GM-CSF is a marker of compartmentalised intrathecal inflammation in multiple sclerosis.

BACKGROUND: Granulocyte-macrophage colony stimulating factor (GM-CSF) is a pro-inflammatory cytokine secreted by various immune cells. Several studies have demonstrated an expansion of GM-CSF producing T cells in the blood or CSF of people with MS (pwMS). However, whether this equates to greater concentrations of circulating cytokine remains unknown as quantification is difficult with traditional assays. OBJECTIVE: To determine whether GM-CSF can be quantified and whether GM-CSF levels are elevated in pwMS. METHODS: We employed Single Molecule Array (Simoa) to measure GM-CSF in both CSF and blood. We then investigated relationships between GM-CSF levels and measures of blood-CSF-barrier integrity. RESULTS: GM-CSF was quantifiable in all samples and was significantly higher in the CSF of pwMS compared with controls. No association was found between CSF GM-CSF levels and Q-Albumin - a measure of blood-CSF-barrier integrity. CSF GM-CSF correlated with measures of intrathecal inflammation, and these relationships were greater in primary progressive MS compared with relapsing-remitting MS. CONCLUSION: GM-CSF levels are elevated specifically in the CSF of pwMS. Our results suggest that elevated cytokine levels may reflect (at least partial) intrathecal production, as opposed to simple diffusion across a dysfunctional blood-CSF-barrier.

Benefits of sulfamethoxazole-trimethoprim prophylaxis on rates of sepsis after kidney transplant.

BACKGROUND: The use of potent immunosuppression increases the risk of infectious complications following kidney transplantation. Sulfamethoxazole-trimethoprim (SMX/TMP) is an inexpensive broad-spectrum antimicrobial agent used in our center as lifelong prophylaxis against Pneumocystis jirovecii, unless contraindicated. This study evaluated the clinical impact of SMX/TMP prophylaxis compared with no prophylaxis with SMX/TMP (NoPPx), but with alternative agents. METHODS: This was a retrospective cohort analysis of renal transplant recipients (RTR) transplanted from January 2002 through December 2010. Patients were divided into SMX/TMP group and NoPPX group, based on whether they received prophylaxis with SMX/TMP or not, and rates of sepsis were compared between groups. We also analyzed the pathogens and source implicated in these episodes, as well as the dose of SMX/TMP. Rates were compared using multivariate logistic regression. RESULTS: With a mean follow-up of 4.8 (± 2.5) years, 63 cases of sepsis occurred in 1224 patients (5.1%), and 60% of these cases had a urinary source. The risk of sepsis was significantly reduced with prophylaxis vs. NoPPx (13.3% vs. 4.3% for SMX/TMP, P < 0.001), and this association was maintained through multivariate regression. Sepsis was associated with a numerically increased risk of graft loss and death that was not significantly affected by use of SMX/TMP. CONCLUSIONS: Prophylaxis with SMX/TMP is an inexpensive way to reduce the incidence of sepsis in RTR.

Function and effect of bone morphogenetic protein-7 in kidney bone and the bone-vascular links in chronic kidney disease.

In two independent and separate studies, we have shown that renal injury and chronic kidney disease (CKD) directly inhibit skeletal anabolism, and that stimulation of bone formation decreased the serum phosphate. In the first study, the serum Ca PO(4), parathyroid hormone (PTH), and calcitriol were maintained normal after renal ablation in mice, and even mild renal injury equivalent to stage 3 CKD decreased bone formation rates. More recently, these observations were rediscovered in low-density lipoprotein receptor null (LDLR-/-) mice fed high-fat/cholesterol diets, a model of the metabolic syndrome (hypertension, obesity, dyslipidemia and insulin resistance). We demonstrated that these mice have vascular calcification (VC) of both the intimal atherosclerotic type and medial calcification. We have also shown that VC is made worse by CKD and ameliorated by bone morphogenetic protein-7 (BMP-7). The finding that high-fat fed LDLR-/- animals with CKD had hyperphosphatemia which was prevented in BMP-7-treated animals lead us to examine the skeletons of these mice. It was found that significant reductions in bone formation rates were associated with high-fat feeding, and superimposing CKD resulted in the adynamic bone disorder (ABD), while VC was made worse. The effect of CKD to decrease skeletal anabolism (decreased bone formation rates and reduced number of bone modelling units) occurred despite secondary hyperparathyroidism. The BMP-7 treatment corrected the ABD and hyperphosphatemia, owing to BMP-7-driven stimulation of skeletal phosphate deposition reducing plasma phosphate and thereby removing a major stimulus to VC. A pathological link between abnormal bone mineralization and VC through the serum phosphorus was demonstrated by the partial effectiveness of directly reducing the serum phosphate by a phosphate binder that had no skeletal action. Thus, in the metabolic syndrome with CKD, a reduction in bone forming potential of osteogenic cells leads to the ABD producing hyperphosphatemia and VC, processes ameliorated by BMP-7, in part through increased bone formation and skeletal deposition of phosphate and in part through direct actions on vascular smooth muscle cells. We have demonstrated that the processes leading to vascular calcification begin with even mild levels of renal injury affecting the skeleton before demonstrable hyperphosphatemia and that they are preventable and treatable. Therefore, early intervention in the skeletal disorder associated with CKD is warranted and may affect mortality of the disease.

Two-dimensional time correlation relaxometry of skeletal muscle in vivo at 3 Tesla.

A hybrid two-dimensional relaxometry (2DR) sequence was used to simultaneously measure both the spin-spin (R2) and spin-lattice relaxation rates (R1) of skeletal muscle in vivo. The 2DR sequence involved a 180 degrees inversion pulse followed by a variable delay time (30 values from 40 to 7000 ms); a projection presaturation (PP) scheme to localize a 16-ml cylindrical voxel; and a CPMG sequence (950 even echoes, effective echo spacing = 1.2 ms, equilibrium time = 12 s). The 2DR data were collected at 3.0 Tesla from the flexor digitorum profundus of eight healthy males, 26 +/- 2 years old. Analysis was performed with a 2D version of the non-negative least-squares algorithm and a one-way ANOVA. All subjects exhibited at least three spin-groups (R2 < 200 s(-1)), designated B, C, and D, with R2 values of 42.7, 26.5, and 8.1 s(-1), and fractional volumes of 52, 35, and 7%, respectively. The R1 values of B and C were similar, congruent with0.7 s(-1), but different from that of D (P < 0.001), which had an R1 of 1.0 s(-1). The results suggest that exchange between B and C ranges from 0.7-16.2 s(-1), while exchange between either of these spin-groups with D is slower. If the data are interpreted with a compartment model, in which spin-groups with short and long R2 values are attributed to extra- and intracellular fluid, respectively, the exchange of water across the cell membrane in living skeletal muscle is slow or intermediate relative to both R1 and R2.

Effects of exercise on muscle transverse relaxation determined by MR imaging and in vivo relaxometry.

The purpose of this study was to determine the effects of intense exercise on the proton transverse (T(2)) relaxation of human skeletal muscle. The flexor digitorium profundus muscles of 12 male subjects were studied by using magnetic resonance imaging (MRI; 6 echoes, 18-ms echo time) and in vivo magnetic resonance relaxometry (1,000 echoes, 1.2-ms echo time), before and after an intense handgrip exercise. MRI of resting muscle produced a single T(2) value of 32 ms that increased by 19% (P < 0.05) with exercise. In vivo relaxometry showed at least three T(2) components (>5 ms) for all subjects with mean values of 21, 40, and 137 ms and respective magnitudes of 34, 49, and 14% of the total magnetic resonance signal. These component magnitudes changed with exercise by -44% (P < 0.05), +52% (P < 0.05), and +23% (P < 0.05), respectively. These results demonstrate that intense exercise has a profound effect on the multicomponent T(2) relaxation of muscle. Changes in the magnitudes of all the T(2) components synergistically increase MRI T(2), but changes in the two shortest T(2) components predominate.

Alcoholysis reactions from starch with alpha-amylases.

The ability of alpha-amylases from different sources to carry out reactions of alcoholysis was studied using methanol as substrate. It was found that while the enzymes from Aspergillus niger and Aspergillus oryzae, two well-studied saccharifying amylases, are capable of alcoholysis reactions, the classical bacterial liquefying alpha-amylases from Bacillus licheniformis and Bacillus stearothermophilus are not. The effect of starch and methanol concentration, temperature and pH on the synthesis of glucosides with alpha-amylase from A. niger was studied. Although methanol may inactivate alpha-amylase, a 90% substrate relative conversion can be obtained in 20% methanol at a high starch concentration (15% w/v) due to a stabilizing effect of starch on the enzyme. As the products of alcoholysis are a series of methyl-oligosaccharides, from methyl-glucoside to methyl-hexomaltoside, alcoholysis was indirectly quantified by high performance liquid chromatography analysis of the total methyl-glucoside produced after the addition of glucoamylase to the alpha-amylase reaction products. More alcoholysis was obtained from intact soluble starch than with maltodextrins or pre-hydrolyzed starch. The biotechnological implications of using starch as substrate for the production of alkyl-glucosides is analyzed in the context of these results.

Multicomponent T2 relaxation of in vivo skeletal muscle.

In vivo spin-spin (T2) relaxation measurements were acquired from the flexor digitorum profundus (FDP) of 13 subjects. A standard imaging T2 measurement technique [number of points (N) = 6, TE = 18 msec, signal-to-noise ratio (SNR) approximately equal to 300] yielded a single T2 value of 31 msec. A novel technique, projection presaturation combined with a CPMG sequence, was used to acquire data (N = 1000, TE = 1.2 msec, SNR 3500) from a cylindrical voxel (2 cm diameter, 5 cm length) within the FDP. All 13 subjects had at least four T2 components, at < 5, 21 +/- 4, 39 +/- 6, and 114 +/- 31 msec, with fractional areas of 11 +/- 2, 28 +/- 15, 46 +/- 12, and 11 +/- 5% respectively. The shortest and longest components have been observed in ex vivo muscle studies, probably corresponding to water associated with macromolecules and extracellular water, respectively. The middle T2 components are suggestive of an organization of in vivo intracellular water.

Adrenalectomy does not modify the suppressive effect of angiotensin II on voluntary ethanol drinking in rats.

Enhancement of activity in the renin-angiotensin system reduces voluntary ethanol consumption in rats. Because angiotensin II, which is a major bioactive component of the renin-angiotensin system, stimulates the release of aldosterone, aldosterone may play a role in the reduction of ethanol intake by angiotensin II. The present study examined ethanol drinking in a group of rats that was bilaterally adrenalectomized and incapable of producing aldosterone, and in a sham group that underwent similar surgery except that the adrenal glands were left intact. Rats were maintained on ad libitum food, water and 1.5% saline solution in their home cages. Access to ethanol (6% weight/volume) was restricted to a daily 40 min period and was always offered as a choice in conjunction with water. Adrenalectomy did not alter the effect of angiotensin II on ethanol intake as subcutaneous injections of angiotensin II (400 micrograms/kg) significantly reduced ethanol intake to the same degree in both the adrenalectomized and sham groups. In the next phase, daily subcutaneous injections of aldosterone (100 micrograms/kg) reduced the home cage intake of 1.5% saline in the adrenalectomized group indicating that this dose of aldosterone was biologically active. These aldosterone injections did not affect ethanol intake in either the adrenalectomized or sham groups. Under the present conditions of testing aldosterone does not appear to play a role in the angiotensin II-induced reduction of ethanol consumption.

Blood leukocyte contribution to serum ferritin levels in patients on chronic hemodialysis.

Serum ferritin level has been shown by many investigators to be a good indicator of bone marrow iron stores in normal subjects. Although this correlation may hold in some pathological situations, it is lost in others. In leukemia a dissociation has been observed between serum ferritin levels and bone marrow iron stores. Leukemic cells were demonstrated to contain high levels of ferritin and to secrete it in the serum, causing this dissociation. In this study we investigated the possibility of having an analogous situation in patients on chronic hemodialysis. The latter patients have normal or high ferritin levels irrespective of bone marrow iron stores. Our results show that blood neutrophils and lymphocytes do not contribute to the high serum ferritin levels in these patients. Ferritin level in blood monocytes, however, was found to correlate with the serum ferritin levels and bone marrow iron stores in dialysis patients. Hence we concluded that sources other than blood leukocytes must be contributing to the high serum ferritin level in these patients. On the other hand, to unravel the role played in these changes by the monocytic cell population requires dynamic studies.

Prolonged chlorpromazine infusion as antiemetic in patients on daily cisplatin infusion. A pilot study.

Continuous chlorpromazine infusion 120 mg/m2/24 h was administered for a period of 84-110 h to 24 consecutive patients with various advanced solid malignancies receiving concomitantly a 3-day infusion of cisplatin. The latter was given at a dose of 40 mg/m2/day over 6 h every day, in combination with either doxorubicin and cyclophosphamide or 5-fluorouracil infusion or vinblastine and bleomycin. This novel approach of using prolonged continuous chlorpromazine infusion as antiemetic therapy proved quite safe with no incidence of extrapyramidal toxicity, hepatotoxicity, or agranulocytosis. Only one episode of convulsions occurred, promptly reversed. Also, antiemesis was demonstrated in 66% of patients receiving such highly emetogenic chemotherapy. Blood levels of chlorpromazine did not correlate with antiemetic efficacy.

Efficacy of continuous high-dose metoclopramide in patients receiving daily cisplatin infusions.

Continuous high-dose metoclopramide (MCP), 2 mg/kg/24 hours, was administered for a period of 84-90 hours to 30 consecutive patients with various advanced solid malignancies receiving concomitantly a 3-day infusion of cisplatin. The latter was given at a dose of 40 mg/m2/day over 6 hours every day, in combination with doxorubicin and cyclophosphamide. Diphenhydramine and dexamethasone were also administered. This prolonged antiemetic therapy proved to be safe with only a 16% incidence (five of 30 patients) of extrapyramidal side effects not necessitating discontinuation of MCP. Also, antiemetic efficacy was demonstrated with 63% of the patients not experiencing any emesis.

Breast carcinoma metastatic to the nasopharynx.

A case report of a patient with adenocarcinoma of the breast with metastasis to the nasopharynx is described. The patient presented initially with pulmonary metastasis followed later by metastasis to the left jugulo-digastric lymph nodes. A prominent but asymptomatic nasopharyngeal mass was concomitantly discovered on head and neck examination. Three months later, symptoms of panhypopituitarism developed. Invasion of the base of the skull and pituitary were documented. Patients with adenocarcinoma of the breast and high cervical node metastasis should have a thorough otolaryngologic and head and neck evaluation. Metastatic carcinoma to the nasopharynx is an extremely rare occurrence. Only two cases of bronchogenic carcinoma of the lung and two cases of hypernephroma metastatic to the nasopharynx have been reported in the literature (Bernstein et al., 1966). We present what we believe to be the first case of metastatic adenocarcinoma of the breast to the nasopharynx.

Ferritin synthesis by monocyte-derived macrophages in thalassemic patients with intrinsic iron overload.

Macrophage ferritin content was determined following culture of peripheral blood monocytes for a period of 8 d in 40% autologous plasma to render them mature macrophages. Ferritin content was measured prior to and following culture using the radioimmunoassay. The normal range of values was established in a group of 22 healthy volunteer blood donors. A significant increase in the ratio of macrophage/monocyte ferritin was observed in every donor studied (range 1.2 - 1.8, p less than 0.001). Also, a further significant increase was observed when these macrophages were additionally incubated for 6 h with heterologous antibody-coated sheep red blood cells (range 1.2 - 1.57, p less than 0.001). Finally, the same studies were performed on a group of thalassemic patients with and without intrinsic iron overload. Again there were significant increases in monocyte ferritin content following culture as well as ingestion of heterologous sheep red cells, with magnitudes similar to those obtained with normal donor monocytes. Therefore we could not demonstrate the presence of a cellular ferritin synthesis defect in macrophages of thalassemic patients with intrinsic iron overload to explain the uncontrolled absorption of dietary iron from their gut.

Monocyte ferritin in idiopathic haemochromatosis, thalassaemia and liver disease.

Monocyte ferritin (MF) content was measured in normal subjects and patients with a variety of disorders of iron storage. MF was above the normal range in 4 patients with idiopathic haemochromatosis (IHC). However, in 4 patients with transfusion siderosis (TS), secondary to aplastic anaemia, who had similar elevations in serum ferritin, MF was highly elevated. 10 patients with thalassaemia intermedia and thalassaemia major with no previous history of transfusions, but with elevated serum ferritin, also had significantly elevated MF. Disproportionately low MF in IHC could reflect defective ferritin metabolism in reticuloendothelial cells in this disorder. Finally, in 3 patients with acute rises in serum ferritin caused by acute hepatitis, MF was not increased. This suggests that MF is not directly affected by high circulating levels of serum ferritin raised acutely, but rather reflects iron storage status in conditions not associated with primary disorders of iron metabolism.

Graft-versus-host disease in a patient with acute lymphoblastic lymphoma.

A young man with acute lymphoblastic lymphoma on chemotherapy developed acute graft-versus-host disease following nonirradiated blood transfusions during a period of pancytopenia. The importance of the cutaneous manifestations, in particular the histopathologic changes, in facilitating an early diagnosis of the disease are stressed. The question of irradiating blood transfusions for immunosuppressed patients with malignancies is discussed.