[Adenomas of Vater's ampulla and of the duodenum. Presentation of diagnosis and therapy by endoscopic interventional and surgical methods]

BACKGROUND

Adenoma of the ampulla of Vater and the duodenum are rare tumors. The leading symptoms are unspecific; sometimes they are due to the disturbances of the passage or erosion of the tumor. Early and correct diagnosis and the appropriate therapy are of decisive importance because these tumors are precancerous.

PATIENTS AND METHODS

We report the cases of seven patients with periampullary adenoma of the duodenum, in one case with incorporation of the the distal bile duct. The diagnostic steps and the surgical treatment are reported and discussed. In achieving a definitive diagnosis, endoscopic retrograde cholangiopancreatography is of paramount importance. Three patients subsequently underwent partial pancreatoduodenectomy (Whipple's procedure); in three patients transduodenal local tumor excision was performed. Postoperative course was without complications in each case and no operative mortality occurred. One patient was treated by argon-coagulation.

RESULTS

The histopathological examination showed a tubular villous adenoma in six cases and in one case a villous adenoma (ranging from low to high grade dysplasia). Because there is evidence of an adenoma-carcinoma-sequence, radical surgical treatment is recommended, even in adenoma with low grade dysplasia, in spite of the absence of malignancy.

Genetic parameters of dairy character, protein yield, clinical mastitis, and other diseases in the Danish Holstein cattle

The primary aim of this study was to estimate genetic correlations between dairy character, protein yield, clinical mastitis, and other diseases. Data consisted of first lactation records of Danish Holstein cows calving from 1990 to 1999. After editing, the data included records on 934,639 cows, of which 101,853 were assessed for dairy character, 472,421 for diseases, and 834,993 for protein yield. The disease traits were defined as binary traits in the period from 10 d before to 50 d after calving for clinical mastitis, and from 10 d before to 100 d after calving for diseases other than mastitis. Data were analyzed with a linear sire model using the method of AI-REML. Heritabilities were estimated to be 0.265 for protein yield, 0.261 for dairy character, 0.035 for clinical mastitis, and 0.020 for diseases other than mastitis. Estimates of genetic correlations between protein yield and dairy character, protein yield and clinical mastitis, and protein yield and diseases other than mastitis were 0.38, 0.33, and 0.14. Between the two disease traits, the genetic correlation was 0.24. The genetic correlation between dairy character and clinical mastitis was 0.24. Between dairy character and diseases other than mastitis the genetic correlation was 0.41. Thus, cows with high score for dairy character were more prone to diseases. The genetic correlation between dairy character and the disease traits, when both traits were adjusted for protein yield, was 0.13 for clinical mastitis and 0.39 for diseases other than mastitis. These findings suggest that, dairy character should be given a negative rather than a positive weight in the breeding goal.

Is one 60 degrees fundus photograph sufficient for screening of proliferative diabetic retinopathy?

OBJECTIVE

To compare one 60 degrees fundus photograph to seven field stereo fundus photographs in identifying proliferative diabetic retinopathy.

RESEARCH DESIGN AND METHODS

A total of 44 eyes in 23 patients with moderate/severe nonproliferative diabetic retinopathy were included. Evaluation of each eye was based on one 60 degrees fundus photograph. Eyes were re-examined using seven field 30 degrees stereo fundus photographs according to the protocol of the Early Treatment Diabetic Retinopathy Study, and the photographs were examined independently by three ophthalmologists to identify retinal neovascular lesions. In addition, fluorescein angiography was performed in all patients to verify the presence of the lesions.

RESULTS

In four eyes of three patients (11.1% of eyes) evaluated based on seven field stereo photographs, retinal neovascularization was found. This condition was not found on examination of 60 degrees fundus photographs.

CONCLUSIONS

Examination of one 60 degrees fundus photograph was found to be insufficient as a screening procedure in patients with moderate/severe nonproliferative diabetic retinopathy.

Importance of the amino-acid composition of the shutter region of plasminogen activator inhibitor-1 for its transitions to latent and substrate forms

The serpins are of general protein chemical interest due to their ability to undergo a large conformational change consisting of the insertion of the reactive centre loop (RCL), which becomes strand 4, into the central beta sheet A. To make space for the incoming RCL, the 'shutter region' opens by the beta strands 3A and 5A sliding apart over the underlying alpha helix B. Loop insertion occurs during the formation of complexes of serpins with their target serine proteinases and during latency transition. This type of loop insertion is unique to plasminogen activator inhibitor-1 (PAI-1). We report here that amino-acid substitutions in a buried cluster of three residues forming a hydrogen bonding network in the shutter region drastically accelerate PAI-1 latency transition; that the rate was in all cases normalized by the PAI-1 binding protein vitronectin; and that substitution of an adjacent beta strand 5A Lys residue, believed to anchor beta strand 5A to other secondary structural elements, had differential effects on the rates of latency transition in the absence and the presence of vitronectin, respectively. An overlapping, but not identical set of substitutions resulted in an increased tendency to substrate behaviour of PAI-1 at reaction with its target proteinases. These findings show that vitronectin regulates the movements of the RCL through conformational changes of the shutter region and beta strand 5A, are in agreement with RCL insertion proceeding by different routes during latency transition and complex formation, and contribute to the biochemical basis for the potential use of PAI-1 as a therapeutic target in cancer and cardiovascular diseases.

Multicenter phase II study of gemcitabine in previously untreated patients with advanced epithelial ovarian cancer

Gemcitabine has activity in advanced ovarian cancer, with responses in platinum-resistant disease. This study assessed the activity of gemcitabine in previously untreated patients with advanced epithelial ovarian cancer. All patients had histologically verified invasive epithelial ovarian cancer, International Federation of Gynecology and Obstetrics (FIGO) stage III/IV disease and no prior chemotherapy. Patients received gemcitabine 1250 mg/m(2) on days 1, 8 and 15 of a 28-day cycle. Radiological response was assessed after two cycles. Between December 1992 and October 1995, 35 patients were enrolled. Of 33 evaluable patients, there was one complete response and five partial responses, for an overall response rate of 18% (95% confidence interval 7-36%). Forty-two percent of patients had a greater than 50% decrease in their CA-125 levels. Of the 25 patients who received platinum-based chemotherapy following treatment with gemcitabine, 12 achieved an overall response rate of 48%. Toxicity was mild, with two episodes of WHO grade 4 neutropenia (not associated with fever) and two episodes of grade 4 thrombocytopenia (not associated with bleeding). Gemcitabine has single-agent activity for poor-prognosis patients with advanced ovarian cancer. Similar results with subsequent platinum-based therapy indicate a lack of cross-resistance. This, combined with gemcitabine's favorable toxicity profile, warrants testing in comparative trials.

Differential effects of autologous serum on CD34(+) or monocyte-derived dendritic cells

Dendritic cells (DC) with potentially important clinical applications have been generated from human peripheral blood monocytes and CD34(+) cells in the presence of recombinant cytokines granulocyte-macrophage colony-stimulating factor (GM-CSF) + interleukin-4 (IL-4) and GM-CSF + tumor necrosis factor-alpha (TNF-alpha), respectively. Many of the studies generating DC have included fetal calf serum, which is not desirable due to the risk of immune reactions and infectious disease transmission. Additionally, low DC yields have been reported using serum-free media. In this study, we investigate supplementing serum-free media with autologous serum and plasma for DC generation from monocytes and CD34(+) cells. Our results show that functional DC can be reproducibly obtained in the presence of autologous serum using monocytes and CD34(+) cells as the starting populations. However, with the addition of autologous serum, a differential effect is observed in the phenotypic characterization of these culture-derived DC. Monocytes cultured for 7 days in X-VIVO 15 serum-free media in the presence of GM-CSF + IL-4 showed down-regulation of CD14 with increased expression of HLA-DR, mannose receptor, CD80, and CD86, along with highly up-regulated CD1a(+) expression. The addition of autologous serum to serum-free media in monocyte cultures resulted in a dose-dependent decrease in the CD1a(+) expression generating a distinct subset of CD1a(+/-) cells expressing HLA-DR, mannose receptor, CD80, and CD86. Upon stimulation with CD40L cells, both monocyte-derived DC subsets CD1a(+/-) and CD1a(++) were capable of maturation measured by CD83 and CD86 up-regulation. Data suggest the differences in the monocyte-derived DC in serum-free (CD1a(++)) or autologous serum (CD1a(+/-)) supplemented cultures is of a qualitative nature, rather than quantitative. CD1a(+) and CD14(+) cells expressing HLA-DR, mannose receptor, CD80, and CD86 were generated in 7 days from CD34(+) cells in serum-free media. A quantitative effect was obtained when cultures were supplemented with autologous serum, resulting in a significant enhancement of CD34-derived DC generated. These results demonstrate generation of DC from two different starting populations using serum-free media that can be enhanced with the addition of autologous serum. Interestingly, a differential effect was observed in the phenotypic characterization of these culture-derived DC.

Localization of epitopes for monoclonal antibodies to urokinase-type plasminogen activator: relationship between epitope localization and effects of antibodies on molecular interactions of the enzyme

We localized the epitopes for several murine mAbs to human urokinase-type plasminogen activator (uPA) by Ala scanning mutagenesis and related the localization to the effects of the mAbs on the molecular interactions of uPA. Several antibodies against the serine proteinase domain (SPD) were found to have overlapping epitopes composed of variable combinations of Arg178, Arg179, His180, Arg181, Tyr209, Lys211, and Asp214 in the so-called 37-loop and 60-loop, located near the active site and taking part in the binding of uPA to plasminogen activator inhibitor-1 (PAI-1). Besides inhibiting uPA-catalysed plasminogen activation, all antibodies to SPD strongly delayed the binding of uPA to PAI-1, decreasing the second-order rate constant 15- to 6500-fold. There was no correlation between the relative effects of the 37-loop and 60-loop substitutions on the second-order rate constant and on the binding of the antibodies, indicating that the antibodies did not delay complex formation by blocking residues of specific importance for the uPA-PAI-1 reaction, but rather by steric hindrance of the access of PAI-1 to the active site. The affinity of the SPD antibodies for the uPA-PAI-1 complex was only slightly lower than that for free uPA, indicating that the 37-loop and 60-loop are exposed in the complex. The epitopes for two antibodies to the kringle included Arg108, Arg109, and Arg110. The ability of these antibodies to block the binding of uPA to polyanions correlated with a reduced uPA-polyanion affinity after substitution of the three Arg residues.

Folic acid enrichment of bread does not appear to affect zinc absorption in young women

BACKGROUND

In several countries cereals are now enriched with folic acid to reduce the risk of neural tube defects. Human studies suggest that folic acid interferes with zinc absorption. This raises concerns about the zinc status of high-risk groups such as infants, pregnant women, and older persons.

OBJECTIVE

We sought to determine the effect of added folic acid on zinc absorption from white bread with high and low zinc contents.

DESIGN

Zinc absorption was measured in 15 healthy women (22-33 y), each of whom consumed 4 single meals spaced 2 wk apart in a randomized crossover design. The servings of bread (100 g) differed in zinc and folic acid contents as follows: A, 1.2 mg Zn and 17 microg folic acid; B, 1.2 mg Zn and 144 microg folic acid; C, 3.0 mg Zn and 17 microg folic acid; and D, 2.9 mg Zn and 144 microg folic acid. Meals were extrinsically labeled with 65Zn and absorption was estimated from whole-body retention measurements. Folate status was assessed by measuring plasma and erythrocyte folate and plasma homocysteine concentrations.

RESULTS

Mean (+/-SD) zinc absorption did not differ significantly in relation to the folate content of the breads at either the low zinc content (38.8 +/- 13.5% and 40.6 +/- 16.5% for A and B, respectively; P = 0.74) or the high zinc content (26.7 +/- 9.3% and 22.7 +/- 6.6% for C and D, respectively; P = 0.16). There was no significant correlation between folate status and zinc absorption (r < 0.3, P > 0.1).

CONCLUSION

Fortification of white bread with a commonly used amount of folic acid did not appear to influence zinc absorption at either a high or a low zinc content.

Adaptive fuzzy logic restriction rules for error correction and safe stimulation patterns during functional electrical stimulation

Adaptive restriction rules based on fuzzy logic have been developed to eliminate errors and to increase stimulation safety in the foot-drop correction application, specifically when using adaptive logic networks to provide a stimulation control signal based on neural activity recorded from peripheral sensory nerve branches. The fuzzy rules were designed to increase flexibility and offer easier customization, compared to earlier versions of restriction rules. The rules developed quantified the duration of swing and stance phases into states of accepting or rejecting new transitions, based on the cyclic nature of gait and statistics on the current gait patterns. The rules were easy to custom design for a specific application, using linguistic terms to model the actions of the rules. The rules were tested using pre-recorded gait data processed through a gait event detector and proved to reduce detection delay and the number of errors, compared to conventional rules.

Gentamicin dosing in critically ill patients

Gentamicin is used worldwide in the treatment of serious infections in critically ill patients. The therapeutic efficacy of gentamicin is correlated to the peak serum concentration and the adverse effects to the trough concentrations. Information concerning the pharmacodynamics in critically ill patients is scarce, but pharmacokinetic data are available. A once-daily dosage regimen has replaced multiple dosing of gentamicin in most intensive care units. No studies evaluating the superiority of either of these dosage recommendations in critically ill patients have ever been conducted. Based on 8 meta-analyses performed addressing this issue on a wide range of patients and theoretical considerations, we consider a once-daily dosage regimen feasible in critically ill patients. In septic patients the volume of distribution is significantly increased compared to normal patients, implying that the initial dose should be increased in this patient population. Additionally a general trend towards using higher loading doses (5-7 mg/kg) has been observed in USA, and the appropriateness of this dosing strategy is based on a large descriptive American study. We recommend that the initial dosage of gentamicin in critically ill hyperdynamic septic patients should be 7 mg/kg. Optimal and appropriate monitoring of the treatment with gentamicin in the critically ill patient is still an issue for further investigation. The treatment period with gentamicin should be short (3-5 days), bearing the pharmacological properties of aminoglycosides (small volume of distribution and poor tissue penetration) in mind. In patients with reduced renal function the initial dose of gentamicin should also be increased and maintenance dose reduced preferentially by prolonging the dosing intervals. However, the use of aminoglycosides in a high dose regimen in oliguric or anuric patients or patients who present with a rapidly decreasing renal function needs further consideration.

Green tea or rosemary extract added to foods reduces nonheme-iron absorption

BACKGROUND

Phenolic compounds act as food antioxidants. One of the postulated mechanisms of action is chelation of prooxidant metals, such as iron. Although the antioxidative effect is desirable, this mechanism may impair the utilization of dietary iron.

OBJECTIVE

We sought to determine the effect of phenolic-rich extracts obtained from green tea or rosemary on nonheme-iron absorption.

DESIGN

Young women aged 19-39 y consumed test meals on 4 separate occasions. The meals were identical except for the absence (meal A) or presence (meal B) of a phenolic-rich extract from green tea (study 1; n = 10) or rosemary (study 2; n = 14). The extracts (0.1 mmol) were added to the meat component of the test meals. The meals were extrinsically labeled with either 55Fe or 59Fe and were consumed on 4 consecutive days in the order ABBA or BAAB. Iron absorption was determined by measuring whole-body retention of 59Fe and the ratio of 55Fe to 59Fe activity in blood samples.

RESULTS

The presence of the phenolic-rich extracts resulted in decreased nonheme-iron absorption. Mean (+/-SD) iron absorption decreased from 12.1 +/- 4.5% to 8.9 +/- 5.2% (P < 0.01) in the presence of green tea extract and from 7.5 +/- 4.0% to 6.4 +/- 4.7% (P < 0.05) in the presence of rosemary extract.

CONCLUSION

Phenolic-rich extracts used as antioxidants in foods reduce the utilization of dietary iron.

Linkage disequilibrium mapping of the bolting gene in sea beet using AFLP markers

The possibility of using linkage disequilibrium mapping in natural plant populations was assessed. In studying linkage disequilibrium among 137 mapped AFLP markers in four populations of sea beet (Beta vulgaris ssp. maritima (L.) Arcang.) it was shown that tightly linked loci could be detected by screening for associations. It was hypothesized that the short distances spanned by linkage disequilibrium enable markers that are very tightly linked to a target gene to be identified. The hypothesis was tested by whole-genome screening of AFLP markers for association with the gene for the annual growth habit, the B gene, in a sample of 106 sea beets. Despite the dominant nature of AFLP, two markers showing significant linkage disequilibrium with the B gene were detected. The results indicate the potential use of linkage disequilibrium for gene mapping in natural plant populations.

A simplified method for determination of radioactive iron in whole-blood samples

For studies on iron absorption in man radioisotopes represent an easy and simple tool However, measurement of the orbital electron emitting radioiron, 55Fe, in blood is difficult and insufficiently described in the literature. The present study describes a relatively simple method for simultaneous determination of 55Fe and 59Fe in blood, using a dry-ashing procedure and recrystallization of the remaining iron. The detection limit of the method permits measurements of 0.1 Bq/ml blood thus allowing detection of less than 1% absorption from a 40 kBq dose, which is ethically acceptable in humans. The overall recovery of radioiron from blood is more than 90%, and the coefficient of variation, as judged by the variation in the ratio 55Fe/59Fe is in the order of 4%. Combined with whole-body counting of 59Fe and direct gamma-counting of 59Fe on blood samples, this method represents a sensitive method for studying the intestinal absorption of 55Fe and 59Fe in man and at the same time allows estimation of the amount of radioiron located in the vascular compartment.

Maintenance electroconvulsive therapy in affective and schizoaffective disorder

Twenty-one patients (13 depressives and 8 schizoaffectives) who underwent maintenance electroconvulsive therapy (M-ECT) were compared with controls who received maintenance pharmacotherapy alone. Measures of effectiveness and safety of maintenance treatment were prospectively obtained during a 1-year follow-up. Survival analysis demonstrated a significantly better outcome defined by time to rehospitalization for all patients of the M-ECT group. Regarding the subgroups, depressives of the M-ECT group had markedly decreased rehospitalization rates compared to depressive controls. Furthermore, M-ECT in depressives resulted in a significant reduction in hospitalization rates and duration during follow-up. In schizoaffective patients, a significant difference in survival time was found in favor of the M-ECT group. In both groups, schizoaffectives had a markedly poorer outcome compared to depressive subjects. Our results indicate that in selected patients M-ECT, at least in combination with supporting medication, may be an efficient and safe alternative to pharmacological continuation or maintenance therapy alone.

Working without accumulation membrane in flow field-flow fractionation

Nonideal interaction of sample with the separation device is a difficulty found in chromatographic methods as well as in field-flow fractionation. However, in field-flow fractionation (FFF), greater flexibility in the choice of carrier solution composition is possible, thus reducing the need of a wide choice of surface chemistry when nonideal sample interaction is to be minimized. The use of an ultrafiltration membrane as the surface for the accumulation wall is common practice in flow field-flow fractionation. Typical membranes in use are laminates of a skin membrane onto a backing material such as woven polyester. At this point, only a limited choice of membrane chemistries is available. Many membranes have been developed for protein applications as membranes are widely used in the pharmaceutical industries. While these membranes work well for protein applications, flow field-flow fractionation is applicable to polymeric particulate as well as protein samples. Thus, sample interaction with the membrane surface is possible with nonprotein applications and these interactions can induce significant secondary effects on retention ratio and affect instrumental reliability. Also, the woven texture of membranes may detrimentally affect the FFF separation. For these reasons, the study of flow field-flow fractionation using a flat, smooth surface of controlled chemistry is of relevance. We present here the results of a new, membraneless channel that uses a bare frit as the accumulation wall and that is intended for analysis of micrometer-sized particles only. Selectivity results are comparable to those obtained with the membrane, while relative sample recovery indicates that the best quantitative performance can be obtained without the membrane. Moreover, neither sample immobilization nor losses through the frit occur when operating membraneless. On the other hand, first experimental evidence of a certain level of frit surface activity suggests that optimization of experimental conditions is required.

Outpatient laparoscopic cholecystectomy: experience of a nonovernight surgicenter

From April 1994 to September 1998, a total of 66 laparoscopic cholecystectomies were performed at the same-day freestanding Surgicenter of the Yankton Medical Clinic. All patients (ages 15 to 62 years; 91% women) were discharged the same day, and no patient required hospitalization despite two conversions to open cholecystectomy. Cholangiofluoroscopies were completed in 70% of the patients. Pathologic evaluation showed chronic cholecystitis in all patients except one, who also had acute disease. No patient was lost to follow-up, and 98% responded that they "would do it again." These results confirm the safety of laparoscopic cholecystectomy in selected patients in a low- and controlled-cost environment of a freestanding surgical facility. Interestingly, Medicare does not allow facility reimbursement for cholecystectomy in any nonovernight outpatient surgery center in South Dakota.

The effect of grape-skin extract on oxidative status

Epidemiological studies indicate that moderate alcohol consumption, particularly wine, reduce the risk of CHD. The present study was designed to investigate the effect of grape-skin extract on markers of oxidative status. The study was designed as a randomised crossover. A diet with a low content of flavonoids was served with strict control of intake in two consecutive 1-week intervention periods to fifteen subjects (nine women, six men) divided randomly into two groups. During one of the weeks the subjects from either group consumed 200 ml grape-skin extract in water (1 mg extract/ml) at each of three daily meals (31.3 mg total phenolics, including 9.0 mg catechin). An increased activity of glutathione reductase and a borderline increase of glutathione peroxidase activity in erythrocytes were observed after grape-skin intervention, while the intervention had no significant effect on superoxide dismutase or catalase. Likewise, no effect was found on 2-aminoadipic semialdehyde (AAS) residues, a plasma protein oxidation product, or on malondialdehyde in plasma or in LDL, which are markers of lipoprotein oxidation. A marginal effect of grape-skin intervention was observed on plasma ascorbate levels. Intake of the experimental diet significantly reduced plasma vitamin C and plasma AAS in both groups. This effect was most pronounced in the particular week with no grape-skin extract addition. We speculate that grape-skin extract may have a sparing effect on vitamin C. The effects of the experimental diet may be partly ascribed to a low content of several fruit- and vegetable-related antioxidants like flavonoids and vitamin C and a relatively high content of carrot-derived antioxidants, such as carotenes.

Exploratory phase III study of paclitaxel and cisplatin versus paclitaxel and carboplatin in advanced ovarian cancer

PURPOSE

To determine the side effects and feasibility of cisplatin and carboplatin each in combination with paclitaxel as front-line therapy in advanced epithelial ovarian cancer.

PATIENTS AND METHODS

Patients were randomly allocated to receive paclitaxel 175 mg/m(2) intravenously as a 3-hour infusion followed by either cisplatin 75 mg/m(2) or carboplatin (area under the plasma concentration-time curve of 5), both on day 1. The schedule was repeated every 3 weeks for at least six cycles. Women allocated to paclitaxel-cisplatin were admitted to the hospital, whereas the carboplatin regimen was administered to outpatients.

RESULTS

A total of 208 eligible patients were randomized. Both regimens could be delivered in an optimal dose and without significant delay. Paclitaxel-carboplatin produced significantly less nausea and vomiting (P: <.01) and less peripheral neurotoxicity (P: =.04) but more granulocytopenia and thrombocytopenia (P: <.01). The overall response rate in 132 patients with measurable disease was 64% (84 of 132 patients), and in patients with elevated CA 125 levels at start, it was 74% (132 of 178 patients). With a median follow-up time of 37 months, the median progression-free survival time of all patients was 16 months and the median overall survival time was 31 months. The small number of patients entered onto the study caused wide confidence intervals (CIs) around the hazards ratio for progression-free survival of paclitaxel-carboplatin compared with paclitaxel-cisplatin (hazards ratio, 1.07; 95% CI, 0.78 to 1.48) and did not allow conclusions about efficacy.

CONCLUSION

Paclitaxel-carboplatin is a feasible regimen for outpatients with ovarian cancer and has a better toxicity profile than paclitaxel-cisplatin.

Profiling the immune responses in patient sera with peptide and cDNA display libraries

Peptide and cDNA phage display libraries can be used to determine the specificities of antibodies present in the whole sera of patients where information about the parental antigens is unknown. In this respect, patient serum antibody binding ligands have been identified. Such ligands would facilitate the design of diagnostic assays and therapeutic vaccines. In the case of cancer, this novel technology is expected to improve our understanding of the immune responses against tumour cells and to discriminate between autoantigen and true tumour specific antigens. Here, we review work on how peptide and cDNA phage display libraries can be used to address the specificity of the immune responses in patients with autoimmune diseases and cancer.