Brain death: timing of apnea testing in primary brain stem lesion

In a 73-year-old patient complete areflexia of the cerebral and peripheral nerves following the rupture of an aneurysm of the basilar artery was diagnosed. During apnea testing the spectral analysis of electroencephalography (EEG) revealed an irreversible shift of peak from 6 to 3 Hz within the low-frequency bands. These findings suggest that apnea testing in patients with primary lesion of the brain stem should be carried out only after an isoelectric EEG.

Kinetics of pore-mediated release of marker molecules from liposomes or cells

We present a general mathematical treatment of marker efflux from liposomes or cells mediated by pore formation with the idea of using it in practice to obtain basic information about the underlying rates and mechanism. The approach encompasses permeation of molecules through any kind of pore-like defects in a cell membrane as they are induced by the action of some external agent. The approach broadens an earlier treatment to the more realistic general case in which a distribution of pore lifetimes must be taken into account. We derive a theoretical retention function describing the amount of marker remaining in the cells, formulated in terms of the pore activation and inactivation kinetics. The phenomenological efflux function evaluated directly from experimental data, is directly comparable with this retention function so long as the experimental signal is linearly related to the marker concentration. With the use of self-quenching dyes the relationship between signal and concentration is not, in general, linear, so that a more complicated treatment may be required. Even for these dyes, however, linearity holds under the frequently encountered condition of "all-or-none" release of dye from vesicles, a condition that can itself be verified experimentally.

Tumor necrosis factor beta gene polymorphisms in Graves' disease

The physical mapping of tumor necrosis factor alpha (TNF alpha) and lymphotoxin (TNF beta) genes to the short arm of chromosome 6 in man between the loci for histocompatibility leucocyte antigens (HLA)-B and the complement system focused attention to this genetic region that controls immune responses in many ways. It also holds susceptibility genes for a variety of autoimmune disorders that are linked to specific alleles of loci in the HLA D subregion. We have recently identified a TNF restriction fragment length polymorphism with the enzyme NcoI (K. Badenhoop, G. Schwarz, J. Trowsdale, et al. Diabetologia. 1989;32:445-8). The less frequent fragment of 5.5 kilobase (kb) is in strong linkage disequilibrium with the HLA haplotype A1B8DR3. Since Graves' disease is linked to A1B8DR3, we analyzed TNF gene polymorphisms in a large group of Graves' disease patients and normal controls derived from four Centers. We show here a significant association of TNF beta polymorphisms with Graves' disease. The patients have less homozygotes for the 10.5 kb band (60 of 174, 34%) and more heterozygotes 10.5/5.5 kb (96 of 174, 55%), than 173 controls (49% homozygotes 10.5 kb and 42% heterozygotes; chi 2 = 7.45, P less than 0.03). When DR3+ patients and controls were analyzed separately, heterozygotes were still significantly increased in DR3+ Graves' disease patients (54 of 77, 70%) compared to DR3+ controls (21 of 45, 47%; chi 2 = 6.6, P less than 0.04). Furthermore, TNF fragment heterozygotes were found predominantly in patients, who had TSH-receptor antibodies (29/45, 64%, P less than 0.007), implying that these patients might represent an immunogenetic subset of the disease. Although TNF beta polymorphisms are linked to A1B8DR3, these results suggest that they represent an additional susceptibility marker in Graves' disease.

A combined study of aggregation, membrane affinity and pore activity of natural and modified melittin

The pore activity of melittin and several chemically modified derivatives has been investigated using conductance measurements on planar lipid bilayers and marker release from small unilamellar vesicles. The modifications included N-terminal formylation, acetylation, succinylation and modification of the tryptophan residue. All of the compounds showed bilayer permeabilizing properties, though quantitative differences were evident. These comprised changes in the voltage dependence of the conductance, in the single-pore kinetics, in the concentration of aqueous peptide required to induce a given pore activity and in the apparent 'molecularity' reflected by the power law of its concentration dependence. A strong tendency for disrupting bilayers was not always correlated with strong pore activity. For a better understanding of these results, measurements of pore activity were complemented by studying the aggregation behavior in solution and the water-membrane partition equilibrium. Modifications of charged residues gave rise to significant changes in the aggregation properties, had virtually no influence on the partition coefficient. The latter decreased strongly, however, as a result of tryptophan modification. Analysis of the isotherms was consistent with the assumption that the arginine residues in melittin do not contribute very much to charge accumulation at the immediate membrane/water interface.

Melittin induced voltage-dependent conductance in DOPC lipid bilayers

Melittin-induced conductance was measured on planar bilayers made from dioleoylphosphatidylcholine. Upon application of a fixed voltage, the current response was monophasic and remained so even after prolonged observation times. The conductance of melittin-doped bilayers increased exponentially with voltage. In addition, an ohmic contribution appeared after some current had passed. The voltage-dependent conductance increased e-fold every 22 mV and was proportional to the fourth power of the aqueous monomeric peptide concentration, for all salt concentrations investigated (0.4-1.8 M NaCl). Discrete conductance steps could be resolved at all these salt concentrations. The amplitudes of these steps were highly variable. In each experiment, conductance was initially only observed for potentials which were positive on the side of peptide addition. As more and more current passed across the bilayer, the current-voltage curves became symmetric. The system needed some time to reach stationary current-voltage characteristics: about 50 min at pH 7 but only about 15 min at pH 8, suggesting involvement of the N-terminus (pK around 7.5) of melittin in the slow formation of a 'prepore'.

Primary structure of Torpedo marmorata chloride channel isolated by expression cloning in Xenopus oocytes

A complementary DNA encoding a voltage-gated chloride channel from Torpedo marmorata electric organ was cloned by expressing hybrid-depleted messenger RNA in Xenopus oocytes. The predicted protein has a sequence of 805 amino acids containing several putative membrane-spanning domains. Expression of the protein in Xenopus oocytes shows that it is sufficient for channel function.

Susceptibility to thyroid autoimmune disease: molecular analysis of HLA-D region genes identifies new markers for goitrous Hashimoto's thyroiditis

Hashimoto's thyroiditis has been shown to be associated with the HLA-specificities DR4 and DR5. Since former association studies yielded variable results, we used novel molecular typing methods to assess predisposing immunogenetic factors. Gene analysis of the HLA-DR-DQ and tumor necrosis factor region was performed in a group of Hashimoto's thyroiditis patients and randomly chosen controls using standards and nomenclature of the 10th International Histocompatibility Workshop. Genomic DNA of patients and controls was analyzed using a cDNA probe of the DQB1 gene. The resulting restriction fragment patterns allowed the determination of newly defined DQw-types 1-9. We find the strongest relative risk conferred by DQw7 (RR = 4.7), that is observed in 36 of 64 patients (56%) and only 21 of 98 controls (21%) (P corr less than 0.002). Comparison of DNA sequence variation in the DQB1 gene, that is found predominantly in Hashimoto's thyroiditis patients, indicates that codons 45 and 57 are critical features in DQw7 which distinguish it from other DQw specificities. The adjacent DQA1 genes also display a significant association with Hashimoto's thyroiditis (DQA1*0201/*0301 heterozygotes were found in 37% of patients and 15% controls, P less than 0.03). No significant association could be found with polymorphisms of the tumor necrosis factor gene. These results provide a new basis for the concept of genetic susceptibility in Hashimoto's thyroiditis and will help to elucidate the underlying autoimmune mechanisms that lead to disease at the functional level.

BRAINDEX: an interactive, knowledge-based system supporting brain death diagnosis

BRAINDEX (Brain-Death Expert System) is an interactive, knowledge-based expert system offering support to physicians in decision making concerning brain death. The physician is given the possibility of communicating in almost natural language and, therefore, in terms with which he is familiar. This updated version of the system is implemented on an IBM-PC/AT with the expert system shell PC-PLUS and consists of about 430 rules. The determination of brain death is realized with backward chaining and for the optional coma-scaling a forward-chaining mechanism is used.

Electrostatics of a peptide at a membrane/water interface. The pH dependence of melittin association with lipid vesicles

The association of the peptide melittin with small unilamellar DMPC vesicles was studied as a function of pH. The results are discussed quantitatively assuming a water-membrane partition equilibrium. Electrostatic surface charging is taken into account as more and more of the strongly basic peptide accumulates at the bilayer/water interface. The data could be well described in terms of a Gouy-Chapman approach involving an effective interfacial charge well below the actual physical charge carried by the individual peptide molecules. The partition coefficient turned out to be pH invariant, so that one can exclude deprotonation reactions upon insertion of the peptide into the bilayer. The effective interfacial charge per associated melittin molecule decreased over a broad range of pH (pH 7 to pH above 10). Contributions of the free amino terminus and of the arginine residues could be determined by comparing with results obtained using modified melittin (N-terminally formylated and fully acetylated). The data suggest approximately equal fractional contributions of the amino terminus and the three lysines to the effective interfacial charge. The two arginines contribute less. Thus, they may be located farther away from the interface or be closely associated with counter-ions. The analysis is extended to the effect of different ionic strengths.

HLA associations in patients with polycystic ovaries and in patients with congenital adrenal hyperplasia caused by 21-hydroxylase deficiency

Ninety-nine Caucasian patients with ultrasonically detected polycystic ovaries (PCO) were typed for human leucocyte (HLA) antigens. Fifty patients with congenital adrenal hyperplasia (CAH) caused by 21-hydroxylase deficiency were similarly typed. Among the patients with PCO, there was a significant increase in the frequency of HLA DRW6 (P = 0.0027) compared with that found in a control population, which remained significant (P = 0.027) when corrected for the number of antigens tested. This difference was reduced, but remained significant (P = 0.006), when the patients with CAH and PCO were added. There was also a significant decrease in the frequency of HLA DR7 (P = 0.017) among the patients with PCO compared with a control population, but there was no distortion of the frequencies of HLA A, B or Cw antigens. Among the patients with CAH, previously well documented associations of HLA B14 and DR1 with non-classical disease were confirmed. The frequency of HLA Bw47 was increased among the whole group of CAH patients (P = 0.05) but was not increased among those with classical salt-wasting (SW) or simple virilizing (SV) disease. Family studies were performed in close female relatives of 16 of the PCO patients and 21 of the CAH patients but no evidence for genetic linkage between HLA and PCO status could be found. These data suggest that there is no significant component of disturbed adrenal steroid 21-hydroxylase activity to account for the PCO morphology, although there may be some other genetic factor, more proximal to the centromere on chromosome 6, affecting the development of polycystic ovaries.

[Multimodal evoked potentials and heart rate variability in comatose patients. 3. Electrophysiologic findings in inflammatory diseases of the brain]

Multimodal evoked potentials and heart-rate variability (HRV) measurements were performed in a total of 15 comatose patients with inflammatory diseases of the brain. The following potentials were recorded: Brainstem auditory evoked potentials (BAEP), early (SSEP) and long latency (SEP) somatosensory evoked potentials and visual evoked potentials (VEP). The results of the initial BAEP recordings indicate that in 83% of the patients the IV-V interpeak latency was prolonged and out of the range of normal values. Additionally an atypical form of the IV-V wave complex was detected. The SSEP after electrical stimulation demonstrated pathological findings in 90% of the patients; long latency components after mechanical vibration could be identified only by 30%. The results of the VEP show an attenuation of vertex VEP (mean value: 43%). Heart-rate variability of the patients was calculated (mean +/- SD) to be 2.5 +/- 1.4% (norm: 7.8 +/- 2.5%) with a mean heart-rate of 95.2 +/- 16.6/min (norm: 67.8 +/- 10.7/min).

Restriction fragment length polymorphism analysis of HLA haplotypes in families with type I diabetes mellitus

HLA Class II polymorphisms were analysed in 27 families with at least one Type I diabetic proband using Southern blotting technique according to 10th Histocompatibility Workshop Standards. The probes used were DRB, DQA1, DQB1 and DOB. We have studied 108 haplotypes and performed segregation analysis with HLA serology and restriction fragment length polymorphism (RFLP) data and compared "affected" with "non-affected" haplotypes (not inherited by IDDM patients). RFLPs correlated well with DR and DQ serology and detected additional polymorphisms. In particular, DQB polymorphism analysis showed segregation of the DQw3 splits with 88.5% of the DR4 affected haplotypes bearing the DQw3.2 split (now DQw8) and 11.5% the DQw3.1 split (now DQw7) while in the non-affected DR4 haplotypes 33.3% were DQw3.2 and 66.6% were DQw3.1. Haplotype analysis showed that DR4-DQw3.2 was in strong linkage with the U fragment (2.1 kb Taq I) of DQA2 (DX alpha) and with the L fragment (5.4 kb BamH I) of DOB. This study confirms previous observations of DQB polymorphisms in heterozygous IDDM patients, supports the protective effect of DQw3.1 (DQw7) against the development of the disease and demonstrates the importance of DQw3.2 (DQw8) for susceptibility to Type I diabetes.

TNF-alpha gene polymorphisms: association with type I (insulin-dependent) diabetes mellitus

The localization of TNF genes on the short arm of chromosome 6 between HLA B and the complement genes focused attention to that genetic region which harbors many immunologically relevant genes and is also thought to hold susceptibility genes for a variety of autoimmune diseases that are linked to specific alleles of particular loci in the HLA D region. Since the recently established HLA-DR-DQ variation accounts only for part of the genetic susceptibility to insulin-dependent diabetes mellitus (IDDM) we searched for genomic variation of the tumour necrosis factor (TNF) alpha. We have identified a TNF-alpha restriction fragment length polymorphism (RFLP) with NcoI and analysed diabetic patients including their families, controls and homozygous typing cell lines (HTC) defined by the 10th International Histocompatibility Workshop. Segregation analysis in families and HTC results show a strong linkage of the TNF-alpha 5.5 kb allele with DR types in particular with A1B8DR3. This tight linkage of TNF-alpha alleles with extended haplotypes and the significant increase of heterozygotes in patients could lead to some explanation of the DR3 association with a variety of autoimmune diseases particularly IDDM.

Microbial metabolism of quinoline and related compounds. II. Degradation of quinoline by Pseudomonas fluorescens 3, Pseudomonas putida 86 and Rhodococcus spec. B1

Quinoline catabolism was investigated with different bacterial strains, able to use quinoline as sole source of carbon, nitrogen and energy. Some degradation products of quinoline were isolated from the culture fluids and identified. With Pseudomonas fluorescens and Pseudomonas putida we found 2-oxo-1,2-dihydroquinoline, 8-hydroxy-2-oxo-1,2-dihydroquinoline, 8-hydroxycoumarin and 2,3-dihydroxyphenylpropionic acid as intermediates. With a Rhodococcus strain 2-oxo-1,2-dihydroquinoline, 6-hydroxy-2-oxo-1,2-dihydroquinoline, a red meta-cleavage product and a blue fluorescent compound were isolated. The red compound was identified as 5-hydroxy-6-(3-carboxy-3-oxopropenyl)-1H-2-pyridone. From this the blue fluorescent azacoumarin 2H-pyrano-2-one-[3,2b]-5H-6-pyridone is formed by chemical decomposition. Therefore it can be considered a by-product of quinoline-degradation in Rhodococcus spec. With the present results two different degradation pathways for quinoline in different microorganisms are proposed.

Lipid dependence of peptide-membrane interactions. Bilayer affinity and aggregation of the peptide alamethicin

Membrane incorporation and aggregation of the peptide alamethicin have been investigated as a function of lipid type. Head group and acyl chain regions both contribute to modulate alamethicin incorporation. Specifically, the peptide prefers thin membranes and saturated chains; incorporation is reduced by the presence of cholesterol. Aggregation of the peptide in the bilayer is virtually insensitive to changes in lipid composition. These findings show some analogies to results obtained with intrinsic membrane proteins and cast doubt on the use of global membrane parameters for interpreting lipid-peptide interactions.

TNF-alpha gene polymorphisms in type 1 (insulin-dependent) diabetes mellitus

Type 1 (insulin-dependent) diabetes mellitus, like some other autoimmune diseases, is linked to certain alleles coded by genes in the HLA-D region. Sequence analysis of DQ beta chains indicates that aspartic acid at codon 57 confers resistance to the development of Type 1 diabetes. However, a full explanation for the HLA-association of Type 1 diabetes, particularly the increased susceptibility of DR3/4 heterozygotes is still awaited. The localisation of tumour necrosis factor genes on the short arm of chromosome 6 between HLA-B and the complement genes (Class III) prompted us to investigate a possible polymorphism of TNF-alpha at the genomic level in relation to Type 1 diabetes susceptibility. A dialleleic TNF-alpha restriction fragment length polymorphism was found with Ncol and its segregation with HLA-haplotypes analysed in diabetic families. We describe here a strong linkage of TNF-alpha alleles with certain DR haplotypes. For example, the common extended haplotype HLA A1-B8-DR3 was almost exclusively associated with the 5.5 kb TNF-alpha allele whereas Bw62-DR4 with the 10.5 kb allele. Thus both alleles segregate to diabetic patients. DR matched haplotypes of affected family members differed significantly from those of the non-affected at the TNF alpha locus. All affected sibling pairs in 11 multiplex affected families were identical for TNF-alpha alleles, even if they were only haploidentical for HLA-B-DR haplotypes. In addition, heterozygosity for the TNF-alpha alleles was significantly more frequent in the patients. This tight linkage of TNF-alpha alleles with some extended haplotypes could help to explain the HLA-association of Type 1 diabetes as well as some other autoimmune diseases.

Persistent reduction of CD4/CD8 lymphocyte ratio and cell activation before the onset of type 1 (insulin-dependent) diabetes

Over a period of 5 years, lymphocyte subpopulations and their markers of activation were studied prospectively in 56 first degree relatives of Type 1 (insulin-dependent) diabetic probands. Lymphocytes were phenotyped using a panel of monoclonal antibodies which recognise CD3, CD4, CD8 lymphocytes, K/NK cells, HLA Class II products and IL-2 receptors (IL-2r). Twenty-six subjects were negative for islet cell antibody (ICA), 18 had complement fixing ICA (CF-ICA) and 12 only conventional ICA (ICA-IgG). The total number of observations (blood samples collected) was 386. Overall, changes in T cell data were observed in the three groups of first degree relatives compared to 70 normal subjects without a family history of diabetes. Six individuals developed Type 1 diabetes in the course of the study. They all possessed CF-ICA and five out of six showed a persistent reduction (less than 1.5) of the CD4/CD8 lymphocyte ratio before the clinical onset of the disease. Activated lymphocytes were found on two occasions in two of these subjects. We conclude that imbalance of lymphocyte immunoregulatory subsets is present before the onset of Type 1 diabetes in susceptible individuals; the persistence of a reduced CD4/CD8 lymphocyte ratio may reflect the ongoing process leading to B-cell destruction.

Multifocal necrotizing fasciitis in varicella

We describe a two-year-old patient who developed severe necrotizing fasciitis in three nonadjacent sites of his extremities during varicella. The recovery of purulent material by aspiration of deep soft tissues after seven days of fever, leukocytosis, and no response to antimicrobial therapy raised the suspicion of this diagnosis. The patient recovered following surgical drainage, debridement, and subsequent skin grafts. It is emphasized that early diagnosis of this severe complication is important since early surgical intervention decreases morbidity and facilitates recovery.

Thermodynamic and kinetic studies on the association of melittin with a phospholipid bilayer

Association of the amphiphilic peptide melittin with unilamellar vesicles of dioleoylphosphatidylcholine has been experimentally investigated by means of circular dichroism, fluorescence energy transfer and stopped-flow experiments. Circular dichroism changes upon titration of the peptide with vesicles (at low salt concentration) were analyzed to yield thermodynamic association isotherms. These isotherms are quantitatively interpreted in terms of a monomer-monomer partitioning of melittin between the aqueous and bilayer media. The data can be very well fitted by theoretical curves based on a Gouy-Chapman surface potential. Energy transfer involving chemically modified tryptophan confirms a lack of aggregation of the associated peptide. According to the kinetic measurements the association proceeds in practice as a one-step process, which is rather fast but not fully diffusion-controlled. We propose a simple mechanism where the inherent conformational transition determines the overall rate.

Thermodynamics and kinetics of incorporation into a membrane

Some very recent work on the equilibrium and rate of incorporation of the pore forming peptide alamethicin into phospholipid bilayers is briefly reviewed. The experimental methods and the proceedings to evaluate and interpret the data are generally applicable analogously to other cases of substrates which somehow associate with a membrane. For the special system under consideration, a very high degree of incorporation is observed, reflecting internal aggregation and thermodynamically non-ideal repulsive interactions. These points are included in a basic model which is shown to provide a quantitative fit of the measured results. Stopped-flow experiments have shown that the overall incorporation occurs as a practically one-step process. Its rate is remarkably fast, only slightly slower than the diffusion controlled upper limit. All the kinetic data can be quite satisfactorily interpreted in terms of a reaction scheme with steady-state intermediates comprising the obvious diffusional translocations as well as the accompanying conformational change. In particular, the special findings for the alamethicin system suggest a most simple working hypothesis of the molecular mechanism underlying the voltage-dependent gating effect.