Kidney-limited AL amyloidosis: a case report and review of the literature.

Amyloidosis involves the deposition of abnormal proteins in various tissues and results in progressive organ dysfunction, commonly affecting multiple organs. Two types of systemic amyloidosis are AA and AL; the former is associated with acute phase reactions and the latter is composed of light chain immunoglobulins. This disease commonly affects the kidneys and is evidenced by massive proteinuria. A biopsy is the gold standard of diagnosis, with Congo Red staining revealing an apple-green birefringence under polarized light. Although the kidneys are frequently affected in this disease, it is rare that amyloidosis is limited to the kidneys without involvement of other organs. We present an 83-year-old female with bilateral lower extremity swelling for several months who was found to have 12.374 grams of protein in a 24-hour urine sample and a large amount of free lambda chains. A renal biopsy demonstrated renal amyloidosis of the AL type. Serum immunofixation and flow cytometry were unremarkable for any plasma dyscrasia; a bone marrow biopsy did not reveal systemic amyloidosis and imaging with PET/CT scan did not show evidence of other organ involvement. She was diagnosed with renal-limited amyloidosis and started on bortezomib, melphalan, and steroids. Clinicians should be aware of the signs and symptoms of amyloidosis, specifically its ability to present with unusual involvement of individual organs.

Awareness and knowledge among internal medicine house-staff for dose adjustment of commonly used medications in patients with CKD.

BACKGROUND: Drug dosing errors result in adverse patient outcomes and are more common in patients with chronic kidney disease (CKD). As internists treat the majority of patients with CKD, we study if Internal Medicine house-staff have awareness and knowledge about the correct dosage of commonly used medications for those with CKD. METHODS: A cross-sectional survey was performed and included 341 participants. The outcomes were the awareness of whether a medication needs dose adjustment in patients with CKD and whether there was knowledge for the level of glomerular filtration rate (GFR) a medication needs to be adjusted. RESULTS: The overall pattern for all post-graduate year (PGY) groups in all medication classes was a lack of awareness and knowledge. For awareness, there were statistically significant increased mean differences for PGY2 and PGY3 as compared to PGY1 for allergy, endocrine, gastrointestinal, and rheumatologic medication classes but not for analgesic, cardiovascular, and neuropsychotropic medication classes. For knowledge, there were statistically significant increased mean differences for PGY2 and PGY3 as compared to PGY1 for allergy, cardiovascular, endocrine, and gastrointestinal, medication classes but not for analgesic, neuropsychotropic, and rheumatologic medication classes. CONCLUSIONS: Internal Medicine house-staff across all levels of training demonstrated poor awareness and knowledge for many medication classes in CKD patients. Internal Medicine house-staff should receive more nephrology exposure and formal didactic educational training during residency to better manage complex treatment regimens and prevent medication dosing errors.

Ursolic acid differentially modulates apoptosis in skin melanoma and retinal pigment epithelial cells exposed to UV-VIS broadband radiation.

The signaling pathways via mTOR (mammalian target of rapamycin) and AMPK (AMP-activated protein kinase) play key roles in transcription, translation and carcinogenesis, and may be activated by light exposure. These pathways can be modulated by naturally occurring compounds, such as the triterpenoid, ursolic acid (UA). Previously, the transcription factors p53 and NF-κB, which transactivate mitochondrial apoptosis-related genes, were shown to be differentially modulated by UA. UA-modulated apoptosis, following exposure to UV-VIS radiation (ultraviolet to visible light broadband radiation, hereafter abbreviated to UVR), is observed to correspond to differential levels of oxidative stress in retinal pigment epithelial (RPE) and skin melanoma (SM) cells. The cellular response to this phytochemical was characterized using western blot, flow cytometry, microscopy with reactive oxidative species probes MitoTracker and dihydroethidium, and membrane permeability assay. UA pretreatment potentiated cell cycle arrest and UVR-induced apoptosis selectively in SM cells while reducing photo-oxidative stress in the DNA of RPE cells presumably by antioxidant activity of UA. Mechanistically, the nuclear transportation of p65 and p53 was reduced by UA administration prior to UVR exposure while the levels of p65 and p53 nuclear transportation in SM cells were sustained at a substantially higher level. Finally, the mitochondrial functional assay showed that UVR induced the collapse of the mitochondrial membrane potential, and this effect was exacerbated by rapamycin or UA pretreatment in SM preferentially. These results were consistent with reduced proliferation observed in the clonogenic assay, indicating that UA treatment enhanced the phototoxicity of UVR, by modulating the activation of p53 and NF-κB and initiating a mitogenic response to optical radiation that triggered mitochondria-dependent apoptosis, particularly in skin melanoma cells. The study indicates that this compound has multiple actions with the potential for protecting normal cells while sensitizing skin melanoma cells to UV irradiation.

Modulation of photochemical damage in normal and malignant cells by naturally occurring compounds.

Certain phytochemicals, such as the stilbene, resveratrol (RES, found in red grapes and berries), and the triterpenoid, ursolic acid (UA, found in waxy berries and herbs such as rosemary and oregano), have antioxidant, anti-inflammatory and antiproliferative effects. Two human-derived cell lines, hTERT-RPE with a nonmalignant phenotype derived from retinal pigment epithelium, and ATCC CRL-11147 derived from a malignant skin melanoma, were used as in vitro models of photooxidative stress produced by exposure to the broadband output of a 150 W Hg vapor arc lamp at an irradiance of 19-26 mW cm(-2). In untreated cells, UV-VIS broadband light exposure produced a loss of proliferative ability, an activation of NF-κB and an increase in protein carbonyl adducts at 24 h postexposure. Pretreatment of the cells with RES or UA at 1-2 µmsignificantly reduced the amount of phosphorylated NF-κB at 24 h postexposure. RES pretreatment reduced the burden of light-induced protein carbonyl adducts by up to 25% in exposed cells. UA treatment markedly increased the sensitivity of melanoma cells to UV radiation, while conferring some photoprotection to RPE cells. These observations indicate that phytochemicals modulate the cellular response to photochemical stress by interacting with specific cell-signaling pathways.

An adaptable HPLC method for the analysis of frequently used antibiotics in ocular samples.

Four different antibiotics, delivered individually to rabbit eyes via hydrophilic intraocular lenses soaked in the drug solution prior to implantation, were measured in aqueous and vitreous humor samples from the eyes. To meet this analytical need, we developed a sensitive, high performance liquid chromatographic (HPLC) method for measuring the concentrations of moxifloxacin, gatifloxacin, linezolid, and cefuroxime in the ocular tissue. Separations were carried out on a LichroSpher RP-18 column, maintained at room temperature. The fluoroquinolones were eluted with a mobile phase consisting of 20% acetonitrile, in 0.1% trifluoroacetic acid (pH 3.0) with 30 mM tetrabutylammonium chloride. Linezolid and cefuroxime were eluted with 25% acetonitrile in 25 mM Na acetate buffer, pH 5.0. All elutions were isocratic. With ultraviolet detection, the lower limit of quantitation (LLOQ) for these compounds approached 1 ng (on-column injection). By using fluorescence detection, the LLOQ for the fluoroquinolones improved to 200 pg. The overall accuracy of the method was >or=90%. With minor modifications, the method was optimized for each of the agents, and the resulting analytical sensitivity made the method suitable for clinical investigations of the ocular penetration of these drugs.

Retinal function assessed by ERG before and after induction of ocular aspergillosis and treatment by the anti-fungal, micafungin, in rabbits.

This study was conducted to evaluate the effectiveness of a new antifungal drug, micafungin, and standard antifungal drugs against endophthalmitis induced in a rabbit by intravitreal injection of Aspergillus fumigatus, an important fungal pathogen. Effectiveness was evaluated by the preservation of b-wave amplitude at 72 h after injection of the fungus relative to the b-wave amplitude at baseline before any intravitreal injections. A 0.06 ml inoculum of 10(6) conidia of A. fumigatus was injected into the vitreous of the right eye of all rabbits; and, 12 h later, a 0.06 ml solution containing one of 3 antifungal drugs or saline was injected into the vitreous of both eyes. All three antifungal drugs produced significant b-wave preservation at 72 h in infected eyes compared to that in infected eyes receiving saline injections. There was no statistically significant difference between the effects of micafungin and amphotericin B in the right eyes with fungal endophthalmitis, and both produced significantly more preservation of b-wave amplitude than voriconazole. Amphotericin B, but neither micafungin nor voriconazole produced significant reduction of the b-wave amplitude in the left eyes.

Photodynamic actions of indocyanine green and trypan blue on human lens epithelial cells in vitro.

PURPOSE: The purpose of this study was to evaluate the toxicity and photodynamic activity of indocyanine green (ICG) and trypan blue (TryB) on cultured human lensepithelial cells (LECs). DESIGN: Experimental study. METHODS: Lens epithelial cell viability was assessed after treatment with ICG and TryB concentrations ranging from 0.025 to 5.0 mg/ml, and exposure to 806 nm diode laser. RESULTS: At ICG concentrations below 0.5 mg/ml, there was > or =75% cell viability; at higher ICG concentrations there was dose-dependent cytotoxicity in addition to loss of cellular viability due to ICG photosensitization. TryB had little cytotoxicity to the LECs: >80% cells were viable irrespective of the dye concentration or laser treatment. CONCLUSIONS: These data indicate that ICG may have application as a photosensitizer in the selective eradication of residual LECs after cataract surgery to reduce the incidence of posterior capsule opacification.

A Robust Visual Tracking System for Patient Motion Detection in SPECT: Hardware Solutions.

Our overall research goal is to devise a robust method of tracking and compensating patient motion by combining an emission data based approach with a visual tracking system (VTS) that provides an independent estimate of motion. Herein, we present the latest hardware configuration of the VTS, a test of the accuracy of motion tracking by it, and our solution for synchronization between the SPECT and the optical acquisitions. The current version of the VTS includes stereo imaging with sets of optical network cameras with attached light sources, a SPECT/VTS calibration phantom, a black stretchable garment with reflective spheres to track chest motion, and a computer to control the cameras. The computer also stores the JPEG files generated by the optical cameras with synchronization to the list-mode acquisition of events on our SPECT system. Five Axis PTZ 2130 network cameras (Axis Communications AB, Lund, Sweden) were used to track motion of spheres with a highly retro-reflective coating using stereo methods. The calibration phantom is comprised of seven reflective spheres designed such that radioactivity can be added to the tip of the mounts holding the spheres. This phantom is used to determine the transformation to be applied to convert the motion detected by the VTS into the SPECT coordinates system. The ability of the VTS to track motion was assessed by comparing its results to those of the Polaris infra-red tracking system (Northern Digital Inc. Waterloo, ON, Canada). The difference in the motions assessed by the two systems was generally less than 1mm. Synchronization was assessed in two ways. First, optical cameras were aimed at a digital clock and the elapsed time estimated by the cameras was compared to the actual time shown by the clock in the images. Second, synchronization was also assessed by moving a radioactive and reflective sphere three times during concurrent VTS and SPECT acquisitions and comparing the time at which motion occurred in the optical and SPECT images. The results show that optical and SPECT images stay synchronized within a 150 ms range. The 100Mbit network load is less than 10%, and the computer's CPU load is between 15 and 25%; thus, the VTS can be improved by adding more cameras or by increasing the image size and/or resolution while keeping an acquisition rate of 30 images per second per camera.

Antibody-targeted photodynamic therapy.

PURPOSE: To assess the feasibility of conjugation of verteporfin (Visudyne, Parkedale Pharmaceuticals, Rochester, Minnesota, USA) to antibody against vascular endothelial growth factor. DESIGN: Experimental study. METHODS: Rabbit antimouse vascular endothelial growth factor polyclonal antibody was conjugated to verteporfin. Fluorescence excitation-emission spectra of verteporfin and conjugate were examined. Vascular endothelial growth factor-expressing murine endothelial cells were incubated with saline, verteporfin, or conjugate, followed by laser exposure or no laser exposure. Cell viability at 1 and 24 hours was assessed via trypan blue exclusion. Results were analyzed by two-way analysis of variance with replication and the Bonferroni multiple comparison test. RESULTS: The fluorescence excitation-emission spectrum of the conjugate was similar to that of verteporfin. After laser exposure, cell viability in conjugate-treated cells was reduced to 6% at 1 hour (P <.0001) and to 4% at 24 hours (P <.0001), compared with approximately 40% in nonlaser-exposed, conjugate-treated cells. The cytotoxicity in the conjugate-treated cells was higher than in verteporfin-treated cells exposed to laser, although the difference did not reach statistical significance. CONCLUSIONS: The conjugation of verteporfin to polyclonal antibody is possible without the loss of its photosensitizing properties. Conjugated verteporfin destroys cellular targets at least as effectively as verteporfin alone.