Diagnostic accuracy of SSR-PET/CT compared to histopathology in the identification of liver metastases from well-differentiated neuroendocrine tumors

BACKGROUND

Histopathology is the reference standard for diagnosing liver metastases of neuroendocrine tumors (NETs). Somatostatin receptor-positron emission tomography / computed tomography (SSR-PET/CT) has emerged as a promising non-invasive imaging modality for staging NETs. We aimed to assess the diagnostic accuracy of SSR-PET/CT in the identification of liver metastases in patients with proven NETs compared to histopathology.

METHODS

Histopathologic reports of 139 resected or biopsied liver lesions of patients with known NET were correlated with matching SSR-PET/CTs and the positive/negative predictive value (PPV/NPV), sensitivity, specificity, and diagnostic accuracy of SSR-PET/CT were evaluated. PET/CT reading was performed by one expert reader blinded to histopathology and clinical data.

RESULTS

133 of 139 (95.7%) liver lesions showed malignant SSR-uptake in PET/CT while initial histopathology reported on 'liver metastases of NET´ in 127 (91.4%) cases, giving a PPV of 91.0%. Re-biopsy of the initially histopathologically negative lesions (reference standard) nevertheless diagnosed 'liver metastases of NET' in 6 cases, improving the PPV of PET/CT to 95.5%. Reasons for initial false-negative histopathology were inadequate sampling in the sense of non-target biopsies. The 6 (4.3%) SSR-negative lesions were all G2 NETs with a Ki-67 between 2-15%.

CONCLUSION

SSR-PET/CT is a highly accurate imaging modality for the diagnosis of liver metastases in patients with proven NETs. However, we found that due to the well-known tumor heterogeneity of NETs, specifically in G2 NETs approximately 4-5% are SSR-negative and may require additional imaging with [18F]FDG PET/CT.

Are Si-C bonds formed in the environment and/or in technical microbiological systems?

Organosiloxanes are industrially produced worldwide in millions of tons per annum and are widely used by industry, professionals, and consumers. Some of these compounds are PBT (persistent, biaccumulative and toxic) or vPvB (very persistent and very bioaccumulative). If organosiloxanes react at all in the environment, Si-O bonds are hydrolyzed or Si-C bonds are oxidatively cleaved, to result finally in silica and carbon dioxide. In strong contrast and very unexpectedly, recently formation of new Si-CH3 bonds from siloxanes and methane by the action of microorganisms under mild ambient conditions was proposed (in landfills or digesters) and even reported (in a biotrickling filter, 30 °C). This is very surprising in view of the harsh conditions required in industrial Si-CH3 synthesis. Here, we scrutinized the pertinent papers, with the result that evidence put forward for Si-C bond formation from siloxanes and methane in technical microbiological systems is invalid, suggesting such reactions will not occur in the environment where they are even less favored by conditions. The claim of such reactions followed from erroneous calculations and misinterpretation of experimental results. We propose an alternative explanation of the experimental observations, i.e., the putative observation of such reactions was presumably due to confusion of two compounds, hexamethyldisiloxane and dimethylsilanediol, that elute at similar retention times from standard GC columns.

Arthroplasty of the trapeziometacarpal joint with or without bioabsorbable polylactide scaffold (RegJoint™) interposition

The RegJoint™, a bioabsorbable polylactide scaffold, was introduced in 2011 for scaphometacarpal interposition following trapeziectomy for osteoarthritis. As previous clinical trials provided controversial results, we aimed to prove the non-inferiority of RegJoint™ interposition. In this retrospective study, first metacarpal suspension arthroplasty alone (SA) was compared to suspension with RegJoint™ interposition (RJ). Thirty-four patients with 37 treated thumbs (SA: 14; RJ: 23) were assessed clinically and radiologically at a mean follow-up of 5.3 ± 2.6 years (SA: 7.96; RJ: 3.73). Patient-reported outcomes were measured on three questionnaires (DASH, PRWE and PEM) and a visual analogue pain scale; there were no significant differences between the 2 groups. Clinical assessment comprised range of motion, opposition, pain, first-ray length, hand span, prominence, instability, force and sensitivity to touch. The RJ group showed significantly better palmar abduction (p = 0.026); the other outcome parameters were comparable in the 2 groups. Follow-up radiographs showed osteolysis in 2 SA hands and 3 RJ hands (p = 0.551). First-ray length had decreased by a mean 4.7 ± 2.7 mm at follow-up (SA: -3.8; RJ: -5.2; p = 0.056). No signs of adverse tissue reactions were observed. We conclude that RegJoint™ spacers do not produce more complications than suspension alone but provide no added benefit.

Osteoporosis is accompanied by reduced CD274 expression in human bone marrow-derived mesenchymal stem cells

Underlying pathomechanisms of osteoporosis are still not fully elucidated. Cell-based therapy approaches pose new possibilities to treat osteoporosis and its complications. The aim of this study was to quantify differences in human bone marrow-derived mesenchymal stem cells (hBMSCs) between healthy donors and those suffering from clinically manifest osteoporosis. Cell samples of seven donors for each group were selected retrospectively from the hBMSC cell bank of the Trauma Department of Hannover Medical School. Cells were evaluated for their adipogenic, osteogenic and chondrogenic differentiation potential, for their proliferation potential and expression of surface antigens. Furthermore, a RT2 Osteoporosis Profiler PCR array, as well as quantitative real-time PCR were carried out to evaluate changes in gene expression. Cultivated hBMSCs from osteoporotic donors showed significantly lower cell surface expression of CD274 (4.98 % ± 2.38 %) than those from the control group (26.03 % ± 13.39 %; p = 0.007), as assessed by flow cytometry. In osteoporotic patients, genes involved in inhibition of the anabolic WNT signalling pathway and those associated with stimulation of bone resorption were significantly upregulated. Apart from these changes, no significant differences were found for the other cell surface antigens, adipogenic, osteogenic and chondrogenic differentiation ability as well as proliferation potential. These findings supported the theory of an influence of CD274 on the regulation of bone metabolism. CD274 might be a promising target for further investigations of the pathogenesis of osteoporosis and of cell-based therapies involving MSCs.

The dorsal tangent line - A new approach in the radiological analysis of metacarpal fractures

Traditionally, the angle between the intersecting central axes (lateral projection intersecting central axes - LCA) of the proximal and distal fragments of metacarpal fractures is measured on radiographs. We recommend using the angle between the intersecting dorsal tangent lines instead (lateral projection intersecting dorsal tangent lines - LDT). We analyzed radiographs of 25 fractures of the fifth metacarpal bone shaft in three planes. Intraclass correlation coefficients (ICC) were used to estimate inter-rater and intra-rater reliability. Mean palmar tilt was 35.6° ± 12.5° according to LCA and 27.6° ± 12.0° according to LDT. There were no differences during repeated measurements. Intra-rater reliability was high: ICC (95% CI) for LDT was 0.82 (0.74-0.88) and for LCA it was 0.71 (0.51-0.83). Mean values of palmar tilt using LCA exceeded those using LDT by 8.0° ± 7.7° (p < 0.001). Only LDT measurements provided comparable results between all raters. In conclusion, we demonstrated the feasibility and reliability of intersecting dorsal tangent lines for measuring palmar tilt in fifth metacarpal fractures as an alternative to the commonly used angle between the intersecting central axes.

Fractures of the transverse processes of the fourth and fifth lumbar vertebrae in patients with pelvic ring injuries

Aims

This study aimed to analyze the correlation between transverse process (TP) fractures of the fourth (L4) and fifth (L5) lumbar vertebrae and biomechanical and haemodynamic stability in patients with a pelvic ring injury, since previous data are inconsistent.

Patients and Methods

The study is a retrospective matched-pair analysis of patients with a pelvic fracture according to the modified Tile AO Müller and the Young and Burgess classification who presented to a level 1 trauma centre between January 2005 and December 2014.

Results

A total of 728 patients with pelvic ring injuries were included, of whom 183 (25.1%) had a biomechanically unstable pelvic fracture. Of these patients, 84 (45.9%) had a fracture of a TP of L4 and/or L5. A total of 73 patients (13.4%) with a stable pelvic ring injury (p < 0.001) had a fracture of a TP. Patients with a fracture of a TP of L4 and/or L5 had a 5.5-fold risk (odds ratio (OR)) of having a biomechanically unstable pelvic injury. TP fractures (OR 1.6, p = 0.2) could not be confirmed as an independent predictor of haemodynamic instability.

Conclusion

This is the first study that has demonstrated a positive correlation between a TP fracture of L4 and/or L5 and a biomechanically unstable pelvic ring injury. The presence of transverse process fractures of L4 and/or L5 indicates increased severity of pelvic injury and therefore can help in the planning of emergency treatment. Cite this article: Bone Joint J 2018;100-B:1214–19.

[Injury prevention in amateur football with FIFA 11+ : What is implemented on the football pitch?]

BACKGROUND

The warm-up and injury prevention program FIFA 11+ was developed to reduce injuries in recreational and amateur level football. Despite systematic education it is uncertain what amount of knowledge is passed down to the lower recreational level football players and what exercises are implemented in the daily routine. This study presents the summarized experiences of German coaches about the implementation of exercises on the football pitch.

MATERIAL AND METHODS

In this study 142 coaches who participated in 1 (of 5) of the 2‑day courses between 2013 and 2017 were sent a questionnaire. The questionnaire consisted of 24 questions, which were developed by the football union of Lower Saxony. Incomplete questionnaires were excluded from the study.

RESULTS

A total of 121 questionnaires could be analyzed, which is a response rate of 85.2%. The mean time period between the 2‑day training and answering the questionnaire was 29 months. Of the participating coaches 82.6% indicated that they use the program regularly (22% of the coaches use it twice a week or more frequently, 34% use it only once a week) and 6% of the coaches use additional programs to prevent injuries. A total of 86% of the participants believed in a reduction in the incidence of injuries induced by the FIFA 11+ concept, 89% of the participants rated the FIFA 11+ program as good ors very good, 91% rated the teaching concept as good or very good and 94% of the participants would recommend the 2‑day advanced course to others.

DISCUSSION

The prevention program as well as the advanced training concept were evaluated very positively. Most coaches use the program regularly. Nevertheless, many coaches use the FIFA 11+ exercises less than the recommended twice a week. Most coaches praised the good structure of the program, but also wished for the possibility of variations.

CONCLUSION

The prevention program FIFA 11+ is seen by coaches in recreational and amateur football as an effective tool to prevent injury. Implementation on the football pitch is regular but not as frequent as the evidence-based recommendations in the training concept.

Injuries to the upper extremities in polytrauma: limited effect on outcome more than ten years after injury - a cohort study in 629 patients

AIMS

To analyse the influence of upper extremity trauma on the long-term outcome of polytraumatised patients.

PATIENTS AND METHODS

A total of 629 multiply injured patients were included in a follow-up study at least ten years after injury (mean age 26.5 years, standard deviation 12.4). The extent of the patients' injury was classified using the Injury Severity Score. Outcome was measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form (SF)-12, rehabilitation duration, and employment status. Outcomes for patients with and without a fracture of the upper extremity were compared and analysed with regard to specific fracture regions and any additional brachial plexus lesion.

RESULTS

In all, 307 multiply-injured patients with and 322 without upper extremity injuries were included in the study. The groups with and without upper limb injuries were similar with respect to demographic data and injury pattern, except for midface trauma. There were no significant differences in the long-term outcome. In patients with brachial plexus lesions there were significantly more who were unemployed, required greater retraining and a worse HASPOC.

CONCLUSION

Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus. Cite this article: Bone Joint J 2017;99-B:255-60.

Is there a benefit for health care workers in testing HIV, HCV and HBV in routine before elective arthroplasty?

INTRODUCTION

Occupational infection of clinical health care workers with blood-borne viruses (BBVs) like human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV) is a current and often emotionally discussed issue. HCV and especially HIV are still stigmatized. The consequence is a broad and maybe irrational fear of professional health care workers being infected occupationally. Therefore, we assessed preoperative screening to: (1) answer whether this can detect not previously diagnosed blood-borne virus infections to a great extent, (2) calculate a cost-benefit ratio to find out, if the screening's potential ability to prevent occupational transmission of BBVs to health care workers faces unjustifiable high costs.

HYPOTHESIS

Preoperative routine screening is limited suitable for enhancement of detecting fomites compared to interview the patient.

MATERIALS AND METHODS

Retrospective cohort study of preoperative screening for HIV, HBV and HCV (HBsAg, anti-HCV and HIV-Ab/Ag-Combination) for every patient who was admitted to the traumatologic department for elective arthroplasty between 01/01/1997 and 31/12/2008.

RESULTS

Among the 1534 patients who underwent elective prosthetic surgery [total hip (879) and knee arthroplasty (508), followed by shoulder, elbow and upper ankle joint], 693 (45.2%) patients were male and 841 (54.8) female. Mean age was 64.2±13.8 years. Screening tests were available for 1373 patients (89.5%). Among all screened patients, we found 21 HCV, 10 HBV and 1 HIV infections. 5 HBV (0.5%) and 7 HCV infections (0.7%) were unknown before. Every newly detected infectious patient occasions screening costs about 7250€. Considering this data, the risk of HCV transmission from an index patient with unknown status of infectiousness to health care worker after percutaneous contact to blood is 0.08 ‰ and of HIV transmission is 0.00054 ‰ in our study population.

DISCUSSION

Routine preoperative screening for BBVs of patients undergoing elective arthroplasty, who were asked for HBV, HCV and HIV, should be reconsidered and is, in times of sparse funds, overpriced.

LEVEL OF EVIDENCE

IV.

Quantitative determination of ultra-trace carbazoles in sediments in the coastal environment

Carbazole and some of its derivatives may possess dioxin-like toxicity and could be persistent in the environment, but information on their distribution and environmental fate is limited. This study developed and validated an ultra-trace targeted-analysis method for the determination of carbazole, 1,2-benzocarbazole, and 13 halogenated carbazoles in sediments from the river, coast, and North Sea. An 8-g sediment sample was extracted using accelerated solvent extraction combined with in-cell cleanup and analyzed using gas chromatography-tandem mass spectrometry. The method was sensitive and reliable with method detection limits ranging from 4.54 to 52.9 pg/g, and most of the quantification biases and relative standard deviations were <20 and <15%, respectively. Carbazole and 1,2-benzocarbazole were the predominant substances in the sediments (median 565 and 369 pg/g, respectively) followed by 3,6-dichlorocarbazole (median 196 pg/g). The detection frequencies of carbazole, benzo-, 3-chloro-, and 3,6-dichlorocarbazole were >75%, while those of 3,6-dibromo-, 1-bromo-3,6-dichloro-, and 1,8-dibromo-3,6-dichlorocarbazole were approximately 50%. Brominated carbazoles occurred more frequently in marine than river-influenced sediments, which could indicate halogenation after discharge into the river. This is the first study regarding these substances in coastal environments without apparent contamination history. The ubiquity and bioaccumulative potential of these substances needs to be considered.

Kinetic therapy in multiple trauma patients with severe blunt chest trauma: an analysis at a level-1 trauma center

BACKGROUND AND OBJECTIVES

Chest trauma is a relevant risk factor for mortality after multiple trauma. Kinetic therapy (KT) represents a potential treatment option in order to restore pulmonary function. Decision criteria for performing kinetic therapy are not fully elucidated. The purpose of this study was to investigate the decision making process to initiate kinetic therapy in a well defined multiple trauma cohort.

METHODS

A retrospective analysis (2000-2009) of polytrauma patients (age > 16 years, ISS ⩾ 16) with severe chest trauma (AIS(Chest) ⩾ 3) was performed. Patients with AIS(Head) ⩾ 3 were excluded. Patients receiving either kinetic (KT+) or lung protective ventilation strategy (KT-) were compared. Chest trauma was classified according to the AIS(Chest), Pulmonary Contusion Score (PCS), Wagner Jamieson Score and Thoracic Trauma Severity Score (TTS). There were multiple outcome parameters investigated included mortality, posttraumatic complications and clinical data. A multivariate regression analysis was performed.

RESULTS

Two hundred and eighty-three patients were included (KT+: n=160; KT-: n=123). AIS(Chest), age and gender were comparable in both groups. There were significant higher values of the ISS, PCS, Wagner Jamieson Score and TTS in group KT+. The incidence of posttraumatic complications and mortality was increased compared to group KT- (p< 0.05). Despite that, kinetic therapy failed to be an independent risk factor for mortality in multivariate logistic regression analysis.

CONCLUSIONS

Kinetic therapy is an option in severely injured patients with severe chest trauma. Decision making is not only based on anatomical aspects such as the AIS(Chest), but on overall injury severity, pulmonary contusions and physiological deterioration. It could be assumed that the increased mortality in patients receiving KT is primarily caused by these factors and does not reflect an independent adverse effect of KT. Furthermore, KT was not shown to be an independent risk factor for mortality.

Performance of calorimetric methods for the investigation of microbial systems in combination with additional sensors

Calorimetric methods are used in combination with online oxygen measurement (using an amperometric sensor) and determination of the optical density (using a fibre optic sensor) to investigate microbial growth behaviour. The calorimetric curves of different batch experiments show a characteristic and reproducible course. Changes in the slope of the DeltaT-time curves indicate the effects of limiting factors on the microbial activity during the cultivation. A first limitation could be correlated with the depletion of oxygen in the medium; a second correlates with the depletion of the carbon source. Measurements of optical density in some cases provide reliable information about the growth of a microorganism culture. Our measurements show a good correlation of the universal calorimetric signal (heat-time curve) to the signal of the miniaturised photometric (OD) sensor.

Chemically patterned, metal oxide based surfaces produced by photolithographic techniques for studying protein- and cell-surface interactions I: Microfabrication and surface characterization

Chemical patterns on smooth wafer substrates comprising areas with two different metals have been produced by vacuum metal deposition and photolithographic techniques. The combination of metals has been chosen from the series titanium (Ti), aluminium (Al), vanadium (V) and niobium (Nb), producing patterns (dots and stripes with dimensions of 50, 100 and 150 micrometer) with one of the metals as the background and with the second metal (foreground pattern) deposited on the background metal. The structure and chemical composition of the patterned surfaces were evaluated by scanning electron microscopy, X-ray photoelectron spectroscopy and imaging time-of-flight secondary-ion mass spectrometry. The surfaces proved to be geometrically well defined with the expected surface-chemical composition, i.e. a surface oxide (passive) film essentially composed of TiO(2),Al(2)O(3),V(2)O(5), or Nb(2)O(5). Ti/Ti patterned surfaces were produced as controls and found to show no chemical composition contrast. The surface roughness of the pattern was greater than that of the background by a factor of 2-3, but was still extremely smooth with Ra<2nm. The patterns serve as model surfaces for studying in vitro the behaviour of cells as well as the adsorption of serum proteins on different metal oxides, which will be reported in a companion paper. These surfaces can be used to compare and contrast the response of osteoblasts to Ti and other alloy components, such as Al, V, or Nb, which are used in load-bearing medical implants.

Chemically patterned, metal-oxide-based surfaces produced by photolithographic techniques for studying protein- and cell-interactions. II: Protein adsorption and early cell interactions

Protein adsorption and adhesion of primary human osteoblasts on chemically patterned, metal-oxide-based surfaces comprising combinations of titanium, aluminium, vanadium and niobium were investigated. Single metal samples with a homogeneous surface and bimetal samples with a surface pattern produced by photolithographic techniques were used. The physical and chemical properties of the samples have been extensively characterised and are presented in a companion paper. Here, we describe their properties in terms of cell responses during the initial 24h of cell culture. Regarding the cell number and activity there was no significant difference between any of the single metal surfaces. However the morphology of cells on vanadium surfaces became spindle-like. In contrast to the behaviour on single metal samples, cells exhibited a pronounced reaction on bimetallic surfaces that contained aluminium. Cells tended to stay away from aluminium, which was the least favoured metal in all two-metal combinations. An initial cell alignment relative to the pattern geometry was detectable after 2h and was fully developed after 18h of incubation. The organisation of f-actin and microtubules as well as the localisation of vinculin were all more pronounced on non-aluminium regions. We hypothesised that the differences in cell response could be associated with differences in the adsorption of serum proteins onto the various metal oxides. Protein adsorption experiments were performed using microscopy in conjunction with immunofluorescent stains. They indicated that both fibronectin and albumin adsorption were significantly greater on the non-aluminium regions, suggesting that differences in cellular response correlate with a modulation of the concentration of serum proteins on the surface.

Elevated DNA sequence diversity in the genomic region of the phosphatase PPP2R3L gene in the human pseudoautosomal region

The evolution, inheritance and recombination rate of genes located in the pseudoautosomal region 1 (PAR1) is exceptional within the human genome. Pseudoautosomal genes are identical on X and Y chromosomes and are not inherited in a sex linked manner. Due to an obligatory recombination event in male meiosis, pseudoautosomal genes are exchanged frequently between X and Y chromosomes. During the isolation, characterization and sequencing of a novel gene PPP2R3L, which was classified by sequence homology as a novel member of the protein phosphatase regulatory subunit families, it became apparent that cosmids of different origin harboring this gene are highly polymorphic between individuals, both at the nucleotide level and in the number.

Abnormal XY interchange between a novel isolated protein kinase gene, PRKY, and its homologue, PRKX, accounts for one third of all (Y+)XX males and (Y-)XY females

XX males and XY females have a sex reversal disorder which can be caused by an abnormal interchange between the X and the Y chromosomes. We have isolated and characterized a novel gene on the Y chromosome, PRKY. This gene is highly homologous to a previously isolated gene from Xp22.3, PRKX, and represents a member of the cAMP-dependent serine threonine protein kinase gene family. Abnormal interchange can occur anywhere on Xp/Yp proximal to SRY. We can show that abnormal interchange happens particularly frequently between PRKX and PRKY. In a collection of 26 XX males and four XY females, between 27 and 35% of the interchanges take place between PRK homologues but at different sites within the gene. PRKY and PRKX are located far from the pseudoautosomal region where XY exchange normally takes place. The unprecedented high sequence identity and identical orientation of PRKY to its homologous partner on the X chromosome, PRKX, explains the high frequency of abnormal pairing and subsequent ectopic recombination, leading to XX males and XY females and to the highest rate of recombination outside the pseudoautosomal region.

Pseudoautosomal deletions encompassing a novel homeobox gene cause growth failure in idiopathic short stature and Turner syndrome

Growth retardation resulting in short stature is a major concern for parents and due to its great variety of causes, a complex diagnostic challenge for clinicians. A major locus involved in linear growth has been implicated within the pseudoautosomal region (PAR1) of the human sex chromosomes. We have determined an interval of 170 kb of DNA within PAR1 which was deleted in 36 individuals with short stature and different rearrangements on Xp22 or Yp11.3. This deletion was not detected in any of the relatives with normal stature or in a further 30 individuals with rearrangements on Xp22 or Yp11.3 with normal height. We have isolated a homeobox-containing gene (SHOX) from this region, which has at least two alternatively spliced forms, encoding proteins with different patterns of expression. We also identified one functionally significant SHOX mutation by screening 91 individuals with idiopathic short stature. Our data suggest an involvement of SHOX in idiopathic growth retardation and in the short stature phenotype of Turner syndrome patients.

FISH localization of the human Y-homolog of protein kinase PRKX (PRKY) to Yp11.2 and two pseudogenes to 15q26 and Xq12-->q13

Recently, we reported the isolation of a new subfamily of serine-threonine protein kinases. This subfamily was shown to consist of at least four members. Sequencing and FISH mapping of all 4 members now reveals that the Y-homolog (PRKY) of the previously mapped PRKX gene (Xp22.3) is located in Yp11.2, in close vicinity to AMELY. The other two copies reside on Xq12-->q13 (PRKXP2) and 15q26 (PRKXP1, containing CA repeat STS D15S87) and represent pseudogenes.

Association of primary renal non-Hodgkin's lymphoma with mesangioproliferative glomerulonephritis

A 27-year-old male developed nonoliguric renal failure. Renal biopsy of the left kidney showed infiltration by a diffuse large-cell non-Hodgkin's lymphoma (NHL). Laparoscopy, CT scans of the abdomen and thorax, and bone-marrow biopsy revealed no further manifestations of lymphoma. Primary renal NHL was diagnosed. The patient attained complete remission with cyclophosphamide, adriamycin, vincristine, and prednisone (CHOP) chemotherapy and remained disease-free for 13 years. Eight years after his first presentation, the patient developed acute oliguric renal failure with nephrotic syndrome. Mesangioproliferative glomerulonephritis was diagnosed in a biopsy of the left kidney. Chronic hemodialysis was required until cadaver kidney transplantation was successfully performed 5 years later. Although the association of NHL and glomerulonephritis has been described several times before, to our knowledge this is the first report of glomerulonephritis in primary renal lymphoma.

The human protein kinase gene PKX1 on Xp22.3 displays Xp/Yp homology and is a site of chromosomal instability

We have isolated a gene, PKX1, by virtue of its position within the candidate region for chondrodysplasia punctata in Xp22.3. Although data from one patient render it unlikely that PKX1 is the CDPX gene, this gene shows several interesting features. First, PKX1 appears to encode a novel type of human protein kinase that is related to the catalytic subunit of cAMP-dependent protein kinases and has striking homology to the DC2 protein kinase from Drosophila melanogaster. Second, PKX1 is part of a family of at least four genes or pseudogenes, of which three map to the human sex chromosomes. In contrast to all other genes from the X-specific region of Xp22.3, PKX1 has a homologue on Yp rather than Yq. This is intriguing as it indicates that the single pericentric inversion event hypothesized to have occurred during primate evolution is not sufficient to explain the present X/Y-homology pattern of Xp22.3. Third, we have characterized patients with different chromosomal rearrangements in Xp22.3 or Yp and show that a high proportion of these have occurred within the PKX1 locus. This suggests that the PKX1 gene, besides harbouring a previously described hot-spot for illegitimate Xp/Yp-recombination, contains additional sequences predisposing to chromosomal breakage events.

Results of conventional-dose cytosine arabinoside and idarubicin in elderly patients with acute myeloid leukemia

Conventional-dose Ara-C (200 mg/m2 d 1-5) combined with idarubicin (12 mg/m2 d 1-3) was employed as remission induction and consolidation therapy in 23 elderly AML patients with a median age of 66 years (range, 60-75) with AML according to the FAB criteria (M1 n = 3, M2 n = 10, M4 n = 6, M5 n = 2, M6 n = 2), eligible for the study. In seven patients earlier MDS had been documented by previous bone marrow aspirates. The CR rate after one induction course was 65% (15/23). Toxicity was acceptable, with four patients dying during the chemotherapy-induced hypoplasia (4/23). Although 80% of the CR patients received two additional cycles of Ara-C and idarubicin as consolidation therapy, only two patients are still in continuous complete remission more than 12 months after achieving CR. The median disease-free survival of the CR patients was 11.5 months and the median survival of the entire group was 10 months. We conclude that conventional dose Ara-C/idarubicin is an effective protocol for inducing complete remission in elderly patients with AML, but that consolidation therapy consisting of two courses of the same regimen does not produce a relevant rate of long-term disease-free survival.

Serum deoxythymidine kinase in myelodysplastic syndromes

BACKGROUND

Previous studies have shown that serum levels of deoxythymidine kinase (sTK) provide useful prognostic information in various malignancies, such as Hodgkin's disease, non-Hodgkin's lymphomas, multiple myeloma, and acute myeloid leukemia (AML).

METHODS

Using a radioenzyme assay, the authors determined sTK in 146 patients with primary myelodysplastic syndromes (MDS). Morphologic subtypes were refractory anemia (RA) in 18 patients, RA with ring sideroblasts (RARS) in 24, RA with excess of blasts (RAEB) in 41, RAEB in transformation (RAEB/T) in 29, and chronic myelomonocytic leukemia (CMML) in 34.

RESULTS

Enzyme levels ranged from 1.1 to 829 U/microliters. One hundred fifteen (79%) patients had elevated sTK levels (more than 5 U/microliters) at the time of diagnosis. In advanced stages of MDS (RAEB, CMML, and RAEB/T) enzyme activities were higher than in early stages (RA and RARS) (P < 0.05). However, sTK levels were not correlated with the percentage of medullary blast cells. Among other parameters tested, the best correlation with sTK was found for serum lactate dehydrogenase (LDH) activity (r = 0.29; P < 0.0005). As shown by life table analysis, sTK activity at diagnosis provided useful information regarding the prognosis of patients. For patients with sTK levels of less than 10 U/microliters, actuarial survival after 2 years was 65%, compared with 33% for those with enzyme values of 10 U/microliters or greater. The 5-year cumulative survival rates were 34% and 14%, respectively (P < 0.0005). However, sTK levels at diagnosis were not useful for predicting transformation to AML. Nine of 61 (15%) patients with sTK of less than 10 U/microliters had AML develop, whereas 15 of 57 (26%) patients with sTK of 10 U/microliters or greater had disease progress to acute leukemia (chi-square, 1.64; P = 0.2).

CONCLUSIONS

Considering the lack of correlation with bone marrow blasts, the authors conclude that increased sTK levels in MDS are primarily attributable to intramedullary destruction of hematopoietic precursors and do not reflect the leukemic blast cell burden. This appears similar to the ineffective hematopoiesis of vitamin B12 deficiency, which is associated with elevated levels of sTK and LDH. The data suggest that sTK is a prognostic parameter that can be used to predict the survival of patients with MDS. However, multivariate analysis shows that the predictive value of sTK is not superior to that of LDH.

Anticipatory nausea in cancer patients receiving chemotherapy: classical conditioning etiology and therapeutical implications

The delivery of cytotoxic drugs in cancer treatment is often accompanied by posttreatment side effects (e.g., nausea). Moreover, there is evidence that cancer patients are at risk to develop these side effects in anticipation of chemotherapy (i.e., anticipatory nausea [AN]). AN can be explained as the result of a classical conditioning process with the cytotoxic drug as the unconditioned stimulus (US). Stimuli paired with the US (e.g., smells, tastes) can become conditioned stimuli (CSs) eliciting AN as the conditioned response (CR). The present study was conducted to test whether AN shows characteristics of a CR. Fifty-five ambulatory cancer patients were asked to record nine kinds of physical symptoms (e.g., nausea, vomiting, sweating) on time-scheduled symptom lists: after an infusion (indicating posttreatment symptoms) and prior to their next infusion (indicating anticipatory symptoms). Each measurement period covered a maximum of 48 hours. AN was reported by ten patients (18.08%). Data revealed (a) a statistically significant association between posttreatment nausea and vomiting, respectively, and AN; (b) the occurrence of AN increased with drug emetogenity (i.e., US-intensity); and (c) the duration of AN increased with temporal proximity to the infusion. The results support the conditioning model. Thus, it is proposed to prevent AN by classical conditioning techniques (e.g., overshadowing).

Treatment results of the thioether lipid ilmofosine in patients with malignant tumours

In a multicentre study patients with liver metastases stratified to the histology of the primary tumour were investigated. A total of 102 patients with colorectal adenocarcinoma, non-small-cell lung cancer, pancreatic cancer, primary liver carcinoma and malignant melanoma were treated with the thioether lipid ilmofosine. The drug was administered orally as a tablet at a dosage of 150-300 mg/day (75 mg/tablet). The tolerability of ilmofosine was poor. There was a dose-limiting gastrointestinal toxicity with nausea, vomiting and loss of appetite (WHO grade II-IV) in 67% of patients. During the period of therapy (1-29 weeks, 8.5 weeks mean) no complete remission and no partial response were observed. We thus conclude that treatment with oral ilmofosine is not effective in patients with liver metastases due to various malignancies.

A randomized controlled trial of adjuvant immunotherapy (murine monoclonal antibody 494/32) in resectable pancreatic cancer

In a prospective randomized multicentric trial, 61 patients from six hospitals with resectable pancreatic cancer were recruited between 1987 and 1989. All patients underwent a Whipple resection. Two weeks after surgery, the patients were randomized to be given either intravenous (IV) treatment with 370 mg (100 mg loading dose, 9 x 30 mg continuing within 10 days) of monoclonal antibody (MoAb) 494/32 (Behringwerke AG, Marsburg, Germany) or no additional anti-cancer treatment. This murine immunoglobulin (Ig) G1 antibody has been shown to strongly bind to human pancreatic cancer cells and to induce an antibody-dependent cellular cytotoxicity (ADCC). Both study groups were well matched with respect to age, sex, tumor staging, and grading. Six patients suffered from minor toxicity (vomiting and abdominal pain) after immunotherapy. Ten months after the end of the recruitment period, 65% and 53% of the patients in the treatment and control groups, respectively, had died. Of the living patients, 60% and 53% are alive with recurrent or progressive cancer disease. Median survival time was 428 days (range, 248 to 510 days) and 386 days (range, 296 to 509 days) in the treatment and control groups, respectively. The authors concluded that repeated IV treatment with the antibody 494/32 is not helpful in resectable pancreatic cancer. This study provides the first controlled data on passive immunotherapy in solid cancer.

Lavage fluid from continuous ambulatory peritoneal dialysis. A model for mesothelial cell changes

Continuous ambulatory peritoneal dialysis (CAPD) lavage can be interpreted as an artificial short-term ascites. The cellular content of 362 CAPD specimens from 32 patients was investigated. Irregular inflammatory reactions were seen in 85.3% of the specimens and eosinophilia in 27.6%. Mesothelial aggregates of great variability were registered in 59.4% of the specimens and mainly atypical mitoses in 7.5%. The cytologic changes seen in those patients from whom lavage fluids were examined over 10 to 12 months did not correlate with the changes in blood chemistry (BUN and creatinine) in those cases.

Significance of polyploidy in megakaryocytes and other cells in health and tumor disease

Polyploidy--the doubling of chromosome sets of cells caused by a stop of mitosis at different levels of the mitotic cycle--is a phenomenon widely observed in plants, protozoa, metazoa, and animals. In man obligate polyploid tissues are found in liver parenchyma, heart muscle cells, and bone marrow megakaryocytes. Polyploidy occurs mostly in stable and highly differentiated cells and tissues. Besides age, stimulation of proliferation and increased metabolic function lead to polyploidization in these organs. Aneuploidy, however, is exclusively found in tumor cells. Megakaryocyte differentiation and polyploidy are controlled by thrombopoietin-like activities, of which the loci of production are still unknown. Megakaryocytes are unique among polyploid mammal cells. On the precursor level they maintain their proliferative activity independently of the mammal's age. Once having entered the incomplete mitotic cycle they stop cytokinesis and develop into highly polyploid cells. Polyploidization of megakaryocytes is the basic requirement for establishing highly effective hemostasis in mammals, which exhibit blood circulation based on high blood pressures. Every polyploidization results in increased production of membrane materials with which the platelet becomes endowed. By shedding cytoplasmic fragments approximately 3000 platelets are set free from a 32c megakaryocyte, compared with only 16 nucleated thrombocytes by mitotic division. There is further evidence that the heterogeneity of platelets mostly depends on the different polyploidy classes of the megakaryocytes from which they are derived. Changes in the polyploidy pattern of megakaryocytes could therefore have consequences for hemostatic disorders in several human diseases, particularly in malignancy.

Acute myelofibrosis in megakaryoblastic leukemia with translocation between chromosomes 8 and 14

In a 45-year-old woman with severe normochromic anemia (Hb 2.8 g%) an extensive myelofibrosis and infiltration of the bone marrow with small blasts was observed histologically. Cytochemical examination of the blasts showed a negative peroxidase and a strongly positive alpha-NE reaction. PAS reaction was slightly granular positive in the cytoplasmic protuberances of the blasts and in the platelets. Marker analysis yielded no evidence of lymphatic origin of the blasts. In flow-cytometric studies of 230,000 cells a homogeneous 2c blast population could be identified. Cytogenetic analysis revealed an abnormal pseudo-diploid karyotype characterized by 2 acrocentric marker chromosomes caused by a translocation of chromosomes 8 and 14, as usually seen in Burkitt type lymphoma. Finally the reaction product of platelet-specific peroxidase could be demonstrated in the perinuclear cisternae of the endoplasmic reticulum by electron microscopy. Highly elevated beta-thromboglobulin and platelet factor 4 plasma levels were also measured. Following an ineffective treatment with daunoblastine and ARA-C, the patient died of pseudomonas aeruginosa septicemia after having received high-dose ARA-C treatment.

Correlation of abdominal CT imaging with autopsy findings in patients with malignant tumors

The value of abdominal computed tomography (CT) in diagnosing localized involvement of liver, pancreas, adrenals, and lymph nodes was evaluated in 117 patients with suspected or known malignant tumors by correlation with autopsy findings. Sensitivity, specificity, and accuracy of CT for localized liver disease was calculated to be 80% (84%), 96% (97%), and 90% (92%); for pancreatic tumors: 81% (86%), 98% (100%), and 95% (97%); for adrenal tumors: 65% (92%), 100% (100%), and 92% (98%); and for lymph node enlargement 75 (88%), 97% (98%), and 87% (94%), respectively. Results of routine evaluation could be improved, especially in the adrenal region, when scans were reevaluated by highly experienced examiners (results given in parenthesis). Computed tomography is a highly valuable diagnostic tool in the primary diagnosis and in the follow-up of tumor patients. The high costs are offset by a reduction in invasive procedures and a shortened hospital stay.

Severe hemolysis caused by antibodies against the mushroom Paxillus involutus and its therapy by plasma exchange

It has been shown that fatal "poisoning" with the mushroom species Paxillus involutus is caused by antibodies against the fungus in sensitized patients. Because circulating immune complexes play an important role, therapeutic procedures which can eliminate those complexes could stop immune hemolysis. A 37-year-old patient became severely ill after repeated ingestion of sufficiently cooked Paxillus involutus. As a result of hemolysis with reversible shock symptoms, acute renal failure developed. Plasma exchange with 3,000 ml albumin 5% was carried out daily during the first 3 days after admission. Each plasma exchange lowered free hemoglobin and immune complex levels by 60%-75%. Acute renal failure was successfully treated with hemodialysis. Specific IgG-antibodies against membrane particles of Paxillus involutus were detected by hemagglutination tests in the serum of the patient. The sequence of reactions resulting from the testing procedures strongly suggests the formation of immune complexes. These complexes are likely to bind to erythrocytes acting as innocent bystanders. Activation of the complement system finally results in hemolysis and shock. In addition to adequate shock treatment elimination of these immune complexes by plasma separation seems to be the therapy of choice.