[Usefulness of thallium-201 myocardial SPECT using dipyridamole infusion combined with low level exercise for the detection of the ischemic heart disease--comparison with SPECT images by maximum physical exercise in the same patients]

To evaluate the usefulness of thallium-201 myocardial SPECT using dipyridamole infusion combined with low level exercise (Dp-method) for the detection of the ischemic heart disease, we performed both Dp-method and maximum physical exercise SPECT (Ex-method) in the same 28 patients, and compared the results obtained by the two methods. In the visual evaluation, the detectability of each stenotic coronary territory by Dp-method tended to be higher than that by Ex-method (accuracy 71% vs 67%). The severity of the defect and the degree of the redistribution were higher by Dp-method than those by Ex-method. In the washout rate (WR) analysis in 14 angina pectoris patients, the detectability (accuracy) by Dp-method was significantly higher than that by Ex-method (86% vs 64%; p less than 0.05). In comparison of mean WR values in normal subjects (10 cases for Dp-method and other 8 cases for Ex-method), mean WR by Dp-method was as high as that by Ex-method and the deviation of WR value among subjects was very small. This was probably due to the effect of the low level exercise. These results suggested that Dp-method was more excellent than Ex-method in the evaluation of the ischemic heart disease, and was a useful method of the daily routine work. The incidence of chest symptom and the electrocardiographic ST-depression was as high by Dp-method as that by Ex-method. The filling defects in Dp-method were thought to be induced not only by the difference in the relative increase of the myocardial perfusion, but also by the myocardial ischemia.

Transhepatic portal vein catheterization for localization of insulinomas: a ten-year experience

One of the most important factors in the management of insulinomas is the ability to localize the tumor accurately either before or during surgery. We prospectively carried out transhepatic portal venous sampling (THPVS) for tumor localization in 35 of 40 patients with organic hyperinsulinism during a 10-year period. In 32 patients who underwent THPVS and in whom a single tumor was subsequently identified surgically, the maximal insulin gradient was located in the vicinity of the tumor in 100% of cases. Specific regionalization of the tumor on the basis of the site of the maximal insulin gradient to one of three regions (the tail, the body/neck region, and the head/uncinate region) gave a sensitivity of 81% and a specificity of 91%. In contrast, the use of specific cutoff levels for the insulin gradient as a guide to the presence of a tumor in one of these three regions did not increase the accuracy, leading instead to a significant loss of sensitivity with no comparable increase in specificity. There were no major complications from the procedure in any patient. The initial use of computed tomographic/ultrasound scanning and selective angiography localized only 46% of tumors, whereas subsequent THPVS led to the accurate preoperative localization of 100% of all tumors submitted to surgery. Although the surgeon would have identified 81% of the tumors correctly at operation, in 19% (n = 6) he would have failed. Four tumors were in the uncinate and two were in the head. It seems that in patients with proved or established organic hyperinsulinism, THPVS may continue to be of value, if only to regionalize the tumor, especially those in the pancreatic head and uncinate process so as to preclude noncurative operations on the body and tail of the pancreas.

Hypocalcemic focal seizures in a one-month-old infant of a mother with a low circulating level of vitamin D

We present a case of a one-month-old infant with hypocalcemia and rickets, with symptoms of focal seizures. The ictal EEG showed left occipital spikes spreading over all of the left hemisphere. From the laboratory studies, we concluded that a low maternal circulating level of vitamin D would cause infantile hypocalcemia and rickets, while immature renal response to parathyroid hormone and transient hypoparathyroidism in infancy would induce hyperphosphatemia. Hypocalcemia may be an important factor in the cause of focal seizures which start even after the age of one month. Further, investigation of maternal vitamin D levels should be done in infantile hypocalcemia.

Somatostatin analogue in treatment of coexisting glucagonoma and pancreatic pseudocyst: dissociation of responses

After an acute episode of pancreatitis, a 63-year-old man was found to have a pancreatic glucagonoma. The tumor was resected without evidence of metastases. Three years later he had symptoms of uncontrolled diabetes, no skin lesions, and diarrhea and was found to have a pancreatic pseudocyst and multiple hepatic metastases. Glucagon concentrations were raised but were suppressible by glucose and somatostatin and responded to arginine stimulation. He was treated for 6 months with octreotide (Sandostatin), which reduced his symptoms; the pseudocyst resolved, but liver metastases continued to grow. Although spontaneous resolution of the pseudocyst is possible, this case appears to illustrate differences in sensitivity of endocrine and exocrine tissues to suppression by Sandostatin.

The use of somatostatin analog in gastroenteropancreatic tumors other than carcinoid

We have used the gastrinoma syndrome to examine the effects of SMS. Acutely, SMS decreased acid secretion and restored the BAO/MAO to normal in eight of eight patients. Basal and secretin-stimulated gastrin responses were suppressed but not normalized. Treatment for up to 2 years with SMS controlled symptoms, suppressed serum gastrin, and suppressed acid secretion. Treatment for 1 year or longer decreased tumor secretion of gastrin and diminished basal acid secretion, an effect that persisted for 48 hours after withdrawal of SMS. SMS treatment arrested progression of tumor growth only in patients in whom there was a reduction in gastrin and gastric acid secretion. In patients with metastatic disease who had high levels of gastrin, SMS treatment for 5 to 24 months did not inhibit tumor growth or decrease gastrin levels. In those patients in whom a reduction in the blood flow to liver tumors was shown angiographically, there was a progressive improvement in hormone secretion and in tumor size in the ensuing year of treatment, suggesting that a major target of SMS is that vascular supply of the tumors. Tumors shown to produce peptides other than gastrin, for example ACTH, were found to be markedly resistant to the action of SMS and continued to grow in an unbridled manner.

Plasma substance-P in neuroendocrine tumors and idiopathic flushing: the value of pentagastrin stimulation tests and the effects of somatostatin analog

We examined the role of the potent vasoactive kinin substance-P (SP) in flushing derived from various causes. SP was measured in plasma after acetone/ether extraction using an antiserum directed at the carboxy-terminal 5-11 amino acid region of undecapeptide SP. The antiserum had less than 1% cross-reaction with the other neurokinins, neurokinin-A and neuropeptide-K, that derive from the beta-preprotachykinin gene and share carboxy-terminal residues. Basal and pentagastrin-stimulated SP levels were measured in 22 healthy controls, 11 patients with histologically proven carcinoid tumors, 8 patients with tumors other than carcinoid, and 7 patients with idiopathic flushing (IF). Basal SP levels were less than 10 pg/mL in normal subjects. All patients with midgut carcinoid tumors had SP levels greater than 25 pg/mL, as did 7 of 8 patients with noncarcinoid tumors and 5 of 7 patients with IF. Using 50 pg/mL as the cutoff point, the sensitivity was 63% for detection of a tumor, and 100% of nontumor patients were excluded. Pentagastrin administration uniformly induced flushing and caused a rise in SP levels greater than 150 pg/mL in 5 of 10 patients with carcinoid tumors, 3 of 8 with noncarcinoid tumors, and 0 of 7 with IF, i.e. a SP rise of more than 100 pg/mL suggests a tumor. Administration of somatostatin (150 micrograms) 0.5 h before the pentagastrin abolished flushing in all carcinoid patients and reduced SP levels, but not into the normal range. Long term treatment with SMS significantly reduced flushing and lowered SP levels, but did not restore these to normal. We conclude that 90% of patients with carcinoid/noncarcinoid tumor have raised COOH-terminal SP levels. A basal level above 50 pg/mL or a pentagastrin-stimulated rise of more than 100 pg/mL distinguishes carcinoid from IF. The dissociation between SP concentrations and flushing suggests that SP may not be the only kinin involved in the flushing associated with carcinoid tumors.

A simple, combined fluorogenic and chromogenic method for the assay of proteases in gingival crevicular fluid

Substrate impregnated paper discs were prepared using peptidyl derivatives of 7-amino-4-trifluoromethylcoumarin (AFC). After incubation with test solutions, the green, UV-induced fluorescence of AFC liberated by enzyme activity was distinguishable from the blue-violet fluorescence of the substrates. The AFC could then be coupled with p-dimethylaminocinnamaldehyde to form a colored Schiff base. Semi-quantiative assessments of disc fluorescence and color were made by comparison with AFC/substrate standards. Assays with discs impregnated with MeOSuc-Ala-Ala-Pro-Val-AFC, Z-Gly-Gly-Arg-AFC and Ala-Pro-AFC for elastase-, trypsin-, and dipeptidyl peptidase (DPP) IV-like activities respectively were evaluated using purified DPP IV and 100 eluates of crevicular fluid collected on filter paper strips from 10 gingivitis and periodontitis patients. The results showed that, within their working ranges, scores of disc fluorescence and color were reasonably accurate and reliable by comparison with enzyme activities measured in parallel quantitative fluorimetric assays with the same substrates. Using disc color, which was more sensitive than fluorescence, it was generally possible to measure all three enzyme activities in crevicular fluid samples from 5 periodontitis patients with varying degrees of gingival inflammation and pocketing. Disc color assays require no special apparatus and could be used for enzyme estimations in the clinical setting.

Transhepatic portal vein catheterization for localization of sporadic and MEN gastrinomas: a ten-year experience

We review here the 10-year experience at the University of Michigan with 35 patients with gastrin hypersecretion who underwent transhepatic venous sampling (THVS) for tumor localization. Since 1978 THVS has been done routinely in all patients with gastrinoma syndrome considered for operation. Thirty-one patients had proved gastrinomas--21 benign sporadic tumors and 10 tumors associated with multiple endocrine neoplasia type-I (MEN I) syndrome. The correlation between the site of the maximal gradient and location of a sporadic tumor was poor. Overall sensitivity was only 35%, specificity 89%, and negative predictive value 89%. If gradients were regionalized to three areas--body and tail, gastrinoma triangle, and hepatic lobes--then sensitivity was 94%, positive predictive value 94%, and specificity 97%, with a negative predictive value of 97%. The maximal gastrin gradient above the mean for other values gave the greatest sensitivity and specificity. In MEN I syndrome, only four of eight patients with macroadenomas had their tumors correctly localized, a sensitivity of 50% and specificity and negative predictive value of 75%. In 19 patients who had operative localization of sporadic gastrinoma, computed tomography had a sensitivity of 31%, specificity of 66%, positive predictive value of 83%, and negative predictive value of 15%. Selective angiography was better, with a sensitivity of 29%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 100%. Regionalization to the triangle proved valuable for detection of microgastrinomas, as was measurement of hepatic vein gastrins for identification of intrahepatic tumors. In MEN I syndrome, if regionalization was achieved (50%), tumor resection appeared to offer hope of "cure." We conclude that THVS is the best tool for tumor regionalization to the pancreatic tail and body, gastrinoma triangle, and hepatic lobes. It has allowed us to achieve surgical cure in 19 of 21 patients with sporadic gastrinomas and improvement in four of eight patients with MEN I syndrome.

Clinical features, diagnosis, and localization of carcinoid tumors and their management

In this article, we have focused on the evolving face of neuroendocrine tumors, newer approaches to their diagnosis and localization, the importance of sophisticated immunohistochemistry, tracer scanning, and the role of peptide therapy in the management of the symptom complex as well as the tumor. With recent expansion in our understanding of the pathophysiology of these tumors have come new and innovative approaches to their management. There is, however, much that remains unsolved and that requires diligent research and evaluation if we are ultimately to include neuroendocrine tumors among the curable cancers.

Isoproterenol-induced myocardial fibrosis in relation to myocyte necrosis

Treatment of rats with the beta-adrenergic agonist isoproterenol results in cardiac hypertrophy, myocyte necrosis, and interstitial cell fibrosis. Our objectives in this study have been to examine whether hypertrophy and fibrosis occur in a compensatory and reparative response to myocyte loss or whether either process may be occurring independently of myocyte loss and thus be a reactive response to adrenergic hormone stimulation. We have examined this question by evaluating each of these responses in rats treated with different doses and forms of isoproterenol administration. Myocyte necrosis was evaluated using in vivo labeling with monoclonal antimyosin for identification of myocytes with permeable sarcolemma, which was indicative of irreversible injury. Myocardial fibrosis was evaluated by morphometric point counting of Gomori-stained tissue sections and by assessment of the stimulation of fibroblast proliferation by determination of increased levels of DNA synthesis. Stimulation of fibroblast DNA synthesis was determined from DNA specific radioactivities and radioautography after pulse labeling with [3H]thymidine. The evidence provided by this study suggests that the degree and timing of myocardial hypertrophy does not follow the course of myocyte loss and, thus, appears to be either a response to altered cardiac loading or a reactive response to beta-adrenergic hormone stimulation rather than a compensation for myocyte loss. Myocardial fibrosis, on the other hand, appears to be more closely related to myocyte necrosis with respect to collagen accumulation in the same areas of the heart, its dose-response relation to the amount of isoproterenol administered, and the timing of increased DNA synthesis, or fibroblast proliferation, after myocyte loss.

Efficient synthesis of adeno-associated virus structural proteins requires both adenovirus DNA binding protein and VA I RNA

We have shown previously that replication of defective parvoviruses [adeno-associated viruses (AAV)] requires several early adenovirus (Ad) gene products [J. E. Janik, M. M. Huston, and J. A. Rose (1981) Proc. Natl. Acad. Sci. USA 78, 1925-1929]. To examine their possible roles in the transcription and translation of AAV mRNA, 293-31 cells, a human embryonic kidney cell line that constitutively expresses the Ad early region IA and IB gene products, were transfected with a pBR325 plasmid (pLH1) that contains a duplex AAV2 DNA segment (0.03-0.97 map units) which encompasses the promoters and coding sequences necessary for expression of all AAV polypeptides. When cells were transfected with pLH1 alone, both spliced and unspliced AAV-specific cytoplasmic RNAs accumulated. These transcripts were capable of directing synthesis of the three AAV capsid polypeptides in vitro, whereas in vivo synthesis of AAV protein was not detected by immunofluorescence or immunoprecipitation. When cells were cotransfected with pLH1 and intact Ad DNA, the level of cytoplasmic AAV RNA was enhanced and AAV protein was synthesized in vivo. Additional experiments demonstrated that in vivo AAV protein synthesis also could be induced when pLH1 was cotransfected with plasmids that contain the Ad DNA-binding protein (pDBP) and VA I RNA (p2BalM) genes; however, a low level of in vivo AAV capsid protein was occasionally detected in cotransfections with pLH1 and a plasmid that contains both VA I and VA II RNA coding sequences (p2SalC). Cotransfection of pLH1 and pDBP or pLH1 and p2SalC showed complex alterations in the steady-state patterns of AAV cytoplasmic transcripts. In both cases, increased levels of transcripts, particularly the 2.3-kb spliced species, were detected in comparison to levels seen in cells transfected with pLH1 alone. Despite these increases, however, there was little, if any, induction of AAV protein synthesis unless both the DNA-binding protein (DBP) and VA I RNA coding sequences were present in cotransfection with pLH1. We conclude that, in 293-31 cells, the Ad VA I RNA and DBP gene products regulate AAV capsid protein synthesis at least at two levels: (i) by increasing the steady-state levels of structural protein transcripts in the cytoplasm, especially the spliced species, and (ii) by enhancing the translation of these messages.

Transcription elongation factor SII interacts with a domain of the large subunit of human RNA polymerase II

Genomic sequences for the large subunit of human RNA polymerase II corresponding to a part of the fifth exon were inserted into an expression vector at the carboxy-terminal end of the beta-galactosidase gene. The in-frame construct produced a 125-kilodalton fusion protein, containing approximately 10 kilodaltons of the large subunit of RNA polymerase II and 116 kilodaltons of beta-galactosidase. The purified bacterially produced fusion protein inhibited specific transcription from the adenovirus type 2 major late promoter, while beta-galactosidase had no effect. This effect of the fusion protein was during RNA elongation, not at the level of initiation, resembling the faithfully initiated but incomplete transcripts produced with purified factors in the absence of SII. Similarly, monoclonal antibody 2-7B, which reacts with the RNA polymerase II region represented in the fusion protein, inhibited specific transcription at the level of elongation in a whole-cell extract. Both monoclonal antibody 2-7B and the fusion protein, although unable to inhibit purified RNA polymerase II in a nonspecific transcription assay, selectively blocked the stimulation elicited by transcription elongation factor SII on the activity of the purified enzyme in vitro. This suggests that the fusion protein traps the SII in nonstimulatory interactions and that antibody 2-7B inhibits SII binding to RNA polymerase II. Thus, this suggests that an SII-binding contact required for specific RNA elongation resides within the fifth exon region of the largest RNA polymerase II subunit.

Overlap of granulomatous vasculitis and sarcoidosis: presentation with uveitis, eosinophilia, leg ulcers, sinusitis, and past foot drop

A 24-year-old black woman with a history of pulmonary and hepatic sarcoidosis followed by foot drop presented with uveitis, eosinophilia, leg ulcers, and sinus opacification. Biopsy of the leg ulcer and review of the past lung biopsy revealed numerous epithelioid noncaseating granulomas and granulomatous vasculitis. Although her clinical presentation raised the possibility of Wegener's granulomatosis, the many discrete granulomas and lack of necrosis on her biopsies were more in favor of sarcoidosis. Although granulomatous vasculitis has been reported as part of necrotizing sarcoid granulomatosis, our patient was unique in the extent and type of her extrapulmonary symptomatology.

Functional and scintigraphic evaluation of the silent adrenal mass

Seven patients with unilateral and one patient with bilateral and asymmetric (R greater than L) incidentally discovered adrenal mass abnormalities depicted by computed tomography (CT) were studied by 131I-6 beta-iodomethyl-19-norcholesterol (NP-59) scintigraphy. There was marked lateralization of NP-59 uptake to the side of the mass lesion in the seven patients with unilateral masses and prominent asymmetric, (R greater than L) bilateral uptake in the patient with bilateral masses despite the fact that there were no obvious abnormalities of adrenocortical or adrenomedullary function as determined from peripheral blood and 24-hr urinary hormone measurements. Simultaneous bilateral adrenal vein catheterization (AVC) was employed to measure the levels of hormone effluent from the adrenal cortex and medulla and in all instances the cortisol concentrations were greatest from the side of the mass lesion in those patients with unilateral masses and from the larger of the two adrenals in the patient with bilateral adrenal masses. Thus, there was congruence between the anatomic (CT) and functional (NP-59 scintigraphy and AVC) investigations that depicted asymmetry of the adrenal glands which were not associated with abnormalities of overall adrenal function or hypothalamic-pituitary-adrenal axis integrity.

Synthesis of fluorescent peptidyl thioneamides and the assay of papain in the presence of trypsin

Fluorescent peptidyl thioneamides are synthesized for the first time. The carbonyl oxygen of the scissile amide bond of the substrates was replaced by a sulfur atom. The proteolytic activities of trypsin and papain were measured against 5-(benzyloxycarbonyllysylthioamido)-isophthalic acid dimethyl ester (Z-Lys-psi[CS]-AIE) and 5-(benzyloxycarbonylphenylalanylarginylthioamido)-isophthalic++ + acid dimethyl ester (Z-Phe-Arg-psi[CS]-AIE) and were compared to the corresponding oxyamides. Kinetic constants were measured. With thioneamide substrates, no tryptic hydrolysis was observed. Papain, on the other hand, hydrolyzed both oxy and thioneamides. The Km values of the thioneamides were shown to be slightly lower for papain than for the oxyamides, but the efficiency of the overall catalytic activity was off set by the lower turnover number for the thio derivatives. With the present synthetic substrate technology, selective detection of cysteine proteases in the presence of serine proteases is difficult. The thioneamides reported here were hydrolyzed by papain alone in the presence of trypsin.

Transfer of maternal specific cell-mediated immunity to the fetus

The extent of specific cell-mediated immunity was measured in 67 consecutive newborns and their mothers. The stimulation index of blast transformation of the infants' lymphocytes in the presence of purified protein derivative, Candida extract and streptokinase was greater than 2.0 in 54%, 18% and 23% respectively. This was seen only in infants whose mothers' index was also greater than 2.0 to the same antigen. Leucocyte inhibition factor generated from lymphocytes of four babies in the presence of purified protein derivative inhibited migration of indicator cells over 50%; their stimulation index with purified protein derivative was greater than 2.0. Newborns have cell mediated immunity to the same antigens as their mothers, and this wanes during the first few months of life.

Somatostatin analogue (SMS 201-995) in the management of gastroenteropancreatic tumors and diarrhea syndromes

SMS 201-995 (Sandostatin) was studied using low doses (50 to 100 micrograms) administered subcutaneously every 12 hours. A single 50-micrograms dose of SMS 201-995 effectively controlled gastric acid and blood gastrin levels for 12 hours in three patients with benign gastrinomas and was useful in their perioperative management. Higher doses of the agent (500 to 800 micrograms per day) had no effect on metastases in one of two patients with metastatic gastrinoma. In the other patient, one tumor shrank but the other continued to grow after three months of treatment while serum gastrin levels did not change. Cultured metastatic tumor tissue from this patient released different forms of gastrin; growth rates varied, independent of uptake of SMS 201-995, and gastrin release increased. A neonate with nesidioblastosis maintained normal blood glucose levels while receiving SMS 201-995 therapy following a 95 percent pancreatic resection. In two elderly patients with organic hypoglycemia--one with a single benign adenoma and one with multiple adenomatosis--the somatostatin analogue did not prolong the hypoglycemia-free interval. In nine patients with carcinoid syndrome, flushing was uniformly controlled with 50 micrograms of SMS 201-995 administered every eight to 12 hours. One of the nine required exocrine pancreatic replacement. After six months of treatment, three of the nine had no change in tumor size and one had remission of symptoms and stopped treatment. In two patients with vipoma, SMS 201-995 controlled diarrhea and reduced levels of vasoactive intestinal peptide; tumor necrosis occurred in one patient. In a patient with diabetic diarrhea unresponsive to all treatments, SMS 201-995 therapy controlled the diarrhea but did not interfere with control of the diabetes.

[Laboratory and clinical studies on BRL 25000 (clavulanic acid -amoxicillin) granules in the pediatric field]

Laboratory and clinical studies on BRL 25000 granules (containing clavulanic acid (CVA) 1 part plus amoxicillin (AMPC) 2 parts) were performed in infections in the pediatric field. Following oral administration of BRL 25000 granules at a dose of 15 mg/kg body weight, the maximum serum levels of AMPC and CVA achieved approximately 1 hour after dosing were 8.68 micrograms/ml and 4.09 micrograms/ml and declined thereafter with half-lives of 1.39 and 0.80 hours, respectively. The 6-hour urinary recovery rates for AMPC and CVA were 55.81% and 26.08%, respectively. Following oral administration of BRL 25000 granules at a dose of 22.5 and 24.3 mg/kg body weight, the serum levels of AMPC and CVA peaked at 7.37 micrograms/ml and 2.98 micrograms/ml after 1 hour and declined with half-lives of 2.52 and 0.99 hours, respectively. The 6-hour urinary recovery rates for AMPC and CVA were 40.02% and 13.95%, respectively. The clinical efficacy of BRL 25000 granules was evaluated in 23 patients with upper respiratory tract infections, skin infections, etc. Overall the clinical efficacy was good to excellent in 21/23 (91.3%). The bacteriological and clinical efficacy rates for beta-lactamase producing bacteria and non-producing bacteria were 50% (1/2) and 100% (12/12), respectively. Side effects were observed in 1 patient, who experienced mild diarrhea and abdominal pain but not of a severe nature.

Peptide thioesters and 4-nitroanilides as substrates for porcine pancreatic kallikrein

A series of 14 4-nitroanilide substrates and 17 thioester substrates have been used to measure kinetic constants with porcine pancreatic kallikrein. All of the substrates have a P1 arginine residue. The 4-nitroanilide substrates consist of seven P2-glycine and seven P2-phenylalanine tripeptides. As expected from previous results, the phenylalanine series substrates were generally 100-fold 'better' than those in the glycine series. The S3 subsite was found to 'prefer' lysine or phenylalanine, whereas glutamic acid in this position was distinctly unfavourable. The thioester substrates consisted of various thioester derivatives of arginine as well as 12 dipeptides. These substrates exhibited kcat./Km values generally 1000 times higher than the P2-phenylalanine 4-nitroanilides. With the thioesters, a P2 phenylalanine or tryptophan residue yielded the best substrates, but some of the simple derivatives of arginine were nearly as good. A comparison of the kinetic constants of the thioester substrates between the porcine enzyme and human plasma kallikrein provides further evidence that these enzymes have a similar preference for bulky P2 residues, but otherwise are quite different enzymes. The thioester substrates are nearly as reactive as oxygen ester substrates such as acetylphenylalanylarginine methyl ester for the porcine enzyme [Levison & Tomalin (1982) Biochem. J. 203, 299-302; Fiedler (1983) Adv. Exp. Med. Biol. 156A, 263-274], and owing to the greater ease in assaying with the thioesters, they should find use in routine assays for the glandular kallikreins.

Active-site mapping of bovine and human blood coagulation serine proteases using synthetic peptide 4-nitroanilide and thio ester substrates

A series of 14 tripeptide 4-nitroanilide substrates of the type Z-AA-Gly-Arg-NA and Z-AA-Phe-Arg-NA where AA = Ala, Asn, Glu, Lys, Phe, Pro, or Ser were used to map the S3 subsite of several serine proteases involved in blood coagulation. The enzymes studied included bovine thrombin, factor IXa, factor Xa, factor XIa, human beta-factor XIIa (factor XIIa fragment), and activated bovine and human protein C. Kinetic constants (kcat, KM, and kcat/KM) for the enzymatic hydrolysis of the substrates by each enzyme were determined and used to compare the relative reactivities of the individual enzymes. Most of the enzymes reacted with all the substrates, although a few showed considerable specificity. Human beta-factor XIIa showed the highest reactivity of all the coagulation proteases studied and was also very substrate specific (kcat/KM ranged over 470-fold). The best substrate was Z-Lys-Phe-Arg-NA with kcat/KM = 140 000 M-1 s-1. Activated bovine protein C (best substrate = Z-Ser-Phe-Arg-NA), factor Xa (best substrate = Z-Glu-Gly-Arg-NA), and thrombin (best substrate = Z-Lys-Gly-Arg-NA) were the group of enzymes that showed next highest reactivity toward the substrates. Activated bovine protein C, thrombin, and factor Xa displayed relatively little substrate specificity. Activated human protein C (best substrate = Z-Ser-Phe-Arg-NA) and factor XIa (best substrate = Z-Glu-Gly-Arg-NA) are moderately reactive enzymes. Activated human protein C is an extremely specific enzyme since it has such a large range of kcat/KM values.(ABSTRACT TRUNCATED AT 250 WORDS)

Mammalian tissue trypsin-like enzymes. Comparative reactivities of human skin tryptase, human lung tryptase, and bovine trypsin with peptide 4-nitroanilide and thioester substrates

The subsite specificity of human lung and skin tryptase (trypsin-like enzyme) has been studied at pH 7.5 using 17 amino acid and dipeptide thioester substrates and 14 tripeptide 4-nitroanilide substrates. The reactivity and specificity of the human tryptases were compared with bovine trypsin and other trypsin-like enzymes. Neither tryptase was similar to either kallikrein or factor XIIa (Hageman factor). The skin enzyme was the most reactive as measured by the specificity constant kcat/KM. The best substrate was benzyloxycarbonyl(Z)-Lys-Arg-S-CH2CH(CH3)2 which had a kcat/KM value of 59,000,000 M-1 S-1. Only a single substrate, Z-Glu-Phe-Arg-4-nitroanilide, was slightly more reactive with the lung tryptase. Both enzymes have extended substrate-binding sites and proline residues at P3 substantially decrease kcat/KM. Both enzymes preferred the tripeptide 4-nitroanilides with a P2 Gly residue over Phe, and both favored the substrate Z-Lys-Gly-Arg-4-nitroanilide over similar substrates containing six other representative amino acid residues at P3. The lung enzyme was inhibited over three times faster by p-amidinophenylmethanesulfonyl fluoride than the skin enzyme. The preference of the skin tryptase for substrates with two terminal basic residues indicates that this enzyme could process prohormones and proproteins which contain this structural feature at the cleavage site. The substrates reported in this paper should be useful for the further characterization of the physiologic function of tryptases.

Improved regional selectivity of hepatic arterial BCNU with degradable microspheres

Starch microspheres 40 micrometers in diameter, which are rapidly degraded by serum amylase, have been administered through hepatic arterial catheters to five patients with primary and metastatic liver cancer to determine whether (1) arterial blood flow through the liver could be temporarily blocked, and (2) such occlusion at the level of the arteriolar capillary bed would enhance regional uptake and catabolism and decrease systemic exposure to simultaneously administered hepatic arterial bischlorethylnitrosourea (BCNU). It was possible with 10 ml of microspheres (9 X 10(6) microspheres/ml) injected into the hepatic artery to transiently (for 15-30 minutes) reduce hepatic flow by 80-100% in the five patients. When BCNU (50 mg/m2 in one minute) was given with microspheres there was a 30-90% reduction in systemic nitrosourea exposure and in peak levels. No myelosuppression was noted and hepatic toxicity consisted of acute pain due to BCNU and 1.5-2.0 fold transient enzyme elevations. One patient with cholangiocarcinoma showed a partial response lasting three months; three patients had stable disease and one patient with colon carcinoma had progressive disease. Thus, this pilot study suggests that concurrent intra-arterial microspheres and BCNU may have the potential to improve selective regional drug effect with marked diminution in systemic toxicity.

Alpha-fetoprotein and carcinoembryonic antigen in pancreatobiliary disease with and without jaundice

A comparative study of alpha-fetoprotein (AFP) and carcinoembryonic antigen (CEA) in serum was made by radioimmunoassay in 66 patients with pancreatobiliary disease with and without obstructive jaundice. biliary concentrations of these proteins were assayed in 12 patients with benign and 7 patients with malignant disease. There was no statistical difference in serum AFP between these two groups but there was a difference in serum CEA. Although CEA and AFP in bile in both groups were higher than in serum there was no statistical difference in serum CEA and AFP in patients with and without obstructive jaundice in either benign or malignant disease. In benign disease, patients with inflammation had higher serum CEA than normal. Although there was no statistical difference in serum CEA in patients with a without liver metastases, the serum CEA in liver metastases was significantly higher than in benign disease. We concluded that AFP is unlikely to be important in the assessment or management of patients with cancers other than those derived from the liver or yolk sac, and that the elevation of serum CEA in patients with malignant pancreatobiliary disease either with or without obstructive jaundice occurs mainly in the presence of widespread malignancy, especially in liver metastases.

Gastrointestinal/pancreatic hormone concentrations in the portal venous system of nine patients with organic hyperinsulinism

Percutaneous transhepatic sampling of blood in the portal venous system (TPVS) was used to; (1) localize hormone secreting tumors and help in differentiating tumors from diffuse disease (nesideoblastosis and hyperplasia with adenomata) in 9 patients with fasting hypoglycemia and hyperinsulinism, and (2) study the concentration an distribution of the immunoreactive peptides: insulin (IRI), gastrin (IG), glucagon (IRG), pancreatic polypeptide (hPP), and somatostatin (SRIF-LI), in the venous drainage of the uninvolved portion of the pancreas and GI tract. Localized elevations of IRI (64-920 microunits/ml) predicted tumor localization in 6 patients with single tumors that were not demonstrable angiographically. In one patient with nesideoblastosis and another with islet cell hyperplasia with adenoma, elevated IRI concentrations at multiple locations suggested a diffuse or multicentric process. Elevations of SRIF-LI in the same region as IRI elevations in one patient and of IRG in another patient suggested that these tumor produced two hormones. Some problems in the interpretation of portal venous insulin concentrations are discussed. The locations of maximum portal venous system plasma concentrations and portal-arterial gradients (mean +/- SE pg/ml) in five patients with small single insulinomas were: IG, gastrocolic trunk (126 +/- 27, 46 +/- 22); IRG, proximal splenic vein (130 +/- 30, 47 +/- 13) and gastrocolic trunk (131 +/- 23, 60 +/- 13); hPP, portal vein (164 +/- 48, 49 +/- 22); SRIF-LI, superior mesenteric vein (186 +/- 50, 57 +/- 20) and gastrocolic trunk (178 +/- 59, 55 +/- 21). It is concluded; (1) TPVS can be used successfully to localize single insulin-secreting tumors of the pancreas and to help distinguish them from diffuse disease but problems in such differentiation do occur, (2) circulating SRIF-LI and IRG are derived from both the pancreas and the gut, IG predominantly from the proximal gut and hPP from the head of the pancreas, and (3) The data provide new information for the interpretation of portal insulin concentrations in patients with organic hyperinsulinism and of hormone concentrations for localization of peptide-producing tumors of the pancreas other than insulinomas.

Evaluation of cholangeographic procedures in diagnosis of obstructive jaundice

Endoscopic retrograde cholangiography, percutaneous transhepatic cholangiography with external bile drainage and a combined method utilizing both procedures were evaluated in 187 patients with obstructive jaundice. Ductal obstructive regions were located in 90 per cent of cases by endoscopic retrograde cholangiography, and 55 per cent of these were correctly diagnosed. Complications were observed in 7.9 per cent with a mortality rate of 2.9 per cent. The most serious complication was cholangitic sepsis. By percutaneous transhepatic cholangiography with external bile drainage, ductal obstructive regions were correctly located in 82 per cent, 37 per cent of these patients were correctly diagnosed. Complications occurred in 9.2 per cent with a mortality rate of 1.5 per cent. The most serious complication was massive bleeding. Successful external bile drainage could be obtained in most cases. The combined method overcomes the disadvantages of the single methods and the cause of obstructive jaundice can be diagnosed more precisely. The surgeon has a better knowledge of the type and the extent of the lesion prior to definitive surgery and can operate more safely on patients with obstructive jaundiced when the serum total bilirubin, has decreased to a level below 5 mg/dl.

[Clinical results of cefadroxil in children and pharmacokinetics of the drug (author's transl)]

Cefadroxil was administered orally at a daily dose of 30-40 mg/kg to 8 cases of the infection of upper respiratory tract mainly due to beta-hemolytic Streptococcus, and efficacy was obtained in 7 cases, this rate being considered to be satisfactory, though the cases were too few to reach a conclusion. As to pathogens of bacterial infection of upper respiratory tract, beta-hemolytic Streptococcus and Staphylococcus aureus were encountered especially frequently, and in view of antibacterial activity against these 2 bacteria, our results could be approved. Further investigations should be performed carefully, however, to determine if cefadroxil may be a drug of first choice in the treatment of severe bacterial pneumonia and pyothorax. No side effects were observed throughout our treatment, though digestive tract disorders, especially diarrhea, are most frequent in literatures. As to pharmacokinetical characteristic of cefadroxil, almost the same results were obtained to other reports, though our data are insufficient as our experience was limited in only 1 case. Serum levels were determined after 35.7 mg/kg of cefadroxil were administered once orally, and a peak of about 38 mcg/ml appeared 2 hours later, and a high level of about 30 mcg/ml was maintained at 5 hours, though an oral dose was high. Efficacy for large area of bacterial infections may be expected from these serum levels. From urine collected simultaneously, about 74% of cefadroxil was recovered within more than 4 hours. This showed that cefadroxil was well absorbed from digestive tract, and a major part was excreted rapidly through kidney. From the results of our experiment, characteristics of cefadroxil may be summarized as follows. Cefadroxil is absorbed well after oral administration, antibacterial action is fully expected from serum level, a major part is excreted through kidney, and clearance is good. Cefadroxil will be recommended especially for bacterial infections of upper respiratory tract due to beta-hemolytic Streptococcus and Staphylococcus aureus.