The role of endotoxin immunity, neutrophil degranulation and contact activation in the pathogenesis of post-operative organ dysfunction

Gut mucosal hypoperfusion is associated with a poor outcome following major surgery but the pathogenetic mechanisms remain poorly understood. We have examined the relationship between gut mucosal hypoperfusion, endotoxin core antibodies (EndoCAb), neutrophil elastase alpha-1 antitrypsin complexes (NE) and components of the contact system during elective major surgery. Of the 26 patients studied 16 developed gut mucosal hypoperfusion (pHi < 7.32) by the end of surgery; of these four developed multiple organ failure (MOF) and three subsequently died. In this group there was a significant rise in NE (P < 0.005) and significant reductions in components of the contact system (factor XII, antithrombin III, prekallikrein and C1-inhibitor; P < 0.001) from immediately before surgery to 24 h later. Ten patients maintained gut mucosal perfusion (pHi > or = 7.32); none of these developed life threatening complications. In this group there was no significant increase in NE and, although there were significant reductions in some components of the contact system (P < 0.01), levels of C1-INH were not reduced. All patients demonstrated a significant reduction in both IgG and IgM EndoCAbs (P < or = 0.005) indicating exposure to endotoxin. However, the group that maintained gut mucosal perfusion had significantly higher IgG EndoCAb levels at baseline and 24 h (P < or = 0.005). These data suggest that all patients were exposed to endotoxin and that high levels of anti-endotoxin antibodies may contribute to the prevention of endotoxin-induced contact activation, neutrophil degranulation and gut mucosal hypoperfusion occurring during major surgery and thus reduce the likelihood of the development of post-operative MOF.

Reduction in circulating levels of CD4-positive lymphocytes in acute pancreatitis: relationship to endotoxin, interleukin 6 and disease severity

The proportion of peripheral blood mononuclear cells expressing the T helper cell phenotype and levels of antiendotoxin core antibody, interleukin (IL) 6 and C-reactive protein (CRP) were determined within 48 h of admission in a group of 29 patients with acute pancreatitis (16 mild, 13 severe attacks). There was a significant decrease in the proportion of T helper cells (12.2 versus 34.9 per cent, P < 0.01) and significant increases in levels of IL-6 (69.5 versus < 10 pg/ml, P < 0.01) and CRP (119 versus 30.5 mg/l, P < 0.01) in severe compared with mild attacks. During the convalescent stage at 3 months after admission, severe attacks were characterized by a significant increase in the proportion of T helper cells compared with the acute period (22.4 versus 10.6 per cent, P < 0.01). A persistently low proportion of T helper cells was associated with residual pancreatic necrosis. The presence of circulating endotoxin was demonstrated in two mild and two severe attacks using the Limulus amoebocyte lysate assay, and abnormal levels of antiendotoxin core antibodies were found in 70 and 92 per cent of mild and severe attacks respectively. There was a strong inverse correlation between levels of CRP and the proportion of T helper cells in severe disease (r = -0.76, P = 0.004). Translocation of endotoxin from the gastrointestinal tract may partly explain the abnormal levels of T helper cells, IL-6 and CRP.

A broadly cross-protective monoclonal antibody binding to Escherichia coli and Salmonella lipopolysaccharides

During the last decade, episodes of sepsis have increased and Escherichia coli has remained the most frequent clinical isolate. Lipopolysaccharides (LPS; endotoxin) are the major toxic and antigenic components of gram-negative bacteria and qualify as targets for therapeutic interventions. Molecules that neutralize the toxic effects of LPS are actively investigated. In this paper, we describe a murine monoclonal antibody (MAb; WN1 222-5), broadly cross-reactive and cross-protective for smooth (S)-form and rough (R)-form LPS. As shown in enzyme-linked immunosorbent assay and the passive hemolysis assay, WN1 222-5 binds to the five known E. coli core chemotypes, to Salmonella core, and to S-form LPS having these core structures. In immunoblots, it is shown to react with both the nonsubstituted core LPS and with LPS carrying O-side chains, indicating the exposure of the epitope in both S-form and R-form LPS. This MAb of the immunoglobulin G2a class is not lipid A reactive but binds to E. coli J5, an RcP+ mutant which carries an inner core structure common to many members of the family Enterobacteriaceae. Phosphate groups present in the inner core contribute to the epitope but are not essential for the binding of WN1 222-5 to complete core LPS. Cross-reactivity for clinical bacterial isolates is broad. WN1 222-5 binds to all E. coli clinical isolates tested so far (79 blood isolates, 80 urinary isolates, and 21 fecal isolates) and to some Citrobacter, Enterobacter, and Klebsiella isolates. This pattern of reactivity indicates that its binding epitope is widespread among members of the Enterobacteriaceae. WN1 222-5 exhibits biologically relevant activities. In vitro, it inhibits the Limulus amoebocyte lysate assay activity of S-form and R-form LPS in a dose-dependent manner and it neutralizes the LPS-induced release of clinically relevant monokines (interleukin 6 and tumor necrosis factor). In vivo, WN1 222-5 blocks endotoxin-induced pyrogenicity in rabbits and lethality in galactosamine-sensitized mice. The discovery of WN1 222-5 settles the long-lasting controversy over the existence of anti-core LPS MAbs with both cross-reactive and cross-protective activity, opening new possibilities for the immunotherapy of sepsis caused by gram-negative bacteria.

Role of serum endotoxin and antiendotoxin core antibody levels in predicting the development of multiple organ failure in acute pancreatitis

It has been proposed that endotoxin contributes to the development of multiple organ failure (MOF) in acute pancreatitis. Endotoxaemia is transient and may not be detected by intermittent blood sampling. By contrast, not only can changes in the patient's endogenous antiendotoxin core antibody pool persist for many days, but depletion of this pool may be a key event in determining the physiological significance of endotoxaemia. A series of 33 patients with acute pancreatitis had daily measurement of Acute Physiology Score (APS) and levels of C-reactive protein, interleukin 6, endotoxin, immunoglobulin (Ig) G and IgM antiendotoxin core antibodies, and prospective documentation of complications. Endotoxin was detected in the serum of 13 patients, while a significant change in levels of endogenous antiendotoxin core antibodies was detected in all those with severe pancreatitis and in 28 overall. MOF developed in seven patients, five of whom died. The combination of a rising APS over the first 48 h of admission and a significant fall in endogenous IgG antibody level was observed in all patients who developed MOF (seven of seven), but in only one of 16 without MOF (P = 0.00003; overall predictive value 91 per cent). This study suggests that measuring the initial trend in APS and the concentration of endogenous IgG antiendotoxin core antibody provides a means of identifying patients with acute severe pancreatitis who are at high risk of developing MOF. This group might benefit from passive immunotherapy with antiendotoxin antibodies.

Frequencies of lipopolysaccharide core types among clinical isolates of Escherichia coli defined with monoclonal antibodies

Mouse monoclonal antibodies (MAbs) specific for the lipopolysaccharide (LPS) core types R1, R2, and R3 of Escherichia coli and a cross-reactive MAb that binds to the LPS core of almost all E. coli were used in ELISA to determine the frequency of cores resembling R1, R2, and R3 in strains of E. coli isolated from clinical samples (blood and urine specimens) and from the feces of asymptomatic individuals. Of the 180 wild-type isolates, 123 were assigned to R1 core type, 14 to R2, and 18 to R3. Twenty-five wild-type E. coli isolates could not be assigned to a particular core type and may have either an R4 or K12 core or a previously unrecognized core type. R1 core type was associated with O types 1, 4, 6, 8, and 18 and with K1 or K5 capsules. R3 was associated with O15. O75 isolates could be of either R1 or R2 core type.

Production and characterisation of mouse monoclonal antibodies reactive with the lipopolysaccharide core of Pseudomonas aeruginosa

Monoclonal antibodies (MAbs) to the core antigen region of lipopolysaccharide (LPS) of Pseudomonas aeruginosa were produced from mice immunised with whole cells of heat-killed rough mutants of Pseudomonas aeruginosa expressing partial or complete core LPS. MAbs were screened in an enzyme-linked immunosorbent assay (ELISA) against three different antigen cocktails: S-form LPS from three P. aeruginosa strains, R-form LPS from six P. aeruginosa strains and, as a negative control, R-form LPS from Salmonella typhimurium and Escherichia coli. Selected MAbs were subsequently screened against a range of extracted LPS and whole cells from both reference strains and clinical isolates of P. aeruginosa. The antibodies were also screened in ELISA against whole-cell antigens from other Pseudomonas spp. as well as strains of Haemophilus influenzae, Neisseria subflava and Staphylococcus aureus. Five MAbs reacting with the core component of P. aeruginosa LPS were finally selected. Two of these, MAbs 360.7 and 304.1.4, were particularly reactive in immunoblots against unsubstituted core LPS, including that from O-antigenic serotypes of P. aeruginosa. The MAbs also reacted with some of the other Pseudomonas spp., but not with P. cepacia or Xanthomonas (Pseudomonas) maltophilia. Cross-reactivity with whole cells from other bacterial species was minimal or not observed. Reactivity of MAbs with some Staph. aureus strains was observed, and binding to the protein A component was implicated. The reactivity of the MAbs was investigated further by flow cytometry and immunogold electronmicroscopy. The suitability of the MAbs for an immunological assay for detection of P. aeruginosa in respiratory secretions from CF patients is discussed.

The effect of dietary yeast on the activity of stable chronic Crohn's disease

The effect of dietary yeast on the activity of stable Crohn's disease was assessed in 19 patients. During the 1st month patients continued their usual diet (base-line period), but during the next 2 months dietary yeast was excluded except that during 1 month patients took baker's yeast capsules while for the other month they took placebo capsules. The patients' mean Pettit Crohn's disease activity index (CDAI) while taking baker's yeast (mean, 107.9; SE, 6.1) was significantly greater than during yeast exclusion (mean, 102.1; SE, 5.7; p less than 0.05). The mean of each patient's maximum CDAI during yeast exclusion (mean, 107.1; SE, 5.7) was significantly lower than those during the base-line (mean, 115.2; SE, 6.1; p less than 0.05) and baker's yeast inclusion periods (mean, 113.9; SE, 6.7; p less than 0.05). Patients with elevated yeast antibodies tended to develop a higher CDAI while receiving baker's yeast (13 of 15). These results suggest that dietary yeast may affect the activity of Crohn's disease.

Tissue plasminogen activator in the treatment of superior vena caval thrombosis associated with parenteral nutrition

Two patients, one of whom was pregnant, developed superior vena caval thrombosis while receiving central parenteral nutrition. They were successfully treated with recombinant tissue plasminogen activator (t-PA).

Changes in anti-endotoxin-IgG antibody and endotoxaemia in three cases of gram-negative septic shock

Circulating endotoxin levels and IgG antibodies to a range of Gram-negative bacterial lipopolysaccharides (LPS) (endotoxins) of different sizes and structures were measured daily in three cases of septic shock. There was an inverse relationship between endotoxin levels and cross-reactive antibodies to the core glycolipid (CGL) region of lipopolysaccharide. This suggests that antibody to LPS-CGL was initially consumed by a superabundance of endotoxin, and that a resurgence of intrinsic anti-LPS-CGL antibody levels may be associated with a reduction of circulating endotoxin. The implications of these findings for passive antibody therapy of septic shock are discussed.

Effect of moderate exercise on salt and water transport in the human jejunum

The effect of moderate exercise on jejunal absorption was examined in seven healthy subjects using a triple lumen perfusion technique. Moderate exercise on a bicycle ergometer significantly reduced net absorption of water from 32.0 (4.0) to 16.2 (6.1) ml/30 cm/50 min (p less than 0.02), sodium from 2.4 (0.4) to 0.5 (0.9) mmol/30 cm/50 cm (p less than 0.05), chloride from 2.0 (0.4) to 0.3 (0.7) mmol/30 cm/50 min (p less than 0.05), and potassium from 0.20 (0.02) to 0.01 (0.04) mmol/30 cm/50 min (p less than 0.01). After exercise, water, sodium, and chloride absorption returned towards basal values, but potassium absorption remained significantly decreased. These results suggest that moderate exercise can influence jejunal absorption of salt and water in man. They support the possibility that the autonomic nervous system has a physiological role in the control of intestinal transport, although other mechanisms may be involved.

Effect of cold-induced pain on salt and water transport in the human jejunum

The possibility that the central and autonomic nervous systems might be involved in the control of intestinal absorption was assessed by measuring the effect of physical stress (cold-induced pain) on jejunal transport in 13 healthy subjects. Using a triple-lumen perfusion technique to determine jejunal absorption, cold pain significantly reduced net water absorption from 34.9 to 15.7 ml/30 cm.50 min (p less than 0.005), net sodium absorption from 2.6 to 0.2 mEq/30 cm.50 min (p less than 0.005), and net chloride absorption from 2.2 to 0.6 mEq/30 cm.50 min (p less than 0.02). These changes were associated with an elevation of blood pressure and plasma norepinephrine during cold pain. During the period following cold pain, systolic blood pressure remained significantly elevated and net jejunal water absorption significantly reduced. These results suggest that physical stress can influence jejunal absorption of salt and water in humans and support the possibility that the central and autonomic nervous systems have a physiologic role in the control of intestinal function.

Serological relationships between Escherichia coli and Salmonella smooth- and rough-mutant lipopolysaccharides as revealed by enzyme-linked immunosorbent assay for human immunoglobulin G antiendotoxin antibodies

Reactions of sera from healthy blood donors to smooth and rough mutant lipopolysaccharides (LPS) from Escherichia coli O111:B4 and Salmonella minnesota which had been complexed with polymyxin B were determined by enzyme-linked immunosorbent assay. Relative enzyme-linked immunosorbent assay reactivities were examined for prima facie evidence of cross-reactivity by analyses of correlation and relative scatter. Patterns of reactivity were interpreted in relation to published structures. Evidence was obtained for two dominant epitopes associated with the lipid A-2-keto-3-deoxyoctulosonic acid and heptose regions of the LPS core. Sera demonstrated apparent exclusive antibody homogeneity in that given sera showed only one of the two possible specificities, which occurred with equal frequency. Cross-reactivity was found in the lipid A-2-keto-3-deoxyoctulosonic acid region for all LPS. Cross-reactivity was found in the heptose region for larger rough mutant S. minnesota LPS and smooth S. minnesota LPS and for E. coli O111:B4 LPS but not for E. coli rough mutant J5 LPS, whose heptose region appears to be different from those of the other organisms.

Effect of psychological stress on salt and water transport in the human jejunum

The possibility that the central and autonomic nervous system might be involved in the control of intestinal absorption was assessed by measuring the effect of psychological stress, induced by dichotomous listening, on jejunal transport in 15 healthy subjects. Using a triple-lumen perfusion technique to determine jejunal absorption, dichotomous listening significantly reduced mean net water absorption from 31.2 to 8.7 ml X 30 cm-1 X h-1 (p less than 0.005) and changed mean net sodium and chloride absorption to secretion (sodium +1.14 to -1.2 mEq X 30 cm-1 X h-1, p less than 0.01; and chloride +1.5 to -0.9 mEq X 30 cm-1 X h-1, p less than 0.02). During the hour following dichotomous listening these changes were maintained. Jejunal water, sodium, and chloride absorption measured in 9 subjects during three consecutive stress-free periods did not change significantly. Mean transit time over the 30-cm test segment, measured by a dye dilution technique, in 7 subjects was not significantly different during control and dichotomous listening periods, being 2.8 and 4.0 min, respectively. During the hour following dichotomous listening there was a significant increase in mean transit time to 6.4 min (p less than 0.02). In 7 subjects who received a constant intravenous infusion of atropine throughout the control, dichotomous listening, and recovery periods, jejunal sodium, chloride, and water absorption did not change significantly. These results suggest that psychological stress can influence jejunal absorption of salt and water and that this effect may be mediated by a cholinergic parasympathetic nervous mechanism.

Endotoxin-polymyxin complexes in an improved enzyme-linked immunosorbent assay for IgG antibodies in blood donor sera to gram-negative endotoxin core glycolipids

Common or cross-reactive epitopes of Gram-negative endotoxins are found in the inner-core glycolipid region of the outer membrane lipopolysaccharides (LPS). Hydrophobic LPS from rough mutants of Gram-negative bacteria, lacking serotype polysaccharide O-antigen chains, did not bind satisfactorily to polystyrene microplates for ELISA detection of cross-reactive IgG anti-endotoxin antibodies. When these LPS molecules were reacted with the cationic polypeptide polymyxin B, complexes were formed which were stable when coated on microplates. LPS-polymyxin complexes allowed optimisation of conditions for an ELISA for IgG antibodies to the core glycolipid region of endotoxins which could be used for screening large numbers of blood donor sera.

Double-blind comparative trial of standard (commercial) and antibody-affinity-purified tetanus toxoid vaccines

Tetanus toxoid purified by antibody-affinity chromatography, was compared with conventionally purified material in a double-blind trial in 205 healthy blood donors. There was neither any difference in immunogenicity as assessed by enzyme-linked immunoassay nor in side-reactions between the two vaccines. This study confirms that side-reactions to tetanus toxoid are not eliminated by purifying it.

ERCP in late post-traumatic biliary fistula

A case is described in which a huge subcapsular bile collection due to biliary fistula presented late after hepatic trauma and in which ERCP indicated the diagnosis.

Selection of plasma donors suitable for tetanus boosting

As a result of a comparative trial examining the immunogenicity and clinical reactivity of two tetanus vaccines, 33 donors with high antibody levels were plasmapheresed over 6 months for the collection of tetanus hyperimmune plasma. Serial antibody assay results and the frequency of adverse reactions were analysed to define the donors most suitable for an immune plasma programme. A high proportion of boosted donors were withdrawn from plasmapheresis because of poor persistence of antibody levels. Donors most suitable for boosting appear to be males under 25 years old with a tetanus antibody level of around 8 IU/ml prior to boosting.

Food antibodies, intestinal permeability and HLA status in IgA deficient blood donors identified by a new rapid screening test

Circulating food antibodies, intestinal permeability and HLA status were studied in twelve blood donors previously identified as being selectively IgA deficient from screening 10,000 donations by means of a latex agglutination inhibition test, and confirmed by laser nephelometry. Assessment of intestinal function also included clinical history and standard laboratory tests. The donors proved to be healthy with no evidence of autoimmune disease or allergy. Nine donors (75%) had precipitins to food antigens. None had increased intestinal permeability as measured by the cellobiose/mannitol absorption test. HLA-A, B and DR antigen distribution was normal. IgG sub-class distribution was normal with the exception of an IgG2 level slightly below normal in one donor (0.9 g/l). An unexpected finding was a return of IgA levels to normal in four donors (33%) within 6 months.

Influence of sham feeding on salt and water absorption in the human jejunum

Vagal stimulation induced by sham feeding in 11 healthy subjects was used to examine the possibility that the autonomic nervous system might be involved in the control of human jejunal absorption. Gastric acid secretion was measured from gastric aspirates corrected for recovery, and jejunal absorption was determined using a triple lumen perfusion technique. Sham feeding induced a significant increase in gastric acid secretion from 1.29 to 7.73 mmol/h (p less than 0.02). Jejunal absorption of water decreased significantly from 41.0 to 26.8 ml/30cm/h (p less than 0.02), sodium from 2.60 to 0.74 mmol/30cm/h (p less than 0.05, and chloride from 2.68 to 0.74 mmol/30cm/h (p less than 0.02). During the hour after sham feeding gastric acid secretion and jejunal absorption returned towards basal values. These results suggest that vagal stimulation may have influenced jejunal absorption of salt and water in man and supports the possibility that the autonomic nervous system has a physiological role in the control of intestinal mucosal function.

Characterisation of mouse monoclonal antibodies produced by immunisation with a single serotype component of a polyvalent Pseudomonas aeruginosa vaccine

Mouse monoclonal antibodies raised by immunisation with a protective antigen extract from Pseudomonas aeruginosa serotype 1 varied in immunoglobulin isotype, in passive protective properties against infection by homologous P. aeruginosa serotype 1, and in cross-reactions in ELISA against antigen preparations from 15 other P. aeruginosa serotypes. All monoclonal antibodies with specificity in ELISA for the immunising antigen gave some degree of protection to mice against lethal infection by the homologous P. aeruginosa serotype. The IgG antibodies were more protective than the IgM antibodies.

ADCC lysis of human erythrocytes sensitized with rhesus alloantibodies. IV. Characterization of anti-D sera which are inactive in ADCC

Certain anti-D sera, selected on the basis of their agglutination characteristics in vitro, fail to induce lysis of Rh(D) positive red cells by lymphocyte mediated antibody dependent cell mediated cytotoxicity (ADCC). Further investigation revealed that the non-lytic anti-D blocked in an antigen specific manner the effect of other anti-D sera which were normally lytic in ADCC. Absorption selection studies and fractionation of a non-lytic anti-D serum showed that the blocking effect was associated with IgG anti-D. Antigen binding and lymphocyte Fc-receptor binding studies indicated that the non-lytic anti-D was bound to Rh(D) positive red cells and enabled them to be bound by lymphocytes, but failed to mediate ADCC.

Severe oesophageal injury caused by Steradent

An elderly woman swallowed 2 tablets of a denture-cleansing agent (Steradent) believing them to be her sleeping tablets. This caused severe burning pain in the throat and resulted in a tight postcricoid oesophageal stricture. Treatment by repeated dilatation of the stricture has been only partially successful. Characteristic containers for non-medicinal tablets might help those with poor vision, and medicinal and non-medicinal tablets should never be stored in the same place.

Rhesus immunization in male volunteers: changes in lymphocyte functions following secondary immunizations in anti-D responders and non-responders

After secondary immunizations of rhesus(D)-negative male volunteers with Rh(D)-positive red cells, changes were found in the in vitro transformation and antibody-dependent cell-mediated cytotoxicity (ADCC) capacities of the volunteers' lymphocytes. Responders, who produced anti-D, showed marked depressions of ADCC which were not found in non-responders. Responders and non-responders in general showed similar changes in lymphocyte transformation. The relationships between altered lymphocyte functions following immunization, immunoregulatory activity and responsiveness to the Rh(D) antigen are discussed.

Adverse effect of plasma exchange on anti-D production in rhesus immunisation owing to removal of inhibitory factors

Intensive plasma exchange was used to reduce the maternal anti-D concentration in case of severe rhesus haemolytic disease. Initially the concentration fell from 30 to 4 IU/ml, but after six exchanges it increased to 490 IU/ml despite continued exchanges, and intrauterine fetal death eventually ensued. The increase in the rate of maternal anti-D production coincided with, and may have resulted from, removal of plasma immuno-regulatory factors that inhibited in-vitro lymphocyte functions. These results that the role of plasma exchange in haemolytic disease of the newborn is more complex than simply removing the antibody and that further investigations are needed.

Frozen lymphocyte pools as technical and reference controls for lymphocyte transformation

Healthy individuals' peripheral blood lymphocytes show wide ranges of response to mitogens and allogeneic lymphocytes. When individuals' lymphocytes are pooled together, the responses of the pool are equivalent to the means of the responses of the lymphocytes which comprise the pool. Pooled lymphocytes retain their responsiveness when stored frozen, and may be used as standard responding cells in lymphocyte transformation tests, but are not suitable controls for antigen-induced lymphocyte transformation.

The effect of transfer factor on neutrophil function in chronic mucocutaneous candidiasis

Chronic mucocutaneous candidiasis with hypoparathyroidism in a 6-year-old-boy is described. In addition to defects of in vivo and in vitro correlates of delayed-type hypersensitivity to Candida albicans the child also had abnormalities of neutrophil function in terms of their capacity to respond by chemotaxis to a known attractant and to kill suspensions of C. albicans. Dialysable transfer factor was given on six occasions at intervals of between 26 and 45 days. Neutrophil chemotaxis (optimal conditions) was restored following each of the six injections, neutrophil chemotaxis (sub-optimal conditions) following five of the six injections and candidicidal capacity following four of the six injections. The effects of transfer factor were transient requiring repeated injections. The Candida delayed-type hypersensitivity skin test was restored to normal but lymphocyte transformation to Candida extract was not consistently positive following treatment. There was a slight clinical improvement following therapy. These abnormalities of neutrophil and lymphocyte function point to the complexity of chronic mucocutaneous candidiasis. The improvement in neutrophil chemotaxis and candidicidal capacity following treatment suggests that transfer factor may be a heterogeneous group of molecules, some of which affect granulocytes and restore defects in their function.

Leucocyte function in a case of chronic benign neutropenia of infancy associated with circulating leucoagglutinins

A case of chronic benign neutropenia is described in association with circulating leucoagglutinins. IgG and IgM leucoagglutinins demonstrated by Sephadex G-200 chromatography agglutinated neutrophils and monocyte enriched leucocyte preparations. Total IgG, IgA, IgM and IgE, total haemolytic complement, C3 and C4 complement components were all within normal limits. Lymphocyte populations and transformation were normal apart from a relative increase in the number of B lymphocytes. In vitro studies showed that the patient's monocytes responded in chemotaxis, phagocytosis and intracellular killing of S. aureus in a comparable fashion to that of control neutrophils. Although the patient's serum also agglutinated monocytes these findings do not exclude the possibility that leucoagglutinins may have aetiological significance in this disease. The study also emphasizes the versatility of the monocyte in benign neutropenia.

Aspects of influenza C virus replication

Influenza C virus antigen could be detected by immunofluorescence in chick amniotic epithelium 4 hr. after inoculation with undiluted amniotic fluid. Antigen could be detected in the nucleus of rhesus monkey kidney tissue cultures 10 hr. after infection. Only cytoplasmic fluorescence was observed 17-21 hr. after infection.The pattern of replication was similar to that reported for group I myxoviruses, indicating that the virus is correctly classified as an influenza virus.

Effect of polymerized orosomucoid on some strains of influenza virus

1. Polymers of orosomucoid were produced in two molecular shapes, filamentous (;chain') and spherical (;ball'), by heating the sodium salt of the monomer in either water or high concentrations of sodium chloride. An ;intermediate' state containing both shapes in various proportions was found in preparations obtained by polymerizing orosomucoid in intermediate concentrations of sodium chloride. 2. The filamentous form of polymer was found to inhibit strongly the haemagglutination of some (;sensitive') strains but not of other (;insensitive') strains of influenza virus; the ;intermediate' form feebly inhibited haemagglutination by ;sensitive' strains. 3. The filamentous form agglutinated both ;sensitive' and ;insensitive' strains of virus; the other forms of polymer did not. It also inhibited multiplication of both ;sensitive' and ;insensitive' strains when inoculated into embryonated and de-embryonated eggs. 4. The ;intermediate' and spherical forms of the polymer had no effect on the virus multiplication. 5. Polymers of orosomucoid from which neuraminic acid had been split off had no detectable effect on influenza viruses.

The thermal polymerization of orosomucoid

1. Orosomucoid was prepared from the urine of a nephrotic patient and polymerized by heating it in a range of salt concentrations at pH4.1. 2. Heating at low ionic strengths produced a ;chain' polymer of indefinite length but having the same width as the diameter of the monomer (5.0nm.). Similar treatment in high ionic strengths also produced a spherical (;ball') polymer of limited diameter (14.8nm.). 3. The size and shape of both polymers were determined from ultra-centrifuge, gel-filtration and electron-microscope results. The results suggest that eight monomer units condense to form the ball polymer. 4. Heating orosomucoid at pH1.8 hydrolysed the N-acetylneuraminic acid off the molecule; only chains could then be formed, even in high ionic strengths. 5. Both polymers were stable under normal conditions but could be depolymerized in 3m-guanidine hydrochloride. The monomer could be repolymerized on heating: the ;chain monomer' only formed chains at all ionic strengths, but the ;ball monomer' was indistinguishable from the original monomer in its immunological properties and polymerization reaction.

Early increase in intestinal permeability in patients with severe acute pancreatitis: correlation with endotoxemia, organ failure, and mortality

Sepsis accounts for 80% of deaths from acute pancreatitis. This study aimed to investigate early changes in intestinal permeability in patients with acute pancreatitis, and to correlate these changes with subsequent disease severity and endotoxemia. The renal excretion of enterally administered polyethylene glycol (PEG) 3350 and PEG 400 was measured within 72 hours of onset of acute pancreatitis to determine intestinal permeability. Severity was assessed on the basis of APACHE II scores and C-reactive protein measurements. Serum endotoxin and antiendotoxin antibodies were measured on admission. Eight-five patients with acute pancreatitis (mild in 56, severe in 29) and 25 healthy control subjects were studied. Urinary excretion of PEG 3350 (median) was significantly greater in patients who had severe attacks (0.61%) compared to those with mild disease (0.09%) and health control subjects (0.12%) (P <0. 0001), as was the permeability index (PEG 3350/400 excretion) (P <0. 00001). The permeability index was significantly greater in patients who subsequently developed multiple organ system failure and/or died compared with other severe cases (0.16 vs. 0.04) (P = 0.0005). The excretion of PEG 3350 correlated strongly with endotoxemia (r = 0.8; P = 0.002). Early increased intestinal permeability may play an important role in the pathophysiology of severe acute pancreatitis. Therapies that aim to restore intestinal barrier function may improve outcome.

Early increase in intestinal permeability in patients with severe acute pancreatitis: correlation with endotoxemia, organ failure, and mortality

Sepsis accounts for 80% of deaths from acute pancreatitis. This study aimed to investigate early changes in intestinal permeability in patients with acute pancreatitis, and to correlate these changes with subsequent disease severity and endotoxemia. The renal excretion of enterally administered polyethylene glycol (PEG) 3350 and PEG 400 was measured within 72 hours of onset of acute pancreatitis to determine intestinal permeability. Severity was assessed on the basis of APACHE II scores and C-reactive protein measurements. Serum endotoxin and antiendotoxin antibodies were measured on admission. Eight-five patients with acute pancreatitis (mild in 56, severe in 29) and 25 healthy control subjects were studied. Urinary excretion of PEG 3350 (median) was significantly greater in patients who had severe attacks (0.61%) compared to those with mild disease (0.09%) and health control subjects (0.12%) (P <0. 0001), as was the permeability index (PEG 3350/400 excretion) (P <0. 00001). The permeability index was significantly greater in patients who subsequently developed multiple organ system failure and/or died compared with other severe cases (0.16 vs. 0.04) (P = 0.0005). The excretion of PEG 3350 correlated strongly with endotoxemia (r = 0.8; P = 0.002). Early increased intestinal permeability may play an important role in the pathophysiology of severe acute pancreatitis. Therapies that aim to restore intestinal barrier function may improve outcome.