Optimized serological isolation of lung-cancer-associated antigens from a yeast surface-expressed cDNA library

The technique of serological analysis of antigens by recombinant cDNA expression library (SEREX) uses autologous patient sera as a screening probe to isolate tumor-associated antigens for various tumor types. Isolation of tumor-associated antigens that are specifically reactive with patient sera, but not with normal sera, is important to avoid false-positive and autoimmunogenic antigens for the cancer immunotherapy. Here, we describe a selection methodology to isolate patient sera-specific antigens from a yeast surface-expressed cDNA library constructed from 15 patient lung tissues with non-small cell lung cancer (NSCLC). Several rounds of positive selection using patient sera alone as a screening probe isolated clones exhibiting comparable reactivity with both patient and normal sera. However, the combination of negative selection with allogeneic normal sera to remove antigens reactive with normal sera and subsequent positive selection with patient sera efficiently enriched patient sera-specific antigens. Using the selection methodology described here, we isolated 3 known and 5 unknown proteins, which have not been isolated previously, but and potentially associated with NSCLC.     

The best strategy of blood transfusion in patients with Rhnull syndrome

Rh_null syndrome is a very rare disease. Patients with this syndrome present with negative serological Rh typing of E, e, C, c, and D antigens. Only one study has previously discussed Rh_null syndrome in Chinese individuals. We experienced two patients with Rh_null syndrome in China, Rh genotypes being CcDEe in the first patient and CCDee in the second patient. The first patient was a pregnant woman (gravida 2, para 1) with a negative red blood cell (RBC) antibody screen test. The second patient was a middle-aged man, transfused with ccdee, ccdEe, and ccdee RBC products, the pre-transfusion specimen was negative and post-transfusion specimen was anti-c,e, respectively. The hemoglobin level continued to increase in the second patient after being transfused with ccdEe RBC products. In the first patient, the result of the antibody screen test was still negative after artificial abortion. In patients with Rh_null syndrome, RBC products that have the same Rh genotype as the patient can be safely transfused.     

Isolated lissencephaly sequence associated with a microdeletion at chromosome 17p13

Summary DNA markers YNZ22.1, YNH37.3, 144D6 and VAW508 were studied in a patient with the isolated lissencephaly sequence (ILS). A normal karyotype was found in the patient. The DNA of the patient showed deletions of markers YNZ22.1 and YNH37.3. This is the first report of a case of ILS (with grade 3 lissencephaly) with a submicroscopic deletion. The presence of a micro deletion in 17p13 in an ILS patient indicates that Miller-Dieker syndrome and ILS have a common etiology.     

A Hypernychthemeral Sleep-Wake Syndrome: A Treatment Attempt

The wake and sleep-onset times of a patient with a sleep-wake cycle longer than 24 hr were recorded by the patient for 4 years. During this time, the patient found himself unable to maintain a 24-hr sleep-wake schedule. When treated with 1-2 mg clonazepam, taken nightly, he was able to become entrained to a 24-hr day. Despite entrainment of his sleep-wake cycle, the patient reported depression, lack of motivation and fatigue and chose not to continue taking the drug.     

Regional mapping of clotting factors VII and X to 13q34. Expression of factor VII through chromosome 8

Summary Blood clotting factors were investigated in a patient with trisomy 8 mosaicism, a patient with an r(13), and a patient with distal trisomy 13q. Results are compatible with the assignment of the structural genes of factors VII and X to 13q34 and the existence of a regulatory mechanism associated with chromosome 8 controlling the expression of factor VII alone.     

Events upstream of mitochondrial protein import limit the oxidative capacity of fibroblasts in multiple mitochondrial disease

To investigate whether protein import is defective in mitochondrial disease, we compared the rate of import and the expression of protein import machinery components in skin fibroblasts from control subjects and a patient with multiple mitochondrial disease (MMD). The patient exhibited a 35% decrease in cytochrome c oxidase activity and a 59% decrease in cellular oxygen consumption compared to control. Western blot analyses revealed that patient levels of MDH, mtHSP70, HSP60, and Tom20 protein were 57%, 20%, 75% and 100% of control cells, respectively. MDH and Tom20 mRNA levels were not different from control levels, whereas mtHSP70 mRNA were 50% greater than control. Radiolabeled MDH was imported into mitochondria with equal efficiency between patient (44% of total synthesized) and control (43%) cells, although the total MDH synthesized in patient cells was reduced by about 40%. The unaffected levels of mRNA and post-translational import into mitochondria, combined with reduced protein levels of MDH, mtHSP70, and HSP60 suggest a translational defect in this patient with MMD. This was verified by the 50% reduction in overall cellular protein synthesis in the patient compared to control. Further, the similar import rates between patient and control cells suggest an important role for Tom20, but a lesser role for mtHSP70 in regulating protein import into mitochondria.     

Mitochondrial ND5 gene variation associated with encephalomyopathy and mitochondrial ATP consumption

Mitochondrial encephalomyopathy and lactic acidosis with strokelike episodes (MELAS) is a severe young onset stroke disorder without effective treatment. We have identified a MELAS patient harboring a 13528A-->G mitochondrial DNA (mtDNA) mutation in the Complex I ND5 gene. This mutation was homoplasmic in mtDNA from patient muscle and nearly homoplasmic (99.9%) in blood. Fibroblasts from the patient exhibited decreased mitochondrial membrane potential (Deltapsim) and increased lactate production, consistent with impaired mitochondrial function. Transfer of patient mtDNA to a new nuclear background using transmitochondrial cybrid fusions confirmed the pathogenicity of the 13528A-->G mutation; Complex I-linked respiration and Deltapsim were both significantly reduced in patient mtDNA cybrids compared with controls. Inhibition of the adenine nucleotide translocase or the F1F0-ATPase with bongkrekic acid or oligomycin caused a loss of potential in patient mtDNA cybrid mitochondria, indicating a requirement for glycolytically generated ATP to maintain Deltapsim. This was confirmed by inhibition of glycolysis with 2-deoxy-D-glucose, which caused depletion of ATP and mitochondrial depolarization in patient mtDNA cybrids. These data suggest that in response to impaired respiration due to the mtDNA mutation, mitochondria consume ATP to maintain Deltapsim, representing a potential pathophysiological mechanism in human mitochondrial disease.     

PEX13 is mutated in complementation group 13 of the peroxisome-biogenesis disorders.

The peroxisome-biogenesis disorders (PBDs) are a genetically and phenotypically diverse group of diseases caused by defects in peroxisome assembly. One of the milder clinical variants within the PBDs is neonatal adrenoleukodystrophy (NALD), a disease that is usually associated with partial defects in the import of peroxisomal matrix proteins that carry the type 1 or type 2 peroxisomal targeting signals. Here, we characterize the sole representative of complementation group 13 of the PBDs, a patient with NALD (patient PBD222). Skin fibroblasts from patient PBD222 display defects in the import of multiple peroxisomal matrix proteins. However, residual matrix-protein import can be detected in cells from patient PBD222, consistent with the relatively mild phenotypes of the patient. PEX13 encodes a peroxisomal membrane protein with a cytoplasmically exposed SH3 domain, and we find that expression of human PEX13 restores peroxisomal matrix-protein import in cells from patient PBD222. Furthermore, these cells are homozygous for a missense mutation at a conserved position in the PEX13 SH3 domain. This mutation attenuated the activity of human PEX13, and an analogous mutation in yeast PEX13 also reduced its activity. The mutation was absent in >100 control alleles, indicating that it is not a common polymorphism. Previous studies have demonstrated extragenic suppression in the PBDs, but the phenotypes of patient PBD222 cells could not be rescued by expression of any other human PEX genes. Taken together, these results provide strong evidence that mutations in PEX13 are responsible for disease in patient PBD222 and, by extension, in complementation group 13 of the PBDs.     

Should your hospital implement wireless solutions?

A standards-based wireless patient monitoring technology can lead to significant improvements in productivity and workflow, provide the potential for reduced errors, and decrease the costs of patient care. A properly implemented wireless patient monitoring system can provide caregivers with increased access to vital patient information at all times. This will help health care institutions build a real-time care process, provide a continuous patient record across the continuum of care, and improve outcomes by creating an environment where clinicians can make evidence-based decisions.     

Adaptive patient enrichment designs in therapeutic trials

The utility of clinical trial designs with adaptive patient enrichment is investigated in an adequate and well‐controlled trial setting. The overall treatment effect is the weighted average of the treatment effects in the mutually exclusive subsets of the originally intended entire study population. The adaptive enrichment approaches permit assessment of treatment effect that may be applicable to specific nested patient (sub)sets due to heterogeneous patient characteristics and/or differential response to treatment, e.g. a responsive patient subset versus a lack of beneficial patient subset, in all patient (sub)sets studied. The adaptive enrichment approaches considered include three adaptive design scenarios: (i) total sample size fixed and with futility stopping, (ii) sample size adaptation and futility stopping, and (iii) sample size adaptation without futility stopping. We show that regardless of whether the treatment effect eventually assessed is applicable to the originally studied patient population or only to the nested patient subsets; it is possible to devise an adaptive enrichment approach that statistically outperforms one‐size‐fits‐all fixed design approach and the fixed design with a pre‐specified multiple test procedure. We emphasize the need of additional studies to replicate the finding of a treatment effect in an enriched patient subset. The replication studies are likely to need fewer number of patients because of an identified treatment effect size that is larger than the diluted overall effect size. The adaptive designs, when applicable, are along the line of efficiency consideration in a drug development program.     

Axillary lymphadenopathy: a complication of BCG immunotherapy for melanoma

We present a patient with a Clark level IV melanoma who received BCG immunotherapy by scarification for 12 months after wide excision. Six months after cessation of treatment, the patient developed regional lymphadenopathy that histology showed to be reactive epithelioid granuloma. Regional immunotherapy thus represents a potentially confusing factor in the post-operative assessment and management of the patient with melanoma.     

Growing into My White Coat: Improving the Patient-Provider Relationship Through Diverse Patient Interviews

The “Patient Diversity” assignment is an integral component for all medical and other health care professional students rotating through the Surgery clerkship at the Yale School of Medicine. Students are instructed to interview a surgical patient who is of a varied social or cultural background to identify how psychosocial factors impact patient coping strategies. In the process, students often appreciate how health care providers’ own social and cultural backgrounds similarly shape their sentiments and reactions in patient care. In this interview with a 26-year-old surgical patient, one student strives to come to terms with her personal insecurities in patient interactions and seeks to overcome them through open conversation and honest introspection. By working to acknowledge and understand patient diversity, health care providers can enhance understanding of their patients’ conditions and form more trustful and empathic relationships with both their patients and colleagues.     

Comparisons between written and computerised patient histories.

Patient histories were obtained from 99 patients in three different ways: by a computerised patient interview (patient record), by the usual written interview (medical record), and by the transcribed record, which was a computerised version of the medical record. Patient complaints, diagnostic hypotheses, observer and record variations, and patients'' and doctors'' opinions were analysed for each record, and records were compared with the final diagnosis. About 40% of the data in the patient record were not present in the medical record. Two thirds of the patients said that they could express all or most of their complaints in the patient record. The doctors found that the medical record expressed the main complaints better (52%) than the patient record (15%) but that diagnostic hypotheses were more certain in the patient record (38%) than in the medical one (26%). The number of diagnostic hypotheses in the patient record was about 20% higher than that in the medical record. Intraobserver agreement (51%) was better than interobserver agreement (32%), while the inter-record agreement varied from 25% (between the medical and patient records) to 35% (between the transcribed and patient records). One third of final diagnoses were seen in the medical record, with 29% and 22% for the transcribed and patient records, respectively. Interobserver agreement in the final diagnosis was 35%. The results of the study suggest that computerised history taking is suitable for certain patients in addition to, and not as a substitute for, the oral interview with a doctor.     

Two new mutations in the sterol 27-hydroxylase gene in two families lead to cerebrotendinous xanthomatosis

This report concerns two new mutations in the sterol 27-hydroxylase gene in two patients with cerebrotendinous xanthomatosis (CTX). In a Surinam-Creole patient (patient A), a G deletion on position cDNA 546/547 in exon 3 led to a frameshift and the introduction of a premature termination codon. In a Dutch patient (patient B), a C→T transition at position 496 in exon 3 also led to a premature termination codon. Patient A was homozygous for the mutation, whereas patient B was compound heterozygous, a C→T transition also being found in exon 6 at position 1204. The two new mutations were confirmed by restriction analysis with the restriction enzymes FokI and MaeI, respectively. Received: 24 July 1996 / Revised: 9 August 1996     

A Case Study of a Patient with Gliosarcoma with an Extended Survival and Spinal Cord Metastases

Gliosarcoma is a rare brain tumor consisting of both glial and mesenchymal components. Metastatic gliosarcoma is rare; however, here we report a 31-year-old Chinese woman with cranial gliosarcoma metastatic to the liver, lymph nodes and the spinal cord. Initially, the patient presented with dizziness, headache and vomiting and after surgery and histological examination, was diagnosed with cranial gliosarcoma. The patient was treated with surgical resection followed by chemotherapy and radiotherapy. Three years after completing treatment, the patient again presented with similar symptoms with the addition of a seizure. Test revealed recurrence of the gliosarcoma, and the same treatment was prescribed. Three years after treatment completion, the patient again presented with dizziness and headache. Masses at the right temple and in the right side of the neck were found. Tumors were surgically removed from the brain, skull, scalp and neck, the latter three diagnosed as metastatic gliosarcomas. The patient received both chemotherapy and radiotherapy following resection. One month after treatment, bone scans revealed possible metastasis in the right skull, lumbar and left ileum, soft neck tissue, lungs, collarbone, humeri, vertebrae, liver and abdominal lymph nodes. No further therapy was recommended due to the poor condition of the patient. The patient died 5 months later.     

Local anesthetic resistance in a pregnant patient with lumbosacral plexopathy

BACKGROUND: We report a case of a patient with apparent resistance to local anesthetics. While similar cases of failure of regional anesthetics are often attributed to technical failure, the overall clinical presentation and history of this patient suggests a true resistance to local anesthetics. CASE PRESENTATION: This patient presented for elective cesarean section and the decision for regional anesthesia was made. While attempting to place an epidural, the patient failed to achieve adequate skin analgesia despite multiple attempts at local infiltration. When a spinal was ultimately placed, sensory or motor blockade was not obtained despite no evidence of technical problems with technique. Further questioning revealed multiple prior episodes of local anesthetic failure in this patient. CONCLUSIONS: While the failure rate of spinal anesthesia has been shown range from 4-13% and is often attributed to technical failure, elements of this particular case suggest a true resistance to local anesthetics.     

HER-2-positive gastric cancer accompanied by liver metastasis: a case report of a rare complete response and literature review

The prognosis of advanced gastric cancer is poor, and the prognosis of late-stage gastric cancer with expression of human epidermal growth factor receptor 2 (HER-2) is worse. Personalized therapy is based on the specific situation of each patient to determine the best treatment plan. We diagnosed a 36-year-old patient with a HER-2-producing adenocarcinoma of the gastric cardia accompanied by liver metastasis. Sixteen cycles of chemotherapy were consecutively administered to the patient, starting with a three-drug combination, followed by a two-drug combination, and finally a single drug as a chemotherapy regimen. During these treatments, the molecular targeted drug trastuzumab was continuously administered. In the end, the patient experienced a complete response (CR). In clinical practice, advanced gastric cancer is not well controlled in certain patients, due to inadequate first-line chemotherapy and its side-effects. If a patient enjoys a strong performance status (PS), we emphasize the importance of molecular-targeted drugs combined with prolonged administration of chemotherapy.     

Control of blood-transmitted infections in dentistry

As knowledge has accumulated on the blood-transmitted pathogenic agents, the contact with biological fluids (blood, plasma, saliva, etc.) from apparently healthy individuals has started to be regarded as a real professional risk for dentists. Theoretically, exposure to a contaminated biological specimen may have as a consequence transmission of infection from patient to dentist, from dentist to patient and from patient to patient via inadequately decontaminated and sterilized dental equipment. The present study is concerned with the analysis of the specific conditions that favor the occurrence of the epidemic process, the estimation of the risk degree of transmission of infections caused by hepatitis B, C viruses as well as of HIV infection in Romania. The data for the study were collected using two processes. First a self reporting survey and secondly an experimental procedure were performed. The testing of dentists' knowledge of blood transmissible diseases and infection control in their offices were performed using a questionnaire with 129 questions. The professional incidents/accidents representing a potential risk were counted using a questionnaire (with 37 questions). Serological markers were tested with ELISA kits. The monitoring of sterilization was accomplished with a questionnaire and biological tests. Many conclusions result from the study. There is an extremely reduced probability and infection transmission from the dentist to the patient. The transmission of infection from the patient to the dentist represents a low risk (for all that, the risk should not be minimized). The rigorous control and observation of infection prevention measures in dental offices is necessary to stop the infection transmission from patient to patient. The dentists' postgraduate training in infection control measures should be completed with knowledge regarding the blood transmissible infections epidemiology. Learning more about the epidemiological process enables the dentists to avoid wrong attitudes and behaviors.     

Mitogen-stimulated phospholipid synthesis in normal and immune-deficient human B cells

Eight patients with common variable panhypogammaglobulinemia were shown in the in vitro Ig biosynthesis assay to have defective B cell responses to pokeweed mitogen (PWM). Phospholipid synthesis was assessed in the B cell plus monocyte fraction (MB) and irradiated T cells (T*) of patients and paired normal controls. Cell populations were studied separately and in the four possible combinations (1:1), with and without PWM, to reveal the effect of cell interactions. At 16 to 20 hr the mean stimulation index (SI) +/- standard error for MB cells alone was 1.01 +/- 0.02 for eight patients and 0.99 +/- 0.02 for the paired normals; the T* cell SI was 1.25 +/- 0.04 for patients and 1.28 +/- 0.05 for normals. Combinations of normal MB cells with normal T* cells showed significantly higher SI when compared with the combinations of normal MB cells with patient T* cells (p less than 0.005). However, the combination of patient MB cells with patient T* cells and the combination of patient MB cells with normal T* cells were not significantly different in SI (0.05 less than p less than 0.1). Isolation of patient and normal B cells, T* cells, and monocytes after the choline pulse showed that patient B cells gave a higher SI with normal T* help than with patient T* help. Of greatest interest is the finding that patient B cells that were defective in PWM-stimulated Ig production nevertheless showed a phospholipid synthesis response to PWM in the normal range, suggesting that the maturation defect in these B cells occurs later than the phospholipid synthesis acceleration step, or on a different pathway.