Introducing extended consultations for patients with severe mental illness in general practice: Results from the SOFIA feasibility study

BACKGROUND

People with a severe mental illness (SMI) have shorter life expectancy and poorer quality of life compared to the general population. Most years lost are due to cardiovascular disease, respiratory disease, and various types of cancer. We co-designed an intervention to mitigate this health problem with key stakeholders in the area, which centred on an extended consultations for people with SMI in general practice. This study aimed to1) investigate general practitioners' (GPs) experience of the feasibility of introducing extended consultations for patients with SMI, 2) assess the clinical content of extended consultations and how these were experienced by patients, and 3) investigate the feasibility of identification, eligibility screening, and recruitment of patients with SMI.

METHODS

The study was a one-armed feasibility study. We planned that seven general practices in northern Denmark would introduce extended consultations with their patients with SMI for 6 months. Patients with SMI were identified using practice medical records and screened for eligibility by the patients' GP. Data were collected using case report forms filled out by practice personnel and via qualitative methods, including observations of consultations, individual semi-structured interviews, a focus group with GPs, and informal conversations with patients and general practice staff.

RESULTS

Five general practices employing seven GPs participated in the study, which was terminated 3 ½ month ahead of schedule due to the COVID-19 pandemic. General practices attempted to contact 57 patients with SMI. Of these, 38 patients (67%) attended an extended consultation, which led to changes in the somatic health care plan for 82% of patients. Conduct of the extended consultations varied between GPs and diverged from the intended conduct. Nonetheless, GPs found the extended consultations feasible and, in most cases, beneficial for the patient group. In interviews, most patients recounted the extended consultation as beneficial.

DISCUSSION

Our findings suggest that it is feasible to introduce extended consultations for patients with SMI in general practice, which were also found to be well-suited for eliciting patients' values and preferences. Larger studies with a longer follow-up period could help to assess the long-term effects and the best implementation strategies of these consultations.

The SOFIA pilot trial: a cluster-randomized trial of coordinated, co-produced care to reduce mortality and improve quality of life in people with severe mental illness in the general practice setting

Background

People with severe mental illness (SMI) have an increased risk of premature mortality, predominantly due to somatic health conditions. Evidence indicates that primary and tertiary prevention and improved treatment of somatic conditions in patients with SMI could reduce this excess mortality. This paper reports a protocol designed to evaluate the feasibility of a coordinated co-produced care program (SOFIA model, a Danish acronym for Severe Mental Illness and Physical Health in General Practice) in the general practice setting to reduce mortality and improve quality of life in patients with severe mental illness.

Methods

The SOFIA pilot trial is designed as a cluster randomized controlled trial targeting general practices in two regions in Denmark. We aim to include 12 practices, each of which is instructed to recruit up to 15 community-dwelling patients aged 18 and older with SMI. Practices will be randomized by a computer in a ratio of 2:1 to deliver a coordinated care program or usual care during a 6-month study period. A randomized algorithm is used to perform randomization. The coordinated care program includes educational training of general practitioners and their clinical staff educational training of general practitioners and their clinical staff, which covers clinical and diagnostic management and focus on patient-centered care of this patient group, after which general practitioners will provide a prolonged consultation focusing on individual needs and preferences of the patient with SMI and a follow-up plan if indicated. The outcomes will be parameters of the feasibility of the intervention and trial methods and will be assessed quantitatively and qualitatively. Assessments of the outcome parameters will be administered at baseline, throughout, and at end of the study period.

Discussion

If necessary the intervention will be revised based on results from this study. If delivery of the intervention, either in its current form or after revision, is considered feasible, a future, definitive trial to determine the effectiveness of the intervention in reducing mortality and improving quality of life in patients with SMI can take place. Successful implementation of the intervention would imply preliminary promise for addressing health inequities in patients with SMI.

Trial registration

The trial was registered in Clinical Trials as of November 5, 2020, with registration number NCT04618250.

Protocol version: January 22, 2021; original version

Postprandial Increase in Blood Plasma Levels of Tissue Factor-Bearing (and Other) Microvesicles Measured by Flow Cytometry: Fact or Artifact?

Tissue factor (TF)–bearing microvesicles (MVs) and exosomes may play a role in hemostasis and thrombosis. MVs may be quantified by flow cytometry (FC)–based detection of phosphatidylserine (PS)-positive submicron particles carrying specific antigens, although interference from lipoproteins complicates this approach. In this study, we evaluated the effect of food intake on blood levels of TF-bearing particles measured by FC and small extracellular vesicles (EVs) measured by a protein microarray–based test termed EV Array. Platelet-free plasma (PFP) was obtained from 20 healthy persons in the fasting state and 75 minutes after consumption of a meal. Postprandial changes in the concentration of PS-positive particles, including subgroups binding labeled antibodies against TF, CD41, CD146, and CD62E, respectively (FC), small EVs (EV Array), and TF antigen and procoagulant phospholipids (PPLs) were measured. Furthermore, we tested the effect on FC results of in vitro addition of lipoproteins to fasting PFP. We found significantly increased plasma concentrations of PS-positive particles and all examined subgroups postprandially, while no changes in small EVs, PPL, or TF antigen levels were found. Levels of all types of particles measured by FC were also elevated by lipoprotein spiking. In conclusion, meal consumption as well as in vitro addition of lipoproteins to fasting plasma induces increased levels of PS-positive particles as measured by FC, including TF-positive subtypes and subtypes exposing other antigens. While the observed postprandial increase may to some extent reflect elevated MV levels, our results indicate a substantial interference from lipoproteins.

Older patients' use of technology for a post-discharge nutritional intervention - A mixed-methods feasibility study

BACKGROUND

Malnutrition is frequent in older people and a precursor for morbidity and hospitalisation; furthermore low intake and weight loss during and after hospitalisation is well-described. Such patients are often excluded from technology projects on account of lack of skills. This is a barrier for their access to many current and future health care offers.

OBJECTIVES

To test the acceptability, feasibility and preliminary efficacy of technology-supported energy- and protein-enforced homedelivered meals for older patients discharged from hospital.

DESIGN

Mixed method design including a quasi-experimental controlled feasibility trial and embedded qualitative interviews.

PARTICIPANTS

Older medical patients (mean age 79.4 years; women 66.7%) at nutritional risk and discharged to own home were included consecutively to first the control group (n=18) and later the intervention group (n=18). Nine intervention and 16 control group patients completed the project.

METHODS

Intervention: group received: 1) enriched meals delivered to participants' homes 12 weeks after discharge, and 2) a tablet computer combining goal setting for intake with self-monitoring and feedback. Control group were treated as usual. Data collection was done at baseline, and at six and 12 weeks follow-up. Feasibility evaluation focused on 1) inclusion and retention and 2) acceptability and functionality of the intervention. Efficacy primary endpoint: Muscle strength and BMI. Secondary: Health related quality of life (HRQoL), depression; readmissions, mortality.

RESULTS

Technology challenges were related to immaturity of the out-of hospital app version; however, participants were motivated and capable of using the device. Inclusion and retention was challenged by the acceptability of the nutritional intervention and exhaustion among patients. Mortality was high. Although weaker at baseline the intervention group increased their muscle strength more consistently than did the control group: Handgrip strength with 2.5kg vs 0.9kg and chairto-stand-test with 3.3 vs. 1.8 times. They also improved their depression score and HRQoL more, and patients reported increased intake, appetite, and energy in the interviews. Relatives confirmed this and also reported positive impact on their level of worry and on the relationship with the older person.

CONCLUSION

The study provided valuable insight into appropriate methods and procedures as well as older people's preferences and views on barriers to successful intervention and use of technology in health care. This will guide the design of a future sufficiently powered study. Effect evaluation provided guidance for future sample size calculation.

Digital questionnaire platform in the Danish Blood Donor Study

OBJECTIVES

The Danish Blood Donor Study (DBDS) is a prospective, population-based study and biobank. Since 2010, 100,000 Danish blood donors have been included in the study. Prior to July 2015 all participating donors had to complete a paper-based questionnaire. Here we describe the establishment of a digital tablet-based questionnaire platform implemented in blood bank sites across Denmark.

METHODS

The digital questionnaire was developed using the open source survey software tool LimeSurvey. The participants accesses the questionnaire online with a standard SSL encrypted HTTP connection using their personal civil registration numbers. The questionnaire is placed at a front-end web server and a collection server retrieves the completed questionnaires. Data from blood samples, register data, genetic data and verification of signed informed consent are then transferred to and merged with the questionnaire data in the DBDS database.

RESULTS

The digital platform enables personalized questionnaires, presenting only questions relevant to the specific donor by hiding unneeded follow-up questions on screening question results. New versions of questionnaires are immediately available at all blood collection facilities when new projects are initiated.

CONCLUSION

The digital platform is a faster, cost-effective and more flexible solution to collect valid data from participating donors compared to paper-based questionnaires. The overall system can be used around the world by the use of Internet connection, but the level of security depends on the sensitivity of the data to be collected.

Effect of protein quality on recovery after intense resistance training

PURPOSE

The present study investigated the effects of high- versus low-quality protein supplementation on the regain of exercise performance during recovery from a period of high-intensity resistance training.

METHODS

In a diet-controlled crossover study, 12 resistance-trained participants performed two identical training periods, with each training period including four sessions of high-intensity resistance exercise during 5 days, while receiving either high- or low-quality protein. Prior to and at 3, 24 and 48 h after the training periods, performance was evaluated in knee extensor and flexor isometric maximal voluntary contraction (MVC), counter-movement jumping height (CMJ), and peak and mean anaerobic power. In addition, prior to and at 48 h after the training periods, performance in time-to-exhaustion at 70 % of VO_2max (TTE) was evaluated.

RESULTS

After the intense training periods, decrements in the order of 4-24 % were observed for MVC_ext, CMJ, mean anaerobic power, and TTE. In particular for TTE, this decrement in exercise performance did not attain full recovery at 48 h post-exercise. The regain of exercise performance was not dictated by type of protein supplement.

CONCLUSION

The regain of muscle strength as well as anaerobic or aerobic performances were not markedly influenced by the type of protein supplement.

Footstrike patterns among novice runners wearing a conventional, neutral running shoe

INTRODUCTION

It has been suggested that striking on the midfoot or forefoot, rather than the rearfoot, may lessen injury risk in the feet and lower limb. In previous studies, a disparity in distribution in footstrike patterns was found among elite-, sub-elite, and recreational runners.

PURPOSE

The purpose of this study was to investigate the footstrike patterns among novice runners.

METHODS

All runners were equipped with the same conventional running shoe. Participants were video filmed at 300 frames per second and the footstrike patterns were evaluated by two observers. The footstrike was classified as rearfoot, midfoot, forefoot, or asymmetrical.

RESULTS

A total of 903 persons were evaluated. The percentages of rearfoot-, midfoot-, forefoot-, and asymmetrical footstrike among men were 96.9%, 0.4%, 0.9%, and 1.8%, respectively. Among women the percentages were 99.3%, 0%, 0%, and 0.7%, respectively.

CONCLUSION

Nearly all novice runners utilize a rearfoot strike when taking up running in a conventional running shoe. Hereby, the footstrike patterns among novice runners deviate from footstrike patterns among elite and sub-elite runners.

Screening of toxicity and genotoxicity in wastewater by the use of the Allium test

Wastewater was collected from two municipal wastewater treatment plants and twelve different industries representing five lines of business (chemical, metallic, petrochemical, pulp- and paper, and textile dye industries). Effect on the growth of Allium roots was measured after five days of exposure. Growth inhibition values, EC50 and EC30, showed no toxic effect for eight of the fourteen plants. The most toxic effect was found in wastewater from one of the pulp- and paper plants. Allium root tip cells were analyzed for chromosome aberrations after 24 h of exposure. Wastewater from nine of the fourteen plants was able to induce chromosome aberrations at a statistically significant level. The textile dye industry was the only line of business which did not show any genotoxic effect. Three of the plants (municipal wastewater, metallic, and pulp- and paper) showed genotoxicity in spite of being nontoxic in the growth inhibition experiment.

Genotoxicity of maleic hydrazide, acridine and DEHP in Allium cepa root cells performed by two different laboratories

The purpose of this paper was to compare the results of the Allium cepa chromosome aberration assay between two laboratories under the same test protocol and at the same time, use chemicals and onions obtained in their own homeland. For this study three chemicals were selected: di(2-ethylhexyl)phthalate (DEHP), maleic hydrazide, and acridine. Both laboratories found genotoxicity with a positive dose-response relationship for maleic hydrazide and acridine. However, for DEHP the results were quite different--one of the laboratories found this compound not genotoxic but the other found a positive response. Although the comparative study was inconclusive for DEHP, it was successful for the maleic hydrazide, acridine and also for the positive control (methyl methanesulfonate). Further studies need to be performed in the case of DEPH.

Genotoxicity testing of wastewater sludge using the Allium cepa anaphase-telophase chromosome aberration assay

Wastewater sludges were analysed in the Allium cepa genotoxicity test. They were sampled during three winter periods from three Danish municipal wastewater treatment plants differing in size and industrial load. The toxicity of the sludge was tested in the Allium root inhibition assay, and the results expressed as EC30 and EC50 values showed that the toxicity could be positive correlated to the industrial load. However, when genotoxicity was tested at concentrations corresponding to the EC30 and EC50 values in the A. cepa anaphase-telophase assay, only two sludge samples from the smallest plant with the lowest industrial load induced significant chromosome aberrations. Concentrations of the heavy metal's Pb, Ni, Cr, Zn, Cu, and Cd were also determined and could partly be correlated with the toxicity of the sludge and the industrial load of the treatment plants.

Different ultrastructural morphology of Pneumocystis carinii derived from mice, rats, and rabbits

Pneumocystis carinii (PC) is a fungus present in the lungs of many mammal species. Even though studies of the genome, the isoenzymes, and the antigens have proved some host-species-linked heterogeneity, the existence of distinct Pneumocystis species or subspecies has still not been accepted. Comparative studies of the ultrastructural morphology of pneumocysts derived from several host species may support evidence of host-species-linked heterogeneity. We have compared the ultrastructural morphology of pneumocysts derived from mice, rats, and rabbits. The density of membrane-limited electron-dense cytoplasmic granules was found to be higher in mouse-derived pneumocysts than in rabbit-derived pneumocysts, and furthermore the average diameter of the granules from mouse pneumocysts was larger than that of granules from rabbit-derived pneumocysts. The average diameter of the filopodia of mouse-derived pneumocysts was smaller than that of filopodia from rat-derived pneumocysts, which was smaller than that of filopodia from rabbit-derived pneumocysts. Globular electron-dense bulbous dilatations at the tip of the filopodia were described for the first time and they were only found on filopodia of mouse-derived pneumocysts. These distinct host-species-linked morphological differences of pneumocysts from mouse, rat, and rabbit may support previous biochemical data indicating the existence of different Pneumocystis species or subspecies.

Allium cepa anaphase-telophase root tip chromosome aberration assay on N-methyl-N-nitrosourea, maleic hydrazide, sodium azide, and ethyl methanesulfonate

The Allium anaphase-telophase assay was used to show genotoxicity of N-methyl-N-nitrosourea (MNU), maleic hydrazide (MH), sodium azide (NaN3) and ethyl methanesulfonate (EMS). All agents induced chromosome aberrations at statistically significant levels. The rank of the lowest doses with positive effect was as follows: NaN3 0.3 mg/l < MH 1 mg/l < MNU 41 mg/l < EMS 100 mg/l. The results were compared with results from other plant assays (Arabidopsis, Vicia, Tradescantia) and for MH and MNU the values were found to be within the same range, whereas the results in the Allium test for NaN3 and EMS were in a lower range than that found for the other plant assays. EMS and MMS (methyl methanesulfonate), two chemicals used as positive controls in mutagenicity testing, were compared in the Allium test, and MMS was found to be about ten times more potent in inducing chromosome aberrations than EMS. Recording of micronuclei in interphase cells showed that this endpoint does not give more information of clastogenicity than recording of chromosome aberrations in anaphase-telophase cells.

Localization of NCAM on NCAM-B-expressing cells with inhibited migration in collagen

The extracellular matrix is a key element in neuronal development and tumour invasion, providing a substratum which sustains the adhesion and migration of cells. In order to study interactions between the neural cell adhesion molecule (NCAM) and collagen, we transfected mouse L cells with cDNA encoding the human transmembrane NCAM isoform of 140 kDa (NCAM-B). An L-cell/collagen type I system was used to study the influence of NCAM expression on in vitro invasion. We here report that migration of NCAM-expressing cells in collagen was inhibited compared to that of NCAM-negative cells transfected with the empty vector. Immunofluorescence confocal laser scanning microscopy (CLSM) and immunogold electron microscopy using anti-human NCAM antibodies demonstrated a heterogeneous distribution of NCAM on the plasma membrane of transfected L cells grown on collagen. NCAM was preferentially located at the surface of broad cytoplasmic protrusions and slender extensions, some of which were facing the collagen. This was in contrast to the homogeneous surface distribution of NCAM on cells grown on plastic. These data suggest that NCAM and collagen type I interact, and that this might lead to the migration inhibition of NCAM-expressing cells.

Epithelial transport and bioavailability of intranasally administered human growth hormone formulated with the absorption enhancers didecanoyl-L-alpha-phosphatidylcholine and alpha-cyclodextrin in rabbits

The transepithelial transport of biosynthetic human growth hormone (hGH) formulated with the absorption enhancers didecanoyl-L-alpha-phosphatidylcholine (DDPC) and alpha-cyclodextrin (alpha-CD) was studied after intranasal administration to rabbits. Plasma concentrations of the hormone were determined until 240 min post administration by ELISA, and the absolute bioavailability was estimated to be in the vicinity of 20%. The localization of hGH was studied 15 min after application of the powder formulation in the initial absorptive phase. To visualize the hormone, a two-step indirect immuno-gold technique was used on semithin and ultrathin cryosections and Epon sections. Polyclonal rabbit anti-hGH was used as primary antibody and gold-conjugated goat anti-rabbit IgG as secondary antibody, succeeded by silver enhancement. Growth hormone was mainly found in the cytoplasm and nuclei of ciliated cells, showing distinct morphological signs of early necrosis, and in lamina propria, including the venules. Minute amounts of hGH were found in endocytotic vesicles in morphologically normal epithelial cells and in the intercellular compartment. We conclude that the major transport route of hGH formulated with absorption enhancers DDPC and alpha-CD was transcellular through lethally damaged ciliated cells.

Immunoelectron microscopy of the receptor for urokinase plasminogen activator and cathepsin D in the human breast cancer cell line MDA-MB-231

Receptors for urokinase-type plasminogen activator (uPAR) are present on the surface of many cell types and appear to be the key determinant controlling extracellular proteolysis catalyzed by the urokinase-type plasminogen activator (uPA). Receptor-bound uPA may be inhibited by the specific inhibitors PAI-1 and PAI-2, and the complex thus formed may subsequently be internalized and degraded in lysosomes. Biochemical evidence has recently indicated that also uPAR is internalized with the uPA/uPAI complex. We report here the subcellular localization of uPAR and cathepsin D in the MDA-MB-231 human breast cancer cell line studied by immuno-electron microscopy of ultrathin cryosections using single or double immunostaining techniques. Cell surface uPAR was preferentially localized at cell-cell junctions; cytoplasmic uPAR was inside large vesicles of different morphology and in flat Golgi saccules. A number of vesicles also contained cathepsin D. The uPAR was exclusively membrane-bound at the cell surface and in cytoplasmic vesicles without cathepsin D. In lysosomal vesicles with both cathepsin D and u-PAR, uPAR was probably degraded as it was observed in the luminal contents.

Isolation and characterization of gelatinase granules from human neutrophils

We recently confirmed the existence of gelatinase granules as a subpopulation of peroxidase-negative granules by double-labeling immunogold electron microscopy on intact cells and by subcellular fractionation. Further characterization of gelatinase granules has been hampered by poor separation of specific and gelatinase granules on both two-layer Percoll gradients and sucrose gradients. We have developed a three-layer Percoll density gradient that allows separation of the different granules and vesicles from human neutrophils; in particular, it allows separation of specific and gelatinase granules. This allows us to characterize these two granule populations with regard to their content of membrane proteins, which become incorporated into the plasma membrane during exocytosis. We found that gelatinase granules, defined as peroxidase-negative granules containing gelatinase but lacking lactoferrin, contain 50% of total cell gelatinase, with the remaining residing in specific granules. Furthermore, we found that 20% to 25% of both the adhesion protein Mac-1 and the NADPH-oxidase component cytochrome b558 is localized in gelatinase granules. Although no qualitative difference was observed between specific granules and gelatinase granules with respect to cytochrome b558 and Mac-1, stimulation of the neutrophil with FMLP resulted in a selective mobilization of the least dense peroxidase-negative granules, ie, gelatinase granules, which, in concert with secretory vesicles, furnish the plasma membrane with Mac-1 and cytochrome b558. This shows that gelatinase granules are functionally important relative to specific granules in mediating early inflammatory responses.

Confocal fluorescence microscopy of urokinase plasminogen activator receptor and cathepsin D in human MDA-MB-231 breast cancer cells migrating in reconstituted basement membrane

Using confocal fluorescence microscopy with a monoclonal antibody, we have localized the receptor for urokinase plasminogen activator (uPAR) in MDA-MB-231 human breast cancer cells migrating into a reconstituted basement membrane. Patchy and polarized uPAR immunoreactivity was found at the cell membrane, and strong staining was found both in the ruffled border or leading edge of the cells and at pseudopodia penetrating into the membrane. Intracellular uPAR staining was localized in the paranuclear region and in rounded granule-like structures; some of these were identified as lysosomes by double staining for uPAR and the lysosomal enzyme cathepsin D. Urokinase plasminogen activator (uPA) activity has previously been shown to play a role in migration of cells into basement membranes, and it has been proposed that uPAR also is involved in this process. uPA is known to be internalized and degraded after complex formation with the inhibitor PAI-1. Lysosomal uPAR immunoreactivity may result from concomitant internalization of the receptor.

Evaluation of the Allium anaphase-telophase test in relation to genotoxicity screening of industrial wastewater

The Allium anaphase-telophase test was evaluated to find out if it could be recommended in the screening of wastewater for genotoxicity. Five mutagenic or carcinogenic chemicals usually found in wastewater were tested in the Allium anaphase-telophase test. Sodium dichromate (25 microM), benzene (100 microM), dichloromethane (175 microM) and 1,1,1-trichloromethane (175 microM) increased the frequency of chromosome aberrations in the root cells, whereas formaldehyde (1 mM) was found to be non-mutagenic in this test system. Other studies where chemicals were tested in the Allium test were reviewed. For 15 chemicals the results were compared with results from the Ames test, the Microscreen assay, and carcinogenicity tests in rodents. The sensitivity of the Allium test was calculated to be 82%. In conclusion the Allium test is recommended for the screening of wastewater because it has a high sensitivity, is cheap, rapid, easy to handle, and because it can be used on wastewater without pretreatment of the sample.

Human neutrophil granules and secretory vesicles

The traditional classification of neutrophil granules as peroxidase-positive (azurophil, or primary) and peroxidase-negative (specific or secondary) has proven to be too simple to explain the differential exocytosis of granule proteins and incorporation of granule membrane into the plasma membrane which is an important aspect of neutrophil activation. Combined subcellular fractionation and immunoelectron microscopy has revealed heterogeneity among both peroxidase-positive and peroxidase-negative granules with regard to their content, mobilization and time of formation. Peroxidase-negative granules may be classified according to their content of lactoferrin and gelatinase: 15% of peroxidase-negative granules contain lactoferrin, but no gelatinase. 60% contain both lactoferrin and gelatinase. The term specific or secondary granule should be reserved for these two subsets. In addition, 25% of peroxidase-negative granules contain gelatinase but no lactoferrin. These should be termed gelatinase granules or tertiary granules. Gelatinase granules are formed later than specific granules and mobilized more readily. In addition, a distinct, highly mobilizable intracellular compartment, the secretory vesicle, has now been recognized as an important store of surface membrane-bound receptors. This compartment is formed in band cells and segmented cells by endocytosis. This heterogeneity among the neutrophil granules is of functional significance, and may also be reflected in the dysmaturation which is an important feature of myeloproliferative and myelodysplastic disorders.

Chromosomal breakage, endomitosis, endoreduplication, and hypersensitivity toward radiomimetric and alkylating agents: a possible new autosomal recessive mutation in a girl with craniosynostosis and microcephaly

A high frequency of spontaneous chromosomal breakage, endomitosis, endoreduplication and hypersensitivity toward both the alkylating agent Trenimon and the radiomimetric drug bleomycin was observed in phytohemagglutinin-stimulated peripheral lymphocytes from a girl with craniosynostosis, microcephaly, ptosis, bird-like facies, and moderate mental retardation. We also observed abnormal chromosomal spiralization and some aspects of abnormal cellular division. Several fruitless attempts were made to establish a cell line. The parents were consanguineous, supporting the existence of a new, rare, autosomal, recessive condition in man. The mutation might involve a gene involved in DNA repair and/or regulation of the mitotic cycle.

Separation of human neutrophil plasma membrane from intracellular vesicles containing alkaline phosphatase and NADPH oxidase activity by free flow electrophoresis

A putative reservoir of functional plasma membrane proteins, the secretory vesicle identified by latent alkaline phosphatase and tetranectin, has previously been demonstrated based on indirect evidence (Borregaard, N., Miller, L. J., and Springer, T. A. (1987) Science 237, 1204-1206; Borregaard, N., Christensen, L., Bjerrum, O. W., Birgens, H. S., and Clemmesen, I. (1990) J. Clin. Invest. 85, 408-416). Difficulties in separating plasma membranes from this entity by density gradient centrifugation has prohibited discriminative dynamic and quantitative studies of secretory vesicles and plasma membranes. By combining density centrifugation with free flow electrophoresis we overcame this obstacle. Freshly prepared unperturbed human neutrophils were subjected to nitrogen cavitation followed by density centrifugation on Percoll gradients. Light membrane fractions containing plasma membranes and secretory vesicles were applied to high voltage free flow electrophoresis on an Elphor VaP 22. Plasma membrane vesicles, identified by HLA class I antigen mixed enzyme-linked immunosorbent assay (Bjerrum, O. W., and Borregaard, N. (1990) Scand. J. Immunol. 31, 305-313) and 125I applied to cells before cavitation, were clearly separated from secretory vesicles. Electron microscopy revealed a morphology typical of plasma membranes in the former fraction and a population of vesicles with markedly different appearance in the latter. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis profiles demonstrated distinct differences in protein patterns between the two fractions. Superoxide generating capacity induced by sodium dodecyl sulfate and cytosol, an entity traditionally ascribed to the plasma membrane, was largely confined to fractions containing secretory vesicles. Thus, the majority of membrane-bound NADPH oxidase components of light membranes of human neutrophils colocalize with secretory vesicles.

Stimulus-dependent secretion of plasma proteins from human neutrophils

In search for matrix proteins released from secretory vesicles of human neutrophils, a prominent 67-kD protein was identified in the extracellular medium of neutrophils stimulated by the chemotactic peptide, FMLP. The protein was purified to apparent homogeneity and partially sequenced. The sequence of the first 32 NH2-terminal amino acids was identical to the sequence of albumin. mRNA for human albumin could not be detected in bone marrow cells, nor could biosynthetic labeling of albumin be demonstrated in bone marrow cells during incubation with [14C]leucine. Immunofluorescence studies on single cells demonstrated the presence of intracellular albumin in fixed permeabilized neutrophils. Light microscopy of immunogold-silver-stained cryosections visualized albumin in cytoplasmic "granules." The morphology of these was determined by immunoelectron microscopy as vesicles of varying form and size. Subcellular fractionation studies on unstimulated neutrophils demonstrated the presence of albumin in the low density pre-gamma and gamma-regions that contain secretory vesicles, but are devoid of specific granules and azurophil granules. Albumin was readily released from these structures during activation of neutrophils with inflammatory mediators. Immunoblotting demonstrated the presence of immunoglobulin and transferrin along with albumin in exocytosed material from stimulated neutrophils. This indicates that secretory vesicles are unique endocytic vesicles that can be triggered to exocytose by inflammatory stimuli.

Fine structure of neutrophils from turpentine-induced pleuritis in mice, simulating rheumatoid arthritis cells

Pleural effusions were made by intrapleural turpentine installation in mice. The fine structure of inflammatory cells from the effusions was normal except for lipid inclusions. The same type of inclusion was previously found in neutrophils from pleural effusions in patients with tuberculous infection, rheumatoid disease, or carcinomatosis. The lipid inclusions observed in neutrophils from an irritative turpentine-induced pleurisy should be considered as "fatty change", and are structurally similar to the rheumatoid arthritis cells seen in patients with different diseases.

Ultrastructural localization of the Pasteurella multocida toxin in a toxin-producing strain

Toxigenic strains of Pasteurella multocida produce the 147 kDa protein Pasteurella multocida toxin (PMT) which is responsible for the osteoclastic bone resorption in progressive atrophic rhinitis in pigs and induces such resorption in all experimental animals tested so far. In the present study we have carried out immunocytochemistry on formaldehyde- and glutaraldehyde-fixed ultracryocut P. multocida using a pool of monoclonal antibodies against different epitopes on PMT as the first layer and affinity purified rabbit anti-mouse IgG as the second layer. Goat anti-rabbit IgG conjugated with 5 nm gold particles was used as marker. The gold particles were silver-enhanced prior to examination in the transmission electron microscope. Whole bacteria were also immunostained after fixation and critical point drying and examined by scanning transmission electron microscopy. The results showed that PMT was located in the cytoplasm of P. multocida. PMT could not be detected on intact, undamaged P. multocida by scanning electron microscopy. Neither pili nor flagella could be detected on the surface of the negatively stained P. multocida strains investigated. PMT has a series of characteristics encompassed in the definition of an exotoxin. However, that PMT was not secreted by living intact P. multocida is unexpected for an exotoxin.

Intracellular maturation and sorting of two herpes simplex virus type 1 glycoproteins. Immunogold staining of ultrathin cryosections

Simultaneous immunocytochemical triple staining of ultrathin cryosections of herpes simplex virus type 1-infected cells was carried out using monoclonal antibodies specific for glycoprotein C, glycoprotein D and alpha + beta tubulin. The viral glycoproteins were identified in the cytoplasm, in the Golgi sacs, on the plasma membrane and on the surface of intra- and extracellular virus particles, but not on the nuclear membrane. The glycoproteins identified in the cytoplasm outside the Golgi region were not always confined to the membranes of vesicles, but were often located in close proximity to the tubulin-labelled structures. The glycoproteins C and D were usually codistributed in the cytoplasm, and both accumulated in the Golgi sacs in the same membrane domains. As the glycoproteins occur in close proximity to the microtubular structures, we speculate that these might be directly involved in the intracellular transport of viral glycoproteins.

Morphology of Pneumocystis carinii and activation of the plasmalemmal vesicular system in alveolar epithelial cells of the host. An ultrastructural study

Lungs from rats with dexamethasone-induced Pneumocystis carinii pneumonia were examined. The ultrastructure of Pneumocystis carinii and their zone of attachment on type I alveolar epithelial cells are described. An activation of the plasmalemmal vesicular system of type I alveolar epithelial cells was observed and is described here for the first time. The significance of this observation is discussed.

Kala-azar in a four-year-old child 18 months after brief exposure in Malta

A four-year-old Danish boy developed kala-azar 18 months after a holiday in Malta. Splenectomy, with liver biopsy, was performed six months after onset of symptoms because of hypersplenism, and the diagnosis of kala-azar was only made four months later, when the histopathological specimens were reviewed. Previous bone marrow biopsies did not show Leishmania. Treatment with sodium stibogluconate was successful. The development of kala-azar after one week's stay in an endemic area stresses the importance of including this potentially fatal disease in the differential diagnosis of cases presenting with fever, splenomegaly, and pancytopenia.

Simultaneous triple-immunogold staining of virus and host cell antigens with monoclonal antibodies of virus and host cell antigens in ultrathin cryosections

The mechanism of intracellular maturation and sorting of herpes simplex virus type I glycoproteins is not known in details. To elucidate the intracellular sorting of viral glycoproteins and their possible interaction with the cytoskeleton, a method for simultaneous immunogold staining of three antigens in ultrathin cryosections is described. Each antigen is stained by an indirect technique using mouse monoclonal IgG as first layer, rabbit anti-mouse IgG as second and gold-conjugated goat anti-rabbit IgG as third layer antibody. After each staining cycle the sections are covered by methyl cellulose and exposed to paraformaldehyde vapour at 80 degrees C for 30 min. This destroys the free antigen combining sites of the second and the third layer IgG and abolish contaminating staining. Simultaneous triple-staining is documented with three mouse monoclonal antisera specific for 1) herpes simplex virus type 1 glycoprotein C, 2) glycoprotein D and 3) alpha- and beta-tubulin as primary antibodies. Labelling for virus glycoproteins was found in some Golgi vesicles and close to the cytoplasmic microtubules as well as on the cell surface and on intracytoplasmic and extracellular virus particles.

Reimplantation of a benign ovarian tumor

An unusual case of a benign ovarian tumor, which had been torn off its primary usual anatomical site and transplanted to a new intra-abdominal location with new blood supply from the omentum, is described.

Simultaneous demonstration of two antigens in ultrathin cryosections by a novel application of an immunogold staining method using primary antibodies from the same species

A recently developed immunocytochemical double-staining method for ultrathin Epon and Lowicryl K4M sections has been adopted for use on ultrathin cryosections. The essential features of the method include: staining for the first antigen by the indirect method using sufficient concentrations of second antibodies conjugated to colloidal gold particles to saturate available epitopes on the primary antibodies; supporting the cryosections by methyl cellulose followed by paraformaldehyde vapour treatment (30-60 min at 80 degrees C); removal of the methyl cellulose followed by staining for the second antigen using primary antiserum from the same species and another size class of colloidal gold particles conjugated to second antibodies. Contaminating staining does not occur if the paraformaldehyde vapour treatment exceeds 30 min, as this treatment destroys the combining sites on the second antibodies applied in the first staining cycle. Successful double-staining was documented using primary rabbit antibodies to growth hormone and corticotropin and anti-rabbit IgG conjugated to 5 and 15 nm colloidal gold particles. Following double-staining, the ultrathin cryosections may be silver-enhanced to improve detectability of the markers at low magnification.

Comparison of characteristics of human small cell carcinoma of the lung in patients, in vitro and transplanted into nude mice

Specimens from 24 patients with metastatic small cell carcinoma of the lung were explanted in vitro as well as transplanted directly into nude mice. A method to obtain fibroblast-free cultures is described. This method resulted in cell lines which could be grown for more than one year in 79% of the cases. Fifty-four % of the tumours could be established as serially transplantable tumours in nude mice. The tumours were characterized by histology, electron microscopy, DNA index, and cell cycle distribution. The in vitro cell lines were furthermore characterized by the plating efficiency and by doubling time. The macroscopic growth of the heterotransplanted tumours was ascribed to a transformed Gompertz function. The tumour cells preserved their light microscopic constitution of small cell carcinoma of the lung in the model systems. The heterogeneity of the original tumours was reflected in vitro and in nude mice and the model systems thus allows an expression of the inherent heterogeneity and instability. The panel of transplantable tumours and the in vitro cell lines offer the study of biology inclusive of tumour progression of SCCL.

Morphological studies of the cytotoxicity of Trichomonas vaginalis to normal human vaginal epithelial cells in vitro

In vitro cultured monolayers of normal human vaginal epithelial cells were incubated with axenic cultures of Trichomonas vaginalis. Two strains freshly isolated from patients with trichomoniasis and one strain that had been maintained in axenic culture for several years were studied. Freshly isolated trichomonads showed amoeboid movements, adherence to epithelial cell surfaces, and were cytotoxic to epithelial cells in vitro. In contrast, the laboratory strain maintained for years in axenic culture did not adhere to the epithelial cell monolayer and was only cytotoxic at a concentration 100 times that of freshly isolated trichomonads. Electron microscopy of monolayers exposed to T vaginalis for 24 hours showed that all epithelial cells in intimate contact with trichomonads had more or less disintegrated, whereas in monolayers exposed for six hours some of the epithelial cells in contact with T vaginalis were normal. T vaginalis organisms with amoeboid morphology contained a dense network of microfilaments in the part of the trichomonad that was in contact with an epithelial cell. Occasionally a pseudopodium was projected into the cytoplasm of disintegrated epithelial cells.

Malignant histiocytosis in childhood. Clinicopathological study of 4 cases

Clinicopathological features of four paediatric cases of malignant histiocytosis (MH) are described. The patients all presented with fever, lymphadenopathy and anaemia. Two died from widespread disease within one month. Two patients, who received combination chemotherapy, were brought into remission and are currently without disease after 30 and 60 months, respectively. Diagnosis was made on the basis of infiltration by a mixture of anaplastic and well-differentiated phagocytic histiocytes in skin, lymph node, bone marrow and spleen. Immunohistochemical studies showed variable presence of lysozyme, alpha 1-antitrypsin (AT), and alpha 1-antichymotrypsin (ACT). Concanavalin A (Con A) receptors, recently suggested as a histiocyte marker, were found in the proliferating cells in all cases. S-100 protein was absent. The findings suggest that the prognosis in childhood MH remains guarded but not hopeless with aggressive combination chemotherapy. The presence of Con A receptors in paediatric MH cells with a more constant occurrence than lysozome, AT and ACT seems promising as an additional diagnostic tool although further studies are needed to examine the specificity of Con A receptors in relation to various other disorders of histiocytic proliferation.

Silver-enhanced colloidal gold probes as markers for scanning electron microscopy

Silver enlargement of small colloidal gold particles has been extensively used for the light microscopical visualization of gold probes. Very recently, a few investigators have employed physical developers in electron microscopy (both pre-embedding and on-grid staining methods). We now demonstrate that physical development of small colloidal gold particles advantageously can be exploited for labelling biological surfaces in scanning electron microscopy. This novel application of silver enhancement of colloidal gold particles is characterized by a high detection efficiency. Thus, specimens are labelled with small gold probes affording high immunocytochemical efficiency but being impossible to detect with the present scanning microscopes. These particles are subsequently scanning electronmicroscopically visualized by silver enhancement.

Disseminated histiocytosis X. A clinical and immunohistochemical retrospective study

Fourteen cases of disseminated histiocytosis x (HX) from a 15 year period were studied clinicopathologically. Morbidity and mortality were comparable to that of previous reports on disseminated HX. S-100 protein, recently established as a HX marker, was demonstrated immunohistochemically in the cytoplasm and the nuclei of the HX cells of 12 examined cases. Neuron specific enolase (NSE) positive material was found in a minority of the cells of 2 cases. Cytoplasmic lysozyme was present in the mononuclear cells accompanying the HX cells in all examined cases. These results show that immunohistochemical demonstration of S-100 protein and lysozyme can be successfully applied to formalin-fixed, paraffin embedded tissue after storage at room temperature for as long as 15 years. The presence of cytoplasmic NSE positivity in the lesions from 2 patients was surprising and has not previously been observed in HX. This finding suggests an antigenic heterogenicity between cases with the disease of unknown prognostic significance. Nor did the presence of lysozyme in the lesions from patients with acute as well as chronic disease yield any prognostic information.

Genetic instability of cell lines derived from a single human small cell carcinoma of the lung

Specimens from a human small cell carcinoma of the lung were established as a cell line in vitro. Flow cytometric DNA analysis demonstrated only one tumor cell population in the parent tumor as well as in the early passages in vitro. After six passages in vitro, two new subpopulations with different DNA content appeared. By cloning, permanent cell lines were established from the new subpopulations, whereas the original population stopped growing. The cloned cell lines were characterized by morphology, chromosomes analysis, electron microscopy and plating efficiency; the stability of the DNA content was examined regularly by flow cytometric DNA analysis and instability was found in one of the cloned cell lines. Chromosome analysis showed that the cloned cell lines consisted of more than one population after 17 in vitro passages. Both cloned cell lines produced tumors in nude mice. Genetic instability was demonstrated in these mouse-grown tumors as well. Development of resistance to antineoplastic treatment may be due to heterogeneity in sensitivity among subpopulations in a tumor. Isolation of populations with different DNA contents allows the study of interaction between subpopulations and the observations provide evidence in support of the hypothesis of clonal evolution.

Persistent subcutaneous nodules in children hyposensitized with aluminium-containing allergen extracts

A follow-up study of 202 children who had received hyposensitization with aluminium-containing allergens showed that 1-3 years after cessation of hyposensitization 13 children still had severely pruiginous treatment-resistant subcutaneous nodules in their forearms. Because of their long persistence the nodules of six children were studied in detail. Histologically, the nodules showed infiltration with lymphocytes (forming germinal centres), macrophages, plasma cells, mast cells and a few eosinophils. In five patients aluminium crystals were found scattered between the cells and, in addition, the phagosomes of the macrophages contained aluminium. Patch tests for aluminium were positive in four of the six patients. It is concluded that persisting nodules during hyposensitization with aluminium-containing allergens may indicate development of aluminium hypersensitivity, and if this is confirmed hyposensitization should be discontinued.

Congenital self-healing reticulohistiocytoma. A clinical, histological and ultrastructural study

A 2 300 g male infant presented at birth with multiple, firm, bluish skin nodules, petechiae and thrombocytopenia. Physical examination was otherwise normal and no biochemical signs of organ dysfunction were found. A skin biopsy, done on the second day of life, was consistent with self-healing reticulohistiocytoma by light and electron microscopy. The nodules spontaneously resolved during the following months. At one year follow-up, he was without evidence of disease, the only sequelae being occasional discrete scarring. The major problem with this rare entity lies in its dramatic presentation and the chance of possible hazardous "overtreatment".

Intracellular pathways of native iron in the maternal part of the porcine placenta

In the diffuse epitheliochorial porcine placenta iron is secreted as uteroferrin by the maternal epithelium of the areola-gland subunit of the placenta. To elucidate the intracellular pathways of physiological iron in uterine gland epithelium material from 10 sows at 15 to 111 days of gestation was processed for electron microscopy by different routine methods with or without postfixation in osmium tetroxide. Ferritin particles were identified by their size and shape and the content of iron was confirmed by X-ray energy dispersive microanalysis of accumulated ferritin particles. Distinct ferritin particles were not observed in the extracellular space either basal to or luminal to the epithelial cells. Intracellular ferritin was observed apparently free in the cytoplasm, but in variable amounts. Transfer tubules and dense bodies were located basally in the secretory cells. Both of these organelles contained ferritin particles, showed reaction sites for acid phosphatase and were stained by periodic acid-thiocarbohydrazide-silver proteinate. The ciliated cells differed by having apically located dense bodies containing numerous ferritin particles. Our finding of native ferritin in cells with hormonally regulated iron transport supports the concept that transfer tubules as part of the lysosomal complex are part of the endocytic pathway in secretory cells and indicate that ferritin here is an intracellular transport or storage intermediate.

The permeability of the blood-brain barrier in mice suffering from fatal lymphocytic choriomeningitis virus infection

The ultrastructure and the blood-brain-barrier (BBB) permeability were studied in mice suffering from lymphocytic choriomeningitis (LCM). Brains and meninges from mice suffering from LCM virus-induced lymphocytic choriomeningitis were studied by investigating the BBB function and by electron and light microscopy. The cellular exudate in the leptomeninges was located in the subarachnoid space, in arachnoidea and pia, and it was dominated by proliferated pial cells and mononuclear cells, most of which were lymphocytes, while there were only a few neutrophil granulocytes. Many intravascular lymphocytes were seen adhering to as well as penetrating the vessel walls. Many of these lymphocytes were morphologically compatible with T cells. Lymphocytes and larger mononuclear cells were also accumulated in the choroid plexus, and lymphocytes were present in the ventricular system with a tendency to adhere to ependymal epithelial cells. Inspection of the ultrathin sections incubated for horseradish peroxidase (HRP)-activity revealed that the overwhelming part of the peroxidase activity was localized in the extracellular space of the meningeal vessel walls and especially in the abundant intercellular fluid which, like the inflammatory cells, was found in the subarachnoid space in arachnoidea and in pia. In the neuropil, only very small quantities of reaction product were seen intercellularly in the most superficial layers of the cortex. The tight junctions were always intact, but the possibility of a non-demonstrable opening is discussed. Evaluation of the BBB permeability for 2-amino[1-14C]isobutyric acid (AIB) was made by quantitative autoradiography, and it was demonstrated convincingly that AIB concentrations in the subpial and perichorodial tissues were markedly increased in diseased animals as compared to the controls. Our results seem to contradict previous theories on the cause of death resulting from the LCM disease. The findings presented here do not speak in favor of a pronounced brain edema, just as results obtained by us and others do not speak for the possibility of the death being caused by convulsive seizures with subsequent brain anoxia. However, our observations are compatible with the hypothesis that cytotoxic T cells may interact in vivo with virus-infected targets, which are essential for the regulation of the composition of the cerebrospinal fluid. On the other hand, the dysfunction of the BBB demonstrated adds a new element to the pathologic mechanism in a model for the study of virus-induced meningitis.

Primary and secondary ciliary dyskinesia

It has recently been shown that patients with Kartagener's triad and also some subjects with similar symptoms, but without situs inversus, have a congenital abnormality of cilia as an explanation for their chronic airway symptoms; this disease has been named "the immotile-cilia syndrome" or more correctly "primary ciliary dyskinesia". Studying 27 such patients, we have found daily nose blowings since birth, chronic-recurrent sinusitis, and chronic secretory otitis media highly characteristic features. The frequency of common colds was not increased, and most patients did not suffer from repeated episodes of acute purulent otitis media. The number of ciliated cells with immotile cilia was increased, but only a single patient had completely immotile cilia; also the degree of asynchrony within the single ciliated cell was increased. Electron microscopy showed a decreased number of dynein arms in some patients, and abnormal arrangement of microtubules in others. Some patients, however, had normal ultrastructure, and this appeared to be associated with a hyperfrequent beating pattern. At least three subgroups of patients with primary ciliary dyskinesia can be delineated based on the motility-ultrastructure studies. Bacterial infection tends to reduce the number of ciliated cells with motile cilia, and viral infection (common cold) gives a very marked and long-lasting reduction in the number of ciliated cells. This may account for some otherwise unexplainable subchronic symptoms from nose and throat.

Carcinoma in situ of the testis. Some ultrastructural characteristics of germ cells

The two cytoplasmic organelles, dense-cored vesicles and "nuages" have been considered to allow positive identification of primordial germ cells in rodents, but no use of these potential markers has been applied to human material. We have observed dense-cored vesicles and "nuages" in the abnormal germ cells of carcinoma in situ of the testis and thus brought further evidence for the germ cell origin of this lesion. These organelles may be useful cytoplasmic markers in the study of germ cell tumors.