High-titre circulating tissue transglutaminase-2 antibodies predict small bowel villous atrophy, but decision cut-off limits must be locally validated.

Numerous studies suggest that high levels of circulating immunoglobulin (Ig)A tissue transglutaminase (TTG2) antibodies predict coeliac disease with high specificity. Accordingly, it has been suggested that duodenal biopsy may not be required routinely for diagnostic confirmation where quantitative serology identifies the presence of high antibody titres. However, defining a cut-off TTG2 threshold is problematic, as the multiple available assay methods are not harmonized and most studies have been focused on the paediatric population. Recent paediatric guidelines proposed a TTG2 antibody diagnostic cut-off at 10 × the upper limit of normal (ULN) for the method; however, concerns remain about errors of generalization, between both methods and laboratories. In this study, we used retrospective laboratory data to investigate the relationship between TTG2 antibody levels and Marsh 3 histology in the seropositive population of adults and children at a single centre. Among 202 seropositive patients with corresponding biopsies, it was possible to define a TTG2 antibody cut-off with 100% specificity for Marsh 3 histology, at just over 10 × ULN for the method. However, UK National External Quality Assurance Scheme returns during the study period showed a wide dispersion of results and poor consensus, both between methods and between laboratories using the same method. Our results support the view that high-titre TTG2 antibody levels have strong predictive value for villous atrophy in adults and children, but suggest that decision cut-offs to guide biopsy requirement will require local validation. TTG2 antibody assay harmonization is a priority, in order to meet the evolving requirements of laboratory users in this field.

A controlled comparison of the word repeating technique with a word association task.

The Word Repeating Technique (WRT) is a cognitive defusion technique used in Acceptance and Commitment Therapy (ACT). In this exercise, a word or short phrase is quickly repeated aloud until the context required for the word to have literal meaning changes. This study compared the WRT to a procedure that requires words to retain their meaning [the Implicit Associations Task (IAT)]. If the WRT operates by inducing a loss of meaning in words, one would not expect similar effects from a task requiring literal processing of words. Participants (N = 160) completed either the WRT or IAT with or without a theoretically consistent rationale for performing the task, while an additional 40 participants were in a control condition. Both the WRT and IAT decreased discomfort and believability ratings from pre- to post-test for words that were targeted in the tasks, with the WRT resulting in a larger pre- to post-test decrease for discomfort ratings. Only the WRT decreased the discomfort of words not targeted in the task from pre- to post-test, while neither task decreased the believability of words that were not targeted in the tasks. Providing a rationale did not have an effect for either task. Although the strengths of the effects for the WRT were larger than those for the IAT, both tasks demonstrated effects in the same direction and neither demonstrated effects that were larger in magnitude than what was accounted for by regression to the mean.

A developmental switch in H4 acetylation upstream of Xist plays a role in X chromosome inactivation.

We have investigated the role of histone acetylation in X chromosome inactivation, focusing on its possible involvement in the regulation of Xist, an essential gene expressed only from the inactive X (Xi). We have identified a region of H4 hyperacetylation extending up to 120 kb upstream from the Xist somatic promoter P1. This domain includes the promoter P0, which gives rise to the unstable Xist transcript in undifferentiated cells. The hyperacetylated domain was not seen in male cells or in female XT67E1 cells, a mutant cell line heterozygous for a partially deleted Xist allele and in which an increased number of cells fail to undergo X inactivation. The hyperacetylation upstream of Xist was lost by day 7 of differentiation, when X inactivation was essentially complete. Wild-type cells differentiated in the presence of the histone deacetylase inhibitor Trichostatin A were prevented from forming a normally inactivated X, as judged by the frequency of underacetylated X chromosomes detected by immunofluorescence microscopy. Mutant XT67E1 cells, lacking hyperacetylation upstream of Xist, were less affected. We propose that (i) hyperacetylation of chromatin upstream of Xist facilitates the promoter switch that leads to stabilization of the Xist transcript and (ii) that the subsequent deacetylation of this region is essential for the further progression of X inactivation.

Histone acetylation and X inactivation.

In mammals, the levels of X-linked gene products in males and females are equalised by the silencing, early in development, of most of the genes on one of the two female X chromosomes. Once established, the silent state is stable from one cell generation to the next. In eutherian mammals, the inactive X chromosome (Xi) differs from its active homologue (Xa) in a number of ways, including increased methylation of selected CpGs, replication late in S-phase, expression of the Xist gene with binding of Xist RNA and underacetylation of core histones. The latter is a common property of genetically inactive chromatin but, in the case of Xi, it is not clear whether it is an integral part of the silencing process or simply a consequence of some other property of Xi, such as late replication. The present review describes two approaches that address this problem. The first shows that Xi in marsupial mammals also contains underacetylated H4, even though its properties differ widely from those of the eutherian Xi. The continued presence of histone underacetylation on Xi in these evolutionarily distant mammals argues for its fundamental importance. The second approach uses mouse embryonic stem cells and places H4 deacetylation in a sequence of events leading to complete X inactivation. The results argue that histone underacetylation plays a role in the stabilisation of the inactive state, rather than in its initiation.

On receiving the patient's transference: the symbolizing and desymbolizing countertransference.

This is an empirical study of the therapist's experience of the patient delineating the boundaries between empathy and constructive and destructive forms of countertransference. The unique step was taken of focusing a video camera on the therapist in order to trace the therapist's nonverbal behavior during listening. The same therapist was observed first in a "not-so-difficult" and then a "difficult" session; the sessions could then be distinguished along dimensions of rhythmicity or arrhythmicity of nonverbal behavior. These observations suggested three modes of experiencing the patient: empathy marked by rhythmicity, a symbolizing countertransference marked by a transitory arrhythmicity, and a desymbolizing countertransference marked by continuous arrhythmicity. The congruence of these formulations based on direct observation of therapist behavior and ones derived from retrospective reconstructions of analysts in sessions (Schwaber, Jacobs, and Laskey) was explored and was found to enhance the validity of the proposed formulations.

X-Inactivation and histone H4 acetylation in embryonic stem cells.

In female mammalian cells, dosage compensation for X-linked genes is achieved by the transcriptional silencing, early in development, of many genes on just one of the two X chromosomes. Several properties distinguish the inactive X (Xi) from its active counterpart (Xa). These include expression of Xist, a gene located in the X-inactivation center (Xic), late replication, differential methylation of selected CpG islands and underacetylation of histone H4. The relationship between these properties and transcriptional silencing remains unclear. Female mouse embryonic stem (ES) cells have two active X chromosomes, one of which is inactivated as cells differentiate in culture. We describe here the use of these cells in studying the sequence of events leading to X-inactivation. By immunofluorescent labeling of metaphase chromosome spreads from ES cells with antibodies to acetylated H4, we show that an underacetylated X chromosome appears only after 4 days of differentiation, and only in female cells. The frequency of cells with an underacetylated X reaches a maximum by Day 6. In undifferentiated cells, H4 in centric heterochromatin is acetylated to the same extent as that in euchromatin but has become relatively underacetylated, as in adult cells, by Day 4 of differentiation (i.e. , when deacetylation of Xi is first seen). The overall deacetylation of Xi follows Xist expression and the first appearance of a single, late-replicating X, both of which occur on Day 2. It also follows the silencing of X-linked genes. Levels of mRNA from four such genes, Hprt, G6pd, Rps4, and Pgk-1, had all fallen by approximately 50% (relative to the autosomal gene Aprt) by Days 2-4. The results show that properties that characterize Xi are put in place in a set order over several days. H4 deacetylation occupies a defined place within this sequence, suggesting that it is an intrinsic part of the X-inactivation process. The stage at which a completely deacetylated Xi is first seen suggests that deacetylation may be necessary for the maintenance of silencing but is not required for its initiation. Nor is it required for, or an immediate consequence of, late replication. However, we note that selective deacetylation of H4 on specific genes would not be detected by the microscopical approach we have used and that such selective deacetylation may still be part of the silencing process.

Long term effect of renal transplantation on dialysis-related amyloid deposits and symptomatology.

We report the five year outcome of nine patients with dialysis-related amyloid (DRA) who underwent successful renal transplantation (RT) and six patients who remained on hemodialysis (HD). Amyloid bone cysts, a radiologic feature of DRA, and scintigraphy with 123I-labeled serum amyloid P component (SAP), a specific technique for evaluating amyloid deposits in vivo, were monitored and compared with clinical features. In all HD patients there was clinical, scintigraphic and/or radiologic evidence that DRA progressed. In contrast, eight of the RT patients experienced profound early relief of DRA symptoms following transplantation that persisted throughout follow-up, despite the reduction or withdrawal of corticosteroids. Amyloid bone cysts improved in four patients and SAP scans demonstrated regression of articular amyloid in eight out of nine cases. The modest radiographic improvement suggests that amyloid is mobilized more slowly in bone cysts than elsewhere or that cystic bone is remodeled poorly. This is the first objective evidence that DRA regresses following renal transplantation, and suggests that this may contribute to the long-term relief of DRA symptoms in transplant recipients who discontinue corticosteroids.

Histone H4 acetylated at lysine 16 and proteins of the Drosophila dosage compensation pathway co-localize on the male X chromosome through mitosis.

In the fruit fly Drosophila, dosage compensation involves several proteins acting in concert to double the transcriptional activity of genes on the single male X chromosome. Three of these proteins, MLE, MSL-1 and histone H4 acetylated at lysine 16 (H4Ac16), have recently been shown to be located almost exclusively on the male X chromosome in interphase (polytene) cells. We show here that in neuroblasts from third instar Drosophila larvae antisera to H4Ac16, MLE and MSL-1 uniquely label the distal, euchromatic region of the male X chromosome through mitosis. The centromere-proximal, heterochromatic region of the male X is not labelled with these antisera, nor are male autosomes or any chromosomes in female cells. That the association of H4Ac16 with the male X chromosome persists, even when the chromosome is maximally compacted and transcriptionally quiescent, argues that this modified histone is an integral component of the dosage compensation pathway. In the nuclei of interphase neuroblasts from male (but never female) larvae, antibodies to H4Ac16 revealed a small, brightly labelled patch against a background of generally weak nuclear staining. In double-labelling experiments, this patch was also labelled, albeit comparatively weakly, with antibodies to MSL-1. These results strongly suggest that the distal, euchromatic region of the X chromosome in male cells occupies a limited and relatively compact nuclear domain.

Acetylated histone H4 on the male X chromosome is associated with dosage compensation in Drosophila.

Dosage compensation in Drosophila occurs by an increase in transcription of genes on the X chromosome in males. This elevated expression requires the function of at least four loci, known collectively as the male-specific lethal (msl) genes. The proteins encoded by two of these genes, maleless (mle) and male-specific lethal-1 (msl-1), are found associated with the X chromosome in males, suggesting that they act as positive regulators of dosage compensation. A specific acetylated isoform of histone H4, H4Ac16, is also detected predominantly on the male X chromosome. We have found that MLE and MSL-1 bind to the X chromosome in an identical pattern and that the pattern of H4Ac16 on the X is largely coincident with that of MLE/MSL-1. We fail to detect H4Ac16 on the X chromosome in homozygous msl males, correlating with the lack of dosage compensation in these mutants. Conversely, in Sxl mutants, we detect H4Ac16 on the female X chromosomes, coincident with an inappropriate increase in X chromosome transcription. These data suggest that synthesis or localization of H4Ac16 is controlled by the dosage compensation regulatory hierarchy. Dosage compensation may involve H4Ac16 function, potentially through interaction with the product of the msl genes.

Cause of regional ventilation-perfusion mismatching in patients with idiopathic pulmonary fibrosis: a combined CT and scintigraphic study.

OBJECTIVE: Regional ventilation and perfusion were studied in patients with idiopathic pulmonary fibrosis (cryptogenic fibrosing alveolitis) to seek an explanation for the mismatched ventilation/perfusion (V/Q) seen on scintigrams, which may suggest pulmonary embolic disease. SUBJECTS AND METHODS: Eight patients with idiopathic pulmonary fibrosis were examined with inspiratory and expiratory CT scans. Planar and tomographic (single-photon emission computed tomography, SPECT) scintigraphy, using inhalation of krypton-81m gas (ventilation) and IV injection of 99mTc-albumin macroaggregates (perfusion), also was performed. The lungs were divided into quadrants (cranial, caudal, right, left) for analysis. RESULTS: Cystic air spaces with a "honeycomb" appearance occupied more than 33% of the cross-sectional area in 75% of all lung quadrants (n = 16), more than 66% of the area in 44% of quadrants, and less than 33% of the area in the remaining 25% of quadrants. On expiratory CT scans, the cross-sectional area of the cystic spaces diminished significantly (unlike emphysematous spaces). Sixty-seven percent of lung quadrants, corresponding to those with marked or moderate involvement with cystic spaces, showed a mismatched V/Q pattern on scintigrams (absent perfusion, normal ventilation); 27% of quadrants had matched V/Q defects, and 6% did not show defects. Two patients had, in addition, large cystic spaces typical of emphysema, but the coexistent fibrosis prevented the gross air trapping seen in bullous emphysema. CONCLUSION: The cystic air spaces that are often seen on CT scans of patients with idiopathic pulmonary fibrosis are unperfused (probably due to vascular obliteration) but are usually normally ventilated. This V/Q mismatch on scintigrams explains the large physiologic dead space seen at rest and on exercise and could suggest pulmonary embolism unless a CT scan is obtained. Conversely, the larger cystic spaces might be mistaken for emphysema unless V/Q scintigraphy is done.

Meta-iodobenzylguanidine (MIBG) scanning in the diagnosis of phaeochromocytoma.

During the period 1984-90, meta-iodobenzylguanidine (MIBG) scans were performed in 23 patients with suspected phaeochromocytoma seen at the Hammersmith Hospital. Sixteen patients had a histologically proven phaeochromocytoma and in 14 of these patients the tumour was demonstrated by abnormal uptake of MIBG. Seven patients did not have a phaeochromocytoma and in all of these the MIBG scan was negative. These findings gave the procedure a sensitivity of 87.5% with a specificity of 100%; positive and negative predictive values were 100% and 77.7%, respectively. MIBG scanning is an extremely valuable technique in the management of patients with suspected phaeochromocytoma but is best employed to localise a tumour which has been confirmed biochemically.

Serum amyloid P component scintigraphy and turnover studies for diagnosis and quantitative monitoring of AA amyloidosis in juvenile rheumatoid arthritis.

OBJECTIVE: To evaluate aspects of the natural history of AA amyloidosis complicating juvenile rheumatoid arthritis (JRA), and its response to therapy with chlorambucil. METHODS: Scintigraphy and 7-day turnover studies were performed in JRA patients with histologically proven (n = 35) or clinically suspected (n = 30) AA amyloidosis, following intravenous injection of 123I and 125I-labeled serum amyloid P component (SAP). Prospective monitoring studies were performed over 2-3 years in 20 patients with amyloidosis. All but 2 amyloidosis patients were treated with chlorambucil. RESULTS: Positive scanning results were obtained in all patients in whom imaging was performed within 12 years of positive biopsy findings of amyloid and in 5 patients with clinically suspected amyloidosis. Negative scanning results with normal SAP metabolism, indicating regression of amyloid, were obtained in 4 patients whose amyloidosis had been in full clinical remission for more than 12 years. Prospective monitoring studies in patients whose JRA-associated inflammatory activity was in remission demonstrated regression of amyloid in 8 patients and no substantial changes in 8 others; however, in 4 further patients with active inflammation, there was accumulation of amyloid. There was a very poor correlation between the amount of amyloid present at a particular site and the resultant organ dysfunction. CONCLUSION: Radiolabeled SAP scintigraphy and turnover studies are useful complementary tools in the diagnosis, screening, and quantitative monitoring of type AA amyloidosis in JRA. The amyloid deposits may progress and/or regress at different rates in different anatomic sites over short periods.

Scintigraphic quantification and serial monitoring of human visceral amyloid deposits provide evidence for turnover and regression.

Radiolabelled serum amyloid P component scintigraphy provides information on the diagnosis and distribution of amyloid which was not previously available. A simple reproducible method for quantifying the uptake of 123I-labelled serum amyloid P component into individual livers, spleens and kidneys was devised and evaluated in 22 patients with different types of systemic amyloidosis. Prospective studies in 10 patients were undertaken in order to monitor aspects of the natural history of visceral amyloid deposits. Although measurements of tracer uptake were not as discriminating for diagnostic purposes as the opinions of two highly experienced visual observers, the availability of objective scintigraphic parameters should facilitate interpretation of serum amyloid P component scans in centres unfamiliar with the technique. The follow-up studies demonstrated several intriguing features of amyloidogenesis. There was very rapid progression of deposits in some individuals with differential rates of accretion in different organs. The single patient with AL amyloidosis treated with cytotoxic drugs showed substantial regression of hepatic amyloid deposits whilst his splenic amyloid increased. His spleen was then removed and further regression of the hepatic amyloid was observed. It is concluded that quantitative serum amyloid P component scintigraphy is a useful method for assessing visceral amyloid and that the deposits not only progress at extremely variable rates, but can evidently also be mobilized. These findings encourage active therapeutic approaches in the management of amyloidosis.

Pulmonary granulocyte margination is increased in patients with inflammatory bowel disease.

The pulmonary granulocyte content of the lung was quantified in patients with inflammatory bowel disease (IBD) after injection of 111In-labelled granulocytes and compared with patient controls, who, on the basis of their negative white cell scans, were not considered to have active inflammation. The mean ratios of lung:liver count rates per pixel on the posterior gamma camera image in patient controls was 0.34 (S.D. 0.16, n = 8) at 1-1.5 h after injection of the cells, and 0.29 (S.D. 0.14, n = 18) at 2-4 h. This ratio was higher in patients with active IBD at both imaging times: 0.45 (0.13, n = 13, P > 0.05) and 0.44 (0.1, n = 19, P < 0.001). Patients with inactive IBD also had increased ratios at both imaging times: 0.6 (0.14, n = 7, P < 0.01) and 0.54 (0.15, n = 12, P < 0.001), respectively. In a further group of 12 patients with active IBD, there was no correlation between the lung:liver ratio and the severity of the IBD as assessed by whole-body 111In retention at 4-6 days after labelled cell injection. These patients were treated for 3 weeks with an oral, non-absorbable corticosteroid, after which there was a significant decrease in disease activity but no significant change in the lung:liver ratio. Inflammatory bowel disease appears to be associated with abnormal pulmonary granulocyte accumulation. It is not apparently related to disease activity but may be the result of an associated pulmonary abnormality.

Inhaled platelet-activating factor causes pulmonary neutrophil sequestration in normal humans.

Inhaled platelet-activating factor (PAF) causes bronchoconstriction and transient peripheral neutropenia in humans. We studied eight normal subjects to investigate whether inhaled PAF caused pulmonary neutrophil sequestration. All subjects received autologous 99mTc-red cells as a blood pool marker, seven received 111In-neutrophils, and one received 111In-platelets. Six subjects inhaled 48 micrograms of PAF. There was immediate pulmonary sequestration of 111In-neutrophils, maximal (218% baseline) at 6 min (p less than 0.001), returning to normal by 3 h. There was no change in circulating platelet count or pulmonary 111In-platelet transit. Methacholine inhalation caused equivalent bronchoconstriction to PAF, but it had no effect on neutrophil count or pulmonary 111In-neutrophil activity. We have demonstrated pulmonary neutrophil, but not platelet, sequestration after PAF. This supports a role for PAF as an inflammatory mediator in humans. This may be a useful model for exploring pulmonary neutrophil kinetics and preinflammatory processes.

Value of scintigraphic localization of obscure gastrointestinal bleeding.

A total of 51 technetium-99m (99mTc)-labelled autologous red cell (LRC) scans performed on 49 patients for the localization of obscure gastrointestinal bleeding over a 5-year period was reviewed. The sensitivity for LRC scanning was 72.7% with a positive predictive value of 84.2%. Forty patients underwent both LRC scanning and visceral angiography during the same admission; angiography had a sensitivity of 38.9% compared with 66.7% for LRC scanning and the positive predictive values were 77.8% and 85.7%, respectively. Overall, the site of bleeding was located in 22 (45%) of 49 patients, but LRC scanning alone was successful in identifying the lesion in 16 (33%) cases. In patients who continue to bleed to the point of requiring operation, a combination of scintigraphy and angiography will localize a source in 70% of patients.

Uses of labelled white cells.

In addition to an established clinical role, labelled white cells have great potential for clinical research. This review will therefore outline the clinical use of labelled white cells and briefly consider their contribution to developments in clinical science.

Platelet imaging of thromboembolism. Natural history of postoperative deep venous thrombosis and pulmonary embolism illustrated using the 111In-labelled platelet-specific monoclonal antibody, P256.

BACKGROUND: Deep venous thrombosis (DVT) and pulmonary thromboembolic disease are difficult to diagnose, particularly following surgery. This report demonstrates the use of 111In-labelled platelet-specific monoclonal antibody, P256 Fab', for the diagnosis and study of the time course of thromboembolic disease in a patient following total hip replacement. METHOD: One hundred micrograms of pentetic acid (DTPA)-P256 Fab' was labelled with 8 to 10 MBq of 111In chloride by incubation at room temperature for 15 min. After dilution in physiologic saline, the tracer was injected intravenously on the third and sixth days postoperatively. Imaging of the chest, pelvis, and legs was carried out at 24, 48 and 72 h following each injection. RESULTS: The first image four days after surgery demonstrated activity in the right heart which moved to the right pulmonary artery on the following day. Activity was seen in both femoral veins; on the left, this increased over two days, followed by a reduction on the seventh day after surgery, at which time new activity was seen in the right heart. After a further two days, this activity moved to the left pulmonary artery. The DVT was confirmed by venography and the pulmonary embolism (PE) by ventilation perfusion scan. CONCLUSIONS: 111Indium-labelled platelet-specific monoclonal antibody, P256 Fab', provides a technique for studying the natural history of thromboembolic disease and its treatment.

Impaired left lower lobe ventilation in patients with cardiomegaly. An isotope study of mechanisms.

Reduced left lower lobe ventilation (V) in patients with enlarged hearts has been commonly observed on routine isotope ventilation-perfusion lung scanning, and there is evidence to show that this reduction is dependent on posture. Clinically, it may have a role in posture-dependent dyspnea and postoperative left lower lobe changes in cardiomegaly. Previous studies have shown improvement in left lower lobe V in the prone compared with the supine position. In 11 patients showing this phenomenon in krypton 81m V scanning, a mean relative reduction in V of 53 percent occurred at the left base. No significant change in perfusion or in the signal from preinjected technetium 99m macroaggregated albumin was observed between the two positions. No significant change in ventilatory turnover (measured with intravenous xenon 133) was seen either, suggesting that no air trapping takes place. By combining the data from the intravenous 133Xe (which gives the ratio, V/lung volume) and continuously inhaled 81mKr (which reflects regional V), an index of relative volume between the two sides was derived and shown to be significantly reduced at the left base on moving from the prone to supine positions (a mean reduction of 40 percent; p less than 0.02 by Wilcoxon signed rank test). Thus, the mechanism of postural left lower lobe hypoventilation in cardiomegaly is predominantly a regional loss of alveolar volume.