Lenalidomide enhances the protective effect of a therapeutic vaccine and reverses immune suppression in mice bearing established lymphomas.

Immunomodulatory drugs (IMiDs) are effective therapeutic agents with direct inhibitory effects on malignant B- and plasma-cells and immunomodulatory effects on the T-cell activation. This dual function of IMiDs makes them appealing candidates for combination with a cancer vaccine. We investigated the immune stimulatory effects of lenalidomide, administrated to mice in doses, which provided comparable pharmacokinetics to human patients, on the potency of a novel fusion DNA lymphoma vaccine. The combination was curative in the majority of mice with 8d pre-established syngeneic A20 lymphomas compared with vaccine or lenalidomide alone and induced immune memory. In vivo depletion experiments established the requirement for effector CD8(+) and CD4(+) T cells in protective immunity. Unexpectedly, lenalidomide alone was also associated with reduced numbers of systemic myeloid-derived suppressor cell (MDSC) and regulatory T cell (Treg) in tumor-bearing but not naïve mice, an effect that was independent of simple tumor burden reduction. These results confirm and extend results from other models describing the effect of lenalidomide on enhancing T-cell immunity, highlight the potency of this effect, and provide a rationale for clinical application. Independently, a novel mechanism of action reversing tumor-induced immune suppression by MDSC is suggested.

Induction of TLR4-dependent CD8+ T cell immunity by murine ß-defensin2 fusion protein vaccines.

Our laboratory previously described the strategy of fusing chemokine receptor ligands to antigens in order to generate immunogenic DNA vaccines. In the present study, we produced mouse ß-2 defensin (mBD2) fusion proteins using both ovalbumin (OVA) and gp100 as model antigens. Superior cross-presentation by dendritic cells (DC) was observed for mBD2 fused antigens over unfused antigens in vitro. In vivo, we observed significant increases in the expansion of adoptively transferred antigen-specific MHC class I, but not class II-restricted T cells after immunization with mBD2 fused antigen over antigen alone. This enhanced expansion of class I restricted T cells was Toll-like receptor 4 (TLR4) dependent, but CC chemokine receptor 6 (CCR6) independent. Superior tumor resistance was observed for mBD2-fusion protein vaccines, compared to unfused antigen, in both B16-OVA and B16 tumor models. These data suggest that production of mBD2 fusion proteins is feasible and that the vaccines facilitate in vivo expansion of adoptively transferred T cells through a TLR4-dependent mechanism.

Mutational analysis of forkhead transcriptional factor 2 (FOXL2) in Korean patients with blepharophimosis-ptosis-epicanthus inversus syndrome.

We screened for mutations in the forkhead transcription factor gene, FOXL2, in Korean patients with sporadic or familial blepharophimosis-ptosis-epicanthus inversus syndrome (BPES) by polymerase chain reaction-single-stranded conformation polymorphism (PCR-SSCP) and direct sequencing. Five of nine BPES families and three of seven sporadic cases were detected to have FOXL2 mutations. We identified four types of FOXL2 mutations, two of which are novel. A new 14 bp deletion (939-952del14) causing a frameshift from G235W and the extension of the predicted protein to 527 amino acids was detected in a BPES family patient. In addition, a novel 845C > A transversion, resulting in a nonsense mutation (S203X), was found in a sporadic case of BPES. The previously reported in-frame 30 bp duplication (909-938dup30) was the most common mutation and was found in eight patients of four BPES families and one sporadic case. A known 17 bp duplication (1080-1096dup17) was observed in a sporadic BPES case. We were unable to find a causal mutation in four BPES families and four sporadic cases. These results suggest that in a fraction of BPES patients, the genetic defect might be associated with a mutation in the non-coding region of the FOXL2 gene or in other genes.

Posterior capsular opacification in phacotrabeculectomy : a long-term comparative study of silicone versus acrylic intraocular lens.

PURPOSE: To investigate the long-term outcomes of silicone versus acrylic intraocular lens (IOL) implantation in phacotrabeculectomy (PT) with special emphasis on posterior capsular opacification. DESIGN: Long-term follow-up on prior 1-year prospective, randomized study. PARTICIPANTS: A total of 200 eyes of 200 consecutive primary open-angle glaucoma patients who had undergone primary PT with capsular bag implantation of either a silicone IOL (102 eyes) or an acrylic IOL (98 eyes) according to the initial short-term prospective, randomized study protocol. INTERVENTION: The study eyes underwent primary trabeculectomy, phacoemulsification, and posterior chamber IOL implantation. Adjunctive mitomycin C was used selectively, primarily in patients with one or more risk factors for filtration failure. MAIN OUTCOME MEASURES: Incidence of posterior capsular opacification (PCO), best-corrected visual acuity (BCVA), intraocular pressure (IOP), number of pressure-lowering medications, and filtration success rates, defined as maintenance of target IOP while on one (criteria 1) or zero (criteria 2) pressure-lowering medications without further surgical intervention. RESULTS: At 3-year follow-up, the PCO rate and BCVA did not differ significantly between the two groups (P: > 0.05 for both). In addition, there were no significant differences in IOP, number of medications, and filtration success rate between the two groups (P: > 0.05 for each). CONCLUSIONS: There were no significant long-term differences between the silicone and acrylic IOL groups in PCO, BCVA, IOP, number of medications, and success of filtration surgery after PT. Both groups attained significant improvement in BCVA and IOP control after surgery.

Cell death in retinoblastoma: electron microscopic, immunohistochemical, and DNA fragmentation studies.

Apparent cell loss by apoptosis occurs in carcinomatous tissue. To investigate cell death in retinoblastoma (Rb), ultrastructural examination, ApopTag staining, electrophoresis to detect apoptotic DNA fragmentation, and flow cytometric studies were performed. Immunostaining for the oncogenic products bcl-2 and p53 was also carried out. Relationships between the proliferation fraction (PF), apoptotic index (AI), and the distribution of bcl-2 and p53 were investigated according to the degree of histologic differentiation of Rb. Ultrastructurally, two patterns of cell death were seen. Necrotic cells exhibited vacuolation of cytoplasmic organelles with a marked lytic change in the karyoplasm and cytoplasm. In contrast, apoptotic cells were characterized by crescentic margination of chromatin, condensation of karyoplasm and cytoplasm, and fragmentation of the nucleus. Differentiated Rb had a low AI value (< 1%), whereas undifferentiated Rb had a high AI value (> 8%). The PF of undifferentiated RB (31%) was significantly higher than that of differentiated RB (14%). Analysis of DNA fragmentation using 3'-end labeling with terminal transferase indicated that undifferentiated Rb has increased DNA cleavage. The distribution of apoptotic bodies within Rb was inversely correlated with the expression of bcl-2. A majority of tumor cells of differentiated Rb were negative for p53, whereas 20-40% of tumor cells of undifferentiated Rb showed a positive reaction for p53. These findings suggest that the degree of susceptibility to apoptosis is closely related to PF, is inversely related to the degree of differentiation of Rb, and is protected by oncogene bcl-2.

Risk factors for early filtration failure requiring suture release after primary glaucoma triple procedure with adjunctive mitomycin.

PURPOSE: Postoperative release of scleral flap closure suture is useful in trabeculectomy combined with cataract surgery. We determined risk factors for early filtration failure requiring suture release during the first month after primary glaucoma triple procedure. METHODS: The medical records of 71 consecutive patients with primary open-angle glaucoma who underwent a primary glaucoma triple procedure (primary trabeculectomy, phacoemulsification, and posterior chamber intraocular lens implantation) were reviewed. Suture release had been performed in 24 of the patients for early filtration failure with postoperative intraocular pressure greater than the target value during the first postoperative month. The long-term filtration failure was defined according to 2 criteria based on medical dependency and requirement of additional surgical procedure for intraocular pressure control. Cox proportional hazards multivariate analysis was performed to identify independent risk factors. RESULTS: African American race (P = .02), more than 2 preoperative glaucoma drugs (P = .02), and intraocular pressure greater than 14 mm Hg during the first postoperative week (P = .006) were identified as significant independent risk factors requiring suture release for filtration failure during the first postoperative month. Their significance was further confirmed by Kaplan-Meier survival analysis with Mantel-Cox log-rank test (P = .03, P = .02, and P = .001, respectively). CONCLUSIONS: African American race, more than 2 preoperative medications, and intraocular pressure greater than 14 mm Hg in the first postoperative week are major independent risk factors for initial filtration failure requiring suture release during the first month after primary glaucoma triple procedure. Presence of the risk factors may warrant a more aggressive antiproliferative regimen and/or earlier suture release.

Long-term brimonidine therapy in glaucoma patients with apraclonidine allergy.

PURPOSE: To report the use of brimonidine in patients with a documented ocular allergy to apraclonidine. METHODS: We conducted a prospective, open-label study on the use of long-term brimonidine therapy in 57 patients with chronic glaucoma with documented allergy to apraclonidine. The study patients were placed on brimonidine tartrate 0.2%, 1 drop three times daily in one or both eyes, either as additive therapy to a medical regimen devoid of apraclonidine for further lowering of intraocular pressure (25 patients) or as a replacement for apraclonidine at the time of diagnosis of apraclonidine ocular allergy for maintenance of intraocular pressure control (32 patients). Clinical symptoms and signs of ocular allergy to brimonidine were monitored for up to 18 months. RESULTS: During the treatment period of up to 18 months, six (10.5%) of 57 patients developed slit-lamp biomicroscopic findings and subjective symptoms of an ocular allergic reaction that led to discontinuation of brimonidine treatment. All six patients developed ocular allergy to topical brimonidine 0.2% during the first 4 months of therapy. The addition of brimonidine 0.2% topical medication or the replacement of apraclonidine with brimonidine resulted in a significant decrease in mean intraocular pressure from 20.5+/-5.3 to 16.5+/-4.2 mm Hg (P < .0001) at the mean treatment period of 10.6+/-4.6 months (range, 0.5 to 18.0 months in all 57 patients: 5 to 18 months in the 51 patients without brimonidine allergy and 0.5 to 3.8 months in the six patients who developed brimonidine allergy. CONCLUSIONS: The incidence of ocular allergy after the use of brimonidine 0.2% topical medication for up to 18 months was 10.5% in patients with a documented history of apraclonidine allergy. Therefore, it is generally safe as well as efficacious to administer brimonidine to patients with an ocular allergy to apraclonidine.

Balloon dilatation of the aortic valve in the fetus. A case report.

Fetal echocardiography has recently caused an impact on the treatment of congenital heart disease and in the field of therapeutic, cardiological intervention. The present study reports on a case of critical aortic stenosis, diagnosed in utero at 27 weeks' gestation, and in which balloon dilatation was attempted to improve the poor prognosis associated with this condition. Since the endocardium at this stage of development was apparently normal, this therapeutic intervention was attempted to avoid irreversible damage to the left ventricle. Although hydrops disappeared and the myocardium hypertrophied, endocardial fibroelastosis progressed and the neonate died within the first day of life, after surgical aortic valvotomy. More data are necessary to clarify whether endocardial fibroelastosis is really a consequence of high pressure in the left ventricle resulting from stenosis of the aortic valve or whether it is a disease, the progression of which is unavoidable once it takes hold.

Fetal idiopathic ventricular tachycardia with nonimmune hydrops: benign course.

A case of idiopathic ventricular tachycardia of left ventricular origin in a hydropic fetus is presented. The accuracy of fetal echocardiography for diagnosing this type of arrhythmia is emphasized, as is its importance in determining appropriate postnatal treatment which in this case resulted in an unusually benign course.

c-erbB-2 and p53 expression in fallopian tube carcinoma.

BACKGROUND: Carcinoma of the fallopian tube is a rare gynecologic malignancy. Its histologic appearance and patterns of spread are similar to those of epithelial ovarian cancer. Alterations in the gene products of c-erbB-2 (HER-2/neu) and p53 are found commonly in ovarian tumors and may have prognostic relevance. The authors sought to determine whether tubal cancers are biologically similar to ovarian cancer with respect to the expression of these two molecular markers. METHODS: A cohort of 43 patients with fallopian tube cancer was studied. Immunohistochemical staining for c-erbB-2 and p53 was performed on pretreatment tissue blocks. Clinical information was available for all patients, with a median follow-up of 9 years. Clinicopathologic correlations were made. RESULTS: Nine patients had Stage I disease, 11 had Stage II disease, 18 had Stage III disease, and 5 had Stage IV disease, with a median survival was 65 months. c-erbB-2 overexpression was found in 11 cases (25.6%), and p53 positivity was noted in 26 cases (60.5%). Log rank survival curves showed no association between staining for c-erbB-2 or p53 expression and clinical outcome. A multivariate analysis identified patient age older than 65 years (P = 0.05) and Stage III or IV disease (P = 0.0065) as the only variables that predicted poor outcome. CONCLUSIONS: Fallopian tube cancers are similar to ovarian cancer with respect to the proportion of tumors with abnormal expression of c-erbB-2 and p53. The authors could not demonstrate that these two molecular markers had prognostic relevance in this disease, but the size of their cohort was limited. However, the potential prognostic relevance of c-erbB-2 and p53 expression in tubal cancers should be pursued in a larger cohort.

Echocardiographic diagnosis of fetal Marfan syndrome at 34 weeks' gestation.

Fetal echocardiography was performed during the third trimester in a normal primigravida. The fetal heart was severely affected with the typical cardiac manifestations of Marfan syndrome. The medical history of the father was investigated and a mild form of the syndrome was diagnosed. The neonate died at 2 months of age of congestive heart failure.

[Use of sympathomimetic agents in fetal atrioventricular heart block]. / Uso de simpaticomimético em bloqueio atrioventricular fetal.

A healthy pregnant was referred at 34 weeks gestation because an obstetrical ultrasound examination had shown fetal bradycardia and nonimmune hydrops. The heart was anatomically normal but complete heart block was present with a ventricular rate of 22bpm and atrial of 101bpm. We injected isoproterenol by cordocentesis direct in the umbilical vein of the fetus and a significant increase into the ventricular and atrial rates were obtained. The direct therapy with sympathomimetic drugs is a simple technique and may save fetuses with complete heart block and hidrops.

Indirect hypertensive actions of long-term intracarotid angiotensin II infusion during ovine pregnancy.

Angiotensin II (AngII) influences the regulation of mean arterial pressure (MAP) through numerous mechanisms, including an action of circulating AngII on the brain to alter autonomic activity. We have obtained evidence that the relative importance of this effect is increased during pregnancy. Consequently, these studies were undertaken to assess the effects of bilateral infusion of AngII (0.35 ng.kg-1.min-1.artery-1) into the internal carotid arteries (ica) of sheep for 13 days. Six non-pregnant (NP) and six 105- to 125-day pregnant (PG) ewes were maintained in large metabolism cages, where MAP was continuously monitored. By day 10 of ica AngII infusion in NP ewes, MAP was increased from 83.9 +/- 1.6 to 92.9 +/- 2.8 mmHg (1 mmHg = 133.3 Pa) (p = 0.001). Twenty-four hour urine volume (UV, 2664 +/- 341 to 1583 +/- 228 mL; p = 0.005) and sodium excretion (UNaV, 190 +/- 5 to 113 +/- 19 mmol/day; p = 0.005) were decreased. 51Cr-tagged blood volume (BV) was increased on day 13 (3643 +/- 187 to 4379 +/- 446 mL; p = 0.05). In contrast, by only day 6 of ica AngII infusion in PG ewes, MAP increased from 79.1 +/- 1.9 to 84.1 +/- 1.4 mmHg (p = 0.03) in association with a BV expansion from 3999 +/- 274 to 4207 +/- 275 mL. These changes were preceded by decreases in UV (2813 +/- 413 to 2198 +/- 362 mL; p = 0.01) and UNaV (190 +/- 15 to 118 +/- 26 mmol/day; p = 0.01). By day 13, MAP had plateaued at 93.0 +/- 1.2 mmHg.(ABSTRACT TRUNCATED AT 250 WORDS)

Tubular handling of fluid and electrolytes during ovine pregnancy.

Pregnancy is characterized by progressive water and sodium accumulation and increases in renal blood flow (RBF) and glomerular filtration rate (GFR). However, the influence of the different nephron segments on the increased tubular reabsorption is controversial. Consequently, four nonpregnant and five pregnant sheep were studied, after chronic instrumentation, to assess salt and water reabsorption in the proximal and distal tubules under basal and volume-loaded conditions. Lithium clearance was used as a marker for proximal tubular reabsorption. Volume loading was achieved by the rapid administration of 1,000 ml isotonic saline followed by 250 ml/h for 2 h. Under basal conditions with reference to the nonpregnant state, pregnant sheep had higher (P < 0.05) levels of right RBF (427 +/- 34 vs. 313 +/- 8 ml/min), GFR (133 +/- 7 vs. 94 +/- 9 ml/min), proximal tubular reabsorption (102 +/- 7 vs. 73 +/- 6 ml/min), distal nephron fluid delivery (31 +/- 2 vs. 20 +/- 2 ml/min), and fractional distal nephron reabsorption of fluid (92 +/- 2 vs. 87 +/- 1%) and sodium (98.8 +/- 0.3 vs. 97.0 +/- 0.7%). However, pregnant animals had significantly (P < 0.05) reduced fractional excretions of fluid (1.6 +/- 0.3 vs. 2.6 +/- 0.2%) and sodium (0.24 +/- 0.06 vs. 0.63 +/- 0.19%), but similar levels of filtration fraction, fractional proximal tubular reabsorption, urine flow, urinary sodium excretion, and osmolar and free water clearance. After saline loading, pregnant sheep excreted significantly (P < 0.05) less sodium (9.2 vs. 28.6%) and water (39.8 vs. 56.5%). Decreases in fractional proximal and distal nephron reabsorption of sodium and water after saline loading were attenuated in pregnant animals.(ABSTRACT TRUNCATED AT 250 WORDS)

[Fetal atrioventricular block]. / Bloqueio atrioventricular fetal.

PURPOSE: To study the pathogenesis, evolution and prognosis of the complete heart block of the fetus. METHODS: Bidimensional echocardiography associated to M-mode and doppler was performed in 600 patients. All cases of congenital heart block were referred because the fetuses presented hydrops, bradycardia and/or cardiac malformation suspected by routine ultrasound. RESULTS: Isolated heart block was found in 6 fetuses (5 cases of complete type and 1 case of 2nd degree type 2:1). Heart block associated with complex cardiac disease and left atrial isomerism was found in 6 fetuses with no survivors (5 cases of complete type and 1 case of 2nd degree type 2:1). Heart block associated with atrioventricular discordante was found in 1 case. CONCLUSION: The findings of this study agree the literature about the relation between maternal anti-RO antibodies and isolated complete heart block. We also found a poor prognosis in the group with heart block and complex cardiac malformations.

Influence of pregnancy on mean systemic filling pressure and the cardiac function curve in guinea pigs.

To assess the degree of circulatory fullness and to evaluate the influence of peripheral and cardiac factors in the regulation of cardiac output during pregnancy, the following studies were conducted using pentobarbital-anesthetized, open-chest nonpregnant and late term pregnant guinea pigs. Mean circulatory filling pressure was taken as the equilibrium pressure when the pulmonary artery was constricted. Total vascular compliance was assessed by +/- 5-mL changes in blood volume performed while this constriction was maintained. A separate group of guinea pigs was prepared with a pulmonary artery electromagnetic flow probe and right atrial catheter. Rapid infusion of saline was used to increase right atrial pressure while the cardiac output was determined. Pregnancy was characterized by the following changes relative to nonpregnant controls: 51Cr-labelled RBC blood volume increased from 55 +/- 3 to 67 +/- 3 mL/kg; mean circulatory filling pressure increased from 7.1 +/- 0.2 to 8.0 +/- 0.5 mmHg (1 mmHg = 133.322 Pa); right atrial pressure decreased from 3.4 +/- 0.2 to 2.1 +/- 0.3 mmHg; and cardiac output increased from 71.8 +/- 3.9 to 96.8 +/- 3.3 mL.min-1.kg-1. Total vascular compliance was not changed (2.1 +/- 0.1 mL.kg-1.mmHg-1) and most of the expanded blood volume was accommodated as unstressed volume. The cardiac function curve was shifted upwards in pregnant animals. The resistance to venous return, as determined from the slope of the venous return curves, was not changed. These data suggest that the circulation of the pregnant guinea pig is slightly overfilled.(ABSTRACT TRUNCATED AT 250 WORDS)

Renal nerve effects on renal adaptation to changes in sodium intake during ovine pregnancy.

To assess the possibility of an enhanced role of renal nerves in the control of urinary sodium excretion (UNaV) and fluid homeostasis during pregnancy, urine output, UNaV, and urinary potassium excretion were assessed hourly for 3 days before and for 6 days after a step reduction in total daily sodium intake from 400 to 40 mmol. Studies were performed in normal conscious sheep (4 nonpregnant and 4 pregnant). Each animal was prepared with a divided bladder so that urine could be collected simultaneously from one normally innervated and one denervated kidney. In nonpregnant ewes, ratios of the rates of excretion by denervated vs. innervated kidneys for UNaV averaged 1.00 +/- 0.07 under steady-state conditions at high levels of sodium intake. This ratio was not different at the low-sodium-intake state. In contrast, this ratio was 1.15 +/- 0.07 at high sodium intake and 1.13 +/- 0.03 at low sodium intake in pregnant ewes. The ratios at both steady-state intake levels were different (P less than 0.05) between nonpregnant and pregnant sheep. During the transition between sodium intake states, these ratios were unchanged in nonpregnant animals, whereas pregnant animals exhibited peak ratios of 2.20 +/- 0.39 (P less than 0.05), indicating sodium wasting by the denervated kidneys. In summary, the data suggest that renal nerve activity may not be completely suppressed by high sodium intakes in pregnant sheep. Furthermore, the renal nerves have an enhanced influence on sodium conservation during and after the transition from high- to low-sodium-intake states during pregnancy.(ABSTRACT TRUNCATED AT 250 WORDS)

Indicacoes e riscos da cordocentese / Indications and risk of cordocentesis

A cordocentese representa um importante avanco em Obstetricia, permitindo diagnosticar, tratar e acompanhar inumeras patologias que afetam o feto. Entretanto, em vista do carater invasivo dessa tecnica, a sua indicacao precisa ser criteriosa. Os autores discutem as principais indicacoes da cordocentese aceitas na atualidade: isoimunizacao ao fator Rh, gestantes com patologias plaquetarias, cariotipagem rapida, esclarecimento de mosaicismo e crescimento intra-uterino retardado. Os riscos da cordocentese relacionam-se com a gravidade do caso e habilidade do operador. As principais causas de perdas fetais foram: corioamnionite, amniorrexe prematura, hemorragia fetal, bradicardia e trombose dos vasos umbilicais.