An assessment of Ultrasound screening for soft tissue lumps referred from primary care.

AIMS: To assess the efficacy of ultrasound as a screening tool in the assessment of soft-tissue masses referred from primary care and to investigate the incidence of malignancy in this population. MATERIALS AND METHODS: Retrospective analysis was performed on patients who underwent ultrasound for a suspected soft-tissue mass at our centre between January 2011 and December 2012. Patient demographics, ultrasound findings, further imaging investigations and histopathology were recorded. Patient records were followed up for a minimum period of 4 years. RESULTS: A benign sonographic diagnosis was found in 95% (2271/2399) patients and 91% (2069/2399) required no further imaging or histopathology assessment. Ninety-six patients with a benign sonographic diagnosis had a benign histological diagnosis and one patient was found to have a histologically proven malignancy. Five percent (122/2,399) had an indeterminate scan. Of these, 40 had a histologically proven benign lesion and 10 had a histologically proven malignancy. Six of the 2,399 (0.2%) patients had scans suggestive of malignancy with histological confirmation. In total, 0.7% (17/2399) had proven malignant lesions. Eight were sarcomas. CONCLUSION: The present study, which to the authors' knowledge is the first to focus on ultrasound assessment of musculoskeletal masses referred solely from primary care, confirms ultrasound as a highly effective screening tool. It often avoids the need for further investigation and inappropriate clinical referrals. Malignant lesions are very rare in this patient cohort.

Contrasting natural histories of thoracic spine pneumatocysts: resolution versus rapid enlargement.

An intraosseous pneumatocyst is an unusual cause of gas in a vertebral body and is rarely reported in the thoracic spine. We report the evolution of thoracic spine pneumatocysts, one that enlarged rapidly with resorption of fluid and one that resolved. A 65-year-old female with lower back and left leg pain underwent MRI of the lumbar spine, which demonstrated a well-defined lesion in a T10 vertebral body of low-signal on T(1) and T(2) weighted imaging. CT confirmed this as a gas-containing cyst. Review of previous imaging showed that this lesion had initially contained fluid and had expanded rapidly over 14 months. It also showed smaller pneumatocysts, which had resolved. The variable natural history and imaging features of pneumatocysts make them an important differential diagnosis of an intravertebral lesion. Their aetiology is not known, but previous case reports suggest that they can occur spontaneously or in association with vacuum phenomenon in adjacent discs or facet joints. Previous reports have observed that they can fill with granulation tissue or fluid, and the case we report demonstrates that this fluid can be resorbed and that the pneumatocyst can undergo rapid enlargement. A pneumatocyst is a differential diagnosis for an expanding intravertebral lesion of indeterminate MRI characteristics. The diagnosis can be made with CT if the lesion is gas or gas and fluid filled.

The Polycystic Ovary Syndrome Health-Related Quality of Life Questionnaire (PCOSQ): a validation.

BACKGROUND: We wished to evaluate the psychometric properties of the Polycystic Ovary Syndrome Questionnaire (PCOSQ), a questionnaire developed to measure the health-related quality of life (HRQoL) of women with polycystic ovary syndrome. METHOD: To assess reliability and validity, women recruited from an outpatient gynaecology clinic at the Jessop Wing, Royal Hallamshire Hospital, Sheffield completed two copies of the PCOSQ and the Short Form-36 (SF-36). Secondary factor analysis was carried out to verify the composition of the dimensions. Semi-structured interviews were conducted to assess face validity. RESULTS: Of the 92 women who consented, 82 women (89%) returned questionnaires at time 1, and 69 women (75%) returned questionnaires at time 2. All five PCOSQ dimensions were internally reliable with Cronbach's alpha scores ranging from 0.70 to 0.97. Intra-class correlation coefficients to evaluate test-retest reliability were high (range 0.89-0.95, P < 0.001). Construct validity was demonstrated by high correlations for all comparisons of similar scales of the SF-36 and PCOSQ (0.49 and 0.54). Acne was identified as an important area of HRQoL missing from the questionnaire. CONCLUSIONS: The PCOSQ is a reliable instrument for measuring the HRQoL in women with PCOS. However, the validity of the questionnaire needs to be improved by incorporating a dimension on acne into the instrument.

Resistance of Pre- and Post-epidemic Strains of Agaricus bisporus to Trichoderma aggressivum f. aggressivum.

Since the early 1990s, the epidemic of green mold on the cultivated mushroom Agaricus bisporus in North America has been caused by Trichoderma aggressivum f. aggressivum. The findings of earlier research suggested that the microevolutionary emergence of T. aggressivum f. aggressivum coincided with the onset of the epidemic. This hypothesis was tested further by determining the disease susceptibility of mushroom strains grown widely before the epidemic manifested. The results of complementary methods of analysis, which entailed a grain protection assay and cropping trials, established that two pre-epidemic strains were more susceptible to green mold than three post-epidemic strains being cultivated at the time of the epidemic. Thus, if T. aggressivum f. aggressivum had been present within cultivated mushrooms prior to the epidemic, it should have been detected. It still appears to be true that T. aggressivum f. aggressivum emerged during the 1990s in a manner that remains unclear.

Selective A1-adenosine receptor antagonists identified using yeast Saccharomyces cerevisiae functional assays.

Evaluation of a biased "library" of pyrrolo[2,3-d]pyrimidines using yeast-based functional assays expressing human A1- and A2a-adenosine receptors, led to the A1 selective antagonist 4b. A direct correlation between yeast functional activity and binding data was established. Practical compounds with polar residues at C-4 of the pyrrolopyrimidine system required H-bond donor functionality for high potency.

Down-regulation of the pharmacokinetic-pharmacodynamic response to interleukin-12 during long-term administration to patients with renal cell carcinoma and evaluation of the mechanism of this "adaptive response" in mice.

BACKGROUND: Interleukin-12 (IL-12) is a cytokine that promotes type-1 helper T-cell responses and may have therapeutic utility in the treatment of cancer, asthma, and a variety of infectious diseases. METHODS: In a phase I trial, recombinant human IL-12 (rHuIL-12) was administered subcutaneously once a week at a fixed dose of 0.1 to 1.0 microg/kg to 24 patients with renal cell carcinoma. A similar study was later performed in mice to evaluate the mechanism of down-regulation of pharmacokinetic-pharmacodynamic response observed in patients with cancer. RESULTS: Adverse events, serum IL-12 levels, and serum levels of interferon-gamma (IFN-gamma) and interleukin-10 (IL-10) produced in response to IL- 12 were all maximum in the week after the first dose of rHuIL-12 and decreased after long-term administration. Similar to these results, repetitive subcutaneous administration of recombinant mouse IL-12 (rMoIL-12) to normal mice led to down-regulation of serum levels of IL-12 and IFN-gamma measured 5 hours after rMoIL-12 injection. Down-regulation of IL-12 serum levels was inversely correlated with the up-regulation of IL-12 receptor expression and may be the result of increased clearance of rMoIL-12 from serum by binding to lymphoid cells expressing increased amounts of IL-12 receptor. The down-regulation of serum IFN-gamma levels correlated with decreased IFN-gamma messenger ribonucleic acid expression and may result from feedback inhibition of IL-12 signaling or from a more specific inhibition of IFN-gamma synthesis. CONCLUSION: Administration of rHuIL-12 in fixed weekly doses resulted in decreased serum levels of IL-12 and of IFN-gamma, a secondary cytokine believed to be critical to response of IL-12. A better understanding of the complex regulation of the pharmacokinetic-pharmacodynamic response to IL-12 should facilitate the development of more effective dosing regimens for its use in the clinic.

Characterization of mouse interleukin-12 p40 homodimer binding to the interleukin-12 receptor subunits.

Interleukin-12 (IL-12) is a heterodimeric cytokine composed of two disulfide-bonded subunits, p35 and p40, which has important regulatory effects on T cells and natural killer (NK) cells. In contrast to heterodimeric IL-12, a homodimer of the p40 subunit, designated (p40)2, has been shown to be a potent IL-12 antagonist. To study the interaction between (p40)2 and the known IL-12 receptor (IL-12R) subunits, IL-12Rbeta1 and IL-12Rbeta2, we directly measured the binding activity of mouse (p40)2 to ConA-activated lymphoblasts and purified B cells from splenocytes of C57BL/6J mice. These results demonstrated the presence of both high (Kd about 5 pM) and low affinity (Kd about 15 nM) binding sites for mouse 125I-labeled (p40)2. To elucidate which of the IL-12R subunits binds mouse (p40)2, binding studies of mouse 125I-labeled (p40)2 to Ba/F3 cells expressing recombinant mouse IL-12Rbeta1 and/or mouse IL-12Rbeta2 were carried out. Mouse IL-12Rbeta1 bound mouse 125I-labeled (p40)2 with high and low affinities, comparable to that observed on Con A blasts and B cells. In contrast, mouse IL-12Rbeta2 bound mouse 125I-labeled (p40)2 very poorly. These data demonstrate that similar to IL-12, mouse (p40)2 binds with both high and low affinity to Con A blasts and B cells, and that IL-12Rbeta1 is responsible for mediating the specific binding of mouse (p40)2.

Analysis of the multiple interactions between IL-12 and the high affinity IL-12 receptor complex.

IL-12 is a heterodimeric cytokine, composed of a p40 and a p35 subunit, that exerts its biological effects by binding to specific cell surface receptors. Two IL-12R proteins, designated human IL-12 (huIL-12) receptor beta1 (huIL-12Rbeta1) and huIL-12Rbeta2, have been previously identified. These IL-12R individually bind huIL-12 with low affinity and in combination bind huIL-12 with high affinity and confer IL-12 responsiveness. In this study the interactions of hulL-12 with these two identified human IL-12R protein subunits are examined. The heterodimer-specific anti-huIL-12 mAb 20C2, which neutralizes huIL-12 bioactivity but does not block 125I-huIL-12 binding to huIL-12Rbeta1, blocked binding of huIL-12 to huIL-12Rbeta2. In contrast, anti-huIL-12Rbeta1 mAb 2B10 and mouse IL-12 p40 subunit homodimer (mo(p40)2) blocked 125I-huIL-12 binding to huIL-12Rbeta1, but not to huIL-12Rbeta2. Therefore, two classes of IL-12 inhibitors can be identified that differ in their ability to block huIL-12 interaction with either huIL-12Rbeta1 or huIL-12Rbeta2. Both mo(p40)2 and 20C2 blocked high affinity binding to huIL-12Rbeta1/beta2-cotransfected COS-7 cells, although, as previously reported, mo(p40)2 does not block high affinity binding to IL-12R on PHA-activated human lymphoblasts. Furthermore, these two classes of IL-12 inhibitors synergistically decreased hulL-12-stimulated proliferation and IFN-gamma production. Therefore, IL-12, in binding to the high affinity IL-12R, interacts with IL-12Rbeta1 primarily via regions on the IL-12 p40 subunit and with IL-12Rbeta2 via 20C2-reactive, heterodimer-specific regions of IL-12 to which the p35 and p40 subunits both contribute.

Treatment with homodimeric interleukin-12 (IL-12) p40 protects mice from IL-12-dependent shock but not from tumor necrosis factor alpha-dependent shock.

The role of interleukin-12 (IL-12) was investigated in different shock models using anti-IL-12 reagents. IL-12 is composed of two disulfide-bonded subunits, p35 and p40. The IL-12 p40 homodimer (p40)2 has been shown to be a potent IL-12 antagonist in vitro. We investigated its in vivo inhibitory capacity in different shock models of mice. We could demonstrate that (p40)2 is able to protect mice from septic shock in primarily IL-12-dependent models such as the Shwartzman reaction and lipopolysaccharide (LPS)-induced shock, whereas (p40)2 has no effect in the tumor necrosis factor alpha-dependent LPS/D-GalN shock model. In IL-12-dependent shock models, (p40)2 inhibits IL-12-induced gamma interferon production and thereby interferes with the cascade of cytokine release, finally leading to death.

Interleukin-12 antagonist activity of mouse interleukin-12 p40 homodimer in vitro and in vivo.

Mo(p40)2 is a potent IL-12 antagonist that interacts strongly with the beta 1 subunit of the IL-12R to block binding of moIL-12 to the high-affinity mouse IL-12R. Mo(p40)2, alone or in synergy with the 2B5 mAb specific for the moIL-12 heterodimer, blocked IL-12-induced responses in vitro, Mo(p40)2 was thus used alone or with 2B5 mAb to examine the role of IL-12 in vivo, Mo(p40)2 caused a dose-dependent inhibition of both the rise in serum IFN-gamma levels in mice injected with endotoxin and the Th1-like response to immunization with KLH. Treatment with mo(p40)2 plus 2B5 anti-moIL-12 mAb also suppressed DTH responses to methylated bovine serum albumin but not specific allogeneic CTL responses in vivo. In each of these models, responses seen in mice treated with mo(p40)2 +/- 2B5 anti-moIL-12 mAb were similar to those observed in IL-12 knockout mice. Thus, mo(p40)2 can act as a potent IL-12 antagonist in vivo, as well as in vitro, and is currently being used to investigate the role of IL-12 in the pathogenesis of some Th1-associated autoimmune disorders in mice.

Characterization of anti-mouse IL-12 monoclonal antibodies and measurement of mouse IL-12 by ELISA.

Enzyme-linked immunosorbent assays (ELISAs) capable of quantitatively measuring pg/ml amounts of mouse IL-12 (moIL-12) were developed as an alternative to the current bioassay procedure used for the measurement of moIL-12. A panel of 40 rat anti-moIL-12 monoclonal antibodies were identified and tested for their ability to bind 125I-moIL-12. Two of the MAbs, 2B5 and 9A5, were able to capture 125I-moIL-12 in the presence of unlabelled moIL-12 p35 and moIL-12 p40, suggesting specificity for the moIL-12 p75 heterodimer. Western blot analysis confirmed that MAb 9A5 specifically recognized only moIL-12 p75. Using MAb 9A5, and an additional anti-moIL-12 p40 MAb 5D9, we developed quantitative ELISAs for the specific detection of moIL-12 p75 and p40, respectively. These ELISAs detect moIL-12 with a sensitivity of 40 pg/ml. Whereas the p40 ELISA detected three forms of moIL-12 (p40 monomer, p40 homodimer, and the heterodimer), the p75 ELISA only detected moIL-12 heterodimer. Neither of these assays crossreacted with a panel of additional cytokines. The levels of moIL-12 measured by the p75 ELISA and the bioassay were directly compared and found to correlate well. Therefore, the p75 ELISA represents an alternative to the bioassay for the measurement of moIL-12.

Cloning and characterization of a mouse IL-12 receptor-beta component.

Using DNA cross-hybridization, we have isolated and characterized cDNA clones encoding a mouse (mo) IL-12R beta component. Two forms of cDNA were found. The first form encodes a receptor protein that has an overall structure very similar to that of the known human (hu) IL-12R beta with 54% amino acid identity, whereas in the second type of mouse cDNA, the equivalent of the transmembrane region has been deleted. This presumed alternative splicing event also gives rise to a frame shift that results in a receptor with an identical extracellular domain but a different C-terminal sequence. Whether this alternative C terminus is capable of signaling is not yet known. Both types of receptors when expressed in COS-7 cells are membrane associated and bind moIL-12 with an affinity of 1 nM, similar to the affinity of huIL-12R beta for huIL-12. The monomeric size of both moIL-12R beta proteins is about 100 kDa. Similar to huIL-12R beta, moIL-12R beta is expressed at the surface of COS-7 and Ba/F3 cells as a dimer/oligomer whose formation is independent of IL-12 binding. When expressed in Ba/F3 cells, moIL-12R beta binds moIL-12 with two affinities of 50 and 470 pM, corresponding to the medium and high affinity IL-12 binding sites previously identified on mouse Con A lymphoblasts. Despite the higher affinity displayed by the moIL-12R beta in Ba/F3 cells, this receptor alone is not sufficient to transduce a signal, suggesting that another subunit is probably required to generate a functional moIL-12R complex.

Consensus repeat domains of E-selectin enhance ligand binding.

To study the structural characteristics of E-selectin necessary for mediating cell adhesion, we examined the role of the consensus repeat (CR) domains in E-selectin function. Soluble constructs containing different numbers of CR domains were stably expressed in Chinese hamster ovary cells, purified to homogeneity, and characterized. The minimum functional unit of soluble E-selectin consisted of the lectin (Lec) and epidermal growth factor (EGF) domains alone (Lec-EGF) as indicated by its ability to mediate in vitro HL-60 cell adhesion. However, E-selectin containing all six CR domains (Lec-EGF-CR6) at its COOH terminus was the most potent in blocking neutrophil or HL-60 cell adhesion to either immobilized E-selectin or cytokine-stimulated human umbilical vein endothelial cells. This increased potency of Lec-EGF-CR6 in blocking cell adhesion was not due to CR-mediated oligomerization of the protein. Lec-EGF-CR6 was most likely monomeric in solution, as judged by gel filtration fast protein liquid chromatography, membrane ultrafiltration, and chemical cross-linking analysis. Therefore, although the lectin and EGF domains are necessary and sufficient for mediating cell adhesion, the additional six CR domains, present in native E-selectin, contribute to the enhanced binding of E-selectin to its ligand.

Production of monoclonal antibodies to prostromelysin (ProMMP-3) and establishment of a quantitative prostromelysin ELISA assay.

Human prostromelysin (59 kDa) was purified from the conditioned medium of IL-1-stimulated human dermal fibroblasts and anti-prostromelysin monoclonal antibodies were produced and identified by ELISA assay. Using prostromelysin, a C-terminally truncated recombinant form of prostromelysin consisting of amino acids 1-255, and their respective activated enzymes, we have begun mapping the epitopes recognized by these monoclonal antibodies. Various patterns of reactivity against the proenzymes and activated enzymes were observed. In further attempts to map the epitopes, we employed synthetic peptides representing hydrophilic regions of the primary amino acid sequence of prostromelysin. Our monoclonal antibodies did not recognize these peptides, suggesting that the antibodies may be recognizing conformational epitopes composed of non-linear portions of prostromelysin. Using these monoclonal antibodies, we have developed a quantitative prostromelysin sandwich ELISA assay.

Association of the human Fc epsilon RI gamma subunit with novel cell surface polypeptides.

It has recently been demonstrated that the gamma-subunits of the high affinity Fc epsilon RI are required for the cell surface expression of not only the Fc epsilon RI alpha-subunit, but also for the low affinity Fc gamma RIIIA alpha (CD16). In addition, formation of heterodimeric complexes of the gamma-subunit with the zeta- and eta-chains of the TCR have also been reported. The exact role of the gamma-subunit in the function of these receptors is not known. To gain additional insight into the association of the gamma-subunit with these and other cell surface polypeptides, we have generated a mAb, 4D8, directed against the human Fc epsilon RI gamma-subunit. Using this antibody we have been able to demonstrate that Fc epsilon RI alpha and Fc gamma RIIIA alpha are associated with Fc epsilon RI gamma at the cell surface. Furthermore, we have identified the expression of Fc epsilon RI gamma in HL60 and U937 cells, which are negative for the TCR, Fc epsilon RI, and Fc gamma RIII. Analysis of these cells reveals the presence of novel Fc epsilon RI gamma-associated polypeptides. These results suggest that Fc epsilon RI gamma plays a common functional role in a number of different receptor complexes. The availability of the anti-gamma antibody 4D8 will help to define this role, and allow the characterization of cell surface polypeptides that are associated with the Fc epsilon RI gamma-subunit.

Group A streptococcus-associated upper respiratory tract infections in a day-care center.

Little information is available about the epidemiology of group A streptococcal upper respiratory tract infections in child day-care centers. During an initial 3-month period, symptomatic upper respiratory tract infections associated with throat cultures or rapid antigen detection tests positive for group A streptococci developed in 55 of 214 (26%) children and adult staff in one day-care center. When the entire day-care center population (except for those receiving antibiotics at the time) was then surveyed, 52 of 146 (36%) children and two of 24 (8%) adult staff had throat cultures positive for group A streptococci. Of the 54 group A streptococcal isolates found during the survey, the three most frequently encountered serotypes were M2,T2/28 (35%), M3,T3/13 (30%), and M-NT, T25 (20%). Rapid antigen detection was performed at the same time as the throat culture in the first 98 individuals examined during the culture survey but was positive in only 11 (35%) of 31 individuals with positive throat cultures. Sensitivity of the rapid antigen test was related to degree of positivity of the throat culture but not to age. The overall group A streptococcal positivity rate was 49% for 187 children and 33% for 27 adult staff; 18 of 66 (27%) children younger than 31/2 years of age were found to have group A streptococci in their upper respiratory tracts. This is the first report of high prevalence rates of group A streptococci associated with upper respiratory tract infections in a day-care center. The group A Streptococcus may represent a significant upper respiratory tract pathogen in the day-care setting.

Selective effect of low protein diets in chronic renal diseases.

It has recently been established that the rate of progression of chronic renal failure in man can be slowed by restricting dietary protein. Consequently, the short term and long term effects of a low protein diet on the course of different chronic nephropathies were studied in an attempt to delineate the factors that determine the response to such a diet. When a low protein diet was given for six months renal function improved significantly in nine patients with chronic tubulointerstitial nephritis (p less than 0.025); the diet had a marginally beneficial effect in 12 patients with chronic glomerulonephritis (p less than 0.05) and no effect in nine with hypertensive nephrosclerosis. The heterogeneous functional response in the patients with chronic glomerulonephritis correlated closely with the effect of the diet on these patients' proteinuria (r = 0.76, p less than 0.01). In a short term study (four weeks) of 12 patients with chronic renal failure changes in renal plasma flow were proportional to dietary protein intake. Renal vascular resistance fell during a high protein diet and increased when dietary protein was restricted. The changes in renal plasma flow during the low protein diet correlated well with the patients' long term functional response to the diet (r = 0.76, p less than 0.01). It is concluded that the response to a low protein diet in chronic renal failure is determined, firstly, by the nature of the underlying nephropathy, with maximal benefit being observed in non-glomerular disorders; secondly, by the effect of the diet on the proteinuria in chronic glomerulonephritis; and, thirdly, by the haemodynamic response to the diet, with patients with a reactive renal vascular bed improving with a low protein diet.

Juvenile chronic arthritis in adolescence: facing the reality.

This paper studies the emotional and social problems of 26 adolescents with severe juvenile chronic arthritis, comparing inpatient and outpatient groups. Social isolation was a serious problem, with lack of opportunity for sexual contacts only partly related to restricted mobility. The main anxieties centered on self-image, lesser height, dependence, and fears for the future. Psychiatric referral was more common in the inpatient group and in girls, and the results suggest a correlation with early age at onset, lesser height, restricted mobility, and broken families, particularly those with additional stresses. The need for better integration and education at school and in society, and for family support, is emphasized.