Antielastases of the human alveolar structures. Implications for the protease-antiprotease theory of emphysema.

The current concepts of the pathogenesis of emphysema hold that progressive, chronic destruction of the alveolar structures occurs because there was in imbalance between the proteases and antiproteases in the lower respiratory tract. In this context, proteases, particularly neutrophil elastase, work unimpeded to destroy the alveolar structures. This concept has evolved from consideration of patients with alpha 1-antitrypsin deficiency, who have decreased levels of serum alpha 1-antitrypsin and who have progressive panacinar emphysema. To directly assess the antiprotease side of this equation, the lower respiratory tract of non-smoking individuals with normal serum antiproteases and individuals with PiZ homozygous alpha 1-antitrypsin deficiency underwent bronchoalveolar lavage to evaluate the antiprotease screen of their lower respiratory tract. These studies demonstrated that: (a) alpha 1-antitrypsin is the major antielastase of the normal human lower respiratory tract; (b) alpha 2-macroglobulin, a large serum antielastase, and the bronchial mucous inhibitor, an antielastase of the central airways, do not contribute to the antielastase protection of the human alveolar structures; (c) individuals with PiZ alpha 1-antitrypsin deficiency have little or no alpha 1-antitrypsin in their lower respiratory tract and have no alternative antiprotease protection against neutrophil elastase; and (d) the lack of antiprotease protection of the lower respiratory tract of PiZ individuals is a chronic process, suggesting their vulnerability to neutrophil elastase is always present.

Aluminum levels in brain in Alzheimer's disease.

In both human Alzheimer's disease and aluminum encephalopathy of animals, changes are observed in neurofibrillary structures. We have found that brains from Alzheimer patients contain approximately 1.4 times the aluminum level found in a control series. Some possible methodological problems are discussed. We have proposed a plausible chemical mechanism for the changes of aluminum encephalopathy.

Role of connective tissue proteases in the pathogenesis of chronic inflammatory lung disease.

The normal structure and function of the human lung is dependent on the maintenance of the connective tissue matrix. These structural macromolecules provide the template for normal parenchymal cell architecture on which efficient gas exchange depends. In addition, the organization and amount of this extracellular matrix accounts for much of the mechanical behavior of the lung parenchyma during the respiratory cycle. The preservation of this intricate connective tissue scaffold depends on the lung's capacity to prevent enzymatic disruption of the component matrix proteins. Specifically, the integrity of the normal connective tissue skeleton of the lung is determined by the maintenance of a balance between proteases capable of cleaving these structural elements and the specific protease inhibitors. The normal extracellular matrix is preserved when the local concentrations of protease inhibitors prohibits expression of active connective tissue proteases within the lung parenchyma. Conversely, the disruption of lung structure during the course of acute and chronic inflammatory diseases of the lung is often associated with an imbalance of protease-antiprotease activity. The consequence is the expression of unimpeded proteolytic attack on the connective tissue matrix of the lung. In this context, the nature of the pulmonary lesion and its physiologic consequences, reflect the specificity of the expressed proteases for the individual connective tissue components. Experimental evidence suggests that the differential expression of collagenase and elastase, prototypes of connective tissue proteases, may determine whether the pathologic outcome is fibrosis (e.g., idiopathic pulmonary fibrosis) or destruction (e.g., emphysema) of the alveolar structures.

Distinction between dysplasia-associated lesion or mass (DALM) and adenoma in patients with ulcerative colitis.

Polyps with epithelial dysplasia in ulcerative colitis (UC) represent either dysplasia-associated lesions or masses (DALMs) or sporadic adenomas. DALMs are frequently associated with associated carcinoma and are an indication for colectomy. Removal of the polyp is treatment of choice for sporadic adenomas. Differentiating between these 2 lesions is not always easy. The goal of this study was to distinguish DALMs from adenomas in patients with UC on a genetic basis. We evaluated genetic alterations in DALMs and compared them with a previously published set of dysplastic polyps in patients with UC that were considered adenomas for the following reasons: (1) polyps were located outside of current active disease; (2) polyps had histological features of sporadic adenomas; and (3) patients displayed a uneventful follow-up after polypectomy (UC-adenomas). In addition, adenomas not associated with UC were studied. Genetic alterations on chromosome 3p were assessed for the markers D3S1766, D3S2409, and D3S2387. LOH with or without microsatellite instability was found in 70%, 37%, and 57% of cases of DALM, respectively. In contrast, UC-adenomas lesions exhibited genetic alterations in 8.3%, 11.7%, and 15.3% for the respective markers. Spontaneous adenomas exhibited genetic alterations in 10.5%, 7.1%, and 0% of cases, which were not significantly different from the UC-adenoma results. These results indicate that UC-adenomas are genetically and biologically similar to sporadic adenomas and that UC-adenomas may biologically represent sporadic adenomas, supporting on a genetic basis the criteria chosen to diagnose adenomas in UC. Genetic markers on chromosome 3p may be useful in the differential diagnosis between DALM and UC-adenomas.

Psychopharmacological correlates of post-psychotic depression: a double-blind investigation of haloperidol vs thiothixene in outpatient schizophrenia.

A 24-week double-blind study was conducted to compare haloperidol and thiothixene for efficacy and safety in 46 schizophrenic outpatients. In addition to the standard psychiatric rating scales, Brief Psychiatric Rating Scale (BPRS), Nurses' Observation Scale for Inpatient Evaluation (NOSIE), and Evaluation of Social Functioning Rating (ESFR), two scales more sensitive to the incidence of treatment emergent depression were utilized. They were the Hamilton Depression Scale (HPRSD) and the Zung Self-rating Depression Scale (ZUNG). On the BPRS factors, haloperidol was significantly superior to thiothixene in Thought Disturbance and Hostility-Suspiciousness, and in Total symptomatology. Haloperidol was also significantly superior to thiothixene in Cognitive Disturbance on the HPRSD. Results of global evaluations suggested haloperidol produced slightly more rapid relief of symptoms than did thiothixene. The inclusion of the depression scales was useful in following patients who exhibited depressive symptoms; clinically significant depression was seen in 5 patients receiving haloperidol and 3 receiving thiothixene. A high incidence of akathisia in the thiothixene group was responsible for a statistically significant difference between groups in the number of central nervous system symptoms. Mean doses of test drugs were 17.5 mg/day for haloperidol an 31.8 mg/day for thiothixene. The study showed that haloperidol was equal to and in some parameters superior to thiothixene in producing improvement in the symptoms of psychosis.

Pulmonary thrombosis in a 10-year-old child with minimal change disease and nephrotic syndrome. A clinical, radiologic, and pathologic correlation with literature review.

The nephrotic syndrome has long been recognized as a hypercoagulable state. Arterial thrombosis is a rare complication of the syndrome. Diuretics and steroids, standard treatment for exacerbations, have been implicated as contributing to the development of arterial thrombosis. The authors present the pathologic, clinical, and radiologic findings of a patient with nephrotic syndrome and minimal change disease. The patient died of pulmonary thrombosis while on high-dose steroid therapy for an acute exacerbation of proteinuria following a recent hospital admission for chest pain and dyspnea.

Utility of the Bard BTA test in detecting upper urinary tract transitional cell carcinoma.

OBJECTIVES: The Bard BTA test has been shown in early studies to be useful in diagnosing transitional cell carcinoma (TCC) of the bladder. However, the utility of this test has not been evaluated for TCC of the upper urinary tract. We therefore evaluated the clinical utility of the BTA test for upper urinary TCC. METHODS: We tested 71 specimens from the ureter and/or renal pelvis in 22 patients with a history or clinical suspicion for TCC and 9 patients with benign disorders. RESULTS: When compared to cytologic diagnoses, BTA had a sensitivity of 65%, a specificity of 40% (when correlated with clinical history), a false-positive rate of 33%, and a false-negative rate of 62%. The test had a positive predictive value of 83% and a negative predictive value of 32%. CONCLUSIONS: The BTA does not have any clinical value in detecting upper urinary tract TCC.

A new radiation dosimeter using a pyroelectric detector.

We describe a new type of radiation dosimeter, for the diagnostic x-ray region, using a pyroelectric detector. It consists of a PZT ceramic crystal thick enough to absorb all the incident radiation at 33 keV. This pyroelectric radiation dosimeter (PERD) produces an electrical signal when exposed to a chopped beam of x-ray photons. The PERD is basically a microcalorimeter. It has the following characteristics: (1) it responds linearly to the energy fluence rate of the radiation; (2) it responds linearly to the radiation intensity for a given radiation spectrum; (3) it has excellent stability; (4) it is simple to construct and inexpensive; and (5) it is rugged.

FHIT protein is expressed in benign mesothelium and has no clinical value in detecting carcinoma in body cavity effusions.

The fragile histidine triad (FHIT) protein is a suspected tumor-suppressor gene frequently expressed in adenocarcinomas of the lung and other organs. Its expression in benign mesothelium has not been reported. This study examined the expression of FHIT in mesothelium from benign body cavity effusions. FHIT expression was also examined in a diversity of malignant effusions to evaluate any value of the FHIT protein to discriminate carcinomas from benign mesothelium. Fifty-eight cases of benign and malignant effusions were immunostained using cell block material and two different antigen retrieval methods with the ABC method. Benign and malignant cases were scored for percentage of cells with strong immunoreactivity. Benign mesothelium exhibited strong immunoreactivity for the FHIT protein in 32 of 32 (100%) cases, with 26 of 32 (81%) cases having expression in at least 50% of cells. Seventeen of 21 (81%) cases of adenocarcinomas also exhibited the FHIT protein in at least 50% of tumor cells. FHIT expression was also noted in small numbers of other malignancies. The FHIT protein is expressed consistently in benign mesothelium as well as many types of adenocarcinomas. Immunostaining for this protein has no value in discriminating adenocarcinomas from reactive mesothelium.

Expression of survivin, YB-1, and KI-67 in sporadic adenomas and dysplasia-associated lesions or masses in ulcerative colitis.

Sporadic adenomas are said to exhibit an orderly growth pattern with a reversal of proliferative and apoptotic cell distribution as compared with normal colonic crypts. Dysplastic polyps of patients with ulcerative colitis (UC) may represent dysplasia-associated lesions or masses (DALM) with a high associated cancer risk, or, alternatively, may represent sporadic adenomas. Histologic criteria to differentiate between sporadic adenomas and DALM have not focused on the balance between cell renewal and cell loss. The expression of the novel anti-apoptosis gene product, survivin, and the proliferation markers, Ki-67 and Y-box binding protein (YB-1), were investigated by immunohistochemical localization in sporadic adenomas and DALM lesions of patients with UC. In adenomas, KI-67 was expressed preponderantly at the luminal aspect of the polyp, whereas its expression was diffuse in DALM. Survivin was detected diffusely in both adenomas and DALM. YB-1 showed positive staining in the deep aspect of adenomatous glands but only to a minor degree at the surface, whereas both deep and diffuse expression patterns of YB-1 were seen in DALM. The authors conclude that DALM and sporadic adenomas exhibit different patterns of cellular proliferation and that molecular markers of cell proliferation, Ki-67 and YB-1, may be useful to distinguish sporadic adenomas from DALM. However, the similar expression of survivin suggests that the underlying mechanisms that regulate apoptotic cell death are uniform in these lesions.

Evaluation of the c-Met immunostain to detect malignant cells in body cavity effusions.

The cytologic diagnosis of malignant cells in serous effusions can be difficult. A wide variety of immunostains and other diagnostic techniques have been studied but without widespread acceptance of one staining panel or technique. Expression of the tyrosine kinase c-Met has been associated with several malignancies but not with benign mesothelium. We investigated the diagnostic value of the c-Met immunostain in serous effusions. Cell block material from 76 cases of unequivocally benign or malignant effusions were studied. Cases were stained with c-Met using the avidin-biotin complex method following antigen retrieval. The presence of strong granular cytoplasmic staining that was distinct from background staining was considered positive. Positive cells were identified in 38 of 42 (90%) malignant cases and in 18 of 34 (53%) benign cases. Typically, benign cases contained only individual positive cells, but positive cell clusters were also identified. The c-Met immunostain lacks sufficient specificity to be clinically useful in this cytologic setting. The expression of c-Met in benign mesothelium may reflect mesothelial proliferation.

Clinical utility of chromosome 17 alpha satellite probe in distinguishing benign mesothelium from malignant cells: a pilot study using routinely fixed specimens.

Fluorescent in situ hybridization has shown promise in detecting malignant cells in body cavity effusions. However, this requires special preparatory techniques not used in many laboratories. We developed an in situ hybridization (ISH) procedure specifically for ethanol-fixed specimens, and using it tested the clinical utility of the chromosome 17alpha satellite probe (C17alpha). ISH with C17alpha was used in 12 malignant and 10 benign ethanol-fixed body cavity effusions. Cells were pretreated with protease K prior to ISH. The probe was detected by an anti-digoxigenin-horseradish peroxidase method. Signals were counted in 100 nuclei and the chromosome index (CI) and percent diploid cells calculated in each case. ISH was successfully performed in all cases. Malignant cells had an average CI of 2.23 with less than 44% diploid nuclei and 50% of specimens exhibited bizarre signals. Benign effusions had an average CI of 1.98 with over 84.6% diploid nuclei. Questionably bizarre signals were seen in two (20%) benign specimens. ISH can be performed on ethanol-fixed specimens. The C17alpha probe may prove valuable in detecting malignant cells in body cavity effusions.

Identification of lymphatic vessels in malignant, adenomatous and normal colonic mucosa using the novel immunostain D2-40.

Distribution of lymphatic vessels in normal and neoplastic colon has been previously analyzed with electron microscopic techniques, as reliable antibodies have not been available for selective lymph vessel staining. A novel monoclonal antibody, D2-40, is recently available to differentiate lymphatic vessels from blood vessels. In this study, we analyzed the distribution of lymphatic vessels in normal colon, adenomas with and without superficial stalk invasion and invasive carcinomas without identifiable polypoid precursor lesions. In contrast to previous studies, we found lymphatic vessels in superficially misplaced stalk stroma in adenomas, and closely associated with early invasive epithelial nests in invasive lesions. Lymphatic vessels were identified within the lamina propria of the in situ aspect of in invasive tumors. We conclude that lymphatic vessel structures are seen more superficially in adenomas and invasive carcinomas than previously described. Since intramucosal carcinomas in adenomas do not metastasize, these lymph vessels may be immature or not communicate with deeper lymphatics. Proliferation and distribution of lymphatic vessels may be related to prognosis and early metastasis.

Ultra fast identification of Aspergillus species in pulmonary cytology specimens by in situ hybridization.

The cytologic diagnosis of pulmonary aspergillosis infection is typically made on a presumptive basis and later confirmed by fungal culture, which may take up to one week to complete. An in situ hybridization (ISH) probe specific for Aspergillus for use in surgical pathology specimens has been developed which has not been used on cytology preparations. We describe a supra-threshold adapted testing (STAT) in situ hybridization test for cytology specimens, which takes less than one hour to finish. We performed ISH on three cases of culture-proven pulmonary aspergillosis and one case with Aspergillus fungal forms but negative cultures to test the feasibility of using this same Aspergillus probe on cytology specimens. Four patients with pulmonary aspergillosis were initially diagnosed by cytologic examination of their respective specimens. The presumptive diagnosis was confirmed by culture to be Aspergillus fumigatus on three cases. ISH on both cytology cytospin and Thin-Prep specimens was performed using an rRNA Aspergillus specific probe. All four cytology specimens exhibited positive staining with the Aspergillus probe. Most, but not all, fungal hyphae were stained with the probe. Even though ISH is more expensive than culture, in situ hybridization can be performed in less than one hour on cytology specimens and may be beneficial for patients in selected clinical circumstances.

A fast non-fluorescent staining method for the detection of primed in situ synthesis products.

For the assessment of chromosomal numeral aberrations in cells, the method of choice is fluorescent in situ hybridisation (FISH) or, a newly introduced technique, oligonucleotide primed in situ hybridisation (PRINS). In the PRINS method labeled nucleotides are incorporated into newly synthesized DNA mediated through the Taq polymerase. Both PRINS and FISH reactions are visualized with a fluorescent light detection system. We present a method whereby PRINS products can be reliably and rapidly visualized by a streptavidin DAB detection system.

Observation of lymphatic vessels in orbital fat of patients with inflammatory conditions: a form fruste of lymphangiogenesis?

In the absence of antibodies specific for lymphatic vessels, analysis of lymphatic vessels within different tissues has been widely performed with light microscopic and, most importantly, electron microscopic techniques. In regard to lymphatic vessels in the ocular globe and the periocular structures, controversy remains about the specific distribution of lymphatic channels. It is postulated that bulbar and retrobulbar tissues are devoid of lymphatic vessels, but lymphatic vessels have been demonstrated in lacrimal gland and epibulbar conjunctiva. In this study, we analyzed orbital fat for the presence of lymphatic tissue using D2-40, a monoclonal antibody, specific for lymphatic vessels. We found lymphatic vessels present within bulbar conjunctiva extending to the level of the ciliary apparatus. No lymphatics were identified in healthy anterior orbital adipose tissue. In two cases of orbital mucor-mycosis and one case of panendophthalmitis, significant lymphovascular proliferation was present within granulation tissue associated with the acute inflammation. We conclude that lymph vessel proliferation may be induced in inflammatory conditions in tissues which are normally devoid of lymph channels.

Proliferation of D2-40-expressing intestinal lymphatic vessels in the lamina propria in inflammatory bowel disease.

Lymphatic vessels in the colon are normally distributed beneath the muscularis mucosae with rare branches reaching through the muscularis mucosae to the most basal aspect of the colonic crypts. In chronic inflammatory bowel disease demonstrating acute inflammation and architectural disarray, lymph vessel proliferation is seen within the lamina propria and within the submucosa. We analyzed the number and distribution of lymphatic vessels within the lamina propria and submucosa in chronic active and treated ulcerative colitis with restoration of architecture by immunostaining with D2-40, a specific monoclonal antibody against lymphatic vessels. We found significantly increased numbers of lymph vessels in chronic active ulcerative colitis both within the lamina propria and the submucosa as compared to normal mucosa. Numbers of lymph vessels in lamina propria were highest in severe chronic active ulcerative colitis and less in moderate and minimal residual disease with minimal architectural disarray (p<0.05). Lymph vessels in the submucosa were increased significantly above normal values in both severe, moderate and minimal residual disease. We conclude that lymph vessel distribution in chronic active ulcerative colitis extends into the lamina propria. With restoration of architectural morphology, the integrity of the lamina propria in regards to the distribution of lymph vessels is restored.

Glut-1 expression in dysplastic and regenerative lesions of the colon.

Monosaccaride transporter proteins are responsible for transmembrane transport of monosaccarides into cells. Glucose transporter protein 1 (Glut-1) is most prevalent in the cell membranes of erythrocytes and facilitates transport of glucose in tissues with barrier functions, i.e. blood brain barrier. Expression of Glut-1 in malignant tumors is increased due to increased metabolic need of the proliferating cell populations. In colorectal adenomas and carcinomas, membranous expression of Glut-1 has been associated with higher grade of tumors and decreased survival time. We studied the expression of Glut-1 in dysplastic proliferations of the colon which included sporadic adenomas and dysplasia associated lesions (DALM) in patients with ulcerative colitis and reactive/regenerative proliferations of the colon, including non-dysplastic chronic colitis, acute colitis and ischemia. Two patterns of Glut-1 expression were detected. Most adenomas and DALMs showed at least focal membranous expression of Glut-1. In addition a second staining pattern was recognized which consisted of prominent supranuclear dots. This pattern of staining was not only seen in adenomas and DALM but also in non-dysplastic areas immediately surrounding sporadic adenomas, in regenerative chronic colitis and in areas surrounding acute inflammation. Areas away from dysplasia did not show any positive staining for Glut-1. We conclude that two distinct patterns of Glut-1 expression may be found in colonic epithelial proliferation: membranous staining, associated with dysplasia, and, heretofore not described, supranuclear staining which may be related to Glut-1 expression secondary to expression of specific growth factors and not necessarily related to dysplasia.

BCL-2 expression and inhibin-A in adrenal neoplasms: a comparative study.

Differential diagnosis between adrenal cortical and adrenal medullary lesions may be difficult in many cases. Different immunohistochemical, histochemical tools as well as ultrastructural diagnostic techniques have been employed to aid in differentiating between these lesions. Recently, both inhibin-A and BCL-2 have been shown to stain selectively adrenal cortical tissue and its derived neoplasms but not adrenal medulla or pheochromocytomas. In this study we compared the staining reactions of inhibin-A and BCL-2 in cases of adrenal cortical adenomas and carcinomas as well as pheochromocytomas. We found that both inhibin-A and BCL-2 stained cortical derived tissues, but not medullary derived tissues. Staining intensity for inhibin-A was significantly weaker than for BCL-2. We found that fixation techniques may influence the staining reactivity, as some cases did not immunoreact with any of the antibodies. We conclude that both inhibin-A, and, preferentially, BCL-2 are useful additions to a staining protocol to help in the differential diagnosis of cortical and medullary neoplasms.

Cytologic atypia in a 53-year-old man with finasteride-induced gynecomastia.

Finasteride has been associated with the development of gynecomastia. Although cytoplasmic vacuolization has been noted in prostatic epithelium in men taking this drug, we found no documentation of the cytologic changes in finasteride-associated gynecomastia. We present the case of a 53-year-old man who developed unilateral gynecomastia following finasteride therapy for alopecia. A fine-needle aspiration biopsy of the mass was diagnosed as adenocarcinoma on the basis of nuclear atypia and particularly because of cytoplasmic vacuolization. Subsequent excisional biopsy revealed benign gynecomastia with no evidence of malignant change. The ductal epithelium did exhibit cytoplasmic vacuolization similar to that described in the prostate following finasteride therapy. We believe this is the first reported case documenting the cytologic changes seen in gynecomastia secondary to finasteride therapy. Cytoplasmic vacuolization in this setting should not be considered evidence of malignancy in men with gynecomastia. As with gynecomastia in general, extreme caution should be used before rendering a cytologic diagnosis of malignancy.