Rituximab in routine care of severe active rheumatoid arthritis : A prospective, non-interventional study in Germany.

OBJECTIVE: To assess safety, effectiveness and onset of effect of rituximab (RTX) in routine clinical treatment of severe, active rheumatoid arthritis (RA). METHODS: Prospective, multi-centre, non-interventional study in rheumatological outpatient clinics or private practices in Germany. RTX-naïve adult patients were to receive RTX according to marketing authorisation and at their physician's discretion. Also according to their physician's discretion, patients could receive a second cycle of RTX (re-treatment = treatment continuation). Major outcome was the change in Disease Activity Score based on 28-joints count and erythrocyte sedimentation rate (DAS28-ESR) over 24 weeks and during 6 months of re-treatment. RESULTS: Overall, 1653 patients received at least one cycle RTX; 99.2% of these had received disease-modifying antirheumatic drugs (DMARD) pre-treatment and 75.5% anti-tumor necrosis factor(TNF)­α pre-treatment. After a mean interval of 8.0 months, 820 patients received RTX re-treatment. Mean DAS28-ESR decreased from 5.3 at baseline to 3.8 after 24 weeks (-1.5 [95% confidence interval, CI: -1.6; -1.4]), and from 4.1 at start of cycle 2 to 3.5 at study end (change from baseline: -1.8 [95% CI: -2.0; -1.7]). Improvements in DAS28-ESR and Health Assessment Questionnaire (HAQ) score occurred mainly during the first 12 weeks of RTX treatment, with further DAS28-ESR improvement until week 24 or month 6 of re-treatment. Improvements in DAS28-ESR and EULAR responses were more pronounced in seropositive patients. RF was a predictor of DAS28-ESR change to study end. Safety analysis showed the established profile of RTX. CONCLUSION: RTX was safe and effective in a real-life setting with rapid and sustained improvement in RA signs and symptoms.

Double pass 595 nm pulsed dye laser at a 6 minute interval for the treatment of port-wine stains is not more effective than single pass.

BACKGROUND: Pulsed dye laser (PDL) is the first choice for treatment of port wine stains (PWS). However, outcome is highly variable and only a few patients achieve complete clearance. The objective of the study was to compare efficacy and safety of single pass PDL with double pass PDL at a 6 minute interval. METHODS: We conducted a randomized within-patient controlled study on PWS resistant to multiple single pass PDL treatments. In each patient two similar PWS areas were randomly allocated to PDL treatment (595 nm, 7 mm spot size, 1.5 mseconds pulse duration) using, as a control treatment, a single pass (12 J/cm(2)) or, as a new treatment, a double pass PDL (11 J/cm(2), second pass 6 minutes after the first pass). Both test areas were treated two times, 8 weeks apart. PWS clearance was assessed by two blinded dermatologists, and by color measurement (L*a*b) using reflectance spectroscopy, at 3 months follow-up. RESULTS: Sixteen out of 17 included patients completed follow-up. The mean number of treatments before inclusion was 15. Overall color assessed by spectrophotometer showed no improvement for either single or double pass PDL. Blinded Physician Global Assessment and Patient Global Assessment showed a high variability in outcome, with mostly only moderate improvement of the PWS for either single pass or double pass PDL. Furthermore, there was no significant difference in any of the outcomes between single pass and double pass PDL. CONCLUSION: At the chosen settings and after two treatment sessions, double pass PDL at a 6 minute interval does not result in improved clearance of PWS as compared to single pass treatment.

Dynamic prediction of mortality in COVID-19 patients in the intensive care unit: A retrospective multi-center cohort study.

Background: The COVID-19 pandemic continues to overwhelm intensive care units (ICUs) worldwide, and improved prediction of mortality among COVID-19 patients could assist decision making in the ICU setting. In this work, we report on the development and validation of a dynamic mortality model specifically for critically ill COVID-19 patients and discuss its potential utility in the ICU. Methods: We collected electronic medical record (EMR) data from 3222 ICU admissions with a COVID-19 infection from 25 different ICUs in the Netherlands. We extracted daily observations of each patient and fitted both a linear (logistic regression) and non-linear (random forest) model to predict mortality within 24 h from the moment of prediction. Isotonic regression was used to re-calibrate the predictions of the fitted models. We evaluated the models in a leave-one-ICU-out (LOIO) cross-validation procedure. Results: The logistic regression and random forest model yielded an area under the receiver operating characteristic curve of 0.87 [0.85; 0.88] and 0.86 [0.84; 0.88], respectively. The recalibrated model predictions showed a calibration intercept of -0.04 [-0.12; 0.04] and slope of 0.90 [0.85; 0.95] for logistic regression model and a calibration intercept of -0.19 [-0.27; -0.10] and slope of 0.89 [0.84; 0.94] for the random forest model. Discussion: We presented a model for dynamic mortality prediction, specifically for critically ill COVID-19 patients, which predicts near-term mortality rather than in-ICU mortality. The potential clinical utility of dynamic mortality models such as benchmarking, improving resource allocation and informing family members, as well as the development of models with more causal structure, should be topics for future research.

Altered Processing of Complex Visual Stimuli in Patients with Postconcussive Visual Motion Sensitivity.

BACKGROUND AND PURPOSE: Vestibular symptoms are common after concussion. Vestibular Ocular Motor Screening identifies vestibular impairment, including postconcussive visual motion sensitivity, though the underlying functional brain alterations are not defined. We hypothesized that alterations in multisensory processing are responsible for postconcussive visual motion sensitivity, are detectable on fMRI, and correlate with symptom severity. MATERIALS AND METHODS: Twelve patients with subacute postconcussive visual motion sensitivity and 10 healthy control subjects underwent vestibular testing and a novel fMRI visual-vestibular paradigm including 30-second "neutral" or "provocative" videos. The presence of symptoms/intensity was rated immediately after each video. fMRI group-level analysis was performed for a "provocative-neutral" condition. Z-statistic images were nonparametrically thresholded using clusters determined by Z > 2.3 and a corrected cluster significance threshold of P = .05. Symptoms assessed on Vestibular Ocular Motor Screening were correlated with fMRI mean parameter estimates using Pearson correlation coefficients. RESULTS: Subjects with postconcussive visual motion sensitivity had significantly more Vestibular Ocular Motor Screening abnormalities and increased symptoms while viewing provocative videos. While robust mean activation in the primary and secondary visual areas, the parietal lobe, parietoinsular vestibular cortex, and cingulate gyrus was seen in both groups, selective increased activation was seen in subjects with postconcussive visual motion sensitivity in the primary vestibular/adjacent cortex and inferior frontal gyrus, which are putative multisensory visual-vestibular processing centers. Moderate-to-strong correlations were found between Vestibular Ocular Motor Screening scores and fMRI activation in the left frontal eye field, left middle temporal visual area, and right posterior hippocampus. CONCLUSIONS: Increased fMRI brain activation in visual-vestibular multisensory processing regions is selectively seen in patients with postconcussive visual motion sensitivity and is correlated with Vestibular Ocular Motor Screening symptom severity, suggesting that increased visual input weighting into the vestibular network may underlie postconcussive visual motion sensitivity.

Contributions of anterior cingulate cortex and basolateral amygdala to decision confidence and learning under uncertainty.

The subjective sense of certainty, or confidence, in ambiguous sensory cues can alter the interpretation of reward feedback and facilitate learning. We trained rats to report the orientation of ambiguous visual stimuli according to a spatial stimulus-response rule that must be learned. Following choice, rats could wait a self-timed delay for reward or initiate a new trial. Waiting times increase with discrimination accuracy, demonstrating that this measure can be used as a proxy for confidence. Chemogenetic silencing of BLA shortens waiting times overall whereas ACC inhibition renders waiting times insensitive to confidence-modulating attributes of visual stimuli, suggesting contribution of ACC but not BLA to confidence computations. Subsequent reversal learning is enhanced by confidence. Both ACC and BLA inhibition block this enhancement but via differential adjustments in learning strategies and consistent use of learned rules. Altogether, we demonstrate dissociable roles for ACC and BLA in transmitting confidence and learning under uncertainty.

Misexpression of the Emx-related homeobox genes cVax and mVax2 ventralizes the retina and perturbs the retinotectal map.

The mechanisms that establish the dorsal-ventral (D-V) axis of the eye are poorly understood. We isolated two homeobox genes from mouse and chicken, mVax2 and cVax, whose expression during early eye development is restricted to the ventral retina. In chick, ectopic expression of either Vax leads to ventralization of the early retina, as assayed by expression of the transcription factors Pax2 and Tbx5, and the Eph family members EphB2, EphB3, ephrinB1, and ephrinB2, all of which are normally dorsally or ventrally restricted. Moreover, the projections of dorsal but not ventral ganglion cell axons onto the optic tectum showed profound targeting errors following cVax misexpression. mVax2/cVax thus specify positional identity along the D-V axis of the retina and influence retinotectal mapping.

A minimal regulatory region maintains constitutive expression of the max gene.

Max is a basic helix-loop-helix/leucine zipper protein that forms heterodimers with the Myc family of proteins to promote cell growth and with the Mad/Mxi1 family of proteins to inhibit cell growth. The role of Max as the obligate binding partner for these two protein families necessitates the observed constitutive expression and relatively long half-life of the max mRNA under a variety of growth conditions. In this study, we have used the chicken max gene to map DNA elements maintaining max gene expression in vertebrate cells. We have identified a minimal regulatory region (MRR) that resides within 115 bp of the max translation initiation site and that possesses an overall structure typical of TATA-less promoters. Within the MRR are two consensus binding sites for Sp1, a ubiquitously expressed transcription factor that plays a role in the expression of many constitutive genes. Interestingly, we show that direct binding by Sp1 to these sites is not required for MRR-mediated transcription. Instead, the integrity of a 20-bp DNA element in the MRR is required for transcriptional activity, as is the interaction of this DNA element with a 90-kDa cellular protein. Our data suggest that it is the persistence of this 90-kDa protein in vertebrate cells which drives max gene expression, insulates the max promoter from the dramatic changes in transcription that accompany cell growth and development, and ensures that adequate levels of Max will be available to facilitate the function of the Myc, Mad, and Mxi1 families of proteins.

Clinical characteristics of prostate cancer in an analysis of linkage to four putative susceptibility loci.

PURPOSE: Hereditary prostate cancer is an etiologically heterogeneous disease with six susceptibility loci mapped to date. We aimed to describe a collection of high-risk prostate cancer families and assess linkage to multiple markers at four loci: HPC1 (1q24-25), PCaP (1q42.2-43), HPCX (Xq27-28), and CAPB (1p36). EXPERIMENTAL DESIGN: Medical record data on 505 affected men in 149 multiply-affected prostate cancer families were reviewed, and correlations of clinical traits within each family were calculated. Logarithm of odds (LOD) score and nonparametric (NPL) linkage analyses were performed; white families were stratified by age of diagnosis, grade and stage of disease, and evidence of linkage to the other loci to increase genetic homogeneity. RESULTS: Age at diagnosis was the most correlated clinical trait within families. A maximum NPL score of 2.61 (P = 0.007) appeared to confirm HPC1 linkage for families that had a prevalence of high-grade or advanced-stage prostate cancer and which were not likely to be linked to PCaP, HPCX, or CAPB. Because the NPL scores improved when families more likely to be linked to the other loci were excluded, HPC1 may act independently of the other loci. The relationship of HPC1 and aggressive disease was strongest in families with median age at diagnosis > or =65 years (NPL, 3.48; P = 0.0008). CONCLUSIONS: The current results suggest that HPC1 linkage may be most common among families with more severe prostate cancer. Stratification by clinical characteristics may be a useful tool in prostate cancer linkage analyses and may increase our understanding of hereditary prostate cancer.

The Adrenomedullin gene is a target for negative regulation by the Myc transcription complex.

The Myc family of transcription factors plays a central role in vertebrate growth and development although relatively few genetic targets of the Myc transcription complex have been identified. In this study, we used mRNA differential display to investigate gene expression changes induced by the overexpression of the MC29 v-Myc oncoprotein in C3H10T1/2 mouse fibroblasts. We identified the transcript of the adrenomedullin gene (AM) as an mRNA that is specifically down-regulated in v-Myc overexpressing C3H10T1/2 cell lines as well as in a Rat 1a cell line inducible for c-Myc. Nucleotide sequence analysis of the mouse AM promoter reveals the presence of consensus CAAT and TATA boxes as well as an initiator element (INR) with significant sequence similarity to the INR responsible for Myc-mediated repression of the adenovirus major late promoter (AdMLP). Reporter gene assays confirm that the region of the AM promoter containing the INR is the target of Myc-mediated repression. Exogenous application of AM peptide to quiescent C3H10T1/2 cultures does not stimulate growth, and constitutive expression of AM mRNA in C3H10T1/2 cells correlates with a reduced potential of the cells to be cotransformed by v-Myc and oncogenic Ras p21. Additional studies showing that AM mRNA is underrepresented in C3H10T1/2 cell lines stably transformed by Ras p21 or adenovirus E1A suggest that AM gene expression is incompatible with deregulated growth in this cell line. We propose a model in which the repression of AM gene expression by Myc is important to the role of this oncoprotein as a potentiator of cellular transformation in C3H10T1/2 and perhaps other cell lines.

Target genes and cellular regulators of the Myc transcription complex.

Precisely how the Myc proteins promote cellular growth and transformation remains an enigma. Structural and functional studies unequivocally demonstrate that Myc proteins have the potential to function as regulators of gene transcription in vivo. Therefore, the current view is that Myc-induced cellular growth is orchestrated by products of the genes regulated by Myc and that efforts to curtail Myc function are best directed toward the accessory proteins that interact with Myc to modulate its function as a transcription factor. This review is focused on recent work designed to identify the genetic targets of Myc activity in cells and to characterize Myc-interacting proteins. These studies have provided an intriguing set of molecular tools that can be exploited to generate new information on the role of Myc in cell growth and oncogenic transformation.

Expression of a biologically active analogue of somatomedin-C/insulin-like growth factor I.

A synthetic gene coding for an analogue of somatomedin-C/insulin-like growth factor I (Sm-C/IGF-I) was synthesized by solid support phosphoramidite chemistry and subsequently cloned and expressed in Escherichia coli as a fusion protein. The gene, designed with a threonine codon substituted for a methionine codon at position 59 was expressed fused to an eight-amino acid leader peptide under the direction of the E. coli tryptophan promoter. The fusion protein, termed L0-[Thr59]-Sm-C/IGF-I was purified extensively (greater than 97%) and found to be 60% as active as native Sm-C/IGF-I in a radioimmunoassay and 50% as potent as native Sm-C/IGF-I in a radioreceptor assay. Like native Sm-C/IGF-I it was also mitogenic for Balb/c 3T3 cells. After removal of the eight amino acid leader peptide by cyanogen bromide treatment, the resulting threonine analogue, termed [Thr59]-Sm-C/IGF-I was 80% as potent as native Sm-C/IGF-I in both the RIA and the radioreceptor assays. It was also mitogenic in Balb/c 3T3 cells. These two analogues, therefore, display biological activities similar to human-derived Sm-C/IGF-I.

Ageing, testicular tumours and the pituitary-testis axis in dogs.

Dogs of different ages without testicular diseases were evaluated to study possible age-related changes in hormone concentrations in serum. Dogs with testicular tumours were also investigated to study the relation between tumour type and hormone concentrations; in this study, dogs with Sertoli cell tumours, Leydig cell tumours and seminomas were included. We measured testosterone, oestradiol, LH, FSH and inhibin-like immunoreactivity concentrations in peripheral venous and testicular venous blood of these animals. In normal dogs there appeared to be no age-related changes in the concentrations of the investigated hormones, except for a significant age-related decrease in oestradiol concentrations in testicular venous blood (P<0.02). Dogs with a Sertoli cell tumour had greater oestradiol concentrations and inhibin-like immunoreactivity in both peripheral and testicular venous blood than did dogs without a neoplasm (P<0. 05). Testosterone concentrations were reduced in dogs with Sertoli cell tumours, as were FSH and LH. Feminisation occurred in eight of 13 dogs with a Sertoli cell tumour and in two of 14 dogs with a Leydig cell tumour; it was accompanied by a significantly greater oestradiol concentration than in normal dogs and in dogs with Sertoli cell tumours without signs of feminisation. Dogs with a Leydig cell tumour had greater concentrations of oestradiol and inhibin-like immunoreactivity in both peripheral venous and testicular venous blood than did dogs without a neoplasm (P<0.05). The testosterone concentration in testicular venous blood of these dogs was lower than that in dogs with normal testes. The concentration of LH in peripheral venous blood was also reduced (P<0. 05). Hormone concentrations in dogs with a seminoma were not different from those in normal dogs. It was concluded that seminomas are not endocrinologically active. In contrast, both Sertoli cell tumours and Leydig cell tumours can cause increased oestrogen production leading to signs of feminisation. These tumours also have considerable amounts of inhibin-like immunoreactivity, but only in Sertoli cell tumours does this result in a reduction in FSH concentrations, suggesting that Sertoli cell tumours secrete dimeric inhibin, whereas Leydig cell tumours presumably produce loose alpha-subunits that cross-react in the inhibin assay but are not biologically active.

Preliminary report on the effects of totigestational exposure to ethchlorvynol.

Ethchlorvynol, a sedative-hypnotic drug used clinically since 1955, has recently been the subject of renewed interest primarily because of its chemical relationship to vinyl chloride. In our totigestational studies, sperm-positive female rats were given a daily dose of ethchlorvynol dissolved in olive oil for 21 consecutive days. The dams were allowed to deliver and their offspring were observed for alterations in development by monitoring a number of gross behavioral, histological and biochemical parameters at newborn, weanling, puberty, adult and geriatric stages. Gross development appeared normal at time of weaning: however, offspring of treated dams showed increased behavioral activity in addition to alterations in a number of clinical chemistry parameters. The dose-response seen with most of the parameters suggests that the changes are drug related. However, the clinical pathological significance has not been ascertained.

A two-stage technique for intraoperative fluid-gas exchange following pars plana vitrectomy.

We describe herein a two-stage technique of intraoperative fluid-gas exchange following pars plana vitrectomy. The first stage is a complete fluid-air exchange using an air pump and intraocular linear suction. The air pump then maintains the intraocular pressure at the desired level during adjunctive procedures, such as laser endophotocoagulation. The second stage is an air-gas mixture exchange in which the desired gas, premixed in air to the desired final intraocular concentration, is manually flushed through the eye. This technique allows the attainment of an accurate concentration of intraocular gas if the air-gas mixture exchange is complete. In vitro and in vivo experiments in aphakic human eyes demonstrated that an effectively complete air-gas mixture exchange occurs with a 25-mL flush volume. This result compares favorably with the theoretical prediction derived from a "pharmacokinetic approximation" equation.

Diabetic keratopathy as a manifestation of peripheral neuropathy.

In a study of 102 patients (64 women and 38 men; 63 whites and 39 nonwhites; 77 with adult-onset disease and 25 with juvenile-onset disease), the data, after being adjusted for age, showed that diabetic peripheral neuropathy was associated with diabetic keratopathy. The strongest predictor of both keratopathy and corneal fluorescein staining was vibration perception threshold in the toes (P less than .01); the severity of keratopathy was directly related to the degree of diminution of peripheral sensation. Other predictors of keratopathy were reduced tear break-up time (P less than .03), the type of diabetes (P less than .01), and metabolic status, shown by fasting C-peptide levels (P less than .01). No significant relationships were found between keratopathy and tear glucose levels, endothelial cell densities, corneal thickness, or duration of disease.

The nonexpansile, equilibrated concentration of perfluoropropane gas in the eye.

Bubbles of 100% perfluoropropane (0.4 ml) were injected into the vitreous cavities of 31 New Zealand White rabbits. Gas bubbles were aspirated from eyes at six and 12 hours and at one, two, three, four, five, seven, nine, and 14 days, and were analyzed by gas chromatography. The nonexpansile concentration of perfluoropropane (found at maximum expansion of the gas bubble at four days) was approximately 12%. The gas bubble concentration equilibrated at seven days with a perfluoropropane concentration of approximately 10% with little change through 14 days. Using a similar protocol, we injected 0.56-ml bubbles of 100% perfluoropropane into the vitreous cavities of three owl monkeys. When sampled on day 4 for analysis by gas chromatography, results were comparable to the rabbit data. A 12% concentration of perfluoropropane should approximate the ideal composition of a gas mixture for a total fluid-gas exchange. This would achieve complete retinal tamponade without later compromise of intraocular pressure by further expansion.

Comparison of the urinary metabolite profiles of hexachlorobenzene and pentachlorobenzene in the rat.

The urinary metabolite profile of hexachlorobenzene (HCB) and pentachlorobenzene (PCBz) in the rat is compared after dietary exposure for 13 weeks. Both HCB and PCBz are oxidized to pentachlorophenol (PCP) and tetrachlorohydroquinone (TCHQ), which were the only two mutual metabolites formed. Additional urinary metabolites of HCB are N-acetyl-S(pentachlorophenyl)cysteine (PCTP-NAC), which appeared to be quantitatively the most important product, and mercaptotetrachlorothioanisole (MTCTA), which was excreted as a glucuronide. PCBz is more extensively metabolized to the major metabolites 2,3,4,5-tetrachlorophenol (TCP), mercaptotetrachlorophenol (MTCP) and the glucuronide of pentachlorothiophenol (PCTP), and the minor metabolites methylthiotetrachlorophenol (MeTTCP), hydroxytetrachlorophenyl sulphoxide (HTCPS), and bis(methylthio)-trichlorophenol (bis-MeTTriCP). The biotransformation of HCB and PCBz was modulated by selective inhibition of cytochrome P450IIIA in rats which received combined treatment of HCB or PCBz with triacetyloleandomycin (TAO). Rats receiving this diet had a strongly diminished excretion of both PCP and TCHQ, as compared to rats fed HCB or PCBz alone, indicating the involvement of P450IIIA in the oxidation of both compounds. However, the excretion of 2,3,4,5-TCP was not diminished by co-treatment of rats with PCBz and TAO, indicating that: (i) the oxidation of PCBz to PCP and 2,3,4,5-TCP does not proceed via a common intermediate; and (ii) oxidation of PCBz to 2,3,4,5-TCP is not mediated by P450IIIA. Co-treatment of rats with PCBz and TAO had a differential effect on the excretion of sulphur-containing metabolites, resulting in a decrease in the excretion of PCTP glucuronide, whereas no change was observed in the excretion of MTCP, as compared to rats receiving PCBz alone. The observed differences in HCB and PCBz metabolites clearly deserve further in vitro studies to elucidate their origin.

Analgesic effect of opiates in offspring of opiate-treated female rats.

The purpose of this study was to determine the effect that chronic maternal exposure to narcotics has on the effectiveness of analgesic drugs in the offspring. No exposure related differences were observed in the base level response to the noxious stimuli used. However, offspring of methadone and morphine-treated mothers tended to show decreased response latencies compared to control offspring, in both the hotplate and tail flick test, following the subcutaneous administration of narcotic analgesic drugs. In all groups studied, methadone offspring had significantly reduced latencies while morphine offspring had latencies that were intermediate between the control and methadone-treated groups (in general, control latencies greater than morphine latencies greater than methadone latencies). Morphine offspring were significantly different from the controls only in the 120-day-old female group. Treatment-related decreases in the effectiveness of the analgesics in both 25- and 120-day-old offspring suggest that exposure of developing rat pups to narcotics during gestation and early postnatal development is associated with long-lasting alterations in those processes involved with pain perception and/or interpretation.

Opiate self-administration in adult offspring of methadone-treated female rats.

Chronic treatment of female Sprague-Dawley rats with methadone 5 mg/kg IP throughout gestation and lactation resulted in an increased oral self-administration (S.A.) of morphine by their 85-90-day-old offspring. By day 16 of the S.A. treatment schedule methadone offspring were taking 75 to 80% of their total fluid intake as morphine solution when given a choice between morphine solution and water, while control offspring under the same conditions took 33% of their total fluids as morphine solution. When the subjects were again given a choice between water and morphine solution following a 12-day drug free period, methadone offspring drank a significantly greater percentage of morphine solution than controls. Methadone S.A. in methadone offspring was not different from controls. The reasons for this marked difference between morphine and methadone S.A. are not clear. However, it does appear that chronic maternal exposure to methadone may facilitate development of a morphine-S.A. behavior in their offspring.

Alkaline earth separations on microcrystalline cellulose columns.

Magnesium, calcium, strontium and barium may be separated quantitatively from each other on a column of micro-crystalline cellulose. Barium and radium are also separated from each other. The metal ions are eluted from the column by methanol-hydrochloric acid in varying proportions. The separated metal ions can be titrated with EDTA. Trace amounts of metal ions may be determined by neutron activation.