How does angioplasty work? Serial analysis of human iliac arteries using intravascular ultrasound. Previous studies regarding the mechanism by which balloon angioplasty increases luminal patency have generally used animal models or postmortem specimens from occasional fatal cases of angioplasty performed in human patients. In either case, conclusions regarding participatory mechanisms have relied exclusively on nonserial, postangioplasty histopathological examination. In the present study, intravascular ultrasound examination was performed before and after balloon angioplasty in 40 consecutive patients with iliac artery stenoses. The areas of the arterial wall, plaque, lumen, and areas resulting from angioplasty-induced plaque fractures were measured immediately after angioplasty in vivo and compared with findings recorded immediately before angioplasty. Angioplasty increased luminal cross-sectional area (CSA) from 11.5 +/- 0.6 mm2 before angioplasty to 25.4 +/- 1.2 mm2 after angioplasty (p = 0.0001). CSA of the portion of the postangioplasty neolumen contained within angioplasty-induced plaque fractures measured 10.0 +/- 0.8 mm2; the neolumen excluding the area contributed by these plaque fractures measured 15.4 +/- 0.8 mm2. Thus, the area contained within plaque fractures accounted for 10.0 mm2 (71.9%) of the 13.9-mm2 increase in luminal CSA after angioplasty. Analysis of CSA occupied by atherosclerotic plaque disclosed that plaque CSA decreased from 33.8 +/- 1.8 mm2 before angioplasty to 22.5 +/- 1.5 mm2 after angioplasty (p = 0.0001). Plaque CSA was thus reduced ("compressed") by 11.3 +/- 1.1 mm2. Total artery CSA increased ("stretched") slightly from 45.3 +/- 2.6 mm2 before angioplasty to 47.8 +/- 2.0 mm2 after angioplasty (p = 0.0025). In vivo analysis of iliac stenoses by intravascular ultrasound immediately before and after angioplasty demonstrates that plaque fractures and "compression" of atherosclerotic plaque are the principal factors responsible for increased luminal patency resulting from balloon angioplasty. "Stretching" of the arterial wall provides an additional, but minor, contribution.


Endothelial dysfunction in patients with chest pain and normal coronary arteries. A subgroup of patients with chest pain and angiographically normal epicardial coronary arteries have reduced dilator response to metabolic or pharmacological stimuli, but the mechanisms responsible for this reduced dilator response are unknown. In this study, we have investigated whether microvascular endothelial dysfunction is a cause of the observed reduced vasodilator reserve. The functional response of the microvasculature was studied with rapid atrial pacing at 150 beats per minute. Fifty-one patients, 20 hypertensive and 31 normotensive, with chest pain and normal epicardial coronary arteries (< 10% stenosis) were studied. Endothelial function was tested with incremental infusions of acetylcholine to achieve estimated intracoronary concentrations ranging from 10(-7) M to 10(-5) M. Endothelium-independent smooth muscle vasomotion was measured using intracoronary sodium nitroprusside. Endothelial dysfunction of epicardial coronary arteries, demonstrated as severe (> 50%) constriction with < 10(-5) M acetylcholine concentration, was evident in five patients (10%). In the remaining 46 patients, coronary blood flow increased with acetylcholine (mean, 78 +/- 43%) and atrial pacing (mean, 51 +/- 37%), and coronary vascular resistance decreased by 35 +/- 16% and 29 +/- 14%, respectively, but the responses were heterogeneous. There was a correlation between the coronary resistance change with acetylcholine and the change with atrial pacing: r = 0.68, p < 0.001 in these 46 patients. Thus, patients with depressed dilation with atrial pacing had reduced endothelium-dependent dilation with acetylcholine, and vice versa. However, the microvascular dilation caused by sodium nitroprusside was not significantly different between patients with and those without reduced dilation with atrial pacing, indicating that the vasodilator defect was not caused by smooth muscle dysfunction. There were no differences in the vasodilator responses with atrial pacing, acetylcholine, or nitroprusside between normotensive and hypertensive patients. Multivariate regression analysis was performed to determine whether age, sex, serum cholesterol level, hypertension, presence of mild epicardial vessel atherosclerosis, resting left ventricular function, change in left ventricular ejection fraction with exercise, vasodilation with acetylcholine, and vasodilation with sodium nitroprusside were independently related to the vasodilator response to atrial pacing. Only the change in coronary vascular resistance with acetylcholine was independently correlated with the change in resistance with atrial pacing: R2 = 0.46, p < 0.0001. Patients with chest pain, normal epicardial coronary arteries, and reduced vasodilation in response to atrial pacing appear to have associated endothelial dysfunction of the coronary microvasculature. Thus, microvascular endothelial dysfunction may contribute to the reduced vasodilator reserve with atrial pacing and anginal chest pain in these patients.


Reentrant and focal mechanisms underlying ventricular tachycardia in the human heart. To determine the mechanisms of ventricular tachycardia (VT) in humans, three-dimensional intraoperative mapping of up to 156 intramural sites was performed in 13 patients with healed myocardial infarction and refractory VT. Mapping was of sufficient density to define the mechanism of 10 VTs in eight patients. In five of 10 cases, sustained VT was initiated in the subendocardium or epicardium by intramural reentry with marked conduction delay as well as functional and anatomic block most prominent in the subendocardium and midmyocardium. The initiating beats of reentrant VT induced by programmed electrical stimulation arose in the endocardium or midmyocardium by progressive slowing of conduction leading to unidirectional block. Multiple simultaneous reentrant circuits can be present. In contrast, five of the 10 sustained VTs were initiated by a focal mechanism as defined by the absence of electrical activity between the termination of one beat and the initiation of the next despite the presence of multiple intervening intramural electrode recording sites. Comparisons of the mapping data with results of histopathological analysis of tissue demonstrated that the location of infarction as well as that of adjacent fibrotic muscle determined sites of both fixed and functional conduction block during macroreentrant VT and that slowing of conduction occurred in a direction transverse rather than longitudinal to fiber orientation. Both intramural reentry and a focal mechanism underlie sustained VT in patients with healed myocardial infarction.


Contribution of myocardium responsible for ventricular tachycardia to abnormalities detected by analysis of signal-averaged ECGs. Current methods of signal-averaged ECG analysis interrogate the terminal 40 msec of the QRS complex and/or the ST segment and have a low positive-predictive accuracy for detecting vulnerability to sustained ventricular tachycardia (VT). The extent to which abnormalities detected during these ECG intervals are generated by myocardial tissue responsible for VT has not been well defined. The purpose of this study was to determine when, during sinus rhythm, myocardium responsible for VT is activated. Three-dimensional ventricular activation maps were analyzed during sinus rhythm and during 10 VTs in eight patients with healed myocardial infarctions undergoing arrhythmia surgery for sustained monomorphic VT. The mechanism of VT was focal in five instances and macroreentrant in five. During sinus beats, myocardium responsible for all focal VTs activated 43 +/- 38 msec before the onset of the terminal 40-msec interval of the QRS complex. During sinus rhythm, activation of the myocardium critical to macroreentrant VT began 72 +/- 13 msec before the onset of the terminal QRS interval and in only three instances extended 2-25 msec into the terminal 40 msec of the QRS complex. Electrograms recorded during the ST segment represented late activation of epicardial sites overlying zones of infarction that were temporally and spatially remote from tissue critical to VT. Current methods of signal-averaged ECG analysis limiting interrogation to the terminal QRS/ST segment exclude detection of > 95% of the signals generated by myocardium responsible for sustained VT. These results establish a pathophysiological basis for expanding signal-averaged ECG analysis to include more of the cardiac cycle.


Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Many have proposed a relation between presence of a patent foramen ovale, with or without atrial septal aneurysm, and cryptogenic stroke. The effect of foramen ovale closure on the risk for subsequent strokes is unknown. Transcatheter closure of a patent foramen ovale was undertaken in 36 patients with known right-to-left atrial shunting and presumed paradoxical emboli (31 strokes, 25 transient neurological events, four systemic arterial emboli, and two brain abscesses). Individual patients had between one and four such events. None had a left heart or carotid source of embolism; 31 of 35 had no known risk factors for stroke. Events occurred in 12 patients while they were taking warfarin. At cardiac catheterization, patent foramina ovalia were significantly larger than predicted for age in 67% of the patients. Implantation of a double-umbrella device in the patent foramen ovale was achieved in all without serious procedural complications. Of 34 who have returned for follow-up, one has a residual atrial communication that may be clinically important, five had trivial leaks, and 28 have complete closure. There have been no strokes during a mean follow-up of 8.4 months. Transcatheter closure of a patent foramen ovale can be accomplished with little morbidity and may reduce the risk of recurrence. Further investigations directed toward identifying the population at risk and assessing the effect of intervention are warranted.


Parallel cardiac and vascular adaptation in hypertension. Although vascular damage in the noncoronary circulation is a major cause of complications in hypertension, relatively little is known of the in vivo geometry and function of the arterial circulation in patients with uncomplicated hypertension or of their relation to left ventricular hypertrophy, a marker of enhanced risk of cardiovascular complications. Wall thickness and internal diameter of the common carotid artery and the presence of atherosclerosis within the extracranial carotid arteries were determined by ultrasound in 43 asymptomatic hypertensive patients and 43 normotensive subjects matched for sex, age, and body size. Vascular stiffness was estimated from simultaneous superimposed carotid pressure waveforms obtained with an external solid-state transducer. Left ventricular size and function were determined echocardiographically. Compared with normal subjects, hypertensive patients had greater left ventricular absolute and relative wall thicknesses, left ventricular mass, and carotid absolute and relative wall thicknesses (p < 0.005). Carotid intimal-medial thickness exceeded the 95th percentile of normal values in 28% of hypertensive patients (p < 0.01). Carotid atherosclerosis was equally prevalent within the two blood pressure groups and was associated with older age, larger left ventricular and carotid wall thicknesses, and carotid diameter. Despite similar carotid pulse pressures, vascular stiffness was significantly increased in the hypertensive patients. Among the population as a whole, significant relations existed between cardiac and vascular wall thicknesses and internal dimensions. In multivariate analyses, these relations were statistically independent of age and blood pressure. The present study documents the presence of geometric and functional changes within the common carotid artery in uncomplicated hypertension that parallel findings within the left ventricle. The potential contribution of these changes to the cardiovascular complications of hypertension, particularly in the setting of left ventricular hypertrophy, is unknown.


Evaluation of left ventricular segmental wall motion in hypertrophic cardiomyopathy with myocardial tagging. Segmental wall motion was assessed noninvasively in eight patients with hypertrophic cardiomyopathy and six healthy volunteers by magnetic resonance myocardial tagging. Localization scans were performed for determination of the true short-axis views of the left ventricle (double-angulated view). Spatial modulation of magnetization was used to produce a rectangular grid of landmarks. Distortion of the grid was assessed at end diastole, mid systole, and end systole with multiphase gradient echoes. Image sets were acquired at three different planes, namely, the base, the equator, and the apex. Quantitative evaluation was carried out by computer-assisted image analysis. Each individual grid crossing point was identified automatically and the displacement calculated. A polar coordinate system with the center of gravity as motion reference point was chosen to assess fractional rotation and radial displacement at the endocardial, midwall, and epicardial layers of the septal, anterior, posterior, and inferior regions. A wringing motion of the left ventricle with a clockwise rotation of 5.0 +/- 2.4 degrees at the base and a counterclockwise rotation of -9.6 +/- 2.9 degrees at the apex was observed in control subjects. An equal rotation of 5.0 +/- 2.5 degrees at the base and a slightly reduced rotation of -7.3 +/- 5.2 degrees at the apex was found in patients with hypertrophic cardiomyopathy. A transmural gradient in fractional rotation and radial displacement was observed, with the highest values in the endocardial layer. Rotation in patients with hypertrophic cardiomyopathy was significantly less than in normal volunteers in the posterior region of the equatorial and apical planes. Furthermore, radial displacement was significantly reduced in the septum and inferior wall. In the anterior and posterior wall segments, a reduction of the radial displacement was observed only in the epicardium and midwall layers. Magnetic resonance myocardial tagging allows the noninvasive assessment of regional wall motion. Both in normal volunteers and in patients with hypertrophic cardiomyopathies, cardiac motion occurs in a complex mode, with the base and the apex rotating in opposite directions and the equatorial plane as a transitional zone (wringing motion). A reduced cardiac rotation can be observed in patients with hypertrophic cardiomyopathy mainly in the posterior region, whereas a reduced radial displacement is found in the inferior septal zone.


Control of sympathetic nerve activity by vagal mechanoreflexes is blunted in heart failure. Previous studies have documented abnormalities of arterial baroreflexes in animals and patients with congestive heart failure. This study determined whether cardiopulmonary reflex control of sympathetic nerve activity was abnormal in a canine model of low-output heart failure induced by rapid ventricular pacing. We stimulated mechanoreceptors throughout the cardiopulmonary region by volume expansion and left atrial mechanoreceptors selectively by inflating small balloons at the junctions of the pulmonary veins and left atrium. Responses of renal sympathetic nerve activity and left atrial and systemic arterial pressures were recorded. In the control group, 15% volume expansion raised left atrial pressure 3.5 +/- 0.8 mm Hg and resulted in a 70 +/- 8% reduction in renal nerve activity. In the heart failure group, 15% volume expansion resulted in a 6.8 +/- 3.0 mm Hg rise in left atrial pressure with only a 16 +/- 20% reduction in renal nerve activity (p < 0.01). When volume expansion was performed after pretreatment with hemorrhage to lower left atrial pressure to the normal range in the heart failure group, the markedly attenuated response in the heart failure group persisted. After vagotomy, volume expansion elicited no change in renal nerve activity. Inflation of the atrial balloons caused a 28 +/- 9% reduction in renal sympathetic nerve activity and a 13 +/- 4 mm Hg decrease in arterial pressure in the control group. Renal nerve activity (-5 +/- 3%) and mean arterial pressure (-1 +/- 1 mm Hg) did not change with balloon inflation in the heart failure group. We conclude that dogs with low-output heart failure exhibit marked attenuation of cardiopulmonary mechanoreflex control of sympathetic nerve activity. This attenuated response is mediated via cardiac vagal afferent fibers and is due to either abnormalities in cardiopulmonary baroreceptors or abnormalities in the central nervous system.


Myocardial cell hypertrophy after myocardial infarction with reperfusion in dogs. The potential role of myocardial cell hypertrophy in the ischemic zone in the mechanism of late recovery of regional contractile function after myocardial infarction followed by reperfusion has not been examined. Eight chronically instrumented, conscious dogs were subjected to 90-120 minutes of circumflex coronary artery occlusion followed by reperfusion. The thickness and function of the anterior (AT) and posterior (PT) walls was measured by ultrasonic gauges at control, during occlusion, and after reperfusion. After 3 weeks, cross-sectional areas of surviving cells were determined from subepicardial (epi), midwall (mid), and subendocardial (endo) regions in six dogs and compared with those from six animals without infarction, including three sham-operated control dogs. PT systolic wall thickening showed dyskinesia during occlusion but recovered after reperfusion to 48% of control at 1 week and 67% at 3 weeks. End-diastolic thickness of the PT wall increased markedly after reperfusion, but AT and PT walls were only slightly thicker (p = NS) than in control dogs at 3 weeks. Cross-sectional areas of reperfused dogs in the infarct region averaged 279 (PTepi), 291 (PTmid), and 317 microns 2 (PTendo) and were significantly larger than in control animals (237 [PTepi], 241 [PTmid], and 233 microns 2 [PTendo]). PT cell areas were significantly larger than AT cells, ENDO cell areas were larger than EPI cells (both p < 0.05), and ENDO cells of the AT wall were larger than those of noninfarcted dogs (p < 0.05). In dogs with myocardial infarction followed by reperfusion, the cross-sectional areas of cells in the infarcted PT wall were larger than those in the noninfarcted AT wall, and within both the infarcted and noninfarcted zones, cell areas were larger in the endocardial than the epicardial region. In all regions of the infarcted wall and in the ENDO region of the noninfarcted wall, cell areas were generally larger than those of control dogs without infarction, and the control dogs showed no transmural differences in cell areas. The mechanisms responsible for this significant remodeling of the reperfused infarcted zone, which involves myocardial cellular hypertrophy, are unknown, but it is possible that hypertrophy of surviving regions of the infarcted wall played a role in the late recovery of regional function that accompanied this hypertrophic response.


Effects of calcium and EMD-53998 on oxygen consumption in isolated canine hearts. Most positive inotropic agents increase cardiac contractility by increasing the amount of Ca2+ cycled with each beat. The additional amount of oxygen that is consumed by the heart to cycle this additional Ca2+ is believed to reduce myocardial efficiency. On the other hand, it has been suggested that the agent EMD-53998 increases the Ca2+ sensitivity of the contractile proteins without affecting the intracellular Ca2+ transient in cardiac muscle. Therefore, application of this agent may increase cardiac contractility without decreasing myocardial efficiency. The purpose of the present study was to test this hypothesis. We measured myocardial oxygen consumption (MVO2) in six isolated, isovolumically beating blood-perfused canine hearts. The hearts were paced at 120 beats per minute. Contractility was varied in each heart by infusion of either CaCl2 or EMD-53998. With infusion of either agent, MVO2 was a linearly proportional function of contractility. No significant difference between CaCl2 and EMD-53998 could be detected in the interrelation between contractility and MVO2. We conclude that the "calcium-sensitizing agent" EMD-53998 is a potent positive inotropic agent in the isolated, blood-perfused canine heart. However, EMD-53998 does not provide an energetic advantage over currently used positive inotropic agents.


Diastolic vibration improves systolic function in cases of incomplete relaxation. Incomplete relaxation of the left ventricle (LV) affects LV filling, but the subsequent effect on LV systolic function remains unclear. We attempted to improve relaxation by applying oscillatory mechanical perturbation during diastole (diastolic vibration) and examined the extent to which systolic function improved. Using 10 open-chest canine preparations, pacing tachycardia and administration of propranolol were imposed to induce various levels of incomplete relaxation. Myocardial length perturbation was induced with an oscillator attached to the LV surface (50 Hz, 1-mm amplitude) and was restricted to the period from the beginning of isovolumic relaxation to end diastole. At resting heart rates, diastolic vibration caused an immediate decrease in the time constant (T) of LV pressure fall without any influence on heart rate, LV peak systolic pressure (peak LVP), stroke volume (SV), LV peak positive dP/dt, and total systemic vascular resistance. With pacing tachycardia, diastolic vibration increased both peak LVP and SV at 160 beats per minute (before) and 120 beats per minute (after propranolol), simultaneously decreasing both T and LV diastolic pressures and increasing end-diastolic segment length. The increase in peak LVP and SV caused by diastolic vibration correlated with the T/diastolic interval (r = 0.82), the assumed index of severity of incomplete relaxation. These results suggest that diastolic vibration accelerates the LV relaxation rate and that this increased relaxation improves systolic function through the Frank-Starling mechanism.


Myocardial uptake of 111In monoclonal antimyosin Fab in detecting doxorubicin cardiotoxicity in rats. Morphological and hemodynamic findings. The therapeutic value of doxorubicin (DOX) is limited by its cardiotoxicity, which is dose dependent. To improve the detection of such myocardial damage, this study was designed to determine whether the 111In antimyosin antibody Fab could serve as a marker for cardiotoxicity in treated versus control rats on the basis of comparative morphological and hemodynamic findings. DOX was administered by intravenous injection to rats at a dose of 3 mg.kg-1.week-1 for 5 weeks. Three weeks after the final injection, an intravenous dose of 111In antimyosin, 740 kBq (20 microCi), was administered, and tissue distribution of the radioisotope (percent kilogram dose per gram) was assessed in 48 hours. Myocardial uptake of radioactivity by both ventricles was more prominent in the DOX-treated rats than in control rats (p < 0.001). The heart-to-blood and heart-to-lung uptake ratios were markedly higher in the treated rats than in controls (p < 0.001). As the severity of the myocardial damage increased, there was a progressive increase in myocardial uptake. There was a strong correlation between the severity of myocardial damage and the ventricular end-diastolic pressure (r = 0.84 and r = 0.83 in the left and right ventricles, respectively). On microscopic immunoautoradiography of the DOX-treated heart, there was a specific immunolocalization of the radiotracer in the injured myocytes but no radioactivity in the control myocytes. 111In antimyosin antibody appears to be a useful immunoradiotracer in detecting cardiac damage induced by DOX administration and in assessing the severity of cardiotoxicity. These data reinforce the clinical observation that myocardial imaging using 111In antimyosin Fab is able to provide information to guide the course of patients receiving DOX treatment.


Effects of calcium channel blockers on calcium uptake in rat aortic valve allografts. The life span of human aortic valve allografts is finite, and many fail because of cusp rupture or calcification. Subcellular changes occurring in aortic valves in response to transplantation include the uptake of calcium. This study uses a heterotropic rat aortic valve transplant model to determine whether the calcium channel blockers diltiazem and verapamil might attenuate leaflet calcification. The 60 rats studied were divided into the following groups: 1) control: valves from normal, unoperated F1 generation of Lewis and Brown Norway cross (LBNF1) rats; 2) control: valves from syngeneic transplant combinations (Lewis/Lewis); 3) control: valves from allogeneic transplant combinations (LBNF1/Lewis, donor/recipient); 4) experimental: valves from allogeneic strain combinations treated with 30 mg/kg per day diltiazem; 5) experimental: valves from allogeneic strain combinations treated with 30 mg/kg per day verapamil. Drugs or saline (controls) were administered with osmotic pumps placed subcutaneously 2 days before transplantation. Animals were killed 3 weeks later, and the valves were harvested and prepared for calcium analysis. Energy-dispersive x-ray microanalysis was used to measure the calcium in a section of one leaflet from each valve studied. Paired t tests showed that allograft valves treated with diltiazem or verapamil contained significantly less calcium than allograft controls treated with saline (p < 0.001). When all five groups were subjected to one-way ANOVA, the valves in the allograft control group contained significantly more calcium than all other groups. All other groups were not different from each other. The calcium channel blockers verapamil and diltiazem were effective in preventing early calcification that occurs in aortic valves after transplantation. Thus, these agents might play a role in prolonging the life of human aortic valve allografts.


Effects of vagal stimulation on cesium-induced early afterdepolarizations and ventricular arrhythmias in rabbits. Previous evidence has shown that increased sympathetic tone enhances the cesium chloride (Cs)-induced early afterdepolarizations (EADs) and ventricular tachycardias (VTs). We assessed the effects of vagal stimulation on Cs-induced EADs and ventricular arrhythmias in the rabbit heart. Monophasic action potentials (MAPs) of the left ventricular endocardium were recorded simultaneously with surface ECG. Two protocols were used: 1) While in their intrinsic sinus rhythm, 11 rabbits were given three intravenous Cs injections (1 mM/kg) 20 minutes apart, and the effects of vagal stimulation on the ventricular arrhythmias thus induced were examined. 2) Under constant atrial pacing (cycle length, 250 msec), EAD amplitude was measured after Cs injection (1 mM/kg) without (five rabbits, control group) or with (four rabbits, vagal stimulation group) vagal stimulation. We observed the following. 1) Cs produced EADs and VTs of polymorphic (PVT) and monomorphic (MVT) types. During PVT, the take-off potential of repetitive premature action potentials in MAP recordings was about the same as the peak level of EADs, and during MVT, the take-off potential was the level of full repolarization. Vagal stimulation suppressed PVT but not MVT. Vagal stimulation after spontaneous termination of MVT restarted MVT of the same morphology at a rate much slower than the preceding sinus rate. 2) EAD amplitude was significantly smaller in the vagal stimulation group than in the control group. The results suggest that PVT originated from triggering by EADs, whereas MVT was of different origin, and that vagal stimulation suppressed PVT by decreasing the amplitude of EADs.


Combination of inhibition of thrombin and blockade of thromboxane A2 synthetase and receptors enhances thrombolysis and delays reocclusion in canine coronary arteries. The efficacy of thrombolytic therapy in treating patients with acute myocardial infarction is limited by failure to achieve reperfusion in some patients, by the prolonged time required to achieve reperfusion, and by reocclusion of some coronary arteries. We designed this study to examine the effect of combined inhibition of thrombin and thromboxane synthesis and blockade of thromboxane A2 receptors in addition to tissue-type plasminogen activator (t-PA) on thrombolysis and reocclusion in an experimental canine model with coronary thrombosis. Blood flow velocity in the left anterior descending coronary artery (LAD) of 32 anesthetized mongrel dogs was monitored by a pulsed Doppler flow probe. Coronary thrombosis was induced by applying electrical stimulation to the LAD at the site where an external constrictor was used to narrow the artery. Three hours after the formation of occlusive thrombus, animals were randomly assigned to receive one of the following: 1) t-PA (80 micrograms/kg + 8 micrograms.kg-1.min-1 i.v.) and saline; 2) t-PA and hirulog, a hirudin-based synthetic peptide and specific thrombin inhibitor (2 mg/kg + 2 mg.kg-1.hr-1 i.v.); 3) t-PA and ridogrel, a combined thromboxane A2 synthetase inhibitor and receptor antagonist (5 mg/kg + 2.5 mg.kg-1.hr-1 i.v.); or 4) t-PA, hirulog, and ridogrel. Reperfusion developed in 14% (one of seven) of dogs treated with t-PA alone at an average of 86 +/- 4 minutes after treatment, in 78% (seven of nine) of dogs treated with t-PA plus hirulog at 53 +/- 11 minutes, in 13% (one of eight) of dogs treated with t-PA plus ridogrel at 85 +/- 5 minutes, and in 88% (seven of eight) of dogs treated with t-PA, hirulog, and ridogrel at 37 +/- 10 minutes (comparison of the frequency of and the time to reperfusion, both p < 0.01). Among the dogs with reestablished coronary blood flow, reocclusion developed in the one treated with t-PA alone at 36 minutes after reperfusion, in seven of the seven treated with t-PA plus hirulog at 66 +/- 15 minutes, and in two of the seven treated with t-PA, hirulog, and ridogrel at 151 +/- 21 minutes (comparison of the frequency of and time to reocclusion, both p < 0.05). Reocclusion was not detected in the one dog treated with t-PA and ridogrel or in the other five dogs treated with t-PA, hirulog, and ridogrel within 180 minutes after reperfusion. Hirulog prolonged and maintained activated clotting times at a level twice that of baseline values. Hirulog inhibited ex vivo platelet aggregation induced by thrombin, and ridogrel inhibited platelet aggregation induced by U46619, a thromboxane mimetic. Inhibition of thrombin in addition to treatment with t-PA enhances thrombolysis. A combination of inhibition of thrombin and thromboxane synthetase and blockade of thromboxane A2 receptor enhances thrombolysis and delays or may prevent reocclusion of the recanalized coronary arteries.


Induction of endothelial cell expression of the plasminogen activator inhibitor type 1 gene by thrombosis in vivo. We have shown previously that products from activated platelets can augment synthesis of plasminogen activator inhibitor type 1 (PAI-1) in cultured endothelial and hepatoma (Hep G2) cells in vitro and increase plasma PAI-1 activity in vivo in rabbits. Accordingly, the effects of activation of platelets associated with thrombosis and thrombolysis in vivo on plasma PAI-1 activity and expression of the PAI-1 gene in endothelium, liver, and other organs were characterized. Endothelial injury giving rise to platelet-rich thrombi was induced with electrical stimulation in carotid arteries in rabbits. Clot lysis and recanalization were induced subsequently with intravenous tissue-type plasminogen activator (t-PA) and verified with Doppler flow probes. Plasma PAI-1 activity (mean +/- SD) increased from 6 +/- 2 arbitrary units (AU)/ml to 129 +/- 48 AU/ml (n = 15) within several hours after recanalization. When t-PA had failed to induce recanalization, the increase was much less (from 7 +/- 2 to 42 +/- 23 AU/ml, n = 11). To define mechanisms responsible for these changes, PAI-1 messenger RNA (mRNA) was evaluated by Northern blot analysis and localized in tissues by in situ hybridization. Strong and consistent induction of PAI-1 mRNA was evident in aorta, heart, and liver of animals subjected to thrombosis (twofold to threefold increases compared with values in controls), particularly in those in which thrombolysis had been induced (fourfold to sixfold). After thrombolysis, an intense, PAI-1 mRNA-specific signal was detected in endothelium of aorta, liver, and heart, with less intense signals in endothelium of lung, adrenals, and kidneys. The increases in plasma PAI-1 activity follow a preceding increase in endothelial cell expression of the PAI-1 gene as reflected by PAI-1 mRNA levels. Thus, increased synthesis of endothelial cell PAI-1 after thrombosis and thrombolysis may attenuate endogenous fibrinolysis early after coronary thrombolysis, thereby potentiating early, thrombotic reocclusion.


CT of pelvic infection after cesarean section. The CT findings in 6 women with puerperal sepsis after Cesarean section were reviewed. In four patients a right-sided mass was palpated. CT scan confirmed the diagnosis of Tubo-ovarian abscess in two of the patients, puerperal ovarian vein thrombosis (POVT) in the third and an enlarged adnexa with no signs of abscess formation in the fourth patient. The last two patients had normal adnexae but a large amount of gas in the uterus. All patients recovered after appropriate treatment. In patients with severe puerperal sepsis who do not respond to antibiotic therapy, CT scanning of the abdomen and pelvis is useful. This study can demonstrate whether there is an abscess which requires surgical intervention or POVT which needs additional anticoagulant treatment.


The effectiveness of danazol therapy in postmenopausal women affected by endometrial hyperplasia. Forty eight patients in postmenopause affected by histologically confirmed endometrial hyperplasia (34 with simplex and 14 with complex forms) were administered Danazol therapy, 400 mg/day for 3 consecutive months. At the end of treatment, regression of the endometrial hyperplasia was histologically ascertained in 46 patients (95.9%) with disappearance of the metrorrhagia. Endometrial atrophy was obtained in 75% of the cases, while secretive (14.7%) or proliferative (6.2%) aspects resulted in the others. Only 2 patients (4.1%) showed persistence of the hyperplastic endometrium. On the basis of this experience, treatment with Danazol appears to be effective and safe with only scarce and transient side effects. This therapy is therefore proposed as a valid alternative to progestogen therapy in cases of postmenopausal endometrial hyperplasia.


Twin pregnancy in a patient with complete heart block. A case report. A 22 year old primigravida with previously undiagnosed congenital complete heart block and a twin gestation is described. Early diagnosis of both problems and cardiac consultation allowed a temporary pacemaker to be inserted early in the third trimester. The patient was delivered by caesarean section at 36 weeks following spontaneous rupture of membranes. Maternal and fetal outcomes were excellent.


Effectiveness of magnesium pidolate in the prophylactic treatment of primary dysmenorrhea. To evaluate Magnesium (Mg) effectiveness in the treatment of primary dysmenorrhea, 30 volunteer dysmenorrheic women of mean age 22.6 years were selected from the out-patients of the Dept. of Obstetrics and Gynaecology of the University of Parma during the period January-December 1989. Patients affected by secondary dysmenorrhea were excluded from the trial. The women considered were asked to self-evaluate their menstrual pain for 6 subsequent cycles using the VAS (Visual Analogue Scale). In the first cycle, as control, no drug was administered; in the following ones, every woman was given 4.5 mg oral Mg Pidolate in 3 administrations daily, from the 7th day preceding the onset of menses till the 3rd day of menstruation. Data were statistically analyzed. In Mg-treated cycles compared with the control one, first day dysmenorrhea progressively decreased, with a significant drop (p < 0.05) from the 1st to the 6th cycle. A similar trend, but not statistically significant, was seen for the 2nd and 3rd day of cycle. No side effect was remarked. These data suggest Mg administration to be a reliable therapy of primary dysmenorrhea.


Vaginal sonography of the endometrium in postmenopausal women. The purpose of this study was to compare transvaginal ultrasound scanning and histology of the endometrium obtained by curettage. One hundred twenty women with postmenopausal bleeding were examined by vaginal sonography, before undergoing curettage. Endometrial thickness, as measured by vaginal sonography, was used as an indicator of endometrial abnormality. The mean endometrial thickness in those women with endometrial cancer was 16.6 +/- 5.4 mm as compared with 3.2 +/- 1.1 mm in those women with atrophic endometrium, and 9.5 +/- 2.3 in those with hyperplasia. If a cutoff limit of 5 mm had been used in this study, 82% of the curettage procedures could have been avoided, without missing a single case of serious endometrial pathology. We conclude that vaginal sonography is a reliable examination in the detection of endometrial abnormality in women with postmenopausal bleeding.


Fertility after ovarian cancer treatment. Considering the important improvement of surgical techniques and chemotherapy in the last few years, it is possible today, in selected cases of patients previously treated for ovarian cancer, to support their desire for motherhood, thus improving the quality of life for them. The major problem for the Gynecologic Oncologist in treating young women for ovarian tumour is the lack of statistically significant experience world-wide, because of the very few cases in which the reproductive function is preserved, and pregnancy is subsequently possible. In this report the problem is discussed, and the results obtained in our Institute are presented.


Hazards from hedgehogs: two case reports with a survey of the epidemiology of hedgehog ringworm. Two related cases of ringworm caused by contact with an infected hedgehog are reported. The causal fungus, Trichophyton erinacei, was isolated from human and animal cases. The epidemiology of hedgehog ringworm is discussed.


Topical fish oil in psoriasis--a controlled and blind study. Omega-3 polyunsaturated fatty acids compete with arachidonic acid as substrates for lipoperoxidases, which transform them into leukotrienes with low biological activity. As this process, in skin, may benefit psoriatic patients, a randomized controlled single blind-study was carried out on a sample of 25 patients. In the study fish oil (FO) was compared with liquid paraffin (LP); both were topically applied and administered daily for 6 h under an occlusive dressing over a 4-week period. Evaluations were performed weekly assessing erythema, scaling, plaque thickness (induration) and itching. The results showed statistically significant improvement in erythema and scaling for both treatments compared to basal values; significant differences between treatments were achieved in scaling but not in erythema. Compared to baseline, FO significantly improved plaque thickness while LP did not. After 4 weeks, FO proved to be significantly better than LP. All patients accepted the treatment despite its unpleasant smell. Irritation and a burning sensation were reported in the FO treated plaque of one patient. This adverse effect reverted after completing the treatment. These findings demonstrate that topical FO shows a better performance than LP under an occlusive dressing.


Topical tretinoin: a new treatment for black hairy tongue (lingua villosa nigra). Black hairy tongue is the name given to the appearance of an abnormal coating of the tongue and occurs only in adults. It is the result of hyperkeratosis of the filiform lingual papillae which, on gross examination appear hair-like with a variable tinctorial aspect from yellow-brown to black. The pathogenesis is unknown and often no definite cause can be identified. A number of aetiologic factors have been implicated including the administration of topical or systemic antibiotics, poor oral hygiene, smoking, alcohol and the use of mouthwashes. Often there are no symptoms other than the aesthetic or anxiety over its aetiology. Some patients complain of gagging, nausea, alteration of taste or halitosis. The condition may be very persistent and recognized treatments include brushing with a soft tooth brush which is enhanced by the prior application of a 40% solution of urea, scraping, topical triamcinolone acetonide, gentian violet, thymol, salicylic acid, vitamin B complex, and surgical excision of the papillae.


A double-blind evaluation of topical isotretinoin 0.05%, benzoyl peroxide gel 5% and placebo in patients with acne. A double-blind, randomized study comparing isotretinoin gel (Isotrex), its vehicle base, and benzoyl peroxide was performed on 77 patients with mild to moderate acne vulgaris. The effect of treatment was assessed by acne grade and lesion count. The vehicle base had no effect, but both active groups produced significant improvements. Benzoyl peroxide and isotretinoin significantly reduced non-inflamed lesions at 4 (P < 0.05), 8 (P < 0.01), 12 (P < 0.01) weeks. Benzoyl peroxide had a more rapid effect on inflamed lesions, their being significant reductions at 4, 8 and 12 weeks (P < 0.01), whereas with isotretinoin there was a significant improvement at 12 weeks (P < 0.01). In addition, compared to placebo, both active treatments significantly reduced inflamed and non-inflamed lesions. Acne grade had improved significantly in the benzoyl peroxide group by 4 weeks (P < 0.01) and in the isotretinoin group by 8 weeks (P < 0.05). No significant change in haematological or biochemical parameters occurred. An irritant dermatitis occurred equally with both treatments but was well tolerated by the patients. This data confirms the clinical benefit of benzoyl peroxide in acne. The initial effect of isotretinoin on non-inflamed lesions in this study suggests that the prime mode of action is on comedone formation or separation whereas benzoyl peroxide has an effect on both comedones and inflammation.


Skin conditions in epileptics.

Skin conditions in epileptics. The prevalence of skin and mucous membrane conditions occurring in 173 epileptics between the ages of 6 and 19 years was compared with that of an age-matched group of 211 non-epileptics. The most frequently used anticonvulants, singly or in combination, were carbamazepine in 54.9%, phenytoin in 47.8%, barbiturates in 36.6% and ethosuximide in 11.2% of epileptics. The most frequent combination was phenytoin and carbamazepine in 14% of the males and 18.4% of the females. An increased prevalence of acne was found in epileptic females; 80.3% compared to 30.2% in non-epileptic females. Hirsutism was found in 43.9% of the female epileptics compared to 7.5% of the non-epileptic females. Of interest was the finding of punctate and linear scars on the dorsum of the hands of 27.7% epileptics compared to 3.8% non-epileptics. Both ephilides and naevocellular naevi occurred in 12.7% of the epileptics compared to 29.4% and 52.1% respectively of the non-epileptics. Leukonychia was also found more frequently in epileptics than in non-epileptics; 52% and 28.9% respectively.


Seborrhoea--an indicator for poor clinical response in acne patients treated with antibiotics. The relationship between sebum excretion rate (SER) and clinical improvement was investigated in 255 acne patients treated for 6 months with either oral erythromycin (1 g/day), minocycline (100 mg/day), oxytetracycline (1 g/day) or cotrimoxazole (400 mg/day); topical therapy was 5% benzoyl peroxide. In all but the cotrimoxazole treated group, there was a significant correlation between a high SER and reduced clinical response. This was particularly evident in those patients with an SER of greater than 2.5 micrograms/cm2/min. These patients showed only 17% improvement compared with 100% improvement in those subjects with an SER of 1.0 micrograms/cm2/min or less. The presence of obvious seborrhoea in a patient who has failed to respond to an adequate 6-month course of antimicrobial therapy, should indicate the earlier rather than later use of isotretinoin for their acne.


Coexistence of numerous superficial basal cell epithelioma of the back and non-specific ulcers of the small intestine: occurrence of two rare diseases in the same patient. A 53-year-old female developed multiple disseminated brownish macules that were confirmed histologically as superficial basal cell epitheliomas on her lower back. She also suffered from short bowel syndrome after repeated resection of a segment of the small intestine because of non-specific ulcers of the small intestine, a rare ulcerative disorder of unknown aetiology. The association of these two rare conditions in the same patient is of interest because it may be more than a simple coincidence.


Reticulate porokeratosis--successful treatment with CO2-laser vaporization. A 35-year-old male patient affected with extensive, itching skin lesions of reticulate porokeratosis is reported. He was successfully treated by CO2-laser vaporization.


Unilateral linear capillaritis.

Unilateral linear capillaritis. We present four cases of a distinctive type of pigmented purpuric eruption occurring in a striking linear and pseudo-dermatomal distribution in young males. Whilst these cases share some of the clinical and histological features of other pigmented purpuric dermatoses, they are not readily classified with any of the entities so far defined in this group of disorders. We believe these cases represent a distinct group not previously described. Four patients with an unusual pigmented purpuric eruption are presented.


Inflammatory ringworm with unusual features. Zoophilic dermatophyte infections are often inflammatory but severe widespread inflammatory lesions of glabrous skin, as in the female patient described, are unusual. Most cases of M. canis ringworm can be traced to an infected animal. This dermatophyte is associated with a variety of clinical presentations on glabrous skin and is being isolated with increasing frequency in some countries.


Hereditary hypotrichosis (Marie-Unna type) and juvenile macular degeneration (Stargardt's maculopathy). Hypotrichosis of the Marie-Unna variety is a distinctive syndrome eponymously named following a publication in 1925 describing a family in which 27 individuals in seven generations were affected by a previously unreported type of hypotrichosis. Its inheritance is determined by an autosomal dominant gene and it usually occurs as an isolated abnormality. Hereditary macular degeneration (Stargardt's maculopathy) is also well recognized and has been reported in one family in association with alopecia areata but never in association with Marie-Unna hypotrichosis. Inheritance of Stargardt's maculopathy is autosomal recessive. Our patient demonstrates the co-existence of these two uncommon genetic disorders and it would appear that both defects have been independently inherited.


Subcutaneous nodules as the first clinical manifestation of sarcoidosis. We report the case of a 61-year-old male who presented with a febrile illness accompanied by arthralgia and myalgia. Two months later he developed multiple subcutaneous nodules and enlarged parotid glands. Later two erythematous plaques, clinically compatible with erythema nodosum (EN), were observed. Laboratory investigations revealed abnormal levels of angiotensin converting enzyme and chest radiography showed bilateral hilar enlargement. The biopsy of the cutaneous lesions demonstrated multiple non-caseating granulomas in the subcutaneous tissue without any alterations in the epidermis and the dermis. The cultures for Mycobacteria and fungi were both negative. The clinical picture and histopathological findings were compatible with subcutaneous nodular sarcoidosis. The response to steroid treatment was satisfactory.


Localized multiple neurofibromas.

Localized multiple neurofibromas. Two cases of localized multiple neurofibromas are reported. The patients had fairly large, closely grouped neurofibromas limited to a circumscribed part of the body, a very different clinical feature from segmental neurofibromatosis, but with otherwise had typical histopathological features. Possible aetiology is discussed.


Wegener's granulomatosis presenting as pyoderma gangrenosum. We report three cases of Wegener's granulomatosis presenting with cutaneous ulceration resembling pyoderma gangrenosum. Wegener's granulomatosis classically affects the upper and lower respiratory tracts and the kidneys. Skin involvement occurs in up to 50% of patients. Increased awareness that cutaneous involvement can take the form of pyoderma gangrenosum and that it can be a presenting sign may lead to more rapid diagnosis of Wegener's granulomatosis.


Hailey-Hailey disease--exacerbation by herpes simplex virus and patch tests. Benign familial chronic pemphigus, or Hailey-Hailey disease, is a rare hereditary condition characterized by development of blisters at sites of friction such as the neck, axillae and groin. Contact sensitivity to topical medications is reported to be common and routine patch testing has been strongly advocated. We report a case of Hailey-Hailey disease in a 43-year-old veterinary surgeon who presented with an acute exacerbation of his disease caused by herpes simplex virus type 1 (HSV). Patch testing was carried out to exclude a coexistent contact dermatitis and was complicated by severe local blistering. We are reporting this case to remind clinicians that HSV is a recognized cause of exacerbations of this disease and to warn that patch testing is not without hazard.


Acute monocytic leukaemia in a HIV-seropositive man. Individuals infected with the human immunodeficiency virus (HIV) have been reported to develop a number of malignant neoplasms. We recently treated an HIV patient who had acute monocytic leukaemia which was first evident in the skin. To our knowledge, this is the first report of a case of acute monocytic leukaemia occurring in a HIV-infected person.


Acquired eruptive haemangiomata with primary biliary cirrhosis and prostatic carcinoma. We report a male patient with acquired eruptive haemangiomata occurring in association with primary biliary cirrhosis and a carcinoma of the prostate. The possible explanations include an abnormality of sex sterol metabolism associated with his liver disease, secretion of an angiogenic factor by his carcinoma or a combination of the two mechanisms.


Atypical systemic sclerosis following exposure to vinyl chloride monomer. A case report and review of the cutaneous aspects of vinyl chloride disease. An unusual case of systemic sclerosis occurring in a patient exposed to the vinyl chloride monomer (VCM) is presented. The dermatological aspects of vinyl chloride disease (VCD) are outlined and the mechanisms of pathogenesis discussed.


Normolipaemic plane xanthomas: an association with increased vascular permeability and serum lipoprotein(a) concentration. We present a normolipaemic young man with extensive facial plane xanthomas and xanthelasmas with a high level of lipoprotein(a) and possibly increased vascular permeability. These associations are of potential importance in understanding the pathogenesis of xanthoma formation and in the identification of patients at risk from coronary atherosclerosis.


Selenium plasma levels in psoriasis.

Selenium plasma levels in psoriasis. Little is known about factors that may have modulating effects on inflammatory diseases such as psoriasis. Recently it has been proposed that trace elements like selenium may play an active role. Selenium concentrations were determined in plasma and in whole blood from 64 patients with psoriasis. Values were compared with those of matched controls: no significant reduction was observed in contrast with previous reports of reduced selenium levels in psoriasis.


Factitious purpura.

Factitious purpura. Factitious purpura may present as a perplexing problem for the dermatologist and can mimic serious disease. This form of mechanical purpura, often caused by suction may be deliberately or unknowingly induced by the patient. Some cases may go unrecognized for a considerable length of time and undergo unnecessary investigation before the diagnosis is realized. Three cases of purpura are reported in which the causative agents were very different.


Flow cytometry analysis of adhesion molecules on human Langerhans cells. The Langerhans cell (LC) migrates between the epidermis and the regional lymph nodes to present antigens. This migration pattern requires the expression of a changing repertoire of cell-surface molecules. In this work, we have investigated the expression of the adhesion molecules CD 11/CD 18 and CD 58 on LCs. Human epidermal cell suspensions were enriched in LCs (mean enrichment 75%) using a two-step technique including a Ficoll-Hypaque gradient followed by Fc receptor panning with IgG-coated sheep erythrocytes. The number of cells obtained per experiment was 750,000 (extremes 280,000-1,800,000), and the following antibodies were tested on fresh suspensions and/or after 48 hours in culture: BB3 (antithyroglobulin negative control IgG2a), OKT6 (anti CD1a, Ortho), anti HLA-DR (Becton-Dickinson), MHM 24 (anti CD 11a, leukocyte typing workshop n(0)3), MO1 and 44 (anti CD 11b, leukocyte typing workshop n(0)3), anti CD 11c (Immunotech), 60.3 and MHM 23 (anti CD 18, leukocyte typing workshop n(0)2), TS2/9.1.1 (anti CD 58, leukocyte typing workshop n(0)3). We found that amongst CD 11 subunits, only CD 11c was expressed in fresh suspensions, but was weaker than CD 18, and disappeared with culture. CD 58 was not detected in fresh suspensions but appeared after 2 days of culture, confirming earlier work. Thus the LC exhibits cell surface characteristics similar to tissue macrophages (CD 18 and CD 11c) prior to culture. The expression of CD 58 after culture is in accordance with the interaction of LC with CD2 bearing T-lymphocytes during antigen presentation in peripheral lymph-nodes.


An evaluation of the irritancy potential of povidone iodine solutions: comparison of subjective and objective assessment techniques. A double-blind study has been carried out in 12 normal volunteer subjects in order to determine the relative irritancy of povidone-iodine solutions. Aqueous solutions of 10% povidone-iodine (PI), standardized 10% povidone-iodine (SPI) and reformulated standardized 10% povidone-iodine (RSPI) were applied to the backs and occluded using aluminium chambers. At 1, 2, 3, 4, 5, 6, and 8 hours, chambers were removed and the degree of cutaneous irritancy assessed. As well as subjective assessment of erythema, objective measurement of skin colour was performed using an erythema meter. In addition, laser Doppler blood-flow measurements have been carried out. The results show a rapid increase in cutaneous irritancy as evidenced by an increase in visual scores of erythema, increased erythema meter readings and increased cutaneous blood-flow. The increase was greatest for SPI treated sites for all three methods. Statistically these differences were significant at P < 0.05. Thus in this controlled study it has been possible to discriminate between the similar formulations in terms of their cutaneous irritancy.


Acute Achilles tendonitis following oral isotretinoin therapy for acne vulgaris. We report three cases of acute Achilles tendonitis following administration of isotretinoin for acne vulgaris. In this rarely documented side-effect, the symptoms were intimately related to the isotretinoin therapy. Modification of dose regimes permitted control of the tendonitis and an eventual successful response to isotretinoin therapy. Oral isotretinoin has been in use for more than 10 years and is known to cause a wide variety of predictable side-effects the most common of which are cutaneous and dose related. Musculoskeletal problems are also well known to occur and these include myalgia, arthralgia and less commonly arthritis and muscle damage, however, isolated Achilles tendonitis has been reported on a rare and sporadic basis. We wish to report a series of three patients who developed acute Achilles tendonitis during administration of isotretinoin for acne.


The efficacy of methotrexate in psoriasis--a review of 40 cases. Forty patients with psoriasis treated with methotrexate (MTX) are reviewed. MTX was particularly effective in controlling erythrodermic and generalized pustular psoriasis. The treatment was discontinued in seven patients due to nausea in two and because of abnormal laboratory tests in five. Two patients developed toxic epidermal necrolysis (TEN) and died. Patients under 60 years of age had a liver biopsy before treatment and repeat biopsy after each cumulative MTX dose of 1500 mg. We consider that MTX is the drug of choice for treating difficult psoriasis.


Myiasis due to Parasarcophaga argyrostoma--first recorded case in Britain. A case is described of a 79-year-old man in whom a gangrenous toe was invaded by maggots of the flesh fly Parasarcophaga argyrostoma. This is the first recorded case of myiasis by this fly in Britain.


Toxic epidermal necrolysis treated with cyclosporin. Toxic epidermal necrolysis (TEN) is a severe life-threatening disorder which has many features in common with graft-versus-host disease. However, immunosuppression with steroids gives disappointing results and is possibly detrimental. We treated two patients who had TEN with a combination of cyclosporin and steroids which resulted in an apparent halt to the evolution of the disease, and a further relapse was aborted using cyclosporin in one of these patients. We feel that the use of this drug in the early treatment of TEN where it is used as a specific therapy aimed at the primary immunopathological events and is used in conjunction with the supportive care patients require, needs to be further evaluated.


Skin nodules and macules resembling vasculitis in the antiphospholipid syndrome--a report of two cases. Two patients who demonstrated skin lesions in the presence of antiphospholipid antibodies are documented. The first had a long history of recurrent painful nodules. She had also suffered two deep vein thromboses. The second developed a rash on the lower limbs resembling vasculitis which did not respond to prednisolone, but to low dose salicylate therapy. Histology in both patients revealed microthrombosis of cutaneous vessels.


A primary cutaneous multi-lobed B-cell lymphoma. Multi-lobed non-Hodgkin's lymphoma (NHL) has recently been recognized as a NHL variant. A patient presented with a scalp nodule which, upon skull X-Ray, was seen to be associated with a bone defect. Immunophenotyping clearly demonstrated that this was a B-cell proliferation. Histologically the B-lymphocytes were closely related to centroblasts. There were no other extra cutaneous localizations. The present report emphasizes the importance of this clinico anatomical entity which shows prominent extra-nodal involvement, large lymphoid cells with multi-lobed nuclei and a good response to chemotherapy. Multi-lobed NHL may be a T-cell lymphoma, or a B-cell lymphoma closely related to centroblastic NHL. Although multi-lobed lymphomas have a predilection for cutaneous localizations, our case is the first primary cutaneous multi-lobed B-NHL, proven by immunophenotyping.


Leukonychia due to cytostatic agents.

Leukonychia due to cytostatic agents. Chromonychia induced by antineoplastic agents has been known for several years. The most frequent of these is melanonychia, either diffuse or in tranverse or longitudinal bands, that may co-exist with diffuse pigmentation of the skin. Although any cytostatic agent may be involved in melanonychia, this condition appears most commonly after treatment with adriamycin and cyclophosphamide or in polychemotherapy. Leukonychia, either true or apparent, seems to be less frequent and is the reason for our reporting two patients with this colour change.


Langerhans-cell histiocytosis in an adult patient with multiple myeloma. A 44-year-old man who had suffered for 6 years from multiple myeloma developed multiple papules on the face and chest. Histological examination of these papules revealed the infiltration of predominantly histiocytic cells into the dermis and into parts of the epidermis. These cells were seen on electron-microscopic study to have Langerhans granules in the cytoplasm, which led to a diagnosis of Langerhans-cell histiocytosis concomitant with multiple myeloma. Possible explanations for this unusual association are discussed.


Skin metastasis in laryngeal carcinoma.

Skin metastasis in laryngeal carcinoma. Cutaneous metastases from carcinoma of the larynx are very rare. We observed a 64-year-old Japanese patient with squamous cell carcinoma of the larynx who developed a subcutaneous nodule on the abdomen. It was found to be a metastatic tumour from the laryngeal cancer, histopathologically as well as histochemically.


Elevation of feline interleukin 6-like activity in feline immunodeficiency virus infection. The involvement of feline interleukin 6 (IL-6)-like activity in polyclonal B-cell activation in feline immunodeficiency virus (FIV) infection was investigated by using the proliferative response of hybridoma cell clone B3B1. Cats spontaneously infected with FIV had hyperimmunoglobulinemia, as shown by increases in the percentage of gamma-globulin and the plasma IgG concentration and decrease in the albumin/globulin (A/G) ratio. Because IL-6 plays an essential role in the differentiation of activated B cells into Ig-secreting cells, we examined the effect of FIV infection on the plasma IL-6 level. Plasma IL-6-like activity was found to be significantly higher in FIV-infected cats than in healthy controls. Peripheral blood mononuclear cells (PBMC) isolated from FIV-infected cats and cultured without any exogenous activators of IL-6 production released more feline IL-6-like activity than cells from healthy controls. This phenomenon was mainly due to the increase in the production of IL-6 by adherent cells such as monocytes/macrophages, but also partly by nonadherent cells. These results indicate that elevation of feline IL-6-like activity is associated with FIV infection and that overproduction of IL-6 may contribute to the polyclonal B-cell activation seen in FIV infection.


Expanded macrophage precursor populations in BXSB mice: possible reason for the increasing monocytosis in male mice. The BXSB mouse spontaneously develops an autoimmune disease that resembles human systemic lupus erythematosus (SLE). During their lifetime, male BXSB mice show an increasing monocytosis in the peripheral blood as opposed to their female littermates. This monocytosis is unique among autoimmune-prone mice. To test the hypothesis that alterations at the stem cell level may be responsible for this monocytosis, myeloid bone marrow precursor cells were examined in both male and female BXSB mice from 4 to 40 weeks of age. The number of M-CSF responding stem cells (CFU-M) and the number of GM-CSF responding stem cells (CFU-GM) were higher than in all other inbred mouse strains tested. In addition, male BXSB mice developed a progressive increase of CFU-M and CFU-GM in the bone marrow during their lifetime, which paralleled the peripheral blood monocytosis. The monocytosis in male BXSB mice is the result of a further expansion of the strain-specific high number of macrophage precursors by intrinsic factors, which may be attributed to the influence of the Yaa factor. The sex-specific expanded mononuclear phagocyte system may promote the autoimmune process and may be one reason for the dramatic course of murine SLE in male BXSB mice.


Attenuation of murine acute lethal graft-versus-host disease by the administration of DL-alpha-difluoromethylornithine. Intravenous injection of 5 x 10(7) C57BL/6 (B6) lymphocytes into adult (C57BL/6 x DBA/2)F1 recipient mice results in acute lethal graft-versus-host (ALGVH) disease. This disorder is characterized by anemia, a diminished number of splenocytes, impaired cytotoxicity (CTX) against third party alloantigen, and impaired natural killer cell (NK) activity. Parental anti-F1 CTX is critical to the induction of ALGVH disease, and CTX in general has been reported to be dependent upon the presence of the low molecular weight polyamines essential for cell growth and differentiation. We now report that DL-alpha-difluoromethylornithine, a specific inhibitor of polyamine biosynthesis, attenuates the clinical expression of disease in mice undergoing ALGVH disease.


Immune response to tumor antigens in a patient with colorectal cancer after immunization with anti-idiotype antibody. An active vaccination protocol was performed on one patient with colon carcinoma as a pilot to a prospective randomized double-blind clinical trial with the vaccine SDZ SCV 106. This vaccine is an anti-idiotype goat antibody to the monoclonal antibody 17-1A, which is directed against the tumor antigen 17-1A. To study the effect of the therapy on the immune reactivity, several tests were performed to detect anti-tumor antibodies in the serum as well as in eluates of metastatic tissue. Furthermore metastases removed from the lung were examined by immunohistochemistry. The results suggest that the humoral and cellular immune reactivity against the tumor are enhanced.


Cytokine production and serum levels in systemic sclerosis. Serum levels of various cytokines, tumor necrosis factor-alpha (TNF-alpha), interleukin 1-beta (IL1-beta), and interleukin 2 (IL2), and of soluble IL2 receptors (sIL2R) were determined in 30 patients with definite systemic sclerosis (SSc). Spontaneous and lipopolysaccharide-or mitogen-induced production of the cytokines, TNF-alpha, IL1-beta, and IFN-gamma, by peripheral blood mononuclear cells (PBMNC) of these SSc patients was measured by immunoassays. The patients were divided into three groups: 12 with limited cutaneous disease (lcSSc), 7 with diffuse cutaneous disease (dcSSc) < 3 years duration, and 11 with dcSSc > 3 years duration. None were treated with cytotoxic drugs or biologic response modifiers. Sera of patients with SSc had elevated sIL2R levels, and only low levels of IL2 (1-2 U/ml) were detected in 10/29 sera tested. Spontaneous production of TNF-alpha and IL1-beta by PBMNC of patients with SSc (829 pg/ml +/- 215 SEM and 728 pg/ml +/- 186, respectively) was significantly higher than that by normal PBMNC obtained from 30 volunteers (25 +/- 10 and 34 +/- 6 pg/ml, respectively) and tested at the same time as patients' PBMNC. The largest increases in spontaneous release of TNF-alpha or IL1-beta were seen in patients with early dcSSc. No significant difference in spontaneous IFN-gamma production by patient or control PBMNC was detected. On the other hand, the mean level of mitogen-induced IFN-gamma production by PBMNC was significantly depressed in patients with SSc (103 U/ml +/- 18 vs 255 +/- 33 U/ml in controls). In vitro-induced production of TNF-alpha or IL1-beta by patients' PBMNC was comparable to that of normal PBMNC. These data indicate that in vivo-activated PBMNC of patients with SSc spontaneously secrete excessive amounts of fibrogenic cytokines, which are involved in modulation of connective tissue synthesis.


Parathyroid hormone inhibits immunoglobulin production without affecting cell growth in human B cells. The effect of parathyroid hormone (PTH) on immunoglobulin (Ig) production and proliferation in the human B-cell lines CBL, SKW, and CESS was studied. PTH inhibited Ig production from all the B-cell lines in a dose-dependent manner during 5 days of culture. As little as 0.1 ng/ml was inhibitory. PTH also inhibited Ig production from cell lines stimulated by vasoactive intestinal peptide (VIP), interleukin 2 (IL-2), and IL-6. This inhibition was not due to decreased cell growth since proliferation was not affected and cell viability was always greater than 98%. In contrast to PTH, inactivated PTH or triiodothyronine failed to affect Ig production. Inhibition by PTH was blocked by anti-PTH serum, but not by control serum. Of the various cytokines tested, IL-4 reduced the PTH-induced inhibition of Ig production, whereas other cytokines, including IL-1 beta, IL-3, IL-5, interferon alpha (IFN-alpha), IFN-gamma, and granulocyte-macrophage colony-stimulating factor (GM-CSF), failed to do so. The reducing effect of IL-4 was blocked by anti-IL-4 antibody but not by control antibody. Moreover, IFN-alpha and IFN-gamma, but not GM-CSF, overcame the reducing effect of IL-4. PTH also inhibited IgG, IgM, and IgA production by tonsillar B cells stimulated with Staphylococcus aureus Cowan strain I (SAC) and IL-6 without affecting proliferation. This inhibition was blocked by anti-IL-4 antibody but not by control antibody. These results indicate that, in addition to its regulatory effect on calcium metabolism, PTH also acts as an immunoregulatory factor, and that it interacts with the cytokine, IL-4.


Association between mast cells and the development of experimental autoimmune uveitis in different rat strains. To study the role of anterior uveal mast cells in experimental autoimmune uveitis (EAU), the mast cells in the iris and ciliary body of Lewis rats, Brown Norway (BN) rats, and their F1 hybrids (LBNF1) were quantitated in normal rats and during the induction period of EAU. The mean baseline mast cell number was 68.9 +/- 10.8 per anterior uvea for Lewis rats, 0.3 +/- 0.2 for BN rats, and 4.6 +/- 0.6 for LBNF1 rats. Detectable mast cells in the anterior uvea of S-Ag-immunized Lewis rats decreased to 60% of control at 6 days postimmunization, recovered to 80% at 10 days, and dropped again to 16% at 13 days, with disease onset around 14 days. In Lewis rats that were adoptively transferred with a uveitogenic T-lymphocyte line, a profound drop in anterior uveal mast cell numbers occurred in the eyes with early signs of EAU, 3 days after the transfer. The decrease in detectable mast cells is consistent with mast cell degranulation. The data suggest that anterior mast cells participate in the immunopathogenesis of EAU and may influence the genetic susceptibility to EAU.


Effect of exogenous cytokines on the inhibition of macrophage-induced, antigen-specific T cell proliferation by poly(I:C). We have previously demonstrated that IFN-alpha/beta, poly(I:C) (an inducer of IFN-alpha/beta), or IFN-gamma can inhibit the ability of KLH-pulsed peritoneal macrophages (M phi) to induce the proliferation of syngeneic, KLH-immune T lymphocytes from CBA/J mice. In this study we investigated whether the mechanism by which poly(I:C) inhibits M phi-induced, antigen-specific T cell proliferation involved decreased cytokine production by poly(I:C) treated KLH-pulsed M phi or by T cells cultured with these M phi. The production of IL-2 by T cells cultured with poly(I:C)-treated, KLH-pulsed M phi was decreased by 80%; however, addition of exogenous rIL-2 could not restore proliferation. Although IL-1 production by poly(I:C)-treated M phi was comparable to the level produced by saline-treated, KLH-pulsed M phi controls, addition of exogenous rIL-1 was still examined to explore the possibility that a greater amount of IL-1 may be needed to induce T cell proliferation with poly(I:C)-treated, KLH-pulsed M phi. Increasing concentrations of rIL-1 alone or with rIL-6 did not abrogate the inhibition of M phi-induced, antigen-specific T cell proliferation by poly(I:C). Interestingly, the addition of combinations of IL-1 and IL-6 increased the proliferation of T cells in response to KLH presented by either saline- or poly(I:C)-treated M phi. The effect of the combination of rIL-1 and rIL-6 was synergistic in that addition of either monokine alone had no effect on T cell proliferation. These results suggest that although poly(I:C)-induced inhibition of T cell proliferation is not due to insufficient quantities of IL-1, IL-2, or IL-6, a combination of IL-1 and IL-6 can augment proliferation of freshly isolated T cells in response to antigen presented by freshly isolated accessory cells.


Heterozygosity of the major histocompatibility complex controls the autoimmune disease in (NZW x BXSB) F1 mice. In the F1 hybrid of phenotypically normal NZW (H-2z) and systemic lupus erythematosus (SLE)-prone BXSB mice (H-2b), features of the disease became more severe than those seen in the BXSB mice, regardless of the presence or absence of the Yaa (Y-chromosome-linked autoimmune acceleration) mutant gene. To determine whether the gene(s) linked to the major histocompatibility complex (MHC) of NZW mice is involved in this event, we developed the H-2-congenic NZW.H-2d strain and compared the severity of autoimmune disease between (NZW x BXSB) F1 (H-2z/b) and (NZW.H-2d x BXSB) F1 mice (H-2d/b). The H-2z/b, but not H-2d/b, heterozygous F1 mice of both sexes showed an accelerated, higher incidence of proteinuria and a more severe thrombocytopenia than did the BXSB mice. In NZW x (NZW x BXSB) F1 backcross mice, the H-2z/b heterozygous progeny showed more severe disease than did the H-2z/z homozygotes. Thus, disease-accelerating events in (NZW x BXSB) F1 mice are linked to the H-2z/b heterozygosity. Because H-2d/z heterozygosity plays a crucial role for SLE in (NZB x NZW) F1 mice, in which SLE features differ from those in (NZW x BXSB) F1 mice, the present observations may imply that the different but related MHC heterozygosity acts as a predisposing genetic element in these different SLE syndromes.


Classification of diabetes in patients with end-stage renal disease. Validation of clinical criteria according to fasting plasma C-peptide. An epidemiologic study of end-stage diabetic nephropathy in France (Uremidiab) was performed, aiming to establish the prevalence of both types of diabetes in dialysis patients. Because discrimination between type I and type II diabetes remains mostly clinical, our aim was to evaluate what the most fitted clinical criteria were. We studied 494 hemodialyzed diabetic patients. A first classification (Cn) was offered by the nephrologist. Clinical data of 472 patients (22 patients of the 494 have been excluded) were then collected with a standardized questionnaire, allowing one diabetologist of us to establish the diagnosis of type of diabetes (classification Cd). Plasma C-peptide at this stage of the disease was expected to be very discriminative, measured in 88 patients and defined classification Ccp (< or = 0.6 ng/ml = "negative C-peptide" = type I, > 0.6 ng/ml = "positive C-peptide" = type II). Classification Cd observed 98 type I and 374 type II diabetes. Cn overestimated type I diabetes, 37% of type II diabetes being misclassified because insulin-treated. Classification Ccp observed 74 positive C-peptide patients, classified as type II, among whom 45 were insulin-treated. Only 3 patients were discordant for classification Cd and Ccp. Predictive value of "negative C-peptide" and "positive C-peptide" were 100% and 96% respectively. Multiple regression analysis of the Ccp classification was performed with the clinical criteria and showed very significant correlation with: age at the time of diagnosis of diabetes (AGE), maximal body mass index ever reached (BMI MAX) and delay between diagnosis and consistent insulin use (DI).(ABSTRACT TRUNCATED AT 250 WORDS)


Proteinuria and renal function in relation to renal morphology. A clinicopathological study of IgA nephropathy at the time of kidney biopsy. At the time of kidney biopsy the pattern of urinary protein excretion (UPE) and renal function were studied in 54 patients (age 16-62 years) with IgA nephropathy (IgAN). Serum and urinary albumin (alb), IgG, beta-2-microglobulin and creatinine were analysed, and excretion rates (UV) and clearances were calculated. The glomerular filtration rate (GFR) was determined by plasma 51Cr-EDTA clearance (51Cr-EDTA) and by 24-hour creatinine clearance (C-Cr 24 h). Glomerular mesangial (volume expansion and cell proliferation), tubulo-interstitial (fibrosis and inflammation) and vascular lesions were classified semiquantitatively on a five-degree scale, and the percentage of glomeruli showing global sclerosis, segmental sclerosis and cellular crescents was calculated. One third of our patients had reduced renal function, three patients uremia and 70 per cent of the patients overt albuminuria. The mean GFR was reduced in microalbuminurics and further decreased in albuminurics and nephrotics. A lower GFR and more proteinuria were found in the patients with more advanced morphological lesions also when the uremic patients were excluded. Segmental glomerular sclerosis correlated with GFR as well as with UalbV and UIgGV, while global sclerosis correlated only with GFR. UalbV and UIgGV also correlated with the extent of interstitial damage but not with mesangial lesions. In summary an accurate determination of GFR and UPE at the time of the kidney biopsy may give an indication of the extent of renal damage. A lowered GFR was also found in mild proteinuria.(ABSTRACT TRUNCATED AT 250 WORDS)


Growth, serum lipoproteins and apoproteins in infants with congenital nephrosis. Retarded growth and extremely high cholesterol levels have been reported in infants with congenital nephrotic syndrome of the Finnish type (CNF). In an attempt to normalize growth and lipid disturbances the high-calorie diet (130 kcal/kg/d) containing protein 4 g/kg/d and supplemented with unsaturated fatty acids (mean P/S-ratio 1.40) was given to ten infants with CNF from birth. Growth, lipoprotein and apoprotein concentrations were measured. All patients exhibited normal growth, which allows renal transplantation, the only life-saving treatment in CNF, already at an early age. In spite of the diet lipid profiles at 3 and 9 months revealed marked elevation of triglyceride in all lipoproteins, especially in VLDL fraction, compared to controls. The abnormalities increased significantly with time (p for VLDL-TG 0.04). The elevation of serum cholesterol was mainly attributable to the increase of cholesterol in triglyceride-rich particles (chylomicrons, VLDL, IDL). Analysis of VLDL, LDL and HDL revealed significant triglyceride enrichment and cholesterol deficiency in all lipoproteins. The concentrations of the low-molecular weight apoproteins A-I and A-II were significantly decreased, but the concentration of high-molecular apo B was high. Urinary analysis revealed progression and decreasing selectivity of proteinuria with time. Thus the mechanisms leading to lipid abnormalities in CNF are multiple including stimulated hepatic lipoprotein synthesis, impaired conversion of VLDL and IDL to LDL, compositional changes, urinary loss of low-molecular apoproteins and presumably reduced LPL activity. The abnormalities indicate an increased risk of arteriosclerosis in CNF patients.


Lipids and apolipoproteins change during the progression of chronic renal failure. Uremic hyperlipidemia was recently suggested to contribute to progression of chronic renal failure (CRF). To investigate the relationship between lipoprotein abnormalities and decline of renal function, plasma lipids with apoproteins A1, B, E, CII, CIII, CII/CIII and E/CIII ratios, parathyroid hormone (PTH), insulin and glucose levels were examined in 72 patients with different degrees of CRF and compared to 28 patients of a reference group. A significant decrease of CII/CIII ratio was already evident below a Ccr of 60 ml/min, while increased apo-CIII and triglycerides (TG) with reduced HDL-cholesterol (HDL-C) levels occurred below a Ccr of 30 ml/min. Both TG and apo-CIII showed a positive correlation with creatinine levels. On the contrary, apo-CII/apo-CIII and HDL-C inversely correlated with the progression of renal failure. PTH and insulin showed a positive correlation with TG, the former being also inversely related to apo-CII/apo-CIII ratio. Our results point to early apolipoprotein changes in the course of CRF. Elevated apo-CIII and reduced apo-CII/apo-CIII ratio may be considered the most typical features of uremic hyperlipidemia and likely account for the impaired TG removal and the hypertriglyceridemia (HTG). Secondary hyperparathyroidism may contribute to reduce peripheral lipolytic activity and cause HTG. A contributory role of hyperlipidemia in the progression of renal disease is also supported.


High serum lipoprotein(a) concentrations in uremic patients treated with continuous ambulatory peritoneal dialysis. We measured serum lipoprotein(a) [Lp (a)] concentrations in 50 uremic patients treated on continuous ambulatory peritoneal dialysis (CAPD) and compared them with those in 29 uremic patients on hemodialysis (HD) and those in 62 normal controls. The median values were 47.9 mg/dl in CAPD patients, 25.2 mg/dl in HD patients, and 11.7 mg/dl in controls, respectively. These differences were statistically significant when assessed by Kruskal-Wallis test (p < 0.0001). Thirty-five out of 50 patients on CAPD (70%) and 12 out of 29 patients on HD (41%) had Lp(a) concentrations above 30 mg/dl, whereas these high values were observed in only 15% of normal controls. This difference in prevalence of high Lp(a) was also significant by 2 x 3 chi-square test (p < 0.01). There was a significant positive correlation between Lp(a) and apolipoprotein B (r = 0.517, p < 0.0001). In CAPD patients, 9 with ischemic heart disease had a significantly higher median Lp(a) than those without it (67.4 vs 40.9 mg/dl, p < 0.01 by Mann-Whitney U-test). These results suggest that high levels of serum Lp(a) might contribute to an increased risk for ischemic heart disease in CAPD patients, and that there may be a relationship between Lp(a) and apolipoprotein B metabolism in CAPD patients.


The effects of recombinant human erythropoietin on hemostasis and fibrinolysis in hemodialysis patients. Thromboembolism might complicate the treatment of patients with chronic renal failure with Recombinant Human Erythropoietin (ReHuEPO). In order to detect prothrombotic changes, a number of hemostatic and fibrinolytic parameters was determined during ReHuEPO treatment of fifteen chronic hemodialysis patients (mean age 47.1 years; ten females, five males). To avoid the influence of hemoconcentration and/or dilution, the patients were kept normovolemic, using the method of echography of the inferior vena cava diameter. In a first group of eight patients, we investigated platelet count and function. During ReHuEPO, a significant rise of hematocrit (19 +/- 3 to 34 +/- 5%, p < 0.001) was observed. Bleeding time shortened (7'33'' +/- 3'39'' to 3'41'' +/- 3'19''; p < 0.001) and platelet count increased (222 +/- 45 to 254 +/- 49 10 9/l; p < 0.005). The initial negative in vitro spontaneous platelet reactivity became positive in two of them, whereas the decrease in ADP threshold in the whole group (2.0 +/- 0.1 to 1.10 +/- 0.4 mumol, p < 0.02) indicated an increased induced platelet reactivity. In all patients prothrombotic changes were observed. The protein-C antigen and protein-C activity and the total and free protein-S antigen decreased significantly. The plasminogen activator inhibitor (PAI) activity in the whole group did not change significantly (6.4 +/- 4.1 to 5.4 +/- 4.8 AU/ml). However, in the patients with fistula thrombosis (n = 3), higher values in all test points were found compared to those without thrombosis.


RBC improved survival due to recombinant human erythropoietin explains effectiveness of less frequent, low dose subcutaneous therapy. Effectiveness of less frequent, once weekly, low dose subcutaneous recombinant human erythropoietin (rHuEPO) in maintaining 35% hematocrit in patients with chronic renal failure, predialysis and ESRD receiving dialysis, is dependent on rHuEPO induced prolonged RBC survival. One year of weekly rHuEPO doses to 7 patients originally part of the National Cooperative Protocol were evaluated for a total of 372 weeks for an average of 53 weeks per patient. The original 8 to 12 week dosage was directed by protocol for units per dose at 3 doses per week (4 IV, 3 subcutaneous). Thereafter, all doses were subcutaneous. Units/dose and doses/week were titrated to keep hematocrit at 35-38%. Dosage reduction of rHuEPO was determined by two investigators at the time of each examination. Statistical correlation was performed on effect of rHuEPO on 51Cr T1/2 RBC survival changes and changes of rHuEPO weekly doses. Patients evaluated at specific time points in the study were compared to themselves as their own controls by paired t-test analysis. The long-term increased RBC count correlated with prolonged RBC survival by 51Cr T1/2 rather than reticulocytosis. A relatively increased ease of sustaining the target hematocrit of 35% was demonstrated from the 8th week to 1 year. Thirty-two percent of the expanded RBC mass was older at 12 weeks and 22% was older at 1 year. rHuEPO dosage was reduced to 27% at weeks 8-12, to 21% at weeks 20-24, and to 38% at 1 year corresponding to prolonged RBC survival. 51Cr T1/2 increased from 21.6 days control to 28.6 days at 12 weeks and 26.3 days at 1 year.(ABSTRACT TRUNCATED AT 250 WORDS)


Is folate supplementation necessary in hemodialysis patients on erythropoietin therapy. The need for folate supplementation in hemodialysis (HD) patients receiving erythropoietin (EPO) therapy remains unknown. Twenty stable HD patients, taking folic acid, 5 mg, after a meal during each HD session were divided into two groups. Supplementation was withdrawn at the start of the study in group 1 and after a 12-month-observation period in group 2. EPO treatment, 1500 u x 3/week i.v. was started in both groups. Pre- and post-HD blood samples were obtained at the beginning of the study for baseline values, then 12 and 18 months later. Folate levels decreased to normal after withdrawal of the supplements. The response to EPO treatment was exactly the same in both groups and the anemia was effectively improved. We conclude that there is no need for routine folic acid supplements in HD patients receiving EPO therapy if they are eating an adequate mixed diet.


Up-regulation of TIMP-1 expression in B16-F10 melanoma cells suppresses their metastatic ability in chick embryo. Clonal B16-F10 cell lines with increased expression of tissue inhibitor of metalloproteinase-1 (TIMP-1) have been generated by transfection with a TIMP-1-containing expression vector. The parental B16-F10 and control 1-2 cells, and two TIMP-1 up-regulated clones (2-10, 6-5), were studied for their growth characteristics in tissue culture and their experimental metastatic ability in the chick embryo. Both of the TIMP-1 up-regulated clones showed slower in vitro growth and had lower saturation densities. Both clones were also less metastatic following intravenous injection into chick embryos, and formed significantly fewer metastatic tumors in the chorioallantoic membrane and in the liver than did parental B16-F10 and control cells. Furthermore, the size of tumors formed by TIMP-1 up-regulated cells was significantly reduced in comparison to the tumors produced by B16-F10 or control cells. Our results show that malignant cell lines genetically modified to express increased levels of TIMP-1 exhibit a suppressed experimental metastatic ability in vivo. We propose that TIMP-1 suppresses metastatic ability by decreasing both invasive and growth abilities.


Suppression by interferon-gamma of tumor cell-induced increase in mesothelial permeability. The effect of interferon-gamma (IFN-gamma) on the interaction between tumor cells and mesothelial cell layers was studied from the aspect of changes in mesothelial permeability. Mesothelial permeability was assessed as the percentage diffusion of radiolabeled albumin across the mesothelial cell sheets on Matrigel-coated filter cup assemblies. When lined gastric carcinoma cells (KATO-III) were seeded on the confluent mesothelial cell layers, the fine cobblestone appearance of the cell sheet was disrupted and mesothelial permeability significantly increased. The increase in permeability was suppressed by the addition of as little as 1 U/ml of IFN-gamma. The effect of IFN-gamma was observed when either the conditioned medium of tumor cells alone or the IFN-gamma-resistant tumor cells, K-562, was placed onto the mesothelium. The cobblestone appearance of the cell sheet was relatively well preserved in the presence of IFN-gamma. In contrast, IFN-alpha did not suppress tumor-induced mesothelial permeability. These results suggest that IFN-gamma has the potential to protect the human mesothelial cell layers against tumor cells.


A murine model of intracranial invasion: morphological observations on central nervous system invasion by murine melanoma cells. We describe a model of tumour invasion in which murine melanoma/lymphocyte hybrid cells are injected into the lateral ventricle of neonatal mice. CSF circulation carries cells to the third ventricle where attachment to the ependyma and invasion of the underlying brain may be observed. At this distance from the injection site, invasion can be studied free from trauma or inflammation induced by the injection procedure. Accordingly we restricted our attention to the third ventricle. Our results reveal an unusual form of tumour invasion of the ependyma characterized by progressive attenuation of the ependymal cell layer immediately beneath tumour cell aggregates. Continuity of the ependymal cell layer is ultimately lost at a focal point immediately beneath the tumour, permitting direct contact between tumour cells and the neuropil. Subsequent deep invasion of the brain parenchyma is accomplished by pericapillary infiltration.


Urokinase-type plasminogen activator activity increases during the growth of two murine mammary adenocarcinomas with different metastasizing abilities. Urokinase-type plasminogen activator (u-PA) plays an important role in tumor growth and metastasis. The aim of this work was to study the u-PA production, in vitro and in vivo, in a transplantable murine mammary adenocarcinoma (M3), moderately metastatic to lung, and in a related tumor variant (MM3), highly metastatic to the same organ, during tumor development. At different times post-transplantation, tumors were employed to prepare either primary cell cultures or homogenates. PA activity from conditioned media (CM), cell lysates (CLs) and tumor homogenates (THs) was quantitated by means of a fibrinolytic assay. Immunoneutralization and zymographic assays were performed to identify the PA present in both tumors. PA activity in CM, CLs and THs, that was undetectable at early stages, increased significantly along the growth of M3 adenocarcinoma. Secreted PA activity in MM3 CM was measurable at early stages and consistently increased up to 37 days post-transplantation, but a marked fall of activity was found at 48 days. PA activity in MM3 THs exhibited the same enhancement and late fall found in vitro. A positive correlation was observed between tumor size and THs PA values in both tumors. The PA present in cell cultures and THs was identified as of the u-PA type. These results support the hypothesis that high u-PA levels are important for tumor invasion and that the stage of tumor development is a critical factor in their PA activity.


A quantitative model for spontaneous bone metastasis: evidence for a mitogenic effect of bone on Walker 256 cancer cells. A new model for the study of spontaneous bone metastasis has been developed which allows for the quantification of metastatic tumor burden and cancer cell growth rate, and which describes the progressive changes in bone morphology. Walker 256 (W256) cells or vehicle were injected into the left upper thigh muscle of male Fischer rats, which were killed 7, 10 or 14 days later. By day 7, metastases had appeared in the distal femur, in the glomeruli of the kidney, and diffusely throughout the liver and lungs. The extent of tumor burden in these organs increased over time. In the femur, 14 days of tumor burden was associated with a 53 +/- 10% decrease in trabecular bone content, a 61 +/- 15% increase in osteoclast surface, and a 95 +/- 10% decrease in osteoblast surface, as compared with non-tumor-bearing controls. By autoradiography, metastatic tumor cells in all organs were determined to have greater growth rates than did cells in the primary tumor. However, within the femur, W256 cells located adjacent to trabecular bone surfaces had a 33 +/- 7% greater growth rate than did W256 cells located > 50 microns from bone surfaces (P < 0.05), suggesting a mitogenic effect of bone.


Stimulation of bone resorption results in a selective increase in the growth rate of spontaneously metastatic Walker 256 cancer cells in bone. To test the hypothesis that bone metastasis is related to the rate of bone remodeling, we have examined the effect of enhanced bone resorption on the growth of spontaneously metastatic Walker 256 (W256) cancer cells. Bone resorption was stimulated in male Fischer rats by injecting Rice H-500 Leydig tumor cells subcutaneously. The resorptive response of the skeleton was confirmed in a pilot study by evaluating parameters of bone morphometry after 4, 7 and 10 days of tumor burden. The distal femoral epiphyses had 35 +/- 10% more osteoclast surface, 83 +/- 11% less osteoblast surface, and 46 +/- 5% less trabecular bone after 10 days of tumor burden, compared to non-tumor-bearing controls. To evaluate the effect of Leydig tumor-induced bone resorption on the growth response of W256 cells, 20 rats were injected intramuscularly with 2 x 10(7) W256 cells, and 20 rats were vehicle-injected. Two days later, 10 rats from each group were injected subcutaneously with Leydig tumor cells. Twelve days after W256/vehicle injection, rats were injected with [3H]thymidine, killed 2 h later, and their femurs, liver, lungs and kidneys were processed for histology. In rats injected with Leydig tumor cells only, enhanced bone resorption was confirmed by a 40 +/- 4% increase in serum calcium concentration, a 48 +/- 8% decrease in trabecular bone content, and a 72 +/- 15% decrease in osteoblast surface, compared with non-tumor-bearing rats. Metastatic W256 cells adjacent to trabecular bone in Leydig tumor-bearing rats had a 56 +/- 18% greater relative [3H]thymidine labeling index (TdR) than did W256 cells in the bones of non-Leydig tumor-bearing rats. The TdRs of W256 cells in the liver, lungs, and kidneys were not affected by Leydig tumor burden. In this model, enhanced bone resorption was associated with the selective growth promotion of metastatic W256 cells in bone, suggesting the existence of a bone-derived factor which is mitogenic to W256 cells.


Patterning of B16 melanoma metastasis and colonization generally relates to tumor cell growth-stimulating or growth-inhibiting effects of organs and tissues. The mouse B16 melanoma metastasizes first to the lungs and secondarily to systemic sites, involving mainly the adrenals, ovaries and pancreas. Systemic colonization effected by intracardiac injection of tumor cells establishes similar patterning, but in addition frequently colonizes the bones. To assess possible systemic site influences on metastasis and colony formation, the capacity of B16 melanoma cells to proliferate in these sites in vivo and in ex vivo explants following intracardiac injection was examined. Effects of cells isolated from these sites, and of organ- or tissue-conditioned medium, on growth of B16 cells in monolayer culture were also studied. Injected fluorochrome-labeled tumor cells initially distributed without site preference, but within 48 h had begun proliferating in the adrenals, ovaries and lungs, while remaining static in the pancreas and bones, and disappearing from the spleen, liver, kidneys, brain, and skeletal muscles. Mitogenic activity releasable in soluble form was associated with all favorable organs and tissues and was the predominant influence of those tissues on cultured tumor cells. In contrast, the overall effects of liver, spleen, kidney, and brain tissues were to inhibit tumor cell growth. Soluble growth-promoting activity enhanced clonogenic growth of isolated tumor cells stimulated by mouse serum, suggesting that metastasis or colony formation might be stimulated in favorable sites by those factors together with blood-borne growth factors. The observed effects of organ- and tissue-derived cells and soluble factors on tumor cells generally reflected the in vivo consequences of tumor cell entrapment in the corresponding sites. However, the failure of metastases to develop in the bones, which are favorable sites for colonization by the same cells, remains puzzling.


Combination of interleukin-2 and irradiation in therapy of murine tumors. Experiments were designed to investigate the therapeutic efficacy of interleukin-2 (IL-2) combined with radiotherapy. The effect of IL-2 and local thoracic irradiation (LTI) was determined on 4-day-old lung micrometastases, generated by i.v. injection of tumor cells into mice. IL-2 alone reduced the number of lung nodules more effectively when given from 1 to 4 than 4 to 7 days after tumor cell injection. The combination of IL-2 and LTI reduced the number of lung nodules more than did the individual treatments alone. When IL-2 therapy was combined with local irradiation of 8-mm leg tumors, there was no change in the TCD50 (radiation dose yielding 50% local tumor control). However, the combination of IL-2 treatment on days 1-4 with irradiation of tumor-bearing legs on day 1 after inoculation of tumor cells reduced the TCD50 by a factor of 1.3. These results show that IL-2 improves tumor radiotherapy, but that the improvement depends on anatomic localization and tumor size at the time of treatment.


Alternatives to estrogen for menopausal symptoms. It is not within the scope of this chapter to discuss the long-term effects of menopause, such as osteoporosis or heart disease, or to disentangle the complex psychosocial complications and treatments of menopausal mood disorders. All long-term consequences of hypoestrogenism are more amenable to prevention than to cure, as are all the negative consequences of aging. Women should maintain regular physical activity, consume a diet low in fat and high in fiber, ensure adequate calcium intake, and possibly lower animal protein consumption. Moreover, they should know their cholesterol levels and undergo regular physical examinations with an emphasis on health maintenance. Despite the many advantages of estrogen replacement therapy, it is not appropriate for all women. Cultural, personal, and medical considerations may eliminate the use of estrogen, in which case it is important to offer alternative medical advice and direction to minimize bothersome symptoms of menopause and enhance the quality of life.