Image quality in CT thorax: effect of altering reconstruction algorithm and tube load

Non-linear properties of iterative reconstruction (IR) algorithms can alter image texture. We evaluated the effect of a model-based IR algorithm (advanced modelled iterative reconstruction; ADMIRE) and dose on computed tomography thorax image quality. Dual-source scanner data were acquired at 20, 45 and 65 reference mAs in 20 patients. Images reconstructed with filtered back projection (FBP) and ADMIRE Strengths 3-5 were assessed independently by six radiologists and analysed using an ordinal logistic regression model. For all image criteria studied, the effects of tube load 20 mAs and all ADMIRE strengths were significant (p < 0.001) when compared to reference categories 65 mAs and FBP. Increase in tube load from 45 to 65 mAs showed image quality improvement in three of six criteria. Replacing FBP with ADMIRE significantly improves perceived image quality for all criteria studied, potentially permitting a dose reduction of almost 70% without loss in image quality.

Prevalence of denosumab-induced hypocalcemia: a retrospective observational study of patients routinely monitored with ionized calcium post-injection

We assessed the prevalence of hypocalcemia after denosumab injections in a real-world cohort routinely monitored for calcium during up to 7.5 years of treatment. Among 1096 injections in 242 patients, 6.3% resulted in hypocalcemia, and was independent of the injection number. Severe hypocalcemia was rare (1%).

PURPOSE

To assess the prevalence of and risk factors for hypocalcemia after administration of denosumab in a patient cohort routinely monitored for ionized calcium after each dose.

METHODS

In this retrospective observational study, we analyzed denosumab-induced hypocalcemia in a real-world cohort who were routinely followed up with ionized calcium pre- and post-injection (within 31 days after injection) during the period 2011 to 2020.

RESULTS

In total, we included data from 1096 denosumab injections in 242 individuals (1-15 injections per patient). The mean age for the first injection was 74 ± 10 years, and 88% were female. Post-injection hypocalcemia occurred after 6.3% of all injections (4.6% mild, 0.6% moderate, and 1.1% severe) and was independent of the number of injections (rate of hypocalcemia varied from 3-8%). Risk factors for hypocalcemia were male sex, severe renal failure, pre-injection hypocalcemia, hypomagnesemia, hypophosphatemia, and vitamin D insufficiency. Furthermore, older age was not associated with an increased hypocalcemia risk.

CONCLUSIONS

Denosumab-induced hypocalcemia is a prevalent adverse event, which occurs independently of the number of injections. However, severe hypocalcemia is a rare occurrence, and severe renal failure and nutritional status appear to be important predictive factors. Magnesium and phosphate might add value in the pre-injection risk assessment; however, this observation needs to be confirmed in larger cohorts.

Improved visualization of the bone-implant interface and osseointegration in ex vivo acetabular cup implants using photon-counting detector CT

BACKGROUND

Successful osseointegration of joint replacement implants is required for long-term implant survival. Accurate assessment of osseointegration could enable clinical discrimination of failed implants from other sources of pain avoiding unnecessary surgeries. Photon-counting detector computed tomography (PCD-CT) provides improvements in image resolution compared to conventional energy-integrating detector CT (EID-CT), possibly allowing better visualization of bone-implant-interfaces and osseointegration. The aim of this study was to assess the quality of visualization of bone-implant-interfaces and osseointegration in acetabular cup implants, using PCD-CT compared with EID-CT.

METHODS

Two acetabular implants (one cemented, one uncemented) retrieved during revision surgery were scanned using PCD-CT and EID-CT at equal radiation dose. Images were reconstructed using different reconstruction kernels and iterative strengths. Delineation of the bone-implant and bone-cement-interface as an indicator of osseointegration was scored subjectively for image quality by four radiologists on a Likert scale and assessed quantitatively.

RESULTS

Delineation of bone-implant and bone-cement-interfaces was better with PCD-CT compared with EID-CT (p ≤ 0.030). The highest ratings were given for PCD-CT at sharper kernels for the cemented cup (PCD-CT, median 5, interquartile range 4.25-5.00 versus EID-CT, 3, 2.00-3.75, p < 0.001) and the uncemented cup (5, 4.00-5.00 versus 2, 2-2, respectively, p < 0.001). The bone-implant-interface was 35-42% sharper and the bone-cement-interface was 28-43% sharper with PCD-CT compared with EID-CT, depending on the reconstruction kernel.

CONCLUSIONS

PCD-CT might enable a more accurate assessment of osseointegration of orthopedic joint replacement implants.

KEY POINTS

• The bone-implant interface ex vivo showed superior visualization using photon-counting detector computed tomography (PCD-CT) compared to energy-integrating detector computed tomography. • Harder reconstruction kernels in PCD-CT provide sharper images with lower noise levels. • These improvements in imaging might make it possible to visualize osseointegration in vivo.

Computed tomography-measured body composition and survival in rectal cancer patients: a Swedish cohort study

BACKGROUND

The association between body composition and survival in rectal cancer patients is still unclear. Therefore, we aimed to evaluate the impact of computed tomography (CT)-measured body composition on survival in rectal cancer patients, stratifying our analyses by sex, tumour location, tumour stage and radiotherapy.

METHODS

This retrospective cohort study included 173 patients with rectal adenocarcinoma. CT colonography scans at the time of diagnosis were used to assess the skeletal muscle index (SMI) and the visceral adipose tissue area (VAT). The patients were divided into a low or high SMI group and a low or high VAT group according to previously defined cutoff values. Endpoints included cancer-specific survival (CSS) and overall survival (OS).

RESULTS

In all patients, low SMI was associated with worse CSS (HR, 2.63; 95% CI, 1.35-5.12; P = 0.004) and OS (HR, 3.57; 95% CI, 2.01-6.34; P < 0.001) compared to high SMI. The differences remained significant after adjusting for potential confounders (CSS: adjusted HR, 2.28; 95% CI, 1.13-4.58; P = 0.021; OS: adjusted HR, 3.17; 95% CI, 1.73-5.82; P < 0.001). Low SMI was still related to a poor prognosis after stratifying by sex, tumour location, stage and radiotherapy (P < 0.05). High VAT was associated with better CSS (HR, 0.31; 95% CI, 0.11-0.84; P = 0.022) and OS (HR, 0.40; 95% CI, 0.17-0.97; P = 0.044) compared to low VAT among men with rectal cancer ≤ 10 cm from the anal verge. High VAT was associated with worse CSS (HR, 4.15; 95% CI, 1.10-15.66; P = 0.036) in women with rectal cancer ≤ 10 cm from the anal verge.

CONCLUSIONS

Low SMI was associated with worse survival. High VAT predicted better survival in men but worse survival in women. The results suggest that CT-measured body composition is a useful tool for evaluating the prognosis of rectal cancer patients and demonstrate the need to include the sex and the tumour location in the analyses.

Trabecular bone microstructure analysis on data from a novel twin robotic X-ray device

Background

Bone strength is related to both mineral density (BMD) and the bone microstructure. However, only the assessment of BMD is available in clinical routine care today.

Purpose

To analyze and study the correlation of trabecular bone microstructure from the imaging data of a prototype Multitom Rax system, using micro-computed tomography (CT) data as the reference method (Skyscan 1176).

Material and Methods

Imaging data from 14 bone samples from the human radius were analyzed regarding six bone structure parameters, i.e. trabecular nodes, separation, spacing, and thickness as well as bone volume (BV/TV) and structural model index (SMI).

Results

All six structure parameters showed strong correlations to micro-CT with Spearman correlation coefficients in the range of 0.83–0.93. BV/TV and SMI had a correlation >0.90. Two of the parameters, namely, separation and number, had mean values in the same range as micro-CT. The other four were either over- or underestimated.

Conclusion

The strong correlation between micro-CT and the clinical imaging system, indicates the possibility for analyzing bone microstructure with potential to add value in fracture assessment using the studied device in a clinical workflow.

Photon-counting detector CT and energy-integrating detector CT for trabecular bone microstructure analysis of cubic specimens from human radius

Background

As bone microstructure is known to impact bone strength, the aim of this in vitro study was to evaluate if the emerging photon-counting detector computed tomography (PCD-CT) technique may be used for measurements of trabecular bone structures like thickness, separation, nodes, spacing and bone volume fraction.

Methods

Fourteen cubic sections of human radius were scanned with two multislice CT devices, one PCD-CT and one energy-integrating detector CT (EID-CT), using micro-CT as a reference standard. The protocols for PCD-CT and EID-CT were those recommended for inner- and middle-ear structures, although at higher mAs values: PCD-CT at 450 mAs and EID-CT at 600 (dose equivalent to PCD-CT) and 1000 mAs. Average measurements of the five bone parameters as well as dispersion measurements of thickness, separation and spacing were calculated using a three-dimensional automated region growing (ARG) algorithm. Spearman correlations with micro-CT were computed.

Results

Correlations with micro-CT, for PCD-CT and EID-CT, ranged from 0.64 to 0.98 for all parameters except for dispersion of thickness, which did not show a significant correlation (p = 0.078 to 0.892). PCD-CT had seven of the eight parameters with correlations ρ > 0.7 and three ρ > 0.9. The dose-equivalent EID-CT instead had four parameters with correlations ρ > 0.7 and only one ρ > 0.9.

Conclusions

In this in vitro study of radius specimens, strong correlations were found between trabecular bone structure parameters computed from PCD-CT data when compared to micro-CT. This suggests that PCD-CT might be useful for analysing bone microstructure in the peripheral human skeleton.

The impact of imaging time and contrast agent dose on screening for osteoporosis with contrast-enhanced CT

BACKGROUND

Screening for osteoporosis with contrast-enhanced computed tomography (CT) is promising for identifying high-risk osteoporotic patients. Our aims were (1) to investigate the estimated volume bone mineral density (vBMD) change over time after contrast injection (CT perfusion imaging, CTPI); and (2) to examine the influence of contrast dose on vBMD.

METHODS

Fifteen patients, aged 71 ± 9 years (mean ± standard deviation, range 55-86) underwent a CTPI examination (28 scans within 63 s) of the upper body followed (after a waiting time of 10 min) by a full 4-phase CT examination (4 scans within 4 min). The contrast dose for CTPI was 0.38-0.83 mL/kg, and for 4-phase CT was 0.87-1.29 mL/kg. Vertebrae L1-L3 were analysed totalling 43 vertebrae, using Mindways qCT Pro.

RESULTS

After contrast injection, vBMD showed a near-horizontal line until 17.5 s (non-contrast phase), followed by a steep increase 17.5-41.5 s after contrast injection, i.e., in the arterial phase, which plateaued 41.5 s after, i.e., in the early venous phase. A higher contrast dose per kg yielded significantly higher vBMD increase in both the arterial and venous phase (p < 0.003).

CONCLUSIONS

Both time from contrast administration and contrast dose per kg affected vBMD results. In arterial phase, the steepness of the curve makes vBMD estimation unsure. However, as values plateaued in the venous phase it might be possible to predict the correct vBMD values. Furthermore, contrast dose is a factor that needs to be adjusted for when using such a formula.

Selection of risk assessment methods for osteoporosis screening in postmenopausal women with low-energy fractures: A comparison of fracture risk assessment tool, digital X-ray radiogrammetry, and dual-energy X-ray absorptiometry

Objectives:

Fracture liaison services are designed to identify patients needing osteoporosis treatment after a fracture. Some fracture liaison service designs involve a prescreening step, for example, fracture risk assessment tool (FRAX^®). Another possible prescreening tools are bone mass density assessment in the acute setting. The aim of this study was to assess the effectiveness of prescreening tools.

Methods:

In the present prospective cohort study, women aged >55 years with a radius fracture were included. Patients were recruited at the emergency department after experiencing their fracture. All patients performed fracture risk assessment by fracture risk assessment tool, and bone mass density assessment by digital X-ray radiogrammetry and dual-energy X-ray absorptiometry (prescreening steps) as well as full routine evaluation at the osteoporosis unit (endpoint). The main outcome measures were sensitivity, specificity, predictive values, and area under the curve.

Results:

Forty-one women were recruited (mean age: 70 ± 8 years). Of these, 54% fulfilled the treatment indication criteria of osteoporosis after a full examination. Fracture risk assessment tool without bone mass density (cutoff ⩾ 15%) for prescreening patients had a high sensitivity (90%) but a low area under the curve (0.50) and specificity (16%). The highest area under the curve (0.73) was found prescreening with bone mass density assessment (dual-energy X-ray absorptiometry or digital X-ray radiogrammetry) having a sensitivity of 59%–86% and specificity of 61%–90%.

Conclusion:

This study, though small, raises questions regarding the effectiveness of using a prescreening step in fracture liaison services for high-risk individuals. In this cohort, FRAX^® without bone mass density had a low precision, with a risk of both underestimating and overestimating patients requiring treatment. Bone mass density assessment in the acute setting could improve the precision of prescreening. Further investigations on the effectiveness and health economics of prescreening steps in fracture liaison services are needed.

Comparison of multiphase data from CT perfusion vs clinical 4-phase CT scans with respect to image quality, lesion detection, and LI-RADS classification in HCC patients

Purpose

The aim of this study was to assess the image quality and diagnostic performance of reconstructed arterial (A) and portal venous (PV) phases in computed tomography perfusion (CTP) scans compared to the corresponding phases in standard 4-phase CT and to assess the utility for LI-RADS classification using CTP and 4-phase 4CT.

Methods

A total of 26 scans with each method (CTP and 4-phase CT) from 19 hepatocellular carcinoma patients were analyzed and compared. Arterial and PV phases reconstructed by advanced modeled iterative reconstruction at strength 4 (ADMIRE 4) from raw CTP data were compared with image sets from arterial and PV phases of 4-phase CT (ADMIRE 3) in the same patient with respect to image quality.

Results

Quantitative image analysis showed that reconstructed CTP datasets were equivalent to 4-phase CT image sets. Qualitative image analysis revealed similar lesion detection rates with the 2 methods for patients with an abdominal diameter ≤36 cm and body weight <90 kg, but lower detection rates with CTP for patients with an abdominal diameter >37 cm. There was no difference in Liver Imaging Reporting and Data System (LI-RADS) classifications between the 2 methods.

Conclusion

Reconstructed CTP images can potentially replace 4-phase CT images in patients weighing <90 kg and with a body diameter <37 cm, as the 2 methods are comparable in terms of quantitative image quality and ability to detect and classify lesions based on LI-RADS criteria.

•

Reconstructed A- and PV-CTP images have comparable image quality to 4-phase CT.

•

Reconstructed A- and PV-CTP images can be used for LI-RADS classification of HCC.

•

A-/PV-CTP has the potential to reliably detect lesions in patients weighing <90 kg with body diameter ≤36 cm.

Proactive Construction of an Annotated Imaging Database for Artificial Intelligence Training

Artificial intelligence (AI) holds much promise for enabling highly desired imaging diagnostics improvements. One of the most limiting bottlenecks for the development of useful clinical-grade AI models is the lack of training data. One aspect is the large amount of cases needed and another is the necessity of high-quality ground truth annotation. The aim of the project was to establish and describe the construction of a database with substantial amounts of detail-annotated oncology imaging data from pathology and radiology. A specific objective was to be proactive, that is, to support undefined subsequent AI training across a wide range of tasks, such as detection, quantification, segmentation, and classification, which puts particular focus on the quality and generality of the annotations. The main outcome of this project was the database as such, with a collection of labeled image data from breast, ovary, skin, colon, skeleton, and liver. In addition, this effort also served as an exploration of best practices for further scalability of high-quality image collections, and a main contribution of the study was generic lessons learned regarding how to successfully organize efforts to construct medical imaging databases for AI training, summarized as eight guiding principles covering team, process, and execution aspects.

Deep neural networks with promising diagnostic accuracy for the classification of atypical femoral fractures

Background and purpose - A correct diagnosis is essential for the appropriate treatment of patients with atypical femoral fractures (AFFs). The diagnostic accuracy of radiographs with standard radiology reports is very poor. We derived a diagnostic algorithm that uses deep neural networks to enable clinicians to discriminate AFFs from normal femur fractures (NFFs) on conventional radiographs.Patients and methods - We entered 433 radiographs from 149 patients with complete AFF and 549 radiographs from 224 patients with NFF into a convolutional neural network (CNN) that acts as a core classifier in an automated pathway and a manual intervention pathway (manual improvement of image orientation). We tested several deep neural network structures (i.e., VGG19, InceptionV3, and ResNet) to identify the network with the highest diagnostic accuracy for distinguishing AFF from NFF. We applied a transfer learning technique and used 5-fold cross-validation and class activation mapping to evaluate the diagnostic accuracy.Results - In the automated pathway, ResNet50 had the highest diagnostic accuracy, with a mean of 91% (SD 1.3), as compared with 83% (SD 1.6) for VGG19, and 89% (SD 2.5) for InceptionV3. The corresponding accuracy levels for the intervention pathway were 94% (SD 2.0), 92% (2.7), and 93% (3.7), respectively. With regards to sensitivity and specificity, ResNet outperformed the other networks with a mean AUC (area under the curve) value of 0.94 (SD 0.01) and surpassed the accuracy of clinical diagnostics.Interpretation - Artificial intelligence systems show excellent diagnostic accuracies for the rare fracture type of AFF in an experimental setting.

The transluminal attenuation gradient does not add diagnostic accuracy to coronary computed tomography

BACKGROUND

A method for improving the accuracy of coronary computed tomography angiography (CCTA) is highly sought after as it would help to avoid unnecessary invasive coronary angiographies. Measurement of the transluminal attenuation gradient (TAG) has been proposed as an alternative to other existing methods, i.e. CT perfusion and CT fractional flow reserve (FFR).

PURPOSE

To evaluate the incremental value of three types of TAG in high-pitch spiral CCTA with invasive FFR measurements as reference.

MATERIAL AND METHODS

TAG was measured using two semi-automatic methods and one manual method. A receiver operating characteristic (ROC) analysis was made to determine the usefulness of TAG alone as well as TAG combined with CCTA for detection of significant coronary artery stenoses defined by an invasive FFR value ≤0.80.

RESULTS

A total of 51 coronary vessels in 37 patients were included in this retrospective study. Hemodynamically significant stenoses were found in 13 vessels according to FFR. The ROC analysis TAG alone resulted in areas under the curve (AUCs) of 0.530 and 0.520 for the semi-automatic TAG and 0.557 for the manual TAG. TAG and CCTA combined resulted in AUCs of 0.567, 0.562 for semi-automatic TAG, and 0.569 for the manual TAG.

CONCLUSION

The results from our study showed no incremental value of TAG measured in single heartbeat CCTA in determining the severity of coronary artery stenosis degrees.

Computed tomography-based opportunistic osteoporosis assessment: a comparison of two software applications for lumbar vertebral volumetric bone mineral density measurements

Background

We aimed to compare two volumetric bone mineral density (vBMD) analysis programs, regarding (I) agreement of vBMD values based on mono- and dual-energy computed tomography (MECT and DECT) scans and (II) suitability for analyzing DECT data obtained at different energies.

Methods

We retrospectively analyzed two abdominal CT datasets: one performed in a MECT scan (vertebrae L1-L3) and one in a DECT scan (vertebrae L1-L4). Each dataset included different individuals [MECT 15 patients (45 vertebrae) and DECT 12 patients (48 vertebrae), respectively]. vBMD analysis was conducted using Philips IntelliSpace (IP) and Mindways qCT Pro (MW). Regarding the DECT scans, vBMD analysis was done at three different energies: 80, 150 and synthetic 120 kVp and for MECT scan at 120 kVp. For comparison of vBMD results between different software (aim 1) MECT 120 kVp and DECT synthetic 120 kVp data was used. For analyzing suitability of using different DECT energies for vBMD assessment (aim 2) all three DECT energies were used and results from each software was analyzed separately.

Results

vBMD assessed with MW and IP, respectively correlated significantly for both the MECT (r=0.876; P<0.001) and DECT (r=0.837; P<0.001) scans, but the vBMD values were lower in using IP for vBMD assessment (8% and 14% lower for MECT and DECT, respectively; P=0.001). Regarding the different DECT energies, using MW for vBMD assessment showed significant correlations in vBMD results between 120 kVp and the two other energies (r=0.988 and r=0.939) and no significant differences in absolute vBMD values (P>0.05). The IP analysis as well showed significant correlation between 120 kVp and the other energies (r=0.769 and r=0.713, respectively), but differences in absolute vBMD values between the energies (P≤0.001).

Conclusions

We show that the correlations between the vBMD derived from the two investigated software solutions were generally good but that absolute vBMD value did differ and might impact the clinical diagnosis of osteoporosis. Though small, our study data indicate that vBMD might be assessed in energies other than 120 kVp when using MW but not when using IP.

Iterative reconstruction algorithm improves the image quality without affecting quantitative measurements of computed tomography perfusion in the upper abdomen

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Iterative image-reconstruction algorithm (ADMIRE) did not affect the quantitative measurements in CT perfusion.

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Iterative image-reconstruction algorithm (ADMIRE) did not affect the time attenuation curves in CT perfusion.

•

Image noise was lower, but the SNR was higher, for iterative reconstructions in CT perfusion examinations with higher strength of noise reduction.

Objective

To investigate differences between reconstruction algorithms in quantitative perfusion values and time-attenuation curves in computed tomography perfusion (CTP) examinations of the upper abdomen.

Methods

Twenty-six CTP examinations were reconstructed with filtered back projection and an iterative reconstruction algorithm, advanced modeled iterative reconstruction (ADMIRE), with different levels of noise-reduction strength. Using the maximum-slope model, quantitative measurements were obtained: blood flow (mL/min/100 mL), blood volume (mL/100 mL), time to peak (s), arterial liver perfusion (mL/100 mL/min), portal venous liver perfusion (mL/100 mL/min), hepatic perfusion index (%), temporal maximum intensity projection (Hounsfield units (HU)) and temporal average HU. Time-attenuation curves for seven sites (left liver lobe, right liver lobe, hepatocellular carcinoma, spleen, gastric wall, pancreas, portal vein) were obtained. Mixed-model analysis was used for statistical evaluation. Image noise and the signal:noise ratio (SNR) were compared between four reconstructions, and statistical analysis of these reconstructions was made with a related-samples Friedman’s two-way analysis of variance by ranks test.

Results

There were no significant differences for quantitative measurements between the four reconstructions for all tissues. There were no significant differences between the AUC values of the time-attenuation curves between the four reconstructions for all tissues, including three automatic measurements (portal vein, aorta, spleen). There was a significant difference in image noise and SNR between the four reconstructions.

Conclusions

ADMIRE did not affect the quantitative measurements or time-attenuation curves of tissues in the upper abdomen. The image noise was lower, and the SNR higher, for iterative reconstructions with higher noise-reduction strengths.

MRI Lymph Node Evaluation for Prediction of Metastases in Rectal Cancer

AIM

To explore whether the size and characteristics of the largest regional lymph node in patients with rectal cancer, based on magnetic resonance imaging (MRI), following neoadjuvant therapy and before surgery, is able to identify patients at high risk of developing metachronous metastases.

PATIENTS AND METHODS

A retrospective case-control study with data from the Swedish Colo-Rectal Cancer Registry. Forty patients were identified with metachronous metastases (M+), and 40 patients without metastases (M0) were matched as controls.

RESULTS

Patients with M+ disease were more likely to have a regional lymph node measuring ≥5 mm than patients with M0. (87% vs. 65%, p=0.02). There was also a significant difference between the groups regarding the presence of an irregular border of the largest lymph node (68% vs. 40%, p=0.01).

CONCLUSION

Lymph nodes measuring ≥5 mm with/without displaying irregular borders at MRI performed after neoadjuvant therapy emerged as risk factors for metachronous metastases in patients with rectal cancer. Intensified follow-up programmes may be indicated in these patients.

Adherence to and persistence with zoledronic acid treatment for osteoporosis-reasons for early discontinuation

This retrospective study reports 81% long-term (> 3 years) adherence to and 77% persistence with zoledronic acid (ZA) treatment in osteoporosis patients, with ZA being costfree for patients. Eight percent of patients discontinued treatment because of adverse events (AEs), with a tendency of higher discontinuation rate in older patients.

PURPOSE

This study investigated (1) long-term adherence to and persistence with ZA treatment in a real-world setting, (2) extent to which an adverse reaction to ZA impacted on adherence and persistence, and (3) whether there were sex or age differences in patients that had early treatment termination (ETT) due to AEs and those who adhered to the regimen.

METHODS

All patients treated with ZA at the Endocrinology Department at Linköping University Hospital, Linköping, Sweden between 2012 and 2017 were included. ETT was defined as < 3 ZA infusions, which was confirmed from patients' medical records.

RESULTS

A total of 414 patients were treated with ZA, with 81% receiving > 3 ZA infusions. Three-year persistence was 77% for a treatment window of 365 days ± 90 days (75% with 365 days ± 60 days window). The most common reason for ETT was AEs (8%), followed by medical conditions (5%), biological aging (3%), and other (e.g., lost to follow-up [3%]). Most patients who discontinued treatment because of AEs reported symptoms of acute-phase reaction, and tended to be older than those who adhered to treatment (74 ± 9 vs 70 ± 13 years, p = 0.064). There was no difference in sex ratio between the 2 groups (85% vs 90% females, p = 0.367).

CONCLUSION

Rates of long-term adherence to and persistence with ZA treatment were high with a pre-scheduled 3-year treatment regimen in the tax-financed Swedish healthcare system. AEs-mainly acute-phase reaction-were the most common reason for ETT, occurring in nearly 1 out of 10 patients.

Mobile learning device increased study efficiency for radiology residents but with risk of temporary novelty effect

Background

Digital resources in learning are increasingly available and offer new possibilities in education. Mobile learning devices (MLD) such as tablets provide easy and flexible access for users.

Purpose

To investigate whether the introduction of MLDs in radiology education affected time spent on studies over a longer time frame and whether learning behavior and attitudes changed.

Material and Methods

The radiology residents employed during 2015-2016 were invited to participate in this 12-month MLD intervention study. Results were evaluated using online questionnaires at six months (6 m) and 12 months (12 m).

Results

Thirty-one residents were included, of whom half were in the early stages of residency (<2 years). After the MLD introduction, most participants (91% [6 m] and 83% [12 m]) estimated increased time spent on studies. Of these, 32% stated "a lot more" at 6 m but only 8% at 12 m (P = 0.12). The MLDs showed positive effects on the experience of radiology studies, as a majority of participants stated better quality and effectiveness in their studies (100% [6 m]-92% [12 m]), that MLD facilitated access to educational materials to a high degree (83% [6 m]-75% [12 m]), and that studies had become better and more fun (96% [6 m]-100% [12 m]).

Conclusion

The use of MLDs seems to facilitate learning effectively for radiologic residents. However, a larger scale study is required as a trend of decreasing figures in the longer term was seen, but our results did not show a significant reduction of time spent on radiology studies.

Association of Insulin-like Growth Factor-1, Bone Mass and Inflammation to Low-energy Distal Radius Fractures and Fracture Healing in Elderly Women Attending Emergency Care

OBJECTIVE

Elderly patients suffer fractures through low-energy mechanisms. The distal radius is the most frequent fracture localization. Insulin-like growth factor-1 (IGF1) plays an important role in the maintenance of bone mass and its levels decline with advancing age and in states of malnutrition. Our aim was to investigate the association of IGF1 levels, bone mass, nutritional status, and inflammation to low-energy distal radius fractures and also study if fracture healing is influenced by IGF1, nutritional status, and inflammation.

METHODS

Postmenopausal women, 55 years or older, with low-energy distal radius fractures occurring due to falling on slippery ground, indoors or outdoors, were recruited in the emergency department (ED) and followed 1 and 5 weeks after the initial trauma with biomarkers for nutritional status and inflammation. Fractures were diagnosed according to standard procedure by physical examination and X-ray. All patients were conservatively treated with plaster casts in the ED. Patients who needed interventions were excluded from our study. Fracture healing was evaluated from radiographs. Fracture healing assessment was made with a five-point scale where the radiological assessment included callus formation, fracture line, and stage of union. Blood samples were taken within 24 h after fracture and analyzed in the routine laboratory. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry (DXA).

RESULTS

Thirty-eight Caucasian women, aged 70.5 ± 8.9 years (mean ± SD) old, were recruited. Nutritional status, as evaluated by albumin (40.3 ± 3.1 g/L), IGF1 (125.3 ± 39.9 μg/L), body mass index (26.9 ± 3.6 kg/m² ), arm diameter (28.9 ± 8.9 cm), and arm skinfold (2.5 ± 0.7 cm), was normal. A positive correlation was found between IGF1 at visit 1 and the lowest BMD for hip, spine, or radius (r = 0.39, P = 0.04). High sensitive C-reactive protein (hsCRP) and leukocytes were higher at the fracture event compared to 5 weeks later (P = 0.07 and P < 0.001, respectively). Fracture healing parameters (i.e. callus formation, fracture line, and stage of union) were positively correlated with the initial leukocyte count and to difference in thrombocyte count between visit 1 and 3.

CONCLUSIONS

In elderly women with low-energy distal radius fractures, an association between IGF1 and lowest measures of BMD was found, indicating that low IGF1 could be an indirect risk factor for fractures. Fracture healing was associated with initial leukocytosis and a lower thrombocyte count, suggesting that inflammation and thrombocytes are important components in fracture healing.

Model for improved correlation of BMD values between abdominal routine Dual energy CT data and DXA scans

BACKGROUND

Osteoporosis is a common but underdiagnosed and undertreated disease causing severe morbidity and economic burden. The gold standard for detection of osteoporosis is DXA (dual energy x-ray absorptiometry), which is a dedicated examination for osteoporosis. Dual energy CT (DECT) examinations are increasingly used in daily routine for a wide variety of diagnoses. In the present study, we wanted to examine whether vBMD (volume bone mass density) could be evaluated as a side product in non-contrast as well as contrast phases as well as to evaluate a correction model taking known shortcomings for DXA into account.

METHODS

A total of 20 patients, i.e. 79 vertebrae (one excluded due to vertebral fracture), mean age 71 years (range 43-85) with a mean BMI (body mass index) of 26 (range 17-33) were examined with both abdominal/pelvic DECT as well as DXA. Furthermore, aortic calcium was measured as well as the presence of osteoarthritis of the spine (OAS) and osteoarthritis in facet joints (OAF) with a 5-grade scaling system.

RESULTS

A significant correlation was found between DXA BMD and vBMD from DECT with no contrast (WNC) (r = 0.424, p = 0.001), and with venous contrast (WVC) (r = 0.402, p < 0.001), but no significant correlation was found with arterial contrast (WAC). Using multivariate linear regression with DXA BMD as dependent, two models were created combining DECT WNC, aortic calciumscore (ACS), OAS and BMI yielding an R² = 0.616 (model 1) and replacement of WNC to WVC a R² = 0.612 (model 2). The Pearson correlation between DXA and predictive DXA BMD value of model 1 was r = 0.785 (p < 0.001) and model 2 r = 0.782 (p < 0.001).

CONCLUSION

There is a correlation between DXA BMD and DECT in non-contrast and venous contrast scans but not in arterial scans. The correlation is further improved by quantifying the degree of different confounding factors (osteoarthritis of the spine, body mass index and aortic calcium score) and taking these into account in an explanatory model. Future software solutions with DECT data as input data might be able to automatically measure the BMD in the trabecular bone as well as measuring the confounding factors automatically in order to obtain spinal DXA comparable BMD values.

[Modified British model shortened lead times for CT scans of the colon]

The British national Institute for Health and Care Excellence (NICE) has presented guidelines based on signs and symptoms which should raise a suspicion of colorectal cancer. A slightly modified version of these guidelines, adapted to Swedish conditions, named Swedish NICE (sNICE) criteria, was implemented at eight primary care centres. By following the sNICE criteria, cases with higher degree of suspicion of colorectal cancer were advised for computer tomography (CT) of the colon, whereas cases of low degree of suspicion were advised for the considerably less time and patient demanding CT of the abdomen. For patients with isolated anal symptoms without presence of sNICE criteria, active expectancy for six weeks was recommended, followed by renewed consideration. Results showed that the ratio between CT colon and CT abdomen was reduced from 2.2 to 1.1 after introduction of the sNICE criteria. Also, the proportion of patients undergoing CT colon within two weeks from admittance was increased from 3 to 25 %. We conclude that the sNICE criteria may be a useful supportive tool for the primary care physician.

Activation of eotaxin-3/CCLl26 gene expression in human dermal fibroblasts is mediated by STAT6

Allergic inflammatory conditions such as asthma are characterized by an accumulation of eosinophils at sites of inflammation. Eotaxin-3/CCL26 is a member of the family of CC chemokines, which are known to be potent chemoattractants for eosinophils. This chemokine was shown to be up-regulated by IL-4 and IL-13 in endothelial cells. This study demonstrates that eotaxin-3 transcription and eotaxin-3 protein expression are stimulated by IL-4 and IL-13 in a time- and dose-dependent fashion in human dermal fibroblasts. In contrast to eotaxin-1/CCL11, TNF-alpha could not act as inducer on its own nor did it synergize with IL-4. The activities of eotaxin-3 promoter luciferase constructs were significantly increased by IL-4 and IL-13 in human dermal fibroblasts. This effect was mediated by a binding site for the transcription factor STAT6 in the eotaxin-3 promoter sequence. Mutations in the STAT6 binding site abrogated up-regulation of eotaxin-3 promoter activity. In STAT6-defective human embryonic kidney 293 cells, the wild-type luciferase construct, but not the STAT6 binding mutant, was inducible by IL-4 only upon cotransfection of STAT6 expression vector. In addition, eotaxin-3 protein was detectable in the supernatants of STAT6-transfected human embryonic kidney 293 cells upon IL-4 or IL-13 stimulation. In the same experiments, TNF-alpha induced activation of the monocyte chemoattractant protein-1/CCL2 gene was independent of STAT6 transfection. These results indicate that IL-4 and IL-13 activate eotaxin-3 gene expression in a STAT6-dependent fashion. Although both eotaxin-1 and -3 are regulated by this transcription factor, the response of the eotaxin-3 gene to TNF-alpha stimulation appears to be different.

S(+)-4-(1-Phenylethylamino)quinazolines as inhibitors of human immunoglobulin E synthesis: potency is dictated by stereochemistry and atomic point charges at N-1

Since the pathogenesis of allergic diseases is associated with elevated levels of immunoglobulin E (IgE), we developed a high throughput reporter gene assay in a human B-cell line to screen for low molecular weight IgE inhibitory compounds. Monitoring the IL-4 driven IgE-germline promoter activity (IgE-GLP), we discovered 4-(1-phenylethylamino)qinazolines as potent inhibitors of IgE-germline gene expression. Testing of the individual enantiomers (1, 2) revealed that only the S(+) enantiomer 1 was active. A cell viability assay done in the same cell line in parallel discriminated the dose-dependent inhibition from a general antiproliferative effect. The observed correlation of the inhibitory potencies found in the reporter gene assay with those measured by IgE-ELISA in primary human splenocytes provided evidence that the blockade of IgE synthesis is the direct consequence of IgE-germline gene inhibition, thereby validating the reporter gene assay. Parallel synthesis in solution rapidly provided a series of analogues of compound 1 with modifications in the phenethylamine side chain and the quinazoline core for SAR studies. Increasing the lipophilicity of the arylalkylamine moiety yielded S(+)-4-(1-(2-naphthyl)ethylamino)quinazoline (6) as the most potent inhibitor (IC(50) of 14 nM) while the R(-) enantiomer was again found to be inactive. Within the set of S enantiomers, quantum mechanical calculations revealed that the IgE inhibitory activity can be quantitatively described by the charge at N-1 of the heterocyclic core and to a lesser extent by the molar refractivity. These results demonstrate the importance of electron-deficient fused 4-aminopyrimidines and lipophilic side chains for biological activity. The strong preference for the S configuration of the phenethylamine side chain is remarkable insofar as biological activity for fused 4-(1-phenylethylamino)pyrimidines has been published for the R enantiomers only (EGFR tyrosine kinase inhibition).

Inhibition of interleukin-4- and CD40-induced IgE germline gene promoter activity by 2'-aminoethoxy-modified triplex-forming oligonucleotides

Elevated levels of IgE are intimately associated with a number of allergic diseases, such as allergic rhinitis or asthma. Therefore, prevention of IgE production in human B-cells represents an attractive therapeutic target. IL-4-induced IgE germline gene transcription represents a crucial early step during IgE isotype switch differentiation. Gene induction is orchestrated by the coordinated action of the transcription factors STAT6 (signal transducer and activator of transcription), NF-kappaB, PU.1, and C/EBP. This study shows that 2'-aminoethoxy-modified oligonucleotides, which partially overlap with the STAT6 and the adjacent PU.1/NF-kappaB binding site, inhibit DNA binding of all three proteins with high affinity in a dose- and time-dependent fashion in vitro. Loss of protein binding correlated strongly with increasing DNA triplex formation. Importantly, the oligomers also effectively displaced pre-bound recombinant NF-kappaB p50 from double-stranded DNA in vitro. Functionally, the oligonucleotides led to a selective inhibition of IL-4-induced reporter gene activity from a construct driven by the IgE germline gene promoter in human B-cells. These data confirm the critical role of this cytokine-responsive regulatory region in IgE germline gene induction and further support the concept of specific modulation of gene expression by DNA triplex formation induced with chemically modified oligonucleotides.

STAT6 mediates eotaxin-1 expression in IL-4 or TNF-alpha-induced fibroblasts

Eosinophils are attracted to sites of allergic inflammation by a number of chemoattractants including eotaxin-1. This chemokine can be secreted from epithelial cells and fibroblasts after IL-4 and TNF-alpha stimulation in a synergistic fashion. TNF-alpha activated gene expression at the transcriptional level in a STAT6-dependent manner, because: 1) eotaxin-1 promoter luciferase constructs were TNF-alpha inducible in STAT6-defective HEK293 cells only on cotransfection of STAT6 expression vector, an effect that was partially mediated by activation-induced binding of NF-kappa B proteins to a composite STAT6/NF-kappa B element; 2) reporter constructs defective in STAT6 DNA binding did not respond to TNF-alpha stimulation; 3) eotaxin-1 protein secretion was detected only in STAT6-transfected HEK293 cell supernatants on TNF-alpha treatment; and 4) a trans-dominant negative STAT6 protein inhibited TNF-alpha-induced eotaxin-1 secretion in primary fibroblasts. TNF-alpha inducibility of the IL-8 and monocyte chemoattractant protein-1 genes was not dependent on STAT6 expression in the same experimental systems. The inducing effect of IL-4 and IL-13 was also mediated by STAT6. The synergistic effect of IL-4 and TNF-alpha observed at the RNA and the protein level was not seen at the promoter level. The data demonstrate that both IL-4 and TNF-alpha induce eotaxin-1 expression at the level of transcription via a STAT6-mediated pathway.

Export of the high affinity IgE receptor from the endoplasmic reticulum depends on a glycosylation-mediated quality control mechanism

The high affinity IgE receptor (FcepsilonRI) is a multisubunit complex comprised of either alphagamma(2) or alphabetagamma(2) chains. The cotranslational assembly of the IgE-binding alpha-chain with a dimer of gamma-chains occurs in a highly controlled manner and is proposed to involve masking of a dilysine motif present at the cytoplasmic C terminus of the FcepsilonRI alpha-chain that targets localization of this subunit to the endoplasmic reticulum (ER). Here, we show that ER quality control modulates export from the ER of newly synthesized alphagamma(2) and alphabetagamma(2) receptors. We demonstrate that the presence of untrimmed N-linked core glycans (Glc(3)Man(9)GlcNAc(2)) on the FcepsilonRI alpha-chain activates the ER quality control mechanism to retain this subunit in the ER, despite the presence of gamma-chains. At the same time, the untrimmed, ER-localized alpha-chain exhibits IgE-binding activity, suggesting that FcepsilonRI alpha-chain folding occurs before constitutive glucose trimming. In additional experiments, we demonstrate that cell surface expression of an alpha-chain C-terminal truncation mutant is also dependent on glucose trimming, but not on gamma-chain coexpression. We suggest that glucosidase trimming of terminal glucose residues is a critical control step in the export of FcepsilonRIalpha from the ER. Finally, we show that the constitutive ER FcepsilonRI alpha-chain, expressed in the absence of the other FcepsilonRI subunits, associates with the ER lectin-like chaperone calnexin, but not the structurally similar ER chaperone calreticulin, presumably through interaction with monoglucosylated alpha-chain ER glycoforms.

Regulation of Fc epsilonRI expression on human monocytic cells by ligand and IL-4

BACKGROUND

The Fc epsilonRI subunit composition and kinetic of expression differ between antigen-presenting cells and mast cells. Up to now, there has been no human in vitro model available that mimics the characteristics on monocytes.

OBJECTIVE

The characterization of a natural human monocytic cell line (THP1), which expresses Fc epsilonRI, and the comparison to primary human monocytes and other monocytic cell lines, which only express Fc epsilonRI after transfection with the human Fc epsilonRI alpha-chain gene.

METHODS

Surface receptor expression was characterized by flow cytometry, the human Fc epsilonRI alpha-chain gene was introduced by electroporation, and induction of Fc epsilonRI alpha-chain message was detected by semiquantitative RT PCR.

RESULTS

Here we show that the parental human cell line THP1, but none of the other cell lines tested, displays surface Fc epsilonRI in response to IL-4 or incubation with receptor ligand (IgE, antibody). Transfection of Fc epsilonRI alpha-chain resulted in receptor expression on all cell lines, all of which increased surface Fc epsilonRI in the presence of IgE. Only the THP1-alpha transfectant, however, further increased receptor levels in response to IL-4, resulting from mRNA induction for the Fc epsilonRI-alpha, but not the beta- or gamma-subunit.

CONCLUSION

Based on THP1, U937 and HL60 and their alpha-chain transfectants we present a model system for the study of Fc epsilonRI regulation and signalling on human cells. THP1 in particular, due to its responsiveness to both ligand and IL-4, even without prior manipulation, is ideally suited to address questions on Fc epsilonRI modulation in an 'allergic environment'.

Functional synergism of STAT6 with either NF-kappa B or PU.1 to mediate IL-4-induced activation of IgE germline gene transcription

Ig heavy chain class switching to IgE is directed by IL-4 and IL-13 by inducing transcription from the IgE germline promoter. A crucial transcription factor in this process is STAT6, which binds to a specific DNA element upon cytokine activation. In this paper it is shown that the B cell- and monocyte-specific factor PU.1 interacts with a closely spaced sequence in the human IgE germline promoter that overlaps with a previously described binding site for NF kappa B/rel. The authenticity of PU.1 was demonstrated by specific competition and supershifts in EMSA experiments. In addition, in vitro translated PU.1 could interact with an oligonucleotide derived from the IgE germline promoter containing the PU.1 binding site and migrated with the same mobility compared with the complex formed with nuclear extracts. Transient transfection experiments using IgE germline promoter reporter gene constructs demonstrated that mutations affecting DNA binding of PU.1 or NF kappa B/rel had no or little effect on IL-4 inducibility of these plasmids. However, point mutations that abolished binding of both factors abrogated cytokine inducibility. No strict spacing of the STAT6 and the composite PU. 1/NF-kappa B elements is required for IL-4 induction. IL-4-induced STAT6 DNA binding was retained in PU.1-/NF kappa B/rel- double mutants. The data demonstrate that cooperation of STAT6 with at least PU.1 or NF kappa B/rel is necessary for IL-4-induced activation of IgE germline gene transcription.

Cooperation of binding sites for STAT6 and NF kappa B/rel in the IL-4-induced up-regulation of the human IgE germline promoter

Ig heavy chain class switching is directed by cytokines inducing transcription from unrearranged CH genes. Subsequently, such primed cells can undergo switch recombination to express the selected new isotype. In the case of IgE class switching, IL-4 activates the IgE germline promoter by inducing the interaction of the transcription factor STAT6 (IL-4STAT) with a responsive DNA element in the proximal region of the promoter. This study describes the characterization of two additional cis-acting elements that interact with members of the NF kappa B/rel transcription factor family in an IL-4-independent fashion. Electrophoretic mobility shift assays show that the nucleoprotein complex formed on the upstream site (NF kappa B1) contains the classical p50/p65 heterodimer. The complex on the proximal site (NF kappa B2) appears to be composed of p50 and relB. IgE germline promoter reporter gene constructs carrying point mutations in the NF kappa B2 site were largely unresponsive to IL-4 stimulation in transient transfection experiments, while plasmids with similar mutations in the NF kappa B1 site responded to cytokine stimulation better than the wild-type promoter. The NF kappa B2 effect was dependent on the presence of the STAT6 binding site, demonstrating that the NF kappa B2 motif is necessary but not sufficient for mediating cytokine up-regulation. In addition, the combination of a NF kappa B/rel binding site and the STAT6 response element conferred IL-4 inducibility to a heterologous minimal promoter, while the individual sites had no effect. The available data suggest that the NF kappa B2 nucleoprotein complex may cooperate with DNA-bound STAT6 to achieve IL-4-dependent activation of the human IgE germline gene.

Cooperation of binding sites for STAT6 and NF kappa B/rel in the IL-4-induced up-regulation of the human IgE germline promoter

Ig heavy chain class switching is directed by cytokines inducing transcription from unrearranged CH genes. Subsequently, such primed cells can undergo switch recombination to express the selected new isotype. In the case of IgE class switching, IL-4 activates the IgE germline promoter by inducing the interaction of the transcription factor STAT6 (IL-4STAT) with a responsive DNA element in the proximal region of the promoter. This study describes the characterization of two additional cis-acting elements that interact with members of the NF kappa B/rel transcription factor family in an IL-4-independent fashion. Electrophoretic mobility shift assays show that the nucleoprotein complex formed on the upstream site (NF kappa B1) contains the classical p50/p65 heterodimer. The complex on the proximal site (NF kappa B2) appears to be composed of p50 and relB. IgE germline promoter reporter gene constructs carrying point mutations in the NF kappa B2 site were largely unresponsive to IL-4 stimulation in transient transfection experiments, while plasmids with similar mutations in the NF kappa B1 site responded to cytokine stimulation better than the wild-type promoter. The NF kappa B2 effect was dependent on the presence of the STAT6 binding site, demonstrating that the NF kappa B2 motif is necessary but not sufficient for mediating cytokine up-regulation. In addition, the combination of a NF kappa B/rel binding site and the STAT6 response element conferred IL-4 inducibility to a heterologous minimal promoter, while the individual sites had no effect. The available data suggest that the NF kappa B2 nucleoprotein complex may cooperate with DNA-bound STAT6 to achieve IL-4-dependent activation of the human IgE germline gene.

Characterization of Fc epsilonRI expressing human monocytic cell lines. 1. The role of CD45 on signal transduction in primary monocytes and cell lines

BACKGROUND

Recently, the high affinity receptor for IgE (Fc epsilonRI), which plays a major role in allergies, has been identified on a number of different antigen-presenting cell types, including human monocytes from atopic and nonatopic donors. In this report human monocytic cell lines were used to test for the expression of Fc epsilonRI, reasoning that a monocytic cell line expressing Fc epsilonRI constitutively would be a useful tool for large scale studies on the regulation of IgE binding and signal transduction.

METHODS

Reverse transduction polymerase chain reaction was applied to identify Fc epsilonRI alpha-chain message, flow cytometry to detect Fc epsilonRI surface expression and signal transduction on the cell lines generated by transfection.

RESULTS

We report the establishment of monocytic cell lines constitutively expressing Fc epsilonRI (THP1-alpha01 to THP1-alpha40) generated by transfection of the cell line THP1 with a plasmid encoding the Fc epsilonRI alpha-chain only. Fc epsilonRI on the THP1-alpha lines specifically binds IgE and is functional with regard to ligand binding and signal transduction. Comparative studies between the transfectants and primary human monocytes from nonatopic donors demonstrated the regulatory role of the tyrosine phosphatase CD45 on Fc epsilonRI-mediated cell activation.

CONCLUSIONS

Monocytic cell lines carry Fc epsilonRI alpha-chain RNA and enhancement by transfection results in surface Fc epsilonRI expression on THP1. Triggering the receptor on the THP1-alpha lines or on human monocytes, which express native Fc epsilonRI, elicits a rapid and transient calcium mobilization, prevented by co-cross-linking of Fc epsilonRI and CD45.

The transcription factor B-cell-specific activator protein is not involved in the IL-4-induced activation of the human IgE germline promoter

Transcriptional activity of the human IgE germline gene is a prerequisite for a subsequent deletional rearrangement of the Ig heavy-chain locus, the hallmark of isotype switching to IgE. The B-cell-specific transcription factor B cell-specific activator protein (BSAP) was described for being critically involved in the IL-4 up-regulation of the murine IgE germline gene. Our study was initiated to evaluate the regulatory role of BSAP in the human IgE germline promoter. It is shown that BSAP binds to a DNA element located immediately upstream of the most 5' transcriptional start site. The authenticity of BSAP was determined by electrophoretic mobility shift assays in which oligonucleotides corresponding to published BSAP binding sites efficiently competed for binding to the novel identified sequence. In addition, recombinant purified BSAP protein bound this motif and comigrated with the band seen with nuclear extracts. Finally, a polyclonal anti-BSAP antiserum specifically prevented interaction of the protein with its DNA recognition sequence. The affinity of BSAP for its recognition sequence was low compared with the sites identified in the CD19, the blk gene, and an LR1 transcription factor binding sequence located in the Ig gamma 1 switch region. Reporter gene constructs in which binding of BSAP was abolished by site-directed mutagenesis responded to IL-4 stimulation better than the wild-type construct in both cell lines tested. In addition, the basal activity of the mutated promoter did not change significantly despite the close proximity of the BSAP motif to the transcriptional start site. It is concluded that BSAP plays no direct regulatory role in the cytokine-induced response of the human IgE germline promoter.

The transcription factor B-cell-specific activator protein is not involved in the IL-4-induced activation of the human IgE germline promoter

Transcriptional activity of the human IgE germline gene is a prerequisite for a subsequent deletional rearrangement of the Ig heavy-chain locus, the hallmark of isotype switching to IgE. The B-cell-specific transcription factor B cell-specific activator protein (BSAP) was described for being critically involved in the IL-4 up-regulation of the murine IgE germline gene. Our study was initiated to evaluate the regulatory role of BSAP in the human IgE germline promoter. It is shown that BSAP binds to a DNA element located immediately upstream of the most 5' transcriptional start site. The authenticity of BSAP was determined by electrophoretic mobility shift assays in which oligonucleotides corresponding to published BSAP binding sites efficiently competed for binding to the novel identified sequence. In addition, recombinant purified BSAP protein bound this motif and comigrated with the band seen with nuclear extracts. Finally, a polyclonal anti-BSAP antiserum specifically prevented interaction of the protein with its DNA recognition sequence. The affinity of BSAP for its recognition sequence was low compared with the sites identified in the CD19, the blk gene, and an LR1 transcription factor binding sequence located in the Ig gamma 1 switch region. Reporter gene constructs in which binding of BSAP was abolished by site-directed mutagenesis responded to IL-4 stimulation better than the wild-type construct in both cell lines tested. In addition, the basal activity of the mutated promoter did not change significantly despite the close proximity of the BSAP motif to the transcriptional start site. It is concluded that BSAP plays no direct regulatory role in the cytokine-induced response of the human IgE germline promoter.

Transcription of the Epstein-Barr virus nuclear antigen 1 (EBNA1) gene occurs before induction of the BCR2 (Cp) EBNA gene promoter during the initial stages of infection in B cells

The purpose of this study was to gain insights into the regulation of Epstein-Barr virus (EBV) gene transcription during the establishment of viral latency in B cells. During the early stages of EBV infection in B lymphocytes, transcription of six viral nuclear antigens (EBNAs) is initiated from an early promoter (Wp). This is followed by a switch of promoter usage to an upstream promoter, Cp, whose activity is autoregulated by both EBNA1 and EBNA2. Previously it was demonstrated that infection of primary B cells with EBNA2-negative (EBNA2-) EBNA4-mutant (EBNA4mut) virus resulted only in the expression of mutant EBNA4 protein and failure to express the other EBNA gene products (C. Rooney H. G. Howe, S. H. Speck, and G. Miller, J. Virol. 63:1531-1539, 1989). We extended this research to demonstrate that Wp-to-Cp switching did not occur upon infection of primary B cells with an EBNA2- EBNA4mut virus (M. Woisetschlaeger, X. W. Jin, C. N. Yandara, L. A. Furmanski, J. L. Strominger, and S. H. Speck, Proc. Natl. Acad. Sci. USA 88:3942-3946, 1991). Further characterization of this phenomenon led to the identification of an EBNA2-dependent enhancer upstream of Cp. On the basis of these data, a model was proposed in which initial transcription from Wp gives rise to the expression of EBNA2 and EBNA4, and then transcription is upregulated from Cp via the EBNA2- dependent enhancer (Woisetschlaeger et al., as noted above). Implicit in this model is that transcription of the EBNA1 and EBNA3a to -3c genes is dependent on the switch from Wp to Cp, since primary cells infected with EBNA2- EBNA4mut virus fail to switch and also fail to express these viral antigens. Here we critically evaluate this model and demonstrate, in contrast to the predictions of the model, that transcription of both the EBNA1 and EBNA2 genes precedes activation of Cp. Furthermore, the level of EBNA1 gene transcription was strongly reduced in primary B cells infected with EBNA2- EBNA4mut virus compared with that of cells infected with wild-type virus. Switching to Cp, as well as EBNA1 gene transcription, was observed upon infection of EBV-negative Burkitt's lymphoma (BL) cell lines with EBNA2- EBNA4mut virus, thus establishing a correlation between early EBNA1 gene transcription and upregulation of transcription initiation from Cp. However, in EBV-negative BL cell lines infected with EBNA2- EBNA4mut virus, transcription of the EBNA1 gene at early time points postinfection initiated from Qp, the EBNA1 gene promoter active in group I BL cells (B. C. Schaefer, J. L. Strominger, and S. H. Speck, Proc. Natl. Acad. Sci. USA 92:10565-10569, 1995), rather than from Wp. The data support a model in which EBNA1 plays an important role in the cascade of events leading to successful switching from Wp to Cp and subsequent immortalization of the infected B cell.

The 'monocytic' cell line I937 displays typical B cell characteristics

The monocytic cell line I937 was derived from U937 by sorting for cells with high expression of MHC class II molecules. Further analysis of these class II molecules revealed the presence of the HLA-DR3 subtype suggesting that the cell line was a potential candidate for testing antigen presentation to T cells restricted by HLA-DR3. We found that the T cell clones CFTS4:2.80 and CFTS4:2.6 with the required restriction element responded to the house dust mite antigen DPT presented by I937 but not U937, whereas CFTS4:3.1, which is not HLA-DR restricted, did not respond to either cell line. Subsequent analysis of surface markers on I937, however, indicated that the cell line is of B cell origin. In contrast to the parental cell line U937, I937 was tested negative for CD4, CD31 and CD64 but expressed CD19, CD21 and CD40. Although neither surface nor cytoplasmic Ig molecules were detected in either I937 or U937, Southern blot analysis revealed IgH gene rearrangement in I937. In addition, a fragment specific for Epstein-Barr virus nuclear antigen (EBNA2) was amplified in I937 by PCR technique. Therefore, we conclude that I937 is an EBV-transformed B cell line, presumably derived from the same donor and not as reported originally as a subline of U937, which expresses high MHC class II levels.

Serum IgG autoantibodies directed against the alpha chain of Fc epsilon RI: a selective marker and pathogenetic factor for a distinct subset of chronic urticaria patients?

While it is well established that acute allergic urticaria is caused by degranulation of skin mast cells occurring after allergen/IgE-dependent cross-linking of high affinity IgE receptors (FcepsilonRI), the pathophysiologic mechanisms operative in chronic urticaria (CU) are less well understood. Some evidence points to the existence of histamine-releasing activity in the serum of CU patients which possibly acts via triggering of FcepsilonRI. In this study, we aimed to better characterize this anti-FcepsilonRIalpha reactivity of CU patients using affinity-purified, IgE-depleted IgG fractions of such individuals (CU-IgG). Using immobilized, recombinant soluble FcepsilonRIalpha as a a reaction target for Western blot studies, we found that 12/32 (37%) CU-IgG serum samples exhibited IgG autoreactivity against FcepsilonRI- alpha. These findings were confirmed by experiments demonstrating that immunoblot-reactive, but not immunoblot-nonreactive, CU-IgG preparations precipitated the FcepsilonRIalpha from FcepsilonRI- alphagamma-transfected cells. No anti-FcepsilonRIalpha reactivity was observed in IgG fractions from atopic dermatitis (AD) patients (0/15) or healthy control individuals (CO:0/15). As opposed to the selective occurrence of IgG anti-Fc epsilon RI alpha autoantibodies in CU patients, IgG anti-IgE antibodies were detected in all groups investigated (CU: 69%; AD: 73%; CO: 26%). While both types of autoantibodies can exhibit histamine-releasing properties, not all of the autoantibodies proved to be functional in vitro. Our results indicate that the occurrence of IgG anti-FcepsilonRIalpha reactivity defines an autoimmune-mediated subentity of CU and provide a basis for the development of new diagnostic procedures and, perhaps, therapeutic strategies for this disease.

A bifunctional control element in the human IgE germline promoter involved in repression and IL-4 activation

One of the first steps during Ig heavy chain isotype switching to IgE is the IL-4 induced synthesis of IgE germline transcripts. To further characterize the molecular mechanism of the IL-4 action, the regulatory DNA elements involved in the control of expression of these transcripts were analyzed. Transient transfection of a B cell tumor line revealed the presence of a 15 bp IL-4 responsive cis-acting element (IL-4RE) highly homologous to an IL-4 response element in the human CD23b promoter. An IL-4 induced DNA binding protein specifically interacted with this sequence. Point mutations within that sequence not only abolished IL-4 inducibility of reporter constructs but also prevented binding of the nuclear factor to the mutated sequence. A stretch of 16 nucleotides just upstream of the IL-4RE contributed to IL-4 inducibility and formed nucleoprotein complexes with constitutive factors. All reporter constructs containing the functional IL-4RE were transcriptionally very weak but could be readily activated upon IL-4 induction. Transfection of constructs containing the mutated IL-4RE or plasmids lacking that sequence displayed a high constitutive promoter activity and were IL-4 unresponsive. These data suggest that in the absence of the cytokine the activity of the IgE germline promoter is actively repressed through the action of the IL-4RE. The same sequence appears to be critically involved in the IL-4 induced activation of the promoter via the binding of a cytokine induced transcription factor.

Localization of the kdsA gene with the aid of the physical map of the Escherichia coli chromosome

The isolation and analysis of two recombinant plasmids containing the kdsA gene from Escherichia coli chromosomal gene libraries is reported. The subfragments obtained from the inserts correspond to the fragment pattern around coordinate 1,282 kilobases of the physical map of the E. coli chromosome (Kohara et al. Cell 50:495-508, 1987). The kdsA gene has been located at coordinates 1,282 through 1,283 kilobases, corresponding to min 26.7 in the classical map coordinates. The kdsA gene is transcribed from this position toward the nearby nar gene.

The kdsA gene coding for 3-deoxy-D-manno-octulosonic acid 8-phosphate synthetase is part of an operon in Escherichia coli

The kdsA gene of Escherichia coli was sequenced. It consists of 284 codons and is the last gene of a larger transcription unit. The mRNA is terminated by a rho-independent termination signal with the potential to be active in both orientations. This region is followed by another termination signal which seems to be active in the opposite orientation. Upstream of the kdsA gene a second open reading frame (ORF) was found; both this and the kdsA gene are transcribed in the same mRNA molecule when coded from the chromosome. In a plasmid-carried insert transcription starts from a cryptic promoter within the ORF preceding the kdsA gene. This promoter is not active in the intact chromosome.

Cloning and characterization of the gene encoding 3-deoxy-D-manno-octulosonate 8-phosphate synthetase from Escherichia coli

The cloning of the gene for Escherichia coli PL-2 2-keto-3-deoxy-D-manno-octonate 8-phosphate synthetase is reported. Positive transformants showed an increase of approximately three-fold in specific activity of the enzyme both in E. coli and in Salmonella typhimurium as host cells. A subclone containing a 1.5-kilobase PvuII fragment overproduced active enzyme. Minicell experiments that allow the detection of plasmid encoded proteins revealed an insert-coded single protein band of 34 kilodaltons.