Value of stimulated pre-ablation thyroglobulin as a prognostic marker in patients with differentiated thyroid carcinoma treated with radioiodine

OBJECTIVE

To determine which Thyroglobulin (Tg) level after levothyroxine (LT₄) withdrawal (stimulated thyroglobulin - sTg) measured before radioiodine therapy (RAIT) is able to predict incomplete response to treatment of differentiated thyroid carcinoma (DTC) with greater sensitivity and specificity one year after initial treatment with I¹³¹.

METHODS

A chart review was performed in which 375 patients with DTC treated with RAIT were included. The sTg was measured in all patients prior to treatment with I¹³¹. Follow up were then performed one year later. Initial sTg levels were associated to DTC outcomes. A receiver operating characteristic (ROC) curve was performed to achieve a sTg level able to predict which patients would have a greater chance of having an incomplete response to RAIT.

RESULTS

Incomplete response to treatment was found in 122 patients (32.5%), this group had a mean sTg of 23.2 ng/mL. ROC curve showed that the optimal cut-off sTg level was 4.4 ng/mL. (sensitivity: 72.1%; specificity: 72.3%; accuracy: 72.2%; positive predictive value of 55.7%; and negative predictive value: 84.3%).

CONCLUSION

sTg pre-ablation is a valuable predictor of DTC incomplete response to treatment one year after RAIT. Levels of 4.4 ng/ml or more showed higher accuracy to predict this outcome.

Kappa accuracy of prototypical diagnosis and ICD-10 criteria for mental disorders: A cross-sectional study in a real-life setting

Introduction

The use of “operational criteria” in DSM-III was proposed as a solution to low reliability among psychiatrist’s diagnosis. It is considered a turning point in the psychiatric classification and diagnostic process, furtherly adopted in ICD. However, the utility of using such criteria in everyday clinical practice is still not clear.

Objectives

To measure agreement between prototypical and ICD-10 categorical diagnosis.

Methods

In IPUB’s outpatient clinics, psychiatry residents work in a real-life clinical scenario, attending patients from Rio de Janeiro/RJ-Brazil. Although regularly trained in ICD criteria, it is not usual to check every criterion in their daily practice. Thus, patients are diagnosed with a prototype-based disorder, not necessarily strictly attached to ICD criteria. We propose a cross-sectional study, where psychiatry residents check their clinical diagnosis according to ICD criteria and compare its agreement with kappa statistics.

Results

Three of thirty residents joined the study, providing diagnosis for 146 patients under their care. Forty-five diagnoses were obtained before and 51 after ICD-10 criterion application. Diagnoses were grouped under 8 groups (Organic, Schizophrenia Spectrum Disorders, Bipolar Affective Disorder, Depression, Anxiety-Related Disorders, Personality Disorders, Neurodevelopmental Disorders), and kappa agreement obtained using ICD-10 diagnosis as the gold standard against prototypical diagnoses. Overall kappa was 0.77 (IC - 0.69 - 0.85), ranging from 0.58 (Personality Disorders) to 0.91 (Schizophrenia Spectrum Disorder). These findings also were reflected as high sensibility, specificity, Positive Predictive, and Negative Predictive values in all groups.

Conclusions

Prototypical diagnostic elaboration, while probably based on previously learned, but not applied operational criteria, was equivalent to diagnostic obtained through ICD-10 categories.

Disclosure

No significant relationships.

Tumor Markers and Lung Cancer: Correlation between Serum and Bronchial Secretion Levels of Cea, Tpa, Canag Ca-50, Nse and Ferritin

The levels of carcinoembryonic antigeny (CEA), tissue polypeptide antigeny (TPA), CanAg 50, neuron specific enolase (NSE) and ferritin were determined in bronchial secretion and serum of patients with neoplastic and non-neoplastic lung diseases. Simultaneous determination of two or three markers in the serum and in bronchoalveolar lavage (BAL) may be clinically useful for the diagnosis of lung cancer and even for the type of tumor. The positivity of CEA determined simultaneously in serum and in BAL of patients with lung cancer is higher than 80% whereas in patients with benign lung disease it is lower than 40%. The simultaneous assay of TP A in serum and in BAL showed 100% positivity in patients with oat-cell carcinoma, the frequencies of positivity were similar in patients with non-oat-cell carcinoma. For NSE and CanAg CA-50 patients with oat-cell carinoma showed 100% positivity. Simultaneous assay of ferritin in serum and in BAL gave 85% positivity in patients with oat-cell carcinoma and only 23% in patients with non-oat-cell carcinoma. We conclude that the simultaneous determination of CEA and CanAg CA-50 or NSE in serum and in BAL is a useful aid in the diagnosis of lung malignancy.

Hospital-acquired pneumonia: coverage and treatment adequacy of current guidelines

The American Thoracic Society (ATS) guideline for hospital-acquired pneumonia (HAP) released in 1996 and the Trouillet classification published in 1998 supply different rational foundations for the classification of patients with HAP and for the selection of initial antibiotic therapy. The aims of this study were to assess the level of bacterial coverage and to assess and validate the adequacy of antibiotic strategy of each of these classifications. Intensive care unit-admitted patients (n=71) with suspicion of HAP were evaluated. The ATS and Trouillet classifications demonstrated an accuracy to predict the causative microorganism of 91% and 83% respectively. The ATS and Trouillet antibiotic treatment recommendations were adequate in 79% and 80% of the patients, respectively. The microorganisms implicated in the treatment inadequacy of the ATS guideline were Pseudomonas aeruginosa (n=3), Acinetobacter baumanii (n=1), Stenotrophomonas maltophilia (n=1) and methicillin-resistant Staphylococcus aureus (n=1). P. aeruginosa was implicated with Trouillet treatment inadequacy. The current recommendations for empirical antibiotic treatment of hospital-acquired pneumonia (American Thoracic Society and Trouillet) showed a good ability to predict the involved pathogen. However, considering the resistance pattern of the isolated pathogens, both classifications demonstrated a rather lower treatment adequacy; the main reason was the failure to treat highly resistant strains.

Irreversible cancer cell-induced functional anergy and apoptosis in resting and activated NK cells

The interaction of natural killer (NK) cells with target cells, such as K562, results in NK functional inactivation and apoptosis. The role of NK-activating cytokines, IL-2, IL-12, and IL-15, in the regulation of NK inactivation and programmed cell death by target cells was examined. Purified natural killer cells were obtained from human peripheral blood and either co-incubated with K562 target cells and cytokines or the NK cells were pretreated with cytokines for 18 h prior to co-culture with K562 cells. Sorted NK cells were examined for cytotoxic activity and NK co-cultured with K562 were examined for cytokine secretion, phenotyping and DNA fragmentation. The cytotoxic activity was inhibited and was not alleviated by cytokine treatment. Whereas the cytokine treatment maintained NK cell viability for several days, NK cell viability was decreased significantly in the presence of K562 target cells. Downregulation of CD16 and upregulation of CD69 on NK cells were induced by K562 target cells and no modulation of these antigens was observed with cytokine treatment. A subpopulation of target-treated NK cells succumbed to cell death by apoptosis and cell death was not rescued by the activating cytokines. These findings demonstrate that target-induced functional inactivation and apoptosis of NK cells were not rescued by the activating cytokines IL-2, IL-12, and IL-15 regardless of whether the NK cells were pretreated with cytokines prior to exposure to K562 or the cytokines were added to the NK-K562 mixtures. These results also suggest that signals triggered by the target cells and resulting in NK cell anergy and apoptosis override cytokine-mediated signals for activation, cell proliferation, and survival.

Differential regulation of human NK cell-associated gene expression following activation by IL-2, IFN-alpha and PMA/ionomycin

Natural killer (NK) cells are important in host-defense mechanisms against infection and cancer and also participate in regulation of the immune response. The functions of NK cells as well as their maturation and differentiation are regulated by various stimuli such as interleukin-2 (IL-2) and interferon-alpha (IFN-alpha). The mechanisms by which these stimuli regulate distinct NK functions are not known. This study compared the patterns of gene expression for several NK-associated genes namely perforin (PEF), granzymes A and B (GA or B), IL-1beta, IFN-gamma, tumor necrosis factor-alpha (TNF-alpha), CD16 and NK-specific genes, NKG2A, NKG5 and NKG7 in both unstimulated and in IL-2-, IFN-alpha and PMA/Ionomycin (PMA/I)-stimulated NK cells purified from human peripheral blood. IFN-alpha enhanced mRNA expression for PEF, IFN-gamma, TNF-alpha and NKG2A, but did not affect NKG7 mRNA expression. IL-2 augmented mRNA expression for PEF, IFN-gamma, TNF-alpha, NKG2A and NKG7. PMA/I increased mRNA expression for IFN-gamma, TNF-alpha and NKG2A but did not affect mRNA expression for PEF and NKG7. Further, PMA/I inhibited the expression of CD16 mRNA. These findings demonstrate that the three NK-stimuli used share in common the regulation of several genes but each regulates specifically other genes. These findings suggest that stimuli-specific expression of NK-associated genes may underlie the molecular mechanisms responsible for distinct NK-mediated activities induced by different stimuli.

Apoptosis as a mechanism of peripheral blood mononuclear cell death after measles and varicella-zoster virus infections in children

Viral infections may induce an acquired form of immunodeficiency, generally lasting a few weeks. In the more severe form, such as HIV infection, the immunodeficiency is permanent. Programmed death of T cells represents one of the mechanisms by which HIV determines the T cell functional impairment, finally resulting in the destruction of T cells. In this study, we evaluated whether an altered regulation of apoptosis was also implicated in the anergy associated with the common measles or varicella-zoster virus (VZV) infections in infancy. A spontaneous apoptosis of peripheral blood mononuclear cells was observed in children who had suffered from these infections as long as 6 mo after the acute disease. Apoptosis was demonstrated through analysis of cellular DNA content, morphologic evidence of cell nuclei shrinkage, and by analysis of DNA degradation. Stimulation of T cells through anti-CD4 MAb increased the number of apoptotic cells with a maximal effect 72 h after the stimulation. Our results suggest that apoptosis may account for the anergy that follows acute viral infections in infancy.

Increased CD5+CD19+ B lymphocytes at the onset of type 1 diabetes in children

The aim of this study was to determine whether the proportion of circulating B cells expressing the differentiative antigen CD5 was increased in children affected by type 1 diabetes, and whether the number of these cells was correlated with the presence of anti-islet cell autoantibodies. Sixteen children affected by insulin-dependent diabetes mellitus (type 1) were investigated for the presence of B lymphocytes bearing the CD5 surface molecule, T-cell-specific activation markers, organ- and nonorgan-specific autoantibodies. The number of CD5+CD19+ cells was higher in type 1 children with a very recent onset of the disease, as compared with patients on insulin therapy for more than 30 days and controls (P < 0.05). No correlation was found between the number of CD5+CD19+ cells and the presence of either organ- or nonorgan-specific autoantibodies. Our results indicate that CD5+CD19+ cells are involved in the pathogenesis of type 1 diabetes in children. A potential immunoregulatory role of this B cell population is discussed.

Pivotal role of endogenous TNF-alpha in the induction of functional inactivation and apoptosis in NK cells

The interaction of purified nonactivated human NK cells with target cells overnight results in functional anergy and apoptosis in NK cells and in a change of the NK phenotype from CD16+ CD56+ CD69- to CD16(dim/-) CD56(+/dim/-) CD69+. These studies suggested that signaling triggered by the FcR CD16 may be implicated in target cell-mediated anergy/apoptosis of NK cells. We hypothesized that triggering CD16 by anti-CD16 Ab should result in NK cells exhibiting functional and phenotypic properties similar to those obtained following triggering of NK cells with target cells. The findings demonstrate that the anti-CD16 mAb-treated NK cells acquired the CD16- CD56(+/dim) CD69+ Fas+ phenotype and lost their cytotoxic function, a significant number of the NK cells underwent apoptosis, and a selective induction of TNF-alpha synthesis and secretion was observed. The coaddition of IL-2 to anti-CD16 Ab-treated NK cells resulted in enhanced secretion of TNF-alpha and augmentation of the frequency of cell death. However, a minor subset of NK cells exhibited potent cytotoxic function and proliferated. The anti-CD16-induced effects in NK cells were largely abrogated by the addition of either anti-TNF-alpha Ab or TNF-binding protein in the cultures. There was an enhancement of NK cell killing following the addition of exogenous TNF-alpha into the culture. Cytochalasin B selectively triggered the secretion of TNF-alpha and significantly augmented the frequency of apoptosis of anti-CD16-treated NK cells. These findings demonstrate an important and pivotal role of endogenous TNF-alpha synthesis and secretion by NK cells in the induction of functional anergy and apoptosis in anti-CD16-treated NK cells.

Pivotal role of endogenous TNF-alpha in the induction of functional inactivation and apoptosis in NK cells

The interaction of purified nonactivated human NK cells with target cells overnight results in functional anergy and apoptosis in NK cells and in a change of the NK phenotype from CD16+ CD56+ CD69- to CD16(dim/-) CD56(+/dim/-) CD69+. These studies suggested that signaling triggered by the FcR CD16 may be implicated in target cell-mediated anergy/apoptosis of NK cells. We hypothesized that triggering CD16 by anti-CD16 Ab should result in NK cells exhibiting functional and phenotypic properties similar to those obtained following triggering of NK cells with target cells. The findings demonstrate that the anti-CD16 mAb-treated NK cells acquired the CD16- CD56(+/dim) CD69+ Fas+ phenotype and lost their cytotoxic function, a significant number of the NK cells underwent apoptosis, and a selective induction of TNF-alpha synthesis and secretion was observed. The coaddition of IL-2 to anti-CD16 Ab-treated NK cells resulted in enhanced secretion of TNF-alpha and augmentation of the frequency of cell death. However, a minor subset of NK cells exhibited potent cytotoxic function and proliferated. The anti-CD16-induced effects in NK cells were largely abrogated by the addition of either anti-TNF-alpha Ab or TNF-binding protein in the cultures. There was an enhancement of NK cell killing following the addition of exogenous TNF-alpha into the culture. Cytochalasin B selectively triggered the secretion of TNF-alpha and significantly augmented the frequency of apoptosis of anti-CD16-treated NK cells. These findings demonstrate an important and pivotal role of endogenous TNF-alpha synthesis and secretion by NK cells in the induction of functional anergy and apoptosis in anti-CD16-treated NK cells.

The participation of the Fas-mediated cytotoxic pathway by natural killer cells is tumor-cell-dependent

Cytotoxic T lymphocytes and natural killer (NK) cells kill target cells by two main mechanisms, namely, the perforin/granzymes and the Fas ligand (Fas-L) pathways. The preferential activation of either of these two mechanisms by target cells is not known. This study examined whether various NK stimuli regulate preferentially the perforin/granzyme or the Fas pathways during the NK-cell-mediated cytotoxic reaction (NK-CMC). Purified peripheral-blood-derived NK cells were stimulated with interleukin-2 (IL-2), IL-12, or interferon alpha (IFN alpha) and their response was analyzed by the reverse transcriptase/polymerase chain reaction (RT-PCR) for NK-associated gene expression and by the 51Cr-release assay for cytotoxic function. RT-PCR data revealed that the perforin, granzyme A and granzyme B mRNAs were constitutively expressed in unstimulated NK cells and the level of perforin mRNA was augmented following activation. IL-2 enhanced the level of Fas-L mRNA in NK cells; however, the Fas-L level was much lower than that obtained in activated T cells. NK-CMC against Fas-sensitive cells was examined in the presence of neutralizing anti-(Fas antigen receptor) (Fas-R) antibody (ZB-4) or EGTA/Mg2+, which inhibits the perforin/granzyme pathway but not the Fas Fas-L interaction. The human colon adenocarcinoma HT-29 cells were sensitized to anti-Fas-R antibody (CH-11) cytotoxicity following treatment with IFN gamma. NK-CMC against untreated HT-29 cells was completely inhibited by EGTA/Mg2+ and was unaffected by ZB-4, while both EGTA/Mg2+ and ZB-4 partially inhibited NK-CMC against IFN gamma-treated HT-29 cells. Similar findings to those obtained with untreated NK cells were observed with NK cells stimulated with IL-2, IL-2 plus IL-12 or IFN alpha. In contrast to IFN gamma-treated HT-29 cells, the neutralizing anti-Fas antibody ZB-4 did not inhibit NK-CMC against Fas-sensitive U937, CEM or Jurkat tumor cells. These findings demonstrate that the Fas pathway is involved in NK-CMC against certain target cells but not all. Further, the data demonstrate that activation of NK cells by IL-2, IL-2 plus IL-12 or IFN alpha does not preferentially modulate the Fas-L-mediated killing by NK cells.

Concomitant killing in vitro of both gp120-coated CD4+ peripheral T lymphocytes and natural killer cells in the antibody-dependent cellular cytotoxicity (ADCC) system

NK cells play an important immunoregulatory role in first line defense mechanisms against infection. As disease progresses, HIV-1 infected patients show loss of NK cytotoxic function, down-modulation and/or loss of expression of both CD16 and CD56 surface Ags on NK cells and a gradual loss of both CD4+ T cells and NK cell numbers. A potential mechanism by which these manifestations may occur in vivo was investigated. We hypothesized that NK-mediated Ab-dependent cellular cytotoxicity (ADCC), using gp120-coated CD4+ peripheral T lymphocytes as targets and anti-HIV serum, will result in the concomitant killing of the CD4+ T lymphocyte targets and the NK lymphocytes. This hypothesis was examined in an in vitro model system. The findings demonstrate that gp120-coated peripheral T lymphocytes can serve as targets and are killed in ADCC. Further, the NK cells that recover from the ADCC reaction show a loss of cytotoxic function, acquire the CD16(dim/-) CD56(dim/-) phenotype and a significant fraction is killed by activation-induced cell death or apoptosis. These findings are reminiscent of the properties of circulating NK cells in HIV-infected patients. The implication of these findings in the pathogenesis of AIDS is discussed.

Concomitant killing in vitro of both gp120-coated CD4+ peripheral T lymphocytes and natural killer cells in the antibody-dependent cellular cytotoxicity (ADCC) system

NK cells play an important immunoregulatory role in first line defense mechanisms against infection. As disease progresses, HIV-1 infected patients show loss of NK cytotoxic function, down-modulation and/or loss of expression of both CD16 and CD56 surface Ags on NK cells and a gradual loss of both CD4+ T cells and NK cell numbers. A potential mechanism by which these manifestations may occur in vivo was investigated. We hypothesized that NK-mediated Ab-dependent cellular cytotoxicity (ADCC), using gp120-coated CD4+ peripheral T lymphocytes as targets and anti-HIV serum, will result in the concomitant killing of the CD4+ T lymphocyte targets and the NK lymphocytes. This hypothesis was examined in an in vitro model system. The findings demonstrate that gp120-coated peripheral T lymphocytes can serve as targets and are killed in ADCC. Further, the NK cells that recover from the ADCC reaction show a loss of cytotoxic function, acquire the CD16(dim/-) CD56(dim/-) phenotype and a significant fraction is killed by activation-induced cell death or apoptosis. These findings are reminiscent of the properties of circulating NK cells in HIV-infected patients. The implication of these findings in the pathogenesis of AIDS is discussed.

[Aicardi syndrome and choroid plexus papilloma: a rare association. Case report]

The authors report a case of a 5 months old female child with clinical features of Aicardi syndrome: agenesis of the corpus callosum, occular abnormalities ("chorioretinal lacunae" and microphthalmus), infantile spasms, mental retardation, vertebral malformations and thoracic deformity. The pacient was submitted to complementary examinations that confirmed the diagnosis. The neuroradiologic images (MRI) showed besides corpus callosum agenesis a tumor located at the left ventricular atrium (choroid plexus papilloma). This association is a rare occurrence and the present case is the seventh described in literature. Furthermore, we suggest that the choroid plexus pappilloma could be a characteristic tumor of the Aicardi syndrome.

Coexistence of an unusual form of scabies and lepromatous leprosy. A case report

A case of unusual crusted (Norwegian) scabies involving the entire skin of a 26 year old Brazilian patient with lepromatous leprosy is reported. The more prominent histopathological findings were acanthosis, hyperkeratosis and crusting with many mites of Sarcoptes scabiei. In the dermis, numerous foamy histiocytes filled with abundant acid-fast bacilli were seen.

HTLV-I-associated neurologic manifestations in four generations of a Brazilian family

From an index case of tropical spastic paraparesis (TSP), four generations of a Brazilian family of African descent were investigated for human T-lymphotropic virus type I (HTLV-I) infection and its association with neurologic manifestations, as well as the possible routes of transmission. Thirty-two individuals were studied. Polymerase chain reaction (PCR) was used for confirmation of infection. HTLV-I infection was demonstrated in eight subjects (the index case, 6 of 24 blood relatives, and 1 of 7 spouses). The index case and two blood relatives had TSP, whereas subclinical neurologic disturbances were present in three other blood relatives and one spouse. Another member of the family, who had died before this study, had had diagnoses of spastic paraparesis of unknown etiology and small-cell lymphoma. Only 1 of 8 infected individuals was neurologically intact. Of 5 vertically infected individuals, 4 had been breast-fed for long periods (1-2 years). These are the first reported cases of PCR-proved HTLV-I-associated spastic paraparesis in Brazil.