Expression pattern of the urokinase-plasminogen activator system in rat DS-sarcoma: role of oxygenation status and tumour size

The urokinase plasminogen activator system plays a central role in malignant tumour progression. Both tumour hypoxia and enhancement of urokinase plasminogen activator, urokinase plasminogen activator-receptor and plasminogen activator inhibitor type 1 have been identified as adverse prognostic factors. Upregulation of urokinase plasminogen activator or plasminogen activator inhibitor type 1 could present means by which hypoxia influences malignant progression. Therefore, the impact of hypoxia on the expression pattern of the urokinase plasminogen activator system in rat DS-sarcoma in vivo and in vitro was examined. In the in vivo setting, tumour cells were implanted subcutaneously into rats, which were housed under either hypoxia, atmospheric air or hyperoxia. For in vitro studies, DS-sarcoma cells were incubated for 24 h under hypoxia. Urokinase plasminogen activator and urokinase plasminogen activator-receptor expression were analysed by flow cytometry. Urokinase plasminogen activator activity was measured using zymography. Plasminogen activator inhibitor type 1 protein levels in vitro and in vivo were examined with ELISA. PAI-1 mRNA levels were determined by RT-PCR. DS-sarcoma cells express urokinase plasminogen activator, urokinase plasminogen activator-receptor, and plasminogen activator inhibitor type 1 in vitro and in vivo. The urokinase plasminogen activator activity is enhanced in DS-sarcomas compared to normal tissues and rises with increasing tumour volume. The oxygenation level has no impact on the urokinase plasminogen activator activity in cultured DS-sarcoma cells or in solid tumours, although in vitro an increase in plasminogen activator inhibitor type 1 protein and mRNA expression after hypoxic challenge is detectable. The latter plasminogen activator inhibitor type 1 changes were not detectable in vivo. Hypoxia has been demonstrated to contribute to the upregulation of some components of the system in vitro, although this effect was not reproducible in vivo. This may indicate that the serum level of plasminogen activator inhibitor type 1 is not a reliable surrogate marker of tumour hypoxia.

Elevated tumor lactate concentrations predict for an increased risk of metastases in head-and-neck cancer

PURPOSE

Hypoxia shifts the balance of cellular energy production toward glycolysis with lactate generation as a by-product. Quantitative bioluminescence imaging allows for the quantitation of lactate concentrations in individual tumors. We assessed the relationship between pretreatment tumor lactate concentrations and subsequent development of metastatic disease in patients with newly diagnosed head-and-neck cancer.

METHODS AND MATERIALS

At the time of biopsy of the primary site, a separate specimen was taken and flash-frozen for subsequent quantitation of lactate concentration using a luciferase bioluminescence technique. The two-dimensional spatial distribution of the bioluminescence intensity within the tissue section was registered directly using a microscope and an imaging photon counting system. Photon intensity was converted to distributions of volume-related tissue concentrations (micromol per gram wet weight). Treatment consisted of either surgery and postoperative radiotherapy or primary radiotherapy, based on presenting disease stage and institutional treatment policies. The subsequent development of metastatic disease constituted the primary clinical endpoint.

RESULTS

Biopsies obtained from 40 patients were evaluable in 34. The larynx was the most frequent primary site (n = 25). Other sites included oropharynx (n = 5), hypopharynx (n = 3), and oral cavity (n = 1). Most patients (74%) presented with an advanced stage T3 or T4 primary tumor. Nodal involvement was present in 19 (54%) patients. The median tumor lactate concentration was 7.1 micromol/g. Tumors were classified as having either low or high lactate concentrations according to whether these values were below or above the median. The median follow-up time for surviving patients is 27 months. Two-year actuarial survival was 90% for patients with low-lactate-concentration tumor vs. 35% for patients with high-lactate-concentration primaries (<0.0001). Two-year metastasis-free survival was adversely influenced by high tumor lactate concentrations (90% vs. 25%, p < 0.0001). The median lactate concentration for tumors that subsequently metastasized was 12.9 micromol/g vs. 4.8 micromol/g for patients who remained continuously free of disease (p < 0.005). Lactate concentration was not correlated with presenting T stage or N stage.

DISCUSSION

Elevated tumor lactate concentrations are associated with the subsequent development of nodal or distant metastases in head-and-neck cancer patients. This more aggressive malignant phenotype is probably associated with hypoxia-mediated radioresistance and the upregulation of metastasis-associated genes.

Interstitial MR lymphography with gadoterate meglumine: initial experience in humans

Magnetic resonance (MR) lymphography was performed in five healthy volunteers and three patients (two adults and one infant). Subcutaneous administration of gadoterate meglumine in the foot allowed visualization of draining lymph vessels and nodes. In one patient, an inguinal fluid collection could be characterized as a lymphocele. In the infant, a chylothorax was diagnosed. The authors conclude that interstitial MR lymphography with commercially available compounds is feasible.

DNA damage-activated kinase Chk2 is independent of proliferation or differentiation yet correlates with tissue biology

The Chk2 kinase is a tumor suppressor and key transducer of DNA-damage checkpoints. We show that the human Chk2 protein is relatively stable, nuclear, and responding to gamma-radiation throughout the cell cycle. Contrary to the retinoblastoma protein-regulated, labile Chk1 kinase restricted to S-G(2) phases, Chk2 remains activatable even in quiescent and differentiating cells. In human tissues, Chk2 is homogeneously expressed in renewing cell populations such as epidermis or intestine, heterogeneous in conditionally renewing tissues, and absent or cytoplasmic in static tissues such as muscle or brain. These data highlight striking differences between Chk2 and Chk1 and show unexpected correlation of Chk2 expression with tissue biology.

Generation of functionally mature dendritic cells from the multipotential stem cell line FDCP-mix

Dendritic cells (DCs) are crucial components of the immune system because of their unique ability as antigen-presenting cells for the initiation of a primary immune response. DCs, macrophages (Ms) and granulocytes (Gs) are believed to originate from a common myeloid progenitor cell. However, little is known about the molecular mechanisms leading to DC sublineage commitment. To establish a cell system that allows the molecular and biochemical analysis of DC differentiation and activation, we used the murine non-leukaemic, multipotential stem cell line FDCP-mix. FDCP-mix cells were cultured in various amounts of GM-colony stimulating factor (CSF) and interleukin (IL)-4 for up to 16 d and analysed for morphology, expression of CD34, c-kit, Gr-1, Mac-1, CD40, MHC-I, MHC-II and co-stimulatory molecules (CD80, CD86) using flow cytometry, and for their capacity to present foreign antigen to autologous T cells. Up to d 7, the majority of FDCP-mix cells consisted of cells differentiating along the G and M lineage. Thereafter, the number of dendritic cells increased until d 13. Differentiation along the DC lineage vs. the G and M lineage was favoured when FDCP-mix cells were cultured in high concentration GM-CSF (500 U/ml) throughout the culture and IL-4 from d 9 onwards. The dendritic cells generated from FDCP-mix cells were large, non-adherent cells with veiled processes and expressed MHC II, CD40, CD80 and CD86. After pulsing with a foreign antigen (keyhole limpet haemocyanin), FDCP-mix-derived dendritic cells stimulated [(3)H]-thymidine incorporation of naive T-cells in an autologous mixed lymphocyte reaction (MLR). Our results show that functionally mature dendritic cells are generated from the multipotential stem cell line FDCP-mix. This cell line thus provides the unique possibility of establishing multipotential transgenic cell lines capable of differentiation along the DC lineage. The experimental system described here should prove a valuable tool for studying DC differentiation and function.

mNotch1 signaling reduces proliferation of myeloid progenitor cells by altering cell-cycle kinetics

Notch receptors are involved in the regulation of cell-fate decisions, differentiation, and proliferation in many tissues. The expression of Notch receptors on hemopoietic cells and of cognate ligands on bone marrow stromal cells suggests a possible role for Notch signaling in the regulation of hemopoiesis. We were interested to assess the involvement of Notch1 signaling on cell proliferation of myeloid progenitor cells. Proliferation, cell-cycle status, and apoptosis of myeloid progenitor 32D cell lines engineered to permit the conditional induction of the constitutively active intracellular domain of mNotch1 (mN1(IC)) by the 4-hydroxytamoxifen(OHT)-inducible system were analyzed in the presence or absence of OHT. The induction of mN1(IC) by OHT resulted in reduction of proliferation (p<0.01) and accumulation of cells in the G(1)/G(0) phase of the cell cycle (p<0.001) without substantially affecting apoptosis of 32D cells. These effects were observed under culture conditions that allow differentiation and, to a lesser degree, under conditions that normally promote self-renewal in the absence of differentiated cells. Our data suggest that mNotch1 signaling suppresses proliferation of myeloid progenitor cells by altering cell-cycle kinetics.

Notch signalling via RBP-J promotes myeloid differentiation

The expression of Notch receptors on hematopoietic cells and of cognate ligands on bone marrow stromal cells suggests a possible role for Notch signalling in the regulation of hematopoiesis. In order to assess the involvement of Notch1 signalling in myelopoiesis, 32D myeloid progenitor cell lines were engineered to permit the conditional induction of the constitutively active intracellular domain of murine Notch1 (mN1(IC)) by the 4-hydroxytamoxifen-inducible system. The induction of mN1(IC) resulted in accelerated and increased granulocytic differentiation. These effects were observed under growth conditions that support differentiation and, to a lesser degree, under conditions that normally promote self-renewal. Transient transfection of mN1(IC) deletion mutants showed that the differentiation promoting activity correlated with RBP-J transactivation. Furthermore, expression of a transcriptionally active derivative of RBP-J (RBP-J-VP16) increased myeloid differentiation. To test further the role of Notch signalling in a physiological context, 32D cells expressing mNotch1 were cultured on fibroblast layers that either expressed or did not express the Notch ligand Jagged1. Similar to the induction of mN1(IC), Jagged1 accelerated granulocytic differentiation of 32D cells. Taken together, our data suggest that activation of mNotch1 promotes myeloid differentiation via RBP-J transactivation.

Structure-activity relationships of omega-conotoxins at N-type voltage-sensitive calcium channels

Due to their selectivity towards voltage-sensitive calcium channels (VSCCs) omega-conotoxins are being exploited as a new class of therapeutics in pain management and may also have potential application in ischaemic brain injury. Here, the structure-activity relationships (SARs) of several omega-conotoxins including GVIA, MVIIA, CVID and MVIIC are explored. In addition, the three-dimensional structures of these omega-conotoxins and some structurally related peptides that form the cysteine knot are compared, and the effects of the solution environment on structure discussed. The diversity of binding and functional assays used to measure omega-conotoxin potencies at the N-type VSCC warranted a re-evaluation of the relationship between these assays. With one exception, [A22]-GVIA, this analysis revealed a linear correlation between functional (peripheral N-type VSCCs) and radioligand binding assays (central N-type VSCCs) for the omega-conotoxins and analogues that were tested over three studies. The binding and functional results of several studies are compared in an attempt to identify and distinguish those residues that are important in omega-conotoxin function as opposed to those that form part of the structural scaffold. Further to determining what omega-conotoxin residues are important for VSCC binding, the range of possible interactions between the ligand and channel are considered and the factors that influence the selectivity of MVIIA, GVIA and CVID towards N-type VSCCs examined.

Role of third intracellular loop of galanin receptor type 1 in signal transduction

To determine the domains essential for G-protein coupling of the human galanin receptor type 1 (GalR1), we have used both GalR1 mutants and synthetic receptor-derived peptides in(125)I-galanin and [(35)S]-GTPgammaS binding studies. Replacement of potential phosphorylation sites by Leu in the third intracellular loop (IC3) of GalR1 did not affect K(D)values for the receptor. Peptides derived form the IC3 loop, and especially the N-terminal part of it were able to increase the rate of [(35)S]-GTPgammaS binding to the trimeric Gialpha1beta1gamma2, but not to Gsalphabeta1gamma2, whereas the peptides corresponding to the IC1 and IC2 loops had no such effect. IC3 loop peptides also inhibited the binding of(125)I-galanin to GalR1 in membranes from Rin m5F cells. Our results suggest that the IC3 loop of GalR1, especially its N-terminal part, defines the coupling of the receptor to the Gialpha1beta1gamma2 protein and consequently, to the signal transduction cascade.

Effects of chirality at Tyr13 on the structure-activity relationships of omega-conotoxins from Conus magus

The effects of chirality inversions of Tyr13 on the structure-activity relationships of omega-conotoxins MVIIA and MVIIC were examined using a combination of 2D 1H NMR spectroscopy and radioligand binding studies specific for N-type ([125I]GVIA) and P/Q-type ([125I]MVIIC) voltage-sensitive calcium channels (VSCCs). A comparison of the Halpha secondary shifts suggests that the structural scaffolds of MVIIA and MVIIC are little altered by the L- to D- inversion of Tyr13; however, the conformations of several residues in loop 2 (residues 9-14) are significantly altered. The experimentally determined 3D structure of [D-Y13]MVIIA indicates that the positions of key residues in this loop which are involved in the binding of MVIIA to the N-type VSCC (Tyr13, Arg10, and Leu11) are so changed as to render the peptide unrecognizable by its cognate ion channel. The large reduction in potency observed for MVIIA and MVIIC at both N-type and P/Q-type VSCCs is likely to stem from the change in conformation and orientation of loop 2.

Heparan sulfate proteoglycan expression is induced during early erythroid differentiation of multipotent hematopoietic stem cells

Heparan sulfate (HS) proteoglycans of bone marrow (BM) stromal cells and their extracellular matrix are important components of the microenvironment of hematopoietic tissues and are involved in the interaction of hematopoietic stem and stromal cells. Although previous studies have emphasized the role of HS proteoglycan synthesis by BM stromal cells, we have recently shown that the human hematopoietic progenitor cell line TF-1 also expressed an HS proteoglycan. Immunochemical, reverse transcriptase-polymerase chain reaction (RT-PCR), and Northern blot analysis of this HS proteoglycan showed that it was not related to the syndecan family of HS proteoglycans or to glypican. To answer the question of whether the expression of HS proteoglycans is associated with the differentiation state of hematopoietic progenitor cells, we have analyzed the proteoglycan synthesis of several murine and human hematopoietic progenitor cell lines. Proteoglycans were isolated from metabolically labeled cells and purified by several chromatographic steps. Isolation and characterization of proteoglycans from the cell lines HEL and ELM-D, which like TF-1 cells have an immature erythroid phenotype, showed that these cells synthesize the same HS proteoglycan, previously detected in TF-1 cells, as a major proteoglycan. In contrast, cell lines of the myeloid lineage, like the myeloblastic/promyelocytic cell lines B1 and B2, do not express HS proteoglycans. Taken together, our data strongly suggest that expression of this HS proteoglycan in hematopoietic progenitor cell lines is associated with the erythroid lineage. To prove this association we have analyzed the proteoglycan expression in the nonleukemic multipotent stem cell line FDCP-Mix-A4 after induction of erythroid or granulocytic differentiation. Our data show that HS proteoglycan expression is induced during early erythroid differentiation of multipotent hematopoietic stem cells. In contrast, during granulocytic differentiation, no expression of HS proteoglycans was observed.

Temperature adaptation of house keeping and heat shock gene expression in Neurospora crassa

Adaptation of house keeping and heat shock gene expression was determined in Neurospora crassa during continuous exposure to different temperatures. Steady-state values of total protein synthesis differed little after incubation for 24 h at temperatures between 15 and 42 degreesC. Adaptation kinetics at 42 degreesC showed an initial, transient inhibition of total protein synthesis. Similar kinetics were observed with actin synthesis and tubulin mRNA. A priming 1-h heat shock of 42 degreesC 2 h prior to a second continuous exposure to 42 degreesC abolished the inhibitory effect of the second treatment and resulted in "acquired translational tolerance." Steady-state values of HSP70 synthesis rates revealed increasing levels with increasing temperatures after incubation for 24 h at different temperatures. Adaptation kinetics of the synthesis rates of different HSPs in vivo revealed maximal rates after 2 h and then a decrease to the elevated steady-state levels. The total amount of the major constitutive and inducible HSP70 isoform as determined by Western blots reached a maximum 2 h after the beginning of 42 degreesC exposure and only a slight decrease (25%) of the maximal value after 24 h. The inducible isoform of HSP70, in contrast, reached a maximum after 4-8 h and then decreased strongly after 24 h. HSP mRNAs reached maximal amounts 45-60 min after the beginning of 42 degreesC exposure and then declined after 8 h as determined by in vitro translation. Northern blots revealed maximal mRNA amounts of the inducible HSP70 after 30 min and zero amounts after 4 h exposure to 42 degreesC. After a shift to 42 degreesC HSP70 isoforms were immediately translocated into the nucleus and reshuttled into the cytoplasm during the following 6 h. The nuclear content of HSP70 remained elevated during the adapted steady state at 24 h. It is concluded that the adapted state after 24 h is based on enhanced amounts of constitutive isoforms in the cytoplasm and in the nucleus, whereas the inducible isoforms of HSP70 show faster adaptation kinetics.

Preoperative ultrasound mapping of the saphenous vein: prognostic value on early post operative results, a prospective study

A prospective series of 92 patients had their greater saphenous vein assessed with duplex ultrasound scanning prior to planned infrainguinal bypass procedures. Sixteen (17%) bypass procedures thrombosed within the first week postoperatively. A naturally occurring optimal vein diameter was discovered: 3.5-4.2 mm at mid-thigh level and 0-1.5 mm less at mid-calf level. It was significantly correlated with higher one week patency: thrombosis occurred in 11% in veins with this optimal diameter combination and in 19% in all other combination (P < 0.05). These results confirm and expand a retrospective study.

Are self-expanding stents superior to balloon-expanded in dilating aortas? An experimental study in pigs

OBJECTIVE

To study the stent/vessel interaction and distensibility following the natural increase in vascular diameter using self-expanding and balloon-expanded stents.

DESIGN

Open experimental study.

SETTING

Animal laboratory, university hospital.

MATERIALS AND METHODS

Eight Palmaz (P) and eight Gianturco (G) stents were transluminally placed in the infrarenal aortas of 16 pigs. Pulsatile diameter changes above, at and below the stents were non-invasively monitored with an ultrasound phase-locked echo-tracking system before and immediately after stenting and at 4 and 18 weeks. Blood pressure was registered intra-arterially and stiffness (beta) was calculated. Intravascular ultrasound (IVUS) was performed at 18 weeks.

RESULTS

Median weight increased from 20 kg (19-26) to 93 kg (62-130). Diameter of the aorta increased 60%. In group P no pulsatile diameter change could be measured at the stent (beta = infinity). In group G stenting increased stiffness from beta 20.7 (9.2) to 43.2 (8.0) (p < 0.05). After 18 weeks stiffness returned to beta 20.1 (12.4). Expanded, median diameter of the P stents was 7.4 (0.8) mm, not increasing after 18 weeks. Initial diameter of the G stents was 7.8 (1.0) mm, increasing 56% to 12.2 (2.3) mm (p < 0.05). IVUS revealed the G stents to be well attached to the vascular wall, but five P stents were detached within half of the circumference.

CONCLUSION

Self-expanding stents follow the pulsatile diameter change of the vessel wall, not adversely affecting distensibility after 18 weeks. They show good attachment despite 56% dilation. In contrast, the balloon-expanded stents do not show pulsatile movement and may detach during vessel diameter increase. This may be of importance when choosing stents for endovascular treatment of abdominal aortic aneurysms.

Increased expression of proliferating cell nuclear antigen in liver allograft rejection

Detection of proliferating cell nuclear antigen is useful for the study of proliferative activity of neoplastic and non-neoplastic lymphoid, parenchymal, and mesenchymal cells. Allograft rejection is associated with the recruitment of circulating cells and their proliferation in the graft. The intrahepatic expression of proliferating cell nuclear antigen on paraffin-embedded liver biopsy specimens (n = 110 from 32 patients) was examined by an avidin-biotin peroxidase method using a monoclonal antibody to proliferating cell nuclear antigen. The percentage of positive nuclei was determined in hepatocytes, biliary epithelium, and lymphocytes. There were four histologic groups: 1, moderate-to-severe rejection (n = 19); 2, mild rejection (n = 28); 3, nonspecific inflammation (n = 45); and 4, donor livers (n = 18). The percentage of positive nuclei was higher in group 1 compared to group 2 (hepatocytes p = 0.01; biliary epithelium p = 0.0007; lymphocytes p = 0.0001), to group 3 (hepatocytes p = 0.0002; biliary epithelium p = 0.0001; lymphocytes p = 0.0001), and to group 4 (for all three locations p < 0.0001). When group 2 was compared to group 3 the results were significant for biliary epithelium (p = 0.0001) and lymphocytes (p = 0.0001), but not for hepatocytes (p = 0.07). We conclude that proliferating cell nuclear antigen expression, especially in lymphocytes, correlates with the severity of histologic rejection. Proliferating cell nuclear antigen expression may be useful in predicting the progression and response to different antirejection therapies.

Correction of blood pH attenuates changes in hemodynamics and organ blood flow during permissive hypercapnia

OBJECTIVES

To determine whether changes in cardiac output, regional blood flow, and intracranial pressure during permissive hypercapnia are blood pH-dependent and can be attenuated by correction of intravascular acidemia.

DESIGN

Prospective, controlled study.

SETTING

Research laboratory.

SUBJECTS

Female Marino ewes.

INTERVENTIONS

Animals were instrumented with a pulmonary artery catheter, femoral arterial and venous catheters, a catheter in the third cerebral ventricle, and ultrasonic flow probes on the left carotid, superior mesenteric, and left renal arteries 1 wk before experimentation. At initiation of the protocol, ewes underwent endotracheal intubation and mechanical ventilation under general anesthesia. Minute ventilation was reduced to induce hypercapnia with a target PaCO2 of 80 torr (10.7 kPa). In the pH-uncorrected group (n = 6), arterial blood pH was allowed to decreased without treatment. In the pH-corrected group (n = 5), 14.4 mEq/kg of sodium bicarbonate was given intravenously as a bolus to correct arterial blood pH toward a target arterial pH of 7.40 (dose calculated by the Henderson-Hasselbalch equation).

MEASUREMENTS AND MAIN RESULTS

Arterial blood pH, PCO2, cardiac output, intracranial pressure, and carotid, superior mesenteric, and renal artery blood flow rates were measured at normocapnic baseline and at every hour during hypercapnia for 6 hrs. In the pH-uncorrected group, arterial blood pH decreased from 7.41 +/- 0.03 at normocapnia to 7.14 +/- 0.01 (p < .01 vs. normocapnia) as blood PCO2 increased to 81.2 +/- 1.8 torr (10.8 +/- 0.2 kPa). In the pH-corrected group, arterial blood pH was 7.42 +/- 0.02 at normocapnia and was maintained at 7.37 +/- 0.01 while PaCO2 was increased to 80.3 +/- 0.9 torr (10.7 +/- 0.1 kPa). Significant increases in cardiac output occurred with the initiation of hypercapnia for both groups (pH-uncorrected group: 4.3 +/- 0.6 L/min at normocapnia vs. 6.8 +/- 1.0 L/min at 1 hr [p < .05]; pH-corrected group: 4.1 +/- 0.4 at normocapnia vs. 5.7 +/- 0.4 L/min at 1 hr [p < .05]). However, this increase was sustained only in the uncorrected group. Changes in carotid and mesenteric artery blood flow rates, as a percent of baseline values, showed sustained significant increases in the pH-uncorrected groups (p < .05) and only transient (carotid at 1 hr) or no (superior mesenteric) significant change in the pH-corrected groups. Conversely, significant increases in renal artery blood flow were seen only in the pH-uncorrected group during the last 2 hrs of the experiment (p < .05). Organ blood flow, as a percent of cardiac output, did not change significantly in either group. Intracranial pressure increased significantly in the pH-uncorrected group (9.0 +/- 1.5 mm Hg at normocapnia vs. 26.8 +/- 5.1 at 1 hr, p < .05), and remained increased, while showing no significant change in the pH-corrected group (8.5 +/- 1.6 mm Hg at normocapnia to 7.7 +/- 4.2 at 1 hr).

CONCLUSIONS

Acute hypercapnia, induced within 1 hr, is associated with significant increases in cardiac output, organ blood flow, and intracranial pressure. These changes can be significantly attenuated by correction of blood pH with the administration of sodium bicarbonate, without adverse effects on hemodynamics.

Serial monitoring of soluble interleukin-2 receptor as a rapid marker of cytomegalovirus infection and response to antiviral therapy

Serial sIL-2R serum levels were evaluated as an indicator of cytomegalovirus infection and response to antiviral therapy. All cases of post-transplant CMV infection or disease were studied over a 2.5-year period with serial sIL-2R serum levels monitored daily post-transplant until discharge, during each inpatient admission and with each outpatient laboratory analysis. Mean sIL-2 levels +/- S.E.M. rose from a baseline level of 3662 +/- 321 U/ml to 11657 +/- 3311 U/ml at the time of diagnosis. Serum sIL-2R concentrations were significantly elevated from baseline as early as 14 days prior to diagnosis of CMV. Mean peak sIL-2R levels occurred an average of 4 days after the initiation of ganciclovir therapy and remained significantly elevated for an average of 20 days of treatment. Serum sIL-2R levels in patients with resolved CMV returned to within 20% of baseline after 20 days of therapy. These data support the idea that serial monitoring of sIL-2R serum levels may be useful adjunctively in the diagnosis of CMV as well as determining the response to and duration of antiviral therapy.

Paradoxical puborectalis contraction in patients after pelvic pouch construction

Normal defecation is associated with relaxation of sphincters during the evacuation process. However, obstructive defecation is sometimes seen clinically manifested by abnormal contraction of the puborectalis during defecation rather than relaxing. This condition has not previously been described after pelvic pouch construction.

PURPOSE

This study was done to evaluate patients for defecation difficulties caused by paradoxical puborectalis contraction after pelvic pouch procedures.

METHODS

Prospectively, patients with defecation difficulties were questioned. They then underwent electromyography if they met particular criteria. Biofeedback was offered to all patients demonstrating paradox on electromyography. Follow-up was by clinic visits and interviews.

RESULTS

After pelvic pouch construction, 13 patients were found to have paradoxical puborectalis contraction. Twelve of 13 patients elected to have biofeedback therapy. Eleven of these 12 were available for follow-up an average of eight (1-15) months after biofeedback. Nine improved, and two had no change in their defecation difficulty. Of the initial 13, 10 had an event, either pouchitis or abdominal trauma, directly before their defecation problems.

CONCLUSION

Paradoxical puborectalis contraction can occur in patients after pelvic pouch surgery. It should be suspected in patients with defecation difficulties in the absence of an anatomic abnormality. Biofeedback is effective treatment.

Improved gas exchange performance of the intravascular oxygenator by active blood mixing

The intravascular oxygenator and carbon dioxide removal device (IVOX; CardioPulmonics, Salt Lake City, UT) has been shown to perform 30% of the gas exchange in animals and patients with acute respiratory failure. Among the factors that limit gas exchange is the mass transfer resistance in the blood phase. To determine if a reduction in mass transfer resistance by mixing venous blood can enhance the O2 transfer and CO2 removal by IVOX, a right atrium-pulmonary artery venovenous bypass circuit was used in sheep to model the adult vena cava. A size 9 IVOX (894 fibers with 0.41 m2 surface area, n = 5) was incorporated in the bypass circuit and the blood flow controlled by a roller pump ranging from 1 to 4 l/min. An intra-aortic balloon was placed near the shaft of the IVOX and pulsated at the rate adjusted to best improve CO2 removal (100-120 bpm). O2 transfer and CO2 removal were measured with balloon pulsation on and off at different flow rates. Results showed that blood mixing by pulsation of the balloon caused a 25-49% increase in O2 transfer by IVOX, and this increase remained relatively constant throughout the full flow range. CO2 removal was also increased by up to 35%, but at flows between 3.5 and 4 l/min, the effect of mixing was diminished. It is concluded that reduction in the mass transfer resistance by blood mixing improves gas exchange. Because O2 is more diffusion limited, it is more dependent upon mixing of blood for gas exchange than CO2. More design improvements to incorporate active mixing may further enhance the gas exchange performance of IVOX.

Analysis of the neutralizing antibody response to the measles virus using synthetic peptides of the haemagglutinin protein

Infection or immunization with measles virus induces a protective immune reaction including neutralizing antibodies against the haemagglutinin and fusion protein. The reactivity of the polyclonal IgG response of sera obtained from late convalescent donors was studied, using overlapping 15mer peptides covering the complete sequence of the measles virus haemagglutinin. Most sera reacted with a similar set of peptides generating a characteristic binding pattern. The reactive peptides correspond to a region mediating cell hemolysis (aa310-325), to regions which serve as targets to neutralizing antibodies and to a putative transmembrane region (aa35-58). The latter region contains also a human T-cell epitope providing evidence of a non-random association of T- and B-cell epitopes. We also immunized different strains of mice and rabbits with measles virus. In contrast to the human sera, animal sera with strong neutralizing activities did not react with any of the H-protein peptides. The mostly weak reactivities with the linear sequences contrast with the strong neutralizing activities of the human or animal antibodies, suggesting that these primarily recognize the fusion protein or conformational epitopes of the haemagglutinin protein.

Predicting the functional result of anastomoses to the anus: the paradox of preoperative anal resting pressure

This article examines the effect of ileal pouch-anal (n = 134) and coloanal (n = 16) anastomoses on resting anal canal pressures in 150 patients.

METHODS

Patients underwent anal manometry before ileal pouch-anal anastomosis (IPAA) and coloanal anastomosis (CAA) and again six weeks after ileostomy closure following these procedures. A water-perfused catheter system with four radial ports was used for manometry, pressures being recorded during both station and continuous pull through.

RESULTS

Patients with IPAA were younger than those with CAA (34 years vs. 50 years) and had a different ratio of hand-to-stapled anastomosis (1:2.6 vs. 1.3:1). All CAA patients had had rectal cancer while IPAA patients suffered mainly from ulcerative colitis (n = 114) or familial polyposis (n = 10). The mean preoperative resting pressure for all patients was 79 mmHg (75-87, 95 percent confidence limit) and the mean fall in this pressure after surgery was 25 mmHg (-21 to -29, 95 percent confidence limit). There was no difference in preoperative pressure or fall between handsewn and stapled anastomoses, or between IPAA and CAA.

CONCLUSION

There was a significant relationship between preoperative pressure and change in pressure that held true for all subgroups (change = -0.7 x preoperative pressure + 31, r = 0.69). Analysis of the functional results confirmed that patients with high preoperative pressure are at risk for severe falls after surgery and are not guaranteed a good result. Conversely, patients with low preoperative pressures may actually have an increase with surgery and are not always incontinent. Patients with low preoperative anal resting pressures should not be denied anastomosis to the anus if they are continent.

Endoluminal ultrasound is preferable to electromyography in mapping anal sphincteric defects

Assessment of complex sphincteric defects in patients with fecal incontinence by digital rectal examination and intraoperative dissection can be difficult in the presence of excessive scarring. Adjunctive investigation such as endoluminal ultrasound (ELUS) and needle electromyography (EMG) may provide objective evidence of the nature and extent of the sphincteric defects. In a series of 11 patients, ELUS of the anal canal with a 10-MHz transducer (focal zone of 1-4 cm) accurately detected defects in the external anal sphincter (EAS) in seven of seven patients, defects in the internal anal sphincter (IAS) in eight of eight patients, and integrity of both sphincters in two patients. These findings were confirmed by needle EMG of the EAS alone in five patients, by operative findings at a perineal sphincteroplasty operation in six patients, and by both in two patients. ELUS was associated with less pain than was needle EMG (pain score 4 vs. 10, 10 being most painful) and provided high-resolution radial images of both the EAS and the IAS. Thus, ELUS seems preferable to EMG in mapping anal sphincteric defects and can be a useful anatomic adjunct to physiologic studies of anorectal function in patients with fecal incontinence.

Intra-arterial papaverine and leg vascular resistance during in situ bypass surgery with high or low epidural anaesthesia

In situ saphenous vein arterial bypass flow was studied in 16 patients with respect to level of epidural anaesthesia. Arterial pressure and electromagnetic flow were used to evaluate arterial tone by intra-arterial (i.a.) papaverine. Eight patients had a low epidural block (< or = Th. 10) and eight patients were operated during high epidural anaesthesia (> Th. 10). Flow increased and arterial pressure decreased after i.a. papaverine in all patients. When compared with patients operated during high epidural anaesthesia, flow increase and decrease in vascular resistance took place in patients operated during low epidural anaesthesia (P < 0.02). Increase in arterial flow after i.a. papaverine was not significantly different in patients operated in low epidural and general anaesthesia (n = 8). In eight patients with insulin-dependent diabetes mellitus who had low epidural anaesthesia, the increase in flow after i.a. papaverine was not significantly different to that noted during high epidural anaesthesia. The results indicate that the level of analgesia influences graft flow after i.a. papaverine, probably reflecting differences in the effect of epidural anaesthesia on sympathetic tone to the leg.

Noncytotoxic drug therapy for intra-abdominal desmoid tumor in patients with familial adenomatous polyposis

Forty of 416 patients with familial adenomatous polyposis were noted to have intra-abdominal desmoid tumors, and a subgroup of 16 were treated with noncytotoxic drug therapy. Drugs used were sulindac (14 patients), sulindac plus tamoxifen (3 patients), indomethacin (4 patients), tamoxifen (4 patients), progesterone (DEPO-PROVERA; Upjohn Co., Kalamazoo, MI) (2 patients), and testolactone (1 patient). Therapy with these drugs for continuous periods of six months or more resulted in three complete and seven partial remissions. When treated patients were compared with untreated patients (n = 12), there were significant benefits for the treated group, both in reduction of desmoid size and in improvement of symptoms, despite the inherent selection bias against this. Sulindac was the only drug used in enough patients to permit independent evaluation of its effect, with one complete and seven partial reductions of tumor size. Some patients had a delayed response to sulindac, with tumor shrinkage occurring after an initial period of tumor enlargement. When using sulindac for the treatment of desmoid tumors, this phenomenon should be considered.

The effect of arteriovenous fistulas on in situ saphenous vein bypasses

Intraoperative identification and later development of arteriovenous fistulas were investigated prospectively in 70 in situ saphenous vein bypass procedures. Surveillance was performed by completion arteriography and intra- and postoperative continuous wave Doppler examination. The intraoperative Doppler examination identified 89% of those branches with sufficient flow to opacify the deep venous system on completion arteriogram. Half of the missed fistulas underwent spontaneous thrombosis, and in only one case did the arteriovenous fistula lead to hemodynamic symptoms demanding surgical closure of the fistula. Pursuing a policy of selectively ligating fistulas that only fill the deep venous system on completion arteriography led to an additional nine arteriovenous fistulas. Developed over an average follow-up of six months, four patients presented symptoms of edema and swelling and were relieved upon closure of the fistulas. The incidence of bypass thrombosis did not differ significantly among patients with remaining arteriovenous fistulas, patients who developed fistulas during follow-up, and patients who had no signs of arteriovenous fistulas. It seems justified to continue selective intraoperative ligation of arteriovenous fistulas based on continuous wave Doppler.

Surgery for abdominal aortic aneurysms. A survey of 656 patients

Between 1979 and 1988, 656 patients were operated upon for abdominal aortic aneurysm. Elective operation was performed in 287 patients (44%) and acute operation in 369 patients. A ruptured aneurysm was found in 218 patients (33%). Patients with arteriosclerotic heart disease, hypertension, impaired renal function or chronic pulmonary disease showed an increased perioperative mortality. Development of postoperative cardiac and renal complications could not be related to previous cardiac or renal diseases. The major postoperative complications were renal failure in 81 patients (12%), pulmonary insufficiency in 77 patients (11%) and cardiac complications in 96 patients (13%). Failure of one or more organs occurred in 153 patients (23%) and the mortality rate for patients with multiorgan failure was 68%. Complications leading to reoperation occurred in 93 patients (14%). The perioperative mortality was 18.8%. The mortality for elective cases was 4.8%, for symptomatic cases 17.2% and 37% for ruptured aneurysms. The five-year survival rate was 48% for ruptured aneurysms, 70% for symptomatic cases and 75% for elective cases. After six months the life expectancy in these three groups of patients were identical and comparable to the expected survival for a sex and age matched control population.

[Mortality and survival after surgery for abdominal aortic aneurysm. A 10-year follow-up]

From 1979-1988, 656 patients were operated for abdominal aortic aneurysm. The perioperative mortality was 18%. The mortalities for elective, symptomatic and ruptured aneurysms were 5%, 17% and 38% respectively. The overall five year survival rate was 58%. In 87% of the patients one or more risk factor was found. Survival was unaffected in patients with a single risk factor, whereas patients with two or more risk factors had lower five year survival. Postoperative organ failure increased the perioperative mortality and the five year survival in patients with multiorgan failure was 20%. In view of the fact that 56% of the patients are operated on as emergencies, this study stresses the importance of early diagnosis and elective treatment.

Effect of labetalol on cerebral blood flow and middle cerebral arterial flow velocity in healthy volunteers

The effect of labetalol, a combined alpha- and beta-adrenoceptor antagonist, on the cerebral circulation was investigated in 7 normotensive subjects. Cerebral blood flow (CBF) was measured with the intravenous 133Xe method and mean flow velocity (Vmean) in the middle cerebral artery was determined using transcranial Doppler (TCD) ultrasound. Examination was performed before and then 15, 60 and 120 min after 0.75 mg/kg i.v. labetalol. Reactivity to inhalation of 5% CO2 in air was studied before, and again 90 min after labetalol administration. Neither CBF nor Vmean changed following labetalol administration, whereas a marked increase occurred during inhalation of CO2. The median CO2 reactivity was 3.2%/mmHg (range: 1.8-4.0) for CBF and 4.4%/mmHg (1.5-5.6) for Vmean. These results indicate that labetalol, given in moderate but clinically relevant doses, does not affect the cerebral circulation in normotensive subjects. Neither does it affect CO2 reactivity. The uniform results obtained with the two methods suggest TCD as a usable alternative to conventional CBF technique in the assessment of cerebral vasoactivity of various drugs in subjects with a normal cerebral circulation.

Renal failure after operation for abdominal aortic aneurysm

Among 656 patients undergoing surgery for abdominal aortic aneurysm, 81 patients (12%) developed postoperative renal failure. Before operation hypotension and shock occurred in 88% of the patients with ruptured aneurysm, whereas none of the patients operated electively were hypotensive. Dialysis was performed in 32 patients, while the remaining 49 patients were managed without dialysis. Within 30 days after the operation 47 patients (58%) had died. There was no difference in mortality between patients in dialysis and patients managed without dialysis. Thirteen patients died during follow-up. In six cases the death was caused by renal failure only or in combination with failure of other organs. Analysis of the cumulative survival shows that, if the patients survive the postoperative period, their life expectancy is comparable to that of patients without renal complications.

Intraoperative 133Xe cerebral blood flow measurements by intravenous versus intracarotid methods

To document the comparability of cerebral blood flow (CBF) values determined by quantification of 133Xe washout after either intravenous or intracarotid administration, 12 patients undergoing elective carotid endarterectomy anesthetized with N2O/O2 and either isoflurane or halothane were studied. Scintillation counters were placed over the middle cerebral artery territory ipsilateral to the operated carotid artery. CBF was measured by the intravenous method during dissection of the carotid sheath and was calculated as the initial slope index from head washout curves collected for 11 min after injection of 10-20 mCi 133Xe in saline into a large vein. Immediately prior to carotid occlusion, CBF was determined by direct injection of 1 mCi 133Xe in saline into either the internal carotid artery or the common carotid artery with the external carotid artery occluded. For the intracarotid injections, the initial slope was calculated from the 1st min of washout. Data were analyzed by linear regression and analysis of variance. Values are expressed as mean +/- SD. The mean CBF for intravenous and intracarotid methods were both 29 +/- 10 ml.100 g-1.min-1. The correlation between CBF measured by intravenous and intracarotid methods was excellent and was described by the line y = x + 0.6, r = 0.92. We conclude that in the flow range studied, the intravenous technique may be applied to measure CBF in physiologically stable situations in which direct intracarotid injection is not feasible.

[Hemodynamic assessment of cerebrovascular circulation using transcranial Doppler ultrasound in patients with carotid stenosis]

Transcranial Doppler-ultrasound (TCD) is a new non-invasive technique which renders continuous monitoring of the rate of flow in the major intracerebral arteries possible. The method appears, therefore, to be attractive for perioperative monitoring of patients submitted to operation on account of carotid stenosis. Seventeen patients were included in this preliminary investigation. These patients were submitted for thromboarterectomy of the internal carotid artery. Preoperatively the average flow rate (Vmean) in the ipsilateral medial cerebral artery measured at rest was 54 cm/second (range 34-94) as compared with 57 cm/second (range 32-86) in the contralateral medial cerebral artery. During occlusion, Vmean in the ipsilateral medial cerebral artery decreased momentarily, on an average 35% (p less than 0.001), and returned to the preoperative level after reopening of the internal carotid artery. Corresponding but no significant changes were observed in the pulsatile index. The preliminary experience suggests that TCD is scarcely useful as a diagnostic method in individual cases but that it is well suited for continuous monitoring of changes in cerebral circulating during surgery on the internal cerebral artery. Further assessment of the technique is necessary before the method can be employed routinely, mainly on account of the great interindividual scatter.

[Femoro-crural reconstruction in Denmark 1983-1987]

From 1983 to 1987, 293 femoro-crural bypasses were performed in eight centers for vascular surgery in Denmark. The activity increased in the period from 15 to 135 bypasses per year. The increase took place particularly 1986, when the in situ saphenous vein bypass was introduced in Denmark. A total of 203 bypasses were performed at the University Hospital of Copenhagen, Rigshospitalet: 108 in situ bypasses, 51 bypasses with arterial protheses and 44 bypasses using reversed vein. The cumulated graft patency after one year was 76% for the in situ bypasses, 26% for the bypasses with arterial protheses and 32% for reversed vein. The cumulated limb survivals after one year were 90%, 66% and 63%, respectively.

[Early and late results after surgery of abdominal aortic aneurysm]

From 1983-1987, 388 patients were operated upon for abdominal aortic aneurysm. Elective operation was performed on 171 patients (44%) with a mortality of 2.9%. Emergency operation was done in 277 patients of whom 132 (34%) had ruptured aneurysms. The mortality for ruptured aneurysms was 36% and 21% for patients operated on as emergencies without signs of rupture of the aneurysm. The five year survival rate was 75% after elective operation, 60% after emergency operation and 40% after operation for ruptured aneurysm. The high mortality after emergency operation for abdominal aortic aneurysm confirms the importance of early diagnosis and elective operation before rupture occurs.

Cerebral blood flow during static exercise in humans

Cerebral blood flow (CBF) was determined in humans at rest and during four consecutive unilateral static contractions of the knee extensors. Each contraction was maintained for 3 min 15 s with the subjects in a semisupine position. The contractions corresponded to 8, 16, 24, and 32% of the maximal voluntary contraction (MVC) and utilized alternate legs. CBF (measured by the 133Xe clearance technique) was expressed by a noncompartmental flow index (ISI). Heart rate and mean arterial pressure increased from resting values of 73 (55-80) beats/min and 88 (74-104) mmHg to 106 (86-138) beats/min and 124 (102-146) mmHg, respectively (P less than 0.0005), during the contraction at 32% MVC. Arterial PCO2 and central venous pressure did not change. Corrected to the average resting PCO2, CBF during control was 55 (35-73) ml.100 g-1.min-1 and remained constant during contractions. Cerebral vascular resistance increased from 1.5 (1.0-2.2) to 2.4 (1.4-3.0) mmHg. 100 g.min.ml-1 (P less than 0.025) at 32% of MVC. There was no difference in CBF between the two hemispheres at rest or during exercise. In contrast to dynamic leg exercise, static leg exercise is not associated with an increase in global CBF when measured by the 133Xe clearance technique.

Eight to ten years follow-up after carotid endarterectomy: clinical evaluation and Doppler examination of patients operated on between 1978-1980

Follow-up information was obtained on 185 patients who consecutively underwent carotid endarterectomy eight to ten years previously. Doppler ultrasound examination was performed in 59 patients who were still alive and living within 100 miles of the hospital. Using lifetable analysis, the annual rate of focal strokes was estimated to be 2% and 1.5% on the operated and the contralateral, non-operated carotid artery, respectively. Doppler examination revealed 48% re-stenoses, including 14% occlusion and 15% greater than 50% stenosis. However, there was no association between the occurrence of restenosis and the development of symptoms, perhaps with the exception of internal carotid artery occlusion, which is not an accepted indication for carotid endarterectomy. Together with recent data from the literature, these observations challenge the indication for reoperative carotid surgery.

[Neurologic complications in connection with the surgical treatment of 577 cases of carotid artery stenosis]

During the period January 1982 till June 1988, 536 patients underwent 577 carotid thrombendartectomies in the Department of Vascular Surgery RK in the University Hospital in Copenhagen. Preoperatively, 270 patients (47%) had experienced transient ischaemic attacks (TIA), 247 (43%) had experienced stroke (APC) and 19 (3%) had non-focal symptoms while 41 (7%) had asymptomatic stenoses. Postoperatively, 17 (2.9%) patients developed TIA, 22 (3.8%) developed slight neurological symptoms and 40 (7%) had more severe neurological complications and six of these (1%) died. None of the patients died from other causes during the first month. The frequency of complications had no relationship to the preoperative focal symptoms, but in patients with non-focal symptoms this was 37%. The degree of stenosis of the contralateral internal carotid artery (ICA) was correlated positively with the occurrence of severe neurological complications which were observed in 5% without contralateral ICA changes, in 7% with stenoses and in 20% with contralateral ICA occlusion. Patients with cerebral infarction developed complications significantly more frequently (20%) than patients with normal CT scans. The risk was also found to be increased in cases with a high pressure gradient across the stenosis and low pressure peripherally in the occluded artery (stump pressure). Follow-up examination of the 73 patients with complications on average 39 months after operation revealed that 37 patients (6.4%) had severe neurological symptoms resulting either from the operation or subsequent APC; seven patients required complete nursing care (1.2%) and 17 patients died during the period of observation. On follow-up examination, 15 patients had been occupationally active for at least 1.5 years.

Pressure/cross-sectional area probe in the assessment of urethral closure function. Reproducibility of measurement

A probe, which enables measurement of related values of pressure and cross-sectional area, was used for in vitro studies and in vivo measurements in the female urethra. Six healthy females underwent two successive investigations. Measurements were performed at the bladder neck, in the high-pressure zone and distally in the urethra. The in vitro study showed that cross sectional areas of 13-79 mm2 were determined with a SD of 1.4 mm2. In vivo measurements revealed that the urethral parameters: elastance, hysteresis, pressure and power of contraction during coughing and squeezing were fairly reproducible. However, a certain interindividual variation of the parameters was found.

Carotid artery disease and low cerebral perfusion pressure: symptomatology, operative risk and outcome

Direct internal carotid artery blood pressure measurements in patients undergoing carotid endarterectomy identified 49 patients, among 239 consecutive cases (21%), who had a reduction in perfusion pressure of 20% or more. The clinical history, objective findings and angiographic data were compared with those of a control group of a further 49 patients selected from the remaining patients operated on over the same period. The two groups were compared for short- and long-term outcome of surgery. We were unable to delineate a symptomatic neurological profile that identified patients with low perfusion pressures. Surgery in patients with low perfusion pressures seemed to be associated with an increased complication rate (12% versus 4%), although this was not statistically significant. Definite postoperative improvements in persisting neurological deficits were observed only in one patient. Long-term results were equal in the two groups with an annual stroke risk of 3%.

Improvement of peroral absorption of cyclosporine A by microemulsions

The rat was found to be a suitable model for pharmacokinetic and bioavailability studies of cyclosporine A (CsA). All pharmacokinetic parameters studied were in the same order of magnitude as those found in man. Two peroral formulations in the form of microemulsions were compared with a commercially available P.O. solution (to be diluted for administration) and a solution for intravenous administration. Of the two microemulsions, one resulted in an extent of absolute and relative bioavailability significantly higher than that of the available P.O. solution. Biliary recycling was observed upon all routes of administration. If uncorrected for biliary recycling, both absolute and relative bioavailability are overestimated.

Cerebral blood flow during submaximal and maximal dynamic exercise in humans

Cerebral blood flow (CBF) in humans was measured at rest and during dynamic exercise on a cycle ergometer corresponding to 56% (range 27-85) of maximal O2 uptake (VO2max). Exercise bouts were performed by 16 male and female subjects, lasted 15 min each, and were carried out in a semisupine position. CBF (133Xe clearance) was expressed as the initial slope index (ISI) and as the first compartment flow (F1). CBF at rest [ISI, 58 (range 45-73); F1, 76 (range 55-98) ml.100 g-1.min-1] increased during exercise [ISI to 79 (57-94) and F1 to 118 (75-164) ml.100 g-1.min-1, P less than 0.01]. CBF did not differ significantly between work loads from 32 (24-33) to 86% (74-96) of VO2max (n = 10). During exercise, mean arterial pressure increased from 84 (60-100) to 101 (78-124) Torr (P less than 0.01) and PCO2 remained unchanged [5.1 (4.6-5.6) vs. 5.4 (4.4-6.3) kPa, n = 6]. These results demonstrate a median increase of 31% (0-87) in CBF by ISI and a median increase of 58% (0-133) in CBF by F1 during dynamic exercise in humans.

Congenital hypertrophy of the retinal pigment epithelium in familial adenomatous polyposis

One hundred fifty-three members of 56 kindreds with familial adenomatous polyposis (FAP) underwent funduscopic examination for congenital hypertrophy of the retinal pigment epithelium (CHRPE). All patients underwent wide-angle fundus photography to document lesions, proctosigmoidoscopy to document polyps, and examination for extracolonic manifestations. Ninety-seven patients were diagnosed as having FAP and 56 patients were offspring of FAP patients and thus at 50% risk of inheriting the disease. In two thirds of the kindreds, CHRPE could be used as a congenital phenotypic marker to predict the presence or development of polyps. In these kindreds, all patients with diagnosed FAP and 39% of the patients at risk had at least four CHRPE lesions. In one third of the kindreds, CHRPE could not be used as a predictive congenital marker, and in these kindreds all patients had zero to three total lesions of CHRPE. The presence of CHRPE did not correlate with any other extracolonic manifestations. In kindreds without any other extracolonic manifestations, CHRPE can still be present and can be used as a predictive congenital phenotypic marker.