Danish National IVF Registry 1994 and 1995. Treatment, pregnancy outcome and complications during pregnancy

SUBJECT

Data from the compulsory Danish National IVF Registry from 1994 and 1995 regarding treatments, abortions and complications following assisted reproductive technologies.

METHODS

Data were generated through registries and compared to pregnancies in Denmark in 1995. Those pregnancies that resulted in a delivery were compared to a matched control group.

RESULTS

In 1994 and 1995 5219 women were treated in 9471 initiated cycles. The numbers increased over the period. The overall delivery rate per initiated cycle was 19%, egg donation 24%, IVF 20%, ICSI 16% and frozen egg replacement 10%. The rates increased over the period. The rate of spontaneous abortions was highest for ICSI (25%) and egg donation (27%). For IVF and ICSI the birth rates per transfer of 1 embryo was 13, 1%, 2 embryos 25, 4%, 3 embryos 25, 8% and 4 or more 3, 8%. Transfer of 2 embryos resulted in 75% singleton, 25% twin and 0.2% triplet deliveries. After transfer of 3 embryos the corresponding rates were 68%, 29% and 4%. No quadruplet deliveries occurred. Totally, 1.4% reported complications to the treatment, the most frequent being ovarian hyperstimulation syndrome. In the study group 5.8% of the women who gave birth were diagnosed with imminent abortion vs. 3.0% in the control group (OR 1.98, CI 1.41-2.78).

CONCLUSIONS

Transfer of three embryos did not result in higher pregnancy rates as compared to transfer of two embryos. The first data from the Danish IVF Registry support data from other registries regarding treatment, pregnancy outcome and complications during pregnancy.

Fetal antigen 1, an EGF multidomain protein in the sex hormone-producing cells of the gonads and the microenvironment of germ cells

Fetal antigen 1 (FA1), an epidermal growth factor (EGF) multidomain glycoprotein, was investigated in the human reproductive system. Immunohistochemical analysis of the male reproductive system revealed staining for FA1 in the Leydig cells only. Concentrations of FA1 in seminal plasma and serum were similar and significantly correlated in weekly samples from three men (P < 0.0065). The concentrations in seminal plasma from vasectomized men (n = 4) were not significantly different from those of normal men (n = 187). The concentration of FA1 in seminal plasma was significantly correlated with the sperm counts of normozoospermic men (P < 0.0001), and significantly higher in seminal plasma from men with sperm counts > 20 x 10(6)/ml, compared with those with counts </= 20 x 10(6)/ml (P < 0. 0001). Immunohistochemical analysis of the ovary showed the presence of FA1 in the theca interna and the hilus cells but not in the granulosa cells or the oocyte. In follicular fluid the concentration of FA1 (median; 73.3 ng/ml, n = 28) was three times higher than that of serum (median; 23.8 ng/ml). These data suggest a role for this novel member of the EGF superfamily in relation to human reproduction, but further experiments are needed to define the biological function and to elucidate its clinical potential.

A Danish national cohort of 730 infants born after intracytoplasmic sperm injection (ICSI) 1994-1997

This national cohort study included all clinical pregnancies obtained after intracytoplasmic sperm injection (ICSI) registered in Denmark between January 1994 and July 1997 at five public and eight private fertility clinics. Laboratory and clinical data were obtained from the fertility clinics. The couples answered a questionnaire regarding the pregnancy and the health of the child (response rate 94%). Data validation was carried out through discharge charts. The mean age of the women was 32.1 years. In 84.2% of couples, male factor was the main reason for performing ICSI, and in 4.8% epididymal spermatozoa were used. The mean number of embryos replaced was 2.3 (range 1-3) and in 95% of cases fresh embryos were transferred. Only 183 women (28.5%) underwent prenatal diagnosis, resulting in 209 karyotypes with seven (3.3%) chromosome aberrations. Six major chromosomal abnormalities (2.9%) and one inherited structural chromosome aberration (0.5%) were found, but no sex chromosome aberrations. The frequency of multiple birth, Caesarean section rate, gestational age, preterm birth, and birth weight were comparable with previous studies. The perinatal mortality rate was 13.7 per 1000 children born with a gestational age of 24 weeks or more. In 2.2% (n = 16) of the liveborn infants, and in 2.7% (n = 20) of all infants, major birth defects were reported by the parents. Minor birth defects were found in nine liveborn infants (1.2%). In conclusion, the results of this study on outcome of ICSI pregnancies are in line with earlier reports, except that no sex chromosome abnormalities were found.

Danish National In-Vitro Fertilization Registry 1994 and 1995: a controlled study of births, malformations and cytogenetic findings

This paper reports data from the Danish in-vitro fertilization (IVF) registry from 1994 to 1995 including data on treatments and the results of these (perinatal outcome, cytogenetic findings and fetal malformations) in comparison with a control group matched for maternal age, parity, multiplicity and year of birth. There were 1756 deliveries of 2245 children (24.3% twins, 1.8% triplets). The rate of prematurity among IVF children was 23.8% (NS) [singletons 7. 3% (P < 0.05), twins 41.2% and triplets 93.5%], 23.6% weighed <2500 g [singletons 7% (P < 0.05), twins 42.2% and triplets 87.1%]. The perinatal mortality rate was 21.8 in the study group compared to 17. 4 in the control group (NS). In total, 13.2% of all clinical pregnancies and 15.4% of the pregnancies that resulted in a delivery had a prenatal genetic examination. Of all examined, 3.5% had an abnormal karyotype. In total, 107 (4.8%) children in the study group and 103 (4.6%) in the control group were born with malformations (NS), compared to 2.8% in the background population. Our results indicate that it is the characteristics of the patients and multiplicity of pregnancy, rather than the assisted reproductive technology that determines the fetal risks of IVF pregnancies compared to the background population.

Dose-proportionality of oral thioctic acid--coincidence of assessments via pooled plasma and individual data

Thioctic acid (TA), a racemate of R-(+)- and S-(-)-enantiomers of alpha-lipoic acid, acts as a powerful lipophilic, free-radical scavenger and is used in the treatment of diabetic neuropathy. This trial investigated the dose-linearity of enantiomer pharmacokinetics following the oral administration of single doses of 50 to 600 mg TA (formulation provided by ASTA (Medica)) in healthy volunteers. TA enantiomer concentrations in individual and pooled plasma samples were determined using enantioselective, high-performance liquid chromatography. TA was rapidly absorbed (tmax, 0.5 to 1 h). Maximum plasma concentrations (Cmax) of the R-(+)-enantiomer were about 40-50% higher than those of the S-(-)-enantiomer (50 mg: 135.45 ng/ml R-(+)-TA, 67.83 ng/ml S-(-)-TA; 600 mg: 1812.32 ng/ml R-(+)-TA, 978.20 ng/ml S-(-)-TA; geometric means). The decline observed in the plasma concentration was steep (t1/2, 0.5 h). The dose-linearity and proportionality of pharmacokinetic parameters could be demonstrated on an intra-individual basis and for the group geometric means. An analysis of pooled plasma samples proved to be a suitable means for deriving reliable first-sight results prior to individual assessments.

Stereoselective disposition of tiaprofenic acid enantiomers in rats

The pharmacokinetics and metabolic chiral inversion of the S(+)- and R(-)-enantiomers of tiaprofenic acid (S-TIA, R-TIA) were assessed in vivo in rats, and in addition the biochemistry of inversion was investigated in vitro in rat liver homogenates. Drug enantiomer concentrations in plasma were investigated following administration of S-TIA and R-TIA (i.p. 3 and 9 mg/kg) over 24 hr. Plasma concentrations of TIA enantiomers were determined by stereospecific HPLC analysis. After administration of R-TIA it was found that 1) there was a time delay of peak S-TIA plasma concentrations, 2) S-TIA concentrations exceeded R-TIA concentrations from approximately 2 hr after dosing, 3) Cmax and AUC(0-infinity) for S-TIA were greater than for R-TIA following administration of S-TIA, and 4) inversion was bidirectional but favored inversion of R-TIA to S-TIA. Bidirectional inversion was also observed when TIA enantiomers were incubated with liver homogenates up to 24 hr. However, the rate of inversion favored transformation of the R-enantiomer to the S-enantiomer. In conclusion, stereoselective pharmacokinetics of R- and S-TIA were observed in rats and bidirectional inversion in rat liver homogenates has been demonstrated for the first time. Chiral inversion of TIA may involve metabolic routes different from those associated with inversion of other 2-arylpropionic acids such as ibuprofen.

Immunoregulatory networks in asthma

It is now well established that a subset of T-cell-derived cytokines (termed Th2 cytokines) programme the timing and characteristics of atopic airway disease including mast-cell sensitization, eosinophil and lymphocyte infiltration and recently mucus secretion. To date, attempts to devise ways to selectively limit the activities of Th2 cytokine-producing cells have been frustrated. However, the recent identification of the molecules which direct the activation and maturation of T cells has led to some successful attempts to block the activities of Th2 cells in models of atopic airway inflammation. Some of the agents with the most potential include antagonists of the T-cell costimulatory molecule CD28, local stimulators of the Thl subset of cytokines such as the BCG vaccine and potentially, antagonists of the eotaxin chemokine receptor and agonists of the T-cell costimulatory molecule CTLA-4. Not only do such agonists and antagonists represent potential new therapies, they could represent a rich hunting ground for those who aim to determine the ways in which atopic airway disease can be diagnosed and understood.

[The effectiveness of in vitro fertilization. A cohort study of 300 couples]

A cohort of 300 couples, starting their first in-vitro fertilization (IVF) attempt between 1990 and 1992, were followed until completion of their treatment. A total of 897 treatment cycles were initiated. Of these 213 (23.7%) were cancelled, giving a total of 684 embryo replacements. One hundred and forty-one (47%) couples completed their treatment with delivery of at least one healthy baby. Ninety-eight (31.3%) couples completed their treatment without achieving delivery of a living baby, and 40 (13.7%) couples cancelled their treatment due to varying reasons. The treatment in seven couples was cancelled before completion due to medical reasons. In 12 women no transfer took place. IVF treatment is an effective procedure giving a "baby take home rate" of 47% within one to three cycles. A cohort study gives a realistic view of the probability of childbirth.

No evidence for decreasing semen quality in four birth cohorts of 1,055 Danish men born between 1950 and 1970

OBJECTIVE

To compare the quality of semen in 1,055 Danish men born between 1950 and 1970 who are assumed to represent a random sample of the Danish male population of fertile age.

DESIGN

Retrospective review of data on semen quality at the time of the female partner's first IVF treatment.

SETTING

The Fertility Clinic, Odense University Hospital, Odense, Denmark.

PATIENT(S)

One thousand fifty-five male partners of women with tubal infertility who were referred for IVF treatment consecutively during the period 1990-1996.

INTERVENTION(S)

Analysis of the semen samples delivered and used in connection with the couples' first IVF treatment.

MAIN OUTCOME MEASURE(S)

Year of birth, age at time of sample collection, sperm concentration, and semen volume.

RESULT(S)

The mean sperm concentration (+/- SD) was 183.7 x 10(6) mL and the mean semen volume (+/- SD) was 3.9 mL. A considerable variation in both parameters was found from year to year, but no significant change occurred in either parameter throughout the entire period. When four birth cohorts were compared, a later year of birth was not associated with any change in sperm concentration or semen volume.

CONCLUSION(S)

Sperm concentration and semen volume were not related to year of birth, indicating that sperm quality has not changed in the Danish male population during the last 20-30 years.

Reduced in vitro fertilization of human oocytes correlates with raised circulating FSH levels during ovarian stimulation in normogonadotropic women downregulated with GnRH-analogues

PURPOSE

The possible effects of circulating FSH levels as used during IVF treatment on oocyte maturation and subsequent preembryo development were evaluated.

METHODS

Serum levels of FSH and LH on days 1 and 8 of ovarian stimulation and on the day of oocyte retrieval (OR) were correlated with subsequent preembryo development in vitro. After pituitary downregulation, 244 normogonadotropic women followed a fixed protocol for the first 7 days of stimulation.

RESULTS

The average FSH concentration on day 8 of stimulation was 11.5 IU/L and exceeded the expected midcycle surge of FSH by more than 25%. In contrast, levels of LH were below an average of 2 IU/L throughout the stimulation period. The concentration of FSH on day 8 and on the day of OR showed a significant inverse correlation with cleavage rate, whereas levels of LH, age, and body mass index showed no such correlation.

CONCLUSIONS

Supraphysiologic levels of FSH seems to affect oocyte maturation negatively. Premature resumption of meiosis, leading to retrieval of postmature oocytes with a reduced developmental potential, is suggested as the underlying mechanism.

Pilot scale purification of human monoclonal IgM (COU-1) for clinical trials

No standard procedure is available for the purification of human monoclonal antibodies for human i.v. administration. Here we describe the procedure developed for pilot scale purification of the human IgM monoclonal antibody COU-1 directed against a cancer-associated antigen. The hybridoma cells were grown in protein-free medium and purification from the clarified culture supernatant was carried out in 4 simple chromatographic steps: (1) hydroxylapatite chromatography; (2) hydrophobic interaction chromatography on phenyl-Sepharose: (3) cation-exchange chromatography on sulphonyl-Sepharose; and (4) anion-exchange chromatography on tetraethylamino-Sepharose. The product was substantially pure with regard to protein after step 3, but contained DNA which was removed in step 4. The average recovery of the IgM was 54% with a range of 40-65%. Importantly, the ability of the antibody to bind to its antigen in ELISA was fully maintained during the purification. Subsequently, the purified antibody was isotope labelled and successfully used for in vivo detection of colon, rectal and pancreas carcinomas in patients. The purification procedure described appears to compare favourably with previously published methods, but a critical comparison is not possible due to the lack of necessary information in the available literature.

Spinally delivered nociceptin/orphanin FQ reduces flinching behaviour in the rat formalin test

The aims of this study were to investigate the dose-dependent effects of spinally delivered nociceptin (0.3, 1, 3.3 and 10 nmol) on flinching behaviour in the rat formalin test and whether these effects were influenced by the concomitant systemic administration of naloxone (3 mg/kg, i.p.). The effect of the highest nociceptin dose differed statistically from vehicle, 0.3 and 1 nmol nociceptin. Following the administration of 1, 3.3 or 10 nmol nociceptin mean total flinches decreased dose-dependently. The effects of 10 nmol nociceptin were not reversed by a high dose of naloxone. We observed a decrease in flinching behaviour with intrathecally to the lumbar enlargement delivered nociceptin and conclude that nociceptin has antinociceptive effects in the rat formalin test.

Evaluation of the noninvasive estimates of cardiac output by Doppler aortoechography according to test-theoretical principles

The usability of noninvasive methods can be quantified by a formal assessment of empirical quality criteria based on test-theoretical principles. The ACVF Doppler aortoechography is a pulsed dual-beam ultrasound technique with online estimates of cardiac output (CO) based upon the measurement of the mean Doppler shift frequency across the ascending aorta, its estimated cross-sectional area and the cycle's heart rate. The method has a relatively high reliability, sensitivity, and pharmacosensitivity (for inodilatory changes in particular), but tends to underestimate cardiac output. Furthermore, the method lacks objectivity because it is highly observer-dependent. Precise method description and stringent standardization thus are required. Because of the method specificity of its estimates, data should not be combined with those of other methods. The inherently poor validity of its CO estimates, using this method, call for caution in the mechanistic interpretation of its observations.

Differentiation of inodilatory responses by non-invasive measures of cardiovascular performance in healthy man

The cardiovascular responses to various inodilatory interventions were investigated noninvasively in healthy man by monitoring heart rate (HR), blood pressure (SBP/DBP, according to Korotkoff I and IV criteria), systolic time intervals (PEP, VET and QS2) and impedance cardiographic estimates of stroke volume (SV) and cardiac output (CO). The following inodilatory interventions were evaluated and compared: the i.v. infusion of adrenaline (1 microgram/min), the i.v. infusion of isoprenaline (1 microgram/min) with and without pretreatment with 100 mg talinolol (a beta 1-selective beta-adrenoceptor antagonist), the p.o. administration of 1200 mg celiprolol (a beta 1-adrenoceptor antagonist with ancillary beta-adrenergic agonistic properties at the chosen dose level), the p.o. administration of 0.4 mg bimakalim (a K+ channel activator without direct cardiac effect) with and without pretreatment with 5 mg bisoprolol and the p.o. administration of the PDE-III inhibitors meribendan and isomazole. The extent of the inodilatory rise of HR, shortening of PEP, rise of SV and CO relative to the associated reduction of the calculated total peripheral resistance (TPR) proved a powerful tool to differentiate inodilatory properties: adrenaline, isoprenaline after beta 1-selective beta-adrenoceptor blockade and celiprolol led to similar ancillary adrenaline-like cardiovascular changes relative to the vasodilatation; bimakalim led to similar associated changes except for a relatively larger rise in HR, which could be blocked by bisoprolol; isoprenaline induced clearly larger associated changes, for which HR, VET, and QS2c were particularly sensitive; meribendan and isomazole resulted in the largest ancillary changes, characterized by a critical shortening of the ejection time VET, so that the rise of CO was almost exclusively defined by the rise of HR. These differences could be detected and differentiated sufficiently and adequately by HR, SV, CO, TPR, PEP, and VET. There seems little value in using more assumptive variables such as HR-corrected VETc and QS2c, the Weissler index and the impedance cardiographic Heather index.

Transfer of different nonsteroidal antiinflammatory drugs via the lymphatic system in the rat

The motility of lymphatic vessels is regulated by arachidonate metabolites and can, therefore, be altered by cyclooxygenase blockers such as nonsteroidal antiinflammatory drugs (NSAIDs). To investigate the transfer of different NSAIDs via the lymphatic system, pharmacokinetics in plasma and lymph after peroral administration of three model compounds (namely, racemic ibuprofen, tenoxicam, and nabumetone) were investigated in rats. Microsurgical cannulation of the thoracic duct allowed cumulative sampling of lymph fluid up to 48 hr (N = 16). Pharmacokinetic parameters in plasma were determined in a control group (N = 12). Concentrations of R-ibuprofen, S-ibuprofen, tenoxicam, nabumetone, and the metabolites OH-ibuprofen, COOH-ibuprofen and 6-methoxy-2-naphthylacetic acid (6MNA; a metabolite of nabumetone) were monitored in lymph and plasma by HPLC. The observed peak concentrations in lymph of the investigated drugs are likely to produce different biological effects with regard to cyclooxygenase-1 inhibition. To quantify the appearance in lymph fluid, a "lymphatic clearance" of the investigated compounds was defined by dividing the amount recovered in lymph by the corresponding area under the plasma concentration-time curve. The "lymphatic clearance" differed substantially between the investigated compounds (mean +/- SD: R-ibuprofen, 19.8 +/- 9.4; S-ibuprofen, 9.6 +/- 3.6; tenoxicam, 32.5 +/- 31.3; nabumetone, 133.6 +/- 75.2; 6MNA, 18.3 +/- 8.5 microliters/min/kg). Overall recovery of the investigated compounds in lymph did not exceed 5% of the doses given. The known fact that lymphatic drainage is regulated by arachidonate metabolites suggests that NSAIDs differing in their transfer via the lymphatic system could result in different responses of lymphatic vessels to an inflammatory fluid load.

Leishmania major infection in major histocompatibility complex class II-deficient mice: CD8+ T cells do not mediate a protective immune response

In order to evaluate the role of CD8+ T cells in cutaneous leishmaniasis, major histocompatibility complex (MHC) class II-deficient mice of C57BL/6 background lacking functional CD4+ T cells were infected with Leishmania major. In contrast to C57BL/6 wild-type mice which are resistant to infection with L. major, these mice developed severe skin lesions that did not heal. In comparison to susceptible BALB/c mice, however, lesion development in MHC class II-deficient mice was very much retarded, even though the increase in the parasite load in lymphoid organs was only slightly delayed. Lymph node cells from L. major-infected MHC class II-deficient mice produced very low levels of interferon-gamma upon stimulation with L. major antigen, whereas the response to the mitogen concanavalin A was not impaired. Interestingly, they did not release lymphokines associated with disease exacerbation (interleukin 4 and interleukin 10) either, suggesting that the delayed lesion development is caused by the lack of disease-promoting CD4+ cells rather than by the presence of protective CD8+ cells. The lack of L. major-reactive immunoglobulins in the serum of infected MHC class II-deficient mice indicates that B cells also cannot respond to parasite antigens in the absence of MHC class II-mediated helper signals. The data demonstrate that MHC class II-deficient mice are unable to restrict the spreading of L. major, although they contain highly increased proportions of CD8+ T cells. Thus, MHC class II-restricted immune responses, most likely mediated by functional CD4+ T cells, are essential for the control of primary infections with L. major.

The effect of human menopausal gonadotrophin and highly purified, urine-derived follicle stimulating hormone on the outcome of in-vitro fertilization in down-regulated normogonadotrophic women

It has been suggested that the luteinizing hormone (LH) activity of human menopausal gonadotrophin (HMG) preparations used for ovarian stimulation in in-vitro fertilization (IVF) may have adverse effects on reproductive outcome. In the present prospective, randomized trial of 218 infertile couples this notion was investigated. A total of 114 women were treated with Pergonal (HMG group) and 104 with Fertinorm HP (HP-FSH group). The two groups were comparable with regard to duration of infertility, cause of infertility, age and number of previous IVF attempts and all had normal basal gonadotrophin concentrations before treatment was started. A standard hormonal treatment consisting of pituitary down-regulation with gonadotrophin-releasing hormone analogue (GnRHa) for 14 days starting on cycle day 21, followed by either HMG or highly purified follicle stimulating hormone (HP-FSH), three ampoules (225 IU) per day for 7 days, was used in all cases. The daily hormone dose was thereafter individualized according to the ovarian response. A maximum of two pre-embryos were transferred after 3 days of culture. Luteal support with progesterone (300 mg per day intravaginally) was used in all cases. Serum concentrations of oestradiol, FSH and LH were measured on days 1 and 8 of stimulation and on the day of oocyte retrieval. The mean number of days of stimulation, mean number of ampoules of HMG or HP-FSH used, mean total motile sperm count on the day of oocyte retrieval and mean numbers of oocytes retrieved (13.4 versus 13.7) or pre-embryos transferred (1.8 versus 1.8) were similar for both groups. Significantly (P < 0.05) more cycles in the HP-FSH group (17 = 16%) were cancelled due to complete failure of fertilization than in the HMG group (7 = 6%). The mean fertilization rate was significantly (P < 0.05) higher in the HMG group (56%) than in the HP-FSH group (50%), and significantly more transferable pre-embryos were obtained in the HMG than in the HP-FSH group (mean: 4.0 versus 3.2; P < 0.01). Serum hormone concentrations were similar to the two groups on stimulation day 1, but differed significantly with regard to FSH, LH and oestradiol on stimulation day 8. The clinical outcome was similar in the two groups, with an ongoing pregnancy rate (> 12 weeks of gestation) per started cycle of 33% in the HMG group and 29% in the HP-FSH group. The clinical abortion rates were similar (10 and 14%), and the implantation rate was 30% in each group. In conclusion, no detrimental effect of the LH activity of HMG on the clinical outcome of IVF in GnRHa down-regulated normogonadotrophic women was found. To the contrary, some beneficial effects of HMG on fertilization rates and pre-embryo development as compared with HP-FSH were demonstrated. These effects, as well as the differences in serum hormone concentrations during ovarian stimulation, may be caused by differences in LH content and/or in the composition of FSH isoforms of the HMG and HP-FSH preparations.

Murine epidermal Langerhans cells do not express inducible nitric oxide synthase

In Leishmania-infected macrophages (M phi), the formation of reactive nitrogen intermediates by the inducible isoform of nitric oxide synthase (iNOS) is critical for the killing of the intracellular parasites. We have recently shown that, in addition to M phi, epidermal Langerhans cells (LC) can phagocytose Leishmania major, but they do not allow parasite replication. Therefore, we analyzed whether LC and M phi display the same leishmanicidal effector mechanism. Unlike M phi, stimulation of unselected epidermal cells with interferon-gamma/lipopolysaccharide did not lead to the release of nitric oxide (NO), and inhibition of NO production had no effect on the rate of infection of LC. iNOS mRNA was clearly detectable in M phi as well as unselected epidermal cells (the majority of which consists of keratinocytes) after stimulation with different cytokines. In contrast, pure LC obtained by single-cell picking from cytokine-activated or L. major-infected epidermal cells did not express iNOS mRNA. Addition of the NO donor S-nitroso-N-acetylpenicillamine to already-infected LC did not alter their rate of infection, indicating that LC do not utilize exogenous NO for the control of intracellular Leishmania. These results suggest that in the L. major-infected skin, activated M phi and keratinocytes, but not LC have the ability to express iNOS activity. Therefore, an as yet unidentified, NO-independent mechanism appears to be responsible for the control of parasite replication in LC.

Influence of antihypertensive therapy with cilazapril and hydrochlorothiazide on the stiffness of the aorta

The purpose of this study was to examine the effects of the angiotensin-converting enzyme (ACE) inhibitor cilazapril on the elastic properties of the aorta. A standard diuretic antihypertensive drug, hydrochlorothiazide, served for comparisons. Increased aortic stiffness leads to a reduction of the buffering windkessel function and is a major component in the pathophysiology of systolic hypertension, inducing an increase in left ventricular afterload and arterial pulsatile stress as well as a decrease in the subendocardial blood supply. Stiffness of arteries increases with age and blood pressure, and depends on the functional elastic structures of the aortic wall. ACE inhibitors have been shown to directly influence elastic properties of peripheral arteries. Seventeen patients with mild to moderate essential hypertension (age 45-67 years) were treated for 3 months double-blind randomized with either cilazapril (C) 5 mg daily (n = 9) or hydrochlorothiazide (HCTZ) 25 mg daily (n = 8). Aortic elastic properties were noninvasively assessed by measurement of pulse wave velocity along the aorta at rest and during isometric handgrip stress. Accelerated pulse wave velocity indicates elevated arterial stiffness and vice versa. A pressure standardized index of aortic cross-sectional distensibility (2 m) was calculated from arterial mean pressure and pulse wave velocity. Compared with pretreatment values, both therapies significantly reduced blood pressure and pulse wave velocity at rest (C: 9.4 +/- 0.9 vs. 7.7 +/- 0.7 m/sec; HcTZ: 8.9 +/- 0.3 vs. 7.8 +/- 0.4 m/sec; means +/- SEM p < 0.05). During isometric stress only C showed a significant decrease in pulse wave velocity (C: 11.3 +/- 0.8 vs. 9.1 +/- 0.8 m/sec; HCTZ: 9.9 +/- 0.5 vs. 9.0 +/- 0.5 m/sec; means +/- SEM p < 0.05). The index 2m at rest and during handgrip increased significantly (p < 0.05) after C but not after HCTZ. With cilazapril we obtained steeper slopes for the treatment-induced reductions in blood pressure and pulse wave velocity for both rest and handgrip stress values. Correlation of the data at rest and during stress revealed a direct relationship between blood pressure and pulse wave velocity. HCTZ linearly extended the relation observed before treatment toward lower values of blood pressure and corresponding pulse wave velocity without changing the relation per se. Cilazapril, in contrast, moved the relation between these variables and decelerated the pulse wave velocities to a greater extent than would have been expected from the corresponding blood pressure reduction (delta approximately 1 m/sec). These results in patients with mild to moderate essential hypertension support the idea that ACE inhibitors, in addition to reducing blood pressure, may exert an additional hemodynamic effect in improving the elastic properties of the aorta.

Cutaneous leishmaniasis: a model for analysis of the immunoregulation by accessory cells

In the mammalian host, Leishmania are obligate intracellular parasites and invade macrophages and Langerhans cells. The accessory functions of both types of host cells are important for regulation of the specific cellular immune response and involve the following activities: infiltration into the site of infection, initiation of a T cell response, maintenance of immunity and the effector mechanisms that control intracellular parasite replication.

Clinical pharmacological equivalence of a novel FCH-free GTN spray with low ethanol content vs a FCH-containing GTN spray

The overall therapeutic equivalence of a fluorochlorohydrocarbon (FCH)-free glyceryl trinitrate (GTN) pump spray with a low ethanol content (TL) was investigated relative to an FCH-containing GTN spray (Nitrolingual; R), in terms of: (1) pharmacokinetic bioavailability, (2) pharmacodynamic responses as assessed by digital plethysmography (DPG), and (3) clinical perception upon application. Pharmacokinetically, the time courses of the plasma concentrations of GTN and its dinitrate metabolites, 1,2- and 1,3-GDN, subsequent to the sublingual administration of 0.8 mg GTN showed somewhat lower bioavailability of GTN and its metabolites than to the reference. Pharmacodynamically, the changes in the DPG signals after the application of 0.8 mg GTN with TL were biostatistically equivalent with R (estimated ratio TL/R for the maximum decrease of the ratio between the systolic a wave and c incisure: 0.98; 90% CI: 0.84-1.14; and for the average decrease of the c: a ratio: 0.97; 90% CI: 0.80-1.16). The time of occurrence of the maximum effect of TL was not significantly different from that of R (estimated difference TL-R: -2.25 min; 95% CI:-9.5 min to 2 min). In contrast, after the administration of an FCH-free GTN spray with a higher ethanol content (TH, active control), the effect had a slightly earlier onset (TH-R: -6 min, 95% CI:-9.5 to -2 min) and there was a higher average response (TH/R: 1.12: 90% CI: 0.95 to 1.34). However, TH was consistently judged to cause an extremely unpleasant burning sensation in the mouth and thus was perceived as distinctly different from R. In contrast, TL was well tolerated and could not be distinguished from R.

[Pharmacodynamic equivalence and clinical trial of a new fluorocarbon-free glycerol trinitrate pump spray with low ethanol content in comparison to a fluorocarbon-containing reference spray and a fluorocarbon-free pump spray with high ethanol content]

The pharmacodynamic equivalence of a fluorohydrocarbons-(FCH)-free glyceryl trinitrate (GTN, CAS 55-63-0)-containing pump spray with low ethanol content (Nitrolingual-Spray N; TL) versus a conventional FCH-containing GTN spray (Nitrolingual-Spray, R) as reference and a FCH-free GTN pump spray with high ethanol content (TH) was investigated by digital plethysmography (DPG) in a double-blinded, placebo-controlled (TL-matched placebo spray), randomized, period-balanced, 4-way cross-over design. Additionally the clinical tolerability (as perceived by the subjects and reported to the treatments-administrating investigator) was determined. The DPG-changes (cla; ratio of c-incisure and systolic a-wave) after the sublingual (s.l.) administration of 0.8 mg GTN of TL were biostatistically equivalent with R: the confidence intervals (CI) of the point estimates of the maximal decrease in cla (TL/R: 0.98, 90%-CI: 0.84 to 1.14) and the area-weighted average decrease in cla (TL/R: 0.97, 90%-CI: 0.80-1.16) were well in a 80-125% tolerance range. The time of occurrence of the maximal DPG-effect of TL was not different from R (distribution-free estimate of the difference TL-R: -2.25 min, 95%-CI: -9.5 min to 2 min). In contrast the maximal DPG-effect of TH after the s.l. administration of 0.8 mg GTN had a statistically significant earlier onset (TH-R: -6 min, 95%-CI: -9.5 min to -2 min) and a higher area-weighted average response (TH/R: 1.12, 90%-CI: 0.95 to 1.34). TH consistently caused an utterly unpleasant burning sensation in the mouth, thus this perceived local discomfort was distinctly different compared to all other treatments.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunoscintigraphy of colon cancers with the human monoclonal antibody COU-1

The human monoclonal immunoglobulin M (IgM) antibody, COU-1 is obtained from a human-human hybridoma, which is derived by fusion between a human B-lymphoblastoid cell line and lymphocytes obtained from mesenteric lymph nodes from a patient with colorectal cancer. COU-1 recognizes a 43 kilodaltons intracellularly located cytokeratin-like protein, strongly expressed by adenocarcinoma tissue as compared to normal tissues. In tumor-bearing nude mice, antibody COU-1 labeled with 125I has been shown to accumulate in human colon cancer grafts when compared to human melanoma grafts and the normal mouse tissues. The observed accumulation was sufficient to be detected externally by immunoscintigraphy. Antigen-binding fragments of the antibody were also prepared and were shown to accumulate in colon cancer grafts. Improved tumor to normal tissue ratio was seen with the half-monomeric fragment, and the time required was reduced. In the clinic, five patients with suspected colorectal cancer were given 2 mg of 131I-labeled COU-1. No adverse effects were detected in any of the patients. Planar images were obtained on days 1, 2, 3, 5, and 7 after administration. The best images were obtained on days 5 and 7. Tumors were localized by immunoscintigraphy in four of the patients. Of these patients, surgery revealed that three of them had primary colorectal cancers located in the cecum, the ascending colon, and the rectum, respectively, while one patient had a pancreatic cancer. The smallest lesion observed had a diameter of 3 cm. In one of the patients, otherwise undiagnosed multiple liver metastases were revealed by the immunoscintigraphy and confirmed at surgery. An x-ray of the colon performed on the fifth patient had shown a stricture in the descending colon suspected to be caused by cancer. The tumor scintigraphy showed no accumulation of the antibody. Surgery revealed that the stricture was caused by adherence and not cancer. These findings are encouraging for further studies of this human monoclonal antibody in cancer patients.

Tumor detection with 131I-labeled human monoclonal antibody COU-1 in patients with suspected colorectal carcinoma

A major factor limiting the use of rodent monoclonal antibodies for diagnosis and therapy of cancer is the development of human anti-mouse immunoglobulin antibodies. Here we report a phase I/II immunodetection study of a human monoclonal antibody, COU-1, labeled with 131I. COU-1 is produced by a human-human hybridoma and recognizes a M(r) 43,000 cytokeratin-like protein strongly expressed by adenocarcinomas of the colon, breast, and ovary. Ten patients were given an i.v. infusion of 2 mg of antibody COU-1 labeled with 185 MBq of 131I. No adverse effects or toxicity were detected by conventional clinical tests nor by a complement activation assay for C3d. None of the patients developed antibodies against antibody COU-1 as determined by enzyme-linked immunosorbent assay and agglutination analysis. Tumor detection was successful in 7 of 9 cancer patients. The tenth patient proved to be a true negative. In several instances immunoscintigraphy gave additional or more correct information than conventional detection techniques. Tumors were most clearly outlined at days 5 and 7 after infusion. Primary colorectal carcinomas were detected by planar imaging in the cecum, ascending colon, and rectum with the smallest lesion measuring 3.0 cm in diameter. Immunoscintigraphy revealed multiple liver metastases in 1 of 3 patients. However, the livers of all 3 patients contained significantly more radioactivity (P < 0.005) than tumor-free livers of the other patients. Pharmacokinetics was evaluated in all patients. The clearance of 131I-labeled COU-1 from the circulation followed a triphasic pattern; an initial phase [t1/2 = 0.4 +/- 0.4 (SD) h] cleared 23% of the radioactivity followed by a rapid phase with a half-life of 13 +/- 3.8 h. The third phase (beta-phase) exhibited a half-life of 119 +/- 36 h, which is similar to the half-life reported for normal IgM. The human monoclonal antibody COU-1 directed against a predominantly intracellular cancer-associated antigen does not produce toxicity or induce antibody formation and seems to be a promising agent for detecting tumors with immunoscintigraphy.