[Study of the long term sequelae of traumatic brain injury: evaluation of declarative and procedural memory, and its neuroanatomic substrate]

INTRODUCTION AND OBJECTIVES

The hippocampus and the striatum have been proposed as respectively cerebral substrates of declarative and procedural memory. Both structures are vulnerable to traumatic brain injury. Although declarative and procedural memory have been reported to be impaired in traumatic brain injury (TBI), volumetric measures have so far failed to associate this impairment with atrophy of hippocampal and striatal structures. In our study, we investigated the profile of declarative and procedural memory in children who suffered from moderate to severe traumatic brain injury during childhood (injury test interval: 9.42+/-1.98 years).

PATIENTS AND METHODS

Nineteen patients and matched controls were evaluated on tests of declarative memory and motor learning. Results showed that TBI subjects exhibit poorer performance in both tasks. Moreover, structural magnetic resonance images were obtained from TBI subjects. In order to relate neuropsychological performance with hippocampal and neostriatal volumetric data, correlation analyses were performed.

RESULTS

Significant positive correlations were obtained between hippocampal volume and memory for objects. Striatal volume correlated positively with motor learning and with verbal memory.

CONCLUSIONS

It thus seems that plasticity does not completely compensate for the memory deficits resultant from neural loss in the immature brain.

Acetylcholinesterase-amyloid-beta-peptide interaction and Wnt signaling involvement in Abeta neurotoxicity

Previous studies have indicated that acetylcholinesterase (AChE) promotes amyloid-beta-peptide (Abeta) fibril formation and AChE-Abeta complexes increase Abeta-dependent neurotoxicity. Here we present evidence for the: i) identification of the AChE motif that promotes amyloid formation, ii) in vivo effect of AChE on brain plaque formation, and iii) connection between AChE-Abeta neurotoxicity and the Wnt signal transduction pathway. Computer modeling, stereotaxic infusions and cell biological techniques were used to study the above problems. Results indicated that a 3.4 kDa AChE peptide promotes Abeta fibril formation. AChE infusion into rat hippocampus determines the appearance of anti-Abeta and thioflavine-S positive plaques, and AChE-Abeta toxicity on hippocampal cultures was blocked by lithium, an activator of the Wnt cascade. We suggest that AChE-Abeta/Abeta dependent neurotoxicity may result in loss of function of Wnt signaling components, and open the possibility that lithium may be considered as a candidate for therapeutic intervention in Alzheimer's disease pathology.

A pharmacogenomic approach to Alzheimer's disease

Single nucleotide polymorphisms (susceptibility genetics) and genomic point mutations (mendelian genetics) can be used in Alzheimer's disease (AD) for diagnostic, predictive and therapeutic purposes. Using a matrix genetic model, including APOE, PS1 and PS2 allelic variants, we have studied the distribution of 36 different genotypes in the AD population (N= 479) and the genotype-related cognitive response to a multifactorial therapy in AD patients with mild-to-moderate dementia. The 10 most frequent AD genotypes are the following: 1) E33P112P2 + (17.75%), 2) E33P112P2- (15.55%), 3) E33P111P2+ (10.85%), 4) E34P112P2+ (9.60%), 5) E34P112P2- (7.56%), 6) E33P111P2- (7.10%), 7) E34P111P2+ (4.80%), 8) E33P122P2+ (4.38%), 9) E34P111P2- (4.18%), and 10) E34P122P2+ (3.55%). APOE-4/4-related genotypes represent less than 3% in the following order: E44P112P2 + > E44P111P2+ = E44P111P2- > E44P112P2+ > E44P122P2+ = E44P122P2. Multifactorial therapy with CDP-choline (1,000 mg/day) + piracetam (2,400 mg/day) + anapsos (360 mg/day) did improve mental performance during the first 6-15 months in a genotype-specific fashion. The best responders in the APOE series were patients with APOE-3/4 genotype (r= +0.013), while the worst responders were APOE-4/4 patients (r= -0.93). PS1-related genotypes responded in a similar manner; and patients with a defective PS2 gene exon 5 (PS2+) always showed a poorer therapeutic response than PS2- patients. All these data suggest that the therapeutic outcome in AD exhibits a genotype-specific pattern, and that a pharmacogenomic approach to AD might be a valuable strategy for drug development and monitoring.

Gastrointestinal, liver, and pancreatic involvement in adult patients with cystic fibrosis

BACKGROUND

The clinical prevalence of cystic fibrosis (CF) in adults continues to rise, with a consequent impact on adult gastroenterology practice.

AIM

To characterize the gastrointestinal manifestations of CF in adult patients.

PATIENTS AND METHODS

The clinical records of 89 adult CF patients treated at our institution from 1992 to 1999 were reviewed. Patients were distributed into two groups: group A (39 patients), which consisted of patients who were diagnosed with CF at when they were younger than 14 years old and who survived into adulthood; and group B (50 patients), who were diagnosed with CF at the age of 14 years or older. Data on CF genetic mutations, nutritional state, evidence of pulmonary, gastrointestinal, liver, or pancreatic involvement were collected for each patient.

RESULTS

The most prevalent genetic mutation in our series was deltaF508, present in 50 patients (56.2%), 29 of whom belonged to group A and 21 who belonged to group B. In group A, the deltaF508 mutation was associated with exocrine pancreatic insufficiency (PI) in 26 of 29 patients (89.6%), whereas in group B it was associated with PI in only four patients (19%). Overall, PI was present in 33 of 39 patients (84.6%) in group A and in eight of 50 patients (16%) in group B. Four patients in group B had experienced previous episodes of acute pancreatitis; two of them had associated PI. Of the 89 patients, 12 (10 in group A) were malnourished. Malnutrition was invariably associated with PI. Hepatic and biliary tree abnormalities were particularly prevalent in patients in group A and was usually associated with PI. Intestinal manifestations were uncommon.

CONCLUSIONS

Diagnosis of CF before the age of 14 years is associated with greater gastrointestinal compromise than diagnosis at an older age, particularly with regard to PI. CF carriers of the deltaF508 mutation have an increased risk of developing gastrointestinal manifestations.

Presence of four stem cell populations in monolayer cultures derived from teratocarcinoma embryoid bodies

In the present work, flow cytometry techniques together with morphologic studies were used to perform multiparametric analyses in cell cultures derived from CE44 teratocarcinoma embryoid bodies. The intrinsic cell parameters studied by flow cytometry were size (FALS), cytoplasmic complexity (ISS) and autofluorescence, expressed as LIGFL/FALS (green fluorescence intensity on a logarithmic scale/FALS). Our results showed that CE44 teratocarcinoma yields monolayers whose cells show a marked morphological heterogeneity and can be grouped according to flow cytometric criteria into four populations that remain stable throughout the entire time of culture. Moreover, these populations showed a different immunolabelling with the differentiation markers SSEA-1, TROMA-1 and anti-vimentin.

Prevalence of human immunodeficiency virus type 1 (HIV-1) non-B subtypes in foreigners living in Madrid, Spain, and comparison of the performances of the AMPLICOR HIV-1 MONITOR version 1.0 and the new automated version 1.5

Plasma specimens collected in 1999 from 32 human immunodeficiency virus type 1 (HIV-1)-infected foreigners living in Madrid, Spain, were examined for the presence of non-B subtypes. Furthermore, plasma viremia was quantified using two different AMPLICOR HIV-1 MONITOR tests, version 1.0 and the new upgraded and automated version 1.5 (COBAS). Most patients came from Africa, where they most likely had acquired HIV-1 infection through sexual contact. HIV-1 genetic subtyping was based on the phylogenetic analysis of the protease gene. Twenty-two subtype B, six subtype G, two subtype C, one subtype A, and one D subtype infection were found. Overall, non-B subtypes represented 31.25% of the study population. Irrespective of the HIV-1 variant, viral load values above the detection limit (200 HIV RNA copies/ml) increased from 56.2 to 71.9% for results obtained using MONITOR version 1.0 and COBAS, respectively. Moreover, significant differences in viral load values (>0.5 logs) were recognized in up to 37.5% of samples. In summary, COBAS seemed to be more reliable for testing plasma viral load in HIV-infected immigrants living in Spain, one third of whom carried non-B subtypes.

Immunogenicity of recombinant class 1 protein from Neisseria meningitidis refolded into phospholipid vesicles and detergent

The possibility of eliciting bactericidal antibodies against a recombinant class 1 protein (P1) from Neisseria meningitidis, joined to the first 45 amino acids of the neisserial LpdA protein (PM82), was examined. P1 was produced in Escherichia coli as intracellular inclusion bodies, from which it was purified and reconstituted by (a) inclusion into phospholipid vesicles and detergent and (b) refolding in 0.1% SDS. When Balb/c mice were immunised, high titres of subtype-specific bactericidal antibodies against P1 were obtained in both cases. These results suggest that in spite of being a denaturing agent, it is possible to use SDS to reconstitute the P1 protein in a conformation that exposes the immunodominat regions.

Complications of outpatient parenteral antibiotic therapy in childhood

Complications in children receiving outpatient parenteral antibiotic therapy were reviewed. Catheter-associated complications and/or adverse drug reactions occurred in 50% of courses. Most complications were minor, and almost all infections were successfully treated. Even with early discontinuation of parenteral antibiotics because of adverse drug reactions in 24% of the courses, the outcome was excellent.

Airway complications after lung transplantation: a review of 151 anastomoses

OBJECTIVE

To analyze the incidence, treatment and follow up of airway complications after lung transplantation.

METHODS

From October 1993 to April 2000, 104 lung transplants were performed in 101 patients. One hundred and fifty one bronchial anastomoses at risk were included in the study (29 single lung and 61 sequential double lung). Donor lungs were flushed both antegradely and retrogradely with Eurocollins. In the recipients, either a single or a sequential bilateral lung transplantation was performed when indicated. The bronchial anastomosis was telescoped and covered with peribronchial tissue in all cases. Postoperative fiberoptic bronchoscopic examinations were dictated by clinical grounds. Recipient variables were recorded and analyzed to assess possible differences between both complicated and non-complicated groups.

RESULTS

Eight bronchial anastomotic complications (5.3%) occurred in six patients (6.8%). All complicated cases developed in sequential bilateral lung recipients (P=0.08): stenosis (n=5), granulation tissue (n=2), and bronchial dehiscence (n=1). Treatment consisted of lobectomy and subsequent completion pneumonectomy in one patient, rigid bronchoscopy dilation in two, balloon bronchodilation in two, laser debridement and stenting in one, and conservative therapy in two cases. One patient with severe sepsis and bronchial dehiscence died on day +30. The rest of the patients remain well so far. Airway complications were related to longer intubation periods (P<0.01). Other perioperative donor and recipient factors including the incidence of infections and acute rejection episodes, and actuarial survival, did not differ between groups.

CONCLUSION

In our experience, the incidence of airway complications after lung transplantation is 5.3%. The careful surgical technique and organ preservation, the close surveillance of rejection and infection, and early postoperative extubation might play a role in reducing this incidence. Either surgical therapy or bronchoscopic dilation and stenting methods may contribute to resolve these complications.

A Cdk5-p35 stable complex is involved in the beta-amyloid-induced deregulation of Cdk5 activity in hippocampal neurons

The cdk5 and its activator p35 constitute one of the main tau-phosphorylating systems in neuronal cells. Under normal conditions for neurons, its activity is required for modulating tau involvement in neuronal polarity and in development of the mammalian central nervous system. Recently, we reported that the treatment of rat hippocampal cells in culture with fibrillary beta-amyloid (Abeta) results in deregulation of the protein kinase cdk5. The neurotoxic effects of Abeta fibrils were prevented by inhibition of cdk5 activity by butyrolactone I or by using antisense oligonucleotides that control the expression of this kinase. Here, we show that the Abeta-promoted increase of cdk5 activity is associated with changes in tau phosphorylation patterns and in the intraneuronal distribution of tau. In addition to hippocampal cells, deregulation of cdk5 was observed in other cell types. However, butyrolactone I prevented Abeta-induced cell death only in neuronal cells in which cdk5 activation was sensitive to Abeta fibrils. This lost of cdk5 regulation in hippocampal cells exposed to Abeta fibrils appears to be associated with an increase in the cdk5-p35 complex stability. Complex stabilization was sensitive to phosphorylation of cdk5. However, no changes in cdk5 and p35 mRNAs were observed, suggesting that the main effects on cdk5 occur at the posttranslational level. These studies indicate that cdk5 phosphorylation and the formation of an abnormally active cdk5-p35 complex are directly involved in the molecular paths leading to the neurodegenerative process of rat hippocampal neurons triggered by Abeta fibrils.

Anti-inflammatory effect of Pimenta racemosa var. ozua and isolation of the triterpene lupeol

Pimenta racemosa var. ozua (Myrtaceae) is a tropical plant, used in different inflammatory processes by the folk medicine of the Caribbean region. From the methanol extract of the leaves a terpenic compound identified as lupeol has been isolated for the first time in this species. The anti-inflammatory activity of the extract has been evaluated against two experimental models of acute inflammation: paw edema in rats, using carrageenan or dextran as phlogogen agents, and ear edema in mice, inducing the inflammation with 12-o-tetradecanoylphorbol acetate (TPA). Myeloperoxidase activity (MPO) was also assayed as an indicator of leukocytary migration in the inflamed ears. In the carrageenan test, the methanol extract (125 and 250 mg kg(-1) p.o.) had a dose-dependent and significant effect at different time intervals. On the contrary, when the dextran was injected in paw, the extract did not reduce the inflammation provoked. This behavior was similar to indomethacine (25 mg kg(-1)) used as a standard drug. In the TPA-induced ear edema, the methanol extract (0.5, 1 and 3 mg ear(-1)) significantly reduced the inflammation. In the MPO assay a significant inhibition of the enzyme was observed in the inflamed tissue in all the samples assayed. These results show that the methanol extract from the leaves of Pimenta racemosa var. ozua, is effective against acute inflammation processes, by oral route and when topically applied. The anti-inflammatory behavior of the extract was similar to that exhibited by the selective cyclo-oxygenase inhibitor, indomethacin. On the other hand, the reduction of MPO activity shows that the action mechanism is clearly related with the neutrophil migration.

Correlation of atrophy measures on MRI with neuropsychological sequelae in children and adolescents with traumatic brain injury

To examine the relationship between neuropsychological sequelae and atrophy parameters from magnetic resonance imaging (MRI) following paediatric moderate-to-severe traumatic brain injury (TBI), 19 head injured children and adolescents were studied at least 6 years after injury. Three-dimensional MRI scans were obtained. A semi-automatic computerized method was used to estimate ventricular volumes and the corpus callosum area. Tests of intellectual, memory, visuospatial, frontal lobe, and motor speed functioning were administered to all patients and to 19 matched normal control subjects. Patients' performance significantly differed from controls in general intellectual function, visual memory, visuospatial and frontal lobe tests. The corpus callosum area correlated strongly with several measures involving processing speed and visuospatial function. Ventricular enlargement was less related to neuropsychological outcome. In conclusion, quantitative measurement of the corpus callosum on MRI reflects neuropsychological outcome better than ventricular dilation in paediatric patients.

Induction of cell proliferation by cyclosporine A in primary cultures of rat hepatocytes

Cyclosporine A (CsA) has been reported to be able to promote cell proliferation, although the precise mechanism by which CsA stimulates cell growth remains uncertain. In the present study, we examined, in hepatocyte cultures, the effect of CsA on parameters related to the cell cycle as well as the levels of proteins involved in the control and progression of the cycle. Flow cytometry analysis detected an increase in the percentage of cells involved in the S phase of the cycle, which correlated with increases in the levels of cyclins D1 and E (two G1-progression regulators), as well as in those of PCNA (proliferating cell nuclear antigen), and without modification in p27, an inhibitory protein of CDKs. We also examined in nucleus the levels of nuclear factor kappaB (a nuclear factor involved in the transcription of the cyclin D1 gene) and found that this transcription factor increased in the presence of CsA. We conclude that the increases in cyclin D1, PCNA, and cyclin E, together with the invariable level of p27, clearly show that CsA induces hepatocytes to proliferate. These results reinforce the idea of the growth-promoting effect of CsA in cultured hepatocytes.

Akt1/PKBalpha protects PC12 cells against the parkinsonism-inducing neurotoxin 1-methyl-4-phenylpyridinium and reduces the levels of oxygen-free radicals

The phosphatidylinositol (PI)-3 kinase-Akt/PKB survival pathway protects neurons from apoptosis caused by diverse stress stimuli. However, its protective effect against neurotoxins that produce oxidative stress and neurodegeneration has not been investigated. We analyzed the effect of this pathway on the action of the parkinsonism-inducing neurotoxin 1-methyl-4-phenylpyridinium (MPP+). Overexpression of a membrane-targeted, N-myristylated fusion protein of enhanced green fluorescence protein (EGFP) and mouse Akt1 attenuated the apoptotic effect of the neurotoxin in PC12 cells. This effect was not due to protection of mitochondrial complex I activity or restoration of energy charge. Following MPP+-treatment, myr-EGFP-Akt1-transfected cells exhibited an unaltered mitochondrial membrane potential and lower ROS levels than control cells. These results provide a new site of action of Akt/PKB at the level of the oxidative detoxifying cell machinery and suggest that this effect may be responsible in part for the resistance of myr-EGFP-Akt1-expressing cells to oxidative stress and MPP+-induced apoptosis.

[Death in medical practice. Excluded subjectivity]

Medical practice when facing death is reviewed in this article. It is considered the result of two circumstances. First, the development of medical technology which has been an important support to physicians, but has led them to give less importance on patient's subjectivity. Second, changes on society' attitudes toward death which over time have led to its present negation. Nowadays, doctors do not respond to the emotional needs of their patients at the end of life. Medical students should receive education to be prepared to stay close to their patients when a cure is no longer possible.

A five-year report on experience in the detection of pheochromocytoma

OBJECTIVE

The purpose of the study is to identify biochemical tests that are good predictors for the diagnosis of pheochromocytoma in patients at hypertension.

SETTING

Review of data from of 3826 patients studied over a 5-year period, between 1994 and 1998, at the University Hospital Virgen de la Arrixaca, Murcia, Spain.

DESIGN AND METHODS

A retrospective study for the diagnosis of pheochromocytoma of 24-h urinary free catecholamines (norepinephrine, epinephrine, and dopamine) measured by high-performance liquid chromatography (HPLC)-electrochemical detector (ECD), total metanephrines (MNt), and vanillylmandelic acid measured by spectrophotometric methods.

RESULTS

During this period, 57 patients were found to have pheochromocytoma, being 47 sporadic, 9 with multiple endocrine neoplasia type 2A, and 1 with neurofibromatosis. In all patients multiple endocrine neoplasia type 2A the tumor were bilateral but only in four of the sporadic tumor group (p < 0.0001, Fisher's exact test). MNt was determined to be the best discriminator of hypertension and pheochromocytoma. It scored a sensitivity of 94.7% (95% confidence interval, 88.3-99.9%), a specificity of 95.3% (89.5-99.9%), and thus had the best negative predictive value of 99.9% (99.8-99.9%), and this biochemical test also had the best positive predictive value of 23.3% (10.8-59.9%). When combining both MNt and norephinephrine, the positive predictive value to increases to 85.6% (65.3-95.6%).

CONCLUSION

Urinary 24-h MNt excretion level is the best single biochemical test for screening and, in combination with norephinephrine, is diagnostic of the presence of pheochromocytoma.

Angiotensin II induces leukocyte-endothelial cell interactions in vivo via AT(1) and AT(2) receptor-mediated P-selectin upregulation

BACKGROUND

Angiotensin II (Ang II) plays a critical role in the development of vascular lesions in hypertension, atherosclerosis, and several renal diseases. Because Ang II may contribute to the leukocyte recruitment associated with these pathological states, the aim of the present study was to assess the role of Ang II in leukocyte-endothelial cell interactions in vivo.

METHODS AND RESULTS

Intravital microscopy of the rat mesenteric postcapillary venules was used. Sixty minutes of superfusion with 1 nmol/L Ang II induced a significant increase in leukocyte rolling flux (83.8+/-20. 7 versus 16.4+/-3.1 cells/min), adhesion (11.4+/-1.0 versus 0.8+/-0. 5 cells/100 microm), and emigration (4.0+/-0.7 versus 0.2+/-0.2 cells/field) without any vasoconstrictor activity. These effects were not mediated by mast cell activation. Intravenous pretreatment with AT(1) (losartan) or AT(2) (PD123,319) receptor antagonists significantly reduced Ang II-induced responses. A combination of both receptor antagonists inhibited the leukocyte rolling flux, adhesion, and extravasation elicited by Ang II at 60 minutes. Pretreatment of animals with fucoidin or an adhesion-blocking anti-rat P-selectin monoclonal antibody abolished Ang II-induced leukocyte responses. Furthermore, rat platelet P-selectin expression was not affected by Ang II stimulation.

CONCLUSIONS

-Ang II induces significant leukocyte rolling, adhesion, and emigration, which may contribute not only to hypertension but also to the onset and progression of the vascular damage associated with disease states in which plasma levels of this peptide are elevated.

Forecasting confined spatiotemporal chaos with genetic algorithms

A technique to forecast spatiotemporal time series is presented. It uses a proper orthogonal or Karhunen-Loève decomposition to encode large spatiotemporal data sets in a few time series, and genetic algorithms to efficiently extract dynamical rules from the data. The method works very well for confined systems displaying spatiotemporal chaos, as exemplified here by forecasting the evolution of the one-dimensional complex Ginzburg-Landau equation in a finite domain.

Biologic parameters that correlate with the prognosis of human gliomas

Much clinical and biologic data have been processed in the search for useful objective parameters to predict brain tumor behavior. Seventy cases of astrocytic glioma collected by a single clinical team were studied using a full complement of clinical procedures: follow up (7 years), histologic analysis, DNA content estimation, and cell kinetics by flow cytometry. Proliferating cell nuclear antigen (PCNA) was determined by immunocytochemical-coupling flow cytometry (PFC) and also by counting under light microscopy (PIHC). A statistical evaluation was carried out to establish the usefulness of several parameters for glioma prognosis. The cases were histologically classified as 14 low-grade astrocytomas, 20 anaplastic astrocytomas, and 36 glioblastomas multiforme. The survival curve showed significant differences between histologic groups. Diploid populations were more frequent in low-grade astrocytomas, and aneuploid tumors often had increased S-phase and proliferative fractions. The PCNA-labeled index (PCNA-LI) increased with malignancy and correlated with histologic grading (P = 0.01). The PCNA-LI and age segregated low- from high-grade astrocytomas (including anaplastic astrocytoma and glioblastoma multiforme), but none of the variables considered differentiated anaplastic astrocytoma from glioblastoma multiforme. The Cox regression test displayed significant values for age, histologic diagnosis, and PCNA determinations when considered in tandem. Discriminant analysis obtained a function integrating age and specifically PIHC-LI to help in the prognosis of doubtful cases. The results emphasize the importance of parameters integrating different variables in an attempt to provide an accurate prognosis, the most significant being age, histopathologic diagnosis, and the proliferative fraction determined by PCNA.

Increase in the expression of the neuronal cyclin-dependent protein kinase cdk-5 during differentiation of N2A neuroblastoma cells

Cytoskeleton organization is sensitive to regulatory signals at both spatial and temporal levels. In differentiating neurons, regulation of cell architecture is specially relevant, and tau plays a major role in the outgrowth of neurites and axonal development. Tau activity in determining neuronal polarity is modulated by protein kinases including cdk5. A significant increase in the expression of cdk5 was observed in N2A neuroblastoma cells induced to differentiate in the presence of dibutyryl cAMP. This induction of cdk5 was concomitant with changes in the distribution of tau, and with an increase in the microtubule assembling activity of neuronal extracts of cells undergoing differentiation. The course of cdk5 expression with time followed a linear relationship within a 48 h period. These findings were corroborated by RT-PCR in which higher levels of the transcripts for cdk5 were detected in N2A cells with differentiated morphology, as compared with undifferentiated cells. Studies suggest that the role of tau in the sequence of molecular events leading to extension of neurites in neuroblastoma cells is mediated by selective phosphorylations by cdk5.

[(99m)Tc]-sestamibi parathyroid scintigraphy in chronic haemodialysis patients: static and dynamic explorations

BACKGROUND

The place of parathyroid gland imaging by [(99m)Tc](technetium)-sestamibi scintigraphy in uraemic patients with secondary hyperparathyroidism remains a matter of debate. The purpose of the present study was (i) to assess its value with respect to plasma intact parathyroid hormone (iPTH) levels and to surgical parathyroidectomy (PTx), and (ii) to explore the possibility of suppressing parathyroid [(99m)Tc]-sestamibi uptake by calcitriol.

METHODS

In a first cross-sectional, static study 52 chronic haemodialysis (HD) patients with plasma iPTH levels between 14 and 2791 pg/ml (normal, 10-65 pg/ml) had a [(99m)Tc]-sestamibi scan, and 21 of them underwent surgical PTx. In a second longitudinal, dynamic study 14 chronic HD patients with advanced secondary hyperparathyroidism received short-term calcitriol treatment in an attempt to suppress [(99m)Tc]-sestamibi imaging of parathyroid glands. Calcitriol was given intravenously for 2 weeks, 2 microg after each haemodialysis session. Scintigraphy was carried out before and at the end of this inhibition test.

RESULTS

[(99m)Tc]-Sestamibi scan led to imaging of one or more (maximum three) parathyroid glands in most, but not all, HD patients with plasma iPTH values >600 pg/ml. Based on surgical findings, overall sensitivity of [(99m)Tc]-sestamibi scan in correctly locating parathyroid glands was only 50%, whereas specificity was 100%. In contrast, its sensitivity was 100% in locating single glands in the subgroup of five patients with recurrent hyperparathyroidism. The calcitriol inhibition test showed suppression of [(99m)Tc]-sestamibi uptake by at least one parathyroid gland in eight patients (57%), with complete suppression in five of them (36%). Basal plasma iPTH or decrease of plasma iPTH in response to calcitriol was not predictive of suppressible [(99m)Tc]-sestamibi uptake in the individual case, although mean iPTH was markedly higher in patients with non-suppressible parathyroid glands.

CONCLUSION

Because of its relatively low sensitivity the [(99m)Tc]-sestamibi scan is of limited help in the exploration of uraemic patients with severe secondary hyperparathyroidism before a first surgical PTx. However, it is very useful in locating the remaining parathyroid gland(s) in case of reoperation. The novel calcitriol inhibition test of [(99m)Tc]-sestamibi uptake could help to better distinguish parathyroid glands with non-suppressible, autonomous activity from glands whose activity might be amenable to long-term suppression.

P64k meningococcal protein as immunological carrier for weak immunogens

Previously, the P64k meningococcal protein, an antigen of 64 kDa expressed in Escherichia coli, has been extensively characterized. We have successfully conjugated several synthetic peptides and meningococcal group C polysaccharide to P64k. In three out of four model peptides, the murine humoral immune response against the homologous peptide, evaluated after three doses of conjugate, was higher in the animals immunized with the coupled peptide than in those that received free peptide. The fourth and largest was immunogenic by itself. Similarly, the antigroup C polysaccharide levels reached by conjugated polysaccharide were significantly higher than those produced against unconjugated polysaccharide. As a carrier for one of the peptides, P64k was compared with bovine serum albumin (BSA) and tetanus toxoid (TT), being able to induce slightly higher or similar antipeptide antibody levels than these well-establish protein carriers. Our results suggest that recombinant P64k protein could be a readily available immunological carrier, as efficient as other commonly used large carrier molecules.