In vivo analysis of intramuscular gene transfer in human subjects studied by on-line ultrasound imaging.

The current study was designed to test the hypothesis that intramuscular (i.m.) injection of naked DNA leads to distribution of the injectate remote from the site of needle placement, a finding that might be expected to facilitate i.m. gene transfer. Transcutaneous ultrasound imaging was employed to monitor online the extent to which a solution of phVEGF165 was distributed among the skeletal musculature during 288 i.m. injections in 18 consecutive patients. In 237 (82.3%) of 288 muscle sites, the injection was performed into the distal calf muscle. In 51 (17.7%) of 288 muscle sites, injection was performed into the first and/or second interosseous muscles of the dorsal foot. Unperturbed muscle was recognized by a characteristic echogenic, stippled texture that was bounded by more intensely echogenic fascia. When i.m. gene transfer was performed into the calf muscles, the injectate was distributed along a longitudinal dimension of 3.59 +/- 0.79 cm (1.39-5.87 cm); the corresponding area of injectate measured by on-line planimetry was 1.83 +/- 0.51 cm2 (0.62-3.41 cm2). When i.m. gene transfer was performed into the interosseous muscles of the foot, the longitudinal extent of injectate distribution was 2.49 +/- 0.66 cm (1.61-3.91 cm), with a corresponding injectate area of 1.71 +/- 0.54 cm2 (0.51-2.86 cm2). These findings establish that a solution of plasmid DNA administered by direct i.m. injection into the skeletal muscles of the limb is distributed well beyond the site of needle entry. Thus, the use of multiple injections performed at different sites is likely to result in broad distribution of DNA injectate, a physical factor that may act to facilitate naked DNA and/or other gene transfer strategies.

Familial defective apolipoprotein B100: clinical characteristics of 54 cases.

Familial defective apolipoprotein B100 (FDB) is a recently identified dominantly inherited genetic disorder, which is characterized by a decreased affinity of low density lipoprotein (LDL) for the LDL receptor. FDB is caused by a G to A mutation at nucleotide 10 708 in exon 26 of the apo B gene creating a substitution of glutamine for arginine in the codon for amino acid 3500. To determine the consequences of the arginine(3500)----glutamine mutation on plasma lipid levels and other clinical features, we have investigated 54 FDB heterozygotes from Germany (24 men, 30 women, mean age 37.2 (4-73) years). The average total cholesterol level in plasma was 308 mg/dl (average LDL-cholesterol 242 mg/dl), which was 116 mg/dl (120 mg/dl) above the 50th percentile of the age and sex-matched controls reported in the LRC population studies (Lipid Research Clinics' Program 1980). Tendon xanthoma and arcus lipoides were present in 25.9% and 22.2% of the patients, respectively. Plaques in the carotid arteries, determined by duplex scanning, were present in 38.9%, and coronary artery disease was present in 22.2%. This study shows that the combination of tendon xanthoma, arcus lipoides and premature atherosclerosis is no longer totally appropriate for the diagnosis of familial hypercholesterolemia (FH). It rather seems that these features are characteristic of a defective LDL receptor pathway, which could be caused by a defective LDL receptor or a defective ligand apo B100. The distinction between FH and FDB may have therapeutic implications, because certain lipid lowering drugs act by stimulation of the LDL receptor, which has a normal function in FDB.

Genetic evidence from 7 families that the apolipoprotein B gene is not involved in familial combined hyperlipidemia.

Familial combined hyperlipidemia (FCHL) is the most common genetic form of hyperlipidemia in which affected individuals manifest multiple lipoprotein phenotypes. Although the molecular defect is still unknown, several kinetic studies have demonstrated increased turnover rates of apolipoprotein B (apo B) in patients with FCHL, irrespective of their lipoprotein phenotype. Using 3 restriction fragment length polymorphisms (RFLPs) of the apo B gene (XbaI, MspI and EcoRI) we have investigated 33 families which fulfill the diagnostic criteria of FCHL. No significant difference in allele frequency was found between 33 unrelated individuals with FCHL and 107 normolipidemic controls. 3-RFLP haplotypes were constructed in each pedigree. A co-segregation analysis was performed in 7 informative families. In no family was co-segregation observed between the haplotype of the apo B gene and the phenotype of FCHL. These data are not compatible with the hypothesis that FCHL is caused by mutations of the apo B gene acting as a simple mendelian trait.

Familial defective apolipoprotein B-100: haplotype analysis of the arginine(3500)----glutamine mutation.

Familial defective apolipoprotein B-100 (FDB) is a recently identified, dominantly inherited genetic disorder, which leads to an increased serum level of low density lipoprotein (LDL) cholesterol with reduced affinity for the LDL receptor. It is postulated that this disorder results from a G to A mutation at nucleotide 10,708 in exon 26 of the apo B gene creating a substitution of glutamine for arginine in the codon for amino acid 3500. To investigate whether recurrent mutation has contributed to the high frequency of FDB, we have conducted a haplotype analysis in previously reported and newly detected FDB heterozygotes in Germany. 5 FDB families and 6 unrelated FDB heterozygotes were genotypes at 4 polymorphic sites in the 3' end of the apo B gene. These sites consisted of the diallelic markers XbaI, MspI, EcoRI and the hypervariable region (3'HVR). In 5 FDB families and 1 unrelated FDB heterozygote the arginine(3500)----glutamine mutation could be unambiguously assigned to the haplotype XbaI-/MspI+/EcoRI-/3'HVR48, in the other 5 FDB unrelated heterozygotes this finding was consistent with the combination of the genotype. The existence of the arginine(3500)----glutamine mutation on the same and supposedly rare allele suggests that the mutant alleles are identical by descent in our population. The fact that the same mutant allele was identified in North America and Austria suggests a common European origin of the arginine(3500)----glutamine mutation.

Factor XIII insufficiency in a patient with severe psoriasis vulgaris, arthritis, and infirmity.

Factor XIII (FXIII) links soluble fibrin monomers and collagen fibres to stable fibrin connections. Deficiency of FXIII, caused by dyspoiesis or increased consumption, results in a bleeding tendency and wound healing complications. Although the decrease of FXIII and successful replacement in patients with wound healing complications after surgery have been described by several authors, it is rarely considered that patients with autoimmune diseases, bleeding or healing complications may suffer from FXIII deficiency. We report a patient with severe psoriasis vulgaris generalisata with large, painful erythemas, bleeding tendency, joint contractions and infirmity, whose FXIII activity was 19%. After successful replacement the bleeding tendency vanished, and a marked improvement of skin and joint mobility allowed mobilisation and administration of physical therapy, whereby some independence and mobility were restored to the patient.

Disappearing bone disease (Gorham-stout disease): report of a case with a follow-up of 48 years.

A patient with osteolysis of the right hand after a metatarsal fracture at the age of 12 years is reported. The osteolysis progressed until the age of 21 years and was stable until the age of 59 years, when the patient died from a metastatic colon cancer. The article discusses the clinical, radiographic, and histologic features, and prognosis of idiopathic osteolysis (Gorham-Stout disease). Gorham-Stout disease is characterized by a non-familial, histological benign vascular proliferation producing lysis of the bone. The therapeutic options of Gorham-Stout disease is limited; radiotherapy has been used with success in single cases. Usually, the disease undergoes spontaneous arrest, as it occurred in our patient.

Blue toe syndrome after initiation of low-dose oral anticoagulation.

Cholesterol emboli are a known complication after arterial catheterization, arterial surgery, and after lysis with plasminogen activators. The clinical presentation of cholesterol emboli is variable ranging from a localized blue toe syndrome to a multisystem disease. The purpose of this case report is to report on a patient with blue toe syndrome and livedo reticularis occuring two months after initiation of low-dose oral anticoagulation with phenproucomon. The non-invasive studies revealed an infrarenal abdominal aneurysma lined by a thin wall thrombus as a potential source of cholesterol emboli. The patient had a benign course with resolution of toe pain after a period of four weeks, without development of an ulceration. The case report demonstrates that cholesterol emboli may also occur in patients treated with low-dose oral anticoagulation and no previous arterial catheterization.

Relapsing poly(peri)chondritis diagnosed by biopsy during inflammatory free interval: destructive polychondritis versus fibrosing perichondritis.

Relapsing poly(peri)chondritis (RP) is a connective tissue disorder characterized by recurrent inflammatory episodes of cartilaginous structures and the involvement of special sense organs. The diagnostic criteria of McAdam 1976 include at least three of the following criteria: a) bilateral auricular chondritis, b) nonerosive sero-negative inflammatory polyarthritis, c) nasal chondritis, d) ocular inflammation, e) respiratory tract chondritis, f) audiovestibular chondritis. A cartilage biopsy according to these criteria is not mandatory. Nevertheless, unclear cases still remain as there is a broad spectrum of differential diagnosis. In these individuals it is important to obtain a biopsy from the affected cartilage. Although up to 89% develop auricular inflammation, only few electron microscope studies are performed on cartilage specimens. The purpose of this study is to report on a patient with a history of recurrent swelling of both ears, where the diagnosis could only be established by ear biopsy which was studied by light and electron microscopy. Differential diagnosis is discussed and a review of the literature is given.

Evaluation of atherosclerosis in patients with central retinal vein occlusion by carotid artery duplex scanning and echocardiography: a prospective case-control study.

BACKGROUND AND PURPOSE: Central retinal vein occlusion (CRVO) is a common cause of retinal vascular visual loss second to diabetic retinopathy. Atherosclerotic risk factors are thought to affect vascular flow or cause retinal vascular wall abnormalities, thereby contributing to development of CRVO. Previous studies did not fully evaluate the degree of atherosclerotic disease. The purpose of this study was to determine the degree of atherosclerosis of the carotid artery by duplex scanning and to investigate cardiac manifestations of atherosclerotic risk factors by echocardiography in patients with CRVO. MATERIAL AND METHODS: 39 patients (age 63.1 years [50-84 years], 21 men, 18 women) with CRVO were compared with a control group consisting of 39 individuals (age 59.3 years [49-81 years], 19 men, 20 women) in whom echocardiography was performed to rule out endocarditis. Clinical examination, laboratory testing, carotid artery duplex scanning and echocardiography were performed in all patients. RESULTS: Echocardiography revealed significantly increased prevalence of left ventricular hypertrophy (30.8% in CRVO patients, 5.1% in controls) as a typical sign of hypertensive heart disease in CRVO patients, which is consistent with the increased prevalence of hypertension (HTN) (46.2% in CRVO patients, 15.4% in controls). The prevalence of atherosclerosis of carotid artery and ascending aorta, and all other echocardiographic findings were comparable in CRVO patients and controls: regional wall motion abnormality, left ventricular dilatation, aortic valve calcification, and mitral valve calcification. CONCLUSION: Our study demonstrates that CRVO is not associated with atherosclerosis of large arteries, such as the carotid artery and the ascending aorta. We propose that the retinal artery atherosclerosis seen in most CRVO patients is caused by HTN.

Unusual presentation of Takayasu arteritis with cardiac involvement and imitation of juvenile arteriosclerosis. A case report.

A twenty-five-year-old Caucasian man with Takayasu arteritis, who was formerly diagnosed as suffering from premature arteriosclerosis, is described. Necropsy disclosed involvement of the entire aorta and its major branches, the pulmonary arteries, the coronary arteries, the intramyocardial arteries, and the heart valves, a combination hitherto not described. Literature concerning heart involvement in Takayasu arteritis is reviewed, and the differential diagnosis is discussed.

[Gas gangrene after abdominal surgery]. / Gasbrand nach Eingriffen im Abdomen.

This is a report on nine cases of gas-gangrene which developped after abdominal surgery. In five patients the diagnosis was made at the bedside, three of these patients survived. Cardinal symptoms were rapid deterioration of the general condition, severe pain around the incision, tachycardia, and the appearance of jaundice along with a fall of the hemoglobin.

[Mezlocillin in the antibiotic therapy of severe bacterial infections in visceral surgery]. / Mezlocillin in der antibiotischen Therapie schwerer bakterieller Infektionen in der Viszeralchirurgie.

Fifty-six patients suffering from severe and very severe bacterial infections received additional antibacterial treatment with mezlocillin following abdominal or chest surgery. There were 18 intestinal-peritoneal infections, 15 pleuropulmonary infections, seven patients with sepsis, six localized abscesses and ten patients receiving perioperative application. In 36 patients treatment had to be initiated before the pathogens had been identified. Twenty patients received mezlocillin alone and 37 in combination with an aminoglycoside. The clinical course and laboratory data were recorded while the patients were receiving antibiotic therapy. In 43 of the 56 patients, most of whom were suffering from mixed infections caused by anaerobes and aerobes or from fecal infections, a cure without complications could be achieved. In six patients a generalized infection was reduced to a local one which could be cured. Eight patients died, six of their surgical primary disease and two of septic complications. Apart from four instances of phlebitis at the site of the infusion, no side-effects resulted from our antibiotic therapy.

Relapsing polychondritis presenting as cutaneous polyarteritis nodosa.

Relapsing polychondritis is an infrequently diagnosed, though not necessarily uncommon, systemic disorder characterized by recurrent and potentially destructive inflammation of cartilaginous structures, the eye, and the audiovestibular and cardiovascular systems. Although dermal involvement occurs in approximately 25% of patients with relapsing polychondritis, in only few cases has a skin biopsy been obtained revealing lesions such as leukocytoclastic vasculitis, livedo reticularis, erythema nodosum or keratodermia blenorrhagicum. We describe a patient with relapsing polychondritis in whom a cutaneous polyarteritis nodosa preceded cartilage inflammation by 6 months. Cutaneous polyarteritis nodosa is a rare form of vasculitis that appears to be limited primarily to the skin, muscles, and joints. In contrast to the systemic form of the disease it is characterized by the absence of visceral lesions and a relapsing but benign course. The present case and the fact that vasculitis is a concomitant feature in approximately 30% of patients with relapsing polychondritis [21] demonstrates that this condition may not represent a distinct clinical entity.

[Chronic recurrent polychondritis]. / Die chronisch rezidivierende Polychondritis.

Relapsing polychondritis (RP) is a recurrent, chronic und rare disease of unknown etiology, characterized by inflammation of cartilaginous structures of the ears, nose, respiratory tract and joints. The association with HLA-DR4 and the occurrence of antibodies to type-II collagen and other autoantibodies suggest that an immunologic mechanism is involved in its pathogenesis. In about 30% of occurrences RP is associated with other rheumatic or autoimmune diseases. Ocular inflammation, involvement of the cardiovascular system, skin, central nervous system and audiovestibular organ are most probably caused by vasculitis. The course of RP is variable. Severity and outcome primarily depend on the occurrence of associated autoimmune diseases and vasculitis. According to the activity and systemic manifestations, medical treatment includes nonsteroidal antiinflammatory drugs, corticosteroids and cytotoxic agents.

[Sweet syndrome in chronic myeloid leukemia]. / Sweet-Syndrom bei chronisch myeloischer Leukämie.

A 31-year-old woman with chronic myeloid leukemia developed bullous skin changes not responding to antibiotic therapy. A biopsy showed a sterile predominantly neutrophilic infiltrate consistent with Sweet's syndrome. These skin changes responded well to methylprednisolon. Seven months later the patient died in a blast crisis.

Basic biochemical data on blood from antarctic Weddell seals (Leptonychotes weddelli): ions, lipids, enzymes, serum proteins and thyroid hormones.

1. Standard laboratory values of blood samples taken from Weddell seals in Antarctica were determined. 2. Numerous blood parameters are similar to those observed in man. 3. Comparatively high cholesterol levels but normal triglyceride levels were observed when compared with humans. 4. In comparison to laboratory findings in humans, T4 levels were decreased although T3 levels were normal. 5. The levels of alkaline phosphatase are considerably higher than those in humans. 6. The data obtained indicate different lipid and thyroid hormone metabolism in Weddell seals when compared with humans.

Bone marrow pathology in relapsing polychondritis: high frequency of myelodysplastic syndromes.

Haemopathologic changes were studied in 19 patients (13 male, six female, age 33-85 years, mean 56 years) with relapsing polychondritis (RP). Anaemia was found in eight, thrombocytopenia in two and splenomegaly in three patients. A total of 17 bone marrow biopsies were obtained from seven individuals. Bone marrow evaluation revealed myelodysplastic syndromes (MDS) with marked trilineage hyperplasia and dysplasia in three cases. Since an excess of myeloblasts or an increase of CD34 positive progenitor cells was not seen, the disorders were designated as 'refractory anaemia' or with regard to the dysplastic megakaryopoiesis 'MDS, unclassifiable'. Two of the three patients died after 10 and 55 months of follow-up due to infectious complications. In a further patient, bone marrow analysis repeatedly showed an unexplained granulopoietic hyperplasia, which, however, was not dysplastic enough to allow a diagnosis of MDS. The remaining patients had clearly reactive changes. Our findings support the notion that RP is a heterogenous disorder and suggest that RP may at times represent a paraneoplastic phenomenon of an underlying MDS. Since HLA typing revealed a significantly increased frequency of the antigen DR4 (10/17 patients positive = 59%), we hypothesize that immunological imbalances due to the MDS in conjunction with a specific immunogenetic background may play key roles in the pathogenesis of RP in these patients.

Similar frequency of autoantibodies against pneumocytes type II and Clara cells in patients with interstitial lung diseases and healthy persons.

Several experimental findings suggest an association between interstitial lung diseases and autoantibodies. Antibodies against lung tissue including pneumocytes type II in patients suffering from idiopathic pulmonary fibrosis (IPF) were reported in recent years. In this investigation the serum of 103 persons (10 with IPF, 23 with M. Boeck, 18 with rheumatoid arthritis (RA) and 52 healthy controls) was examined for autoantibodies against pneumocytes type II and Clara cells by indirect immunofluorescence on human lung tissue. These antibodies against both cell types are an additional proof for common antigens in pneumocytes type II and Clara cells. The autoantibodies were present in similar frequency in the 4 groups (IPF: 20%, M. Boeck: 26.1%, RA: 22.2% and 23.1% of the healthy controls). So no significant association was found between the antibodies and the interstitial lung diseases. A role of the antibodies in the pathogenesis of the diseases, however, can not be excluded by this study. A possible role as parameter of development of interstitial lung diseases should be subject to further investigations in form of a prospective follow up study.

Identification of a heterozygous compound individual with familial hypercholesterolemia and familial defective apolipoprotein B-100.

Familial defective apolipoprotein B-100 (FDB) is a recently identified dominantly inherited genetic disorder, which leads to increased serum levels of low density lipoprotein (LDL) cholesterol with reduced affinity for the LDL receptor. This genetic disorder is characterized by defective binding of the apolipoprotein B-100 (apo B-100), which is virtually the sole protein constituent of LDL, to the LDL receptor. The defective binding results from a G to A mutation at amino acid 10,708 in exon 26 of the apolipoprotein B (apo B) gene creating a substitution of glutamine for arginine in the codon for amino acid 3500. It is postulated that FDB can exhibit the same clinical features as familial hypercholesterolemia (FH) caused by a defective LDL receptor. The purpose of this paper is to report on an individual with a defective LDL and a defective LDL receptor. The clinical features of this individual were the same as in the family members with either defective LDL or a defective LDL receptor: premature arcus lipoides, tendon xanthomata, and premature atherosclerosis. Although the clinical features were present to the same degree as in individuals with either defect the prognosis and treatment of such an individual could be different.