Evaluation of bowel wall flow by color Doppler ultrasound in the assessment of inflammatory bowel disease activity in pediatric patients

Objective

To assess inflammatory bowel disease (IBD) activity with Doppler ultrasound in pediatric patients, comparing the accuracy of the ultrasound findings with that of the concentrations of fecal calprotectin (FC).

Materials and Methods

In a consecutive series, we evaluated 53 examinations of 44 pediatric patients seen between 2014 and 2020: 28 with Crohn's disease, 15 with ulcerative colitis, and one with IBD unclassified. The diagnosis of IBD was made in accordance with the Porto criteria. The alteration studied in the greatest detail was bowel wall flow, which was classified by the lead investigator and two pediatric radiologists, all of whom were blinded to the FC concentrations and the other ultrasound findings. Bowel wall flow was categorized as low if there were up to 2 Doppler ultrasound signals/cm2, moderate if there were 3-5 signals/cm2, and high if there were more than 5 signals/cm2.

Results

The agreement among the radiologists was substantial (kappa = 0.73). In cases in which ultrasound showed low bowel wall flow, the median FC concentration was 92 µg/g (interquartile range, 33-661 µg/g), whereas it was 2,286 µg/g (interquartile range, 1,728-5,612 µg/g) in those in which ultrasound showed high bowel wall flow. In the sample as a whole, the sensitivity and specificity of ultrasound was 89.7% and 92.0%, respectively, for the detection of inflammatory activity; 95.5% and 90.9%, respectively, for the detection of Crohn's disease; and 81.3% and 100.0%, respectively, for the detection of ulcerative colitis.

Conclusion

Ultrasound of the bowel wall showed a strong correlation with FC concentrations in the assessment of inflammatory activity in pediatric patients with IBD.

Predictors of cognitive functioning in presentations to a community-based specialist addiction neuropsychology service

INTRODUCTION

Cognitive impairment is common in individuals presenting to alcohol and other drug (AOD) settings and the presence of biopsychosocial complexity and health inequities can complicate the experience of symptoms and access to treatment services. A challenge for neuropsychologists in these settings is to evaluate the likely individual contribution of these factors to cognition when providing an opinion regarding diagnoses such as acquired brain injury (ABI). This study therefore aimed to identify predictors of cognitive functioning in AOD clients attending for neuropsychological assessment.

METHODS

Clinical data from 200 clients with AOD histories who attended for assessment between 2014 and 2018 were analysed and a series of multiple regressions were conducted to explore predictors of cognitive impairment including demographic, diagnostic, substance use, medication, and mental health variables.

RESULTS

Regression modelling identified age, gender, years of education, age of first use, days of abstinence, sedative load, emotional distress and diagnoses of ABI and developmental disorders as contributing to aspects of neuropsychological functioning. Significant models were obtained for verbal intellectual functioning (Adj R2 = 0.19), nonverbal intellectual functioning (Adj R2 = 0.10), information processing speed (Adj R2 = 0.20), working memory (Adj R2 = 0.05), verbal recall (Adj R2 = 0.08), visual recall (Adj R2 = 0.22), divided attention (Adj R2 = 0.14), and cognitive inhibition (Adj R2 = 0.07).

CONCLUSIONS

These findings highlight the importance of careful provision of diagnoses in clients with AOD histories who have high levels of unmet clinical needs. They demonstrate the interaction of premorbid and potentially modifiable comorbid factors such as emotional distress and prescription medication on cognition. Ensuring that modifiable risk factors for cognitive impairment are managed may reduce experiences of cognitive impairment and improve diagnostic clarity.

Maybe It's Not the Meth: Considering Biopsychosocial Contributors to Cognitive Impairment in Methamphetamine Polydrug Use

OBJECTIVE

In considering the cognitive harms of methamphetamine (MA) use, there is currently a limited appreciation of the profile of pre-existing, comorbid, or modifiable risk factors for cognitive impairment in individuals with MA-polydrug use who present to clinical services. This is in contrast to the well-recognized evidence in alcohol use groups. The aim of this study was to investigate the biopsychosocial and neuropsychological profiles of MA-polysubstance using individuals reporting cognitive impairment in comparison to an alcohol-using group.

METHODS

A retrospective file audit was undertaken of individuals who presented for assessment to a specialist addiction neuropsychology service and reported either more than 1 year of heavy MA use as part of a polydrug use history (n = 40) or having only used alcohol (n = 27). Clinical histories including demographic, medical, mental health, substance use, and neuropsychological assessment results were extracted from medical records. Between group comparisons were conducted to explore differences in the MA-polydrug vs. the alcohol group.

RESULTS

Individuals in the MA-polydrug group were significantly younger, commenced substance use at an earlier age, were more likely to have an offending history, and experienced an overdose than those in the alcohol group. No differences in comorbid neurodevelopmental, psychiatric or acquired brain injury diagnoses were observed between groups. For neuropsychological functioning, significant group differences were observed in overall IQ, semantic verbal fluency, and psychomotor tracking, where individuals in the alcohol group performed significantly worse.

CONCLUSIONS

Neuropsychological profiles were largely equivalent between groups across cognitive domains, with minor differences in favor of the MA-polydrug group. Relative to the general population, cognitive functioning was reduced for both groups across a range of domains. High rates of comorbid mental health concerns were common across both groups, however, individuals in the MA-polydrug group presented with a higher risk of overall harm from substance use at a significantly younger age which is a unique concern for this group. These findings highlight the importance of considering the biopsychosocial factors, such as age of first use, emotional distress, indirect substance related harms including overdose and blood born virus infection that may be relevant to experiences of cognitive difficulty in MA-polydrug users.

Sleep disturbance in clients attending a specialist addiction clinic

BACKGROUND AND OBJECTIVES

Sleep problems are common among clients attending alcohol and drug services, yet the specific components of sleep disturbed by primary drug of concern (PDOC), and their relationships to affective disorder symptoms are unclear.

METHODS

We examined sleep problems in clients (n = 32) attending a specialist addiction clinic.

RESULTS

Global sleep quality was rated poor by >90% of participants (particularly disturbances, latency and efficiency components), with significant associations (p < .05) between poor sleep quality and depression (r = .517), anxiety (r = .571) and stress (r = .503). Sleep quality was significantly poorer among those with a nonalcohol PDOC compared with alcohol as PDOC, t(22) = 3.09, p = .005.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

Poor sleep is almost ubiquitous among clients attending alcohol and drug services. However, components of sleep quality disturbed differ in terms of PDOC, highlighting the need for individualised sleep interventions.

Characterisation of presentations to a community-based specialist addiction neuropsychology service: Cognitive profiles, diagnoses and comorbidities

INTRODUCTION AND AIMS

Cognitive impairment is a common feature of individuals with substance-use disorders. However, research tends to exclude highly complex clinical cases, limiting the generalisability of findings for 'real-world' populations. The objective of this study was to examine the complexities associated with addiction, substance use and cognitive impairment through the characterisation of client presentations to a newly established specialised addiction neuropsychology service.

DESIGN AND METHODS

Retrospective case file audit. Neuropsychological assessment reports for consenting clients over a 4-year period were de-identified and reviewed. Cognitive domains assessed included attention, processing speed, working memory, intellectual functioning, memory and executive functioning.

RESULTS

Of the 200 case files examined, the majority were male clients, with 11 years or lower of education and a history of daily substance use, with 30% continuing to use daily. Seventy-one percent had a formal mental health diagnosis and 41% had reported a history of trauma. The most prevalent cognitive impairments were observed in complex attention (50%) and memory (40%). New diagnoses were conveyed in 25% of cases, comprising acquired brain injury (16%) and neurodevelopmental disabilities (9%).

DISCUSSION AND CONCLUSIONS

It is common for clients with substance use histories referred to an addiction neuropsychology service to present with complex histories including psychosocial difficulties, comorbid mental health and medical issues and cognitive impairment. As such, careful diagnostic formulations are required when multiple factors may contribute to cognitive deficits. This study highlights the importance of a state-wide specialist addiction neuropsychology service in supporting diagnostic clarification and informing relevant treatment approaches.

Polymorphism in male genitalia of Aedes (Ochlerotatus) scapularis Rondani, 1848

Morphology of male genitalia of culicids is generally species-specific and often used as a taxonomic marker. However, some characters of the male genitalia vary intraspecifically and are not taxonomically diagnostic. This might be the case of Aedes scapularis, a Neotropical culicid with vector competence for arboviruses and filarial worms. Males of this species may or not present a retrorse process (RP) in the genitalic claspette filaments, which led authors to suspect that this variance might be indicative of population divergence or incipient speciation process. This suspicion has not been investigated hitherto and it is not known if there are variable patterns of RPs. We hypothesized that the presence of the RP varies intraspecifically in Ae. scapularis and then we statistically evaluated the variability of this character in a single population. To this study the genitalia of 73 males of Ae. scapularis were prepared, and their RPs were meristically quantified and categorized according to the phenotypes observed. We noted that the presence or RPs is a polymorphic character because it varied inter and intra-individually. The presence of a single RP on each claspette filament was the predominant pattern (77%), but absent or multiple RPs in each filament were also found either in bilateral symmetry or asymmetry. Thus, we conclude that the presence of RPs owing to its high variability is not indicative of populational divergence or diagnostic of species complex within Ae. scapularis.

Abstract P5-21-02: Hormone receptor status and endocrine therapy in a prospective observation study on trastuzumab (Herceptin®) in the adjuvant treatment of breast cancer

Background: Based on the findings from large randomized studies, Trastuzumab (T) was registered in 2006 for the treatment of early stage, HER2+ breast cancer (BC), after surgery, (neo)adjuvant chemotherapy (CT) and/or radiotherapy. However, limited systematic evidence is available on preceding, concomitant or sequential endocrine treatment (ET) based on the hormone receptor (HR) status. This large prospective observation study, reflecting the unrestricted routine practice of HER2 antibody treatment in Germany, allows to examine this topic.

Methods: At present, more than 4000 patients (pts) have been enrolled in this ongoing study; 3446 pts from more than 316 centres were already sufficiently documented to be analysed. Details on concomitant treatment was collected at baseline and for 12 months after start of T.

Results: With respect to an overall HR positivity (HR+), i.e. estrogen and/or progesterone receptor (ER, PR) being positive, of 2181/3446 (63%), these HER2+ pts do not differ from the general BC population. Both hormone receptor types are positive in 47%, while ER+ only or PR+ only was detected in 13% and 3%, respectively. Adjuvant ET of any type, starting before or during T treatment, was given in 87% of HR+ and in 3% of HR- pts. 6% of HR+ pts received T and ET without concomitant CT. Details on the adjuvant treatment options are provided in the table:

Patterns of maintenance treatment (Tx) following first-line bevacizumab (bev) plus chemotherapy (CT) for metastatic colorectal cancer (mCRC): Results from a large German community-based cohort study

502

Background: As a result of the long PFS with bev-containing combinations in first-line mCRC, discontinuation of at least one CT component after an “induction” period and continuation with “maintenance” Tx is common. It is anticipated that duration and patterns of maintenance Tx may affect PFS.

Methods: We analysed induction and maintenance Tx in a large observational cohort study of bev + various first-line CT regimens. Results of the entire cohort were reported earlier [Arnold et al. ASCO GI 2010].

Results: From Jan 05 to Jun 08, 1620 patients (pts) were enrolled at 261 sites. 1,307 pts (81% of total) received bev + fluoropyrimidine-oxaliplatin (n=306, 23.5%) or fluoropyrimidine-irinotecan (n=1,001, 76.5%). While Tx reduction was not predefined, after induction 271 pts (21%) received de-escalated maintenance Tx: bev alone (n=106; 8%), or bev + CT (n=165; 13%). Median Tx duration for pts receiving bev alone was 8.7 mo for induction and 3.2 mo for maintenance. Pts receiving bev + CT maintenance had shorter induction (5.1 mo) but longer maintenance (4.4 mo). Median PFS (after induction) with bev maintenance was 10.8 mo vs. 13.5 mo for bev + CT maintenance. Data are available from 161 pts with bev + CT maintenance after induction with oxaliplatin (n=97) or irinotecan (n=64). Median total Tx duration was 9.6 mo for oxaliplatin-based induction and 10.9 mo for irinotecan-based induction; median induction duration was 4.1 and 5.5 mo, and maintenance duration was 4.3 and 4.4 mo, respectively. Median PFS (after induction) was 12.8 and 14.1 mo, respectively. Progressive disease (PD) has not yet occurred in 165 pts (62% of maintenance cohort). A high proportion of pts received Tx until PD (74% and 79%, respectively).

Conclusions: Both de-escalation strategies led to long PFS and a high number of pts treated ′until PD′. A trend towards better PFS was observed in pts receiving bev + CT maintenance vs. single-agent bev. The ongoing randomized AIO KRK 0207 trial is prospectively evaluating three different maintenance strategies after induction with bev + fluoropyrimidine + oxaliplatin.

[Table: see text]

Bevacizumab (BV) plus chemotherapy (CT) as first-line treatment of patients with metastatic colorectal cancer (mCRC): First results from a large community-based observational cohort study in Germany

e15057

Background: BV prolongs overall survival (OS) and progression-free survival (PFS) when added to standard CT for patients (pts) with mCRC. After approval of BV in Germany in 01/05, this observational cohort study was initiated in pts receiving BV with various first-line CT regimens to evaluate safety events and effectiveness. Methods: To facilitate and evaluate enrollment of a typical mCRC population, eligibility criteria were minimized. Choice of the CT regimen was at physician´s discretion, but influenced by the current registration status. Predefined endpoints were treatment characteristics, response rate (RR), PFS, OS, and adverse events assessed as potentially related to the treatment (AERT) or as severe (SAE). Pts are followed for up to 4 years, and clinical data were updated every cycle (2–4 weeks). Results: 1,300 pts were enrolled at 261 sites from 01/05 through 06/08; abstract data cutoff date was 11/24/08. Median age: 64 (range 19–100) years, > 70 years.: 25%; male 63%; ECOG PS status 0–1/2/>2 88%/11%/1%. CT choice was fluoropyrimidine (FU)/BV alone (any 5-FU or capecitabine) 12%; FU/BV/oxaliplatin 18%; FU/BV/irinotecan 69%; other 1%. Median treatment duration with BV was 7.4 (range 0–28) months; duration > 10 months 21%. 60-day mortality was 4.0%. In total, 183 AERT were reported in 10% of pts., most commonly diarrhea (34 AERT), nausea (26) and hypertension (18). Reported SAE were deep venous TE in 0.8% of pts, bleeding 1.2%, pulmonary embolism 0.5%, arterial TE 0.4%. Best investigator- assessed RR was 59% (CR 10%, PR 49%; all pts) with 64% for FU/BV/oxaliplatin, 59% for FU/BV/irinotecan and 53% for FU/BV alone. Conclusions: The safety profile of BV in this population of mCRC pts with different CT regimens appears consistent with that observed in the other reports like BRiTE or first BEATrial. RR in this preliminary dataset are higher than that reported in the randomized controlled trials, but likely biased by the methodology of evaluation. However, activity with FU/BV alone was surprisingly high. Updated efficacy data including PFS will be presented.

[Table: see text]

CT planning for breast cancer

Radiotherapy to the affected breast or chest wall is well established as an integral part of postoperative management of breast cancer. However, it is known to be associated with increased cardiac and pulmonary morbidities and mortalities. Modern technologies, such as CT planning, have shown to improve treatment planning by accurately delivering optimal doses to the target volumes, while minimizing doses to sensitive structures, thus reducing potential treatment-related adverse effects. The purpose of this study is to report on our experiences with CT planning of adjuvant radiotherapy for breast cancer.

The impact of parental divorce for adolescents: a consideration of intervention beyond the crisis

The effects of divorce on children and adolescents remain a major public health issue. Over the last three decades, there has been ongoing debate among researchers and mental health and legal professionals who counsel divorcing families as to whether the effects are acute but time-limited or more enduring. This chapter looks at the tasks of normal adolescent psychosocial development and how divorce complicates those tasks. It suggests ways that pediatricians and other health professionals can intervene effectively with divorcing families within the context of their role. Divorce-specific resources and services are explained.

Analysis of autoantibody epitopes on steroid 21-hydroxylase using a panel of monoclonal antibodies

A panel of five mouse monoclonal antibodies (MAbs) to human recombinant steroid 21-hydroxylase (21-OH) were produced, characterized, and used to study the interaction of 21-OH autoantibodies (AAbs) with different epitopes on human 21-OH. AAbs in patients with isolated autoimmune Addison's disease, autoimmune polyglandular syndromes types I and II, and 21-OH antibody-positive patients without overt Addison's disease (25 patients in total) were studied. Four MAbs were IgG1 subclass, one was IgG2a, and all had kappa light chains. The affinities of four of the antibodies were in the range 2.0 x 10(8) M(-1) to 7.0 x 10(8) M(-1), and the affinity of the other was 2.3 x 10(7) M(-1) 21-OH MAbs did not cross-react with 17alpha-hydroxylase (17alpha-OH)) or P450 side chain cleavage enzyme. Studies using a series of 21-OH fragments allowed the identification of short stretches of amino acids (AA) that were involved in forming the MAb binding sites. AA 391-405, defined as epitope region (ER) 1, were found to be important for binding of M21-OH1 and M21-OH2, AA 406-411 (ER2) were important for M21-OH3 and M21-OH4 binding, and AA 335-339 (ER3) for M21-OH5 binding. In addition, MAb Fab or F(ab')2 fragments were used to study 21-OH AAb epitopes in competition experiments. These investigations demonstrated that 21-OH AAbs recognize similar epitopes to the MAbs, with ER2 and ER3 being part of two distinct major epitopes, and ER 1 being part of a minor epitope. Mixtures of M21-OH antibody Fab or F(ab')2 fragments caused almost complete inhibition (80%-95%) of AAb binding in 24 out of 25 sera, and in the case of the remaining serum, the effect was marked but incomplete (67% inhibition). There were no major differences between the binding characteristics of AAbs from patients with different forms of autoimmune adrenal disease. All five 21-OH MAbs reacted with human adrenal tissue in an immunofluorescence test, but only M21-OH1 and M21-OH2 reacted with bovine adrenal tissue in these experiments. None of the MAbs reacted with human ovarian tissue in an immunofluorescence test. Overall, these studies indicate that 21-OH AAbs bind to at least three different epitopes in the C-terminal part of 21-OH, and two of these epitopes appear to be human 21-OH specific.

Glutamic acid decarboxylase autoantibody assay using 125I-labelled recombinant GAD65 produced in yeast

We describe a new method for measuring autoantibodies (Ab) to the 65 kDa isoform of glutamic acid carboxylase (GAD65). In particular, GAD65 without the hydrophobic N-terminal region has been produced in yeast, purified, labelled with 125I and reacted with GAD65 Ab. Antibody bound 125I-GAD65 is then precipitated by the addition of solid phase protein A. With the assay, GAD65 Ab were detected in 59 of 71 (83%) islet cell antibody (ICA) positive IDDM patients and in 8 of 23 (35%) ICA negative IDDM patients (overall 67 of 94 (71%) of IDDM patients). Low concentrations of GAD65 Ab were also detected in 2/98 (2%) healthy blood donors and 1/27 (4%) Graves' disease patients had a high level of antibody. GAD65 Ab were not detected in any of 10 Hashimoto's thyroiditis, 20 Addison's disease or 19 myasthenia gravis sera. There was good agreement between the 125I assay and the current reference method based on 35S-labelled full-length GAD65 (produced by in vitro transcription/translation reaction) and solid phase protein A (r = 0.91, n = 108). Overall, our 125I assay showed sensitivity, precision and disease group specificity at least as good as any assay so far described. These features, combined with a simple assay protocol and the convenience of 125I counting and handling indicate that the method is suitable for routine GAD65 Ab measurements.

Pharmacology and regional distribution of the binding of 6-[3H]nitro-7-sulphamoylbenzo[f]-quinoxaline-2,3-dione to rat brain

6-Nitro-7-sulphamoylbenzo[f]quinoxaline-2,3-dione (NBQX) is a competitive antagonist selective for alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate (AMPA) receptors. Here we report the pharmacological characteristics and anatomical distribution of [3H]NBQX binding to rat brain. The association rate of [3H]NBQX to rat cerebrocortical membranes was rapid, with peak binding occurring within 10 min at 0 degree C. The off-rate was also rapid, with near-complete dissociation of the radioligand within 5 min of addition of 1 mM unlabelled L-glutamate. [3H]NBQX bound to a single class of sites with KD and Bmax values of 47 nM and 2.6 pmol mg-1 of protein, respectively. The rank order of inhibition of [3H]NBQX binding by AMPA receptor ligands was NBQX > > 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX) > or = (S)-5-fluorowillardiine > or = AMPA > > L-glutamate. The chaotrope KSCN had no effect on the IC50 value of unlabelled NBQX displacement of [3H]NBQX binding. The kainate receptor-selective ligands NS102 and kainate were only very weak displacers. It is interesting that NBQX and CNQX displaced significantly more [3H]NBQX than any of the agonists tested. Autoradiographic analysis of the binding of [3H]NBQX to coronal sections showed a distribution compatible with that of [3H]AMPA binding. These data indicate that [3H]NBQX provides a useful novel tool to characterise the antagonist binding properties of AMPA receptors.

Effects of the antiparkinsonian drug budipine on central neurotransmitter systems

Budipine is a novel antiparkinsonian drug which is particularly beneficial in the treatment of parkinsonian tremor. The mechanism of action of budipine is not fully understood. To study whether budipine has dopaminergic activity in vivo, we used the 6-hydroxydopamine rotational model of Parkinson's disease. Budipine (0.78-12.5 mg/kg i.p.) did not induce ipsilateral or contralateral rotations, suggesting that it does not possess direct or indirect dopaminergic activity. This conclusion is further supported by the observation that budipine (10 mg/kg) i.v. did not facilitate striatal dopamine release measured in vivo by brain microdialysis. To investigatate possible antimuscarinic and N-methyl-D-aspartic acid (NMDA) antagonistic properties of budipine, we compared budipine with the antimuscarinic antiparkinsonian drug biperiden and the NMDA receptor antagonist 3-[(+/-)-2-carboxypiperazine-4-yl]-propyl-1-phosphonic acid (CPP). In receptor-binding assays, budipine inhibited thienylcyclohexylpiperidyl-3,4-[3H](n) ([I3H]TCP) (2.5 nM)-binding with an IC50 of 36 microM and [3H]3-quinuclidinol benzilate-binding with an IC50 of 1.1 microM. The respective values for biperiden were 170 and 0.053 microM. In line with these findings, budipine and CPP increased the threshold for NMDA-induced seizures in mice with an ED50 of 10.2 and 4.4 mg/kg, respectively, whereas biperiden was not effective. In 6-hydroxydopamine-lesioned rats, budipine (3.13-12.5 mg/kg) and CPP (0.1-0.39 mg/kg) increased the number of contralateral rotations induced by apomorphine, whereas biperiden was not effective. The present data suggest that budipine acts by blocking muscarinic and NMDA transmission while facilitation of dopaminergic transmission does not appear to contribute to its in vivo action. In comparison to biperiden, which has also antimuscarinic and NMDA receptor antagonistic properties, the anti-NMDA action of budipine is more prominent.

Cellular uptake of albumin from lungs of anesthetized rabbits

Resolution of alveolar edema depends on clearance of serum protein, as well as liquid from the alveolar space. Protein clearance is slower than liquid clearance and may take days to weeks. Our earlier studies presented evidence for the importance of paracellular removal of soluble protein from the air spaces. However, long-term protein clearance may also depend on uptake by alveolar epithelial cells or macrophages. This study examined cellular uptake of soluble human albumin and insoluble colloidal gold-albumin from the lungs of anesthetized rabbits. Native albumin was endocytosed by both alveolar type I and type II cells and appeared in vesicles and endosomes. Neither cell type took up colloidal gold-albumin over periods as long as 8 h. Alveolar macrophages took up native albumin and colloidal gold-albumin to a greater extent and more rapidly than alveolar epithelial cells. The tracer proteins were found in vesicles, endosomes, and phagolysosomes. Similarly, cultured alveolar macrophages took up native albumin more rapidly than cultured type II cells. Thus macrophages may be important in clearing precipitated protein from the air spaces, and they may have a role in completing the clearance of soluble protein. The potential for transepithelial transport of soluble alveolar protein exists, but based on this work and our prior studies, it appears to be a low-capacity pathway.

Monoclonal thyroglobulin autoantibodies: variable region analysis and epitope recognition

A panel of human monoclonal thyroglobulin (Tg) autoantibodies (TgAAb) has been used to analyze autoantigenic determinants on human Tg and to investigate the relationship between variable (V) region gene sequences and epitope specificity. Two monoclonal TgAAb bound to the same (or closely related) epitope on Tg, and these were defined as type I TgAAb. Three other monoclonals bound to a different site and were defined as type II TgAAb. Inhibition studies with mixtures of type I and type II monoclonal TgAAb (Fab)2 preparations indicated that a mixture of the (Fab)2s almost completely inhibited (> 75%) labeled Tg binding to intact TgAAb in the sera of apparently healthy blood donors and patients with autoimmune thyroid disease (AITD). Type I TgAAb predominated in apparently healthy blood donors' sera, whereas type II TgAAb predominated in AITD sera. Analysis of V region gene sequences of the TgAAb indicated that a range of light chain and heavy chain genes from different gene families was used. Furthermore, the same germline genes that are used by TgAAb are also well represented in the genes coding for other self- and nonself-reactive antibodies. No homology in terms of light chain and heavy chain gene families, germline gene usage, or complementarity determining region sequences was observed in TgAAb directed to the same or closely related epitopes. Our studies show that TgAAb are directed to two major conformational epitopes on the Tg molecule and that the proportion of TgAAb directed to these epitopes in apparently healthy blood donors and that in patients with AITD appear to be different. TgAAb derived from different germline genes and with different complementarity determining region sequences can display similar epitope specificity, and this indicates that AAb directed to the same or a closely related epitope show considerable heterogeneity at the molecular level.

[Successful operation of right ventricular cardiac fibroma in an infant]

Cardiac tumors are rare in infants. We describe the diagnostic procedure and the good postoperative outcome despite the very large cardiac fibroma.

Subcellular distribution and life cycle of Epstein-Barr virus in keratinocytes of oral hairy leukoplakia

The authors investigated the life cycle of Epstein-Barr virus (EBV) in keratinocytes of oral hairy leukoplakia by combining immunohistochemistry. DNA in situ hybridization, and lectin histochemistry with electron microscopy. Diffuse-staining components of the EBV early antigen complex (EA-D), EBV 150-kd capsid antigen (VCA), EBV membrane antigen (gp350/220), and double-stranded DNA were labeled with monoclonal antibodies. An EBV-DNA probe was used to locate EBV DNA. Wheat-germ agglutinin (WGA) was employed to distinguish Golgi-associated compartments. The authors found EBV proteins and EBV DNA only in keratinocytes with apparent viral assembly. In situ hybridization showed EBV DNA in free corelike material and in electron-dense cores of mature nucleocapsids. Monoclonal antibodies to nonspecific double-stranded DNA attached to the same structures and to marginated chromatin. Components of EA-D were dispersed throughout the nuclei but accumulated near condensed chromatin and in 'punched-out' regions of the chromatin. Epstein-Barr virus 150-kd capsid antigen was found only in the nuclei, where it appeared preferentially on mature nucleocapsids. As yet unexplained arrays of intranuclear particles that remained unlabeled with all EBV-specific probes reacted intensely with an antiserum against common papillomavirus antigen. Gp350/220 was detectable in various cellular membrane compartments and was highly concentrated on EBV envelopes in peripheral Golgi-associated secretory vesicles. It was less abundant on the extracellular EBV, indicating that viral membrane antigen partly dissociates from the mature virus. Combined lectin-binding histochemistry and electron microscopy demonstrated for the first time that EBV is processed in the Golgi apparatus, which eventually releases the virus by fusion with the plasma membrane. These results provide insight into the biologic events that occur during complete EBV replication in vivo.

[Massive ascites formation due to unabsorbed cerebrospinal fluid following abdominal surgery in ventriculoperitoneal shunt. A case report]

A 15-year-old girl with a congenital heart disease (pulmonary stenosis and aortic insufficiency), who had a ventriculoperitoneal shunt operation because of hydrocephalus internus at the age of two years, 12 years later underwent colectomy because of juvenile colonic polyposis. After this operation, enormous production of ascites began which, because of progressive development, finally required ventriculoatrial shunt operation. A total volume of 17 liters of fluid was removed in two ascites drainages before and during the latter operation. Postoperatively the ascites production stopped completely.

Fine structure of EBV-infected keratinocytes in oral hairy leukoplakia

We evaluated biopsy specimens of 42 cases of clinically suspected oral hairy leukoplakia for the pattern and frequency of ultrastructural alterations specific to epithelial cells infected with Epstein-Barr virus. Some structures could clearly be identified as Epstein-Barr virus at different stages of assembly, but other intranuclear and cytoplasmic alterations were not conclusively identifiable as any known structure. Keratinocytes producing Epstein-Barr virus contained intranuclear particles of different size and shape; some of them were arranged in a monodispersed pattern and others formed arrays. In contrast, both lesional keratinocytes not producing virus and keratinocytes in uninvolved mucosa contained intranuclear particles reminiscent of perichromatin granules. The nuclei of productive cells also contained marginated chromatin, tubular structures, and, occasionally, crystalline and fibrillar formations as well as enveloped virus. Formations of electron-dense bilayers were seen on both sides of the nuclear membrane. In the cytoplasm of productive cells we observed aggregates of parallel tubules and enveloped electron-dense bodies. Although many of these observations are of diagnostic and pathobiological significance, the morphogenesis, composition, and function of alterations with uncertain morphological identification remain unclear.

Absence of Langerhans cells in oral hairy leukoplakia, an AIDS-associated lesion

Oral hairy leukoplakia (HL) is a recently described manifestation of human immunodeficiency virus (HIV) infection in which Epstein-Barr virus (EBV) has been shown to replicate. To seek evidence for a local defect in mucosal immunity, we assessed the presence of epithelial Langerhans cells (LC) in these lesions and in autologous nonlesional mucosa. We used monoclonal antibodies against HLA-DR, HLA-DQ, and T6 antigens to identify LC in biopsy specimens of HL from 23 homosexual men. In all lesion specimens, LC either were not detected or were present only in greatly reduced numbers with at least 1 of the antibodies. In nonlesional oral mucosa from the same patients, LC were detected with all 3 antibodies in 11/12 specimens (92%) and were found in approximately normal numbers with at least 1 antibody. There was close correlation between the absence of LC and positive staining for EBV, human papillomavirus antigens, and candidal hyphae in the epithelium. We conclude that LC are absent or greatly reduced in the lesions of HL. Absence of normal LC function may be important in the pathogenesis of HL and may reflect an event in the pathogenesis of other features of the acquired immune deficiency syndrome.

Operative treatment of chronic acromioclavicular dislocation

Six patients (median age 35 years) were reviewed at an average of 24 months after operation for chronic acromioclavicular dislocation. The operation consisted of resection of the lateral part of the clavicle and transference of the coracoacromial ligaments as a substitute for the coraco-clavicular ligament. The ligament was secured by an AO screw for 6 weeks. In five patients the reasons for operation were pain, when working and sleeping, and, in one patient, pressure on the skin. Three of the patients complained of weakness. At follow-up the results were excellent in four patients and good in two. Three patients had mild pain when lying on the shoulder and three had complaints where the flake of bone attached to the transferred ligament was inserted into the clavicle. We now recommend a modification of the method, omitting the flake of bone.

Replication of Epstein-Barr virus within the epithelial cells of oral "hairy" leukoplakia, an AIDS-associated lesion

We conducted a study to identify the viruses in tissue specimens of oral "hairy" leukoplakia, a lesion that is found in immunosuppressed male homosexuals and that is associated with the subsequent development of the acquired immunodeficiency syndrome. When stained for papillomavirus core antigen, 49 of 67 biopsy specimens (73 per cent) yielded positive results in epithelial-cell nuclei. Electron microscopy showed papillomavirus-like particles in all of 25 specimens, and the herpes-type virus described in a previous report was seen in 23 of the 25 specimens. Three specimens had both types of particle in the same individual epithelial cells. Immunofluorescence for herpes simplex virus, varicella-zoster virus, and cytomegalovirus gave negative results in all cases, but 19 of 20 specimens showed intense nuclear staining in epithelial cells for the viral capsid antigen of Epstein-Barr virus (EBV). DNA hybridization using EBV probes in Southern blots demonstrated EBV DNA in all of 13 specimens and found 200 or more viral DNA molecules per cellular genome in 11 of the 13. The whole EBV genome was also demonstrated in the specimens and found to be in linear virion form. We conclude that EBV replicates within the epithelial cells in hairy leukoplakia.

Oral "hairy" leucoplakia in male homosexuals: evidence of association with both papillomavirus and a herpes-group virus

An outbreak of a new form of oral leucoplakia, found principally on the lateral borders of the tongue, is reported in male homosexuals in the San Francisco area. Many of the patients showed evidence of immunosuppression, and candida was often found in the lesions. The characteristic histology is similar to that of the flat wart of skin. There was immunocytochemical evidence of papillomavirus core antigen in 77% of 30 biopsy specimens, but no papillomaviruses were detected by electron microscopy in samples from 6 randomly selected patients. In 5 of these 6 patients there was evidence of a herpes-type virus. Pneumocystis carinii pneumonia has developed in 8 of 37 patients in a 33-month period. This leucoplakia may presage AIDS, may be associated with both papillomavirus and a herpes-type virus, and may offer clues to the pathogenesis of other forms of oral epithelial hyperplasia and dysplasia.

[Traumatic tricuspid insufficiency a clinical study (author's transl)]

Four cases of surgically confirmed traumatic tricuspid insufficiency are presented. There is a characteristic long interval between blunt trauma and onset of cardiac symptoms. Common clinical, radiographic and echocardiographic features of tricuspid insufficiency are described. Cardiac catheterisation and right ventricular angiography confirm the diagnosis and the surgical aspect verifies the traumatic etiology. The indication for surgical treatment by valve replacement is discussed. The results of surgery have been good.

DNA in synovial fluid and the circulation of patients with arthritis

DNA levels were measured in synovial fluids and sera of 106 patients with rheumatoid arthritis (RA), osteoarthritis (OA), gout, pseudogout, and posttraumatic arthritis (TRA). In synovial fluids, the highest concentration was found in rheumatoid arthritis (mean +/- SE 18 +/- 3 microgram/ml for seropositive and 9 +/- 1 microgram/ml for seronegative variants), gout and pseudogout (17 +/- 3 microgram/ml). In contrast, the levels in patients with OA or acute TRA were very low: 0.8 +/- 0.1 microgram/ml an 1.1 +/- 0.2 microgram/ml, respectively. The differences between the means of the first disease group and OA or TRA is statistically significant. A similar pattern was observed for DNA levels in the circulation: in rheumatoid arthritis, the mean concentration was 135 +/- 28 ng/ml and 164 +/- 39 ng/ml for seropositive and seronegative RA, respectively. Again the levels in OA and TRA were much lower, 52 +/- 18 ng/ml and 0 ng/Ml, respectively. The latter are not significantly different from the mean levels of 95 normal, healthy controls (14 +/- 3 ng/ml), whereas the concentration of DNA in the serum of RA patients is significantly higher than in OA, TRA, or normal controls. Serial determinations of DNA and other criteria of disease activity (leukocytes and protein levels in synovial fluid, blood sedimentation rate) in individual patients revealed a strong correlation of elevated values with active episodes. THe results suggest that these parameters reflect tissue damage.

[The vessels of the retropancreatic space in grey-scale-ultrasound. A contribution to the topography of the pancreas (author's transl)]

Normal pancreatic parenchyma and retropancreatic vessels can be well visualized and differentiated by grey-scale-tomography. The posterior border of the head and body of the pancreas can be defined better with the grey-scale-technique than with other ultra-sound-techniques by visualization of the retropancreatic vessels. For this purpose the venous system (portal vein, splenic vein and superior mesenteric vein) is more important than the arteries because of their closer topographic relationship to head and body of the pancreas. Identification and separation of those veins from other vascular structures is easily possible because of their constantly reliable topography and typical configuration on transverse section. The spleno-porto-vascular bundle--resembling a tadpole--should be demonstrated well enough to avoid the occasional confusion with the pancreas itself.

[Ultrasound for differentiated carcinoma of the thyroid, autonomous adenoma and thyroiditis (author's transl)]

The article deals with a number of thyroid abnormalities which produce similar sonographic patterns, characterised by a paucity of echos of low amplitude. It concerns three more or less circumscribed changes (differentiated carcinoma of the thyroid, autonomous adenoma and focal thyroiditis) and two diffuse thyroid conditions (sub-acute and lymphocytic diffuse thyroiditis, hyperthyroidism). Carcinoma of the thyroid is of particular interest. The distinguishing features and differential diagnosis are discussed.

A study of thyroid stimulating activity in human serum with the highly sensitive cytochemical bioassay

The cytochemical bioassay is able to detect minute amounts of thyroteopin and thyroid stimulating immunoglobulins. Estimations of serum TSH by the cytochemical bioassay are in good agreement with values obtain by radioimmunoassay. In untreated hyperthyroid patients with Graves' disease the TSH levels are significantly lower than in control subjects. Thyroid stimulating immunoglobulins showed a delayed time corse of action in the bioassy and this provided a voncenient method of distinguishing between the two thyroid stimulators.

Effect of prolonged thiazide treatment on renal lithium clearance

Renal lithium clearances were determined after the administration of a small test dose of lithium carbonate in 22 patients when they were on long-term treatment with thiazides and when they were not on such treatment. Thiazide administration led to a 24% reduction in the lithium clearance. Diuretic drugs should be used with caution in patients given lithium treatment, and lithium should be used with caution in patients receiving diuretic treatment.