Parallel induction of epithelial surface-associated chemokine and proteoglycan by cellular hypoxia: implications for neutrophil activation

Neutrophil-induced damage to the protective epithelium has been implicated in mucosal disorders associated with hypoxia, and such damage may be initiated by epithelial-derived chemokines. Because chemokines can bind to membrane proteoglycans, we hypothesized that chemokines may associate with epithelial surfaces and activate polymorphonuclear neutrophils (PMN). Epithelial hypoxia (pO2 20 torr) resulted in a time-dependent induction of interleukin-8 (IL-8) mRNA, soluble protein, as well as surface protein. Such surface IL-8 expression was demonstrated to be dependent on heparinase III expression, and extensions of these experiments indicated that hypoxia induces epithelial perlecan expression in parallel with IL-8. Finally, co-incubation of post-hypoxic epithelia with human PMN induced IL-8-dependent expression of the PMN beta2-integrin CD11b/18. These data indicate that chemokines liberated from epithelia may exist in a surface-bound, bioactive form and that hypoxia may regulate proteoglycan expression.

Documentation of clinical interventions by pharmacy faculty, residents, and students

OBJECTIVE

To describe the influence of pharmacy faculty, residents, and students at a community hospital by documenting the number and types of interventions attributable to their involvement in patient-care activities.

METHODS

Between September 1, 1997, and May 31, 1999, data were collected using a computerized documentation system to characterize the intervention type, significance, and value of services rendered by an education group composed of pharmacy faculty (n = 2), residents (n = 4), and students (n = 22).

RESULTS

The number, nature, and outcome category for all interventions were documented using an existing computerized documentation system. The education group accounted for 13% (n = 2,873) of total clinical activities documented (n = 21,817). The most common activities reported were discharge counseling/education (31%), consultation by physicians and therapeutic recommendations (15%), and route conversion (6%). Interventions documented by the education group were classified as medium or high significance 50% of the time. Sixteen percent ($172,655) of the estimated cost avoidance documented by the pharmacy department was attributed to the education group.

CONCLUSIONS

This study demonstrates that educational activities by pharmacy faculty, residents, and students have a positive influence on patient care in a community hospital.

Vitamin K to reverse excessive anticoagulation: a review of the literature

We conducted an extensive literature review to evaluate the appropriate use, route, and dose of vitamin K to reverse excessive anticoagulation. Issues such as sample size, study design, different patient populations, and various study end points confounded results. Of 18 studies published, 8 enrolled 229 patients to evaluate parenteral vitamin K administration. Nine studies with 288 patients evaluated oral administration, and only 2 retrospective studies (280 patients) compared routes of administration. Reductions in international normalized ratios at 24 hours ranged from 21-42%, 47-86%, 25-67%, and 40-75% for temporary warfarin discontinuation alone, and intravenous, subcutaneous, and oral routes of vitamin K administration, respectively. Methodologically weak studies and indeterminate results plague interpretation of the literature on vitamin K. In general, results of this review support current guidelines for reversing excessive warfarin anticoagulation. However, it is important to realize that the quality of literature on which these recommendations are based is poor and that optimal dose and route of vitamin K administration remain unclear. Large, well-designed, randomized, controlled trials are necessary to define optimum management strategies for excessively anticoagulated patients.

Therapeutic targets for hypoxia-elicited pathways

Diminished oxygen supply to tissues (hypoxia) can stem from many sources, and is a contributing factor to diverse disease processes. Cell and tissue responses to hypoxia are diverse and include dramatic changes in metabolic demand, regulation of cellular gene products, and release of lipid and protein mediators. Surprisingly little attention has been paid to targeted development of therapeutics for hypoxia-related disease processes. This review will focus on recent advances in cellular and molecular biology pertaining to the hypoxia response, and will discuss paradigms used to study hypoxia and the potential targets for therapeutic intervention.

Treatment of Wegener's granulomatosis with immune globulin: CNS involvement in an adolescent female

OBJECTIVE

To describe the use of intravenous immune globulin (IVIG) to treat Wegener's granulomatosis (WG) in an adolescent female with an abnormal magnetic resonance imaging (MRI) scan and electroencephalogram (EEG), as well as central nervous system involvement manifesting as generalized seizures.

CASE SUMMARY

A 15-year-old white girl diagnosed with WG and receiving prednisone and cyclophosphamide was admitted with new-onset tonic-clonic seizures. The patient received phenobarbital and phenytoin to control seizures and was receiving cyclophosphamide and corticosteroids for WG. She developed cyclophosphamide-induced cystitis and was started on a four-day therapeutic course of IVIG following the discontinuation of cyclophosphamide. After 16 days of hospitalization, repeat EEG and MRI were within normal limits, and laboratory and clinical improvement was evident in at least nine of the affected organ systems including pulmonary, hematologic, renal, ocular, cutaneous, musculoskeletal, central nervous system, gastrointestinal, and genitourinary. The patient was discharged with clinical involvement of WG documented in two organ systems, hematologic and renal.

DISCUSSION

WG is a form of vasculitis believed to develop due to an autoimmune disorder. The diagnosis is based on radiographic and histopathologic findings, as well as the presence of elevated antineutrophil cytoplasmic antibodies and a suggestive clinical presentation. The presentation is widely variable and is most commonly associated with upper-airway involvement such as sinusitis, cough, pulmonary infiltrates, and cavitary nodules. Renal involvement signifies generalized disease. Conventional treatment for WG includes cyclophosphamide and prednisone. Little information is available describing therapeutic alternatives. Cytotoxicity related to immunosuppressant regimens limits continuous treatment and may necessitate the use of alternative agents.

CONCLUSIONS

This case describes the use of IVIG in an adolescent patient presenting with WG as a generalized, active disease with neurologic complications. IVIG may be useful in generalized, active WG complicated by intolerance to cyclophosphamide and seizures, but further study is necessary to define its role.

Critical role of cAMP response element binding protein expression in hypoxia-elicited induction of epithelial tumor necrosis factor-alpha

Tissue hypoxia is intimately associated with a number of chronic inflammatory conditions of the intestine. In this study, we investigated the impact of hypoxia on the expression of a panel of inflammatory mediators by intestinal epithelia. Initial experiments revealed that epithelial (T84 cell) exposure to ambient hypoxia evoked a time-dependent induction of the proinflammatory markers tumor necrosis factor-alpha (TNF-alpha), interleukin-8 (IL-8), and major histocompatibility complex (MHC) class II (37 +/- 6.1-, 7 +/- 0.8-, and 9 +/- 0.9-fold increase over normoxia, respectively, each p < 0.01). Since the gene regulatory elements for each of these molecules contains an NF-kappaB binding domain, we investigated the influence of hypoxia on NF-kappaB activation. Cellular hypoxia induced a time-dependent increase in nuclear p65, suggesting a dominant role for NF-kappaB in hypoxia-elicited induction of proinflammatory gene products. Further work, however, revealed that hypoxia does not influence epithelial intercellular adhesion molecule 1 (ICAM-1) or MHC class I, the promoters of which also contain NF-kappaB binding domains, suggesting differential responses to hypoxia. Importantly, the genes for TNF-alpha, IL-8, and MHC class II, but not ICAM-1 or MHC class I, contain cyclic AMP response element (CRE) consensus motifs. Thus, we examined the role of cAMP in the hypoxia-elicited phenotype. Hypoxia diminished CRE binding protein (CREB) expression. In parallel, T84 cell cAMP was diminished by hypoxia (83 +/- 13.2% decrease, p < 0.001), and pharmacologic inhibition of protein kinase A induced TNF-alpha and protein release (9 +/- 3.9-fold increase). Addback of cAMP resulted in reversal of hypoxia-elicited TNF-alpha release (86 +/- 3.2% inhibition with 3 mM 8-bromo-cAMP). Furthermore, overexpression of CREB but not mutated CREB by retroviral-mediated gene transfer reversed hypoxia-elicited induction of TNF-alpha defining a causal relationship between hypoxia-elicited CREB reduction and TNF-alpha induction. Such data indicate a prominent role for CREB in the hypoxia-elicited epithelial phenotype and implicate intracellular cAMP as an important second messenger in differential induction of proinflammatory mediators.

Omeprazole and vitamin B12 deficiency

The mainstay for cobalamin deficiency is correction of the underlying disorder and replacement therapy. Because the defect is often one of absorption, parenteral or intranasal routes are recommended. In most cases, replacement therapy is all that is needed. The vitamin preparation most commonly used is cyanocobalamin (also called vitamin B12), which has no known physiologic role but instead is converted to a biologically active form before it can be used by tissues. The studies reviewed in this article clearly show that omeprazole therapy will decrease the absorption of vitamin B12 by preventing its cleavage from dietary proteins. However, these data are insufficient to infer that clinically significant deficiency will occur over time. In fact, some of the studies suggest that the simple addition of juices or other acidic drinks into the diet may dramatically increase cobalamin absorption. Clearly, well-designed clinical trials are needed to evaluate this theory over an extended follow-up period to determine the clinical significance of omeprazole-associated vitamin B12 deficiency and possibly identify patients at risk for deficiency. In conclusion, the possibility of dietary vitamin B12 malabsorption should be considered in patients receiving chronic omeprazole treatment and presenting with signs and symptoms of deficiency. All healthcare workers should be made aware of the potential clinical complications of omeprazole-associated vitamin B12 deficiency since it may go unrecognized and is easily corrected. This is particularly relevant for elderly patients with poor dietary intake of vitamin B12, impaired vitamin B12 stores, and certain gastrointestinal disorders.

Scrub typhus in north Queensland

Scrub typhus was once common in north Queensland, but no reports from this region have been published for nearly 30 years, and the focus has turned to cases from the Northern Territory and Western Australia. In 1996, diagnosis of scrub typhus in a Queensland soldier led to recognition of an earlier outbreak with up to 17 cases. Another outbreak occurred a year later with 11 confirmed cases. All cases were in soldiers who had visited a training area near Innisfail. Review of other laboratory diagnoses of scrub typhus shows it is still prevalent in north Queensland, with several "hot spots".

Quality of life and Parkinson's disease

BACKGROUND

People with Parkinson's disease (PD) have a progressive loss of function eventually leading to severe disability. Although PD would be expected to have a profound impact on an individual's psychosocial health, there is relatively limited research on its psychosocial effect. The purposes of this study were (a) to examine the relationships between physical disability, depression, and control beliefs and quality of life in people with PD and (b) to characterize how these psychosocial variables differ by stage of disease.

METHODS

Eighty-six individuals from five stages based on clinical disability, ages 51-87, were interviewed. Established instruments were used to measure physical disability, depression, and control beliefs. Quality of life (QOL) was rated on a 5-point Likert scale.

RESULTS

A multivariable regression model including physical disability, stage of disease, depression, mastery, and health locus of control predicted QOL (R2 = 0.48), with mastery as the only significant predictor (p = .0001). There were significant differences by PD stage for all variables (p < .05).

CONCLUSIONS

Mastery predicted quality of life in individuals with PD even when depression and physical disability were included in the model. Differences in psychosocial variables by stage of PD suggest that the psychosocial profile of PD patients may change as the disease progresses.

Two instruments to determine activated partial thromboplastin time: implications for heparin monitoring

STUDY OBJECTIVE

To measure the difference in therapeutic ranges of activated partial thromboplastin time (APTT) between two laboratory devices.

DESIGN

Prospective, controlled laboratory study.

SETTING

University-affiliated hospital.

PATIENTS

Thirty inpatients receiving intravenous unfractionated heparin for treatment of myocardial infarction, unstable angina, deep venous thrombosis, or pulmonary embolism.

INTERVENTIONS

Therapeutic APTT ranges were determined by a portable (whole blood assay) and a central laboratory device (plasma assay) based on heparin serum concentrations. They were compared with APTT ranges equivalent to 1.5-2.5 times the mean normal determination.

MEASUREMENTS AND MAIN RESULTS

The central laboratory and portable devices produced therapeutic ranges of 61-93 and 56-73 seconds, respectively. Both differed from conventional therapeutic ratios of 1.5-2.5 times the mean normal (41-68 sec). Mean absolute APTT differences between instruments were statistically significant (12 +/- 20 sec, p<0.006), and 58% of paired APTT values differed by more than 10 seconds.

CONCLUSION

A fixed APTT ratio as a goal for monitoring unfractionated heparin may result in significant underanticoagulation. Individual therapeutic APTT ranges must be reported for each instrument if more than one is used for heparin monitoring.

Berberine inhibits ion transport in human colonic epithelia

The effects of berberine on ion transport in both human colonic mucosal epithelia and an intestinal epithelial cell line (T84) were examined. Berberine (concentration range 0-500 microM) reduced both basal and stimulated ion transport responses in human colonic mucosae in a manner which was non-specific for Ca2+ -or cAMP-mediated signals. Similarly, in cultured intestinal epithelial monolayers, berberine inhibited Ca2+ -and cAMP-mediated responses indicating an inhibitory activity directly at the level of the epithelium rather than an indirect effect through other mucosal element(s). Berberine did not alter the rate of generation of cAMP by adenylyl cyclase or the activity of protein kinase A, the effector enzyme of the cAMP pathway. Berberine inhibited carbachol-stimulated 86Rb+ efflux from T84 monolayers. Berberine also inhibited K+ conductance in apically-permeabilised re-sected mucosae. These results indicate i) that berberine exerts an anti-secretory action directly upon epithelial cells and ii) the mechanism of action may be at the level of blockade of K+ channels.

Vancomycin-induced neutropenia associated with fever: similarities between two immune-mediated drug reactions

A 39-year-old woman being treated for osteomyelitis with vancomycin developed severe neutropenia and drug fever. After she discontinued therapy, both disorders quickly resolved. These adverse reactions have rarely been reported with vancomycin, and share many similarities with regard to clinical features and postulated mechanisms of induction. To our knowledge this is the first case documenting drug fever as a principal component of vancomycin-induced neutropenia, and provides further evidence in support of an immune-mediated mechanism.

Neutrophil-derived 5'-adenosine monophosphate promotes endothelial barrier function via CD73-mediated conversion to adenosine and endothelial A2B receptor activation

During episodes of inflammation, polymorphonuclear leukocyte (PMN) transendothelial migration has the potential to disturb vascular barrier function and give rise to intravascular fluid extravasation and edema. However, little is known regarding innate mechanisms that dampen fluid loss during PMN-endothelial interactions. Using an in vitro endothelial paracellular permeability model, we observed a PMN-mediated decrease in endothelial paracellular permeability. A similar decrease was elicited by cell-free supernatants from activated PMN (FMLP 10(-6) M), suggesting the presence of a PMN-derived soluble mediator(s). Biophysical and biochemical analysis of PMN supernatants revealed a role for PMN-derived 5'-adenosine monophosphate (AMP) and its metabolite, adenosine, in modulation of endothelial paracellular permeability. Supernatants from activated PMN contained micromolar concentrations of bioactive 5'-AMP and adenosine. Furthermore, exposure of endothelial monolayers to authentic 5'-AMP and adenosine increased endothelial barrier function more than twofold in both human umbilical vein endothelial cells and human microvascular endothelial cells. 5'-AMP bioactivity required endothelial CD73-mediated conversion of 5'-AMP to adenosine via its 5'-ectonucleotidase activity. Decreased endothelial paracellular permeability occurred through adenosine A2B receptor activation and was accompanied by a parallel increase in intracellular cAMP. We conclude that activated PMN release soluble mediators, such as 5'-AMP and adenosine, that promote endothelial barrier function. During inflammation, this pathway may limit potentially deleterious increases in endothelial paracellular permeability and could serve as a basic mechanism of endothelial resealing during PMN transendothelial migration.

Activated endothelial cells elicit paracrine induction of epithelial chloride secretion. 6-Keto-PGF1alpha is an epithelial secretagogue

Endothelial cells play a central role in the coordination of the inflammatory response. In mucosal tissue, such as the lung and intestine, endothelia are anatomically positioned in close proximity to epithelia, providing the potential for cell-cell crosstalk. Thus, in this study endothelial-epithelial biochemical crosstalk pathways were studied using a human intestinal crypt cell line (T84) grown in noncontact coculture with human umbilical vein endothelia. Exposure of such cocultures to endothelial-specific agonists (LPS) resulted in activation of epithelial electrogenic Cl- secretion and vectorial fluid transport. Subsequent experiments revealed that in response to diverse stimuli (LPS, IL-1alpha, TNF-alpha, hypoxia), endothelia produce and secrete a small, stable epithelial secretagogue into conditioned media supernatants. Further experiments identified this secretagogue as 6-keto-PGF1alpha, a stable hydrolysis product of prostacyclin (PGI2). Results obtained with synthetic prostanoids indicated that 6-keto-PGF1alpha (EC50 = 80 nM) and PGI2 stable analogues (EC50 = 280 nM) activate the same basolaterally polarized, Ca2+-coupled epithelial receptor. In summary, these findings reveal a previously unappreciated 6-keto-PGF1alpha receptor on intestinal epithelia, the ligation of which results in activation of electrogenic Cl- secretion. In addition, these data reveal a novel action for the prostacyclin hydrolysis product 6-keto-PGF1alpha and provide a potential endothelial- epithelial crosstalk pathway in mucosal tissue.

Epithelial permeability induced by neutrophil transmigration is potentiated by hypoxia: role of intracellular cAMP

Mucosal tissues, such as the lung and intestine, are primary targets for ischemic damage. Under these conditions, neutrophil (polymorphonuclear leukocyte; PMN) infiltration into the protective epithelium has been implicated as a pathophysiologic mediator. Because PMN transepithelial migration results in increased paracellular permeability, and because our previous data revealed that epithelial hypoxia enhances PMN transmigration, we hypothesized that macromolecular permeability may be altered in epithelium exposed to hypoxia and reoxygenation (H/R) in the presence of PMNs. Human intestinal epithelia (T84) were grown on permeable supports, exposed to cellular hypoxia (pO2 20 torr) for 0-72 hr, and examined for increases in PMN-evoked permeability by using standard flux assays. Increasing epithelial hypoxia potentiated PMN-induced permeability of labeled paracellular tracers (size range 3-500 kD). Such increases were blocked by monoclonal antibody (mAb) to the PMN integrin CD11b (82 +/- 1% decreased compared with control mAb) and were partially blocked by anti-CD47 mAb (51 +/- 1%). Assessment of barrier recovery revealed that monolayers exposed to H/R were significantly diminished in their ability to reseal following PMN transmigration (recovery of 36 +/- 6% in H/R vs. 94 +/- 2% in normoxic controls). Because intracellular cyclic AMP (cAMP) has been demonstrated to regulate epithelial permeability, and because PMN-derived compound(s), (i.e., 5'-adenosine monophosphate; AMP) elevate epithelial cAMP, we examined the impact of hypoxia on epithelial cAMP responses. These experiments revealed that hypoxic epithelia were diminished in their ability to generate cAMP, and pharmacologic elevation (8-bromo-cAMP) of intracellular cAMP in hypoxic cells normalized both PMN-induced permeability changes and restoration of barrier function. These results support a role for PMN in increased intestinal permeability associated with reperfusion injury and imply a substantial role for cAMP signaling in maintenance of permeability during PMN transmigration.

Autocrine regulation of epithelial permeability by hypoxia: role for polarized release of tumor necrosis factor alpha

BACKGROUND & AIMS

The intestinal mucosa is lined by a monolayer of protective epithelial cells. This barrier is regulated by immune-derived factors such as interferon gamma (IFN-gamma). Because of the high volume of blood flow, the intestine is a primary target for hypoxic damage. We hypothesize that epithelial cytokine responses are regulated by hypoxia.

METHODS

T84 intestinal epithelial cells were used to assess alterations in permeability, major histocompatibility complex class II induction, cytokine receptor expression, and cytokine release in response to combinations of IFN-gamma and cellular hypoxia.

RESULTS

Hypoxia potentiated the influence of IFN-gamma on epithelial barrier function. Such responses were conferrable in a >/=10-kilodalton conditioned media fraction from hypoxic epithelia. Subsequent experiments identified this factor as epithelium-derived tumor necrosis factor alpha (TNF-alpha). Add-back of recombinant TNF-alpha in combination with IFN-gamma to normoxic epithelia recapitulated hypoxia and identified basolaterally polarized TNF-alpha receptor types I and II on intestinal epithelia. A similar pattern of TNF-alpha-receptor expression was observed on native intestinal epithelia. Specific inhibition of TNF-alpha using neutralizing antibody or alpha-N-phthalimidoglutarimide (thalidomide) resulted in reversal of the hypoxia-evoked responses.

CONCLUSIONS

These studies indicate that during hypoxia, epithelium-derived mediators such as TNF-alpha have the potential to regulate permeability through autocrine pathways.

Hypoxia inhibits cyclic nucleotide-stimulated epithelial ion transport: role for nucleotide cyclases as oxygen sensors

Decreased oxygen delivery to cells (hypoxia) is prevalent in a number of important diseases. Little is known about mechanisms of oxygen sensing at the cellular level or about whether functional correlates of oxygen sensing exist. In this study, we examined the impact of hypoxia on stimulated epithelial ion transport function. T84 cells, a model of intestinal epithelia, were grown on permeable supports, exposed to hypoxia (range 1-21% O2) for periods of time between 0 and 72 h and assessed for stimulated ion transport. Hypoxia evoked a specific decrease in cyclic nucleotide-stimulated (cAMP and cGMP) but not Ca++-stimulated ion transport. 86Rb (K+ tracer) uptake and 125I (Cl- tracer) efflux were reduced in hypoxic cells by >50% and >40%, respectively, fluid movement was reduced by hypoxia (>50% decrease) and reoxygenation resulted in partial recovery of the ion transport responses. Stimulated and basal levels of both cAMP and cGMP were decreased in response to hypoxia, although intracellular ATP levels were unaltered under similar conditions. Exogenous addition of cobalt, nickel or manganese, all of which compete for oxygen binding on heme-containing proteins, mimicked hypoxia. Because guanylate cyclase is a heme protein, we measured the influence of cobalt on activity of guanylate cyclase in purified plasma membrane preparations and found cobalt to inhibit stimulated cGMP levels in this cell-free system. Finally, pharmacological lowering of intracellular cGMP (using LY83583) resulted in decreased cAMP-stimulated Cl- secretion, and direct elevation of cGMP (using 8-bromo-cGMP or dibutyryl-cGMP) restored this hypoxia-induced activity. We conclude that a potential oxygen-sensing mechanism of epithelial cells involves the cooperation of heme-containing proteins such as guanylate cyclase and that biochemical cross-talk between cAMP- and cGMP-stimulated pathways may be important in such responses.

Temperature-compensated cryogenic Fabry-Perot cavity

We show that temperature compensation based on differential thermal expansion between sapphire and fused silica can be used to create a Fabry-Perot cavity with an exceptionally low coefficient of thermal expansion at low temperatures. We describe the design of such a cavity that utilizes shaped fused silica mirrors and a sapphire spacer. The geometry of the fused silica mirror was designed using a finite element model to have a small platform, giving a frequency temperature turning point of 16.6 K. The measured turning point was 16.2 K and the curvature was 6 x 10(-10) K(-2), both of which were consistent with the model.

Changes in barrier function of a model intestinal epithelium by intraepithelial lymphocytes require new protein synthesis by epithelial cells

BACKGROUND

Elements of the mucosal immune system may play an important part in regulating epithelial barrier function in the intestinal tract. Intraepithelial lymphocytes (IELs) represent a subtype of immunocyte which is strategically placed to regulate epithelial function at most mucosal sites.

AIMS AND METHODS

An IEL derived cell line (SC1) was used to examine its effects on the model epithelium T84--a tumour derived cell line which retains the phenotype of colonic crypt cells. Transepithelial electrical resistance (TER) was used as a marker of epithelial integrity.

RESULTS

Coculture of T84 cells with SC1 produced a significant fall in TER as did exposure of T84 monolayers to IEL derived supernatant. Recombinant interferon-gamma (rIFN gamma) also reduced TER in T84 monolayers. Cycloheximide prevented the effects of IEL supernatant and of rIFN gamma on TER. The fall in TER in response to rIFN gamma was attenuated by blocking antibodies, which did not alter the fall in resistance induced by IEL supernatant. Fractions of IEL supernatant, separated on the basis of size, evoked temporally distinct changes in TER. Ultrastructural studies support the hypothesis that the slow onset but severe fall in TER indicates catastrophic effects on the monolayer. The more rapid onset fall in TER was not associated with gross changes in monolayer morphology. Reduction of TER by IEL supernatant was not influenced by inhibitors of tyrosine phosphatase or of protein kinase C. Although herbimycin did reduce the rapid onset change in TER, the tyrosine kinase inhibitor genistein did not alter responses to IEL supernatant.

CONCLUSIONS

Mucosal T cells may influence barrier function by a process involving new protein synthesis by epithelial cells. This model may have relevance in some inflammatory conditions of the gastrointestinal tract.

Development of low-loss sapphire mirrors

We report on the successful development of low-loss sapphire mirrors for use at a 1-mum wavelength. Methods for polishing and coating are described. The analysis of each process shows a roughness of better than 0.1 nm, a coating scattering of 1 ppm, and a surface scattering of 13 ppm. The mirrors have been characterized in a Fabry-Perot cavity, having a finesse of 100, 000. Mode doublets result from the birefringence of the coatings.

Soluble CD46 (membrane cofactor protein, MCP) in human reproductive tract fluids

CD46 (membrane cofactor protein, MCP) is a cell surface complement regulatory protein which may have an additional role in human sperm-egg interaction. A soluble form (sCD46) has also been detected in a number of biological fluids, most notably seminal plasma. The present study has employed a monoclonal antibody-based ELISA to assay sCD46 in reproductive tract fluids in normal and pathological conditions. Large amounts of sCD46 were detected in seminal plasma of both fertile and infertile men (combined mean, 4859 ng/ml). Vasectomized men had lower levels (mean, 2421 ng/ml), indicating contributory sources both before and after the vas deferens ligation site. Pre-colostrum also contained relatively high quantities (mean, 445 ng/ml), whereas breast milk (mean, 117 ng/ml), peritoneal fluid (mean, 154 ng/ml) and follicular fluid (mean, 107 ng/ml), as well as uterine (mean, 208 ng/ml), umbilical (mean, 166 ng/ml) and peripheral (mean, 206 ng/ml) blood plasma, had sCD46 levels within a comparable range. Amniotic fluid had low sCD46 concentrations (mean, 22 ng/ml). In endometriosis, peritoneal fluid levels of sCD46 were significantly raised (mean, 199 mg/ml). These results indicate distinctive fluid compartmentalisation of sCD46 consistent with a biological function in human reproductive tract fluids.

Effect of abnormal hypo-osmotic swelling test on fertilization rate and pregnancy outcome in in vitro fertilization cycles

OBJECTIVE

To assess the value of the hypo-osmotic swelling test in predicting fertilization, pregnancy, implantation, miscarriage, and live birth rates in IVF-ET cycles.

DESIGN

Prospective study.

SETTING

Academic tertiary referral center for fertility treatment.

PATIENTS

Three hundred twenty-six couples having IVF-ET for tubal damage or male factor infertility with the female partner < 38 years of age.

INTERVENTIONS

Each male had a hypo-osmotic swelling test performed between 4 and 8 weeks before IVF-ET.

MAIN OUTCOME MEASURES

Fertilization, implantation, miscarriage, and live birth rates.

RESULTS

Eighty of 326 men had abnormal hypo-osmotic swelling tests. An abnormal test was not associated with lower fertilization rates (odds ratio [OR] = 1.14; 95% confidence interval [CI] = 0.97 to 1.14) or pregnancy rate (OR = 0.98; CI = 0.50 to 1.96). However, although couples with a normal test had a miscarriage rate of 26.9% (14/52), in the group with an abnormal test the miscarriage rate was 50.0% (7/14) (OR = 0.37; CI = 0.09 to 1.49). This resulted in a reduction in the live birth rate from 14.1% in the group with a normal test to 11.8% in patients with an abnormal test (OR = 1.23; CI = 0.45 to 3.87).

CONCLUSIONS

The hypo-osmotic swelling test has little value in predicting fertilization in IVF-ET procedures. However, an abnormal test may help predict adverse outcome if pregnancy is achieved.

U50,488H-induced pressor effect in the ovine foetus is mediated by sympathetic activation and vasopressin

The purpose of this study was to investigate the mechanism behind the increase in blood pressure observed after intravenous administration of U50,488H (trans-3,4-dichloro-N-[2-(1-pyrrolidinyl)cyclohexyl]benzeneacetamide), a selective Kappa-opioid receptor agonist, to the ovine foetus. Intravenous administration of U50,488H (1.0 mg/kg) to the foetus resulted in an immediate increase in foetal blood pressure which lasted 15 min. Pretreatment with phentolamine (1.0 mg/kg i.v.) completely blocked the immediate (1-4 min) pressor effect of U50,488H, but not the subsequent increase in blood pressure after 5 min. In contrast, pretreatment with the vasopressin antagonist ([beta-mercapto-beta, beta-cyclopentamethylene-propionyl)-O-Me2-Tyr,Arg8]vasopressin, 0.06 mg/kg) did not affect the immediate pressor effect of U50,488H, but completely blocked the latter increase in blood pressure after 4 min. These data suggest that the immediate increase in blood pressure caused by U50,488H was mediated by sympathetic activation which was then further sustained by a release of vasopressin.

Complement-binding proteins are strongly expressed by human preimplantation blastocysts and cumulus cells as well as gametes

Human preimplantation embryos, gametes and cumulus cells were studied for expression of the complement-binding proteins CD46 (membrane cofactor protein), CD55 (decay accelerating factor) and CD59 (membrane attack complex inhibitory factor) as well as complement receptors type 1 (CRI), type 2 (CR2) and type 3 (CR3). Both the CD55 and CD59 glycosyl phosphatidylinositol (GPI)-anchored proteins were expressed by the plasma membrane and zona pellucida of oocytes, early embryos and expanded preimplantation blastocysts; in contrast, CD46 was expressed only on the plasma membrane. Cumulus cells consistently expressed CD46 and, most strongly, CD59 whereas CD55 expression was variable. Monoclonal antibodies (mAbs) to CRI, CR2 and CR3 epitopes gave only occasional reactivity on oocytes and were unreactive with blastocysts, spermatozoa and cumulus cells. CD46 is expressed only on the spermatozoal inner acrosomal membrane, and CD59 on the plasma membrane; CD55 expression was confirmed on the plasma membrane as well as the inner acrosomal membrane. Control mAbs specific for factor H were usually unreactive with gametes, blastocysts and cumulus cells. These data support the concept that gametes and early embryonic cells are protected from complement-mediated attack by expression of CD46, CD55 and CD59, although these complement-binding proteins may have additional roles in reproductive events.

Exaggerated effects of progestogen on uterine artery pulsatility index in Turner's syndrome patients receiving hormone replacement therapy

OBJECTIVE

To investigate the effect of estrogen and progestogen on the resistance to blood flow in the uterine arteries of Turner's syndrome patients.

DESIGN

Prospective clinical study.

SETTING

A tertiary infertility clinic.

PATIENTS

Five Turner's syndrome patients, six patients who had surgical castration, and five patients with idiopathic primary ovarian failure.

INTERVENTIONS

The patients were treated with 2 mg E2 valerate to which 500 micrograms norgesterel was added for 10 days in a 28-day cycle. Transvaginal color Doppler was used to measure pulsatility index in the uterine arteries at eight regular intervals during a single cycle.

MAIN OUTCOME MEASURE

Pulsatility index of the uterine arteries.

RESULTS

The administration of norgesterel to Turner's syndrome patients resulted in an increase in pulsatility index that was significantly higher than in patients who had surgical castration (confidence interval = 0.17 to 2.42).

CONCLUSION

The uterine arteries of Turner's syndrome patients are more sensitive to the tonic effect of progestogen. If manifest in cardiac arteries also this phenomenon may be partly responsible for the increased incidence of cardiovascular disease and shorter life expectancy in Turner's syndrome patients. To achieve optimal protection from cardiovascular disease, Turner's syndrome patients may benefit from hormone replacement treatment containing altered doses of estrogen and progestogen.

Berberine inhibition of electrogenic ion transport in rat colon

1. The effects of the alkaloid berberine on basal and stimulated ion transport were investigated in voltage-clamped rat colonic epithelia. 2. Berberine (100-500 microM) reduced basal short circuit current (SCC) when applied basolaterally but not when applied apically. 3. SCC responses to mast cell activation by anti-rat IgE were significantly attenuated in the presence of berberine. 4. Berberine, applied to the basolateral bathing solution, also reduced SCC responses to the following agents which stimulate chloride secretion in rat colon: carbachol, forskolin, sodium nitroprusside, dibutyryl cyclic-AMP, heat-stable E. coli enterotoxin, 8-bromo-cyclic GMP and thapsigargin. Calcium mediated ion transport responses appear to be more sensitive to berberine inhibition than those which are cyclic GMP-mediated, which in turn are more sensitive than cyclic AMP-mediated responses. 5. Berberine added apically was without effect upon forskolin-stimulated ion transport. Cytochalasin D treatment of the lumenal surface of rat colon conferred apical-side sensitivity to berberine. 6. Berberine (at concentrations up to 500 microM) was without effect on generation of cyclic AMP by forskolin or on generation of cyclic GMP by sodium nitroprusside in isolated mucosal segments. Protein kinase A activity stimulated by dibutyryl cyclic AMP was unaffected by berberine (at concentrations up to 500 microM). 7. The precise mechanism of action of berberine remains to be elucidated. However, its site of action appears to be distal to second messenger production and may be at a level common to all stimuli of colonic chloride secretion.

Trizygotic quadruplet pregnancy following in-vitro fertilization: an additional factor against replacement of three embryos in young patients?

A study of a 25 year old woman with a previous history of tubal damage, ectopic pregnancy and unsuccessful tubal surgery is reported. Following in-vitro fertilization (IVF) treatment, four viable fetuses were revealed by ultrasound scan at 10 weeks gestation. Two shared the same gestational sac, thus establishing a trizygotic quadruplet pregnancy. The implications of monozygotic twinning in humans are discussed. It is concluded that embryo splitting and its consequences should be seriously considered when multiple embryo transfer in young patients is contemplated.

Evaluation of different sperm function tests as screening methods for male fertilization potential--the value of the sperm migration test

OBJECTIVE

To assess the value of different sperm function screening tests in predicting fertilization.

DESIGN

Prospective study.

SETTING

Academic tertiary referral center for fertility treatment.

PATIENTS

Ninety-five couples attending for initial screening and IVF-ET. Only cycles where three or more grade I oocytes were collected were included, and patients with endometriosis were excluded.

INTERVENTIONS

Each patient had a standard semen analysis, cervical mucus (CM) penetration test, hypo-osmotic swelling test, and sperm migration test performed between 4 and 8 weeks before IVF-ET.

MAIN OUTCOME MEASURES

The correlation between sperm function test results and the percentage of fertilized oocytes and the power of the tests to predict fertilization.

RESULTS

The sperm migration test correlated highly with fertilization rate (r = 0.62) and was most useful in identifying the group of patients likely to achieve fertilization (Odds ratio [OR] 0.07, confidence interval [CI] 0.02 to 0.2). The CM penetration test showed a moderate correlation with fertilization rate (r = 0.45) and some predictive power (OR 0.37, CI 0.13 to 1.00). Sperm concentration, but not motility or normal morphology, showed slight correlation with fertilization rate (r = 0.28) but the combination of normal semen parameters did not distinguish patients likely to achieve fertilization (OR 1.51, CI 0.62 to 3.65). The hypo-osmotic swelling test did not correlate with fertilization rate (r = 0.21).

CONCLUSIONS

This study evaluated the predictive power of several simple tests available for use in most laboratories as screening tests of sperm fertilization potential. Apart from sperm concentration, normal traditional semen characteristics were of little clinical benefit. The hypo-osmotic swelling test had no predictive power. The CM penetration test correlated with fertilization rate but might be difficult to perform routinely as a continuous supply of suitable CM would be required. The sperm migration test proved to be the best discriminator of sperm fertilization potential and should be considered as a first level screening test in the assessment of male fertility.

Inhibition of human spermatozoon-oocyte interaction in vitro by monoclonal antibodies to CD46 (membrane cofactor protein)

CD46 (membrane cofactor protein) is a cell surface complement regulatory glycoprotein that facilitates enzymatic cleavage of complement component C3b; it is expressed by both human oocytes and acrosome-reacted spermatozoa. Murine anti-CD46 monoclonal antibody (mAb) has been reported to decrease significantly the ability of human spermatozoa to penetrate hamster oocytes. We have investigated the effect of purified anti-CD46 mAbs on spermatozoon-oocyte interaction in an autologous zona-free oocyte penetration test. Oocytes and/or spermatozoa were preincubated with either of two anti-CD46 murine mAbs, TRA.2.10 (a non-blocking mAb) and MH61 (a mAb that functionally blocks C3b-ligand binding activity), or a control isotype-matched mAb, in medium supplemented with human serum albumin. Preincubation of both spermatozoa and zona-free oocytes with TRA.2.10, but not MH61, caused a significant decrease in the number of oocytes showing sperm binding and pronuclear formation (9/23) compared with controls (21/26) in this complement component-depleted medium. This effect was not observed if oocytes or spermatozoa alone were preincubated. These data suggest that CD46 has a role in human spermatozoon-oocyte interaction at the level of the oocyte plasma membrane, and indicate that a novel function other than direct C3b binding could be involved.

Oscillations in intracellular free calcium induced by spermatozoa in human oocytes at fertilization

Calcium has an important role in the events of egg activation and early preimplantation development. We investigated changes in intracellular calcium concentration in human oocytes at fertilization using the calcium-sensitive photoprotein aequorin. Oocytes were donated for research by patients undergoing in-vitro fertilization treatment in the Department of Obstetrics and Gynaecology. Cumulus cells, and in some cases zonae pellucidae, were removed by appropriate enzyme treatment. Single oocytes were micro-injected with aequorin and incubated in a chamber perfused with pre-equilibrated culture medium in a photomultiplier system. Eleven zona-intact and 15 zona-free oocytes were incubated with sperm, and oocytes from each group were incubated without sperm as controls. Dramatic transient increases in intracellular free calcium concentration were recorded in three zona-intact and seven zona-free oocytes, thought to be the first direct measurements of intracellular changes in human oocytes at fertilization. The amplitude (up to 2.5 microM), duration (120 s) and frequency (every 10-35 min) of these transients were similar in zona-intact and zona-free oocytes. They resemble those recorded in mouse oocytes, which may therefore be a suitable model for biochemical events at human fertilization.

Effect of aspirating needle calibre on outcome of in-vitro fertilization

Thirty patients with intact ovaries undergoing ultrasound-guided transvaginal oocyte retrieval for in-vitro fertilization treatment had their ovaries randomized for follicular aspiration with small and large aspiration needles while under mild sedation. Collections using smaller diameter needles had no significant effect upon the number of oocytes collected per follicle aspirated, or on the subsequent fertilizing capacity of those oocytes. There was significant reduction in pain perceived by the patient when the smaller needle was used during the collection.

Requirement of inner cell mass for efficient chorionic gonadotrophin secretion by blastocysts of common marmosets (Callithrix jacchus)

The role of the inner cell mass in the induction of chorionic gonadotrophin synthesis and secretion by the trophoblast of the peri-implantation primate blastocyst was studied in common marmoset monkeys. An in vitro system for the culture of blastocysts commencing with blastocysts collected 8 days after conception was developed. Chorionic gonadotrophin measured in the spent culture fluid was first detected in most blastocysts after 3 or 4 days (day 11 or 12) of culture at a time equivalent to implantation in vitro. Initial secretion of chorionic gonadotrophin coincided with development of parietal endoderm and histological appearance of syncytiotrophoblast in the polar trophoblast. Little chorionic gonadotrophin was secreted by blastocysts with a poorly developed, or absent, inner cell mass. Mural trophoblast removed from blastocysts after 2 days of culture (day 10) grew in vitro as a unilaminar vesicle but failed to secrete significant amounts of chorionic gonadotrophin. However, mural trophoblast from older blastocysts (days 13 and 14) after chorionic gonadotrophin secretion had commenced continued to secrete chorionic gonadotrophin, with trophoblast from day 14 blastocysts secreting significantly more than that from day 13. It was concluded from these studies that while mural trophoblast from marmoset blastocysts will proliferate in vitro in the absence of an inner cell mass, efficient induction of chorionic gonadotrophin secretion requires the presence of the inner cell mass or its derivatives. Once chorionic gonadotrophin secretion has commenced, secretion will continue in the absence of the inner cell mass.

Transport in vitro fertilization--a novel scheme for community-based treatment

OBJECTIVE

To provide an inexpensive and extensive in vitro fertilization (IVF) service for the Mersey Region, United Kingdom.

DESIGN

Twenty-four transport IVF patients treated in two district general hospitals using the central university laboratory as co-ordination point for treatment schedule and embryology. Outcomes were compared with 26 control patients treated in the central unit.

SETTING

Royal Liverpool University Hospital, a central IVF unit, and two district general hospitals in the Mersey Region.

PATIENTS

Fifty patients under 35 years of age with irreversible tubal damage selected and treated by IVF, half in the central unit and the other half in two district general hospitals.

MAIN OUTCOME MEASURES

Pregnancy rate (PR) in the different centers.

RESULTS

A PR of 42.3% per cycle in the peripheral hospitals compared with 30.7% per cycle in the central unit.

CONCLUSION

Transport IVF is an inexpensive and feasible alternative to standard IVF in a central unit for patients without access to central units.

Expression of the CD46 antigen, and absence of class I MHC antigen, on the human oocyte and preimplantation blastocyst

Expression of CD46 and class I major histocompatibility complex (MHC) antigens by human oocytes and 6-8-day unhatched expanded preimplantation blastocysts has been studied by immunocytochemistry. The CD46 antigen, a cell surface complement regulatory protein, was expressed by unfertilized oocytes as well as strongly by both the inner cell mass and trophectoderm of preimplantation blastocysts. In contrast, class I MHC antigens were not usually expressed by either oocytes or blastocysts. These data support the concept that gametes and embryonic cells involved in fertilization and early implantation events, respectively, may be protected from immunological recognition or attack both by the lack of class I MHC antigens and by expression of the CD46 complement regulatory protein.

Is follicular flushing necessary for oocyte retrieval? A randomized trial

A prospective randomized trial was performed to evaluate the necessity of follicular flushing during transvaginal, ultrasonically guided oocyte recovery under mild sedation. Patients with tubal damage as the sole cause of their infertility were randomized into one of two groups. Group one had their follicles aspirated only. Follicles of patients in Group 2 were aspirated and flushed with a total of 10 ml of flushing medium. There was no significant difference in the number of oocytes retrieved, fertilization rate or pregnancy rate in each group. There was, however, a significant shortening of operating time in the aspiration only group.

Development of spare human preimplantation embryos in vitro: an analysis of the correlations among gross morphology, cleavage rates, and development to the blastocyst

Following in vitro fertilization, the criteria commonly used to select human embryos for transfer are the cleavage rate and gross morphology, the contention being that those embryos which divide more rapidly and have regular, spherical blastomeres are more likely to lead to a pregnancy. In order to assess the validity of this assumption, the development in vitro of spare embryos was investigated. Eggs and embryos were cultured in Earle's balanced salt solution containing 10% heat-inactivated patient's serum, and insemination was performed at 40 hr post human chorionic gonadotropin (hCG). At 82-90 hr post hCG, up to four embryos were transferred. Any spare embryos were cultured in the same medium for up to 6 days and scored daily for cell number and morphology using a "quality" scale of 4-1 according to degree of fragmentation and shape of the blastomeres. Of 317 fertilized eggs, 55 (17%) developed to the fully expanded blastocyst stage. The remaining embryos ceased development at the one-cell (6; 2%), two-cell (49; 15%), four-cell (110; 35%), eight-cell (61; 19%), and cavitating morula (36; 11%) stages. The relationship between developmental arrest and gross morphology is discussed.

Characteristics of trophoblastic tissue derived from in vitro culture of preimplantation embryos of the common marmoset monkey

The features of trophoblastic tissue derived from the in vitro culture of marmoset monkey embryos have been described. Long-term trophoblast cultures (in excess of three years in one case) were established from the primary trophoblast monolayer of four of 38 embryos; division of one of these embryos produced two long-term cultures. The trophoblast cells retained their ability to synthesize and secrete chorionic gonadotrophin (CG) during maintenance in vitro and were capable of prolonging the luteal phase when transferred to the uterus of marmosets. A characteristic feature of the cultures was the formation of multiple fluid-filled vesicles enclosed by a single layer of cytotrophoblast cells and attached to the culture dish by a small monolayer of syncytiotrophoblast cells. The tissue was propagated by cutting vesicles into small pieces and placing into a fresh culture dish; attempts to subculture using single-cell suspensions were unsuccessful. These cultures provide a convenient source of marmoset CG for purification as well as an in vitro system for studying other secretory products of primate trophoblast.

The effects of cryopreservation and transfer on embryonic development in the common marmoset monkey, Callithrix jacchus

Embryos were collected at the 4-10-cell stage from the oviducts (Day 4; Day 1 = ovulation) or as morulae (Day 7) from the uterus of marmosets and frozen in 1.5 M-DMSO (Days 4 and 7) or 1.0 M-glycerol (Day 4 only), using a slow freezing and thawing technique. Of 22 Day-4 embryos frozen in DMSO, 18 were recovered and 16 of these were transferred to 10 synchronized recipients; 7 recipients became pregnant compared with all 7 control recipients receiving 10 unfrozen embryos. Fifteen frozen-thawed morulae were transferred to 9 Day-6 recipients; the pregnancy rate (55.6%) was lower than for control embryos (85.7%). Embryos frozen in glycerol suffered severe osmotic stress during glycerol addition and removal. Of 8 recipients, 3 (37.5%) became pregnant but only one fetus was carried to term. These results on embryo collection, freezing and transfer in the marmoset have important implications for developing improved methods for freezing human embryos and the breeding of endangered primates.