De-escalating therapy in inflammatory bowel disease: Results from an observational study in clinical practice

BACKGROUND AND OBJECTIVES

Combination therapy with an immunomodulator (IMM) and an anti-TNF is commonly recommended in Crohn's disease (CD) and ulcerative colitis (UC) patients. However, little is known about relapse rates after therapeutic de-escalation. This study aimed to evaluate the risk of relapse in a cohort of UC and CD patients with long-standing clinical remission after discontinuation of IMM or anti-TNF and to identify predictive factors for relapse.

METHODS

This retrospective study included patients with UC or CD on combination therapy and clinical remission for at least 6 months. IMM or anti-TNF was stopped upon physician decision. Primary objective was to evaluate the relapse rates after discontinuation of IMM or anti-TNF and to analyze predictors of relapse.

RESULTS

The study included 88 patients, 48 patients (54.5%) discontinued IMM and 40 (45.5%) anti-TNF. During follow-up, relapse rates were 16.7% and 52.5% in the IMM discontinuation group and anti-TNF discontinuation group, respectively (p<0.001). Multivariate analysis showed that anti-TNF discontinuation (HR=3.01; 95% CI=1.22-7.43) and ileal CD location (HR=2.36; 95% CI=1.02-5.47) were predictive factors for relapse while inflammatory CD phenotype was a protective factor (HR=0.32; 95% CI=0.11-0.90). Reintroduction of anti-TNF upon relapse was effective and safe.

CONCLUSION

Anti-TNF discontinuation led to significantly higher relapse rates compared to IMM discontinuation in UC and CD patients on combination therapy. Anti-TNF discontinuation and ileal CD location were identified as predictive factors for relapse while inflammatory CD phenotype was a protective factor. Retreatment after anti-TNF discontinuation was effective and safe.

Endoscopic response to tumor necrosis factor inhibitors predicts long term benefits in Crohn’s disease

BACKGROUND

Identifying predictors of therapeutic response is the cornerstone of personalized medicine.

AIM

To identify predictors of long-term mucosal healing (MH) in patients with Crohn’s disease (CD) treated with tumor necrosis factor α (TNF-α) inhibitors.

METHODS

Prospective single center study. Consecutive patients with clinically active CD requiring treatment with a TNF-α inhibitor were included. A baseline segmental CD Endoscopic Index of Severity (CDEIS) ≥ 10 in at least one segment or the presence of ulcerations were required for inclusion. Clinical, biological and endoscopic data were obtained at baseline, weeks 14 and 46. Endoscopic response (ER) was defined as a decrease ≥ 50% from baseline CDEIS and MH as partial CDEIS ≤ 5 in all segments.

RESULTS

Of 62 patients were included. At baseline, median CD Activity Index and CDEIS were 201 and 6.7, respectively with a significant reduction after one year of treatment (53 and 3.0 respectively, P < 0.001). At week 14, 56% of patients achieved ER and 34% MH. At week 46, the corresponding percentages were 52% and 44%. Baseline disease characteristics or biomarkers did not predict MH. A decrease from baseline CDEIS at week 14 of at least 80% was the best predictor of MH at week 46 (59% sensitivity and 91% specificity; area under the curve = 0.778).

CONCLUSION

Clinical and biomarker data are not useful predictors of response to TNF-α inhibitors in CD, whereas ER to induction therapy, defined as 80% reduction in global CDEIS, is a robust predictor of long-term MH. Achievement of this endoscopic endpoint may be considered as a therapeutic target for anti-TNF-α therapy.

Immune cells from patients with psoriasis are defective in inducing indoleamine 2,3-dioxygenase expression in response to inflammatory stimuli

BACKGROUND

Indoleamine 2,3-dioxygenase (IDO) is an inducible enzyme that suppresses the immune response. The role of IDO as a negative regulator of inflammatory responses has been documented in several experimental autoimmune diseases.

OBJECTIVES

To explore the regulation of IDO by immune cells in psoriasis and its relation with disease severity.

METHODS

The expression and activity of IDO were assessed by reverse-transcriptase polymerase chain reaction, flow cytometry and high-performance liquid chromatography in peripheral blood of patients with moderate-to-severe plaque-type psoriasis. The ability of immune cells to express IDO in response to inflammatory stimuli was studied. The functional role of IDO expression was evaluated in a regulatory T cell (Treg) differentiation assay, using cocultures of immature monocyte-derived dendritic cells with autologous peripheral CD4⁺ T cells.

RESULTS

Analysis of the kynurenine-to-tryptophan ratio in serum samples indicated higher IDO activity in patients with psoriasis than in healthy controls. However, correlation studies showed lower IDO activity in those patients with higher Psoriasis Area and Severity Index (PASI). Although myeloid dendritic cells from patients with psoriasis expressed higher levels of IDO than those from healthy controls, these cells did not upregulate IDO in response to a combination of tumour necrosis factor-α, interleukin (IL)-1β and IL-6 cytokines. The defective expression of IDO correlated with PASI. Immature monocyte-derived dendritic cells from patients with psoriasis also expressed low levels of IDO and induced CD4⁺ Treg differentiation poorly.

CONCLUSIONS

Immune cells from patients with psoriasis have a defect in upregulating IDO in response to inflammation associated with the severity of psoriasis.

Fraxinus pollen and allergen concentrations in Ourense (South-western Europe)

In temperate zones of North-Central Europe the sensitization to ash pollen is a recognized problem, also extended to the Northern areas of the Mediterranean basin. Some observations in Switzerland suggest that ash pollen season could be as important as birch pollen period. The allergenic significance of this pollen has been poorly studied in Southern Europe as the amounts of ash pollen are low. Due to the high degree of family relationship with the olive pollen major allergen (backed by a sequence identity of 88%), the Fraxinus pollen could be a significant cause of early respiratory allergy in sensitized people to olive pollen as consequence of cross-reactivity processes. Ash tree flowers in the Northwestern Spain during the winter months. The atmospheric presence of Ole e 1-like proteins (which could be related with the Fra a 1 presence) can be accurately detected using Ole e 1 antibodies. The correlation analysis showed high Spearman correlation coefficients between pollen content and rainfall (R(2)=-0.333, p<0.01) or allergen concentration and maximum temperature (R(2)=-0.271, p<0.01). In addiction CCA analysis showed not significant differences (p<0.05) between the component 1 and 2 variables. PCFA analysis plots showed that the allergen concentrations are related to the presence of the Fraxinus pollen in the air, facilitating the wind speed its submicronic allergen proteins dispersion. In order to forecast the Fraxinus allergy risk periods, two regression equations were developed with Adjusted R(2) values around 0.48-0.49. The t-test for dependent samples shows no significant differences between the observed data and the estimated by the equations. The combination of the airborne pollen content and the allergen quantification must be assessed in the epidemiologic study of allergic respiratory diseases.

Oleaceae cross-reactions as potential pollinosis cause in urban areas

It is worth noting the allergological problems induced by a not accurate design of the ornamental vegetation in the parks and streets of the cities. Usually, in the Oleaceae family, only the olive pollen is considered an important aeroallergen but other species of the family could be an important source of airborne pollen allergens. Pollen from Fraxinus, Olea and Ligustrum and its main aeroallergens were sampled in the atmosphere of an urban area in North-Western Spain during 2011. The allergen bioaerosol content was quantified by using specific 2-site ELISA and Ole e 1 antibodies. The Fra e 1 and Lig v 1 allergens were detected by means Ole e 1 antibodies. This fact demonstrates the cross-reactivity between the main allergens of Fraxinus, Olea and Ligustrum, plants widely species used as ornamental in the cities. Therefore, the urban allergenic people sensitized to Olea pollen could present allergenic reactions during the winter (due to ash pollen allergens), the spring (caused by olive pollen allergens) and the early summer (triggered by the privet flowering). As a consequence, sensitivity to the pollen of one species may favour development of sensitivity to all three species as consequence of the priming effect. The combination of pollen count and the allergen quantification must be assessed in the epidemiologic study of allergic respiratory diseases.

Reduced expression of galectin-1 and galectin-9 by leucocytes in asthma patients

Accumulating evidence shows that galectins play roles in the initiation and resolution phases of inflammatory responses by promoting anti- or proinflammatory effects. This study investigated the presence of three members of the galectin family (galectin-1, -3 and -9) in induced sputum samples of asthma patients, as well as their possible implication in the immunopathogenesis of human asthma. Levels of interleukin (IL)-5, IL-13, and galectins were determined in leucocytes isolated from induced sputum samples by reverse transcription-polymerase chain reaction (RT-PCR) immunofluorescence and flow cytometry. High levels of IL-5 and IL-13 mRNA were detected in sputum cells from asthma patients. In parallel, immunoregulatory proteins galectin-1 and galectin-9 showed a reduced expression on macrophages from sputum samples compared with cells from healthy donors. In-vitro immunoassays showed that galectin-1 and galectin-9, but not galectin-3, are able to induce the production of IL-10 by peripheral blood mononuclear cells from healthy donors. These findings indicate that macrophages from sputum samples of asthma patients express low levels of galectin-1 and galectin-9, favouring the exacerbated immune response observed in this disease.

Evidence for the involvement of diacylglycerol kinase in the activation of hypoxia-inducible transcription factor 1 by low oxygen tension

Hypoxia-inducible factor 1 (HIF-1) induces a gene expression program essential for the cellular adaptation to lowered oxygen environments. The intracellular mechanisms by which hypoxia induces HIF-1 remain poorly understood. Here we show that exposure of various cell types to hypoxia raises the intracellular level of phosphatidic acid primarily through the action of diacylglycerol kinase (DGK). Pharmacological inhibition of DGK activity through use of the specific DGK inhibitors and abrogated specifically HIF-1-dependent transcription analyzed with a HIF-1-responsive reporter plasmid. A more detailed analysis revealed that pharmacological inhibition of DGK activity prevented the hypoxia-dependent accumulation of the HIF-1alpha subunit and the subsequent HIF-1-DNA complex formation as well as hypoxia-induced activity of the HIF-1 transactivation domains localized to amino acids 530-582 and 775-826 of the HIF-1alpha subunit. Our results demonstrate for the first time that accumulation of phosphatidic acid through DGK underlines oxygen sensing and provide evidence for the involvement of this lipid kinase in the intracellular signaling that leads to HIF-1 activation.

[Idiopathic retroperitoneal fibrosis]

OBJECTIVE

A case of idiopathic retroperitoneal fibrosis in a 34-year-old man with anemia and elevated erythrocyte sedimentation rate is presented.

METHODS/RESULTS

Ultrasound, CT and MRI evaluation and pathological study were performed. These diagnostic imaging techniques demonstrated an infiltrating mass in the upper portion of the abdomen which was resected. Histological and immunohistochemical studies of the surgical specimen demonstrated sclerosing retroperitonitis.

CONCLUSIONS

Idiopathic retroperitoneal fibrosis (Ormond's disease) is a rare disease entity whose etiology is obscure and is characterized by retroperitoneal fibrosis with inflammatory infiltrates composed of plasma cells, lymphocytes and eosinophils. This case is of interest due to its atypical location, and because the patient was young with no remarkable clinical history and only mild anemia and an elevated erythrocyte sedimentation rate.

Parotid metastasis from renal clear cell adenocarcinoma. An unusual site for metastasis

Metastasis to the parotid region is rare, and originates primarily from head and neck squamous cell carcinoma and melanoma of the skin. Renal clear cell adenocarcinoma has considerable metastatic potential and the parotid gland is one possible destination. Histopathologic study is important to differentiate this entity from primary clear cell parotid neoplasm.

[An aggressive inguinal (parafunicular) angiomyxoma in a male patient]

OBJECTIVE

To report a case of aggressive inguinal angiomyxoma in a male patient.

METHODS

An 82-year-old male patient presented with a well-defined, 6 cm. parafunicular mass in the right groin. The mass was located adjacent to the spermatic cord and had been noted 8 years earlier. Patient evaluation included CT, ultrasound and immunohistochemical studies.

RESULTS

The CT and US findings suggested lymph node enlargement. Microscopic analysis showed a myxoid tumor with partially infiltrating margins, vascular channels of small-sized vessels with thick walls occasionally with hyalinization and spindle-shaped or stellate mesenchymal cells with ill-defined margins without atypia or mitosis that were positive for vimentin and negative for actin, desmin, keratins, CD34 and protein S-100. No tumor recurrence or metastasis has been observed at 26-months' follow-up.

CONCLUSIONS

To our knowledge, this is one of the few cases of inguinal angiomyxoma in male patients; 16 have been reported to date. This neoplasm appears to originate from pelvic soft tissue fibroblasts.

[Inhalation administration of nitric oxide during selective pulmonary ventilation decreases the intrapulmonary shunt]

OBJECTIVE

To assess the effects of inhaled nitric oxide (NO) on oxygenation and hemodynamics in patients undergoing lung resection surgery during one-lung ventilation (OPV).

PATIENTS AND METHODS

Prospective study of 16 patients aged 62 +/- 10 years scheduled for chest surgery under combined general and epidural anesthesia. During ventilation of only one lung, NO was administered for 15 minutes. Arterial blood and mixed venous blood samples were taken for analysis of blood gases and the calculation of intrapulmonary shunt. Pulmonary and systemic hemodynamic variables were also recorded using a Swan-Ganz catheter at three times: baseline (ventilation of both lungs), OLV, and with OLV plus NO (OLV NO).

RESULTS

The most relevant data consisted of a significant decrease in shunt after start of NO inhalation in comparison with the level during OLV (31.1 +/- 0.5% versus 36 +/- 0.6%; p < 0.05). Arterial oxygen pressure decreased significantly during OLV and increased after start of NO (118.9 +/- 53.6 versus 155.4 +/- 78.5 mmHg; p < 0.05). Mean pulmonary artery pressure, pulmonary and systemic vascular resistances, and cardiac index did not change with inhalation of NO.

CONCLUSIONS

Inhalational administration of NO during OLV significantly improves arterial oxygenation and decreases intrapulmonary shunt during OLV, without causing hemodynamic or systemic effects.

[Inflammatory pseudotumor of the spleen. An old concept with many questions]

Inflammatory pseudotumor of spleen is an infrequent benign condition. It is difficult to differentiate, on a clinical and radiological basis, from haematologic neoplasms, granulomatous diseases as sarcoidosis and splenic hamartoma. Sometimes can be an incidental finding. Two women, aged 72 years, are presented. On the first case the sympthons mi micked a malignant disease. The second one was an incidental finding in a routine study for cholecystitis. Histological and immunohistochemical study showed a polymorphic cellular population including plasma cell, lymphoid cells, histiocytes, eosinophils and spindle cells, showing a reactive benign character. Plasma cells presented light chains polyclonality. Lymphoid cells were mature and with T inmunophenotype. Spindle cells were focally positive for muscle spe-cific actin and vimentine. In the first case, ultraestructural study showed myofibroblast morphology on the stromal spindle cells. Like many other authors have already postulated, immunohistochemical and ultraestructural findings would corroborate the mesenchymal reactive and benign nature of this type of lesions.

Pyrrolidine dithiocarbamate inhibits the production of interleukin-6, interleukin-8, and granulocyte-macrophage colony-stimulating factor by human endothelial cells in response to inflammatory mediators: modulation of NF-kappa B and AP-1 transcription factors activity

Endothelial cells (EC) play a key role in the inflammatory response, both by the production of proinflammatory cytokines and by their interaction with leukocytes. Molecular genetic analysis has demonstrated that functional NF-kappa B sites are involved in the transcription of interleukin-6 (IL-6), IL-8, and granulocyte-macrophage colony-stimulating factor (GM-CSF) genes in response to inflammatory mediators. Thus, we have explored the effect of two inhibitors of the NF-kappa B activation, pyrrolidine dithiocarbamate (PDTC) and N-acetylcysteine (NAC), on the production of these cytokines by EC. Both PDTC and NAC inhibited, in a dose-dependent manner, the synthesis of IL-6, IL-8, and GM-CSF induced by tumor necrosis factor (TNF)-alpha or bacterial lipopolysaccharides (LPS) in human umbilical vein endothelial cells (HUVEC). PDTC appeared to prevent IL-6, IL-8, and GM-CSF gene transcription, as it blocked the induction of specific mRNA by TNF-alpha or LPS. The TNF-alpha mediated transcriptional activation of a chloramphenicol acetyltransferase (CAT) plasmid containing three copies of the -72 kappa B binding site from the IL-6 promoter was abrogated by PDTC. According to transfection experiments, electrophoretic mobility shift assays (EMSA) demonstrated that the antioxidant prevented the induction of NF-kappa B DNA-binding activity by TNF-alpha. Under the same conditions, PDTC by itself or in combination with TNF-alpha, enhanced the DNA-binding activity of AP-1, as well as c-fos and c-jun mRNA levels. Altogether, these results indicate that the antioxidant PDTC specifically inhibits the transcription of IL-6, IL-8, and GM-CSF genes through the inhibition of the NF-kappa B activation, while increasing the expression of AP-1. Our data make evident the antiinflammatory and immunoregulatory potential of the pharmacological inhibition of the NF-kappa B activation. In addition, PDTC and related molecules may be a useful tool to explore the expression of genes involved in the inflammatory response.

Transcriptional up-regulation of intracellular adhesion molecule-1 in human endothelial cells by the antioxidant pyrrolidine dithiocarbamate involves the activation of activating protein-1

The redox status of the cell plays an essential role in regulating signal transduction, transcription factor activity, and expression of cell surface molecules. In this study, we show that pyrrolidine dithiocarbamate (PDTC), a potent antioxidant agent, upregulated the cell surface expression of intercellular adhesion molecule-1 (ICAM-1) in human endothelial cells (EC). Further analysis of PDTC-mediated ICAM-1 up-regulation revealed that PDTC increased ICAM-1 mRNA levels and augmented its gene promoter activity. Transfection experiments in EC with reporter constructs harboring nested deletion fragments of the ICAM-1 promoter indicated the presence of a functional PDTC-responsive region located between positions -136 to -353 of the promoter. Gel retardation assays together with supershift analysis revealed that PDTC induced the binding of c-fos and c-jun to a consensus activating protein-1 (AP-1) binding site located at position -284. PDTC alone or in combination with TNF-alpha enhanced AP-1-dependent transactivation in HUVEC, as determined by DNA binding assays. The functional implication of AP-1 in the transcription of the ICAM-1 gene was further demonstrated by cotransfection experiments in which a c-jun expression vector induced the promoter activity of the PDTC-responsive element of the ICAM-1 promoter. Taken together, these results indicate that the antioxidant PDTC induces transcriptional activation of ICAM-1 and that this induction is mediated at least in part by the transcription factor AP-1. This mechanism might be operative in pathologic conditions in which a redox imbalance plays a key role, such as ischemia/reperfusion injury or arteriosclerosis.

Transcriptional up-regulation of intracellular adhesion molecule-1 in human endothelial cells by the antioxidant pyrrolidine dithiocarbamate involves the activation of activating protein-1

The redox status of the cell plays an essential role in regulating signal transduction, transcription factor activity, and expression of cell surface molecules. In this study, we show that pyrrolidine dithiocarbamate (PDTC), a potent antioxidant agent, upregulated the cell surface expression of intercellular adhesion molecule-1 (ICAM-1) in human endothelial cells (EC). Further analysis of PDTC-mediated ICAM-1 up-regulation revealed that PDTC increased ICAM-1 mRNA levels and augmented its gene promoter activity. Transfection experiments in EC with reporter constructs harboring nested deletion fragments of the ICAM-1 promoter indicated the presence of a functional PDTC-responsive region located between positions -136 to -353 of the promoter. Gel retardation assays together with supershift analysis revealed that PDTC induced the binding of c-fos and c-jun to a consensus activating protein-1 (AP-1) binding site located at position -284. PDTC alone or in combination with TNF-alpha enhanced AP-1-dependent transactivation in HUVEC, as determined by DNA binding assays. The functional implication of AP-1 in the transcription of the ICAM-1 gene was further demonstrated by cotransfection experiments in which a c-jun expression vector induced the promoter activity of the PDTC-responsive element of the ICAM-1 promoter. Taken together, these results indicate that the antioxidant PDTC induces transcriptional activation of ICAM-1 and that this induction is mediated at least in part by the transcription factor AP-1. This mechanism might be operative in pathologic conditions in which a redox imbalance plays a key role, such as ischemia/reperfusion injury or arteriosclerosis.

Characterization of the CD11a (alpha L, LFA-1 alpha) integrin gene promoter

Human lymphocyte function-associated antigen-1 (LFA-1, CD11a/CD18, alpha L/beta 2) is a cell surface heterodimer, which, together with Mac-1 (CD11b/CD18, alpha M/beta 2) and p150,95 (CD11c/CD18, alpha X/beta 2), constitutes the leukocyte integrin beta 2 (CD18) subfamily. LFA-1 is the only integrin expressed on all leukocyte lineages and functions both as a key adhesion receptor in immune and inflammatory processes and as a signal-transducing molecule. To elucidate the molecular basis for the leukocyte-restricted expression of LFA-1, the promoter region of the CD11a gene has been isolated and functionally characterized. The 5' region of the CD11a gene exhibits a similar exon/intron organization as the CD11b, CD11c, and VLA-2 alpha genes but is different from that of the genes encoding VLA-4 alpha, VLA-5 alpha, and gpIIb. Several tightly clustered transcription initiation sites have been identified on the CD11a gene, with the major site resembling the "initiator" sequence. Transient expression of CD11a promoter-based reporter gene constructs in both LFA1+ and LFA1- cell lines demonstrated that the fragment spanning from -880 to +83 is involved in the tissue-specific expression of LFA-1. Functional analysis of different fragments within the -880/+83 fragment suggested the presence of negative regulatory elements between -880 and -226 and demonstrated that the proximal region of the CD11a gene promoter exhibits tissue-specific activity.

Characterization of the p150,95 leukocyte integrin alpha subunit (CD11c) gene promoter. Identification of cis-acting elements

The leukocyte integrin p150,95 (CD11c/CD18) is involved in a number of cell-cell and cell-extracellular matrix interactions and mediates signal transduction into the cytoplasm. p150,95 is expressed on cells of the myeloid lineage as well as on certain activated T and B lymphocytes, and its expression is regulated during cell activation and differentiation. Since CD18 is expressed on all leukocyte lineages, the restricted expression of p150,95 must be controlled at the level of CD11c gene transcription. To understand the mechanisms that direct the constitutive and regulated leukocyte expression of p150,95 we have structurally characterized the CD11c promoter region and initiated its functional dissection. The CD11c promoter lacks TATA- and CCAAT-boxes, directs the synthesis of transcripts with heterogeneous 5'-ends, and contains an initiator-like sequence at the major transcription initiation site. Several putative binding sequences for ubiquitous (Sp1, AP-1, AP-2, and NF-kB) and leukocyte-specific (PU.1) transcription factors have been identified in the proximal region of the CD11c promoter which may participate in the regulation of the expression of p150,95. Transient expression of CD11c-based reporter gene constructs indicates that the CD11c promoter dictates the tissue-specific expression of p150,95 and that sequences contained within 160 base pairs 5' from the major transcriptional start site are involved in the tissue-specific and regulated expression of p150,95. DNase I protection analysis on the promoter region spanning from -160 to +40 revealed four regions of DNA-protein interactions (FPI-FPIV), two of which (FPII and FPIV) correlate with the cell type-specific and regulated expression of the CD11c gene.

Molecular basis for a severe case of leukocyte adhesion deficiency

The leukocyte integrins LFA-1, Mac-1 and p150,95 (CD11a/CD18, CD11b/CD18, CD11c/CD18) mediate crucial leukocyte adhesive functions in immune and inflammatory reactions. Leukocyte adhesion deficiency (LAD) disease is caused by the defective expression of these adhesion molecules on leukocytes, and is characterized by recurrent infections and impaired pus formation due to the blockade of leukocyte migration into inflamed tissues. LAD is originated by heterogeneous mutations affecting the CD18 gene and, based on the severity of the deficiency, two phenotypes (severe and moderate) have been defined. Biochemical and genetic studies have allowed the classification of five different types of LAD. We have identified a type V LAD patient (severe phenotype, and normal size and levels of both CD18 precursor and CD18 mRNA), and determined its molecular basis. Reverse transcription-polymerase chain reaction and cloning and sequencing of CD18 cDNA derived from this patient revealed three silent mutations and a missense mutation that leads to the substitution of glycine at position 169 for an arginine. Analysis of patient-derived cDNA clones revealed the concomitant presence of aberrant splicing within the 5' region of the CD18 gene. The description of an identical mutation at residue 169 in an unrelated severe LAD patient raises the possibility that severe LAD type V is caused by a unique genetic defect.

A single mRNA encodes the alpha 150 and alpha 80/70 forms of the alpha subunit of VLA4

VLA4 is a cell surface heterodimer (alpha 4 beta 1, CD49d/CD29) which belongs to the integrin family and is involved in cell-extracellular matrix interactions, as well as in intercellular adhesion. Unlike other integrin alpha subunits, the alpha subunit of VLA4 (alpha 4) can appear as a 150-kDa polypeptide (alpha 150), or cleaved into two non-covalently associated polypeptides (alpha 70-80). The relative proportion of each form is highly variable among different cells and is dependent on the state of cellular activation. The alpha 4 cleavage site has recently been shown to occur between residues Arg558-Ser559. We report the isolation of genomic clones encoding the alpha 4 subunit, the location of the cleavage site-encoding nucleotides to a specific exon and the determination of the exon-intron organization around the cleavage site. Comparison with the gpIIb (CD41) and the alpha x (p150,95 alpha, CD11c) genes revealed a similar genomic structure in this region, with exons of similar length separated by introns of identical phase. The structure of the alpha 4 mRNA in cells expressing the alternative forms of alpha 4 has been analyzed by means of reverse transcription-polymerase chain reaction. Our results indicate that the exon encoding the cleavage site is present in alpha 4 mRNA molecules from cells expressing either the alpha 150 or the alpha 70-80 form on the cell surface. Moreover, the structure of the alpha 4 mRNA around the cleavage site does not change during the switch towards the alpha 70-80 form that takes place upon lymphocyte activation. Therefore, both forms of alpha 4 arise from a common mRNA, the alpha 150 form contains the cleavage sequence and the alpha 70-80 form must be generated by a post-translational proteolytic event.

Displaced stress fractures of the femoral neck in young male adults: a report of twelve operative cases

The results of 12 operatively treated displaced stress fractures of the femoral neck in young male adults are reported. The mean age of the patients was 19.8 years (range, 19-24 years) and the mean followup period 4.0 years (range, 1-9 years). Sliding hip compression screw was used in ten cases, Jewett nail in one and 130 degrees angled A0-plate in one case. Aseptic necrosis (AN) of the femoral head developed in five cases treated by sliding hip compression screw. It was correlated with increased operative trauma in four patients: open reduction in two, reoperation in one, and osteotomy in one case. Nonunion developed in three cases and it was combined with AN in two cases. In six cases the results were acceptable, but for the last three patients the followup period was only 1-2 years.