Isolated bulbar conjunctival Kaposi's sarcoma

We present a case of an isolated bulbar conjunctival Kaposi's sarcoma in a man with HIV infection. This is an unusual site for the initial presentation of Kaposi's sarcoma and in this site can be confused with a caroticocavernous fistula, cavernous haeman-gioma or chronic subconjunctival haemorrhage. Biopsy is required to confirm the diagnosis in isolated disease. Local radiotherapy is the preferred treatment for isolated Kaposi's sarcoma.     

Effects of monoclonal antibodies raised against the common acute lymphoblastic leukemia antigen on endopeptidase-24.11 activity.

The common acute lymphoblastic leukemia antigen (CALLA, CD10) has been identified as neutral endopeptidase-24.11 (NEP), a mammalian ectoenzyme involved in the inactivation of regulatory peptides, such as the enkephalins and atrial natriuretic peptide. Twenty monoclonal antibodies directed against the human antigen, were tested for their ability to inhibit the enzymatic activity of the human and rat peptidases expressed by cell lines. Six anti-CALLA antibodies were found to inhibit 50% or more of the hydrolysis of D-Ala2-leucine enkephalin by the neutral endopeptidase present on the human leukemic cell line Reh6 and, to a lesser extent, the hydrolysis of atrial natriuretic peptide. This may indicate that their binding may affect regions of the active site more important for the dipeptidylcarboxypeptidase activity of the enzyme. Only four antibodies cross-reacted with the peptidase from the rat epithelial cell line Rat2, as shown by membrane immunofluorescence, and these also partially inhibited enzyme activity. No antibody was able to inhibit completely the activity of the human and rat enzymes and all the active antibodies appeared to behave as non-competitive inhibitors of substrate cleavage. These monoclonal antibodies could be used in mapping studies of NEP.     

Back pain.

1. Back pain is very common and can be the result of a wide range of different conditions. A detailed history of the complaint often points towards the cause. Positional backache suggests a mechanical cause, unremitting pain may indicate malignancy or infection especially if accompanied by night sweats, whereas morning stiffness is more often the result of inflammation. 2. Examine the patient lying and standing as outlined. A general examination should also be performed if there is a history of weight loss, night sweats, or if the patient looks ill. 3. The vast majority of cases of backache are mechanical in origin. Plain x-rays are not normally contributory and should be avoided unless there are factors in the history and examination suggestive of infection or malignancy. 4. Patients with backache and sphincter disturbance and/or perineal anaesthesia require immediate hospital admission. 5. Analgesia and bed rest are the mainstays of treatment for acute backache of mechanical origin. Once there has been some improvement, physiotherapy can be beneficial. 6. Chronic back pain is present if the complaint lasts for more than 8 weeks. Investigations should include full blood count, ESR, calcium and alkaline phosphatase. The patient needs to be referred to a rheumatologist or orthopaedic surgeon for further assessment and possible imaging studies. If no cause other than mechanical dysfunction is found the patient should be assessed by a physiotherapist and taught back care.     

Nonlinear oral pharmacokinetics of the alpha-antagonist 4-amino-5-(4-fluorophenyl)-6,7-dimethoxy-2-[4-(morpholinocarbonyl)-perhydro-1,4-diazepin-1-yl]quinoline in humans: use of preclinical data to rationalize clinical observations.

4-amino-5-(4-fluorophenyl)-6,7-dimethoxy-2-[4-(morpholinocarbonyl)-perhydro-1,4-diazepin-1-yl]quinoline (UK-294,315) is an antagonist of the human alpha1-adrenoceptor and exhibits nonlinear oral pharmacokinetics in humans. Superproportional increases in Cmax occur (220-fold, over a 1- to 50-mg dose range), area under the curve increases linearly, but time to maximum concentration decreases with dose, suggesting variation in rate but not extent of absorption. Oral absorption in humans is extensive, with only 14% of an orally administered (20 mg) radiolabeled dose excreted unchanged in the feces. In rats and dogs, UK-294,315 is partially eliminated as unchanged drug in feces (29 and 14% of an intravenous dose, respectively). Oral bioavailability is low in rats (11%) and high in dogs (71%), in keeping with systemic clearance. Fecal elimination of unchanged drug was 60% after oral administration to rats, indicating incomplete absorption in this species, whereas absorption in dogs is complete. UK-294,315 is a P-glycoprotein (P-gp) substrate (Km, 15 microM) exhibiting polarized flux in Caco-2 cell monolayers, saturable across a concentration range of 5 to 200 microM. Furthermore, the observations in vitro occurred at similar concentrations to those estimated in the gut lumen in clinical trials (dose range, 1-100 mg). It is considered that P-gp acts as a saturable absorption barrier to UK-294,315, slowing the rate of absorption at low doses, and is responsible for the observed nonlinearity in oral disposition in humans. Rat and dog pharmacokinetic studies offered limited insight into the process(es) driving nonlinear pharmacokinetics in humans. Our current understanding of the functional effects of P-gp in the human intestine, in combination with in vitro studies at clinically relevant concentrations, has helped rationalize the clinical data for UK-294,315.     

Hormone replacement therapy may reduce the return of endogenous lead from bone to the circulation.

Hormone replacement therapy (HRT) in postmenopausal women suppresses the increase in bone resorption expected as circulating levels of endogenous estrogen decline. We tested the hypothesis that bone lead content might remain elevated in women on HRT. Fifty six women who at recruitment were on average 35 years postmenopausal were placed on calcium supplementation. Six months later 33 of these women were prescribed either low dose or moderate dose hormone replacement in addition to the calcium supplementation. After approximately 4 years of hormone replacement, lead content was measured at the tibia and calcaneus by in vivo fluorescence excitation, and lead concentrations were measured in serum, whole blood, and urine. Women not taking hormones had significantly lower lead concentrations in cortical bone compared to all women on HRT (p = 0.007). Tibia lead content (mean +/- SD) for women on calcium only was 11.13 +/- 6.22 microgram/g bone mineral. For women on HRT, tibia bone lead was 19.37 +/- 8.62 micrograms/g bone mineral on low-dose HRT and 16.87 +/- 11.68 micrograms/g bone mineral on moderate-dose HRT. There were no differences between groups for lead concentrations measured in trabecular bone, whole blood, serum or urine. Hormone replacement maintains cortical bone lead content. In women not on HRT, there will be a perimenopausal release of lead from bone.     

Regulatory region single nucleotide polymorphisms of the apolipoprotein E gene and the rate of cognitive decline in Alzheimer's disease

The aim of this study was to investigate whether single nucleotide polymorphisms (SNPs) in the regulatory regions of the apolipoprotein E (APOE) gene modify the well-established epsilon4-associated risk for Alzheimer's disease (AD). Sequencing of the APOE gene regulatory regions revealed four previously reported promoter SNPs and one novel SNP in the previously described macrophage enhancer (ME.1). In addition, we also studied the two classic allelic missense SNPs that define epsilon2/epsilon3/epsilon4 status in a case-control association study. Analysis of pair-wise linkage disequilibrium (LD) of the five regulatory region SNPs with classic APOE SNPs revealed a previously unreported 7 kb LD block covering the entire APOE gene, part of the promoter and 3' enhancer region. We report here that in a case-control association study (N=719) of the seven SNPs, the genotype at codon 112 captures all the information required to assess disease risk. To explore correlations with quantitative traits, 169 patients were studied in whom rates of cognitive decline were available. In addition to the epsilon4 allele, two regulatory region SNPs were associated with the rate of cognitive decline in AD patients. This study highlights the effect of APOE gene variation on risk of AD and rate of cognitive decline and demonstrates that a single SNP, which confers epsilon4 status, captures all of the risk of developing AD but two SNPs in the regulatory region may affect the rate of cognitive decline in AD patients.