Suppression of inducible nitric oxide synthase expression in RAW 264. 7 macrophages by two beta-carboline alkaloids extracted from Melia azedarach

We investigated the mechanism of suppression of inducible nitric oxide synthase (iNOS) by two beta-carboline alkaloids isolated from Melia azedarach, 4,8-dimethoxy-1-vinyl-beta-carboline (compound 1, C-1) and 4-methoxy-1-vinyl-beta-carboline (compound 2, C-2). iNOS activity in a cell-free extract of lipopolysaccharide/interferon-gamma-stimulated RAW 264.7 cells was found to be markedly increased, and this increase was prevented by C-1 and C-2, accompanied by the parallel reduction in nitrite accumulation in culture medium. However, C-1 and C-2 had no further effect on the iNOS activity prepared from fully lipopolysaccharide/interferon-gamma-stimulated RAW 264.7 cells. Treatment with C-1 or C-2 decreased the levels of iNOS protein and mRNA in a concentration-dependent manner. In addition, prostaglandin E(2) production, cyclooxygenase-2 protein and DNA binding of nuclear factor-kappaB (NF-kappaB) in lipopolysaccharide-stimulated RAW 264.7 cells were reduced by these compounds. These results indicate that C-1 and C-2 primarily inhibit iNOS and cyclooxygenase-2 activities via the suppression of de novo synthesis of these two enzymes, and that the inhibition of iNOS expression may be associated with the inhibition of NF-kappaB activation. Taken together, the results suggest that suppression of iNOS and cyclooxygenase-2 induction by lipopolysaccharide is responsible for the anti-inflammatory activity of these alkaloids through selective inhibition of the expression of genes, which play important roles in inflammatory signaling pathways.

Statistical validation of reproducibility of HPLC peptide mapping for the identity of an investigational drug compound based on principal component analysis

Peptide mapping is a key analytical method for studying the primary structure of proteins. The sensitivity of the peptide map to even the smallest change in the covalent structure of the protein makes it a valuable "fingerprint" for identity testing and process monitoring. We recently conducted a full method validation study of an optimized reverse-phase high-performance liquid chromatography (RP-HPLC) tryptic map of a therapeutic anti-CD4 monoclonal antibody. We have used this method routinely for over a year to test production lots for clinical trials and to support bioprocess development. One of the difficulties in the validation of the peptide mapping method is the lack of proper quantitative measures of its reproducibility. A reproducibility study may include method and system precision study, ruggedness study, and robustness study. In this paper, we discuss the use of principal component analysis (PCA) to quantitate peptide maps properly using its projected scores on the reduced dimensions. This approach allowed us not only to summarize the reproducibility study properly, but also to use the method as a diagnostic tool to investigate any troubles in the reproducibility validation process.

Conservative management of adenocarcinoma in situ of the cervix

OBJECTIVE

The purpose of this study was to determine the method of treatment and outcome of women with cervical adenocarcinoma in situ (AIS).

METHODS

Following institutional review board approval, all women diagnosed with cervical AIS from 1987 to 1999 were identified. Data were retrospectively collected by record review and correspondence with medical providers.

RESULTS

Of 132 women treated with cone biopsy for AIS, 95 (72%) were managed conservatively after cold knife cone or loop electrical excisional procedure alone; 37 (28%) eventually underwent hysterectomy. The median age of diagnosis was 29 years (range, 17-47) in the conservative management group and 40 years (range, 25-72) in the hysterectomy group (P < 0.0001). Seventy-four percent were nulliparous in the conservative group compared with 27% in the hysterectomy group (P < 0.0001). Of the 95 conservatively managed patients, 92 obtained negative margins; three were followed despite positive or unevaluable margins. During a median follow-up of 30 months, 9 women required evaluation for follow-up abnormalities after cone biopsy with negative margins. None had pathologic evidence of recurrent AIS. Twenty-three infants were delivered. Hysterectomy was generally performed for undesired fertility or persistently positive cone margins. One woman required hysterectomy for recurrent AIS. Thirteen (62%) of twenty-one hysterectomy specimens had residual AIS following cone biopsy with positive or unevaluable margins; 1 (6%) of 16 had residual AIS following cone biopsy with negative margins (P < 0.0001). No patient developed invasive adenocarcinoma.

CONCLUSIONS

Younger women with cervical AIS may be effectively treated with cone biopsy alone if negative margins can be achieved.

Early invasive adenocarcinoma of the cervix

BACKGROUND

Adenocarcinoma of the cervix is increasing in frequency. There is a dearth of specific detail concerning the histomorphology, histogenesis, and associated findings in early invasive cervical adenocarcinoma.

METHODS

Forty cases of cervical adenocarcinoma invasive to 5 mm or less were examined in detail.

RESULTS

Mean patient age was 40.9 years. In 78% of the cases, the midpoint of the invasive focus was in the region of the squamocolumnar junction or transformation zone; more than 1 invasive focus was present in 4 cases. Eighty-five percent of cases also had adenocarcinoma in situ (AIS). In 9 of 10 minimally invasive cases, small invasive glands were present in the stroma adjacent to AIS. In some of these, the AIS had preinvasive buds that were still attached. Endometrioid adenocarcinomas were associated with AIS but were located higher in the canal than the more common endocervical type. All three adenosquamous carcinomas were associated with both squamous intraepithelial neoplasia and AIS. Vascular space invasion was observed in two cases, microglandular hyperplasia in four.

CONCLUSIONS

Adenocarcinoma in situ is the precursor to most adenocarcinomas of the cervix with an average interval between clinically detected AIS and early invasion of approximately 5 years, supporting the potential for Papanicolaou test screening to prevent this disease. However, the existence of small carcinomas in the absence of AIS suggests the possibility of rapid progression in some cases. Invasion occurs by budding from or expansion of AIS glands, usually in the region of the squamocolumnar junction. Multifocal invasion is uncommon, as is vascular invasion in early lesions. The endometrioid variant has the same histogenesis as the endocervical type but may arise higher in the canal. The precursor of adenosquamous carcinoma has a similar bimorphic differentiation potential. Microglandular hyperplasia is not related to early invasive adenocarcinoma.

The value of skin testing for penicillin allergy in an inpatient population: analysis of the subsequent patient management

It was decided to assess the value of skin testing in a group of inpatients with a remote history of penicillin allergy, in terms of whether or not beta-lactams were subsequently given, if any adverse reactions occurred as a result of this therapy, and if labeling of the patient record was changed subsequent to skin testing and/or challenge. All patients seen in consultation with a history of penicillin allergy were assessed. When done, skin tests were performed with the major and minor determinants of penicillin and semisynthetic penicillins. Charts were reviewed after discharge in terms of the antibiotics given during admission, adverse events, and the medical record and hospital database labeling for drug allergy at discharge. Skin testing was carried out in 79% of 67 patients assessed and in all, the tests were negative. Beta-lactam therapy was recommended in 51/53 patients but was given in only 57% of these cases. At discharge, 49% of patients' records still carried the penicillin allergy label, despite negative skin testing and/or successful completion of a course of beta-lactam therapy. So, in approximately half of the patients reviewed, beta-lactams were not given despite negative skin tests and a recommendation to do so, if indicated, and 49% of patients were still inappropriately labeled as being penicillin-allergic on discharge.

Prospective management of stage IA(1) cervical adenocarcinoma by conization alone to preserve fertility: a preliminary report

OBJECTIVE

Microinvasive cervical adenocarcinoma has an excellent prognosis and emerging data support the hypothesis that it should be treated in the same way as its squamous counterpart. We report our preliminary experience prospectively treating stage IA(1) cervical adenocarcinoma by conization alone in women who strongly desired to preserve their fertility.

METHODS

Since May 1998, all patients with stage IA(1) cervical adenocarcinoma who expressed a strong desire to preserve fertility have been offered cold knife conization (CKC) and careful surveillance without hysterectomy. Women with lesions identifiable only microscopically, up to 3 mm invasive depth, up to 7 mm tumor width, and a conization specimen including the entire lesion with negative margins were eligible for conservative management. Postconization surveillance consisted of a Pap smear and endocervical curettage every 4 months. Medical records were reviewed for clinical data, follow-up, and disease status.

RESULTS

Five women ages 26-33 elected CKC and surveillance. Four were nulliparous and one primiparous. Four tumors were endocervical cell type; one was adenosquamous. Three were grade 1, one was grade 2, and one grade 3. None had lymph-vascular space invasion. None of the patients has developed recurrent disease after 6-20 months of follow-up.

CONCLUSIONS

Our preliminary data suggest that patients with FIGO stage IA(1) cervical adenocarcinoma who strongly desire to preserve their fertility may be treated by conization alone if they are fully informed of the unknown risks for disease recurrence and are carefully followed. A multicenter trial is the next logical step to test the efficacy of this approach.

Endocervical intraepithelial glandular atypia (dysplasia): a histopathologic, human papillomavirus, and MIB-1 analysis of 25 cases

The purpose of this study was to determine the likelihood that intraepithelial endocervical glandular atypias that are less severe than adenocarcinoma in situ (AIS) are precursors to AIS and, if so, whether they can be recognized by morphological or other means. We first assessed the frequency of atypias found in association with either AIS or invasive adenocarcinoma (ACA) and then tested these cases and additional randomly encountered cases for the presence of human papillomavirus (HPV) and for their proliferative (Ki-67) index. Lesions not fulfilling the classic criteria for AIS were subdivided into high-grade (HGGA) and low-grade glandular atypias (LGGA). Atypias and controls were microdissected and tested for HPV by the polymerase chain reaction. Serial sections were labeled for Ki-67 by immunohistochemistry with the MIB-1 antibody. Eight cases (6.8%) containing glandular atypia were found in a search of 117 consecutive cone biopsy or hysterectomy specimens that also had either AIS, ACA, or both. An additional 17 cases were either randomly encountered or were received in consultation. In 3 cases, both HGGA and LGGA were present, yielding a total of 28 lesions for study. Of the 9 HGGA cases that were associated with either AIS, ACA, or CIN II/III, 6 were positive for HPV; MIB-1 reactivity in all 6 was present in greater than 25% of the nuclei. Of the 3 HPV-negative HGGA cases in this group, the 2 that were tested showed low MIB-1 reactivity. All 3 cases of HGGA that were not associated with a diagnostic lesion were HPV-negative and had low MIB-1 reactivity. Of the 6 LGGAs associated with either AIS, ACA, or CIN II/III, 1 was positive for HPV; MIB-1 was nonreactive in this case and was low in all of the HPV-negative cases in this group that were tested. Of 10 LGGAs not associated with a diagnostic lesion, or with a low-grade squamous lesion as the only other abnormality, 2 were positive for HPV. Of these 2, one had an MIB-1 reactivity of greater than 25% and also had intestinal differentiation. MIB-1 reactivity was elevated in 2 of the 8 HPV-negative LGGAs from this group. All 10 ciliated atypias (3 HGGA, 7 LGGA) were HPV-negative and had low MIB-1 reactivity. One HPV-positive AIS control case was focally ciliated. Six of 7 foci with apoptotic bodies (5 HGGA, 2 LGGA) were HPV-positive. The infrequent occurrence of glandular atypias with AIS and ACA and the low rate of HPV DNA positivity when they are found in isolation are evidence that most AIS lesions do not evolve through morphologically identifiable antecedents and that most isolated atypias are not AIS precursors. HGGAs associated with AIS or CIN II/III maybe either precursors to or subtle variants of AIS. However, LGGAs similarly encountered are unlikely to be either. Elevated MIB-1 reactivity may be helpful diagnostically in selected cases, but it is not reliable as an independent criterion. The presence of cilia in isolated glandular atypias favors a nonneoplastic process, whereas intestinal differentiation and apoptotic bodies each suggest neoplasia.

Calibration and LOD/LOQ estimation of a chemiluminescent hybridization assay for residual DNA in recombinant protein drugs expressed in E. coli using a four-parameter logistic model

Calibration is the process of fitting a model based on reference data points (x, y), then using the model to estimate an unknown x based on a new measured response, y. In DNA assay, x is the concentration, and y is the measured signal volume. A four-parameter logistic model was used frequently for calibration of immunoassay when the response is optical density for enzyme-linked immunosorbent assay (ELISA) or adjusted radioactivity count for radioimmunoassay (RIA). Here, it is shown that the same model or a linearized version of the curve are equally useful for the calibration of a chemiluminescent hybridization assay for residual DNA in recombinant protein drugs and calculation of performance measures of the assay.

Clinical wear of 63 ultrahigh molecular weight polyethylene acetabular components: effect of starting resin and forming method

This study compares the clinical wear rates and implant characteristics of 63 surgically retrieved acetabular components. All components were made by the same manufacturer, implanted by the same surgeon, in articulation against the same type of femoral component, and revised for the same reason; 19 were made from directly compression molded, calcium stearate free, ultrahigh molecular weight polyethylene (UHMWPE) and 44 were made from machined, ram extruded, calcium stearate containing UHMWPE. There were significant differences in wear, duration, and wear rate between the molded (type I) and machined (type II and III) components. Most importantly, the wear rates of type I (molded) components were significantly (p < 0.0001) lower than the wear rates of type II, type III, and type II and III components as a group (all machined). The machined components had wear rates 2.3 times greater than the molded components. The wear rates between the two different groups of machined components (type II and III) were not significantly different. The scanning electron microscope observations did not reveal any major differences in wear mechanisms between the three types of components, although the machined components did show more evidence of brittleness. The molded components were better consolidated (or had less fusion defects) than the ram extruded components.

New cytotoxic butanolides from Lindera obtusiloba BLUME

Three new butanolides, 2-(1-methoxy-11-dodecenyl)-penta-2,4-dien-4-olide (1), (2Z,3S,4S)-2-(11-dodecenylidene)-3-hydroxy-4-methylbutano lide (2) and (2E,3R,4R)-2-(11-dodecenylidene)-3-hydroxy-4-methoxy-4-methylbu tanolide (3), were isolated from the stems of Lindera obtusiloba BLUME. Their chemical structures were assigned by spectroscopic evidence. They exhibited cytotoxicity against cultured human tumor cell lines with their ED50 values ranging from 3.19 to 14.63 microg/ml.

Cytotoxic peroxides from Artemisia stolonifera

Two sesquiterpene endoperoxides, 1S, 4R, 6R-1, 4-endoperoxy-bisabola-2, 10-diene (I), 1R, 4S, 6R-1, 4-endoperoxy-bisabola-2, 10-diene (II), and a sesquiterpene hydroperoxide, 1beta-hydroperoxygermacra-4 (15), 5, 10 (14)-triene (III) were isolated from the aerial parts of Artemisia stolonifera (Compositae). Their chemical structures were assigned by spectral evidences. Compounds I and II exhibited cytotoxicity against five human tumor cell lines with their ED50 values ranging from 0.20 to 5.43 microg/ml and from <0.1 to 0.87 microg/ml, respectively.

Total hip arthroplasty in young patients. 8- to 13-year results using an uncemented stem

One hundred eight uncemented total hip arthroplasties were performed in 91 patients who were 50 years of age or younger using the Taperloc femoral component. The average age of the patients at time of surgery was 37 years (range, 20-50 years). The mean followup was 10.2 years (range, 8-13 years). No patient was lost to followup. Seven patients (eight hips) died before obtaining the minimum time of 8 years for inclusion in this study. All seven died with their femoral components in place. Of the remaining 100 total hip arthroplasties, no femoral component required revision for aseptic loosening. One femoral component was revised to correct a leg length discrepancy, and one well-fixed femoral component was revised for sepsis. In the 98 total hip arthroplasties that had not undergone femoral component revision, complete radiographic and clinical followup was obtained. Radiographically, 96 (98%) femoral components were determined to have fixation by bone ingrowth, two (2%) femoral components showed stable fibrous ingrowth, and no femoral component was unstable. Femoral cortical osteolysis occurred in seven (7%) hips; major lysis was present in only one (1%). Clinically, 91 (93%) total hip arthroplasties were rated good or excellent; six (6%) were rated fair, and one (1%) was rated poor. Thirty-nine patients with 47 total hip arthroplasties (48%) were engaged in moderate to strenuous manual labor. These results indicate that excellent fixation and minimal lysis can be achieved with an uncemented femoral component in young and active patients at 10 years.

Chemometrics approach to the determination of polymorphism of a drug compound by infrared spectroscopy

A chemometrics approach, multivariate calibration in particular, was used to determine the polymorphism of a drug compound based on Fourier transform infrared (FTIR) spectroscopy. The partial least-squares projection to latent structure makes use of all of the data, and the latent variables created by the method make use of hidden or partially separated peaks for quantitation. This paper illustrates the usefulness of the partial least-squares multivariate calibration method as an efficient tool to determine the polymorphism of a drug. Also, the analysis suggests the use of information from the modeling as diagnostic tools to gain more insight from the data. In particular, the diagnostic tools allow an analyst to assess design characteristics and any shortcomings of a calibration experiment for the polymorphism of a drug compound.

Ruggedness study of HPLC peptide mapping for the identity of a drug compound: a chemometrics approach

A statistically more reliable approach than the traditional visual inspection of peptide maps to identify a drug compound is to generate a set of reference standards from a designed experiment that incorporates many possible factors that affect variation of peptide mapping. In fact, the experiment can be done for a ruggedness study as part of a high-performance liquid chromatography (HPLC) method validation. Once the ruggedness is proved with the study, those articles in the experiment may form a set of reference standards, and future articles can be compared to the set later to prove identity. A quantitative analysis of the ruggedness study can be done using a chemometrics approach, principal component analysis (PCA). The analysis is used to reduce the many channels of peptide maps to a few manageable dimensions. The scores projected onto the reduced dimensions are used to test factor effects of the ruggedness study. As a by-product, the analysis provides visual inspection of the set of articles in the experiment for any outliers and anomalies.

Validation of a peptide mapping method for a therapeutic monoclonal antibody: what could we possibly learn about a method we have run 100 times?

Peptide mapping is a key analytical method for studying the primary structure of proteins. The sensitivity of the peptide map to even the smallest change in the covalent structure of the protein makes it a valuable 'finger-print' for identity testing and process monitoring. We recently conducted a full method validation study of an optimised reverse-phase high-performance liquid chromatography (RP-HPLC) tryptic map of a therapeutic anti-CD4 IgG1 monoclonal antibody. We have used this method routinely for over 1 year to support bioprocess development and test production lots for clinical trials. Herein we summarize the precision and ruggedness of the testing procedure and the main findings with respect to 'coverage of amino acid sequence' and limits-of-detection for various hypothetical structural variants. We also describe, in more detail, two unanticipated insights into the method gained from the validation study. The first of these is a potentially troublesome side-product arising during the reduction/alkylation step. Once the cause of this side-product was identified, it was easily prevented. We also report on subtle changes to the peptide map upon extended storage of the digest in the autosampler. These findings helped us to develop a 'robust' method for implementation in a quality control laboratory.

Adenocarcinoma in situ with a small cell (endometrioid) pattern in cervical smears: a test of the distinction from benign mimics using specific criteria

BACKGROUND

Papanicolaou smears have been less effective in preventing cervical adenocarcinoma than in preventing squamous carcinoma. One reason may be a lack of awareness of certain smear patterns of adenocarcinoma in situ (AIS) such as those with crowded small cells (endometrioid pattern).

METHODS

A test set of 29 smears (17 AIS with an endometrioid pattern, 12 benign mimics) was reviewed by 11 cytologists (4 experienced cytotechnologists, 3 cytopathology fellows, and 4 cytopathologists with varying levels of experience). Participants were blinded as to the actual diagnosis and the number of cases in each category and were instructed to diagnose either AIS or a benign lesion. Results of this review were not disclosed before a second review conducted after instruction in specific criteria for "endometrioid" AIS. Results were compiled using kappa statistics.

RESULTS

In the first round, the ability to distinguish these lesions was poor for 8 of the 11 reviewers, and no reviewer was in excellent agreement with the actual diagnosis. In the second round, only 1 reviewer had a poor rating, and 4 of 11 were in the excellent category. Misdiagnoses in both rounds were more commonly the result of underdiagnosis of AIS than overdiagnosis of benign cases.

CONCLUSIONS

The presentation of AIS in smears as groups of crowded small cells is prone to underdiagnosis. Awareness of this problem and use of criteria improves sensitivity. [See editorial on pages 243-4, this issue.] Cancer (Cancer Cytopathol)

Stability and cytotoxicity of Fab-ricin A immunotoxins prepared with water soluble long chain heterobifunctional crosslinking agents

The effects of the hindered and non-hindered water soluble long-chain disulfide bonds on the stability and cytotoxicity of the ricin A chain (RTA) immunotoxin were examined. The RTA immunotoxins were prepared with the Fab fragments of anti-common acute lymphoblastic leukemia antigen (CALLA) monoclonal antibody (Fab-RTA) using sulfosuccinimidyl-6-[(-methyl-(-(2-pyridyldithio)toluamido]hexanoate (S-LC-SMPT) and sulfosuccinimidyl-6-[3-(2-pyridyldithio)-propionamido]hexanoate (S-LC-SPDP). The prepared Fab-RTA immunotoxins were evaluated for their conjugation yield, immunoreactivity, thermal and disulfide bond stability and cytotoxicity. The conjugation yield of the Fab-RTA immunotoxin from the water soluble long chain crosslinking agents, S-LC-SMPT and S-LC-SPDP, were comparable. Both Fab-RTA immunotoxins exhibited a similar immunoreactivity and thermal stability in aqueous solution. However, S-LC-SMPT -mediated Fab-RTA, sterically hindered, showed an enhanced disulfide bond stability in vitro over S-LC-SPDP mediated one. In the cytotoxicity against antigenic cell Daudi, the S-LC-SMPT -mediated RTA immunotoxin maintained a comparable cytotoxicity, compared with S-LC-SPDP mediated Fab-RTA immunotoxin.

Subclassifying atypical squamous cells in Thin-Prep cervical cytology correlates with detection of high-risk human papillomavirus DNA

Recent studies have proposed subclassifying ASCUS into "favor reactive" (ASFR), "not otherwise specified" (ASNOS), and "favor squamous intraepithelial lesion (SIL)" (ASFS). This study explored the reproducibility of these diagnoses with Thin-Prep cytology and their association with high-risk human papillomavirus DNA (HRHPV). Three pathologists and 1 cytotechnologist with 2 to 25 years of experience reviewed 144 Thin-Prep (Cytyc, Boxborough, MA) specimens previously diagnosed as normal, ASFR, ASNOS, ASFS, and SIL. Interobserver reproducibility was computed with the kappa statistic. The original laboratory diagnosis was compared with the presence of HRHPV types. Interobserver reproducibility for a normal or SIL diagnosis was very good (kappa = .68 and .63). Reproducibility for ASFR, ASNOS, and ASFS ranged from poor to fair (kappa = .21, .19, and .32). In a weighted analysis, kappa values for ASFR/ASNOS and ASFS/SIL were .36 and .62, respectively. HRHPV-positivity for preparations originally diagnosed as N, ASFR, ASNOS, ASFS, and SIL were 5.7%, 8.8%, 17.4%, 47.8%, and 54.5%, respectively. The difference in index of HRHPV for either N or ASFR and ASFS or SIL was significant (P < .001). Reproducibility for ASCUS is generally poor, but better reproducibility is obtained by combining ASFS with SIL and, to a lesser degree, ASNOS with ASFR. ASFS and SIL confer a similar index of HRHPV and merit similar management. ASFR may be managed with cytologic follow-up; but this may depend upon the individual laboratory. HPV testing, in conjunction with cytologic and biopsy follow-up, appears useful for estimating the significance of ASCUS subgroups in laboratory practice.

Early cervical adenocarcinoma: selection criteria for radical surgery

OBJECTIVE

To identify selection criteria for radical surgery in early cervical adenocarcinoma based on pretreatment clinical stage and correlation with high-risk surgical-pathologic factors.

METHODS

One hundred seventy-five women with International Federation of Gynecology and Obstetrics (FIGO) clinical stage IB1 (n = 132) and IB2-IIA (n = 43) cervical adenocarcinoma were treated primarily at our institutions from 1982 to 1996. Histopathologic sections were reviewed by a gynecologic pathologist. Medical records were reviewed retrospectively and clinical follow-up was done.

RESULTS

The overall 5-year survival rate was 87% (95% confidence interval [CI] 81%, 93%) for stage IB1 and 61% (95% CI 46%, 77%) for stage IB2-IIA (P<.001). Adenosquamous cell type, deep cervical invasion, and lymph-vascular space invasion were significant independent high-risk surgical-pathologic factors that affected disease-free survival (each P<.002). One hundred fourteen (86%) of 132 stage IB1 patients and 19 (44%) of 43 stage IB2-IIA subjects were treated primarily with radical surgery. Lymph node metastases, lymph-vascular space invasion, adenosquamous cell type, deep cervical invasion, and positive surgical margins were more than twice as frequent in stage IB2-IIA patients who had radical surgery than in stage IB1 patients (each P <.05). Based on high-risk surgical-pathologic factors in 133 subjects who had radical surgery, postoperative radiotherapy was recommended for 18 (16%) of 114 stage IB1 patients and 18 (95%) of 19 stage IB2-IIA subjects (P<.001).

CONCLUSION

Radical surgery for FIGO clinical stage IB1 cervical adenocarcinoma and primary radiotherapy for stage IB2-IIA disease would largely avoid combined-modality therapy, thereby reducing treatment-related toxicity and cost.

Inducible nitric oxide synthase inhibitors from Melia azedarach var. japonica

In bioassay-guided search for inducible nitric oxide synthase (iNOS) inhibitory compounds from higher plants of South Korea, two beta-carboline alkaloids, 4-methoxy-1-vinyl-beta-carboline (1) and 4,8-dimethoxy-l-vinyl-beta-carboline (2) have been isolated from the cortex of Melia azedarach var. japonica. The structures of these compounds were elucidated on the basis of spectroscopic data. Compounds 1 and 2 showed marked inhibitory activity of iNOS on LPS- and interferon-gamma-stimulated RAW 264.7 cells.

Two new lignans from Lindera obtusiloba blume

Two new furanolignans (3, 5), together with three known lignans (1, 2, 4), were isolated from the stem of Lindera obtusiloba (Lauraceae). The structures of the compounds were determined as actifolin (1), pluviatilol (2), 5,6-dihydroxymatairesinol (3), (+)-syringaresinol (4), and (+)-9'-O-trans-feruloyl-5,5'-dimethoxylariciresinol (5) on the basis of physicochemical and spectroscopic evidences. Compounds 1, 2, 3, and 5 showed cytotoxicity against a small panel of human tumor cell lines with ED50 values of 3.40 to approximately 19.27 microg/ml.

False negative rate of cervical cytologic smear screening as determined by rapid rescreening

OBJECTIVE

To determine the reliability of the false negative rate (FNR) of cervical cytologic smear screening by rapid rescreening.

STUDY DESIGN

A test set of 401 cases (311 originally diagnosed as negative, 74 as atypical squamous cells of undetermined significance [ASCUS], 14 as low grade squamous intraepithelial lesion [LSIL] and 2 as high grade squamous intraepithelial lesion [HSIL]) were rapidly (30 seconds each) rescreened by five cytotechnologists with no prior experience in rapid rescreening, and the FNRs of rapid rescreening and primary screening were determined. These results were compared with each other and with the FNR of primary screening as determined by routine rescreening of all cases with no time limit.

RESULTS

All five observers detected a different group of abnormal cases; only 9% of all cases originally diagnosed as ASCUS or worse and 43% of all cases diagnosed as LSIL or worse were detected by all five observers. Nevertheless, using ASCUS as the threshold for an abnormal result, the FNR of rapid rescreening fell into a relatively narrow range, 61-74% (mean, 68.2 +/- 5.0); using LSIL as the threshold resulted in FNRs of rapid rescreening between 25% and 38% (30.0 +/- 4.7). Each observer, using rapid rescreening, detected between one and three false negative cases; routine rescreening of all cases without a time limit detected five cases. The FNR of cervical cytologic smear screening, as determined by rapid rescreening, was 18.4 +/- 6.1% as compared with 14.8% by routine rescreening without a time limit.

CONCLUSION

The FNR of rapid rescreening is relatively reproducible even though the individual cases identified varied between reviewers. The FNR of rapid rescreening is similar to that of routine rescreening. Rapid prescreening may be the most logistically simple method to determine the true FNR of a laboratory.

Cytologic characteristics of abnormal cells in prior "normal" cervical/vaginal Papanicolaou smears from women with a high grade squamous intraepithelial lesion

BACKGROUND

Some cervical/vaginal Papanicolaou (Pap) smears previously diagnosed as normal in women with a high grade squamous intraepithelial lesion (HSIL) are found to contain abnormal cells on retrospective review. This study characterized and quantitated such cells in 100 Pap smears.

METHODS

One hundred prior negative Pap smears from 49 women with a newly diagnosed HSIL were rescreened, as were 107 negative Pap smears from 100 women with normal subsequent smears. Cases were assorted randomly so that the rescreener was unaware of the subsequent follow-up.

RESULTS

All 12 Pap smears found to contain atypical mature and immature metaplastic cells belonged to the group with a subsequent HSIL (P = 0.001). In addition, 18 of the 100 previously negative Pap smears (18%) had immature metaplastic cells without nuclear atypia compared with 4 of 107 Pap smears (4%) in the control group (P = 0.0007).

CONCLUSIONS

This study supports the observations of other authors that atypical metaplastic cells, especially those of the immature type, are associated with HSIL. These cells most likely are HSIL lesional cells, which are not easily recognizable as such. Immature metaplastic cells without atypia also were shown to be associated significantly with HSIL in this study. These cells may be unrecognizable lesional cells or a marker of increased risk for HSIL and deserve further study.

A new cytotoxic acyclic diterpene from Carpesium divaricatum

A new acyclic diterpene (1) and a known acyclic diterpene, 12(S)-hydroxygeranylgeraniol (2) were isolated from the aerial parts of Carpesium divaricatum. The structure of 1 was determined to be (2E,10E)-1,12-dihydroxy-18-acetoxy-3,7,15-trimethylhexadeca- 2,10,14-triene (1) on the basis of spectroscopic studies. Compounds 1 and 2 exhibited cytotoxicity against cultured human tumor cell lines, A549, SK-OV-3, SK-MEL-2, XF498, and HCT15, with ED50 values ranging from 4.3-10.2 micrograms/ml and 4.1-8.3 micrograms/ml, respectively.

Antioxidative flavonoids from the leaves of Morus alba

Nine flavonoids (1-9) were isolated from the leaves of Morus alba (Moraceae). The structures of compounds were determined to be kaempferol-3-O-beta-D-glucopyranoside (astragalin, 1) kaempferol-3-O-(6"-O-acetyl)-beta-D-glucopyranoside (2), quercetin-3-O-(6"-O-acetyl)-beta-D-glucopyranoside (3), quercetin-3-O-beta-D-glucopyranoside (4), kaempferol-3-O-alpha-L-rhamnopyranosyl-(1-->6)-beta-D-glucopyranoside (5), quercetin-3-O-alpha-L-rhamnopyranosyl-(1-->6)-beta-D-glucopyranoside (rutin, 6), quercetin-3-O-beta-D-glucopyranosyl-(1-->6)-beta-D-glucopyranoside (7), quercetin-3,7-di-O-beta-D-glucopyranoside (8) and quercetin (9) on the basis of spectroscopic and chemical studies. Compounds 7 and 9 exhibited significant radical scavenging effect on 1,1-diphenyl-2-picrylhydrazyl radical.

Stage IA1 cervical adenocarcinoma: definition and treatment

OBJECTIVE

To propose a definition for stage IA1 cervical adenocarcinoma, based on the International Federation of Gynecology and Obstetrics (FIGO) staging system, and to determine if patients meeting criteria might be candidates for conservative surgery.

METHODS

Two hundred women were diagnosed with early-stage cervical adenocarcinoma from 1982 to 1996. Histopathologic sections were reviewed by a gynecologic pathologist. Medical records were reviewed, and patients included in this study had microscopically identifiable lesions, up to 3 mm invasive depth, up to 7 mm tumor width, and negative margins if cone biopsy was performed.

RESULTS

Twenty-one patients with microinvasive adenocarcinoma met criteria for FIGO stage IA1 carcinoma of the cervix. The median (range) follow-up was 76 (30-172) months and median (range) patient age was 38 (24-75) years. Definitive treatment included type II or III radical hysterectomy in 16 cases, simple abdominal or vaginal hysterectomy in four cases, and loop electrosurgical excision procedure in one case; one patient received adjuvant pelvic radiation. The histologic subtypes were endocervical adenocarcinoma in 18 cases, adenosquamous carcinoma in two cases, and clear-cell adenocarcinoma in one case. There was no evidence of parametrial invasion or lymph node metastases in any patient who had radical surgery, and there were no disease recurrences.

CONCLUSION

Patients with microinvasive adenocarcinoma who met criteria for FIGO stage IA1 cervical carcinoma had disease limited to the cervix, and conservative surgery, such as cone biopsy or simple hysterectomy, might offer them definitive treatment.

A hemorrhagic factor (Apicidin) produced by toxic Fusarium isolates from soybean seeds

Fifty-two isolates of Fusarium species were obtained from soybean seeds from various parts of Korea and identified as Fusarium oxysporum, F. moniliforme, F. semitectum, F. solani, F. graminearum, or F. lateritium. These isolates were grown on autoclaved wheat grains and examined for toxicity in a rat-feeding test. Nine cultures were toxic to rats. One of these, a culture of Fusarium sp. strain KCTC 16677, produced apicidin, an antiprotozoal agent that caused toxic effects in rats (including body weight loss; hemorrhage in the stomach, intestines, and bladder; and finally death) when rats were fed diets supplemented with 0.05 and 0.1% apicidin. The toxin was toxic to brine shrimp (the 50% lethal concentration was 40 microg/ml) and was weakly cytotoxic to human and mouse tumor cell lines.

Thymol derivatives from Carpesium divaricatum

Four thymol derivatives, 2,5-dimethoxythymol (1), 2-methoxythymol isobutyrate (2), 10-isobutyloxy-8,9-epoxythymolisobutyrate (3) and 10-(2-methylbutyloxy)-8,9-epoxythymolisobutyrate (4) were isolated from the aerial parts of Carpesium divaricatum. The structures were elucidated by high field 1D and 2D NMR techniques.

Performance of liquid-based, thin-layer cervical cytology: correlation with reference diagnoses and human papillomavirus testing

The performance of thin-layer cervical cytology with the use of ThinPrep (Cytyc Corporation, Boxborough, MA) was assessed by comparing the original independent diagnosis of ThinPrep slides and conventional smears prepared from 1780 split samples with the most abnormal diagnosis per patient on the basis of an independent pathologist's masked review and with the detection of cancer-associated types of human papillomavirus (HPV) DNA. Cases were selected on the basis of the original diagnoses to include all discordant pairs (those diagnosed as atypical squamous cells of undetermined significance or higher grade, n = 1017), all concordant abnormal pairs (n = 444), and a random 5% of concordant normal pairs (n = 319). In screening centers, thin-layer cytology detected 135 (70.3%) of 192 women diagnosed as having squamous epithelial lesions or a higher grade in the independent review, whereas locally read smears detected 91 (47.4%) of these patients (P < .001). In hospital-based cytology laboratories, thin-layer cytology detected 308 (86.3%) of 357 women diagnosed with SILs or a higher grade in the independent review, compared with 283 (79.3%) diagnosed with smears (P = .011). Cancer-associated types of HPV DNA were detected in a slightly higher proportion of women with smears diagnosed as SILs than in women with thin-layer cytology diagnosed as SILs, whereas the overall number of HPV-associated SILs diagnosed was higher with thin-layer cytology. These data suggest that the ThinPrep method detects a higher percentage of SILs as defined in a masked, independent review than do concurrently prepared smears and that diagnoses of SILs rendered with ThinPrep correlate with the detection of cancer-associated types of HPV.

A new epoxynaphthoquinol from Rumex japonicus

A new epoxynaphthoquinol derivative, 3-acetyl-2-methyl-1, 5-dihydroxy-2,3-epoxynaphthoquinol (I), was isolated from the root of Rumex japonicus. The structure was elucidated by high field 1D and 2D NMR techniques.

Matching for private or public HLA epitopes reduces acute rejection episodes and improves two-year renal allograft function

BACKGROUND

The current role of HLA matching in renal transplantation is controversial. Public HLA epitope matching has been suggested to be as advantageous as private HLA matching, with the added benefit of increasing recipients' access to well-matched grafts.

METHODS

In this single-center study of 105 renal transplant recipients, we examined the association of HLA matching with early (0-3 months) and late (4-6 months) rejection episodes (RE), as well as renal allograft function up to 2 years after transplant.

RESULTS

Poor HLA-DR, but not HLA-A or -B, matching was associated with early RE (0 DR matches, RE=2.7+/-0.19, 1 DR match, RE=2.37+/-0.18, vs. 2 DR matches, RE=1.5+/-0.38; P < 0.01). In contrast, poor HLA-B, but not HLA-A or -DR, matching was associated with late rejections (0 HLA-B matches, RE=1.1+/-0.51 vs. 1-2 HLA-B matches, RE=0.51+/-0.1; P < 0.004). HLA-B matching was also associated with a significantly lower serum creatinine (SCr) level at 24 months (0 HLA-B matches, SCr=178+/-20 micromol/L vs. SCr=132+/-6 micromol/L for 1-2 HLA-B matches; P < 0.025). Matching for 10 supertypic HLA-A and -B cross-reactive groups was associated with reduced late graft rejection (0-2 residue matches, RE=1.15+/-0.18 vs. RE=0.62+/-0.12 for 3 to 7 residue matches; P < 0.013) as well as a significantly lower SCr level at 24 months (0-2 residue matches, SCr=205+/-29 micromol/L vs SCr=131+/-6 micromol/L for 3 to 7 residue matches; P < 0.001) after transplantation.

CONCLUSIONS

HLA-DR matching was associated with a reduced frequency of early rejection episodes, whereas HLA-B or residue/cross-reactive group matching was associated with a reduced frequency of late rejection episodes and improved graft function at 2 years.

Two new monogalactosylacylglycerols from Hydrocotyle ramiflora

Two new monogalactosylmonoacylglycerols ( 1, 2) and two known compounds ( 3, 4) were isolated from Hydrocotyle ramiflora. Based on physicochemical evidence and spectral data, the structures of 1, 2, 3, and 4 were determined as (2 S)-1- O-(7 Z,10 Z,13 Z-hexadecatrienoyl)-3- O-beta-galactopyranosylglycerol, (2 S)-1- O-(9 Z,12 Z-octadecadienoly)-3- O-beta-galactopyranosyl-glycerol, alpha-spinasterol, and capsidiol 3-acetate, respectively.

Comparison of microparticle enzyme and fluorescence polarization immunoassays in pediatric patients not receiving digoxin

Previously, investigators have measured endogenous digoxin-like immunoreactive substances (DLIS) in pediatric patients. Digoxin-like immunoreactive substances may cross-react with digoxin assays to produce false-positive digoxin concentrations; hence, the validity of digoxin concentrations in pediatric patients is questionable. The authors compared the presence and magnitude of apparent DLIS using the microparticle enzyme immunoassay (MEIA) AxSYM Digoxin II and the fluorescence polarization immunoassay (FPIA) TDx Digoxin II, in the serum of 80 pediatric patients who were hospitalized with normal serum creatinine but had not been administered digoxin. Patients ranged in age from 1 day to 16 years (mean age, 4.96 +/- 5.17 years). Serum creatinine and total bilirubin were 0.5 +/- 0.18 mg/dl and 1.3 +/- 0.17 mg/dl, respectively. Forty-eight percent of MEIA samples and 79% of FPIA samples had measurable DLIS values. Digoxin-like immunoreactive substance concentrations for the MEIA (0.07 +/- 0.09 ng/ml) and FPIA assays (0.1 +/- 0.1 ng/ml) were statistically different (p = 0.01); however, no sample had a DLIS value >0.38 ng/ml. A poor correlation was noted between patient age, serum creatinine, total bilirubin, and DLIS concentration. The MEIA and FPIA assays effectively minimized DLIS cross-reactivity making both technologies clinically acceptable for serum digoxin measurement in pediatric patients with normal serum creatinine and total bilirubin.

Cytologic correlates of papillary immature metaplasia (immature condyloma) of the cervix

Papillary immature metaplasia (PIM) of the cervix (immature condyloma) is a variant of low-grade squamous intraepithelial lesions (LSIL). It is frequently associated with human papillomavirus (HPV) types 6 and 11. The purpose of this study was to characterize the cytologic changes associated with this lesion. We analyzed 10 cases of PIM from our files and reviewed the Papanicolaou smears taken proximate to the time of the biopsy. Four cases had either reactive epithelial changes (2 cases) or cytologic findings typical of low-grade SIL, with koilocytosis (2 cases). Six cases displayed a spectrum of metaplastic cells with varying maturation that ranged from atypical reactive cells to atypical immature metaplastic cells. Binucleation was common. Some cells exhibited features characteristic of SIL, although the degree of nuclear atypia generally was less than that associated with high-grade SIL. Papanicolaou smears from all cases were interpreted as atypical (ASCUS) metaplasia or low-grade SIL. Follow-up biopsy in one case revealed a PIM in association with a high-grade SIL, the latter undiagnosed by smear alone. PIM is a distinct histologic entity that can present with a spectrum of cytologic findings. Its recognition histologically can resolve some cytologic/histologic discrepancies. Confusion with an immature HSIL or atypical immature metaplasia can occur in some instances and the diagnosis of PIM by cytology alone is not recommended, unless the diagnosis is qualified.

Adenocarcinoma in situ in cervical smears with a small cell (endometrioid) pattern: distinction from cells directly sampled from the upper endocervical canal or lower segment of the endometrium

Adenocarcinoma in situ (AIS) with small, endometrioid cells in cervicovaginal smears, is a source of false-negative diagnoses because of the difficulty in distinguishing these cells from endometrial cells of the lower uterine segment or benign cells from the upper endocervical canal. This study was designed to elucidate the most useful criteria for this distinction. Three observers blinded to the actual diagnoses reviewed 29 preselected cases (AIS, 17; benign, 12) that had originally caused diagnostic difficulty. Each observer made a diagnosis and evaluated 15 preselected diagnostic criteria. All 3 observers agreed on the correct diagnosis in 19 (66%) of 29 cases, and at least 2 observers agreed on the correct diagnosis in 27 (93%) of 29 cases. No case was misdiagnosed by all 3 observers. The most useful criteria for the diagnosis of AIS are a predominance of groups with marked crowding, focal feathering, nuclear hyperchromatism with coarsening of chromatin, and occasional mitotic figures. Sheets of cells, endometrial tubules, and endometrial stroma favor a benign diagnosis. Although 12 (14%) of 87 possible diagnoses were erroneous, well-preserved, small, endometrioid AIS cells can be identified correctly on cervical smears and distinguished from epithelium from the lower uterine segment and high endocervical canal in most cases using the aforementioned criteria.

Isolation of a multidrug resistance inhibitor from Aconitum pseudo-laeve var. erectum

To overcome multidrug resistance (MDR) in cancer chemotherapy, we prepared various plant extracts and searched for a component which is effective for inhibition of MDR. MDR inhibition activity was determined by measuring cytotoxicity to MDR cells using multidrug resistant human fibrocarcinoma KB V20C, which is resistant to 20 nM vincristine and expresses high level of mdr1 gene. Of various plant extracts, the MeOH extract of the root of Aconitum pseudo-laeve var. erectum was found to have potent inhibitory activity on MDR. The bioassay-guided fractionation of the MeOH extract of the plant led to the isolation of an alkaloid, lycaconitine, as an active principle. And the IC50 of lycaconitine for KB V20C cells was 74 micrograms/ml.

Qualifying the cytologic diagnosis of "atypical squamous cells of undetermined significance" affects the predictive value of a squamous intraepithelial lesion on subsequent biopsy

OBJECTIVE

To evaluate whether different qualifications of a cytologic diagnosis of "atypical squamous cells of undetermined significance" predict a greater or lesser likelihood of cervical pathology.

DESIGN

Comparison of different cytologic qualifications of atypical squamous cells of undetermined significance with the frequency of significant cervical disease as documented by tissue biopsy.

PARTICIPANTS AND SETTING

Four hundred, fifty-two consecutive Papanicolaou smears showing atypical squamous cells of undetermined significance (diagnosed by nine cytopathologists) in women who had undergone cervical biopsy within the previous 90 days at Brigham and Women's Hospital, Boston, Mass (January-June 1995).

MAIN OUTCOME MEASURE

The histopathologic diagnosis of squamous intraepithelial lesion of the cervix.

RESULTS

The 452 smears were qualified as "favor reactive" (22%), "not otherwise specified" (42%), "favor squamous intraepithelial lesion" (29%), and "favor high-grade squamous intraepithelial lesion" (6%). High-grade squamous intraepithelial lesions and total squamous intraepithelial lesions were pathologically confirmed by cervical biopsy in 3.6% and 6% of the favor reactive smears, in 11% and 21% of the not otherwise specified smears, in 12% and 30% of the favor squamous intraepithelial lesion smears, and in 53% and 59% of the favor high-grade squamous intraepithelial lesion smears. Significant associations were seen between a favor reactive smear and a benign finding on cervical biopsy (94%, P = .04) and between a favor high-grade squamous intraepithelial lesion smear and a biopsy that showed a high-grade squamous intraepithelial lesion (53%, P = .00001).

CONCLUSIONS

Qualifying atypical squamous cells of undetermined significance stratifies women into different risk groups for squamous intraepithelial lesion. It is reasonable for physicians to make patient management decisions based, at least in part, on such qualifications.

Evaluation of vancomycin use in a pediatric teaching hospital based on CDC criteria

This study was performed to determine whether vancomycin use at our pediatric hospital was consistent with modified Centers for Disease Control and Prevention guidelines. Vancomycin use was inappropriate in 54% of patients. Inappropriate use briefly decreased by 14% after educational efforts. Further education regarding vancomycin use was deemed necessary and is continuing.