Immunoglobulin heavy chain gene fingerprinting reveals widespread oligoclonality in B-lineage acute lymphoblastic leukaemia.

Acute lymphoblastic leukaemia (ALL) of B-cell lineage typically arises as a monoclonal expansion of committed B-lymphocyte precursors that are arrested at an immature stage of differentiation. From Southern hybridization analysis of immunoglobulin heavy chain (IgH) genes in leukaemic blasts, the occurrence of a sizeable minority of patients displaying multiple (greater than two) rearranged heavy chain alleles has been widely reported. In at least some patients these data are consistent with the presence of oligoclonal populations of precursor B-cells. We have used a more sensitive, polymerase chain reaction based immunoglobulin gene 'fingerprinting' approach in the analysis of B-cell clonality in eight patients with common ALL which were apparently monoclonal on the basis of Southern blot analysis of their IgH genes. The results revealed an oligoclonal pattern of IgH gene rearrangement in half of the patients analysed, implying that oligoclonality at the level of B-cell commitment, as defined by IgH gene rearrangement, is much more widespread in this disease than has previously been recognized.

Independent clonal origin of T- and B-cell clones in a composite lymphoma.

We present a detailed immunohistological and genotypic analysis of an unusual case in which a peripheral T-cell lymphoma, with features of Lennert's and angioimmunoblastic lymphoma, occurred after treatment of a low grade plasmacytoid lymphoma. By analysis of immunoglobulin and T-cell receptor genes, we show that the two diseases had an independent clonal origin at the level of lymphoid commitment. However, by employing a novel polymerase chain reaction-based technique for analysis of B-cell clonality, we show the persistence of a residual minor clonal B-cell population in the subsequent T-cell lymphoma. Only 2 previous cases of composite lymphoma involving B- and T-cell clones have been demonstrated by molecular analysis. This study underlines the immunophenotypic and genotypic heterogeneity of peripheral T-cell lymphomas and illustrates an unusual disease course in which a T-cell lymphoma has arisen in the context of, and perhaps as a consequence of, a B-cell lymphoma.

Association between HLA antigens and progression of HIV infection in Greek haemophiliacs.

The frequencies of HLA antigens in 33 HIV seronegative and in 88 HIV seropositive haemophiliacs, who have been followed for at least 6 years since seroconversion or first HIV positive test, were evaluated in relation to disease susceptibility and disease progression. A high frequency of HLA-A2 and -DR2 antigens and a low frequency of HLA-A9 were found to characterize HIV seropositive patients (p < 0.05). Progressors to symptomatic CDC stage IV had a higher frequency of HLA-A9 (p < 0.01) and DR3. Rapid decline of CD4+ T cells in these patients was associated with HLA-A9, -DR1 and DR3. Our data suggest that HLA antigens may contribute to susceptibility to HIV infection and disease progression in Greek haemophiliacs.

HLA antigens in microscopic polyarteritis (MP) with renal involvement.

Serological HLA-A, B, C, DR and DQ typing was performed in 23 patients with microscopic polyarteritis and renal involvement and in 405 healthy individuals, all of Greek origin. An increased frequency of HLA-A26 (26% vs. 11.3%, x2 = 4.423, p < 0.05) and HLA-A11 (26% vs. 9.6%, x2 = 6.825, P < 0.02), and a decreased frequency of HLA-DR3 (4.3% vs. 24.1%, x2 = 5.935, p < 0.025) were found. Five out of six patients, who did not respond to treatment possessed HLA-DR5. These observations suggest that HLA gene products may influence the clinical expression, as well as the outcome of this disease.

Autosomal dominant foveal hypoplasia and presenile cataracts. A new syndrome.

An autosomal dominant syndrome of mild foveal hypoplasia (visual acuity, 20/50), congenital nystagmus, corneal pannus, and presenile cataracts was seen in four patients from a single family. There is variable expressivitly of this trait. The differential diagnosis includes aniridia, ocular albinism, and isolated foveal hypoplasia. Cataract surgery is indicated for affected patients with substantial visual impairment.

Prevention of intraocular pressure elevation following neodymium-YAG laser posterior capsulotomy.

Thirty-two eyes of 32 patients were treated with 0.5% timolol, 2% pilocarpine, or normal saline five and 30 minutes following neodymium-YAG laser posterior capsulotomy in a randomized, double-masked study. Mean maximum intraocular pressure (IOP) elevation was 8 +/- 2 mm Hg following treatment with normal saline, 5 +/- 3 mm Hg following treatment with 2% pilocarpine, and 1 +/- 2 mm Hg following treatment with 0.5% timolol. Fewer patients treated with 0.5% timolol developed an IOP elevation of 5 mm Hg or more than control patients. On aphakic patient treated with 0.5% timolol developed a maximum IOP greater than or equal to 40 mm Hg. We found that treatment with 0.5% timolol after neodymium-YAG laser posterior capsulotomy provides partial protection from IOP elevation.

Seminal plasma biochemical markers and their association with semen analysis findings.

OBJECTIVES: To examine the clinical value of six seminal plasma components in the evaluation of sperm quality and in the differential diagnosis of men with infertility. METHODS: We analyzed 202 seminal plasmas for prostate-specific antigen, glucose, pepsinogen C, insulin-like growth factor binding protein-3, prostaglandin D synthase (PGDS), and BRCA1-like immunoreactive protein (BRCA1-LIP) using quantitative immunofluorometric procedures. The semen donors were categorized in four clinical groups: normal, oligospermic, azoospermic, and vasectomy patients. We then evaluated whether any of these biochemical markers were associated with other parameters of sperm quality, including patient age, total cell concentration, percentage of motility, and percentage of normal morphology. RESULTS: We found that only PGDS concentration was significantly associated with other parameters of sperm quality. PGDS concentration correlated positively with total cell concentration (r = 0.55), percentage of motility (r = 0.31), and percentage of normal morphology (r = 0.31). Median PGDS concentration in seminal plasma decreased progressively from normal to oligospermic to azoospermic to vasectomy patients (P <0.001). There was no overlap between seminal plasma PGDS concentration of normal subjects versus vasectomy patients. The only other parameter that was moderately decreased in vasectomy patients was BRCA1-LIP. The source of PGDS in seminal plasma was determined with various techniques, including immunohistochemistry. This protein is produced and secreted by the Sertoli cells. CONCLUSIONS: Our findings suggest that PGDS concentration in seminal plasma correlates with other known indicators of semen quality and is a new marker of post-testicular obstruction. This biochemical parameter could be used to aid in the differential diagnosis of obstructive and nonobstructive azoospermia in men with infertility.

Topical indomethacin therapy before argon laser trabeculoplasty.

Fifty treatment sessions for 43 eyes (35 patients) receiving argon laser trabeculoplasty to one-half the angle were randomly assigned in a double-masked fashion to pretreatment with either topical indomethacin 1% or placebo. In 25 treatments intraocular pressure increased 3 mm Hg or more within four hours. Topical indomethacin pretreatment had no effect on the incidence, magnitude, or time course of this acute increase. It also did not alter the long-term effectiveness of the laser treatment (-3.8 mm Hg in the indomethacin-treated group vs -4.3 mm Hg in the placebo-treated group). The overall incidence of new peripheral anterior synechiae found on gonioscopy at one month was 32% (16 of 50 treatments). Synechiae formation was much higher in blacks (ten of 11 eyes or 91%) than in whites (five of 38 eyes or 13%). Although there was an association between acute anterior chamber inflammation after laser treatment and ultimate synechia formation (P less than .05), indomethacin pretreatment did not alter its occurrence.

Ambulatory blood pressure monitoring in hemodialysis patients.

The aim of our study was the detection of blood pressure (BP) variability during a dialysis session and in the interdialytic period in normotensive and hypertensive hemodialysis (HD) patients using ambulatory blood pressure monitoring (ABPM). Twenty-two HD patients aged 54 (range, 33-78) years who were on HD for a mean of 17.7 (range, 1-70) months were studied. Twelve patients were hypertensives, while the remaining 10 were normotensives (BP < 140/90 mm Hg). In all patients ABPM was performed for a total of 48 h including an HD session. A significant decrease in systolic BP, diastolic BP and mean BP was observed at the end of a dialysis session in hypertensive HD patients. However, in only five patients a reduction of more than 5% In mean arterial BP was noticed. No significant differences were observed in the BP values between the first and the second day after the HD in hypertensive HD patients. Interdialytic BP (both systolic and diastolic) was significantly higher than the postdialysis BP measured either in the clinic or with the ABPM in these patients. Normotensive HD patients exhibited a normal diurnal variation of BP during the first day after the HD session (decrease in BP during the night). On the second day after the HD session an increase in BP (mainly of systolic BP), as well as a loss of diurnal variation were observed. On the contrary, hypertensive HD patients did not exhibit the normal diurnal variation of BP during the first or the second day after the HD session. Hypertensive HD patients exhibited increased daytime and night time BP loads. On the other hand, normotensive HD patients presented with BP loads within normal limits, even though a small increase in these loads was observed on the second day after dialysis. In conclusion, while hypertensive HD patients present a loss of the normal diurnal variation of BP, normotensive HD patients exhibit normal variation during the first day after the HD session. The loss of the diurnal variation during the second day in these patients suggests a volume-dependent state.

Ambulatory blood pressure monitoring in normotensive pregnant women.

Ambulatory blood pressure monitoring (ABPM) provides a profile of blood pressure (BP) during daily activities and sleep and could uncover the inter-individual variability of BP. The aims of this study were to establish the normal values of the ABPM during the three trimesters of normal pregnancy, and to compare these values with those obtained in the office. ABPM was carried out on 22 normotensive pregnant women. BP values were compared with those obtained in the office. BP during the third trimester was significantly higher than the BP recorded during the first two gestational periods. In the three trimesters of pregnancy mean ambulatory systolic and diastolic BP were lower than the BP measured in the office in lying and standing positions. On the other hand, mean ambulatory BP (systolic and diastolic) measured during daily activities was not significantly different from the BP measured in the office. Sleeping BP was significantly lower than waking values in all trimesters, while there were not significant differences in the degree of BP fall among the three trimesters. Six women were sequentially studied during the three trimesters of pregnancy and particularly at the 12, 24 and 32 weeks of pregnancy. In these women, a small but significant rise in mean 24 h systolic and diastolic BP was observed at 32 weeks of pregnancy. Sleeping BP was significantly lower than waking values in the three trimesters. No significant difference in the degree of BP fall on the three gestational dates was found. It is concluded that ABPM is a useful tool for the evaluation of BP variability during pregnancy. During normal pregnancy ambulatory BP levels are highest in the day and lowest at night at all gestational ages and increased at the third trimester of pregnancy compared to the values observed during the first two gestational periods.

Effectiveness and metabolic effects of perindopril and diuretics combination in primary hypertension.

The effectiveness as well as the metabolic effects of the combination of diuretics [hydrochlorothiazide (HCT) vs indapamide (IND)] and perindopril (P) in 14 patients (7 male, 7 female) aged 37-62 years with mild idiopathic hypertension were studied. Following a 4-week wash-out period and a 4-week period of monotherapy with P (4 mg/daily), IND (2.5 mg/daily) or HCT (25 mg/daily) was added for 4 weeks. Selection of the diuretic agent was random. Following a 4-week wash-out period from the diuretic, in which only P was given, the alternative diuretic was administered for another period of 4 weeks. P decreased blood pressure levels significantly. However, the drug was more efficacious in patients with higher plasma renin activity (PRA). Combination treatment induced an additional decrease in the blood pressure levels, mainly in patients with lower PRA. The combination of P + HCT was more effective than the combination P + IND. The addition of either HCT or IND evoked a small but statistically significant increase in serum glucose levels while fasting as well as during the 75 g oral glucose challenge. However, insulin levels did not change significantly during the study. Small but not statistically significant changes in serum electrolytes and lipid parameters were observed during the various phases of the study, while a statistically significant increase in the serum uric acid was noticed when the combination P + HCT was given. We conclude: (1) P in small doses is an effective and safe antihypertensive agent, (2) PRA has a predictive value in determining the effectiveness of P treatment, (3) the combination of P with small doses of HCT or IND is more efficacious than P alone, (4) the combination treatment has adverse effects in the carbohydrate tolerance, while there are not significant changes in serum electrolyte and lipid parameters.

Renal abnormalities in patients with sickle cell-beta thalassemia.

We examined renal abnormalities in Greek patients with sickle-cell beta thalassemia (S-beta thal). A total of 17 patients aged 16-59 years suffering from S-beta thal and 17 age- and sex-matched healthy controls were studied. In all individuals we carried out a detailed study of renal function including electrolytes in serum and urine, concentrating or diluting ability, urine acidification ability, glomerular filtration rate (GFR), and hormones [such as plasma renin activity (PRA), serum aldosterone, and erythropoietin (EPO)]. Though the GFR did not differ significantly in patients and controls, half the patients had either supranormal or subnormal values. Serum potassium and uric acid were significantly higher in patients than controls. Serum phosphorus was similar in both groups, though patients with S-beta thal had significantly lower phosphate excretion indices. All patients were unable to maximally concentrate the urine, and seven also had limited ability to maximally dilute it. Five patients had incomplete distal renal tubular acidosis. Four had mild proteinuria, and six had microalbuminuria. Serum EPO and aldosterone were higher in S-beta thal patients than controls, but there was no difference in PRA between the two groups. There was a strong correlation between hemoglobin concentration and EPO levels, which was strongest in patients with GFR < 50 ml/min. We conclude that patients with S-beta thal, like sickle-cell anemia patients, present multiple abnormalities of renal function.

HLA antigens as predictors of disease progression in HIV-infected haemophilia patients (a 22 years' follow up).

Our objective was to assess the influence of genetic factors such as HLA classes I and II antigens and other clinical and laboratory variables on the progression of HIV disease in a cohort of 118 HIV infected haemophilic subjects of Greek origin who had been typed for HLA antigens and were followed up prospectively for 22 years since seroconversion. At the end of the follow up we compared two groups of patients: 22 patients who had a fast progression to AIDS (median 6 years since seroconversion) vs. 33 patients who remained asymptomatic in stage A2 for up to 22 years (median 15 years). The results showed that the two groups did not differ significantly in age at seroconversion or baseline CD4+ T cell count. However there was a difference in the frequencies of certain HLA antigens in the two groups. The fast progressors had a higher frequency of HLA-A28, B21 and DR3, which was statistically significant (P = 0.02, 0.04, 0.05, respectively) compared to the slow progressors. These findings based on classical HLA typing techniques confirm other published observations and support the effect of genetic background in the progression of HIV infection in haemophilics.

Acid-base and electrolyte abnormalities in febrile patients with bacteraemia.

OBJECTIVES: Very commonly febrile patients with bacteraemia develop a variety of acid-base and electrolyte disturbances which play a significant role in the morbidity and mortality of these patients. This study was undertaken to describe the pathogenetic mechanisms of these abnormalities in febrile patients with bacteraemia. METHODS: Fifteen febrile patients with bacteraemia, aged 24-62 years, were studied. In all patients blood cultures revealed Gram-negative rods. None of them had septic shock, diabetes mellitus, renal or liver failure and none was receiving drugs influencing acid-base balance and electrolyte levels or was a heavy alcohol consumer. RESULTS: Nine patients had respiratory alkalosis, which was possibly due to bacterial toxins, while the remaining 6 had a wide-gap metabolic (lactic) acidosis coexisting with respiratory alkalosis. Hypokalaemia was found in four patients and was mainly due to respiratory alkalosis. However, kaliuria due to hypomagnesaemia contributed to hypokalaemia in 2 patients. Hypomagnesaemia was detected in 3 patients and was attributed to respiratory alkalosis as well as to magnesiuria induced by metabolic acidosis or phosphate depletion. Hypophosphataemia was found in 5 patients who also had respiratory alkalosis and/or phosphaturia due to metabolic acidosis or hypomagnesaemia. Finally, one patient had multifactorial origin hypocalcaemia. CONCLUSION: Febrile patients with bacteraemia develop a number of acid-base and electrolyte disturbances attributed to various pathogenetic mechanisms.

A shared HLA-DRB1 sequence confers RA susceptibility in Greeks.

Previous serological studies of Greek rheumatoid arthritis (RA) patients have failed to demonstrate an association with DR4. Using sequence specific oligonucleotide typing we have identified the DRB1 alleles in panels of Greek RA patients and controls. When patient and control HLA-DRB1 frequencies were compared, significantly higher frequencies of DRB1*0101 (23.3% vs. 7.0%, odds ratio [OR] 4.0, 95% confidence intervals [CI] 1.4-12.0) and DRB1*1001 (20.9% vs. 5.8%, OR 4.3, 95% CI 1.3-13.7) were found in RA patients compared with controls. No association of DRB1*04 with RA was observed (20.9% vs. 14.0% in controls) confirming earlier reports. However DRB1*04 subtyping demonstrated a small but significant increase of DRB1*0405 in patients (14.0% vs. 3.5%, OR 4.5, 95% CI 1.1-18.9). When the frequency of individuals carrying the shared RA susceptibility epitope was compared between patients and controls it was found to be significantly higher in RA patients (60.5% vs. 22.1%, OR 5.4, 95% CI 2.4-12.0). We conclude that the shared epitope is significantly associated with RA in this population, but that it is predominantly accounted for by DRB1*0101 and DRB1*1001. Previous studies of UK RA patients have demonstrated a negative association of DR2 with disease and articular erosions. HLA-DR2 variants, DRB1*1501 and *1502 are not at reduced frequency in Greek RA patients (DRB1*1501, 14.0% in patients vs. 7.0% in controls; DRB1*1502, 7.0% in patients vs. 7.0% in controls). Genes conferring RA resistance may be in linkage disequilibrium with DR2 in UK patients. This does not appear to be the case in Greek RA patients. No association was seen between RA and HLA-DPB1 type.

Diagnostic vitrectomy in metastatic breast carcinoma in the vitreous.

Pars plana vitrectomy was employed to establish the diagnosis of intraocular carcinoma in a 72-year-old woman with a history of breast carcinoma and cerebral astrocytoma. Cytologic study of the material obtained from the vitreous cavity established the diagnosis of metastatic breast carcinoma, and this was later confirmed by study of the eyes obtained postmortem. The clinical and cytologic features of the ocular metastasis of breast carcinoma are presented.

Intraocular pressure elevation following Nd:YAG laser posterior capsulotomy.

Intraocular pressures (IOP) and tonographic outflow facilities were measured following neodymium (Nd): YAG laser posterior capsulotomy in 13 pseudophakic and 8 aphakic eyes. Mean intraocular pressure (IOP) peaked by three hours with a mean increase of 13 mmHg, remained elevated by 5 mmHg at 24 hours but returned to baseline by one week. Fourteen eyes (67%) had greater than or equal to 10 mmHg elevation and eight (38%) had greater than or equal to 40 mmHg maximum IOP. All the patients who eventually demonstrated a greater than or equal to 10 mmHg elevation within six hours of the capsulotomy initially had an IOP elevation greater than or equal to 5 mmHg at one hour. The mean outflow facility was reduced from 0.18 microl/min/mmHg before capsulotomy to 0.08 microl/min/mmHg (55%, P less than 0.0001) at four hours and was still decreased at 0.13 microl/min/mmHg (27%, P less than 0.05) at one week. Seventy-five percent of aphakic and 15% of pseudophakic patients had maximum IOP greater than or equal to 40 mmHg (P less than 0.01). Measurements should be performed one hour postlaser in all patients for IOP and three to four hours in aphakic patients, glaucomatous patients, patients receiving greater than or equal to 200 mjoules total laser energy, and patients with greater than or equal to 5 mmHg elevation at one hour in order to detect and treat significant IOP elevations.

Human leukocyte antigens as genetic markers in colorectal carcinoma.

PURPOSE: Similar to findings obtained for most carcinomas, the pathogenesis of colorectal cancer is considered to be multifactorial. There is strong evidence for an inherited, genetic predisposition to disease in patients with familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer. There is still debate, however, about the contribution of genetic factors to the pathogenesis of sporadic colorectal cancer. The present study was undertaken to search for human leukocyte antigen associations in a group of patients with colorectal cancer and to correlate the findings with both the histology of the disease and family history. SUBJECTS AND METHODS: The allele frequencies of serologically defined human leukocyte antigen class I and II antigens were studied in 101 patients with a recent, histologically confirmed diagnosis of colorectal cancer. All individuals in this study were unrelated to each other. After surgical treatment, all patients were grouped according to the stage (Dukes Stages A, B, C, and D), differentiation (Grades 1, 2, and 3), and the site of the tumor. Patients were also classified with regard to family history for colorectal cancer. The results obtained for human leukocyte antigen frequencies were compared with those of 105 healthy control subjects (control group). RESULTS: An increased frequency of human leukocyte antigen-B18 (27.72 vs. 14.28 percent; P < 0.025; odds ratio = 2.3) and of human leukocyte antigen-DQ5 (43.56 vs. 22.5 percent; P < 0.01; odds ratio = 2.65) was observed for patients with colorectal cancer vs. control subjects, respectively. In addition, human leukocyte antigen-B18 was present with increased frequency (30.76 percent; P < 0.05; odds ratio = 2.66; and 26.67 percent; P < 0.05; odds ratio = 2.18) among patients with rectal and colon carcinoma, respectively. A higher frequency of human leukocyte antigen-DQ5 (45.33 percent; P < 0.01; odds ratio = 2.84) was observed among patients with colon carcinoma. Remarkably, human leukocyte antigen-DQ5 (50 vs. 22.5 percent; P < 0.05; odds ratio = 3.43) and human leukocyte antigen-A1 (41.66 vs. 12.38 percent; P < 0.01; odds ratio = 5.05) were found to be strongly associated with a family history of colorectal cancer. CONCLUSION: The observation of specific human leukocyte antigen associations with particular subsets of colorectal cancer strongly suggests that genetic susceptibility for the development of colorectal cancer exists. Although the multifactorial pathogenesis of colorectal cancer must be considered, human leukocyte antigens may have useful predictive and diagnostic value.