[Chronic fatigue syndrome--a controlled cross-sectional study]

Twenty-one patients fulfilling the Center for Disease Control criteria for chronic fatigue syndrome (CFS) were examined in a controlled study. Viral antibodies and tests evaluating the immune system were investigated in the patients and in a control group of 21 sex- and age-matched individuals. Production in vitro of the predominantly T-cell-derived cytokines interleukin-2 and interferon-gamma was significantly higher in patients with CFS compared the control group. Furthermore, the serum concentrations of IgA and IgE were significantly lower in patients with CFS; however, the values were within the normal reference range. All other variables were similar in the two groups. This study does not suggest a clearly disordered immune system or a chronic viral infection as a major pathogenetic factor in CFS. Longitudinal studies of immunological and virological parameters in CFS are warranted as are studies on patients that are severely handicapped.

Short-term myeloid growth factor mediated expansion of bone marrow haemopoiesis studied by localized magnetic resonance proton spectroscopy

Previously we have shown that short-term myeloid growth factor priming of haemopoiesis prior to bone marrow harvest increased the yield of myeloid progenitors in the graft. The present study is intended to investigate the expansion of haemopoiesis by volume selective proton magnetic resonance spectroscopy (MRS). Six patients were treated with daily subcutaneous injections of recombinant human granulocyte colony-stimulating factor (rhG-CSF, n = 2) or granulocyte-macrophage colony-stimulating factor (rhGM-CSF, n = 4) for 5d before marrow harvest. MRS investigations were performed prior to treatment (day 0), day 5 and day 12. Spectroscopic examinations were performed with the stimulated echo acquisition mode (STEAM) method on a 1.5 T clinical whole-body imaging unit. A cubic volume of interest (VOI) was selected in the bone marrow of the left iliac bone. The patients responded with a rise in blood absolute neutrophil count from median 3.3 x 10(9)/l (range 1.3-7.3 x 10(9)/l) before to 15.6 x 10(9)/l (range 6.8-22.0 x 10(9)/l) after treatment. Concomitantly an increase in bone marrow cellularity and myeloid:erythroid ratios documented the stimulation of myelopoiesis. During priming, the light-density cell proliferation rate in marrow samples increased from median 21.9 (range 4.5-31) x 10(3) cpm to 54.7 (range 13.9-94) x 10(3) cpm and the total number of myeloid progenitors enumerated as day 7/14 GM-CFUs per volume aspirated marrow increased from median 11/8 x 10(3) (range 4.0-87.5/2.2-103.0) to 64/76 x 10(3) (range 28.4-1180.6/23.2-2850.0). MRS detected a significant increase in bone marrow 'relative water content' day 12, 1 week after myeloid growth factor treatment was stopped, from median 30.5% (range 16-45) to 79% (range 56-93). In parallel, haemopoiesis was detected in new areas of femur. In conclusion, the non-invasive MRS method may be a useful and reliable in vivo examination for expansion of haemopoiesis and a correspondent reduction of fat tissue in bone marrow after priming with recombinant human haemopoietic growth factors.

Protamine neutralization of intravenous and subcutaneous low-molecular-weight heparin (tinzaparin, Logiparin). An experimental investigation in healthy volunteers

The aim of the present study was to investigate whether tinzaparin sodium (a low-molecular-weight heparin (LMWH)) was fully and permanently neutralized in vivo in man by protamine sulphate (PS) after intravenous (i.v.) or subcutaneous (s.c.) injection. Fifty healthy adults equally divided in five age- and sex-matched groups were included. The groups received 50 IU unfractionated heparin (UH)/kg body weight (b.w.) i.v., 50 anti-factor Xa (anti-Xa) IU tinzaparin/kg b.w. i.v., 75 anti-Xa IU tinzaparin/kg b.w. s.c., 175 anti-Xa IU tinzaparin/kg b.w. s.c., or 1 ml of saline s.c. PS was given as a 10 min infusion in a dose of 1 mg/100 IU of heparin in the four first groups while 0.5 mg PS/kg b.w. was given in the placebo group. In the i.v. groups PS was administered 45 min after the heparin injection, and in the s.c. groups 180 min post-heparin injection. In the UH group PS fully and permanently neutralized all three activities. In the i.v. tinzaparin group PS reversed 80% of the anti-Xa activity, while the anti-IIa and aPTT activities were fully reversed. A slight, but statistically significant, increase in anti-Xa and anti-IIa activities were seen following i.v. tinzaparin. In the s.c. groups 60-65% of the observed peak anti-Xa activity was neutralized, anti-IIa was almost completely reversed, and aPTT returned nearly to baseline values. A gradual return of the anti-Xa activity (65-75%), anti-IIa activity (55%) and aPTT activity (35-45%) was seen in the s.c. groups 3 h after reversal compared with the observed peak values.(ABSTRACT TRUNCATED AT 250 WORDS)

Short chain fatty acids relax isolated resistance arteries from the human ileum by a mechanism dependent on anion-exchange

Ileal resistance arteries (internal diameter 184-337 microns) were discussed out under microscope and mounted in a microvascular myograph for isometric tension recording. Experiments were designed to test compounds trophic to the small intestine, namely, epidermal growth factor, glutamine and the three short chain fatty acids, acetic, propionic and butyric acid, for effects on vascular tone. Glutamine in concentrations up to 30 mM and epidermal growth factor in concentrations up to 1 microM had no contractile or relaxant effects on the resistance arteries. The three short chain fatty acids alone and in combination, however, caused a concentration-dependent (range 0.1-30 mM) relaxation of resistance arteries precontracted with 50 mM KCl. This relaxant effect was significantly inhibited by the presence of the anion-exchange inhibitor 4,4'-diisothiocyanatostilbene-2,2'-disulphonic acid whereas it was unaffected by removal of the endothelium, presence of indomethacin, propranolol or phentolamine. These data suggest that the trophic effects of glutamine and epidermal growth factor on the small intestinal mucosa cannot be explained through actions on the resistance vasculature. In contrast, the relaxant effect of short chain fatty acid on resistance arteries in vitro suggests that these compounds may be able to improve the microcirculation in vivo. An improved microcirculation will, all things considered, facilitate the growth of the small intestinal mucosa.

Chronic fatigue syndrome--a controlled cross sectional study

OBJECTIVE

To look for signs of immunodeficiencies and/or longstanding infections underlying chronic fatigue syndrome (CFS).

METHODS

Twenty-one patients fulfilling the Centers for Disease Control criteria for CFS were compared to 21 age and sex matched controls. A number of viral antibodies as well as the following tests evaluating the immune system were studied: autoantibody profile, cell surface markers on isolated blood mononuclear cells, cytokine production, lymphocyte proliferative responses, natural killer cell activity and quantitation of immunoglobulin secreting cells.

RESULTS

Production in vitro of the predominantly T cell derived cytokines interleukin 2 and interferon gamma was significantly higher in patients with CFS compared to the control group. Furthermore, the serum concentrations of IgA and IgE were lower in patients with CFS; however, this difference was caused by a larger number with values of IgA and IgE above the upper limit of the normal range among the controls than among the patients with CFS. All other variables were similar in the 2 groups.

CONCLUSION

A pathogenically significant imbalance of the immune system in patients with CFS cannot be excluded. However, evidence of a causal link between abnormal immunity and CFS was not obtained.

Neutrophil activation by Helicobacter pylori lipopolysaccharides

Helicobacter pylori-induced release of toxic substances by neutrophils could be of potential importance in the pathogenesis of gastroduodenal inflammatory diseases. Lipopolysaccharide (LPS) has the ability to induce neutrophil activation at very low concentrations. Neutrophil oxidative metabolism and enzyme release were assessed after stimulation of neutrophils with various preparations of LPS from H. pylori and compared with that obtained with Salmonella typhimurium LPS. No direct activation of neutrophils by LPS was observed. Preincubation with LPS showed a significant priming for increased activity on subsequent stimulation, particularly with rough-form LPS. The potency of H. pylori LPS was 10-fold lower than that of S. typhimurium LPS, probably reflecting the unique biochemical structure of H. pylori LPS. Chronic low-grade stimulation by H. pylori LPS in the gastric mucosa may render neutrophils primed for the excessive release of detrimental substances into the tissue on stimulation by other mediators.

Occupational exposure to isothiazolinones. A study based on a product register

A national data base on chemical products (the Danish Product Register (PROBAS)) was searched in order to survey occupational exposure to isothiazolinones. 5-chloro-2-methyl-4-isothiazolin-3-one/2-methyl-4-isothiazolin+ ++-3-one(MCI/MI) was registered in 550 products, 1,2-benzisothiazolin-3-one(BIT) in 156 products and 2-n-octyl-4-isothiazolin-3-one in 16 products. For the MCI/MI-containing products, of which 343 had information on concentration, 64% of the products contained above or equal to 0.001% (10 ppm) MCI/MI. Main product categories were paints, hair shampoos, skin care products, and cleaning agents. For BIT-containing products, of which 139 had information on concentration, 54% of the products contained above or equal to 0.01% (100 ppm) BIT. Main product categories were cleaning agents, polishes, and paints. Only a few products were registered with content of 2-n-octyl-4-isothiazolin-3-one and these were not studied further. The dermatological literature has often focused on isothiazolinones in cosmetics as the source of allergy. The present study showed that attention should also be paid to occupational exposure, as isothiazolinones occur in many industrial product categories.

[Needles for bone marrow examination]

Over the past decades, numerous new bone biopsy needles have been introduced. Pathological investigation requires sufficiently large and well-preserved specimens. This article reviews the literature concerning the quality of the instruments. Comparison of the various types of needles in controlled studies is not available. Bone-marrow biopsy is discussed in the context of obtaining optimal specimens and choice of biopsy needle.

Metabolic remission with octreotide in patients with insulinoma

OBJECTIVES

The efficacy of octreotide was studied in a group of patients with biochemical evidence of insulinoma.

DESIGN

A phase-II study.

SETTING

A university department of internal medicine.

SUBJECTS

Seven patients with biochemical evidence of insulinoma and without metastatic lesions.

INTERVENTION

Daily treatment with octreotide, a somatostatin analogue, mainly within the dosage of 100-300 micrograms day-1. The treatment was continued in patients with biochemical evidence of response or until surgery was undertaken.

MAIN OUTCOME

Five patients avoided hypoglycaemic symptoms and had normalization of blood glucose values for a median of 15+ months (range 0.2-54 months). Two did not improve metabolically. The treatment was well tolerated and had no deleterious effects on blood glucose regulation.

CONCLUSION

Octreotide seems to be a promising treatment for many of the patients with insulinoma who are not suitable for surgery.

Ranitidine improves postoperative monocyte and neutrophil function

BACKGROUND

The histamine H2-receptor antagonist ranitidine hydrochloride has been shown to improve trauma-, blood transfusion-, and sepsis-induced immunosuppression.

OBJECTIVE

To evaluate the effect of ranitidine on postoperative impairment in monocyte and neutrophil function.

METHODS

Twenty-four patients undergoing major elective abdominal surgery were randomized to receive adjuvant treatment with ranitidine hydrochloride (100 mg) administered twice a day intravenously from skin incision for 4 days, followed by oral ranitidine hydrochloride (150 mg) administered twice a day for 5 days (n = 11), or no adjuvant treatment (n = 13). Blood monocyte and neutrophil chemotaxis and chemiluminescence were analyzed before the operation and on postoperative days 1, 3, and 9.

RESULTS

Monocyte chemotaxis to C5a in the 13 control patients was significantly decreased on day 1 compared with day 0. Chemotaxis in the 11 ranitidine-treated patients increased significantly from day 0 to day 1 (P < .01 between groups). Neutrophil chemiluminescence to zymosan and N-f-methionyl-leucyl-phenylalanine was significantly increased in control patients on day 1 compared with day 0 (P < .05), while ranitidine reduced chemiluminescence to zymosan insignificantly on day 1 (P < .07 between groups). Five of the 13 control patients developed postoperative infectious complications, which were related to decreased monocyte chemotaxis to C5a and increased neutrophil chemiluminescence to zymosan, compared with noninfected patients. A significant difference (P < .05) in chemiluminescence to zymosan between infected and noninfected control patients was observed on day 3 before clinical signs of infectious disease could be detected. There were no infectious complications in ranitidine-treated patients.

CONCLUSION

These results support previous studies on the effect of ranitidine to improve postoperative immunosuppression.

Modulation of the counts and functions of neutrophils and monocytes under in vivo hyperthermia conditions

The present work was designed to examine the effect of in vivo hyperthermia on the cell number and functions of polymorphonuclear leucocytes (PMN) and monocytes in human beings. Eight healthy volunteers were immersed into a waterbath (WI) (water temperature 39.5 degrees C) for 2 h, whereby their rectal temperature rose to 39.5 degrees C. On a later day they served as their own controls, being immersed into thermoneutral water (34.5 degrees C) for 2 h. Blood samples were collected before immersion, at body temperatures of 38, 39 and 39.5 degrees C as well as 2 h after water immersion. The neutrophil count was significantly increased at 39.5 degrees C, as well as 2 h after hot WI, compared with control. The monocyte count was significantly augmented at 38 and 39 degrees C and 2 h after hyperthermic load. The FMLP-induced chemiluminescence response, for a given number of PMN, was significantly reduced 2 h after hot WI. The total amount (per litre of blood) of superoxide production by PMN stimulated with opsonized zymosan (OZ) was significantly augmented at 39 and 39.5 degrees C and 2 h after WI. In vivo hyperthermia did not affect the function of monocytes, but when correlated to the changes in the concentrations of monocytes (response per litre blood) a significant increase in the phorbol myristate acetate (PMA)- and OZ-enhanced superoxide production occurred at 38 and 39 degrees C, as well as 2 h after termination of hot WI. Furthermore the OZ-enhanced monocyte chemiluminescence response per litre of blood was significantly enhanced 2 h after hot WI.(ABSTRACT TRUNCATED AT 250 WORDS)

Oral candidiasis and immune status of HIV-infected patients

A total of 84 HIV-infected homosexual men having either normal oral mucosa (NOM), erythematous candidiasis (EC) or pseudomembranous candidiasis (PsC) were included in the study. The patients were evaluated by median number of peripheral CD4+ cells, CD8+ cells and by lymphocyte function assessed by poke-weed mitogen test. There was a significant difference between CD4+ counts among patients with the two subtypes of candidiasis (95% CI of median difference: 10-240/mm3; P = 0.03), but not for pokeweed mitogen response. Survival analysis showed that after 2 y there was no significant difference in development of AIDS between patients with EC and PsC (P = 0.29). If patients with both types of oral candidiasis were pooled and compared with patients with NOM, a significant difference in development of AIDS was found (P = 0.04). It is concluded that HIV-infected patients with oral candidiasis of any subtype (EC or PsC) are significantly more immune suppressed and show a faster development of AIDS than HIV-infected patients with NOM. However, in this cohort, EC and PsC are of equal importance as predictors for immune suppression and AIDS development.

Identification, molecular cloning, expression and chromosome mapping of a family of transformation upregulated hnRNP-K proteins derived by alternative splicing

Acidic nuclear proteins (M(r) between 64,000 and 66,000; pI 4.9 to 5.5) that are highly upregulated in transformed cells and that belong to the hnRNP-K family have been identified using a monoclonal antibody (mAB B4B6) that distinguish between quiescent and proliferating human keratinocytes. The family, which is composed of four major proteins (hnRNPs-K A, B, C and D) and their modified forms, is present in similar overall levels in quiescent and proliferating normal keratinocytes although clear differences were observed in the levels of some of the individual variants. Immunofluorescence staining of proliferating normal keratinocytes with mAB B4B6 showed that about 40% of the keratinocytes, corresponding mainly to G1 and to half of the cells in S-phase, reacted with the antibody depicting a dotted, nucleoplasmic staining that excluded the nucleolus. Only 3 to 4% of the quiescent keratinocytes reacted with the antibody while simian virus 40 (SV40) transformed keratinocytes (K14) stained constitutively throughout the cell cycle. Using mAB B4B6 as a probe we cloned a cDNA coding for one member of the family (hnRNP-K B) and this was used to screen for additional family members. Sequencing of the positive clones revealed four different cDNAs, all resulting from alternative splicing of a common primary transcript of a gene that mapped to chromosome 9. Expression of the cDNAs in the vaccinia virus system confirmed their identity as hnRNPs-K A, B, C and D and showed that their modified forms are phosphorylated. All four hnRNPs bound poly(rC) on NorthWestern blots, although the more acidic of the phosphorylated forms, did so at a much reduced level. hnRNP-K has been implicated in pre-mRNA metabolism of transcripts containing cytidine-rich sequences and our results point towards a role during cell cycle progression.

Immunoglobulin preparations for intravenous administration. A review of their biologic activities and comparison of various preparation methods

Substitution therapy with human immunoglobulin preparations is well established in disorders of primary or secondary deficiencies of humoral immunity. However, modifications of the immunoglobulins are required to achieve tolerance for the preferred intravenous route of administration. Several procedures are employed by different commercial suppliers of immunoglobulins, and from the literature it appears that various important biologic functions, e.g., opsonic activity, complement fixation, and Fc-receptor function, are subject to alterations during the preparation. The best preservation of such activity, when assessed in vitro, is obtained with polyethylene glycol precipitation or DEAE-Sephadex fractionation, whereas enzymatic or chemical treatment can potentially reduce the biologic activity. It is recommended that immunoglobulin preparations be evaluated in vitro for intact biologic function before being given to immunodeficient patients.

[Postoperative rehabilitation of patients operated for lumbar disk prolapse. An analysis of the socioeconomic consequences]

A new postoperative rehabilitation program consisting of intensive back training without low back pain being the limiting factor has been tested in a clinical trial and found effective compared to a more traditional training program. The objective of the present investigation was to evaluate the social economic consequences (cost-effectiveness analysis) of the introduction of this new program as a general offer for all patients undergoing first time discectomy for a herniated lumbar intervertebral disc in Denmark. Ninety-six consecutive patients operated on at the Dept. of Neurosurgery. Copenhagen County Hospital of Glostrup were randomized into two intervention groups. One group was offered intensive back training and the other group was offered traditional back training. A historical control group was also selected. The effectiveness of the training programmes was evaluated by a "Low Back Pain Rating Scale" and by the number of patients out of employment one year after operation. The social economic evaluation showed that the new intensive training programme was more effective. Savings in medical expenditure are to be expected if the new programme is offered. Further, as more people are to be expected to keep their employment, a production gain for the society can be expected as well as reduced public expenditures on social benefits.

[Carbon monoxide poisoning due to lack of maintenance of a natural gas boiler]

Carbon monoxide causes one third of all poisoning deaths in Denmark, but is probably grossly underdiagnosed. We present a case where an elderly couple was admitted on several occasions to local hospitals with a variety of symptoms and signs; e.g. flu-like symptoms, generalized seizures, polycythaemia, chest pain, and ventricular tachycardia. The correct diagnosis, carbon monoxide poisoning, was made when the dog in the family was found dead; examination of the natural gas boiler revealed sooting, clogging of the flue, and a carbon monoxide concentration above 0.2 percent. The natural gas boiler had not been checked after installation five years earlier. Natural gas installations are becoming still more prevalent in Danish homes, but present regulations regarding the installations are apparently not yet able to prevent new incidents of carbon monoxide poisoning.

[rhG-CSF treatment in cyclic neutropenia. Continuous versus intermittent rhG-CSF treatment in cyclic neutropenia]

Cyclic neutropenia is a stem-cell disorder characterized by regular 21-day cyclic fluctuations in the number of neutrophils in the blood and bone marrow. The neutropenic periods may be complicated by fever, stomatitis and severe infections. In this case report only daily continuous and later intermittent treatment with recombinant human granulocyte colony-stimulating factor (two micrograms/kg) administered subcutaneously effectively prevented recurrent infections.

Peptic ulcer: an infectious disease?

Since the ingestion studies by Marshall and Morris, Helicobacter pylori has been known to cause both acute and chronic infection in the human stomach activating both the cellular and the humoral immune system. It is of little or no value to evaluate the causative relationship of an infectious agent using Koch's criteria. The more recent criteria for causative relationships used in the science of epidemiology are more useful. These criteria include: (i) the characteristic of the association which is fulfilled for most cases of both duodenal and gastric ulcer; (ii) the temporal relationship which is fulfilled for duodenal ulcer and has not been investigated for gastric ulcer; (iii) the biological gradient which has been fulfilled for duodenal ulcer in a few studies but not investigated for gastric ulcer; (iv) the biological plausibility which is easily fulfilled for both duodenal and gastric ulcer; (v) the effect of an intervention which has been fulfilled for duodenal ulcer and in a few studies for gastric ulcer; and (vi) the coherence of these data with what is known about the disease which is fulfilled for both duodenal and gastric ulcer. Even though there is no need for all criteria to be fulfilled, further studies are necessary to confirm the temporal relationship between H. pylori and peptic ulcer, and the biological gradient of H. pylori in relation to the gastric ulcer. Even so, there is a strong indication that most of the peptic ulcers, apart from those caused by non-steroid anti-inflammatory drugs and Zollinger-Ellison-like syndromes, are caused by H. pylori infection.

Recombinant human granulocyte colony-stimulating factor (rhG-CSF; filgrastim) treatment of clozapine-induced agranulocytosis

After 10 weeks of treatment with clozapine, severe agranulocytosis was diagnosed in a 33-year-old female. The patient was treated with filgrastim (granulocyte colony-stimulating factor [G-CSF]) 5 micrograms kg-1 day-1. The neutrophil count was 0.234 x 10(9) l-1 on admission, with a further decrease the next day to < 0.050 x 10(9) l-1, and this complete agranulocytosis continued for 10 days. As no response was obtained after 1 week the dosage of filgrastim was increased to 10 micrograms kg-1 day-1 with immediate improvement. A rapid and pronounced leucocytosis developed with maximal value of neutrophil granulocytes (including immature forms) of 33.108 x 10(9) l-1 on day 12 after admission. The patient only had minor infectious complications during the neutropenic period. In conclusion, early treatment with filgrastim seems warranted in severe cases of clozapine-induced agranulocytosis. A dosage of 10 micrograms kg-1 day-1 can be recommended.

Activation of human phagocytes by Helicobacter pylori. A novel interaction with neutrophils and monocytes distinct from that of N-formylated oligopeptides

Sonicate proteins from Helicobacter pylori activate human neutrophils and monocytes for chemotactic and oxidative burst responses. The molecular nature of this activity and its interaction with the phagocyte membrane is unknown. Cross-stimulation experiments were performed with human neutrophils and monocytes preincubated in H. pylori sonicate and subsequently stimulated with the established and characterised stimuli N-f-methionyl-leucyl-phenylalanine (fMLP), the complement split product C5a (in zymosan-activated serum, ZAS), and phorbol-myristate-acetate (PMA). Checkerboard experiments confirmed the sonicate to be truly chemotactic, whereas no chemokinetic activity was demonstrated. At high concentrations of sonicate (1 mg/ml), a depressed chemotactic and oxidative burst response was observed, whereas the viability was > 98%. At lower concentrations (0.01-0.1 mg/ml), only weak deactivation could be induced for monocytes, i.e. the cells had a normal function. With neutrophils, even low concentrations of sonicate depressed the oxidative burs responsiveness. However, the reduced activity was unrelated to the stimulus applied indicating that H. pylori protein(s) activate human neutrophils and monocytes by a membrane binding site distinct from that of previously described receptors.