[The Danish screening programme for haemoglobinopathies]

The prevalence of people in Denmark descending from areas with a high prevalence of haemoglobinopathies is approximately one tenth and increasing. Since 1995, the Danish Health Authority has recommended haemoglobinopathy screening of pregnant women with ethnic roots outside Northern Europe. Partners of pregnant haemoglobinopathy carriers are also tested. Carrier state in both parents leads to genetic counselling, and prenatal diagnostics of the foetus (chorionic villus biopsy or amniocentesis) is offered, which can lead to abortion and/or preimplantation genetic screening for future pregnancies, as discussed in this review.

[Sickle cell disease and pregnancy]

Sickle cell disease (SCD) is the most common severe hereditary disease worldwide. SCD during pregnancy is associated with increased incidence of perinatal mortality, premature labour, foetal growth restriction, and acute painful crises. Global migration has contributed to a greater geographical spread of individuals with hereditary haemoglobinopathies. This has led to an increased incidence of pregnant women with SCD in Denmark. In this review, we descibe the aetiology, assessment, antenatal care and treatment of pregnant women with SCD.

Pneumococcal antibody protection in patients with autoimmune inflammatory rheumatic diseases with varying vaccination status

Objectives: The aims of this cross-sectional study were to assess the pneumococcal antibody coverage in patients with autoimmune inflammatory rheumatic disease (AIRD) and to identify predictors associated with inadequate protective antibody levels. Method: Antibodies to 12 serotypes occurring in the commonly applied pneumococcal vaccines in Denmark were measured in AIRD patients with a diagnosis of rheumatoid arthritis, spondyloarthritis, or psoriatic arthritis attending the Department of Rheumatology at the North Denmark Regional Hospital. Immunization against pneumococcal infection was defined as a geometric mean level ≥ 1 μg antibodies/mL. Clinical information about vaccination status and disease/treatment history was retrieved from the medical file system. Results: Results of antibody measurement and vaccination status were available from 346 AIRD patients, of whom 200 (58%) were registered as receiving pneumococcal vaccination, whereas the remaining 146 patients (42%) were not. Of all 346 patients, only 61 (18%) were measured with an adequate level of protective antibodies (30% vs 1%, respectively). Methotrexate treatment at the time of vaccination and increasing age were identified as predictors of poor vaccination outcome in multiple logistic regression analysis. Conclusions: This post-vaccination study showed that less than one-fifth of the AIRD patients are adequately protected against pneumococcal infection, although the immunization programme had been implemented in more than half of the study population. Development of improved vaccination strategies is required to achieve a higher immunization coverage rate and more efficient lasting antibody response.

The effect of Lactobacillus paracasei subsp. paracasei L. casei W8® on blood levels of triacylglycerol is independent of colonisation

Gut microbiota (GM) dysbiosis has been linked to obesity and its metabolic complications such as cardiovascular disease (CVD). The risk of developing CVD increases with elevated concentration of serum triacylglycerol (TAG). In a blinded, randomised two-arm parallel human intervention study we have previously found that four weeks of supplementation with Lactobacillus paracasei subsp. paracasei L. casei W8® (L. casei W8) compared to placebo reduced the concentration of TAG in 64 young healthy adults, an effect, likely mediated by a decreased stearoyl- CoA desaturase-1 (SCD1) activity. In the present study we analysed faecal samples obtained during the intervention study to investigate whether this effect was related to the ability of L. casei W8 to colonise the human gut after supplementation of L. casei W8 (1010 cfu daily) as determined by qPCR specific for L. paracasei and L. casei (L. casei group); whether L. casei W8 consumption affected GM composition as determined by 16S rRNA gene targeted 454/FLX amplicon sequencing; and whether these changes were associated with changes in TAG concentration and SCD1 activity. Faecal samples were collected at baseline, after four weeks supplementation and two weeks after the supplementation was ended, and fasting blood samples were collected at baseline and after 4 weeks. Four weeks supplementation with L. casei W8 did not affect the overall composition of the GM; however, an increase in the relative abundance of the L. casei group from 8.48×10-6% of the total GM compared to 2.83×10-3% at baseline (P<0.001) was observed. Two weeks after supplementation ended, the relative abundance of the L. casei group was still increased 14 times compared to before the intervention (P<0.01). However, neither the increase in the abundance of the L. casei group nor overall GM composition correlated with changes in blood lipids or SCD1 activity.

Prognostic implications of ventricular ectopy one week, one month, and sixteen months after an acute myocardial infarction. Danish Study Group on Verapamil in Myocardial Infarction

BACKGROUND

Ventricular ectopy early after an acute myocardial infarction (AMI) has previously been demonstrated to predict mortality. Less information is available about the prognostic implications of ventricular ectopy occurring late after an AMI, and no information is available about the prognostic implication of the development of ventricular ectopy during the first year after an AMI.

HYPOTHESIS

The purpose of the present prospectively conducted trial, a part of the Danish Verapamil Infarction Trial II (DAVIT II), was to evaluate the prognostic implication of (1) ventricular premature complexes (VPCs) recorded by 24-h Holter monitoring 1 week, 1 month, and 16 months after an AMI; and (2) development of > 10 VPCs/h or of any complex ventricular ectopy, that is, pairs, more than two types of VPCs, ventricular tachycardia, or > 10 VPCs/h during follow-up after an AMI.

METHODS

Patients were monitored 1 week (n = 250), 1 month (n = 210), and 16 months (n = 201) after AMI.

RESULTS

Multivariate analyses based on history, clinical findings, and ventricular ectopy showed the following results: After 1 week, > 10 VPCs/h (p = 0.0006) and heart failure (p < 0.007); after 1 month, > 10 VPCs/h (p = 0.003) and resting heart rate (p < 0.02); and after 16 months, ventricular tachycardia (p = 0.002) independently predicted long-term mortality. Mortality was significantly predicted by the development of > 10 VPCs/h from 1 week to 1 month (p = 0.003) and 16 months (p = 0.03), and from 1 to 16 months (p = 0.007) after AMI, as well as by the development of any complex ventricular ectopy from 1 week to 1 month (p = 0.02) and 16 months (p = 0.01), and from 1 to 16 months (p = 0.04) after AMI.

CONCLUSION

The present study demonstrated that 1 week and 1 month after an AMI the quantity of VPCs, that is, > 10 VPCs/h, predicted mortality, whereas 16 months after an AMI the quality of VPCs, that is, ventricular tachycardia, predicted mortality.

Measurement of Aortic Blood Flow by Magnetic Resonance Below and Above the Origin of the Coronary Arteries in Postmenopausal Hormone Replacement Therapy

PURPOSE

Principal blood flow measures might be assessable by velocity-encoded cine magnetic resonance (VENC MR) of aortic blood flow. The feasibility of using VENC MR for clinical research was tested in a contemporary and controversial human model: the effects of 17beta-estradiol (E) and cyclic norethisterone acetate (NETA) in postmenopausal women.

METHODS

Sixteen postmenopausal women were included in a crossover study (two 12-week periods, 3-month washout) and randomized to E and NETA or placebo. Aortic blood flow (ABF) was measured eight times by VENC MR below and above the coronary arteries (CA) and was used for estimation of coronary artery blood flow (CABF) and peak flow velocity (Vmax). The calculated value of CABF was negative and was corrected by averaging systolic flow. Data were analyzed in a repeated measurement model including analysis of repeatability (CR) and group variability (CV).

RESULTS

The CR and CV of ABF were low (11% and 7%) and corresponded at the two levels. Vmax showed similar levels of reproducibility at the two levels. The coronary artery blood flow was less reproducible (39% and 31%). During treatment, ABF above CA was reduced after 12 weeks (p=0.03), ABF below CA was unchanged, and CABF was significantly increased without detrimental effects of NETA. Vmax was increased at NETA addition (p<0.01).

CONCLUSIONS

Aortic flow quantification by VENC MR is reproducible and useful for assessment of principal haemodynamic changes in smaller studies. Derived measurement of CABF lacks precision. Differences in change below and above CA indicate that oral high-dose E and NETA may induce coronary artery dilatation.

Obesity and sarcopenia after menopause are reversed by sex hormone replacement therapy

OBJECTIVE

Menopause is linked to an increase in fat mass and a decrease in lean mass exceeding age-related changes, possibly related to reduced output of ovarian steroids. In this study we examined the effect of combined postmenopausal hormone replacement therapy (HRT) on the total and regional distribution of fat and lean body mass.

RESEARCH METHODS AND PROCEDURES

Sixteen healthy postmenopausal women (age: 55 +/- 3 years) were studied in a placebo-controlled, crossover study and were randomized to 17beta estradiol plus cyclic norethisterone acetate (HRT) or placebo in two 12-week periods separated by a 3-month washout. Total and regional body composition was measured by DXA at baseline and in the 10th treatment week in both periods. Changes were compared by a paired Student's t test.

RESULTS

The change in body weight during HRT was equal to the change during placebo (-24.6 g vs. -164 g, p = 0.42), but relative fat mass was significantly reduced (-0.5% vs. +1.24%, p < 0.01). During HRT, compared with during placebo, lean body mass increased (+347 g vs. -996 g, p < 0.01) and total fat mass decreased (-400 g vs. +836 g, p = 0.06). Total bone mineral content increased (+28.9 g vs. -4.4 g, p = 0.04) and abdominal fat decreased (-185 g vs. +253 g, p = 0.04) during HRT compared with placebo.

DISCUSSION

HRT is linked to the reversal of both menopause-related obesity and loss of lean mass, without overall change in body weight. The increase in lean body mass during HRT is likely explained by muscle anabolism, which in turn, prevents disease in the elderly.

Polycomb group genes control pattern formation in plant seed

Transcriptional activators of the Trithorax group (TRX-G) and repressors of the Polycomb group (Pc-G) are involved in multiple aspects of embryogenesis in Drosophila and the mouse [1, 2] and appear to have a conserved role in the zygotic control of the development of the anterior-posterior axis [3, 4, 5]. In the model plant Arabidopsis, three Pc-G genes have been isolated and characterized to date. CURLY LEAF (CLF) represses the expression of a floral homeotic gene in vegetative tissues but does not appear to have a role in plant embryogenesis [6]. Two other Pc-G genes, FIS1/MEDEA [7, 8, 9], and FIS3/FIE [8, 10] have been characterized in studies of mutants that produce seeds in the absence of fertilization. Seeds resulting from autonomous development in fis mutants do not contain an embryo but only endosperm, the second product of double fertilization in flowering plants [11, 12]. Thus, FIS genes are considered to be repressors of endosperm development before fertilization. We report that when fis ovules are fertilized, the endosperm patterning along the major polar axis is perturbed. Posterior structures develop in more anterior domains of the endosperm. This correlates with the ectopic expression of a posterior molecular marker. FIS genes appear to be potent regulators of the establishment of the anterior-posterior polar axis in the endosperm.

Temporal changes in cardiac function and cerebral blood flow during sequential postmenopausal hormone replacement

OBJECTIVE

The purpose was to assess the temporal changes in cardiac function and cerebral blood flow during postmenopausal administration of estrogen with and without progestogen.

STUDY DESIGN

Sixteen postmenopausal volunteers were assessed during estradiol plus sequential norethindrone acetate and placebo in two 12-week periods. Temporal changes were measured by magnetic resonance flow mapping 8 times.

RESULTS

Systemic vascular resistance was reduced during estradiol (-6.9%; P <.05), declined further during the addition of norethindrone acetate, and was accompanied by an increase in stroke volume (maximum increase, 5.2%; P <.05) without fluid retention. Both systolic (-5 mm Hg; P =.03) and diastolic (-3 mm Hg; P =.03) blood pressure were reduced during estradiol. Cerebral blood flow was reduced after 9 weeks of hormone replacement therapy (-37 mL/min; P =.01) but increased to baseline after the addition of norethindrone acetate.

CONCLUSIONS

Sequential hormone replacement therapy is associated with changes in cardiac function, which are of therapeutic potential in cardiovascular disorders. Sequential hormone replacement therapy exhibits an overall neutral effect on cerebral blood flow.

Temporal changes in clinic and ambulatory blood pressure during cyclic post-menopausal hormone replacement therapy

OBJECTIVE

Post-menopausal hormone replacement (HRT) might protect against cardiovascular disease, possibly by arterial vasodilation and reduced blood pressure. Progestogens are needed to avoid endometrial disease but vascular effects are controversial. The objective was to assess temporal changes in blood pressure (BP) by two measurement techniques during a cyclic hormone replacement regimen.

DESIGN AND METHODS

Sixteen healthy and normotensive post-menopausal women (age 55 +/- 3 years) were studied in a placebo-controlled, randomized crossover study, and were randomized to 17beta-oestradiol plus cyclic norethisterone acetate (NETA) or placebo in two 12-week periods separated by a 3-month washout Clinic blood pressure was measured sitting by the same observer with a mercury manometer at four visits in each period. Twenty-four hour ambulatory blood pressure was measured at baseline and in the ninth weeks of treatment in both periods.

RESULTS

Clinic systolic and diastolic BP were reduced after 10 days of oestradiol (-5.1 and -3.2 mmHg respectively, P < or = 0.05). After 9 weeks of cyclic HRT, prior to progestogen addition, clinic BP returned to baseline. During addition of NETA, diastolic blood pressure was again reduced (-3.6 mmHg, P= 0.037). Mean 24 h ambulatory systolic and diastolic blood pressures were significantly lower than clinic measurements (-15.7 and -5.9 mmHg, P < 0.001) but were unaffected by HRT.

CONCLUSIONS

Clinic blood pressure is reduced during a cyclic HRT regimen but the reduction varies with the HRT regimen, which might explain the diversity in previous BP findings during HRT. Norethisterone acetate might possess additive blood pressure-lowering effects in postmenopausal women.

Differences between users and non-users of emergency contraception after a recognized unprotected intercourse

Knowledge of emergency contraception is crucial but might not transform into use. Factors influencing decision-making related to use of emergency contraception after an unprotected intercourse and the characteristics of users of emergency contraception (EC) were assessed. In an abortion clinic setting, 217 women referred for termination of pregnancy were asked to fill in a questionnaire. Of the 217 women, 139 (64%) were aware of pregnancy risk but only 9 (4%) had used EC after the unprotected intercourse. 42% were estimated to have sufficient knowledge to use hormonal emergency contraception. In a larger background population, a calculated 29% used EC after a recognized unprotected intercourse. EC users were older, better educated, more often in stable relationships, had experienced more abortions, and gestation age was less. However, younger women were in general better informed of EC. Knowledge of EC does not necessarily transform into action. Neglect of risk after an unprotected intercourse is frequent in younger well-informed women and information has to be better targeted.

Zinc, magnesium and calcium in human seminal fluid: relations to other semen parameters and fertility

The effects of zinc, magnesium and calcium in seminal plasma on time-to-pregnancy (TTP) in healthy couples, on conventional semen parameters and computer-assisted semen analysis (CASA) parameters were evaluated. The localization of chelatable zinc ions in seminal plasma and spermatozoa were assessed by autometallography (AMG). Differences in chelatable zinc localization in samples with high and low total zinc were evaluated. Semen samples from 25 couples with short TTP and 25 couples with long TTP were subjected to conventional semen analysis, CASA, zinc and magnesium measurements by inductively coupled plasma mass spectrometry, and calcium by flame atomic absorption spectrometry. The cations were strongly inter-correlated, but no correlation with TTP or conventional semen parameters was found. Semen samples with high zinc concentrations exhibited statistically significant poorer motility assessed by the CASA parameters straight line velocity and linearity than samples with low zinc content. Calcium concentration also showed statistically significant differences for the same parameters, but the effect was removed by entering zinc concentration into a multiple regression model. Semen samples with high total zinc exhibited stronger staining of the seminal plasma at AMG. It is suggested that high seminal zinc concentrations have a suppressing effect on progressive motility of the spermatozoa ('quality of movement'), but not on percentage of motile spermatozoa ('quantity of movement').

Chelation of intracellular zinc ions affects human sperm cell motility

The effects of two different zinc chelators, diethyldithiocarbamate (DEDTC) and calcium ethylenediaminetetraacetic acid (EDTA), in full semen samples and 'swim-up' samples were investigated. DEDTC, which crosses cell membranes, and EDTA, which does not cross cell membranes, were added to semen samples in different concentrations. Sperm cell motility parameters were assessed by computer-assisted semen analysis (CASA). It was found that very small concentrations (0.01 mM) of DEDTC immobilized the sperm cells within 80 min, while EDTA had no depressing effect at the concentrations used. In full semen samples EDTA enhanced straight line velocity (VSL) at concentrations of 1.0 and 0.5 mM; this effect was not found at higher concentrations. It is suggested that intracellular mitochondrial zinc ions play a crucial role for sperm cell motility, while loosely bound or free zinc ions in the seminal plasma exert a secondary role on human sperm cell motility.

Whipple's operation for carcinoma of the pancreatic head and the ampullary region. Short-and long-term results

BACKGROUND AND METHODS

In this retrospective review short- and long-term perspectives have been evaluated for 108 patients who, during 1982 through 1992, had Whipple's operation performed for carcinoma of the pancreatic head (PC, n=63) or the ampullary region (AC, n=45). In 24 patients the operation was not radical (21 with PC and 3 with AC).

RESULTS

Total perioperative morbidity was 60%, and 13 patients (12%) died within 30 days of operation. This decreased from 15.2% in the first half of the study period to 8.2% in the second half. Recurrence occurred in 56.2% of the remaining 73 patients, with no significant differences between PC and AC. Recurrence was related to regional lymph node metastases and poor tumour differentiation. Overall 5-year survival was 7.4% for PC and 24.8% for AC. For patients with radically excised tumours surviving 30 days the 5-year survival rates were 13.1% for PC and 30% for AC.

CONCLUSION

Careful preoperative evaluation is still of great importance.

Histochemical tracing of zinc ions in the rat testis

To detect free zinc ions in the rat testes four rats were transcardially perfused with Na2S, and the seminiferous tubules from two other rats were incubated in Na2S. Sections from the two sources were autometallographically (AMG) developed, whereby zinc sulphide crystal lattices created in the tissue by the sulphide treatment were silver enhanced. Light microscopical analysis showed zinc ions in primary spermatogonia until the zygotene primary spermatocytes (stage I), in late pachytene spermatocytes (stages XII and XIII), and in late spermatids from step 15 to step 19 (stages I-VIII). The highest intensity of AMG grains was detected in the residual bodies and tails of step 19 spermatids. Grains were occasionally found in the cytoplasm of Leydig cells. Sections from animals treated with the chelator diethyldithiocarbamate prior to sulphide treatment showed a complete lack of AMG staining. At ultrastructural levels the AMG grains were found in smooth-surfaced endoplasmic reticulum of all spermatogonial stages, and in the acrosome, midpiece, and tail of late spermatids. The presence of zinc ions in preleptotene spermatocytes and cytoplasmic lobes of late spermatids suggests a specific role of free zinc at the onset of meiosis and at spermiation.

Women at cardiac risk: is HRT the route to maintaining cardiovascular health?

Cardiovascular disease is the leading cause of death in women of postmenopausal age. Data from observational studies suggest that the risk of coronary heart disease in postmenopausal women can be reduced by 30-50% by estrogen replacement therapy. The protective effect of estrogen is multifactorial, affecting lipids, carbohydrate metabolism, hemostasis, body-fat distribution and blood pressure. Although the unopposed use of estrogen is associated with an increased risk of endometrial cancer, this risk can be reduced or even neutralized by the addition of progestogen. The protection against cardiovascular disease provided by combined estrogen/progestogen treatment has been the subject of much debate. However, results from epidemiological studies, intervention trials and animal experiments now suggest that the addition of progestogen does not attenuate the beneficial effects of estrogen. While secondary prevention studies are needed to evaluate the various hormone regimens, the use of combined estrogen/progestogen therapy can be supported.

Autometallographic demonstration of zinc ions in rat sperm cells

An in-vitro technique for autometallographic (AMG) demonstration of chelatable zinc in electroejaculated sperm cells and spermatozoa from the epididymis is presented and the localization of zinc ions in rat spermatozoa is described. Sperm cells from caput epididymis showed zinc staining in all parts of the tail and a sparse, dispersed staining in the acrosome. Spermatozoa from cauda epididymis showed heavy staining in the acrosome but no staining in the tail, or post-acrosomal part of the sperm head. This distinct acrosomal AMG staining was also found in ejaculated spermatozoa, but additionally a segmentation of the tail was seen based on differences in staining intensity. The membrane penetrating chelator diethyldithiocarbamate (DEDTC) was found to block the AMG staining whereas calcium-EDTA, known not to pass through cell membranes, did not influence the staining, proving that the detected zinc ions are intracellularly located. Two different approaches for demonstrating the presence of a chelatable zinc pool at electron microscope levels are presented, and the ultrastructural presence of AMG grains located in the acrosome and in the mitochondria of the midpiece is demonstrated. It is postulated that an exchange of zinc ions takes place between the epididymal epithelium and the sperm cells as they pass along the epididymal duct.

Histochemical demonstration of zinc ions in ejaculated human semen

A revised in-vitro technique for autometallographic demonstration of chelatable zinc in the human ejaculate is presented, and the localization of the loosely bound pool of zinc ions is described in semen smears and at the ultrastructural level. In semen smears, black autometallographic (AMG) grains indicated the presence of zinc ions dispersed between the spermatozoa. These AMG grains have the same size as grains associated with the sperm tail and may have the same origin. EM analysis of AMG-developed smears fixed in osmium suggested that the detected zinc ions might be related to huge protein molecules present in semen and adhering to the surface of the spermatozoa. Spermatozoa in AMG-stained smears exhibited zinc ions in the midpiece and head, and also joined to the membrane of the tail. Washed spermatozoa exhibited zinc ions only within the midpiece. Ultrastructurally, they were found located in the helecine mitochondria. A few grains were found in the acrosome of the washed spermatozoa. Treatment with the chelating agent DEDTC resulted in complete bleaching of the zinc staining. These findings and the fact that calcium EDTA acid blocks the plasma and surface staining, but not the acrosomal and mitochondrial staining, suggest that chelatable zinc ions exist in two separate pools in human semen.

Prehospital treatment of patients with i.v. heroin overdose: what are we treating?

OBJECTIVE

To measure blood levels of morphine and additional drugs in patients suspected of intravenous (i.v.) heroin abuse and to evaluate the effects of antidote treatment.

DESIGN

Prehospital blood sampling in 52 patients.

RESULTS

Forty-five patients were blood-positive for heroin, eight of whom were hospitalized. Forty-one patients also had abused additional drugs: minor tranquilizers, ethanol, amphetamine, cocaine, and/or carbamazepine. Seven patients had taken either only methadone or ketobemidione: one was admitted. Treatment with increasing doses of naloxone indicated a necessity for hospitalization. Six of 14 patients treated with naloxone (1.8 mg were hospitalized. Seven patients had an extremely high blood level of morphine (0.2 mg/kg), that could be reverted with naloxone in moderate doses.

CONCLUSION

This study indicates that under prehospital conditions, it is difficult to identify a patient intoxicated only with intravenous heroin. Nearly all patients treated were cases of multiple drug/alcohol overdoses. Even the symptoms associated with extremely high blood levels of morphine could be reversed with naloxone in moderate doses.

[Resectability of papillary and pancreatic cancer assessed by ultrasonography and computer tomography]

A retrospective study of 65 patients with postoperatively verified pancreatic or peripancreatic cancer was conducted. Before surgery all patients had ultrasonography (US) performed, and 46 patients had computed tomography (CT) performed as well. After operation description of pre-operative radiological findings has been compared to description of operative and pathological findings. Three of the 65 patients were excluded either because of lacking radiological descriptions (two patients) or uncertain operative findings (one patient). When both investigations were performed, they were carried out independently by two skilled radiologists without knowledge of the result of the other investigations. The following criteria were used for non-resectability encasement of splanchnic vessels, liver metastases, peritoneal thickening with ascites, and glandular enlargement. As assessed by US, 15 of 16 (94%) were truly predicted to be non-resectable, whereas only 21 of 38 (55%) were truly predicted resectable. CT was performed in 46 patients of which 19 of 21 (90%) were truly predicted non-resectable, and 17 of 21 (81%) were truly predicted resectable. It was not possible to perform a conclusive radiological investigation in eight of 62 (13%) cases by US, and four of 46 (9%) cases by CT. One patient was falsely predicted non-resectable by US and an additional one by CT. Both were falsely predicted non-resectable on suspicion of vessel involvement. Overall, invasion of vessels was the most common cause for non-resectability, at the same time this was the index of non-resectability that was most often not detected pre-operatively. US is reliable when predicting non-resectability. When resectable tumour is detected by US, supplementary investigations such as CT should be applied, and when necessary endoscopic procedures or laparoscopy as well. Hereby unnecessary laparotomies may be avoided. Care should be taken when suspecting papillary tumour; only 66% of these were detected by either of the two methods.

Drugs in blood samples from unconscious drug addicts after the intake of an overdose

This investigation includes whole blood samples from 53 drug addicts found unconscious in the Copenhagen area with evidence of a heroin overdose. Heroin/morphine was detected in 85% of the patients and other opioids in 11%. One or more benzodiazepines, most often diazepam, were detected in 75% of the patients. A blood alcohol concentration higher than 1.00 mg/g was detected in 57% of the patients. Methadone was detected in seven patients, ketobemidone in four, amphetamine in five and cocaine in one. This investigation showed widespread multi-drug abuse and heroin/morphine alone was detected in only one patient. As indicators of heroin intake, 6-mono-acetylmorphine (MAM) and morphine were detected in this investigation.

Hordein promoter methylation and transcriptional activity in wild-type and mutant barley endosperm

B- and C-hordein gene transcription is severely reduced in the endosperm of the regulatory barley mutant lys3a, and this is correlated with persistent hypermethylation of the promoters. In contrast, D-hordein is expressed at normal levels in the mutant. To confirm the connection between methylation and transcriptional activity, a genomic D-hordein clone was isolated and sequenced. The nucleotide composition of the promoter region revealed a CpG island and methylation analysis, using bisulphite treatment of genomic DNA, confirmed that the D-hordein promoter is unmethylated in endosperm and leaf tissue. Immunocytochemical studies localized D-hordein to the reticular component of protein bodies in both the wild-type Bomi and lys3a. Transient expression of GUS reporter gene constructs in barley endosperm, following transfection by particle bombardment revealed the D-hordein promotors. Comparison of transient expression in Bomi and lys3a endosperm demonstrated that the activities of the unmethylated D-hordein and the Hor1-14 C-hordein promoters were equivalent, while the activities in the mutant of the Horl-17 C-hordein and the Hor2-4 B-hordein promoters were reduced two- and tenfold, respectively. Methylation of plasmids in vitro prior to expression severely inhibited B- and D-hordein promoter activities. Based on these observations two categories of promoters for endosperm-specific expression of storage proteins are recognized and a model involving methylation and modulation of chromatin structure in the regulation by the Lys3 gene is presented.

[Acute asthma outside hospital. The predictive value of pulse oximetry in manifestation of respiratory insufficiency]

The objective of the study was to evaluate the predictive value of pulse oximetry before treatment of acute asthma in the prehospital setting. Unfavorable outcome was defined as need for mechanical ventilation during the acute attack. The study was carried out prospectively. The patients were divided into two groups: SpO2 < 80% and SpO2 > or = 80%. The study group consisted of 44 patients with 47 asthmatic attacks. Eleven patients had SpO2 < 80%, of whom two required mechanical ventilation. Thirty-three patients with 36 attacks had SpO2 > or = 80%, none required mechanical ventilation. Oximetry before treatment with a cut off point of < 80% had a specificity of 18% and a sensitivity of 100% for prediction of unfavourable outcome. We conclude at SpO2 < 80% in the acute asthmatic attack is a serious prognostic sign which should warn the physician that the patient's condition is lifethreatening.

[Azoospermia in 2 body-builders after taking anabolic steroids]

During investigations for infertility azoospermia was diagnosed in two men who were concomitantly using anabolic steroids for body-building. Following cessation of anabolic steroid use the semen quality was normalized. Suppression of spermatogenesis during treatment with testosterone and derivatives hereof is wellknown. Usage of anabolic steroids should be remembered as a cause of oligo- and azoospermia and asked about in cases of sperm counts approaching or at zero.

[Prehospital pain relief with nitrous oxide (Entonox)]

Many patients suffering from trauma or acute illness are in need of pain treatment in the prehospital phase, a treatment they seldom receive. In Denmark, it has been considered whether ambulance personnel should be allowed to administer pain treatment. Inhalation of 50% nitrous oxide and 50% oxygen has been administered for many years by non-physicians around the world. Therefore considerations concerning implementation of this treatment in Denmark are relevant. The aim of this paper was to evaluate the available knowledge about and experiences in using nitrous oxide outside the hospital for patients suffering from acute pain. The papers so far published are positive, but give no definite background for uncritical recommendation of prehospital pain treatment with nitrous oxide. There are no controlled studies concerning the effect of pain treatment in the prehospital phase. The few available controlled studies conducted inside the hospital have not shown significant pain-relieving effects of nitrous oxide for patients suffering from pain of acute medical of surgical origin when compared to other methods of pain treatment. Controlled studies of the effects of prehospital treatment with nitrous oxide need to be done. Technical problems and problems concerning indications, side effects, complications, pollution and possible addiction remain to be fully elucidated before prehospital treatment with nitrous oxide can be recommended for routine use in the Danish ambulances.

Pharmacokinetics and pharmacodynamics of eltanolone (pregnanolone), a new steroid intravenous anaesthetic, in humans

Eltanolone, a new intravenous steroid anaesthetic agent was administered intravenously in a dose of 0.6 mg.kg-1 over 45 s to eight healthy male volunteers to evaluate some of its pharmacokinetic and pharmacodynamic effects. Drug concentration-time data were analysed by PCNONLIN, a non-linear regression programme, showing data consistent with a three-compartment model with initial distribution half-life t1/2 lambda 1 between 0.3 and 2 min, intermediate distribution half-life t1/2 lambda 2 between 12 and 29 min and terminal half-life t1/2 lambda z between 72 and 212 min. The total body clearance of eltanolone was rapid and with individual values in the range 1.6-2.3 l.h-1.kg-1. Eltanolone was initially distributed into a relatively large central compartment V1 between 0.09 and 0.98 l.kg-1 and then extensively further distributed (Vss between 1.80 and 5.44 l.kg-1 and V between 4.87 and 11.87 l.kg-1). The excretion of unchanged of eltanolone in urine was very small, the renal clearance was less than 0.5% of the total clearance. Induction of anaesthesia was trouble free with onset and duration of anaesthesia between 1-2 min and 6-13 min, respectively. There was slight respiratory depression, a small transient increase in heart rate, and a maximum reduction in arterial blood pressure of 23%, as compared with the resting level. Pain on injection and venous sequelae were not seen. Involuntary movements were seen in one subject. We conclude that eltanolone has a favourable pharmacokinetic profile with relatively rapid half-lives, large distribution volumes and rapid total body clearance.(ABSTRACT TRUNCATED AT 250 WORDS)

The potential of an anaesthesiologist-manned ambulance service in a rural/urban district

The use of anaesthesiologists in prehospital emergency care is controversial. We wanted to assess the impact of an anaesthesiologist and a short time interval from acceptance of a mission to take-off at survival rates in a rural/urban emergency medical service. Prospectively registered data for 991 consecutive patients through a 12-month period were retrospectively evaluated by an independent foreign expert. Of all primary missions, 3.3% were considered probably lifesaving from site of injury to receiving hospital. Of these, the lifesaving result in 50% were dependent on both the qualifications of the anaesthesiologist and a short response time. Survival from hospital admission to discharge was 44%. All patients were discharged to their own homes, able to live a fully functional life. The consistent use of anaesthesiologists compared to less qualified personnel and the maintaining of response times below presently required minima doubles the potential for lives saved in services comparable to the one studied.

Effects of eltanolone on cerebral blood flow and metabolism in healthy volunteers

BACKGROUND

Eltanolone is a new steroid anesthetic agent that may prove to be useful in clinical practice. The aim of the present study was to evaluate the effects of eltanolone on cerebral blood flow (CBF) and metabolism in healthy volunteers.

METHODS

In a randomized cross-over study, eight subjects received intravenous eltanolone 0.6 mg/kg or its vehicle. CBF was measured with the intravenous xenon 133 technique before and 2 and 30 min after administration of eltanolone or vehicle. Cerebral metabolic rate for oxygen (CMRO2) was calculated as the product of the measured cerebral arteriovenous oxygen content difference and the blood flow.

RESULTS

CBF decreased from a baseline value of 64 +/- 4 (mean +/- SD) to 42 +/- 6 ml.100 g-1.min-1 at 2 min after administration of eltanolone and only 4% after vehicle. Cerebral oxygen consumption was 4.1 +/- 0.4 ml.100 g-1.min-1 at baseline and decreased to 2.7 +/- 0.6 at 2 min after eltanolone, whereas metabolism did not change significantly after administration of vehicle. At 30 min CBF and Cerebral metabolic rate for oxygen were 16 and 10% less than baseline values, respectively. Coupling between CBF and Cerebral metabolic rate for oxygen was preserved at all measurements. After administration of eltanolone a significant decrease in mean arterial blood pressure of 6 mmHg and a period of hypoventilation were observed. This did not occur after injection of vehicle.

CONCLUSIONS

Eltanolone was shown to reduce cerebral oxygen consumption and blood flow in healthy volunteers. Coupling between metabolism and flow was preserved.

Phosphorous and proton spectroscopy in relation to near incarceration and incarceration of the human brain

We report 3 cases of 31P and 1H MR spectroscopy (MRS) performed at different stages on patients with clinical signs of near or fulminant incarceration of the brain. The measurements were made on a whole body, 1.5 T scanner. 1H-MRS was obtained with the STEAM sequence and 31P-spectra were obtained using the chemical shift imaging technique. Medical treatment including controlled ventilation and sedation of the patients was carried out during the examination. The first patient was evaluated on days 6 and 10 after evacuation of an acute subdural haematoma. An intracranial pressure of 35 mm Hg was registered during the first examination. The 2nd patient had suffered a spontaneous intracerebral haemorrhage and showed clinical signs of imminent incarceration during the examination. The 3rd patient showed clinical signs of incarceration just prior to the examination. In the 1st patient 1H-MRS showed a 3-fold increase in the concentration of choline-containing compounds and a small decrease in N-acetyl aspartate from the 1st to the 2nd examination, which we interpret as a loss of neurones. In case 2 only small changes in metabolism could be detected, indicating that, despite signs of imminent clinical incarceration, the energy supply to the brain was substantial. 1H-MRS of the 3rd patient showed massive lactate concentration, and 31P-MRS revealed the total absence of high-energy phosphorous compounds leaving only one single peak of inorganic phosphate, indicating irreversible brain death.

Effect of verapamil on arrhythmias and heart rate during 16 months following an acute myocardial infarction. The Danish Study Group on Verapamil in Myocardial Infarction

The present study was a prospectively planned subset of the postinfarction, double blind, randomized, multicenter, placebo controlled trial of verapamil, DAVIT II. Patients had 24 hours of Holter monitoring before randomization, i.e., second week after infarction (placebo, n = 122; verapamil, n = 128), after 1 month (placebo, n = 108; verapamil, n = 94) and after 16 months (placebo, n = 75; verapamil, n = 63) of treatment. The purpose was to evaluate the effect of verapamil on the prevalence and changes over time of arrhythmias and heart rate. In patients monitored twice, a significant increase of average ventricular premature complexes (VPC) per hour from before to 1 month (p = 0.0007) and 16 months (p = 0.02) after was demonstrated in the placebo group, and from before to 1 months (p = 0.01) after in the verapamil group. Average VPC/hr did not change from 1 to 16 months of treatment. A significant increment of > 10 VPC/hr was found after 1 (p = 0.03) and 16 months (p = 0.05) compared to prerandomization in the placebo, but not in the verapamil group. A significant increase of supraventricular arrhythmias after 1 month compared with prerandomization was found in the placebo group (p = 0.003) but not in the verapamil group. The prevalence of VPC and supraventricular tachycardia was significantly lower in the verapamil compared with the placebo group after 1 month of treatment. At 16 months no significant difference was found between the two groups. The 24 hour mean heart rate was significantly lower, 3 beats/min, in the verapamil compared with placebo after 1 and 16 months of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Use of pneumatic anti-shock equipment (MAST = military anti-shock trousers) in prehospital emergency treatment. A review]

Employment of pneumatic anti-shock (MAST) equipment is a therapeutic possibility in some countries for hypovolaemic and shocked patients. This treatment may be associated with particularly serious side effects and no documentation is available to prove that MAST is beneficial for the patients. The only meticulous clinically controlled investigation concludes that MAST is without effect in city regions with well-trained paramedical or medical staff and employment of MAST can thus not be recommended. The effect of MAST outside urban regions is unknown and should be assessed by means of a clinically controlled investigation.

Methylation of B-hordein genes in barley endosperm is inversely correlated with gene activity and affected by the regulatory gene Lys3

The methylation status of B-hordein genes in the developing barley endosperm was analyzed by digestion with methylation-sensitive restriction enzymes. Southern blotting revealed specific demethylation of Hpa II sites in DNA from wild-type endosperm, whereas leaf DNA and lys3a mutant endosperm DNA were highly methylated at these sites. Similar methylation patterns were observed at an Ava I site situated at position -260 in the B-hordein promoter. This differential methylation was confirmed by genomic sequencing with ligation-mediated PCR. The analyzed sequence covers most of the B-hordein promoter and includes 10 CpGs from the promoter and 4 CpGs from the adjacent coding region. These sites were all hypomethylated in wild-type endosperm, whereas--except for three partially methylated sites--full methylation was seen in leaf DNA. The four sites in the coding region were partially methylated in lys3a endosperm DNA, but the promoter sites remained highly methylated. The possible role of methylation in the regulatory function of the Lys3 gene product is discussed.

[Emergency prehospital treatment of severe hypoglycemia in the Copenhagen Municipality. A retrospective analysis of 180 episodes]

A retrospective study concerning prehospital treatment of 180 consecutive patients with severe hypoglycaemia, treated by the Mobile intensive care unit (MICU) in Copenhagen was performed. A total of 113 (63%) were male. Of these 104 patients had blood-glucose concentrations less than 2 mmol/l. Eleven patients had blood-glucose concentrations between 2 and 4 mmol/l. After treatment with 50% glucose solution: (25-50 ml I.V.), 131 patients could remain at home. During the 24 hour period after the initial event, two patients needed a second treatment by the mobile intensive care unit on account of secondary hypoglycaemia. Four further patients were admitted to hospital; none of these suffered secondary hypoglycaemic events. One case was registered as "life-saving" on account of treatment of severe airway obstruction. It seems that prehospital treatment of severe hypoglycaemia is beneficial mainly because transportation of delirious, abusive patients can be avoided and the workload of emergency-rooms can be reduced. 69% of patients suffering a severe hypoglycaemic event, were treated prehospitally without subsequent transportation to hospital.

[Monitoring of anesthesia during magnetic resonance imaging]

Clinical employment of magnetic resonance scanning presents great diagnostic possibilities, partly in the form of the quality of the imaging and also on account of the possibilities for carrying out spectroscopic measurements by mens of which in vivo non-invasive chemical analysis of drug concentrations in the tissues may be performed. In anticipation of the possibility of employing MR-scanning as an important diagnostic aid for assessing the causes of unconsciousness in patients in intensive care, attempts have been made to establish reliable and justifiable equipment for monitoring which can render possible investigation of unconscious or anaesthetized patients in scanners with magnetic fields of over 1.5 Tesla. The medical technical difficulties involved are mentioned and the solutions which are employed in the Danish scientific Centre for Magnetic Resonance in Hvidovre Hospital in Copenhagen are described. This monitoring includes continuous ECG recording, measurements of pulse and blood-pressure once per minute and continual monitoring of respiration including concentrations of carbon dioxide in the inspired and expired air and the concentration of oxygen in the inspired air. In addition, model solutions have be outlined for establishing mechanical ventilation with the servorespirator and the possibility of producing an employable pulse oxymeter is described. It is stated that, provided all of the elements in the above mentioned model solution for monitoring during anaesthesia in the MR laboratory have been carried out, it is considered justifiable to place all patients, including children, in the MR-scanner.

[Sudden unexpected respiratory arrest outside hospital among young patients with asthma]

In a prospective investigation lasting for one year, the medically staffed ambulance in Copenhagen registered patients under the age of 60 years with asthma who developed respiratory arrest outside hospital. The circumstances involved in the acute serious cases were illustrated as far as possible by review of the case records and interviews with the surviving patients. Five patients participated in the investigation. All of these were young with a median age of 24 years (19-28). Two patients had cardiac arrest, four patients survived after tracheal intubation at the site of the onset of illness and subsequent mechanical ventilation. One patient died in hospital on account of anoxic encephalopathy. The common denominators of all of the patients were that the condition had been recognized for many years, that before the attack involved they had been well and without asthmatic symptoms, the attack commenced hyper-acutely and the patients had not taken medicine regularly during a prolonged period. On the basis of these observations, the present authors recommend that young patients with asthma should receive optimal medication and that the necessity of taking the prescribed medicine despite possible good health should be emphasized.

[Emergency prehospitalization treatment of cardiac arrest in the municipality of Copenhagen]

A retrospective study was performed concerning prehospital cardiac arrest. This revealed that 177 consecutive patients received advanced medical resuscitation by an anaesthesiologist at the site of the accident during the period 01.01.1988-31.12.1988. A total of 61 (35%) were admitted to hospital and 24 of these (14%) survived for more than 30 days. All 24 were discharged to their homes without major cerebral sequelae. After one year, 21 were still alive. Compared with the results of previous studies in Copenhagen, this study reveals that the overall survival rate may have improved and that cerebral function after cardiac arrest seems to have been improved by the introduction of prehospital medically staffed ambulances.

[Prognosis and costs of patients with prehospital cardiac arrest treated with respirators]

A retrospective study was undertaken of prehospital cardiac arrest and revealed that mechanical ventilation was employed in 132 consecutive patients after resuscitation. A total of 24 of these survived for more than three months; 14 were discharged to their homes while ten were discharged to nursing homes on account of cerebral sequelae. No patients in whom the cardiac arrest had lasted more than 25 minutes survived for more than three months and patients with cerebral sequelae were more frequently mechanically ventilated for longer than 48 hours. The total cost of treatment for the 132 patients was estimated to be 10,500,000 Danish crowns (approximately 954,000 pounds). A total of 7% of the patients survived with cerebral sequelae but these were responsible for more than 60% of the expenses.

Pregnanolone emulsion. A preliminary pharmacokinetic and pharmacodynamic study of a new intravenous anaesthetic agent

Pregnanolone emulsion, a new steroid anaesthetic agent, was administered intravenously as bolus doses to six young healthy male volunteers in a preliminary pharmacokinetic and pharmacodynamic study. The plasma concentration-time curves fitted a two-compartment model. The elimination half-life was between 0.9 and 1.4 hours, volume of central compartment between 0.95 and 2.10 litres/kg, volume of distribution between 3.75 and 5.58 litres/kg and total body clearance between 1.80 and 3.07 (litres/hour)/kg. The excretion in urine of unchanged pregnanolone was less than 0.1%. The pharmacodynamic properties were found to be similar to those of Althesin, with immediate induction of anaesthesia of short duration. The anaesthetic affected haemodynamics only slightly; minor depression of ventilation, with an increase in PaCO2, occurred in several of the subjects. Excitation of short duration occurred in one subject during induction of sleep and slight involuntary muscle movements in another subject during sleep. It is impossible to draw any clear conclusions of the clinical efficacy and tolerance from this limited normal subject trial, but pregnanolone emulsion seems worthy of further clinical trial.

[Pre-hospital care]

Organisatory and therapeutic characteristics for selected pre-hospital medical treatment systems are described. It is emphasized that all of the links in the therapeutic chain must function optimally to achieve effective treatment of acute disease and injuries. The importance of rapid decision-making by highly qualified medical staff is emphasized. On the basis of experience from Denmark and from abroad, a model for up-to-date pre-hospital treatment in Denmark is outlined.

Mapping of the Hor2 locus in barley by pulsed field gel electrophoresis

High molecular weight DNA released from isolated protoplasts was digested with rare-cutting restriction enzymes and separated by pulsed field gel electrophoresis. The average size of undigested DNA was above 1500 kbp. Digests made with NotI, SfiL, Mlul and SalI was hybridized to a probe, common to all genes of the Hor2 locus encoding B-hordein polypeptides, and this revealed the maximum size of the locus to be 360 kbp. Two probes, specific for individual B-hordein genes, enabled the identification of two fragment classes in the locus, each containing an equal number of B-hordein genes. Double digests allowed ordering of sites and construction of a map covering 650 kbp around the Hor2 locus. No evidence for physical linkage of the two fragment classes was obtained. The possible assignment of the two classes of hybridizing fragments to the B1- and B3-hordein subgroups is discussed.

Effect of scavengers of active oxygen species and pretreatment with acetyl-salicylic acid on the injury to cultured endothelial cells by thrombin-stimulated platelets

Thrombin-stimulated human platelets adhere to and injure cultured human endothelial cells. We hypothesize that generation of active oxygen species by the stimulated platelets are involved in the injury. To confirm this, catalase [final concentration (8.25 micrograms/ml)], superoxide dismutase (SOD) (10 micrograms/ml), of D-mannitol (9 mg/ml) were added to the cell culture medium before the experiments. Platelet suspension (200,000/microliters) and thrombin (4 U/ml) were added and the culture dishes shaken for 15 min at room temperature. In separate experiments the endothelial cells were pretreated with acetylsalicylic acid (0.05, 0.1, or 0.5 mM) to test whether the arachidonic acid metabolism of the endothelial cells is involved in the injury process. In preliminary experiments we were able to confirm that platelets, when stimulated by thrombin, produce chemiluminescence which was suppressed by mannitol but not by catalase or SOD. The degree of injury to cultured endothelial cells by thrombin-stimulated platelets, as measured by release of 51Cr from prelabeled endothelial cells, was reduced significantly with the presence of mannitol, but only moderately when catalase or SOD had been added. Morphometric quantification based on scanning electron micrographs of the endothelial cells after exposure to thrombin-stimulated platelets in the presence of catalase or mannitol showed a reduced number of injured cells. Pretreatment of the endothelial cells with acetylsalicylic acid did not cause any significant change in the degree of endothelial cell injury as measured by the 51Cr release. It is concluded that active oxygen species, in particular hydroxyl radicals, may be generated during thrombin stimulation of platelets and cause injury to the endothelial cells.