The natural history of encephalomyocarditis virus-induced myositis and myocarditis in mice. Viral persistence demonstrated by in situ hybridization.

Picornaviruses can initiate chronic inflammation that persists after the virus can no longer be cultured from inflamed tissues. In an attempt to understand this transition we have sought evidence for viral persistence by methods that detect viral genome independent of whether or not whole competent virus is present. In mice infected with a myotropic variant of encephalomyocarditis virus, EMC-221A, virus can be cultured in high yield at 1 wk and in low yield at 2 wk from skeletal muscle, heart, and brain; a small number of plaque-forming units could be cultured from brain at 4 wk. By contrast, in situ hybridization detected viral nucleic acid at least a week or two thereafter, often in single cells. In the skeletal muscle, inflammation disappeared by 3 wk, but in heart it remained for the full 12 wk of observation. In the brain, microglial nodules, sometimes with associated viral nucleic acid, were present for a long period. Application of this technique allows a more accurate assessment of the role of viral persistence in the pathogenesis of virus-initiated but apparently autoimmune inflammation.

Pathological and immunological effects of ingesting L-tryptophan and 1,1'-ethylidenebis (L-tryptophan) in Lewis rats.

The eosinophilia-myalgia syndrome (EMS) has been associated with ingestion of L-tryptophan (L-TRP) produced by a single manufacturer. Epidemiological data implicated 1,1'-ethylidenebis (L-tryptophan) (EBT) (peak 97 or peak E) as a possible etiologic agent. We showed previously that Lewis rats treated with the L-TRP implicated in EMS develop fasciitis and perimyositis similar to those seen in human EMS. We now report the pathology associated with the treatment of Lewis rats with synthetic EBT and/or L-TRP. All animals treated for 6 wk with case-associated L-TRP or EBT developed significant myofascial thickening, compared with animals in the vehicle control and control L-TRP groups. However, even those animals receiving the control L-TRP showed a mild but significant increase in the thickness of the myofascia, compared with vehicle-treated control animals. All animals except vehicle controls also exhibited significant pancreatic pathology, including fibrosis and acinar changes. Only animals treated with case-associated L-TRP for 6 wk showed evidence of immune activation with increased frequency of CD8, Ia, and IL-2 receptor-positive cells in the peripheral blood. Animals receiving L-TRP or EBT for < 6 wk did not show significant differences in myofascial thickness, although these animals did show pancreatic acinar changes. Although these results demonstrate for the first time the pathological effects of EBT, they do not rule out the possibility that other impurities in the EMS-case-associated L-TRP may also contribute to some of the features of EMS.

Effect of intestinal microflora suppression on liver carcinogenicity of dimethylnitrosamine in Syrian hamsters.

Liver tumors induced by dimethylnitrosamine showed an increased incidence in Syrian hamsters with intestinal microflora suppressed by antibiotics, as compared with the incidence in animals not treated with antibiotics. The possible mechanisms, including metabolic alterations caused by changes in the normal microflora population, were discussed.

Chaparral-associated hepatotoxicity.

BACKGROUND: Personal health care practices that may include the use of dietary supplements are common in the United States. Products marketed as dietary supplements are diverse and may include botanicals, vitamins, and/or minerals. Chaparral (Larrea tridentata) is a botanical dietary supplement made from a desert shrub and used for its antioxidant properties. Several reports of chaparral-associated hepatitis have been published since 1990, but a complete picture of the clinical presentation is still unclear. MATERIALS AND METHODS: We reviewed the 18 case reports of adverse events associated with the ingestion of chaparral reported to the Food and Drug Administration between 1992 and 1994. These reports were from health care professionals, state health departments, and individual consumers. RESULTS: Of 18 reports of illnesses associated with the ingestion of chaparral, there was evidence of hepatotoxicity in 13 cases. Clinical presentation, characterized as jaundice with a marked increase in serum liver chemistry values, occurred 3 to 52 weeks after the ingestion of chaparral, and it resolved 1 to 17 weeks after most individuals stopped their intake of chaparral. The predominant pattern of liver injury was characterized as toxic or drug-induced cholestatic hepatitis; in 4 individuals, there was progression to cirrhosis; and in 2 individuals, there was acute fulminant liver failure that required liver transplants. CONCLUSIONS: These data indicate that the use of chaparral may be associated with acute to chronic irreversible liver damage with fulminant hepatic failure, and they underscore the potential for certain dietary supplement ingredients to cause toxic effects on the liver. Health professionals should be encouraged to inquire routinely about the use of dietary supplements and other products, to be alert to potential adverse effects that may be associated with these products, and, finally, to report any serious adverse events associated with these products through the MEDWatch Program of the Food and Drug Administration.

A new approach to the classification of idiopathic inflammatory myopathy: myositis-specific autoantibodies define useful homogeneous patient groups.

The IIM are a heterogeneous group of systemic rheumatic diseases which share the common features of chronic muscle weakness and mononuclear cell infiltrates in muscle. A number of classification schemes have been proposed for them, but none takes into consideration the marked immunologic, clinical, and genetic heterogeneity of the various clinical groups. We compared the usefulness of myositis-specific autoantibodies (anti-aminoacyl-tRNA synthetases, anti-SRP, anti-Mi-2 and anti-MAS) to the standard clinical categories (polymyositis, dermatomyositis, overlap myositis, cancer-associated myositis, and inclusion body myositis) in predicting clinical signs and symptoms, HLA types, and prognosis in 212 adult IIM patients. Although patients with inclusion body myositis (n = 26) differed in having significantly more asymmetric and distal weakness, falling, and atrophy than other patients, there were few other significant differences among the other clinical groups. In contrast, autoantibody status defined distinct sets of patients and each patient had only 1 myositis-specific autoantibody. Patients with anti-amino-acyl-tRNA synthetase autoantibodies (n = 47), compared to those without these antibodies, had significantly more frequent arthritis, fever, interstitial lung disease, and "mechanic's hands"; HLA-DRw52; higher mean prednisone dose at survey, higher proportion of patients receiving cytotoxic drugs, and higher death rates. Those with anti-signal recognition particle antibodies (n = 7) had increased palpitations; myalgias; DR5, DRw52; severe, refractory disease; and higher death rates. Patients with anti-Mi-2 antibodies (n = 10) had increased "V-sign" and "shawl-sign" rashes, and cuticular overgrowth; DR7 and DRw53; and a good response to therapy. The 2 patients with anti-MAS antibodies were the only ones with alcoholic rhabdomyolysis preceding myositis; both had insulin-dependent diabetes mellitus, and both had HLA-B60, -C3, -DR4, and -DRw53. These findings suggest that myositis-specific autoantibody status is a more useful guide than clinical group in assessing patients with myositis, and that specific associations of immunogenetics, immune responses, and clinical manifestations occur in IIM. Thus the myositis-specific autoantibodies aid in interpreting the diverse symptoms and signs of myositis patients and in predicting their clinical course and prognosis. We propose, therefore, that an adjunct classification of the IIM, based on the myositis-specific autoantibody status, be incorporated into future studies of their epidemiology, etiology, and therapy.

Drug therapy of the idiopathic inflammatory myopathies: predictors of response to prednisone, azathioprine, and methotrexate and a comparison of their efficacy.

PURPOSE: To identify factors associated with responses to treatment with prednisone, methotrexate, or azathioprine in patients with idiopathic inflammatory myopathy, and to compare the efficacy of these drugs. PATIENTS AND METHODS: Data were collected on 113 adult patients meeting criteria for definite idiopathic inflammatory myopathy in this retrospective cohort study. Patients were categorized as responding completely, partially, or not at all to each therapeutic trial based upon clinical and laboratory criteria. RESULTS: Clinical group, presence of certain myositis-specific autoantibodies, and time from disease onset to diagnosis influenced rates of complete clinical response to these therapeutic agents. Patients with inclusion body myositis responded comparatively poorly to prednisone and the other drugs: 43% had no clinical response to prednisone and none responded completely to any medication. Patients with autoantibodies to aminoacyl-tRNA synthetases or to signal recognition particle proteins were likely to respond partially, but not completely, to prednisone. No patient with a long delay to diagnosis (greater than 18 months) responded completely, compared with 34% of those with a short delay (less than 3 months). A patient's response to the first course of prednisone predicted subsequent responses to prednisone and to azathioprine better than response to methotrexate. Men responded to methotrexate better than women. Among certain subgroups of patients, responses to methotrexate were better than to either azathioprine or retreatment with prednisone. CONCLUSION: Determining the clinical group, autoantibody status, and time from disease onset to diagnosis of patients with myositis provides useful information in predicting clinical responses to therapy, and these factors should be considered in designing future therapeutic trials. Methotrexate therapy may be superior to either azathioprine or further steroid treatment alone in certain patients who do not respond completely to an initial adequate course of prednisone.

Lymphocyte fluorescent profiles (LFP): a possible screening technique in neoplasia.

A technique involving fluorescent protein staining and microfluorometry has been developed for measuring the lymphocyte fluorescent profile (LFP) of peripheral blood lymphocytes. In contrast to normal humans who display a regular bell-shaped curve, the profile from patients with cancer is irregular, showing a bimodal distribution of fluorescence, with a significant population of cells fluorescing at a higher relative intensity. It is suggested that this elevation in protein concentration is due to an immune response to the presence of a neoplasm, and thus this technique may prove to be a useful indicator of malignancy.

Pathologic changes in the cardiac interstitium of mice infected with encephalomyocarditis virus.

Patients with myocarditis often develop dilated cardiomyopathy and congestive heart failure. Histologically, myocarditis is manifested by rare foci of myocyte necrosis with interstitial inflammation, while cardiomyopathy is characterized by diffuse interstitial fibrosis, myocyte hypertrophy, and an absence of active interstitial inflammation. The relationship between myocardial inflammation and interstitial fibrosis is poorly understood. This relationship was examined in mice that developed a diffuse interstitial inflammation of the heart over a period of 21 days following infection with encephalomyocarditis virus. Typical early lesions (day 7) included focal zones of myocytolysis containing mononuclear and polymorphonuclear inflammatory cells that were associated with the focal loss of reticular fibers. Later pathology (days 14-21) was characterized by a sparse, diffuse interstitial myocarditis with little ongoing necrosis. Changes within the myocardial interstitium remote from healing necrotic foci were marked by reticular fiber thickening and disorganization, often associated with pleomorphic fibroblasts. Reticulin fiber deposition was quantitatively increased in sparsely inflamed regions of hearts from infected animals as compared to noninflamed regions from the same hearts (p < 0.005) or hearts of control animals (p < 0.001). Scanning electron microscopy revealed interstitial changes that were more extensive than indicated by routine staining with hematoxylin and eosin for Masson's trichrome. The progressive changes within the cardiac interstitium during the development of postmyocarditic cardiomyopathy suggest that direct viral infection of fibroblasts or an interaction between the interstitium and inflammatory cells and their secreted products may contribute to pathologic changes within the interstitial collagen matrix.

Scatter estimation for a digital radiographic system using convolution filtering.

The use of a convolution-filtering method to estimate the scatter distribution in images acquired with a digital subtraction angiography (DSA) imaging system has been studied. Investigation of more than 175 convolution kernels applied to images of anthropomorphic head, chest, and pelvic phantoms using 15-, 25-, and 36-cm fields of view (digitized onto a 512 X 512 pixel image matrix) showed that two-dimensional exponential kernels with a full width at half maximum (FWHM) of 50-150 pixels best reproduced the scatter fields within these images with a root-mean-square percentage error from 4% to 8%. A two-dimensional exponential kernal with a FWHM of 75 pixels in each dimension applied to ten different anatomic presentations and fields of view, resulted in an average root-mean-square percentage error of 6.6% for the ten cases studied. The method should be implementable using an array of small lead beam stops placed in the field of only a single mask image and the above described convolution kernel applied to both mask and postopacification images. The mask beam-stop data are used to scale both mask and postopacification convolution-filtered images. This scaled, convolution-filtered image is then subtracted from the original image to produce a largely scatter-corrected image.

Adapting mobile robotic technology to intralaboratory specimen transport.

OBJECTIVE: To evaluate and implement two identical inexpensive robotic vehicles for transport of patient specimens within our clinical laboratory. DESIGN: We accepted delivery of the first two robotic vehicles produced by a local vendor and studied the vehicles for 13 months. The first 4 months of familiarization and customization were followed by 9 months of routine use. SETTING: Within the specimen-processing, hematology, and chemistry sections of a large academic medical center's clinical laboratory, one floor below ground. INTERVENTION: The vehicles replaced 1.5 individuals who transported specimens. OUTCOME MEASURES: The number of kilometers the vehicles traveled and the number of routes begun, completed, not completed, and with unknown status. In addition, we assessed the types of problems that occurred, employee satisfaction, and financial payback. RESULTS: When used on all shifts for 13 months, the vehicles traveled an average of over 2000 routes and 212 km per month. At any one time, at least one vehicle was operational. Of the 17 problems that occurred, the most frequent were navigational problems caused by obstacles, such as personnel, in the vehicle's right-of-way. For 6 of the last 9 months, navigational, mechanical, and electronic problems together occurred no more than two or three times per week. Financial payback for the vehicles occurred in less than one year. CONCLUSIONS: By the end of the study, the robotic vehicles completed 99.4% of their routes. Specimen-processing and transport personnel reported the vehicles made their jobs easier and improved timeliness of specimen delivery. We anticipate our potential savings over 5 years to be approximately $200,000 (US).

Detection of early atherosclerosis in M. fascicularis with transcutaneous ultrasonic measurement of the elastic properties of the common carotid artery.

The elastic properties of 22 common carotid arteries from 13 male cynomolgus monkeys (M. fascicularis) that were fed either a high cholesterol (test) diet or a standard monkey chow (control) diet for 18 months were measured noninvasively with 5 MHz ultrasound. A B-mode image of the artery was obtained with a 32-element linear array transducer, and a single line of video ultrasonic information was selected for tracking the echoes from the adventitial side of the near wall to the lumen-intima interface of the far wall. This technique measured lumen diameter plus anterior wall thickness. The diastolic diameter (Dd) (mean +/- SEM) of the test arteries was slightly larger than controls (2.9 +/- 0.1 vs 2.5 +/- 0.1 mm), whereas the fractional diameter change from diastole to systole (DeltaD/Dd, where DeltaD = diameter change) was slightly less (0.062 +/- 0.010 vs 0.082 +/- 0.011). Direct subclavian artery pulse pressure (DeltaP) in the test animals (63 +/- 4 mm Hg) was significantly greater than in the controls (41 +/- 2 mm Hg), whereas there was no difference in diastolic pressure (85 +/- 3 vs 81 +/- 2), respectively. The pressure-strain elastic modulus Ep = (DeltaP/DeltaD) Dd was significantly greater in the test monkeys (182 +/- 33 kPa) than in the controls (73 +/- 9 kPa). Morphometric analysis of atherosclerosis revealed more connective tissue and intra- and extracellular lipids in the test arteries than in the controls. Based on the average of three cross-sections equally spaced along each common carotid artery, the intimal area and the maximal intimal thickness averaged 0.89 +/- 0.16 mm2 and 0.26 +/- 0.04 mm for the test monkeys compared to negligible intimae from the controls. Medial area also was significantly greater in the test monkeys (0.71 +/- 0.03 mm2) compared to controls (0.57 +/- 0.04 mm2). Percentage stenosis defined as intimal area/IEL area, where IEL area is that within the internal elastic lamina, showed the test arteries to have 30 +/- 5% stenosis compared to 0% for the controls. However, dilatation appeared to compensate for any loss in lumen area due to intimal thickening. In this study, significant carotid artery stiffening associated with diet-induced atherosclerosis is demonstrated. This noninvasive technique may be useful in pediatrics and in preventive medicine for the detection of arterial stiffening associated with early progressive atherosclerotic lesions.

Denture cream: an unusual source of excess zinc, leading to hypocupremia and neurologic disease.

BACKGROUND: Chronic, excess zinc intake can result in copper deficiency and profound neurologic disease. However, when hyperzincemia is identified, the source often remains elusive. We identified four patients, one previously reported, with various neurologic abnormalities in the setting of hypocupremia and hyperzincemia. Each of these patients wore dentures and used very large amounts of denture cream chronically. OBJECTIVE: To determine zinc concentration in the denture creams used by the patients as a possible source of excess zinc ingestion. METHODS: Detailed clinical and laboratory data for each patient were compiled. Tubes of denture adhesives were analyzed for zinc content using dynamic reaction cell-inductively coupled plasma-mass spectrometry. Patients received copper supplementation. Copper and zinc levels were obtained post-treatment at varying intervals. RESULTS: Zinc concentrations ranging from about 17,000 to 34,000 mug/g were identified in Fixodent and Poli-Grip denture creams. Serum zinc levels improved in three patients following cessation of denture cream use. Copper supplementation resulted in mild neurologic improvement in two patients who stopped using denture cream. No alternative source of excess zinc ingestion or explanation for hypocupremia was identified. CONCLUSION: Denture cream contains zinc, and chronic excessive use may result in hypocupremia and serious neurologic disease.

New environmental agents associated with lupus-like disorders.

An increasing number of environmental agents are being investigated as possible risk factors in the etiology of certain connective tissue disorders. Exposure to a variety of therapeutic agents, foods and dietary supplements, occupational and other toxic exposures, and infectious agents has been associated with the onset of lupus-like disorders. The mechanisms by which these agents might induce lupus remain unknown but may involve alteration of cellular components or activation of the immune system. Individual host susceptibility factors, including pre-existing organ dysfunction and particular metabolic enzyme or immunogenetic phenotypes, may also be important risk factors for development of environmentally-associated lupus-like disorders. Awareness of the many environmental agents implicated with lupus and related disorders, and dissection of their pathogenetic mechanisms through appropriate case-controlled investigations, may identify additional toxic agents and may lead to a better understanding of the idiopathic lupus syndromes.

Noninfectious environmental agents associated with myopathies.

Increasing attention is being focused on environmental agents as possible factors in the etiology of certain connective tissue disorders. As our awareness in this area increases, the number and diversity of these agents is expanding yearly and now includes, in addition to infectious agents, a variety of foods and dietary supplements, drugs, occupational and other toxic exposures, biologics, and medical devices. Some of these agents have been associated with the development of muscle disease through mechanisms that involve alterations in the vascular supply to muscle, depletion of electrolytes, direct toxic effects on mitochondria or other metabolic processes, or activation of the immune system. Individual host susceptibility factors, including preexisting organ dysfunction and particular metabolizer or immunogenetic phenotypes, also appear to be important for development of the clinical syndromes identified as environmentally associated myopathies. Although data in this area are limited, they suggest that when susceptible individuals are exposed to selected agents, physiologic alterations occur that lead to myopathy. Physician awareness of chemicals implicated with myopathy and dissection of their pathogenetic mechanisms through human and animal studies may aid in the identification of additional toxic agents, minimize new cases in the future, and lead to a better understanding of the idiopathic myopathies.

Experimental induction of melanotic tumors in syrian golden hamsters by transplacental and topical application of ethylnitrosourea.

Pregnant Syrian golden hamsters were treated with a single intra-peritoneal injection of ethylnitrosourea (ENU) solution a few hours pre-parturition. Offspring either received no further treatment or from 6 weeks of age, bi-weekly application of ENU solution in acetone for 20 consecutive weeks. Progeny from non, transplacentally treated mothers were also treated topically. Among all treated groups, 8.6% of the animals developed pigmented skin tumors, most of these animals having received the combined treatment. This group also showed a significantly decreased latency period in females compared to males. One of the skin tumors, which was histologically and clinically benign, was transplanted several times and subsequently exhibited malignant features.

The computerized perinatal database: are the data reliable?

The purpose of this study is to examine the correctness of the clinical data from the computerized perinatal database (PC-Log) at a Mayo Health System hospital. This computerized database is used for electronic transmission of birth certificates in Wisconsin. The paper medical record is chosen for the comparison. Random selection of 99 charts from a total of 893 births at a tertiary perinatal center during 1995. Of 310 fields in the database, 32 variables were compared to a hand abstraction of the paper medical record. PC-Log had 100% positive-predictive value (PPV) for eclampsia, prolonged rupture of membranes, pre-existing diabetes, cesarean section, and transports. The sensitivity, specificity, and PPV for other variables (abortion, congenital anomalies, gestational diabetes, maternal hypertension, and maternal employment) showed moderate to high agreement, but was poor for maternal ethanol use during pregnancy. Compared to hand abstraction, PC-Log had no recorded cases of substance abuse, antenatal steroids, hyaline membrane disease, circumcision, maternal and infant length of stay. Means for birth weight 5 minute Apgar scores did not differ, and the correlations were r = 0.982 and r = 0.960. The PC-Log showed good agreement for many but not all the variables of clinical interest.

Chronic oral administration of 1-nitrosopiperazine at high doses to MRC rats.

1-Nitrosopiperazine was fed to two groups of rats as drinking water solutions containing 400 mg/liter (3.5 millimolar) and 800 mg/liter (7.0 millimolar), respectively. The treatment was 20 ml per rat per day, 5 days per week for life. In both groups many animals died with olfactory tumors (mostly esthesioneuroblastomas), the first at 36 weeks in the higher dose group, the first at 64 weeks in the lower dose group. There was also a small number of liver tumors in both groups. None of these tumors was seen in the untreated controls. The similarity of this tumor distribution to that produced by 1,4-dinitrosopiperazine suggests that the observed carcinogenicity of 1-nitrosopiperazine may be entirely due to its disproportionation in the acidic medium of the rat stomach. Chemical data supporting this interpretation are presented.