometrial tissue.

RESULTS

In our study MSP revealed GATA4 promoter methylation in 44 of 54 in the carcinoma group (81.5%), and in none of the control group. No methylation was observed in TP53 gene.

CONCLUSIONS

In conclusion, our study showed that there is significantly higher methylation in GATA4 gene in the endometrial cancer group compared with samples of non-neoplastic endometrium. The finding suggests the importance of hypermethylation of this gene in endometrial carcinogenesis and could have implications for future diagnostic and therapeutic strategies for endometrial cancer based on epigenetic changes.

Displacement of malignant cells into the portal triad of the liver results in reduced liver perfusion, mimicking segmental Fatty liver

Liver steatosis is often observed in different clinical situations. Oncological patients undergoing systemic therapy often develop liver steatosis, which can be diagnosed with normal routine scans such as CT and ultrasound. In this case report, we show that an isolated infiltration of the portal triad with tumor cells could mimic a fatty-like infiltration of the liver. Radiologists and clinicians should be aware of this pitfall and should perform a biopsy in cases of doubt.

Challenges in diagnosing extrapulmonary tuberculosis in the European Union, 2011

In the European Union (EU) 72,334 tuberculosis (TB) cases were notified in 2011, of which 16,116 (22%) had extrapulmonary tuberculosis (EPTB). The percentage of TB cases with EPTB ranged from 4% to 48% in the reporting countries. This difference might be explained by differences in risk factors for EPTB or challenges in diagnosis. To assess the practices in diagnosis of EPTB we asked European Union/European Economic Area (EU/EEA) countries to participate in a report describing the diagnostic procedures and challenges in diagnosing EPTB. Eleven EU Member States participated and reports showed that in the majority EPTB is diagnosed by a pulmonologist, sometimes in collaboration with the doctor who is specialised in the organ where the symptoms presented. In most countries a medical history and examination is followed by invasive procedures, puncture or biopsy, to collect material for confirmation of the disease (by culture/histology/cytology). Some countries also use the tuberculin skin test or an interferon-gamma-release-assay. A wide variety of radiological tests may be used. Countries that reported challenges in the diagnosis of EPTB reported that EPTB is often not considered because it is a rare disease and most medical professionals will not have experience in diagnosing EPTB. The fact that EPTB can present with a variety of symptoms that may mimic symptoms of other pathologies does pose a further challenge in diagnosis. In addition, obtaining an appropriate sample for confirmation of EPTB was frequently mentioned as a challenge. In summary, diagnosis of EPTB poses challenges due to the diversity of symptoms with which EPTB may present, the low level of suspicion of clinicians, and due to the difficulty in obtaining an adequate sample for confirmation.

Challenges in diagnosing extrapulmonary tuberculosis in the European Union, 2011

In the European Union (EU) 72,334 tuberculosis (TB) cases were notified in 2011, of which 16,116 (22%) had extrapulmonary tuberculosis (EPTB). The percentage of TB cases with EPTB ranged from 4% to 48% in the reporting countries. This difference might be explained by differences in risk factors for EPTB or challenges in diagnosis. To assess the practices in diagnosis of EPTB we asked European Union/European Economic Area (EU/EEA) countries to participate in a report describing the diagnostic procedures and challenges in diagnosing EPTB. Eleven EU Member States participated and reports showed that in the majority EPTB is diagnosed by a pulmonologist, sometimes in collaboration with the doctor who is specialised in the organ where the symptoms presented. In most countries a medical history and examination is followed by invasive procedures, puncture or biopsy, to collect material for confirmation of the disease (by culture/histology/cytology). Some countries also use the tuberculin skin test or an interferon-gamma-release-assay. A wide variety of radiological tests may be used. Countries that reported challenges in the diagnosis of EPTB reported that EPTB is often not considered because it is a rare disease and most medical professionals will not have experience in diagnosing EPTB. The fact that EPTB can present with a variety of symptoms that may mimic symptoms of other pathologies does pose a further challenge in diagnosis. In addition, obtaining an appropriate sample for confirmation of EPTB was frequently mentioned as a challenge. In summary, diagnosis of EPTB poses challenges due to the diversity of symptoms with which EPTB may present, the low level of suspicion of clinicians, and due to the difficulty in obtaining an adequate sample for confirmation.

Protocolised inpatient care of diabetes mellitus

BACKGROUND

The prevalence of hyperglycaemia in patients with diabetes mellitus at admission is high. Prevention and treatment is important to prevent further clinical complications. We have conducted a study evaluating implementation of a new protocol to standardise inpatient care of patients with diabetes mellitus.

METHODS

A retrospective study including all glucose measurements of adult patients with diabetes mellitus type 1 o r 2 , admitted to a surgery department, was performed before and after implementation of the new protocol. This protocol included direct consultation of an internist and diabetes specialist nurse at admission, who initiated a daily treatment program and adjustment scheme based on glucose measurements four times a day by the HemoCue201DM glucose point of care device. We compared the prevalence of hyperglycaemia and hypoglycaemia before and after implementation with logistic regression analyses adjusted for age and gender.

RESULTS

Overall, 360 patients with diabetes mellitus type 1 or 2 with 5322 glucose measurements were included. The risk of developing hyperglycaemia was significantly reduced after implementation of the protocol (22 patients with 65 hyperglycaemias) compared with before the intervention (70 patients with 417 hyperglycaemias) (RR adjusted 0.24 (95% confidence interval 0.19; 0.32)). Overall, 45 patients experienced 95 episodes of hypoglycaemia, which did not differ significantly between the two groups.

CONCLUSION

After implementation of a new protocol to standardise inpatient care of diabetes mellitus we established a decrease in the risk to develop hyperglycaemia of 76% without an increased risk of developing hypoglycaemia. Implementation of this protocol required frequent glucose measurements which are facilitated by point of care glucose measurements.

Ab initio modeling of complex amorphous transition-metal-based ceramics

Binary and ternary amorphous transition metal (TM) nitrides and oxides are of great interest because of their suitability for diverse applications ranging from high-temperature machining to the production of optical filters or electrochromic devices. However, understanding of bonding in, and electronic structure of, these materials represents a challenge mainly due to the d electrons in their valence band. In the present work, we report ab initio calculations of the structure and electronic structure of ZrSiN materials. We focus on the methodology needed for the interpretation and automatic analysis of the bonding structure, on the effect of the length of the calculation on the convergence of individual quantities of interest and on the electronic structure of materials. We show that the traditional form of the Wannier function center-based algorithm fails due to the presence of d electrons in the valence band. We propose a modified algorithm, which allows one to analyze bonding structure in TM-based systems. We observe an appearance of valence p states of TM atoms in the electronic spectra of such systems (not only ZrSiN but also NbO(x) and WAuO), and examine the importance of the p states for the character of the bonding as well as for facilitating the bonding analysis. The results show both the physical phenomena and the computational methodology valid for a wide range of TM-based ceramics.

[Solitary pulmonary nodule]

Primary pulmonary amyloidosis is rare. Three patterns of involvement have been described: tracheobronchial, nodular and diffuse parenchymal. The nodular parenchymal amyloid deposits are often multiple, much less common focal. We hereby present a case of a 70 year old patient, a former smoker, with coincidentally diagnosed solitary, pulmonary nodule, a rather common finding in CT. The list of differential diagnosis is long, as shown above, the amyloidosis is a quite uncommon cause, but it should be kept in mind.

Diagnostic pitfalls in postinterventional intraarterial magnetic resonance angiography after recanalization of femoropopliteal arterial occlusions

BACKGROUND

Magnetic resonance (MR)-guided vascular interventions are of increasing interest, and, with the use of contrast-enhanced techniques, intraarterial contrast-enhanced MR angiography (ia-ce-MRA) competes with intraarterial digital subtraction angiography (ia-DSA) for the diagnostic evaluation of the infrainguinal vessel tree.

PURPOSE

To assess the diagnostic value of ia-ce-MRA and high-resolution T1-weighted (hr-T1w) imaging compared to the gold-standard ia-DSA for residual stenosis and local dissections after femoropopliteal recanalization in patients with peripheral arterial occlusive disease (PAOD).

MATERIAL AND METHODS

Eight patients with PAOD and short vessel occlusion of their femoropopliteal arteries underwent recanalization and balloon positioning under DSA. Patients were transferred to a short-bore MR scanner. Percutaneous transluminal angioplasty (PTA) was accomplished under MR fluoroscopy. Pre- and postinterventional ia-ce three-dimensional (3D) gradient-echo MRA with gadopentate dimeglumine was performed using the intraarterial introducer sheath. Maximum intensity projections (MIP) and multiplanar reconstructions (MPR) were calculated from the data set. High-resolution T1w images of the angioplasty region before and after dilatation were acquired. Control ia-DSA images were obtained.

RESULTS

The postinterventional angioplasty results for stenosis grading were comparable in ia-MRA and ia-DSA. Only two of five local dissections in ia-DSA were visualized with the ia-ce-MRA runs including MIPs and MPRs. To clearly depict dissection, hr-T1w images were needed.

CONCLUSION

Grading of stenotic lesions with ia-ce-MRA after PTA is comparable to ia-DSA. Intraarterial ce-MRA with calculated MIPs and MPRs is only partially sufficient to visualize local dissections after PTA. High-resolution T1w images are required for precise diagnosis of dissections in magnetic resonance tomography.

Hormone-inactive pituitary macroadenoma: an uncommon cause for the syndrome of inappropriate antidiuresis

A 76-year-old patient was admitted with dizzy spells and fainting. Laboratory analysis indicated the syndrome of inappropriate antidiuresis, which was further characterized as type C ("reset osmostat"). Extended workup revealed a hormone - inactive pituitary macroadenoma. After complete transsphenoidal resection, serum sodium levels and plasma and urinary osmolality promptly normalized. Except for the gonadal axis, the anterior pituitary functions remained intact. There was no adenoma recurrence over a five-year follow-up, and repetitive testing on ad libitum fluid intake showed normal sodium concentrations. Thus, the pituitary macroadenoma represents the sole detectable cause for the syndrome of inappropriate antidiuresis in this patient.

[Gorlin-Goltz syndrome: manifestations in an elderly patient]

Gorlin-Goltz syndrome is a rare inherited genodermatosis with an autosomal dominant trait. We hereby present a case of a 69 year old patient with known Gorlin-Goltz syndrome to emphasize the peculiar syndrome manifestations in the elderly.

[Recommendations for the treatment of tobacco dependence]

This first Czech version of guidelines formulated by the working group of mentioned medical associations is based on current literature and international guidelines. They are aimed mainly on clinical medicine and on incorporation of this treatment into the health care system according to WHO recommendations. They should serve to the treatment of tobacco dependence at any level: during any contact with the smoking patient (short intervention), in specialised centres or for the health care providers or health system itself.

[Diagnostics and differential diagnostics of the chronic obstructive pulmonary disease]

The author builds upon present definition of chronic obstructive pulmonary disease (COPD) and states that diagnosis of COPD is based on history of risk factors and on presence of bronchial obstruction which is not entirely reversible. The main examination method for diagnosing and confirmation of COPD is spirometry. Differential diagnostics is necessary for identifying other diseases with similar symptoms: bronchial asthma, congestive heart failure, lung carcinoma, bronchiectasia, pulmonary tuberculosis, bronchitis obliterans, interstitial pulmonary processes. The author presents a list of symptoms and findings which help to distinguish these diseases from COPD.

Low-frequency spin dynamics in the CeMIn5 materials

We measure the spin lattice relaxation of the planar In(1) nuclei in the CeMIn5 materials, extract quantitative information about the low energy spin dynamics of the lattice of Ce moments in both CeRhIn5 and CeCoIn5, and identify a crossover in the normal state. Above a temperature T(*) the Ce lattice exhibits "Kondo gas" behavior characterized by local fluctuations of independently screened moments; below T(*) both systems exhibit a "Kondo liquid" regime in which interactions between the local moments contribute to the spin dynamics. Both the antiferromagnetic and superconducting ground states in these systems emerge from the Kondo liquid regime. Our analysis provides strong evidence for quantum criticality in CeCoIn5.

Platelet adhesion enhances the glycoprotein VI-dependent procoagulant response: Involvement of p38 MAP kinase and calpain

In the final stages of activation, platelets express coagulation-promoting activity by 2 simultaneous processes: exposure of aminophospholipids, eg, phosphatidylserine (PS), at the platelet surface, and formation of membrane blebs, which may be shed as microvesicles. Contact with collagen triggers both processes via platelet glycoprotein VI (GPVI). Here, we studied the capacity of 2 GPVI ligands, collagen-related peptide (CRP) and the snake venom protein convulxin (CVX), to elicit the procoagulant platelet response. In platelets in suspension, either ligand induced full aggregation and high Ca(2+) signals but little microvesiculation or PS exposure. However, most of the platelets adhering to immobilized CRP or CVX had exposed PS and formed membrane blebs after a prolonged increase in cytosolic [Ca(2+)](i). Platelets adhering to fibrinogen responded similarly but only when exposed to soluble CRP or CVX. By scanning electron microscopic analysis, the bleb-forming platelets were detected as either round, spongelike structures with associated microparticles or as arrays of vesicular cell fragments. The phosphorylation of p38 mitogen-activated protein kinase (MAPK) elicited by CRP and CVX was enhanced in fibrinogen-adherent platelets compared with that in platelets in suspension. The p38 inhibitor SB203580 and the calpain protease inhibitor calpeptin reduced only the procoagulant bleb formation, having no effect on PS exposure. Inhibition of p38 also downregulated calpain activity. We conclude that the procoagulant response evoked by GPVI stimulation is potentiated by platelet adhesion. The sequential activation of p38 MAPK and calpain appears to regulate procoagulant membrane blebbing but not PS exposure.

Cognitive dysfunction following subcortical infarction

OBJECTIVE

To determine the association between computed tomographic scan findings of subcortical infarction, periventricular lucency, and ventricular enlargement and a patient's performance on a range of neuropsychological tests.

DESIGN

Prospective study of patients in whom computed tomographic scanning identified discrete areas of subcortical lucency that were consistent with multiple subcortical infarcts and in whom there was no evidence for additional cerebral computer tomographic pathology.

SETTING

Hospital practice that included both inpatients and ambulatory patients.

PATIENTS

One hundred forty-seven consecutive appropriate computed tomographic scans were identified. Sixty-two patients were excluded because of concomitant medical disorders, and eight refused participation. We describe 77 patients.

MAIN OUTCOME MEASURES

Performance on a battery of neuropsychological tests.

RESULTS

The number of infarcts but not the volume of infarction, periventricular lucency, and cerebral ventricular enlargement but not cortical atrophy were significantly associated with impaired performance on neuropsychological tests. The number of infarcts correlated with impaired performance on tests, and this impaired performance was thought to be dependent on the function of frontal systems, while periventricular lucency and ventricular enlargement correlated with impaired performance on a wider range of tests, including tests that depended on memory and language.

CONCLUSIONS

The number of infarcts, periventricular lucency, and ventricular enlargement are the computed tomographic head scan parameters that correlated with severity of impaired performance on neuropsychological tests in patients with subcortical infarction. Cognitive impairment is presumed to be the result of cortical disconnection following disruption of the connections between the subcortical regions and the frontal cortex.

Metastatic carcinoma in the neck: a clinical computerized tomography scan and ultrasound study

Metastatic cervical lymph node involvement is a major determinant of treatment planning and prognosis of upper aerodigestive tract tumours. If the metastatic tumor invades the carotid artery wall then complete tumour excision is not possible unless carotid artery ligation or replacement is planned. A prospective study was performed to assess the role of palpation, computerized tomography (CT) and B-mode ultrasound scanning in the detection of metastatic cervical lymph node involvement in patients with upper aerodigestive tract tumours. In particular, detection of carotid artery wall invasion by tumour was examined. Thirty-two neck dissection specimens were available for histopathological confirmation of findings. Palpation under general anaesthesia was 87.5% sensitive and 87.5% specific in the detection of involved nodes. If a positive finding was defined as detection of a node greater than 15 mm in largest diameter, CT scanning was 78.6% sensitive and 93.8% specific, and the sensitivity of ultrasound was 81.3% and specificity was 84.6%. Ultrasound scanning was sensitive in excluding carotid artery wall invasion, identifying five out of five cases with one false positive and no false negative reports. The combination of palpation under general anaesthesia and B-mode ultrasound imaging provides a sensitive means of detecting the presence of metastatic cervical lymphadenopathy and invasion of the carotid artery wall.

Sudden blindness and total ophthalmoplegia in mucormycosis. A clinicopathological correlation

A case of rhino-orbitocerebral mucormycosis is presented, illustrating the serious nature of this disease. Clinical features and their pathological correlations are demonstrated. The need for a high index of clinical suspicion, and an early biopsy of the affected area is emphasized so that the benefits of early diagnosis and therapy may be gained.

The effect of low-dose cyclical etidronate and calcium on bone mass in early postmenopausal women

This 2-year study was carried out in 36 healthy women of mean age 53.9 +/- 3.8 (SD) years and 3.4 +/- 2.3 years postmenopausal. Bone mineral density (BMD) in the spine, measured by single-energy quantitative computed tomographic scanning, gave a mean initial value of 110 +/- 26 mg/ml. The women were divided randomly into group 1 (n = 11), calcium 600 mg/day; group 2 (n = 15), calcium plus etidronate sodium 400 mg/day for 14 days every 3 months; and group 3 (n = 10), calcium plus etidronate plus phosphate, the 14-day etidronate course being preceded by phosphate 1 g twice daily for 3 days. During the first year of the study BMD decreased by 6.0 +/- 5.8% (p < 0.005) in group 1 subjects and increased by 4.5 +/- 7.8% (p < 0.005) in the combined etidronate-treated groups (difference between control and treated p < 0.001). Inclusion of phosphate in the regimen did not affect the response to etidronate. In the second year there was no significant mean change in BMD in any of the three groups. However, whilst there was little change in BMD values for most of the group 1 subjects, there was considerable variation in individual response within the etidronate-treated groups, with some subjects gaining and some losing bone. The change in BMD during the second year in the subjects as a whole was highly correlated with the change in plasma calcium after 3 months of treatment (r = 0.60, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Ophthalmic manifestations of perineural spread of facial skin malignancy

Facial skin malignancy, when complicated by perineural spread (PNS), can lead to devastating orbital, intracranial and paranasal sinus involvement, the management of which requires a multidisciplinary approach and which itself may be devastating. Adequate surgical excision with frozen section control, and specific inspection of histological specimens for perineural invasion, are essential to avoid this problem. This report presents four patients who manifested such involvement, and emphasises the importance of recognition of such ominous symptoms as facial pain, paraesthesiae and weakness. Thorough neuro-ophthalmic examination is mandatory to detect signs of nerve involvement which may indicate perineural spread both at the initial assessment of primary tumour and at suspected recurrence. In this series, the most common sensory and motor nerves affected were, respectively, single, small branches of the ophthalmic and facial nerves.

Perineural spread of cutaneous head and neck cancer. Its orbital and central neurologic complications

The ability of cutaneous squamous cell carcinoma of the face to cause ophthalmoplegia or central nervous system dysfunction via perineural spread is not well recognized. Five patients presenting to a general neurology unit are described in whom partial or complete ophthalmoplegia developed following fifth and seventh cranial nerve involvement by cutaneous squamous cell carcinoma. Two patients subsequently developed a contralateral hemiparesis; and one, multiple cranial nerve palsies as the tumor spread centrally. Normal radiologic findings or complete healing of the primary skin lesion caused delay in the diagnosis in three of the patients. When ophthalmoplegia or central nervous system dysfunction develops as a consequence of perineural spread of cutaneous facial cancer, management is palliative.

Measurement of bone in the os calcis: a clinical evaluation

Bone mineral content (BMC) was measured in the os calcis of 232 normal subjects aged 17-82 years. The mean reproducibility (coefficient of variation) of the measurement was 1.8%. Substantial bone loss occurred between the ages of 20 and 50 years, and in females the menopause was associated with additional bone loss. There was no significant difference in the rate of bone loss in females and males, but the mean BMC was greater at all ages in males than in females. We also compared os calcis BMC with spinal bone mineral density (BMD), measured by quantitative computed tomographic (CT) scanning, in 85 subjects: 33 were normal controls, 19 had osteoporosis defined by the presence of one or more pathological fractures, and in the remainder the CT examination was performed at the patient's request. Os calcis BMC correlated with spinal BMD in both females (r = 0.69, p less than 0.001) and males (r = 0.84, p less than 0.001). However, the os calcis BMC did not reliably predict spine values around the CT "fracture threshold" of 90-100 mg/cm3 and did not correlate with osteoporotic fracture as well as did spinal BMD. It is concluded that measurement of the os calcis BMC is of limited clinical usefulness for the early diagnosis of osteoporosis.

Lethal extrapulmonary mycobacteriosis

A 60 yr old previously healthy man was treated for gradually elevating fever and rash followed by leucopenia and mycosis of the gastrointestinal tract; he died within 6 weeks of the first symptoms appearing. Histologic examination revealed disseminated tuberculosis of paratracheal lymph nodes, liver, spleen and bone marrow with the presence of acid fast bacilli by smear examination. Multiple colonies of the same strain of Mycobacterium kansasii were isolated by bacteriological examination of lymph node and spleen tissue. Neither macroscopical nor histological examination showed any evidence of lung tuberculosis. The final diagnosis of the described acute disease and rapid death was stated as generalized extrapulmonary mycobacteriosis, which is a rare observation.

Lethal extrapulmonary mycobacteriosis

A 60 yr old previously healthy man was treated for gradually elevating fever and rash followed by leucopenia and mycosis of the gastrointestinal tract; he died within 6 weeks of the first symptoms appearing. Histologic examination revealed disseminated tuberculosis of paratracheal lymph nodes, liver, spleen and bone marrow with the presence of acid fast bacilli by smear examination. Multiple colonies of the same strain of Mycobacterium kansasii were isolated by bacteriological examination of lymph node and spleen tissue. Neither macroscopical nor histological examination showed any evidence of lung tuberculosis. The final diagnosis of the described acute disease and rapid death was stated as generalized extrapulmonary mycobacteriosis, which is a rare observation.

How useful is pre-operative computerized tomography scanning in staging rectal cancer?

This study evaluates prospectively the reliability of computerized tomography (CT) in the pre-operative staging of 80 patients with rectal cancer. The scans were performed and reviewed by one radiologist without knowledge of either the operative findings or the final clinicopathological stage of the tumours. Fourteen of 60 patients (23%) who had a potentially curative resection were correctly staged by CT. The tumour was understaged in 28 patients (47%) and was overstaged in 18 patients (30%). CT did not identify the one patient with histological demonstration of invasion of an adjacent organ was equivocal or incorrect in 10 others on the question of adjacent organ invasion. CT failed to define accurately local tumour spread confined to the rectal was (positive predictive value (PPV) 23%), identify venous invasion (PPV 35%) or involved regional lymph nodes (PPV 42%). However, the negative predictive value for excluding synchronous liver metastases was 90%, and 11 patients who subsequently developed histologically confirmed local recurrence were all correctly diagnosed on CT. These findings suggest that pre-operative examination of patients with rectal cancer by CT is not routinely justified specifically for purposes of staging the disease.

Bone mass is low in relatives of osteoporotic patients

STUDY OBJECTIVE

To determine whether the failure to attain normal bone mass in young adulthood contributes to the later development of osteoporotic fractures.

DESIGN

Case-control study.

SETTING

Referral-based bone clinic at a large teaching hospital.

PATIENTS

Sequential sample of 35 asymptomatic relatives, aged 19 to 59 years, of patients with osteoporotic fractures, and 24 patients with osteoporotic fractures.

MEASUREMENTS AND MAIN RESULTS

Bone mineral density in the spine was measured by quantitative computed tomographic scanning. Bone mineral content in the os calcis was measured in 19 of the relatives of osteoporotic patients by single-photon absorptiometry. The values for bone mineral density in the spine were corrected to age 50 years with the regression equation derived from the normal values in the controls. The values were lower in relatives of osteoporotic patients than in controls. In men, the mean values (+/- standard deviation [SD]) for relatives were 91 +/- 16 mg/cm3, and for controls, 129 +/- 21 mg/cm3 (P less than 0.001). In women, the mean values for relatives were 96 +/- 17 mg/cm3 and for controls, 126 +/- 19 mg/cm3 (P less than 0.001). In the osteoporotic patients, the corrected mean value for men was 53 +/- 12 mg/cm3, and for women, 77 +/- 20 mg/cm3. The os calcis values did not correlate with the spine values and were mostly well within the normal range.

CONCLUSIONS

Mean bone mass is lower in apparently healthy young and middle-aged adult relatives of osteoporotic patients than in normal persons with no family history of osteoporosis. Our findings suggest that the failure to attain an adequate peak bone mass may play an important role in the later development of osteoporotic fractures. Relatives of osteoporotic patients should be advised to have measurements of bone mass taken. This measurement should be taken at the spine, because peripheral sites do not appear to provide adequate information about early osteoporosis.