Medication with ursodeoxycholic acid enhances the biliary clearance of polyethylene glycol 900, but not mannitol

Ursodeoxycholic acid (UDCA) is a nontoxic bile acid currently used in the treatment of different cholestatic diseases. This bile acid is also considered to be a 'hypercholeretic bile acid'. The effects of daily administration of UDCA on bile flow and the bile acid secretion rate in man are not fully known. The aim of this study was to explore the effects by UDCA on bile flow and its different functions. The biliary clearances of polyethylene glycol 900 (PEG 900) and mannitol were measured simultaneously in patients with an indwelling T tube after cholecystectomy. One group (n = 6) were given UDCA (10 mg/kg/day) for at least 14 days before the investigation and a control group (n = 8) received no bile acid treatment. The bile secretion was studied in acute experiments where bile was drained for 6 h. The bile plasma ratio for PEG 900 was 31 and that for mannitol was 0.7 which corresponds well with the results obtained in different animal species. The relationship between bile flow and the bile salt secretion rate, as expressed by linear regression analysis, showed no difference between the 2 groups (control y = 0.22 + 0.012x, r = 0.61, p < 0.001; UDCA y = 0.20 + 0.016x, r = 0.88, p < 0.001). The relationship between the biliary clearance of PEG 900 and the bile salt secretion rate, as expressed with linear regression analysis, showed a significantly steeper slope for the UDCA-treated patients (control y = 8.1 + 0.34x, r = 0.41, p < 0.05; UDCA y = 5 + 1.58x, r = 0.78, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Prediction of dental caries development in 1-year-old children

Dietary habits, oral hygiene, fluoride exposure and occurrence of mutans streptococci were studied in 1-year-old children (n = 786) as well as the socio-economic and immigrant background of their parents. The purpose was to evaluate the predictive ability of variables studied in 1-year-old children that could be used to identify children at risk for early caries development. In a multivariate logistic regression analysis, the variables significantly associated with caries at 3.5 years of age were immigrant background (p < 0.001), mother's education (p < 0.001), consumption of sugar-containing beverages (p < 0.001), mutans streptococci (p < 0.05) and candy (p < 0.05). The probability of caries development was 87% when all the variables associated with caries were present at 1 year of age. The relative risk (odds ratio) of those children to develop manifest caries at 3.5 years of age was estimated to be 32 times higher than in the children where corresponding risk factors were not present. The results indicate that prediction at 1 year of age, built on risk factors associated with dental caries, can provide an indication of possible preventive interventions.

Improved long-term preservation of the coronary vasculature with University of Wisconsin solution

Experiments were designed to investigate coronary vascular function after prolonged cold storage of isolated rat hearts, using University of Wisconsin (UW) solution. Hearts perfused with crystalloid cardioplegic solution (Plegisol) were used as controls. After perfusion with 10 ml at 4 degrees C, hearts were stored for 1 or 10 hours in the respective solutions at 4 degrees C. To evaluate coronary vascular function after perfusion and storage, endothelium-dependent vasodilation was induced with 5-hydroxytryptamine (5-HT) and smooth muscle-dependent dilation with nitroglycerin (GTN). After perfusion only, or perfusion plus 1-hour storage, there was no intergroup difference in response to 5-HT and GTN. After 10-hour storage the vasodilatory response to 5-HT was abolished in the Plegisol group and slight vaso-constriction was observed, whereas in the UW group the vasodilatory effect of 5-HT persisted. The findings suggest that UW solution may be more favorable for prolonged cardiac preservation, as the coronary vascular reactivity was less affected.

Impairments in complement receptor- and Fc receptor-mediated functions in vivo in patients with psoriasis

The function of the fixed macrophage system in 18 psoriasis patients was evaluated by measuring the elimination rate of injected autologous erythrocytes coated with iC3b or IgG. The mean half-life of iC3b-coated erythrocytes was significantly prolonged in patients with psoriasis compared with healthy controls (4.7 +/- 0.8 vs 2.7 +/- 0.2 min, P = 0.01). There was also a decrease in the total number of cells eliminated from the circulation (2.5 +/- 0.2 x 10(8) vs 3.3 +/- 0.2 x 10(8), P = 0.01). There was an even more pronounced increase in the half-life of IgG-coated erythrocytes (85 +/- 18 vs 20 +/- 5 min, P < 0.001), with normal values in only 5 of 15 patients, and 4 of these 5 patients were receiving systemic treatment. The slow elimination was interpreted as being caused by primary or secondary defects in receptor function rather than by blocking of the receptors by immune complexes, since patients with psoriasis show normal levels of circulating immune complexes. Further studies are needed to elucidate the nature of these defects.

Analysis of protein glycosylation by mass spectrometry

There is a growing pharmaceutical market for protein-based drugs for use in therapy and diagnosis. The rapid developments in molecular and cell biology have resulted in production of expression systems for manufacturing of recombinant proteins and monoclonal antibodies. These proteins are glycosylated when expressed in cell systems with glycosylation ability. For glycoproteins intended for therapeutic administration it is important to have knowledge about the structure of the carbohydrate side chains to avoid cell systems that produce structures, which in humans can cause undesired reactions, e.g., immunological and unfavorable serum clearance rate. Structural analysis of glycoprotein oligosaccharides requires sophisticated instruments like mass spectrometers and nuclear magnetic resonance spectrometers. However, before the structural analysis can be conducted, the carbohydrate chains have to be released from the protein and purified to homogeneity, and this is often the most time-consuming step. Mass spectrometry has played and still plays an important role in analysis of protein glycosylation. The superior sensitivity compared to other spectroscopic methods is its main asset. Structural analysis of carbohydrates faces several problems, however, due to the chemical nature of the constituent monosaccharide residues. For oligosaccharides or glycoconjugates, the structural information from mass spectrometry is essentially limited to monosaccharide sequence, molecular weight, an only in exceptional cases glycosidic linkage positions can be obtained. In order to completely establish an oligosaccharide structure, several other structural parameters have to be determined, e.g., linkage positions, anomeric configuration and identification of the monosaccharide building blocks. One way to address some of these problems is to work on chemical pretreatment of the glycoconjugate, to specifically modify the carbohydrate chain. In order to introduce specific modifications, we have used periodate oxidation and trifluoroacetolysis with the objective of determining glycosidic linkage positions by mass spectrometry.

Absence of effect on exercise capacity of 12-weeks treatment with ramipril in patients with moderate congestive heart failure. Ramipril Study Group

Pharmacological therapy in cases of chronic congestive heart failure (CHF) is usually evaluated by maximal exercise time. To assess the effect of an angiotensin converting enzyme inhibitor, ramipril, 223 patients with moderate CHF were studied in 24 centres in four Nordic countries in a randomized, double-blind, placebo-controlled, parallel group design. The study drug was titrated from 1.25 mg to a maximum of 10 mg once daily (o.d) over a period of 4 weeks (mean dose 8 mg). A symptom-limited bicycle exercise test, starting at 30 watts and increasing by 10 watts.min-1, was used to evaluate exercise capacity. Reproducible tests were required at baseline, and the test was repeated after 4, 8 and 12 weeks of treatment. Seven deaths were recorded in the placebo group and one death in the ramipril group. A total of 195 patients completed 12 weeks of treatment (placebo group n = 91, ramipril group n = 104). The groups had similar baseline characteristics. Maximal exercise time was increased by mean (SD) 35 s (9) and 41 s (8) in the placebo and ramipril groups, respectively. The adjusted difference between the groups at 12 weeks was 9 s (12) (ns). A significant decrease in blood pressure and rate-pressure product at rest and at end of exercise was obtained by ramipril as compared with placebo. Significantly fewer patients deteriorated in NYHA class from baseline to 12 weeks of ramipril treatment compared to placebo (P = 0.012). Concomitant medication for CHF increased significantly in the placebo group as compared with ramipril-treated patients (P = 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)

Neurohormonal activation in patients with mild or moderately severe congestive heart failure and effects of ramipril. The Ramipril Trial Study Group

OBJECTIVES

To describe neurohormonal activation in patients with mild or moderate heart failure and how it may be modified by treatment with ramipril.

SETTING

Cardiology departments at 24 hospitals in Denmark, Finland, Norway, and Sweden.

PATIENTS

223 patients with mild or moderately severe congestive heart failure who were taking diuretics with or without digitalis.

DESIGN

Randomised, double bind, multicentre, placebo controlled comparison of ramipril and placebo. Venous blood samples were drawn at rest, before blind treatment, and after 12 weeks of treatment with the study drug. A probability prediction score for mortality derived by stepwise linear discriminant from neurohormone data in the first cooperative north Scandinavian enalapril survival study (CONSENSUS I) was used to assess combined activity of the different neurohormonal systems.

RESULTS

Plasma concentrations of atrial natriuretic peptide were raised at baseline but angiotensin II, aldosterone, and noradrenaline concentrations were within normal limits. There was, however, a wide interindividual variation. Plasma noradrenaline concentration and prediction score were higher among patients with class III congestive heart failure according to the New York Heart Association's classification than among patients with class II congestive heart failure (P < 0.05). There was a modest but significant inverse correlation between exercise duration at baseline and plasma noradrenaline concentration (r = -0.21, P = 0.0023), aldosterone concentration (r = -0.14, P = 0.04), and prediction score (r = -0.24, P = 0.0004). Prediction score at baseline was significantly higher among those who died (n = 10) than among survivors (P = 0.03). Angiotensin converting enzyme activity was suppressed and plasma concentrations of aldosterone and atrial natriuretic peptide were reduced after 12 weeks of treatment with ramipril compared with placebo. In patients with the most pronounced neurohormonal activation at baseline (highest third of noradrenaline concentration or prediction score), noradrenaline concentration and prediction score were significantly lower after 12 weeks of taking ramipril compared with placebo. Patients with a prediction score in the highest third at baseline had a higher heart rate than to those in the lowest third (P = 0.003).

CONCLUSIONS

Neurohormonal activation is associated with the degree of symptoms and the severity of disease in mild or moderately severe congestive heart failure. Treatment with ramipril attenuates neurohormonal activation. This effect is most pronounced among patients with the highest circulating concentrations of neurohormones before the start of treatment.

The prevalence of locomotor complaints in middle age and their relationship to health and socioeconomic factors

The prevalence and coincidence of symptoms or signs or both of degenerative changes in the back, shoulders, hips, and knees were analyzed in 575, 55-year-old residents of Malmö, Sweden, and the relationship of these complaints to smoking and alcohol habits, nervous problems, body weight, social background, intelligence test in 1938, education, job satisfaction, income, life success, employment, and occupational workload were analyzed. Back pain was the most common complaint--nearly 1/3--in men and women. Locomotor discomfort coincided more often and was more frequent in women. Overweight was related to knee and back complaints in men. Men with shoulder complaints were more often smokers. Men with knee complaints had higher levels of serum glutamyl-transferase, indicating a higher alcohol intake. Sleeping disturbances were more common in subjects with shoulder, back, and knee complaints. Subjects with moderate or heavy work loads had more locomotor complaints, particularly in the back, hips, and knees. Job dissatisfaction was the variable with the strongest independent relation to locomotor discomfort in both genders.

Carcinoma of the fallopian tube. A clinical and histopathologic review. The Radiumhemmet series

A histopathologic and clinical review of the Radiumhemmet series of primary fallopian tube carcinoma (PFTC) treated from 1923 to 1991 revealed that 128 cases fulfilled the diagnostic criteria for PFTC. These cases were staged according to the new FIGO staging rules for PFTC. Survival was studied with respect to prognostic factors such as age, stage, histologic subgroups, degree of differentiation and mode of treatment. The mean age at diagnosis was 56 years. Seventy-four per cent were found to be in stage Ia-IIa and 26 % in stage III-IV. Forty-five per cent were nulliparous and 22 % had evidence of previous pelvic inflammatory disease. Treatment modalities changed during the studied period. Thirty-three per cent of patients underwent surgery with total abdominal hysterectomy and bilateral salpingo-oophorectomy while 67 % were incompletely operated. A trend towards improvement in results was noticed-however, it was not statistically significant. Among the 14 prognostic variables tested in the multivariate analysis the first in rank were stage (P = 0.001) and degree of differentiation of the tumors (P = 0.070). Patients receiving chemotherapy had superior survival rates compared with those without chemotherapy (P = 0.0006) and patients with cisplatinum-containing chemotherapy did better than those without cisplatin.

Reconstitution of the alternative pathway of complement by plasma infusions given to a patient with an SLE-like syndrome associated with a hereditary C3 dysfunction

OBJECTIVE

To reconstitute a dysfunctional form of complement factor C3 in a patient with a systemic lupus erythematosus (SLE)-like syndrome.

METHODS

The propositus was treated with plasma infusions during five sessions over a period of eight months.

RESULTS

The alternative pathway was reconstituted to normal levels for approximately two to three days after each infusion. C3 fragments were incorporated into previously detected deposits of IgG and IgM at the dermal-epidermal junction and the immune complex levels gradually decreased during the whole treatment period.

CONCLUSION

The reconstitution appears to result in the solubilisation of tissue immune complexes and a subsequent transportation to the fixed macrophage system.

Different types of rupture of the tumor capsule and the impact on survival in early ovarian carcinoma

The significance of tumor spill in the early stages of ovarian carcinoma has been the subject of controversy. Since rupture of the capsule of the tumor may occur in several different ways, we analyzed all cases of early ovarian cancer treated at Radiumhemmet, Stockholm, Sweden, during the period 1974-1986, in which possible spill of tumor cells was catalogued in different groups. In 247 out of 394 patients (62%) the risk of spill had to be considered. There was no difference in survival between patients whose tumors had intact capsules and patients in whom rupture occurred during surgery-78% and 85%, respectively. On the other hand, a significant difference in survival was found between patients in whom rupture occurred before surgery and those with intraoperative rupture-59% and 85%, respectively. The conclusion can be drawn that manipulation during surgery which results in puncture or rupture does not have a negative influence on the outcome for the patients.

Role of antibody synthesis and complement activation in concordant xenograft retransplantation

A mouse-to-rat heart retransplantation model was used to study the effects of complement depletion and antibody production with regard to graft survival and anti-donor antibody specificity. Retransplantation was performed 3 weeks after the first transplantation in the presence of absence of 15-deoxyspergualin (DSG) immunosuppression. Untreated animals rejected their first graft after 3 days and retransplantation resulted in a hyperacute rejection within 2 min. A low titer of preformed anti-mouse lymphocytotoxic antibodies of the IgM subclass was found in serum collected from the unoperated rat. The rejection gave rise to a synthesis of IgG antidonor antibodies reacting with both graft endothelium and sarcolemma. Immunofluorescent staining of the rejected first heart graft showed moderate IgM and IgG antibody deposits on the graft vascular endothelium, while only IgG was found in the second graft. There was no C3 deposition found in the first mouse graft, as was the case in the second mouse graft. Anti-mouse antibodies cross-reacted with hamster antigens and a hyperacute rejection of a hamster heart graft occurred in a mouse-sensitized rat. Immunofluorescent staining revealed that the antibodies did not bind to hamster heart endothelium, as was expected, but, instead, to graft sarcolemma. DSG treatment prolonged the survival of the first graft by a median of 8 days. Continuous treatment until retransplantation resulted in a prolongation to 30 (20-127) min of the survival of the second graft and no increase in antibody titers against mouse antigens was observed. However, immunofluorescent staining revealed a weak binding of anti-mouse antibodies of the IgM subclass in the rejected mouse heart graft. Additional complement depletion with cobra venom factor in DSG-treated animals resulted in a prolongation of the median graft survival to 48 hr (6-96). No sign or minimal signs of antibody deposition were found in these grafts, but histology revealed massive mononuclear infiltration. In conclusion, xenograft transplantation in a concordant situation results in a shift of antidonor antibody Ig synthesis from IgM to IgG. If daily DSG treatment is administered from the day of transplantation, this reduces the synthesis of antidonor antibodies, and if complement is also depleted, the survival of the second graft is prolonged. The significance of the mononuclear infiltration remains to be established.

Short-term kinetics of the humoral anti-C1q response in SLE using the ELISPOT method: fast decline in production in response to steroids

Twenty four systemic lupus erythaematosus patients and 17 patients with other diagnoses were investigated regarding the presence of cells producing C1q reactive antibodies in peripheral blood mononuclear cells using the ELISPOT technique. These results were then compared with parallel serum levels of C1q reactive antibodies. Current production of anti-C1q was almost entirely confined to the systemic lupus erythaematosus group. Longitudinal analysis of anti-C1q ELISPOT positive patients showed rapid changes in the number of anti-C1q producing cells, but only slowly changing serum levels of the corresponding antibodies in response to glucocorticoids. In one systemic lupus erythaematosus patient prednisolone treatment had a selective effect on this autoantibody production, as the production of anti-C1q spot forming cells rapidly dropped to zero, at the same time as the number of total spot-forming cells showed only less change. In another patient, self-limiting connective tissue disease was associated with temporal occurrence of IgM anti-C1q. We believe, from these data, that the ELISPOT method for determination of current antibody production may be of particular value in longitudinal evaluation of disease course and therapeutic effects in systemic lupus erythaematosus and other rheumatic diseases.

Complement activation during cardiopulmonary bypass: effects of immobilized heparin

The role of complement in biocompatibility reactions and the correlation between complement activation during cardiopulmonary bypass (CPB) and postperfusion syndrome have inspired attempts to improve the biocompatibility of extracorporeal blood oxygenation devices. Here we assessed the effect of immobilized heparin on the generation of C3a and terminal complement complexes during CPB. Thirty patients undergoing aortocoronary bypass were randomized to CPB with either heparin-coated (Duraflo II; Bentley, Irvine, CA) or noncoated control membrane oxygenators (Univox; Bentley). A standard dose of heparin (300 IU/kg) was given to the control group while the heparin dose was reduced to 30% (100 IU/kg) in the heparin-coated group. Significantly lower levels of terminal complement complexes were detected in the heparin-coated group by the end of CPB. From 28 +/- 5 AU/mL (heparin-coated group) and 26 +/- 3 AU/mL (control group, mean +/- standard error of the mean) the terminal complement complex levels increased to 391 +/- 35 AU/mL and 602 +/- 47 AU/mL, respectively (p < 0.002). This difference was still apparent 180 minutes after CPB. Although there was no difference in C3a levels between the two groups at the end of CPB, C3a levels were significantly lower in the heparin-coated group 30 minutes after CPB (194 +/- 18 ng/mL and 307 +/- 18 ng/mL in heparin-coated and control groups, respectively; p < 0.001). We conclude that the heparin-coated surface is more biocompatible with regard to complement activation than is the ordinary unmodified surface in extracorporeal circuits.

Retroperitoneal endodermal sinus tumor. Report of a case with an abnormal cervicovaginal smear

An unusual case of an endodermal sinus tumor arising in the retroperitoneum and invading the fallopian tube is reported. The patient presented with malignant cells mimicking adenocarcinoma in the cervicovaginal smear. The differential diagnoses of such cells in cervicovaginal cytology are discussed. The cytohistologic, immunohistochemical and ultrastructural findings of the tumor are correlated.

Raised pressure in the bile ducts after orthotopic liver transplantation

Biliary complications are common after orthotopic liver transplantation. Bile leakage in the immediate postoperative period and on removal of the T-tube could possibly be caused by a raised bile duct pressure. In order to test this hypothesis, bile duct pressure was studied in seven consecutive liver transplant patients. During the operation, the common bile duct was anastomosed end-to-end over a T-tube. The initial bile duct pressure measurement was performed a median of 12 days (range 10-17 days) after the transplantation and on one or two more occasions during the following 3 months. Seven cholecystectomized gallstone patients with indwelling T-tubes were used as controls. The bile duct pressure at the level of the xiphoid process in the transplanted group was 7.7 +/- 1.4 cm H2O and in the control group 0.5 +/- 0.8 cm H2O (P < 0.001). The initially increased bile duct pressure after liver transplantation decreased with time (P < 0.05) towards normal during the following 3 months. The raised pressure may increase the risk of bile leakage in the postoperative period.

Intratumoral heterogeneity for amplified genes in human breast carcinoma

Intratumoral heterogeneity was studied in human breast cancer by examining separate tumor lesions of individual patients. Tumor samples were obtained from each patient by fine-needle biopsies from 2 to 4 separate tumor lesions. We used a semi-quantitative PCR to distinguish between samples with gene amplification and single gene copy samples. Five genes were analyzed in each biopsy: MDR-1, dihydrofolate reductase, thymidylate synthase, c-erb-B2 and int-2. Three groups of patients were examined: those awaiting initiation of treatment; those receiving first-line endocrine therapy; and those receiving second-line endocrine treatment. A pattern of intratumoral heterogeneity for gene amplification was clearly apparent. The frequency of amplification was lowest before initiating therapy and highest in patients receiving second-line treatment (p = 0.023).

Folding of insulin-like growth factor I is thermodynamically controlled by insulin-like growth factor binding protein

Insulin-like growth factor I (IGF-I) is thermodynamically unable to quantitatively form its native disulfides under reversible redox conditions in vitro [Hober et al. (1992) Biochemistry 31, 1749-1756]. These results prompted the question of how IGF-I may overcome this energetic problem in its folding in vivo. Here, we report that an IGF-I precursor, IGF-I-Ea, shows disulfide-exchange folding properties similar to those of mature IGF-I and, thus, is concluded not to overcome the identified folding problem of mature IGF-I. However, correct disulfide bonds are formed very efficiently when insulin-like growth factor binding protein 1 is added in equimolar amounts to IGF-I to the refolding mixture. On the basis of these results, we propose that one important function of at least one of the six homologous insulin-like growth factor binding proteins is to assist in the formation and maintenance of the native disulfides of IGF-I. To our knowledge, this is the first example where the folding of a mammalian protein or peptide in circulation has been demonstrated to be thermodynamically controlled by its binding protein. Speculatively, this could provide a mechanism to regulate the half-life of IGF-I in vivo by altering the interaction with insulin-like growth factor binding proteins.