Schizophrenia and the life cycle

We reframe the longitudinal treatment of persons with schizophrenia from the perspective of phases in adult development. This approach articulates the need for different interventions of varying intensities over the person's lifetime. The paper discusses the implications of an adult developmental perspective in managing pharmacologic treatment and psychosocial interventions, and in reallocating financial resources for improved long-term outcomes. This perspective is especially useful in the context of a comprehensive community mental health program permitting access to a continuum of services throughout the lifecycle.

Histopathologic consequences of moderate concussion in an animal model: correlations with duration of unconsciousness

Although duration of unconsciousness is commonly used as a prognostic index following traumatic brain injury (TBI), few controlled studies have statistically evaluated the relationship between unconsciousness and histologic pathology, particularly after moderate head injury. Using a pendulum-striker concussive device, a reproducible model of TBI in rats was developed. This model is uncomplicated by skull fractures, contusions, or experimenter-induced craniotomies. In the present study, the severity of the histopathology observed in this model of moderate closed-head injury at 48 h posttrauma is linearly related to the duration of unconsciousness (p < 0.0001). The pathology, assessed with a silver stain for neurodegeneration, is particularly striking if unconsciousness persists for 4 minutes or more. These data suggest that the initial period of unconsciousness may be a useful predictor of clinical brain histopathology associated with moderate closed-head injury, predicting either the degree of pathology and/or the rate it progresses if left untreated.

Interpretation of large intestinal mucosal biopsy specimens

The development of flexible endoscopes has led to a great increase in the examination and mucosal biopsy evaluation of all portions of the large intestine and rectum. Examinations are now performed not only for the determination of diagnosis but also for the monitoring of the course of a wide variety of conditions and for the early detection of complications. This review concentrates on the uses and interpretations of such biopsies in a large number of inflammatory conditions, with special emphasis on the correlations with clinical and functional features. Illustrated are examples of infections, idiopathic inflammatory bowel disease (IBD), vascular disorders, motor and mechanical conditions, toxic and physical reactions, and other inflammatory conditions. Mucosal biopsy specimens also are obtained to identify dysplasia and to evaluate mass lesions, and these subjects are well covered in other articles within this symposium. In patients with chronic disorders multiple examinations are now expected to follow the course of the disease and to detect and correct any complications at an early stage. The exact reasons for the endoscopy and relevant clinical data are essential for the optimal analysis of these mucosal biopsy specimens.

Global function scales

There is a close relationship between impairment of global functioning and mental illness. However valid measurement of global functioning is difficult, and there is no perfect scale. The instruments reviewed in this paper illustrate a range of different approaches. Despite the inherent difficulties the measurement of functioning is a critical domain in mental health evaluative research.

alpha-Phenyl-tert-butyl-nitrone inhibits free radical release in brain concussion

Traumatic brain injury (TBI) is one of the important causes of mortality and morbidity. The pathogenesis of the underlying brain dysfunction is poorly understood. Recent data have suggested that oxygen free radicals play a key role in the primary and secondary processes of acute TBI. We report direct electron spin resonance (ESR) evidence of hydroxyl (.OH) radical generation in closed-head injury of rats. Moderate brain concussion was produced by controlled and reproducible mechanical, fixed, closed-head injury. A cortical cup was placed over one cerebral hemisphere within 20 min of the concussion, perfused with artificial cerebrospinal fluid (aCSF) containing the spin trap agent pyridyl-N-oxide-tert-butyl nitrone (POBN, 100 mM), and superfusate samples collected at 10 min intervals for a duration up to 130 min post brain trauma. In addition, POBN was administered systemically (50 mg/kg body wt.) 10 min pretrauma and 20 min posttrauma to improve our ability to detect free radicals. ESR analysis of the superfusate samples revealed six line spectra (alpha N = 15.4 G and alpha beta H = 2.5 G) characteristic of POBN-OH radical adducts, the intensity of which peaked 40 min posttrauma. The signal was undetectable after 120 min. Administration of alpha-phenyl-tert-butyl-nitrone (PBN), a spin adduct forming agent systemically (100 mg/kg body wt. IP 10 min prior to concussion) alone or along with topical PBN (100 mM PBN in aCSF), significantly (p < 0.001) attenuated the ESR signal, suggesting its possible role in the treatment of TBI.

Resuscitation. Myocardial infarction--diagnosis and treatment

This article provides a comprehensive account of the pathophysiology and treatment of myocardial infarction and offers guidelines related to the nurse's role in caring for patients who are in the acute phase of this condition.

Stromal tumors of the stomach: prognostic value of the PCNA index

Reliable indicators of behavior in stromal tumors of the gastrointestinal tract have yet to be elucidated. Aggressive behavior has been associated with large size, hypercellularity, tumor necrosis, nuclear atypia, and high mitotic rate. Recently, new methods of measuring proliferation have been developed that exploit the phenomenon of cell cycle specific protein synthesis. In this study the expression of the S-phase specific nuclear protein proliferating cell nuclear antigen (PCNA) is tested as an indicator of malignancy. Sixteen stromal tumors of the stomach were reviewed for tumor size, cellularity, nuclear atypia, mitotic rate, necrosis, vascular invasion, and predominant cell type. Local recurrence and/or mortality were ascertained with a minimum follow-up of 5 yr. An immunohistochemical assay for PCNA was performed on a paraffin section of tumor and the percentage of positively stained cells ("PCNA index") was determined. Among the nine men and seven women, age 37 to 80 (median 66) yr, two had local recurrences that were treated surgically with no metastases. Only positive resection margin correlated with local recurrence. Two other patients developed distant metastases at 8 and 15 mo and died. Mortality did not correlate with age, sex, size, cellularity, necrosis, cell type, and vascular invasion. High grade nuclear atypia (2/2 versus 1/14, P = 0.02) and high mitotic rate (20.5 versus 5.5 per 40 hpfs, P = 0.01) did correlate with mortality. PCNA index did not correlate with local recurrence, but was sharply higher in fatal cases (6.4 versus 1.2, P = 0.001). Both fatal tumors had PCNA values above 6.0, and all others had values of 4.0 or less. The PCNA index is a proliferative marker that may have prognostic value in gastric stromal tumors.

Localization of tumor-associated glycoprotein DF3 in normal, inflammatory, and neoplastic lesions of the colon

BACKGROUND

The expression of DF3 was assessed by a monoclonal antibody in normal, inflammatory, and neoplastic conditions in the large bowel.

METHODS

Using immunohistochemistry, expression was examined in formalin-fixed paraffin-embedded biopsy and resection samples of 19 normal colonic mucosal specimens, 49 inflammatory lesions, 34 adenomas, and 38 primary colonic adenocarcinomas. In addition, Western blots of normal colonic mucosa and adenocarcinoma were examined.

RESULTS

DF3 expression was detected in 84% of the adenocarcinomas with coarse membrane staining, intense positivity of luminal secretions, and focal cytoplasmic and intracytoplasmic vacuole staining. Nine of 32 areas of transitional mucosa revealed reactivity along apical membranes in crypt cells. Five adenomas containing carcinoma revealed DF3 positivity in the malignant areas only, whereas the remaining 29 were negative. Staining was membrane, luminal, and intracytoplasmic. Two examples of active ulcerative colitis revealed focal reactivity along the apical membrane of crypt cells. No other areas of staining were noted, including 12 cases containing dysplasia. Four of 10 other inflammatory lesions also revealed similar membrane reactivity in crypt cells. Normal colonic mucosa was nonreactive. Examples of normal colonic mucosa were negative for DF3 by Western blot analysis, whereas two carcinoma samples that reacted immunohistochemically were positive.

CONCLUSIONS

DF3 is not detectable in normal colonic tissues. It is expressed focally and predominantly along the apical membrane of crypt cells in some inflammatory lesions and in the transitional mucosa of primary adenocarcinomas. Most adenocarcinomas of the colon and adenomas with foci of invasive carcinoma demonstrate reactivity in the cytoplasm and luminal secretions.

Dorsal vein sclerosis as a predictor of outcome in penile venous ligation surgery

We studied the pathological specimens obtained from 24 impotent men who underwent proximal penile vein ligation and 6 potent men who underwent total penectomy as part of male-to-female transsexual surgery to determine if a correlation exists between venous pathology and surgical outcome. Pathology specimens, consisting of cavernosal tissue and penile veins, were independently reviewed by a single uropathologist (V. A.). The degree of vein wall thickness was carefully quantified for each patient. Venous leakage was documented by cavernosometry and cavernosography. Followup ranged from 7 to 19 months (mean 11 months). Within 6 months of the procedure 10 patients (41%) achieved rigid erections while 14 (59%) did not. Although no preoperative index could predict operative success, in the 10 patients with successful outcome histological examination of the excised vein segments revealed normal venous architecture with minimal vein wall thickness (calculated mean per cent vein wall thickness 39.4, range 17.5 to 51.7). In contrast, in the 14 patients in whom ligation failed there was marked vein wall thickness and sclerosis (calculated mean per cent vein wall thickness 68.0, range 55.3 to 85.6). In comparison, the vein segments obtained from the 6 potent patients had a wall thickness of 32.8% (range 8 to 39), which was equivalent to the 10 patients with postoperative erections. These findings suggest that there may be a correlation between vein wall thickness and the prognosis of patients who undergo venous ligation surgery for erectile dysfunction secondary to presumed corporeal venous incompetence.

Oxypurinol inhibits free radical release from the cerebral cortex of closed head injured rats

Traumatic brain injury (TBI) is a significant cause of mortality and morbidity. Although the sequence of events underlying the resultant neuronal loss is still poorly understood, there are indications that oxygen-free radical generation is critically involved. Free radical generation in the cerebral cortex of closed head injury rats was monitored by measuring free radical release into cortical superfusates containing the spin trap agent 4-pyridyl-1-oxide-N-tert-butylnitrone (POBN, 100 mM). ESR analysis of the superfusates revealed six line spectra (alpha N = 15.4 G and alpha H beta = 2.5 G) characteristic of POBN-OH adducts. Administration of oxypurinol (40 mg/kg) 15 min prior to TBI prevented the formation of these radical adducts.

Effect of topical 5-aminosalicylic acid (5-ASA) therapy on rectal mucosal biopsy morphology in chronic ulcerative colitis

Classic teaching emphasizes that chronic ulcerative colitis is characterized morphologically by the presence of fixed architectural and cellular mucosal changes that categorize the process as chronic. To examine the effect of topical 5-aminosalicylic acid (5-ASA) enemas on the presence of six histological features of chronicity in established chronic ulcerative colitis, 123 mucosal biopsies were taken prospectively at 1-month intervals, all from the same anatomic location (10 cm), from 14 patients treated with either 5-ASA or placebo enemas. The biopsies were evaluated for the presence of mixed inflammation in the lamina propria, crypt architectural abnormalities, basally located lymphoid aggregates, basal plasmacytosis, villiform surface epithelial configuration, and Paneth cell metaplasia. Overall, 29% of biopsies from 64% of patients were histologically normal (no chronic features, no active disease). Compared with patients treated with placebo enemas, patients treated with 5-ASA enemas showed a significantly higher percentage of normal biopsies (36% ASA group vs. 12% placebo group; p = 0.005) and a lower percentage occurrence of each individual histological feature of chronicity. In addition, patients treated with 5-ASA had a higher average number of normal biopsies per patient (3.0) than those treated with placebo enemas (1.3). Therefore, histologically normal-appearing mucosal biopsies do occur in established cases of chronic ulcerative colitis, and this finding is enhanced by treatment with 5-ASA enemas. Awareness of these results should prevent the presence of normal rectal mucosal biopsy findings in chronic ulcerative colitis patients from being misinterpreted as either evidence against this diagnosis or as representing focal skip areas characteristic of Crohn's disease.

Esophageal squamous papillomas. A clinicopathologic study of 38 lesions and analysis for human papillomavirus by the polymerase chain reaction

The pathogenesis of esophageal squamous papilloma is not known, but chronic mucosal irritation and infection with human papillomavirus are two proposed etiologies. To investigate these hypotheses, we analyzed the clinical data and histological features of 38 esophageal squamous papillomas from 33 patients and performed the polymerase chain reaction technique for detection of several common human papilloma virus types on a subset of cases (n = 26) with sufficient available material. Clinically, males were affected more often than females (M:F ratio = 24:9); average age was 50 (range, 2-86 years). Most papillomas occurred singly (85%) and were located in the distal esophagus (70%). Patients with esophageal squamous papillomas, especially those with lesions in the distal esophagus, commonly had an associated chronic and often severe form of esophageal mucosal irritation such as esophagitis or Barrett's esophagus. Esophageal squamous papillomas were small polyps (average size, 0.5 cm) that we classified histologically into three types (exophytic, 50%; endophytic, 37%; spiked, 13%) based on the predominant shape of the squamous papillae. Fifty percent of the papillomas (13 of 26) tested, from 57% of patients (12 of 21), were positive for human papilloma virus, most commonly type 16 (nine of 13), less often type 16 and 18 together (3/13), and rarely type 6b/11 (1 of 13). We propose a multifactorial etiology in which the synergistic action of mucosal irritation and human papilloma virus may be necessary for the development of esophageal squamous papillomas.

Effect of 3'-azido-3'-deoxythymidine on human immunodeficiency virus type 1 replication in human fetal brain macrophages

We investigated whether cells derived from the fetal central nervous system can support productive infection by a human immunodeficiency virus type 1 (HIV-1) isolate termed UHC-1, produced by a cellular clone derived from HIV-1 strain HIV-IIIB chronically infected U-937 promonocytic cells, and what the effect of nucleoside analogs might be on viral replication in this system. Fractionation of human fetal brain tissue into two different populations, enriched for either astrocytes or macrophages, showed that only the latter were able to support productive UHC-1 replication and generation of detectable progeny virus. Pretreatment of fetal brain macrophages with either of two nucleoside analogs, 3'-azido-3'-deoxythymidine (AZT) or the (-) enantiomer of 2'-deoxy-3'-thiacytidine, efficiently blocked production of progeny virus. Generation of unintegrated proviral DNA and HIV-1 transcripts were inhibited by pretreatment of fetal brain macrophages with 1 microM AZT. Administration of AZT at 24 h postinfection led to a slight reduction in viral transcript levels and viral progeny production by day 15 postinfection; however, brain macrophages under these conditions did not contain detectable amounts of unintegrated viral DNA. These results suggest that AZT may interfere with the accumulation of unintegrated HIV-1 DNA in brain macrophages. This is the first demonstration that nucleoside analogs are able to block HIV-1 replication in primary cultures of brain cells.

Allergic proctocolitis in infants: a prospective clinicopathologic biopsy study

Allergic proctocolitis is a major cause of rectal bleeding in infants, but its clinical features and laboratory results are often nonspecific. Our previous retrospective study demonstrated that large numbers of eosinophils in colonic mucosal biopsy specimens were highly associated with cases of allergic proctocolitis. Therefore, we prospectively examined 60 colonic mucosal biopsy specimens from the same sites (4, 8, and 12 cm from the anal verge) in 20 infants with clinically confirmed allergic proctocolitis to validate this morphologic feature, to characterize its distribution, and to correlate these data with the clinical information. The patients (age range, 4 to 304 days) were fed breast milk or a variety of formulas and all presented with rectal bleeding. Sigmoidoscopic examination was abnormal in 19 cases, typically characterized by focal areas of mucosal erythema. The major histologic finding was a strikingly focal increase in the number of eosinophils in all mucosal compartments, with a predilection to aggregate in close association with lymphoid nodules. Eosinophilic infiltration varied not only between biopsies at different sites, but also within individual biopsy specimens. Only 12 of 20 patients (60%) had all three of their biopsy specimens categorized as abnormal; in the remainder, only one (four patients) or two (four patients) of the three biopsy specimens were abnormal. The average number of eosinophils per high-power field of lamina propria for all cases was 15.6. No significant correlation was identified between the number of eosinophils in the mucosa and the patient's age, length of illness, endoscopic appearance, or type of inciting formula. In summary, eosinophils appear to be an excellent marker for infantile allergic proctocolitis. Given the focal distribution of the eosinophils, multiple mucosal biopsy specimens should be obtained and several levels of each examined to confirm the diagnosis.

Use of adrenocorticotrophic hormone analog to minimize brain injury

STUDY OBJECTIVES

To investigate the effects of a vasoactive analog of adrenocorticotrophic hormone (GMM2) on time-dependent disturbances in regional cerebral blood flow, permeability-capillary surface area products, and intracranial pressure in a rat model of moderate concussion/brain injury.

SETTING AND DESIGN

Regional permeability-capillary surface area products and cerebral blood flow were measured at two hours after trauma. Intracranial pressure was monitored for 120 hours after trauma.

SUBJECTS

Male Wistar rats (330 to 430 g) (regional cerebral blood flow studies, n = 35; permeability-capillary surface area product studies, n = 36; intracranial pressure studies, n = 32).

INTERVENTIONS

Post-traumatic subcutaneous administration of nanomolar concentrations of GMM2 (31 nmol per rat).

MEASUREMENTS AND MAIN RESULTS

Untreated trauma acutely increased average brain permeability-capillary surface area products for sucrose and decreased average brain cerebral blood flow. Moreover, it produced marked and prolonged increases in intracranial pressure. Post-traumatic subcutaneous administration of nanomolar concentrations of GMM2 effectively reduced the early hypoperfusion, blood-brain barrier leakiness, and pathologic elevation of intracranial pressure.

CONCLUSION

Post-traumatic administration of GMM2, in nanomolar amounts, can prevent or reverse significantly the serious cerebrovascular sequelae of moderate head injury in this animal model. In view of its potency, low toxicity, and other neuroprotective properties, in both rats and human beings, these data suggest that GMM2 may have considerable clinical benefits in the treatment of central nervous system trauma.

An ACTH analog minimizes cerebrovascular damage in an animal model of moderate brain injury

An ACTH1-14-related analog (GMM2) was tested for efficacy in reducing the cerebrovascular pathology that follows moderate, closed-head injury in our rat model. Posttraumatic subcutaneous administration of nanomolar amounts of GMM2 significantly minimized both the hypoperfusion and the increased blood-brain permeability observed 2 h following a concussion. Posttraumatic administration of the peptide also reduced the elevated brain water content observed at 24 and 48 h postinjury to nonsignificant levels. These findings complement previously described observations that GMM2 treatment prevents dangerous elevations of ICP (> 25 mm Hg) at 24 to 72 h in this model of head injury. In view of the potency and low toxicity of GMM2 these observation suggest that the peptide may have considerable clinical application in interrupting pathologic sequelae of traumatic brain injury.

Cerebrovascular responses to pentylenetetrazol: time and dose dependent effects

The effects of subconvulsant and convulsant doses of pentylenetetrazol (PTZ) on cerebral blood flow (rCBF), permeability-capillary surface area products (rPS), and brain vascular spaces (BVS) were examined in 15 brain regions at 1 h, 24 h and 1 week after injection in male Sprague-Dawley rats. Brain histology was examined 3 days after injection. A dose of PTZ (50 mg/kg, i.p.), sufficient to trigger a single convulsive seizure, produced small regional changes in rCBF at 1 h, but not at 24 h or 1 week after injection. No significant changes in rPS or BVS were found at any time, and only mild histologic changes were observed. In contrast, a dose of PTZ (25 mg/kg) which failed to cause either convulsions or significant electrocorticographic changes, markedly increased rCBF and rPS. Some of these regional effects were still observed 1 week later. Similarly, more severe and extensive cellular changes followed treatment with the subconvulsive dose. These findings indicate that PTZ treatment can have prolonged effects on cerebrovascular functions and neuronal integrity even in the absence of convulsive activity.

Sucrase-isomaltase expression in chronic ulcerative colitis and dysplasia

Sucrase-isomaltase (SI) is a mucosal disaccharidase that is present in normal small intestine and fetal colon. It also has been noted in colonic adenomas and adenocarcinomas. We used a polyclonal antibody to human SI to investigate enzyme presence and utility in detecting dysplastic changes in chronic ulcerative colitis. Sections from 32 cases were reviewed for the presence or absence of active colitis and dysplasia. Immunostaining of these cases for SI was performed and the results were reported based on location of immunoreactivity (ie, membrane and cytoplasmic staining in superficial and crypt epithelial cells) and percentage of positivity. Of 81 sections examined, 48 were rated negative for dysplasia (23 inactive colitis, 20 active, and five probably negative) and 28 were rated positive (eight low grade and 20 high grade). Surface membrane staining of epithelial cells was noted in all 28 dysplastic slides and positive cases (sensitivity, 100%) but also in 29 of 48 negative sections (P less than .001). In contrast, cytoplasmic positivity was present in 25 of 28 dysplastic and in only two of 48 negative slides (P less than .0001). The presence of cytoplasmic staining of SI in the superficial or crypt cells revealed a sensitivity of 92% and a specificity of 94%. There were five additional sections rated as indefinite for dysplasia (probably positive or unknown); two showed staining patterns typical of negative slides and three showed positive staining patterns. Of the 18 samples of transitional mucosa next to areas of dysplasia, surface membrane staining of SI was seen in all samples and cytoplasmic staining was seen in 15. We conclude that membrane staining of SI can be detected in inflammatory, regenerative, and dysplastic mucosa in ulcerative colitis. Cytoplasmic staining, however, correlates strongly with the presence of dysplastic change and may help in its detection.

Cerebrovascular permeability and cognition in the aging rat

Regional cerebrovascular permeability-capillary surface area products (rPS) and brain vascular space (BVS) were measured in aging, conscious, unrestrained Sprague-Dawley rats. Three groups of animals were examined: young-mature (6 months), middle-aged (12-14 months), and old (24-26 months) rats. Complex maze learning had been previously characterized in these same animals. Maze learning declined with age. Brain vascular space did not differ significantly with age in any brain region. However, small, but significant age-dependent decreases in rPS (25-33%) were observed. These decreases occurred mainly in the old animals in the basal ganglia and parietal cortex, and in the middle-aged and old rats in the olfactory bulbs. Significant and unexpected positive average correlations between brain permeability-capillary surface area products (PS) and learning errors occurred primarily in young rats and were attributable mainly to changes in 5 of 14 brain regions; hypothalamus, hippocampus, parietal cortex, septal area and superior colliculus. The higher correlations between maze learning errors and PS in young animals may indicate dynamic regulation of this cerebrovascular parameter which is lessened with aging. Average correlations between PS and cerebral blood flow also were determined and found to be generally small and not significant for most brain regions and age groups.

Thymic epithelial cell transplantation in patients with acquired immunodeficiency syndrome. Evidence for infection by HIV-I of newly differentiated T cells at the site of transplantation

From October 1983 to July 1984, 11 adult AIDS patients have received single or repeated thymic grafts. All have had opportunistic infections and 3 also had Kaposi's sarcoma. Thymic tissue from infants undergoing cardiac surgery was cultured to provide a thymocyte- and fibroblast-free epithelial cell inoculum. 18-21 days post-explantation, cells and explants were injected intraperitoneally, intramuscularly or intrahepatically. Transplants were well tolerated in all cases. In 7 cases liver biopsy was performed at the time of grafting and 2 months later. Ten patients have died after a mean survival time following transplantation of 8.7 months while 1 patient was lost to follow up. Clinical improvement and absence of new opportunistic infections were apparent for 4 months following transplantation. Partial immunoreconstitution was evidenced by an increase in peripheral blood lymphocytes (8 of 10 cases) and lymphocyte subsets (7 of 10 cases) as well as by presence of T4 and T8 positive cells in the liver (5 of 7 cases). In 5 of 7 patients, double-staining immunofluorescence showed that HIV-I antigens were present in T4-phenotype cells, at the site of the graft, 2 months after grafting, but were not detected in the liver at the time of grafting. Transient immunoreconstitution, therefore, maybe related to destruction of newly differentiated T lymphocytes.

Cerebrovascular changes in a rat model of moderate closed-head injury

We have developed and tested a rat (Wistar) model of moderate concussion. Concussion is produced by controlled and repeatable mechanical fixed, closed-head injury. Moderate concussion in this model is characterized by 4 to 10 minutes of unconsciousness, absence of skull fractures or brain contusions, and few, if any, acute neurologic symptoms. By 2 hours postinjury, the subsequent trauma is further characterized by regional and global increases in cerebrovascular permeability and decreases in cerebral blood flow. Such changes are accompanied by brain swelling and two phases of elevated intracranial pressure; one lasting about 5 hours with a peak of about 10 mmHg, the other lasting more than 3 days postinjury with a peak of about 30 mmHg. Regional neurohistologic damage detected between 3 and 4 days postinjury correlates for the most part with earlier changes in regional permeability and blood flow. Significant morphologic changes which are characterized by patchy neuronal degeneration can be found in numerous forebrain locations, particularly in the frontal (coup) and entorhinal (contre coup) cortices. These observations have important parallels in human head trauma and suggest that this reliable physiological model may be a useful, relatively simple and inexpensive tool for investigating the mechanisms and therapeutics of head trauma.

Barrett's esophagus in children and young adults. Frequent association with mental retardation

Since few data are available on epidemiologic features of Barrett's esophagus in young persons, we reviewed the case records of patients undergoing esophageal biopsies at Children's Hospital, Boston, from 1982 through 1986. There were 1423 esophageal biopsies obtained from 1173 patients, and histological evidence of esophagitis was present in 397 cases; Barrett's epithelium was diagnosed in 10 patients (0.9% of total and 2.5% of esophagitis cases). Specialized columnar epithelium was present in seven of these 10 patients. The mean age of those with Barrett's epithelium was 19.0 +/- 7.9 years (range 3.7-27 years) compared to 8.7 +/- 6.7 years (range 4 days to 31 years) for all patients biopsied (P less than 0.0001); 80% (8/10) of the Barrett's cases were male compared to 54% of all cases. The relative importance of the possible risk factors was assessed by comparing the 10 patients with Barrett's with the 541 patients that had esophageal biopsies in calendar years 1984-1985. Mental retardation, a risk factor not previously described for young persons with Barrett's esophagitis, was present in 70% (7/10) of the Barrett's patients but in only 15% of all patients biopsied (P less than 0.0002). The frequency of mental retardation was also higher, but not significantly so (P greater than 0.07), in patients with biopsies that were positive for esophagitis (19%) than in those with normal biopsies (14%). No significant differences were found between the Barrett's group and all patients biopsied in regards to racial origin, prior stricture, or fundoplication.

Infection by human cytomegalovirus and rubella virus of cultured human fetal islets of Langerhans

Several viruses are implicated in the pathogenesis of pancreatic beta cell destruction and the onset of insulin-dependent (type 1) diabetes mellitus (IDDM). However, it is still controversial as to whether viral infection can exert direct cytopathic effects on beta cells. We have studied the effect of infection by human cytomegalovirus (CMV) and rubella virus on human fetal pancreatic islets in tissue culture. Although morphological changes were observed in CMV-inoculated islet cells, such infection did not lead to changes in levels of secreted immunoreactive insulin. On the other hand, infection by rubella virus did lead to significantly lower levels of immunoreactive insulin in the absence of demonstrable cytopathic effect. These results indicate that viral infection of human pancreatic islet tissue can occur as demonstrated through tissue culture techniques, and that such infection leads to changes in levels of secreted insulin in some cases but not others.

Allergy-related proctocolitis in infants: diagnostic usefulness of rectal biopsy

To evaluate the diagnostic utility of rectal mucosal biopsies in infants with proctocolitis, we compared the clinical and histologic features of an allergy-related group (N = 36) with those of normal (N = 12) and inflammatory (N = 8) controls. Clinical features were nondiscriminatory among the three groups of patients, except for an increased absolute peripheral eosinophil count in the allergic group. Similarly, morphologic evidence of proctitis (cryptitis and crypt abscesses) and small or moderate numbers of eosinophils (less than or equal to 60 per ten high power fields) in the lamina propria of the biopsies did not discriminate among the three groups. However, large numbers of eosinophils (greater than 60 per ten high power fields) and eosinophils located in the muscularis mucosae or as the predominant cell in crypt abscesses were significantly associated with allergy-related disease. No histologic features of chronic colitis were noted in the allergy-related group. Thus, in tandem with the remainder of the clinical data, rectal mucosal biopsy is a useful adjunct in the diagnosis of allergic proctocolitis.

Effects of infection by HIV-1, cytomegalovirus, and human measles virus on cultured human thymic epithelial cells

A tissue culture system for the growth of human fetal and infantile thymic epithelial (TE) cells has been established and characterized. We have investigated the effects of infection of these cells by human cytomegalovirus (CMV), measles virus, and human immunodeficiency virus type-1 (HIV-1). In the case of CMV, morphological changes were apparent by 2-4 days after viral inoculation of infantile TE cells. CMV-related antigens were detected by immunofluorescence after 12 days, and progeny infectious CMV was recovered from culture media after 18 days. Following infection by measles virus, distinctive, multinucleated giant TE cells appeared in both cultures of fetal and infantile TE cells. Measles virus-inoculated TE cells displayed an altered phenotype, as revealed by reaction with monoclonal antibodies with specificity for a variety of TE markers. Finally, infection of TE cells by HIV-1 resulted in cellular disarrangement, increased numbers of Hassall's corpuscles, and multinucleated giant cells. An increase in the number of cells reactive with monoclonal antibodies, specific for Hassall's corpuscles, was observed in the case of cells infected by either measles virus or HIV-1. These findings suggest that a variety of different viruses can successfully infect thymic epithelial tissue. Because of the important role of the thymus in development of the immune system, it is reasonable to conclude that viral infection of thymic tissue might play an important role in virus-mediated suppression of immune responsiveness.

Infection of cultured human thymic epithelial cells by human immunodeficiency virus

We have succeeded in growing the HTLV-IIIB strain of human immunodeficiency virus type 1 (HIV-1) in cultured human thymic epithelial (TE) cells. Expression of the HIV-1 proteins p17 and p24 was detected by immunofluorescence and reached a peak at 3 days after infection. Antigen capture and reverse transcriptase assays were used to detect HIV-1 in culture fluids, with positive results also being realized. The infection was cytolytic; cellular disarrangement, increased numbers of Hassall's corpuscles, and giant cells first appeared in monolayers of TE cells at 2 days after inoculation. By 4 days these changes were increased, and by 7 days, retraction and involution of TE cells were evident. The infection of TE cells by HIV-1 was blocked by preincubation with monoclonal OKT4A antibodies directed against CD4 target molecules.

Infection of cultured human fetal pancreatic islet cells by rubella virus

A high incidence of insulin-dependent diabetes mellitus (IDDM) has been reported in children and young adults previously afflicted with congenital rubella syndrome (CRS). The authors have studied the effect of rubella virus infection on human pancreatic islet cells in tissue culture. These experiments were performed with the use of both monolayers and free-floating human fetal islets of Langerhans tissue. Levels of production of immunoreactive insulin by islet cells that had been infected by rubella virus were lower than those observed in control cultures, under conditions of high glucose concentration (11.1 mmol/L) in the medium. The presence of rubella viral antigens in human pancreatic beta and non-beta cells was demonstrated by double-label immunofluorescence. These results suggest that rubella virus can infect human pancreatic islet cells and that such infection may lead to significant reductions in levels of secreted insulin.

Maturation of human fetal and infantile thymic cells in tissue culture

Human fetal and infantile thymic epithelial (TE) cells were grown in tissue culture and were phenotypically characterized using monoclonal antibodies reactive against a number of individual components of human thymus. Cultures of infantile TE cells formed confluent monolayers after 14-17 days. This was accompanied by a dramatic increase in numbers of Hassall's corpuscles, septae formation and pseudolobulation. After 3 weeks in culture, the rate of cell growth slowed, and by 4 weeks an accumulation of fat cells was noted. Involution of the cultures occurred after this time. In contrast, cultures of fetal TE cells achieved confluence after only 6-8 days, and increased numbers of Hassall's corpuscles, septae formation and pseudo-lobulation could be observed after only 10 days. Fat cells appeared after 3 weeks in culture and involution occurred soon after. Cells which reacted with monoclonal antibodies specific for keratin and GQ ganglioside were predominant during the early stages of tissue culture. These cells ceased to play as important a role with increased time in culture; in contrast, cells reactive with monoclonal antibodies specific for distinct thymic components increased in number as time in culture progressed.

Financing the medical management of mental disorders

In 1987 Medicare benefits for the mentally ill were expanded for the first time in 22 years. A major change was the removal of limits and copayments for the "medical management of psychopharmacologic agents." Payment for medical management recognizes the trend toward the remedicalization of psychiatry; however, medical management can be defined either broadly or narrowly. The authors suggest pricing strategies for both medical management of mental disorders and psychotherapy. Enlightened design of psychiatric benefits will cover all forms of treatment according to appropriate rules. Access to treatment for mental illness is at stake as these rules develop.

Replication of cytomegalovirus in human thymic epithelial cells

Cytomegalovirus (CMV) has often been cited as a cause of immune suppression in children, yet little is known of the mechanisms through which this agent might affect immune function. We have succeeded in using CMV to productively infect cultured human fetal and infantile thymic epithelial (TE) cells. Morphological changes were apparent by 2-4 days after viral inoculation. CMV-related early antigen (EA) and late antigen (LA) were detected by immunofluorescence after 8 days, and progeny infectious CMV was recovered from culture media after 12-17 days. TE cells that reacted with monoclonal antibodies specific for keratin and for GQ ganglioside were predominant throughout the culture period. In contrast, infection by CMV resulted in a significant decrease in numbers of cells reactive with monoclonal antibodies specific for mesoderm-derived components. Inoculation of TE cells with CMV also caused a diminution in levels of detectable interleukin-1 (IL-1)-related antigen by 17 days after infection.

Replication of measles virus in cultured human thymic epithelial cells

Measles virus can replicate in cultures of both infantile and fetal human thymic epithelial cells. Virus-induced cytopathology including syncytium formation was first evident around 24 hr after viral inoculation of these cultures. At the same time, the cultures began to lose their characteristic thymus-like organizational structure. Viral antigens were detected in infected cells by indirect immunofluorescence, and the presence of progeny virions was demonstrated in culture fluids.

Pulmonary disease in infants and children

Pulmonary diseases contribute significantly to the morbidity and mortality in children infected with the human immunodeficiency virus. The wide array of lung diseases spans from early acute bacterial infections, to the lymphoid interstitial pneumonitis/pulmonary lymphoid hyperplasia complex, to opportunistic infections. The unique clinical and histopathologic features of these diseases are reviewed.

Increased subepithelial collagen deposition is not specific for collagenous colitis

To refine the pathologic diagnosis of collagenous colitis and to determine whether increased subepithelial collagen deposition (SCD) is specific for collagenous colitis (CC), we reviewed histologic sections of 1549 colonic mucosal biopsy procedures obtained from 1332 patients and 157 consecutive colonic resections. Quantitative evaluation of SCD was performed for those patients who showed thickness of SCD that was 5 microns or greater in either biopsies or resections, and the overall histologic and clinical features were correlated. A focal or diffuse increase of SCD greater than or equal to 5 microns was noted in 22 (1.7%) of the patients with biopsies and in 11 (7%) of the cases with resections. An otherwise unexplained, prolonged watery diarrhea was present in 6 (27%) of the 22 biopsy patients but in none of the patients with resections. These 6 patients with unexplained watery diarrhea had significantly greater amounts of SCD than those without this clinical feature both in terms of average thickness (21 microns versus 11 microns; P less than 0.02) and of the percentage of surface epithelium involved (47% versus 15%; P less than 0.02). Also, biopsies and resections with increased SCD from patients without watery diarrhea were all from the rectum and rectosigmoid region. These results lend further support to the nonspecificity of increased SCD and to the importance of the quantity of SCD, rather than its mere presence. In summary, increased SCD is not specific for CC; however, a greater amount of SCD is associated with a greater probability of associated watery diarrhea.(ABSTRACT TRUNCATED AT 250 WORDS)

Age-related changes in regional cerebral blood flow and behavior in Sprague-Dawley rats

Studies of regional cerebral blood flow (rCBF) were carried out in male, Sprague-Dawley rats at ages 6, 12 and 24 months. These animals were characterized behaviorally for their ability to learn a complex 14-choice sequential T-maze (i.e., Stone maze) for food reward. Old animals (i.e., 24 month) demonstrated a clear and consistent impairment in maze performance which correlated significantly with decreased cortical blood flow. The results are discussed in relation to cerebral blood flow studies in aging humans and as they relate to the use of rats, the Sprague-Dawley strain in particular, to study brain aging.

Viral infection of human fetal islets of Langerhans. Replication of human cytomegalovirus in cultured human fetal pancreatic islets

Tissue monolayer cultures of human fetal islets of Langerhans were infected with human cytomegalovirus (CMV). On the fourth day after inoculation, morphologic changes of monolayers were observed, including rounding up and floating of many cells. In addition, after this time CMV late antigen (LA) was detected in the inoculated cells. On the seventh day, CMV was recovered from the culture medium, and infected beta cells were identified by use of a double-label antibody technique. However, CMV apparently did not cause direct destruction of beta cells nor did infection by CMV lead to changes in production of insulin as measured by radioimmunoassay. Thus, despite the fact that CMV can successfully infect a variety of cells in fetal islets of Langerhans, the absence of a significant effect on beta cells does not support the notion that congenital CMV infection is involved in the origin of insulin-dependent diabetes mellitus.

Impact of SMBG on control of diabetes as measured by HbA1. 3-yr survey of a juvenile IDDM clinic

Three hundred twelve diabetic children and adolescents were seen in our diabetic clinic and instructed to test their capillary blood glucose (CBG) twice daily and to use an algorithm to adjust their short-acting insulin. Of this group, 219 youngsters had a full 3-yr period of observation. At each clinic visit, blood was obtained for fasting blood glucose and HbA1 and, once a year, cholesterol and triglycerides were also measured. Patient and parent accuracy in measuring CBG was found to be adequate. The changes over time in HbA1 were nondifferential across age and sex, and there was no difference in the level of HbA1 between age and sex groups, the number of tests reported to have been done by the patients, the number of injections of insulin per day, or the serum cholesterol. There was a significant relationship between the HbA1 and the fasting blood glucose (P less than .001) measured by the laboratory as well as with the serum triglyceride (P less than .01). The failure to improve diabetic control, despite measures that would have been expected to do so, was believed to relate more to a lack of compliance than to a flaw in the therapeutic approach. It was interesting to note that the adolescent patients in the study were in no worse control than the younger children in the group. Although better technical skills are available today to manage diabetes, the psychosocial approach to patient motivation requires improvement.

Infection of human thymic epithelial cells by human cytomegalovirus and other viruses: effect on secretion of interleukin 1-like activity

Cultures of human thymic epithelial (TE) cells are able to produce a interleukin 1 (IL-1) like activity. This IL-1 activity can be detected either using mouse thymocytes in a traditional IL-1 assay, or using thymic lymphocytes obtained from cases of pediatric cardio-vascular surgery. Production of IL-1 activity by TE cells was found to be maximal between 3 and 4 weeks after culture initiation. Human thymocytes worked best as targets in an IL-1 assay, when these cells were derived from donors younger than 1 year of age. Infection of human TE cells by any of human cytomegalovirus, herpes simplex virus type 2, adenovirus 7, Coxsackie B1, and respiratory syncytial virus led to marked reductions in the ability of these cells to secrete measurable IL-1 activity. In the case of TE cells infected by cytomegalovirus, respiratory syncytial virus, and Coxsackie B1, this abrogation of production of IL-1 activity occurred in the absence of any obvious virus-induced cytopathic effect.

The decision to seek an exemption from PPS

This paper examines the receipt of exemptions from Medicare's Prospective Payment System (PPS) for distinct part psychiatric units of general hospitals. A logit model of the exemption status of 1,045 psychiatric units is estimated using 1984 data. The results suggest that units that were expected to profit from a change in payment method (cost based on PPS) were least likely to obtain an exemption from PPS.

Morphology, yield and functional integrity of islet-like cell clusters in tissue culture of human fetal pancreata obtained after different means of abortion

Morphology, yield and function were studied in cultured islet-like cell clusters (ICC) from 140 human fetal pancreata obtained after abortions of different types performed at 11-23 weeks of gestation (12 by hysterotomy, 75 by mechanical dilation and extraction, and 53 induced with prostaglandin). After collagenase digestion and culture in medium supplemented with 10% human serum, up to 2000 free-floating ICC were formed from a single pancreas. Randomly scattered insulin- and glucagon-immunoreactive cells were found in the medullary part of the ICC. More than 100 ICC developed in 100% of the hysterotomies and 87% of the mechanical abortions, but in only 53% of the prostaglandin-induced abortions. Insulin and glucagon levels in the culture medium decreased rapidly during the first 7 days of culture, but then remained stable for at least 31 days. The hysterotomy-derived ICC responded to 10 mmol/l theophylline plus 20 mmol/l glucose by a 12.2 +/- 3.1 (SEM, N = 7) fold increase in insulin release, as compared with a 5.4 +/- 0.9 fold response of the prostaglandin ICC (N = 16; P less than 0.02). Despite the low proportion of B-cells, (pro)insulin biosynthesis accounted for 10% of the total protein biosynthesis in low (2 mmol/l) glucose. In conclusion, the yield and viability of the ICC were clearly better, if prostaglandin had not been used for the induction of the abortion.

Effect of cytomegalovirus on lectin-driven mitogenesis of human thymic and peripheral blood lymphocytes

Human cytomegalovirus (CMV), when added to cultures of either thymic or peripheral blood lymphocytes, was able to prevent these cells from responding to mitogenic stimulus. This effect was only obtained when live virus was utilized, and is apparently dependent on the ability of such virus to establish abortive infections in the cell cultures. CMV-infected cultures became deficient in terms of ability both to produce interleukin-2 (IL-2) activity as well as to respond to purified, recombinant IL-2 which was added exogenously. Similar results were obtained using either a laboratory strain (AD-169) of CMV or freshly-obtained clinical isolates of this virus which had been grown in tissue culture.

Effect of co-incubation with cytomegalovirus on growth of interleukin 2-dependent lymphocytes

We have tested the ability of human cytomegalovirus (CMV) to interfere with the interleukin-2 (IL-2)-dependent proliferation of T lymphocytes in long-term tissue culture. The results indicate that CMV was able to establish an apparently abortive infection in approximately 40% of such cells, although productive viral replication could not be detected, and was able to impede cellular proliferation almost completely. The addition of high concentrations of exogenous IL-2 to cultures of CMV co-incubated cells was not readily able to overcome the anti-proliferation inhibitory effect induced by this virus. Exposure to CMV led to an approximate 50% decrease in the number of cells which expressed Tac Ag, or IL-2 receptor, at the cell surface.

Observer variation in the diagnosis of dysplasia in Barrett's esophagus

The potential value of biopsy surveillance of patients with Barrett's esophagus for dysplasia is diminished by a lack of agreement on the diagnostic criteria for dysplasia. In a preliminary consensus conference, experienced gastrointestinal pathologists from four medical centers agreed on criteria for a five-tiered histologic classification of dysplasia in Barrett's esophagus--negative for dysplasia, indefinite for dysplasia, low-grade dysplasia, high-grade dysplasia, and intramucosal carcinoma. Eight morphologists in the four centers tested the criteria for interobserver agreement by examining a set of coded slides that had been chosen to include some especially difficult interpretative problems in all five histologic classifications. Interobserver agreement of 85 and 87% was achieved in successive reviews when the combined group of high-grade dysplasia and intramucosal carcinoma was compared with the combined group of low-grade dysplasia, indefinite for dysplasia, and negative for dysplasia. Comparison of other groups yielded less agreement. For example, negative for dysplasia could be distinguished from all other diagnoses with an interobserver agreement of 72%. We conclude that experienced gastrointestinal morphologists can diagnose high-grade dysplasia and intramucosal carcinoma with a high degree of agreement and thus can detect those patients who may need immediate rebiopsy or esophageal resection. Either further refinement of histologic criteria or alternate diagnostic methods will be needed to achieve the reproducible diagnosis of indefinite changes and low-grade dysplasia. This is important because patients with such changes theoretically merit closer endoscopic surveillance.