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.

Human desmocollin 1 (Dsc1) is an autoantigen for the subcorneal pustular dermatosis type of IgA pemphigus.

IgA pemphigus showing IgA anti-keratinocyte cell surface autoantibodies is divided into subcorneal pustular dermatosis (SPD) and intraepidermal neutrophilic IgA dermatosis (IEN) types. We previously showed by immunoblotting that IgA from some IgA pemphigus patients reacted with bovine desmocollins (Dsc), but not human Dsc. To determine the antigen for IgA pemphigus, we focused on conformation-dependent epitopes of Dsc, because sera of patients with classical pemphigus recognize conformation-sensitive epitopes of desmogleins. We constructed mammalian expression vectors containing the entire coding sequences of human Dsc1, Dsc2, and Dsc3 and transiently transfected them into COS7 cells by lipofection. Immunofluorescence of COS7 cells transfected with single human Dscs showed that IgA antibodies of all six SPD-type IgA pemphigus cases reacted with the surface of cells expressing Dsc1, but not with cells expressing Dsc2 or Dsc3. In contrast, none of seven IEN-type IgA pemphigus cases reacted with cells transfected with any Dscs. These results convincingly indicate that human Dsc1 is an autoantigen for SPD-type IgA pemphigus, suggesting the possibility of an important role for Dsc1 in the pathogenesis of this disease. This study shows that a Dsc can be an autoimmune target in human skin disease.

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.

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.

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.

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.

Novel non-radioisotope immunoprecipitation studies indicate involvement of pemphigus vulgaris antigen in paraneoplastic pemphigus.

We have developed two different novel immunoprecipitation assays in which radioisotopes are not used, and have examined antigens for four cases of paraneoplastic pemphigus (PNP) including three new patients. The PNP sera showed a clear reactivity with transitional epithelia of rat urinary bladder by immunofluorescence, and reacted with a characteristic doublet of the 210 and 190 kD proteins by immunoblotting of normal human epidermal extract, confirming the diagnosis of PNP. In addition, by immunoprecipitation using silver-stain to detect immunoprecipitated proteins, the PNP sera detected the 250, 210 and 190 kD proteins, while control bullous pemphigoid sera detected only the 230 kD bullous pemphigoid antigen. Furthermore, with another immunoprecipitation using cell surface biotinylation, three of the four PNP sera specifically reacted with the 130 kD pemphigus vulgaris antigen (Dsg3), indicating that pemphigus vulgaris antigen may be involved in PNP. This reactivity was further suggested by the immunoblot analysis using recombinant pemphigus vulgaris antigen. In future, these non-radioisotope immunoprecipitation assays should become a useful tool not only to unravel the complex situation for the PNP antigens, but also to study antigens in other autoimmune bullous skin diseases.

Emergence of immunoreactivities for phosphorylated tau and amyloid-beta protein in chronic stage of fluid percussion injury in rat brain.

Head injury is one of the potential environmental factors in Alzheimer's disease (AD). To study the chronic stage of concussive brain injury, histological analyses were performed 2-6 months after right lateral fluid percussion (FP) brain injury (3.6-4.8 atm) in rats. Six months after injury, numerous normal-looking neurons in the telencephalon and brain stem were immunoreactive with either antibody to phosphorylated tau or with four antibodies to beta-amyloid protein. Neuronal counts in the cortices were gradually decreased after injury, up to 42% loss at 6 months after injury. These neuropathological changes suggest that this animal model could serve as a good animal model of neurodegenerative diseases such as AD.

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.

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.

Serum from normal elderly individuals contains anti-basement membrane zone antibodies.

BACKGROUND: Bullous pemphigoid is an autoimmune bullous disease with circulating anti-basement membrane zone antibodies, and it commonly affects elderly individuals; however, the reasons for the late onset of the disease are unclear. DESIGN: The anti-basement membrane zone antibodies in serum samples from normal elderly subjects were compared with those in serum samples from normal young subjects. PARTICIPANTS: Serum samples from 32 elderly and 28 young normal individuals and 10 patients with bullous pemphigoid were used. INTERVENTIONS: Indirect immunofluorescence against guinea pig esophagus or human salt-split epidermis and immunoblotting against human and guinea pig epidermis were performed. RESULTS: Serum samples from young individuals were devoid of anti-basement membrane zone antibodies against guinea pig esophagus and human salt-split epidermis. Among 32 serum samples from elderly patients, 6 cases (19%) were positive for anti-basement membrane zone antibody for guinea pig esophagus, and in those the titers were 10 in 3 cases and 40, 80, and 320 in the others. One case was positive against human split epidermis at a titer of 10. An immunoblotting analysis showed that the antigenicity of the 230-kd and 180-kd bullous pemphigoid antigen from guinea pig epidermal extract was similar to that of human epidermal extract; however, the molecular weight was slightly different. The 4 cases of elderly serum that recognized guinea pig esophagus basement membrane zone showed positivity with the 230-kd peptide in the guinea pig epidermal extract; however, they were negative with the human epidermal extracts. Direct immunofluorescence observation of these cases showed that deposition of IgG or C3 was not present in cryostat sections from flexor arm surfaces. CONCLUSIONS: The serum samples from elderly subjects possessed a relatively high incidence of anti-basement membrane zone antibodies detectable with guinea pig esophagus as substrate. This observation of a specific immune defect in elderly individuals might explain why they are more susceptible to developing bullous pemphigoid.

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.

Apoptosis in murine hair follicles during catagen regression.

Catagen hair follicle involution has been reported to involve apoptosis, although the precise mechanism has not been satisfactorily resolved. Previous studies have involved solely morphological or electron microscopical methods. We report here studies on murine hair follicles during the first postnatal hair cycle conducted using the terminal deoxy-nucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) method. Electrophoresis of DNA isolated from the hair follicles of the same animals was carried out in order to confirm the systematic fragmentation of DNA that typifies apoptosis. On day 10, when all the follicles were growing, there was no evidence of staining with TUNEL in the hair bulbs. Electrophoresis similarly did not show characteristic DNA ladders. By day 15, a few positive cells were observed in the hair bulbs and the numbers had increased by day 17 when many positive cells were seen, especially in the lower portions of the follicles. Electrophoresis demonstrated DNA ladders on days 15, 16 and 17, although the DNA ladder on day 15 was less prominent than that on day 17. These studies confirmed that apoptosis, as identified by techniques that measure DNA fragmentation, occurs in the lower regions of hair follicles towards the end of catagen.

Effect of antianaphylactic agents on substance-P induced histamine release from rat peritoneal mast cells.

Substance P is known to be a potent histamine liberator for mast cells. The influence of antianaphylactic agents, disodium cromoglycate (DSCG), ketotifen, and tranilast was studied on substance-P and compound 48/80-induced histamine release from rat peritoneal mast cells. Substance-P induced histamine release was inhibited by these agents, while compound 48/80-induced histamine release was not inhibited by tranilast. Our findings suggest that these antianaphylactic agents are assumed to be effective for cutaneous diseases which might be concerned with substance P and histamine.

Expression of ras p21 in mammary and extramammary Paget's disease.

With the use of immunohistochemical techniques, we examined the expression of ras oncogene product p21 in 4 cases of mammary and 13 cases of extramammary Paget's disease. In every mammary case, positive immunostaining was observed in Paget's cells and the underlying tumor (in the 3 cases where a tumor was present). Among the extramammary cases, the cells in 6 cases were immunoreactive. In 4 of these positive extramammary cases, dermal invasion and metastases of regional lymph nodes were observed. Another 2 extramammary cases were weakly reactive. An enhanced expression of ras p21 therefore seems to depend on the region of the tumor or on the biologic behavior. This work suggested that an enhanced expression of ras p21 in Paget's cells may represent a new clinical marker for tumors in cases of mammary and extramammary Paget's disease.

Immunohistochemical demonstration of epithelial membrane antigen (EMA), carcinoembryonic antigen (CEA), and keratin on mammary and extramammary Paget's disease.

We examined the presence and the distribution of epithelial membrane antigen (EMA), carcinoembryonic antigen (CEA), and keratin in 4 cases (6 specimens) of mammary Paget's disease and 9 cases (18 specimens) of extramammary Paget's disease utilizing immunoperoxidase technique. Paget's cells in 23 out of 24 specimens were demonstrable for EMA. Positive staining was observed for CEA in every specimen. Among the 24 specimens, 16 showed positivity for keratin. In addition, CEA was positive in Paget's cells and the staining for CEA was stronger than that of EMA and keratin. On the other hand, some Paget's cells were negative for EMA of keratin although other positive cells were observed in the same sections. This findings indicates that Paget's cells might express CEA and/or EMA and/or keratin depending on their differentiation. EMA is present in most organs showing glandular differentiation, and anti-keratin antibody used in this study recognizes not only keratinocytes but glandular cells. Thus, our study suggests Paget's cells are of glandular origin.

Expression of ras proto-oncogene related protein p21 in normal human skin and cutaneous tumours.

The cellular proto-oncogene, ras, is known to play an important role in the regulation of cell growth and proliferation in normal and malignant conditions. The present study was undertaken to immunohistochemically examine the expression of ras protooncogene product p21 in normal human skin and some cutaneous tumours. In normal skin, the expression of p21 was found in sweat glands, sebaceous glands, capillary endothelium, and smooth muscles, while epidermis was devoid of reaction product. Keratoacanthoma and the granular cells of verruca vulgaris were immunoreactive to the antibody for p21. Bowen's disease and squamous cell carcinoma were positive for p21, but basal cell carcinoma and seborrheic keratosis were negative. In mammary and extramammary Paget's diseases, the immunoreactivity was inconsistent. The expression of p21 in malignant melanoma cells was intense, whereas normal melanocytes and nevus cells were devoid of the expression. These results suggest that the expression of p21 does not correlate with nuclear anaplasia and malignant behaviour of cutaneous tumours.

Microfluorometric study of nuclear DNA in normal human epidermis.

Quantitative and qualitative changes of nuclear DNA were analyzed by microfluorometry in normal human epidermis during terminal differentiation. Normal human epidermis from five healthy volunteers was separated by an EDTA-trypsin method and fractionated by Percoll density gradient. Staining was carried out with either Feulgen reaction, Acridine Orange or 4'-6-diamidino-2-phenylindole (DAPI). When the cells with lower density (granular layer cells) were stained with Acridine Orange or DAPI, the greatest population was found at lower value of DNA than that in the cells stained with Feulgen reaction. After thermal denaturation procedure, a ratio of double-stranded DNA to single-stranded DNA was highest in the cells with lower density. These results seem to suggest the qualitative and quantitative changes of nuclear DNA during terminal differentiation of human epidermal keratinocytes.