Factor VIII gene inversions in severe hemophilia A: results of an international consortium study

Twenty-two molecular diagnostic laboratories from 14 countries participated in a consortium study to estimate the impact of Factor VIII gene inversions in severe hemophilia A. A total of 2,093 patients with severe hemophilia A were studied; of those, 740 (35%) had a type 1 (distal) factor VIII inversion, and 140 (7%) showed a type 2 (proximal) inversion. In 25 cases, the molecular analysis showed additional abnormal or polymorphic patterns. Ninety-eight percent of 532 mothers of patients with inversions were carriers of the abnormal factor VIII gene; when only mothers of nonfamilial cases were studied, 9 de novo inversions in maternal germ cells were observed among 225 cases (approximately 1 de novo maternal origin of the inversion in 25 mothers of sporadic cases). When the maternal grandparental origin was examined, the inversions occurred de novo in male germ cells in 69 cases and female germ cells in 1 case. The presence of factor VIII inversions is not a major predisposing factor for the development of factor VIII inhibitors; however, slightly more patients with severe hemophilia A and factor VIII inversions develop inhibitors (130 of 642 [20%]) than patients with severe hemophilia A without inversions (131 of 821 [16%]).     

Mechanisms of tumor necrosis factor-granulocyte-macrophage colony- stimulating factor-induced dendritic cell development

In a previous report, we described that tumor necrosis factor (TNF) and granulocyte-macrophage colony-stimulating factor (GM-CSF) synergistically enhanced the development of dendritic cell (DC) progeny from early stem cells and that there is a common monocyte-DC progenitor cell. Low levels of DC were obtained with GM-CSF alone, and TNF by itself failed to induce stem cell development. Here, we investigate mechanisms by which TNF and GM-CSF institute increases in DC, and how these same molecules support later stages of DC differentiation. We show that TNF is required as the first signal, that there is upregulation of GM-CSF receptors (GM-CSFRs), and that TNF inhibits the differentiation of colony-forming units-granulocyte. High levels of GM- CSFR were always associated with conditions yielding a large number of DC, and a kinetic analysis showed a close ontogenic relationship between DC and GM-CSFR levels. The addition of anti-GM-CSF or anti-TNF antibodies blocked synergistic responses related to DC development, including high levels of GM-CSFRs. Anti-GM-CSF was the most potent inhibitor of proliferation (80%) and macrophage, DC, and polymorphonuclear (PMN) cell development. With polyclonal anti-TNF, inhibition was less (35%), and there was a shift from myelomonocytic and DC to PMN progeny. Our results support the concept that receptor upregulation is an important mechanism for growth factor synergy. Our data also indicate that the opposing effects of TNF on hematopoiesis contribute to the selection of the DC pathway and emphasize the importance of GM-CSFRs not only in initiated DC development, but also in controlling DC viability and function.     

Coordinated inhibition of actin-induced platelet aggregation by plasma gelsolin and vitamin D-binding protein

Actin is an abundant intracellular protein that is released into the blood during tissue injury and its injection into rats causes microthrombi to form in the vasculature. This report and others have shown that actin filaments are able to aggregate platelets in an adenosine diphosphate (ADP)-dependent manner. The effects on this process of two plasma actin-binding proteins, vitamin D-binding protein (DBP) and gelsolin, were examined separately and together. The addition of DBP, a monomer-binding protein, to actin filaments did not affect their ability to induce platelet aggregation. However, severing of actin filaments with gelsolin resulted in an increased degree of platelet aggregation. Preincubation of F-actin with both gelsolin and DBP resulted in a significant inhibition of aggregation. The effects of DBP and gelsolin on actin-induced aggregation paralleled their effects on exchange of actin-bound adenine nucleotides. DBP inhibited 1, N6- ethenoadenosine 5' triphosphate (epsilon-ATP) exchange with G-actin but not with F-actin. Gelsolin increased epsilon-ATP exchange with F-actin, which was largely abrogated by the addition of DBP. These results suggest that gelsolin's severing (and subsequent capping) of actin filaments not only results in an increase in the number of pointed filament ends but also in the dissociation of actin monomers containing ADP. Phalloidin, which stabilizes actin filaments while decreasing both monomer and nucleotide exchange, inhibited actin-induced aggregation, as well, indicating that depolymerization of actin filaments is not required to inhibit aggregation. Platelet activation by either G- or F- actin may thus be regulated by the local concentrations of the plasma actin-binding proteins gelsolin and DBP. Together, these proteins inhibit platelet aggregation in a manner that can be explained by their effects on actin's filament structure and the accessibility of its bound ADP. Depletion of DBP or gelsolin may allow actin released from injured tissues to stimulate purinergic receptors on platelets, and perhaps other cells, via its bound adenine nucleotides.     

Intravenous digital subtraction angiography of the intracranial veins and dural sinuses

When combined with computed tomography, IV DSA is usually of sufficient quality to replace conventional angiography in most patients with abnormalities of the larger intracranial veins and sinuses. Preoperatively, IV DSA can be used to evaluate normal anatomic variations of venous outflow to determine what sinuses can be safely occluded if necessary in the region of the temporal bone, jugular fossa, and base of the skull. Patients with glomus jugular tumors and carotid-cavernous fistulas also need conventional angiograms to define the feeding vessels of these lesions for obliteration by embolization or surgery.     

Intraarterial digital subtraction angiography in diagnostic arteriography

Intraarterial digital subtraction angiography (DSA) was performed in 133 diagnostic arteriographic procedures during a 10-month period. The increased contrast resolution of DSA permitted the use of a dilute (15%) contrast material. A significant reduction in contrast material dose compared with conventional film-screen arteriography and intravenous DSA was thus achieved. This was especially advantageous in patients with diminished renal function. The dilute contrast material also resulted in less patient discomfort. Subtracted images were available immediately on cathode ray tube display, resulting in faster procedures, and a considerable saving in film cost compared with conventional arteriography. It is concluded that intraarterial DSA is a useful technique that may replace conventional film-screen arteriography in many applications.     

Value of chest radiography in excluding traumatic aortic rupture

A retrospective review of chest radiographs from 205 patients with blunt chest trauma who also underwent aortography was performed. Forty-one of the 205 had aortographically proved aortic rupture. Discriminant analysis of 16 radiographic signs indicated that the most discriminating signs were loss of the aorticopulmonary window, abnormality of the aortic arch, rightward tracheal shift, and widening of the left paraspinal line without associated fracture. No single or combination of radiographic signs demonstrated sufficient sensitivity to indicate all cases of traumatic aortic rupture on plain chest radiographs without the performance of a large number of aortographically negative studies. The bedside anteroposterior "erect" view of the chest proved far more valuable than the supine view in detecting true-negative studies. Despite significant reader variability in the interpretation of the various radiographic signs, in general the analysis confirmed the role of chest radiography in this clinical situation, but suggests that its most beneficial use is in excluding the diagnosis and eliminating unwarranted aortography rather than in predicting aortic rupture.     

Percutaneous insertion of the Kimray-Greenfield filter: technical considerations and problems

Kimray-Greenfield filters were inserted percutaneously into the inferior vena cava (IVC) in 57 patients. Thirty-six were placed from the right femoral vein, 14 from the left femoral vein, and seven from the right internal jugular vein. There were no deaths or major complications and only six minor complications. Inferior vena cavography was done before filter insertion in all cases. Cavography is vital to determine feasibility of filter insertion, route of insertion, and filter location; pertinent findings include caval size, presence or absence of clot in the IVC or iliac veins, and position of the renal veins. The guide wire provided with the standard filter introduction set has a tendency to catch on the filter as the wire is withdrawn. A stiff wire with a straight, tapered, floppy tip was substituted. The femoral approach is preferred when it is feasible. Though there was only one known occurrence of femoral vein thrombosis at the filter insertion site, other cases may have occurred and may not have been detected. If the frequency of this complication proves to be significant, the preferred route for filter insertion may have to be reconsidered.     

Absorbed breast dose: dependence on radiographic modality and technique, and breast thickness

The increased use of mammography has brought into focus the necessity for radiation dose reduction. In particular, the effect of radiographic technique on radiation dosimetry is not well documented. In this paper, the dependence of absorbed dose on radiographic modality, radiographic technique, and breast thickness is studied, with the following principal results: Breast thickness and incident half-value layer (HVL) are sufficient to characterize the normalized (mrad/incident roentgen) breast dose. The average breast dose depends on both beam HVL and kVp; the dependence on breast thickness is more pronounced for screen-film mammography, indicating the need for firm compression. Screen-film mammography shows substantial dose savings over xeromammography for thinner breasts imaged without a grid; this dose advantage disappears for thicker breasts and is generally reversed when a grid is used.