Increased concentrations of neopterin in plasma, ascites and ovarian cyst fluid in malignant tumours compared with benign ovarian tumours

Neopterin is a marker of the activation of cell-mediated immunity. The aim was to determine whether the concentrations of neopterin differ in plasma, ascites and ovarian cyst fluid between patients with ovarian cancer and patients with benign ovarian tumours. Neopterin was measured in 29 patients with cystic ovarian tumours of unknown histology. 14 ovarian cancers and 15 benign ovarian tumours were diagnosed histologically. Patient age and tumour size did not differ significantly between the groups. Neopterin levels were determined in plasma, and in ascites and cyst fluid by ELISA. The neopterin concentration in plasma, ascites and ovarian cyst fluid was significantly higher in patients with ovarian cancer compared with patients with benign ovarian tumours of the same size. The study shows that activation of cell-mediated immunity, defined as increased formation of neopterin, was increased in patients with ovarian cancer compared with patients with benign ovarian tumours.

Increased release of tumor necrosis factor-alpha and interleukin-6 in women with the syndrome of hemolysis, elevated liver enzymes, and low platelet count

BACKGROUND

Complement is activated in preeclampsia and complement products are known to activate macrophages. The aim of this study was to determine whether the macrophage derived cytokines, interleukin-1 beta, interleukin-6 and tumor necrosis factor-alpha, are released in patients with a form of severe preeclampsia characterized by the syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome).

METHODS

Complement activation and plasma levels of cytokines were studied in 11 women with HELLP syndrome and in 11 controls with uncomplicated pregnancies. To further evaluate the connection between complement activation and cytokine release an in vitro study on heparinized whole blood incubated with recombinant C5a was performed.

RESULTS

In the HELLP group, complement anaphylatoxin C5a was increased in plasma at delivery (p < 0.01) and one day after delivery (p < 0.05), terminal C5b-9 complement complex was elevated in plasma at delivery (p < 0.001) and one day after (p < 0.01), plasma levels of interleukin-6 were increased one day after delivery (p < 0.01), and plasma concentrations of tumor necrosis factor-alpha were elevated at delivery (p < 0.01), compared with corresponding levels in controls. All parameters normalized within one week. Interleukin-I beta did not differ between the groups. In vitro, recombinant C5a incubated in whole blood gave a dose-dependent release of interleukin-6. No increased release of interleukin-1 or tumor necrosis factor-alpha was seen after incubation.

CONCLUSIONS

Since cytokine release occurs in severe preeclampsia, inflammatory mechanisms may participate in the pathophysiology of severe preeclampsia.

Tissue Trauma after Laparoscopic and Abdominal Hysterectomy Measuring Inflammatory Response

It is suggested that laparoscopic surgery reduces postoperative pain and shortens hospital stay and convalescence because of the small amount of tissue trauma. We evaluated the inflammatory response during abdominal hysterectomy (AH, 12 women) and laparoscopic hysterectomy (LH, 12 women) by measuring interleukin (IL)-6, neopterin and terminal C5b9 complement complex (TCC). Blood samples were drawn preoperatively, perioperatively, 1 minute, 24 hours, and 7 days postoperatively. Levels of IL-6 were determined to evaluate cytokine release, neopterin was determined as a marker for macrophage-monocyte activation, and TCC was determined to assess complement activation. The IL-6 concentrations, as a percentage of preoperative level, were significantly elevated postoperatively in both groups, and also perioperatively in the LH group. Neopterin concentrations, as a percentage of perioperative level, were significantly increased in the LH group preoperatively and postoperatively. No elevation was seen in the AH group. There was no sign of complement activation in either group. Our results indicate significant tissue trauma during both LH and AH. The extent of trauma might be greater in laparoscopic surgery. Despite this, the LH group had a shorter hospital stay and convalescence than the AH group. The proposed advantages to the patient of laparsocopic surgery thus seem to be attributable to other factors than the amount of tissue trauma.

Frequency of edentulism and identification marking of removable dentures in long-term care units

There were two aims of this study. First, the frequency of edentulism and denture wearers among 464 residents in long-term units in Göteborg, Sweden, was evaluated. Second, the dentures were examined to determine whether they were marked correctly for identification. Of the subjects, 46% were edentulous in both jaws, and 13% in one jaw. Among complete denture wearers, 47% of the patients had at least one identification-marked denture. Removable partial dentures, worn by 26 subjects, were marked to a lesser extent (32%). Since there are many edentulous people among the elderly in most parts of the world we suggest that removable dentures are marked with the patient's name or identification number.

Evaluation of tissue trauma after laparoscopic and abdominal hysterectomy: measurements of neutrophil activation and release of interleukin-6, cortisol, and C-reactive protein

BACKGROUND

Trauma and major surgery stimulate a cascade of events that mediate the inflammatory response. The aim of our study was to determine whether or not hysterectomy leads to release of cytokines, cortisol, and C-reactive protein (CRP), activation of neutrophils, and activation of the complement cascade. A further aim was to compare laparoscopic and abdominal hysterectomy with regard to the same parameters.

STUDY DESIGN

Twenty-four consecutive patients were randomized to either abdominal (n = 12) or laparoscopic hysterectomy (n = 12). Blood samples were drawn preoperatively, intraoperatively, and then at one minute, 24 hours, and seven days postoperatively. Interleukin-6 (IL-6) levels were used to evaluate cytokine release, cortisol and CRP to evaluate the inflammatory response, and polymorphonuclear (PMN) elastase to detect neutrophil activation. To evaluate complement activation, the terminal C5b-9 complement complex (TCC) was determined.

RESULTS

Interleukin-6 concentrations were significantly elevated one minute and 24 hours postoperatively in both groups. Independent of the surgical technique or operative time, the highest IL-6 concentration was reached four hours after beginning the operation. Cortisol levels were significantly elevated during and after the operation in both groups. C-reactive peptide levels were significantly elevated in both groups 24 hours and seven days after the operation. Polymorphonuclear elastase was elevated 24 hours postoperatively in both groups. There were no signs of complement activation during the operative period or postoperatively in either patient group.

CONCLUSIONS

Our results indicate serious tissue trauma during both laparoscopic and abdominal hysterectomy. The extent of surgical trauma did not differ between the two operative methods.

Gas kinetics during nitrous oxide analgesia for labour

Hypoxaemia may occur after hyperventilation with nitrous oxide during labour. The purpose of this study was to assess whether diffusion hypoxia is a contributory factor. Twenty-four parturients were randomly allocated to receive 50 or 70% nitrous oxide in oxygen. The median nitrous oxide inhalation time per contraction was 58 s and 33 s, respectively. The end-tidal carbon dioxide and the minute ventilation remained unchanged. The end-tidal oxygen concentration was lowest at 120 s, reaching 15.4% in both groups. The oxygen saturation did not differ between the groups with a lowest median value of 96% before the start of nitrous oxide inhalation. Two parturients had episodes of desaturation. Both had low end-tidal oxygen concentrations in association with the desaturation but, as the end-tidal nitrous oxide concentrations were low, the desaturations could not be attributed to diffusion hypoxia.

Neutrophil and macrophage activation and anaphylatoxin formation in orthotopic liver transplantation without the use of veno-venous bypass

BACKGROUND

Activation of neutrophils and activation of complement may be an aetiologic factor behind circulatory insufficiency in association with reperfusion of the grafted liver.

METHODS

Neutrophil and macrophage activation (determined as PMN elastase and neopterin release) and complement activation were evaluated in 15 consecutive patients undergoing orthotopic liver transplantation without the use of veno-venous bypass.

RESULTS

The PMN elastase concentrations were increased at the end of the anhepatic phase, 2, 5 and 30 min after start of reperfusion and 6 and 24 h postoperatively. There were significantly higher PMN elastase concentrations in patients with circulatory instability (postreperfusion syndrome) compared with those without postreperfusion syndrome. The neopterin concentration was increased 2 min after the start of reperfusion and remained elevated until 6 h postoperatively. The plasma complement C3a concentrations were increased at the end of the anhepatic phase and 2, 5 and 30 min after the start of reperfusion. The plasma C3a levels were higher in patients with postreperfusion syndrome compared to those without.

CONCLUSIONS

Activation of neutrophils and macrophages and of the complement cascade with the formation of biologically active substances may be one explanation for the circulatory instability often seen in patients undergoing orthotopic liver transplantation.

Effects on complement activation and cytokine (TNF-alpha and IL-8) release of infusion of anti-TNF-antibodies or a xanthine derivative (HWA 138) in septic baboons

BACKGROUND

Sepsis and septic shock lead to activation of the complement cascade and to the release of pro-inflammatory cytokines.

METHODS

The effects of E coli infusion and of infusion of anti-TNF antibodies and a xanthine derivative (HWA 138) on complement activation and cytokine release was evaluated in 17 baboons. All animals received 5 x 10(8) live bacteria per kg body weight. Five animals received only bacteria, five received in addition 0.5 mg per kg body weight of anti-TNF-antibody, and seven received an infusion of 6 mg per kg body weight of HWA 138 in addition to the bacteria.

RESULTS

In baboons receiving 5 x 10(8) live E coli per kg body weight increased plasma levels of TCC, TNF-alpha and IL-8 were found. The release of TNF-alpha was lower in the group receiving HWA 138 at 2 h after the infusion. In baboons receiving an infusion of anti-TNF antibody the concentration of IL-8 was lower at 2 and 4 h than in animals receiving just E coli or HWA 138.

CONCLUSION

Infusion of anti-TNF-antibody before E coli infusion will decrease the formation of IL-8. Infusion of HWA 138 before the E coli infusion will also inhibit the formation of TNF-alpha.

Complement anaphylatoxin C3a and C5a formation in premature children with respiratory distress

Premature children (n = 25) with respiratory distress (RD) were studied regarding complement activation and formation of the anaphylatoxins C3a and C5a. Blood samples were drawn on admission to the paediatric intensive care unit. In 18 of the patients RD was accompanied by other perinatal complications like pneumothorax or intracerebral haemorrhages. Seven of the premature children had RD without such complications. Preterm children with RD and with peri- and postnatal complications such as pneumothorax or intracerebral haemorrhage had increased concentrations in plasma of the anaphylatoxins C3a and C5a compared with preterm children with RD without these complications. There was a positive correlation between the plasma C3a and C5a concentrations in the preterm children.

CONCLUSION

The present study indicates that isolated RD will appear without signs of complement activation and that complications like pneumothorax or intracerebral haemorrhages are associated with release of the anaphylatoxins C3a and C5a.

Not only Th2 cells but also Th1 and Th0 cells express CD30 after activation

To investigate whether the CD30 molecule, expressed only by a minority of T and B cells, defines a subtype of T helper cells, Pityrosporum orbiculare-specific CD4+ T cell clones were assessed for CD30 protein and gene expression. The clones were defined as Th1, Th0, and Th2 according to their cytokine mRNA profile detected by reverse transcription PCR (RT-PCR). The kinetics of CD30 expression after OKT3 (anti-CD3) stimulation was analyzed by flow cytometry, immunocytochemistry, and RT-PCR. OKT3 activation induced a high expression of CD30 in cells of both Th1 and Th0 as well as Th2 type after 1-3 days. A difference between the clones was noted in that the Th2 clones remained highly positive in CD30 expression, whereas expression in the other clones started to decline from day 3. These data indicate that CD30 is expressed in activated CD4+ T cells of all three subtypes, and that the expression is sustained in Th2 cells.

Release of inflammatory mediators in association with collection of wound drainage blood during orthopaedic surgery

Ten patients undergoing hip replacement surgery were studied regarding activation of complement and leukocytes in association with collection of wound drainage blood. The blood was collected postoperatively but not reinfused due to the possible risks with reinfusion of blood containing inflammatory mediators. Blood samples for analysis of complement activation (TCC), leukocyte activation (PMN elastase) and cytokines (Interleukin-6) were drawn preoperatively from the patients. Blood samples were also drawn intraoperatively from the wound. Samples were also drawn from the collected wound drainage blood, before and after blood was passed through a microporous filter. There were elevated concentrations of TCC, PMN elastase and IL-6 in the collected wound drainage blood before and after the filter. The filtration did not significantly reduce the concentrations of these factors. In the wound blood the concentrations were higher compared to those found in the systemic blood preoperatively, but lower compared to concentrations found in the collected drainage blood. The study demonstrates that the collection of wound drainage whole blood is associated with activation of complement, release of PMN elastase and cytokines.

Leukocyte activation by isolated hyperthermic liver and limb perfusion due to malignancy

Fourteen patients with liver tumor malignancy and sixteen patients with malignant melanoma localized to one limb were studied regarding leukocyte activation with the release of polymorphonuclear neutrophilic (PMN) elastase and of neopterin and formation of cytokines (TNF-alpha and IL-6) during the surgical treatment. Patients undergoing liver resection (n = 10), abdominal hysterectomy (n = 10), or hip replacement surgery (n = 10) served as control groups. Isolated hyperthermic liver perfusion was performed with cytostatic-containing perfusate (melphalan and cisplatinum). Patients with recurrent malignant melanoma confined to one limb underwent isolated hyperthermic limb perfusion with cytostatic-containing perfusate (melphalan). Blood samples for determination of PMN elastase, neopterin, TNF-alpha, and IL-6 were drawn from the patients preoperatively, 1 minute before the start of the perfusion, 60 and 120 minutes after the start of the perfusion, and 24 hours postoperatively. Samples from the perfusate were drawn 60 minutes after the start of the perfusion. High concentration of plasma PMN elastase were found in both patients undergoing liver and limb perfusion and in patients undergoing liver resection surgery. Elevated concentrations of IL-6 were found in the patients undergoing liver perfusion and in patients undergoing liver resection. In none of the patients were there increased concentrations of neopterin or TNF-alpha. The perfusate contained high concentrations of PMN elastase, neopterin, and IL-6. This study also demonstrated that major surgery leads to elevated concentrations of PMN elastase and IL-6. An increase of PMN elastase and IL-6 was seen in response to perfusion and to surgical trauma.

Effects of ephedrine on oxygen consumption and cardiac output

Bolus doses of ephedrine are often used by anaesthesiologists for intraoperative hypotension. This randomized single-blind cross-over study was designed to simultaneously evaluate circulatory, respiratory and metabolic effects of intravenously given ephedrine in 12 healthy male volunteers. Oxygen uptake and carbon dioxide excretion were measured with indirect calorimetry and non-invasive transthoracic electrical bioimpedance was used for cardiac output measurements. The maximum effect on most variables was reached at 4-5 min. At 5 min after the administration of ephedrine 0.1 mg per kilogram body weight, there were significant increases in cardiac index, systolic and mean arterial blood pressure, expired minute volume, oxygen uptake and carbon dioxide excretion rates. There were no significant changes in the quotient between oxygen uptake rate and cardiac index, VO2/CI during the 30 min study period. The O2 saturation was not altered. The present study indicates that ephedrine increases oxygen demand and supply in a similar magnitude.

Why does clozapine stimulate the motor activity of reserpine-pretreated rats when combined with a dopamine D1 receptor agonist?

The aim of the present experiments was to investigate the locomotor stimulant effects of the atypical antipsychotic agent, clozapine, in rats depleted of their dopamine by reserpine and alpha-methyl-p-tyrosine pretreatment. Clozapine itself induced a slight but never significant stimulation of locomotor activity which was enhanced by the addition of the selective dopamine D1 receptor agonist, SKF38393 (2,3,4,5-tetrahydro-7,8-dihydroxy-1-phenyl-1H-3- benzazepine), but not by the selective dopamine D2 receptor agonist, quinpirole. The stimulation produced by clozapine plus SKF38393 was blocked by the selective dopamine D1 receptor antagonist, SCH23390 (7-chloro-8-hydroxy-3-methyl-1-phenyl-2,3,4,5- tetrahydro-1H-3-benzapine hydrochloride), while the selective dopamine D2 receptor antagonist, haloperidol, was ineffective. A combination of SCH23390 and haloperidol blocked the clozapine plus SKF38393-induced locomotion. Unlike clozapine, neither the selective 5-HT2 receptor antagonist, ritanserin, nor the dopamine D2 receptor antagonists, haloperidol and remoxipride, caused locomotor activation when given alone or in combination with SKF38393. The indirectly acting sympathomimetic amine, d-amphetamine, was inactive in the monoamine-depleted rats, indicating that no dopamine was available for release by d-amphetamine. The muscarinic receptor antagonist, scopolamine, alone did not alter locomotion, but produced marked stimulation when combined with SKF38393 but not with quinpirole. This stimulation was not affected by haloperidol. However, the scopolamine plus SKF38393-induced stimulation was partially blocked by SCH23390 or by a combination of haloperidol and SCH23390. The data indicate that clozapine, in rats depleted of their dopamine stores, exhibits properties consistent with those of a dopamine receptor agonist.(ABSTRACT TRUNCATED AT 250 WORDS)

Release of cytokines, polymorphonuclear elastase and terminal C5b-9 complement complex by infusion of wound drainage blood

25 patients undergoing total hip replacement surgery were studied in an investigation of release of cytokines (interleukin-1 beta, IL-1 beta; interleukin-6, IL-6; interleukin-8, IL-8; and tumor necrosis factor-alpha, TNF-alpha), PMN elastase and terminal C5b-9 complement complexes (TCC) at the time of collection and transfusion of autologous blood. 15 patients received wound blood that was washed and centrifuged before being transfused as an erythrocyte suspension. In this blood there were no elevations in the concentrations of cytokines, TNF-alpha, PMN elastase or TCC, and there was no increase in these variables in plasma after transfusion of wound blood. 10 patients received postoperatively-collected drainage blood. There were high amounts of cytokines, PMN elastase and TCC in this blood, and filtration of the collected drainage blood did not reduce the concentrations of these factors, except those of TCC. When the collected drainage blood was infused, elevated plasma concentrations of IL-6, IL-8 and PMN elastase were observed 1 and 60 minutes after completing the transfusion. No differences regarding blood pressure, oxygen saturation (SpO2), and hemoglobin concentration between the groups were recorded.

Time course of bromocriptine induced excitation in the rat: behavioural and biochemical studies

The aim of the present study was to further investigate the behavioural and biochemical pharmacology of the directly acting dopamine (DA) receptor agonist bromocriptine (BRC). BRC produced an initial depression of locomotion followed after about an hour by a weak but significant locomotor stimulation. The stimulation was potentiated by concomitant administration of the D1 agonist SKF38393. Ex vivo biochemical determinations indicated that reductions in dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA) levels occurred in the striatum after BRC injection without a significant change in DA levels, indicating a reduced DA turnover. An increase in 5-hydroxytryptamine (5HT) and 5-hydroxyindoleacetic acid (5HIAA) levels occurred in the striatum leading to a significant increase in turnover (i.e. ratio of 5HIAA to 5HT). Noradrenaline concentrations increased in the striatum. In the cortex, sharp falls in HVA and DOPAC levels without a corresponding change in DA were observed. While there was no significant change in noradrenaline levels in this brain region, an increase in 5HIAA, but not in 5HT, levels occurred. These changes indicate an increase in 5HT turnover (ratio of 5HIAA to 5HT). In vivo dialysis indicated that extracellular levels of DA, DOPAC and HVA in the striata of freely moving rats were sharply reduced for at least 6 h after injection. In vitro binding studies showed that BRC exhibited high (Ki values in low nanomolar range) affinities for DA D2A, D2B, D3, alpha 1 and alpha 2 adrenergic receptors together with unexpectedly high affinity (about 1 nM) for 5HT1A receptors. The data indicate that the initial behavioural depression and later locomotor stimulation induced by BRC are accompanied by a sharp monophasic fall in striatal extracellular DA levels as indicated by dialysis studies. Since the behavioural stimulation was augmented by concomitant D1 receptor stimulation, the data suggest that the reduced DA turnover is influencing the amount of DA available to stimulate postsynaptic D1 receptors. However, the biochemical studies indicated that BRC has a high affinity for 5HT1A receptors and affects the turnover of 5HT in the brain. Thus, the behavioural effects of BRC may depend not only on effects on the DA system but also on 5HT systems.

Pain analysis in patients with fibromyalgia. Effects of intravenous morphine, lidocaine, and ketamine

Pain intensity, muscle strength, static muscle endurance, pressure pain threshold, and pain tolerance at tender points and control points were assessed in 31 patients with fibromyalgia (FM), before and after intravenous administration of morphine (9 patients), lidocaine (11 patients), and ketamine (11 patients). The three different studies were double-blind and placebo-controlled. The patients were classified as placebo-responders, responders (decrease in pain intensity by > 50%) and non-responders. The morphine test did not show any significant changes. The lidocaine test showed a pain decrease during and after the infusion. The ketamine test showed a significant reduction in pain intensity during and after the test period. Tenderness at tender points decreased and endurance increased significantly, while muscle strength remained unchanged. The present results support the hypothesis that the NMDA receptors are involved in pain mechanisms in fibromyalgia. These findings also suggest that central sensitization is present in FM and that tender points represent secondary hyperalgesia.

Allergenic cross-reactivity among peach, apricot, plum, and cherry in patients with oral allergy syndrome: an in vivo and in vitro study

BACKGROUND

Oral allergy syndrome in response to fruits and vegetables frequently occurs as clusters of hypersensitivity to members of the same botanical family, for which the immunologic basis lies in a number of common allergens, most of them still unidentified.

OBJECTIVE

This study was designed to assess the in vivo and in vitro cross-reactivity between fruits of the Prunoideae subfamily (i.e., peach, cherry, apricot, and plum) and to identify their major allergens and the cross-reactivity of the peach extract with grass and birch pollen.

METHODS

The in vivo study was conducted by skin prick tests and open food challenges with fresh fruits in 23 patients with oral allergy syndrome for peach and positive skin prick test and RAST results for the other Prunoideae. In vitro sodium dodecylsulfate-polyacrylamide gel electrophoresis was followed by immunoblotting and immunoblotting-inhibition.

RESULTS

A 13 kd component was identified as the only major allergen common to all the Prunoideae, the other major allergens were found at 14 kd in peach and at 30 kd in cherry. Immunoblotting inhibition showed wide cross-reactivity within the Prunoideae, whereas grass and birch pollen partially inhibited the peach blotting.

CONCLUSIONS

Clinical cross-reactivity to Prunoideae is essentially due to a common 13 kd IgE-binding component, which seems to be the most important major allergen of this subfamily, not shared with grass and birch pollen.

Development of tolerance to 8-OH-DPAT induced blockade of acquisition of a passive avoidance response

We examined the effects of manipulating 5-HT1A receptors on the performance of a passive avoidance task in rats. Firstly, we studied the effect of racemic 8-OH-DPAT and compared it to the pure enantiomers (subcutaneous injection, s.c.). Secondly, we investigated the effect (s.c.) of the selective 5-HT1A receptor antagonist (S)-UH-301 [(S)-5-fluoro-8-hydroxy-2-(dipropylamino)tetralin] both alone and on 8-OH-DPAT-induced disruption of acquisition. Thirdly, we examined whether tolerance occurs to the effects of 8-OH-DPAT on passive avoidance acquisition. Finally, we examined the effects (s.c.) of the selective NMDA receptor antagonist dizocilpine, (+)-MK-801[(5R,10S)-(+)-5-methyl-10,11-dihydro-5H-dibenzo(a,d)cyclohe pten-5, 10-imine], on this tolerance development. Different doses of racemic 8-OH-DPAT were injected 10 min before rats were exposed to the acquisition phase of a step through passive avoidance response. When tested for retention 24 h later, 8-OH-DPAT-pretreated rats failed to exhibit any avoidance. R(+) and S(-)-8-OH-DPAT were also active with the R(+)-isomer being more active than the S(-)-isomer. The 5-HT1A antagonist (S)-UH-301 [(S)-5-fluoro-8-hydroxy-2-(dipropylamino)tetralin] was without effect on avoidance performance but antagonized the effect of 8-OH-DPAT. In a further experiment, rats were pretreated with racemic 8-OH-DPAT (0.3 mg/kg). Twenty four hours later, they received a challenge dose of 8-OH-DPAT and exposed to the acquisition phase of the avoidance response. When tested 24 hr later for retention, 8-OH-DPAT challenged rats failed to show any indication of an avoidance response.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of hyperventilation on the inspiratory to end-tidal oxygen difference

We assessed the inspiratory to end-tidal oxygen difference (PIO2-PE'O2) during voluntary hyperventilation in 10 healthy male volunteers. The oxygen difference was measured with a fast-response paramagnetic differential oxygen sensor. As simultaneous changes in metabolism and cardiac output also influence (PIO2-PE'O2), oxygen uptake was measured with indirect calorimetry and non-invasive transthoracic electrical bioimpedance was used for measurement of cardiac output. After a rest period, subjects were instructed to double their minute ventilation volume (VE) and after 5 min triple their resting VE for another 5 min. (PIO2-PE'O2) decreased from a zero value of 6.4 kPa to 3.9 kPa at 5 min (P < 0.01) and 2.9 kPa at 10 min (P < 0.01). At 15 min (i.e. 5 min after the end of hyperventilation) there was an increase in (PIO2-PE'O2) to 8.3 kPa (P < 0.05). Regression analysis between (PIO2-PE'O2) (kPa) and VE (litre m-2 min-1) gave the formula: (PIO2-PE'O2) = 1/(0.059 + 0.034 VE), r = -0.92, n = 158. Oxygen uptake and cardiac output did not change significantly during hyperventilation, but decreased in the post-hyperventilation period. An oxygen difference of more than 8 kPa was associated with significant arterial desaturation.

Complement system activation during orthotopic liver transplantation in man. Indications of peroperative complement system activation in the gut

Sixteen patients with acute and chronic liver disease undergoing OLT were studied regarding the role of the liver and the gut in complement activation. Also, the relation between complement activation and clinical manifestations during the liver transplantation reperfusion period was investigated. Blood samples for measurement of complement anaphylatoxin C3a (C3a), complement anaphylatoxin C5a (C5a), and terminal C5b-9 complement complex (TCC) were taken simultaneously from the central venous catheter and the radial arterial line before starting the operative procedure, 1 min before declamping, and 1-2 min, 5 min, 30 min and 6-12 hr after declamping. Simultaneous blood sampling from the radial arterial line, central venous catheter, portal vein, and hepatic vein was performed 1-2 min and 5 min after completed unclamping. Elevated plasma levels of C3a and TCC were found upon reperfusion, while C5a levels remained unchanged throughout the operation compared with the preoperative levels. The levels of C3a in the portal vein were higher compared with the levels in the simultaneously obtained samples from the radial artery. The results indicate complement cascade activation located to the gut during the reperfusion phase of OLT. Seventy-five percent of the patient studied suffered from the postreperfusion syndrome, indicated by profound hypotension upon reperfusion of the transplanted liver. There was a significant correlation between high concentration of C3a anaphylatoxin and development of profound hypotension.

Dopamine receptor antagonists block amphetamine and phencyclidine-induced motor stimulation in rats

d-Amphetamine (DEX) and phencyclidine (PCP) increased motor activity in rats as measured in automated activity cages. Analysis of the stimulation indicated that both drugs increased horizontal activity (total activity), locomotion, and peripheral activity. However, DEX increased while PCP decreased the incidence of rearing. The ability of different drugs to antagonise DEX- and PCP-induced increases in total activity (called stimulation) was measured. Dopamine (DA) D1 receptor antagonists (SCH23390, NNC-01-0112) were 7-8 times more potent in blocking DEX than PCP. DA D2 receptor antagonists (raclopride, remoxipride, haloperidol) were only 1-2 times more potent against DEX-induced stimulation. Nonselective DA receptor antagonists were also tested. Chlorpromazine was more potent against DEX than against PCP. Buspirone and sertindole were slightly more potent in blocking PCP than DEX. Ritanserin (5-HT2 receptor antagonist) was inactive against both stimulants. 8-OH-DPAT (5-HT1A receptor agonist) potentiated the stimulant effects of DEX and PCP. Prazosin (alpha 1-adrenergic receptor antagonist) partially blocked both DEX and PCP. Most drugs tested depressed spontaneous motor activity. Remoxipride and sertindole, however, caused very little depression even at doses several times higher than those needed to block DEX or PCP. The data show clear pharmacological differences between DEX- and PCP-induced stimulation.

Formation of cytokines by retransfusion of shed whole blood

We have studied, in 10 patients undergoing hip replacement surgery, the release of cytokines (tumour necrosis factor-alpha (TNF-alpha), interleukin-1 alpha (IL-alpha), interleukin-1 beta (IL-1 beta), interleukin-4 (IL-4), interleukin-6 (IL-6) and interleukin-8 (IL-8)) in association with retransfusion of autologous shed blood. The patients were reinfused with whole blood collected after operation. The median volume returned to the patients was 300 ml whole blood (25-75% range = 300-425 ml). Before reinfusion, blood was filtered. Plasma concentrations of IL-6 increased 1 and 60 min after retransfusion (P < 0.05). The plasma concentrations of TNF-alpha, IL-1 alpha, IL-1 beta, IL-4 and IL-8 did not change significantly after retransfusion of shed wound blood. However, there were increased concentrations of IL-1 alpha, IL-1 beta, IL-6 and IL-8 in the collected blood (P < 0.001). The filtration procedure did not reduce significantly the concentrations of these factors. This study shows that whole blood collected from a surgical wound contains large concentrations of cytokines. Filtration of the shed wound blood did not reduce significantly these levels and retransfusion caused increased plasma concentrations of IL-6.

Isolated hyperthermic liver perfusion with chemotherapy for liver malignancy

In an open study of unresectable liver tumours, isolated regional perfusion with hyperthermia and cytotoxic drugs has been tested in 29 patients. Four patients had primary hepatocellular cancer, 10 patients had metastases from malignant melanoma, remaining from breast cancer, colorectal cancer, midgut carcinoids and miscellaneous primaries. At laparotomy the proper hepatic artery and portal vein were canulated and connected to a pump oxygenator. The inferior vena cava was canulated with a triple lumen catheter (Perfufix) allowing for porto-caval shunting, drainage of lower body and renal veins to the heart and separate drainage of liver veins to the pump oxygenator. Liver perfusion was performed with a mean flow of 900 ml per min. Melphalan and cis-platinum 0.5 mg/kg body-weight were added to the perfusate for 1 h after liver temperature reached 40 degrees C. Four patients died within 30 days of perfusion due to multiple organ failure. These patients had more than 50% of liver volume occupied by cancer. All surviving patients developed reversible hepato- and renal toxicity. Partial tumour regression was registered in 20% of the patients. Five patients have survived more than three years. Hyperthermic liver perfusion is feasible but in patients with massive liver tumour, there is a significant risk of developing multiple organ failure.

Predictable nitrous oxide uptake enables simple oxygen uptake monitoring during low flow anaesthesia

The uptake rate of oxygen and nitrous oxide were studied during low flow anaesthesia with enflurane or isoflurane in nitrous oxide with either spontaneous or controlled ventilation. The excess gas flow and composition were analysed. The nitrous oxide uptake rate was in agreement with Severinghaus' formula VN20 1000.t-0.5. The composition of excess gas was predictable and the following formula for oxygen uptake could be derived: VO2 = VfgO2-0.45 (VfgN2(0)-(kg: 70.1000.t-0.5)) where oxygen uptake rate (VO2, ml.min-1) equals oxygen fresh gas flow (VfgO2) minus 0.45 times the difference between the fresh gas flow of nitrous oxide (VfgN2O), ml.min-1 and estimated uptake of nitrous oxide. The equation assumes constant inspired gas concentrations of 30% oxygen and 65-70% nitrous oxide. The oxygen uptake rates calculated from this formula were in good agreement with measured uptake rates. Thus, continuous monitoring of oxygen uptake rates is possible by using only reliable flowmeters and analysis of inspired oxygen concentration.

Increased antiretroviral antibody reactivity in sera from a defined population of patients with systemic lupus erythematosus. Correlation with autoantibodies and clinical manifestations

OBJECTIVE

The implied role of retroviruses in the pathogenesis of murine systemic lupus erythematosus (SLE) led us to study antiretroviral antibodies in a population-based SLE cohort.

METHODS

Immunoassays using whole virus and synthetic peptides were performed on sera from 72 patients with SLE and 88 control subjects.

RESULTS

Reactions with whole baboon endogenous virus occurred more frequently in patients with SLE, and correlated with the presence of anti-RNP and anti-Sm. Some retroviral env and gag peptides, several of which were similar to U1 small nuclear RNP, reacted more strongly in patients with SLE, and their presence was correlated with discoid rash, hematologic disorder, and other symptoms.

CONCLUSION

These results provide circumstantial evidence for involvement of retroviruses in the pathogenesis of human SLE; further studies should be carried out using other techniques for measurement of retroviral expression.

Nitrous oxide uptake during spontaneous and controlled ventilation

The rate of uptake of nitrous oxide was studied in 40 orthopaedic patients anaesthetised with either enflurane or isoflurane in nitrous oxide and with either spontaneous or controlled ventilation. A variant of the Douglas bag method was used in combination with low fresh gas flows to a circle system. There were no significant differences in nitrous oxide uptake between the groups and the uptake rates followed 'the square root of time concept', with an overall best fit curve of 1080.t-0.505 ml.70 kg-1 x min-1. During spontaneous ventilation, the nitrous oxide uptake rate was similar or even higher than the corresponding rate during controlled ventilation, in spite of lower minute volumes.

Hemofiltration modifies complement activation after extracorporeal circulation in infants

Complement and fibrinolytic factors were measured in 9 infants undergoing hemofiltration immediately after cardiopulmonary bypass in an attempt to reduce activation of these systems. Plasma levels of C3a, C5a, and terminal complement complexes increased during bypass by 460%, 85%, and 745%. Plasma levels were reduced after hemofiltration in 8 of the 9 infants, and C3a and C5a fractions were recovered in the ultrafiltrate. The observed activation of the fibrinolytic system seemed to be unaltered by hemofiltration. Fibrinolytic factors were not filtered. Our study shows that increased concentrations of complement factors in the plasma after bypass in infants may be reduced by hemofiltration.

Sampled gas need not be returned during low-flow anesthesia

OBJECTIVE

The purpose of this investigation was to study the N2 flux between the patient and the breathing circuit, and the excess gas during N2O anesthesia with the low, fresh gas flow technique.

METHODS

Forty patients were studied. After a 6-minute high, fresh gas flow denitrogenation period, the O2 fresh gas flow was set at about 4 ml/kg/min and the N2O fresh gas flow was set to maintain an inspired O2 fraction of 0.30. The excess gas flow and N2 excretion were measured by a variant of the Douglas bag method.

RESULTS

The mean inspired N2 concentration reached a peak of 5.9% at 40 minutes. The estimated mean N2 excretion was 39 ml/min at 10 minutes, declining to 18 ml/min at 60 minutes. A calculation of N2 homeostasis during closed-circuit anesthesia based on the results of the patient study indicated that sampling for gas analysis actually reduces the gas costs if the sampled gas is scavenged instead of returned to the circle system, since intermittent flushing with high, fresh gas flow for denitrogenation is unnecessary in the former situation.

CONCLUSIONS

Regardless of the fresh gas flow used, sampled gas need not be returned during N2O anesthesia.

Nitrous oxide elimination and diffusion hypoxia during normo- and hypoventilation

We studied the elimination rate of nitrous oxide in 36 patients undergoing orthopaedic surgery. They were allocated randomly to one of six groups which differed in time of nitrous oxide exposure and mode of ventilation. In order to simulate recovery conditions, nitrous oxide administration was discontinued after 30, 60 or 120 min of exposure. Either normoventilation or hypoventilation was used. The mean excretion rate was 1 litre min-1 at 1 min, declining to 100 ml min-1 at 30 min, with relatively small effects of different modes of ventilation and times of exposure. In spite of an FIO2 of 0.30, there were significant decreases in SpO2 during both normo- and hypoventilation. The smallest end-tidal oxygen concentrations were reached at 10-15 min in the groups with hypoventilation, after 1 or 2 h of nitrous oxide exposure.

Cascade system activation in shock

Trauma and sepsis activate different cascade systems. Activation of the coagulation and clotting systems, of the kinin-kallikrein system and of the complement system are important etiological mechanisms behind development of the adult respiratory distress syndrome (ARDS) and multisystem organ failure (MOF) after extensive trauma or severe septic situations. Activation of complement with the release of anaphylatoxins and terminal complement complexes is associated with increased mortality and development of ARDS and MOF after major surgery and in situations of septic shock. The anaphylatoxins have potent vascular properties and they activate leukocytes. Their effects on the leukocytes lead to the release of free oxygen radicals, different lysosomal enzymes and cytokines, leukotrienes and histamine. All these inflammatory mediators may, if released in extensive amounts, induce microvascular injury and interstitial edema. If this process takes place in the lung, ARDS may develop and if other organs, i.e the liver and the kidneys, are involved, MOF may be the result.

[Respiratory gas exchange. Anesthesia with enflurane or isoflurane in nitrous oxide during spontaneous and controlled ventilation]

The estimation of oxygen consumption and carbon dioxide elimination is essential for predicting the metabolic activity and needs of any patient having anaesthesia. During anaesthesia oxygen consumption can be measured and compared to a predicted value. However, oxygen uptake is affected by anaesthetic agents, which complicates the interpretation of measured oxygen uptake rate. The purpose of this study was to investigate whether there are any differences in respiratory gas exchange during anaesthesia with enflurane and isoflurane and also to assess the effects of spontaneous versus controlled ventilation. METHODS. Forty orthopedic patients were randomized to enflurane or isoflurane anaesthesia in nitrous oxide with either spontaneous or controlled ventilation. A fresh low-gas-flow technique was used. Inspiratory oxygen and end-tidal carbon dioxide concentrations and expiratory minute ventilation were measured in a circle absorber system between the y-piece and the endotracheal tube with a sampling analyser. Between the mixing box and the absorption canister, carbon dioxide concentration was continuously measured. The carbon dioxide elimination was calculated from mixed expired concentration and expiratory minute ventilation. Excess gas was collected every 10 min in a non-permeable mylar plastic bag connected to the excess valve. The excess gas flow was calculated and the oxygen uptake rate was assumed to be the difference between the oxygen fresh gas flow and the oxygen excess gas flow. RESULTS. The grand mean oxygen uptake rate was 2.5 ml.kg-1 x min-1 or 100 ml.min-1 x m-2. There were no statistically significant differences in oxygen uptake between enflurane and isoflurane anaesthesia or between spontaneous and controlled ventilation. The mean oxygen uptake rate at 10 min was between 2.0 and 2.2 ml.kg-1 x min-1 in all groups. At 30 min the mean oxygen uptake rates were 2.6 to 2.8 ml.kg-1 x min-1. Carbon dioxide elimination was closely associated with expired minute ventilation, with a carbon dioxide excretion of about 30 ml per litre gas exhaled, irrespective of ventilatory mode employed.

Complement activation during liver transplantation

Twelve patients with end-stage liver disease undergoing liver transplantation were studied regarding complement activation and formation of anaphylatoxins (C3a and C5a) and terminal C5b-9 complement complexes (TCC) after reperfusion of the grafted liver. Blood samples for complement variables (C1INH, C3, C4, C5, C3a, C5a, and TCC) were drawn preoperatively, before the anhepatic phase, 1 min before, and 2, 15, and 60 min after the start of reperfusion of the grafted liver. Activation of complement was observed during the operation. The C1INH, C3, C4, and C5 plasma concentrations decreased during the entire operation while the anaphylatoxin C3a and the terminal C5b-9 complement complex increased after the reperfusion of the grafted liver. Activation of complement with the formation of biologically active substances like anaphylatoxins and terminal C5b-9 complement complexes may be one explanation for circulatory complications often seen in patients undergoing orthotopic liver transplantation.

Complement activation in septic baboons detected by neoepitope-specific assays for C3b/iC3b/C3c, C5a and the terminal C5b-9 complement complex (TCC)

We have investigated the cross-reactivity of various species in neoepitope-specific methods for quantification of human complement activation products. In contrast to most other species examined, baboon showed a substantial cross-reactivity supporting a high degree of homology between human and baboon complement. An assay for C3b, iC3b and C3c (MoAb bH6) showed moderately good reactivity, in contrast to a C3a assay which did not cross-react. Excellent reactivity was found for C5a using MoAbs C17/5 and G25/2. The reactivity of an established TCC assay (MoAb aE11 to a C9 neoepitope and polyclonal antibody to C5) was improved substantially by replacing the anti-C5 antibody with a new MoAb to C6 particularly selected on the basis of baboon cross-reactivity. Plasma samples from baboons receiving 2.5 x 10(9) and 1.0 x 10(10) live Escherichia coli bacteria/kg were examined with the assays described. In vivo complement activation with the lowest dose was moderate and kept under control, in contrast to the highest dose, where an uncontrolled increase in all activation products continued throughout the infusion period. These results support the hypothesis that sufficiently high amounts of endotoxin lead to uncontrolled activation of complement as seen in irreversible septic shock. The results are discussed with particular emphasis on activation of the terminal complement pathway.

Complement and leukocyte activation in septic baboons

The effect of Escherichia coli infusion on complement and leukocytes was evaluated in a baboon model. During 8 hr, different amounts of live E. coli (5 x 10(8), 2.5 x 10(9) and 10(10) live bacteria kg body weight) were infused. Twenty-one baboons were investigated. Activation of complement (terminal C5b-9 complement complex; TCC) and activation of leukocytes (PMN elastase) and plasma concentrations of endotoxin (lipopolysaccharide; LPS) were determined before the start of bacteria infusion and 2, 4, 6, and 8 hr after the start of infusion. In baboons receiving 2.5 x 10(9) and 10(10) live E. coli per kilogram body weight, increasing plasma levels of TCC were found (P < 0.05). No significant alterations of TCC were observed when animals were infused with 5 x 10(8) live E. coli per kilogram body weight during an 8 hr period. Plasma levels of PMN elastase increased significantly in baboons receiving 5 x 10(8), 2.5 x 10(9), and 10(10) live bacteria per kilogram body weight. High levels of LPS were detected in animals receiving 10(10) live E. coli bacteria per kilogram body weight and in animals receiving 5 x 10(8) or 2.5 x 10(9) live E. coli bacteria per kilogram body weight. There was a positive correlation between the formation of TCC and the plasma levels of PMN elastase and LPS and between plasma levels of PMN elastase and of LPS. Activation of complement and leukocytes may contribute to the development of organ dysfunction seen in baboons infused with high amounts of live E. coli.

Isolated hyperthermic liver perfusion with cytostatic-containing perfusate activates the complement cascade

Eight patients with advanced liver malignancy undergoing isolated hyperthermic liver perfusion with melphalan and cisplatin were studied with regard to complement activation and formation of anaphylatoxins (C3a and C5a) and terminal C5b-9 complement complexes (TCCs). Blood samples for complement variables (C1-INH, C3, C4, C5, C3a, C5a and TCCs) were taken before surgery, 1 min before the start of perfusion, 1, 2 and 3 h after the start of perfusion, and 24 h after operation. Samples were drawn from the perfusate 1 h after the start of perfusion. Activation of complement was observed during perfusion. Raised plasma concentrations of C3a and TCCs were recorded and high levels of C3a and TCCs were found in the perfusate. In vitro tests indicated that melphalan and cisplatin may activate complement. This activation occurred at 37 and 42 degrees C but was more pronounced at 42 degrees C.

Living with fibromyalgia. Consequences for everyday life

The influence of chronic pain on daily life was studied in 58 patients (55 women and three men) with fibromyalgia. The mean age was 45 +/- 11 (SD) years. A mail questionnaire including a 2-day diary was used for data collection. Information was gathered on social background, employment status, symptoms, physical training habits, patients' experience of general health, physical condition, and difficulties in performing motor tasks. The patient reported every half hour in the activity diary the degree of pain and fatigue, whether the activities were difficult to perform, and whether the patient considered them to be enjoyable, valuable, and meaningful. Fifty-five percent of the group had gainful employment. Most were working shorter hours and with changed work tasks. Motor tasks, such as carrying, holding, and running were more difficult to perform than before the onset of the symptoms, and half of the group reported most of their activities as strenuous to perform. Thirty-nine persons (67%) reported no, or very short, pain-free periods during the 2 days. In conclusion, symptoms influenced daily life considerably, and almost all patients reported changes in habits and routines as a consequence of fibromyalgia. An assessment of the patient's total life situation gives valuable information for understanding the patients' ability to handle everyday life.

Inspiratory to end-tidal oxygen difference during nitrous oxide anaesthesia

In order to evaluate the value of the inspiratory to end-tidal oxygen concentration difference (Io2-E'o2) as a monitor during general anaesthesia, we studied 40 orthopaedic patients allocated randomly to four groups: anaesthesia with enflurane or isoflurane in nitrous oxide with either spontaneous or controlled ventilation. (Io2-E'o2) followed an asymptotically increasing curve because of decreasing uptake of nitrous oxide. At 1 h, (Io2-E'o2) approached the end-tidal carbon dioxide concentration (E'o2). During spontaneous ventilation, (Io2-E'o2) correlated best with E'co2. During controlled ventilation, there was a negative correlation between (Io2-E'o2) and nitrous oxide uptake rate. Changes in oxygen uptake rate were reflected in (Io2-E'o2), provided that the total ventilation volume was constant and the nitrous oxide uptake rate approached steady state conditions.

Uptake of enflurane and isoflurane during spontaneous and controlled ventilation

The uptake of enflurane and of isoflurane were studied in forty patients during anaesthesia with nitrous oxide using either spontaneous or controlled ventilation. A Douglas bag method was used in combination with low fresh gas flows to a circle system and constant end-tidal anaesthetic concentration. The mean enflurane uptake rates were between 24 and 14 ml.70kg-1.min-1 between 10 and 60 minutes. Corresponding isoflurane uptake rates were between 15 and 8 ml. 70 kg-1.min-1. The initial uptake rates were lower than expected from "the square root of time concept". During spontaneous ventilation, the anaesthetic uptake rates were similar or even higher than corresponding rates during controlled ventilation in spite of lower minute ventilation volumes.

Complement, neutrophil, and macrophage activation in women with severe preeclampsia and the syndrome of hemolysis, elevated liver enzymes, and low platelet count

Activation of complement, neutrophils, and macrophages was studied in 14 women with severe preeclampsia, 11 of whom had the syndrome of hemolysis, elevated liver enzymes, and low platelet count; in 14 women with normal pregnancies; in seven normal pregnant women undergoing cesarean deliveries; and in 15 healthy nonpregnant women. Activation of complement, neutrophils, and macrophages was measured by plasma determinations of complement split products, polymorphonuclear (PMN) elastase, and neopterin, respectively. Women with severe preeclampsia had increased levels of C5a, terminal complement complex, PMN elastase, and neopterin at delivery and 1 day postpartum as compared with the normal pregnant group. One week postpartum, neopterin remained higher in preeclamptic women, whereas the complement components and PMN elastase had returned to normal. Cesarean delivery after normal pregnancy did not increase the levels of complement split products, PMN elastase (except for one value), or neopterin. The nonpregnant women had normal PMN elastase and neopterin levels. Accordingly, complement, neutrophils, and macrophages are activated in women with severe preeclampsia at delivery. The plasma levels of PMN elastase correlated positively to the formed terminal complement complexes in vivo. An in vitro study was performed to elucidate further the connection between complement and leukocyte activation. Recombinant C5a incubated in whole blood and in a neutrophil cell suspension gave a dose-dependent release of PMN elastase. Both the clinical and the in vitro results indicate that activation of the complement system may affect the function of neutrophils. This study supports the theory that the pathologic manifestations of severe preeclampsia may be explained by complement-induced release of biologically active substances from activated leukocytes.

Intestinal symptoms and serological response in patients with complicated and uncomplicated Yersinia enterocolitica infections

Clinical course, serological response and effect of antibiotic treatment were evaluated in 34 patients with uncomplicated enterocolitis and in 27 patients with reactive arthritis (ReA) due to Yersinia enterocolitica. Patients participating in this prospective multicentre trial were randomised to treatment or no treatment with antibiotics. Only 3 (11%) of the patients who later developed ReA asked for medical care because of intestinal symptoms and fever and they all developed arthritis within 2 days after admission to hospital, i.e. before an etiological diagnosis was obtained. Patients with ReA had a history of milder intestinal symptoms than patients with uncomplicated enterocolitis. The peak IgA titer to Y. enterocolitica, as measured by enzyme linked immunosorbent assay, was higher in ReA patients and it was not affected by the presence of HLA-B27 antigen. On the other hand, untreated patients with uncomplicated enterocolitis had the longest duration of IgG antibodies. The duration of IgG antibody response was shortened in uncomplicated enterocolitis patients treated with antibiotics, but not in ReA patients. Treatment did not influence intestinal or ReA symptoms. It is concluded, that patients with uncomplicated enterocolitis due to Y. enterocolitica differ in intestinal symptoms and serological response, compared with patients who develop ReA. These parameters could however not be used to predict the development of arthritis in individual patients.

The immunologic response to thermal injury

Thermal injury is associated with altered immune defense. Extensive and deep thermal injuries lead to depressed immune defense function with both cellular and humoral defense affected. There is an intricate interaction between various components of the immune system. The altered specific immune response is seen as a depressed ability to produce active rosette-forming cells. Depressed stimulation of lymphocyte proliferation as well as the mixed lymphocyte response have also been recorded following burns. These effects are modulated by the release of kinins, prostaglandins, anaphylatoxins, superoxides, and leukotrienes, all of which can influence the inflammatory response following thermal injury. The humoral immunity is altered as seen by decreased levels of immunoglobulins, activation of complement with release of anaphylatoxins, and formation of membrane attacking complexes leading to inflammation and cytolysis. The immune response to burns is also affected by factors other than this injury, such as nutrition or diseases such as diabetes mellitus or disorders of the lymphoproliferative type. The immune response is also influenced by some drugs used for other reasons such as steroids, chemotherapeutic agents, and topical agents used for burn wound care. The immune reaction to a burn is also influenced by the additive effect of superimposed infections. Removal of injured tissue without the need for extensive transfusion will improve the ability of the burned patients to use their immune defense system in a fruitful way.

Complement activation in relation to development of preeclampsia

Six hundred eighty-five primigravidas followed as a series had complement activation evaluated by the formation of anaphylatoxins (C3a and C5a) and terminal C5b-9 complement complexes in venous blood. Samples for complement determinations were obtained four times during pregnancy, in pregnancy weeks 12-16, 20-24, 28-32, and 34-36. Seven of the women developed preeclampsia and one of them the syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome). Eleven others with uncomplicated pregnancies were selected as a control group. Plasma samples were taken from these 18 women at delivery and 1 and 7 days after delivery. At delivery, plasma C5a levels were significantly greater in the preeclamptics than in controls, and four of the seven preeclamptics had elevated plasma C3a values compared with controls. One week after delivery, these plasma anaphylatoxins had returned to normal. Elevations of the anaphylatoxins could not be detected before the women developed clinical signs of preeclampsia. No alterations in terminal C5b-9 complement complexes could be observed in the women with preeclampsia. However, the women who developed HELLP syndrome had elevated plasma concentrations of C3a, C5a, and terminal C5b-9 complement complex at delivery. These values returned to the normal range 1 week after delivery. We conclude that complement activation in the systemic circulation does not occur early in pregnancy and that plasma concentrations of C3a, C5a, or terminal C5b-9 complement complex cannot be used as predictors of preeclampsia.

Fibromyalgia--a clinical entity?

Fibromyalgia (FM) is a syndrome characterized by widespread musculoskeletal pain and tenderness at specified sites, fatigue, and unrefreshing sleep. The American College of Rheumatology (ACR) has recently accepted diagnostic criteria for FM. The ACR criteria have high diagnostic specificity, sensitivity, and accuracy. Laboratory investigations show a disturbed microcirculation in painful muscles, a decrease in adenosine triphosphate and phosphocreatine, and a reduced relaxation rate. Pain analyses indicate that the pain is nociceptive. A characteristic physiological sleep disturbance has been described that is correlated to the symptoms. The etiology of FM is not known. The etiology may be different in different patients. FM is a clinical entity, but should be regarded as a syndrome rather than a disease.

Early antibiotic treatment of reactive arthritis associated with enteric infections: clinical and serological study

OBJECTIVE

To find out whether a 10-14 days' course of antibiotics early in the course of reactive arthritis associated with enteric infections could reduce the severity and duration of the disease and whether the antibody response in patients with reactive arthritis associated with yersinia infection differed between those treated and those not treated with the antibiotics.

DESIGN

Prospective multicentre trial in which patients were randomised to treatment or no treatment with antibiotics. Patients were seen at three and six weeks and three, six, nine, 12, and 18 months after their first visit.

SETTING

Departments of infectious diseases in three hospitals in Linköping, Malmö, and Stockholm, Sweden.

PATIENTS

40 Consecutive patients who had had symptoms of reactive arthritis associated with enteric infection for less than four weeks.

INTERVENTIONS

20 Patients were allocated to treatment with antibiotics and 20 patients did not receive antibiotics. All patients received non-steroidal anti-inflammatory drugs, and four also received intra-articular steroid injections after at least six weeks' observation.

MAIN OUTCOME MEASURES

Arthritic symptoms assessed clinically and by using Ritchies' index; blood measurements reflecting inflammatory activity; serum IgG, IgM, and IgA antibody titres; HLA tissue type.

RESULTS

No difference was observed concerning duration of arthritis, grade of inflammation, and number of joints affected between patients treated and those not treated with antibiotics. Furthermore, there was no significant difference between the two groups in erythrocyte sedimentation rate and haptoglobin, IgG, and IgA concentrations. All values had returned to normal within three months. No patient developed chronic arthritis, but sustained slight arthralgia occurred in three patients. The HLA-B27 antigen was found in 23 (58%) of the patients, and its presence did not affect clinical outcome. The IgG, IgM, and IgA antibody responses were similar in patients treated with antibiotics and those not treated.

CONCLUSION

Short term antibiotic treatment has no beneficial effect on the clinical outcome of reactive arthritis associated with enteric infection.