Mutations that prevent caspase cleavage of RIPK1 cause autoinflammatory disease

Receptor Interacting Protein Kinase 1 (RIPK1) is a key regulator of innate immune signalling pathways. To ensure an optimal inflammatory response, RIPK1 is post-translationally regulated by well characterised ubiquitylation and phosphorylation events, as well as caspase-8 mediated cleavage^1–7. The physiological relevance of this cleavage remains unclear, though it is believed to inhibit activation of RIPK3 and necroptosis⁸. Here we show that heterozygous missense mutations p.D324N, p.D324H and p.D324Y prevent caspase cleavage of RIPK1 in humans and result in early-onset periodic fever episodes and severe intermittent lymphadenopathy, a condition we designate ‘Cleavage-resistant RIPK1-Induced Autoinflammatory’ (CRIA) syndrome. To define the mechanism for this disease we generated a cleavage-resistant Ripk1^D325A mutant mouse strain. While Ripk1^-/- mice die postnatally from systemic inflammation, Ripk1^D325A/D325A mice died during embryogenesis. Embryonic lethality was completely prevented by combined loss of Casp8 and Ripk3 but not by loss of Ripk3 or Mlkl alone. Loss of RIPK1 kinase activity also prevented Ripk1^D325A/D325A embryonic lethality, however the mice died before weaning from multi organ inflammation in a RIPK3 dependent manner. Consistently, Ripk1^D325A/D325A and Ripk1^D325A/+ cells were hypersensitive to RIPK3 dependent TNF-induced apoptosis and necroptosis. Heterozygous Ripk1^D325A/+ mice were viable and grossly normal, but were hyper-responsive to inflammatory stimuli in vivo. Our results demonstrate the importance of caspase-mediated RIPK1 cleavage during embryonic development and show that caspase cleavage of RIPK1 not only inhibits necroptosis but maintains inflammatory homeostasis throughout life.

Why is there a lower prevalence of chronic immobility in geriatric departments with a high turnover of patients?

There is little information available about the characteristics of patients admitted to geriatric units with high and low turnover rates of patients. It is often suggested that high turnover units do not admit the more physically disabled person. This study set out to investigate whether this view is true. Six geriatric units with different patient discharge rates were investigated. Those units with a high turnover of patients tend to admit more severely immobile people per bed, when compared to those units with below average throughput. Although these immobile people admitted to high turnover units suffered a higher mortality rate, a significantly greater proportion regained the ability to transfer themselves independently from bed to chair and to the toilet.

Brief Report: Cryopyrin-Associated Periodic Syndrome Caused by a Myeloid-Restricted Somatic NLRP3 Mutation

OBJECTIVE

To identify the cause of disease in an adult patient presenting with recent-onset fevers, chills, urticaria, fatigue, and profound myalgia, who was found to be negative for cryopyrin-associated periodic syndrome (CAPS) NLRP3 mutations by conventional Sanger DNA sequencing.

METHODS

We performed whole-exome sequencing and targeted deep sequencing using DNA from the patient's whole blood to identify a possible NLRP3 somatic mutation. We then screened for this mutation in subcloned NLRP3 amplicons from fibroblasts, buccal cells, granulocytes, negatively selected monocytes, and T and B lymphocytes and further confirmed the somatic mutation by targeted sequencing of exon 3.

RESULTS

We identified a previously reported CAPS-associated mutation, p.Tyr570Cys, with a mutant allele frequency of 15% based on exome data. Targeted sequencing and subcloning of NLRP3 amplicons confirmed the presence of the somatic mutation in whole blood at a ratio similar to the exome data. The mutant allele frequency was in the range of 13.3-16.8% in monocytes and 15.2-18% in granulocytes. Notably, this mutation was either absent or present at a very low frequency in B and T lymphocytes, in buccal cells, and in the patient's cultured fibroblasts.

CONCLUSION

Our findings indicate the possibility of myeloid-restricted somatic mosaicism in the pathogenesis of CAPS, underscoring the emerging role of massively parallel sequencing in clinical diagnosis.

Early-onset stroke and vasculopathy associated with mutations in ADA2

BACKGROUND

We observed a syndrome of intermittent fevers, early-onset lacunar strokes and other neurovascular manifestations, livedoid rash, hepatosplenomegaly, and systemic vasculopathy in three unrelated patients. We suspected a genetic cause because the disorder presented in early childhood.

METHODS

We performed whole-exome sequencing in the initial three patients and their unaffected parents and candidate-gene sequencing in three patients with a similar phenotype, as well as two young siblings with polyarteritis nodosa and one patient with small-vessel vasculitis. Enzyme assays, immunoblotting, immunohistochemical testing, flow cytometry, and cytokine profiling were performed on samples from the patients. To study protein function, we used morpholino-mediated knockdowns in zebrafish and short hairpin RNA knockdowns in U937 cells cultured with human dermal endothelial cells.

RESULTS

All nine patients carried recessively inherited mutations in CECR1 (cat eye syndrome chromosome region, candidate 1), encoding adenosine deaminase 2 (ADA2), that were predicted to be deleterious; these mutations were rare or absent in healthy controls. Six patients were compound heterozygous for eight CECR1 mutations, whereas the three patients with polyarteritis nodosa or small-vessel vasculitis were homozygous for the p.Gly47Arg mutation. Patients had a marked reduction in the levels of ADA2 and ADA2-specific enzyme activity in the blood. Skin, liver, and brain biopsies revealed vasculopathic changes characterized by compromised endothelial integrity, endothelial cellular activation, and inflammation. Knockdown of a zebrafish ADA2 homologue caused intracranial hemorrhages and neutropenia - phenotypes that were prevented by coinjection with nonmutated (but not with mutated) human CECR1. Monocytes from patients induced damage in cocultured endothelial-cell layers.

CONCLUSIONS

Loss-of-function mutations in CECR1 were associated with a spectrum of vascular and inflammatory phenotypes, ranging from early-onset recurrent stroke to systemic vasculopathy or vasculitis. (Funded by the National Institutes of Health Intramural Research Programs and others.).

The risk of exotic and native plants as hosts for four pest thrips (Thysanoptera: Thripinae)

Interactions among insect pests, crops and weeds are well recognised. In fact, the elimination of weed hosts outside of the crop is a common practice to control many insect-vectored viruses. However, little is known about interactions among insect pests, crops and native vegetation, and whether native plants may be used to revegetate areas where weed hosts have been eliminated as part of horticultural management regimes. We used the Northern Adelaide Plains horticultural region (South Australia, Australia) as a model system to study the potential of various plant taxa in hosting four pest thrips (three exotic, one native; Frankliniella occidentalis, F. schultzei, Thrips tabaci and T. imaginis) when located adjacent to, and distant from, horticultural crops. Flower funnels were used for standardised sampling of thrips on flowers from 19 exotic weed and 12 native plant species, representing 13 and three families, respectively. Flowers were sampled monthly over a year, and statistical analyses were performed to identify significant determinants of probability of thrips occurrence and density. Plant family was found to significantly influence both measures for each thrips species. In addition, crop proximity influenced the probability of occurrence for the two Frankliniella species (but only influenced density of the key pest F. occidentalis), and season influenced density of all four pest thrips. All native plant species tested had a low likelihood of hosting the three exotic thrips species. Overall, results suggest that judicious choice of surrounding vegetation has potential to be an important component of integrated pest management (IPM) while increasing biodiversity conservation.

Preference by Vespula germanica (Hymenoptera: Vespidae) for processed meats: implications for toxic baiting

The German yellowjacket, Vespula germanica (F.) (Hymenoptera: Vespidae), was introduced into Australia in 1959 and has established throughout southern Australia. In urban environments, V. germanica is frequently a nuisance pest at public gatherings and to homeowners. In native environments, it has the potential to pose a threat to native invertebrates. The current practice for controlling the wasps is nest destruction with pesticide. However, locating the nest(s) is not always practical or possible. Meat baits impregnated with an insecticide that foraging wasps cut and carry back to the nest offer a means of suppressing wasps where the nest sites are unknown. The success of meat baits depends on the attractiveness and acceptance of the meat to the wasp and the mode of action of the insecticide. Our objective was to determine wasp preference and acceptance of five processed meats: canned chicken or fish and freeze-dried chicken, fish, or kangaroo. We found that more wasps visited and took freeze-dried kangaroo and canned chicken than the other baits. Canned and freeze-dried fish were similarly preferred, and freeze-dried chicken was the least attractive and accepted by foraging wasps. Our findings demonstrate that wasps prefer some processed meats and hence take more loads back to the nest. By combining a suitable insecticide with a meat bait preferred by wasps, the likelihood of effective suppression of nuisance wasp populations should be increased.

Phenotypic and Genetic Influences on Test-Day Measures of Acetone Concentration in Milk

The objectives of this study were to estimate heritability of acetone concentration in milk, based on monthly samples of milk obtained as part of a routine milk testing program, and to evaluate the feasibility of using such data in a genetic evaluation program for selection against ketosis incidence. Milk samples were collected from January to December of 1999 in herds enrolled in the Ontario Dairy Herd Improvement Association, and acetone concentration was measured using an inline chemical procedure. The original data included more than 50,000 records. Because ketosis is generally a problem during early lactation, only the single test with the fewest days in milk was retained. In addition, data were retained only for cows with pedigree information. The final data set included 10,375 records. Among these data, only 6.56% had detectable levels of acetone. Acetone data were log-transformed prior to statistical analysis. Simple ANOVA indicated that herd, parity number, days in milk, and month of test had significant effects on acetone concentration. Acetone levels increased with lactation number and were higher in early lactation. Three approaches were applied for genetic analysis. First, REML was used with a simple linear animal model. Then, a separate procedure used data augmentation and Gibbs Sampling to obtain continuously distributed underlying values for records with zero acetone concentration, and these data were analyzed with both an animal and sire model. Heritability of acetone concentration was less than 1% for all 3 analyses. Herd effects accounted for about 5% of the phenotypic variance. Low estimates of heritability were due either to low actual levels of genetic variance or inability to detect all of the genetic variance present, due to infrequent recording during the early part of the lactation. Genetic evaluation based on recording of acetone concentration on a monthly basis seems of little use as a selection tool to decrease incidence of ketosis.

Estimation of genetic parameters for concentrations of milk urea nitrogen

The objective of this study was to use field data collected by dairy herd improvement programs to estimate genetic parameters for concentrations of milk urea nitrogen (MUN). Edited data were 36,074 test-day records of MUN and yields of milk, fat, and protein obtained from 6102 cows in Holstein herds in Ontario, Canada. Data were divided into three sets, for the first three lactations. Two analyses were performed on data from each lactation. The first procedure used ANOVA to estimate the significance of the effects of several environmental factors on MUN. Herd-test-day effects had the most significant impact on MUN. Effects of stage of lactation were also important, and MUN levels tended to increase from the time of peak yield until the end of lactation. The second analysis used a random regression model to estimate heritabilities and genetic correlations of MUN and the yield traits. Heritability estimates for MUN in lactations one, two, and three were 0.44, 0.59, and 0.48, respectively. Heritabilities for the yield traits were of a similar magnitude. Little relationship was observed between MUN and yield. Raw phenotypic correlations were all <0.10 (absolute value). Genetic correlations with production traits were close to zero in lactations one and three and only slightly positive in lactation two. The results indicate that selection on MUN is possible, but relationships between MUN and other economically important traits such as metabolic disease and fertility are needed.

Monocytic fasciitis: a newly recognized clinical feature of tumor necrosis factor receptor dysfunction

Tumor necrosis factor receptor-associated periodic syndrome (TRAPS) is a dominantly inherited autoinflammatory syndrome that results from mutations in TNFRSF1A, the gene that encodes the 55-kd tumor necrosis factor receptor. Clinically, patients present with recurrent episodes of fever in conjunction with localized inflammation at various sites. Myalgia is one of the most characteristic features of this syndrome and is frequently associated with an overlying erythematous, macular rash that, together with the myalgia, displays centrifugal migration. This has previously been believed to occur as a result of myositis. We describe herein the case of a 60-year-old man with TRAPS, in whom magnetic resonance imaging of the left thigh demonstrated edematous changes in the muscle compartments and surrounding soft tissues. A full-thickness wedge biopsy was performed, and hematoxylin and eosin staining and immunohistochemistry analysis of the specimen demonstrated normal myofibrils but a severely destructive monocytic fasciitis. These results suggest that the myalgia experienced by individuals with TRAPS is due to a monocytic fasciitis and not to myositis.

Emerging technologies in health care and the patient encounter of the future

In the last five years, the Web has changed the way information is disseminated, knowledge is gained, and health care is provided. Even though the health care industry has yet to fully realize the potential of the Internet, the Web is only the beginning. Several emerging technologies will be changing the rules again. With new forms of network connectivity and faster, new wireless technologies, the adoption rate of mobile, handheld computers in health care will grow feverishly. Intelligent, autonomous software agents that guide the patient through the continuum of care will extend the reach of health care providers to all places at all times. The author discusses these new concepts, how they might be applied in health care, and the doctor-patient health care transaction.

The changing role of the health care chief information officer

Information is the lifeblood of the health care organization. In the past, chief information officers were responsible for nothing else but assuring a constant flow of information. Today, they are being asked to do a great deal more. From E-business to E-health strategy, the chief information officer is the focal point of an organization's ability to leverage new technology.

Conservative management of a transdiaphragmatic fistula

Case reports of transdiaphragmatic fistulas connecting subphrenic collections and empyemas are uncommon. We report the rare complication of a fistulous connection between a subphrenic collection and the bronchial tree.

Protein S alters the active site location of activated protein C above the membrane surface. A fluorescence resonance energy transfer study of topography

The location of the active site of membrane-bound activated protein C (APC) relative to the phospholipid surface was determined both in the presence and absence of its cofactor, protein S, using fluorescence resonance energy transfer (FRET). APC was chemically modified to create the FRET donor species, Fl-FPR-APC, with a fluorescein dye (Fl) covalently attached to the active site via a D-Phe-Pro-Arg (FPR) tether and located in the active site near S4. FRET was observed when Fl-FPR-APC was titrated in the presence of Ca2+ ions with phosphatidylcholine/phosphatidylserine (4:1) vesicles containing the FRET acceptor, octadecylrhodamine (OR). Assuming a random orientation of transition dipoles (kappa2 = 2/3), the average distance of closest approach between the fluorescein in the active site of the membrane-bound APC and the OR at the membrane surface is 94 A. The same calcium-dependent distance was obtained for both small and large unilamellar vesicles and for vesicles that contained phosphatidylethanolamine. The active site of membrane-bound APC is therefore located far above the phospholipid surface. Upon addition of protein S, the efficiency of Fl-FPR-APC to OR energy transfer increased due to a protein S-dependent rotational and/or translational movement of the APC protease domain relative to the surface. If this movement were solely translational, then the average height of the fluorescein in the membrane-bound APC.protein S complex would be 84 A above the surface. The extent of Fl-FPR-APC to OR energy transfer was unaltered by the addition of thrombin-inactivated protein S. The protein S effect was also specific for APC, since the addition of protein S to similarly-labeled derivatives of factor Xa, factor IXa, or factor VIIa did not alter the locations of their active sites. This direct measurement demonstrates that the binding of the protein S cofactor to its cognate enzyme elicits a relocation of the active site of APC relative to the membrane surface and thereby provides a structural explanation for the recently observed protein S-dependent change in the site of factor Va cleavage by APC.

Ochratoxin A in wheat: certification of two reference materials

The preparation of two wheat reference materials and the certification of their ochratoxin A content is described. The materials were prepared and certified within the European Commission. Measurements and Testing Programme (M&T). The first and second phases of this project, two intercomparisons of procedures for the determination of ochratoxin A in wheat, at levels of approximately 13 micrograms/kg, and 7 micrograms/kg, respectively have already been reported. This paper describes the work carried out in certification of the ochratoxin A content (mass fraction) of two wheat reference materials: a blank wheat CRM 471, and a contaminated wheat, CRM 472. These materials were prepared for use in the second intercomparison referred to above and reported previously. Reference material CRM 472 was prepared from naturally-contaminated wheat blended with the blank wheat (CRM 471). Details are given of the milling, blending and packaging procedure, and the checks to ensure homogeneity and stability of the material. The certification exercise was carried out by 15 laboratories using a variety of extraction and clean-up procedures, and the certified ochratoxin A content (mass fraction) of CRM 471 was < 0.6 microgram/kg. The value for CRM 472 was 8.2 micrograms/kg with an uncertainty of 1.0 microgram/kg.

Ochratoxin A in wheat: a second intercomparison of procedures

The European Commission, Measurements and Testing Programme (BCR) has undertaken a project to improve methodology and to prepare certified reference materials for ochratoxin A determination. The first phase of this project, an intercomparison of procedures for the determination of ochratoxin A in wheat, at a content of approximately 13 micrograms/kg, has already been reported. The second intercomparison study, described in this paper, involved 26 European laboratories, from 11 countries, which analysed wheat naturally contaminated at a level of approximately 7 micrograms/kg, and a 'blank' wheat sample (ochratoxin A content < 0.2 microgram/kg). The participants used a variety of procedures which involved different extraction solvents and clean-up procedures. All laboratories used HPLC as the determinative step. Some laboratories also used immunoaffinity column clean-up in comparison with their normal method. Recoveries of the normal methods used by laboratories ranged from 58 to 114%; only three laboratories obtained recoveries outside the accepted range of 70 to 110%. Recoveries of the immunoaffinity column methods, using two sources of column, ranged from 58 to 114% for one and from 4 to 86% for the other. The between-laboratory reproducibility coefficient of variation for all results was 34% for the normal methods, and 34 and 42% for the two types of immunoaffinity columns. It was noted that, after the results were corrected for spike recovery, some laboratories became outliers owing to low spike recoveries. Further investigations of the spiking protocols used by each laboratory showed that the time left for evaporation of the spiking solvent was crucial to the recovery obtained.

Moraxella catarrhalis: pathogenic significance in respiratory tract infections treated by community practitioners

We prospectively studied the pathogenic significance of Moraxella (Branhamella) catarrhalis isolated from 212 patients of community practitioners in Australia. This organism was most commonly isolated during winter and early spring, and 92% of isolates were beta-lactamase producers. On the basis of predetermined clinical and microbiological criteria, 42% of the isolates were definitely pathogenic, 7% were probably pathogenic, 21% were of indeterminate pathogenicity, and 30% were nonpathogenic. Factors associated with pathogenic significance included pneumonia or bronchitis (87% of patients), predisposing respiratory or systemic conditions (62%), isolation from sputum, and pure isolation. Thirty-six percent of patients were < 5 years old, but only 9% of isolates from these patients were pathogenic or probably pathogenic, a finding that reflects the fact that nasal-swab and nasopharyngeal-aspirate sampling is a common practice. Isolates from older patients were more likely to be pathogenically significant. An assessment of the pathogenic significance of M. catarrhalis isolated from a patient in a community practice should take into consideration factors such as the patient's age, clinical illness, and underlying conditions; the presence of other organisms; and the source of the isolate.

Ochratoxin A in cereals and the BCR-M&T-projects

Reliable analytical procedures and certified reference materials are essential for the establishment and enforcement of tolerance levels for ochratoxin A in foods. The inadequacy of analytical procedures, together with the need for certified reference materials, led the Commission of the European Communities Community Bureau of Reference (BCR) to undertake a project to prepare suitable reference materials for ochratoxin A in wheat, in order to improve methodology and to harmonise agreement of results between member states. The first intercomparison study indicated problems in the analysis due to the influence of co-extractives in the matrix, and demonstrated that further work was necessary to improve recovery, clean-up and reproducibility. The second intercomparison study, in the EC Measurements and Testing Programme, correlated the performance of the different methods for ochratoxin A measurement in a separate batch of contaminated wheat, and compared novel immunoaffinity column methods with the standard laboratory methods. Results were obtained from 26 laboratories within 11 European countries, which therefore gives a good representation of the scope of methods currently used in Europe. Considerable improvements in the determination of ochratoxin A were noted compared with the first intercomparison study.

Characteristics of HPRT-mutant T cell lines in a lupus patient treated with cyclophosphamide

This report describes T cell lines derived from a patient with subacute cutaneous lupus after treatment with intravenous pulse cyclophosphamide. We selected for mitotically active, hypoxanthine-guanine phosphoribosyltransferase-deficient (HPRT-) T cells, by culture in a selective medium containing 6-thioguanine. When HPRT- cell lines were derived 6 days after pulse cyclophosphamide (CYC) treatment, they were predominantly CD8+ and T cell receptor (TCR) gamma/delta+, producing interferon-gamma (IFN gamma). Cell lines derived 21 days after CYC treatment were CD4+, TCR alpha/beta+ and produced both IFN gamma and interleukin-4. These results support a possible role for gamma/delta+ T cells in subacute cutaneous lupus and suggest a mechanism for the therapeutic effect of CYC.

Ochratoxin A in wheat: an intercomparison of procedures

The Commission of the European Communities' Community Bureau of Reference (BCR) has undertaken a project to improve methodology and to prepare suitable certified reference materials in order to provide a basis for analytical quality control for the determination of ochratoxin A. The first phase of the project, an intercomparison of procedures for the determination of ochratoxin A in wheat at a level of approximately 13 micrograms/kg, is described. The study involved 24 European laboratories which analysed a naturally contaminated wheat and a 'blank' wheat sample (ochratoxin A content < 1 microgram/kg). The participants used a variety of procedures, including chloroform, methanol, toluene and ethyl acetate for extraction, and silica-, reversed phase- and immunoaffinity columns for clean-up. HPLC (one laboratory used TLC) was applied as the determinative step. Several performance characteristics were checked and the ochratoxin A content was determined. Recoveries were found to range from 25 to 100%. The coefficient of variation from all the results calculated on the basis of peak height was 23%. The study showed that the variation of results was influenced more by the clean-up step than by the extraction solvent. Some laboratories suffered significant day-to-day effects while others found difficulties with interfering peaks in the 'blank' material. It is planned for the next study to improve the recovery range, the clean-up step and the reproducibility (within-laboratory, between-days) and to check the influence of co-extractives from the matrix.

Clinical features of human infection with Scedosporium inflatum

We report on 17 Australian cases of human infection or colonization with Scedosporium inflatum. The spectrum of clinical manifestations was similar to that in infection caused by Scedosporium apiospermum. The patients were classified into three groups. Four immunocompetent patients who presented with localized infections of a joint, nail bed, eye, or sphenoidal sinus made up the first group. Our first case, in a boy with posttraumatic septic arthritis, responded to surgical drainage with amphotericin B followed by treatment with itraconazole. The other three cases were cured by surgery alone. The second group consisted of five immunocompromised patients who presented with disseminated infections in a variety of sites. Four of these patients did not respond to antifungal therapy and died. The fifth apparently responded to antifungal drugs after correction of his neutropenia. The third group included eight patients with asymptomatic colonization in the external ear (five cases) or respiratory secretions (three cases). The nine isolates of S. inflatum tested by both disk and agar dilution methods were resistant to antifungal drugs. In our first case, which responded clinically to itraconazole, the MIC of this drug for the fungal isolate was 25 micrograms/mL. Thus S. inflatum can cause a broad spectrum of human infections whose severity and prognosis depend largely on the host's immune status.

Studies of bone marrow progenitor cells in lupus-prone mice. I. NZB marrow cells demonstrate increased growth in Whitlock-Witte culture and increased splenic colony-forming unit activity in the Thy-1-, lineage- population

Previous studies have demonstrated that NZB marrow can transfer features of autoimmunity. Therefore, we undertook a study of NZB marrow to determine whether it demonstrated any phenotypic abnormalities. In Whitlock-Witte cultures, NZB marrow cells generated nonadherent cells at low seeding densities, densities at which marrow from other strains did not generate nonadherent cells. In contrast, NZB marrow grew less well than controls in Dexter cultures. Inasmuch as the latter favor growth of granulocyte-macrophage precursors and the former B cells, these results suggest a possible skewing of NZB marrow cells toward lymphocyte production. Unfractionated marrow cells from NZB mice were found to produce 10-fold more splenic colonies in lethally irradiated recipients than marrow cells from control mice. This result was independent of the genotype of the recipient. When the progenitor Thy-1lo, Lin- marrow subpopulation was studied, NZB mice did not differ substantially from controls regarding splenic CFU. Therefore, Thy-1-, Lin- marrow cells were studied as a possible source of the excess splenic CFU in NZB mice. Indeed, the NZB Thy-1-, Lin- population contained 30-fold more splenic CFU than did the Thy-1-, Lin- population from control mice. These results suggest that NZB mice have unusual marrow progenitor cells; such cells may play a role in their autoimmune disease.

Studies of bone marrow progenitor cells in lupus-prone mice. I. NZB marrow cells demonstrate increased growth in Whitlock-Witte culture and increased splenic colony-forming unit activity in the Thy-1-, lineage- population

Previous studies have demonstrated that NZB marrow can transfer features of autoimmunity. Therefore, we undertook a study of NZB marrow to determine whether it demonstrated any phenotypic abnormalities. In Whitlock-Witte cultures, NZB marrow cells generated nonadherent cells at low seeding densities, densities at which marrow from other strains did not generate nonadherent cells. In contrast, NZB marrow grew less well than controls in Dexter cultures. Inasmuch as the latter favor growth of granulocyte-macrophage precursors and the former B cells, these results suggest a possible skewing of NZB marrow cells toward lymphocyte production. Unfractionated marrow cells from NZB mice were found to produce 10-fold more splenic colonies in lethally irradiated recipients than marrow cells from control mice. This result was independent of the genotype of the recipient. When the progenitor Thy-1lo, Lin- marrow subpopulation was studied, NZB mice did not differ substantially from controls regarding splenic CFU. Therefore, Thy-1-, Lin- marrow cells were studied as a possible source of the excess splenic CFU in NZB mice. Indeed, the NZB Thy-1-, Lin- population contained 30-fold more splenic CFU than did the Thy-1-, Lin- population from control mice. These results suggest that NZB mice have unusual marrow progenitor cells; such cells may play a role in their autoimmune disease.

Isolated hepatitis B core antibody--can response to hepatitis B vaccine help elucidate the cause?

The finding of a positive hepatitis B core antibody (anti-HBc) in the absence of hepatitis B surface antigen (HBsAg) or hepatitis B surface antibody (anti-HBs) is relatively uncommon. This finding is known to occur during the 'window period' of acute hepatitis B between loss of HBsAg and the appearance of anti-HBs. It may also occur with active infection or following resolution. The aim of this study was to determine if response to hepatitis B vaccination would allow the separation of these subgroups of patients with isolated anti-HBc. Seventeen patients with persistent isolated core antibody were vaccinated and serum obtained at 2, 4 and 8 weeks. Results were compared with a seronegative control group. Six subjects (35%) but no control patients (p = 0.016) responded with a titre of greater than 50mIU/mL at two weeks, suggesting an anamnestic response due to prior infection and immunity. A further seven subjects (41%) finally seroconverted (anti-HBs titre greater than 10mIU/mL) thus excluding chronic infection and suggesting initial false positive results. Only two subjects did not respond to a full course of vaccination, but neither they nor any other subjects were positive for HBV DNA. These results indicate that hepatitis B vaccination and subsequent measurement of anti-HBs will identify evidence of past infection in the form of an anamnestic response in up to one third of the patients and will also exclude chronic infection on the grounds of a normal vaccine response in a majority of the remainder.

Is persistent adenovirus 12 infection involved in coeliac disease? A search for viral DNA using the polymerase chain reaction

It has been shown that partial amino acid sequence homology between alpha gliadin and an early region protein (E1B-58 kDa) of adenovirus 12 results in immunological cross reaction. This led to the proposal that prior infection by adenovirus 12 could be associated with the development of coeliac disease. To examine this hypothesis, evidence was sought of persistent adenovirus 12 infection in the small intestinal mucosa of patients with coeliac disease. DNA isolated from biopsy samples from 24 control and 18 coeliac disease patients was analysed by the polymerase chain reaction for adenovirus 12 DNA encoding the E1B-58 kDa protein. Four of 18 coeliac disease and two of 24 control patients were positive. There is thus a low prevalence of this infection on both groups of patients but certainly no significantly increased incidence in coeliac disease. These results suggest that persistent adenovirus 12 infection is not a major element in the pathogenesis of coeliac disease.

The preparation, validation and certification of the aflatoxin content of two peanut butter reference materials

The preparation of two peanut butter reference materials and the certification of their aflatoxins B1, B2, G1, G2 and total aflatoxin contents is described. The materials were prepared and certified within the BCR Programme of the Commission of the European Community as part of a broad activity to improve accuracy and agreement of measurements of importance in food and agriculture (Wagstaffe and Belliardo 1990). Reference material RM 385 was prepared from naturally contaminated peanuts, roasted and ground into a paste and then blended with uncontaminated peanut butter to achieve the desired aflatoxin concentrations. Details are given of the blending and canning procedure, and the checks to ensure homogeneity and stability of the material. Reference material RM 401 was similarly prepared but from an uncontaminated peanut butter. The certification exercise was carried out by nine laboratories using a variety of extraction and clean-up procedures, but all using high performance liquid chromatography (HPLC) as the determinative stage although operating under a variety of chromatographic conditions. RM 385 was certified as containing aflatoxins B1, B2, G1 and G2 at levels of 7.0 +/- 0.8 micrograms/kg, 1.1 +/- 0.2 micrograms/kg, 1.7 +/- 0.3 micrograms/kg and 0.3 +/- 0.2 micrograms/kg respectively (total aflatoxin content of 10.1 +/- 1.5 micrograms/kg) and RM 401 as containing aflatoxin B1, B2 and G2 at less than 0.2 micrograms/kg and aflatoxin G1 at less than 0.3 micrograms/kg (total aflatoxin content less than 0.9 micrograms/kg). The materials are intended for the verification of methods used to determine aflatoxins in nuts and nut products.

Small bowel morphology in British Indian and Afro-Caribbean subjects: evidence of tropical enteropathy

Distal duodenal biopsy specimens taken from 30 white, 35 Indian, and 20 Afro-Caribbean residents of West Birmingham during routine endoscopy for dyspepsia, were assessed by dissecting microscopy and morphometry. Finger-shaped villi were significantly less frequent in the Indian and Afro-Caribbean subjects than in the white subjects when assessed by dissecting microscopy (p less than 0.005), and both immigrant groups had decreased mucosal thickness (p less than 0.01), villous height (p less than 0.001), villous:crypt ratios (p less than 0.01) and enterocyte height (p less than 0.05) compared with the white group. In the Indian subjects, villous height and villous:crypt ratios correlated significantly with the time since the last visit to the Indian subcontinent (p less than 0.005). Serum alkaline phosphatase values were significantly higher in the Indian subjects compared with the whites (p less than 0.02), and serum globulins were increased in both the Afro-Caribbean and Indian subjects (p less than 0.01). There were no correlations between morphometric indices and body habitus or biochemical or haematological indices and the long term effect of the morphological changes is not clear.

Studies on a toxic metabolite from the mould Wallemia

While monitoring the occurrence of toxigenic moulds in foods, using a bioassay screen, it was shown that an isolate of Wallemia sebi produced toxic effects in several of the bioassays. The toxic metabolite was isolated and purified using solvent extraction, TLC and HPLC coupled with the brine shrimp assay to monitor the toxic fractions. The purified toxin, which we propose to call walleminol A, has been partially characterized by mass spectroscopy, nuclear magnetic resonance, ultraviolet and infrared spectroscopy. It can be provisionally interpreted as a tricyclic dihydroxy compound, C15H24O2, with structural features characteristic of a sesquiterpene with an isolated double bond, but further work is required to characterize this compound unequivocally. The minimum inhibitory dose of walleminol A in the bioassays is approximately 50 micrograms/ml, which is comparable with a number of mycotoxins such as citrinin and penicillic acid.

Chronic liver disease. A case control study of the effect of previous blood transfusion

A means of assessing hepatitis NANB virus infection, via blood transfusion, as a cause of chronic liver disease was investigated in a hospital in each of two cities in England. Patients with chronic liver disease were matched for age and sex with other patients in the same hospital and histories taken included details of previous operations and blood transfusions; if these were within ten years of the study enquiries were made of hospital records officers. All positive histories were found correct, but about one third of previous transfusions had been omitted by both case and control patients. Sixty-seven male and 35 female patients with chronic liver disease and their controls were included in analyses. The only clear difference which emerged related to residence for more than a year in the Middle or Far East by male case- (40%) or control- (21%) patients (P less than 0.05). The exclusion of patients with this history left only 34 pairs in which five (15%) of the case patients and one (3%) of the control patients had a transfusion history: this difference was not statistically significant. Although the study results have shown no clear evidence of blood transfusion as a major cause of chronic liver disease in Britain, the study method, with sufficient numbers to allow analyses of newly diagnosed patients with confirmed transfusion histories, could be used to provide an ongoing assessment of the risk.

Vitamin K-dependent carboxylase. Stoichiometry of vitamin K epoxide formation, gamma-carboxyglutamyl formation, and gamma-glutamyl-3H cleavage

The rat liver microsomal vitamin K-dependent carboxylase catalyzes the carboxylation of peptide-bound glutamyl residues to gamma-carboxyglutamyl (Gla) residues with the concomitant formation of vitamin K 2,3-epoxide (KO). These studies have demonstrated that the half-reaction, formation of KO, occurs in the absence of carboxylation at low glutamyl substrate concentration but that the ratio of KO/Gla approaches unity as the glutamyl substrate concentration is increased. Utilization of the carboxylase substrate Phe-Leu-[gamma-3H] Glu-Glu-Leu has demonstrated that the ratios of KO/gamma-C-H bonds cleaved and Gla/gamma-C-H bonds cleaved are equivalent at high substrate concentrations and that these ratios approach unity. At low substrate concentrations, KO formation occurs at a higher rate than gamma-H bond cleavage. These data are consistent with a mechanism involving the formation of an oxygenated intermediate from vitamin KH2 and O2 that is converted to KO during hydrogen abstraction from the gamma-position of the Glu substrate. In the absence of a Glu substrate, the intermediate is converted to KO by a mechanism not coupled to glutamyl activation.

Disappearing hypercalcaemia

Four women presented with symptomatic hypercalcaemia and raised concentrations of serum parathyroid hormone (PTH). In each case, serum calcium returned spontaneously to normal. In two patients serum PTH also fell to the normal range and biochemical relapse has not occurred despite prolonged follow-up. In the others, serum PTH remained elevated and subsequent symptomatic hypercalcaemia necessitated parathyroidectomy. In the first two cases, autoparathyroidectomy is the most likely explanation; the initial fall in serum calcium in the other two patients is unexplained. Large fluctuations in serum calcium may occur in some patients with hyperparathyroidism and prolonged and careful observation is required when this occurs.

Jejunal plasma cells and in vitro immunoglobulin production in adult coeliac disease

IgA, IgE, IgG and IgM plasma cells in small bowel mucosal biopsies from 15 controls, 16 untreated and 14 treated coeliac patients and five patients with selective serum IgA deficiency (four of whom also had coeliac disease) were quantified using an indirect immunoperoxidase technique. The IgA, IgG and IgM plasma cell counts were significantly increased in the untreated coeliac patients. The cell counts were intermediate in the treated coeliac group. These changes were in parallel to production in vitro of IgA and sIgA, IgG, and IgM by cultured mucosal biopsies from the same patients. The IgA deficient patients had very few mucosal IgA cells but elevated IgG and IgM plasma cell numbers; again these changes were reflected in the production in vitro of immunoglobulins. IgE plasma cell counts were very low in all patients and there were no differences between patient groups. The changes in cell counts and mucosal immunoglobulin production were not reflected in serum IgA, IgM and IgG concentrations but serum secretory IgA was significantly elevated in the untreated coeliac patients compared with controls, with the treated coeliac patients being intermediate. The raised mucosal plasma cell counts reflect the local mucosal production of immunoglobulin but not the immunoglobulin concentrations of serum, emphasising the importance of studying the immune function of the gut itself in coeliac disease rather than immunological abnormalities in serum.

Chronic hepatitis B carriers found at blood donation: do they need regular follow-up?

It is recommended by the Department of Health and Social Security that hepatitis B virus (HBV) carriers found at blood donation should be followed up by specialist liver units. We attempted to do this in 74 such patients found by the Yorkshire Regional Blood Transfusion Service during a 4.5-year period. Only 32 of the patients eventually attended for further investigation and follow-up. However, 43 chronic HBV carriers found at blood donation have been followed for varying periods from 2 to 14 years, and the prognosis has been good. Although this raises the question as to whether such carriers need to be seen routinely in a specialist unit, we suggest that there are good reasons to continue to advocate this policy.

ELISA for measurement of secretory IgA distinct from monomeric IgA

A micro enzyme-linked immunoassay (ELISA) is described for the quantitation of secretory IgA as distinct from monomeric IgA. The assay is sensitive (linear down to 30 ng/ml) and reproducible (inter-assay variation: 17.0%; intra-assay variation: 11.5%). The assay has the further advantages of rapidity, the ability to handle large numbers of samples, and uses commercially available reagents throughout. Minimal interference from a large (greater than 25-fold) excess of monomeric IgA was observed. The results obtained for serum secretory IgA concentrations by this method correlated well with those reported by other workers for normal control patients, patients with IgA deficiency and patients with liver disease.

Immunoglobulin production by coeliac biopsies in organ culture

The production of immunoglobulins by jejunal mucosa during organ culture has been studied. In 18 untreated coeliac patients the amounts of IgA, secretory IgA and IgM in the culture medium were higher than in those from 17 normal controls. The results in 15 treated coeliac patients did not differ from the control subjects. Mucosal biopsies from patients with serum IgA deficiency produced very little IgA, but large amounts of IgG and IgM. The addition of neither Frazer's gluten fraction III, nor alpha-gliadin to the culture system stimulated any additional increased secretion of immunoglobulins from the untreated coeliac patients. Production of IgA and IgM by the small bowel mucosa continues during organ culture, but that of IgG appears insignificant.

Secretion of gliadin antibody by coeliac jejunal mucosal biopsies cultured in vitro

The role of gliadin antibodies in coeliac disease is unknown. We have investigated this by maintaining jejunal biopsies from control subjects, treated and untreated coeliac patients in organ culture for 24 h. The tissue culture supernatants were assayed by enzyme-linked immunosorbent assay (ELISA) for total IgG, IgM and IgA, anti-gliadin and casein antibodies. Jejunal biopsies from untreated coeliac patients secreted more total IgM and IgA but not IgG, than biopsies from control subjects: values for treated coeliac patients were similar to those from control subjects. There was increased secretion of IgG and IgM gliadin antibody, but not casein antibody, by jejunal biopsies from untreated coeliac patients compared with those from control subjects.

The microenvironment of coeliac disease: T cell phenotypes and expression of the T2 'T blast' antigen by small bowel lymphocytes

Peroral jejunal biopsies were studied by double-label immunofluorescence on cryostat tissue sections from control patients of normal histology and patients with coeliac disease. A panel of monoclonal antibodies was used to identify T cells and T cell subsets, together with antibody markers of cell stimulation (the T2 40 kdalton T blast specificity), proliferation (T9 and Ki67) and activation (HLA-DR and Ig receptors). In normal mucosa, expression of T2 was predominantly found in the T8+ intraepithelial cytotoxic/suppressor population. In coeliac disease there was little alteration of T4:T8 ratios per se, but a much higher percentage of T8-T4+ helper/inducer cells expressed the T2 antigen (approx. 30% compared to approx. 10%), manifest as an accretion of T2+T8- cells in the epithelium and subjacent stroma. Additionally, T cell lymphoid aggregates were observed in the lamina propria, consisting of greater than 90% T4+ cells, of which the majority (60-80%) were also T2+. The increase of stimulated helper cells correlated well with the pathology of coeliac disease, being most marked in untreated cases of maximal tissue damage, and least in well treated cases with restoration of normal morphology. By contrast, an increased tendency for the T8+ cells to co-express T1 in untreated coeliac disease was not observed in treated disease, even in cases where failure to adhere to a strict gluten free diet had resulted in little histological improvement. There was little evidence of T cell activation or proliferation. The observation that T helper cells undergo migration and stimulation suggests an imbalance in immunoregulation which causes a breakdown of normal immune tolerance to dietary gluten, and therefore may be a crucial mechanism of tissue damage in coeliac disease.

"Angiodysplasia' of the tongue with acquired von Willebrand's disease

A case of acquired von Willebrand's disease is reported in which the patient developed a swelling on the dorsum of the tongue. Histology of this lesion closely resembled that described in angiodysplasia of the colon.

Prolonged dystonic reaction to chlorpromazine in myxoedema coma

A case of myxoedema coma is reported where the administration of chlorpromazine resulted in a prolonged dystonic reaction. A similar challenge with a butyrophenone when the patient was on thyroxine caused a similar but much abbreviated response.

The relation between skin histamine concentration, histamine sensitivity, and the resistance of cattle to the tick, Boophilus microplus

Cattle with different degrees of resistance to Boophilus microplus have responses to tick allergen which correlate with their resistance level. The total amount of histamine in the skin also correlates with both resistance and the immediate hypersensitivity reactions, but the sensitivity to injected histamine does not. Treatment with the antihistamine drug mepyramine maleate suppresses the cutaneous hypersensitivity reactions. The results suggest that the main pharmacologically active agent in these reactions is histamine, and that the total amount of it available locally in the skin may have a role in the resistance to this parasite.