T cell responses to SARS-CoV-2 vaccination differ by disease-modifying therapy for multiple sclerosis

Immune responses in people with multiple sclerosis (pwMS) on disease-modifying therapies (DMTs) have been of significant interest throughout the COVID-19 pandemic. Lymphocyte-targeting immunotherapies including anti-CD20 treatments and sphingosine-1-phosphate receptor (S1PR) modulators attenuate antibody responses after vaccination. Evaluation of cellular responses after vaccination is therefore of particular importance in these populations. In this study, we analysed CD4 and CD8 T cell functional responses to SARS-CoV-2 spike peptides in healthy controls and pwMS on five different DMTs by flow cytometry. Although pwMS on rituximab and fingolimod therapies had low antibody responses after both two and three vaccine doses, T cell responses in pwMS on rituximab were preserved after a third vaccination, even when an additional dose of rituximab was administered between vaccine doses two and three. PwMS taking fingolimod had low detectable T cell responses in peripheral blood. CD4 and CD8 T cell responses to SARS-CoV-2 variants of concern Delta and Omicron were lower than to the ancestral Wuhan-Hu-1 variant. Our results indicate the importance of assessing both cellular and humoral responses after vaccination and suggest that even in the absence of robust antibody responses vaccination can generate immune responses in pwMS.

Determinants of humoral and cellular immune responses to three doses of mRNA SARS-CoV-2 vaccines in older adults: a longitudinal cohort study

BACKGROUND

Older age is associated with poorer outcomes to COVID-19 infection. The Norwegian Institute of Public Health established a longitudinal cohort of adults aged 65-80 years to study the effects of the COVID-19 pandemic. Here we describe the characteristics of the cohort in general, and specifically the immune responses at baseline and after primary and booster vaccination in a subset of longitudinal blood samples, and the epidemiological factors affecting these responses.

METHODS

4551 participants were recruited, with humoral (n=299) and cellular (n=90) responses measured before vaccination and after two and three vaccine doses. Information on general health, infections, and vaccinations were obtained from questionnaires and national health registries.

FINDINGS

Half of the participants had a chronic condition. 849 (18·7%) of 4551 were prefrail and 184 (4%) of 4551 were frail. 483 (10·6%) of 4551 had general activity limitations (scored with the Global Activity Limitation Index). After dose two, 295 (98·7%) of 299 participants were seropositive for anti-receptor binding domain IgG, and 210 (100%) of 210 participants after dose three. Spike-specific CD4 and CD8 T cell responses showed high heterogeneity after vaccination and responded to the alpha (B.1.1.7), delta (B.1.617.2), and omicron (B.1.1.529 or BA.1) variants of concern. Cellular responses to seasonal coronaviruses increased after SARS-CoV-2 vaccination. Heterologous prime boosting with mRNA vaccines was associated with the highest antibody (p=0·019) and CD4 T cell responses (p=0·003), and hypertension with lower antibody levels after three doses (p=0·04).

INTERPRETATION

Most older adults, including those with comorbidities, generated good serological and cellular responses after two vaccine doses. Responses further improved after three doses, particularly after heterologous boosting. Vaccination also generated cross-reactive T cells against variants of concern and seasonal coronaviruses. Frailty was not associated with impaired immune responses, but hypertension might indicate reduced responsiveness to vaccines even after three doses. Individual differences identified through longitudinal sampling enables better prediction of the variability of vaccine responses, which can help guide future policy on the need for subsequent doses and their timing.

FUNDING

Norwegian Institute of Public Health, Norwegian Ministry of Health, Research Council of Norway, and Coalition for Epidemic Preparedness Innovations.

Quality of antibody responses by adults and young children to 13-valent pneumococcal conjugate vaccination and Streptococcus pneumoniae colonisation

Childhood pneumococcal conjugate vaccine (PCV) protects against invasive pneumococcal disease caused by vaccine-serotype (VT) Streptococcus pneumoniae by generating opsonophagocytic anti-capsular antibodies, but how vaccination protects against and reduces VT carriage is less well understood. Using serological samples from PCV-vaccinated Malawian individuals and a UK human challenge model, we explored whether antibody quality (IgG subclass, opsonophagocytic killing, and avidity) is associated with protection from carriage. Following experimental challenge of adults with S. pneumoniae serotype 6B, 3/21 PCV13-vaccinees were colonised with pneumococcus compared to 12/24 hepatitis A-vaccinated controls; PCV13-vaccination induced serotype-specific IgG, IgG1, and IgG2, and strong opsonophagocytic responses. However, there was no clear relationship between antibody quality and protection from carriage or carriage intensity after vaccination. Similarly, among PCV13-vaccinated Malawian infants there was no relationship between serotype-specific antibody titre or quality and carriage through exposure to circulating serotypes. Although opsonophagocytic responses were low in infants, antibody titre and avidity to circulating serotypes 19F and 6A were maintained or increased with age. These data suggest a complex relationship between antibody-mediated immunity and pneumococcal carriage, and that PCV13-driven antibody quality may mature with age and exposure.

Immune responses in Omicron SARS-CoV-2 breakthrough infection in vaccinated adults

The SARS-CoV-2 Omicron variant has more than 15 mutations in the receptor binding domain of the Spike protein enabling increased transmissibility and viral escape from antibodies in vaccinated individuals. It is unclear how vaccine immunity protects against Omicron infection. Here we show that vaccinated participants at a super-spreader event have robust recall response of humoral and pre-existing cellular immunity induced by the vaccines, and an emergent de novo T cell response to non-Spike antigens. Individuals with Omicron SARS-CoV-2 breakthrough infections have significantly increased activated SARS-CoV-2 wild type Spike-specific cytotoxic T cells, activated follicular helper (T_FH) cells, functional T cell responses, boosted humoral responses, and rapid release of Spike and RBD-specific IgG⁺ B cell plasmablasts and memory B cells into circulation. Omicron breakthrough infection affords significantly increased de novo memory T cell responses to non-Spike viral antigens. Concerted T and B cell responses may provide durable and broad immunity.

The SARS-CoV-2 Omicron variant possess many mutations within the receptor binding domain of the Spike protein, which confer increased transmissibility and higher antibody escape. Here, the authors carry out analysis of the serological and cellular immune responses of individuals with Omicron breakthrough infection.

Thirteen-Valent Pneumococcal Conjugate Vaccine-Induced Immunoglobulin G (IgG) Responses in Serum Associated With Serotype-Specific IgG in the Lung

Pneumococcal conjugate vaccine (PCV) efficacy is lower for noninvasive pneumonia than invasive disease. In this study, participants were immunized with 13-valent PCV (PCV13) or hepatitis A vaccine (control). Bronchoalveolar lavage samples were taken between 2 and 6 months and serum at 4 and 7 weeks postvaccination. In the lung, anti-capsular immunoglobulin G (IgG) levels were higher in the PCV13 group compared to controls for all serotypes, except 3 and 6B. Systemically, IgG levels were elevated in the PCV13 group at 4 weeks for all serotypes, except serotype 3. IgG in bronchoalveolar lavage and serum positively correlated for nearly all serotypes. PCV13 shows poor immunogenicity to serotype 3, implying lack of protective efficacy. Clinical Trials Registration. ISRCTN 45340436.

Age-Related Dynamics of Circulating Innate Lymphoid Cells in an African Population

Innate lymphoid cell (ILC) lineages mirror those of CD4+ T helper cell subsets, producing type 1, 2 and 3 cytokines respectively. Studies in adult human populations have shown contributions of non-cytotoxic ILC to immune regulation or pathogenesis in a wide range of diseases and have prompted investigations of potential functional redundancy between ILC and T helper cell compartments in neonates and children. To investigate the potential for ILC to contribute to immune responses across the human lifespan, we examined the numbers and frequencies of peripheral blood ILC subsets in a cohort of Gambians aged between 5 and 73 years of age. ILC2 were the most abundant peripheral blood ILC subset in this Gambian cohort, while ILC1 were the rarest at all ages. Moreover, the frequency of ILC1s (as a proportion of all lymphocytes) was remarkably stable over the life course whereas ILC3 cell frequencies and absolute numbers declined steadily across the life course and ILC2 frequencies and absolute numbers declined from childhood until the age of approx. 30 years of age. Age-related reductions in ILC2 cell numbers appeared to be partially offset by increasing numbers of total and GATA3+ central memory (CD45RA-CCR7+) CD4+ T cells, although there was also a gradual decline in numbers of total and GATA3+ effector memory (CD45RA-CCR7-) CD4+ T cells. Despite reduced overall abundance of ILC2 cells, we observed a coincident increase in the proportion of CD117+ ILC2, indicating potential for age-related adaptation of these cells in childhood and early adulthood. While both CD117+ and CD117- ILC2 cells produced IL-13, these responses occurred predominantly within CD117- cells. Furthermore, comparison of ILC frequencies between aged-matched Gambian and UK young adults (25–29 years) revealed an overall higher proportion of ILC1 and ILC2, but not ILC3 in Gambians. Thus, these data indicate ongoing age-related changes in ILC2 cells throughout life, which retain the capacity to differentiate into potent type 2 cytokine producing cells, consistent with an ongoing role in immune modulation.

Differentiation and adaptation of natural killer cells for anti-malarial immunity

Natural killer cells employ a diverse arsenal of effector mechanisms to target intracellular pathogens. Differentiation of natural killer (NK) cell activation pathways occurs along a continuum from reliance on innate pro-inflammatory cytokines and stress-induced host ligands through to interaction with signals derived from acquired immune responses. Importantly, the degree of functional differentiation of the NK cell lineage influences the magnitude and specificity of interactions with host cells infected with viruses, bacteria, fungi, and parasites. Individual humans possess a vast diversity of distinct NK cell clones, each with the capacity to vary along this functional differentiation pathway, which - when combined - results in unique individual responses to different infections. Here we summarize these NK cell differentiation events, review evidence for direct interaction of malaria-infected host cells with NK cells and assess how innate inflammatory signals induced by malaria parasite-associated molecular patterns influence the indirect activation and function of NK cells. Finally, we discuss evidence that anti-malarial immunity develops in parallel with advancing NK differentiation, coincident with a loss of reliance on inflammatory signals, and a refined capacity of NK cells to target malaria parasites more precisely, particularly through antibody-dependent mechanisms.

Influenza Vaccination Primes Human Myeloid Cell Cytokine Secretion and NK Cell Function

Cytokine-induced memory-like (CIML) NK cells generated in response to proinflammatory cytokines in vitro and in vivo can also be generated by vaccination, exhibiting heightened responses to cytokine stimulation months after their initial induction. Our previous study demonstrated that in vitro human NK cell responses to inactivated influenza virus were also indirectly augmented by very low doses of IL-15, which increased induction of myeloid cell-derived cytokine secretion. These findings led us to hypothesize that IL-15 stimulation could reveal a similar effect for active influenza vaccination and influence CIML NK cell effector functions. In this study, 51 healthy adults were vaccinated with seasonal influenza vaccine, and PBMC were collected before and up to 30 d after vaccination. Myeloid and lymphoid cell cytokine secretion was measured after in vitro PBMC restimulation with low-dose IL-15, alone or in combination with inactivated H3N2 virus; the associated NK cell response was assessed by flow cytometry. PBMC collected 30 d postvaccination showed heightened cytokine production in response to IL-15 compared with PBMC collected at baseline; these responses were further enhanced when IL-15 was combined with H3N2. NK cell activation in response to IL-15 alone (CD25) and H3N2 plus IL-15 (CD25 and IFN-γ) was enhanced postvaccination. We also observed proliferation of less-differentiated NK cells with downregulation of cytokine receptors as early as 3 d after vaccination, suggesting cytokine stimulation in vivo. We conclude that vaccination-induced "training" of accessory cells combines with the generation of CIML NK cells to enhance the overall NK cell response postvaccination.

Cellular Immune Function in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a debilitating condition with unknown aetiology, Myalgic encephalomyelitis unclear pathophysiology and with no diagnostic test or biomarker available. Many patients report their ME/CFS began after an acute infection, and subsequent increased frequency of infections, such as colds or influenza, is common. These factors imply an altered immunological status exists in ME/CFS, in at least a proportion of patients, yet previous studies of peripheral immunity have been discrepant and inconclusive. The UK ME/CFS Biobank, which has collected blood samples from nearly 300 clinically-confirmed ME/CFS patients, enables large-scale studies of immunological function in phenotypically well-characterised participants. In this study, herpes virus serological status and T cell, B cell, NK cell and monocyte populations were investigated in 251 ME/CFS patients, including 54 who were severely affected, and compared with those from 107 healthy participants and with 46 patients with Multiple Sclerosis. There were no differences in seroprevalence for six human herpes viruses between ME/CFS and healthy controls, although seroprevalence for the Epstein-Barr virus was higher in multiple sclerosis patients. Contrary to previous reports, no significant differences were observed in NK cell numbers, subtype proportions or in vitro responsiveness between ME/CFS patients and healthy control participants. In contrast, the T cell compartment was altered in ME/CFS, with increased proportions of effector memory CD8⁺ T cells and decreased proportions of terminally differentiated effector CD8⁺ T cells. Conversely, there was a significantly increased proportion of mucosal associated invariant T cells (MAIT) cells, especially in severely affected ME/CFS patients. These abnormalities demonstrate that an altered immunological state does exist in ME/CFS, particularly in severely affected people. This may simply reflect ongoing or recent infection, or may indicate future increased susceptibility to infection. Longitudinal studies of ME/CFS patients are needed to help to determine cause and effect and thus any potential benefits of immuno-modulatory treatments for ME/CFS.

NK Cells: Uncertain Allies against Malaria

Until recently, studies of natural killer (NK) cells in infection have focused almost entirely on their role in viral infections. However, there is an increasing awareness of the potential for NK cells to contribute to the control of a wider range of pathogens, including intracellular parasites such as Plasmodium spp. Given the high prevalence of parasitic diseases in the developing world and the devastating effects these pathogens have on large numbers of vulnerable people, investigating interactions between NK cells and parasitized host cells presents the opportunity to reveal novel immunological mechanisms with the potential to aid efforts to eradicate these diseases. The capacity of NK cells to produce inflammatory cytokines early after malaria infection, as well as a possible role in direct cytotoxic killing of malaria-infected cells, suggests a beneficial impact of NK cells in this disease. However, NK cells may also contribute to overproduction of pro-inflammatory cytokines and the consequent immunopathology. As comparatively little is known about the role of NK cells later in the course of infection, and growing evidence suggests that heterogeneity in NK cell responses to malaria may be influenced by KIR/HLA interactions, a better understanding of the mechanisms by which NK cells might directly interact with parasitized cells may reveal a new role for these cells in the course of malaria infection.

Synergy between Common γ Chain Family Cytokines and IL-18 Potentiates Innate and Adaptive Pathways of NK Cell Activation

Studies to develop cell-based therapies for cancer and other diseases have consistently shown that purified human natural killer (NK) cells secrete cytokines and kill target cells after in vitro culture with high concentrations of cytokines. However, these assays poorly reflect the conditions that are likely to prevail in vivo in the early stages of an infection and have been carried out in a wide variety of experimental systems, which has led to contradictions within the literature. We have conducted a detailed kinetic and dose-response analysis of human NK cell responses to low concentrations of IL-12, IL-15, IL-18, IL-21, and IFN-α, alone and in combination, and their potential to synergize with IL-2. We find that very low concentrations of both innate and adaptive common γ chain cytokines synergize with equally low concentrations of IL-18 to drive rapid and potent NK cell CD25 and IFN-γ expression; IL-18 and IL-2 reciprocally sustain CD25 and IL-18Rα expression in a positive feedback loop; and IL-18 synergizes with FcγRIII (CD16) signaling to augment antibody-dependent cellular cytotoxicity. These data indicate that NK cells can be rapidly activated by very low doses of innate cytokines and that the common γ chain cytokines have overlapping but distinct functions in combination with IL-18. Importantly, synergy between multiple signaling pathways leading to rapid NK cell activation at very low cytokine concentrations has been overlooked in prior studies focusing on single cytokines or simple combinations. Moreover, although the precise common γ chain cytokines available during primary and secondary infections may differ, their synergy with both IL-18 and antigen-antibody immune complexes underscores their contribution to NK cell activation during innate and adaptive responses. IL-18 signaling potentiates NK cell effector function during innate and adaptive immune responses by synergy with IL-2, IL-15, and IL-21 and immune complexes.

Functional profiling in Streptococcus mutans: construction and examination of a genomic collection of gene deletion mutants

A collection of tagged deletion mutant strains was created in Streptococcus mutans UA159 to facilitate investigation of the aciduric capability of this oral pathogen. Gene-specific barcoded deletions were attempted in 1432 open reading frames (representing 73% of the genome), and resulted in the isolation of 1112 strains (56% coverage) carrying deletions in distinct non-essential genes. As S. mutans virulence is predicated upon the ability of the organism to survive an acidic pH environment, form biofilms on tooth surfaces, and out-compete other oral microflora, we assayed individual mutant strains for the relative fitness of the deletion strain, compared with the parent strain, under acidic and oxidative stress conditions, as well as for their ability to form biofilms in glucose- or sucrose-containing medium. Our studies revealed a total of 51 deletion strains with defects in both aciduricity and biofilm formation. We have also identified 49 strains whose gene deletion confers sensitivity to oxidative damage and deficiencies in biofilm formation. We demonstrate the ability to examine competitive fitness of mutant organisms using the barcode tags incorporated into each deletion strain to examine the representation of a particular strain in a population. Co-cultures of deletion strains were grown either in vitro in a chemostat to steady-state values of pH 7 and pH 5 or in vivo in an animal model for oral infection. Taken together, these data represent a mechanism for assessing the virulence capacity of this pathogenic microorganism and a resource for identifying future targets for drug intervention to promote healthy oral microflora.

Thoracic vessel injury

Thoracic trauma occurs in an estimated 25% of all trauma victims, with approximately 50% of trauma mortalities attributable to these injuries. Only 4% of thoracic traumas involve injuries to thoracic vessels, including the aorta, innominate veins and artery, left carotid artery, internal mammaries, and pulmonary hilar vessels. These vascular injuries can range from minor to major with advances in prehospital management increasing the number of patients surviving in the field and presenting to the hospital with life-threatening vascular injuries. Rapid assessment during the initial survey and interventions to maintain airway, breathing, and circulation of the patient can be life-saving. The patient's hemodynamic status will often dictate the extent of the initial workup or whether the patient requires emergent operation. Stable patients can undergo further assessment and detailed imaging, such as computed tomography and/or angiography. Treatment of thoracic vessel injuries may include advanced endovascular techniques, traditional open surgery, or non-operative management with observation. The following review systematically details the initial workup, evaluation and management techniques of thoracic vessel injuries.

[The overweight and underweight girl: from findings to prevention]

Both preponderance as well as underweight normally starts in childhood and puberty and hurt the fate of young women mostly a life long. Weight and fat tissue as an energy storage regulates through the hormone Leptin appetite, food intake and therefore the energy reserves. With this hormone exist a common pathophysiological regulation unit, which causes in case of preponderance an increased, in case of underweight a decreased cyclus activity. Besides short term influences (like the development of the PCO-syndrome and/or fatigue fractures) the long-term consequences especially the accumulation of the visceral fat, the cardio-vascular diseases, metabolic syndrome, type-II-diabetes, mammary- and endometrial carcinoma play a special role. On the other hand chronic underweight very frequently leads through chronic estrogen defect to osteopenia, osteoporosis and therefore to cyclus disturbances, sterility and osteoporosis. A simple finding like weight, has thus an important predictive quality for later illnesses and their prevention.

PALML, a novel paralemmin-related gene mapping on human chromosome 1p21

We describe PALML, a novel gene encoding a 551 amino acid protein with similarity to paralemmin and the paralemmin-like amino terminal domain of AKAP2, a protein kinase A anchor protein. PALML mRNA is expressed in many tissues and is most abundant in cardiac and skeletal muscle, while absent from brain and blood. Exogenously expressed PALML fusion protein has a widespread cytoplasmic localization, and it is excluded from the nucleus. Human PALML maps on human chromosome 1p21 (between D1S2767 and D1S223). SSCP-HD analysis of exonic sequences in patients with VUR (familial non-syndromic vesicoureteral reflux syndrome) excluded mutations in the PALML gene from causing this disease. PALML, paralemmin and AKAP2 share the presence of a conserved coiled coil region that may mediate protein interactions with shared partners. Based on its resemblance to paralemmin and AKAP2, PALML is hypothesized to be involved in regulating intracellular signaling and membrane-cytoskeletal interactions.

[Obesity--significance in adolescence and for reproduction]

According to the actual knowledge obesity is a serious, nutrition-dependent pathology with a high number of consequences. Endocrine sequence of obesity such as PCO-HAIR-syndrome (polycystic ovarian syndrome, hyperandrogenemia-insulin-resistance) with its cycle disorders and sterility are beginning already in adolescent and women of young reproductive age. With ageing more serious risks such as non-insulin dependent diabetes mellitus (NIDDM), arteriosclerosis followed by coronary disease, stroke and hypertension, metabolic syndrome and a higher prevalence of malignant diseases will appear. Based on these five risks obesity should be treated early when therapeutic strategies are more successful than in older ages. The definition of a diagnosis and the beginning of a weight reduction programme combined with intense motivating treatment as well as medical and psychotherapeutic guidance is an important preventive contribution.

Agonadism in two sisters with XY gonosomal constitution, mental retardation, short stature, severely retarded bone age, and multiple extragenital malformations: a new autosomal recessive syndrome

We report on 12- and 14-year old sisters with a 46, XY chromosome constitution, normal female external genitalia, and absence of gonadal tissue. Except for omphalocele, right renal agenesis and malrotation of the colon in the elder sister, the internal organs were normal. Both were mentally retarded, of short stature, and had extremely retarded bone age. In addition, they had an almost identical pattern of minor anomalies: peculiar face, hypodontia, short neck, inverted nipples, thoracolumbar scoliosis, "dysplastic" hips, partial clino-/syndactyly of toes. The occurrence of a basically similar set of malformations in two sisters and the first cousin consanguinity of the parents suggests autosomal recessive inheritance. The conserved region of the SRY gene ([high mobility group] HMG box) was sequenced in the elder sib and was normal. No consistent malformations are observed at present in agonadal patients. This supports the idea that several autosomal genes have the potential of influencing the sequence of events of sex determination.

Argon laser laparoscopy: an effective technique for conservative treatment of unruptured ectopic pregnancy

Between October 1987 and January 1990, 60 patients with unruptured ectopic pregnancy in the ampullary portion of the tube were treated with linear salpingotomy, using the argon laser laparoscopically. In all cases, salpingotomy was performed by the "bare-fiber" technique, with a power of 3-6 watts. The same fiber was used for incision and coagulation either with a contact or a non-contact technique. There were no instrument-related intra- or postoperative complications. Twenty-four patients were evaluated by second-look laparoscopy or hysterosalpingography for tube patency and possible formation of adhesions. In all of these patients the tubes were patent. In one patient, the tube failed to close, resulting in a fistula. Four patients had filmy adhesions, covering the tube near the incision site. There were no adhesions covering the distal part of the tube.

[Hormonal changes in aging from the viewpoint of the gynecologist]

The major relevant age-related changes that take place in women are caused by estrogen deficiency of rapid onset. This deficiency results in such changes as vaginal and vulval atrophy, atrophic urethrocystitis, breast flabbiness, thinning of the skin and its appendages, and also the severe metabolic changes like osteoporosis and cardiovascular disorders. All of these changes, in concert or alone, are capable of impairing a woman's sex life. Numerous genital complaints can be eliminated by local treatment with estriol cream, estriol vaginal suppositories, or systemic estriol. For the successful treatment of pronounced menopausal symptoms and the prevention of osteoporosis and cardiovascular disorders, estrogens at medium, so-called replacement, doses, given in combination with progestagen, are applied sequentially.

[Tube-preserving endoscopic surgical procedures in unruptured tubal pregnancy. What significance does laser use have?]

Between 1985 and 1989 115 non-ruptured tubal pregnancies were operated upon, using a pelviscope and preserving of the tube. For the purpose of prophylactic haemostasis 2,5 I.U. ornipressin (Por 8) were injected into the mesosalpinx. The tube was opened (linear salpingotomy) by using various instruments. This method was used in 49 patients by means of the thermocoagulator and hooked scissors; with the remaining 66 patients the following laser systems were employed: CO2-laser (n = 13); Nd: YAG-laser by the contact method (n = 22); argon-laser (n = 31). No intraoperative complications were noted. Postoperative rebleeding occurred in three patients requiring subsequent treatment, and pelviscopy had to be repeated in two patients, because of incompletely removed trophoblastic tissue. The tubal condition (patency; occurrence of adhesion) was checked in 53 (47%) of the patients by means of hysterosalpingography (n = 15) or second-look pelviscopy (n = 38). Tubal patency/peritubal adhesion were found after conventional surgery in 64%/55% of the controlled cases and after laser salpingotomy in 90%/11%, respectively. Summing up, we can say, that the various laser systems are suitable for operating non-ruptured pregnancies due to their accurate incision and simultaneously coagulating effect. Due to the lower postoperative tubal occlusion rate and lower tendency to adhesion, it appears, that the laser systems are superior to the conventional endoscopy instruments, although the rate of complications was highest after CO2-laser application.

[LH episodes in high performance sports]

For the elucidation of hypothalamic factors, which predominantly cause exercise-amenorrhea 10 untrained and 6 trained volunteers were experimentally tested during 6 hours of rest (R) and 2 hours long distance run (E). The exercise exerted several physical and metabolic demands, leading to increment of LH pulse frequently mainly in trained women (interpulse-interval IPI, R: 104 +/- 50, E: 78.8 +/- 33), due to unaltered beta-endorphin (R: 6.4 +/- 2, E: 6.5 +/- 1.5) and augmented norepinephrine (R: 462 +/- 275, E: 1267 +/- 773 pg/ml). In untrained subjects LH pulses decreased in frequency, as a consequence of increased beta-E and NE (R: 6 +/- 3, E: 12.2 +/- 7.4 pg/ml) (R: 432 +/- 208, E: 947 +/- 473).

Endocrine dynamics during pulsatile GnRH administration in patients with hypothalamic amenorrhea and polycystic ovarian disease

The LH secretory patterns and ovarian endocrine responses have been determined during pulsatile gonadotropin-releasing hormone (GnRH) administration for induction of ovulation in patients with hypothalamic amenorrhea (HA). However, until now these endocrine dynamics during GnRH therapy have not been thoroughly investigated in patients with polycystic ovarian disease (PCOD). Seven patients with HA and 4 patients with PCOD have therefore been studied to determine changes in LH pulsatile activity and in serum sex steroid levels in response to chronic intermittent GnRH stimulation. GnRH was administered intravenously (5-10 micrograms/90 minutes) by means of a portable infusion pump. Blood samples were obtained at 15-minute intervals for 4 hours on the day before the start of GnRH stimulation (control day) and on treatment days 5, 10 and 15. LH was determined in all samples and FSH, serum androgens and estrogens were measured in baseline samples by RIA. While 8 (62%) ovulations and 5 conceptions were observed in 13 treatment cycles in patients with HA, no ovulations were achieved during 9 treatment cycles in patients with PCOD. On the control day significantly (p less than 0.05) higher basal LH and testosterone (T) levels and significantly (p less than 0.05) lower FSH levels were found in the PCOD patients. The LH pulsatile profiles of the PCOD patients showed significantly (p less than 0.05) higher pulse amplitudes and areas under the curve (integrated responses). Pulsatile GnRH administration induced a significant (p less than 0.05) increase in LH pulse amplitudes in both HA and PCOD patients, and also increased (p less than 0.05) the integrated responses in patients with HA. During the GnRH stimulation, the LH interpulse intervals of both HA and PCOD patients were found to be similar to the frequency in which exogenous GnRH was administered. FSH levels rose continuously (p less than 0.001) during stimulation in patients with HA, but remained unchanged in patients with PCOD. In HA patients, T, androstenedione (AD) and estrone (E1) did not change during the GnRH treatment, but estradiol (E2) rose so that the ratios of aromatized estrogens to non-aromatized androgens (E1/AD, E2/T) increased. In contrast, T and AD increased significantly (p less than 0.05 or less) and E2 remained unchanged during stimulations in PCOD patients, which resulted in decreasing ratios of estrogens to androgens. These observations confirm that pulsatile GnRH administration can successfully induce ovulation in patients with HA by restoring the ovarian physiology. The data also demonstrate that pulsatile GnRH administration can influence the LH secretory patterns in PCOD patients.(ABSTRACT TRUNCATED AT 400 WORDS)

Psychiatry and the criminal justice system: testing the myths

Several states are changing legislation and treatment programs for mentally ill offenders without knowing how current laws and programs operate. To address this problem the authors linked data from police records, court reports, and clinical files for 2,735 psychiatric referrals from the criminal justice system of Alaska from 1977 through 1981. They found that only 0.2%-2.0% of all schizophrenic persons in the community were arrested for violent crimes each year, accounting for 1.1%-2.3% of all arrests for violent crimes; that psychiatrists agreed about competency and responsibility in 79% of the cases evaluated by more than one clinician; and that a successful insanity defense occurred in 0.1% or less of all criminal cases.

Initial experiences with subcutaneous pulsatile human menopausal gonadotropin administration: successful induction of ovulation in patients with polycystic ovarian disease

Human menopausal gonadotropin (hMG) was administered to 10 patients with polycystic ovarian disease (PCOD) who had failed to ovulate in response to clomiphene citrate. Five patients (group 1) were treated with intramuscular hMG injections daily, on an individually adjusted regimen. Five others (group 2) were stimulated with subcutaneous hMG in a pulsatile fashion by means of a portable infusion minipump. The pulse doses ranged between 3.5 and 7.7 IU FSH per pulse at a constant frequency of 90 minutes. Sixteen of 18 treatment cycles were ovulatory, 9 under intramuscular, and 7 under subcutaneous treatment. A total of two patients conceived with singleton pregnancies, one in each treatment group. Neither ovarian hyperstimulation nor complications of injections were noted. The amount of subcutaneous hMG required to achieve ovulation was significantly less (46.5%; P less than .001) than that needed with intramuscular administration. However, there were no differences in the duration of stimulation periods, the lengths of luteal phases, or serum E2 and gonadotropin levels between the groups. In conclusion, pulsatile subcutaneous hMG administration may be an alternative delivery mode for patients with PCOD.

Calcitonin secretion by human placental tissue

We have investigated the synthesis in vitro of calcitonin (CT) by human placenta at term. Separate placental tissue samples were incubated in culture medium with various Ca concentrations for 6 h. The CT concentrations in the medium were determined by radio-immunoassay. In addition the effect of DB-cAMP on the synthesis was also studied. We could demonstrate CT secretion in all experiments. The CT concentrations were determined by two different antibodies. Both antibodies registered the CT secretion. Addition of DB-cAMP to the culture medium stimulates the synthesis.

Bacterial colonization of intrauterine devices (IUDs)

The bacterial colonizing of the intrauterine device (IUD) and its tail were studied in 152 IUDs obtained from 70 symptomless IUD wearers, 13 women with dysfunctional bleeding, 23 women with pelvic inflammatory disease, 31 women in whom the tail of an IUD was no longer visible and 17 women who were pregnant with an IUD in situ. The IUDs were either removed by the transcervical route or through a fundal incision in the uterus after hysterectomy. Most IUD were heavily contaminated by bacteria, especially Staphylococcus epidermidis, Enterococci and anaerobic Lactobacilli. The number of colonies was higher in women with dysfunctional bleeding and pelvic inflammatory disease than in others with a predominance of pathogenic bacteria, namely beta-hemolytic Streptococci, Staphylococcus aureus and Escherichia coli. Almost half of the IUDs without a tail protruding through the cervix were sterile. With pregnancy in the presence of an IUD, 71% of devices grew bacteria which were mainly anaerobic.

Treatment of hyperprolactinemic amenorrhea with Metergoline

The ergoline derivative, Metergoline, in a dosage of 4 to 24 mg/day, was administered for one to eight months to 42 patients with hyperprolactinemic amenorrhea. Mean serum prolactin (PRL) concentrations before treatment were 91.2 ng/mL in the patients with functional hyperprolactinemia (N = 29) and 256.9 ng/mL in the patients with pituitary tumor (N = 13). Within four weeks, Metergoline treatment reduced these PRL concentrations to 39.5 ng/mL and 82.9 ng/mL, respectively. In this study Metergoline treatment resulted in restoration of menstruation in a total of 37 patients; 28 patients ovulated, and eight became pregnant. It is considerably more effective in functional hyperprolactinemia than in hyperprolactinemia caused by adenoma.

Degradation of parathyroid hormone by placental homogenate

Degradation of the bovine parathyroid hormone (PTH) fragment (amino acids 35-84) up to 70% was observed during passage through human placenta in an in vitro perfusion model. Fractionation of the subcellular fractions of human placental homogenate revealed the degradation to take place only in the mitochondrial fraction. It is concluded that human placenta, like kidney and liver, has the ability to degrade PTH.

Placental transfer of parathyroid hormone

We investigated the in vitro transfer of three parathyroid hormone (PTH) fragments (amino acids 35-84, 44-68 and 65-84) through human placenta at term. The perfused and transferred fragments were measured radioimmunologically and identified by three different methods: high-pressure-liquid chromatography (HPLC), preparative flat-bed electrofocusing (PEGG), and gel filtration (GF). The study demonstrated that PTH fragments traverse the human placenta. The transferred and perfused fragments were identical. We observed a significant degradation of the perfused hormone during the passage through the placenta in both fetal and maternal directions. In addition, we measured the PTH concentrations on forty samples of maternal and umbilical cord artery and vein plasma obtained immediately after delivery. A highly significant correlation of PTH concentrations in the maternal and umbilical cord vessels was observed. These findings support the contention that human placenta at term is permeable for PTH fragments.

[Death following fructose and sorbitol infusions]

Hereditary Fructose Intolerance (HFI) is a rare inherited metabolic disease. Because of the wide application of infusions containing fructose and sorbitol, patients suffering from this disease are at special risk. The disease is frequently not diagnosed until adulthood and the danger associated with this delay is insufficiently recognized. This report therefore included a case history in which this is highlighted.

Metabolism of dehydroepiandrosterone (DHA) in the mature perfused human placenta (I)

A design for the perfusion of one (monoperfusion) or two (parallelperfusion) cotyledos of one placenta was developed for studies of the metabolism of the precursor steroid dehydroepiandrosterone (DHA). Several parameters are used as viability criteria: vascular resistance, glucose and oxygen consumption, lactate/pyruvate ratio, activity of lactate-dehydrogenase (LDH) in the perfusate, extent of perfusion by dye infusion, and morphological description by electron microscopy. A dosage of 2 mg DHA with 2.5 microCi 14C-radioactive labelled marker is given for testing the metabolizing capacity of the placenta. The labelled metabolites DHA, androstenedione (A), testosterone (T), estrone (Oe 1), and estradiol-17 beta (Oe 2) are separated by thin-layer chromatography and measured by scanning and measurements of scraped radioactive spots by scintillation counting. The steroidogenesis is evaluated with the concentrations of Oe 1 at 15 min (Oe 1.15'), Oe 1 + Oe 2 at 90 min (Oe tot, 90'), total aromatization rate (from perfusate and homogenate after 120 min). Results comparable to DHA are found using DHA-sulphate (DHA-S) as precursor, higher amounts of estrogens are metabolized from A. Mature placentas metabolize DHA in relation to the initial DHA concentration: optimal aromatization is found at 250-350 pmol DHA/ml/g, decreased aromatization at higher or lower concentrations. Oe 1 represents the main placental metabolite.

[Comparison of two methods for the determination of oestrogens in pregnancy urine (author's transl)]

A method based on the inhibition of hemagglutination for the determination of estriol-16-alpha-glucuronide is compared to the method of Kober and Ittrich. A sufficient degree of correlation (p less than 0.001) is found, when the daily estrogen production (Kober-Ittrich) in the last trimenon is compared to the estriol-concentration in the morning urine, analyzed by the hemagglutination method, which is suitable for the total estrogen determination too. Results below 23 microgram estriol/ml morning urine are pathological. Advantages of this method result from the fact, that no special equipment is required to carry out this fast assay.

Homicide and blackout in alaskan natives: a report and reproduction of five cases

Alcoholic amnesia was reproduced clinically in 5 Alaskan Native men who had committed homicide during previous alcoholic blackouts but had no recollection of events.

Influence of bromocriptine on plasma levels of prolactin and steroid hormones in the 20th week of pregnancy

The influence of bromocriptine, a prolactin antagonist, on maternal plasma and amniotic fluid prolactin (PRL) was investigated in two pregnancies at the 20th week with medical indication for abortion. Voluntary consensus of the patients was obtained. Blood sample determinations demonstrated that bromocriptine inhibits the secretion of PRL both in plasma and amniotic fluid. Since no changes were observed in peripheral maternal steroid concentrations of dehydroepiandrosterone, dehydroepiandrosterone-sulfate, delta 4-androstene-3, 17-dione, testosterone, estradiol, estriol, and cortisol, it is concluded that PRL does not seem to affect maternal and fetal adrenal cortex as supposed in amenorrhoic patients with hyperprolactinemia.

[Diagnostic assessment of normal and risk pregnancies. 1. Comparison of two radioimmunological methods for the determination of human placental lactogen (author's transl)]

The HPL-concentrations of 103 plasma samples from normal and 58 samples from risk pregnancies were analyzed with two radioimmunological assay kits from Pharmacia/Freiburg (I) and Ames/Frankfurt (II). Intra- and inter-assay-variation of both methods are similar. The absolute values of HPL-concentrations analyzed by the two methods correspond to a value of about 3.5 microgram/ml (about week 24 of pregnancy). Above this value higher concentrations are analyzed with method II. These differences probably result from use of different standards and different methods of separation of free and bound hormone. Analysis of variance shows a high degree of correlation (r = 0.93, P less than 0.001, n = 147) of the results obtained by both methods.

[Clinical and biochemical studies in three pregnancies with placental sulphatase deficiency (author's transl)]

Three pregnancies (two I. parae and one II. para) with abnormally low urinary estrogen excretion of less than 5 mg estrogens per day have been investigated in this study. After intravenous injection of 100 mg DHA-S to the mothers no increase of estrogen production was observed. The level of human placental lactogen, was found within normal range. Ultrasonographic measurement of fetal size and monitoring of the fetal heart rate have demonstrated fetal benefit. At the end of pregnancy the cervix of both did not dilate after infusion of Syntocinon. Healthy male infants were delivered by Caesarean sections in both cases. The II. para, however, developed spontaneous labour and delivery at term. Clinical and laboratory tests have indicated the possibility of rare placental sulphatase deficiency. After delivery the placental steroid sulphatase activity was measured as the rate of hydrolysis of (6,7-3H) oestrone-sulphate or (4-14C) dehydroepiandrosterone-sulphate during in vitro incubation with the homogenate or the microsomal fraction from the pathological placentae. In all three cases the specific activity of 3-sulphatase was considerably (more than 80%) decreased when compared to three normal placentas, whereas the activity of the other enzymes (17beta-hydroxysteroidoxidoreductase, delta4/5-isomerase, aromatizing enzyme system) was found within the normal range.

Steroid metabolism in the perfused human placenta. I. Metabolism of dehydroepiandrosterone sulphate

A new model for the perfusion of human term-placentas has been developed for studies on the placental biogenesis of C-18 and C-19 steroids. For viability criteria, the glucose- and oxygen-consumption, regional perfusion control by dye-infusions or scanning after injection of 99Tc-labelled macroparticles, and the histological qualification were chosen. The recycled perfusate was investigated for the steroids oestrone (Oe1), oestradiol-17β (Oe2), oestriol (Oe3), 4-androstene-3,17-dione (A), testosterone (T), and human placental lactogen (HPL) by radioimmunoassay in controls and perfusions with the foetal steroid precursor dehydroepiandrosterone sulphate (DHA-S). In control perfusions, steroid hormones were found in constant ratios (Oe1:Oe2:Oe3:T:A = 30:1.5:100:0.35:1). Following the administration of 10 mg DHA-S for testing the metabolic capacity of the organ, high concentrations of Oe1 (90–720 ng/ml = 250–3970 % as compared to 100% pre-injection values) were found, shortly preceded by a rapid increase of A (66–1000 ng/ml = 100–16 000 %). A typical surge of T (5.3–147 ng/ml = 265–4640 %) preceded the normally slower increment of Oe2 (22–220 ng/ml = 1570–4330 %). The concentrations of Oe3 and HPL remained nearly unchanged. From different steroid patterns after DHA-S-load, two distinct responses of term-placentas could be differentiated: Group I (n=12) showed high concentrations of Oe1 (3200 ± 940 %), a small increase of T (1020 ± 500%), as well as low and delayed values of Oe2 (1660 ± 450%). In Group II (n = 5), values were high for T (3160 ± 1020%) and Oe2 (3300 ± 1110%), whereas Oe1 was found in a lower range (508 ± 302%).

In contrast to in vivo findings in maternal venous blood after DHS-S injection to the mother, oestrone was found in perfusions as the main oestrogen fraction from DHA-S. Thus, the analysis of such metabolic differences might be of help in the interpretation of complex results from the DHA-S-loading test.

Hemorrhage induced by intrauterine devices: control by local proteinase inhibition

The intrauterine application of proteinase inhibitors, tranexaminc acid and the pancreatic trypsin inhibitor (Trasylol), reduces or eliminates menorrhagia and intermenstrual bleeding (spotting) produced by an intrauterine device (IUD). A decrease in pain and vaginal (cervical) discharge is also frequently observed. A single application is usually sufficient, more than three never being required. The effect lasts for an average of three cycles. In addition to the clinical use of these agents for the treatment of uterine hemorrhage, the slow release of proteinase inhibitors from an IUD may well be useful in minimizing its side effects without interfering with its contraceptive activity.