Multiple ER-to-nucleus stress signaling pathways are activated during Plantago asiatica mosaic virus and Turnip mosaic virus infection in Arabidopsis thaliana

Pathogens and other adverse environmental conditions can trigger endoplasmic reticulum (ER) stress. ER stress signaling increases the expression of cytoprotective ER-chaperones. The inositol-requiring enzyme (IRE1) is one ER stress sensor that is activated to splice the bZIP60 mRNA that produces a truncated transcription factor that activates gene expression in the nucleus. The IRE1/bZIP60 pathway is associated with restricting potyvirus and potexvirus infection. This study shows that the Plantago asiatica mosaic virus (PlAMV) triple gene block 3 (TGB3) and the Turnip mosaic virus (TuMV) 6K2 proteins activate alternative transcription pathways involving the bZIP17, bZIP28, BAG7, NAC089 and NAC103 factors in Arabidopsis thaliana. Using the corresponding knockout mutant lines, we show that bZIP17, bZIP60, BAG7 and NAC089 are factors in reducing PlAMV infection, whereas bZIP28 and bZIP60 are factors in reducing TuMV infection. We propose a model in which bZIP60 and bZIP17 synergistically induce genes restricting PlAMV infection, while bZIP60 and bZIP28 independently induce genes supporting PlAMV infection. Regarding TuMV-green fluorescent protein (GFP) infection, bZIP60 and bZIP28 serve to repress local and systemic infection. Finally, tauroursodeoxycholic acid treatments were used to demonstrate that the protein folding capacity significantly influences PlAMV accumulation.

Evaluation of the Prognostic Accuracy of Astler-coller's and Jass’ Classifications of Colorectal Cancer

Aim

The study aim was to determine whether the Jass classification is superior to that of Astler-Coller (modification of Dukes’ stage) in determining prognosis of patients treated for colorectal carcinoma.

Study Design

The authors used Jass’ classification to restage 263 patients who had undergone radical colorectal surgery and classified according to Astler-Coller.

Results

The results revealed that: 1) Astler-Coller's classification enables more accurate selection of patient groups where life expectancy can be predicted; 2) Jass’ classification enables statistically significant (P <0.05) improved prognostic discrimination of Astler-Coller's B2 patients, for which the probability of nonrecurrence of the disease is around 60%.

Conclusions

Although Astler-Coller's classification is still valid, Jass’ classification is useful for the prognostic discrimination of Astler-Coller's B2 patients.

Association of adiposity, telomere length and mortality: data from the NHANES 1999-2002

BACKGROUND/OBJECTIVES

Telomere shortening is associated with age and risk of medical comorbidity. We assessed the relationship between measures of adiposity, leukocyte telomere length, and mortality and whether it is modified by age.

SUBJECTS/METHODS

Subjects with dual-energy X-ray absorptiometry measures were identified using the National Health and Nutrition Examination Survey 1999-2002. Obesity was categorized using two body fat definitions (BF1%: men ⩾25%; females ⩾35%; BF2% ⩾28% and ⩾38%, respectively), body mass index (BMI) and waist circumference (WC; men ⩾102 cm; females ⩾88 cm). Telomere length relative to standard reference DNA (T/S ratio) was assessed using quantitative PCR. Weighted multivariable regression models evaluated the association of telomere length with adiposity, both continuously and categorically (low/normal BF%, low/high WC and standard BMI categories). Differences in telomere length by age and adiposity were ascertained and subsequent models were stratified by age. Proportional hazard models assessed the risk of mortality by adiposity status. A telomere by adiposity interaction was tested in the entire cohort and by age category (<60 vs ⩾60 years; <70 vs ⩾70 years).

RESULTS

We identified 7827 subjects. Mean age was 46.1 years. Overall telomere length was 1.05±0.01 (s.e.) that differed by BF1% (low/high: 1.12±0.02 vs 1.03±0.02; P<0.001), BF2% (1.02±0.02 vs 1.11±0.02; P<0.001), BMI (underweight 1.08±0.03; normal 1.09±0.02; overweight 1.04±0.02; and obese 1.03±0.02;P<0.001) and WC (low/high 1.09±0.02 vs 1.02±0.02; P<0.001). Adjusted β-coefficients evaluating the relationship between telomere length and adiposity (measured continuously) were as follows: BF1% (β=-0.0033±0.0008; P<0.001), BF2% (-0.041±0.008; P<0.001), BMI (β=-0.025±0.0008; P=0.005) and WC (β=-0.0011±0.0004; P=0.007). High BF% (BF1%: β=-0.035±0.011; P=0.002; BF2%: β=-0.041±0.008; P<0.001) and WC (β=-0.035±0.011; P=0.008) were inversely related to telomere length (TL). Stratifying by age, high BF1% (-0.061±0.013), BF2% (-0.065±0.01), BMI-obesity (-0.07±0.015) and high WC (-0.048±0.013) were significant (all P<0.001). This association diminished with increasing age. In older participants, TL was inversely related to mortality (hazard ratio 0.36 (0.27, 0.49)), as were those classified by BF1% (0.68 (0.56, 0.81)), BF2% (0.75 (0.65, 0.80)), BMI (0.50 (0.42, 0.60)) and WC (0.72 (0.63, 0.83)). No interaction was observed between adiposity status, telomere length and mortality.

CONCLUSIONS

Obesity is associated with shorter telomere length in young participants, a relationship that diminishes with increasing age. It does not moderate the relationship with mortality.

Lipomatous myofibroblastoma of the breast: case report with diagnostic and histogenetic considerations

We report rare case of myofibroblastoma (MFB) of the breast comprised predominantly of a mature fatty component, representing approximately 70% of the entire tumour area. This tumour, designated "lipomatous MFB", should be interpreted as the morphological result of an unbalanced bidirectional differentiation of the precursor mammary stromal cell, with the adipocytic component overwhelming the fibroblastic/myofibroblastic one. Lipomatous MFB is a rare variant of mammary MFB, which can mimic malignancy because of the close juxtaposition of fibroblasts/myofibroblasts with mature adipocytes, resulting in a finger-like infiltrative growth pattern of the former towards the latter. Histogenetic considerations and differential diagnostic problems with other bland-looking spindle cell tumours containing infiltrating fat are provided.

Atypical dermatofibroma with predominant epithelioid/deciduoid-like cell component. Histogenetic considerations in the wide spectrum of fibrohistiocytic dermal tumours

Atypical and epithelioid cell variants of dermatofibroma may represent a potential diagnostic pitfall. Only rarely atypical dermatofibroma may show focal epithelioid cell features. We herein report a rare case of dermatofibroma composed of a predominant (> 90%) epithelioid/deciduoid-like cell component, in which rare multinucleated bizarre cells and atypical mitoses were additional findings. Tumour was classified as "atypical dermatofibroma with predominant epithelioid/deciduoid-like cell component". The coexistence of at least two different variants, i.e. epithelioid and atypical variants, in the same dermatofibroma suggests that dermal fibrohistiocytic tumours belong to a continuous morphological spectrum. Accordingly, the morphological variants of dermatofibroma should be regarded as variations on a common basic theme. Differential diagnosis with other epitheliod cell dermal tumour- and tumour-like lesions is discussed.

Lichen amyloidosis in a dark skinned patient

Lichen amyloidosis is a primary localized cutaneous amyloidosis without systemic involvement, characterized by a persistent pruritic eruption of multiple discrete hyperkeratotic papules. The etiology is unknown, but chronic irritation of the skin has been proposed as an etiological factor. We herein report a typical case of lichen amyloidosis in a dark skinned patient. Physical examination revealed slightly shiny, brownish and fine uniform papules approximately 1 cm in diameter, with no accompanying macular lesions. Biopsy specimens taken from some of these papules on the legs showed small globular deposits of an amorphous and slightly eosinophilic substance in the dermis. This substance stained positively with Congo red, indicating the presence of amyloid. In addition, amyloid gave an apple green birefringence when viewed with polarized light.

Efficacy results from a multicenter phase II noncomparative two-arm pilot trial of bevacizumab with anastrozole or fulvestrant as first-line endocrine therapy for metastatic breast cancer

1091

Background: Estrogen modulates angiogenesis via effects on endothelial cells with subsequent induction of vascular endothelial growth factor (VEGF). VEGF promotes tumor growth and is associated with poor response to antiestrogen therapy. This trial was designed to evaluate the progression-free survival (PFS) of bevacizumab (B) in combination with anastrozole (A) or fulvestrant (F) as first-line endocrine therapy (ET) in metastatic breast cancer (MBC). Methods: Eligibility criteria: no prior hormonal or chemotherapy for MBC, measurable or evaluable disease, normal LVEF, post-menopausal. Treatment: Arm A: anastrozole 1 mg po QD in pts who were a) ET naïve, b) ≥ 12 months from adjuvant ET, and c) intolerant of or progressed on prior tamoxifen. Arm B: fulvestrant 500 mg D1 and 250 mg D15 IM loading dose followed by 250 mg q28 days in pts who were a) < 12 months from adjuvant aromatase inhibitors (AIs), b) intolerant of or progressed on AIs, and c) MD's discretion. Bevacizumab 10 mg/kg IV D1 q2 weeks was given in both arms. Trastuzumab permitted in HER-2+ pts only. Response assessments were q8 weeks; pts were treated until disease progression or toxicity. Results: 79 pts were enrolled fromNovember 2006 to November 2008. 42 pts are evaluable for response and toxicity, Arm A - 25 pts and Arm B - 17 pts. Median age was 64, ECOG PS 0 - 55%, 1- 43 %, adjuvant chemo 27%, adjuvant hormonal -38%, hormone receptor status: ER+/PR+ 80%, ER+/PR- 14%, ER-/PR+ 2 %. HER-2+ 5 pts, 31% had ≥ 2 metastatic disease sites predominately lung and bone only disease - 40%. Median # cycles - 4. 24% achieved a partial response and 57% stable disease; 7 pts progressed. G3 hypertension (12%) was the most common toxicity. Median PFS for Arm A was 16.3 months and has not yet been reached for Arm B. Conclusions: Bevacizumab in combination with anastrozole or fulvestrant is feasible and well tolerated with no unanticipated toxicities. The addition of bevacizumab resulted in prolongation of the median PFS to16.3 months with anastrozole as compared to the 7–9 month historical control PFS reported for first-line AI monotherapy in MBC. Further evaluation of bevacizumab endocrine combinations is warranted.

[Table: see text]

Molecular determinants of insulin resistance, cell apoptosis and lipid accumulation in non-alcoholic steatohepatitis

BACKGROUNDS AND AIMS

Non-alcoholic-steatohepatitis (NASH) is closely related to insulin resistance, but it is unknown whether insulin resistance may be localized in hepatocytes. This study investigates insulin signalling in liver tissue from NASH, and the molecular mechanisms by which insulin-resistance could lead to liver damage (apoptosis). Moreover, to investigate the mechanisms of lipid overload we studied key enzymes in hepatocytes lipid metabolism.

METHODS AND RESULTS

In liver specimens from 11 patients with NASH and 7 histological normal livers, we measured total and phosphorylated Akt (active form), Bax and Bcl-2 by Western-blot analysis. In addition, we studied AMP-activated protein Kinase and Carnitine-Palmitoyl-Transferase-1 gene expression, key regulators of non-esterified fatty acid synthesis and oxidation, by reverse transcription polymerase chain reaction. In NASH, phosphorylated Akt was impaired (104.3+/-10.6 vs 152.6+/-22.4 AU, p<0.002) and correlated with necroinflammatory score (r=-0.62; p<0.05). Bax/Bcl-2 ratio was increased in NASH. Moreover, we observed a decrease of AMP-activated protein Kinase (10.74+/-6 vs 144.7+/-41.6 AU, p<0.0001) and Carnitine-Palmitoyl-Transferase-1 gene expression (38.7+/-14.6 vs 192.1+/-26.2 AU, p<0.0001), and both were correlated with steatosis score (r=-0.56, p<0.05, r=-0.87, p<0.05 respectively).

CONCLUSIONS

Akt, a key molecule of insulin signalling and cell apoptosis is impaired in NASH, suggesting an important role of hepatic insulin resistance in liver failure. Moreover, decreased non-esterified fatty acid oxidation may cause hepatic lipid overload.

Different effects of spinally applied prostaglandin D2 on responses of dorsal horn neurons with knee input in normal rats and in rats with acute knee inflammation

Prostaglandin D2(PGD2) is the most produced prostanoid in the CNS of mammals, and in behavioral experiments it has been implicated in the modulation of spinal nociception. In the present study we addressed the effects of spinal PGD2 on the discharge properties of nociceptive spinal cord neurons with input from the knee joint using extracellular recordings in vivo, both in normal rats and in rats with acute inflammation in the knee joint. Topical application of PGD2 to the spinal cord of normal rats did not influence responses to mechanical stimulation of the knee and ankle joint except at a high dose. Specific agonists at either the prostaglandin D2 receptor 1 (DP1) or the prostaglandin D2 receptor 2 (DP2) receptor had no effect on responses to mechanical stimulation of the normal knee. By contrast, in rats with inflamed knee joints either PGD2 or a DP1 receptor agonist decreased responses to mechanical stimulation of the inflamed knee and the non-inflamed ankle thus reducing established inflammation-evoked spinal hyperexcitability. Vice versa, spinal application of an antagonist at DP1 receptors increased responses to mechanical stimulation of the inflamed knee joint and the non-inflamed ankle joint suggesting that endogenous PGD2 attenuated central sensitization under inflammatory conditions, through activation of DP1 receptors. Spinal application of a DP2 receptor antagonist had no effect. The conclusion that spinal PGD2 attenuates spinal hyperexcitability under inflammatory conditions is further supported by the finding that spinal coapplication of PGD2 with prostaglandin E2 (PGE2) attenuated the PGE2-induced facilitation of responses to mechanical stimulation of the normal joint.

[Mammary hamartoma with atypical stromal cells: a potential diagnostic dilemma]

Hamartoma of the breast is a pseudotumoural lesion that does not usually pose diagnostic problems for the pathologist. Although atypical stromal cell (ASCs) can be encountered in several benign and malignant breast lesions, their occurrence in hamartoma has not been reported to date. The authors report a case of breast hamartoma containing numerous atypical mono- or multinucleated stromal cells within the fibro-fatty component. This unusual feature raised differential diagnostic problems with pleomorphic lipoma, well-differentiated liposarcoma and malignant phylloid tumour with a lipomatous heterologous component. Immunohistochemistry, showing positivity to vimentin and CD34, revealed that ASCs are fibroblastic in nature, and thus are likely to represent a morphological variant of the fibroblasts of the native mammary stroma.

[Carcinoma of the Bellini collecting duct in paediatric patients: a case report and review of the literature]

Collecting duct carcinoma is an uncommon variant of renal cell carcinoma that usually occurs at an earlier age compared to conventional renal cell carcinoma. It is characterised by an aggressive, often fatal, course. Renal cell carcinoma rarely occurs in paediatric patients, and is almost always in association with specific genetic alterations; the most common histotypes are the clear cell and chromophobe cell variants. Collecting duct carcinoma is rare, and only 8 cases have been reported in the literature. The authors describe the clinico-pathological features of a fatal collecting duct carcinoma in an 11-year-old boy.

Experimental study on the toxicity and the local and systemic tolerability of gemcitabine after topical treatment of the rabbit bladder

This study investigated gemcitabine administered intravesically to establish the local and systemic tolerability necessary for clinical trials. Gemcitabine was directly administered via catheter into the bladders of 24 male New Zealand rabbits weighing an average of 1.9+/-0.08 kg. Three groups received weekly gemcitabine for 5 (50 mg/kg) or 8 (25 mg/kg or controls) weeks. Animals were inspected daily for signs of toxicity and distress, body weight changes, and water and food consumption; electrocardiogram, blood pressure, and urinalysis were recorded before dosing and after 4 and 8 weeks of treatment. The rabbits were euthanized, and a full necropsy was performed on day 1 after the last instillation. Principal organs (spleen, thymus, testis, and muscle) and plasma samples were analyzed for the systemic absorption of gemcitabine. The 25-mg/kg dose was well tolerated with no clinical side effects. At 50 mg/kg, signs of mild myelosuppression and severe symptomatic toxicity (leg weakness, and hair and body weight loss) was evident after 3 weeks of treatment and three of the seven animals in this group died after four doses. Necropsies revealed normal bone marrow cellularity and organ histology at both doses. No significant systemic drug absorption was seen. These findings suggest that intravesical administration of gemcitabine does not produce organ-specific toxicity, but the higher dose (50 mg/kg) may represent the threshold above which increasing morbidity may occur.

A sulfonic anhydride derivative from dibenzyl trisulphide with agro-chemical activities

In the present study, the biologically active natural product dibenzyl trisulphide (DTS) which was previously isolated from the sub-tropical shrub Petiveria alliacea was transformed to methyl benzyl sulphonic anhydride (MBSA) using a "one pot" transformation method. The anhydride was evaluated for anti-microbial activities on the bacteria, Bacillus subtilis and Pseudomonas fluorescens and found to be 2.5 fold more effective than the commercial agents isoniazid and ampicillin in inhibiting the growth of B. subtilis, while on P. fluorescens it was 2.5, 5.0 and 10.0 fold more inhibitory than isoniazid, ampicillin and dibenzyl trisulphide, respectively. DTS was inactive on B. subtillis. The MIC value (microgram/spot) found for DTS on the plant pathogenic fungus, Cladosporium cucumerinum was 5.0 microgram/spot, while MBSA gave a value of 0.1 microgram/spot, compared with 1.25 and 0.16 microgram/spot for the commercial agents ketoconazole and nystatin, respectively. On the larval nematode (Meloidogyne incognita) MBSA inflicted 97.72% and 57.47% Abbotts nematicidal activities at 125.0 and 62.5 ppm, respectively, while DTS had no effect at 125.0 ppm. Nematodes which were immobilized by the low concentrations of MBSA were unable to re-activate when exposed to 10.0 ppm picrotoxin, thus suggesting that the anhydride nematicidal activity is independent of the GABA-ergic neurophysiological pathway.MBSA demonstrated a strong dose dependent radicular suppression effect (r=0.984), on the radicles of Latuca sativa germinating seeds. DTS was weakly active.

CD 34 expression in chronic and neoplastic liver diseases

BACKGROUND

Capillarisation of hepatic sinusoids is a well recognized phenomen occurring in long standing liver disease, in hepatic cirrhosis as well as in hepatocellular carcinoma. To study immunohistochemically the expression and distribution of CD34 in chronic liver disease and hepatocellular carcinoma in order to evaluate the possible diagnostic implication of this marker.

METHODS

Sixty-five samples of liver tissue showing normal liver, different degrees of chronic inflammation, cirrhosis and histological features of hepatocellular adenoma and carcinoma (HCC) were included in the study. The specimens were fixed in formalin and embedded in paraffin and an immunohistochemical investigation was performed by the standard avidin-biotin-peroxidase complex method with CD34.

RESULTS

The sinusoids of normal liver showed no immunoreactivity. The sinusoids of liver affected by different degrees of chronic active hepatitis showed no or focal immunostaining for CD34; an increased immunoreactivity was observed in the periportal sinusoids of the cirrhotic nodules whereas diffuse and strong staining was observed in the overall HCC as well as in the hepatocellular adenoma tested.

CONCLUSIONS

In HCC, immunoreactivity for CD34 represents an effective method to evaluate angiogenesis and to distinguish well-differentiated HCC from non-neoplastic liver. Its role in clinical stage and prognostic evaluation needs further investigation.

[Uterus in a male: persistent Mullerian duct syndrome. Report of a case with embryological considerations]

We describe a case of persistent mullerian duct syndrome incidentally found in a 79-year-old man. It was characterized by the presence of a uterus-like retroperitoneal mass composed of an ovoidal corpus and rudimental portio with a central lumen. Histologically the mass was leiomyomatous in nature, closely resembling myometrium, while the central lumen was lined by a monolayer of ciliated cuboidal to columnar epithelium similar to embryo-fetal celomatic epithelium. Although this is a dysembryogenetic syndrome due to the lack of regression of the mullerian duct, it may be incidentally discovered in elderly patients, as in the present case during hernioplastic surgery. We also briefly discuss the regression of mullerian duct, focusing on morphological features observed in a large collection of human embryos and fetuses, in order to better understand the pathogenesis of a "uterus' in a male without evidence of sexual abnormalities.

Spinal prostaglandins are involved in the development but not the maintenance of inflammation-induced spinal hyperexcitability

Prostaglandins (PGs) are local mediators of several functions in the CNS. Both primary afferent neurons and intrinsic cells in the spinal cord produce PGs, with a marked upregulation during peripheral inflammation. Therefore, the significance of spinal PGs in the neuronal processing of mechanosensory information was herein investigated. In anesthetized rats, the discharges of spinal nociceptive neurons with input from the knee joint were extracellularly recorded. Topical administration of prostaglandin E(2) (PGE(2)) to the spinal cord facilitated the discharges and expanded the receptive field of dorsal horn neurons to innocuous and noxious pressure applied to the knee joint, the ankle, and the paw, thus mimicking inflammation-induced central sensitization. Conversely, topical administration of the PG synthesis inhibitor indomethacin to the spinal cord before and during development of knee joint inflammation attenuated the generation of inflammation-induced spinal neuronal hyperexcitability. However, after development of inflammation, the responses of spinal neurons to mechanical stimuli were only reduced by systemic indomethacin but not by indomethacin applied to the spinal cord. Thus, spinal PG synthesis is important for the induction and initial expression but not for the maintenance of spinal cord hyperexcitability. Spinal PGE(2) application facilitated dorsal horn neuronal firing elicited by ionophoretic delivery of NMDA, suggesting that an interaction of PGs and NMDA receptors may contribute to inflammation-induced central sensitization. However, after development of inflammation, spinal indomethacin failed to reduce responses to ionophoretic delivery of NMDA or AMPA, suggesting that such an interaction is not required for the maintenance of central sensitization.

Nurse practitioners and parent education: a partnership for health

PURPOSE

To present the findings from a pilot-test of an innovative curriculum for parent education classes that included information about well child care and the care of sick children presented to substance abusing women at a residential drug treatment facility.

DATA SOURCES

Selected literature and the results of a comparison of pre- and post-tests from the 37 women who received the classes over a 6 week period.

CONCLUSIONS

The Healthy Children, Happy Children parent education program was successful overall in increasing the knowledge of the mothers about common skin disorders, care of infants, toddlers, and preschoolers, and basic first aid.

IMPLICATIONS FOR PRACTICE

Nurse practitioners (NPs) are well suited to teach parent education classes that contain information on growth and development, well child care and diagnosis and management of acute minor conditions. The Healthy Children, Happy Children curriculum can be adapted to a variety of settings and populations.

Comparative immunohistochemical analysis of the expression of cytokeratins, vimentin and alpha-smooth muscle actin in human foetal mesonephros and metanephros

The human mesonephros is currently regarded as a simplified version of the foetal metanephros, primarily due to the close morphological resemblance between these two structures. The aim of the present study was to define whether human mesonephric and foetal metanephric nephrons share immunophenotypical traits in their corresponding structures (glomeruli, proximal and distal tubules). For this purpose we first investigated immunohistochemically the overall expression and topographical distribution of cytokeratins 7, 8, 18, 19, and 20, vimentin and alpha-smooth muscle actin in mature mesonephric nephrons and compared the results with those obtained in maturing-stage foetal metanephric nephrons. No expression of cytokeratins 7 and 20 was found. Cytokeratins 8, 18, and 19 and vimentin showed a restricted and basically coincident expression along the different components of both mesonephric and metanephric nephrons. These findings indicate that the intermediate filament protein profile of human mature mesonephric nephrons closely recapitulates that observed in developing metanephros and thereby strengthens the concept that human mesonephros, a transient ontogenic structure, is largely similar to the foetal metanephros. The sole difference between human mesonephros and foetal metanephros was the divergent expression of alpha-smooth muscle actin. This protein exhibited an increasingly accentuated mesangial expression paralleling the morphological maturation of metanephric glomerulus, whereas it was absent from the mesonephric one. This would suggest that the mesangial cells in these two renal structures have a different function during the foetal life.

Clotrimazole increases tacrolimus blood levels: a drug interaction in kidney transplant patients

In order to substantiate a previous case report of a drug interaction between tacrolimus and clotrimazole, we randomly assigned tacrolimus-treated renal allograft recipients to therapy with either clotrimazole or nystatin for oral thrush prophylaxis immediately following transplantation. Patients receiving other agents known to interact with cytochrome P450 were excluded from the study. The clotrimazole group consisted of 17 patients and the nystatin group, which served as the control group, consisted of 18 patients. An oral loading dose (approximately 0.3 mg/kg) of tacrolimus was given pre-operatively. Post-transplant, tacrolimus (approximately 0.15 mg/kg) was orally administered twice daily. Clotrimazole therapy consisted of a 10-mg troche administered three times daily. Nystatin therapy consisted of the oral suspension (5 mL) administered as a 'swish and swallow' four times daily. We evaluated tacrolimus trough blood levels and tacrolimus doses on days 1, 3, 5, and 7 following transplantation. On post-transplant day 1, mean tacrolimus trough levels did not differ between clotrimazole- and nystatin-treated patients. Mean tacrolimus blood trough levels were significantly higher in clotrimazole-treated patients on days 3, 5, and 7 post-transplant, 42+/-14, 53+/-7, and 33+/-17 ng/mL, respectively, compared to 15+/-8, 15+/-7, and 14+/-6 ng/mL in nystatin-treated patients (p<0.05). The mean tacrolimus dose was significantly lower in the clotrimazole group by day 7 post-transplant (p<0.05). We conclude that clotrimazole therapy may cause a significant rise in tacrolimus trough blood levels. Recognition of this potential drug interaction is essential to minimize tacrolimus-associated toxicities in the early post-transplant period.

Postcardiotomy delirium: an overview

Any one of a number of psychologic patterns may appear cardiotomy: (1) Some patients may be elated and confident after awakening from anesthesis and have no severe changes of affect or neurologic deficit. Denial seems to be for them an adequate defense against anxiety. (2) Others are disoriented and manifest neurologic disturbance immediately after awakening, without a lucid interval. The sensorium begins to clear five days after surgery. (3) Some patients go into delirium after being lucid for as long as a week and have hallucinations, illusions, and motor excitation for a few days-or over several weeks. Pathologic brain changes that are apparently anatomical correlates of neurologic deficits in delirium include anoxic lesions of the hippocampus, and infarcted foci. Physiologic factors that contribute to this reaction include: long periods of extracorporeal circulation, arterial hypotension during surgery, emboli, and low postoperative cardiac output. Age, and the type and severity of heart impairment are also factors. Psychologic factors to be taken into account include preexisting psychopathology and the failure of denial under the stress of physical symptoms or hospitalization. Delirium is fostered by sensory overload (or deprivation) in the recovery room and intensive care unit, and by staff tension. Modification of the intensive care unit environment, the administration of antipsychotic drugs, and metabolic correctives are recommended. Preoperative psychologic evaluation, with therapy as needed, preliminary familiarization with perioperative procedures, as well as collaboration between psychiatrist and surgeon, can do much to prevent post-cardiotomy delirium.

Isoterchebulin and 4,6-O-isoterchebuloyl-D-glucose, novel hydrolyzable tannins from Terminalia macroptera

Two new hydrolyzable tannins, isoterchebulin (1) and 4,6-O-isoterchebuloyl-D-glucose (2), together with six known tannins, 3-8, were isolated from the bark of Terminalia macroptera. Their structures were elucidated by extensive 1D and 2D NMR studies, MS, and chemical transformations. Biological activities of all compounds were evaluated against the snail Biomphalaria glabrata, the bacteria Bacillus subtilis and Pseudomonas fluorescens, the nematode Caenorhabditis elegans, and four cancer cell lines (Hep G2, MCF-7/S, MDA-MB-231, and 5637 cells). All compounds except 3 showed antimicrobial activities against B. subtilis (MIC 8-64 microg/mL), whereas only 1 was active against C. elegans (100 microg/mL) and B. glabrata(LC(100) = 60 microg/mL). 3 and 8 were toxic against 5637 cells with LC(50) = 84.66 and 41.40 microM, respectively.

Lipomatous myofibroblastoma: a potential diagnostic pitfall in the spectrum of the spindle cell lesions of the breast

We report on two cases of myofibroblastoma (MFB) of the breast comprised predominantly of a mature fatty component, representing approximately three quarters of the entire tumour area. Both tumours consisted of a well-circumscribed lipomatous tumour mass containing dispersed nodular or irregularly shaped spindled cellular areas. The fatty component was represented exclusively by mature adipocytes, uniform in size and shape, lacking nuclear pleomorphism. The cellular areas contained spindly to oval cells with morphological and immunophenotypical features typical of MFB. The two components were so intimately admixed that a finger-like infiltrating growth pattern was apparent. The cases reported here as "lipomatous MFB" aim to clarify further the morphological spectrum of MFB of the breast. Lipomatous MFB may potentially mimic other benign or aggressive tumour-like lesions or even bland-looking malignant spindle cell tumours such as fibromatosis, nodular fasciitis, spindle cell lipoma, spindle cell liposarcoma, spindle cell variant of metaplastic carcinoma, spindle cell malignant myoepithelioma, and low-grade fibrosarcoma/malignant fibrous histiocytoma. The histogenesis of the present bimorphic mesenchymal tumours could be explained as the result of a dual, myofibroblastic and lipomatous, differentiation from a common pluripotential mesenchymal precursor cell, probably represented by the vimentin+/CD34+ fibroblast of the mammary stroma.

The antinociceptive effect of PAG-microinjected dipyrone in rats is mediated by endogenous opioids of the rostral ventromedical medulla

Microinjection of non-opioid analgesics, such as dipyrone (DIP), into the periaqueductal gray matter (PAG) in rats causes an inhibition of nociceptive circuits in the spinal cord. We have herein investigated whether this effect is mediated by opioidergic mechanisms in the rostral ventromedial medulla (RVM), which is an important relay between the PAG and the spinal cord. The responses of spinal wide-dynamic-range neurons to noxious stimulation of their receptive field (RF) were inhibited by microinjection of DIP (100 microg/0.5 microl) into PAG. Subsequent microinjection of naloxone (NAL; 0.5 microg/0.5 microl) into RVM reversed this inhibition. The present and previous results suggest that non-opioid analgesics, as well as opiates, inhibit nociception by activating descending opioidergic mechanisms in PAG and RVM.

Epithelial inclusion in axillary lymph node associated with a breast carcinoma: report of a case with a review of the literature

Since epithelial inclusions in axillary lymph nodes are rare, some diagnostic problems concerning their nature have arisen. We report a case of a cystic squamous epithelial inclusion in an axillary lymph node of a patient affected by a high grade breast carcinoma with focal squamous differentiation. Although the lesion was histologically benign, the possibility that it represents a well-differentiated squamous metastasis cannot be completely ruled out. To our knowledge, this is the first case of an epithelial lymph node inclusion associated with a breast carcinoma showing morphological evidence of squamous differentiation. Here, we discuss the diagnostic problems and give a review of the literature.

Gastric carcinoma with ovarian metastases in an adolescent

Gastric carcinoma represents only 0.05% of malignant paediatric gastrointestinal tumours. This condition is associated with a poor prognosis because its rarity and non-specificity of the symptoms usually delay its diagnosis. The authors present a 16-year-old girl with a poorly differentiated gastric carcinoma (signet-ring-cell type) with bilateral ovarian metastases who died of peritoneal carcinomatosis despite extensive surgery and chemotherapy. The epidemiological, clinical, and pathological features of gastric carcinoma in childhood are discussed.

Metanephric adenoma of the kidney: histologic, immunohistochemical and DNA content analysis study. A case report

Metanephric adenoma is an uncommon and distinct clinicopathologic entity, recently described among benign epithelial kidney tumors. The authors report a case of a metanephric adenoma in a 70-year-old man. Because of its benign clinical course, it is important to distinguish metanephric adenoma from renal cell carcinomas and adult Wilms' tumor for which it is usually mistaken. Clinical, pathologic features and diagnostic problems of the case are discussed.

Safety and tolerability of cyclosporine microemulsion versus cyclosporine: two-year data in primary renal allograft recipients: a report of the Neoral Study Group

BACKGROUND

The new microemulsion formulation of cyclosporine (CsA-ME) is more bioavailable than cyclosporine (CsA) in de novo renal transplant patients. Therefore, it was of interest to compare the safety profile of each formulation in such patients.

METHODS

In a multicenter, double-blind, parallel-group study, 101 renal transplant recipients were randomized after transplantation to receive either CsA (n=50) or CsA-ME (n=51) capsules twice daily for 2 years. Of these patients, 54 (CsA, n=26; CsA-ME, n=28) completed 1 year of the study and entered the second-year, double-blind extension. Initial dose at the time of transplantation was 5 mg/kg b.i.d.; doses were titrated to target trough levels.

METHODS

The mean (+/- SD) doses at the end of 2 years were 4.6 +/- 1.8 and 3.8 +/- 1.1 mg/kg per day for CsA- and CsA-ME-treated patients, respectively. The mean (+/- SD) CsA trough levels at end point were 187 +/- 63 and 210 +/- 95 ng/ml for CsA- and CsA-ME-treated patients, respectively. At least one adverse event was reported by 25/26 (96%) of CsA- and 27/28 (96%) of CsA-ME-treated patients. No patient discontinued the study because of adverse events. No deaths occurred during the study. Renal function, as measured by serum creatinine levels, and blood pressure were comparable over time in both treatment groups.

CONCLUSIONS

There was no significant difference in safety and tolerability between CsA- and CsA-ME-treated kidney recipients for 2 years after transplantation.

The safety and tolerability of cyclosporine emulsion versus cyclosporine in a randomized, double-blind comparison in primary renal allograft recipients. The Neoral Study Group

A 12-week, randomized, double-blind, multicenter pharmacokinetics study was conducted to compare the clinical safety and tolerability of cyclosporine capsules and oral solution for microemulsion and cyclosporine in 101 primary renal transplant recipients Cyclosporine emulsion has more complete absorption and improved bioavailability compared with cyclosporine, and dosing of both cyclosporine formulations was adjusted to achieve comparable whole-blood trough levels. Mean serum creatinine values were higher in the cyclosporine emulsion group at baseline, 8, and 12 weeks (P<0.05). The incidence of acute rejection was similar in both treatment groups although fewer patients required monoclonal antibody therapy in the cyclosporine group (31% vs. 82%, respectively). Despite the increased bioavailability of cyclosporine emulsion, no significant differences in the incidence of adverse events were observed; the safety, tolerability, and efficacy of cyclosporine emulsion and cyclosporine were comparable.

The pharmacokinetics of a microemulsion formulation of cyclosporine in primary renal allograft recipients. The Neoral Study Group

This study was a randomized, double-blind, 12-week comparison of the pharmacokinetics, safety, and tolerability of two cyclosporine (CsA) formulations, cyclosporine emulsion capsules and oral solution for microemulsion and cyclosporine, in the postoperative management of renal transplant patients. Of the 101 patients, aged 18 to 65, who entered the study, 89 were evaluable for pharmacokinetics. Initial dosage was 10 mg/kg per day, administered twice daily in two equal doses. Dosages were adjusted to achieve target CsA concentrations. The pharmacokinetic (PK) parameters (dose-normalized) of greatest interest were maximum blood concentration (C(max)/dose), time to reach maximum concentration (t(max), area under the blood concentration-vs.-time curve (AUC/dose), and trough blood concentrations (Co h/dose). The relative CsA bioavailabilty was found to be significantly enhanced with cyclosporine emulsion compared with cyclosporine with a 16% to 31% increase in AUC and a 32% to 42% increase in C(max). Intrapatient variability of PK parameters was significantly lower with cyclosporine emulsion than with cyclosporine for AUC, C(oh), t(max), and C(max) in many instances. This indicates a more consistent, rapid, and more complete total absorption of CsA. Despite higher CsA C(max) levels and AUCs with cyclosporine emulsion, safety and tolerability (detailed in a parallel report) were comparable to those of cyclosporine. The PK advantages of cyclosporine emulsion over cyclosporine are either independent of food conditions or possibly reflective of more consistent absorption of CsA with cyclosporine emulsion. The findings suggest that de novo use of cyclosporine emulsion may simplify and improve management of organ transplant recipients and that the PK advantages of cyclosporine emulsion may translate into clinical benefits.

Aneurysmal bone cyst of the acromion: a case report

The case of 6-year-old girl with an asymptomatic aneurysmal bone cyst of the acromion is reported. Such tumors are rarely located in the scapula and are especially rare in the acromion. The diagnosis was confirmed by biopsy and surgical resection of the lesion. Roentgenographic, CT and histologic features of the cyst are discussed.

Creating paths: living with a very-low-birth-weight infant

OBJECTIVE

To describe parents' method of adaptation to the problems of caring for a very-low-birth-weight (VLBW) infant at home.

DESIGN

Exploratory, involving three interview sessions, 1 month, 3 months, and 5 months after hospital discharge of a VLBW infant.

SETTING

A newborn intensive-care unit in a tertiary-care center.

PARTICIPANTS

Fourteen parents of VLBW (< 1,500 g) infants after hospital discharge.

RESULTS

A basic social process, Creating Paths, was identified. It is the continuous process experienced by parents living with a VLBW infant the first 5 months after hospital discharge. The process consists of three stages: gathering, emerging, and affirming.

CONCLUSIONS

This grounded theory systematically tracks and describes the adaptation process of parents with VLBW infants during the first 5 months of living at home. The theory may be used to anticipate concerns and provide guidance and support to parents and their infants.

Effect of enteral feeding temperature on feeding tolerance in preterm infants

Thirty preterm infants were randomly assigned to one of three milk temperature groups: 37 degrees C, 24 degrees C, and 10 degrees C. Infants were fed by gavage every two hours, and gastric residuals were measured immediately prior to the next feeding. Feeding tolerance was determined by dividing the volume of gastric residual by the total volume of the feeding. Abdominal and axillary skin temperatures were monitored half-hourly. Tolerance differed significantly among the three milk temperature groups, using ANCOVA, F(2, 26) = 41.06, p < .01, accounting for 75 percent of variance shared. Post hoc Scheffe's procedure on adjusted means indicated that the infants fed the warmer milk (BT group) had significantly smaller gastric residuals (6 percent) than those fed the colder milk (RT group, 22 percent and CT group, 18 percent). No significant differences in body temperature for any of the three milk temperature groups were found. Warming milk to body temperature may promote greater feeding tolerance in the VLBW infant (< or = 1,500 gm). Results from this study provide objective data that will help nurses provide optimal nutrition to preterm infants.

Cholera in Piura, Peru: a modern urban epidemic

In late January 1991, epidemic cholera appeared in Peru. Within 2 months, 7922 cases and 17 deaths occurred in Piura, a Peruvian city of 361,868. A hospital-based culture survey showed that 79%-86% of diarrhea cases were cholera. High vibriocidal antibody titers were detected in 34% of the asymptomatic population. A study of 50 case-patients and 100 matched controls demonstrated that cholera was associated with drinking unboiled water (odds ratio [OR], 3.9; 95% confidence interval [CI], 1.7-8.9), drinking beverages from street vendors (OR, 14.6; CI, 4.2-51.2), and eating food from street vendors (OR, 24.0; CI, 3.0-191). In a second study, patients were more likely than controls to consume beverages with ice (OR, 4.0; CI, 1.1-18.3). Ice was produced from municipal water. Municipal water samples revealed no or insufficient chlorination, and fecal coliform bacteria were detected in samples from 6 of 10 wells tested. With epidemic cholera spreading throughout Latin America, these findings emphasize the importance of safe municipal drinking water.

[The effect of Lactobacillus acidophilus and Bifidobacterium bifidum on the intestinal ecosystem of the elderly patient]

The authors have tested the therapeutic efficacy of a multibacterial combination consisting of Lactobacillus acidophilus (10(9)) and Bifidobacterium bifidum (10(9)) in elderly patients with bowel disorders. Bacteriological and histopathologic investigation showed this combination to yield excellent biologic results with restoration of duodenal bacterial flora and subsidence of clinical symptoms. The function of the muciparous glands was restored and the duodenal mucosa was normalized.