Varicella-Like Cutaneous Toxoplasmosis in a Patient with Aplastic Anemia

A 60-year-old patient with aplastic anemia presented with vesicular varicella-like skin lesions on her face, arms, legs, back, and abdomen. However, diagnosis for herpetic infection was negative. Findings of a skin biopsy led to a tentative histologic diagnosis of toxoplasmosis, and infection with Toxoplasma gondii was confirmed by immunohistochemistry and PCR. Cutaneous toxoplasmosis is a rare finding in immunocompromised patients and might mimic other infectious diseases, and vesicular lesions associated with toxoplasmosis have not been reported previously.     

The role of activation functions 1 and 2 of estrogen receptor‐α for the effects of estradiol and selective estrogen receptor modulators in male mice

Estradiol (E2) is important for male skeletal health and the effect of E2 is mediated via estrogen receptor (ER)‐α. This was demonstrated by the findings that men with an inactivating mutation in aromatase or a nonfunctional ERα had osteopenia and continued longitudinal growth after sexual maturation. The aim of the present study was to evaluate the role of different domains of ERα for the effects of E2 and selective estrogen receptor modulators (SERMs) on bone mass in males. Three mouse models lacking either ERαAF‐1 (ERαAF‐1⁰), ERαAF‐2 (ERαAF‐2⁰), or the total ERα (ERα^?/?) were orchidectomized (orx) and treated with E2 or placebo. E2 treatment increased the trabecular and cortical bone mass and bone strength, whereas it reduced the thymus weight and bone marrow cellularity in orx wild type (WT) mice. These parameters did not respond to E2 treatment in orx ERα^?/? or ERαAF‐2⁰ mirx ERαAF‐1⁰ mice were tissue‐dependent, with a clear response in cortical bone parameters and bone marrow cellularity, but no response in trabecular bone. To determine the role of ERαAF‐1 for the effects of SERMs, we treated orx WT and ERαAF‐1⁰ mice with raloxifene (Ral), lasofoxifene (Las), bazedoxifene (Bza), or vehicle. These SERMs increased total body areal bone mineral density (BMD) and trabecular volumetric BMD to a similar extent in orx WT mice. Furthermore, only Las increased cortical thickness significantly and only Bza increased bone strength significantly. However, all SERMs showed a tendency toward increased cortical bone parameters. Importantly, all SERM effects were absent in the orx ERαAF‐1⁰ mice. In conclusion, ERαAF‐2 is required for the estrogenic effects on all evaluated parameters, whereas the role of ERαAF‐1 is tissue‐specific. All evaluated effects of Ral, Las and Bza are dependent on a functional ERαAF‐1. Our findings might contribute to the development of bone‐specific SERMs in males. © 2013 American Society for Bone and Mineral Research.     

Longer term effects of ouabain on the contractility of rat isolated cardiomyocytes and on the expression of Ca and Na regulating proteins

Cardiac glycosides like ouabain are used in the therapy of heart failure and atrial fibrillation. They exert a positive inotropic effect on cardiomyocytes by inhibiting the plasma membrane sodium pump (Na,K-ATPase), decreasing the Ca-extrusion by the sarcolemmal cardiac sodium/calcium exchanger (NCX) and increasing the intracellular Ca-concentration and Ca-release during subsequent contraction cycles. The longer term effects of ouabain treatment on the expression of proteins important for Ca- and Na-homeostasis are not well known and were investigated in this study. Isolated adult rat cardiomyocytes were cultured in the presence or absence of ouabain (30 μM). In these cells, the expression of the Na,K-ATPase, Na,Ca-exchanger (NCX), the sarcoplasmic reticulum Ca-ATPase (SERCA 2a) and phospholamban (PLB) were studied by Western blot. In addition, the contractile function of these cells was studied after electrical stimulation. After 2 days of ouabain treatment immunoreactivity of the NCX was increased significantly relative to control which was set 1 (1.78 ± 0.16 vs. 1 ± 0.13; n = 8; P = 0.003) and at day 4 (1.96 ± 0.35 vs. 1 ± 0.20; n = 6; P = 0.02). All other proteins (SERCA 2a, PLB and Na,K-ATPase a1 and b1) remained unchanged (n ≥ 4). Ouabain treatment increased the fractional shortening of isolated cardiomyocytes at day 0 (1 Hz: 9.64 ± 0.73 %, n = 24, vs. 7.18 ± 0.60 %; n = 21; P = 0.01), whereas at day 2 the contractility was unchanged (1 Hz: 7.23 ± 1.08 %, n = 9 vs. 7.70 ± 0.63 %; n = 10, P = 0.71). The inhibition of SERCA 2a (10 μM cyclopiazonic acid (CPA)) decreased contractility in both the ouabain treated group and in controls, at day 0 and at day 2. These results show that chronic ouabain treatment increases the protein expression of the NCX. The positive inotropic effect of ouabain can no longer be observed after a chronic treatment for 2 days. Thus, both protein expression and contractile function of the cells are specifically altered by longer term cardiac glycoside exposure. Whether such regulation can be found in human cardiomyocytes and the resulting consequences in the clinical setting remain to be determined. Received: 2 September 2002, Returned for revision: 1 October 2002, Revision received: 20 December 2002, Accepted: 8 January 2003 Correspondence to: Dr. med. J. Müller-Ehmsen     

Immunoglobulin heavy/light chain analysis enhances the detection of residual disease and monitoring of multiple myeloma patients

Aim

To evaluate the clinical utility of incorporating a novel heavy/light chain immunoassay (HLC) into the existing methods for the assessment of multiple myeloma (MM) patients.

Methods

Convenience sera samples from 90 previously treated IgG and IgA MM patients in different disease stages were analyzed. The study was conducted in Clinical Hospital Center Zagreb between 2011 and 2013. The collected sera were analyzed by standard laboratory techniques (serum protein electrophoresis, quantification of total immunoglobulins, serum immunofixation, serum free light chain [FLC] assay) and HLC assay.

Results

HLC ratios outside the normal range were found in 58 of 90 patients, including 28 out of 61 patients with total immunoglobulin measurements within the normal range and 5 out of 23 patients in complete response. Both elevated HLC isotype level and abnormal HLC ratio correlated with the parameters of tumor burden, including percentage of plasma cells in the bone marrow (P < 0.001 and P = 0.002, respectively) and an abnormal serum FLC ratio (for both P < 0.001). In addition, abnormal HLC isotype level correlated with serum beta-2-microglobulin level (P = 0.038). In terms of prognosis, abnormal HLC isotype level and abnormal HLC ratio were significantly associated with shorter overall survival (P < 0.001 and P = 0.002, respectively). Interestingly, suppression of the uninvolved (polyclonal) isotype pair, but not other non-myeloma immunoglobulin isotypes, was also associated with a shorter overall survival (P = 0.021). In a multivariate analysis, an abnormal HLC ratio and β₂-microglobulin level >3.5mg/L were independent risk factors for survival.

Conclusion

The new HLC assay has greater sensitivity in detecting monoclonal protein, correlates with tumor burden markers, and affects patients'' outcome.Hematological malignancy multiple myeloma is characterized by the proliferation of monoclonal plasma cells in the bone marrow, which usually leads to the secretion of monoclonal intact immunoglobulins (Ig), free light chains (FLC), or both, into the serum. Consequently, the measurement of monoclonal proteins is integral to diagnosing multiple myeloma, monitoring of response to treatment, and detecting relapse (1-3). Conventional methods rely principally on serum electrophoresis together with either urine electrophoresis for the detection of FLC M-proteins or nephelometric quantification of total Igs for intact Ig paraprotein measurement. However, these standard techniques often do not have the required sensitivity or do not correlate with the patient’s clinical status (4-7).The ability to detect monoclonal serum FLC has been substantially increased by the introduction of the serum FLC assay, improving the diagnosis, monitoring, and prognosis of a number of plasma cell dyscrasias (8,9). Still, a number of problems associated with the detection of monoclonal intact Igs persist. Serum Ig concentrations can change for ≥50% with fluctuations in blood volume and/or hematocrit (10). In the case of monoclonal IgGs, the serum concentration can be also influenced by altered metabolism due to recycling of IgG by the neonatal Fc receptors (11-13). Furthermore, monoclonal proteins, in particular IgA paraproteins, may not be accurately quantified by serum protein electrophoresis (SPE) due to co-migration with other serum proteins (14,15). Finally, one of the major limitations of measuring total Igs is the inability to distinguish between the monoclonal component and polyclonal Ig background.These problems can be addressed by a recently developed heavy/light chain (HLC) immunoassay. Using specific antibodies targeted to junctional epitopes of the heavy and light chains of Ig molecules, HLC immunoassay separately quantifies different light chain types of each Ig class (IgGκ, IgGλ, IgAκ, IgAλ, etc), thus providing accurate quantification of both the involved and uninvolved components of the patient''s affected Ig isotype. The ratio of the monoclonal and polyclonal Igs of the same isotype (IgGκ/IgGλ, IgAκ/IgAλ) provides a sensitive measure of monoclonality, while minimizing the influence of changes in blood volume/hematocrit and the effect of IgG recycling (16,17).Previous studies using this novel assay in specific, controlled patient cohorts found the HLC ratio to be useful for screening, monitoring, and risk stratification of patients with multiple myeloma, but also with other monoclonal gammopathies, such as monoclonal gammopathy of undetermined significance (MGUS) and amyloid light-chain (AL) amyloidosis (18-20). The aim of this study was to evaluate the ability of the new assay – HLC isotype measurements – to detect monoclonal protein (ie, residual disease) in previously treated multiple myeloma patients and to determine whether these patients can benefit from adding the new assay into a routine assessment.     

The human leucocyte antigen DQB1*0602 allele is associated with electroencephelograph differences in individuals with obstructive sleep apnoea syndrome

Human leucocyte antigen (HLA) DQB1*0602 allele, a well‐known genetic risk factor for narcolepsy, has been associated with sleep parameters in healthy subjects. We aimed to assess the association of this allele with daytime sleepiness and altered sleep electroencephalogram characteristics in the general population and in patients with obstructive sleep apnoea syndrome (OSAS). Eight hundred and ninety‐four individuals from the Epidemiologic Study of Sleep were genotyped for the HLA DQB1*0602 allele. Full‐night polysomnography was performed, and daytime sleepiness was analysed according to the Epworth Sleepiness Scale. HLA‐DQB1*0602 allele‐positive and ‐negative subjects in the general population, as well as in patients with OSAS, exhibited similar sleep parameters and levels of daytime sleepiness. However, spectral analysis showed that allele‐positive individuals with OSAS exhibited higher theta power during sleep Stage 1 (P < 0.05) in occipital derivations, and lower delta power during sleep Stages 1 and 2 (P < 0.01) compared with individuals negative for the allele, even after correction for potential confounders as age, sex, body mass index and European ancestry. No significant differences in the electroencephalogram variables were found in individuals without OSAS. The data highlight the HLA‐DQB1*0602 as a potential genetic factor influencing sleep physiology in individuals diagnosed with OSAS.     

Pellagra encephalopathy as a differential diagnosis for Creutzfeldt-Jakob disease

In the present study we evaluated cases referred as suspected Creutzfeldt-Jakob disease (CJD). Five out of 59 without prion disease showed neuropathological features of pellagra encephalopathy with widespread chromatolytic neurons (age range 40–48 years at death; one woman). These patients presented with a progressive neuropsychiatric disorder lasting for 2 to 24 months. Common symptoms included gait disorder, para- or tetraspasticity, extrapyramidal symptoms, incontinence, and myoclonus. Protein 14-3-3 in the cerebrospinal fluid was examined in a single patient and was positive, allowing the clinical classification as probable sporadic CJD. Pellagra encephalopathy may be considered as a differential diagnosis of CJD including detection of protein 14-3-3.     

The Impact of Patient’s Socio-Demographic Characterictics,Comorbidities and Attitudes on Flu Vaccination Uptake in Family Practice Settings

Objectives

In Slovenia, the role of family physicians in primary care and preventive procedures is very important. Influenza vaccination rates in Slovenia are low. The reasons for low vaccination rates in Slovenia were not clear. We suppose that patient’s beliefs and attitudes are important factors. We assessed patients’ opinions regarding the acceptance of flu vaccination by their family physicians and their beliefs and attitudes about flu and vaccination. The aim was to check out factors that influence the decision to take the vaccine in family physician offices.

Methods

This was a cross-sectional, multicenter, observational study in the Styria region in Slovenia. We included patients from seven family physicians during regular office visits. They filled in a questionnaire about their general demographic data and attitudes regarding influenza and vaccination. The main outcome was the decision to be vaccinated.

Results

The logistic regression model identified five predictors for influenza vaccination, namely: heart disease, previous vaccination, an agreement with the beliefs ‘the vaccination is an efficient measure to prevent influenza’, ‘after the vaccination there are usually no important side effects’ and ‘the vaccination is also recommended for a healthy adult person’. The belief that vaccinations harm the immune system is negatively associated with vaccination.

Conclusions

Patients’ beliefs are an important factor to decide for vaccination or not. Family physician teams should discuss with patients their beliefs and concerns about vaccination.     

Analysis of behavior of the wear coefficient in different layers of acrylic resin teeth

Statement of problemAnalysis of the wear coefficient (k) of the superficial and deep layers of acrylic resin teeth can help predict denture durability, but little has been published on the wear coefficient of denture teeth.PurposeThe purpose of this in vitro study was to determine the k value for the superficial and deep layers of the acrylic resin teeth of 6 different brands by using the fixed-ball microabrasive wear method.Material and methodsSix artificial tooth specimens of 4 commercial brands were tested: Artiplus IPN (Ar), Biotone IPN (Bi), Magister (Ma), Premium (Pr), Trilux (Tr), and SR Vivodent (Vi). Two specimens from each brand were created, one for the superficial layer and the other for the deep layer. The test was performed on fixed-ball microabrasive wear equipment set to operate at a constant normal force of 0.5 N and a rotation speed of 100 rpm. The test time periods were 5.00, 8.33, and 11.66 minutes. The characteristics of the wear craters were measured by using an optical microscope at a magnification of ×50 and Leica Microsystems software. Wear coefficient (k) values were deduced by using the Archard equation for abrasive wear, Q=k·N, and were analyzed by using 1-way analysis of variance, complemented by the Tukey HSD test (α=.05). A different analysis was used for each layer.ResultsThe analysis of variance of the wear coefficient revealed significant differences among the groups regarding the superficial layers (P=.009). The Tukey HSD test showed that the k values for the superficial layers of Artiplus specimens were significantly lower than those of the Vivodent and Magister specimens.ConclusionsOne brand (Ar) presented significantly lower wear coefficient value for the surface layer. No difference in wear coefficient values was found among the tooth brands for the deep layer.