Wandering spleen in a postpartum female: a case report

Introduction and importance

Wandering spleen (WS) is a rare condition that occurs when the spleen is not in its normal anatomical location, but in the abdominal or pelvic cavity. The mechanism of this condition may be due to dysfunction of ligaments that fixate the spleen in its position. Female hormonal alterations during pregnancy and other unknown causes in children may also play role in an ectopic spleen.

Case presentation

The authors report a case of a 34-year-old woman who presented to the emergency department with intermittent abdominal pain that persisted after childbirth without other symptoms.

Clinical discussion

Clinically the symptoms are varied and abdominal pain is the most common presentation. Radiological investigation of WS include ultrasound, MRI, and CT, which is the most preferred tool. Treatments after the diagnosis include splenectomy or splenopexy either through laparoscopy or laparotomy.

Conclusion

Physicians should include ectopic spleen as a differential diagnosis in a multiparous woman with the presentation of acute or chronic abdominal pain.

Dropped gallstones mimicking intraabdominal implants or tumor: A report of two cases

Introduction and importance

Case presentation

Clinical discussion

Conclusion

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Dropped gallstones are an uncommon complication of laparoscopic cholecystectomy (LC).

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We report two cases of dropped gallstones that were unexpectedly found during surgery.

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Clinicians should check the history of LC in patients presenting with a mass-forming lesion in the peritoneal cavity.

Abstract PD2-02: NEO-EXCEL phase III neoadjuvant trial of pre-operative exemestane or letrozole +/- celecoxib in the treatment of ER positive postmenopausal early breast cancer

COX2 has been implicated in breast tumorigenesis, tumour proliferation & invasion. The role of COX2 in carcinogenesis is thought to be related to its abilities to increase production of prostaglandins, convert pro-carcinogens to carcinogens, inhibit apoptosis, promote angiogenesis, modulate inflammation & immune function & increase tumour cell invasiveness. COX2 inhibition may synergise with aromatase inhibition in controlling endocrine responsive breast cancer. The COX2 product prostaglandin E2 (PGE2) & cytokines such as interleukin-6 (IL6) can up regulate aromatase expression suggesting that aromatase inhibition may be more effective in combination with a COX2 inhibitor. There may be additional COX2 mediated anticancer activity. The hypothesis addressed is that activity of aromatase inhibitors(AI) as neoadjuvant endocrine therapy for early breast cancer may be enhanced by the addition of a COX2 inhibitor.

TRIAL OBJECTIVES

To determine whether the activity of AIs as neo-adjuvant endocrine therapy for ER positive breast cancer in postmenopausal women may be enhanced by the addition of the selective COX2 inhibitor celecoxib.

TRIAL DESIGN

Prospective phase III multicentre randomised trial. Patients were randomised to receive 16 weeks of exemestane 25 mg daily or letrozole 2.5 mg daily (open label) and celecoxib 400 mg twice daily or matched placebo (double blinded). Translational research tumour samples were collected before, during & after therapy.

KEY ELIGIBILITY CRITERIA

Post menopausal, ER positive, invasive cancer, 2cms or greater with calipers & visible on USS.

PRIMARY OUTCOME MEASURE

Objective clinical response to neoadjuvant treatment by RECIST criteria.

RESULTS

Primary Outcome; Response to treatment has been calculated for 266 patients (Table 1). Response rate was 73% in the celecoxib arm & 55% in the placebo arm (p=0.0022). The response rates 4 arm comparison are shown in Table 2. After adjustment for AI effect the significant difference in response rates remained (p=0.0023); the difference in response rates was greater in the exemestane treated group (29%) compared to the letrozole group (7%) although heterogeneity between AI arms was statistically non-significant (p=0.06).

Table 1 Primary Outcome Results: response ratesOUTCOMEPLACEBO N (%)CELECOXIB N (%)TOTAL N (%)X2statisticP-valueRESPONSE73(55)97(73%)170 (64%)9.38820.0022NO RESPONSE60 (45%)36 (27%)96 (36%)  TOTAL133133266  

Table 2: Response Rates 4 Arm Comparison EXEMESTANELETROZOLERESPONSEPLACEBO n(%)CELECOXIB n(%)TOTAL n(%)PLACEBO n(%)CELECOXIB n(%)TOTAL n(%)RESPONSE33 (49)52(78)85(63)40(61)45(68)85(64)NO RESPONSE34(51)15(22)49(37)26(39)21(32)47(36)TOTAL67671346666132

Secondary outcome; There was an USS response rate of 42% v 37% for celecoxib & placebo arms respectively (p=0.2513)

CONCLUSION

The addition of the COX2 inhibitor celecoxib to an AI significantly & substantially increased the clinical response from 55% to 73%. Effect on tumour size assessed with USS is less marked with a non-significant increase in responses from 37% to 42%.

This work was supported by CRUK: CRUK/06/005 and Pfizer.

Citation Format: Rea D, Francis A, Poole C, Brookes C, Stein R, Bartlett J, Dunn J, Canney P, Sutton R, Daoud R, Hallissey M, Achuthan R, Grant M, Babrah J, Smith S, Fraser J, Desai A, Al Dubaisi M, Patel A, Bristol J, Chandrasekharan S, Prest C, Jewkes A. NEO-EXCEL phase III neoadjuvant trial of pre-operative exemestane or letrozole +/- celecoxib in the treatment of ER positive postmenopausal early breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD2-02.

[Angiolymphoid hyperplasia with eosinophilia]

INTRODUCTION

Angiolymphoid hyperplasia with eosinophilia (HALE) is a rare, benign proliferative vascular disorder of unknown etiology which typically presents as tumor-like nodules of the skin or subcutaneous tissue. It concerns mostly young female adults. We report a case of HALE located on the ear auricle diagnosed by biopsy. The outcome was total regression.

OBSERVATION

An 81-year-old male patient presented with a lesion of the whole ear auricle. A diagnosis of HALE was confirmed histologically on biopsy. The evolution was marked by spontaneous and complete regression in 2 months. There was no recurrence after 1 year of follow-up.

DISCUSSION

The etiology of this disease remains hypothetical. It poses real diagnostic problems with other types of proliferation, but its main differential diagnosis is Kimura disease. Its treatment has not been codified yet. Spontaneous regression is possible and justifies following the patient from 3 to 6 months, before a possible surgery.

P2-16-16: Nipple Sparing Mastectomy and Immediate Breast Reconstruction: Critical Appraisal of Five Year, Single Centre Outcomes

Background

Approximately 5,000 patients undergo breast reconstruction annually in the United Kingdom ( 2:1 ratio of immediate versus delayed respectively). Whilst skin sparing mastectomy is an accepted modality for local control in appropriately selected patients, nipple preservation remains controversial. In over 1,800 peer reviewed nipple sparing mastectomy (NSM) cases, the local event rate attributable to NAC preservation following NSM (therapeutic and prophylactic) is 0.16% with no evidence of deleterious impact on disease free survival. This study aims to evaluate in a selected cohort of patients, the oncological safety and aesthetic outcome of nipple- sparing mastectomy and immediate breast reconstruction (IBR). We highlight the surgical technique used and propose in/exclusion criteria.

Material and Methods: Patients were identified retrospectively from our Institution's electronic patient records and WinPath™ database by searching clinical codes corresponding to NSM & IBR, performed by the senior authors (IJL and RD) between January 2004 and December 2008. Pre-operative selection criteria included: 100% pre-operative lesion characterisation; 5mm margin acceptance; submission of separate nipple core specimens for paraffin block histological assessment and re-excision of all involved/close margins. Follow-up data was verified from patients’ case notes, histo- pathological review and standardised photographic views. Endpoints include: local recurrence rate, disease free survival, peri-operative NAC subcutaneous tissue loss and validated aesthetic outcome measures.

Results*: 84 patients underwent NSM & IBR for invasive disease. The mean age was 52.1 years and a median follow-up of 38 months. IBR utilised autologous tissue (latissimus dorsi or transverse rectus abdominus musculocutaneous flaps) with/without implant prosthesis. There was one case of local recurrence (1.2%) in a patient who declined re-excision of close/involved margins and no recorded breast cancer related deaths. Peri-operative complication rates were within the national mastectomy breast reconstruction audit outcome guidelines.

Conclusion: In this cohort of patients, nipple sparing mastectomy and immediate breast reconstruction achieves comparable oncological outcomes with excellent aesthesis relative to traditional ablative procedures for local control. Nipple preservation although not evaluated independently does enhance cosmetic outcomes.

*(Preliminary analysis)

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-16-16.

Nipple-sparing mastectomy and immediate breast reconstruction: Critical appraisal of five-year, single-center outcomes

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Background: Approximately 5,000 patients undergo breast reconstruction annually in the United Kingdom (2:1 ratio of immediate versus delayed respectively). Preservation of the breast envelope, i.e., skin and nipple areola complex (NAC) improves cosmesis. While skin-sparing mastectomy is an accepted modality for local control in appropriately selected patients, nipple-sparing mastectomy (NSM) remains controversial. In over 1,800 published NSM cases, the local event rate attributable to NAC preservation following NSM (therapeutic and prophylactic) is 0.16% with no evidence of deleterious impact on disease-free survival. In our cohort, patient selection criteria included: preoperative lesion characterisation; 5-mm margin acceptance; submission of separate nipple core specimens for paraffin block histological assessment and re-excision of all involved margins. This study is intended to evaluate the efficacy of loco-regional control in a consecutive cohort of patients, under uniform conditions undergoing nipple-sparing mastectomy and immediate breast reconstruction. We highlight the surgical technique used and propose in/exclusion criteria for appropriate patient selection.

Methods: 84 consecutive patients underwent NSM and IBR at Frimley Park Hospital, Surrey, UK (IJL, RD) between January 2004 and December 2008. Data was accrued retrospectively from the institution’s clinical coding, electronic records, and WinPath database. Endpoints recorded include: the incidence of (occult) malignancy at the nipple margins; NAC subcutaneous tissue loss; local (NAC) recurrence rates and disease free survival.

Results: The mean age was 51.1 years and follow-up 4.9 years. There was one case of local recurrence in a patient who declined re-excision of close/involved margins. The immediate peri-operative complication rate was within the national mastectomy breast reconstruction audit outcome guidelines.

Conclusions: In appropriately selected patients, our findings support nipple preservation at the time of mastectomy and immediate reconstruction as this enhances the cosmetic outcome without compromising oncologic safety.

A step towards decentralized wastewater management in the Lower Jordan Rift Valley

In order to address serious concerns over public health, water scarcity and groundwater pollution in Jordan, the expansion of decentralized wastewater treatment and reuse (DWWT&R) systems to small communities is one of the goals defined by the Jordan government in the "Water Strategy 2009-2022". This paper evaluates the general potential of decentralized wastewater system solutions to be applied in a selected area of the Lower Jordan Rift Valley in Jordan. For the study area, the connection degree to sewer systems was calculated as 67% (5% in the rural sector and 75% in the urban sector). The annual wastewater production available for DWWT&R in the rural sector of the investigation area was calculated to be nearly 3.8 million m(3) at the end of 2007. The future need of wastewater treatment and reuse facilities of the rural sector was estimated to be increasing by 0.11 million m(3) year(-1), with an overall potential of new treatment capacity of nearly 15,500 population equivalents (pe) year(-1). The overall potential for implementing DWWT&R systems in the urban sector was estimated as nearly 25 million m(3) of wastewater in 2007. The future need of wastewater treatment and reuse facilities required for the urban sector was estimated to be increasing at a rate of 0.12 million pe year(-1). Together with the decision makers and the stakeholders, a potential map with three regions has been defined: Region 1 with existing central wastewater infrastructure, Region 2 with already planned central infrastructure and Region 3 with the highest potential for implementing DWWT&R systems.

The implementation of guidelines and computerised forms improves the completeness of cancer pathology reporting. The CROPS project: a randomised controlled trial in pathology

The aim of this study was to determine whether reporting guidelines and computerised form-based reports improve the completeness of histopathological cancer data available for patient management and population cancer registration and to evaluate the acceptability of the intervention. The study was a randomised controlled trial with a split unit design and stratified cluster randomisation. All 16 hospital pathology laboratories in Wales were randomly allocated to report either breast or colorectal resection specimens by computerised form or conventional free text. 1044 reports were analysed in the study arm, 998 in the control arm. Use of pre-defined forms led to a 28.4% (95% confidence interval (CI): 15.7-41.2%) increase in complete reporting of a minimum dataset required for cancer registration and a 24.5% (95% CI: 11.0-38.0%) increase in complete reporting of minimum data required for patient management. Form-based reporting was acceptable to pathologists and preferred by clinicians. In conclusion, guidelines and computerised forms significantly improve the quality of histopathology reporting.

Functional expression of multidrug resistance protein 1 in Pichia pastoris

Overexpression of the multidrug resistance-associated protein (MRP1) causes multidrug resistance in cultured cells. MRP1 transports a large number of glutathione, glucuronide, and sulfate-conjugated organic anions by an ATP-dependent efflux mechanism. Six other MRP proteins exist (MRP2-7), and mutations in some of these genes cause major pathological conditions in humans. A detailed characterization of the structure and mechanism of action of these proteins requires an efficient expression system from which large amounts of active protein can be obtained. We report the expression of a recombinant MRP1 in the methylotrophic yeast Pichia pastoris. The protein is expressed in the membrane fraction of these cells, as a stable and underglycosylated 165 kDa peptide. Expression levels are very high, and 30 times superior to those seen in multidrug-resistant HeLa/MRP1 transfectants. MRP1 expressed in P. pastoris binds 8-azido[alpha-(32)P]ATP in a Mg(2+)-dependent and EDTA-sensitive fashion, which can be competed by a molar excess of ADP and ATP. Under hydrolysis conditions (at 37 degrees C), orthovanadate induces trapping of the 8-azido[alpha-(32)P]nucleotide in MRP1, which can be further modulated by known MRP1 ligands. MRP1 is also labeled by a photoactive analogue of rhodamine 123 (IAARh123) in P. pastoris/MRP1 membranes, and this can be competed by known MRP1 ligands. Finally, MRP1-positive membrane vesicles show ATP-dependent uptake of LTC(4). Thus, MRP1 expressed in P. pastoris is active and shows characteristics of MRP1 expressed in mammalian cells, including drug binding, ligand-modulated formation of the MRP1-MgADP-P(i) intermediate (ATPase activity), and ATP-dependent substrate transport. The successful expression of catalytically active and transport-competent MRP1 in P. pastoris should greatly facilitate the efficient production and isolation of the wild type or inactive mutants of MRP1, or of other MRP proteins for structural and functional characterization.

Major photoaffinity drug binding sites in multidrug resistance protein 1 (MRP1) are within transmembrane domains 10-11 and 16-17

MRP1 is an ABC (or ATP binding cassette) membrane transport protein shown to confer resistance to structurally dissimilar drugs. Studies of MRP1 topology suggested the presence of a hydrophobic N-domain with five potential membrane-spanning domains linked to an MDR1-like core (MSD1-NBD1-L1-MSD2-NBD2) by an intracellular linker domain (L0). MRP1-mediated multidrug resistance is thought to be due to enhanced drug efflux. However, little is known about MRP1-drug interaction and its drug binding site(s). We previously developed several photoreactive probes to study MRP1-drug interactions. In this report, we have used eight MRP1-HA variants that were modified to have hemagglutinin A (HA) epitopes inserted at different sites in MRP1 sequence. Exhaustive in-gel digestion of all IAARh123 photoaffinity-labeled MRP1-HA variants revealed the same profile of photolabeled peptides as seen for wild type MRP1. Photolabeling of the different MRP1-HA variants followed by digestion with increasing concentrations of trypsin or Staphylococcus aureus V8 protease (1:800 to 1:5 w/w) and immunoprecipitation with anti-HA mAb identified two small photolabeled peptides ( approximately 6-7 kDa) from MRP1-HA(574) and MRP1-HA(1222). Based on the location of the HA epitopes in the latter variants together with molecular masses of the two peptides, the photolabeled amino acid residues were localized to MRP1 sequences encoding transmembranes 10 and 11 of MSD1 (Ser(542)-Arg(593)) and transmembranes 16 and 17 of MSD2 (Cys(1205)-Glu(1253)). Interestingly, the same sequences in MRP1 were also photolabeled with a structurally different photoreactive drug, IACI, confirming the significance of transmembranes 10, 11, 16 and 17 in MRP1 drug binding. Taken together, the results in this study provide the first delineation of the drug binding site(s) of MRP1. Furthermore, our findings suggest the presence of common drug binding site(s) for structurally dissimilar drugs.

Pharmacokinetics and immunological effects of exogenously administered recombinant human B lymphocyte stimulator (BLyS) in mice

B lymphocyte stimulator (BLyS; also known as TNFSF20, BAFF, TALL-1, zTNF4, and THANK), a tumor necrosis factor ligand family member, has recently been identified as a factor that promotes expansion and differentiation of the B cell population, leading to increases in serum immunoglobulin levels. Here, pharmacokinetic parameters for BLyS administered i.v. and s.c. to mice are described, and the effects of different dosing regimens on serum and salivary immunoglobulin levels as well as splenic cell populations are reported. The pharmacokinetics of BLyS following i.v. injection are monophasic with a half-life of 160 min, a clearance of 0.22 ml/min-kg, and a volume of distribution of 53 ml/kg. Systemic administration of BLyS to mice resulted in increased serum IgG, IgA, IgM, and IgE and salivary IgA as well as splenic B cell population expansion and differentiation. The i.v. and s.c. routes of administration were pharmacologically equivalent, even though s.c. bioavailability of BLyS is only 25%. BLyS (s.c.) dramatically elevated serum IgG and IgA levels, and the duration of the responses after cessation of treatment (t(1/2) = 4.4 and 1.3 days, respectively) are similar to the half-lives of endogenous IgG and IgA in mice. The IgM response is more modest than that of IgG and IgA but lasts longer (t(1/2) = 7.0 days) than the half-life of endogenous IgM. A linear pharmacodynamic response was identified between days of dosing x log(dose), and increases in serum IgG, IgA, and IgM indicating that the response is more sensitive to the duration of dosing than to the cumulative dose. The implications of these findings for therapeutic administration of BLyS are discussed.

Rhodamine 123 binds to multiple sites in the multidrug resistance protein (MRP1)

The mechanisms of MRP1-drug binding and transport are not clear. In this study, we have characterized the interaction between MRP1 and rhodamine 123 (Rh123) using the photoreactive-iodinated analogue, [(125)I]iodoaryl azido-rhodamine 123 (or IAARh123). Photoaffinity labeling of plasma membranes from HeLa cells transfected with MRP1 cDNA (HeLa-MRP1) with IAARh123 shows the photolabeling of a 190 kDa polypeptide not labeled in HeLa cells transfected with the vector alone. Immunoprecipitation of a 190 kDa photolabeled protein with MRP1-sepcific monoclonal antibodies (QCRL-1, MRPr1, and MRPm6) confirmed the identity of this protein as MRP1. Analysis of MRP1-IAARh123 interactions showed that photolabeling of membranes from HeLa-MRP1 with increasing concentrations of IAARh123 was saturable, and was inhibited with excess of IAARh123. Furthermore, the photoaffinity labeling of MRP1 with IAARh123 was greatly reduced in the presence of excess Leukotreine C(4) or MK571, but to a lesser extent with excess doxorubicin, colchicine or chloroquine. Cell growth assays showed 5-fold and 14-fold increase in the IC(50) of HeLa-MRP1 to Rh123 and the Etoposide VP16 relative to HeLa cells, respectively. Analysis of Rh123 fluorescence in HeLa and HeLa-MRP1 cells with or without ATP suggests that cross-resistance to Rh123 is in part due to reduced drug accumulation in the cytosol of HeLa-MRP1 cells. Mild digestion of purified IAARh123-photolabeled MRP1 with trypsin showed two large polypeptides (approximately 111 and approximately 85 kDa) resulting from cleavage in the linker domain (L1) connecting the multiple-spanning domains MSD0 and MSD1 to MSD2. Exhaustive proteolysis of purified IAARh123-labeled 85 and 111 kDa polypeptides revealed one (6 kDa) and two (approximately 6 plus 4 kDa) photolabeled peptides, respectively. Resolution of total tryptic digest of IAARh123-labeled MRP1 by HPLC showed three radiolabeled peaks consistent with the three Staphylococcus aureus V8 cleaved peptides from the Cleveland maps. Together, the results of this study show direct binding of IAARh123 to three sites that localize to the N- and C-domains of MRP1. Moreover, IAARh123 provides a sensitive and specific probe to study MRP1-drug interactions.

Randomized trial of a specialist genetic assessment service for familial breast cancer

BACKGROUND

Because of the growing demand for genetic assessment, there is an urgent need for information about what services are appropriate for women with a family history of breast cancer. Our purpose was to compare the psychologic impact and costs of a multidisciplinary genetic and surgical assessment service with those of current service provisions.

METHODS

We carried out a prospective randomized trial of surgical consultation with (the trial group) and without (the control group) genetic assessment in 1000 women with a family history of breast cancer. All P: values are from two-sided tests.

RESULTS

Although statistically significantly greater improvement in knowledge about breast cancer was found in the trial group (P: =.05), differences between groups in other psychologic outcomes were not statistically significant. Women in both groups experienced statistically significant reductions in anxiety and found attending the clinics to be highly satisfying. An initial specialist genetic assessment cost pound 14.27 (U.S. $22.55) more than a consultation with a breast surgeon. Counseling and genetic testing of affected relatives, plus subsequent testing of family members of affected relatives identified as mutation carriers, raised the total extra direct and indirect costs per woman in the trial group to pound 60.98 (U.S. $96.35) over costs for the control subjects.

CONCLUSIONS

There may be little benefit in providing specialist genetics services to all women with a family history of breast cancer. Further investigation of factors that may mediate the impact of genetic assessment is in progress and may reveal subgroups of women who would benefit from specialist genetics services.

The multidrug resistance protein is photoaffinity labeled by a quinoline-based drug at multiple sites

Tumor cells overcome cytotoxic drug pressure by the overexpression of either or both transmembrane proteins, the P-glycoprotein (P-gp) and the multidrug resistance protein (MRP). The MRP has been shown to mediate the transport of cytotoxic natural products, in addition to glutathione-, glucuronidate-, and sulfate-conjugated cell metabolites. However, the mechanism of MRP drug binding and transport is at present not clear. In this study, we have used a photoreactive quinoline-based drug, N-(hydrocinchonidin-8'-yl)-4-azido-2-hydroxybenzamide (IACI), to show the photoaffinity labeling of the 190 kDa protein in membranes from the drug resistant SCLC H69/AR cells. The photoaffinity labeling of the 190 kDa protein by IACI was saturable and specific. The identity of the IACI-photolabeled protein as the MRP was confirmed by immunoprecipitation with the monoclonal antibody QCRL-1. Furthermore, a molar excess of leukotriene C(4), doxorubicin, colchicine, and other quinoline-based drugs, including MK571, inhibited the photoaffinity labeling of the MRP. Drug transport studies showed lower IACI accumulation in MRP-expressing cells which was reversed by depleting ATP levels in H69/AR cells. Mild digestion of the purified IACI-photolabeled MRP with trypsin showed two large polypeptides ( approximately 111 and approximately 85 kDa). The 85 kDa polypeptide which contains the QCRL-1 and MRPm6 monoclonal antibody epitopes corresponds to the C-terminal half of the MRP (amino acids approximately 900-1531) containing the third multiple spanning domain (MSD3) and the second nucleotide binding site. The 111 kDa polypeptide which contains the epitope sequence of the MRPr1 monoclonal antibody encodes the remainder of the MRP sequence (amino acids 1-900) containing the MSD1 and MSD2 plus the first nucleotide binding domain. Cleveland maps of purified IACI-labeled 85 and 111 kDa polypeptides revealed 6 kDa and approximately 6 plus 4 kDa photolabeled peptides, respectively. In addition, resolution of the exhaustively digested IACI-photolabeled MRP by HPLC showed two major and one minor radiolabeled peaks that eluted late in the gradient (60 to 72% acetonitrile). Taken together, the results of this study show direct binding of IACI to the MRP at physiologically relevant sites. Moreover, IACI photolabels three small peptides which localize to the N- and C-halves of the MRP. Finally, IACI provides a sensitive and specific probe for studying MRP-drug interactions.

Activity-dependent regulation of alternative splicing patterns in the rat brain

Alternative splicing plays an important role in the expression of genetic information. Among the best understood alternative splicing factors are transformer and transformer-2, which regulate sexual differentiation in Drosophila. Like the Drosophila genes, the recently identified mammalian homologues are subject to alternative splicing. Using an antibody directed against the major human transformer-2 beta isoform, we show that it has a widespread expression in the rat brain. Pilocarpine-induced neuronal activity changes the alternative splicing pattern of the human transformer-2-beta gene in the brain. After neuronal stimulation, a variant bearing high similarity to a male-specific Drosophila tra-2179 isoform is switched off in the hippocampus and is detectable in the cortex. In addition, the ratio of another short RNA isoform (htra2-beta2) to htra2-beta1 is changed. Htra2-beta2 is not translated into protein, and probably helps to regulate the relative amounts of htra2-beta1 to beta3. We also observe activity-dependent changes in alternative splicing of the clathrin light chain B, c-src and NMDAR1 genes, indicating that the coordinated change of alternative splicing patterns might contribute to molecular plasticity in the brain.

Candidemia: current epidemiologic characteristics and a long-term follow-up of the survivors

All consecutive patients with positive blood culture for Candida species over a 6-year period were evaluated to define recent epidemiologic characteristics of candidemia, and to assess the prevalence of late complications. We encountered 106 cases; medical records were available for 99 of them. The rate of candidemia was increasing until 1990, after which it declined. C. albicans was the most common species, but in the last 2 years, C. tropicalis and C. parapsilosis were emerging. Overall mortality rate was 54.5% without significant variation during the study period. Antifungal therapy was withheld in 24/99 cases (24.2%). Decision to withhold treatment was taken in 19/59 cases (32.2%) before the availability of fluconazole in 1990, compared with 5/40 cases (12.5%) afterward (p < 0.05). Follow-up was possible in 35 instances for an average period of 17.1 months (range: 1-48 months); 7 of these individuals, all with transient candidemia, were untreated. None of the survivors developed late complications. These findings demonstrate that candidemia appears to be declining since 1990, with a noticeable decrease in the prevalence of C. albicans but an increase in that of C. tropicalis and C. parapsilosis, that fewer patients are left untreated since fluconazole became available, and that the risk of late complications among the survivors is low.