Cost-effectiveness of active case-finding of household contacts of pulmonary tuberculosis patients in a low HIV, tuberculosis-endemic urban area of Lima, Peru.

We compared the cost-effectiveness (CE) of an active case-finding (ACF) programme for household contacts of tuberculosis (TB) cases enrolled in first-line treatment to routine passive case-finding (PCF) within an established national TB programme in Peru. Decision analysis was used to model detection of TB in household contacts through: (1) self-report of symptomatic cases for evaluation (PCF), (2) a provider-initiated ACF programme, (3) addition of an Xpert MTB/RIF diagnostic test for a single sputum sample from household contacts, and (4) all strategies combined. CE was calculated as the incremental cost-effectiveness ratio (ICER) in terms of US dollars per disability-adjusted life years (DALYs) averted. Compared to PCF alone, ACF for household contacts resulted in an ICER of $2155 per DALY averted. The addition of the Xpert MTB/RIF diagnostic test resulted in an ICER of $3275 per DALY averted within a PCF programme and $3399 per DALY averted when an ACF programme was included. Provider-initiated ACF of household contacts in an urban setting of Lima, Peru can be highly cost-effective, even including costs to seek out contacts and perform an Xpert/MTB RIF test. ACF including Xpert MTB/RIF was not cost-effective if TB cases detected had high rates of default from treatment or poor outcomes.

Serial histologic observation of endometrial adenocarcinoma treated with high-dose progestin until complete disappearance of carcinomatous foci--review of more than 25 biopsies from five patients.

This study aimed to document chronologic histologic changes of endometrial biopsies from patients with endometrial adenocarcinoma on high-dose progestin therapy. Seven patients with presumptive FIGO stage IA endometrial adenocarcinoma treated with medroxyprogesterone acetate 600 mg/day were investigated retrospectively. Good response was defined as complete disappearance of carcinoma foci within 16 weeks of treatment and poor response as the presence of residual foci at 16 weeks. Two patients were poor responders and were excluded from the study, while five good responders were analyzed. Hematoxylin and eosin (H&E)-stained slides were reviewed and analyzed based on nine histologic features to describe the histology observed commonly in good responders. All the five good responders showed relatively uniform morphologic changes during the high-dose progestin therapy and the common histology was described as follows. The first change was swelling of the neoplastic glandular epithelial cells with pale vacuolated cytoplasm and round to oval nuclei. Mitotic arrest was also observed. Next, the epithelia were disrupted by lymphoplasmocytic infiltration and replaced by low cuboidal epithelium with or without squamous or morular metaplasia. The stromal area increased with predecidual changes. The final morphology was small atrophic glands scattered in predecidual stroma with dilated vessels. Therefore, the morphologic change of the endometrial biopsy observed in earlier stage of treatment might be able to predict good response to high-dose progestin therapy.

Different conformation of neuronal tau deposits distinguished by double immunofluorescence with AT8 and thiazin red combined with Gallyas method.

Different kinds of tau deposits were quantitatively investigated with thiazin red (TR), a fluorochrome that binds to fibrillary structures like neurofibrillary tangles (NFTs), in brains obtained at autopsy from patients with Alzheimer's disease (AD), Pick body (PB) disease, corticobasal degeneration (CBD) or diffuse NFTs with calcification (DNTC). After recording double-labeling fluorescence images with anti-paired helical filament tau (AT8) and TR, the sections were subjected to Gallyas method (GAL). This enabled three different staining properties to be compared on the identical neuron. AT8-positive neocortical neurons of AD and DNTC were fibrillary and uniformly positive for TR and GAL, consistently forming NFTs. NFTs lacking AT8 immunoreactivity (IR) were more frequent in DNTC than in AD, suggesting that evolution of NFTs is more accelerated in DNTC. Scarce TR staining in tau-positive neocortical neurons of CBD suggests their paucity of fibrillary structure. Since the affinity of TR for PB was not consistent, this may be dependent not only on the amount but also the characteristics of fibrillary structures. PBs were further characterized by the scarcity of GAL staining. This approach, which quantitatively clarifies differences between AT8-IR, TR and GAL, provides a morphological basis for further investigations of the different conformational states of tau from its deposition to fibril formation of various types.

Progressive supranuclear palsy on Guam.

This is the first report demonstrating that progressive supranuclear palsy (PSP) exists on Guam. This 75-year-old Guamanian Chamorro patient with slight dementia and rigidity with restriction of ocular up gaze was diagnosed as parkinsonism-dementia complex (PDC) of Guam clinically. However, neurofibrillary tangles (NFTs) were scarcely seen in the cerebral cortices and hippocampus, but many NFTs, composed of 15-17 nm straight tubules, were detected in the subthalamic nucleus and brain stem. A large number of tuft-shaped astrocytes were observed in the putamen and motor cortex, and numerous argyrophilic grains were seen in the CA1 and subiculum. These pathological findings are different from those of PDC and consistent with PSP. The present case indicates that PSP and PDC clinically resemble each other, and that precise neuropathological examination is indispensable for the final diagnosis of the patient with parkinsonism, dementia and disturbance of vertical external ocular movement.

Evolution from pretangle neurons to neurofibrillary tangles monitored by thiazin red combined with Gallyas method and double immunofluorescence.

Double immunofluorescence for paired helical filament (PHF)-tau (AT8) and ubiquitin, enhanced by catalyzed reporter deposition amplification, was combined with thiazin red (TR), a fluorochrome, which has an affinity to fibrillary structures such as neurofibrillary tangles (NFTs). After recording these triple-fluorescent images, sections were subjected to the Gallyas silver impregnation method, so that four different staining properties could be compared on the same structure. Among pyramidal neurons quantified in the hippocampus from six cases of Alzheimer's disease, 60.3% were positive for ubiquitin, and were consistently positive for TR. TR-positive neurons (77.1%) harbored fibrillary structures in the cytoplasm and were always positive for the Gallyas stain, which stained the largest number of legions (94.5%). AT8-positive neurons without fibrillary structure were negative for TR (11.6%, pretangle neurons). Some of the pretangle neurons were positive for the Gallyas stain even without fibrillary structures. Appearance of TR stain and ubiquitin in NFTs, but not in pretangle neurons, suggests that ubiquitin is integrated into tau-positive neurons after their transformation into NFTs. Because TR-positive NFTs sometimes lacked ubiquitin-like immunoreactivity, involvement of ubiquitin may not be an early event during NFT formation. This combined method is now found useful in determining how molecules other than tau are involved during the evolution from tau-positive neurons to NFTs in various neurological disorders characterized by the deposition of tau.

Alpha-synuclein-positive structures in cases with sporadic Alzheimer's disease: morphology and its relationship to tau aggregation.

Alzheimer's disease (AD) and Parkinson's disease share common clinical and pathological features. In this study, we examined the relationship between AD pathology and alpha-synuclein aggregation. The frequency and distribution of alpha-synuclein-positive structures were systematically investigated in 27 cases with sporadic AD by alpha-synuclein immuno-histochemistry. Thirteen (48.2%) of 27 cases had various alpha-synuclein-positive structures as well as Lewy bodies. The frequency and density of senile plaques and neurofibrillary tangles were not significantly different between cases with alpha-synuclein structures and those without. alpha-Synuclein-positive structures were found most frequently in the amygdala. The alpha-synuclein-positive inclusions that are different from Lewy bodies were observed at the highest rate in the hippocampus. The discovery of alpha-synuclein as the constituent of Lewy bodies facilitated the detection of Lewy-related structures even in AD cases with widespread and numerous neurofibrillary tangles. alpha-Synuclein-positive inclusions except for Lewy bodies are exposed, and the distribution of them indicates that Lewy body formation may be influenced by the degree of tau aggregation. This study also supports the suggestion that cases with AD pathology can be classified into two groups according to the existence or absence of alpha-synuclein aggregation.

Anticancer drugs induce apoptosis in mouse hair follicles.

Apoptosis represents an important mode of cell death induced by chemotherapeutic drugs. It is plausible that apoptosis may also play an important role in alopecia caused by anticancer drugs. C57 BL/6 mice were induced to enter into anagen by hair shaft depilation and a single intraperitoneal injection of cyclophosphamide (150 mg/kg) was given. Skin specimens were taken from the backs of mice at day 9, 10, 11, 12 and 13 postdepilation (p.d.). Specimens were stained with TUNEL method, and DNA was isolated from the plucked hair follicles and was electrophoresed. Many TUNEL-positive cells were observed in hair bulbs in the cyclophosphamide group at days 10-13. At day 13 p.d., most follicles were damaged and extensive hair loss was observed. Fragmented DNA, but not so distinct, were observed in a DNA ladder pattern corresponding to the in situ results. This study suggests that anticancer drugs can induce apoptosis-related damage to the hair follicles in mice. Control mice when treated with saline also showed apoptosis when they spontaneously entered into catagen, but they never showed hair loss. Consequently, hair loss induced by anticancer drugs may result from a wave of induced apoptotic death.

Cultured keratinocytes from plectin/HD1-deficient epidermolysis bullosa simplex showed altered ability of adhesion to the matrix.

Epidermolysis bullosa simplex associated with late onset of muscular dystrophy has been found to show defective expression of plectin, an intracytoplasmic protein in hemidesmosomes. In this report, we examined ability of cell-to-matrix attachment of cultured keratinocytes derived from a case with this disease by various cell biological methods, and compared it to that of normal keratinocytes. In cell adhesion assay, the patient keratinocytes showed more prominent short-time cell adhesion than normal keratinocytes. In contrast, the patient keratinocytes could be detached much easier than normal keratinocytes in cell detachment assay by treatment with dispase. In phagokinetic track assay, no apparent difference of cell migration was observed between the patient and normal keratinocytes. These results indicate that plectin-deficiency may up-regulate short-term cell contact and reduce stable cell-matrix adhesion at the epidermal basement membrane zone.

Mitochondrial encephalomyopathy with lactic acidosis and stroke like episodes (MELAS) with prominent degeneration of the intestinal wall and cactus-like cerebellar pathology.

A 67-year-old woman had frequent subacute ileus, hearing difficulty, muscle atrophy and stroke-like episodes. Computed tomography revealed multiple low-density areas, which did not correlate with the vascular supply, in the cerebral cortex. She had metabolic disturbance comprising lactic acidosis and elevated pyruvate level. Her skeletal muscle biopsy specimen showed ragged-red fibers, and mitochondrial DNA analysis revealed a point mutation at position 3243, findings consistent with MELAS. Examination of her small intestine revealed a necrotic zone and numerous abnormal large mitochondria in the smooth muscle cells, vascular media and endothelium, and intestinal ganglion cells. The cerebral cortex showed multiple microcystic necrotic foci in cerebral cortex. Cactus-like pathology resembling the changes associated with Menkes' kinky hair disease and torpedoes were observed in the cerebellar Purkinje cells. The intestinal dysmotility due to MELAS and cerebellar changes were presumed to be associated with a disturbance of copper metabolism.

Ependymal cyst producing alpha-fetoprotein. Case report.

This 17-year-old man was admitted to the hospital due to progressive headache and diplopia. Neuroradiological studies revealed a cystic mass in the pineal region without a parenchymal lesion. In addition, serum alpha-fetoprotein (AFP) levels were elevated. A cyst-to-third-ventricle and cistern fenestration was performed, but the cyst enlarged 3 months after the first operation. In the second operation, subtotal resection of the cyst was performed. The AFP level in the cyst fluid was very high preoperatively but was decreased postoperatively. The patient was discharged with no neurological deficit. Pathological examination of resected tissue showed a single layer of cuboidal cells that resembled an ependymal structure. The cells were immunoreactive for AFP immunostain, which indicated AFP production from these cells.

Adhesion molecule detection in a case of early cerebral malaria: immunohistochemical and electron microscopic findings.

A case of early cerebral malaria caused by Plasmodium falciparum was studied. P-selectin glycoprotein ligand 1 (PL1) was detected along the inner surface of the infected red blood cells (IRBCs), which ordinarily are not positive for PL1 immunohistochemically, suggesting PL1 being the product of parasite. The electron microscopic finding showed granular deposits in the corresponding lesion, consistent with PL1 deposition, in the IRBCs firmly attached to the endothelium of small cerebral vessels. Most of the IRBCs were round shaped as though they lost their capacity to change shape. The therapeutic strategy was expected against adhesion molecules such as PL1 and for maintaining or restoring the metamorphic capacity of IRBCs.

Tau-positive neurons in corticobasal degeneration and Alzheimer's disease--distinction by thiazin red and silver impregnations.

Thiazin red (TR), a fluorochrome that has an affinity to fibrillary structures such as neurofibrillary tangles (NFTs) or senile plaques, was utilized to investigate assembly of tau protein into fibrils in tau-immunopositive neocortical neurons of corticobasal degeneration (CBD) and of Alzheimer's disease (AD). Double fluorescence with anti-paired helical filament monoclonal antibody (AT8) and TR was followed by either the Gallyas or Bodian silver impregnation method, which enabled a comparison of the staining features by three different methods on the same neuron. NFTs of AD were uniformly stained by TR and Gallyas method. Most of tau-immunopositive neurons of CBD were similarly stained by Gallyas method but barely or only weakly by TR or Bodian method, suggesting that tau in neocortical neurons of CBD is less liable to form fibrillary structures than in those of AD, easily distinguishable by TR staining. Clarifying the process of tau assembly using this fluorochrome will give a clue to understanding mechanisms of tau deposition, which may be different in various neurological disorders.

Defective terminal differentiation and hypoplasia of the epidermis in mice lacking the Fgf10 gene.

Here, we characterized the skin and hair phenotype of mice lacking the fibroblast growth factor 10 gene (Fgf10), a newly identified member of the fibroblast growth factor family. Histological examination of Fgf10(-/-) newborn mouse skin revealed abnormalities in epidermal morphogenesis. The number of proliferating cells in the basal layer was decreased, the granular layer was hypoplastic and lacked distinctive keratohyaline granules and tonofibrils. The expression of loricrin, a marker of epidermal differentiation, was dramatically reduced. Despite the presence of Fgf10 transcripts in normal hair follicles, abnormalities of hair development were not observed in Fgf10(-/-) skin. These data suggest that Fgf10 is required for embryonic epidermal morphogenesis but is not essential for hair follicle development.

Alpha-synuclein inclusions in amygdala in the brains of patients with the parkinsonism-dementia complex of Guam.

We investigated by immunohistochemistry the deposition of alpha-synuclein in the brains of deceased patients with the parkinsonism-dementia complex (PDC) of Guam. Five of 13 PDC brains showed numerous alpha-synuclein positive neuronal inclusions and abnormal neurites, chiefly in the amygdala. Similar alpha-synuclein positive lesions were observed, although to a lesser extent, in the entorhinal cortex and the dorsal vagal nucleus. No alpha-synuclein positive inclusions were observed in motor cortex or locus coeruleus, and only a small number of positive inclusions were found in the Sommer's sector, temporal cortex, or substantia nigra. Some of the alpha-synuclein positive inclusions were reminiscent of cortical Lewy bodies (LB), but many of those in the amygdala coexisted with tau-positive pretangles and/or neurofibrillary tangles (NFT) within the same neurons. In these neurons, tau-positive shells encapsulated alpha-synuclein positive central cores or irregularly shaped alpha-synuclein-positive deposition intermingled with pretangles/NFT. Thus, the present study suggests that a common mechanism may govern aggregation of alpha-synuclein and tau in the amygdala, and that aggregation of alpha-synuclein may play some role in the neurodegenerative process of a tauopathy (i.e. PDC) in which Abeta deposition is virtually absent.

Histological distribution of class III alcohol dehydrogenase in human brain.

The distributions of class III alcohol dehydrogenase (ADH), a glutathione-dependent formaldehyde dehydrogenase, and class I ADH in the human brain were examined immunohistochemically. The most intense immunostaining of class III ADH was observed in the dendrites and cytoplasm of cerebellar Purkinje cells. Scattered cerebral cortical neurons in layers IV and V, and some hippocampal pyramidal neurons were also immunopositive. The neuronal distribution of class III ADH resembled that of the vulnerable neurons in patients with hypoxic encephalopathy, which in view of the intense staining in the Purkinje cells, raises the possibility that this enzyme contributes to the hypoxia and cerebellar degeneration suffered by chronic alcoholics. Perivascular and subependymal astrocytes, which contribute to the maintenance of the cerebral cellular milieu and isolate the brain from the systemic circulation and cerebrospinal fluid, were also class III ADH positive. As the substrates of this enzyme include intrinsic toxic formaldehyde, inflammatory intermediate of 20-hydroxy-leukoteiene B4, and possibly ethanol, the distribution of class III ADH immunostaining indicates this enzyme contributes to the defence of the brain against degenerative processes. The finding that, unlike ependymal cells, subependymal astrocytes were class III ADH positive, suggests this enzyme may be useful for differentiating astrocytes and ependymal cells.

Dual enhancement of double immunofluorescent signals by CARD: participation of ubiquitin during formation of neurofibrillary tangles.

Amplification with catalyzed reporter deposition (CARD) greatly enhances peroxidase signals, which has been utilized to amplify immunohistochemical labelings including fluorochromes. Here we describe a strategy to amplify each of two immunofluorescent signals without crosstalk on double-stained histological sections from human autopsied brains with Alzheimer's disease (AD). One of the two primary antibodies (anti-Abeta or anti-PHF-tau) was probed by a species-specific secondary antibody conjugated with horseradish peroxidase (HRP), which was visualized by FITC-labeled tyramide. After inactivation of HRP, the other primary antibody was probed by another species-specific secondary antibody conjugated with HRP. Amplification with biotinylated tyramide was followed by streptavidin-conjugated Cy-5, which specifically labeled the latter epitope. It was found that Abeta and PHF-tau were localized to senile plaques and neurofibrillary tangles (NFTs), respectively, which verified lack of crosstalk on the double-stained section. Localization of ubiquitin and PHF-tau was looked for at higher magnification in NFT-bearing neurons. Although these two epitopes were colocalized in some neurons, ubiquitin was not always present in PHF-tau positive NFTs. Discrepancy between PFH-tau and ubiquitin, verified inter- and intracellularly, may represent different stages of NFT formation. This is the first report of successful CARD amplification of two different fluorescent signals on double-labeling immunohistochemistry, which is now proved to be powerful in detecting epitopes in relation to AD-related lesions. Improved intensity over tenfold of the two fluorescent signals without crosstalk will expand the application of the multilabeling method with fluorochromes.