A primate model for discordant pig to primate kidney xenotransplantation without hyperacute graft rejection

Organs transplanted between phylogenetically disparate species, such as from the pig into the primate, are subject to intragraft deposition of preformed recipient immunoglobulin M (IgM) antibodies with subsequent complement activation finally leading to complete and rapid destruction of the xenograft (hyperacute graft rejection, HAR). Current therapeutic strategies for abrogation of HAR include pretransplant antibody absorption by specific or nonspecific extracorporeal column perfusion, ex vivo donor organ perfusion, the administration of substances interfering with complement activation, or even the genetic alteration of the donor. Here, in the pig to cynomolgus monkey species combination, we are describing an experimental model for abrogation of HAR by using large, relative to the recipient weight, oversized donor kidneys as xenotransplants. Porcine kidney xenotransplantation (n = 15) was performed using large white pigs of different weights and ages as organ donors and cynomolgus monkeys as recipients. In grafts with an organ weight below 50 g (20 to 48 g, median 25 g), primary nonfunction (PNF) of the porcine kidney was observed in 11 out of 12 cases and complete HAR in 5 out of 12 experiments. In contrast, none of three grafts with a donor organ weight >70 g showed signs of HAR or PNF. In one animal, a second porcine kidney from the same donor (23 g) was successfully transplanted immediately after HAR and subsequent removal of a first porcine kidney (20 g). By using appropriate immunohistochemistry stainings of reperfusion biopsies, profound deposition of recipient natural antibodies in both small and large xenografts was shown, with only scarce deposition of C3 and C5b-9 in the latter, indicating only incomplete intragraft activation of the complement cascade in these organs. Intraoperative cardiac output (CO) measurements performed in 7 experiments demonstrated a 20 to 50% decrease in CO following reperfusion in 6 out of 7 grafts irrespective of the donor organ weight. The intraoperative decrease in CO was not associated with perioperative morbidity or mortality. The use of oversized doner kidneys can enable the study of a variety of immunologic and physiologic sequela beyond HAR associated with life-supporting discordant primate kidney transplantation.

CT-based needle marking of superficial intracranial lesions for minimal invasive neurosurgery

A CT-based method of marking superficial intracranial lesions with a needle is presented. This form of neuronavigation can be applied in every neurosurgical centre. Owing to its rapid application it is also suitable for cases of emergency. The neurosurgical approach can be centred precisely over the lesion providing for a minimally invasive operation. The method has proved its efficacy in numerous cases of haematomas and cystic lesions.

Endoscopic ultrasound criteria for vascular invasion in the staging of cancer of the head of the pancreas: a blind reevaluation of videotapes

BACKGROUND

It has been claimed in several prospective studies that endoscopic ultrasonography (EUS) is highly accurate in the locoregional staging of pancreatic cancer. However, the value of the EUS criteria for the diagnosis of vascular involvement is less well established. To totally exclude potential bias introduced by the availability of prior information, a completely blinded analysis of videotapes of patients with cancer of the pancreatic head was therefore conducted.

METHODS

Videotape sequences of 75 patients with cancer of the head of the pancreas with surgical confirmation or unequivocally positive angiography demonstrating vascular invasion were reevaluated without any clinical data or information from other imaging studies. Involvement of the vascular system (portal vein with confluence, superior mesenteric vein, celiac axis) was assessed on EUS with special emphasis on EUS parameters of the tumor-vessel relationship.

RESULTS

The overall sensitivity and specificity of EUS in the diagnosis of venous invasion were 43% and 91%, respectively, when using predetermined parameters (visualization of tumor in the lumen, complete obstruction, or collateral vessels). If the parameter "irregular tumor-vessel relationship" had been added to these criteria, the sensitivity would have risen to 62%, but the specificity would have fallen to 79%. The only vascular system that could be properly visualized by EUS was the portal vein/confluence area. The positive and negative predictive values for the single parameters chosen to diagnose portal venous involvement were as follows: 42% and 33% for irregular tumor-vessel relationship, 36% and 34% for visualization of tumor in the vascular lumen, 80% and 28% for complete vascular obstruction, and 88% and 18% for collateral vessels.

CONCLUSIONS

In a completely blinded evaluation of the EUS diagnosis of vascular invasion by cancer of the head of the pancreas it was not possible to find suitable morphologic parameters with clinically useful sensitivity and specificity values (over 80%).

Decline of caries prevalence after the cessation of water fluoridation in the former East Germany

In contrast to the anticipated increase in dental caries following the cessation of water fluoridation in the cities Chemnitz (formerly Karl-Marx-Stadt) and Plauen, a significant fall in caries prevalence was observed. This trend corresponded to the national caries decline and appeared to be a new population-wide phenomenon. Additional surveys (N=1017) carried out in the formerly-fluoridated towns of Spremberg (N=9042) and Zittau (N=6232) were carried out in order to support this unexpected epidemiological finding. Pupils from these towns, aged 8/9-, 12/13- and 15/16-years, have been examined repeatedly over the last 20 years using standardised caries-methodological procedures. While the data provided additional support for the established fact of a caries reduction brought about by the fluoridation of drinking water (48% on average), it has also provided further support for the contention that caries prevalence may continue to fall after the reduction of fluoride concentration in the water supply from about 1 ppm to below 0.2 ppm F. Caries levels for the 12-year-olds of both towns significantly decreased during the years 1993-96, following the cessation of water fluoridation. In Spremberg, DMFT fell from 2.36 to 1.45 (38.5%) and in Zittau from 2.47 to 1.96 (20.6%). These findings have therefore supported the previously observed change in the caries trend of Chemnitz and Plauen. The mean of 1.81 DMFT for the 12-year-olds, computed from data of the four towns, is the lowest observed in East Germany during the past 40 years. The causes for the changed caries trend were seen on the one hand in improvements in attitudes towards oral health behaviour and, on the other hand, to the broader availability and application of preventive measures (F-salt, F-toothpastes, fissure sealants etc.). There is, however, still no definitive explanation for the current pattern and further analysis of future caries trends in the formerly fluoridated towns would therefore seem to be necessary.

Selective mobilization of CD14(+)CD16(+) monocytes by exercise

Strenuous, anaerobic exercise leads to an increase of leukocytes that are mobilized from the marginal pool. We have analyzed in human peripheral blood the effect of exercise on the number of CD14(+)CD16(+) monocytes as determined by two-color immunofluorescence and flow cytometry. We show herein that this type of monocyte responds with a dramatic up to 4.8-fold increase. Mobilization does not occur after 1 min at 100 or 200 W but 1 min at 400 W leads to a twofold increase of the CD14(+)CD16(+) monocytes immediately after exercise. The numbers remain high at 5 min and gradually decrease to reach the initial level at 20 min postexercise. After 20 min of rest, the CD14(+)CD16(+) monocytes can be mobilized again by a second exercise. The CD14(+)CD16(+) monocytes appear to be mobilized from the marginal pool where they preferentially home because of a higher expression of adhesion molecules like CD11d and very late antigen-4. Exercise goes along with an increase of catecholamines, and mobilization of the CD14(+)CD16(+) monocytes can be substantially reduced by treatment of donors with the beta-adrenergic receptor blocker propranolol. Mobilization of CD14(+)CD16(+) monocytes by a catecholamine-dependent mechanism may contribute to the increase of these cells in various clinical conditions.

Modern imaging methods versus clinical assessment in the evaluation of hospital in-patients with suspected pancreatic disease

OBJECTIVE

Various modern imaging procedures such as endoscopic retrograde cholangiopancreatography (ERCP), computed tomography (CT), and endoscopic ultrasonography (EUS) have been shown to be highly accurate in the diagnosis of specific disorders of the pancreas. However, prior information often causes bias in the interpretation of these results. Little information is available concerning the value of these examinations in the primary and differential diagnosis of suspected pancreatic disease-particularly in comparison with clinical evaluation, including laboratory tests and transabdominal ultrasound (TUS).

METHODS

Clinical and imaging information (EUS, ERCP, and CT) was collected for 184 inpatients who were referred over a 5-yr period for evaluation of suspected pancreatic disease. On the basis of patient history, laboratory tests, and the results of routine TUS, one gastroenterologist, who was unaware of any of the other procedures or the final diagnosis, made a presumptive clinical diagnosis. CT and ERCP images and EUS videotapes were then analyzed by three different and independent examiners, who had the same clinical information except for the TUS results, but were completely blinded to the results of the other examinations and the patients' diagnoses. The final diagnoses were obtained by surgery, histology, and cytology, plus a follow-up of at least 1 yr (mean 35 months) in all noncancer cases.

RESULTS

The final diagnoses were: normal pancreas (n = 36), chronic pancreatitis without a focal inflammatory mass (n = 53) or with a focal inflammatory mass (n = 18), and pancreatic malignancy (n = 77). Clinical evaluation, including ultrasonography, achieved a sensitivity for pancreatic disease of 94% but a specificity of only 35%. The figures for the sensitivity and specificity of the three imaging procedures were 93% and 94%, respectively, for EUS; 89% and 92% for ERCP; and 91% and 78% for CT (p < 0.05 for the specificity of clinical assessment vs all three imaging tests, p > 0.05 for comparison of the three imaging procedures). In the differential diagnosis between cancer and chronic pancreatitis as well as between malignant and inflammatory tumors, there was no difference among clinical assessment and the three imaging tests.

CONCLUSIONS

In a group of patients with a high suspicion of pancreatic disease, little additional sensitivity in the diagnosis of pancreatic disease is provided by sophisticated imaging procedures such as EUS, ERCP, and CT, in comparison with clinical assessment including laboratory values and TUS. However, the specificity can be substantially improved. To confirm the diagnosis, one of the three examinations is needed, depending on the suspected disease and local expertise. The imaging procedures should be performed in a stepwise fashion for specific purposes, such as exclusion of pancreatic disease and the planning of treatment in chronic pancreatitis and pancreatic cancer.

Pregnancy intention: how PRAMS data can inform programs and policy. Pregnancy Risk Assessment Monitoring System

BACKGROUND

In most states, the Pregnancy Risk Assessment Monitoring System (PRAMS) is the only source for state-specific, population-based data on the prevalence of unintended pregnancy among women having a live birth. These data can be used in a variety of ways to inform state policies and programs aimed at the prevention of unintended pregnancy.

OBJECTIVES

This paper highlights the programmatic and policy development activities undertaken by three states in relation to unintended pregnancy as well as the role that PRAMS data played in those efforts.

RESULTS

Georgia, Oklahoma, and Washington have used PRAMS data to gain support for program initiatives directed at unintended pregnancy, to promote policies aimed at either monitoring or reducing unintended pregnancy, and to acquire additional funds for related programs, such as family planning.

Long term follow up after perimesencephalic subarachnoid haemorrhage

OBJECTIVES

To evaluate the long term sequelae of perimesencephalic subarachnoid haemorrhage (PMSAH).

METHODS

Twenty one consecutive patients were studied. All patients were examined by CT, angiography, MRI, multimodal evoked potentials, and transcranial Doppler sonography. All relevant clinical data during hospital stay and outcome at discharge were obtained by reviewing the charts. Long term follow up was evaluated by reviewing the outpatient files and dedicated outpatient review. Patients were specifically questioned about their perceived recovery, residual complaints, and present occupational status.

RESULTS

Apart from the initial CT confirming the diagnosis of PMSAH all other examinations disclosed no abnormalities. None of the patients developed any complications during hospital stay, and all patients were discharged in good clinical condition and without neurological deficits. At long term follow up 62% of the patients had residual complaints consisting of headaches, irritability, depression, forgetfulness, weariness, and diminished endurance. Apart from four patients who had already retired before the PMSAH, only seven of the remaining 17 patients (41%) returned to their previous occupation, whereas nine patients (53%) retired from work and one man became unemployed. One patient had a recurrence of PMSAH 31 months after the first event.

CONCLUSION

PMSAH can have considerable long term psychosocial sequelae, and may also recur. Prognosis may not be as good as previously reported.

Utility of a brief self-efficacy scale in clinical training program evaluation

Self-efficacy is often studied as a predictor of professional practice behaviors or as an outcome of clinical training, using brief scales with little validation. This study examines the utility of a brief self-efficacy scale in the evaluation of a clinical training program. Subjects were 119 registered dietitians who participated in diabetes training. Hypothesized relationships between self-efficacy ratings and indices of skill mastery, participation in training, and subsequent practice change were examined. Self-efficacy ratings after training correlated significantly with relevant prior experience (r = .4 and .29, p < .01) but not total experience and with knowledge post-test score (r = .21, p < .02). Self-efficacy for all 12 program objectives increased significantly after training. Post-training self-efficacy for two program objectives correlated significantly with self-reported successful practice changes related to those objectives (r = .4, p < .04 and r = .51, p < .01). The data suggest that brief self-efficacy assessments can contribute meaningfully to clinical training program evaluation.

Influence of cold ischemia time, pretransplant anti-porcine antibodies, and donor/recipient size matching on hyperacute graft rejection after discordant porcine to cynomolgus kidney transplantation

Organs transplanted between phylogenetically disparate species, such as from the pig into the primate, are subject to hyperacute rejection (HAR). This form of xenograft rejection is mediated by preformed natural antibodies and is believed to occur invariably in discordant xenografts thus leading to rapid destruction and complete thrombosis of the graft. Recent data, however, have shown that in the porcine to cynomolgus monkey setting, HAR is not inevitably seen after porcine kidney transplantation. The influence of preoperative antiporcine antibody levels in the recipient, cold ischemia time, and donor organ weight on the onset of HAR was investigated by using unmodified large white pigs (aged 3-12 weeks) as organ donors and adult cynomolgus monkeys (aged 1.5-3.5 years) as recipients. Porcine kidney xenotransplantation was performed in either a non-life-supporting model (n=7) or in a life-supporting model (n=8). In both models, no correlation was found between cold ischemia time and HAR. When preoperative anti-porcine antibody levels were investigated, a significant increase in incidence of HAR was observed in animals with elevated anti-porcine IgM (P<0.05) but not IgG levels (P=NS). Interestingly, although 5 of 12 grafts with an organ weight of less than 50 g underwent HAR, none of three grafts with a donor organ weight of more than 70 g showed signs of HAR. In addition, all three larger grafts showed intraoperative and postoperative urine production, although only in 1 (48 g) of the 12 grafts weighing less than 50 g primary graft function was observed. In one animal, a second porcine kidney (23 g) was successfully transplanted (without HAR) immediately after HAR and subsequent removal of a first porcine kidney (20 g). These results indicate that in the porcine to cynomolgus monkey setting anti-porcine IgM rather than IgG anti-porcine antibody levels seem to be of predominant importance for the induction of HAR. By increasing the donor organ size and weight the frequency of the onset of HAR can be at least reduced. This is most likely due to immunoabsorption of the recipients preformed antibodies in the porcine kidney without lethal damage for the graft.

Performance, patient acceptance, appropriateness of indications and potential influence on outcome of EUS: a prospective study in 397 consecutive patients

BACKGROUND

Although there is a large body of data on the accuracy of endoscopic ultrasonography (EUS) in the diagnosis and staging of various gastroenterological disorders, little has been published on the influence of EUS in the management of patients. Data on the performance of EUS and patient acceptance are also sparse.

METHODS

During a 10-month period, all consecutive EUS examinations were categorized by the examiner according to the appropriateness of the indications. Prior examinations, performance of EUS (duration, premedication, complications), and patient acceptance (assessed using a questionnaire by an independent investigator) were recorded. A mean of 2 months after the procedure, referring physicians were asked about the extent to which the EUS results had influenced their further diagnostic and therapeutic approach.

RESULTS

A total of 397 patients were included; they were referred for EUS after a mean of 1. 8 specific tests had been performed. The appropriateness of the indications for EUS was categorized as "classic," "useful," and "potentially useful" (categories 1 to 3) in 81% of cases. The referring physicians replied that EUS had provided useful additional information in 55% of cases; the EUS findings prompted further tests in 22% and made further examinations unnecessary in 30%. A change in therapy was believed to be directly due to EUS in only 6% of cases. The duration of the EUS examinations ranged from a mean of 8.1 minutes (esophageal indications) to 18.9 minutes (biliary indications). There were no complications. In patients who were able to remember the EUS examination (42%), 90% found it tolerable, and 83% of all the patients interviewed were willing to have the examination repeated with the same level of sedation.

CONCLUSIONS

EUS is a safe examination that can be carried out within a reasonable time frame by experienced examiners and without significant patient discomfort when performed under conscious sedation. With regard to patient management, EUS mainly influences further diagnostic tests.

Lovastatin decreases the receptor-mediated degradation of acetylated and oxidized LDLs in human blood monocytes during the early stage of differentiation into macrophages

3-Hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors are used therapeutically to upregulate the LDL receptor-mediated removal of plasma cholesterol by the liver. Several lines of evidence indicate that these drugs also exert direct effects on the metabolism of native and modified LDL in extrahepatic cells. We studied the effects of lovastatin (LOV) on the degradation of native, acetylated, and oxidized LDL, and on levels of mRNA encoding for the LDL, types I and II class A macrophage scavenger, and CD36 receptors in human blood monocytes at different stages of their maturation into adherent macrophages. LOV (10 micromol/L) reduced the degradation of acetylated LDL when added to freshly isolated cells cultured for 2 (81+/-4% of control, P<0.05) and 5 (76+/-6%, of control, P<0.05) days. The degradation of oxidized LDL was also reduced in cells treated with LOV for 2 days after seeding (51+/-3% of control, P<0. 001) but not in 5-day-old cells. LOV had no significant effect on the degradation of either acetylated or oxidized LDL when added to fully matured macrophages allowed to differentiate under control conditions for 7 days before incubations with 10 micromol/L LOV for an additional 2 days. In contrast, LOV increased the degradation of native LDL in these cells at all 3 stages of cell differentiation. LOV also reduced class A types I and II macrophage scavenger receptor and CD36 mRNA levels in 2- and 5-day-old cells but not in the more mature macrophages. These data suggest that 3-hydroxy-3-methylglutaryl-coenzyme A inhibitors may reduce the expression and function of the class A types I and II macrophage scavenger receptor and CD36 in monocytes, during the early stages of their differentiation into adherent macrophages. These effects, if operative in vivo, may slow down the development of the atherosclerotic plaque and thus contribute to the beneficial effects of these drugs.

Lipid treatment of inflammatory bowel disease

The aetiology of inflammatory bowel disease remains unclear. Local mediators such as arachidonic acid metabolites and peptide mediators (cytokines) appear to contribute to the disease process. The successful administration of neutralizing antibodies against TNF-alpha has confirmed a pathophysiological role for this cytokine in Crohn's disease. Established therapy of inflammatory bowel disease with 5-aminosalicylic acid compounds has been shown to reduce local leukotriene B4 formation by inhibiting lipoxygenases. This therapeutic mechanism formed one rationale for examining the effect of n-3 fatty acids, which also inhibit leukotriene B4 formation, on the course of these diseases. In the first study, published in 1989, we found no beneficial effects of n-3 fatty acids in patients with Crohn's disease; however, there was clinical improvement, just falling short of significance, in patients with ulcerative colitis. Since then two uncontrolled and five controlled studies have further investigated the therapeutic effect of n-3 fatty acids in patients with ulcerative colitis. The size of the patient population in the controlled studies ranged from 10 to 96 patients in the largest study. Two of these studies showed a significant improvement in clinical activity and a steroid-sparing effect, respectively. Another study found only a trend towards improvement and one trial, which also included a treatment group receiving evening primrose oil, found no beneficial effect in the 16 patients receiving n-3 fatty acids. A large, 2 year trial of n-3 fatty acids in patients with ulcerative colitis off steroids, which was recently completed at the Universities of Munich and Mainz, showed a delay of the first episode of relapse, but no reduction in the cumulative relapse rate at 2 years. Controversial results have been published for Crohn's disease. A new enteric-coated formulation reportedly increased the proportion of patients in remission where as another trial using a conventional preparation found no significant effect.

Microbiological examinations and in-vitro testing of different antibiotics in therapeutic endoscopy of the biliary system

BACKGROUND AND STUDY AIMS

Prior to endoscopic therapeutic procedures, no antibiotic prophylaxis is administered routinely. Because of the reported incidence of infectious complications, which may reach up to 10%, a prospective study was undertaken to investigate the effects of a prophylactic dose of cefuroxime on the incidence of bacteremia and clinical signs of infection, but no significant effects could be demonstrated. In addition to this published work, blood and bile cultures obtained in this trial were also investigated, and the in-vitro susceptibility to several antibiotics was tested in order to recommend the appropriate substances.

PATIENTS AND METHODS

Ninety-nine consecutive patients (51 men, 48 women; mean age 61.4 +/- 17 years) with biliary obstruction who underwent an endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography with drainage (PTCD) were included. Sequential blood cultures were taken before and up to 60 minutes after the endoscopic intervention. Bile cultures were obtained in 56 patients with biliary drainage. Aerobic and anaerobic cultures were prepared from all obtained specimens and the isolated organisms were identified. In the case of positive cultures, an in-vitro resistance test for 15 different antibiotics was performed.

RESULTS

The incidence of bacteremia was 11.1% (n = 11), and 16 bacteria were isolated. Twelve different microorganisms were detected, with Escherichia coli found in four cases. From 41 positive out of 56 prepared bile cultures (73.2%), 91 isolates were found with 25 different species. A single agent was detected in eight cases (19.5%), while a mixed growth, with pathogens ranging from two to six species, was found in 33 cases (80.5%). The seven most frequently isolated germs were E. coli and Enterococcus (each n = 19), Klebsiella (n = 10), Streptococcus viridans (n = 9), Staphylococcus epidermidis (n = 5), Morganella morganii (n = 4), and Bacteroides fragilis (n = 3), representing 76% of all agents. Examination for fungal infection revealed positive cultures of Candida albicans in 16.1% of bile cultures (nine of 56). Interestingly, the use of proton-pump inhibitors (PPIs), with a consequent rise in the gastric pH value, led to an increase in the rate of bacteremia to 26.2% (five of 19) compared to the other patients not on PPIs (n = 80), who developed bacteremia in only six cases (7.5%; p = 0.02). In-vitro testing of different antibiotics was carried out in 73 isolates. Imipenem showed the best antimicrobial activity (98.4%), followed by trimethoprim and sulfamethoxazole (90%), amoxicillin plus clavulanic acid (87.3%), vancomycin (82.4%), and ofloxacin (76.9%).

CONCLUSIONS

Escherichia coli was found to be the pathogen most frequently detected in blood and bile following endoscopic interventions in the biliary tract. Enterococci, Klebsiella and Streptococcus viridans were found in bile cultures with an incidence exceeding 10%. In view of the in-vitro test results, possible side effects, and contraindications, amoxicillin plus beta-lactamase inhibitors or quinolones are considered to be suitable antibiotics for the prophylaxis of biliary infections.

Long-term results of percutaneous transhepatic biliary drainage for benign and malignant bile duct strictures

BACKGROUND

Long-term percutaneous transhepatic biliary drainage (PTBD) is a valid alternative to surgery in patients with benign or malignant bile duct strictures in whom endoscopic drainage has failed. However, few data are available on the long-term outcome with percutaneous drainage, specially when the application of Yamakawa-type prostheses is considered.

METHODS

During 1996, 48 patients who were either treated with primary PTBD insertion followed by PTBD exchanges (n = 15) or who presented only for exchange of an earlier PTBD (n = 33) were included in the study. Thirty-one patients had malignant strictures, and 17 had benign ones. The PTBD catheters were scheduled for exchange every 3 months or earlier if signs and symptoms of obstruction or other problems were present. The data were collected prospectively during each follow-up visit and included both symptoms and the status and function of the PTBD at the time of exchange.

RESULTS

Although PTBD was highly effective in relieving jaundice (progression of cholestasis was observed in only 2 cases), 73 of the 157 PTBD exchanges (47%) had to be carried out earlier than scheduled. Premature exchange was needed for clinical reasons, such as fever indicating PTBD dysfunction, in only 19% of these cases. The other reasons were related to the PTBD catheter and consisted of bile leakage alongside the drain (33%), PTBD disconnection or complete dislocation (30%), or occlusion suspected during regular flushing of the drain (15%). In most cases exchanging the drain was sufficient to solve the problem; in cases of complete dislocation, dilation of the same tract (n = 6) or fresh puncture and establishment of a new drainage site (n = 2) were necessary. Reducing the PTBD exchange interval from 3 to 2 months would have decreased the number of premature stent exchanges by 26%.

CONCLUSIONS

Although PTBD is an effective method of biliary drainage, there are frequently minor problems-mostly catheter-related-which require premature exchange of the drain in almost half of the cases, and this may affect the patients' quality of life. Improvements in PTBD materials and catheter design are therefore needed. The effectiveness of reducing the intervals between PTBD exchanges should also be examined.

Nonmarital births in Oklahoma 1975-1995

This report uses data from the Oklahoma State Department of Health to describe past trends and current patterns of nonmarital births in Oklahoma. Between 1975 and 1995, the percentage of unmarried women delivering a live birth in Oklahoma increased from 12% to 31%. Adult nonmarital births increased faster than teen nonmarital births, but teens had a higher percentage of nonmarital births. White rates increased faster than African-American and Native American rates, but African-Americans had a higher percentage of nonmarital births. Unmarried women who give birth were more likely to be poor and lack education; additionally, they were less likely to receive early prenatal care, more likely to have had low weight births, and more likely to have had an unintended pregnancy. Birth outcomes are poorer among unmarried women, but this may be due to poverty and education rather than marital status alone.

Use of the recursion formula of the Gompertz function for the quantitation of PCR-amplified templates

One common drawback of the currently used procedures to quantitate the polymerase chain reaction (PCR) is that the statistical evaluation of the experimental data depends on many, not just trivial, model assumptions. In the present study we report on an improvement in this crucial step of the quantitative PCR. The experimental design underlying the introduced method is exactly the same as in the case of the so-called PCR. However, by applying growth curve analysis based on the recursion formula of the Gompertz function the kinetics of the accumulation of the amplicon are estimated conjointly from data spanning both the and phases of the reaction. We demonstrate the method by determining the relative number of templates (a 206 bp segment spanning the exon 3 of the X-chromosomal murine Hprt-gene) contained in known orders of dilutions of DNA isolated from the spleen of the C57BL/6J-mouse. [32P]-dATP incorporation was used in duplicate experiments to quantify the amplicons as a function of amplification cycles. Our results: i) indicate that the accumulation of the PCR product as a function of PCR cycles follows a sigmoidal pattern compatible with the Gompertz growth model (P<0.0000001); ii) directly support the thesis that the kinetical pattern of accumulation of amplicons of a given DNA fragment does not depend on the number of corresponding DNA templates provided to the reaction; iii) permit a simple direct evaluation of the parallelity in the course of the accumulation of amplicons from different template numbers as a function of amplification cycles, which is a silent preposition in the evaluation of the so-called PCR; iv) allow an easy quantitation of the relative number of provided templates.

Similar effects of diets rich in stearic acid or trans-fatty acids on platelet function and endothelial prostacyclin production in humans

The effects of stearic acid (C18:0) and trans-fatty acids (trans-FAs) on measures of platelet function and prostacyclin (PGI2) production are poorly understood in humans. In this controlled dietary study, platelet function and endothelial PGI2 production were studied in healthy humans after they consumed diets rich in C18:0 or trans-FAs. For 5 weeks, 80 subjects consumed a baseline diet high in saturated FAs and were then switched to a diet containing 9.3% of energy as stearic acid or a diet containing 8.7 energy% as trans-FAs from hydrogenated vegetable oils for another 5 weeks. All diets contained 32.2 to 33.9 energy% fat, 14.6 to 15.8 energy% saturated plus trans-FAs, 12.2 to 12.5 energy% cis-monounsaturated, and 2.9 to 3.5 energy% polyunsaturated FAs. No significant differences between the C18:0 and trans-FA diets were found in the urinary excretion of 2,3-dinor-thromboxane B2 or 2,3-dinor-6-keto-prostaglandin F1alpha. In vitro production of thromboxane B2 by platelets as well as urinary excretion of beta-thromboglobulin were also similar after both diets. Collagen-induced in vitro aggregation was significantly enhanced after the C18:0 diet compared with the trans-FA diet (P=.02), whereas no differences between the diets were found with ADP. The results indicate similar effects of C18:0 and trans-FA diets on platelet activation and endothelial PGI2 production.

The effect of short-term diets rich in fish, red meat, or white meat on thromboxane and prostacyclin synthesis in humans

Foods which increase tissue arachidonic acid levels have been proposed to increase thrombosis tendency, presumably through increased platelet aggregation. This study examined the effect of doubling the dietary arachidonic acid (20:4n-6) using meat- or fish-based diets on the systemic production of prostacyclin (PGI2) and thromboxane (TXA2) in 29 healthy, nonsmoking adults. There were three, 3-wk low-fat dietary periods (< 15% energy as fat) in which subjects consumed a vegetarian diet for 1 wk followed by 2 wk on diets containing meat or fish as sources of 20:4n-6. Between each diet period, there was a 3-wk washout period, during which subjects returned to their normal diets. The level of 20:4n-6 consumed during the last 2 wk of each study was approximately double the usual intake (mean 140 mg/d), while the mean eicosapentaenoic acid (20:5n-3) content of the diets varied from 1 mg/d on the white meat diet to 70 mg/d on the red meat diet and to 847 mg/d on the fish diet. The serum phospholipid (PL) 20:4n-6/20:5n-3 ratios were 11:1 on the vegetarian diet, 15:1 on the white meat diet, 8:1 on the red meat diet, and 2:1 on the fish diet (P < 0.001). Neither white nor red meat diets affected platelet 20:4n-6 levels, platelet aggregation, ex vivo platelet TXB2 production, or the systemic PGI2 or TXA2 production as measured by gas chromatography-mass spectrometry analysis of the excretion levels of the principal urinary metabolites 2,3-dinor-6-keto-PGF1 alpha (PGI2-M) and 11-dehydro-TXB2 (TXA2-M), respectively. The fish diet decreased the 20:4n-6/20:5n-3 ratio in platelet PL from the baseline level of 45:1 to 13:1 (P < 0.001), had no effects on platelet aggregation, but significantly decreased platelet TXB2 production (collagen-stimulated) and TXA2-M production, while PGI2-M levels were unaltered. These results indicate that short-term diets which double the usual 20:4n-6 intake using white meat (175-330 g/d) or red meat (275-530 g/d) are not associated with an increased TXA2 production, but this does not rule out the adverse effects of 20:4n-6 at higher levels in the diet, or for more prolonged periods. Short-term diets containing fish (100-200 g/d with 90-210 mg/d 20:4n-6 and approximately 650-1000 mg/d 20:5n-3) led to significant increases in platelet 20:5n-3 levels and a decrease in the ex vivo and systemic TXA2 production.

Arachidonic acid of platelet phospholipids is decreased after extracorporeal removal of plasma low density lipoproteins in patients with familial hypercholesterolemia

Platelet phospholipid composition was analyzed before and after extracorporeal removal of low density lipoproteins (LDL) by LDL apheresis in six patients with familial hypercholesterolemia. Elevated levels of total plasma cholesterol and the portion of plasma cholesterol carried by LDL were reduced by 56 and 66% after LDL apheresis. Platelet cholesterol contents remained unaffected. While the phosphatidylcholine (PC):sphingomyelin (SM) ratio in plasma lipoproteins was increased by 22% following apheresis, the same parameter was lowered by 14% in platelets. LDL apheresis induced decreases in the percentages of distinct molecular species containing arachidonic acid in platelet diacyl subgroups of PC, phosphatidylinositol (PI) and phosphatidylserine (PS) as well as in alkenylacyl (plasmalogen) phosphatidylethanolamine (PE). Directly after apheresis, the percentages of molecular species with arachidonic acid of diacyl PC, diacyl PI and alkenylacyl PE were reduced by 20, 23 and 8%, respectively. Two days after the procedure, total arachidonic acid of diacyl PC, diacyl PS and alkenylacyl PE was lowered by 11, 20 and 8%. Overall, the amount of phospholipid bound arachidonic acid was reduced by 16% after apheresis (from 79.1 to 66.4 nmol/10(8) platelets). The results are thus in agreement with previous data indicating decreased phospholipid bound arachidonic acid in red blood cells after apheresis (Engelman B. Bräutigam C, Kulschar R et al. Biochim Biophys Acta 1994:1196:154). Urinary 2,3-dinor thromboxane B2, an estimate of platelet thromboxane A2 (TXA2) production, tended to be decreased following the procedure. The percentage change in the TXA2 metabolite was positively related to the magnitude of change induced by apheresis in phospholipid bound arachidonic acid. In summary, the results suggest that in patients with hypercholesterolemia, the level of plasma LDL is an important determinant of the arachidonic acid content of several platelet phospholipids.

[The value of sonography for the discovery of complications after the implantation of silicone gel prostheses for breast augmentation or reconstruction]

PURPOSE

To determine sensitivity and specificity of real-time ultrasonography in detecting breast implant complications.

MATERIAL AND METHODS

The results of preoperative ultrasonography of 121 silicone implants in 65 patients were compared with the results after operative implant removal.

RESULTS

With a sensitivity of 89.25% and a specificity of 92.1%, complications such as gel bleeding (n = 43), rupture with leakage (n = 63), and implant dissolution (n = 4) become manifest. Capsule formation, fibrosis, siliconoma and calcifications were often underestimated in their extent. Negative ultrasonography findings were found in 10.7% (n = 13) with positive clinical findings.

CONCLUSIONS

The combination of clinical and ultrasonography findings leads to the detection of implant complications.

n-3 fatty acids only delay early relapse of ulcerative colitis in remission

Relapse prevention by dietary n-3 fatty acids (5.1 g/day) was studied in a double-blind, placebo-controlled trial of 64 patients with ulcerative colitis in remission and off steroids. 5-ASA compounds were stopped three months after randomization and clinical disease activity monitored for two years. Macroscopic and histologic activity and extension was assessed by colonoscopy at entry and at exit. Both treatment groups were well matched at start. Nine patients on placebo and eight on n-3 fatty acids stopped taking their medication prematurely. Actuarial relapse-free survival was improved by n-3 fatty acids only during months 2 and 3 (2P < 0.05-0.01), but cumulative relapse rate at two years was similar for those taking placebo (18/33 = 55%) and n-3 fatty acids (18/31 = 58%). There was also no consistent difference in clinical, macroscopic, and histologic disease activity between treatment groups. The n-3 fatty acids temporarily retard, but do not prevent, relapse of ulcerative colitis.

Factor XIII in chronic inflammatory bowel diseases

Severe acute inflammation in chronic inflammatory bowel disease is associated with large wound areas and ulcerations that show spontaneous hemorrhage or marked friability. Therefore, an enormous potential of hemostasis and wound healing is required. Coagulation studies demonstrate a deficiency of factor XIII that is important for both clot formation and wound healing. Consequently, the substitution of factor XIII may be beneficial; the first case reports present favorable clinical results. In a prospective pilot study, we treated 12 patients with therapy-resistant ulcerative colitis. The colitis activity index (CAI) and the endoscopic score (ES) according to Rachmilewitz were elevated; all patients suffered from hematochezia. After substitution therapy with factor XIII concentrate (1,250 U/d) the stool frequency dropped and no further hematochezia was detected. The CAI and the ES declined highly significantly. Because of these encouraging results two placebo-controlled multicenter trials have been initiated. In the first study, patients with acute stage of ulcerative colitis associated with severe intestinal blood loss are treated with two different dosages of factor XIII concentrate (1,250 and 500 U/d, respectively) or placebo for 10 days. In the second trial, patients with therapy-resistant ulcerative colitis with a lack of remission in spite of a consequent therapy for 2 weeks are included; factor XIII concentrate or placebo is administered for 10 days. The aim of both trials is an end of intestinal bleeding and the fostering of a more effective wound-healing process.

Improved determination of variant erythrocytes at the glycophorin A (GPA) locus and variant frequency in patients treated with radioiodine for thyroid cancer

Red blood cells from individuals with the blood group MN express each form of the allelic GPA protein (GPAM and GPAN) on their cell surface. Variant cells have lost one form of the protein. Their frequency is about 10(-5) in blood from unexposed persons. The BR6 assay is currently the most widely used assay to determine variant frequency (VF) by immunolabelling and flow cytometry. The precision of the BR6 assay is mainly limited by the Poisson error because only small numbers of variant cells are detected in each assay. The BR6 assay has been improved by magnetic cell separation (MACS) of variant erythrocytes prior to their determination by this assay. This new version of the assay is named 'MACS-BR6'. It allows enumeration of variant cells from 2 x 10(8) or more blood cells instead of 5 x 10(6) in the BR6 assay with a precision which is about 5 times higher than that of the BR6 assay. The MACS-BR6 assay was used to determine the VF of GPAN/0 and GPAN/N variant cells in 12 healthy adults and 11 patients treated with radioiodine for thyroid cancer 2 to 16 years before. The average red bone marrow dose was 347 mGy. In healthy adults the mean VF of GPAN/0 and GPAN/N variant cells was 16.1 x 10(6) and 5.3 x 10(-6) respectively. In patients the corresponding mean VF was 25.4 x 10(6) and 11.9 x 10(-6), respectively. The patients GPAN/0 VF was significantly higher than that of controls. In patients VF increases linearly with the dose. The linear regression parameters of VF were 16.6 x 10(-6) (intercept), 23.7 x 10(-6) GY-1 (slope) and 6.3 x 10(-6) (intercept), 12.9 x 10(-6) Gy-1 (slope) for GPAN/0 and GPAN/N variant cells, respectively.

A minimally invasive palliative approach to advanced pancreatic and papillary cancer causing both biliary and duodenal obstruction

BACKGROUND

In patients with both duodenal and biliary obstruction in whom endoscopic drainage is not feasible, the standard approach has been gastroenterostomy plus biliodigestive anastomosis. We present our results of percutaneous biliary drainage in combination with gastroenterostomy.

PATIENTS AND METHODS

Twenty-one patients, who received permanent percutaneous transhepatic biliary drainage (PTBD) and gastroenterostomy in case of symptomatic gastric outlet obstruction were retrospectively evaluated.

RESULTS

PTBD insertion succeeded in all patients; minor complications were encountered in 47.6% of cases. Bilirubin fell from 9.2 mg/dl (SD 7.6) to 4.9 mg/dl (SD 3.6). Gastroenterostomy, either open (n = 10) or laparoscopic (n = 6), had to be performed in 16 patients before, during or after PTBD. Thirty day mortality was 23.8%, not related to the procedure, but due to advanced neoplastic disease. Mean survival and hospital stay were 4.9 months (SD 3.6) and 21.5 days (SD 7.3) respectively.

CONCLUSIONS

The combination of PTBD and gastroenterostomy offers a promising alternative to surgery. However efforts to reduce complications as well as the duration of hospital stay are necessary.

[Clinical electro-ophthalmology at the Max Planck Institute of the Frankfurt University Ophthalmology Clinic 1970-1991]

The survey shows the frequency and distribution of diseases evaluated by electroophthalmological methods. Patients with retinal diseases (51.2%) and those with diseases of the optic nerve (21.8%) were examined most frequently. In a high percentage these investigations lead to a clinically useful assessment: described as confirmation or exclusion of a clinical diagnosis, as establishing a possible differential diagnosis or clearing up formerly unknown aspects of a disease. In cases of hereditary retinal disorders only 11% remained unclear, with presumed optic neuritis only 6%. The importance of electroophthalmological investigations is there ability to assess functional deficits in the visual system especially in somehow more rare retinal and centrally located disorders, functional deficits of unknown origins or in general diseases including the visual system.

Anterior decompression and stabilization using a microsurgical endoscopic technique for metastatic tumors of the thoracic spine

It is well accepted that the treatment of spinal tumors that threaten neurological integrity comprises resection, vertebral body reconstruction, and stabilization if the patient's condition is suitable. In spite of the excellent results reported using thoracotomy, the majority of investigators recommend posterolateral techniques because of lower morbidity, shorter hospitalization time, and the possibility of performing dorsal stabilization via the same incision. To overcome some of the disadvantages of thoracotomy, the authors developed an anterior procedure that permits vertebrectomy, reconstruction, and stabilization to be performed entirely by endoscopic technique. Microsurgical endoscopy and stabilization were performed in four patients with metastatic disease of the thoracic spine. All were ambulatory after surgery and at follow up; preoperative neurological and neurophysiological deficits improved as well. No complications occurred in this small series. Microsurgical endoscopy achieves a substantial reduction in trauma, use of analgesic medications, and hospitalization time. Early results seem to indicate that adequate decompression, stabilization and reduction of surgical morbidity can be achieved with this technique.

Age dependent selection against HPRT deficient T lymphocytes in the HPRT+/- heterozygous mouse

The fraction of HPRT deficient T lymphocytes was measured in the HPRT +/- female mouse between birth and an age of about 2 years. The animals were the F1 offspring of the HPRT deficient strain 129MF1 and HPRT competent C57BL/6J-mice. T lymphocytes from spleen were cloned in vitro and HPRT deficient clones were detected by double-labeling with [3H]thymidine and [14C]hypoxanthine. During the first weeks of life the fraction of deficient lymphocytes sharply decreases from about 50% at birth to 10-30% at an age of 10 weeks. In adult animals the fraction of HPRT deficient T cells smoothly further decreases to values about 10% at 80-90 weeks. The equation gamma(t)=[0.547 x exp(-0.405 x t)] + [0.453 x exp(-0.0116 x t)] was found to be a good approximation of the time course of HPRT deficient cells in spleen; gamma(t) is the fraction of deficient cells per competent cell and t is the age of animals in weeks. It is postulated that the selection against HPRT deficient T lymphocytes is the consequence of the reduced proliferative capacity of HPRT deficient cells (=selection factor). The time course of the ratio of deficient cells can be described as a function of the proliferation rate of the HPRT competent T cells and this selection factor. The sharp initial decrease is explained by a high selection pressure against HPRT deficient cells in young animals when the proliferation rate of the expanding T cell population is high and when T cells proliferate in the bone marrow. In adult animals the selection pressure against HPRT deficient cells is reduced, since T cells arise in general in peripheral lymphatic organs, where the salvage pathway is of lesser importance compared to the de novo purine synthesis. Implications of the selection against HPRT deficient lymphocytes for the widely used HPRT mutation assay are discussed.

Accumulation of nuclear p53 protein and prognosis of astrocytomas in childhood and adolescence

The aim of the study was to investigate whether nuclear immunopositivity for p53 is a factor of prognostic significance in astrocytomas of childhood and adolescence. Paraffin-embedded tissues of astrocytomas (10 WHO grade II, 11 WHO grade III) from 21 patients under 18 years of age, when operated for the first time, were studied immunohistochemically. We used a set of 6 different antibodies against p53, suitable for paraffin section (PAb1801, PAb240, DO-1, DO-7, BP53-12, CM-1). The intensity of the nuclear staining was scored and the percentage of stained nuclei counted. A tumor was scored positive if at least 10% of nuclei showed at least medium staining intensity with at least 1 primary antibody. No single antibody detected all cases designated immunopositive. This shows the advantage of using a set of antibodies. The time of survival in the immunopositive cases was significantly shorter, but immunopositivity was correlated with grade III (WHO). Comparing the time of survival between p53-immunopositive and -immunonegative grade III (WHO) astrocytomas no significant difference was found. We conclude that p53 immunoreactivity is not an independent unfavorable prognostic factor in astrocytomas of childhood and adolescence.

[Antibiotic prophylaxis using cefuroxime in bile duct endoscopy]

OBJECTIVE

To assess prospectively the effectiveness of a single prophylactic dose of cefuroxim before therapeutic endoscopy, in view of the general practice not to give antibiotics routinely.

PATIENTS AND METHODS

In a prospective study endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography with drainage (PTCD) together with simultaneous stone extraction, dilatation or stent implantation were performed in 99 patients (51 men, 48 women; mean age 60.6 +/- 19.2 years). Group A (n = 49) received 1500 mg cefuroxim i.e. 30 min before the procedure, while none was given to group A patients (n = 50). Several blood cultures were taken up to 60 min after the endoscopy. The number of septicaemias (bacteraemia with fever, rigor, circulatory reactions, leukocytosis or leukopenia) were noted. Bile cultures were obtained in 56 patients with indwelling biliary drainage.

RESULTS

Incidence of bacteraemia was 6.1% (3 of 49) in group A, 16% (8 of 50) in group B, but this difference is not statistically significant. The septicaemia rate was 6.1% in group A and 10% in group B (not significant). There were eleven positive blood cultures with 12 different microorganisms, Escherichia coli in four (A: n = 3). In vitro cefuroxim sensitivity was 53.3%. 25 different bacterial species were isolated from 73.2% of bile cultures, of which 53.4% were sensitive to cefuroxim and 8.2% moderately so.

CONCLUSION

Although the obtained differences between the two groups were not statistically different, the reduction in bacteraemia/septicaemia rate may be of clinical use. Further studies are needed with higher dosages or antibiotic combinations to improve these results.

Thoracic vertebrectomy and reconstruction using a microsurgical thoracoscopic approach

A video-assisted thoracoscopic microsurgical approach was developed in the laboratory and subsequently used clinically to resect abnormalities of the thoracic vertebrae, to decompress the thoracic spinal cord, and to reconstruct the thoracic vertebral bodies. This report describes the development of the clinical operative techniques for microsurgical thoracoscopic vertebrectomy, neural decompression, and spinal reconstruction. This minimally incisional approach was clinically used in 17 patients to treat vertebral osteomyelitis, tumors, and compression fractures. Microsurgical thoracoscopic techniques were performed using several narrow, flexible, working portals placed in small incisions in the intercostal spaces. Access to the thoracic spine was achieved through the pleural cavity after temporary deflation of one lung using a double-lumen endotracheal tube. The parietal pleura, segmental vessels, and rib heads were dissected off the surfaces of the involved vertebrae to expose the region of interest. Long narrow spine dissection tools were used to perform the spinal decommpression and reconstruction. This technique achieved the same amount of spinal dissection as that achieved with conventional open spinal procedures and used microsurgical visualization techniques. The small incisions with reduced soft tissue dissection may reduce postoperative pain, shorten the length of hospitalization, and have cosmetic and functional advantages. Thoracoscopic vertebrectomies and reconstruction of the spine were technically feasilble procedures that were performed with excellent clinical results. This minimally incisional technique provides a viable alternative to thoracotomy or to posterolateral approaches for thoracic vertebrectomy and vertebral body reconstruction.

Colonic bacterial activity determines the symptoms in people with fructose-malabsorption

BACKGROUND/AIM

This study was performed to find a parameter to discriminate symptomatic from asymptomatic subjects with fructose-malabsorption.

PATIENTS AND METHODS

Thirty-four subjects (12 m, 22 f; average age, 28.6 years; range 16-60) were investigated after an overnight fast. After intake of 25 g fructose, H2-tests were carried out. Endexspiratory breath samples were taken before the ingestion of the tested sugar and at 30 minute intervals over a 2 hour period. Hydrogen determination was performed immediately after sampling. Results were considered pathological if there was a rise in hydrogen over 20 ppm and a twofold increase from the initial value. Aerobic and anaerobic cultures from stool bacteria were set and incubated with 0.5 g fructose.

RESULTS

Among 34 healthy controls, 13 malabsorbers (38%) were detected. Out of these malabsorbers, 6 (46%) reported gastrointestinal concomitant symptoms. Symptomatic and asymptomatic subjects with fructose-malabsorption showed a comparable increase in hydrogen levels. The disappearance rate of fructose in the stool cultures was significantly elevated in the symptomatic group compared with the asymptomatic, but only in the anaerobic culture.

CONCLUSION

This activity of colonic bacteria, significantly discriminating symptomatic subjects with fructose-malabsorption from asymptomatic, enhances the importance of fructose-malabsorption in the differential diagnosis of people with non-specific abdominal complaints. Antibiotic therapy in severe cases should be considered a therapeutical approach. Moreover these results may support the role of nutritional carbohydrates in the pathogenesis of colonic diseases.

Interaction of antiplatelet drugs in vitro: aspirin, iloprost, and the nitric oxide donors SIN-1 and sodium nitroprusside

The interaction of three antiplatelet drugs was studied in vitro: aspirin, an inhibitor of the cyclooxygenase pathway of platelet activation; iloprost, a stable analog of prostacyclin that increases platelet cAMP; and the nitrix oxide donors SIN-1 and sodium nitroprusside (SNP), which both raise platelet cGMP. Platelet adhesion and aggregation evoked by collagen/ADP were measured in anticoagulated blood under physiological flow conditions using the new Thrombostat. Aggregation was also measured in platelet-rich plasma (PRP) upon stimulation by a low (2.5 micrograms/ml) and high (20 micrograms/ml) dose of collagen, ADP, or thrombin-receptor activating peptide (TRAP). We found a synergism between iloprost and aspirin in inhibiting platelet adhesion/aggregation in flowing blood and aggregation of PRP stimulated by collagen. The mean inhibitory concentrations (IC50) of iloprost in the presence of aspirin were much lower (0.7 nM and 0.5 nM in flowing blood and low-dose collagen-stimulated PRP, respectively) than in the absence of aspirin (3 and 3.6 nM, respectively). Synergism between SIN-1 and aspirin was observed in inhibiting platelet activation in flowing blood but was much less pronounced in inhibiting collagen-induced aggregation of PRP. SIN-1/SNP and iloprost synergistically inhibited the aggregation of PRP induced by collagen as well as platelet adhesion/aggregation in blood. We found that two protein substrates of cAMP- and cGMP-dependent protein kinases, rap1B and a 50 kD protein, were associated with the functional synergism between SIN-1 and iloprost and were synergistically phosphorylated by platelet treatment with both iloprost and SIN-1. Platelet inhibition by SIN-1, iloprost, and aspirin was synergistic when measured in blood. In contrast, only additive effects of SIN-1 and iloprost were observed when platelet aggregation was measured in aspirin-treated PRP stimulated by ADP, TRAP, or collagen. Our study defines the basis for a more effective antiplatelet therapy using a combination of cGMP- and cAMP-elevating and cyclooxygenase-inhibiting drugs. The results also emphasize the importance of using various methods for the evaluation of antiplatelet drugs.

Mildly oxidized LDL induces platelet aggregation through activation of phospholipase A2

Native LDL and LDL oxidized under various conditions were compared in terms of their ability to activate platelets. Native LDL did not induce platelet shape change or aggregation, even at high concentrations (2 mg protein/mL). LDL was mildly oxidized with either CuSO4 (mox-LDL) or 3-(N-morpholino)sydnonimine (SIN-1-LDL). Analysis of mox-LDL and SIN-1-LDL showed a small increase of dienes (E234nm from 0.28 +/- 0.04 to 0.55 +/- 0.09, mean +/- SD) and thiobarbituric acid-reactive substance (from 0 to 10.6 +/- 1.5 nmol/mg, mean +/- SEM), no change in apo B electrophoretic mobility, and a minor (12% to 30%) decrease in polyunsaturated fatty acid content. Interestingly, this small oxidative modification of LDL dramatically changed its effect on platelets. Irreversible aggregation and secretion were induced by a threshold concentration of 0.4 mg protein/mL. In contrast, LDL thoroughly oxidized with CuSO4 (ox-LDL) did not aggregate platelets. Although mox-LDL was depleted in antioxidants (alpha- and gamma-tocopherol, alpha- and beta-carotene, and other carotenoids), incubation of mox-LDL with exogenous alpha-tocopherol did not reverse its ability to induce platelet aggregation and secretion. Preincubation of platelets with the cyclooxygenase inhibitor aspirin or the phospholipase A2 inhibitors trifluoperazine, quinacrine, 4-bromophenacyl bromide, and propranolol completely prevented platelet aggregation and secretion caused by mox-LDL or SIN-1-LDL. These results indicate that mildly oxidized LDL activates platelets through a phospholipase A2/cyclooxygenase-dependent pathway. The complete inhibition of mox-LDL-induced platelet aggregation by aspirin could contribute to its beneficial effect in cardiovascular disease.

Mutant frequency at the H-2K class 1 and HPRT genes in T lymphocytes from the X-ray-exposed mouse

The frequency of H-2Kk and HPRT-deficient T cells was measured in the H-2Kb, kDd,k genotype mouse 8-10 weeks after X-ray exposure at doses up to 6 Gy to compare the mutant frequency (MF) of an autosomal gene with that of an X-chromosomal gene. H-2K mutants were enriched by magnetic cell separation (MACS) using the H-2Kk-specific monoclonal antibody H100.5/28 and were isolated by limiting dilution cloning. Finally, the mutant phenotype was verified by flow cytometric analysis in a representative number of clones. The frequency of HPRT-deficient T cells rises from 2.5 x 10(-6) at 0 Gy to a maximum of 1.13 x 10(-4) at 4 Gy, and decreases to 2.9 x 10(-5) at 6 Gy. The H-2K- MF in the non-irradiated mouse was 8.4 x 10(-7). It increases with dose to a maximum of 8.1 x 10(-6) at 4 Gy and declines to 3.3 x 10(-6) at 6 Gy. The H-2K- MF measured depends on the monoclonal antibody used for the isolation of mutants. In a pilot study with another H-2Kk-specific monoclonal antibody (11.4.1), the spontaneous MF was four times higher than in experiments with the H100.5/28 monoclonal antibody. The expression of other class 1 antigens was investigated in H-2K- clones. The H-2Dd antigen had also disappeared in six of 41 clones from irradiated animals. This gene is situated at a distance of 1500 kb from the K-locus. The H-2Kb antigen was present in every investigated clone. In the discussion a model is presented that explains the shape of the dose-response curve of MF by selection against mutants in vivo systems under homeostasis. The results of the present investigation indicate that observed X-ray mutagenicity depends on many factors and that several genes have to be explored before reliable risk estimates are possible.

Preserved antioxidative defense of lipoproteins in renal failure and during hemodialysis

Contact to artificial surfaces during hemodialysis activates leukocytes, which then form oxidized arachidonic acid products and free radicals. This might promote the oxidative modification of low-density lipoproteins (LDL) that play a key role in the initiation of atherosclerosis. Thus, leukocyte activation could specifically contribute to the high mortality from atherosclerotic complications on long-term hemodialysis. Therefore monitored LDL and high-density lipoprotein (HDL) resistance to copper-stimulated oxidation in patients with end-stage renal disease on maintenance hemodialysis with cellulose acetate or polysulfone membranes (n = 12), in patients with chronic renal failure (n = 13) and in healthy controls (n = 12). Six of the dialysis patients were restudied during a single cuprophane dialysis. Circulating leukocytes were reversibly reduced early in hemodialysis with cellulose acetate (minimum, 83.6% +/- 7.4% of baseline values at 30 minutes after dialysis start), polysulfone (minimum, 80.4% +/- 10.5% at 15 minutes; P < 0.05) and cuprophane (minimum, 24.5% +/- 8.5% at 60 minutes; P < 0.0001). Despite the leukocyte activation, LDL oxidation lag time was not shortened in comparison with healthy controls and was even prolonged at the end of cellulose acetate (P < 0.05) and cuprophane (P < 0.05) dialysis. HDL oxidation lag time increased (12.6% +/- 0.9%; P < 0.0001) 15 to 60 minutes after start of hemodialysis and returned to predialysis values thereafter. In patients with chronic renal failure, the lag time of HDL oxidation was significantly prolonged (13.34 minutes +/- 0.9) compared with healthy controls (10.91 +/- 2.0 minutes; P < 0.01) as well as compared with the dialysis patients at baseline (9.9 minutes +/- 1.4; P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of antithrombin III and antivenom on procoagulant activity of Russell's viper venom in a whole blood model

The procoagulant activities of Russell's viper venom were assessed in an in vitro whole blood model. Sequential samplings showed that the generation of fibrinopeptide A (FPA), a marker of thrombin activity, and platelet factor 4 (PF4), a marker of platelet activity, exhibited bi-phasic kinetics with an initial slow phase followed by a rapid phase of secretion. In the presence of Russell's viper venom, the generation of both FPA and PF4 was accelerated with the bi-phasic kinetics of PF4 being maintained while that of FPA completely disappeared. Administration of either antivenom (1,600 ng) or 10 IU antithrombin III (AT-III) had no antagonistic effect against the venom but combination of both resulted in a significant prolongation of both FPA and PF4 release (p < 0.05). High dose AT-III (20 IU) resulted in normalization of both FPA and PF4 kinetics and serial levels of both parameters were lower than those treated with the combined regimen, although these were not statistically significant. Unlike the untreated venom activated whole blood, there was no clot formation following treatment with either the combined regimen or high dose AT-III. The results of this study suggested that the effect of Russell's viper venom on the clotting cascade is more potent and direct than that on platelet activity. There were complementary effects between antivenom and AT-III is controlling of both FPA and PF4 release induced by the venom. Furthermore, in this in vitro experiment, AT-III alone when administered in a sufficient dose, abolished the procoagulant effects of Russell's viper venom.