Monozygotic twins with Crohn's disease and ulcerative colitis: a unique case report

Background—A large number of monozygotic anddizygotic twin pairs with inflammatory bowel disease have beenreported. To date no twin pair has developed phenotypically discordantinflammatory bowel disease. This case report is the first documentedoccurrence of discordant inflammatory bowel disease occurring inmonozygotic twins.
Case report—Twenty two year old identical maletwins presented within three months of each other with inflammatorybowel disease that proved to be discordant in overall disease type,disease distribution, clinical course, and histopathological findings. Twin 1 developed a severe pancolitis necessitating total colectomy while twin 2 developed a predominantly distal patchy colitis with frequent granulomas, controlled by aminosalicylates. Twin 1 was antineutrophil cytoplasmic antibody (ANCA) negative at the time oftesting while twin 2 (Crohn's disease) was ANCA positive.Significantly, the twins possessed the HLA type DR3-DR52-DQ2 previouslyassociated with extensive colitis.
Conclusion—This case report confirms the importantrole played by genetic factors in the development of inflammatory bowel disease. It also highlights the crucial role of undeterminedenvironmental agents in dictating disease expression and phenotype.

Keywords:monozygotic twins; ulcerative colitis; Crohn'sdisease; inflammatory bowel disease

     

Treatment with coumarin to prevent or delay recurrence of malignant melanoma

Both coumarin (1,2-benzopyrone) and warfarin (4-hydroxycoumarin) have been shown to prevent the recurrence of malignant melanoma. Their action is macrophage-dependent and the dosage is critical. In 1984 a multicentre, prospective, randomised, double-blind trial of coumarin, given as a daily 50-mg dose for 2 years after surgery in patients with high-risk melanoma, was started. The patients had lesions greater than 1.70 mm thick and TNM stage IB or stage II disease. To date there are 4 recurrences in the coumarin-treated group of 13 patients, and 10 recurrences in the placebo-treated group of 14 patients (P<>There were no toxic effects.     

Intra-articular methotrexate in knee synovitis

OBJECTIVE: To test whether methotrexate prolongs the effect of intra-articular corticosteroid in suppressing knee synovitis. METHODS: Thirty-eight patients with chronic knee synovitis were randomly allocated to receive intra-articular triamcinolone hexacetonide with or without methotrexate. Variables were knee pain and swelling, assessor and patient global assessment, morning stiffness, ESR and CRP. The primary endpoint was the duration of improvement. RESULTS: After treatment, both groups of patients demonstrated a significant improvement in all variables. However, there was no significant difference between the two groups in the degree or duration of the response. No side-effects were encountered with methotrexate apart from a slight elevation of transaminase levels in some patients. CONCLUSIONS: In the context of this study, the addition of methotrexate to triamcinolone did not add significantly to the clinical response to intra-articular corticosteroid in chronic knee synovitis. However, further controlled studies using different designs are probably warranted.     

Heterotypic adherence between human B-lymphoblastic and pre-B- lymphoblastic cells and marrow stromal cells is a biphasic event: integrin very late antigen-4 alpha mediates only the early phase of the heterotypic adhesion

Heterotypic adherence between marrow stromal cells (MSC) and lymphoblastic cells is essential for normal lymphopoiesis and malignant lymphoblastic development. However, the detailed molecular mechanisms by which this heterotypic adherence occurs are poorly understood. The cell-cell interactions between a B-lymphoblastic cell line (UTMB-460) and a pre-B-cell line (NALM-6) with MSC were chosen as models to investigate potential mechanisms and adhesion molecules involved in the apposition between normal and malignant lymphoblastic cells and MSC. A parallel-flow detachment assay (PFDA) and a 51Cr detachment assay, coupled with monoclonal antibody (MoAb) blocking experiments, were used to quantify the attachment of lymphoblastic cells to confluent monolayers of MSC. The apposition between MSC and B-lymphoblastic cells (UTMB-460 cells) was investigated for variable time periods, ranging from 1 minute to 4 hours. Results from the temporal study suggest that the heterotypic adherence of the B-lymphoblastic cells to MSC is a biphasic event and the interactions occur rapidly (< or = 1 minute) after the two cells come into contact. More specifically, the early phase of adherence (< or = 15 minutes) solely involves very late antigen-4 alpha (VLA-4 alpha)/vascular cell adhesion molecule 1 (VCAM- 1) interactions, as evidenced by the nearly complete inhibition (93%) of UTMB-460 cell adherence in the presence of anti-VLA-4 alpha. The late phase (> or = 30 minutes) proceeds despite the continuous presence of anti-VLA-4 alpha. In addition, the late-phase adherence is not affected by MoAbs to LFA-1, CD44, VCAM-1, E-selectin, or L-selectin, which suggests the possible involvement of other adhesion molecules. Adherence of pre-B-lymphoblastic cells (NALM-6) to MSC is also biphasic. Integrin VLA-4 is again a major player in the early phase of pre-B-lymphoblastic cell/MSC interactions. The early phase of adherence may be important in homing of the malignant lymphoblastic cells to the MSC and the late phase in retention of malignant lymphoblastic cells in the bone marrow.     

Development of an intraoperative pathology consultation service at a free-standing ambulatory surgical center: clinical and economic impact for patients undergoing breast cancer surgery

BackgroundSecond surgeries represent a significant detriment to breast cancer patients. We examined the impact an intraoperative pathology consultation service had on multiple facets of breast cancer surgery.MethodsWe compared the 8 months before the establishment of a pathology laboratory, when intraoperative pathology consultation was not available, with the 8 months subsequent, when it was performed routinely.ResultsThe average number of surgeries per patient decreased from 1.5 to 1.23, and the number of patients requiring one surgery increased from 59% to 80%. Re-excisions decreased from 26% to 9%. Frozen section allowed 93% of node-positive patients to avoid a second surgery for axillary lymph node dissection. A cost analysis showed savings between $400 and $600 per breast cancer patient, even when accounting for fewer axillary lymph node dissections based on the American College of Surgeons Oncology Group Z0011 data.ConclusionsIncorporation of routine intraoperative margin/sentinel lymph node assessment at an outpatient breast surgery center is feasible, and results in significant clinical benefit to the patient. Use of frozen section decreased both the time and cost required to treat patients.     

Alcohol and anxiety reduction in female social drinkers

The present study used a 3 X 2 factorial design to investigate effects on assertive behavior and social anxiety of different doses of alcohol and individual differences in female social drinkers. Contrary to previous findings with men, a dose-dependent effect of alcohol was not found during the social interaction task. The high dose had mixed effects, reducing anxiety on some but not other dependent measures. The moderate dose resulted in significantly less assertiveness and increased heart rate during the social interaction, in high-tolerant subjects. Expectancies about intoxication failed to show significant effects. Of the individual difference variables, only acute tolerance significantly influenced alcohol's effects on anxiety. Alcohol did not reduce self-awareness.     

Abnormal pregnancy: early diagnosis by US and serum chorionic gonadotropin levels

Simultaneous sonography and quantitative serum human chorionic gonadotropin (HCG) levels from 126 women with threatened abortion were compared. Of 56 women with normal outcome, 39 (70%) had a gestation sac greater than or equal to 5 mm in mean sac diameter, and in each case the HCG level was 1,800 milli-international units (mIU/ml) or greater. The serum HCG levels strongly correlated with the gestation sac sizes to a mean sac diameter of 25 mm. Of 70 abnormal pregnancies, 31 demonstrated a gestation sac. Of these, 20 women (65%) had disproportionately low HCG levels relative to sac size, including 12 in whom the HCG level was less than 1,800 mIU/ml. One woman with an early molar pregnancy had a disproportionately elevated HCG level. Correlation of sonograms with a simultaneous measurement of serum HCG level is a useful method for evaluating threatened spontaneous abortion. A disproportionately low HCG level relative to gestation sac size is evidence for an abnormal pregnancy.     

Optic disc oval ness,refractive error and axial length of Hong Kong Chinese

Myopic crescent, refractive error and axial length were previously investigated in Hong Kong Chinese subjects. The myopic crescent was found to correlate with axial length and myopic refraction. In this study, three groups of Hong Kong Chinese with different degrees of myopia were assessed for optic disc ovalness, refractive error and axial length. The axial length was significantly correlated with the degree of myopia, indicating that the myopia was axial in nature. The regression line shows that 0.44 mm of axial elongation would give about one dioptre of increase in myopia. The elliptical ratio of the optic disc was defined as the maximal disc diameter divided by the minimal disc diameter. All three groups showed an oval disc with vertical axis greater and an increased ovalness for the high myopic group with an elliptical ratio from 1.11 in low myopia to 1.29 in high myopia. There is a small amount (about four degrees) of temporal rotation of this vertical oval orientation, which is independent of the amount of myopia. This result shows an association between axial elongation of the globe and optic disc ovalness, in addition to the previously described temporal myopic crescent. Therefore, in myopic subjects, a vertically oval disc may be associated with a myopic refraction rather than glaucoma.     

Herpes simplex keratitis in renal transplant recipients.

Herpes simplex epithelial keratitis developed in four renal transplant recipients while they were receiving high-dose systemic corticosteroid and immunosuppressive therapy. In all cases the presentation was atypical, and in two cases the course was protracted, leading to some visual loss from corneal scarring and opacification. With the immunocompromised patient it is important to seek early ophthalmologic consultation when even minor ocular symptoms develop.