Joint replacement risk is markedly increased in alkaptonuria (AKU) in those with prior arthroplasty.

Background: Increased homogentisic acid (HGA) in alkaptonuria (AKU) causes severe arthritis. Nitisinone reduces the production of HGA, but whether it also decreases arthroplasty was examined in 237 AKU patients. Patients and methods: Patients attending the United Kingdom National Alkaptonuria Centre (NAC) and the Suitability of Nitisinone in Alkaptonuria 2 (SONIA 2) study were studied. Assessments included questionnaires eliciting details of arthroplasty. Nitisinone was administered from baseline, 2 mg in the NAC and 10 mg in SONIA 2. In SONIA 2, subgroups consisted of those with baseline arthroplasty on and not on nitisinone (BR + N+, BR + N-), as well as those without baseline arthroplasty on and not on nitisinone (BR-N+, BR-N-). Results: In the SONIA2 subgroups, new joint replacement (JR) probabilities after baseline were significantly different (BR + N+, BR + N-, BR-N+, BR-N-) (χ2 = 23.3, p < 0.001); mean (SD) was 3.8 (0.1) years in BR-N-, 3.7 (0.1) years in BR-N+, 3.4 (0.3) years in BR + N-, and 3.0 (0.3) years in BR + N+. Further, the BR + N- showed more JR than the BR-N- subgroup (p < 0.01), while BR + N+ similarly showed more JR than the BR-N+ subgroup (p < 0.001).In the NAC, the BR- group had a mean age of 51.6 (7.0) years at baseline but 57.7 (8.7) years at final follow up during nitisinone therapy and showed only 7 incident JR. The BR+ group had an age at baseline of 57.4 (8.5) years and had undergone 94 JRs at baseline. Conclusion: The incidence of arthroplasty was earlier and more frequent after the first JR and was not affected by nitisinone.

White matter lesions in euthymic patients with bipolar disorder.

OBJECTIVE: We aimed to quantify both load and regional distributions of hyperintensities on magnetic resonance imaging (MRI) in prospectively verified euthymic bipolar patients and matched controls. METHOD: Cerebral hyperintensities on T2, proton density and fluid-attenuated inversion recovery (FLAIR) MRI were compared between 48 bipolar and 47 control subjects using semi-quantitative rating scales. RESULTS: Bipolar subjects had more severe frontal deep white matter lesions (DWML). Hyperintensity load was independent of age in bipolar patients but increased with age in controls. Global prevalence and severity of hyperintensities did not differ between groups. Exploratory analysis showed DWML in excess in the left hemisphere in bipolar subjects but not in controls. CONCLUSION: Findings are consistent with clinical, particularly some neurocognitive, features of bipolar disorder and implicate fronto-subcortical circuits in its neurobiology. They more probably reflect a trait abnormality or illness scar rather than a mood state-dependent finding. Processes other than ageing and vascular factors may underlie their development.

The symptoms and recognition of post-traumatic stress reactions.

The three most common clinical sequelae of trauma have been outlined above. However, the vast majority of cases will produce a normal reaction, which would not fulfil any of the diagnostic criteria. Overall, therefore, clinically significant traumatic responses are rare in the military environment, and for the most part short lived. For the conditions that are not self-limited, there are effective treatment options available which will be outlined later in this series.

Interleukin 1 inhibits insulin secretion from isolated rat pancreatic islets by a process that requires gene transcription and mRNA translation.

Recombinant human IL 1 beta inhibits glucose-induced insulin secretion from isolated pancreatic islets and from purified beta-cells obtained by fluorescence-activated cell sorting (FACS) of dispersed islet cells. Brief (1 h) exposure of isolated islets to IL 1 produces sustained inhibition of insulin secretion for at least 17 h after the IL 1 has been removed from the culture medium. An inhibitory effect of IL 1 on insulin secretion is not observed when islets are coincubated with an inhibitor of DNA transcription (actinomycin D). This finding indicates that the inhibitory effect of IL 1 on insulin secretion requires transcription of one or more genes during the first hour of exposure of islets to IL 1. The inhibitory effect of IL 1 on insulin secretion also requires mRNA translation, because three structurally distinct inhibitors of protein synthesis (cycloheximide, anisomycin, and puromycin) prevent IL 1-induced inhibition of insulin secretion when added to islets after the 1-h exposure to IL 1. Two-dimensional gel electrophoresis of islet proteins metabolically labeled with [35S]methionine demonstrates that IL 1 augments the expression of a 65-kD (pl approximately 6.5) protein by greater than 2.5-fold. These findings indicate that biochemical events occurring within 1 h of exposure of islets to IL 1 lead to an inhibition of insulin secretion that persists for at least 17 h after the removal of IL 1. One of the early biochemical effects of IL 1 on islets is gene transcription (0-1 h), which is followed by mRNA translation (after 1 h). Our results suggest that the inhibitory effect of IL 1 on insulin secretion is mediated by protein(s) whose synthesis is induced by IL 1.

Computed tomography features of recurrent ovarian carcinoma according to time to relapse.

BACKGROUND: Although the sites of recurrent ovarian cancer are individually described in the literature, patterns of recurrent disease are poorly understood. PURPOSE: To describe CT patterns of disease in recurrent ovarian cancer. To emphasize common patterns, recognise subtle and unusual sites of recurrent disease. MATERIALS AND METHODS: We identified patients between 1981-2004 presenting with clinical recurrence or elevated CA 125 after complete primary clinical and radiological response. CT imaging at primary diagnosis, during and after treatment and at recurrence was retrospectively reviewed. Site, distribution, stage of disease and time to relapse was recorded. RESULTS: 400 patients were treated for ovarian cancer. 214(54%) achieved complete primary response. 161(75%) relapsed with complete imaging available in 67 patients. Of the 67 patients, 14 (21%) recurred within 1 year, 44 (66%) relapsed between 1-5 years. Therefore 87% of relapses occurred within 5 years following primary treatment. Five (8%) relapsed between 5-10 years and 4 (6%) relapsed after 10 years. Commonest pattern of relapse was pelvic mass in 35 (48%) patients, solitary in 15 (22%). 27 (45%) relapsed with peritoneal thickening, 27 (45%) had small or large bowel serosal disease, 22 (33%) had enlarged lymphadenopathy, 6 as sole manifestation of recurrence, 20 (30%) presented with unusual sites of recurrence: 6 splenic, 10 hepatic, 2 biliary, 3 brain and 2 muscle. CONCLUSION: Our study is the first to describe common patterns of recurrence in ovarian cancer. Most frequent site is pelvis, followed by peritoneum, serosal surfaces and nodal disease. 30% presented with disease at 'unusual' sites.

Lymphocyte transformation for the detection of herpesvirus-induced tumor-associated antigens.

Cell-mediated immunity to fibroblasts transformed by herpes simplex virus type 2 was investigated with a lymphocyte assay system. The assay system was first standardized with phytohemagglutinin, a nonspecific stimulator of blastogenesis. Hamster splenic and blood lymphocytes reacted to phytohemagglutinin with a dose-response curve similar to that reported for other rodent species. Splenic lymphocytes from hamsters bearing isografts, induced by herpes simplex virus type 2, were transformed by cell-free virus-induced tumor antigens. The reactions with cell-free tumor antigens were dose-dependent and paralleled the findings with phytohemagglutinin. The initial transformation response of immune lymphocytes to homologous tumor antigens occurred after 72 hr incubation with antigen. Immune splenic lymphocytes from hamsters were also significantly stimulated with antigens obtained from cells productively infected with herpes simplex virus type 2. Immune lymphocytes were not stimulated with heterologous antigens from simian virus 40-transformed mouse or hamster cells. Likewise, lymphocytes from hamsters sensitized to cells transformed by simian virus 40 reacted with both simian virus 40-transformed mouse and hamster cells but did not react with cells transformed by a heterologous virus. The results suggest that under defined conditions a lymphocyte transformation assay may be useful for the specific detection of common viral-induced antigens on tumor cells.

Arachidonic acid metabolism in isolated pancreatic islets. V. The enantiomeric composition of 12-hydroxy-5,8,10,14-eicosatetraenoic acid indicates synthesis by a 12-lipoxygenase rather than a monooxygenase.

Recent evidence indicates that the arachidonate metabolite 12-hydroxy-5,8,10,14-eicosatetraenoic acid (12-HETE) or its precursor may act as a second messenger in stimulus-response coupling in a variety of cells including Aplysia neurons, adrenal glomerulosa cells, and pancreatic islets. The compound 12(S)-HETE is generated from the precursor 12(S)-hydroperoxy-5,8,10,14-eicosatetraenoic acid (12(S)-HPETE), which is a product of the 12-lipoxygenase enzyme. Some cells have recently been found to produce the enantiomer 12(R)-HETE, apparently via a cytochrome P-450 monooxygenase, and the biologic actions of 12(R)-HETE and 12(S)-HETE differ. We have examined the stereochemistry of 12-HETE from isolated pancreatic islets both radiochemically and by a new mass spectrometric method capable of quantitating subnanogram amounts of 12-HETE stereoisomers. Endogenous 12-HETE from islets was found to be exclusively the S-isomer. D-Glucose stimulated both insulin secretion and islet accumulation of 12(S)-HETE but not of 12(R)-HETE. Pharmacologic inhibition of islet 12-HETE biosynthesis also suppressed glucose-induced insulin secretion. These findings suggest that islet 12-HETE is a product of a 12-lipoxygenase rather than of a cytochrome P-450 monooxygenase and further implicate 12-lipoxygenase products in stimulus-secretion coupling.

Descriptive and mechanistic considerations of interleukin 1 and insulin secretion.

Insulin-dependent diabetes mellitus (IDDM) may be mediated in part by an autoimmune mechanism, as suggested by associated cytologic and serologic phenomena, e.g., insulitis, beta-cell necrosis, and the presence of both islet cell and insulin antibodies. Immunological approaches to the prediction and intervention in the progression of beta-cell destruction in this disease are under evaluation. A recent hypothesis is that cytokines, including interleukin 1 (IL-1), play causative roles in such autoimmune processes. Several studies have convincingly demonstrated that IL-1 is a potent modulator of beta-cell function and can potentiate or inhibit glucose-induced insulin secretion, depending on the concentration and length of exposure to IL-1. IL-1 alone or in concert with other cytokines is cytotoxic to beta-cells. The cellular mechanisms responsible for the potent effects of IL-1 on the beta-cell are unknown and just beginning to emerge. Although speculative at this time, this perspective delineates cellular mechanisms that are likely to represent possible primary sites for the IL-1 action on beta-cells. A mechanistic understanding of the effects of IL-1 on the beta-cell may clarify its role in modulating insulin release in vivo or yield insight into the pathogenesis of IDDM.

Interleukin 1-induced prostaglandin E2 accumulation by isolated pancreatic islets.

Recombinant human interleukin 1 alpha (IL-1) has been found to induce prostaglandin E2 (PGE2) accumulation by isolated rat islets of Langerhans at concentrations similar to those at which the cytokine inhibits glucose-induced insulin secretion and islet glucose oxidation. Maximal stimulation of PGE2 accumulation (5 times control value) occurred at 200 pM IL-1, and half-maximal stimulation occurred at 25 pM IL-1. Significant augmentation of PGE2 accumulation by IL-1 required 10-18 h of exposure to the cytokine. Islets that had been pretreated with IL-1 for 18 h showed elevated rates of PGE2 production at basal (3-mM) and stimulatory (16.5-mM) glucose concentrations and converted exogenous arachidonic acid to PGE2 at twice the maximal rate of control islets. Exogenous PGE2 did not mimic the inhibitory effects of IL-1 on glucose-induced insulin secretion or glucose oxidation. To rule out the possibility that endogenous PGE2 is involved in the inhibitory effects of IL-1, the effect of a cyclooxygenase inhibitor on IL-1-treated islets was examined. Pharmacological blockade of PGE2 biosynthesis by 10 microM indomethacin did not influence the inhibitory effects of IL-1 on glucose-induced insulin secretion or glucose oxidation. Thus, exogenous PGE2 does not mimic the effects of IL-1 on islets, and inhibition of endogenous PGE2 biosynthesis does not suppress the effects of IL-1 on islets. These results suggest that PGE2 is not a principal mediator of the inhibitory effects of IL-1 on glucose-induced insulin secretion or glucose oxidation.

Arachidonic acid metabolism and insulin secretion by isolated human pancreatic islets.

Isolated human pancreatic islets converted [3H8]arachidonate to compounds with the high-performance liquid-chromatographic mobility of cyclooxygenase products, including prostaglandin E2 (PGE2), PGF2 alpha, and the lipoxygenase product 12-HETE. Human islet synthesis of PGE2, PGF2 alpha, and 12-HETE from endogenous arachidonate was demonstrated with stable isotope dilution-gas chromatographic-negative ion-chemical ionization-mass spectrometric analysis. Pharmacologic inhibition of arachidonate metabolism by both lipoxygenase and cyclooxygenase pathways with BW 755C strongly suppressed glucose-induced insulin secretion from perifused human islets, and the selective cyclooxygenase inhibitor indomethacin enhanced insulin secretion. These findings are similar to those reported for islets isolated from rats and suggest that arachidonate metabolites may modulate glucose-induced insulin secretion in humans.

Interleukin-1 induces rapid and transient expression of the c-fos proto-oncogene in isolated pancreatic islets and in purified beta-cells.

The effect of interleukin-1 beta (IL-1) on expression of c-fos mRNA in isolated rat pancreatic islets was examined. Accumulation of c-fos mRNA was demonstrable after 30 min of exposure to IL-1, peaked by 60 min, and declined thereafter. Fluorescence-activated cell sorting (FACS) of dispersed islet cells was employed to localize the accumulation of c-fos mRNA to the beta-cell. Cycloheximide did not influence the induction of c fos mRNA by IL-1. Accumulation of c-fos mRNA therefore appears to be an early signal transduction event in the beta-cell and a component of the cellular mechanism(s) by which IL-1 influences beta-cell function.

Interleukin-1 inhibits glucose-induced Ca2+ uptake by islets of Langerhans.

Recombinant interleukin-1 (rIL-1) is known to inhibit glucose-induced insulin secretion by islets of Langerhans, a novel target tissue of cytokine. We have investigated whether rIL-1 pretreatment affects biochemical mechanisms known to be involved in the regulation of Ca2+ homeostasis during glucose-induced insulin secretion. Glucose-induced Ca2+ uptake by intact islets through the plasma membrane was dramatically inhibited (96%) by rIL-1 (2 nM). rIL-1, however, did not affect Ca2+ uptake by, or Ins 1,4,5-P3-induced Ca2+ efflux from, the endoplasmic reticulum in digitonin-permeabilized islets, although glucose-induced accumulation of inositol trisphosphates was inhibited (38%). These results suggest that perturbation of intracellular Ca2+ homeostasis in islets is involved in inhibition of insulin secretion by rIL-1.

Demographic characteristics of elderly drug overdose patients admitted to a hospital emergency department.

This study was undertaken to identify the demographic characteristics of patients aged 55 or older in a drug-overdose group admitted to the Emergency Department of Arizona Health Sciences Center during the 3-year period, August 1975-July 1978. Of the 646 overdose patients observed, 60 (9.5 percent) were aged 55 or older; of these, 77 percent were women--a significantly higher proportion than in the rest of the overdose group. The majority of the overdose incidents were unintentional, and most patients required hospitalization. For the elderly, the drugs involved in the overdoses did not differ significantly from those ingested by others in the overdose group. Concurrent traumatic injury occurred more often in the older age group, necessitating a longer hospital stay and higher health care costs. Drug overdosage is a significant problem in the elderly population. Since many overdose are unintentional, elderly persons in particular require the counsel of physicians and pharmacists in the medication process.

Nuclear matrix proteins and their potential applications to diagnostic pathology.

The nuclear matrix is the nonchromatin scaffolding of the cell nucleus that confers nuclear shape, organizes the nuclear chromatin, and regulates many important intranuclear biochemical events. Although our understanding of the nuclear matrix and its proteins is still evolving, it is clear that nuclear matrix proteins (NMPs) hold considerable promise as diagnostic tools for pathologists. Early evidence suggests that NMPs may be useful biomarkers of neoplastic disease in serum, body fluids, and tissues. NMPs are also potential candidates for use as tumor prognostic factors and targets of anticancer drugs. Moreover, NMPs may hold the key to understanding important cellular events, such as neoplastic transformation, steroid hormone binding, and apoptosis. Despite impressive gains made by cellular biologists and biochemists toward understanding the structure and function of the nuclear matrix, many of the potential applications of NMPs to diagnostic pathology are largely unexplored. Thus, NMPs should prove an exciting and fruitful area of investigation for experimental and clinical pathologists who are interested in developing diagnostic tests for detecting, quantitating, and characterizing these proteins in human tissues and body fluids and translating these applications into the clinical pathology laboratory.

The cytologic diagnosis of low-grade transitional cell carcinoma.

Current theory suggests that transitional cell carcinoma (TCC) occurs as either of 2 disease processes, each of which has a distinct cytologic appearance and clinical course: low-grade and high-grade TCC. Urinary cytology has become a mainstay technique for monitoring disease recurrence in patients with TCC. Most cases of high-grade TCC can be diagnosed accurately in urinary cytology specimens. However, the cytologic diagnosis of low-grade TCC is difficult; these tumors exhibit subtle cytomorphologic alterations that are difficult to distinguish from benign or reactive processes. The cytologic criteria most useful for diagnosing low-grade TCC in urinary cytology specimens are reviewed. Additionally, the discussion includes some of the new ancillary tests that are emerging as possible diagnostic aids for the detection of low-grade urothelial neoplasms.

Effect of clinical history on diagnostic accuracy in the cytologic interpretation of bronchial brush specimens.

There has been little study of the effect of clinical history on pathologic diagnostic accuracy. Five pathologists retrospectively examined 97 bronchial brush specimens with and without clinical historic information. Forty-nine patients had a biopsy-proven malignant lesion, and 48 had a benign lesion. Diagnostic accuracy with and without history for each pathologist was determined with likelihood ratios and receiver operating characteristic curves. The overall diagnostic accuracy with and without history was 0.84 and 0.76, respectively. The average negative predictive value of a benign diagnosis decreased from 89.2% (with history) to 74.0% (without history). Overall, the cytopathologists were more reluctant to make a definitive malignant diagnosis without history compared with history. The average positive predictive value of a malignant diagnosis with and without history was almost identical. The absence of history leads to lower diagnostic accuracy in the cytologic interpretation of bronchial brush specimens partly because pathologists underdiagnose malignant lesions.

Direct genetic testing for Smad4 mutations in patients at risk for juvenile polyposis.

BACKGROUND: The identification of germline mutations in juvenile polyposis (JP) families has made presymptomatic genetic testing possible. In this study we report the results of genetic testing in two large JP families and develop an algorithm for the clinical management of these patients. METHODS: DNA was extracted from 55 members of 2 JP kindreds, and the Smad4 mutations in the germline were determined by direct sequencing. All family members were then tested for mutations with use of single-strand conformational polymorphism analysis and were invited for genetic counseling. RESULTS: All 18 affected members of both kindreds had a 4-bp deletion in exon 9 of the Smad4 gene. In 30 patients at risk for JP, 17 had previously had negative endoscopic screening results and 13 had never been screened. Five patients at risk had inherited germline Smad4 mutations. Two carriers have had hematochezia but have not been screened, whereas 3 were asymptomatic. The mean age of carriers was 29.8 years (range 9.1-49.5 years), whereas that of noncarriers was 41.0 years (range 8.1-76.5 years). CONCLUSIONS: Compliance has been a problem with endoscopic screening for JP. With genetic testing non-carriers may no longer require frequent screening endoscopy, whereas gene carriers can be targeted for close endoscopic surveillance and early intervention to prevent the development of gastrointestinal cancers. Direct genetic testing significantly improves the presymptomatic diagnosis of gene carriers in JP families with Smad4 mutations.

Picornaviruses: rapid differentiation and identification by immune electronmicroscopy and immunodiffusion.

Immune electronmicroscopy (IEM) was used to identify human picornaviruses rapidly and to differentiate enteroviruses from rhinoviruses. Human sera, diluted 10- to 50-fold beyond the neutralisation endpoints for homologous virus, readily agglutinated C-type antigens of seven human picornaviruses. Human sera did not react by IEM with a control animal picornavirus. By IEM after acid treatment, differentiation of a human enterovirus from a human rhinovirus was possible. There was an excellent correlation between the results of IEM and immunodiffusion (ID) tests for the presence of antibody to human picornavirus group antigens. By ID, only one of 21 human sera reacted with one of six animal picornaviruses. Immune electronmicroscopy appears to be a sensitive and simple techinque for the detection of picornavirus C-type antigens, and may be useful for identifying viruses belonging to groups comprising many serotypes and sharing a common group antigen.

Enhanced production of poxvirus vectors by high speed rolling.

The amount of CPE produced by vaccinia vectors in cultures rolled at 96 revolutions per minute (rpm) was significantly enhanced when compared to cultures rolled at 2 rpm or held stationary. Cultures rolled at 96 rpm had significantly more foci (46.3 +/- 8.4) than cultures held stationary (16.3 +/- 6.5) or rolled at 2 rpm (27.6 +/- 2.8). The size of foci in cultures rolled at 96 rpm was also significantly larger than foci in cultures rolled at 2 rpm or held stationary (F = 12.65, P less than 0.01). Cultures infected with a low multiplicity of infection and rolled at 96 rpm developed maximum CPE 4 days earlier than stationary cultures. When compared to stationary conditions, cultures rolled at 2 rpm had a 7.0-fold geometric mean increase in viral yield. However, cultures rolled at 96 rpm had a 75-fold geometric mean increase in viral yield. These data suggest that cultures inoculated with vaccinia vectors should be rolled to maximize viral replication.

Effect of rolling on foci development and viral replication for herpes simplex virus (HSV).

The effect of rolling on the number of herpes simplex virus (HSV) foci and yield of infectious virus was examined for cultures inoculated with clinical specimens. Inoculated cultures were either rolled at 2 revolutions per minute (rpm) or held stationary. Cultures that were rolled at 2 rpm showed a significantly greater number of foci and plaque forming units (PFU) over stationary cultures. The geometric mean fold increase in PFU between rolled and stationary cultures was 8-fold. Rolling of inoculated cultures should be used in the clinical virology laboratory to aid in the rapid detection of HSV.