Breast-conserving therapy for mammary carcinoma: psychosocial aspects, indications and limitations. Breast-conserving therapy (BCT) for invasive cancer comprises complete tumour excision and axillary dissection, followed by irradiation. The object is to perform local treatment and determine the stage of disease on lines similar to those of mastectomy. In selected series of patients the efficacy of BCT has been equivalent to that of mastectomy with a view to distant relapse and survival. On the other hand, it has not been proved whether local relapse pattern is comparable to that of mastectomy, especially in high-risk patients. The advantage of BCT is of psychological nature, since preserving the configuration of the body maintains the sensation of female identity and body image to a better extent than that seen after mastectomy. BCT does not, however, reduce the high frequency of anxiety phenomena, mental instability, and depression. The selection of patients for BCT is based primarily upon a clinical-technical assessment, patient's preference and surgeon's preference, rather than eligibility based on biological risk factors. Demands on surgical technique, radicality of operation, and irradiation are important issues regarding local control. The relation between local recurrence rate and distant relapse will be discussed. The conclusion is that BCT is a method eligible for selected patients and that the increased used of mammography is going to extend the intake of patients for the method. However, it must be an obligation to keep following up the therapeutic results, in order not to lose the advantage of an early diagnosis by altered treatment.(ABSTRACT TRUNCATED AT 250 WORDS)


Fragile X syndrome: molecular analysis reveals a new mechanism of mutation in human genetic diseases. The fragile X syndrome belongs to the most common genetic diseases and has a prevalence of one in every 2000 children. The syndrome is named after the fragile site in q27.3 on the X chromosome. The molecular cloning of the DNA containing the fragile site has resulted in the identification of a heritable unstable DNA sequence revealing a new mechanism of mutation in human genetic disorders. This DNA sequence significantly facilitates the diagnosis and provides a rapid method for carrier detection and prenatal diagnosis. The unstable element is located within a candidate gene, FMR1. The FMR1 protein is not made in fragile X patients and nothing is known about its function. We will have to await studies on this protein to be able to understand the variable phenotype of this disease.


Remission of angina pectoris and dyspnea by fundoplication in gastro-oesophageal reflux disease. This study investigates 113 consecutive patients with gastro-oesophageal reflux disease before and after fundoplication and crural repair with respect to symptomatic improvement of chest pain, angina pectoris, exercise-linked chest pain, meal-linked chest pain, dyspnea, and air hunger, and any correlation between these items and smoking habits. The patients were followed by identical questionnaires completed at the time of oesophageal manometric examination prior to operation and from 6 months up to more than 5 years after operation. There was a highly significant reduction in all kinds of chest pain including angina pectoris, and of dyspnea at follow-up independent of smoking habits. However, air hunger was not significantly reduced. The present results suggest that gastro-oesophageal reflux disease should be taken into consideration in the symptomatic diagnosis of angina pectoris.


Multiple metabolic syndrome: aspects of genetic epidemiology and molecular genetics. Epidemiological studies have documented the association between cardiovascular disease and high blood pressure, dyslipidaemia, impaired glucose tolerance, non-insulin-dependent diabetes mellitus (NIDDM), and central obesity. In fact, several of these abnormalities, often all of them, can be identified in the very same individuals, constituting the entity of the multiple metabolic syndrome. Furthermore, many of these abnormalities seem to run in families. These findings raise important questions about the genetic epidemiology of the disease and about the molecular genetic background of the most likely common nominator of this syndrome, namely insulin resistance. Therapeutic actions must also be carefully considered to avoid the encouragement of some abnormalities while treating others.


Abdominal obesity and the metabolic syndrome. Abdominal obesity in man is an integrated part of the Metabolic Syndrome, and is associated with a complex neuroendocrine disturbance. Its consequences for the metabolism of the periphery seems to be insulin resistance caused by a combination of a relative hypercortisolaemia and a relative deficiency of sex steroid hormones. This hormonal aberration, in combination with a relative insufficiency of growth hormone secretion, might also direct depot triglycerides to visceral adipose tissues, a consequence at least partly due to varying densities of the specific receptors for these hormones. Visceral fat accumulation may thus be a consequence of the neuroendocrine aberrations, and may amplify the metabolic symptoms via effects on the liver of free fatty acids released in abundance from the lipolytically sensitive enlarged visceral fat depots. The origin of the neuroendocrine disturbance is not known, but epidemiological and cross-sectional information suggest that psychosocial factors are intimately involved. Animal and human studies indicate that the mediating factor(s) may be stress-sensitivity, leading to the neuroendocrine consequences observed.


Familial dyslipidaemic hypertension and other multiple metabolic syndromes. Data from several different studies are reviewed suggesting that a subset of hypertension is associated with metabolic abnormalities involving lipids, insulin, and often obesity, all aggregating strongly in families. Persons with 'familial dyslipidaemic hypertension (FDH)' have an especially high risk of early coronary disease. The clinical and biochemical features of FDH are compared with Reaven's Syndrome X, familial combined hyperlipidaemia, dense LDL subfractions, diabetes, impaired glucose tolerance, central and general obesity, pre-diabetes, pre-hypertension, and heterozygous lipoprotein lipase deficiency. Some contribution from major gene effects is suggested in specific subsets reported in several different genetic studies reviewed in this report. It seems likely that multiple metabolic abnormalities are genetically heterogeneous. The data also suggest significant contributions from environmental factors such as diet and physical activity.


Genetic epidemiology of low-density lipoprotein subclass phenotypes. Heterogeneity in LDL particles can be described by two distinct phenotypes in individual subjects, denoted A and B, based on gradient gel electrophoresis. Phenotype A is characterized by a predominance of large, buoyant LDL particles, while phenotype B is characterized by a predominance of small, dense LDL particles. Several studies have demonstrated that LDL subclass phenotype B is associated with both increased risk of coronary heart disease and an atherogenic lipoprotein profile. Complex segregation analyses in families, heritability analyses in twins, and recent linkage analyses, uniformly support the presence of genetic influences on LDL subclass phenotypes. However, environmental and behavioural influences on LDL subclasses have also been documented. Understanding the mechanisms underlying LDL subclass phenotypes may lead to targeted intervention to reduce coronary heart disease (CHD) risk in genetically susceptible individuals. Thus, LDL subclass phenotypes represent a common, genetically-influenced risk factor for coronary heart disease.


The etiology and pathogenesis of non-insulin-dependent diabetes. Although environmental factors are important triggers of non-insulin-dependent diabetes mellitus (NIDDM), heredity plays a major role in the pathogenesis of the disease. Insulin resistance manifested as impaired activation of glycogen synthase and thereby storage of glucose as glycogen in skeletal muscle is demonstrable early on in NIDDM relatives, suggesting that NIDDM could be an inherited muscle disease. On the other hand, insulin deficiency is almost unequivocally present before manifest diabetes develops. An intensive search for candidate genes for NIDDM has been initiated; so far it has not been possible to ascribe NIDDM to any alterations in the human genome. Given the heterogenous nature of NIDDM, its age-dependent penetrance and strong influence of environmental factors, it may not be fruitful to use NIDDM as an end-point in genetic linkage or association studies. It is more likely that DNA defects result in either insulin resistance or insulin deficiency, which in turn, can both lead to NIDDM. In accordance with the thrifty gene hypothesis, the insulin resistance gene has protected individuals during long periods of starving by storing energy as fat rather than as glycogen in muscle. The abundance of food in Western society has made this once protective gene a deleterious one, suggesting that these individuals are not equipped with the metabolic machinery to handle overeating.


The genetics of non-insulin-dependent diabetes mellitus in south India: an overview. Non-insulin-dependent diabetes mellitus affects approximately 10% of urban Indian and Indian migrant populations and as such carries major health implications for these groups. Whilst a strong genetic component to the aetiology of non-insulin-dependent diabetes mellitus is incontestable, progress in identifying the specific genetic determinants involved in its pathogenesis has been slow. In studies of South Indian pedigrees, preliminary segregation analysis indicates that non-insulin-dependent diabetes mellitus is likely to be a polygenic disease. A number of candidate genes have been studied with the aim of demonstrating either association or linkage with the disease; in South Indians the only positive results thus far have been associations between non-insulin-dependent diabetes mellitus and the genes for insulin, apolipoprotein D and complement component C4B. However, it seems likely that these genes contribute only a small proportion of the genetic susceptibility to non-insulin-dependent diabetes mellitus in this ethnic group and that the major genes underlying glucose intolerance remain to be determined.


Genetic epidemiology of NIDDM among Asian Indians. Prevalence of non-insulin-dependent diabetes (NIDDM) in India was reported to be 2.3% in the urban and 1.5% in the rural areas in the early 1970s by the Indian Council of Medical Research (ICMR). Recent studies both in the migrant Indians and in the native Indians have shown the prevalence to be much higher than the above values. Similar prevalence of NIDDM in the migrant and native Indians in affluent areas suggests that Indians as an ethnic group have a high genetic risk for diabetes. Our recent study in South India showed a high prevalence of diabetes in the urban area (8.2%) versus a low prevalence of 2.4% in the rural area. Age, urban-rural factor, body mass index (BMI) and the waist:hip ratio (WHR) were positively associated with diabetes. Interestingly, the prevalence of impaired glucose tolerance (IGT) was similar in urban and rural areas (8.7% and 7.8%, respectively) despite a four-fold lower prevalence of diabetes in the latter. The ratio of new to known diabetes was 1:2 in the urban and 3:1 in the rural areas. There was a male preponderance among Indian diabetic patients. Migration from rural to urban environment with changes in dietary habits and physical inactivity may have contributed to the increased prevalence of diabetes. A high rate of familial aggregation is noted in NIDDM in India and the genetic risk of NIDDM increases with increasing family history of diabetes. In the adult offspring of diabetic parents, hyperinsulinaemia and decreased insulin sensitivity are observed before the development of glucose intolerance.


Dyslipidaemias, insulin resistance and atherosclerosis. Recent studies have demonstrated that insulin resistance, a proportionate decrease in insulin action at all insulin concentrations, is associated with clustering of many cardiovascular risk factors, particularly hyperlipidaemias. Already epidemiological studies have indicated that high insulin levels are related to low high-density lipoprotein (HDL) cholesterol and high total and very-low-density lipoprotein (VLDL) triglyceride levels. Recent studies based on the direct quantification of insulin resistance by the euglycaemic clamp method have verified these findings. In contrast, insulin resistance seems not to be associated with high low-density lipoprotein (LDL) cholesterol. Abnormalities in HDL and VLDL levels may contribute to accelerated atherosclerosis, but there is evidence that insulin resistance is also directly associated with asymptomatic atherosclerosis. Thus, prevention of atherosclerosis should not be targeted only to the lowering of LDL cholesterol, but also to the reduction of the degree of insulin resistance either with diet, weight reduction, regular exercise or drug therapy.


Type II diabetes: search for primary defects. Type 2 diabetes is a familial disease, but recent analysis of nuclear families indicates it is unlikely to be due to a single dominant gene with high penetrance and that it could be polygenic. Insulin resistance is a major feature, with obesity being a major determinant. Beta cell deficiency is a sine qua non of Type 2 diabetes. It is possible that obesity, insulin resistance independent from obesity and impaired beta cell function are independently inherited factors. None of these can be said to be 'primary' as diabetes usually results from the interaction of several geometric and environmental factors. This makes linkage analysis of Type 2 diabetes of uncertain benefit, since heterogeneity can occur within a pedigree. The only mutation so far discovered is of glucokinase producing maturity-onset diabetes of the young, that has a clearly defined and unusual phenotype. Identification of genes that cause classical Type 2 diabetes is likely to come from population association studies, molecular scanning techniques and direct sequencing of candidate genes rather than linkage analysis.


Microalbuminuria: a genetic link between diabetes and cardiovascular disease? Non-insulin-dependent diabetes is associated with a 2-3 fold increased risk of cardiovascular disease. The poor relationship between this risk and either glycaemic control or diabetes duration suggests that some other aspect of the diabetic state, and not hyperglycaemia per se, mediates this risk. This other aspect of diabetes does not comprise alterations in recognized cardiovascular risk factors such as blood pressure or lipids, as the major component of the excess risk is in those diabetics with low levels of the other risk factors. It thus appears that there may be some factors that predispose both to diabetes and to cardiovascular disease. In insulin-dependent diabetics most of the excess risk of cardiovascular disease occurs in subjects with proteinuria, and microalbuminuria or proteinuria in non-insulin-dependent diabetics also substantially increases cardiovascular risk. Although changes in recognized risk factors in diabetics with nephropathy may partly explain these observations, we and others have shown that microalbuminuric non-diabetics also have a markedly increased prevalence of cardiovascular disease and substantially increased cardiovascular mortality. The observations that in insulin-dependent diabetics nephropathy shows family clustering and that these patients have elevated sodium lithium counter-transport rate, a possible genetic marker for the vascular complications of hypertension, have led to the suggestion that microalbuminuria may be a marker of a genetic predisposition to vascular disease.(ABSTRACT TRUNCATED AT 250 WORDS)


Role of HLA genes in predisposition to develop insulin-dependent diabetes mellitus. Insulin-dependent diabetes mellitus (IDDM), or type I diabetes, is the end result mainly of a T-cell mediated autoimmune destruction of pancreatic islet beta cells. Genetical and environmental factors are both of importance in the pathogenesis. Genes in the HLA complex seem to be the most important genetical factors. Among Blacks, Caucasoids and Orientals, IDDM susceptibility is associated with some particular combinations of DQA1 and DQB1 genes in cis or trans position. This strongly argues that susceptibility is primarily associated to the corresponding HLA-DQ molecules themselves. However, weaker contributions by other genes in the HLA complex cannot be excluded. Similarly, a dominant protection is strongly associated with some other DQ molecules, in particular HLA-DQ6, in all three ethnic groups. The function of HLA-DQ (and other class II) molecules is to present peptide-fragments of antigens to CD4+ T cells (mainly helper T cells). Thus, the recognition of certain islet beta cell derived peptides by self-reactive CD4+ T cells, may be an initial event in the pathogenesis. The DQ molecules involved in IDDM susceptibility or protection may exert their function either during thymic development of potential self-reactive CD4+ T cells, or by preferential presentation of certain beta-cell derived peptides to CD4+ T cells, or both. The finding that certain DQ molecules as such confer IDDM susceptibility may lead to new methods to prevent IDDM, for example by using blocking peptide analogues.


DQA1 and DQB1 heterodimers in insulin-dependent diabetes mellitus: a genetic-epidemiological study in Finland. DiMe Study Group. Susceptibility to insulin-dependent diabetes mellitus (IDDM) correlates with the absence of aspartic acid in position 57 of the DQB1 and/or the presence of arginine in position 52 of the DQA1. It has been postulated that transcomplementation between the DQ alpha and beta chains of the two haplotypes could create new molecules conferring susceptibility to IDDM. Finland has the highest incidence of IDDM in the world (35/100,000). In a nationwide study of IDDM in childhood (DiMe study) HLA genotyping using conventional serology was carried out according to genetic-epidemiological principles. We simulated DQA1 and DQB1 alleles in 707 consecutively diagnosed IDDM probands and 98 non-diabetic children based on serology, restriction fragment length polymorphism results and sequence data assuming no recombination between DQ and DR. In 34% of Finnish children with IDDM all four combinations (two in cis and two in trans) could lead to SS heterodimers. Two-thirds of these combinations were explained by DR3,DR4 heterozygotes. In 50% of IDDM children half and in 11% a quarter of the combinations could lead to heterodimers. In 38 IDDM patients (5%) the formation of hybrid molecules was not possible. In 59% of the controls SS heterodimers were possible and should therefore have an underlying genetic susceptible for IDDM assuming the theory of transcomplementation is correct. These findings, together with the fact that the lowest frequency of DR3,DR4 heterozygosity (21%) was seen in Finland, show that heterozygosity for DQ and DR cannot explain the differences seen in IDDM incidence.


Biological complexity and strategies for finding DNA variations responsible for inter-individual variation in risk of a common chronic disease, coronary artery disease. Most common chronic diseases of humans aggregate, but do not segregate, in families. The segregation-linkage research paradigm has not provided great insights into their genetic etiology. In this paper, using coronary artery disease as an example, we discuss hierarchical organization, coherence, emergent properties and dynamism as features that characterize the complexity of genotype-phenotype relationships. We summarize a research strategy for evaluating the contribution of genetic and environmental factors to the prediction of inter-individual variation in risk of disease. We then review a statistical strategy that employs cladistic theory to identify individuals carrying mutant DNA sequences responsible for an observed association between marker variation in a gene and inter-individual variation in biological traits that determine risk of a common multifactorial disease. Finding these DNA sequences is a necessary step in our search for an understanding of the nature of the mapping of genetic variation into variation in risk of a disease like coronary artery disease.


Ethical aspects of genetic screening.

Ethical aspects of genetic screening. Public and professional concern associated with the idea of genetic screening has generated numerous publications on the ethics of genetic screening (e.g. 1-4). Concerns revolve around inadequate consultation before screening is carried out, the unearthing of worrying risks, the use of genetic information in ways that could be disadvantageous to the person involved, stigma, and a phenomenon known as the 'technological imperative', which means that simply because a technology is available there is a tendency to use it. Most reports agree that, in practice, the main ethical problems are likely to involve screening for risk of common diseases of adult life, because of the possible impact on a person's healthy self-image, implications for health and life insurance, and the possibility of commercial exploitation of people who know themselves to be vulnerable. In this paper I do not propose to address these issues directly. I have been invited to discuss this subject as a clinician involved with genetic screening, counselling and prenatal diagnosis for the haemoglobin disorders, the most common serious human recessively inherited diseases. Since we are scientists, any recommendations we make should be based on experience: my aim is to show that experience is often surprising, and that it is often possible to meet public concerns by taking quite simple practical steps.


The future of genetic epidemiology.

The future of genetic epidemiology. Starting from a broad definition of genetic epidemiology, current developments in association, segregation, and linkage analysis of complex inheritance are considered together with integration of genetic and physical maps and resolution of genetic heterogeneity. Mitochondrial inheritance, imprinting, uniparental disomy, pregressive amplification, and gonadal mosaicism are some of the novel mechanisms discussed, with speculation about the future of genetic epidemiology.


Protein prenylation: more than just glue? As with other lipid modifications of proteins, prenylation now appears to be critically important in the regulation of protein function. Recent research has led to an explosion of information concerning prenylation signals, prenyl transferase enzymes and the role of prenylation in protein-membrane interactions. Experiments have examined the role of prenylation in protein function and the results suggest that protein prenylation may be involved in facilitating proper subcellular localization, promoting protein-protein and protein-membrane interactions and regulating protein function.


Glycosylation.

Glycosylation. Protein glycosylation is more abundant and structurally diverse than all other types of post-translational modifications combined. Protein-bound saccharides range from dynamic monosaccharides on nuclear and cytoplasmic proteins, to enormously complex 'recognition' molecules on extracellular N- or O-linked glycoproteins or proteoglycans. Recent elucidation of a few of the myriad functions of these saccharides has finally opened a crack in the door to one the last great frontiers of biochemistry.


Novel proteases with unusual specificities. This review describes specific proteases that have been implicated in several interesting biological systems. Proteases have been selected for discussion in those instances where natural substrates appear to have been identified. The studies reviewed point to the critical role that proteases play in protein processing and degradation.


Muscle differentiation.

Muscle differentiation. Recent studies indicate that vertebrate skeletal muscle originates from two distinct populations of muscle precursor cells formed in early embryogenesis. Divergent patterns of expression for the myoD family of myogenic regulatory genes in different vertebrate embryos suggest some functional redundancy amongst the myogenic factors. Initial gene knockout experiments in mice support this view. Systematic mutagenesis has identified a conserved motif in the basic region of these proteins that is necessary for their biological activity. Direct interaction of both MyoD and myogenin with the transcription factor Jun indicates a mechanism for integrating the control of myoblast growth and differentiation.


Flower development.

Flower development. Several homeotic genes controlling flower development have been characterized in Antirrhinum and Arabidopsis. Comparisons of their mutant phenotypes, expression patterns and genetic interactions have revealed that many of the basic mechanisms controlling flower development have been conserved in evolution, although important differences in the balance and interactions of genes also exist.


Cell differentiation and patterning in Dictyostelium. In Dictyostelium development, prestalk cells first differentiate at scattered positions in the aggregate and then sort out, probably by chemotaxis to cAMP. They may regulate their proportions by selective depletion of the stalk cell inducer, DIF-1. Once sorted, prestalk cells form a DIF-1 sink, which can produce gradients of DIF-1 and its metabolites in the slug. Global movements of cells in the slug may be regulated by cAMP signals, as in aggregation. Terminal differentiation of stalk and spore cells requires activation of cAMP-dependent protein kinase, possibly brought about by ammonia depletion. Finally, a technique for insertional mutagenesis promises the ready isolation of developmental genes.


A plethora of intercellular signals during Caenorhabditis elegans development. Reproducible cell-cell interactions contribute to the invariance of Caenorhabditis elegans development and allow high resolution study of molecular mechanisms of intercellular signaling. A number of new cell interactions have been discovered in the past year. The power of nematode molecular genetics has been increased through several technical advances and the genome project, and these new approaches are now being successfully applied both to familiar and new signaling mechanisms.


Sex determination and differentiation in invertebrates: Drosophila and Caenorhabditis elegans. Sex determination in flies and worms is controlled by cascades beginning with the X chromosome: autosome ratio and terminating in transcription factors. We are now gaining an understanding of the molecular mechanisms governing the largely post-transcriptional regulation of the intermediate steps in these cascades.


Molecular mechanisms of determination in Drosophila. A number of Drosophila proteins have been identified that play key roles in the establishment of active or inactive states of selector gene expression. Interactions between these proteins and their target selector genes are beginning to be understood, shaping our molecular view as to how stable determination of cells is achieved.


New blossoms in the neural crest field: trophic and transcription factors. Just as the answers to some of the most basic, long-standing questions concerning neural crest differentiation have become apparent, the field has been invigorated by a cross-fertilization of mouse genetics, and studies on transcription factors and trophic/instructive factors. These findings raise new questions, at a deeper level of inquiry.


Molecular genetics of the Pax gene family. Three members of the Pax gene family are now known to be responsible for the established mouse developmental phenotypes Splotch, Small eye and undulated; two of these genes are implicated in the human congenital diseases Waardenburg's syndrome and aniridia. The mouse mutants will act as model systems for these human disorders and, in addition, will provide insights into the processes of vertebrate development.


Determinants of mRNA localization.

Determinants of mRNA localization. RNA localization provides a mechanism for protein targeting within developing or differentiating cells. Specific cis-acting sequences on mRNA mediate this process. Such 'localizer' or 'zipcode' nucleic acid sequences have been restricted to the 3' untranslated region of several mRNAs. The presence of genetic information denoting a spatial component of translation adds a new dimension to gene expression.


mRNA stability: in trans-it.

mRNA stability: in trans-it. The regulation of mRNA stability is an important step in the control of gene expression. Characterization of the mechanisms involved in the turnover of individual mRNAs has identified a requirement for specific cis-acting sequences and trans-acting factors, as well as an involvement of the translation apparatus. In the past year, significant progress has been made in the identification of trans-acting factors by both biochemical and genetic approaches. This review summarizes that progress and promotes the notion that the ribosome itself should also be considered as a trans-acting component of the mRNA decay machinery.


The mitogen-activated protein kinase activator. The mitogen-activated protein kinase appears to be regulated by another growth factor regulated kinase, the mitogen-activated protein kinase activator. In the past year, much progress has been made in purifying and characterizing the mitogen-activated protein kinase activator, in determining its primary structure, and in identifying another protein kinase that may function upstream to regulate its activity.


Neonatal anatomic repair of transposition of the great arteries and ventricular septal defect. From January 1985 to March 1992, 64 consecutive neonates with transposition of the great arteries (TGA) and ventricular septal defect (VSD) underwent an arterial switch operation and VSD closure. The mean age at operation was 18.5 +/- 12 days and the mean weight was 3.3 kg. Seventeen patients had an associated aortic coarctation, of whom 15 underwent single-stage repair through median sternotomy. Coronary artery distribution was: type A: 45 patients; type B: 2; type D: 11 and type E: 6 patients. The location of the VSD was perimembranous in 42 patients, trabecular in 13, infundibular in 5, and 4 presented with the Taussig Bing heart anomaly. The hospital mortality was 9.3% (n = 6). There were four late deaths (one TGA-VSD and three TGA-VSD and coarctation). Nine patients required reoperation. The mean follow-up of all survivors was 36 +/- 19 months. They were in NYHA class I without medication. Six patients developed mild-to-moderate aortic insufficiency. The actuarial survival and freedom from reoperation at 5 years were 81.06% and 84.6%, respectively. We conclude that neonatal anatomic repair of TGA and VSD offers good medium-term results and avoids iterative operations.


Open-window thoracostomy in pleural empyema. Open-window thoracostomy (OWT) was performed in 21 cases of empyema. The indications were postpneumonectomy empyema with (n = 6) or without (n = 1) fistula, early recurrent empyema after decortication (n = 6), chronical empyema in ill elderly patients with (n = 5) or without fistula (n = 2), and total unilateral lung gangrene with a large fistula of the main bronchus after radiotherapy and chemotherapy (n = 1). All cases presented with severe sepsis, eight of them with acute septic shock, and six with signs of multiorgan failure. Three to five ribs were resected, the muscles and skin were sutured to the ribs confining the window located at the lowest point of the empyema cavity, while the intercostal muscles of the resected ribs were used to close fistulae. The cavity was packed with dressings every day. In all cases, the sepsis subsided immediately after OWT. With the exception of one patient with postpneumonectomy empyema, who died of contralateral pneumonia on day 36, no surgery-related complications were seen. Four further patients died of unrelated causes 2, 4, 5, and 7 months, respectively, after OWT. In one of them, the OWT had been closed. Up to this time, obliteration and closure of the cavity has been carried out in 7 cases by using thoracoplasty (n = 2) or predicted muscle flaps (n = 5) either in the early course or after a delay of 11 to 23 months, with fair functional and cosmetic results. In one further case, operative closure has been planned. In seven of the eight remaining patients, four of whom declined further operations, the cavities closed spontaneously, despite their initial size after intervals of between 11 and 21 months.


Cancer surgery on a single residual lung. A series of nine patients with single lungs operated on for lung cancer is reported. This represents 10% of all the synchronous and metachronous lung cancers operated during the same period. There were three early postoperative deaths and a further three patients died subsequently at 15, 20 and 24 months, respectively, after operation; the remaining three are alive 6, 12 and 29 months, respectively, following their surgery. The analysis of the results of this small series indicates that wedge and segmental resection, when feasible, may be undertaken in patients with a single lung with reasonable life expectancy. The fact that lobectomy is not tolerated in such patients emphasizes the importance of early diagnosis when minimal local excision can be undertaken.


Dynamic cardiomyoplasty for long-term cardiac assist. The principle of cardiomyoplasty is long-term electrostimulation of a latissimus dorsi muscle (LDM) wrapped around the failing heart. Technically, this procedure consists of placing the left LDM flap around the heart via a window created by partial resection of the 2nd or 3rd rib, and subsequent muscle electrostimulation in synchrony with ventricular systole. The aim of cardiomyoplasty is to support ventricular function in ischemic or dilated cardiomyopathies, or to partially replace the ventricular myocardium after large aneurysm or tumor resections. Our clinical experience at Broussais Hospital involves 44 patients. The functional class and quality of life improved after cardiomyoplasty. Improvement of the ventricular performance and limitation of cardiac dilatation were demonstrated over the long-term. The actuarial survival at 6 years was 71%. Risk factors influencing perioperative mortality were: age > 65 years, associated surgical procedures, pulmonary vascular hypertension, and patients hemodynamically unstable or on inotropic drug support. Preoperative risk factors influencing the long-term mortality were: permanent NYHA functional class 4, cardiothoracic ratio > 0.60, LV ejection fraction < 15%, bi-ventricular heart failure, and atrial fibrillation. Cardiomyoplasty does not preclude the use of future orthotopic heart transplantation.


Acute effects of massive transfusion of a bovine hemoglobin blood substitute in a canine model of hemorrhagic shock. The capability of stroma-free hemoglobin solutions to act as a plasma expander with oxygen and carbon dioxide transport properties has encouraged the idea of their possible use in settings of massive blood loss. Using a canine hemorrhagic shock model (systolic arterial pressure < or = 50 torr for 60 min), we evaluated the efficacy of an ultra-pure stroma-free bovine hemoglobin solution (PBHg) as a resuscitation fluid in hypovolemic and acidotic animals, using homologous blood (PRBC) and 10% human serum albumin (HSA) as control solutions. Following volume replacement, dogs were studied for 2 h under anesthesia and for 4 h subsequently while awake. Resuscitation with PBHg (30 +/- 3 ml/kg) was able to restore stable hemodynamics and correct acidosis to an extent comparable to that in animals treated with PRBC. Additionally, oxygen transport was maintained at a higher level than that in dogs treated with HSA. Administration of PBHg in this shock model revealed no significant cardiopulmonary toxicity or adverse effects. These short-term results suggest that PBHg may be useful for effective resuscitation after major blood loss.


Early evidence of beneficial effects of chordal preservation in mitral valve replacement on left ventricular dimensions. Earlier authors have shown the improved left ventricular (LV) function after chordae-preserving mitral valve replacement (MVR) in follow-up studies. Seventy-nine consecutive patients undergoing MVR were studied preoperatively and pre-discharge with M-mode and two-dimensional Color Doppler echocardiography for early LV morphometric changes. Conventional MVR was performed in 42 patients (Group 1) and the posterior leaflet-chordae-papillary muscle complex was preserved in 37 patients (Group 2). Both cohorts were similar in age, sex, preoperative NYHA class and valve pathology. Four St. Jude bioprostheses, 9 Medtronic and 66 Sorin prostheses were implanted. The intraoperative and perioperative management protocol was uniform for both groups. The median left atrial dimension in both groups decreased to better physiological levels (53 to 46 mm in group 1, 52.5 to 46 mm in group 2). The median LV enddiastolic dimension increased from 47 to 48 mm in group 1 while it decreased from 56.5 to 49 min in group 2. The median LV endsystolic dimension remained unchanged in group 1 but decreased in group 2 (37.6 to 36 mm). Echocardiographic documentation of such early changes in the LV dimensions after modified MVR indicates that the beneficial effects of chordal preservation become evident early in the postoperative period and may explain the improved perioperative LV function after modified MVR compared to conventional MVR.


Traumatic mitral insufficiency following percutaneous mitral dilation: anatomic lesions and surgical implications. Percutaneous mitral dilation is a widely accepted technique for treating pure mitral stenosis. Traumatic mitral insufficiency may occur secondary to this technique raising the problem of the feasibility of mitral valve repair. Twenty patients were operated on for traumatic mitral insufficiency following percutaneous mitral dilation. Three patients required emergency operations (within 6 h). In the other cases, surgery was carried out within the following days or weeks. Operative analysis of the mitral valves showed the following lesions: tear of the anterior leaflet (n = 4), tear of the posterior leaflet (n = 2), anterior (n = 4) or posterior (n = 9) paracommissural tear and papillary muscle rupture (n = 1). Associated chordal rupture was found in 3 patients. Septal perforation secondary to transseptal puncture was found in all cases. A septal tear of more than 10 mm was present in 4 patients. Surgery consisted of mitral valve reconstruction (n = 12) or mitral valve replacement (n = 8). Anatomic lesions following percutaneous mitral dilation may affect all the elements of the mitral valve apparatus. The possibility of repair depends more on the degree of calcification of the valve than on the extent of the leaflet tear.


Intraoperative transesophageal echocardiography for the evaluation of mitral, aortic and tricuspid valve repair. A tool to optimize surgical outcome. The present study reviews the clinical applicability and usefulness of intraoperative transesophageal echocardiography (TEE) during valve repair. Intraoperative TEE was performed in 48 consecutive patients, who were divided into three groups: 1. mitral valve repair (MVR), 2. aortic valve repair (AVR), 3. tricuspid valve repair (TVR). Residual valve regurgitation was assessed by color Doppler echocardiography on a scale from 0 to 4. The ratios of the jet area (JA) to the left- and right-atrial areas (JA/LAA and JA/RAA) were analyzed before and after cardiopulmonary bypass (CPB). In group 1, 14 patients were scheduled for MVR, of which 4 patients underwent valve replacement and 10 MVR. Post-repair TEE studies showed a significant decrease of mitral regurgitation. In 2 of the 10 patients, TEE demonstrated severe residual regurgitation requiring valve replacement during the same thoracotomy. In group 2, 11 patients underwent aortic commissurotomy. Post-repair TEE showed an increase in the systolic opening diameter and opening area of the aortic valve. One patient underwent valve substitution because of severe aortic regurgitation. In group 3, 23 patients were scheduled for TVR. In 3 of them TEE showed no significant regurgitation thus rendering tricuspid valve surgery unnecessary. Twenty patients underwent TVR of whom two showed unacceptable post-repair regurgitation requiring further surgery. Eighteen patients showed a significant reduction of valve regurgitation after TVR, and a further reduction was achieved by adjusting the tricuspid annuloplasty under TEE guidance.


Bronchial fistula to the mediastinum in a heart-lung transplant patient. We present a case of heart-lung transplantation complicated by bronchial perforation as the cause or consequence of prolonged lung infection. Periodic bronchoscopic and radiological follow-up showed resolution of the condition following adequate antibiotic and physiotherapeutic treatment.


[Determination of basal and stimulated blood gastrin in duodenal ulcer]. Serum gastrin levels were measured under basal conditions and after hyperproteic meal stimulation in 24 patients with non-stenotic duodenal ulcer, 78% of them were males with a mean age of 36.4 years. Results were compared with those obtained in 20 volunteers. Basal gastrin levels in patients with duodenal ulcer 46.2 +/- 17.5 pg/ml did not show any significant statistical differences when compared with those in the control group (51.01 +/- 28.1 pg/ml). After meal stimulation gastrin levels at different time intervals, were similar in patients with duodenal ulcer and in the control group. We conclude that serum gastrin does not seem to play a relevant pathogenic role in the development of duodenal ulcer; its measurement is of no value as a biological marker of duodenal ulcer disease.


[Prevalence of Helicobacter pylori in gastric pathology in Aragon]. The aim of this study was to evaluate the prevalence of Helicobacter pylori in 400 patients referred for upper digestive tract endoscopy. In our area it hasn't developed yet any epidemiologic study about this disease. Helicobacter pylori was observed in 281 of the 400 patients studied (70%). No significant differences by sex were found in the subjects analyzed. There was a rise in the percentage of positivities as age increased. Helicobacter pylori were positive in 74 of the 88 patients with chronic superficial gastritis (84.1%), in 53 of the 65 with chronic atrophic gastritis (81.5%), in 16 of the 25 with chronic atrophic gastritis and intestinal metaplasia (64%), in 49 of the 63 with gastric ulcer (77.8%), in 73 of the 85 with duodenal ulcer (85.9%), in 9 of the 24 patients with gastric carcinoma (37.5%), in 5 of the 19 with stump gastritis (26.3%), where as only a few Helicobacter pylori were found in 2 of the 31 histologically normal subjects (6.5%). These findings support the wiew that Helicobacter pylori may be etiologically related to chronic gastritis and peptic ulceration, even though their precise role still remains to be determined.


[Perioperative blood transfusion and prognosis in colorectal cancer. Analysis of a series]. The relationship between survival after surgical resection of colorectal carcinoma, and perioperative blood transfusion was studied retrospectively. "Curative" surgery was performed in 164 cases of colorectal cancer--stages B and C--, 72 of them received red-cell concentrates perioperatively. Multiple regression analysis did not show any deleterious effect of blood transfusion on the survival of the surgically treated patients (P = 0.941). The volume of the blood derivative received neither seems to influence their outlook. As it was expected a higher rate of transfusion occurred among rectal cancer patients. Mechanisms and factors involved in this controverted issue are discussed and literature is widely reviewed.


[Intraoperative echography of hepatic metastases]. In order to evaluate the usefulness of intraoperative echography in the study of liver metastases, two groups of patients were submitted to study: A consecutive series of 25 patients operated on for digestive tumours. Before operation, echography was performed to all of them. Four patients operated on for liver metastases. In the patients who were operated for digestive tumors, the authors found 8.6% of metastasis which neither the preoperative echography nor liver palpation had detected. The usefulness of the examination in the patients to whom resective hepatic surgery was going to be performed was based on: The finding of a portal thrombosis which had not been detected in the preoperative study. The possibility of connecting the intrahepatic vascularity with the lesions, in order to decide which technique to choose. The demonstration of the non-existence of other metastases.


[Palliative treatment of carcinomatous ascites with peritoneovenous shunt]. Carcinomatous ascites (CA) is not an uncommon manifestation of a metastatic neoplasia. The aim of this study was to evaluate the utility of peritoneovenous shunt (PVS) in patients with CA refractory to conventional management. Twelve patients in whom a PVS was placed with palliative intention were studied. One patient died in the postoperative period. Permanent control of the ascites was achieved in 7 (63.6%) of the remaining patients. PVS obstruction occurred in 4 patients (36.4%) and no other complications related to the shunt were seen. Results were better in CA of gynecological origin but without reaching significant statistical differences. We conclude that PVS can be useful for palliation of CA with a low complication rate.


[Xanthogranulomatous cholecystitis].

[Xanthogranulomatous cholecystitis]. Ten cases of xanthogranulomatous cholecystitis are presented, 5 women and 5 men, from a total of 439 cholecystectomies (2.2%). In 50% of cases the clinical course was consistent with acute cholecystitis; in 30%, gallbladder cancer was suspected preoperatively; and in 70% of cases cancer was suspected during surgery but intraoperative biopsies showed no malignancy. Definitive pathological findings included early carcinoma of the gallbladder in two patients, and a cholecystocolic fistula in one patient. A perforated gallbladder was found in one patient. The incidence of postoperative septic complications was 18.1%, a figure that doubles that of elective biliary surgery in our hospital.


[Digestive hemorrhage secondary to ileocecal actinomycosis]. Report of a case of abdominal actinomycosis, including the cecoapendicular region, that clinically presented as lower digestive bleeding, and was diagnosed by the anatomopathological study of the surgical resection specimen, since the patient was operated with the preoperative diagnosis of vascular malformation. This type of presentation is uncommon in abdominal actinomycosis, and explains the presentation of this clinical case.


[Acute abdomen caused by transmural eosinophilic enteritis]. A 45 year old man with personal history of B-Lactamic antibiotics allergy and one episode of hemochezia was admitted to hospital because of abdominal pain in the lower right quadrant and nausea, and diagnosed of acute appendicitis. At laparotomy he was found to have histological evidence of transmural eosinophilic enteritis in the terminal ileon and ascitis. After an intestinal resection a full evaluation was performed.


[Enterolithiasis].

[Enterolithiasis]. The term enterolithiasis refers to concretions formed within the gastrointestinal tract. Conditions causing stasis predispose formation of enteroliths, which may be either radiopaque or radiolucent. Thus, a wide spectrum of intestinal disorders are associated with enterolithiasis including intestinal diverticulum, Crohn's ileitis, intestinal tuberculosis, radiation enteritis and strictures after surgery. The authors report one patient with intestinal obstruction as a complication of enterolithiasis and diagnosed previously as gallstone ileus. The pathogenesis and management concerning this entity are also discussed.


[Rupture of splenic artery aneurysm as a cause of acute abdomen]. A male, 52 years old, presenting acute abdominal pain and hypovolemic shock, was diagnosed by ultrasound and CAT of fissured aneurysm of the splenic artery. Emergency laparotomy confirmed that the aneurysm had ruptured into the peritoneal cavity.


[Cystic neoplasm of the pancreas as a cause of intestinal obstruction]. Cystic neoplasms of the pancreas are unusual varieties of pancreatic tumors. We herein report a new case presenting with atypical features, such as mental and electrolytic disturbances secondary to upper intestinal obstruction. We reviewed the literature, and discuss the differential diagnosis, the histopathological characteristics of prognostic value, and the therapeutic strategy. We conclude that these tumors should be included in the differential diagnosis of the upper intestinal obstructions, and emphasize the need to remove the lesion in all cases because of the difficulties of predicting the benign or malignant behaviour of these tumors before and during the surgical procedure.


Survey of services to patients in general practice. Family doctors vary in the range of services they provide for their patients. Of 267 practices in Devon and Cornwall, 245 responded to a questionnaire sent in September 1989 asking for information about services to patients. Most doctors consulted at six to eight patients per hour, whether or not an appointment system operated. About two-thirds of patients had access to a female GP. Nine out of ten practices employed a practice nurse. Almost all offered a surgery on Saturday mornings. Most surgeries took the phone over at 8.30 a.m. in the week and started consulting at 9 a.m. Almost half were consulting until 6.30 p.m. or later on at least one day per week. 80% of practices were offering a non-urgent appointment on the same or next day. All practices offered childhood immunisation. 80% offered some form of personal list system. 80% offered minor operations, one-third manipulations, 10% homeopathy, 6% hypnosis and 5% acupuncture.


Centrosome organization and centriole architecture: their sensitivity to divalent cations. The centrosome plays a major role in the spatial organization of the microtubular network and has a controlled cycle of duplication, the two duplicated centrosomes functioning as mitotic poles during subsequent cell division. However, a comprehensive description of the overall organization of the centrosome in animal cells is lacking. In order to integrate the various pieces contributing to the centrosome structure and to optimize the quality of the data, we have undertaken an extensive ultrastructural study of centrosomes isolated from human lymphoblasts, which involved (i) orientation of centrosomes by sedimentation before embedding and sectioning, (ii) ultrathin serial sectioning, (iii) digitalization of micrographs to obtain quantitative data, and finally, (iv) comparison between two methods of isolation, which differ by the presence or absence of EDTA. Using this strategy, we have unambiguously described the pericentriolar organization of two distinct sets of appendages (distal and subdistal) about the so-called parental centriole. New structures have been also observed in association with the microtubule sets in this study: (i) external columns, which are dense structures localized at the basis of the subdistal appendages and (ii) internal columns, which are made of globular subunits integrated in a more luminal and probably helical structure. We have also observed that removal of divalent cations by the EDTA during the isolation procedure could affect the centrosomal structure at different levels (subdistal appendages, internal and external columns, pericentriolar matrix), including a significant variation in centriole diameter. A scheme of the overall organization of the centrosome from animal cells and of its modulation by divalent cations can be drawn from this study. Our data gives a view of the centrosome as an organelle displaying a complex and possibly dynamic structural organization.


Formation of 2-D paracrystals of F-actin on phospholipid layers mixed with quaternary ammonium surfactants. Two-dimensional paracrystalline arrays of F-actin have been formed on positively charged lipid layers composed of phosphatidylcholine (PC) and quaternary ammonium surfactants. These quaternary ammonium surfactants were found to be better promoters of two-dimensional order than PC lipid layers mixed with stearylamine. In addition, the length of the hydrocarbon chain was found to influence the achievement of 2-D order. Lipid layers composed of dilauryl-PC and didodecyldimethylammonium bromide, which are saturated C12 lipids, promoted 2-D crystallization better than mixtures of dipalmitoyl-PC, a saturated C16 lipid, and dioctadecyldimethylammonium bromide, a saturated C18 lipid. Thus, the hydrocarbon chain length, which influences lipid layer fluidity, had a significant effect on paracrystal formation. We suggest that quaternary ammonium surfactants may have advantages in some cases for forming ordered arrays on lipid layers. In addition to investigating the effect of lipid layer composition on paracrystal formation, we found that the injection of G-actin rather than F-actin under a fluid lipid layer into a polymerizing solution produced better ordered paracrystals.


Transient storage of a nuclear matrix protein along intermediate-type filaments during mitosis: a novel function of cytoplasmic intermediate filaments. We recently identified a nuclear matrix protein, named NMP125 for its molecular weight (M(r) 125 kDa). On the basis of immunofluorescence analysis with monoclonal anti-NMP125 antibodies of differentially extracted cells in situ, including detergents, DNase I, RNase A, and high/low ionic strength conditions, it is concluded that NMP125 is a component of a chromatin- and histone-depleted nuclear substructure, operationally defined as nuclear matrix in interphase cells. The protein revealed evolutionary conservation in man, rat, chicken, and Xenopus, at least at the level of immunological crossreactivity. The subcellular distribution of NMP125 is cell-cycle-dependent; in interphase cells NMP125 is confined to a nuclear substructure with a granular aspect, whereas after nuclear envelope breakdown, it is freed into the cytoplasm. However, most of the protein remains attached to a cytoskeletal ligand that we have identified as the intermediate-type filament vimentin. In late mitotic stages the protein forms punctuate aggregates of relatively large size, which get passively closer to the newly formed telophase nuclei together with the reorganized vimentin around the nuclei in late telophase. From the morphological point of view, although static in nature, a dynamic cell-cycle-dependent distribution of NMP125 is found, revealing dissociation and spreading throughout the cytoplasm in metaphase, binding to vimentin filaments, cytoplasmic aggregation, and transport to nuclei in telophase. The transient affinity of the nuclear protein NMP125 to vimentin filaments during mitosis together with a passive cytoplasmic dislocation of the vimentin/NMP125 conjugate toward the telophase nuclei could represent a novel and dynamic function of cytoplasmic intermediate filaments, implicating a transient repository and passive shift of nuclear proteins during mitosis.


Glial fibrillary acidic protein and its mRNA: ultrastructural detection and determination of changes after CNS injury. We have previously demonstrated that glial fibrillary acidic protein (GFAP) containing intermediate filaments in retinal Müller cells undergo both quantitative induction and subcellular reorganization as a response to long-term retinal detachment (an induced CNS degeneration wherein the Müller cells form a multicellular scar). This study demonstrates by RNA blotting analysis that normal retina expresses a low basal level of GFAP mRNA, which is induced approximately 500% within 3 days of retinal detachment. At the cellular level, electron microscopic in situ hybridization analysis readily detects GFAP mRNA in Müller cells of detached retinas, but not in normal retinas. On the other hand, GFAP mRNA was readily detected in retinal astrocytes (which appear to express GFAP mRNA at high, constitutive levels). In both cell types, the ultrastructural localization of GFAP mRNA was the same. In the nuclei, the GFAP mRNA was associated with amorphous, electron-dense regions within the euchromatin. In the cytoplasm, the GFAP mRNA was associated with intermediate filaments near the nuclear pores, along the filaments when no other structures were apparent, and when the filaments appeared to be associated with ribosomes and polysomes. The ultrastructural location of the GFAP mRNA (especially along the intermediate filaments) may be unique to this mRNA or may represent a more generalized mRNA phenomenon.


Phase diagram of deep rough mutant lipopolysaccharide from Salmonella minnesota R595. The structural polymorphism of deep rough mutant lipopolysaccharide--in many biological systems the most active endotoxin--from Salmonella minnesota strain R595 was investigated as function of temperature, water content, and Mg2+ concentration. Differential scanning calorimetry was used to determine the amount of bound water and the enthalpy change at the beta<==>alpha gel to liquid crystalline acyl chain melting. The onset, midtemperature Tc, and completion of the beta<==>alpha phase transition were studied with Fourier-transform infrared spectroscopy. Synchrotron radiation X-ray diffraction was used to characterize the supramolecular three-dimensional structures in each phase state. The results indicate an extremely complex dependence of the structural behavior of LPS on ambient conditions. The beta<==>alpha acyl chain melting temperature Tc lying at 30 degrees C at high water content (95%) increases with decreasing water content reaching a value of 50 degrees C at 30% water content. Concomitantly, a broadening of the transition range takes place. At still lower water content, no distinct phase transition can be observed. This behavior is even more clearly expressed in the presence of Mg2+. In the lower water concentration range (< 50%) at temperatures below 70 degrees C, only lamellar structures can be observed independent of the Mg2+ concentration. This correlates with the absence of free water. Above 50% water concentration, the supramolecular structure below 70 degrees C strongly depends on the [LPS]:[Mg2+] ratio. For large [LPS]:[Mg2+] ratios, the predominant structure is nonlamellar, for smaller [LPS]:[Mg2+] ratios there is a superposition of lamellar and nonlamellar structures. At an equimolar ratio of LPS and Mg2+ a multibilayered organization is observed. The nonlamellar structures can be assigned in various cases to structures with cubic symmetry with periodicities between 12 and 16 nm. Under all investigated conditions, a transition into the hexagonal II structure takes place between 70 and 80 degrees C. These observations are discussed in relation to the biological importance of LPS as constituent of the outer membrane of gram-negative bacteria and as potent inducer of biological effects in mammals.


The three-dimensional structure of frozen-hydrated bacteriophage phi X174. The three-dimensional structure of bacteriophage phi X174 (phi X174) was determined to approximately 2.6 nm resolution from images of frozen-hydrated 114 S particles. The outer surface of phi X174 is characterized by several prominent features: (i) 12 mushroom-shaped caps (approximately 7.1 nm wide x 3.8 nm high) are situated at each of the vertices of the icosahedral virion and extend to a maximum radius of 16.8 nm; (ii) a "collar" of density surrounds the base of each apical cap; and (iii) 20 conical protrusions (approximately 2.3 nm high) lie along the three-fold symmetry axes. The caps have a pentagonal morphology composed of five globular "subunits" and appear to be loosely connected to the underlying capsid. The distribution of the four gene products present in virions (60 copies each of gpF, gpG, and gpJ, and 12 copies of gpH), and the single-stranded DNA (ssDNA) genome cannot be directly discerned in the reconstructed density map, although plausible assignments can be made on the basis of solvent-excluded volume estimates and previous biochemical data. Thus, gpG accounts for most of the mass in the caps; gpH, a presumed cap protein, cannot be identified in part due to the symmetry-averaging procedures, but may be partially located within the interior of the capsid; and gpF and gpJ make up the remainder of the capsid. The genome appears to be less densely packaged inside the capsid compared to many dsDNA viruses whose nucleic acid is arranged in a liquid-crystalline state.


A new method for the routine spreading of DNA in protein-free conditions. Electron microscopic studies of DNA are hampered by difficulties encountered with the spreading of DNA under protein-free conditions. The established and currently popular technique of spreading DNA on carbon membranes treated by glow discharge in an atmosphere of pentylamine is limited with regard to its reproducibility and the proper distribution of spread molecules on the surface of the membranes. A new, reliable, and highly reproducible technique using tri-L-(dimethylaminomethyl)phenol (DMP 30), a promotor factor for spreading circular DNA, linear DNA, and DNA-protein complexes, is described in this paper. Monolayers of DMP 30 are formed at the air-water interface by a microdiffusion procedure on droplets. DNA molecules that diffuse on this monolayer can easily be picked up on hydrophobic carbon membranes. This method, which is easy, reproducible, and fast, will facilitate electron microscopic studies of DNA-protein interactions.


The role of 5-HT in postoperative nausea and vomiting. In this review it has been speculated that PONV is induced by the anaesthetic and by the trauma and perturbations associated with surgery. Indeed, it is unlikely that PONV is caused by any one pathophysiological input, but is multifactorial in origin. These perturbations may be peripheral, central, or both, and involve direct effects on the vomiting system together with afferent inputs in the vagal, splanchnic and trigeminal nerves. A proposed scheme summarizing these inputs is given in figure 1. The precise mechanisms through which 5-HT and 5-HT3 receptors contribute to the control of PONV is unknown, but their involvement is demonstrated by the antiemetic effect of ondansetron.


Neuroreceptor changes in Alzheimer disease. Multiple neuroreceptor changes are present in Alzheimer disease. These observations are based upon analysis from autopsy brain tissue or more seldom from neurosurgical biopsies. The drawback of information from autopsy material is that the receptor changes represent the final stage of the dementia disorder. It might therefore be somewhat misleading to base therapeutic strategies on these findings. Hopefully, new imaging techniques such as positron emission tomography (PET) and single photon emission tomography (SPECT) will provide valuable new in vivo data from the earlier course of the disease. Among the transmitter systems changed in Alzheimer disease, the cholinergic system shows the most consistent deficits. Cholinergic muscarinic receptors seem to be preserved in Alzheimer brains while nicotinic receptors show losses. The number of serotonin (both 5-HT1 and 5-HT2) and glutamate receptors are also reduced. Interestingly, kainate receptors increase in number while NMDA receptors are reduced in cortical Alzheimer tissue. Common for all receptor changes in Alzheimer disease is that the changes in number of binding sites are seen while the affinity constant remains unchanged. alpha- and beta-receptors and dopamine receptors are relatively preserved in Alzheimer brains. Among the neuropeptides, losses in receptor sites have been reported for somatostatin and neuropeptide Y (NPY). Interestingly, the number of CRF receptors are increased in cortical areas of Alzheimer brains. Thus, the muscarinic (M1), kainate, and CRF receptors show receptor compensatory reactions probably due to degenerative reactions in Alzheimer disease. Few attempts have been made to visualize neuroreceptors in vivo in Alzheimer patients. The field, however, is in dynamic progress. Reduced numbers of nicotinic receptors have been visualized in the brain of Alzheimer patients by PET and [11C]-nicotine and confirm earlier observations in post-mortem brain tissues. A lower uptake of (R)(+)[11C]nicotine compared to (S)(-)[11C]nicotine in patients with a mild form of dementia might be a possible diagnostic marker. SPECT studies indicate preserved muscarinic receptors in Alzheimer brains. Analysis of neuroreceptor changes in peripheral nonneural tissues have shown a reduction in nicotinic and muscarinic receptors in peripheral lymphocytes obtained from Alzheimer patients.


Alteration of blood pressure regulation and cerebrovascular disorders in the elderly. The objective of this study was to review the available data on the effects of management of hypertension on stroke in the elderly. MED-LINE was searched for articles published from 1967 to 1991 for articles on hypertension and hypotension. The following "key words" were used to limit our search to relevant studies: "stroke", "cerebrovascular disease", "elderly", "hypertension", "hypotension", "drug trials in hypertension", "complications of acute stroke", and "stroke management". Original articles with data related to the effects of hypertension management or complications of hypotension were reviewed in detail. Of about 900 papers reviewed, 121 were selected for this review. These papers specifically addressed the long-term prognosis of subjects treated with antihypertensive medications, the prognosis after TIA or stroke, and complications of aggressive antihypertensive therapy. The incidence of hypertension increases with age. Hypertension is the most important correctable risk factor for stroke. Most studies on stroke prevention in asymptomatic hypertension (primary prevention) have shown clear benefits (including management of systolic hypertension in the elderly). Data on stroke prevention in patients with TIAs (secondary prevention) is limited but suggests that management of hypertension will decrease the risk of stroke in such patients. Patients with completed stroke who are hypertensive should have very careful management of their hypertension as they may be at risk for hypotensive complications. Sudden reduction in blood pressure in the elderly (especially in the presence of pseudohypertension) increases the risk of symptomatic cerebral hypoperfusion and stroke. Management of hypertension in the elderly is effective in stroke prevention. Because of the real risk of a sudden decrease in cerebral perfusion, pressure reduction should be done slowly and with care.


Adenosine and brain ischemia.

Adenosine and brain ischemia. Recent experimental data indicate a probable role of adenosine as an endogenous neuroprotective substance in brain ischemia. This nucleoside is rapidly formed during ischemia as a result of intracellular breakdown of ATP and it is subsequently transported into the extracellular space. With use of microdialysis and other techniques, a massive increase of interstitial adenosine has been measured during ischemia in different brain areas. Adenosine acts through two subtypes of receptors, A1 and A2, which are located on neurons, glial cells, blood vessels, platelets, and leukocytes and are linked via G-proteins to different effector systems such as adenylate cyclase and membrane ion channels. There is a very high density of A1-receptors in the hippocampus, an area with specific vulnerability to ischemia. In different in vivo and in vitro models of brain ischemia, the pharmacological manipulation of the adenosine system by adenosine receptor antagonists tended to aggravate ischemic brain damage, whereas the reinforcement of adenosine action by receptor agonists or inhibitors of cellular reuptake and inactivation showed neuroprotection. The up-regulation of adenosine A1-receptor number and affinity by chronic preadministration of the competitive antagonist caffeine also attenuated ischemic brain damage. The mechanisms underlying the neuroprotective effects of adenosine seem to involve both types of adenosine receptors, A1 and A2, but the A1-mediated pre- and postsynaptic neuromodulation may be of special importance. By inhibiting neuronal Ca2+ influx, adenosine counteracts the presynaptic release of the potentially excitotoxic neurotransmitters glutamate and aspartate, which may impair intracellular Ca2+ homeostasis via metabotrophic glutamate receptors or induce uncontrolled membrane depolarization via ion channel-linked glutamate receptors, especially of the N-methyl-D-aspartate (NMDA) type. In addition, adenosine directly stabilizes the neuronal membrane potential by increasing the conductance for K+ and Cl- ions, thereby counteracting excessive membrane depolarization. The latter triggers a number of pathological events including blockade of voltage-sensitive K+ currents, increase of NMDA receptor-mediated Ca2+ influx, and presumably also impairment of glutamate uptake by astrocytes. In the way of a vicious cycle, all these factors again tend to enhance extracellular glutamate levels and membrane depolarization, finally leading to cytotoxic calcium loading and neuronal cell death. In addition to its important neuromodulatory effects, which tend to reduce energy demand of the brain, adenosine acting via A2-receptors in brain vessels, platelets, and neutrophilic granulocytes may improve the cerebral microcirculation and thus oxygen and substrate supply to the tissue. There is evidence that the functional state of adenosine receptors is impaired during ischemia, limiting the time window of the adenosine action.(ABSTRACT TRUNCATED AT 400 WORDS)


Culture media for enterococci and group D-streptococci. Lancefield group D-streptococci are contaminants of various food commodities, especially those of animal origin. They encompass the new genus Enterococcus comprising 13 known species and some species of streptococci which have their habitat in the intestine of animals, e.g. Streptococcus bovis, suis and equinus. The serologically based grouping may no longer constitute the best definition for streptococci from the food chain. Food hygiene monitoring systems using enterococci as indicators need reliable methods for selective cultivation and identification of marker strains. Up to now more than 100 modifications of selective media have been described for isolating streptococci or enterococci from various specimens. The selection of a medium requires either experience or consultation. It depends on the kind of specimen, the method of cultivation (plate count or membrane filter) and whether or not the habitat is heavily contaminated with other organisms. The choice of media is made more difficult as commercial versions of the same culture medium may vary in recipe and/or performance from producer to producer. Therefore, reviewing the literature may help in the choice of medium and confirmation tests. The selectivity and productivity of some commonly used or cited media are reported here, partly based on our own experience: citrate azide tween carbonate agar (CATC), kanamycin aesculin azide agar (KAA) and M-enterococcus agar (ME) including earlier results with aesculin bile azide agar (ABA), and thallous acetate tetrazolium glucose agar (TITG). No medium was completely selective for all group D-streptococci or for all enterococci but some media were highly selective for a single Enterococcus species, e.g., for E. faecalis which serves as indicator of human pollution. Confirmatory tests must be carried out when experience in the evaluation procedure is limited. Selective media for enterococci should be used only after or while checking in parallel their selectivity and productivity against appropriate test organisms.


Culture media for non-sporulating gram-positive food spoilage bacteria. The spoilage association especially of protein-rich foods can be dominated by Gram-positive bacteria, notably lactic acid bacteria (LAB) which affect vacuum packaged refrigerated processed meats and some dairy products. New food ecosystems are being created by novel packaging and processing technologies, resulting in spoilage associations differing from those previously reported. In addition, improvement in identification methods, allow the detection and isolation of 'novel' bacterial groups, e.g., Carnobacterium spp. This review considers the genera Aerococcus, Brevibacterium, Brochothrix, Carnobacterium, Kurthia, Lactobacillus, Leuconostoc, Microbacterium, Micrococcus, Pediococcus and Propionibacterium. Strictly selective procedures, including incubation temperature and atmosphere, are not yet available for the genera Aerococcus, Brevibacterium, Microbacterium and Micrococcus, and only with some limitations for Kurthia and Propionibacterium. On the other hand, a causative role in food spoilage has not been established clearly for all those groups, some of which may be 'opportunistic' in their behaviour. The LAB groups Lactobacillus, Leuconostoc and Pediococcus ('LLP-Group') often share similar habitats and show similar physiological behaviour on a number of elective and selective media. Modifications to increase selectivity have been based mainly on de Man, Rogosa and Sharpe (MRS) or Rogosa agar, and include pH reduction, supplementation with chemical preservatives (e.g., sorbic acid and nitrate) and the use of reduced atmospheres or suboptimal incubation temperatures. Carnobacteria differ from other LAB in their non-aciduric nature, and selective plating procedures use high-pH media (pH 8-9) by which competitors (mainly lactobacilli) are eliminated.


Principles involved in the detection and enumeration of clostridia in foods. The clostridia are a group of anaerobic bacteria that vary considerably in their biochemical and physiological properties. Not surprisingly, attempts to develop a single isolation medium for all species that occur in foods have not been entirely successful, and the problem is compounded by the need to recover both vegetative cells and spores, some of the latter being unable to germinate without heat activation. Most available isolation media, except some of those used in the dairy industry, include sulphite and an appropriate iron salt, so that blackening due to sulphite reduction can serve as a differential test for clostridia. The limitations of this test in solid agar media are discussed and some advantages described in relation to its use in liquid media for Most Probable Number determinations. A medium favoured for the purpose is the Differential Reinforced Clostridial Medium of Gibbs and Freame (1965). An unresolved issue is whether or not special precautions are needed to exclude oxygen during food sample preparation and dilution, preparation of media, and in conditions used for anaerobic incubation. Although such stringency may be required for maximum recovery of sub-lethally damaged cells or spores, practical constraints in food control laboratories necessitate use of relatively simple procedures for detecting clostridia routinely.


Media for detecting and enumerating yeasts and moulds. Dilution plating techniques are designed to determine populations of viable fungal propagules per unit weight or volume of food. Direct plating techniques, on the other hand, are designed to assess the internal mycoflora of individual pieces of foods, e.g., seeds or dried fruits, and results are expressed as a percentage of infected pieces. Both techniques are used by industry and regulatory agencies to monitor levels of fungal contamination at various stages of food handling, storing, processing and marketing. Peptone (0.1%) water is commonly used as a diluent for samples to be homogenized or blended. Buffered diluents containing up to 30% glucose or 60% sucrose are recommended for enumerating xerophiles. No one medium is satisfactory for detection or enumeration of yeasts and moulds in all foods. Dichloran rose bengal chloramphenicol agar, oxytetracycline glucose yeast extract agar and rose bengal chloramphenicol agar are superior to acidified potato dextrose agar for enumeration of yeasts and moulds. Dichloran 18% glycerol agar performs well for enumerating moderately xerophilic yeasts and moulds. Fastidious xerophiles require media containing high concentrations of sugars and/or sodium chloride. Media have been formulated to detect potentially aflatoxigenic aspergilli and mycotoxigenic strains of penicillia and fusaria, but increased selectivity and specificity of media for detecting mycotoxigenic moulds are needed. Heat-resistant mould ascospores often require heat treatment prior to plating in order to activate the germination process. The spread-plate technique is strongly preferred over the pour-plate technique for enumerating yeasts and moulds. The recommended incubation temperature is 25 degrees C, but incubation time between plating and counting colonies ranges from 5 days for determination of general populations of mycoflora to 4 weeks or more for fastidious xerophiles. There is a need for new and improved media for selectively isolating various groups, genera, species and/or strains of fungi capable of growing only under specific environmental conditions, e.g., low aw or, in the case of sublethally injured cells, under conditions which facilitate resuscitation. Improved media are needed which accurately detect moulds producing specific mycotoxins in a wide range of food types.


Microbiological assessment of culture media: comparison and statistical evaluation of methods. In this review methods for the quality control of media were compared, taking the following questions as a guidelines. (i) Which methods are easy to use and give reliable results? (ii) Which experimental design should be used in order to obtain reliable data with a minimal input of resources (staff and materials)? These questions can be answered satisfactorily using statistical methods. This review shows that solid media can be assessed with acceptable accuracy using well established methods like the spread plate technique. In order to assure a minimum of statistical error, at least two plates with an average count of 100 colonies per plate seems to be the best design. This also applies to the ecometric streaking technique, a good alternative to the more quantitative methods. For an accurate assessment of liquid media, large numbers of tubes need to be tested. This is very expensive in terms of laboratory resources and therefore unlikely to be used routinely. Therefore it is proposed to use the serial dilution technique, in which the broths are tested in triplicate (Richard, N. (1982) Monitoring the quality of selective liquid media used in the official serial dilution technique for the bacteriological examination of food. In: J.E.L. Corry (Ed.). Quality Assurance and Quality Control of Microbiological Culture Media. Proceedings of the Symposium held on 6-7 September 1979, Callas de Mallorca, Spain, G.I.T.-Verlag Ernst Giebeler, Darmstadt. pp. 51-58). The recommendations in this review can be used together with the methods recommended by the International Committee for Food Microbiology and Hygiene, Working Party on Culture Media (ICFMH, WPCM: Baird et al., 1987) to assist laboratories setting up QC tests for culture media.


A standard protocol for the quality control of microbiological media. A protocol, comprising standardized analysis and data forms, has been drawn up for the quality control of microbiological media. It was developed in order to standardize the testing procedures in our laboratory and to test media with minimal investment in time and resources. The forms encourage proper recording of the trials, which facilitates internal and external consideration of the results. The protocol was validated in a comparative investigation of the quality of media obtained from different suppliers and were shown to work satisfactorily. Based on the overall results, preferred suppliers for each medium were chosen. The standardized forms can be used in conjunction with the documents drafted by the International Committee for Food Microbiology and Hygiene (ICFMH) Working Party for Culture Media, bringing standardization of testing procedures one step nearer.


Isolation of Yersinia enterocolitica from foods. Many selective enrichment and plating media for the isolation of Yersinia enterocolitica from foods are described. However, at present no single isolation procedure is available for the recovery of all pathogenic strains of Yersinia enterocolitica. Cold enrichment in phosphate-buffered saline plus 1% sorbitol and 0.15% bile salts (PBSSB) and two-step enrichment with tryptone soy broth (TSB) and bile oxalate sorbose (BOS) broth are very efficient methods for the recovery of a wide spectrum of serotypes of Y. enterocolitica. Enrichment in irgasan ticarcillin chlorate (ITC) broth was found to be the most efficient method for the recovery of strains of serotype 0:3, which is the most common clinical serotype of Y. enterocolitica in Europe. Post-enrichment alkali treatment often results in higher isolation rates. Cefsulodin irgasan novobiocin (CIN) agar and Salmonella-Shigella deoxycholate calcium chloride (SSDC) agar are the most commonly used plating media. For the recovery of serotype 0:8 strains, the common clinical isolates in North America, enrichment in BOS and plating on CIN seems the most efficient procedure. Selection of the proper enrichment procedure will depend on the bio/serotypes of Yersinia spp. sought and on the type of food to be examined. The use of more than one medium for both enrichment and plating will result in higher recovery rates of Yersinia spp. from foods. Parallel use of the following two isolation procedures is recommended. (1) Enrichment in ITC for 2 days at 24 degrees C; plating on SSDC agar (2 days at 30 degrees C). (2) Pre-enrichment in TSB for 1 day at 24 degrees C; enrichment in BOS for 5 days at 24 degrees C; alkali treatment (mixing 0.5 ml enriched broth with 4.5 ml of 0.5% KOH in 0.5% NaCl for 5 s); plating on CIN agar (2 days at 24 degrees C).


Media for the detection and enumeration of Bacillus cereus in foods: a review. Bacillus cereus is an established cause of food poisoning in addition to being a troublesome and persistent contaminant, responsible for a variety of spoilage defects in processed foods and dairy products. A range of diagnostic and selective media has been developed to facilitate the detection and enumeration of B. cereus in routine surveillance situations and food poisoning investigations. These media are reviewed with respect to the selective and diagnostic systems they employ, their ability to recover and differentiate the target organism, and their advantages and limitations in particular applications.


Bone marrow cells from A/J mice do not proliferate in interleukin-3 but express normal numbers of interleukin-3 receptors. Haemopoietic cells from A/J mice do not form colonies (proliferate) in response to interleukin-3 (multi-CSF, IL-3). We have examined different populations of cells from A/J mice and shown that, despite their failure to proliferate in response to IL-3, cells from bone marrow, spleen and the peritoneum all bound 125I-labelled IL-3. A wide variety of cell types bound IL-3 as determined by autoradiography, including promyelocytes, myelocytes, metamyelocytes, polymorphs, promonocytes, monocytes, eosinophils and lymphocytes, but not nucleated erythroid cells, and the proportion of each cell type binding label was similar when cells from A/J mice were compared with those of C57B1/6 and Balb/c mice. Bone marrow cells from A/J mice internalized interleukin-3 with normal kinetics and mRNA extracted from these cells contains the same species of IL-3 receptor and IL-3 receptor-like mRNAs as are found in the other strains. Collectively the data suggest that the failure of haemopoietic cells from A/J mice to proliferate in response to IL-3 is related to a selective defect in signalling to proliferation specific genes. This defect is apparently not related to internalization or processing of the IL-3/IL-3-receptor complex, but may be due to failure to activate appropriate accessory molecules in the cell.


Inactivation of the retinoblastoma gene in acute myelogenous leukaemia. To investigate the role of retinoblastoma susceptibility (RB) gene inactivation in leukaemogenesis, we evaluated 36 bone marrow specimens of acute leukaemia for RB protein expression by immunoprecipitation and Western blot analysis. 15 patients had no detectable RB protein at initial screening. However, nine of them were subsequently excluded due to evidence of protein degradation. Of 27 valid cases, six (22%) were repeatedly shown to lack expression of the RB protein with three different anti-RB antibodies. Five were patients with acute myelogenous leukaemia (AML) and one, mixed-lineage acute leukaemia. The RB inactivation was noted more frequently in AML (5/18, 28%) than in acute lymphoid leukaemia (0/7, 0%). By karyotyping, none of these six patients exhibited cytogenetic changes involving chromosome 13q14, the RB locus. There is no correlation between inactivation of the RB gene and FAB subtypes or cytogenetic changes. Four patients achieved complete remission with standard chemotherapy for 6, 12, 20 and 26+ months, respectively. Southern and Northern blot analyses further indicated that the RB genes were grossly intact and the level of RB transcripts did not decrease in the majority of these six patients. These results suggest that the absence of RB products in some of acute leukaemia might be regulated at the post-transcriptional level, and it imposes no significant effect on treatment response and prognosis.


Simultaneous establishment of myeloid and B-lymphoid cell lines with identical chromosome abnormalities from Philadelphia chromosome-positive chronic myelogenous leukaemia. Two continuously growing cell lines, designated YOS-M and YOS-B, were established simultaneously from a patient with Philadelphia (Ph1) chromosome-positive chronic myelogenous leukaemia (CML) in myeloid blast crisis. Both YOS-M and YOS-B had the Ph1 chromosome and identical additional chromosome abnormalities, which were not detected in the chronic phase. Cytochemical analysis showed that YOS-M was significantly positive for peroxidase, whereas YOS-B was entirely negative. YOS-M expressed myeloid-associated antigens (CD14, CD33) as well as CD4, CD25 and CD34. The surface phenotype of YOS-M was identical to that of the leukaemic blasts found in the patient. On the other hand, YOS-B expressed mature B-cell markers, CD19, CD20, CD21 and surface immunoglobulin, but not myeloid-associated antigens. These two cell lines showed an identical rearrangement pattern of the break point cluster region on chromosome 22, but rearrangement of the immunoglobulin heavy chain gene was detected only in YOS-B. These findings provide definite evidence that CML cells still have the capability to differentiate and mature along different haematopoietic cell lineages even after blast crisis.


Effects of bryostatin 1 and rGM-CSF on the metabolism of 1-beta-D-arabinofuranosylcytosine in human leukaemic myeloblasts. The effects of the protein kinase C activator bryostatin 1, either with or without recombinant granulocyte-macrophage colony stimulating factor (rGM-CSF) were examined with respect to the in vitro metabolism of ara-C in leukaemic myeloblasts obtained from 10 patients with acute myelogenous leukaemia (AML). Coincubation of cells with 12.5 x 10(-9) M bryostatin 1 and 10(-5) M ara-C for 4 h resulted in a significant increase in ara-CTP formation (compared to controls) in 6/10 specimens (mean increase 106%; range 38-255%), and no change in the remainder. In contrast, coincubation of cells with 1.25 ng/ml rGM-CSF resulted in a significant increase in only one specimen, and decreases in two. Bryostatin 1 also significantly increased ara-C DNA incorporation in 6/9 evaluable samples, including two which did not display an increase in ara-CTP formation. Coincubation of cells with both bryostatin 1 and rGM-CSF did not lead to a further increase in ara-CTP formation or ara-C DNA incorporation compared to values obtained with either agent alone. Finally, exposure of blasts to bryostatin 1 for 24 h before ara-C led to an increase in ara-CTP formation in 3/8 additional specimens, and a decrease in one sample displaying evidence of bryostatin 1-induced macrophage differentiation. Incubation of cells with both rGM-CSF and bryostatin 1 for this period resulted in ara-CTP levels equivalent to those obtained with bryostatin 1 alone. These studies indicate that while bryostatin 1 exerts a heterogeneous effect on ara-C metabolism in leukaemic myeloblasts, it is capable of potentiating ara-C phosphorylation in a subset of patient samples, including some that do not exhibit an increase in response to rGM-CSF. They also raise the possibility that bryostatin 1-induced potentiation of ara-C metabolism in some leukaemic cells may contribute, at least in part, to the antileukaemic efficacy of this drug combination.


Diagnosis of acute promyelocytic leukaemia by RT-PCR: detection of PML-RARA and RARA-PML fusion transcripts. Acute promyelocytic leukaemia (APL; AML M3) is identified by a unique t(15;17) translocation which fuses the PML gene to the retinoic acid receptor alpha gene (RARA). Reverse transcription coupled with the polymerase chain reaction (RT-PCR) has been used to develop a diagnostic test for APL based on the PML-RARA fusion message. Separate PCR assays were designed to amplify either PML-RARA (15q+ derived) or RARA-PML (17q- derived) chimaeric transcripts. PML-RARA transcripts were detected in every case from a series of 18 APL patients with cytogenetically confirmed t(15;17) translocations, whereas RARA-PML messages were detected in only 67% (12/18) of these patients. This suggests that it is the 15q+ derivative which mediates leukaemogenesis. Furthermore the PCR approach (or Southern analysis) may be used to identify in which of the alternative PML introns the breakpoint occurs; 52% of cases (15/29 patients) utilize a 5' PML intron and 48% the 3' intron (14/29 cases). Neither the choice of PML intron nor the expression of the 17q- derivative could be correlated with the microgranular variant of APL (M3V), overall survival rate, age, sex or presence of coagulopathy. Finally, the fusion message is undetectable in five remission samples. This indicates a possible use for RT-PCR in monitoring remission patients for evidence of relapse.


Expression of the IFN alpha receptor in hairy cell leukaemia. The expression of IFN alpha receptors on the surface of hairy cell leukaemia cells was studied using affinity crosslinking methods, flow cytometry with a recently produced anti-IFN alpha receptor monoclonal antibody (IFNaR3), and binding techniques. IFN alpha receptors were detected by flow cytometry and affinity crosslinking in eight cases showing a normal receptor structure with 125I-IFN alpha 2-receptor complexes with molecular weights of 210, 130 and 110 kD. The hairy cell leukaemia cells from one patient did not express IFN alpha receptors as determined by flow cytometry, affinity crosslinking and binding studies. Northern blot analysis showed expression of mRNA for the gene coding for the putative IFN alpha receptor in all cases studied, including the patient with lack of IFN alpha receptor expression on hairy cells. This patient was refractory to IFN alpha 2 treatment. Our data suggest that lack of expression of IFN alpha receptors in rare cases may be associated with refractoriness to IFN alpha 2 therapy.


Modified adriamycin-vincristine-dexamethasone (m-VAD) in primary refractory and relapsed plasma cell myeloma: an NCI (Canada) pilot study. The National Cancer Institute of Canada Clinical Trials Group. The purpose of this single arm phase II study was to test a modified version of the three drug combination vincristine, adriamycin and dexamethasone (m-VAD), in which intravenous vincristine (0.4 mg/d) and adriamycin (9 mg/m2 per day) infusions are administered for only 2 h on days 1-4 of each 28 d cycle, in patients with refractory multiple myeloma. In addition, only two 4 d courses of dexamethasone 40 mg/d was given during each cycle. The entry criteria for 44 patients included plasma cell myeloma and a measurable monoclonal peak, either refractory to initial treatment with melphalan and prednisone, or resistant to melphalan and prednisone after initially responding (resistant relapsed disease, 27 patients). Patients treated previously with chemotherapy other than melphalan and prednisone were excluded. There were no complete responses. Of the 41 evaluable patients who completed at least one course of therapy 11 had a partial response (27%, 95% C.I. 14-40%). The response rates were 19% for primary refractory disease patients, and 32% for those with resistant relapsed disease. The median duration of response was 4 months. The median survival for all 44 patients was 7.6 months (5.5 months for primary refractory patients, and 10 months for relapsed resistant disease patients). Episodes of documented bacterial infection occurred in 12 patients, and 10 patients had minor viral infection. The dexamethasone dose was reduced in 12 patients. The median neutrophil nadir was 1.2 x 10(9)/l, and median platelet nadir was 147 x 10(9)/l. Five deaths were judged as treatment related and occurred during marrow cytopenia. The results of this modified form of VAD are inferior to that reported previously for 4 d continuous infusions of vincristine and doxorubicin. This could be related to either patient selection factors, or to a reduction of the efficacy of the drug combination produced by either the shortened intravenous infusions and/or omission of one 4 d course of dexamethasone.


Beta 2-glycoprotein 1 (beta 2GP1) enhances cardiolipin binding activity but is not the antigen for antiphospholipid antibodies. Some investigators have reported that a serum protein, beta 2-glycoprotein 1 (beta 2GP1), either alone or in combination with negatively charged phospholipid, may be the antigen for anticardiolipin (aCL) antibodies. To examine these reports further, ELISA tests, inhibition experiments, Ouchterlony and Western blot techniques were used to examine anticardiolipin binding to beta 2GP1. Sera from patients with the antiphospholipid syndrome (APS) and syphilis were studied, as well as whole IgG immunoglobulin and affinity purified (a.p.) IgG aCL antibodies. Results showed no binding of aCL antibodies to beta 2GP1 in the absence of cardiolipin. beta 2GP1 caused enhanced binding of aCL antibodies to cardiolipin, but this enhancement was not observed in inhibition experiments. Binding to cardiolipin occurred in the absence of beta 2GP1. Enhancement of cardiolipin binding activity by beta 2GP1 was observed for APS, but not for syphilis. We conclude that beta 2GP1 is not the antigen for aCL antibodies, nor is it likely that the antibody recognizes shared beta 2GP1-cardiolipin epitopes. Instead, this protein may make cardiolipin more available for aCL binding on solid surfaces by some yet undefined mechanism. This effect may not extend to aqueous suspensions.


Some 'antiphospholipid antibodies' bind to beta 2-glycoprotein I in the absence of phospholipid. Some antiphospholipid antibodies (aPL) only bind to anionic phospholipids in the presence of a serum cofactor, beta 2-glycoprotein I (beta 2GPI). Whether these aPL can bind to beta 2GPI in the absence of phospholipid is controversial. We have purified anticardiolipin antibodies (aCL) from the plasma of four patients and beta 2GPI from normal plasma by solid phase affinity methods. All four aCL bound to cardiolipin and phosphatidylserine in the presence of beta 2GPI but not in its absence. The binding of two of the antibodies to cardiolipin and phosphatidylserine at various concentrations of human beta 2GPI was compared with that obtained using 10% bovine serum. The two antibodies responded differently to increasing beta 2GPI concentrations, and binding to phosphatidylserine was relatively greater than to cardiolipin using human beta 2GPI. All four aCL bound to plastic plates coated with beta 2GPI in the absence of phospholipid, and beta 2GPI in the fluid phase had no effect on binding. Binding to beta 2GPI coated plates was increased equally when bovine serum or bovine albumin were used as the sample diluent in place of gelatine. These findings and those of others have important implications for the design of assays for antiphospholipid antibodies.


Mechanisms of inhibition of T cell IL-2 secretion by factor VIII concentrates. We have continued our previous study of the inhibitory effects of factor VIII concentrates on IL-2 secretion by T cells. Experiments with an extended range of products confirm our previous conclusion that some but not all low, intermediate and high purity concentrates possess inhibitory activity on IL-2 secretion. The inhibition occurs almost immediately after addition of factor VIII concentrate and it was not possible to adsorb inhibitory activity with activated or non-activated cells; this suggests that the mechanism of inhibition involves interference with early T cell activation events rather than simple blocking of cell surface components by inhibitory molecules. The inhibitory components were shown to reside in different molecular weight fractions of concentrates. A strongly inhibitory component of approximately 200 kD and a minor species of approximately 60 kD were identified in strongly inhibitory concentrates. Some products contained a dialysable inhibitory substance which is most likely a salt as it was also present in some formulation buffers. The proportions of the inhibitory components varied widely between products. We have found that the pattern of inhibition using in vitro systems reflects that observed using a mouse in vivo antigen challenge method. In addition we have shown that the previously reported concentrate mediated inhibition of lectin induced low affinity IL-2 receptor (CD25) is mainly a consequence of diminished IL-2 secretion rather than a 'direct' effect on CD25 expression. Considering the wide variation between products of the same purity group, caution should be exercised in drawing conclusions concerning the immunosuppressive effects of a particular type of concentrate in haemophilia patients from study with only one product from that group.