Interleukin 6, but not ciliary neurotrophic factor or leukaemia inhibitory factor, is responsible for the acute phase response to turpentine-induced myositis

The acute phase response to inflammation is mediated in part by the endogenous production of pro-inflammatory cytokines. Interleukin 6 (IL-6) and members of its superfamily, including ciliary neurotrophic factor (CNTF) and leukaemia inhibitory factor (LIF) have been implicated as primary mediators of the hepatic acute phase response. In the present report, mice suffering a turpentine-induced myositis were passively immunized with antibodies against either IL-6, CNTF or LIF. Passive immunization against IL-6 attenuated the anorexia and completely prevented the hypoalbuminaemia, and increases in the serum concentration of the acute phase reactants, amyloid P, amyloid A and seromucoid. In contrast, passive immunization against either CNTF or LIF failed to modulate the anorexia, weight loss or hepatic acute phase protein responses. The findings suggest that IL-6, but not other members of its superfamily, is primarily responsible for the hepatic acute phase response, and contributes to the anorexia, associated with turpentine-induced myositis.

Neutralization of pyrogen-induced tumour necrosis factor by its type 1 soluble receptor in guinea-pigs: effects on fever and interleukin-6 release

1. A soluble form of the tumour necrosis factor (TNF) type 1 receptor (referred to as TNF binding protein, TNF-bp) at a dose of 1 mg per animal, or an equivalent volume of solvent, was injected together with 10 microg kg-1 lipopolysaccharide (LPS) or 50 microg kg-1 muramyl-dipeptide (MDP) directly into the arterial circulation of guinea-pigs and the effects on circulating TNF or interleukin-6 (IL-6) and on abdominal temperature were studied. 2. At 15 or 60 min after injection, LPS-induced and MDP-induced circulating TNF was below the detection limit of the assay and thus completely neutralized in animals treated with TNF-bp. In the control group, TNF was still below the limit of detection in most animals 15 min after LPS was injected; in some animals small traces of TNF could already be detected at that time. However, 60 min after administration of LPS, large amounts of TNF (19508 +/- 4682 pg ml-1) were measured in the control group. MDP-induced TNF in plasma was below the limit of detection 15 min after MDP was injected, and rose to 10862 +/- 3029 pg ml-1 60 min after injection. 3. Low levels of circulating IL-6 (20-40 international units (IU) ml-1) were measured in all groups of animals 15 min after injection of LPS or MDP. This value corresponds to the baseline activity of IL-6 in plasma of guinea-pigs. One hour after administration of LPS, IL-6 rose to 5442 +/- 1662 IU ml-1 in the control group and to a significantly lower value of 1485 +/- 179 IU ml-1 in guinea-pigs treated with TNF-bp. One hour after injection of MDP, circulating IL-6 was 2614 +/- 506 IU ml-1 in the control group, while the corresponding value in animals treated with TNF-bp again was significantly lower (873 +/- 312 IU ml-1). 4. The second phase of the characteristic biphasic LPS fever in guinea-pigs was significantly attenuated in animals treated with TNF-bp. The shorter first phase of the febrile response to LPS was identical in both groups of animals. 5. The late phase of MDP-induced fever (7-22 h after injection) was depressed by treatment with TNF-bp, while the first phase of MDP-induced fever (0-7 h after injection) was significantly enhanced by the neutralization of TNF by TNF-bp.

Cold effect on oxygen uptake, perceived exertion, and spasticity in patients with multiple sclerosis

OBJECTIVE

To determine the effect of a cold bath (24 degrees C) on oxygen consumption and perceived exertion during ambulation and on spasticity in individuals with mild to moderate multiple sclerosis.

DESIGN

A repeated-measures design with random assignment of experimental and control conditions.

SETTING

Outpatient physical therapy department associated with an academic institution.

PATIENTS

Fourteen individuals with clinically definite multiple sclerosis exhibiting spasticity and capable of ambulating at 0.7 m/sec on a motorized treadmill without handrail support.

MEASUREMENT

Assessment of oxygen uptake, heart rate, and perceived exertion occurred during two 10-minute walks interspersed with a 30-minute rest on 2 separate days. Measurement of spasticity occurred three times during each session.

RESULTS

Oxygen consumption and perceived exertion were unchanged. Spasticity was higher immediately (p < .05) after the cold bath.

CONCLUSIONS

Increase in spasticity was statistically significant, but unlikely to be of any clinical importance. Contrary to our hypothesis, a cold bath (24 degrees C) for 20 minutes did not reduce oxygen consumption or rating of perceived exertion during ambulation.

[Role of emergency reconstruction of fingers by the "reposition-flap" technique. Report of eight cases]

Following replantation failure, fingertip reconstruction was performed as an emergency "reposition-flap" procedure in seven patients (eight fingers). This technique was intended for amputations distal to the DIP joint in long fingers, and IP joint in the thumb. Pulp was excised on the amputated segment, and the remaining bone and nail bed were reattached to the proximal stump with Kirschner wires. Pulp was reconstructed with a local advancement and sensitive flap. Trophicity and nail regrowth as well as mobility and strength were satisfactory in five cases. MRI examination showed revascularization of the distal bone fragment in four cases. This procedure is an alternative to amputation after replantation failure when patients do not accept finger shortening. The more distal the amputation, the better is the result.

Validation of a self-report measure of somatic health

The primary purpose was to assess the validity of a new self-report inventory of general somatic health status. In addition, we sought to examine the influence of social desirability and negative affectivity on health reports and to learn whether asking respondents to report concrete, memorable aspects of illness episodes such as seeing a doctor or staying home in bed for all or most of a day would enhance validity. The somatic component of the Cornell Medical Index was used as a criterion measure of health status because that Index has been shown to reflect medical records with great accuracy. Scores on the new health inventory correlated highly with the Cornell somatic scores, and this relationship was independent of negative affectivity and social desirability. The addition of the "concrete, memorable" aspects of illness accounted for no additional variance in the Cornell Index somatic scores beyond that accounted for by mere reporting of the presence of the symptom or illness. This study offers evidence supporting the validity of the Inventory of Health Status as a predictor of somatic health independent of social desirability and negative affectivity and also indicates that a simple indication of whether the patient had the symptoms is sufficient.

Autoradiographic distribution of brainstem substance P binding sites in humans: ontogenic study and relation to sudden infant death syndrome (SIDS)

The precise distribution of substance P (SP) binding sites in the human brainstem was investigated in normal cases (3 fetuses and 24 new-borns) and in 9 cases of Sudden Infant Death Syndrome (SIDS) by in vitro quantitative autoradiography. We discussed the widely but uneven distribution of SP binding sites as regards to the role of SP in brainstem cardio-respiratory ontogenic control and its possible involvement in SIDS.

Primary care physician compensation method in medical groups: does it influence the use and cost of health services for enrollees in managed care organizations?

CONTEXT

Growth of at-risk managed care contracts between health plans and medical groups has been well documented, but less is known about the nature of financial incentives within those medical groups or their effects on health care utilization.

OBJECTIVE

To test whether utilization and cost of health services per enrollee were influenced independently by the compensation method of the enrollee's primary care physician.

DESIGN

Survey of medical groups contracting with selected managed care health plans, linked to 1994 plan enrollment and utilization data for adult enrollees.

SETTING

Medical groups, major managed care health plans, and their patients/enrollees in the state of Washington.

STUDY PARTICIPANTS

Sixty medical groups in Washington, 865 primary care physicians (internal medicine, pediatrics, family practice, or general practice) from those groups and affiliated with 1 or more of 4 managed care health plans, and 200 931 adult plan enrollees.

INTERVENTION

The effect of method of primary care physician's compensation on the utilization and cost of health services was analyzed by weighted least squares and random effects regression.

MAIN OUTCOME MEASURES

Total visits, hospital days, and per member per year estimated costs.

RESULTS

Compensation method was not significantly (P>.30) related to utilization and cost in any multivariate analyses. Patient age (P<.001), female gender (P<.001), and plan benefit level (P<.001) were significantly positively related to visits, hospital days, and per member per year costs. The primary care physician's age was significantly negatively related (P<.001) to all 3 dependent measures.

CONCLUSIONS

Compensation method was not significantly related to use and cost of health services per person. Enrollee, physician, and health plan benefit factors were the prime determinants of utilization and cost of health services.

[Pancreas transplantation with bladder and intestinal drainage technique with systemic-venous and initial experiences with portal venous drainage. Which technique can be recommended today?]

The experience worldwide with pancreas transplantation includes more than 9000 cases. In the most popular patient group (simultaneous pancreas-kidney transplantation, SPK) the graft-function rate at 1 year now reaches more than 80%. More than 90% of all pancreas transplants were performed using the bladder-drainage technique (BD) with systemic venous anastomosis. Late problems with the BD require enteric conversion in 10-20% in the long term. In the present study we report the results of 40 SPK using the BD (n = 20) and enteric drainage (ED) techniques (n = 20). After 3 months, the patients pancreas and kidney survival rates in the BD group were 100, 95 and 100% and in the ED group 100, 100 and 100%, respectively. No anastomosis leakage occurred in either group. In two cases of the ED group the pancreas grafts were drained portal venously via the superior mesenteric vein without surgical complications. With growing experience, excellent SPK results can be reached with both the BD and ED techniques.

Japanese encephalitis among hospitalized pediatric and adult patients with acute encephalitis syndrome in Hanoi, Vietnam 1995

The etiologic spectrum of acute encephalitis syndrome (AES) has not been well defined in Vietnam. Cohort and case-control studies were performed on all adult and pediatric AES patients admitted to the Neurology Service of Bach Mai Hospital between June 5 and August 3, 1995. Among pediatric AES patients, 31 (67%) of 46 had acute Japanese encephalitis (JE), compared with only two (6%) of 33 adult AES patients (P < 0.0001). For confirmed JE cases, serum specimens obtained 15-21 days after symptom onset had the highest mean anti-JE IgM signal-to-noise (P/N) ratios (8.08 + 1.09 SE). A serosurvey of adult household members did not reveal any cases of recent subclinical JE infection, although 26% had evidence of past JE infection. The use of bed netting was nearly universal but did not appear to reduce the risk of AES or JE. Given the high incidence of JE, particularly among children, Vietnam seems well suited for the development of a targeted JE vaccination strategy.

Antimalarial activity of 77 phospholipid polar head analogs: close correlation between inhibition of phospholipid metabolism and in vitro Plasmodium falciparum growth

Seventy-seven potential analogs of phospholipid polar heads, choline and ethanolamine, were evaluated in vitro as inhibitors of Plasmodium falciparum growth. Their IC50 ranged from 10(-3) to 10(-7) mol/L. Ten compounds showed similar antimalarial activity when tested against three different parasite strains (2 chloroquine-sensitive strains and 1 chloroquine-resistant strain). Compounds showing marked antimalarial activity were assayed for their effects on phospholipid metabolism. The most active compounds (IC50 of 1 to 0.03 micromol/L) were inhibitors of de novo phosphatidylcholine (PC) biosynthesis from choline. For a series of 50 compounds, there was a close correlation between impairment of phospholipid biosynthesis and inhibition of in vitro malaria parasite growth. High choline concentrations caused a marked specific shift in the curves for PC biosynthesis inhibition. Concentrations inhibiting 50% PC metabolism from choline were in close agreement with the Ki of these compounds for the choline transporter in Plasmodium knowlesi-infected erythrocytes. By contrast, measurement of the effects of 12 of these compounds on rapidly dividing lymphoblastoid cells showed a total absence of correlation between parasite growth inhibition and human lymphoblastoid cell growth inhibition. Specific antimalarial effects of choline or ethanolamine analogs are thus likely mediated by their alteration of phospholipid metabolism. This indicates that de novo PC biosynthesis from choline is a very realistic target for new malaria chemotherapy, even against pharmacoresistant strains.

Anorectic effects of the cytokine, ciliary neurotropic factor, are mediated by hypothalamic neuropeptide Y: comparison with leptin

Although ciliary neurotropic factor (CNTF) is a tropic factor in nervous system development and maintenance, peripheral administration of this cytokine also causes severe anorexia and weight loss. The neural mechanism(s) mediating the loss of appetite is not known. As hypothalamic neuropeptide Y (NPY) is a potent orexigenic signal, we tested the hypothesis that CNTF may adversely affect NPYergic signaling in the hypothalamus. Intraperitoneal administration of CNTF (250 microg/kg) daily for 4 days significantly suppressed 24-h food intake in a time-dependent manner and decreased body weight. The loss in body weight was similar to that which occurred in pair-fed (PF) rats. As expected, hypothalamic NPY gene expression, determined by measurement of steady state prepro-NPY messenger RNA by ribonuclease protection assay, significantly increased in PF rats in response to energy imbalance. However, despite a similar loss in body weight, there was no increase in NPY gene expression in CNTF-treated rats. Daily administration of CNTF intracerebroventricularly (0.5 or 5.0 microg/rat) also produced anorexia and body weight loss. In this experiment, negative energy balance produced by both PF and food deprivation augmented hypothalamic NPY gene expression. However, despite reduced intake and loss of body weight, no similar increment in hypothalamic NPY gene expression was observed in CNTF-treated rats. In fact, in rats treated with higher doses of CNTF (5.0 microg/rat), NPY gene expression was reduced below the levels seen in control, freely fed rats. Furthermore, CNTF treatment also markedly decreased NPY-induced feeding. These results suggested that anorexia in CNTF-treated rats may be due to a deficit in NPY supply and possibly in the release and suppression of NPY-induced feeding. The possibility that CNTF-induced anorexia may be caused by increased leptin was next examined. Daily intracerebroventricular injections of leptin (7 microg/rat) decreased food intake, body weight, and hypothalamic NPY gene expression in a manner similar to that seen after CNTF treatment. Leptin administration also suppressed NPY-induced feeding. However, peripheral and central CNTF injections markedly decreased leptin messenger RNA in lipocytes, indicating a deficiency of leptin in these rats; thus, leptin was unlikely to be involved in appetite suppression. Thus, these results show that a two-pronged central action of CNTF, causing diminution in both NPY availability and the NPY-induced feeding response, may underlie the severe anorexia. Further, unlike other members of the cytokine family, suppression of NPYergic signaling in the hypothalamus by CNTF does not involve up-regulation of leptin, but may involve a direct action on hypothalamic NPY neurons or on neural circuits that regulate NPY signaling in the hypothalamus.

Effects of macrophage transplantation in the injured adult rat spinal cord: a combined immunocytochemical and biochemical study

Early and robust invasion by macrophages may be one of the reasons why axonal regeneration is more effective in the PNS than in the CNS. Therefore, we have grafted autologous peritoneal macrophages labeled with fluorescent latex microspheres into spinal cord compression lesions. At various survival times, we have studied their effect on the expression of neuronal (neurofilaments [NF], calcitonin gene-related peptide [CGRP], 5-hydroxytryptamine [5-HT]) and nonneuronal markers (myelin-associated glycoprotein [MAG], glial fibrillary acidic protein [GFAP], laminin) by using semiquantitative Western blot and immunohistochemical techniques. After 1 month, we observed a significant decrease of the expression of MAG as well as an important invasion of the lesion site by neurites, chiefly peptidergic axons of presumed dorsal root origin, in macrophage-grafted animals compared with controls. In addition, angiogenesis and Schwann cell infiltration were more pronounced after macrophage grafts, providing an increase in laminin, a favorable substrate for axonal regrowth. By using reverse transcription-polymerase chain reaction (RT-PCR), mRNAs for tumor necrosis factor-alpha (TNF-alpha) were detected in the transplanted cells, whereas results were negative for nerve growth factor (NGF), neurotrophin-3 (NT-3), brain-derived neurotrophic factor (BDNF), or acidic fibroblast growth factor (aFGF) and basic fibroblast growth factor (bFGF). Thus, macrophage grafts may represent an interesting strategy to promote axonal regeneration in the CNS. Our study suggests that they may exert their beneficial effects by degrading myelin products, which inhibit axonal regrowth, and by promoting a permissive extracellular matrix containing notably laminin. No evidence for a direct synthesis of neurotrophic factors by the transplanted macrophages was found in this study, but resident glial cells could secrete such factors as a result of stimulation by macrophage-released cytokines.

[Abdominoplasty with dissociated intraparietal liposuction. Technical note]

Liposuction has greatly contributed to the improvement of the aesthetic result of abdominoplasties. However, one should consider the high rate of seroma when liposuction is performed via an inferior approach during abdominoplasty. The authors present a new approach to achieve complete liposuction of the abdominal wall during conventional abdominoplasty. This approach is carried out via submammary incision after previous undermining of the abdominal wall. A permanent assessment of the thickness of the wall allows the liposuction to stay strictly in fat tissue. Finally, there is a total independence between liposuction and the undermining procedure which allows minimization of the postoperative seroma. This technic seems particularly useful in a context of extensive abdominal adipose with flaccidity of the abdominal wall, requiring extensive undermining. Thanks to this procedure, the authors have performed a one-stage operation in many cases in which two operations would necessary previously have been.

TNF-alpha-induced corticosterone elevation but not serum protein or corticosteroid binding globulin reduction is vagally mediated

Immune activation leads to production of mediators such as cytokines, which act to induce both brain-mediated and peripheral defense processes. We used intraperitoneal administration of the cytokine tumor necrosis factor-alpha (TNF-alpha) to investigate whether defense processes induced by this cytokine are mediated by vagal afferents and/or interleukin-1 (IL-1) receptors. Because some effects of TNF-alpha are mediated, at least in part, by the brain [plasma corticosterone (CORT) elevation] and some are mediated by peripheral organs [reduction of serum protein and corticosteroid binding globulin (CBG)], we also investigated whether the effects of vagotomy are specific to those defense processes mediated by the brain. Both vagotomy and IL-1 receptor antagonist attenuated serum CORT elevation, but had no effects on serum protein or CBG reduction. These results support the idea that vagal afferents provide a true immune-to-brain pathway that may include IL-1 receptors.

Acoustic measures of dysphonic severity across and within voice types

The purpose of the study was to explore an interaction between pathologic voice type and the acoustic prediction of dysphonic severity. One hundred and two phonatory samples, representing a wide range of laryngeal conditions, were categorized by listeners into three voice types: breathy, rough, and hoarse. A second group of trained listeners rated the severity of the samples on a 7-point scale. Twenty-five frequency- and time-domain measures were used to predict perceptual severity. Multiple regression analyses showed that the most useful measure for the prediction of severity across voice types was noise-to-harmonic ratio (NHR). The severity of individual voice types was predicted with differential results on the basis of both short- and long-term measures of perturbation.

Leptin and ciliary neurotropic factor (CNTF) inhibit fasting-induced suppression of luteinizing hormone release in rats: role of neuropeptide Y

Periods of chronic undernutrition and short periods of fasting suppress pituitary luteinizing hormone (LH) secretion and upregulate hypothalamic neuropeptide Y (NPY), the orexigenic peptide. The effect of suppression of NPY upregulation with ciliary neurotropic factor (CNTF), a cytokine, and leptin, an adipocyte hormone, on pituitary LH secretion was evaluated in fasted rats. In the first experiment, daily injection of CNTF (0.2 nmol) intracerebroventricularly (i.c.v.) for 4 days drastically reduced food intake and body weight gain similar to the weight loss seen in pair-fed rats. Food deprivation (FD) also decreased body weight. Despite drastic loss in body weight, plasma LH was reduced in FD and pair-fed rats, but not in CNTF-treated rats. In the second experiment, FD rats received either control vehicle, CNTF (0.2 nmol) or leptin (0.2 nmol) daily for 4 days. FD increased steady state levels of preproNPY mRNA in the hypothalamus over the control freely-fed rats. However, both CNTF and leptin suppressed hypothalamic gene expression and significantly attenuated LH suppression in response to FD. Taken together, these results support the hypothesis that the upregulation of hypothalamic NPY system may underlie diminution in pituitary gonadotropin secretion and that the NPYergic pathway may serve as a communication bridge between the neural processes that regulate reproduction and those that maintain energy balance.

Carotid endarterectomy among Medicare beneficiaries: a statewide evaluation of appropriateness and outcome

BACKGROUND AND PURPOSE

We sought to examine the appropriateness and the surgical outcomes of carotid endarterectomy (CE) in unselected community hospitals to identify opportunities for improvement.

METHODS

We performed a retrospective review of all CEs performed on Medicare beneficiaries in Georgia in 1993 (n = 1945). Conclusions regarding appropriateness were based on current guidelines as interpreted by a physician reviewer and were supported by the aggregate results of structured, blinded overreading by clinicians with relevant expertise. Adverse outcomes were confirmed and rated as to severity by a physician. Outcomes were correlated with demography, vascular anatomic findings, comorbidity, surgical techniques, and hospital characteristics.

RESULTS

The majority of the patients (51%) were asymptomatic at presentation. CEs were performed appropriately in 96.1% of the cases in accordance with current guidelines. There was no significant difference in the rate of appropriateness between the symptomatic (96%) and the asymptomatic patients (96.4%). Survival without stroke or myocardial infarction (MI) was 94.3%. The 30-day mortality was 1.9%; moderate to severe strokes occurred in 1.8%, stroke-related death in 0.7%, MI in 1.1%, and MI-related death in 0.5%. Those hospitals performing <10 CEs in the observed year had a statistically significant higher morbidity and mortality as well as an increase in less severe complications such as hematomas, wound dehiscence, wound infection, and pneumonia than did hospitals with higher volume of CEs.. Older patients and women had statistically significantly higher morbidity and mortality. Patients with a Charlson Severity Index score of > or =1 had a risk for adverse outcomes 3.4 times higher than patients with a score of 0 after adjustment for age and sex.

CONCLUSIONS

The great majority of CEs performed in Georgia on Medicare patients were appropriate, according to current guidelines. Slightly more than half of the patients were asymptomatic as defined in the Asymptomatic Carotid Atherosclerosis Study. In hospitals performing <CEs in the index year, we noted higher morbidity and mortality, as well as an increase in less severe complications. This relationship between the volume of surgery and outcome was confirmed in the analysis of the 30-day mortality for all Medicare cases (n = 10,569) performed in Georgia from 1991 to 1995. This was the most important opportunity for improvement identified in this study. In view of the increased use of CE, it is important to continue to monitor the patterns of practice for this procedure to improve outcomes.

Effect of hepatic disease on the pharmacokinetics and plasma protein binding of eprosartan

STUDY OBJECTIVE

To evaluate the pharmacokinetics and plasma protein binding of eprosartan in hepatic disease.

DESIGN

Single-dose, parallel-group study.

SETTING

Oklahoma Foundation for Digestive Research, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.

PATIENTS

Eight healthy subjects with normal hepatic function and eight patients with hepatic disease.

INTERVENTION

All subjects received a single oral dose of eprosartan 100 mg.

MEASUREMENTS AND MAIN RESULTS

Eprosartan plasma concentrations were quantified by high-performance liquid chromatography; plasma protein binding was determined by ultrafiltration. Using analysis of variance, point estimates (PE) and 90% CIs were calculated. Total and unbound maximum concentrations and degree of plasma protein binding were similar for both groups. Total area under the plasma concentration-time curve (AUC0-t) was approximately 40% higher for the group with hepatic disease (PE 1.42, 90% CI 0.94-2.14). Similarly, unbound AUC0-t was approximately 50% higher (PE 1.53, 90% CI 0.98-2.39).

CONCLUSION

Eprosartan was safe and well tolerated by both groups. Based on the increase in AUC in patients with hepatic disease compared with those with normal hepatic function, the dosage of eprosartan in patients with hepatic disease should be individualized based on tolerability and response.

Neuroprotective effects of TNF binding protein in focal cerebral ischemia

The effect of tumor necrosis factor binding protein (TNFbp) was studied in mice subjected to a permanent middle cerebral artery occlusion (MCAO). TNFbp is a dimeric form of the type I soluble TNF receptor linked to polyethylene glycol (TNFbp), and binds and inhibits TNF-alpha. TNFbp produced a significant reduction in the cortical infarct volume (22.6 +/- 3.5 mm3 immediately after MCAO; 25.2 +/- 2.4 mm3 1 h after MCAO) compared with vehicle-treated animals (30.3 +/- 3.7 mm3 immediately post MCAO; 31 +/- 3.7 mm3 1 h after MCAO (mean +/- S.D.) when administered intracranially up to 60 min post-occlusion. The neuroprotective effect of TNFbp was sustained in mice for 2 weeks after MCAO. DNA fragmentation at the margin of the cortical infarcts was dramatically reduced in mice treated with TNFbp whereas all control animals showed consistent and obvious DNA fragmentation 2 weeks after MCAO. TNFbp could have therapeutic value for the treatment of ischemic stroke if the problem of delivery to brain can be overcome.