Precision Oncology in Melanoma and Skin Cancer Surgery

There has been perhaps no greater advance in the prognosis of solid tumors in the last decade than for patients with metastatic melanoma. This is due to significant improvements in treatment based on two key components of melanoma tumor biology (1) the identification of driver mutations with therapeutic potential and (2) the mechanistic understanding of a tumor-specific immune response. With breakthrough findings in such a relatively short period of time, the treatment of patients with metastatic melanoma has become intensely personalized.

Intellectual capacity of subjects exposed to methimazole or propylthiouracil in utero

Antithyroid drugs, considered the treatment of choice for hyperthyroidism during pregnancy, may have an adverse effect on intellectual development of the offspring. We examined the intellectual capacity of 31 subjects aged 4-23 years, born to women with Graves disease who received antithyroid drugs throughout pregnancy. Methimazole 40-140 mg/week (n = 15) or propylthiouracil 250-1400 mg/week (n = 16) was given. I.Q. was assessed using the Wechsler test appropriate for age. Twenty-five unexposed siblings served as controls. The exposed and unexposed groups did not differ with respect to the total I.Q. Both groups scored equally in verbal and performance skills and in each of six main subcategories of the tests. There was no difference between exposure to methimazole and propylthiouracil or between the higher (greater than 40 mg/week and greater than 600 mg/week, respectively) and lower dosages. All children were euthyroid at birth and none had goitre. We conclude that exposure to methimazole or propylthiouracil during pregnancy in doses sufficient to control maternal hyperthyroidism does not pose any threat to intellectual capacity of the offspring.

The determination of the central static visual acuity

In identical experimental situations we tested 22 adults with our proposed Landolt C wall-chart and the so-called TNO Landolt-C chart. Contrary to theoretical expectations, it appeared that there was only a slight difference in the measured visual acuities. Further study will show whether this is an incidental or a structural occurrence.

Metabolic studies in a patient with idiopathic hypophosphatemic osteomalacia

Studies were conducted in a patient with idiopathic hypophosphatemic osteomalacia to delineate the roles of parathyroid hormone (PTH), vitamin D and renal tubular function. A 43-year-old woman presented with progressive skeletal pains resulting in severe incapacity. Workup revealed: hypophosphatemia with a low tubular maximal phosphate reabsorption per glomerular filtrate (TmP/GFR) of 1.05 mg/dl, normocalcemia, hypocalciuria, elevated alkaline phosphatase and glycinuria. PTH and urinary cyclic AMP (UcAMP) were normal, while calcitriol was low. Renal tubular acidosis or other transport defects were not present and no tumor was found. Biopsy was diagnostic for osteomalacia, and the patient responded to 1-alpha OHD3 and phosphate therapy. Hyperparathyroidism was ruled out by 1) normocalcemia persisting after 1-alpha OHD3 and calcium loading and 2) normal PTH and UcAMP challenged by phosphate supplements. Combined calcium and 1-alpha OHD3 administration resulted in hypercalciuria, decreased UcAMP and increased, but not corrected, TmP/GFR. These findings suggest that the osteomalacia was due to hypophosphatemia caused by a renal leak. PTH is only contributory to the phosphaturia. Low calcitriol level contributes to the osteomalacia directly and indirectly through impaired mineral absorption and, therefore, is also responsible for the hypocalciuria.

Cytotoxic T lymphocytes and natural killer cell activity in the course of mengo virus infection of mice

Inbred C57BL/6 mice were inoculated intraperitoneally (i.p.) with mengo virus. The activity of cytotoxic T lymphocytes (CTL) and natural killer (NK) cells were measured during the first 22 days following infection. The CTL response began 7 days after virus inoculation, persisted for at least 22 days and was related to the dose of the virus inoculated. NK cell activity was elevated within 24 hr, reached its peak level on the fourth day and declined to normal levels on the eleventh day after exposure to the virus. These results suggest that NK cells represent the first cellular immune response to restrict mengo virus spread while specific CTL appear later and are probably responsible for further restriction, elimination and prevention of the viral disease.

Mechanism of warfarin potentiation by amiodarone: dose--and concentration--dependent inhibition of warfarin elimination

Potentiation of the anticoagulant-effect of warfarin by amiodarone was studied in 30 patients. Thirteen received both drugs concurrently, and 17 received warfarin alone and the combination sequentially. Warfarin doses were adjusted to maintain the prothrombin time between 25-30% of control and its kinetics were compared to those in 20 control patients who received warfarin alone. Potentiation occurred in 28/30 patients, presenting as a 35%-65% reduction in the required dose of warfarin, and was correlated with the dose of amiodarone (r = 0.77, p less than 0.01). The free warfarin fraction was not affected by amiodarone (1.8% vs 1.6% in the controls). Warfarin clearance was lower in amiodarone-treated patients than in the controls (1.4 vs 3.1 ml/min, p less than 0.01) with similar plasma concentrations (1.5 vs 1.2 micrograms/ml) despite administration of lower doses (23.3 vs 39 mg/week respectively). The amiodarone concentration was significantly correlated with the warfarin concentrations independent of the effect of amiodarone on the dose of warfarin. Amiodarone hat no effect on prothrombin other than through its actions on the dose and plasma concentration of warfarin. The mechanism of the amiodarone-warfarin interaction is pharmacokinetic through dose - and concentration - dependent inhibition of warfarin elimination.

Spinal epidural abscess: an unusual complication of bacterial endocarditis

We are reporting a case of epidural abscess complicating bacterial endocarditis. To the best of our knowledge, this association has not been reported before. Streptococcus sanguis was isolated from the blood. A full recovery followed surgery and antibiotic therapy. The relevant characteristics of both diseases are reviewed. No explanation for this rare association is available as yet.

Fluid migration through the tail of the Dalkon shield intrauterine device

X-ray radiographs were used to monitor the migration of Renouve -dip radiopaque tracer through the multifilament tail of Dalkon Shield intrauterine devices (IUDs). The movement of the tracer was more rapid and migrated a greater distance through the long end of the tail than through the short end of the tail. The double knot serves as at least a temporary barrier to the migration of tracer from the long end of the tail, but this barrier was circumvented when drops of Renouve -dip radiotracer were placed at both ends of the tail. Migration of Renouve -dip radiotracer was prevented when the end of the Dalkon Shield tail was fused by heating. No migration of this tracer occurred on the tails of commonly used IUDs which possessed monofilament tails, thus demonstrating that fluid migration occurs within and not on the surface of the multifilament tail.

An unusual case of empyema; intrapleural migration of an inhaled oat head in an adult

We report an unusual case of unnoticed aspiration of an oat head by a healthy 19-year-old male. The foreign body migrated to the right pleural cavity and caused a severe persistent empyema, which resolved only after a thoracotomy . The lodging of a grass head in the pleura is a very rare event, almost never reported in an adult.

Freeze fracture morphology of the tight junctions of the eccrine sweat gland from patients with cystic fibrosis

The resorption of Na+ and Cl- across the duct of the human eccrine sweat gland is markedly decreased in individuals with cystic fibrosis (CF). Conceivably, a defective transcellular ion transport mechanism or an increased paracellular backflux of ions could account for the abnormal salt resorption in the sweat gland duct and other organs affected in CF. Tight junctions are thought to regulate paracellular ion flow. Specifically, the number of junctional elements observed by freeze fracture are believed to correspond with the extent of paracellular transport. We compared the freeze fracture morphology of tight junctions of eccrine sweat glands taken from 11 control and seven CF patients. In an attempt to "fingerprint" the junctions morphometrically, the following parameters were measured: the number of strands, the depth of the junction from the apical to the basal strand, the angle of intersection between strands, and the mean distance along a strand between intersections with two other strands. No significant difference was observed between control and CF sweat glands in the freeze fracture morphology of the tight junctions of the duct, the segment where the net reabsorption of Na+ and Cl- is abnormally decreased in CF. Significant changes were observed, however, in the means of the number of strands, the depth, and the distance between intersections for the tight junctions of the intercellular canaliculus of the secretory coil, which appears to function normally in CF.

Anti-thyroid drugs and lymphocyte function. I. The in vitro effect on blastogenesis and suppressor cell activity

The in vitro effect of the anti-thyroid drugs (ATD), propylthiouracil (PTU) and methimazole (MMI) on blastogenesis of peripheral blood mononuclear cells (PBMC) from healthy subjects was studied in 72 hr PHA stimulated cultures. PTU in therapeutic concentrations (10 micrograms/ml) suppressed blastogenesis only when added at the last 18 hr of culture, while at 100 micrograms/ml significant suppression (25%) was recorded also for PTU present throughout culture. PTU had no cytotoxic effect on Raji cells as tested by 51Cr release assay and 3H-thymidine incorporation. Moreover, strong and irreversible suppression (33%) was induced in resting PBMC on 1 hr pre-incubation with PTU. These findings and the fact that suppression was recorded only in cultures exposed to suboptimal concentration of PHA (0.5 micrograms/ml) speak against a direct anti-metabolic effect. MMI in therapeutic concentration (1 microgram/ml) and tri-iodothyronine (T3) in pharmacological concentration (10(-7)M) were much less active. Suppression of blastogenesis by PTU appeared to be mediated through suppressor cell enhancement as indicated by: (a) the augmented blastogenesis following 24 hr pre-incubation, commonly ascribed to suppressor cell depletion, was blunted by pre-incubation with PTU; (b) mixing PTU pre-treated with untreated cells reduced the expected response to PHA and (c) PTU pre-incubated, mitomycin treated cells suppressed blastogenesis of autologous or allogeneic responder cells.

Anti-thyroid drugs and lymphocyte function. II. The in vivo effect on blastogenesis and suppressor cell activity in Graves' disease

The proliferative response (PR) of T lymphocytes in PHA stimulated cultures (5 μg/ml and 0·5 μg/ml; 72 hr) was used to assess the suppressive capabilities of peripheral blood mononuclear cells (PBMC) in the thyrotoxic phase of Graves' disease and their possible modification by propylthiouracil (PTU) and methimazole (MMI) treatment. Graves' patients had 50% higher PR than controls. Treatment with PTU (n=6) for 9·5 weeks (mean) or MMI (n=6) for 18 weeks (mean) resulted in continuous decrease in PR, starting after 3 weeks and down to control values and plateau at 7-10 weeks. This decrease correlated with the decline in plasma thyroxine (T4) levels which had already dropped by 3 weeks. Grouped according to thyroid functional state PR was significantly decreased only in the euthyroid state. Suppressor cell function, expressed as suppressor removal index (PR of PBMC pre-incubated for 24 hr/PR of fresh PBMC), was significantly lower in Graves' patients compared to controls and reached above normal values under PTU treatment: 0·98±0·16, 1·39±0·09 and 1·94±0·19 (mean±s.e.m.) respectively. A direct suppressive effect of PTU in culture, observed in normal subjects, did not exist in untreated patients and evolved under MMI treatment to above normal levels. The cell-mediated PTU effect, exercised by PBMC pre-incubated with PTU on autologous cells pre-incubated in medium alone, increased under PTU treatment to above normal levels. Both this cell-mediated suppressive effect and augmented PR of pre-incubated cells were already significantly increased after 3 weeks of PTU treatment, when all patients were still thyrotoxic. We conclude therefore that PBMC of patients in the untreated, thyrotoxic phase of Graves' disease are deficient in an active cell-mediated suppressive function, a deficiency corrected—with compensatory overshoot—during anti-thyroid drug treatment.

Effects of malaria (Plasmodium berghei) on the maternal-fetal relationship in mice

Plasmodium berghei infection was more severe in pregnant than in nonpregnant mice. Infection initiated on gestation day 7 resulted in rapidly increasing parasitemia and deaths of all pregnant mice within 12 days, while some nonpregnant mice survived until day 21 postinfection. When mice were infected on gestation day 12 or 14, a proportion of mice died before parturition; but some animals survived to deliver living pups. Reduced birthweights and increased spleen weight to body weight ratios were seen in pups from infected mice as compared with pups from uninfected animals. Histopathological abnormalities of placentae from infected animals included degeneration of the normal labyrinthine architecture and thickening of the trophoblast separating maternal and fetal blood vessels.

Propylthiouracil-induced hepatic damage

Two cases of propylthiouracil-induced liver damage have been observed. The first case is of an acute type of damage, proven by rechallenge; the second presents a clinical and histologic picture resembling chronic active hepatitis, with spontaneous remission.

Yersinia enterocolitica antibodies in thyroid disorders

Yersinia enterocolitica agglutinating antibodies were present in 42% of 36 patients with thyroid disease and in none of 77 control subjects. Since the frequency of Yersinia infections in Israel is low, the association of thyroid diseases with Yersinia antibodies is of particular interest. The significance of this finding is discussed in view of some recent observations.

Bacterial and fungal meningitis in adults: a 22-year survey in a large community hospital in Israel

The etiologic, bacteriological, clinical and therapeutic aspects of 95 cases of bacterial or fungal meningitis in adults seen in a large community hospital were reviewed. The study was limited to non-neurosurgical patients in whom positive cerebrospinal fluid cultures were obtained. Overall mortality was 40%, with no appreciable change during the 22-year period. The most common causative organism was the pneumococcus, with a 45% mortality. There were no deaths among the patients with meningococcal meningitis. Cryptococcus neoformans was the third most common single organism encountered. Meningitis due to uncommon organisms usually developed in debilitated or immunologically compromised patients, and had a poor prognosis. Advanced age, underlying debilitating disease and severly impaired consciousness on admission were associated with a high mortality. Bacterial and fungal meningitis in adults remains a serious life-threatening disease, despite advances in antibiotic therapy.

Myo-inositol clearance in renal failure and in patients with normal kidney function

In order to determine the mechanism of elevated serum inositol in renal failure, the clearance values of inositol and of creatinine were measured in patients with normal kidney function and in those whose renal function was impaired due to varying causes. Mean serum inositol level in controls was 5.6 microgram/ml, and in patients with renal failure 28.6 microgram/ml. In control patients, inositol clearance was 2.8 ml/min, and tubular reabsorption of inositol was found to be over 97 percent. The inositol clearance of patients in renal failure varied from 0.62 to 17 ml/min. The ratio inositol clearance/creatinine clearance was elevated in uremic patients. Total amounts of inositol excreted in the urine of uremic patients were consistently higher than those excreted by control patients. The elevated serum inositol levels seen in renal failure were therefore not primarily caused by inability of the diseased kidney to excrete inositol.

Morphology of a naphthalene-induced bronchiolar lesion

Nonciliated bronchiolar epithelial (Clara) cells are selectively damaged by intraperitoneal administration of naphthalene. We examined these changes using light microscopy, transmission electron microscopy, and scanning electron microscopy. Naphthalene administration causes the Clara cells to expand and exfoliated shortly thereafter. Following exfoliation the remaining ciliated cells show morphologic abnormalities, including cilia loss and ballooning of remaining cilia. Upon regeneration of the Clara cells the ciliated cells gradually return to their normal appearance. One possible explanation for these findings is that the Clara cell secretions directly affect the physiologic state of the surrounding ciliated cells.

Evidence for an active immune response in acute hyperthyroidism (Graves' disease)

Activated lymphocytes, identified by an autoradiographic labeling method, were found to be present in the peripheral blood of the majority of 20 patients with acute hyperthyroidism (Graves' disease). The number of such cells in the blood was significantly greater than that found in 30 healthy controls (p less than 0.00001), and in 13 patients who had previously suffered from acute hyperthyroidism, and who were judged to be euthyroid following therapy (p less than 0.025). This latter group included two patients in whom such activated lymphocytes had been found in the blood during the acute phase of their illness. Furthermore, there were significant differences between the number of such activated circulating lymphocytes in the group of patients with acute hyperthyroidism and five patients suffering from hyperthyroidism due to a toxic thyroid nodule (p less than 0.001), five patients suffering from primary myxedema (p less than 0.001), or in 14 patients with a nontoxic multinodular goiter (p less than 0.05). Identification and counting of circulating T and B lymphocytes by fluorescent immunolabeling and rosette-forming techniques in a small number of the patients with acute hyperthyroidism failed to reveal significant differences from the normal. The results suggest that in acute hyperthyroidism there is active stimulation of the cellular immune system, and that this effect is specific to the early, untreated phase of the disease. This response is different to other thyroid diseases, including hyperthyroidism due to a toxic thyroid nodule.

A simple electrode for metallic replication

A simple resistive heating electrode has been designed for use in metallic replication procedures. The electrodes are relatively small, reliable, adaptable to most vacuum systems, and are compatible with ultra-high vacuums. They are easily aligned, have good electrical conductivity and ajustable tensions. Using these electrodes with full wave rectified a.c., we found reduced specimen heating, lower background granularity, and improved resolution compared to commercially available designs.

Streptococcal pancarditis

An unusual association of pancarditis due to Streptococcus viridans is described. The pathologic findings appear to indicate that the myocardial infection and pericarditis were blood borne.

Triiodothyronine radioimmunoassay and its application to thyroid disorders

An accurate, highly sensitive triiodothyrone (T3) radioimmunoassay system is described. Direct measurement in serum is made possible by the use of T3-free serum for standards, and blocking of T3 binding to thyroxine (T4)-binding globulin with salicylate. T4 cross reactivity was less than 0.3%. Mean T3 levels in 55 euthyroid, 32 hyperthyroid and 19 primary hypothyroid patients were 1.46 +/- 0.17, 5.34 +/- 1.86 and 0.49 +/- 0.34 (SD) ng/ml, respectively. T3 was found to be a more sensitive index than T4 in hyperthyroidism; in hypothyroidism it overlapped with euthyroidism. The presence of goiter had no effect on T3 concentrations in euthyroid patients. Among the patients studied, eight were found to have T3 toxicosis, including two patients with recurrent thyrotoxicosis. A significant T3 elevation was also found in euthyroid patients after thyroidectomy whereas T4 remained normal. The extent of T4 and T3 elevation was similar during the initial phase of subacute thyroiditis. There were significantly lower T3 values and higher thyroid-stimulating hormone values in umbilical cord blood than in maternal blood. In two euthyroid subjects, thyrotropin-releasing hormone stimulation caused a 50% rise in T3 levels and no change in T4 levels over a 2-h period.

Systemic amyloidosis in Behçet's disease

Clinical features in two patients with Behcet's disease were dominated by "minor" manifestations of the disease--arthritis and central nervous system involvement in one, chronic stasis ulcers complicating thrombosis of the inferior vena cava in the other. In a third patient, the dominant clinical features were coincidental obstructive airway disease and cor pulmonale. Two patients developed a nephrotic syndrome; the third had intermittent trace proteinuria. Amyloidosis was proved by histologic examination in all three. The two patients examined post-mortem had no focus of chronic suppuration. There is a possibility that systemic amyloidosis is an intrinsic feature of Behcet's disease.