Altered brain structure with preserved cortical motor activity after exertional hypohydration: a MRI study

Hypohydration exceeding 2% body mass can impair endurance capacity. It is postulated that the brain could be perturbed by hypohydration, leading to impaired motor performance. We investigated the neural effects of hypohydration with magnetic resonance imaging (MRI). Ten men were dehydrated to approximately −3% body mass by running on a treadmill at 65% maximal oxygen consumption (V̇o2max) before drinking to replace either 100% [euhydration (EU)] or 0% [hypohydration (HH)] of fluid losses. MRI was performed before start of trial (baseline) and after rehydration phase (post) to evaluate brain structure, cerebral perfusion, and functional activity. Endurance capacity assessed with a time-to-exhaustion run at 75% V̇o2max was reduced with hypohydration (EU: 45.2 ± 9.3 min, HH: 38.4 ± 10.7 min; P = 0.033). Mean heart rates were comparable between trials (EU: 162 ± 5 beats/min, HH: 162 ± 4 beats/min; P = 0.605), but the rate of rise in rectal temperature was higher in HH trials (EU: 0.06 ± 0.01°C/min, HH: 0.07 ± 0.02°C/min; P < 0.01). In HH trials, a reduction in total brain volume (EU: +0.7 ± 0.6%, HH: −0.7 ± 0.9%) with expansion of ventricles (EU: −2.7 ± 1.6%, HH: +3.7 ± 3.3%) was observed, and vice versa in EU trials. Global and regional cerebral perfusion remained unchanged between conditions. Functional activation in the primary motor cortex in left hemisphere during a plantar-flexion task was similar between conditions (EU: +0.10 ± 1.30%, HH: −0.11 ± 0.31%; P = 0.637). Our findings demonstrate that with exertional hypohydration, brain volumes were altered but the motor-related functional activity was unperturbed.

NEW & NOTEWORTHY Dehydration occurs rapidly during prolonged or intensive physical activity, leading to hypohydration if fluid replenishment is insufficient to replace sweat losses. Altered hydration status poses an osmotic challenge for the brain, leading to transient fluctuations in brain tissue and ventricle volumes. Therefore, the amount of fluid ingestion during exercise plays a critical role in preserving the integrity of brain architecture. These structural changes, however, did not translate directly to motor functional deficits in a simple motor task.

Q fever: persistence of antigenic non-viable cell residues of Coxiella burnetii in the host--implications for post Q fever infection fatigue syndrome and other chronic sequelae

BACKGROUND

Our previous studies of persistence of Coxiella burnetii in humans after an initial acute Q fever infection revealed raised, maintained antibody levels and low levels of coxiella genomic DNA at the age of 5 years from onset in Australian patients and at 12 years in patients in the 1989 Birmingham UK Q fever outbreak. Attempts to isolate the coxiella in standard cell culture and susceptible mice by serial passage of PCR positive PBMC and bone marrow were negative.

AIM

To retest PCR positive patient samples by more sensitive methods for viable coxiellas and for the coxiella cell components of antigen and specific lipopolysaccharide (LPS). To re-interpret the previous results in the light of the new information. To review the pertinent literature for a concept of an immuno-modulatory complex generated by the current studies.

DESIGN

Laboratory case study.

METHODS

Stored patient samples were inoculated into SCID mice that were followed for 60 days. Mouse spleen and liver samples were then examined by PCR assay for targets in the COM1 and IS1111a sequences and for antigens by IFA with a polyclonal rabbit antiserum to C. burnetii Phase 1 and a monoclonal antiserum to Phase 1 LPS (details; O. Sukocheva et al., unpublished data).

RESULTS

All specimens, including a recently excised heart valve from a Birmingham patient with late developing endocarditis, were infection negative in SCID mice. Dilutions of SCID mouse spleen and liver homogenates titrated in PCR assays were negative at dilutions attained by control mice inoculated with an endpoint dilution of a viable prototype strain of C. burnetii. Sections of the spleens from all specimens showed a complex of coxiella antigen-LPS by IFA. DISCUSSION/REVIEW: We advance a concept of long-term persistence of a non-infective, non-biodegraded complex of coxiella cell components with its antigens and specific LPS [so called Immunomodulatory complex (IMC)] associated with traces of genomic DNA that signalled its presence in our earlier studies. The IMC's survival in patients for at least 12 years, and in one patient for 70 years implies a capacity for serial passage in macrophages with effective down-regulation of their biodegrading functions. The review assesses the compatibility of the IMC concept in relation to cogent literature on C. burnetii interactions with macrophage and cell-mediated immunity. Some remaining gaps in our knowledge of the organ sites and duration of carriage of viable coxiellas after initial infection are also identified.

Breast tumor characteristics of BRCA1 and BRCA2 gene mutation carriers on MRI

The appearance of malignant lesions in BRCA1 and BRCA2 mutation carriers (BRCA-MCs) on mammography and magnetic resonance imaging (MRI) was evaluated. Thus, 29 BRCA-MCs with breast cancer were retrospectively evaluated and the results compared with an age, tumor size and tumor type matched control group of 29 sporadic breast cancer cases. Detection rates on both modalities were evaluated. Tumors were analyzed on morphology, density (mammography), enhancement pattern and kinetics (MRI). Overall detection was significantly better with MRI than with mammography (55/58 vs 44/57, P = 0.021). On mammography, lesions in the BRCA-MC group were significantly more described as rounded (12//19 vs 3/13, P = 0.036) and with sharp margins (9/19 vs 1/13, P = 0.024). On MRI lesions in the BRCA-MC group were significantly more described as rounded (16/27 vs 7/28, P = 0.010), with sharp margins (20/27 vs 7/28, P < 0.001) and with rim enhancement (7/27 vs 1/28, P = 0.025). No significant difference was found for enhancement kinetics (P = 0.667). Malignant lesions in BRCA-MC frequently have morphological characteristics commonly seen in benign lesions, like a rounded shape or sharp margins. This applies for both mammography and MRI. However the possibility of MRI to evaluate the enhancement pattern and kinetics enables the detection of characteristics suggestive for a malignancy.

Tumor characteristics and detection method in the MRISC screening program for the early detection of hereditary breast cancer

In the MRISC study, women with an inherited risk for breast cancer were screened by a 6-month clinical breast examination (CBE) and yearly MRI and mammography. We found that the MRISC screening scheme could facilitate early breast cancer diagnosis and that MRI was a more sensitive screening method than mammography, but less specific. In the current study we investigated the contribution of MRI in the early detection of breast cancer in relation to tumor characteristics. From November 1999 to October 2003, 1909 women were included and 50 breast cancers were detected, of which 45 were evaluable and included in the current study. We compared the characteristics of tumors detected by MRI-only with those of all other (non-palpable) screen-detected tumors. Further, we compared the sensitivity of mammography and MRI within subgroups according to different tumor characteristics. Twenty-two (49%) of the 45 breast cancers were detected by MRI and not visible at mammography, of which 20 (44%) were also not palpable (MRI-only detected tumors). MRI-only detected tumors were more often node-negative than other screen-detected cancers (94 vs. 59%; P=0.02) and tended to be more often <or=1 cm (58 vs. 31%; P=0.11). MRI was more sensitive than mammography for a wide spectrum of invasive tumor characteristics i.e., size, nodal status, histology, grade and ER status. Half of the breast cancers detected in this study were visible by MRI only and these tumors were smaller and significantly more often node-negative than other screen-detected tumors, suggesting that MRI makes an important contribution to the early detection of hereditary breast cancer.

HIV DNA integration during cell-to-cell transmission of infection: evidence for partially integrated DNA structures in acutely infected cells

A one-step cell-to-cell transmission model of human immunodeficiency virus (HIV) infection was used to study viral DNA integration in the early phase of viral replication. Co-culturing H3B cells as virus donors with CD4+ Hut78 recipient cells in a ratio of 1:4 produced a synchronous, one-step viral infection with de novo synthesis of unintegrated HIV DNA within 4 h p.i., which subsequently integrates in the host genomic DNA to form provirus. To study the kinetics of viral DNA integration, cellular chromosomal DNA was isolated at different times after co-culturing and extensive electrophoresis was used to remove residual unintegrated viral DNA. Removal of contaminating, unintegrated viral DNA in the purified chromosomal DNA fraction was confirmed by various experiments. When purified chromosomal DNA (free of contaminating unintegrated viral DNA)--from the mix of acutely infected cells--was digested with restriction enzymes KpnI, BamHI or PstI and analysed by Southern blot hybridization, integration of viral DNA into chromosomal DNA was first observed at 8 h p.i. and was essentially complete by 72 h p.i. In addition, evidence was found for a relatively stable, partially integrated HIV DNA structure within the chromosomal DNA, that was first detectable at 8 h p.i. and did not become fully integrated until 72 hours post infection.

Development of intrahepatic arterial shunts in a transplanted liver: a potential pitfall for Doppler sonography

We describe the hemodynamic features and anatomic basis of false-negative Doppler sonographic findings compared with angiographic findings in a 42-year-old woman after orthotopic liver transplantation complicated by hepatic artery thrombosis. Complete common hepatic artery thrombosis was demonstrated by Doppler sonography and digital subtraction angiography (DSA) on the first postoperative day. A thrombectomy was performed. DSA on the third day after transplantation again showed occlusion of the left hepatic artery. No perfusion was observed in the left hepatic lobe. Liver function remained normal. Doppler sonography on days 8, 10, and 16 after transplantation demonstrated arterial blood flow in both the right and left lobes of the liver, suggesting patent left and right hepatic arteries. Repeat DSA revealed that the arterial flow in the left lobe depended on large, intrahepatic shunts originating from the right hepatic artery. Apparently, shunts can develop within a few days in a transplanted liver from radiologically undetectable structures into vessel-like channels capable of supplying the entire left hepatic lobe.

Superior diagnostic strength of combined contrast enhanced MR-angiography and MR-imaging compared to intra-arterial DSA in liver transplantation candidates

To evaluate the diagnostic value of combined contrast enhanced MRA (ce-MRA) and MRI compared to that of intra-arterial DSA (i.a.DSA) in liver transplantation, transjugular porto-systemic (TIPSS) and spleno-renal shunt candidates. 50 patients in the workup for liver transplantation underwent ce-MRA/MRI and i.a.DSA within a three days interval. Both examinations were assessed with respect to vessel anatomy and patency of the arterial, portal venous, porto-systemic collateral and systemic venous system. The results were compared with the intra-operative findings when available. Malignancy detection in ce-MRA/MRI and i.a.DSA were compared. There are no significant differences for the arterial part of the vascular supply to the liver that is important for transplantation. Although the differences for the portal system are not significant, the difference between the two techniques is of clinical importance because i.a.DSA failed to detect portal vein occlusion in 4 patients. Ce-MRA is significantly better for the detection of collaterals (p < 0.001) and the assessment of the inferior vena cava, the hepatic and the renal veins (p < 0.001). Although the detection of liver malignancy is poor in both techniques, ce-MRA/MRI is superior to i.a.DSA. This study shows that a one step diagnostic approach with a combination of ce-MRA and MRI is a valuable radiological tool with a superior diagnostic strength compared to i.a.DSA in the liver transplantation and shunt candidate. Therefore, ce-MRA/MRI should replace i.a.DSA in these patients groups.

Comparison of contrast enhanced MR-angiography-MRI and digital subtraction angiography in the evaluation of pancreas and/or kidney transplantation patients: initial experience

To evaluate whether combined contrast enhanced MRA and MRI (ce-MRA-MRI) has the potential to replace intra-arterial DSA (i.a.DSA) in patients with impaired graft function or suspected of vascular complications after pancreas and/or kidney transplantation. 7 patients after combined pancreas-kidney and 22 patients after kidney transplantation underwent ce-MRA-MRI and i.a.DSA within a 3 days interval. Qualitative and quantitative comparison of the arterial and venous supply, the parenchyma and urinary collecting system was made. Both ce-MRA and i.a.DSA showed good results in the detection of arterial stenoses. However, ce-MRA falsely suggested stenoses if vascular clips were used; on the other hand, i.a.DSA was less informative if the graft arteries were very tortuous. Ce-MRA was superior in depicting the venous anatomy (p < 0.001) and the parenchymal enhancement of the pancreatic grafts. For the assessment of the contrast excretion, the pyelocalyceal system and the ureter of the renal graft ce-MRA-MRI was superior (p < 0.001), for small caliber arteries in the renal grafts i.a.DSA was of greater value (p < 0.001). The combination of ce-MRA and MRI is reliable for evaluating the vascular anatomy and has several advantages over i.a.DSA after pancreas and/or kidney transplantation. It can replace i.a.DSA in patients with impaired graft function or suspected of vascular complications after pancreas and/or kidney transplantation.

Arteriography and portal venography on routine follow-up after orthotopic liver transplantation

RATIONALE AND OBJECTIVES

To describe the findings of routinely performed angiographic examinations in patients at discharge 2 months after orthotopic liver transplantation (OLT) and at follow-up 1 year later.

METHODS

The findings of 315 angiographic examinations performed in 190 patients 2 months and 1 year after OLT were reviewed, and the changes at the anastomotic site of the hepatic artery and portal vein were analyzed.

RESULTS

Routine angiography 2 months and 1 year after OLT demonstrated a normal anastomosis or low-grade stenosis in 82% and 84% of the patients (hepatic artery) and in 88% and 84% (portal vein), respectively. High-grade stenosis occurred in 9% and 5% of the patients (hepatic artery) and in 3% and 5% (portal vein). Hepatic artery occlusion and portal vein occlusion were observed in two and seven patients and in one and three patients, respectively. In 76% of patients, the anastomotic site of the hepatic artery did not change significantly. In eight patients, a normal anastomosis or a low- or medium-grade stenosis developed into high-grade stenosis or occlusion. Conversely, in nine patients, medium- or high-grade stenosis developed into a normal anastomosis or a low-grade stenosis. In all eight patients who initially had a high-grade stenosis, the hepatic artery proved to be patent at 1 year. In 98% of patients, the anastomotic site of the portal vein did not change significantly. In one patient who initially had a normal anastomosis, occlusion was found at I year.

CONCLUSIONS

In most patients, routine angiography 2 months and 1 year after OLT demonstrated normal findings or a low-grade stenotic anastomosis of the hepatic artery and portal vein. Significant changes occurred mainly at the anastomotic site of the hepatic artery and could not be predicted by previous angiograms.

Limited role of meta-iodobenzylguanidine scintigraphy in imaging phaeochromocytoma in patients with multiple endocrine neoplasia type II

OBJECTIVE

To compare diagnostic applicability of combined computed tomography (CT) and magnetic resonance imaging (MRI), with that of meta-iodobenzylguanidine (MIBG) scintigraphy in the preoperative localisation of MEN II related phaeochromocytoma.

DESIGN

Retrospective study

SETTING

University hospital, The Netherlands.

MATERIALS

17 patients with MEN II patients (33 adrenal glands) who were operated on for phaeochromocytoma. MIBG scintigraphy, CT and MRI were used to localize phaeochromocytoma. Histopathologically, an adrenomedullary lesion more than 1 cm in size was classified as a phaeochromocytoma.

MAIN OUTCOME MEASURES

Sensitivity, specificity, and diagnostic accuracy of combined CT and MRI and MIBG scintigraphy, compared with histopathological findings.

RESULTS

Sensitivity of combined CT and MRI (27 adrenal glands) was 87%, with a specificity of 100% and a diagnostic accuracy of 89%. MIBG scintigraphy (31 adrenal glands) had a sensitivity of 92%, a specificity of only 17%, and a diagnostic accuracy of 77%.

CONCLUSION

If unilateral adrenalectomy is done when only one adrenal gland contains a phaeochromocytoma, then MRI should be the method of choice for localising MEN type II related phaeochromocytoma. MIBG scintigraphy can be restricted to those patients in whom MRI does not show a tumour.

Comparison of six nucleic acid extraction methods for detection of viral DNA or RNA sequences in four different non-serum specimen types

BACKGROUND

Extraction of viral nucleic acids from serum samples is widely used in diagnostic pathology tests. However, the heterogeneous nature of non-serum samples may contribute to variations in the yields of viral nucleic acids with different extraction methods and specimen types.

OBJECTIVES

Six different methods were compared for optimal extraction of viral DNA or RNA from four types of non-serum specimens.

STUDY DESIGN

The DNA viruses used were herpes simplex virus and cytomegalovirus. The RNA viruses were poliovirus, rotavirus and small round structured virus. The specimens used were from respiratory, genital, faecal and peripheral blood mononuclear cell samples. The extracted nucleic acids were amplified by PCR and detected in an enzyme immunoassay using digoxygenin-labelled amplicons.

RESULTS AND CONCLUSIONS

For extraction of viral DNA, the phenol-chloroform method yielded the highest amount of DNA as judged by endpoint titration. The three methods compared for extraction of viral RNA used guanidine isothiocyanate and the QiaRNA kit was shown to yield the highest amount of viral RNA.

The value of Doppler ultrasound in cirrhosis and portal hypertension

BACKGROUND

Cirrhosis and portal hypertension affect the flow profile of the liver vasculature. In these conditions Doppler ultrasound can provide important information on the hemodynamics of the portal venous system, the hepatic artery and the hepatic veins.

METHODS

The value of Doppler ultrasound in the assessment of the patient with cirrhosis and portal hypertension was determined by reviewing the literature.

RESULTS

Portal venous blood flow becomes reversed with advanced portal hypertension. Reversed flow is also demonstrated in patients with veno-occlusive disease and portosystemic shunts. Despite general agreement that portal flow velocity is decreased in cirrhotic patients, the absolute values of portal flow velocity in both healthy subjects and cirrhotic patients vary considerably. Errors in Doppler measurements, observer variability and collateral pathways contribute to these variations. Furthermore, portal blood flow is influenced by numerous factors such as changes in the body position, phase of respiration, timing of meals, exercise and cardiac output. Finally, portal flow may be unaltered due to a combination of high inflow from the splanchnic organs and increased resistance within the liver. High resistive index of the hepatic artery is seen in patients with end-stage liver disease, particularly in children with severe cirrhosis secondary to biliary atresia. However, hepatic artery flow remains normal in most patients. Abnormal hepatic vein flow profiles are seen in patients with cirrhosis, but dampening or flattening of the flow profile has a multifactorial origin (Budd-Chiari, metastases, ascites) and can be observed in healthy subjects.

CONCLUSIONS

Although many factors may affect the accuracy of volume flow and velocity measurements and the flow profile of the liver vasculature may change in different situations, Doppler ultrasound is useful in the assessment of the patient with cirrhosis and portal hypertension.

Natural history of hepatitis C in HIV-negative patients with congenital coagulation disorders

BACKGROUND/AIMS

Knowledge of the natural history of hepatitis C is useful for counselling patients and planning treatment. More data are needed from unselected patient groups without concomitant disease. The aim of this study was to describe the natural history of hepatitis C, two decades after infection, in a homogeneous and well-defined group of HIV-negative patients with congenital coagulation defects who had not received specific therapy for chronic hepatitis C.

METHODS

Medical history, physical examination, laboratory tests and abdominal ultrasonography were performed in 45 HCV-RNA positive, HIV-negative patients, mainly haemophiliacs, from a single centre. Patients were classified according to results of ultrasonography.

RESULTS

Two patients had experienced an episode of variceal bleeding; all others were asymptomatic. None had ascites. HCV-RNA titres were >500000 copies/ml in 23 patients, genotype was 1 in 31 patients. Forty (89%) had elevated transaminases, liver synthesis function was diminished in 7 (16%), and platelet count in 8 (18%). Ultrasonography was normal in 26 (58%) patients, 12 (27%) had isolated splenomegaly, and 7 (16%) had liver nodularity compatible with cirrhosis. Univariate analysis disclosed higher transaminases and gammaGT, higher age at acquisition of infection and higher present age as risk factors for more advanced disease. Of these, only higher present age was an independent predictor in multivariate analysis.

CONCLUSIONS

Median 19 years after infection, 58% of patients had no other signs of liver disease than raised transaminases, 16% had cirrhosis on ultrasonography. Only 2/45 patients had symptomatic disease. Higher present age is the main risk factor for advanced disease in this group.

Routine Doppler ultrasound for the detection of clinically unsuspected vascular complications in the early postoperative phase after orthotopic liver transplantation

To assess the role of routine Doppler ultrasound in the detection of clinically unsuspected vascular complications in the early postoperative phase after orthotopic liver transplantation (OLT), the findings of 858 routinely performed Doppler ultrasound examinations were analyzed in 268 transplants. At various time intervals after OLT, we encountered 46 abnormal Doppler findings: hepatic artery (thrombosis), portal vein [anastomotic stenosis, (non)occlusive thrombosis or reversed flow], inferior vena cava [anastomotic stenosis with reversed flow, no flow, or (non)occlusive thrombosis], and hepatic veins (to-and-fro flow or stenosis with reversed flow) in 14, 20, 9, and 2 transplants, respectively. Most of these abnormal Doppler findings were confirmed by angiography, cavography, or surgery. The positive predictive value for hepatic artery thrombosis (HAT) was 12 out of 14, or 86%. In the first 2 weeks after OLT, routine Doppler ultrasound revealed 20 of the 46 abnormal findings (43%). Clinically unsuspected complications of the hepatic artery, portal vein, inferior vena cava, and hepatic veins were found in 9 of the 14 (64%), 6 of the 20 (30%), 3 of the 9 (33%), and 2 of the 2 (100%) transplants, respectively. The highest incidence--nine vascular complications--was found on the 1st day. On each of the remaining days (except for the 2nd and 9th days), one or two vascular complications were detected. HAT was found mainly in the 1st week. Vascular complications developed independently or concomitantly. We conclude that routine Doppler ultrasound is very important for the detection of clinically unsuspected vascular complications, particularly HAT, in the first 2 weeks after OLT. We recommend routine Doppler ultrasound of all hepatic vessels every 3 days in the early postoperative phase after OLT. Special attention should be paid to the 1st day.

De novo reverse transcription of HTLV-1 following cell-to-cell transmission of infection

Analogous to transmission of human T-cell leukemia virus type 1 (HTLV-1) in vivo, an in vitro cell-to-cell infection model was established by coculturing MT-2 cells as virus donors and HUT78 cells as recipients. At a donor:recipient ratio of 1:2, cell fusion occurred and a new round of HTLV-1 genome replication was initiated in the cocultured cells. Newly synthesized unintegrated viral DNA was detected by Southern blot within 4-8 h and then increased between 8 and 48 h following cell mixing. The most dominant species of unintegrated viral DNA was 3.7 kb in size which hybridized to a full-length HTLV-1 DNA probe but not to a Kpnl viral DNA fragment that is absent from a defective proviral genome that has been previously identified in MT-2 cells. Northern blot analysis showed large amounts of viral RNA in the virus donor cells and in the cocultured cells, with a 3.4-kb species being the most abundant. This 3.4-kb RNA gave a pattern identical to that of the 3.7-kb unintegrated viral DNA in hybridization studies using the two probes. It seems likely that the unspliced RNA transcript from the defective proviral genome in MT-2 cells was effectively reverse transcribed upon initiation of cell-to-cell viral transmission to susceptible HUT78 cells. Despite active de novo reverse transcription, however, viral RNA levels remained unchanged following cell-to-cell transmission of HTLV-1 infection and no viral antigen production could be attributed to the newly initiated round of viral genome replication. As an abortive infection model this simple cell-to-cell infection system warrants more detailed study as it has the potential to provide reliable information regarding the early events in HTLV-1 transmission and infection.

Rapid detection, culture-amplification and typing of herpes simplex viruses by enzyme immunoassay in clinical samples

BACKGROUND

The laboratory diagnosis of herpes simplex infection may require rapid (direct) tests, as well as cell cultures, for detection of the virus in clinical samples. The quantity of virus present in clinical samples is variable and this may depend on the period from onset of rash. In addition, not all patients may show obvious symptoms with this infection. The successful culture of herpes simplex virus requires prompt transportation after collection of the specimen as the virus is easily inactivated. Hence, rapid and culture tests would enable detection of non-viable and viable viruses.

STUDY DESIGN

We describe the rapid detection of HSV by EIA directly in various clinical samples using commercially available polyclonal sera. In addition specimens were inoculated in microwell cell cultures and 4 days post inoculation the culture fluids were tested for HSV and subtyped by a similar EIA (culture amplified EIA).

RESULTS

The direct EIA showed an endpoint detection of 100 TCID50/ml, sensitivity of 92% (all specimen types) and specificity of 100%. The direct EIA sensitivity was 97% in non-genital specimens and 88% in genital specimens. The culture amplified EIA showed a sensitivity of 95% compared to all confirmed HSV positive samples.

CONCLUSIONS

The results of the HSV rapid tests were available within 24 h from receipt of specimens. Specimens which were culture negative/direct EIA positive were confirmed by blocking antisera. Culture positive specimens which were direct EIA negative were confirmed by subtyping of the virus.

Expression of the multidrug resistance protein (MRP) in squamous cell carcinoma of the oesophagus and response to pre-operative chemotherapy

One of the major problems in the treatment of squamous cell carcinoma of the oesophagus (ESCC) is the unresponsiveness to cytotoxic drugs. So far, the mechanisms underlying the intrinsic drug resistance of ESCC remain unclear. The aim of this study was to determine the role of the newly recognised drug resistance protein, the multidrug resistance protein (MRP), in ESCC drug resistance. Tumour biopsies from ESCCs were analysed by RNase protection assay (RPA) as well as by immunohistochemistry (IHC) for the presence of MRP mRNA or protein, respectively. The ESCC samples were obtained from patients participating in a prospective randomised clinical phase III trial, evaluating pre-operative chemotherapy (cisplatin and etoposide) followed by surgery versus surgery alone in patients with operable ESCC. For most patients, tumour biopsies taken at diagnosis by endoscopy as well as surgically resected primary tumours were available. Of 58 ESCC patients enrolled, 28 received chemotherapy before surgical resection of their tumours, and 30 were treated with surgery alone. 12 patients (3 complete and 9 partial responses; 43%) showed a major response after chemotherapy, 10 patients (36%) had stable disease (SD), and 6 (21%) progressive disease (PD). On 14 surgically resected, untreated, primary ESCCs, the IHC scores correlated with the MRP mRNA levels, quantitated by RPA (multiple testing, P < 0.01). MRP expression was detected by IHC in the vast majority (52/58; 90%) of the diagnostic biopsies. MRP expression did not differ significantly between CR + PR, and patients with SD or PD. In addition, multivariate analysis by logistic regression did not show any effect of tumour cell differentiation or UICC tumour stage on the outcome of pre-operative chemotherapy in relation to MRP expression. However, a difference became apparent (Sign-test, P < 0.05) for higher MRP expression in tumours from patients with PR or SD, when comparing MRP levels in paired tumour samples before and after chemotherapy, suggesting that chemotherapy selected for drug-resistant cell clones.

Detection of Chlamydia trachomatis in urine samples by nucleic acid tests: comparison with culture and enzyme immunoassay of genital swab specimens

Two commercially available nucleic acid-based tests, ligase chain reaction (LCR; Abbott Laboratories) and PCR (Roche Diagnostics), for the detection of Chlamydia trachomatis in male and female urine samples were compared with culture and enzyme immunoassay (EIA) (Microtrak; Syva) for C. trachomatis detection in genital samples. The samples were collected from 1,005 patients who attended a sexually transmitted disease clinic. In this study population, the prevalence of the infection was 4%. Specimens which were reactive in any of the tests were retested with a different PCR test using primers directed against the major outer membrane protein gene. With a "gold standard" of a positive culture, or any other positive test result if it was confirmed by an independent test, the Roche PCR (95% sensitive, 99.9% specific) was more sensitive than the LCR (75% sensitive, 100% specific) (chi2, P < 0.0001) while both tests were more sensitive than culture (58% sensitive, 100% specific) or EIA (45% sensitive, 100% specific) (chi2, P < 0.001). The Roche PCR and Abbott LCR tests of urine identified 65% and 30% more positive patients, respectively, than did testing by culture of urethral or cervical specimens. Nucleic acid testing of urine specimens for C. trachomatis is a more sensitive and convenient method for the detection of genital infection.

Splenic artery aneurysms in liver transplant patients. Liver Transplant Group

BACKGROUND/AIMS

The purpose of the study was to investigate the incidence of and risk factors for splenic artery aneurysms in liver transplant patients.

METHODS

Medical records and the pre- and 1-year postoperative angiograms of 337 liver transplant patients were reviewed to assess the presence and characteristics of these aneurysms.

RESULTS

Forty-five patients with aneurysms were identified (13%): 41 cases in 242 adult patients (17%) and four (4%) in 95 children (p<0.01). The female-to-male ratio was 2:1. The majority of the aneurysms (87%) were located in the distal third of the splenic artery and the majority (87%) of the patients presented multiple aneurysms. In patients without portal hypertension no aneurysms were identified, whereas in 16% of the patients with portal hypertension aneurysms were found (p<0.001). In adult patients the incidence of splenic artery aneurysms was significantly higher in patients with parenchymal diseases than in patients with cholestatic diseases (p<0.0001). Two patients (4%) died due to rupture of the aneurysms. Control angiographies, 1 year after liver transplantation, showed no changes in size and number of the aneurysms, and no new aneurysms were identified.

CONCLUSIONS

The incidence of splenic artery aneurysms in liver transplant patients is 13%. They are generally multiple and located in the distal third of the splenic artery. The incidence is higher in women and in patients with parenchymal liver disease and portal hypertension. The incidence of rupture was 4%.

Prevalence of respiratory viruses and Mycoplasma pneumoniae in sputum samples from unselected adult patients

Sputum samples from adult patients are routinely used for bacteriological tests, but not for the diagnosis of viral/mycoplasmal infections. We examined 511 sputum samples submitted for bacterial tests from patients at the Royal Adelaide Hospital. Each specimen was tested directly (and after six days of cell culture amplification) for antigens to influenza A and B, parainfluenza 1, 2 and 3, adenovirus, respiratory syncytial virus (RSV) and Mycoplasma pneumoniae. Respiratory viruses or M. pneumoniae were found in 11% of all specimens but were most common (14%) in sputa reported as containing only "oral flora". Respiratory virus or M. pneumoniae infection was significantly more common in medical patients (12%) than in surgical patients (5%), and was most common in oncology (hematology/radiotherapy) patients (25%). Influenza A and RSV were equally common in medical patients, while RSV was the most frequent isolate in oncology patients. Respiratory viral infection is an underdiagnosed condition in adults, particularly the immunocompromised, which can be successfully diagnosed by virological examination of sputum.

Changes in portal hemodynamics and acute rejection in the first 2 weeks after orthotopic liver transplantation. A prospective Doppler ultrasound study

RATIONALE AND OBJECTIVES

To analyze changes in Doppler ultrasound variables of the portal vein in relation to liver biopsy findings, the authors performed a prospective study of 316 Doppler ultrasound examinations in the first 2 weeks after orthotopic liver transplantation on 23 patients.

METHODS

Recordings were obtained daily from the portal vein (diameter, maximum velocity, and flow). Correlations were explored between the Doppler ultrasound findings and histologic data. The chi-square test was used to analyze differences in Doppler ultrasound variables in patients with and without acute rejection.

RESULTS

In our series of 23 patients, acute rejection was diagnosed by liver biopsy in nine of them (39%). Changes in portal vein diameter, maximum velocity, and flow did not correlate consistently with liver biopsy findings, due to a multifactorial origin. Changes in portal hemodynamics were observed in patients with hepatic artery thrombosis, portal vein stenosis, acute rejection, and sepsis.

CONCLUSIONS

Although routine screening using Doppler ultrasound proved to be useful for the determination of rapid changes in portal hemodynamics within a short time, serial Doppler ultrasound examinations were not helpful in predicting acute rejection.

Preoperative assessment of the portal vein and hepatic artery in children with end-stage liver disease: is selective angiography still necessary?

BACKGROUND

Selective angiography involves increased risk for children and may cause vascular complications. The aim of this study was to determine whether selective angiography is still necessary for viewing the portal vein and hepatic artery.

METHODS

Doppler ultrasound, abdominal aortography, and selective angiography were performed and interpreted independently in 62 children (median age = 1 year 3 months), with end-stage liver disease, who were candidates for orthotopic liver transplantation.

RESULTS

Selective angiography agreed with the Doppler ultrasound findings of patency, flow direction, and diameter of the extrahepatic portal vein in 84%, 73%, and 79% of the children, respectively. Important additional information was obtained from selective angiography in only five of the 62 children (8%). Selective angiography showed an anomaly of the hepatic artery in 21 of the 62 children (33%). In 18 out of these 21 children (85%), an anomaly of the hepatic artery was already visible on the abdominal aortogram.

CONCLUSION

Selective angiography did not play any significant role in the detection of an anomaly of the hepatic artery and should only be done if the Doppler ultrasound findings of the portal vein are inconclusive or if abdominal aortography cannot provide reliable information about the hepatic artery. For the evaluation of the portal vein and hepatic artery, we recommend Doppler ultrasound and abdominal aortography, a less invasive angiographic procedure.

Analysis of growth in children after orthotopic liver transplantation

Growth after pediatric liver transplantation is an important factor in determining the quality of life. We collected data on height, skeletal age, and liver function of 45 consecutive pediatric transplant recipients and assessed the influence of primary diagnosis, liver function, and immunosuppressive regimen on their growth. Height and skeletal age were plotted as median standard deviation scores versus years post-transplantation. Growth, in terms of both height and skeletal age, were continuous without catch-up growth. Primary diagnosis was found to have no influence on height and poor liver function had a negative effect on both height and skeletal growth. A higher alternate day prednisolone maintenance dose also had negative effect on skeletal growth. Thus, it can be concluded that a pretransplant lack of growth will not be restored and is an indication for early transplantation in end-stage liver disease, especially in younger children.

Fotemustine in patients with advanced gastric cancer, a phase II trial from the EORTC-GITCCG (European Organization for Research and Treatment of Cancer, Gastrointestinal Tract Cancer Cooperative Group)

Fotemustine activity was evaluated in 26 patients, mostly pretreated, with advanced gastric cancer. Its main toxicity was haematological with grade 3-4 neutropenia in 32% and grade 3-4 thrombocytopenia in 50% of the patients, complicated by 2 toxicity-related deaths due to haemorrhage. No complete or partial responses were observed in the 26 eligible patients and median survival was only 11 weeks. Fotemustine therefore has no activity in advanced gastric cancer.

Doppler ultrasound of the hepatic artery and vein performed daily in the first two weeks after orthotopic liver transplantation. Useful for the diagnosis of acute rejection?

RATIONALE AND OBJECTIVES

To analyze changes in Doppler ultrasound variables in relation to liver biopsy findings for the diagnosis of acute rejection after orthotopic liver transplantation (OLT), the authors performed in a prospective study 316 Doppler ultrasound examinations in the first 2 weeks after OLT on 23 patients.

METHODS

Recordings were obtained daily from the hepatic artery (resistive index [RI]) and hepatic vein (damping index [DI]). Correlations were explored between the Doppler ultrasound findings and histologic data. The chi-square test was used to analyze differences in Doppler ultrasound variables in patients with and without acute rejection.

RESULTS

Serial Doppler ultrasound examinations showed a significant increase in the RI in 11 of 22 patients (50%); the 23rd patient was excluded because of hepatic artery thrombosis. Despite an agreement in 15 of 22 patients (68%) no statistically significant correlation could be found (positive predictive value 6/11 = 55%; negative predictive value 9/11 = 82%; chi-square = 3.14; P > 0.05). A significant increase in the DI was observed in 14 of 23 patients (61%). However, no statistically significant correlation could be found as well with this parameter (positive predictive value 6/14 = 43%; negative predictive value 6/9 = 67%; chi-square = 0.00; P > 0.05).

CONCLUSION

Serial Doppler ultrasound examinations were not helpful in predicting acute rejection.

Ultrasound and cholangiography for the diagnosis of biliary complications after orthotopic liver transplantation: a comparative study

The ability of ultrasound to detect biliary obstruction, bile leakage and generalized ductal changes after orthotopic liver transplantation (OLT) was compared to cholangiography. Cholangiography was considered to be the gold standard. Adequate opacification of the biliary tree was achieved in 139 cholangiograms. Biliary obstruction, intermediate or large bile leakage, and generalized ductal changes were diagnosed with cholangiography in 15% (21/139), 14% (20/139), and 16% (22/139), respectively. Normal ultrasound findings could not exclude biliary stricture, generalized ductal changes, or bile leakage, and fluid collections were not correlated with bile leakage. Abnormal ultrasound findings were highly predictive of the cholangiographic diagnosis of biliary obstruction or generalized ductal changes (specificity of 98% and 100%, respectively). An irregular appearance of the bile ducts and increased periductal echogenicity proved to be characteristic features for generalized ductal changes.

Absence of human papillomavirus DNA from esophageal carcinoma as determined by multiple broad spectrum polymerase chain reactions

Strong evidence has implicated human papillomaviruses (HPV) in the pathogenesis of anogenital cancers and a number of other mucosal and cutaneous lesions. Data concerning the involvement of HPV in esophageal cancers are controversial. Different investigators have detected HPV types (mainly types 16 and 18) in biopsy specimens of esophageal cancers. A study was undertaken to determine whether responses to chemotherapy of advanced squamous cell carcinomas could be correlated with the HPV status. Polymerase chain reaction (PCR) amplification was used for the detection of HPV DNA in biopsies of esophageal squamous cell carcinomas treated with either surgical resection alone (n = 42) or chemotherapy followed by surgical resection (n = 21). Different general and consensus PCR primer sets, which allow the detection of most of the known as well as a number of not yet characterized HPV types, were used. HPV DNA was not detected in any of the 61 esophageal squamous cell carcinomas, suggesting that HPV infections are not likely to play a major role in the etiology of this neoplasm.

Familial occurrence of membranous obstruction of the inferior vena cava: arguments in favor of a congenital etiology

Membranous obstruction of the inferior vena cava is a rare disease. The etiology of the membrane is believed to be thrombotic or congenital. In three of 11 siblings from a single family, symptoms of membranous obstruction of the inferior vena cava developed during early adult life. All had signs of more long-standing disease, as judged by the presence of collaterals, cirrhosis and, in one case, hepatocellular carcinoma. On family screening no further cases of membranous obstruction of the inferior vena cava were found. There was also no evidence of inherited defects in the natural coagulation inhibitors (protein C, protein S and antithrombin III) and plasminogen deficiency. This familial occurrence of membranous obstruction of the inferior vena cava supports a congenital etiology, although a thrombotic etiology cannot be totally excluded.

Rapid diagnosis of chlamydial respiratory infection in children

A study was undertaken to determine the incidence of chlamydial respiratory infection in paediatric patients during a 12-month period by antigen detection. Nasopharyngeal aspirates (NPA) from 514 patients were screened for genus-specific chlamydia antigen using the Pharmacia Chlamydia enzyme immunoassay (EIA) and Kallestad immunofluorescence (IF) assays. EIA screen-positive samples were confirmed by specific blocking antibody. Specimens which were EIA positive or IF positive were cultured for chlamydia. The NPAs from 7 patients were positive in the EIA and IF assays. Four of these patients were culture positive for chlamydia. Our results showed that the incidence of chlamydia respiratory infection by antigen detection was 1.4% or 0.8% if confirmed by culture.

Doppler ultrasound and angiography of the vasculature of the liver in children after orthotopic liver transplantation: a prospective study

Despite the availability of Doppler ultrasound, angiography still forms part of the protocol for evaluating children after orthotopic liver transplantation (OLT) at our department. To investigate whether Doppler ultrasound is a reliable method for evaluating the patency of the hepatic artery, portal vein, inferior vena cava, and the anastomotic site of the portal vein in children after OLT, we performed a prospective study in which Doppler ultrasound was compared with angiography in 38 children with 40 transplants (ten examinations on clinical demand and 49 examinations according to protocol). Good correlation was found in relation to demonstrating a patent hepatic artery (sensitivity 96% and specificity 100%). Two false-negative Doppler ultrasound results were attributable to technical difficulties and rejection. For evaluating the patency of the portal vein, Doppler ultrasound agreed with angiography in 58 of the 59 examinations (98%). The one and only false-positive angiography result was explained by inadequate opacification. Doppler ultrasound visualized stenosis of the portal vein three times more often than angiography. In seven children, Doppler ultrasound findings suspicious of pathology of the inferior vena cava were confirmed using cavography or surgery. Doppler ultrasound proved to be a reliable technique for evaluating the patency of the hepatic artery, inferior vena cava, and portal vein and the anastomotic site of the portal vein.

Routine diagnosis of seven respiratory viruses and Mycoplasma pneumoniae by enzyme immunoassay

A composite EIA, using 8-well microstrips, was used for the rapid detection of seven respiratory viruses and M. pneumoniae. The viruses included influenza A and B, parainfluenza 1, 2 and 3, adenovirus and respiratory syncytial virus. During the 61 month period--June 1988 to June 1993--17326 respiratory specimens, submitted from three states, were tested by this EIA. The specimens were mainly from a paediatric population (hospitals and private physicians). RSV was the predominant virus detected, followed by adenovirus, parainfluenza 3, M. pneumoniae, influenza A, parainfluenza 2, influenza B and parainfluenza 1. The use of blocking antibodies confirmed the identification of the agents, in particular with samples showing absorbance values greater than the cutoff with more than one infectious agent. Different methods for processing specimens in order to obtain a uniform suspension, and interpretation of non-specific reactions, are discussed. The assays showed an average sensitivity of 85% and specificity of 99%, compared to virus culture. This EIA system provided an efficient method for the rapid diagnosis of viral and mycoplasmal infections in a busy diagnostic laboratory.

Initiation of reverse transcription during cell-to-cell transmission of human immunodeficiency virus infection uses pre-existing reverse transcriptase

H3B cells, a laboratory clone of H9 cells persistently infected with the HTLV-IIIB strain of human immunodeficiency virus (HIV), contained significant levels of cell-associated reverse transcriptase (RT) activity measured by in vitro assays using either exogenous or endogenous templates. The cell-associated RT activity detected using exogenous template was almost wholly in a soluble (non-sedimentable) form whereas endogenous activity sedimented as a particulate structure associated with viral RNA. Despite this, H3B cells did not contain episomal HIV DNA detectable by Southern blot, indicating that in vivo reverse transcription was not occurring to any significant extent in these cells. However, when susceptible HUT 78 cells were infected by co-cultivation with H3B cells, dramatic synthesis of episomal HIV DNA occurred. Concurrently with this de novo initiation of reverse transcription, however, we found no detectable change in intracellular levels or cleavage profiles of immunoprecipitable RT polypeptides. Finally, actinomycin D pre-treatment of H3B cells to prevent de novo transcription from donor cell proviral DNA after co-cultivation did not affect the initiation of in vivo reverse transcription following cell-to-cell HIV infection. These results demonstrated that cells persistently infected with HIV contained significant fully cleaved cell-associated RT in a form that was active in vitro but not in vivo and that following cell-to-cell transmission of HIV infection to susceptible cells, de novo reverse transcription was initiated without detectable evidence of further synthesis or proteolytic processing of HIV RT. The nature of this initiation process requires further study.

Outbreak of adenovirus type 4 conjunctivitis in South Australia

An outbreak of adenovirus type 4 conjunctivitis occurred in South Australia between April and November 1992. Eye swabs were submitted by general practitioners and ophthalmologists who had seen patients with clinical conjunctivitis or keratitis. Apart from interfamilial spread, there were no other common epidemiological factors. Adenovirus was isolated from the eye swabs of 38 patients. Isolates were typed by neutralisation tests and restriction endonuclease cleavage patterns and found to be adenovirus type 4. This report serves to illustrate an infrequent cause of epidemic conjunctivitis, namely adenovirus type 4. There was no demonstrable focus of the outbreak.

[Different evaluations of the staging of Hodgkin's and non-Hodgkin's lymphomas (NHL) with computer tomography and lymphography by different observers]

In this report, the differences in the evaluation of CT and lymphography findings by different observers is discussed. The study included 132 men and 79 women (146 NHL and 65 Hodgkin lymphomas). A total of 185 CT examinations and 78 lymphographies were available for reevaluation. In the lymphographies, discongruent findings were reported twice as frequently as in the CT scans (15% and 9%). An optimized examination protocol for CT and consistent criteria for the interpretation of lymphographic findings could possible lead to a better diagnostic evaluation.

The use of MDCK, MEK and LLC-MK2 cell lines with enzyme immunoassay for the isolation of influenza and parainfluenza viruses from clinical specimens

Primary Monkey Kidney (PMK) epithelial cells or egg inoculation have been traditionally used for the culture of influenza and parainfluenza viruses. The high cost and variability of obtaining high quality PMK cells prompted us to investigate the use of other cell strains for the growth of these viruses. For this study we investigated three cell lines viz. MDCK, MEK and LLC-MK2 for the culture of influenza A and B and parainfluenza 1, 2 and 3 viruses. Clinical specimens were spun onto cell monolayers in microtitre wells. The growth of these viruses was then identified by specific antibodies in an enzyme immunoassay (EIA). The LLC-MK2 and MDCK cell lines were found to provide optimal growth of parainfluenza and influenza viruses respectively. During the period from November, 1990 to July, 1992, 6501 respiratory specimens were tested. There were 100 influenza A, 36 influenza B and 261 parainfluenza virus isolates. The influenza isolates were further subtyped by the WHO Influenza Reference Centre. The use of these cell lines and the EIA provided an effective method for the routine culture of these viruses.

Successful treatment of veno-occlusive disease of the liver with urokinase in a patient with non-Hodgkin's lymphoma

A 38-year-old man with a non-Hodgkin's lymphoma of intermediate grade malignancy attained partial remission after three courses of CHOP (cyclophosphamide+hydroxydaunorubicin+vincristine+prednisolone). He was assigned to undergo autologous bone marrow transplantation (ABMT). The conditioning regimen consisted of cyclophosphamide and whole body irradiation. Two weeks later he developed veno-occlusive disease (VOD) of the liver. Doppler sonography confirmed the diagnosis showing a reversal of the blood flow in the portal vein. In addition a large thrombus was present in the inferior caval vein. Protein C level was strongly reduced (28%). Because of clinical deterioration intravenous urokinase was started. The transaminases normalised rapidly and the patient showed a dramatic clinical improvement. There were no major bleeding complications. Repeat Doppler sonography showed a normal antegrade flow in the portal vein. This case suggests that a coagulopathy in the hepatic vascular bed might contribute to the development of VOD and that patients with VOD are at risk for other thrombotic complications. Furthermore it shows that urokinase with platelet support can be given safely and effectively to a patient with VOD and severe thrombocytopenia.

Cell-to-cell transmission of human immunodeficiency virus infection induces two distinct phases of viral RNA expression under separate regulatory control

A cell clone persistently infected with human T cell-lymphotrophic virus type IIIB (H3B cells) contained mainly the multiply spliced (2 kb) and singly spliced (4.3 kb) species of human immunodeficiency virus (HIV) RNA. When H3B cells were co-cultured with susceptible HUT78 cells, cell fusion occurred within 4 h of cell mixing and was accompanied by a marked increase of the unspliced full-length (9.2 kb) HIV RNA. This first phase of viral RNA induction (4 to 12 h post-infection) was followed by a second phase of viral RNA synthesis from 24 h p.i. in which there were significant increases in all three species of HIV RNA. Reverse transcriptase (RT) inhibitors such as azidothymidine (AZT) at concentrations that abolished de novo HIV DNA synthesis, abolished the first phase but not the second phase of viral RNA synthesis in our model system. A comparable one-step cell-free virus infection showed a pattern of viral RNA synthesis similar to that of the cell-to-cell transmission of infection. However, viral RNA synthesis following cell-free virus infection was totally inhibited by RT inhibitors. The early phase (4 to 12 h) expression of 9.2 kb HIV RNA is likely to use newly synthesized HIV DNA as template; during this phase, HIV RNA and DNA syntheses occur simultaneously, with each process being dependent on the other for maximal yield. During the later (24 to 48 h) phase, all three HIV RNA species may be transcribed at least in part from proviral DNA from the original donor cells. This later phase may provide one of the mechanisms for natural spread of virus to new cells and for enhanced viral gene expression in vivo, despite the presence of AZT.

Phase II study of miltefosine (hexadecylphosphocholine) in advanced soft tissue sarcomas of the adult--an EORTC Soft Tissue and Bone Sarcoma Group Study

The EORTC Soft Tissue and Bone Sarcoma Group conducted a phase II study with oral miltefosine at a dose of 50 mg thrice daily in patients with metastatic soft tissue sarcomas. No responses were seen in 18 evaluable patients. Toxicity consisted mainly of nausea/vomiting. It is concluded that oral miltefosine has no activity in soft tissue sarcoma.

Activity of cisplatin in adenocarcinoma of the pancreas

The activity of cisplatin in metastatic adenocarcinoma of the pancreas was assessed in 33 patients. Cisplatin was administered in a dose of 100 mg/m2, every 4 weeks. There were 2 complete responses and 5 partial responses (a response rate of 21%). The median duration of response was 5 months (range, 2+ to 15 months). Cisplatin is a modestly active drug in advanced pancreatic cancer.

Treatment of patients with metastatic pancreatic and gastrointestinal tumours with the somatostatin analogue Sandostatin: a phase II study including endocrine effects

Somatostatin analogues can suppress the secretion of some gastrointestinal hormones and growth factors involved in the growth regulation of gastrointestinal cancers and can inhibit the growth of experimental pancreatic tumours. Therefore, in a phase II study 34 patients with metastatic pancreatic (n = 14), colorectal (n = 16) and gastric cancer (n = 4) were treated with three daily subcutaneous injections of 100-200 micrograms of the somatostatin analogue Sandostatin (SMS 201-995). All patients had an extensive tumour load and 13 were pretreated with chemotherapy. Before Sandostatin treatment the patients with pancreatic cancer showed a higher mean plasma concentration of GH (P less than 0.05) and a lower concentration of 'total' somatomedin-C (P less than 0.005) compared with patients with colorectal cancer; there was no significant difference between these two groups in plasma levels of directly assayable somatomedin-C, EGF/TGF-alpha, insulin and prolactin. Within 3 days after start of treatment, somatomedin-C levels initially decreased (without a change in basal plasma GH levels), but returned to pretreatment levels within 4-13 weeks. Plasma insulin levels also were suppressed but only during the first 3-5 days of treatment. Plasma EGF-TGF-alpha levels increased significantly at day 5 of treatment only in the pancreatic cancer patients. Twenty-seven per cent of the patients showed stable disease for 3-9 months, but most patients experienced subjective improvement in the absence of serious side-effects. However, the overall survival remained disappointing, emphasising the need for better treatment regimens.

Evaluation of the Becton Dickinson Directigen test for respiratory syncytial virus in nasopharyngeal aspirates

A premarket trial of the Becton Dickinson Directigen respiratory syncytial virus membrane-based enzyme immunoassay compared the test with virus isolation for the detection of respiratory syncytial virus in 583 nasopharyngeal aspirates. After modification, the Directigen test showed a sensitivity of 83% and a specificity of 90%. It offers the potential for an efficient bedside test--without the need for any equipment--for the diagnosis of respiratory syncytial virus infection and requires only a 0.25-ml sample volume. However, for optimum reliability, freezing-thawing of samples and access to a confirmatory test were shown to be necessary.