In vivo analysis of intramuscular gene transfer in human subjects studied by on-line ultrasound imaging.

The current study was designed to test the hypothesis that intramuscular (i.m.) injection of naked DNA leads to distribution of the injectate remote from the site of needle placement, a finding that might be expected to facilitate i.m. gene transfer. Transcutaneous ultrasound imaging was employed to monitor online the extent to which a solution of phVEGF165 was distributed among the skeletal musculature during 288 i.m. injections in 18 consecutive patients. In 237 (82.3%) of 288 muscle sites, the injection was performed into the distal calf muscle. In 51 (17.7%) of 288 muscle sites, injection was performed into the first and/or second interosseous muscles of the dorsal foot. Unperturbed muscle was recognized by a characteristic echogenic, stippled texture that was bounded by more intensely echogenic fascia. When i.m. gene transfer was performed into the calf muscles, the injectate was distributed along a longitudinal dimension of 3.59 +/- 0.79 cm (1.39-5.87 cm); the corresponding area of injectate measured by on-line planimetry was 1.83 +/- 0.51 cm2 (0.62-3.41 cm2). When i.m. gene transfer was performed into the interosseous muscles of the foot, the longitudinal extent of injectate distribution was 2.49 +/- 0.66 cm (1.61-3.91 cm), with a corresponding injectate area of 1.71 +/- 0.54 cm2 (0.51-2.86 cm2). These findings establish that a solution of plasmid DNA administered by direct i.m. injection into the skeletal muscles of the limb is distributed well beyond the site of needle entry. Thus, the use of multiple injections performed at different sites is likely to result in broad distribution of DNA injectate, a physical factor that may act to facilitate naked DNA and/or other gene transfer strategies.

Lower-extremity edema associated with gene transfer of naked DNA encoding vascular endothelial growth factor.

BACKGROUND: Vascular endothelial growth factor (VEGF) promotes angiogenesis and vascular permeability. The extent to which VEGF may cause tissue edema in humans has not been established. OBJECTIVE: To evaluate patients undergoing VEGF gene transfer for evidence of lower-extremity edema. DESIGN: Prospective consecutive case series. SETTING: Hospital outpatient clinic. PATIENTS: 62 patients with critical limb ischemia and 28 patients with claudication. INTERVENTION: Gene transfer of VEGF DNA. MEASUREMENTS: Semiquantitative analysis of lower-extremity edema. RESULTS: Lower-extremity edema was observed in 31 of 90 (34%) patients. Edema was less common in patients with claudication than in those with pain at rest (P = 0.016) or ischemic ulcers (P < 0.001), and it was less common in patients with pain at rest than in those with ischemic ulcers (P= 0.017). Treatment was typically limited to a brief course of oral diuretics. CONCLUSIONS: Vascular endothelial growth factor may enhance vascular permeability in humans. At the doses of plasmid DNA used in this study, lower-extremity edema responded to oral diuretic therapy and did not seem to be associated with serious sequelae.

Treatment of thromboangiitis obliterans (Buerger's disease) by intramuscular gene transfer of vascular endothelial growth factor: preliminary clinical results.

PURPOSE: Thromboangiitis obliterans (TAO), or Buerger's disease, a distinct form of vascular occlusive disease that afflicts the peripheral arteries of young smokers, is often characterized by an inexorable downhill course even in patients who discontinue smoking once a stage of critical limb ischemia associated with ulceration or gangrene is reached. As part of a phase I clinical trial to document the safety and efficacy of intramuscular gene transfer of naked plasmid DNA-encoding vascular endothelial growth factor (phVEGF165) in the treatment of critical limb ischemia, we treated TAO in 6 patients. METHODS: Seven limbs in 6 patients (3 men, 3 women; mean age, 33 years; range, 33 to 51 years) who satisfied the criteria for TAO and had signs or symptoms of critical limb ischemia were treated twice, 4 weeks apart, with 2 or 4 mg of phVEGF165, which was administered by direct intramuscular injection at 4 arbitrarily selected sites in the ischemic limb. The gene expression was documented by enzyme-linked immunosorbent assay that was performed on peripheral blood samples. RESULTS: The ulcers that were nonhealing for more than 1 month healed completely in 3 of 5 limbs after the intramuscular phVEGF165 gene therapy. Nocturnal rest pain was relieved in the remaining 2 patients, although both continue to have claudication. The evidence of the improved perfusion to the distal ischemic limb included an increase of more than 0.1 in the ankle brachial index in 3 limbs, an improved flow shown with magnetic resonance imaging in 7 of the 7 limbs, and newly visible collateral vessels shown with serial contrast angiography in 7 of the 7 limbs. The adverse consequences of the phVEGF165 gene transfer were limited to transient ankle or calf edema in 3 of the 7 limbs. Two patients with advanced distal forefoot gangrene ultimately required below-knee amputation despite the evidence of improved perfusion. A histologic section disclosed the classic pathologic findings of TAO. CONCLUSION: Therapeutic angiogenesis with phVEGF165 gene transfer, if instituted before the development of forefoot gangrene, may provide a novel therapy for patients with advanced Buerger's disease that is unresponsive to standard medical or surgical treatment methods.

Factor XIII insufficiency in a patient with severe psoriasis vulgaris, arthritis, and infirmity.

Factor XIII (FXIII) links soluble fibrin monomers and collagen fibres to stable fibrin connections. Deficiency of FXIII, caused by dyspoiesis or increased consumption, results in a bleeding tendency and wound healing complications. Although the decrease of FXIII and successful replacement in patients with wound healing complications after surgery have been described by several authors, it is rarely considered that patients with autoimmune diseases, bleeding or healing complications may suffer from FXIII deficiency. We report a patient with severe psoriasis vulgaris generalisata with large, painful erythemas, bleeding tendency, joint contractions and infirmity, whose FXIII activity was 19%. After successful replacement the bleeding tendency vanished, and a marked improvement of skin and joint mobility allowed mobilisation and administration of physical therapy, whereby some independence and mobility were restored to the patient.

Blue toe syndrome after initiation of low-dose oral anticoagulation.

Cholesterol emboli are a known complication after arterial catheterization, arterial surgery, and after lysis with plasminogen activators. The clinical presentation of cholesterol emboli is variable ranging from a localized blue toe syndrome to a multisystem disease. The purpose of this case report is to report on a patient with blue toe syndrome and livedo reticularis occuring two months after initiation of low-dose oral anticoagulation with phenproucomon. The non-invasive studies revealed an infrarenal abdominal aneurysma lined by a thin wall thrombus as a potential source of cholesterol emboli. The patient had a benign course with resolution of toe pain after a period of four weeks, without development of an ulceration. The case report demonstrates that cholesterol emboli may also occur in patients treated with low-dose oral anticoagulation and no previous arterial catheterization.

Anti-phospholipid-antibodies in patients with relapsing polychondritis.

Relapsing polychondritis (RP) is an extremely rare multisystemic disease thought to be of autoimmune origin. In order to assess if RP is associated with anti-phospholipid antibodies (aPL), clinical data and sera of 21 patients with RP were collected in a multicentre study. Concentration of anti-cardiolipin antibodies (aCL) (IgG-, IgM- and IgA-isotypes), anti-phosphatidylserine-antibodies (aPS) (IgG- and IgM-isotypes) and anti-beta-2-glycoprotein I-antibodies (a beta 2 GPI) were measured by ELISA. In eight patients aCL were found to be elevated. One patient had elevated aPS. No patient had elevated a beta 2 GPI. No patient had clinical signs and symptoms of a aPL syndrome. Interestingly, the two RP patients with the highest aPL had concomitant systemic lupus erythematosus (SLE). Therefore the presence of elevated aPL in RP is probably more closely related to an associated SLE than to RP itself. There is no convincing evidence that aPL are associated with RP.

[Ascending varicose vein phlebitis--classification and therapy]. / Aszendierende Varikophlebitis--Klassifikation und Therapie.

Ascending varicophlebitis can cause pulmonary embolism by entering the deep venous system. Classification into four stages permits a differentiated therapeutic strategy: if the thrombus reaches or enters the deep venous system, immediate surgery consisting of crossectomy, resection of the saphenous vein, radical excision of all varicosed veins and ligature of insufficient perforating veins are indicated.

Relapsing polychondritis: clinical and immunogenetic analysis of 62 patients.

OBJECTIVE: In this study we describe clinical and immunogenetic findings in 62 unselected patients with relapsing polychondritis. METHODS: In a multicenter study, clinical data of 26 (41.9%) female and 36 (58.1%) male patients were collected. HLA-DR specificities were identified in 60, and the frequencies were compared with those in healthy controls. RESULTS: The median age at the time of diagnosis was 46.6 years (range 17 to 86). 58 (93.5%) patients had auricular chondritis, 31 (50.0%) ocular symptoms, 35 (56.5%) nasal involvement. Involvement of joints (53.2%), respiratory system (30.6%), skin (24.2%), cardiovascular system (22.6%), central nervous system (9.7%), and kidneys (6.5%) was found as well. 22 (35.5%) patients had associated diseases such as systemic lupus erythematosus or rheumatoid arthritis. Susceptibility to relapsing polychondritis was significantly associated with HLA-DR4 (p < 0.001). There was no difference in the frequency or distribution of DRB1*04 subtype alleles between patients and healthy controls. The extent of organ involvement was negatively associated with HLA-DR6 (p < 0.011). CONCLUSION: Immunogenetic findings as well as similarities and overlapping clinical symptoms with other autoimmune or rheumatic diseases suggest that immunological mechanisms play a major role in the pathogenesis of relapsing polychondritis.

Disappearing bone disease (Gorham-stout disease): report of a case with a follow-up of 48 years.

A patient with osteolysis of the right hand after a metatarsal fracture at the age of 12 years is reported. The osteolysis progressed until the age of 21 years and was stable until the age of 59 years, when the patient died from a metastatic colon cancer. The article discusses the clinical, radiographic, and histologic features, and prognosis of idiopathic osteolysis (Gorham-Stout disease). Gorham-Stout disease is characterized by a non-familial, histological benign vascular proliferation producing lysis of the bone. The therapeutic options of Gorham-Stout disease is limited; radiotherapy has been used with success in single cases. Usually, the disease undergoes spontaneous arrest, as it occurred in our patient.

Relapsing poly(peri)chondritis diagnosed by biopsy during inflammatory free interval: destructive polychondritis versus fibrosing perichondritis.

Relapsing poly(peri)chondritis (RP) is a connective tissue disorder characterized by recurrent inflammatory episodes of cartilaginous structures and the involvement of special sense organs. The diagnostic criteria of McAdam 1976 include at least three of the following criteria: a) bilateral auricular chondritis, b) nonerosive sero-negative inflammatory polyarthritis, c) nasal chondritis, d) ocular inflammation, e) respiratory tract chondritis, f) audiovestibular chondritis. A cartilage biopsy according to these criteria is not mandatory. Nevertheless, unclear cases still remain as there is a broad spectrum of differential diagnosis. In these individuals it is important to obtain a biopsy from the affected cartilage. Although up to 89% develop auricular inflammation, only few electron microscope studies are performed on cartilage specimens. The purpose of this study is to report on a patient with a history of recurrent swelling of both ears, where the diagnosis could only be established by ear biopsy which was studied by light and electron microscopy. Differential diagnosis is discussed and a review of the literature is given.

Evaluation of atherosclerosis in patients with central retinal vein occlusion by carotid artery duplex scanning and echocardiography: a prospective case-control study.

BACKGROUND AND PURPOSE: Central retinal vein occlusion (CRVO) is a common cause of retinal vascular visual loss second to diabetic retinopathy. Atherosclerotic risk factors are thought to affect vascular flow or cause retinal vascular wall abnormalities, thereby contributing to development of CRVO. Previous studies did not fully evaluate the degree of atherosclerotic disease. The purpose of this study was to determine the degree of atherosclerosis of the carotid artery by duplex scanning and to investigate cardiac manifestations of atherosclerotic risk factors by echocardiography in patients with CRVO. MATERIAL AND METHODS: 39 patients (age 63.1 years [50-84 years], 21 men, 18 women) with CRVO were compared with a control group consisting of 39 individuals (age 59.3 years [49-81 years], 19 men, 20 women) in whom echocardiography was performed to rule out endocarditis. Clinical examination, laboratory testing, carotid artery duplex scanning and echocardiography were performed in all patients. RESULTS: Echocardiography revealed significantly increased prevalence of left ventricular hypertrophy (30.8% in CRVO patients, 5.1% in controls) as a typical sign of hypertensive heart disease in CRVO patients, which is consistent with the increased prevalence of hypertension (HTN) (46.2% in CRVO patients, 15.4% in controls). The prevalence of atherosclerosis of carotid artery and ascending aorta, and all other echocardiographic findings were comparable in CRVO patients and controls: regional wall motion abnormality, left ventricular dilatation, aortic valve calcification, and mitral valve calcification. CONCLUSION: Our study demonstrates that CRVO is not associated with atherosclerosis of large arteries, such as the carotid artery and the ascending aorta. We propose that the retinal artery atherosclerosis seen in most CRVO patients is caused by HTN.

Unusual presentation of Takayasu arteritis with cardiac involvement and imitation of juvenile arteriosclerosis. A case report.

A twenty-five-year-old Caucasian man with Takayasu arteritis, who was formerly diagnosed as suffering from premature arteriosclerosis, is described. Necropsy disclosed involvement of the entire aorta and its major branches, the pulmonary arteries, the coronary arteries, the intramyocardial arteries, and the heart valves, a combination hitherto not described. Literature concerning heart involvement in Takayasu arteritis is reviewed, and the differential diagnosis is discussed.

Doppler-duplex evaluation of common carotid artery flow for programming of dual chamber pacemakers

To determine the hemodynamic outcome of different atrioventricular (AV) intervals in dual chamber pacing we examined 20 patients with pacemakers (Relay, Cosmos; Intermedics) by doppler-duplex sonography, recording the flow-veloity time profile in the common carotid artery (CTF). The pacemakers were programmed to a fixed heart rate of 70 min. The CTF was recorded at different AV-intervals in AV-sequential pacing and the in single-chamber pacing (VVI). The measurements showed that setting of an optim AV-delay by doppler-duplex evaluation of the carotid artery is able to provide an average improvement in CTF of 25 por cento comparing the most unfavorable to the optimal AV-delay. Considreing different pacing modes Av-senquential pacing was superior to VVI-pacing. In conclusion these result demonstrate the importance of an individual optimal AV-delay setting and the usefulness of doppler-duplex sonography of the common carotid artery for optimal programming of dual chamber pacemakers.

Bone marrow pathology in relapsing polychondritis: high frequency of myelodysplastic syndromes.

Haemopathologic changes were studied in 19 patients (13 male, six female, age 33-85 years, mean 56 years) with relapsing polychondritis (RP). Anaemia was found in eight, thrombocytopenia in two and splenomegaly in three patients. A total of 17 bone marrow biopsies were obtained from seven individuals. Bone marrow evaluation revealed myelodysplastic syndromes (MDS) with marked trilineage hyperplasia and dysplasia in three cases. Since an excess of myeloblasts or an increase of CD34 positive progenitor cells was not seen, the disorders were designated as 'refractory anaemia' or with regard to the dysplastic megakaryopoiesis 'MDS, unclassifiable'. Two of the three patients died after 10 and 55 months of follow-up due to infectious complications. In a further patient, bone marrow analysis repeatedly showed an unexplained granulopoietic hyperplasia, which, however, was not dysplastic enough to allow a diagnosis of MDS. The remaining patients had clearly reactive changes. Our findings support the notion that RP is a heterogenous disorder and suggest that RP may at times represent a paraneoplastic phenomenon of an underlying MDS. Since HLA typing revealed a significantly increased frequency of the antigen DR4 (10/17 patients positive = 59%), we hypothesize that immunological imbalances due to the MDS in conjunction with a specific immunogenetic background may play key roles in the pathogenesis of RP in these patients.

[Acute kidney failure caused by sulfadiazine stones. A complication of the therapy of toxoplasmosis in AIDS]. / Akute Niereninsuffizienz durch Sulfadiazinsteine. Komplikation der Therapie einer Toxoplasmose bei AIDS.

A 45-year-old man with AIDS was treated for a recurrence of cerebral toxoplasmosis with sulphadiazine, 4 g, and pyrimethamine, 75 mg, daily. Owing to a lack of appetite and dysphagia he drank rather little water during the first week of treatment. On the 13th day after starting the drugs he had bilateral renal colics and renal failure was diagnosed (serum creatinine 3.8 mg/dl). Ultrasound examination demonstrated multiple stones with bilateral urinary retention. After parenteral fluid replacement, alkalization of the urine with sodium-potassium-hydrogen citrate and N-butylcopolamine a stone, consisting of sulphadiazine and acetylsulphadiazine, was passed after two days. Three days later the creatinine concentration was within normal limits, and in further two days the ultrasound picture was normal. It is pointed out that diarrhoea, fever or dysphagia often prevent sufficient fluid intake in AIDS patients. Satisfactory oral fluid intake and alkalization of urine is thus of great importance for avoiding complications during sulphadiazine treatment.

Susceptibility to relapsing polychondritis is associated with HLA-DR4.

OBJECTIVE: To determine the frequency of HLA class II antigens in Caucasian central European patients with relapsing polychondritis (RP). METHODS: HLA class I, DR, and DQ specificities were identified in 41 patients with RP, and the frequencies were compared with those in 204 healthy, unrelated control subjects. HLA typing was performed using the standard complement-dependent microcytotoxicity assay. HLA-DR genotyping of 12 DR4-positive RP patients and 57 controls was performed by allele-specific oligonucleotide probing after amplification of genomic DNA by polymerase chain reaction. RESULTS: A significant increase in DR4 antigen frequency was found in the patients (56.1%) as compared with that in healthy controls (25.5%) (Pcorr < 0.001). Genotyping of DR4-positive patients and controls revealed no predominance of any DR4 subtype. CONCLUSION: There are important clinical similarities and overlaps between RP and rheumatoid arthritis (RA). In RA, the association with DR4 has been well established. Our findings show that although there is a DR4 association with RP, the situation is sufficiently distinct from that of RA to imply considerable differences in pathogenesis of the two conditions.

Independent mutation of arginine(3500)-->glutamine associated with familial defective apolipoprotein B-100.

Familial defective apolipoprotein B-100 (FDB) is characterized by a decreased affinity of low density lipoprotein (LDL) to the LDL receptor resulting in a dominantly inherited increase of plasma LDL. It is postulated that FDB is caused by a G to A mutation at nucleotide 10,708 in exon 26 of the apoB gene creating a substitution of glutamine for arginine in amino acid 3500. The arginine(3500)-->glutamine mutation has been identified on the same haplotype of the apoB gene in several populations from North America and Europe, suggesting that it occurred on a single ancestral gene. Independent mutations were not observed. The purpose of this paper is to report on a family where individuals show a dominantly inherited increase of plasma LDL associated with an independent arginine(3500)-->glutamine mutation as determined by haplotype analysis using polymorphic markers of the apoB gene. The identification of these individuals is strong evidence that the arginine(3500)-->glutamine mutation is causative for the defective binding of apoB-100.

[Chronic recurrent polychondritis]. / Die chronisch rezidivierende Polychondritis.

Relapsing polychondritis (RP) is a recurrent, chronic und rare disease of unknown etiology, characterized by inflammation of cartilaginous structures of the ears, nose, respiratory tract and joints. The association with HLA-DR4 and the occurrence of antibodies to type-II collagen and other autoantibodies suggest that an immunologic mechanism is involved in its pathogenesis. In about 30% of occurrences RP is associated with other rheumatic or autoimmune diseases. Ocular inflammation, involvement of the cardiovascular system, skin, central nervous system and audiovestibular organ are most probably caused by vasculitis. The course of RP is variable. Severity and outcome primarily depend on the occurrence of associated autoimmune diseases and vasculitis. According to the activity and systemic manifestations, medical treatment includes nonsteroidal antiinflammatory drugs, corticosteroids and cytotoxic agents.