Hallermann-Streiff Syndrome in Concordant Monozygotic Twins With Congenital Cataracts, Exudative Retinal Detachments, and One Case of Corneal Perforation Requiring Keratoplasty

PURPOSE

We describe the management of Hallermann-Streiff syndrome in monozygotic female twins with congenital cataracts, exudative retinal detachments, and 1 case of corneal descemetocele with associated dellen and subsequent perforation.

METHODS

This study was a case report and review of the literature.

RESULTS

Twins 1 and 2 exhibited all 7 cardinal characteristics of Hallermann-Streiff syndrome, presenting with spontaneous lenticular resorption, anterior uveitis, and glaucoma. They underwent bilateral cataract extraction with near total capsulectomy. Both twins experienced recurrent glaucoma, for which twin 1 underwent successful endocyclophotocoagulation in both eyes and twin 2 in the left eye alone. The fellow eye developed 2 sites of perilimbal corneal descemetoceles with associated dellen at the inferotemporal limbal corneal junction leading to spontaneous perforation of 1 site, requiring a full-thickness corneal graft. Both twins developed recurrent bilateral exudative retinal detachments unresponsive to oral prednisolone. Twin 1's last best-corrected visual acuity with aphakic spectacles was 20/260 in the right eye and 20/130 in the left eye at age 4 years and 8 months. Twin 2's last best-corrected visual acuity was 20/130 in each eye at age 4 years and 11 months, over a year after right eye penetrating keratoplasty.

CONCLUSIONS

We describe 2 rare cases of Hallermann-Streiff syndrome in monozygotic twins complicated by corneal perforation requiring penetrating keratoplasty in 1 eye of 1 twin. Although corneal opacities have been described in this condition, this is the first case of corneal descemetocele in Hallermann-Streiff syndrome. The cornea was stabilized with a relatively favorable visual outcome over 1 year later.

Erdheim-Chester disease and vemurafenib: a review of ophthalmic presentations and clinical outcomes

PURPOSE

To provide a comprehensive review of ocular and orbital manifestations of Erdheim-Chester Disease (ECD) and compare clinical outcomes with vemurafenib (INN) to historical treatments (HT). Primary outcomes are ophthalmic findings on presentation, changes in visual acuity, and mortality rate. Secondary outcomes include the progression of ocular findings, systemic involvements, and treatment modalities.

METHODS

All published literature from January 1983 to March 2021 was searched for ophthalmic manifestations of ECD. Clinical outcomes following HT were collected and compared with INN.

RESULTS

Forty-seven patients with ECD and ophthalmic presentations were identified. The mean age was 49.6 years (SD = 15.0). Proptosis (65.6%) and extraocular muscle restrictions (42.5%) were the most common presenting signs. Of 41 (87.2%) patients with orbital masses on radiologic examination, 90.2% were bilateral, and 53.7% were located in the intraconal space. Ophthalmic examination was significant for xanthelasma (27.2%), optic disc edema (34.0%), and subretinal changes (21.3%). Common treatments were systemic steroids (76.6%), interferon-α (17.0%), and cyclophosphamide (14.9%). INN was less commonly used (12.8%). The mean change in logMAR visual acuity declined with HT (29.9%) but improved with INN (79.1%) (p > 0.05). The proportion of eyes with complete vision loss increased after HT (p < 0.05). The overall mortality rate was 27.7% and notably higher in the HT group (29.3%) when compared to the INN group (16.7%) (p > 0.05).

CONCLUSION

ECD presents with many ophthalmic manifestations. Although the intraocular treatments remain controversial, INN should be highly considered in treating orbital ECD patients with BRAF-V600E mutations to prevent and reverse vision loss.

Referral patterns for infantile cataracts in two regions of the United States

BACKGROUND

Delayed treatment of congenital or infantile cataracts can cause deprivation amblyopia. Prompt diagnosis and surgical intervention is critical for optimal outcomes. This study assessed referral patterns for congenital or infantile cataracts in two regions of the United States.

METHODS

The medical records of children 0-1 years of age with congenital or infantile cataracts at Stanford University (2008-2018) and Emory University (2010-2015) were reviewed retrospectively.

RESULTS

A total of 111 children were included. Of these, 82 (74%) were initially evaluated by a primary care doctor, of whom 40 (49%) were referred directly to a pediatric cataract surgeon. Of 61 newborns 0-2 months of age, 9 (15%) were initially referred to an eye care provider before 6 weeks of age, but the initial evaluation by a pediatric cataract surgeon was delayed until after 6 weeks of age. Referral patterns were similar between the two institutions (P = 0.06).

CONCLUSIONS

Many children with congenital of infantile cataracts are initially referred by a primary care doctor to an eye care provider who does not perform pediatric cataract surgery. Nevertheless, the majority of newborn infants with cataracts were evaluated by a pediatric cataract surgeon before 6 weeks of age.

Microphthalmia and orbital cysts in DiGeorge syndrome

We report the case of a 4-month-old boy diagnosed with DiGeorge syndrome with novel ocular features. The patient was diagnosed through genetic testing, with a noted 22q11.2 deletion, and had the additional clinical findings of cardiac anomalies, Hirschsprung's disease, and intracranial microhemorrhages. Eye findings included bilateral microphthalmia, persistent fetal vasculature, chorioretinal coloboma, and a unilateral orbital cyst. Given no known additional inciting exposures, a dysgenic mechanism resulting in failed closure of developmental fissures associated with the chromosomal deletion likely gave rise to these combined pathologies.

Choroidal Thickness by Handheld Swept-Source Optical Coherence Tomography in Term Newborns

Purpose

To describe normative values for choroidal thickness in newborns and characterize their relationship to vitreoretinal features.

Methods

Term newborns underwent awake, handheld swept-source optical coherence tomography (SS-OCT) in this prospective cohort study. An automated segmentation algorithm followed by manual adjustments measured choroidal thickness at the fovea and five perifoveal locations. Two masked, trained graders, with a third mediating disagreements, analyzed scans for vitreoretinal findings. OCT vitreoretinal findings, including dome-shaped macula, subretinal fluid, punctate hyperreflective vitreous opacities, persistent inner retinal layers, foveal ellipsoid zone, tractional and non-tractional vitreous bands, epiretinal membrane, cystoid macular edema, vessel elevation, scalloped retinal layers, hyporeflective vessels, and retinal spaces, were assessed and correlated with foveal choroidal thickness using a generalized linear mixed model.

Results

Fifty-nine eyes of 39 infants (mean gestational age, 39.5 weeks; 18 male, 46%) were included. Mean foveal choroidal thickness was 455.5 ± 93.9 µm. Choroid was thinner inferonasally (343.6 ± 106.2 µm) compared to superonasally (368.4 ± 92.9 µm; P = 0.03) and superotemporally (369.6 ± 100.6 µm; P = 0.02). Thinner foveal choroidal thickness was associated with absence of a foveal ellipsoid zone (437.1 ± 78.5 µm vs. 553.7 ± 93.9 µm; P = 0.02). Choroidal thickness was not significantly associated with other OCT findings.

Conclusions

We identified an association between thinner choroid and foveal immaturity. Additional study is needed to determine whether choroidal development impacts visual outcomes.

Translational Relevance

Handheld SS-OCT achieved normative measurements for choroidal thickness across the macula in term newborns, providing a foundation for future investigations into the role of choroidal development in infancy.

Optical coherence tomography findings in Cohen syndrome

Cohen syndrome is a rare disease that causes myopia and retinal degeneration in the setting of developmental delay and characteristic craniofacial features. We report optical coherence tomography (OCT) abnormalities in 4 patients with Cohen syndrome, 2 of whom have longitudinal follow-up. All subjects had schisis-like changes, with cystoid spaces in the inner retina as well as diffuse outer retinal atrophy sparing the subfoveal region. Ophthalmologic findings in 1 patient led to the work-up that resulted in a diagnosis of Cohen syndrome, suggesting that characteristic retinal abnormalities visualized by fundus examination and OCT may represent distinguishing features of this syndrome.

Reversal of severe vergence anomaly associated with convergence insufficiency

Central disruption of fusion refers to a subject's inability to fuse images, resulting in constant diplopia. Severely reduced vergences, or vergence anomalies, producing markedly decreased fusional amplitudes resembling fusional disruption have not been reported previously with convergence insufficiency. We report 3 patients with severe vergence anomalies in the setting of convergence insufficiency.

Global Retinoblastoma Presentation and Analysis by National Income Level

Importance

Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale.

Objectives

To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis.

Design, Setting, and Participants

A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017.

Main Outcomes and Measures

Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis.

Results

The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]).

Conclusions and Relevance

This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs.

Orbital and chorioretinal manifestations of Erdheim-Chester disease treated with vemurafenib

Purpose

We report a patient with severe multi-organ dysfunction of unknown origin who presented with bilateral orbital and chorioretinal manifestations that led to the diagnosis of Erdheim-Chester Disease (ECD).

Observations

ECD is a rare, histiocytic, proliferative disorder characterized by multi-systemic organ involvement that has historically lacked effective therapy. Our patient underwent genetic testing that was positive for the BRAF V600E mutation; therefore, the patient was treated with vemurafenib.

Conclusions and importance

This case demonstrates the rare orbital and intraocular manifestations of ECD and the unfortunate impact of a delayed diagnosis, the importance of early gene therapy testing for management decisions, and the utilization of targeted directed therapy to improve visual outcomes and quality of life.

Endophthalmitis Caused by Corynebacterium Species: Clinical Features, Antibiotic Susceptibility, and Treatment Outcomes

PURPOSE

To report the clinical features, antibiotic susceptibility profiles, treatment, and visual acuity (VA) outcomes of endophthalmitis caused by Corynebacterium species.

DESIGN

Retrospective case series.

SUBJECTS

Patients with endophthalmitis caused by Corynebacterium species.

METHODS

Microbiology database records were retrospectively reviewed for all patients with endophthalmitis caused by Corynebacterium species from January 1, 1990 to December 31, 2012 at a large university referral center. The corresponding clinical records were then reviewed to evaluate the endophthalmitis clinical features and treatment outcomes.

MAIN OUTCOME MEASURES

presenting clinical features, visual acuity outcomes, and antibiotic susceptibility patterns.

RESULTS

Of 10 patients identified, clinical settings included post-cataract surgery (n = 6), post-penetrating keratoplasty (n = 2), and post-trabeculectomy (n = 2). The mean time from surgical procedure to presentation with endophthalmitis was 6.8 months (range: 1 day to 28 months). All isolates were vancomycin susceptible. Presenting VA ranged from 7/200 to no light perception. Initial treatment strategies were vitreous tap and intravitreal antibiotic injection (n = 5) and pars plana vitrectomy with intravitreal antibiotic injection (n = 5). VA outcomes were ≥ 20/60 in 5 (50%) of 10 patients and ≤ 20/400 in 5 (50%) of 10 patients.

CONCLUSIONS

The most common clinical setting was post-cataract surgery. All isolates were susceptible to vancomycin. Despite prompt treatment with appropriate antibiotics, there were variable visual outcomes.

Utilization of Ophthalmology-Specific Emergency Department Services

OBJECTIVE

To describe utilization trends of an ophthalmology-specific emergency department (ED).

METHODS

Prospective cohort study of new patients presenting in the ophthalmology ED for at least a 30-day period in the spring of each year for five consecutive years (2010-14) at a university referral center. A data form, including information about the ED visit and patient demographics, was included in each patient chart. Data were analyzed with Pearson chi-square test and multiple logistic regression.

RESULTS

A total of 5323 chart data forms were completed. An average of 42.2 new patients per day presented to the ophthalmology ED. Most common diagnoses were viral conjunctivitis (8.7%), dry eye syndrome (6.6%), and corneal abrasion (6.6%). Non-emergent visits accounted for 35.8% of surveys completed. Factors associated with non-emergent visits included female gender, age 65 years or older, weekday visits, and patient symptom duration greater than one week (p < 0.0001 for each factor). When compared to all other insurance categories combined, patients who were members of the regional public assistance program were the most likely to present with a non-emergency (48.5% versus 34.9%, p < 0.001), while Workers' Compensation patients were least likely to present with a non-emergency (16% versus 36.5%, p < 0.001).

CONCLUSIONS

Over one-third of new patient visits were non-emergent. Factors predictive of non-emergent patient visits were female gender, age 65 years or older, duration of symptoms greater than one week, weekday visits, and the form of insurance coverage.

Persistently Vitreous Culture-Positive Exogenous Bacterial Endophthalmitis

PURPOSE

To report the clinical settings, bacterial isolates, antibiotic sensitivities, and visual acuity outcomes of patients with persistently positive vitreous cultures after intravitreal antibiotics.

DESIGN

Consecutive, noncomparative case series.

METHODS

setting: Tertiary care center.

PATIENT POPULATION

Thirty-six eyes of 36 patients with exogenous endophthalmitis with the same bacterial organism identified on at least 2 consecutive vitreous cultures from 1981 to 2015.

OBSERVATION PROCEDURES

Vitreous cultures with intravitreal injections of antibiotics and pars plana vitrectomies with intravitreal antibiotics.

MAIN OUTCOME MEASURES

Bacterial isolates, antibiotic sensitivities, visual outcomes.

RESULTS

Thirty-six eyes of 36 patients met the study criteria. The mean follow-up was 26.5 months. The most common clinical settings were after cataract extraction (18/36, 50%) and glaucoma surgery (11/36, 31%). The mean initial visual acuity was 2.16 ± 0.77 logMAR (Snellen equivalent ≈20/2900), and there was no statistically significant change at the final evaluation (2.08 ± 0.97 logMAR, ≈20/1900, P = .72). The most common bacteria were Staphylococcus (11/36, 31%) and Streptococcus (9/36, 25%). Gram-positive bacteria were sensitive to vancomycin (27/27, 100%); gram-negative bacteria were sensitive to amikacin (5/5, 100%). The antibiotic sensitivities were the same on repeat cultures in 34 of 36 patients (94%). The initial treatment was a vitreous culture and intravitreal injection of antibiotics in 28 of 36 patients (78%). The vision at the last follow-up was 20/200 or better in 12 patients (33%) and no light perception in 11 of 36 patients (31%).

CONCLUSIONS

The most commonly identified organisms were gram-positive bacteria. There was good concordance in the antibiotic sensitivities between initial and subsequent cultures. Patients with persistently vitreous culture-positive endophthalmitis had poor visual outcomes.

Nest building is a novel method for indexing severity of alcohol withdrawal in mice

Withdrawal after chronic ethanol (EtOH) affects body temperature, goal-directed behavior and motor function in mice and increases general central nervous system excitability. Nest-building tests have been used to assay these states but to this point have not been employed as measures of EtOH withdrawal severity. We first refined nest-scoring methods using a genetically heterogeneous stock of mice (HS/Npt). Mice were then made physically dependent following three days of chronic EtOH vapor inhalation to produce average blood EtOH concentrations (BECs) of 1.89 mg/mL. EtOH withdrawal affected the progression of nest building over time when mice were tested 2-4 days after removal from three days of chronic exposure to EtOH. In a separate group of mice, chronic EtOH vapor inhalation (BECs 1.84 mg/mL) suppressed nest building over days 1-2 but not days 2-3 of withdrawal. In a following experiment, EtOH withdrawal dose-dependently slowed recovery of nest building for up to 32 h. Finally, we determined that long-lasting nest-building deficits extend to mice undergoing withdrawal from a high dose (4 g/kg) of acute EtOH. Sex differences for nest building were absent following EtOH exposure. In mice naïve to EtOH treatments, male mice had lower pre-test body temperatures and increased nest scores across a two-day testing period compared to females. These results suggest that nest building can be used to assess chronic and acute EtOH withdrawal severity in mice.

Pseudopemphigoid as caused by topical drugs and pemphigus disease

Pseudopemphigoid can cause a chronic cicatricial conjunctivitis that is clinically identical to the manifestations seen in mucous membrane pemphigoid, a disorder with a common clinical phenotype and multiple autoimmune links. For the purpose of this review, we will describe pseudopemphigoid as caused by topical drugs, the most common etiology with ocular manifestations, and as caused by the pemphigus disease, a more rare etiology. Specifically, we will discuss the ophthalmological features of drug-induced cicatricial conjunctivitis, pemphigus vulgaris, and paraneoplastic pemphigus. Other etiologies of pseudopemphigoid exist that will not be described in this review including autoimmune or inflammatory conditions such as lichen planus, sarcoidosis, granulomatosis with polyangiitis (Wegener’s granulomatosis), erythema multiforme (minor, major, and Stevens-Johnson syndrome), bullous pemphigoid, skin-dominated linear IgA bullous dermatosis, and skin-dominated epidermolysis bullosa acquisita. Prompt diagnosis of the underlying etiology in pseudopemphigoid is paramount to the patient’s outcome as certain diseases are associated with a more severe clinical course, increased ocular involvement, and differential response to treatment. A complete history and ocular examination may find early cicatricial changes in the conjunctiva that are important to note and evaluate to avoid progression to more severe disease manifestations. When such cicatricial changes are noted, proper diagnostic techniques are needed to help elucidate a diagnosis. Lastly, collaboration between ophthalmologists and subspecialists such as dermatologists, pathologists, immunologists, and others involved in the care of the patient is needed to ensure optimal management of disease.

Purtscher-Like Retinopathy and Diffuse Alveolar Hemorrhage Caused by Soft Tissue Injection for Gluteal Augmentation

Purpose

To describe a rare occurrence of acute vision loss and diffuse alveolar hemorrhage following a treatment of injectable gluteal cosmetic filler.

Patient and methods

A 20-year-old female underwent a cosmetic injection of unknown components for gluteal augmentation. Within hours she developed progressive shortness of breath secondary to diffuse alveolar hemorrhage. She presented to ophthalmology 6 weeks later with a history of bilateral decreased vision. Clinical examination revealed cotton wool spots and retinal hemorrhages. Fluorescein angiography demonstrated macular vascular pruning and an enlarged foveal avascular zone.

Results

The patient was observed and vision did not improve after 8 months of follow-up.

Conclusion

These findings were attributed to a Purtscher-like retinopathy secondary to systemic inflammation induced by the filler and/or direct microembolization of the injected material or fat. To the best of the authors’ knowledge, this is the first documented case of diffuse alveolar hemorrhage and ischemic bilateral vision loss in a patient undergoing gluteal augmentation with dermal filler.

Progress in a replicated selection for elevated blood ethanol concentrations in HDID mice

Drinking in the dark (DID) is a limited access ethanol-drinking phenotype in mice. High Drinking in the Dark (HDID-1) mice have been bred for 27 selected generations (S27) for elevated blood ethanol concentrations (BECs) after a 4-h period of access to 20% ethanol. A second replicate line (HDID-2) was started later from the same founder population and is currently in S20. An initial report of response to selection in HDID-1 was published after S11. This article reports genetic and behavioral characteristics of both lines in comparison with the HS controls. Heritability is low in both replicates (h(2)  = 0.09) but the lines have shown 4-5 fold increases in BEC since S0; 80% of HDID-1 and 60% of HDID-2 mice reach BECs greater than 1.0 mg/ml. Several hours after a DID test, HDID mice show mild signs of withdrawal. Although not considered during selection, intake of ethanol (g/kg) during the DID test increased by approximately 80% in HDID-1 and 60% in HDID-2. Common genetic influences were more important than environmental influences in determining the similarity between BEC and intake for HDID mice. Analysis of the partitioning of intake showed that 60% of intake is concentrated in the last 2 h of the 4 h session. However, this has not changed during selection. Hourly BECs during the DID test reach peak levels after 3 or 4 h of drinking. HDID mice do not differ from HS mice in their rate of elimination of an acute dose of alcohol.

Simultaneous determination of aflatoxin M1, ochratoxin A, zearalenone and α-zearalenol in milk by UHPLC-MS/MS

In this study, a sensitive and rapid method has been developed for the simultaneous determination of aflatoxin M1, ochratoxin A, zearalenone and α-zearalenol in milk by ultra high performance liquid chromatography combined with electrospray ionisation triple quadrupole tandem mass spectrometry (UHPLC-ESI-MS/MS). The milk samples were purified using Oasis HLB cartridge. The matrix effects were evaluated by determining the signal suppression-enhancement (SSE) and corrected by external matrix-matched calibration. The limits of quantity (LOQ) of the mycotoxins were in the range of 0.003-0.015μgkg(-1). The high correlation coefficients (R(2)⩾0.996) were obtained in the range of 0.01-1.00μgkg(-1) of the mycotoxins, along with good recovery (87.0-109%), repeatability (3.4-9.9%) and intra-laboratory reproducibility (4.0-9.9%) at the concentrations of 0.025, 0.1 and 0.5μgkg(-1). The detected rates of the mycotoxins were from 16.7% to 96.7% in raw milk, liquid milk and milk powder samples collected from the dairy farms and supermarkets in Beijing. The method proposed is suitable for the simultaneous determination of aflatoxin M1, ochratoxin A, zearalenone, and α-zearalenol, and could be performed for analysing the mycotoxins in milk.

PTEN, tau-AP-3, thymidylate synthase immunohistochemistry scoring expression in patients with uterine leiomyomas, uterine smooth muscle tumors of uncertain malignancy potential and uterine leiomyosarcomas

Uterine smooth muscle tumors are frequently classified as benign and malignant. However, an assortment of mitotic counts and nuclear atypia can be indecisive between uncertain malignant potential, and malignant uterine smooth muscle tumors. We applied three immunohistochemical parameters to distinguish between cases of benign, malignant, and those with uncertain malignant histology.

Understanding bamboo flowering based on large-scale analysis of expressed sequence tags

Unlike other plants, bamboo (Bambusoideae) flowering is an elusive physiological phenomena, because it is unpredictable, long-periodic, gregarious, and uncontrollable; also, bamboo plants usually die after flowering. The flowering mechanism in Arabidopsis thaliana, a eudicot model species, is well established, but it remains unknown in bamboo species. We found 4470 and 3878 expressed sequence tags in the flower bud and vegetative shoot cDNA libraries, respectively, of the bamboo species, Bambusa oldhamii. Different genes were found expressed in bamboo flower buds compared to vegetative shoots, based on the Munich Information Center for Protein Sequences functional categorization; flowering-related genes were also identified in this species. We also identified Arabidopsis flowering-specific homologs that are involved in its photoperiod in this bamboo species, along with autonomous, vernalization and gibberellin-dependent pathways, indicating that bamboos may have a similar mechanism to control floral transition. Some bamboo expressed sequence tags shared high similarity with those of rice, but others did not match any known sequences. Our data lead us to conclude that bamboo may have its own unique flowering genes. This information can help us understand bamboo flowering and provides useful experimental methods to study the mechanisms involved.

Normal-sized ovarian papillary serous carcinoma: a case report

A normal-sized ovarian papillary serous carcinoma is rare. We present the case of a 46-year-old woman with progressive abdominal fullness of one week's duration. The medical evaluation revealed abdominal carcinomatosis with normal-sized ovaries and an elevated serum CA-125 level of 147,365.8 U/ml. Cytoreductive surgery (hysterectomy, bilateral salpingo-oophorectomy, omentectomy, lymphadenectomy, infracolic omentectomy, peritoneal biopsy, washing cytology, and appendectomy) was performed. The histologic examination revealed an ovarian serous papillary carcinoma. Adjuvant chemotherapy was administered. The serum CA-125 level decreased after completion of treatment. Normal-sized ovarian serous surface papillary carcinomas should be kept in mind as an origin of disease in patients who have peritoneal carcinomatosis, which sometimes is a diagnostic dilemma of the disease source. We report this case to emphasize the clinical symptoms and importance of the early and accurate diagnosis of a normal-sized ovarian papillary serous carcinoma.

First Report of Rhizoctonia Blight of a Coastal Redwood Tissue-Culture-Derived Saplings Caused by Rhizoctonia solani AG-IV in Taiwan

Coastal redwood (Sequoia sempervirens (D. Don) Endl.) is native to North America. This tall tree species is used for forestation and lumber; its wood is also used for furniture, its burls for art ware, and its bark for fuel, insulation, and mulch. In August 2005, an instance of wilt was observed among 2-year-old tissue-culture-cloned plants (2) in the Sitou Forest of central Taiwan. Essentially, all plants were infected. The leaves or stems near the ground were affected first, but the wilt soon spread over the entire plant with the leaves becoming grayish brown and water soaked, and then wilting, drying, and finally defoliation occurred. Aerial hyphae were present over the affected areas, aerial mycelium was cob-web-like, hyaline, later becoming slightly brown. Hyphae were 6.5 to 10.4 μm wide with right-angle branching and septal constriction at their bases. Sclerotia were hemispherical, subglobose, to irregular in shape, 1 to 2 mm, and brown. The perfect stage of the fungus was not found. The fungus was identified as Rhizoctonia solani Kühn (3). Vegetative cells were stained with alkaline safranin solution and identified as multinucleate (1). Portions of the stem that displayed symptoms, together with adjacent healthy tissue, were disinfested for 1 min in 0.5% NaOCl and plated on to potato-dextrose agar (PDA) (Merck, Darmstadt, Germany) supplemented with 100 mg/L of ampicillin (Sigma, St. Louis, MO). Single hyphal tips were transferred to PDA and two isolates were established as pure cultures. On the basis of hyphal anastomosis with AG-IV tester isolates (exfop234, exfop241, and exfop250) (1), the fungus was identifed as R. solani AG-IV. Pathogenicity of the fungal isolates was confirmed by inoculating 2-month-old tissue-culture-derived S. sempervirens plants that were grown in pots and incubated in a growth chamber maintained at 28°C with a relative humidity above 95%. Inoculum consisted of a single mycelial 5-day-old 0.5-cm disc grown on PDA of the pathogen placed on the soil surface touching the base of each plant. Four plants were inoculated with mycelium and the four control plants were noninoculated. Inoculated plants wilted gradually over 4 days and all plants developed severe stem rot and were dead in 6 days, whereas control plants remained symptomless. The Rhizoctonia solani AG-IV was reisolated from all inoculated plants. This fungus has been observed to cause disease in many species of plants (4), but to our knowledge, this is the first report of Rhizoctonia blight of coastal redwood tissue-culture-derived saplings caused by Rhizoctonia solani AG-IV in Taiwan. References: (1) T. T. Chang. Taiwan J. For. Sci. 12:47, 1997. (2) L. C. Huang et al. Plant Physiol. 98:166, 1992. (3) B. Sneh et al. Identification of Rhizoctonia species. The American Phytopathological Society, St. Paul, MN, 1991. (4) S. T. Su et al. List of Plant Diseases in Taiwan. The Phytopathological Society of the Republic of China, 2002.

A double-blind comparison of the efficacy and tolerability of telmisartan 40-80 mg vs. losartan 50-100 mg in Taiwanese hypertensive patients

A multicentre, randomised, double-blind, double-dummy, parallel-group, dose-titration study was conducted to determine the efficacy and tolerability of telmisartan 40-80 mg once daily compared with losartan 50-100 mg once daily in 180 Taiwanese patients with mild-to-moderate essential hypertension. After an initial 2-week placebo run-in phase, patients were randomised in a double-blind, double-dummy fashion to receive either telmisartan 40 mg or losartan 50 mg. If blood pressure control (diastolic blood pressure [DBP] <90 mmHg or > or = 10 mmHg reduction in DBP) was achieved after 4 weeks, the dose was maintained for the second 4 weeks of the active treatment phase; if not, the dose was doubled to telmisartan 80 mg or losartan 100 mg, respectively, for the second 4 weeks of double-blind treatment. Telmisartan 40-80 mg (n = 86) was as effective as losartan 50-100 mg (n = 90) in reducing trough seated DBP (11.1 vs. 8.7 mmHg, p = 0.144), and was significantly more effective than losartan in reducing trough seated systolic blood pressure (SBP) (22.1 vs. 16.5 mmHg, p = 0.032) and standing SBP (21.0 vs. 16.3 mmHg, p = 0.033). Significantly fewer patients treated with telmisartan than those treated with losartan required uptitration after 4 weeks' treatment (32.6% vs. 61.5%, p = 0.001). Both telmisartan and losartan were well tolerated.

Dyspeptic symptoms and water load test in patients with functional dyspepsia and reflux disease

OBJECTIVE

Hypersensitivity to gastric distension has been reported in functional dyspepsia (FD). The aim of this study was to assess the perception to gastric distension and its relationship to specific symptoms using the water load test (WLT) in FD and gastroesophageal reflux disease (GERD).

MATERIAL AND METHODS

A 5-min WLT was used to evaluate sensitivity of gastric distension in 47 FD and 61 GERD subjects, and 49 healthy controls (HC). A visual analogue scale (VAS) measuring symptom severity was obtained from all subjects and its relationship with the maximal ingested volume was determined. The maximal ingested volume was registered and the subjective symptoms were assessed at baseline and 30 min after the WLT.

RESULTS

The maximal ingested volume by HC was 597 +/- 33 ml, which was statistically greater than that of FD (422 +/- 22 ml, p < 0.001) and GERD (504 +/- 23 ml, p < 0.02) subjects. The maximal ingested volume did not differ significantly between FD and GERD. The maximal ingested volume correlated well with nausea (r = -0.49, p < 0.01) and fullness (r = -0.33, p < 0.05) in FD. Male subjects ingested more water than females in the HC (p < 0.01) and GERD groups (p < 0.05), but not in FD (p = NS).

CONCLUSIONS

Both FD and GERD subjects have altered perception to gastric fullness induced by the WLT compared to healthy controls. Good correlations have been observed between the WLT and dyspeptic symptoms such as early satiety and postprandial fullness, but not in GERD.

Fasting decreases the content of D-chiroinositol in human skeletal muscle

Two classes of inositol phosphoglycans have been implicated as second messengers of insulin, one that activates pyruvate dehydrogenase and contains D-chiroinositol, and one that inhibits cyclic AMP-dependent protein kinase and contains myoinositol. We examined the effects of a 3-day fast on muscle contents of inositols in healthy humans. An oral glucose tolerance test was performed and a biopsy was obtained from the quadriceps femoris muscle after an overnight fast and after a 72-hour fast. The 72-hour fast significantly increased plasma glucose (1.5- to 2-fold) and insulin (2- to 4-fold) after glucose ingestion versus the values after the overnight fast, indicating the manifestation of peripheral insulin resistance. The 72-hour fast resulted in an approximately 20% decrease in the muscle content of D-chiroinositol (P < 0.02), but no change in the myoinositol content. These data demonstrate that fasting specifically decreases the muscle content of D-chiroinositol in human muscle and this may contribute to the finding that insulin-mediated activation of pyruvate dehydrogenase is attenuated after short-term starvation.

Endoscopic thoracic sympathetic block by clipping for palmar and axillary hyperhidrosis in children and adolescents

Endoscopic thoracic sympathectomy or sympathicotomy is a safe and effective method of treating primary hyperhidrosis (PH), but postoperative compensatory sweating may be a problem. There are few reports of sympathetic blockade by clipping for PH. We present our experience of endoscopic thoracic sympathetic block (ETSB) by clipping in treating palmar (PAH) and axillary hyperhidrosis (AH) in children and adolescents. Between May 1997 and June 1998, a total of 78 patients with PAH or AH underwent ETSB by clipping using an 8-mm, 0 degrees thoracoscope. There were 33 males and 45 females with a mean age of 14.1 years (range 9-16 y). All patients were placed in a semi-sitting position under single-lumen intubation anesthesia; 52 patients with PAH underwent T2 sympathetic block by clipping at the 2nd and 3rd rib beds, and T3 and T4 sympathetic block was performed at the 3rd, 4th and 5th rib beds in 26 patients with AH. A total of 156 sympathetic blocks by clipping were achieved. The operation was usually accomplished within 20 min (range 16-30 min). Most patients were discharged within 4 h after the operation. There were neither surgical complications nor mortality. The mean postoperative follow-up period was 32.7 months (range 26-40). Improvement of PAH or AH could be obtained in all cases; 70 patients (85.4%) developed compensatory sweating of the trunk and lower limbs. One patient with PAH underwent a reverse operation with improvement of the sweating 14 days after removal of the endo-clips. ETSB by clipping is thus a safe and effective method for treating PH in children and adolescents; compensatory sweating may be improved after a reverse operation with removal of the endo-clip.

Video-assisted thoracoscopic T2 sympathetic block by clipping for palmar hyperhidrosis: analysis of 52 cases

BACKGROUND

Endoscopic thoracic sympathectomy or sympathicotomy is a standard method in treating palmar hyperhidrosis, but postoperative compensatory sweating may be troublesome in some patients. Therefore, we designed a new technique for only T2 sympathetic blocking by clipping instead of interruption of the sympathetic trunk.

PATIENTS AND METHODS

Between September 2000 and July 2001, we saw a total of 100 patients with palmar hyperhidrosis who underwent video-assisted thoracoscopic sympathetic blocking of the T2 ganglion. All patients were placed in a semisitting position under single-lumen intubated anesthesia. We performed sympathetic blocking by clipping of the T2 ganglion at the level of the second and third rib beds using an 8-mm, 0 degree thoracoscope (Storz).

RESULTS

We supposed that the postoperative improvement in palmar hyperhidrosis would be perfect. The operation could be accomplished within 30 minutes. All patients were discharged within 4 hours after the operation. Surgical complications were minimal, without surgical mortality. A few patients were willing to receive the reverse operation and should get improvement of compensatory sweating after removal of the endo clips.

CONCLUSION

We believe that video-assisted thoracoscopic T2 sympathetic block by clipping will be a safe and effective method of treating patients with palmar hyperhidrosis. Compensatory sweating may be improved by the reverse operation: removal of the endo clip.

Pitfalls and complication avoidance associated with transthoracic endoscopic sympathectomy for primary hyperhidrosis (analysis of 2200 cases)

BACKGROUND

Transthoracic endoscopic sympathectomy (TES) has been already a standard method for the treatment of primary hyperhidrosis. There are rare reports about possibly encountered problems during TES. Therefore, we present our experience in treating palmar and axillary hyperhidrosis and discuss the resoluble methods of potential problems during and after TES.

PATIENTS AND METHODS

From June 1994 to October 1999, there were 2200 patients with palmar or axillary hyperhidrosis underwent TES. There are 926 males and 1274 females. Their mean age was 23.4 years old (range: 5-65). All except 12 patients were placed in half-sitting position under single or double-lumen intubation anesthesia. Either a 6-mm or 8-mm, 0degrees thoracoscope, (Karl Storz, Germany) was used to perform sympathectomy thru 0.8 cm incisions below each axilla. Ablation of T2 ganglion was performed in treating patients with palmar hyperhidrosis. Ablation of T3 and T4 ganglia was performed for patients with axillary hyperhidrosis. All except 22 patients were discharged 4 hours after TES, and returned to their activities within one week.

RESULT

Successful sympathectomy were achieved up to 2178 patients (99%), but the rates of incidental unusual findings and possibly encountered problems during TES were 5.6% and 7.1% alternatively. Surgical complications included pneumothorax (10 patients, 0.45%), Hemothorax (2 patients, 0.09%) segmental atelectasis (12 patients, 0.55%), mild wound infection (3 patients, 0.14%) and compensatory sweating (1936 patients, 88%). There was no surgical mortality case. But pleural adhesion (54 patients, 2.45%), repeat sympathectomy (27 patients, 1.23%), obscured upper sympathetic trunk by adipose tissue (22 patients, 1%), medially located sympathetic trunk (18 patients, 0.81%), great vessels overriding or close to the sympathetic trunk (15 patients, 0.68%), aberrant vessels (3 patients, 0.14%), transient bradycardia (3 patients, 0.14%) and re-expansion pulmonary edema (1 patient, 0.05%) might occur during TES.

CONCLUSION

Potential complications may happen during and after TES. But nearly all endoscopic sympathectomy could be achieved if surgeons acknowledge possible anatomic variation and has ability to overcome pleural adhesions.

Ethnic and geographic variations in the prevalence of hepatitis A, B and C among aboriginal villages in Hualien, Taiwan

BACKGROUND

Taiwan is endemic for viral hepatitis infections. A field survey was performed in the isolated aborigines in Hualien, eastern Taiwan, to investigate the geographic and ethnic variations in hepatitis epidemiology.

MATERIALS AND METHODS

From 1996 to 1998, blood was drawn from 1,748 subjects from two southern Ami and two northern Atayal villages for serum markers of hepatitis A, B and C.

RESULTS

Hepatitis A infection approached 100% in all groups. Hepatitis B infection and carrier rates were higher in the Atayal than in the Ami (92.3% vs. 49.1% and 20.8% vs. 5.3%; p<0.01). Hepatitis C infection rates were higher in three villages (27.5%, 20.1% and 25.4% vs. 3.6%; p<0.01). Hepatitis C infection increased with age (p<0.01) while hepatitis B infection did not.

CONCLUSION

Hepatitis A infected most aborigines before the age of 15 years. Hepatitis B seldom infected people after the age of 15 years, while hepatitis C continued to infect people who were older. Geographic factors are important for hepatitis C infection, whereas for hepatitis B infection, in addition ethnicity is also important.

Phosphoinositol glycan derived mediators and insulin resistance. Prospects for diagnosis and therapy

While much work remains, the evidence has become strong that IPG generation following insulin action is a significant signaling mechanism. A considerable body of data has established IPG release by insulin and other growth factors from cell membranes, cells and in human blood and muscle biopsies in vivo. Two separate IPG species containing D-chiro-inositol and myo-inositol have been separated by ion exchange. These IPGs have separate actions in vitro and are both active as insulin surrogates in vivo. A deficiency of the chiro-inositol system has been demonstrated in urine and tissues in humans and directly related to insulin resistance. Accordingly, D-chiro-inositol was administered to STZ diabetic rats and rhesus monkeys and shown to decrease hyperglycemia and enhance glucose disposal. Two trials in humans with impaired glucose tolerance and women with PCOS have now also proven successful. Thus, the pathophysiology in the chiro-inositol system related to insulin resistance and its reversal by chiro-inositol administration, in addition to the basic work, argues strongly for the physiological significance of this novel signaling system in the control of glucose metabolism.

A model phosphatase 2C --> phosphatase 1 activation cascade via dual control of inhibitor-1 (INH-1) and DARPP-32 dephosphorylation by two inositol glycan putative insulin mediators from beef liver

Two inositol phosphoglycans (IPG) isolated from beef liver and designated as putative insulin mediators were demonstrated to reciprocally enhance the dephosphorylation of inhibitor-1 (INH-1) and DARPP-32, thus directly activating phosphatase 2C and disinhibiting phosphatase 1 in a potential protein phosphatase 2C --> phosphatase 1 cascade mechanism. One IPG termed pH 2.0, containing Dchiro-inositol and galactosamine, stimulated the dephosphorylation of INH-1 and DARPP-32 in a dose-dependent manner in the low micromolar range. A second, termed pH 1.3, containing myo-inositol glucosamine and mannose acted reciprocally to inhibit the cAMP-dependent protein kinase phosphorylation of INH-1 and DARPP-32 in a dose-dependent manner in the low micromolar range. These model experiments are discussed in terms of the observed dephosphorylation of INH-1 with insulin action documented in the literature and the activation of both phosphatase 1 and 2C described in intact cells and in vivo with insulin action.

Maintaining genetic stability through TP53 mediated checkpoint control

TP53 serves as a key relay for signals elicited by cellular stresses arising from diverse environmental or therapeutic insults. This relay then activates a cell cycle arrest or cell death program, depending on the stimulus and cell type. The absence of TP53 function disables the cell death or arrest programmes, thereby allowing the emergence of variants with various types of genomic alterations. The data discussed focus on two different types of signals that trigger the TP53 relay system. Firstly, TP53 arrests cell cycle progression in response to the types of DNA damage most commonly detected in cells undergoing tumour progression. Secondly, TP53 is activated by specific depletion of ribonucleotide pools, which prevent cells from entering S phase under conditions that could lead to chromosome breakage. The contribution of both responses limits the emergence of genetic variants. The DNA damage induced arrest appears to be triggered by as few as one double strand break in normal human fibroblasts. Analysis of the arrest kinetics after ionizing radiation shows that TP53 activates a prolonged arrest response in cells with irreparable DNA damage and that high efficiency cell elimination is achieved by a process that can be activated over multiple cell cycles. These data indicate that the primary function of the TP53 arrest/apoptosis pathway in response to double strand break is to eliminate damaged cells from the proliferating population, not to allow additional time for lesion repair. However, it remains possible that repair of other types of damage may benefit from TP53 mediated arrest. Analyses in model genetic systems indicate that the absence of TP53 function allows, but does not ensure, a high intrinsic rate of genetic variation and that instability is increased substantially when cells proceed through S phase under inappropriate growth conditions. This implies that inactivation of TP53 function in combination with other genetic alterations, such as oncogene activation, could accelerate genomic instability and tumour progression.

Convenient and reversible site-specific targeting of exogenous DNA into a bacterial chromosome by use of the FLP recombinase: the FLIRT system

We have created a system that utilizes the FLP recombinase of yeast to introduce exogenous cloned DNA reversibly at defined locations in the Escherichia coli chromosome. Recombination target (FRT) sites can be introduced permanently at random locations in the chromosome on a modified Tn5 transposon, now designed so that the inserted FRT can be detected and its location mapped with base pair resolution. FLP recombinase is provided as needed through the regulated expression of its gene on a plasmid. Exogenous DNA is introduced on a cloning vector that contains an FRT, selectable markers, and a replication origin designed to be deleted prior to electroporation for targeting purposes. High yields of targeted integrants are obtained, even in a recA background. This system permits rapid and precise excision of the introduced DNA when needed, without destroying the cells. The efficiency of targeting appears to be affected only modestly by transcription initiation upstream of the chromosomal FRT site. With rare exceptions, FRTs introduced to the bacterial chromosome are targeted with high efficiency regardless of their location. The system should facilitate studies of bacterial genome structure and function, simplify a wide range of chromosomal cloning applications, and generally enhance the utility of E. coli as an experimental organism in biotechnology.

Human papillomavirus-16 E6/E7 transfected retinal cell line expresses the Müller cell phenotype

The introduction of viral transforming genes into mammalian cells has been used in establishing cultures of unlimited lifespan. Although Müller cells, the predominant glial cells in the mammalian retina, have been isolated using a variety of techniques, most of these cultures have limited capacity for cell division and are often contaminated by other cell types especially astrocytes, endothelial cells and microglial cells. We have established pure cultures of retinal cells which express Müller cell characteristics and exhibit unlimited growth in vitro. We now report the techniques involved in the propagation and characterization of these cultures. Mixed retinal cultures isolated from dystrophic rat retinas were infected with defective retroviruses coding for human papillomavirus (HPV) type 16 E6 and E7 proteins. The disabled viral constructs also contained the neomycin gene allowing selection of the cultures using Geneticin, a neomycin analogue. Pure cultures were then obtained from Geneticin-selected populations by limiting end-dilution techniques. The expression of the HPV-16 E6/E7 genes in the transfected cell line was established using an HPV-16 E6/E7 PCR product to probe Northern blots. Cloned cells were found to be highly reactive for Müller cell markers including S-100, carbonic anhydrase-C, cellular retinaldehyde binding protein, and glial fibrillary acidic protein but not for glutamine synthetase. Ultrastructural studies showed stacks of cells with long elaborate processes, short microvilli, coated pits, cytoplasmic filaments, abundant perinuclear rough endoplasmic reticulum, and smooth endoplasmic reticulum extending to the cell processes. Growth patterns of late passage cells (> 50 passages) showed a lag phase of 48 hr followed by exponential growth extending past visual confluence at day 5. Since the cultures have undergone more than 240 population doublings, they can be characterized as a continuous cell line with unlimited lifespan. The HPV-16 E6/E7 transfected Müller cell line may prove useful in studies requiring abundant and pure cultures of Müller cells.

p53-dependent cell cycle arrests are preserved in DNA-activated protein kinase-deficient mouse fibroblasts

p53 is involved in at least three cell cycle checkpoints in normal cells: two in G1, activated by either DNA damage or by ribonucleotide pool depletion in the absence of damage, and one in metaphase/anaphase activated by an incomplete mitotic spindle. We tested whether any of these checkpoints require the DNA-activated protein kinase (DNAPK), since data indicate that it is activated by damaged DNA to modify p53 in cultured cells and in cell-free systems. Fibroblasts isolated from mice with severe combined immune deficiency (SCID) were used because the sole genetic defect underlying this syndrome lies within the DNAPK gene. This report shows that age-matched SCID and isogenic wild-type embryonic fibroblasts arrested in response to DNA damage, ribonucleoside triphosphate depletion, and spindle poisons, whereas p53-/- fibroblasts failed to do so. Therefore, DNAPK-deficient scid cells preserve normal p53-dependent cell cycle checkpoints. The data provide one explanation of why scid mice are not tumor prone though they are deficient in double-strand break repair.

Infusion of pH 2.0 D-chiro-inositol glycan insulin putative mediator normalizes plasma glucose in streptozotocin diabetic rats at a dose equivalent to insulin without inducing hypoglycaemia

We compared the effects of infusing a chemically defined chiro-inositol glycan putative insulin mediator with an equivalent dose of insulin in low-dose (45 mg/kg) streptozotocin diabetic rats. Insulin decreased plasma glucose levels from 17.32 +/- 0.17 to 3.96 +/- 0.064 mmol/l (p < 0.0002) in 120 min, a decrease of 77.13%, while the putative mediator promoted a decrease in plasma glucose from 14.85 +/- 0.084 to 7.22 +/- 0.13 mmol/l (p < 0.007) in 60 min. The putative mediator maintained euglycaemia over the ensuing 60 min with a plasma glucose level of 7.01 +/- 0.10 mmol/l at 120 min. Thus, insulin further reduced the plasma glucose from euglycaemia at 60 min to produce hypoglycaemia at 120 min. The lack of production of hypoglycaemia by the putative mediator can be explained by its inhibition of glucose-stimulated insulin secretion by the islet beta cells, thus providing a potential negative feedback regulatory mechanism; or by its selective action on muscle to increase glycogen synthesis. The significance of these results in terms of future directions in drug design is herein considered.

Sensitivity and selectivity of the DNA damage sensor responsible for activating p53-dependent G1 arrest

The tumor suppressor p53 contributes to maintaining genome stability by inducing a cell cycle arrest or apoptosis in response to conditions that generate DNA damage. Nuclear injection of linearized plasmid DNA, circular DNA with a large gap, or single-stranded circular phagemid is sufficient to induce a p53-dependent arrest. Supercoiled and nicked plasmid DNA, and circular DNA with a small gap were ineffective. Titration experiments indicate that the arrest mechanism in normal human fibroblasts can be activated by very few double strand breaks, and only one may be sufficient. Polymerase chain reaction assays showed that end-joining activity is low in serum-arrested human fibroblasts, and that higher joining activity occurs as cells proceed through G1 or into S phase. We propose that the exquisite sensitivity of the p53-dependent G1 arrest is partly due to inefficient repair of certain types of DNA damage in early G1.

Alcoholism, hepatitis B and C viral infections, and impaired liver function among Taiwanese aboriginal groups

Viral hepatitis and alcoholism prevail in four major Taiwanese aboriginal groups. To study the relative importance of the acquisition of hepatitis B virus or hepatitis C virus infection and alcoholism to the presence of impaired liver function in these groups, the authors conducted a semistructured clinical interview for alcoholism and test for seromarkers for viral hepatitis among 993 cohort members enrolled in 1990-1992 in an ongoing prospective study (Taiwan Aboriginal Study Project). The subjects' blood specimens were tested for serum alanine aminotransferase/aspartate aminotransferase levels and for the presence of hepatitis B surface antigen and anti-hepatitis C virus antibody. The prevalence of a combination of an alanine aminotransferase level of > 35 IU/liter and an aspartate aminotransferase level of > 40 IU/liter, implying impaired liver function or advanced liver disease, was 4.3% overall. Univariate and multiple logistic regression analysis showed that, rather than chronic hepatitis B virus infection, hepatitis C virus infection and alcoholism were the two dominant risk factors that signalled the risk of liver damage among these Taiwanese aborigines. In addition, these two contributing factors were able to act synergistically to cause impaired liver function.

Genetic instability as a consequence of inappropriate entry into and progression through S-phase

The stability of the mammalian genome depends on the proper function of G1 and G2 cell cycle control mechanisms. Two tumor suppressors, p53 and retinoblastoma (Rb), play key roles in progression from G1 into S-phase. We address the mechanisms by which these proteins mediate a G1 arrest in response to DNA damage and limiting metabolic conditions. Gamma-irradiation induced a prolonged, p53-dependent G1 arrest associated with a long-term increase in the levels of the cdk-inhibitor p21WAFl/Cipl (p21). Microinjection of linear plasmid DNA also caused a G1 arrest. The p53-dependent arrest induced by inhibitors of UMP biosynthesis was reversible and occurred in the absence of detectable DNA damage. Both arrest mechanisms contribute to limiting the formation and propagation of damaged genomes. Cells containing mutant p53 but wild-type Rb do not generate methotrexate (Mtx) resistant variants. However, pre-treatment with DNA damaging agents prior to drug selection resulted in resistant clones containing amplified dihydrofolate reductase (DHFR) genes, suggesting that DNA breakage is a rate limiting step for gene amplification. The Mtx-induced arrest did not occur in cells with non-functional Rb. Rb acts as a negative regulator of the E2F transcription factors, and Rb-deficient primary mouse embryo fibroblasts (MEFs) produced elevated levels of mRNA and protein for key E2F target genes. Failure to prevent entry into S-phase in Rb-/- MEFs exposed to DNA-damaging or nutrient limiting conditions caused apoptosis and correlated with p53 induction. Taken together, these findings indicate a link between p53 and Rb function and suggest that their coordination insures correct entry into S-phase, minimizing the emergence of genetic variants.

Insulin-induced activation of glycerol-3-phosphate acyltransferase by a chiro-inositol-containing insulin mediator is defective in adipocytes of insulin-resistant, type II diabetic, Goto-Kakizaki rats

Type II diabetic Goto-Kakizaki (GK) rats were insulin-resistant in euglycemic-hyperinsulinemic clamp studies. We therefore examined insulin signaling systems in control Wistar and diabetic GK rats. Glycerol-3-phosphate acyltransferase (G3PAT), which is activated by headgroup mediators released from glycosyl-phosphatidylinositol (GPI), was activated by insulin in intact and cell-free adipocyte preparations of control, but not diabetic, rats. A specific chiro-inositol-containing inositol phosphoglycan (IPG) mediator, prepared from beef liver, bypassed this defect and comparably activated G3PAT in cell-free adipocyte preparations of both diabetic GK and control rats. A myo-inositol-containing IPG mediator did not activate G3PAT. Relative to control adipocytes, labeling of GPI by [3H]glucosamine was diminished by 50% and insulin failed to stimulate GPI hydrolysis in GK adipocytes. In contrast to GPI-dependent G3PAT activation, insulin-stimulated hexose transport was intact in adipocytes and soleus and gastrocnemius muscles of the GK rat, as was insulin-induced activation of mitogen-activated protein kinase and protein kinase C. We conclude that (i) chiro-inositol-containing IPG mediator activates G3PAT during insulin action, (ii) diabetic GK rats have a defect in synthesizing or releasing functional chiro-inositol-containing IPG, and (iii) defective IPG-regulated intracellular glucose metabolism contributes importantly to insulin resistance in diabetic GK rats.

Primary ovarian cancer at National Taiwan University Hospital: 1980-1989

BACKGROUND

Ovarian cancer is a silent killer. Most of the patients came with advanced stages. The retrospective review here was for a better understanding of the current situation of ovarian cancer patients treated at National Taiwan University Hospital.

METHODS

One hundred and eighty-seven patients with primary ovarian cancer were treated at National Taiwan University Hospital from 1980 to 1989. Medical records were reviewed thoroughly. The WHO histological classification and FIGO staging system (1987) were used.

RESULTS

The ages at diagnosis ranged from 2 to 87 years. Peak incidence was noted between 50-59 years. According to the WHO histological classification, the distribution of histological types included 79.1% epithelial, 4.3% sex-cord stromal tumors, 0.5% lipid cell, 12.8% germ cell, and 3.2% non-specific soft tissue origin. Based on FIGO staging system, 31.6% of the patients were in stage I, 11.2% in stage II, 40.6% in stage III and 16.6% in stage IV. Mean ages for common epithelial, non-epithelial, and germ cell ovarian cancers were 49, 26, 23 years, respectively. Cytoreductive surgery was done in 47.4% of stage I, 23.8% of stage II, 15.8% of stage III, and 12.9% of stage IV. The leading treatment modality was surgery plus chemotherapy, which was performed in 50.3% of whole series. Survival in patients with ovarian cancer is a function of clinical stage and histologic type. The 5-year observed survival rates for stage I to IV were 76.3%, 59.9%, 9.1%, and 4.3% respectively. The 5-year survival rate was 29.4% for epithelial ovarian cancer, 51.4% for non-epithelial ovarian cancer, and 64.5% for germ cell tumors.

CONCLUSIONS

The prognosis and survival rate are still unsatisfactory despite the various modalities of treatment. Further improvements need the development of methods for early detection and multiple modalities of therapy.

Insulin stimulates the biosynthesis of chiro-inositol-containing phospholipids in a rat fibroblast line expressing the human insulin receptor

HIRc-B cells (rat fibroblasts expressing the human insulin receptor) were incubated with myo-[3H]inositol for 48 hr, and the biosynthesis of chiro-[3H]inositol was investigated in the absence and presence of insulin following a time course up to 60 min. After phase separation, treatment with insulin for 15 min caused a 2.2-fold increase in the specific radioactivity of chiro-[3H]inositol-containing phospholipids in contrast to a 1.2-fold increase in the specific radioactivity of myo-[3H]inositol-containing phospholipids. No insulin-mediated change in the specific radioactivity was observed in the inositol phosphates or free inositols. Further detailed analysis of individual [3H]inositol-containing phospholipids demonstrated marked increases in specific activity of the chiro-[3H]inositol phospholipids after 15 min of incubation with insulin: phosphatidylinositol 4-phosphate and 4,5-bisphosphate, 4.2-fold; lysophosphatidylinositol, 1.5-fold; phosphatidylinositol, 3.2-fold. In contrast, myo-[3H]inositol-containing phospholipids demonstrated relatively small increases (1.1- to 1.4-fold) after 5 min of incubation with insulin. These findings indicate that insulin stimulates de novo synthesis of chiro-inositol-containing phospholipids at the inositol phospholipid level.

Vulvar neoplasia associated with other primary malignancies

It is recognized that a significant number of patients with vulvar neoplasia have had previous, concurrent, or subsequent genital tract neoplasia. This has resulted in speculation that there may be a common etiology and, in particular, of the possibility of an infection element. Among 59 cases of vulvar cancer diagnosed at the National Taiwan University Hospital from 1976 to 1991, there were seven cases (12%) associated with other primary malignancies. Carcinoma of the cervix was the most frequent other primary cancer (6/7, 86%). The possible role of human papilloma virus infection in genital neoplasia is discussed.

Chiroinositol deficiency and insulin resistance. III. Acute glycogenic and hypoglycemic effects of two inositol phosphoglycan insulin mediators in normal and streptozotocin-diabetic rats in vivo

Two insulin mediators, inositol phosphoglycans, were isolated from bovine liver by methods previously developed for rat liver, i.e. chromatography on an AG 1 x 8 ion exchange column and selective elution with HCl at pH 2.0 and 1.3. The pH 2.0 mediator containing D-chiroinositol stimulated pyruvate dehydrogenase phosphatase, whereas the pH 1.3 mediator containing myo-inositol inhibited cAMP-dependent protein kinase. Each mediator was further purified by thin layer and Bio-Gel P4 column chromatography and injected ip into normal fed rats together with [U-14C]glucose. After 2.5 h, diaphragms were removed, and glycogen isolated. Insulin mediators, like insulin, stimulated [U-14C]glucose incorporation into glycogen by 150-160% in a dose-dependent manner in the nanomolar range. Mediators injected iv in the nanomolar range into low dose streptozotocin-diabetic rats decreased plasma glucose 30-45% in 30-60 min, with a return to basal concentrations after 150-180 min. These in vivo insulin-like effects of mediator were observed without changes in serum insulin concentrations. The pH 2.0 mediator was 50-100 times more active (per nmol organic phosphate) than the pH 1.3 mediator in the ip diaphragm glycogenesis assay. Mediator effects on diaphragm were completely blocked by preincubation with an immunopurified inositol phosphoglycan antibody. Both mediators were equally active iv in lowering plasma glucose (per nmol inositol) at concentrations comparable to those of insulin.

Chiroinositol deficiency and insulin resistance. II. Acute effects of D-chiroinositol administration in streptozotocin-diabetic rats, normal rats given a glucose load, and spontaneously insulin-resistant rhesus monkeys

The acute effects of administration of D-chiroinositol (D-CI), a component of a putative mediator of insulin action, on plasma glucose were examined in low dose streptozotocin-treated rats and normal rats given a glucose load and the effects on plasma glucose and insulin were determined in five obese rhesus monkeys with varying degrees of spontaneous insulin resistance. Single dose intragastric D-CI (10 mg/kg) administered to streptozotocin-treated rats produced a 30-40% decrease in plasma glucose (P < 0.05) at 30-120 min. Single dose intragastric D-CI (2-15 mg/kg) administered to normal rats 2 h before ip glucose produced a 30-50% decrease (P < 0.05) in plasma glucose. D-CI (10 mg/kg) caused a 50% increase (P < 0.05) in glucose disappearance rates in these rats. Myoinositol (10 mg/kg) was without effect. Intravenously administered single dose D-CI (100 mg/kg) increased both the glucose and insulin disappearance rates by 129 +/- 41% (mean +/- SE; P < 0.06) and 89 +/- 39% (P = 0.01), respectively, in all monkeys between 0-30 min compared to control values. D-CI administration, therefore, lowered elevated plasma glucose in streptozotocin-treated hyperglycemic rats, normal rats given a glucose load, and spontaneously insulin-resistant monkeys with or without noninsulin-dependent diabetes mellitus. Intravenous D-CI also lowered plasma insulin in these monkeys.

In vivo conversion of [3H]myoinositol to [3H]chiroinositol in rat tissues

We report here the in vivo conversion of [3H]myoinositol to [3H]chiroinositol. After labeling intraperitoneally with [3H]myoinositol for 3 days to reach radioisotope equilibrium in urine, [3H]chiroinositol was isolated from tissues and purified after 6 N HCl hydrolysis by two sequential paper chromatographies and high performance liquid chromatography (HPLC). Percent conversion of [3H]myoinositol to [3H]chiroinositol was highest in urine (36%), liver (8.8%), muscle (8.8%), and blood (7.6%) with intestine, brain, kidney, spleen, and heart decreasing in percentage from 2.8 to 0.7%. Labeling of other inositol isomers including scyllo-, neo-, and epi-, and mucoinositol was minimal, approximately 0.06% of [3H]myoinositol. Glucose was unlabeled, but glucuronate, the product of myoinositol oxidation, was labeled up to 1.5% of the [3H] myoinositol. Acid hydrolysates of combined inositol-containing phospholipids contain significant labeled chiroinositol. [3H]Phosphatidylinositols and [3H]glycosylphosphatidylinositols were extracted from liver, muscle, and blood, isolated by thin layer chromatography, and inositols purified by HPLC after acid hydrolysis. Percent conversion of [3H]myoinositol to [3H] chiroinositol was highest in blood (60.4%) followed by muscle (7.7%) and liver (2.2%).