Hypoxic induction of interleukin-8 gene expression in human endothelial cells

Because leukocyte-mediated tissue damage is an important component of the pathologic picture in ischemia/reperfusion, we have sought mechanisms by which PMNs are directed into hypoxic tissue. Incubation of human endothelial cells (ECs) in hypoxia, PO2 approximately 14-18 Torr, led to time-dependent release of IL-8 antigen into the conditioned medium; this was accompanied by increased chemotactic activity for PMNs, blocked by antibody to IL-8. Production of IL-8 by hypoxic ECs occurred concomitantly with both increased levels of IL-8 mRNA, based on polymerase chain reaction analysis, and increased IL-8 transcription, based on nuclear run-on assays. Northern analysis of mRNA from hypoxic ECs also demonstrated increased levels of mRNA for macrophage chemotactic protein-1, another member of the chemokine superfamily of proinflammatory cytokines. IL-8 gene induction was associated with the presence of increased binding activity in nuclear extracts from hypoxic ECs for the NF-kB site. Studies with human umbilical vein segments exposed to hypoxia also demonstrated increased elaboration of IL-8 antigen compared with normoxic controls. In mice exposed to hypoxia (PO2 approximately 30-40 Torr), there was increased pulmonary leukostasis, as evidenced by increased myeloperoxidase activity in tissue homogenates. In parallel, increased levels of transcripts for IP-10, a murine homologue in the chemokine family related to IL-8, were observed in hypoxic lung tissue. Taken together, these data suggest that hypoxia constitutes a stimulus for leukocyte chemotaxis and tissue leukostasis.

Effects of dietary supplements of wheat bran and cellulose on faeces and bowel function

In a study of bowel function in normal subjects wheat bran or cellulose was added to the diet for four weeks (16 g/day). Stool weight increased. Intestinal transit time did not significantly alter. Faecal bile acids did not increase but were diluted. It seems that the effect of these materials is to produce a bulky stool and that any symptomatic benefit they produce is secondary to this.

Anatomic anterior cruciate ligament (ACL) reconstruction: a global perspective. Part 1

PURPOSE

In August 2011, orthopaedic surgeons from more than 20 countries attended a summit on anatomic anterior cruciate ligament (ACL) reconstruction. The summit offered a unique opportunity to discuss current concepts, approaches, and techniques in the field of ACL reconstruction among leading surgeons in the field.

METHODS

Five panels (with 36 panellists) were conducted on key issues in ACL surgery: anatomic ACL reconstruction, rehabilitation and return to activity following anatomic ACL reconstruction, failure after ACL reconstruction, revision anatomic ACL reconstruction, and partial ACL injuries and ACL augmentation. Panellists' responses were secondarily collected using an online survey.

RESULTS

Thirty-six panellists (35 surgeons and 1 physical therapist) sat on at least one panel. Of the 35 surgeons surveyed, 22 reported performing "anatomic" ACL reconstructions. The preferred graft choice was hamstring tendon autograft (53.1 %) followed by bone-patellar tendon-bone autograft (22.8 %), allograft (13.5 %), and quadriceps tendon autograft (10.6 %). Patients generally returned to play after an average of 6 months, with return to full competition after an average of 8 months. ACL reconstruction "failure" was defined by 12 surgeons as instability and pathological laxity on examination, a need for revision, and/or evidence of tear on magnetic resonance imaging. The average percentage of patients meeting the criteria for "failure" was 8.2 %.

CONCLUSIONS

These data summarize the results of five panels on anatomic ACL reconstruction. The most popular graft choice among surgeons for primary ACL reconstructions is hamstring tendon autograft, with allograft being used most frequently employed in revision cases. Nearly half of the surgeons surveyed performed both single- and double-bundle ACL reconstructions depending on certain criteria. Regardless of the technique regularly employed, there was unanimous support among surgeons for the use of "anatomic" reconstructions using bony and soft tissue remnant landmarks.

p19ARF targets certain E2F species for degradation

p19ARF suppresses the growth of cells lacking p53 through an unknown mechanism. p19ARF was found to complex with transcription factors E2F1, -2, and -3. Levels of endogenous or ectopically expressed E2F1, -2, and -3, but not E2F6, were reduced after synthesis of p19ARF, through a mechanism involving increased turnover. p19ARF-induced degradation of E2F1 depended on a functional proteasome, and E2F1 was relocalized to nucleoli when coexpressed with p19ARF. Consistent with reduced levels of E2F1 and E2F3, the proliferation of cells defective for p53 function was suppressed by p19ARF, and the effect was partially reversed by ectopic overexpression of E2F1. These results suggest a broader role for p19ARF as a tumor suppressor, in which targeting of certain E2F species may cooperate with stimulation of the p53 pathway to counteract oncogenic growth signals.

Prolonged and continuous percutaneous intra-arterial hepatic infusion chemotherapy in advanced metastatic liver adenocarcinoma from colorectal primary

Sixty patients with advanced metastatic adenocarcinoma of the liver from a colorectal primary were treated by prolonged and continuous intra-arterial hepatic arterial infusion chemotherapy over a period of time from December 1969 through July 1976. A 10-day course of 5-FU was administered in the hospital, and patients were discharged receiving 5-FUDR by continuous arterial infusion through a chronometric infusion pump. Objective responses of 100% were obtained in 15% of patients, 50% response in 39% of patients, and 25% response in 21% of patients. The median survival from onset of treatment was 8.5 months, 6.9 months, and 7 months, respectively, for 100%, 50%, and 25% responders versus 3.6 months for nonresponders. Survivals from onset of treatment were generally less in those with no disease-free interval. No relationship of response to sex and age was found. Patients previously treated with 5-FU intravenously responded to intra-arterial chemotherapy; 13% had a 100% response, and 54% had a 50% response. No relationship of drug dose to response was observed. Drug toxicity was frequently systemic and mild to moderate. Numerous complications occurred due to the catheter, complete or partial thrombosis occurring in 18.6% and 20.8%, respectively, and 30% of patients had displacement of the catheter. The role of partial arterial occlusion in terms of response and survival may be significant. Future studies should involve comparison of direct surgical placement versus percutaneous placement of catheters.

Effects of insulin-like growth factor I and insulin on proliferation and on basal and luteinizing hormone-induced steroidogenesis of bovine thecal cells: involvement of glucose and receptors for insulin-like growth factor I and luteinizing hormone

The objective of the present study was to determine the effects of IGF-I and insulin on cell proliferation, LH receptors, and basal and LH-induced progesterone and androstenedione production by bovine thecal cells. Cells from large (> or = 8mm) bovine follicles were cultured for 1 or 2 d in medium containing 10% fetal calf serum (FCS) and treated for 1 or 2 d in serum-free medium with IGF-I, insulin, and(or) LH. Treatment with 30 and 100 ng/mL of IGF-I for 1 or 2 d increased thecal cell numbers in the absence of LH regardless of whether treatments were initiated after 1 or 2 d of exposure to 10% FCS. Co-treatment with LH reduced the stimulatory effect of IGF-I on thecal cell numbers. Insulin at 10 and 100 ng/mL increased cell numbers in the presence of LH. Both IGF-I and insulin were ineffective at stimulating thecal cell progesterone or androstenedione production in the absence of LH. However, IGF-I and insulin increased (P < .05) androstenedione and progesterone production in the presence of LH. Alone, LH had little or no effect on androstenedione and progesterone production, whereas in the presence of 30 and 100 ng/mL IGF-I or 1 to 100 ng/mL insulin, LH stimulated (P < .05) androstenedione production. The stimulatory effects of IGF-I on cell proliferation and progesterone production were not detected in the presence of 100 ng/mL insulin. However, co-treatment with various doses of IGF-I and 100 ng/mL insulin further increased androstenedione production above that seen with insulin alone. In glucose-deficient medium, 25 to 75 mg/dL of glucose increased (P < .05) thecal cell proliferation, progesterone production, and androstenedione production. In the absence or presence of glucose, insulin (100 ng/mL) increased (P < .05) thecal cell proliferation, progesterone production, and androstenedione production. Treatment with 3, 10, or 100 ng/mL LH had no effect (P > .10) on the numbers of IGF-I binding sites on thecal cells but increased (P < .05) androstenedione production. Treatment with 10 and 100 ng/mL IGF-I increased (P <.01) numbers of LH/hCG binding sites. These results indicate that IGF-I and insulin may each play a significant role in thecal cell mitogenesis and LH-induced thecal cell steroidogenesis during follicular development in cattle and that glucose enhances these effects. Furthermore, the synergism between IGF-I and LH on increasing steroidogenesis does not seem to be mediated through increased binding sites for IGF-I in bovine thecal cells but rather, in part, through increased binding sites for LH.

Measurement of 240Pu/239Pu isotopic ratios in soils from the Marshall Islands using ICP-MS

Nuclear weapons tests conducted by the United States in the Marshall Islands produced significant quantities of regional or tropospheric fallout contamination. Here we report on some preliminary inductively coupled plasma-mass spectrometry (ICP-MS) measurements of plutonium isolated from seven composite soil samples collected from Bikini, Enewetak and Rongelap Atolls in the northern Marshall Islands. These data show that 240Pu/239Pu isotopic signatures in surface soils from the Marshall Island vary significantly and could potentially be used to help quantify the range and extent of fallout deposition (and associated impacts) from specific weapons tests. 137Cs and 60Co were also determined on the same set of soil samples for comparative purposes.

Long-term effectiveness and safety of recombinant human interferon gamma therapy for atopic dermatitis despite unchanged serum IgE levels

OBJECTIVE

To assess the long-term effects of recombinant human interferon gamma treatment of atopic dermatitis (AD).

DESIGN

Case series. Patients were treated for up to 24 months.

SETTING

University dermatology outpatient clinics in Ann Arbor, Mich, and Portland, Ore.

PATIENTS

Twenty-four of 32 eligible patients who participated in a previously reported, 12-week, double-blind, placebo-controlled study of recombinant human interferon gamma treatment for AD were enrolled.

INTERVENTION

Patients self-administered recombinant human interferon gamma, 50 microg/m2, by daily subcutaneous injection.

MAIN OUTCOME MEASURES

Overall response; body surface area of involvement; clinical severity scores for pruritus, erythema, edema, excoriations, dryness, scaling, and lichenification; other atopic symptoms; and laboratory parameters, including serum IgE levels, were monitored at quarterly visits. Results at 1 and 2 years were compared with baseline values.

RESULTS

All efficacy parameters improved (P<.05). For example, pruritus was reduced by 50% after both 1 (n=24, P<.001) and 2 (n=16, P=.005) years. Allergic conjunctivitis and allergic rhinitis also improved (P<.01). Eosinophil counts decreased significantly (P<.001). IgE levels increased. Clinical improvement more closely correlated with changes in eosinophil counts (r=0.3-0.5) than with changes in IgE levels (r=0.0-0.2). Only 1 patient discontinued therapy because of adverse effects (flulike symptoms).

CONCLUSIONS

The initial efficacy and adverse effects reported for recombinant human interferon gamma treatment of patients with AD were maintained after 2 years of long-term use. Recombinant human interferon gamma seems to be a well-tolerated and effective agent in the long-term therapy of patients with AD. Therapies that correct cellular immune defects, but not humoral immune defects, may be effective in the treatment of patients with AD.

The anti-epileptic actions of neuropeptide Y in the hippocampus are mediated by Y2 and not Y5 receptors

Neuropeptide Y (NPY) potently inhibits glutamate release and seizure activity in rodent hippocampus in vitro and in vivo, but the nature of the receptor(s) mediating this action is controversial. In hippocampal slices from rats and several wild-type mice, a Y2-preferring agonist mimicked, and the Y2-specific antagonist BIIE0246 blocked, the NPY-mediated inhibition both of glutamatergic transmission and of epileptiform discharges in two different slice models of temporal lobe epilepsy, stimulus train-induced bursting (STIB) and 0-Mg2+ bursting. Whereas Y5 receptor-preferring agonists had small but significant effects in vitro, they were blocked by BIIE0246, and a Y5 receptor-specific antagonist did not affect responses to any agonist tested in any preparation. In slices from mice, NPY was without effect on evoked potentials or in either of the two slice seizure models. In vivo, intrahippocampal injections of Y2- or Y5-preferring agonists inhibited seizures caused by intrahippocampal kainate, but again the Y5 agonist effects were insensitive to a Y5 antagonist. Neither Y2- nor Y5-preferring agonists affected kainate seizures in mice. A Y5-specific antagonist did not displace the binding of two different NPY ligands in WT or mice, whereas all NPY binding was eliminated in the mouse. Thus, we show that Y2 receptors alone mediate all the anti-excitatory actions of NPY seen in the hippocampus, whereas our findings do not support a role for Y5 receptors either in vitro or in vivo. The results suggest that agonists targeting the Y2 receptor may be useful anticonvulsants.

Neuropeptide Y in the dentate gyrus

Neuropeptide Y (NPY) is contained in at least four types of GABAergic interneurons in the dentate gyrus, many of which also contain somatostatin and give rise to the dense NPY innervation of the dentate outer molecular layer. In humans but not rats, minute amounts of NPY are also normally expressed in dentate granule cells, while seizure activity in rats induces robust NPY expression in granule cells. Y1 and Y2 receptors are the most abundant NPY receptors expressed in the dentate gyrus. Y1 receptors are postsynaptic receptors, primarily located on granule cell dendrites in the molecular layer and some interneurons, while Y2 receptors are presynaptic receptors mediating inhibition of glutamate release, and potentially that of NPY and GABA depending on their presynaptic localization, and may also be expressed on some hilar interneurons. In humans, monkeys and mice, Y2 receptors are also present on mossy fibers, but not in most rat species, though functional evidence suggests their presence. Hilar interneurons containing NPY degenerate in temporal lobe epilepsy and in Alzheimer's disease and reduced levels of NPY in dentate hilus are associated with depression. By activating Y1 receptors, NPY also exerts powerful neuroproliferative effects on subgranular zone progenitor cells, increasing the number of newly born granule cells in the adult dentate gyrus. Functionally, NPY exerts anticonvulsive actions mediated by Y2 receptors at mossy fiber terminals, but there are no presynaptic responses to NPY at perforant path inputs to dentate granule cells in rats or mice. NPY also has potentially complicated actions on NPY-containing interneurons. Elevated expression of NPY in mossy fibers of the rat, sprouting of NPY interneurons in the human dentate, and over-expression of Y2 receptors in mossy fibers indicate an anticonvulsive role of endogenous NPY in epilepsy. However, the physiological role of NPY in the healthy dentate gyrus remains unclear.

A clinical trial in the management of operable cancer of the breast

The results of a randomized controlled clinical trial in the management of operable breast cancer are given. Between 1964 and 1971 498 women, aged 35-69 years, were treated within the trial protocol. Those under 60 years of age on entry underwent ovarian ablation, usually by surgery, and were allocated randomly to treatment by either radical mastectomy (RM) or simple mastectomy and postoperative radiotherapy (SM). Follow-up data for the first 12 years are presented and show that survival in the radical mastectomy group is significantly better (P less than 0.05), particularly in clinical stage 1 disease. The pattern of survival once recurrence was detected also showed interesting differences between the two treatment groups. Overall there was a significantly prolonged survival after detection of recurrence in the RM group (P less than 0.05) which was most marked when local recurrence and distant metastases coincided (P less than 0.01). The duration of survival once recurrence had taken place was independent of tumour size, clinical stage of the disease or menstrual status at the time of presentation, but was directly proportional to the duration of the disease-free inerval (P less than 0.01).

Comparison of urinary 6-beta-cortisol and the erythromycin breath test as measures of hepatic P450IIIA (CYP3A) activity

The production of 14CO2 in the breath from an intravenous dose of [14C-N-methyl]-erythromycin (the erythromycin breath test [ERMBT]) and the measurement of the ratio of 6-beta-cortisol to free cortisol (6-beta-F/FF) in the urine have each been proposed as means of measuring hepatic P450IIIA catalytic activity in patients. We found that there was a significant correlation between the results of each test (r = 0.59, p less than 0.001) in 47 patients who were without liver disease and who were not taking medications believed to influence P450IIIA catalytic activity. In the 24 of these patients who were subsequently treated with the P450IIIA substrate cyclosporine, the ERMBT result was highly correlated with the mean trough cyclosporine blood level observed; however, there was no correlation between urinary 6-beta-F/FF and the cyclosporine blood levels. In a separate study of a patient during the anhepatic phase of liver transplantation surgery, the ERMBT result decreased by greater than 85%, whereas urinary 6-beta-F/FF decreased by just 50%. We conclude that the ERMBT and urinary 6-beta-F/FF do not always provide similar information about P450IIIA catalytic activity in patients, possibly because of extrahepatic production of 6-beta-F. Of the two tests, the ERMBT appears to provide the most relevant information for cyclosporine administration.

Renal cell carcinoma-derived gangliosides suppress nuclear factor-kappaB activation in T cells

Activation of the transcription factor nuclear factor-kappaB (NFkappaB) is impaired in T cells from patients with renal cell carcinomas (RCCs). In circulating T cells from a subset of patients with RCCs, the suppression of NFkappaB binding activity is downstream from the stimulus-induced degradation of the cytoplasmic factor IkappaBalpha. Tumor-derived soluble products from cultured RCC explants inhibit NFkappaB activity in T cells from healthy volunteers, despite a normal level of stimulus-induced IkappaBalpha degradation in these cells. The inhibitory agent has several features characteristic of a ganglioside, including sensitivity to neuraminidase but not protease treatment; hydrophobicity; and molecular weight less than 3 kDa. Indeed, we detected gangliosides in supernatants from RCC explants and not from adjacent normal kidney tissue. Gangliosides prepared from RCC supernatants, as well as the purified bovine gangliosides G(m1) and G(d1a), suppressed NFkappaB binding activity in T cells and reduced expression of the cytokines IL-2 and IFN-gamma. Taken together, our findings suggest that tumor-derived gangliosides may blunt antitumor immune responses in patients with RCCs.

Refractory Pseudomonas Bacteremia in a 2-Year-Old Sterilized by Bacteriophage Therapy

Here, we report a complex case that involved a pediatric patient who experienced recalcitrant multidrug-resistant Pseudomonas aeruginosa infection complicated by bacteremia/sepsis; our antibacterial options were limited because of resistance, allergies, and suboptimal source control. A cocktail of 2 bacteriophages targeting the infectious organism introduced on 2 separate occasions sterilized the bacteremia.

Locoregionally recurrent breast cancer: incidence, risk factors and survival

Locoregional recurrence (LRR) after therapy for early breast cancer is common. Patients with LRR can suffer both local consequences and symptoms of metastatic disease, as LRR is an independent predictor of subsequent distant metastases. Much of the available data on LRR is derived from small, single institution, retrospective studies, so marked differences in the incidence rates for LRR, it's risk factors and subsequent systemic recurrence are reported. The purpose of this review was to try and collate this data in a format that would be useful for both clinicians and their patients.

Levels of insulin-like growth factor (IGF) binding proteins, luteinizing hormone and IGF-I receptors, and steroids in dominant follicles during the first follicular wave in cattle exhibiting regular estrous cycles

Objectives of this study were to determine if concentrations of steroids, insulin-like growth factor -I (IGF-I), and IGF binding proteins (IGFBP) in follicular fluid and numbers of LH and IGF-I receptors change during growth of the dominant follicle. Ovarian follicular development was monitored daily via ultrasound in lactating Holstein cows. Animals underwent bilateral ovariectomy when the dominant follicle was first identified (days 4-6; estrus = day 0; early; n = 5) or when it stopped growing (days 8-12; late; n = 8). All follicles were classified as dominant (DF), large (LG; > = 6 mm in diameter, excluding DF) or small (SM; < 6 mm), follicular fluid was aspirated, and theca and granulosa cells were collected. Levels of IGFBP-2, assessed via ligand blotting, were greater (P < 0.05) in LG and SM follicles compared with DF in early cows. Levels of IGFBP-3 in follicular fluid were unaffected by follicle class. Numbers of specific 125I-hCG/LH binding sites in thecal cells were greater (P < 0.01) in DF compared with LG and SM follicles of both early and late cows. Numbers of specific 125I-hCG/LH binding sites in granulosa cells were similar for follicle sizes in early cows, but, in late cows, were greater (P < 0.01) in DF compared with SM follicles and were severalfold greater (P < 0.01) in late DF compared with early DF. Numbers of receptors for IGF-I in thecal cells were 2-fold greater (P < 0.05) in DP and LG compared with SM in late cows. Numbers of IGF-I receptors in granulosa cells were unaffected by size or growth of follicles, but were severalfold greater than in theca cells. Concentrations of estradiol were severalfold greater (P < 0.01) in DF compared with LG and SM in both early and late cows. Concentrations of androstenedione in early cows were greater (P < 0.05) in DF and SM compared with LG follicles. Concentrations of progesterone and IGF-I did not differ (P > 0.10) among follicle classes, but both were greater (P < 0.10) in late LG compared with early LG follicles. Concentrations of IGF-II in follicular fluid did not differ (P > 0.10) between early and late cows but were greater (P < 0.10) in SM than DF or LG follicles. We conclude that low amounts of IGFBP-2 and increased thecal binding sites for hCG/LH appear to be related to establishment of the dominant follicle during the first follicular wave in cattle exhibiting regular estrous cycles during late lactation.

Ovarian and endocrine characteristics during an estrous cycle in Angus, Brahman, and Senepol cows in a subtropical environment

To determine breed differences in ovarian function and endocrine secretion, daily rectal ultrasonography was conducted on multiparous lactating Angus (temperate Bos taurus; n = 12), Brahman (tropical Bos indicus; n = 12), and Senepol (tropical Bos taurus; n = 12) cows during an estrous cycle in summer. Blood was collected daily to quantify plasma concentrations of FSH, LH, progesterone, estradiol, GH, insulin-like growth factor (IGF)-I, IGF-II, IGF binding proteins (IGFBP), insulin, glucose, and plasma urea nitrogen (PUN). Numbers of small (2 to 5 mm), medium (6 to 8 mm), and large follicles (> or = 9 mm) were greater (P < .05) in Brahman than in Angus and(or) Senepol cows. Length of the estrous cycle (SEM = .6 d) was similar (P > .10) among Senepol (20.4 d), Angus (19.5 d), and Brahman (19.7 d) cows. Senepol cows had greater (P < .05) diameters of the corpus luteum (CL) and a delayed regression of the CL as compared with Angus cows. The secondary surge of FSH (between d 1 and 2; d 0 = estrus) was greater in Angus than Brahman or Senepol cows (breed x day, P < .05). Between d 2 and 14 of the estrous cycle, concentrations of progesterone, LH, IGF-II, and binding activities of IGFBP-3, IGFBP-2, and the 27- to 29-kDa IGFBP in plasma did not differ (P > .10) among breeds. Concentrations of GH, IGF-I, insulin, and PUN were greater (P < .001) and binding activities of the 22-kDa and 20-kDa IGFBP tended (P < .10) to be greater in plasma of Brahman than in Angus or Senepol cows. Plasma glucose concentrations were greater (P < .05) in Senepol than in Brahman or Angus cows. In conclusion, Brahman (Bos indicus) and Senepol cows (tropical Bos taurus) had greater numbers of follicles in all size categories and greater diameter of CL than Angus (temperate Bos taurus) cows. These ovarian differences may be due to changes in the pattern of secretion of FSH, insulin, IGF-I, and GH but not LH, IGF-II, or IGFBP-2 or -3.

Multiple primary melanomas

BACKGROUND

The diagnosis of primary melanoma increases the risk of additional primary melanomas.

OBJECTIVE

We characterize the subgroup of patients with multiple melanomas.

METHODS

We reviewed the melanoma database.

RESULTS

Sixty patients with multiple primary melanomas were identified. Twelve (20%) experienced melanomas in the same regional location, 43 (72%) in different locations, and 5 (8%) in both the same and different locations (> 2 melanomas). Eighteen (30%) were diagnosed concurrently with multiple melanomas, 38 (63%) subsequently, and 4 (7%) concurrently and subsequently (>2 melanomas). Forty-two percent of subsequent melanomas occurred within 3 years of the initial lesion diagnosis, 9 (17%) between 3 and 7 years, and 22 (42%) after more than 7 years. Subsequent melanomas were thinner in 70% of cases (P = .05). The mean age at first melanoma diagnosis was 38 and 59 years, respectively, for those with and without dysplastic nevi (P < .001).

CONCLUSION

In patients with multiple melanomas, subsequent melanomas often occur in different regional locations several years after diagnosis of the initial lesion.

Instituting Surveillance Guidelines and Adverse Outcomes in Preeclampsia

OBJECTIVE

To assess the incidence of combined adverse maternal and perinatal outcomes in women with preeclampsia before and after introducing standardized assessment and surveillance.

METHODS

This study was a preintervention (retrospective) compared with a postintervention (prospective) cohort comparison in a single-tertiary, perinatal unit that included women admitted to hospital with preeclampsia. We interrogated an existing retrospective 24-month database and then introduced the guidelines, assessing the incidence of the combined adverse maternal and perinatal outcomes for 41 months (September 2003 through February 2007). Tests of organ (dys)function were performed at least as often as on the day of admission, admission day +1, every Monday and Thursday, day of delivery, and delivery day +1. All data were checked for errors. The combined maternal outcome was maternal death or one or more of hepatic failure, hematoma, or rupture, Glasgow coma score of less than 13, stroke, at least two seizures, cortical blindness, need for positive inotrope support, myocardial infarction, infusion of any third antihypertensive, renal dialysis, renal transplantation, at least 50% FIO(2) for greater than 1 hour, intubation, or transfusion of at least 10 units of blood products. The combined perinatal outcome was perinatal or infant mortality, bronchopulmonary dysplasia, necrotizing enterocolitis, grade III/IV intraventricular hemorrhage, cystic periventricular leukomalacia, or stage 3-5 retinopathy of prematurity.

RESULTS

Two hundred ninety-five and 405 women were in the preintervention and postintervention cohorts, respectively. The incidence of adverse maternal outcome fell (5.1% to 0.7%; Fisher P<.001; odds ratio 0.14, 95% confidence interval 0.04-0.49). Perinatal outcomes did not change.

CONCLUSION

Standardized surveillance of women with preeclampsia was associated with reduced maternal risk.

Histopathologic and immunohistochemical features in human skin after exposure to nitrogen and sulfur mustard

N-methyl-2,2'-dichlorodiethylamine (HN2)is a topical chemotherapeutic agent used as therapy for cutaneous T-cell lymphomas (CTCL). Di(2-chloroethyl)sulfide (SM), and less often HN2, have been used as chemical weapons, with the skin being a principle target. The mechanisms by which these chemicals produce their therapeutic and toxic effects in skin, however, are not clearly defined. We exposed human skin explants to two doses of HN2 and SM. At 18 hours after exposure, histopathologic features were compared. In addition, immunohistochemical markers to basement membrane proteins were used to evaluate the effects of both chemicals on the basement membrane zone. Gross vesication was not seen. Pyknotic nuclei with or without dyskeratotic changes within epidermal keratinocytes were present at both doses. These changes varied more between skin specimens than they did between doses. Ballooning degeneration was more marked after SM exposures. Diffuse dermal-epidermal separation was present only at high-dose exposures and did not appear to correlate with the degree of changes locally in the overlying epidermis. Antibodies to laminin-5 showed decreased immunoreactivity after exposure to HN2 and SM. Immunoreactivity for laminin- was decreased to a lesser extent, and immunoreactivity for collagen IV and VII was unchanged. HN2 and SM produce similar histopathologic and immunohistochemical features after cutaneous exposure. These features suggest that part of mechanism of action of HN2 and SM is a direct effect on the basement membrane zone. Understanding the effects of HN2 and SM separate from their effect on DNA may be important in designing therapies and in advancing our understanding of the pathophysiologic changes induced by these chemicals when delivered topically.

Solitary melanoma confined to the dermal and/or subcutaneous tissue: evidence for revisiting the staging classification

BACKGROUND

Several patients presented with a single focus of presumed cutaneous metastatic melanoma with an unknown primary tumor based on clinical and histologic staging criteria of the American Joint Committee on Cancer (AJCC). This population is classified as having stage IV disease by the current AJCC staging system, which carries a dismal prognosis (5%-18% 5-year survival). Our clinical observation was that these patients had a higher survival rate than would be expected for stage IV disease. We believe this population represents a subgroup of primary dermal- and or subcutaneously-derived melanoma that simulates cutaneous metastatic melanoma in histologic and clinical presentation but may differ in behavior.

OBSERVATIONS

The database records of 1800 patients from the University of Michigan Melanoma Clinic, Ann Arbor, were retrospectively reviewed to identify the prevalence and survival for patients diagnosed with a single focus of presumed metastatic melanoma to the skin based on accepted histologic and clinical parameters. The prevalence of this population was 0.61% (11 of 1800 patients). The Kaplan-Meier 8-year survival estimate was 83% (95% confidence interval, 58%-100%).

CONCLUSIONS

By AJCC convention, these cases are classified as stage IV metastatic disease. Our data suggest that these presumed metastatic tumors do not behave like stage IV metastatic disease to the skin via lymphatic or hematogenous spread from an unknown primary site; rather, they are behaving like primary tumors originating in the dermal and/or subcutaneous tissue.

Efalizumab: results of a 3-year continuous dosing study for the long-term control of psoriasis

Background

Efalizumab, a T-cell-targeted, recombinant, humanized, monoclonal IgG1 antibody, inhibits key T-cell-mediated steps in the pathogenesis of psoriasis. Efalizumab is approved for the treatment of moderate-to-severe chronic plaque psoriasis in adults in more than 50 countries.

Objectives

To evaluate the efficacy and safety of long-term, continuous efalizumab therapy in patients with psoriasis.

Methods

This open-label, multicentre phase III study enrolled 339 patients with moderate-to-severe chronic plaque psoriasis. During the initial 3-month phase, patients received subcutaneous efalizumab 2 mg kg⁻¹ weekly with randomization to receive concomitant fluocinolone acetonide or placebo ointment during month 3. The second phase was a long-term observational period; patients achieving a ≥ 50% improvement in the Psoriasis Area and Severity Index (PASI) score were eligible to receive efalizumab 1 mg kg⁻¹ weekly for up to 33 months. The final 3-month treatment period was an optional transition period for patients who completed the 33-month segment before efalizumab became commercially available.

Results

After 3 months, 41·3% of patients achieved a ≥ 75% improvement in PASI (PASI-75) and 13·0% achieved a ≥ 90% improvement (PASI-90). Continued improvement was observed: 45·4% and 24·5% achieved PASI-75 and PASI-90, respectively, at the end of the observational phase. The safety profile was stable, with no new or no increase in common events over 36 months of treatment.

Conclusions

This was the longest continuous study using a biologic therapy for psoriasis. Clinical benefit of efalizumab improved over the first 18 months and was maintained during 36 months of continuous therapy. Long-term efalizumab therapy is appropriate for many patients with plaque psoriasis.

Conflicts of interest

C.L. with 3M Pharmaceuticals, Abbott, Allergan, Altana, Amgen, Astellas-Biogen, Bristol Myers, Centocor, CombinatoRx, Fujisawa Healthcare, Galderma, Genentech, Merck Serono International SA, Schering Plough, RTL, Vitae and Warner Chilcott; A.M. with 3M Pharmaceuticals, Abbott, Allergan, Allermed, Amgen, Astralis, Berlex, Biogen Idec, Celgene, Centocor, Cephalon, Collagenex Pharmaceuticals, CombinatoRx, Connetics, Corixa, Dermik Laboratories, Doak Dermatologics, Dow, Ferndale Laboratories, Fujisawa Healthcare, Galderma, Genentech, Genzyme, GlaxoSmithKline, Ligand Pharmaceuticals, Medicis, MedImmune, Novartis Pharmaceuticals, Otsuka Pharmaceutical, Protein Design Labs, QLT USA, Regeneration Pharma AG, Roche, Merck Serono International SA, Sinclair, Synta Pharma, Thermosurgery, Vertex, Warner Chilcott, Wyeth, XOMA and Zars; T.H. with Genentech; A.B.G. with Abbott, Actelion, Almirall, Amgen, Beiersdorf, Biogen Idec, Bristol Myers Squibb, Can-Fite, Celera, Celgene, Centocor, DermiPsor, Eisai, Genentech, Immune Control, Incyte, Kemia, Medacorp, Medarex, Novo Nordisk, Pharmacare, Roche, RxClinical, Sankyo, Schering Plough, TEVA, UCB, Warner Chilcott and Wyeth. All income derived from these sources goes to her employer. I.C. and B.X. are employees and stockholders of Genentech.