Transthyretin amyloidosis with cardiomyopathy after domino liver transplantation: Results of a cross-sectional study

Domino liver transplantation (DLT) has been used widely in patients with hereditary amyloid transthyretin (ATTR) amyloidosis. New-onset polyneuropathy in recipients of DLT has been reported, but there are few cases of cardiac involvement reported. We aimed to perform a cross-sectional study for ATTR amyloidosis with cardiomyopathy (ATTR-CM) in DLT recipients. We evaluated 23 living DLT recipients a median of 9 years since DLT at 2 referral centers with a systematic cardiac evaluation, including bone scintigraphy. Median age was 72 years, 91% had hypertension, 35% had diabetes mellitus, 67% had chronic renal failure, and 8 patients (35%) developed new-onset polyneuropathy. Only 13% had a normal electrocardiogram and a normal echocardiography, and most of them showed some conduction disturbance or increase in left ventricular wall thickness, but only 1 patient with a Glu89Lys mutation developed ATTR-CM diagnosed by bone scintigraphy and endomyocardial biopsy. None of the recipients of a DLT with Val30Met mutation showed cardiac involvement by bone scintigraphy. In conclusion, DLT from Val30Met donors seems to be safe regarding the development of ATTR-CM. Evaluation of cardiomyopathy in DLT recipients is challenging due to concomitant comorbidities and in this context, bone scintigraphy can be helpful to evaluate ATTR-CM.     

Four-contrast defecography: Pelvic “floor-oscopy”

PURPOSE: This study was designed to determine the accuracy of physical examination (as judged by four-contrast defecography) for women with pelvic floor relaxation disorders. METHODS: Sixty-two women (mean age, 59 years) who had obstructed defecation or constipation, vaginal prolapse, urinary difficulty, or pelvic pain underwent four-contrast defecography. Oral, vaginal, bladder, and rectal contrast were administered selectively and fluoroscopy was performed. Radiographic findings were compared with physical examination diagnosis. RESULTS: Four-contrast defecography changed the diagnosis in 46 patients (75 percent); 26 percent of presumed cystoceles, 36 percent of enteroceles, and 25 percent of rectoceles were not present on defecography. Defecography also revealed unsuspected coexisting defects in addition to known abnormalities detected on physical examination. In contrast, when physical examination was negative for these defects, 63 percent of patients were found to have cystoceles, 46 percent to have enteroceles, and 73 percent to have rectoceles on four-contrast defecography. The discovery of Grade 2 or 3 unsuspected abnormalities was significant, especially so for enteroceles. For posterior vaginal eversions extending to or past the introitus, physical examination was accurate in only 61 percent. Physical examination of large anterior defects was more accurate, with 74 percent of patients being correctly diagnosed. CONCLUSIONS: Physical examination diagnosis of pelvic floor relaxation disorders is frequently inaccurate, especially for large vaginal eversions. Four-contrast defecography improves diagnostic accuracy, helps to identify all pelvic floor defects before surgery, and can assist with planning the correct operative approach.     

Actinomyces and nocardia infections in immunocompromised and nonimmunocompromised patients

A retrospective survey of nocardia and actinomyces infections in five local hospitals was conducted over a 3-year period in El Paso, Texas, a border city, in the southwestern United States. The medical records of 42 patients with suspected nocardiosis or actinomycosis were reviewed. One patient was diagnosed with actinomyces and 12 patients with nocardia. Microbiological data included morphologic characteristics, biochemical profile, and susceptibility testing. Predisposing factors included leukemia, renal insufficiency, renal transplant, and lymphoma. No predisposing factors were found in 67% (n = 8) of patients (including the patient with actinomycosis). Twenty-three percent (n = 3) of patients had disseminated disease without evidence of underlying disease or immunosuppression. The mortality and morbidity of these infections appeared to be low.     

A comparison of electrophysiological tests for the early diagnosis of diabetic neuropathy

Clinical criteria and several electrophysiological parameters for detecting nerve damage were compared in 99 patients with diabetes mellitus type 1 and type 2. Abnormal results were found in sural/radial amplitude ratio (51%), minimal F-wave latency of the tibial nerve (36.4%), sensory conduction velocity of the sural nerve (29.8%), and sural sensory nerve action potential amplitude (29.3%) when pooling data from all patients and comparing them to age- and height-matched normal control subjects. Analysis of all the parameters revealed large differences between the diabetes mellitus type 1 and type 2 groups, suggesting that the type of diabetes must be taken into account when comparing the sensitivity of nerve conduction tests. In diabetes mellitus type 1, the sural/radial ratio had the clearest correlation with course of illness and was the first parameter to show a significant reduction. We conclude that the simple ratio between sural and radial amplitudes is a very sensitive parameter and abnormalities in this ratio provide the means for earliest detection of neuropathy in diabetes mellitus type 1.     

Immobilisation of monocytes to a solid support: a model for the study of ligand-binding interactions and plasminogen activation at the cell surface

The functional and immunological identification of receptors expressed by cells of the monocyte/macrophage lineage may be facilitated with the use of immobilised cells. A procedure is described here for attaching human blood monocytes, alveolar macrophages, and THP-1 cells to a solid support activated with polymerised glutaraldehyde. Homogeneous monolayers visualised by optical microscopy were obtained at predefined input cell densities and were quantitatively characterised with the use of ¹²⁵I-plasminogen (35000±2772 cells/well at 76000 cells/50 μL) and ¹²⁵I-pro-urokinase (39000±3839 cells/well at 86000 cells/50 μL). The cells remained stably attached during washing and incubation procedures in ligand-binding studies. The functionality of membrane receptors and acceptors of the immobilised cells for a number of ligands was verified. Parameters of the interaction of plasminogen, urokinase, and human immunoglobulin G with their corresponding receptors were similar to those previously reported using cells in suspension. The functionality of bound ligands, such as urokinase and plasminogen, was verified by measuring their ability to generate plasmin. We conclude that immobilised monocytes/macrophages are a useful tool for studying ligand interactions with membrane proteins and for the realisation of plasminogen activation studies at the surface of the cell membrane.     

Effect of ACTH on PTH-stimulated bone resorption in vitro

In vitro demonstration of PTH effects requires hormone concentrations greater than the "physiological" concentrations reported by radioimmunoassay or cytochemical assays. This discrepancy could be the result of binding or destruction of PTH at nonbiologically active sites. In the present study, ACTH was found to have no effect by itself on bone resorption, but addiction of ACTH to bone cultures together with low concentrations of PTH resulted in a specific enhancement of PTH-stimulated bone resorption. This effect was not observed when bone resorption was stimulated by PGE2 and 1,25(OH)2D3, and it was blocked by human serum. The effect of ACTH is similar to the enhancement in PTH-stimulated bone resorption by poly-l-lysine [7]. We suggest that the amplification of PTH stimulation was the result of displacement of PTH from nonbiologically active sites, making more PTH available for binding to its biologically active receptor. An alternative explanation for our results was that ACTH prevented degradation of PTH by bone-derived proteolytic enzymes. Thus the sensitivity of bioassays for PTH could be improved by adding ACTH.     

Bioavailability study of furosemide prodrugs in rats.

According to the hydrolysis performance "in vitro" and lipophylicity, two Furosemide (F) prodrugs were chosen from a series of acyloxymethylesters of F synthesized previously: P1 (acetyloxymethyl-4-chloro-N-furfuryl-5-sulfamoylanthranilate ) and P4 (pivaloyloxymethyl-4-chloro-N-furfuryl-5-sulfamoylanthranilate+ ++). The bioavailability studies were assayed over two groups of eight male Wistar rats as a randomized two-way crossover and balanced design: group 1) a solution of P1 in propylenglycol/ethyl acetate vs an aqueous solution of F, and group 2) P1 vs. P4 solutions in oleic acid (P1#, P4#). These assays showed a better absorption performance of P1 and P4 than F, while the two prodrugs showed a similar bioavailability. The oleic acid seems to be responsible for the delay in the recovery of 50% of the total amount of F excreted in urine (T50%). When the monitoring is done in plasma after the administration of P1#, P1 was not detected as circulating prodrug. The analytical determinations of F in urine and plasma were done by high performance liquid chromatography (HPLC). From the urinary excretion data, a slope that indicates a slow elimination was found with a half-life of 12 hours approximately.     

Treatment of small cell lung cancer with a combination of VP16-213 and cyclophosphamide with cisplatin or radiotherapy

Summary Fifty five patients with small cell lung cancer were treated with a VP16-213 combination chemotherapy regimen in two consectutive series. The first series included 24 patients; 10 with limited and 14 with extensive disease were treated with VP16-213, 120 mg/m² p.o. daily for 5 consecutive days, Cyclophosphamide 600 mg/m² i.v. and Cisplatin 80 mg/m² i.v. with hydratation and manitol induced diuresis. The cycle was repeated every 3 weeks. The second series included 31 similar patients, 16 limited, and 15 extensive disease, treated with VP16-213 at the same dose and Cyclophosphamide at 1,200 mg/m² i.v. also repeated every 3 weeks; after three cycles the patients were treated with radiotherapy to the primary tumor and regional lymph nodes with 4,000 rads in a split course of three weeks interval, followed by the same combination chemotherapy. Response rate was 75% for the first series with 6 of 24 (25%) of complete responses in four limited and two extensive disease and a median survival time of 24 weeks. In the second series of patients there were 26 of 31 (83.8%) responses with 10 of 31 (32%) complete responses in nine limited and one extensive disease and a median survival time of 33 weeks for responders. Duration of response for complete responders was 36.8 weeks for the first series and 51 weeks for the second. Toxicity was mild and includes nausea and vomiting, myelosupression, alopecia in both series, with one toxic death in the second series.Both regimens are active with a low complete response rate, which was increased in the second series by the addition of radiotherapy, which did not increase overall survival. Send offprint requests to H. Cortés Funes, Section Oncologia Medica, Servicio de Radioterapia y Oncologia