Radiobiological mechanisms in inflammatory diseases of low-dose radiation therapy

PURPOSE

Whereas X-irradiation with high doses is established to exert pro-inflammatory effects, low-dose radiotherapy (LD-RT) with single fractions below 1.0 Gy and a total dose below 12 Gy is clinically well known to exert anti-inflammatory and analgesic effects on several inflammatory diseases and painful degenerative disorders. Experimental studies to confirm the effectiveness, the empirical dose and fractionation schemes, and the underlying radiobiological mechanisms are still fragmentary.

METHOD

The anti-inflammatory efficiency of LD-RT was confirmed in several experimental in vitro and in vivo models.

RESULTS

In vitro studies revealed a variety of mechanisms related to the anti-inflammatory effect, in particular the modulation of cytokine and adhesion molecule expression on activated endothelial cells and leukocytes, and of nitric oxide (NO) production and oxidative burst in activated macrophages and native granulocytes.

CONCLUSION

Inflammatory diseases are the result of complex and pathologically unbalanced multicellular interactions. It is, therefore, reasonable to assume that further molecular pathways and cellular components contribute to the anti-inflammatory effect of LD-RT. This review discusses data and models revealing aspects of the mechanisms underlying the anti-inflammation induced by low doses of X-irradiation and may serve as a basis for systematic analyses, necessary to optimize LD-RT in clinical practice.

Soraprazan: setting new standards in inhibition of gastric acid secretion

After treatment of millions of patients suffering from gastroesophageal reflux disease (GERD) and other acid-related ailments with proton pump inhibitors, there are still unmet medical needs such as rapid and reliable pain relief, especially for nocturnal acid breakthrough. In this work, we introduce and characterize the biochemistry and pharmacology of the potassium-competitive acid blocker (P-CAB) soraprazan, a novel, reversible, and fast-acting inhibitor of gastric H,K-ATPase. Inhibitory and binding properties of soraprazan were analyzed together with its mode of action, its selectivity, and its in vivo potency. This P-CAB has an IC(50) of 0.1 microM if measured with ion leaky vesicles and of 0.19 microM in isolated gastric glands. With a K(i) of 6.4 nM, a K(d) of 26.4 nM, and a B(max) of 2.89 nmol/mg, this compound is a highly potent and reversible inhibitor of the H,K-ATPase. Soraprazan shows immediate inhibition of acid secretion in various in vitro models and in vivo and was found to be more than 2000-fold selective for H,K-ATPase over Na,K- and Ca-ATPases. Soraprazan is superior to esomeprazole in terms of onset of action and the extent and duration of pH elevation in vivo in the dog. Rapid and consistent inhibition of acid secretion by soraprazan renders the P-CABs a promising group of compounds for therapy of GERD.

After shrinkage apoptotic cells expose internal membrane-derived epitopes on their plasma membranes

Apoptosis and phagocytosis of apoptotic cells are crucial processes. At best the phagocytic machinery detects and swallows all apoptotic cells in a way that progression to secondary necrosis is avoided. Otherwise, inflammation and autoimmune diseases may occur. Most apoptotic cells are phagocytosed instantaneously in a silent fashion; however, some dying cells escape their clearance. If the cells are not cleared early, they lose membranes due to extensive shedding of membrane surrounded vesicles (blebbing) and shrink. It is unclear how apoptotic cells compensate their massive loss of plasma membrane. Here, we demonstrate that endoplasmic reticulum- (ER) resident proteins (calnexin, the KDEL receptor and a dysfunctional immunoglobulin heavy chain) were exposed at the surfaces of shrunken late apoptotic cells. Additionally, these cells showed an increased binding of lectins, which recognize sugar structures predominantly found as moieties of incompletely processed proteins in ER and Golgi. In addition the ER resident lipophilic ER-Tracker Blue-White DPX, and internal GM1 were observed to translocate to the cell surfaces during late apoptosis. We conclude that during blebbing of apoptotic cells the surface membrane loss is substituted by immature membranes from internal stores. This mechanism explains the simultaneous appearance of preformed recognition structures for several adaptor proteins known to be involved in clearance of dead cells.

Decreased circulating CD34+ stem cells in early Alzheimer's disease: Evidence for a deficient hematopoietic brain support?

Hematopoietic stem cells contribute to mammalian brain tissue regeneration by transdifferentiation processes. We found decreased counts of circulating CD34+ cells in early Alzheimer's dementia (AD; P = 0.01), which significantly correlated with age (r = -0.661; P = 0.001), cerebrospinal fluid beta-amyloid (Abeta)1-42 (r = -0.467; P = 0.025) and most pronounced the Abeta42/40 ratio (r = -0.688; P = 0.005). Our data suggest a deficient regenerative hematopoietic support for the central nervous system in early AD.

Inheritance and mapping of a powdery mildew resistance gene introgressed from Avena macrostachya in cultivated oat

The powdery mildew resistance from Avena macrostachya was successfully introgressed into hexaploid oat (A. sativa). Genetic analysis of F(1), F(2), F(3) and BC(1) populations from two powdery-mildew resistant introgression lines revealed that the resistance is controlled by a dominant gene, tentatively designated Eg-5. Molecular marker analysis was conducted using bulked-segregant analysis in two segregating F(3) populations. One codominant simple sequence repeats (SSR) marker AM102 and four AFLP-derived PCR-based markers were successfully developed. The SSR marker AM102 and the STS marker ASE41M56 were linked to the gene Eg-5, with genetic distances of 2 and 0.4 cM, respectively, in both mapping populations. Three STS markers (ASE45M56, ASE41M61, ASE36M55) co-segregated with Eg-5 in one population while two (ASE45M56, ASE36M55) of them linked to Eg-5 with a genetic distance of 1 cM in another population. The gene was further mapped to be in a region corresponding to linkage group 22_44+18 in the Kanota x Ogle (KO) hexaploid oat map by comparative mapping. To our knowledge, this is the first report of mapping powdery-mildew resistance in hexaploid oat. The new resistance source of A. macrostachya, together with the tightly linked markers identified here, could be beneficial in oat breeding programmes.

[The program initiative "general practice" of the Conference of the German Federal Health Ministers. Successes of interventions and possible reasons for the shortage of general practitioners]

The number of general practitioners has clearly decreased over the last 10 years in Germany. The situation is more critical in Eastern Germany compared to Western Germany. The article shows the results of the "program initiative to secure primary care in general practice" of the Conference of the Federal Health Ministers. The authors focus on the situation in Saxony-Anhalt, where they are founders of the Institute of General Medicine at the Universities of Halle-Wittenberg and Magdeburg. They also work as general practitioners.

Inefficient clearance of dying cells and autoreactivity

Dying cells were basically unnoticed by scientists for a long time and only came back into the spotlight roughly 10 years ago. The process of recognition and uptake of apoptotic and necrotic cells is complex and failures in this process can contribute to the pathogenesis of autoimmune diseases such as systemic lupus erythematosus (SLE). Here, we discuss the recognition and uptake molecules which are involved in an efficient clearance of dying cells in early and late phases of cell death. The exposure of phosphatidylserine (PS) is an early surface change of apoptosing cells recognized by several receptors and adaptor molecules. We demonstrated that dying cells have cell membranes with high lateral mobility of PS, which contribute to their efficient clearance. Changes of the glycoprotein composition of apoptotic cells occur later than the exposure of PS. We further observed that complement binding is an early event in necrosis and a rather late event in apoptosis. Complement, C-reactive protein (CRP), and serum DNase I act as back-up molecules in the clearance process. Finally, we discuss how the accumulation of secondary necrotic cells and cellular debris in the germinal centers of secondary lymph organs can lead to autoimmunity. It is reasonable to argue that clearance defects are major players in the development of autoimmune diseases such as SLE.

Enzymatically-generated fluorescent detection in micro-channels with internal magnetic mixing for the development of parallel microfluidic ELISA

The Enzyme-Linked Immuno-Sorbent Assay, or ELISA, is commonly utilized to quantify small concentrations of specific proteins for a large variety of purposes, ranging from medical diagnosis to environmental analysis and food safety. However, this technique requires large volumes of costly reagents and long incubation periods. The use of microfluidics permits one to specifically address these drawbacks by decreasing both the volume and the distance of diffusion inside the micro-channels. Existing microfluidic systems are limited by the necessary control of extremely low flow rates to provide sufficient time for the molecules to interact with each other by diffusion only. In this paper, we describe a new microfluidic design for the realization of parallel ELISA in stop-flow conditions. Magnetic beads were used both as a solid phase to support the formation of the reactive immune complex and to achieve a magnetic mixing inside the channels. In order to test the detection procedure, the formation of the immune complex was performed off-chip before the reactive beads were injected into the reaction chamber. Anti-streptavidin antibodies were quantified with low picomolar sensitivity (0.1-6.7 pM), a linear range of 2 orders of magnitude and good reproducibility. This work represents the first step toward a new platform for simple, highly effective and parallel microfluidic ELISA.

[An impaired detection and clearance of dying cells can lead to the development of chronic autoimmunity]

Not properly cleared dead cells are dangerous for the body. The dead cells accumulate, lose their membrane integrity, danger signals are released, and nuclear antigens get accessible in an inflammatory context. In times of increased apoptosis, tolerance can be broken, a chronic inflammation results which then can lead to an autoimmune reaction against nuclear constituents. An impaired clearance of dying cells represents a central pathogenic process in the development of chronic autoimmune diseases like in systemic lupus erythematosus (SLE). Many adaptor molecules and receptors are involved in the clearance of dying cells. Complement components, serum DNase I, phosphatidylserine, and modified glycoproteins participate crucially in the clearance of apoptotic and necrotic cells. We further observed intrinsic defects of macrophages of some SLE patients. Macrophages as well as granulocytes of some SLE patients showed heterogeneous clearance defects. Furthermore, we observed an accumulation of nuclear material in germinal centres of lymph nodes of some SLE patients. The non-ingested nuclear material may provide survival signals for autoreactive B cells and consecutively antinuclear autoantibodies (ANA) will be produced. We therefore conclude that drugs promoting the phagocytosis are important candidates of specific therapies in the future which expect a more gentle and purposive treatment of patients with SLE.

Clearance of apoptotic cells in human SLE

Systemic lupus erythematosus (SLE) is characterized by a diverse array of autoantibodies, particularly against nuclear antigens, thought to derive from apoptotic and necrotic cells. Impaired clearance functions for dying cells may explain accumulation of apoptotic cells in SLE tissues, and secondary necrosis of these cells may contribute to the chronic inflammation in this disease. The exposure of phosphatidylserine (PS) and altered carbohydrates on dying cells are important recognition signals for macrophages. Furthermore, serum factors such as complement, DNase I, pentraxins (e.g. C-reactive protein) and IgM contribute to efficient opsonization and uptake of apoptotic and necrotic cells. Defects in these factors may impact the development of SLE in humans and mice in a variety of ways. We observed impaired clearance of apoptotic cells in lymph nodes and skin biopsies of humans with lupus, as well as intrinsic defects of macrophages differentiated in vitro from SLE patients' CD34+ stem cells, demonstrating that apoptotic cells are not properly cleared in a subgroup of patients with SLE. This altered mechanism for the clearance of dying cells may represent a central pathogenic process in the development and acceleration of this autoimmune disease.

Ex vivo gingival-biofilm consortia

AIMS

To develop a protocol for harvesting ex vivo samples of gingival-biofilm consortia and to investigate their basic characteristics.

METHODS AND RESULTS

Gingival epithelial cells with attached biofilm were collected from healthy subjects by taking a smear. The bacterial viability was estimated via the alteration of the membrane permeability and metabolic activity via the double/single-stranded nucleic acid ratio using a confocal laser-scanning microscope. Morphological analysis was performed by scanning and transmission electron microscopy. Additionally, microbiological estimations were made. The electron microscopy revealed fimbriae-mediated adhesion and the formation of a biofilm matrix. Most bacteria were viable and had a high metabolic activity.

CONCLUSIONS

The presented study offers an easy to follow approach for harvesting samples of gingival-biofilm consortia. The latter differs considerably from the supragingival plaque in viability and zonal distribution. Related to free-living and in vitro-grown biofilms, the gingiva-associated biofilm revealed an atypically high metabolic activity.

SIGNIFICANCE AND IMPACT OF THE STUDY

Biofilm fragments should possess the basic features of the entire gingiva-associated biofilm; which as yet cannot be simulated in vitro. Thus, samples of ex vivo gingival-biofilm consortia can be used to investigate the resistance of oral biofilms against antibiotics and biocides.

Chlorhexidine-induced ultrastructural alterations in oral biofilm

Chlorhexidine, the most used biocide in periodontology, alters the permeability of the bacterial cell membrane. However, the chlorhexidine-induced morphological alterations in the oral biofilm have not been studied. To examine the effects of chlorhexidine on oral biofilm on an electron microscopic level, gingival epithelial cells with attached biofilm were collected from 10 volunteers, subjected to 0.1% chlorhexidine for 1 or 5 min, stained with ruthenium red-tetroxide, and analyzed by scanning electron microscopy (SEM) and transmission electron microscopy (TEM). SEM visualized the bacterial glycocalyces and the biofilm matrix on the biofilm surface; however, no chlorhexidine-induced alterations were observed. TEM revealed loss of bacterial membrane integrity and fimbrial disintegration in a few bacteria. In the proximity of these alterations, a restricted matrix disintegration was also observed. However, the chlorhexidine-induced alterations only effected a minor part of the oral biofilm and did not cause its disintegration. These findings suggest the insufficient efficiency of chlorhexidine against oral biofilm.

[The infected implant: bacteriology]

Periprosthetic infection is a significant complication in joint replacement surgery and develops in 0.5%-2% cases. Staphylococcus aureus and commensal microorganisms of the skin, especially coagulase-negative staphylococci, as well as a broad spectrum of other potential pathogens typically already colonize the surface of the foreign body at the time of implantation. Specific mechanisms such as bacterial adhesion to host factors absorbed in the material, biofilm formation, and a metabolic adaptation of adherent microorganisms play a paticulary important role in the pathogenesis and course of the disease. Microbiological diagnosis requires to some extent complex culture procedures of puncture specimens or tissue removed during surgery; this can be supplemented by modern molecular testing. Antimicrobial treatment must be conceived as a synopsis of clinical picture, confirmed pathogen, and the intended surgical procedure on an individual basis and is routinely administered as combination therapy for several weeks, sometimes also as sequential therapy. Validated preventive measures in joint replacement surgery include mandatory perioperative antibiotic prophylaxis and other additional measures.

Induction of apoptosis by spermine-metabolites in primary human blood cells and various tumor cell lines

Polyamines are involved in the regulation of cellular growth and survival by interacting with processes like translation, transcription or ion transport. The aim of our study was to analyze whether polyamines induce apoptosis in hematopoetic cells and to investigate the molecular mechanisms involved. We found an induction of apoptosis by spermine in primary human cells and malignant tumor cell lines. Spermine-treatment resulted in an intracellular increase of reactive oxygen species. Apoptosis was mediated by a collapse of mitochondrial membrane potential, a decrease in Bcl-2 expression and a release of apoptosis mediating molecules from mitochondrial intermembrane space (cytochrome C, Smac/DIABLO). Spermine-mediated apoptosis was caspase-dependent. To test whether spermine mediates apoptosis through metabolites we analyzed the effects of several molecules that interfere with its catabolism. Aminoguanidine, an inhibitor of serum amine oxidase, aldehyde-dehydrogenase, which degrades aldehydes to less reactive molecules or N-acetyl-cysteine, a glutathion precursor, significantly inhibited spermine-mediated apoptosis. From these data we conclude that spermine-derived aldehydes and intracellular accumulation of reactive oxygen species result in mitochondria mediated apoptosis.

Precision spectroscopy of hydrogen and femtosecond laser frequency combs

Precision spectroscopy of the simple hydrogen atom has inspired dramatic advances in optical frequency metrology: femtosecond laser optical frequency comb synthesizers have revolutionized the precise measurement of optical frequencies, and they provide a reliable clock mechanism for optical atomic clocks. Precision spectroscopy of the hydrogen 1S-2S two-photon resonance has reached an accuracy of 1.4 parts in 10(14), and considerable future improvements are envisioned. Such laboratory experiments are setting new limits for possible slow variations of the fine structure constant alpha and the magnetic moment of the caesium nucleus mu(Cs) in units of the Bohr magneton mu(B).

Reference values of NT-proBNP serum concentrations in the umbilical cord blood and in healthy neonates and children

BACKGROUND

N-terminal brain natriuretic peptide (NT-proBNP) is a neurohormonal substance secreted mainly by the cardiac myocytes of the left ventricle and to a less degree of the left atrium. The releasing mechanism is induced by an increased wall stress on the base of volume or pressure load of the ventricle. The physiologic actions of BNP are prohibition of the sympathetic activity, vasodilatation, natriuresis, diureses and inhibition of the renin-angiotensin system. Because of its high sensitivity and specifity in relation to the left ventricular incompetence, BNP as well as NTproBNP are well accepted markers of ventricular dysfunction. It was the aim of the study to establish reference values of NT-proBNP serum concentrations throughout childhood, in particular in the newborn age group.

METHODS

In a cross sectional study, serum NT-proBNP concentrations were measured by an ElectroChemiLuminescenceImmunoAssay ("ECLIA" Roche) in the umbilical cord blood of 62 healthy full-term neonates and in 222 healthy probands from birth up to the age of 18 years.

RESULTS

The concentration of NT-proBNP in the cord blood samples ranged from 281 to 2595 pg/ml (mean: 818 pg/ml). There was a significant increase in the first days of life followed by a rapid decrease during the first year and a further gradual decrease throughout infancy; beyond the 10(th) year of age normal adult values were approached.

CONCLUSIONS

The knowledge of the normal range of plasma NT-proBNP levels in healthy subjects during childhood serves as a non-invasive marker for differentiation of pathologic conditions such as acute myocarditis, hypertrophic or dilated cardiomyopathy, tachyarrhythmias and pulmonary hypertension.

[Methicillin-resistant Staphylococcus aureus. Types of resistance and clinical consequences]

The problem of methicillin-resistant Staphylococcus aureus (MRSA) is on the rise worldwide. However, significant regional differences exist with respect to incidence, types of prevalent outbreak strains and accompanying resistance patterns as well as local conditions and resources to control epidemics. Intensive care units are regularly epicenters of MRSA epidemics. Accordingly, anaesthesists, intensive care physicians and surgeons need to know the established recommendations and guidelines about early recognition and infection control of MRSA, must be familiar with principles of the antimicrobial MRSA therapy, and should adapt the principles for prevention and therapy of MRSA infections to the needs of the respective institution and situation. The result of this process has to be a rational and efficient approach to this nosocomial pathogen allowing its control under consideration of cost effectiveness.

Microparticles Shed from Different Antigen-Presenting Cells Display an Individual Pattern of Surface Molecules and a Distinct Potential of Allogeneic T-Cell Activation

Various cells such as platelets, lymphocytes, endothelial cells, red blood cells and monocytes do release surface-derived microparticles (mps). We analysed mp isolated from supernatants of cultured antigen-presenting human cells (APCs) and human cell lines. Particle sizing by dynamic light scattering revealed a characteristic size of the particles ranging from 80 nm to 300 nm in viable cells and from 400 nm to 1200 nm in irradiated cells. Employing flow-cytometry, we observed partly an altered surface protein composition of the mp compared to their cellular source. Mp originating from dendritic cells (DCs) differed in their surface composition from those released from monocytes and monocyte-derived macrophages. In functional assays, these mp stimulated alloreactive T-cells. The treatment of the cells with either UV-B or lipopolysaccharide strongly influenced the quantity, the immunostimulatory features and the surface composition of the mp. Mp from apoptotic macrophages were able to reduce the stimulatory capacity of vital macrophages but not of DC. Apoptotic mps from DC, on the other hand, were always stimulatory. This is the first report regarding the study of mp released from DC and compared with those released from other APC.

First laser-controlled antihydrogen production

Lasers are used for the first time to control the production of antihydrogen (H ). Sequential, resonant charge exchange collisions are involved in a method that is very different than the only other method used so far-producing slow H during positron cooling of antiprotons in a nested Penning trap. Two attractive features are that the laser frequencies determine the H binding energy, and that the production of extremely cold H should be possible in principle-likely close to what is needed for confinement in a trap, as needed for precise laser spectroscopy.

[S2 guideline for infectious endocarditis]

Microbe-induced (infectious) endocarditis is an endovascular infection, caused mainly by bacteria, of cardiovascular structures. The major predilection site are the native heart valves, but involvement of implanted intracardiac foreign material is increasingly being seen. The mortality rate of infectious endocarditis depends on clinical factors and the causal agent, but also on the time of the establishment of the diagnosis and the initiation of appropriate treatment. In Germany, the current mortality rate ranges up to 18%. Between January 2003 and July 2004, with the aim of improving patient care and thus the outcome of this condition, a guideline commission worked out recommendations for the diagnosis, treatment and management of the disease for the use of general practitioners and hospital physicians, in particular microbiologists, infectiologists, cardiologists and cardiac surgeons. The basis for this guideline was the systematic search through the literature of the European guideline. On the 16th and 28th of June 2004, the entire guideline was formerly approved in a nominal group process.

Das infizierte Implantat

Periprosthetic infection is a significant complication in joint replacement surgery and develops in 0.5-2% of cases. Staphylococcus aureus and commensal microorganisms of the skin, especially coagulase-negative staphylococci, as well as a broad spectrum of other potential pathogens typically already colonize the surface of the foreign body at the time of implantation. Specific mechanisms such as bacterial adhesion to host factors absorbed in the material, biofilm formation, and a metabolic adaptation of adherent microorganisms play a particularly important role in the pathogenesis and course of the disease. Microbiological diagnosis requires to some extent complex culture procedures of puncture specimens or tissue removed during surgery; this can be supplemented by modern molecular testing. Antimicrobial treatment must be conceived as a synopsis of clinical picture, confirmed pathogen, and the intended surgical procedure on an individual basis and is routinely administered as combination therapy for several weeks, sometimes also as sequential therapy. Validated preventive measures in joint replacement surgery include mandatory perioperative antibiotic prophylaxis and other additional measures.

Experimental Autoimmune Encephalomyelitis (EAE): Lesion Visualization on a 3 Tesla Clinical Whole-body System after Intraperitoneal Contrast Injection

PURPOSE

To investigate the intravital visibility of CNS lesions in rats with experimental autoimmune encephalomyelitis (EAE), the animal correlate of multiple sclerosis, using a 3-Tesla (T) whole-body MR system.

MATERIALS AND METHODS

Three healthy Dark Agouti (DA) rats and 16 DA rats with clinical signs of EAE were examined on a 3T whole body-system using a normal wrist coil. In total, 25 examinations were preformed using T2- and T1-weigthed images in transverse and sagittal orientation with a slice thickness of 2 mm or 1 mm (voxel size up to 0.2 x 0.2 x 1 mm). Sedation was achieved by intraperitoneal injection of ketamine and xylazine. In addition, T1-weighted images were obtained after the instillation of 1.0 ml of gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA) (0.5 mmol/ml) into the peritoneal cavity.

RESULTS

T2- and T1-weighted images of the brain and spinal cord with high spatial and contrast resolution could be obtained in all animals. The anatomical details of the olfactory bulb glomeruli, cerebellum foliae, ventricles and corpus callosum were clearly visible. The EAE lesions presented as hyperintense areas in T2-weighted images and could be demonstrated in all clinically affected animals by MRI and histologically verified. In total, the 16 affected rats had 28 cerebral and 2 spinal cord lesions (range 1 to 4, median 2). Contrast enhancement was noted in 12 animals and ranked as severe in ten and moderate in two cases. No adverse effects were noted due to sedation or intraperitoneal contrast injection.

CONCLUSIONS

The intravital demonstration of cerebral and spinal cord EAE lesions in rats is possible on a 3T whole-body MR scanner using a normal wrist coil. Intraperitoneal injection of ketamine/xylazine and contrast agent is an easy, safe and effective procedure in rats.

UV irradiation inhibits ABC transporters via generation of ADP-ribose by concerted action of poly(ADP-ribose) polymerase-1 and glycohydrolase

ATP-binding cassette (ABC) transporters are involved in the transport of multiple substrates across cellular membranes, including metabolites, proteins, and drugs. Employing a functional fluorochrome export assay, we found that UVB irradiation strongly inhibits the activity of ABC transporters. Specific inhibitors of poly(ADP-ribose) polymerase-1 (PARP-1) restored the function of ABC transporters in UVB-irradiated cells, and PARP-1-deficient cells did not undergo UVB-induced membrane transport inhibition. These data suggest that PARP-1 activation is necessary for ABC transporter functional downregulation. The hydrolysis of poly(ADP-ribose) by poly(ADP-ribose) glycohydrolase (PARG) was also required, since specific PARG inhibitors, which limit the production of ADP-ribose molecules, restored the function of ABC transporters. Furthermore, ADP-ribose molecules potently inhibited the activity of the ABC transporter P-glycoprotein. Hence, poly(ADP-ribose) metabolism appears to play a novel role in the regulation of ABC transporters.

Renal clearance and daily excretion of cortisol and adrenal androgens in patients with rheumatoid arthritis and systemic lupus erythematosus

BACKGROUND

In rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), patients demonstrate low levels of adrenal hormones.

OBJECTIVE

To investigate whether increased renal clearance and daily excretion contribute to this phenomenon.

METHODS

Thirty patients with RA, 32 with SLE, and 54 healthy subjects (HS) participated. Serum and urinary levels of cortisol, cortisone, 17-hydroxyprogesterone (17OHP), androstenedione, dehydroepiandrosterone (DHEA), and DHEA sulphate (DHEAS) were measured.

RESULTS

Clearance of DHEAS and DHEA was lower in patients than in HS, and clearance of androstenedione was somewhat higher in patients than in HS, but daily excretion of this latter hormone was low. Clearance of cortisol, cortisone, and 17OHP was similar between the groups. The total molar amount per hour of excreted DHEA, DHEAS, and androstenedione was lower in patients than HS (but similar for cortisol). Serum DHEAS levels correlated with urinary DHEAS levels in HS and patients, whereby HS excreted 5-10 times more of this hormone than excreted by patients. Low serum levels of adrenal androgens and cortisol in patients as compared with HS were confirmed, and proteinuria was not associated with changes of measured renal parameters.

CONCLUSIONS

This study in patients with RA and SLE demonstrates that low serum levels of adrenal androgens and cortisol are not due to increased renal clearance and daily loss of these hormones. Decreased adrenal production or increased conversion or conjugation to downstream hormones are the most likely causes of inadequately low serum levels of adrenal hormones in RA and SLE.

[Severe, non-infectious mitral valve endocarditis after mitral valve reconstruction in a 32-year old female with primary antiphospholipid syndrome]

BACKGROUND

A 32-year old female with primary antiphospholipid syndrome presented 8 months after mitral valve reconstruction with progressive exertional dyspnea and echocardiographically demonstrable critical mitral stenosis and regurgitation. Tachycardia, weight loss, sleep disturbances and increasing nervosity led to the diagnosis of concomitant hyperthyroidism. After the patient stopped the oral anticoagulation by herself, a 'catastrophic antiphospholipid syndrome' with multiple microthromboembolic events in several organs developed rapidly within a few weeks. Severe respiratory failure was observed 14 days after admission at our hospital because of a pulmonary edema.

TREATMENT

Removal of the annuloplasty ring and alloplastic mitral valve replacement with a 25 mm bilifleat valve. Postoperatively, the patient was placed on oral anticoagulation. Several pre- and postoperative plasmaphereses lowered the level of antiphospholipid antibodies. The patient additionally underwent radioiodtherapy 5 months postoperatively.

RESULTS

While hemodynamics and diuresis remained sufficient, ventilatory support with tracheostomy was necessary for 16 postoperative days to achieve stable respiration. Thirty months later, the patient is well and without further cardiac and neurological dysfunction.

CONCLUSION

Secondary cardiac valve operations on patients with primary antiphospholipid syndrome may be successfully performed within a multidisciplinary approach. Oral anticoagulation remains the treatment of choice to prevent further thromboembolic events.