Obstructive sleep apnoe and cardiovascular, heart failure and mortality outcomes with empagliflozin versus placebo in the EMPA-REG OUTCOME trial

Background/Introduction

Obstructive sleep apnoe (OSA) and type 2 diabetes (T2D) occurs more frequently in persons with obesity, and both OSA and T2D are associated with metabolic disturbances that increases the risk for cardiovascular disease (CVD). In EMPA-REG OUTCOME, a randomized placebo-controlled outcome trial involving 7020 patients with T2D and CVD, the sodium glucose co-transporter (SGLT)-2 inhibitor empagliflozin reduced HbA1c, systolic blood pressure, waist circumference, and weight, and also reduced the risk of 3-point major adverse CV events (3P- MACE) by 14%, CV death by 38% and hospitalization for heart failure (HHF) by 35%.

Purpose

We investigated incidence rates of CV, HHF, and mortality outcomes in patients with or without OSA at baseline, and the treatment effect of empagliflozin, in EMPA-REG OUTCOME.

Methods

The trial included patients from 42 countries with T2D (with HbA1c 7.0–9.0% for drug-naïve patients and 7.0–10.0% for those on stable glucose-lowering therapy), established CVD, and estimated glomerular filtration rate >30 mL/min/1.73 m2. Patients were randomised (1:1:1) to receive empagliflozin 10 mg, empagliflozin 25 mg, or placebo once daily in addition to standard of care. All CV outcomes were independently adjudicated and events were pooled for the 10 and 25mg doses. In this post-hoc analysis, OSA were assessed based on investigator reports using MedDRA 18.0 and incidence rates for outcomes were reported by adjusted event-rates per 100 patient-years. Analysis of effects on outcomes were performed using Cox regression models with multivariable adjustments.

Results

Of 7020 patients with T2D and CVD, OSA was reported in 391 (5.6% [placebo 5.4%; pooled empagliflozin doses 5.7%]. Compared with patients without OSA at baseline, those with OSA were more frequent males (82.9% vs 70.8%), living in region North-America (63.2% vs 17.3%), and had more obesity (BMI ≥35 kg/m2: 55.2% vs 18.2%) and more coronary artery disease (88.0 vs 74.9%). Over a median 3.1 years, individuals with OSA at baseline relative to those without OSA in the placebo group, experienced 1.3–2.0 fold higher event rates for 3P-MACE (OSA vs no OSA: 6.49 vs 4.27/100-patient-year), CV death (2.57 vs 1.99), HHF (2.71 vs 1.38) and all-cause mortality (4.29 vs 2.78). Empagliflozin improved CV, HHF, and mortality outcomes regardless of presence of OSA at baseline (p-for interactions >0.05 [Figure 1]).

Conclusions

In this post-hoc exploratory analysis, patients with OSA had higher frequency of events for 3P-MACE, HHF and mortality. The cardio-protective effects of empagliflozin was consistent in those with and without OSA at baseline.

Figure 1. Sleep apnea and empagliflozin

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boehringer Ingelheim and Eli Lilly Diabetes Alliance

P6272First plus recurrent CV and hospitalization events in the CArdiovascular and Renal Microvascular outcomE study with LINAgliptin (CARMELINA) in patients with type 2 diabetes and cardiorenal disease

Background/Introduction

CARMELINA was a randomized placebo-controlled clinical trial designed to demonstrate the cardiovascular (CV) safety of linagliptin in patients with type 2 diabetes (T2D) and concomitant cardiorenal disease. Despite a particularly elevated CV risk, only limited long-term evidence from randomized controlled trials for safety and efficacy of glucose lowering medications is available for this population.

Purpose

To characterize the effects of linagliptin on net CV disease and hospitalization burden in this population.

Methods

People with T2D and either i) urine albumin creatinine ratio (UACR) >30 mg/g with concomitant CV disease, or ii) estimated glomerular filtration rate (eGFR) <45 ml/min/1.73m2 regardless of UACR, or eGFR ≥45–75 mL/min/1.73m2 and UACR >200 mg/g, were randomized to linagliptin 5 mg or placebo q.d. in a double-blind fashion in addition to standard of care. We assessed the effects of linagliptin versus placebo on all first plus recurrent CV events and all-cause hospitalizations using a using a negative binomial model to account for within-subject correlation.

Results

A total of 6979 participants were enrolled (mean age 66 years, 63% male, eGFR 54.6 ml/min/1.73m2, median UACR 162 mg/g, 59% with history of ischemic heart disease, 27% with history of heart failure (HF)) and followed for a median of 2.2 years. Adding recurrent events increased the number of events for analysis from 5.3–57.5% across CV/HF outcomes and 112.4% for hospitalizations. In analyses of first plus recurrent events, the event rate ratio (95% CI) with linagliptin versus placebo was 0.98 (0.82, 1.16; p=0.78) for 3-point MACE, 1.03 (0.79, 1.35; p=0.83) for myocardial infarction 1.03 (0.83, 1.29; p=0.77) for myocardial infarction plus revascularization, 0.89 (0.65, 1.22; p=0.48) for stroke, 0.94 (0.70, 1.27; p=0.69) for stroke plus TIA, 0.94 (0.75, 1.20; p=0.63) for hospitalized HF, 0.92 (0.77, 1.11; p=0.40) for the composite of CV death or hospitalized HF, and 0.96 (0.87, 1.06; p=0.40) for all-cause hospitalization (Figure).

Conclusion

Linagliptin showed similar risk of either first or recurrent CV or hospitalization events compared with placebo in patients with T2D and cardiorenal disease. These data support the CV safety of linagliptin and, considering the high volume of recurrent events, underscores the significant CV disease burden experienced by patients with T2D and cardiorenal disease

Acknowledgement/Funding

Boehringer Ingelheim and Eli Lilly

Latitude of the study place and age of the patient are associated with incidence of mediastinitis and microbiology in open-heart surgery: a systematic review and meta-analysis

Objective

We aimed to summarize the pooled frequency of mediastinitis following open-heart surgery caused by Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), and Gram-negative bacteria.

Design

This study was a systematic review and a meta-analysis of prospective and retrospective cohort studies.

Materials and methods

We searched the literature, and a total of 97 cohort studies were identified. Random-effect model was used to synthesize the results. Heterogeneity between studies was examined by subgroup and meta-regression analyses, considering study and patient-level variables. Small-study effect was evaluated.

Results

Substantial heterogeneity was present. The estimated incidence of mediastinitis evaluated from 97 studies was 1.58% (95% confidence intervals [CI] 1.42, 1.75) and that of Gram-positive bacteria, Gram-negative bacteria, and MRSA bacteria evaluated from 63 studies was 0.90% (95% CI 0.81, 1.21), 0.24% (95% CI 0.18, 0.32), and 0.08% (95% CI 0.05, 0.12), respectively. A meta-regression pinpointed negative association between the frequency of mediastinitis and latitude of study place and positive association between the frequency of mediastinitis and the age of the patient at operation. Multivariate meta-regression showed that prospective cohort design and age of the patients and latitude of study place together or in combination accounted for 17% of heterogeneity for end point frequency of mediastinitis, 16.3% for Gram-positive bacteria, 14.7% for Gram-negative bacteria, and 23.3% for MRSA bacteria.

Conclusion

Evidence from this study suggests the importance of latitude of study place and advanced age as risk factors of mediastinitis. Latitude is a marker of thermally regulated bacterial virulence and other local surgical practice. There is concern of increasing risk of mediastinitis and of MRSA in elderly patients undergoing sternotomy.

Blood platelet count and reactivity are associated with restenosis 6 months after coronary angioplasty

OBJECTIVES

Restenosis occurs in 40-50% of patients treated with percutaneous transluminal coronary angioplasty (PTCA). Some data indicate that platelet derived growth factor (PDGF) plays a pathogenetic role. The aims of the present study were to measure the plasma levels of PDGF across the coronary circulation during PTCA and relate them to the development of restenosis.

DESIGN AND RESULTS

Blood samples from the aortic root and coronary sinus were drawn simultaneously before, and after completed PTCA in 26 patients. Plasma levels of PDGF and beta-thromboglobulin (BTG), as well as platelet counts were measured. Restenosis was evaluated by quantitative coronary angiography after 6 months. Significant increases both in PDGF and BTG were encountered in the aortic root after PTCA in patients who developed restenosis as compared to patients without restenosis. Patients who developed restenosis also had significantly higher platelet counts compared to those without.

CONCLUSION

Increases in plasma PDGF and BTG in the aortic root after PTCA seem to be markers for restenosis 6 months after PTCA. This finding may strengthen the hypothesis that platelets contribute to the process of restenosis.

Design of an Endoreactor for the Cultivation of a Joint-Like-Structure

To avoid revision surgeries in artificial joint replacements and to allow young people to have a joint replacement, using biological joint replacement created by tissue engineering is a promising alternative. Several research groups have tissue engineered bone [Warnke 2004] and cartilage [Chung 2007] separately. The tissue engineering of a joint, consisting of bone and cartilage is the next frontier. The present study focuses on the design of a novel device, named Endoreactor, that is employing the mechanosensitivity of cells to create a joint-like-structure (JLS) consisting of a bone and cartilage sandwich, similar to an amphiarthrosis, by applying a mechanical loading regime to a stem cell seeded scaffold construct during endocultivation. This way, the patients who will eventually need the new joint will serve as their own bioreactor, having the joint grow in their own body. In the JLS, the outside layers are designed to become bone, using a 6 mm thick scaffold with high stiffness. The center layer is a 4 mm thick scaffold which is compliant so as to experience more strain than the outside scaffolds to stimulate cartilage formation. Compression is realized by placing the JLSs between the long links of a kite-shaped four-bar linkage. This Endoreactor is powered by natural body motion through connection to the musculoskeletal system of the host, which in the experimental phase is a Gottingen minipig. The loading frequency and rest versus active time is dictated by the activity level of the minipig. This results in a natural loading pattern that is employed for the stimulation of cartilage formation in the JLS. A tensile force created during ambulation is converted into compressive action between the two long links of the mechanism. A mechanical stop limits the motion. This way controlled intermittent dynamic compression between 2.5% and 12.5% is realized in the cartilage layer of the JLS. All functions are integrated into a single piece compliant mechanism which is produced out of titanium using 3D rapid prototyping by selective laser melting technology. The mechanism can be fitted with cages that hold the scaffolds for bone and cartilage in place and protect them from external loads while being implanted. A safety spring was added to accommodate for large actuation excursions. A number of prototypes were produced and tested for fatigue, plastic deformation, failure load, and displacements of the long links at the JLS locations under different axial loads. These tests confirmed the proper mechanical functioning of the Endoreactor. Work with animal models making use of the device to culture an amphiarthosis-like joint is foreseen in the near future. This work was carried out at part of MYJOINT: Living Bioreactor—Growing a New Joint in a Human Back, EU FP6-2004-NEST-C-1, Proposal No. 028861.

Elevated plasma beta-endorphin/beta-lipotropin concentration following a radius fracture

Plasma beta-endorphin/beta-lipotropin concentration was assessed soon after a fracture. Blood samples from 14 patients with radius fractures were obtained from both arms soon after admission to the hospital (mean 245 min) after the accident. Follow-up samples were taken after healing of the fractures. Higher plasma beta-endorphin/beta-lipotropin concentrations were found in blood samples taken soon after a fracture in both arms compared with the concentrations after healing of the fracture. At admission, mean beta-endorphin/beta-lipotropin concentrations in the fractured and the contralateral arms were 12.7 pmol/L and 13.2 pmol/L, and after recovery 11.1 pmol/L and 11.5 pmol/L (p = 0.012 and p = 0.041), respectively. The pain decreased according to the visual analogue scale (VAS) (0-10) from 4.64 at admission to 0.58 after healing (p < 0.001). In conclusion, this study showed that beta-endorphin/beta-lipotropin concentrations are increased in both arms following a radius fracture compared to the level after the fracture has healed.

Dietary intake of differently fed salmon: a preliminary study on contaminants

BACKGROUND

In a previous study, a group of coronary heart disease (CHD) patients exhibited positive cardioprotective effects of fatty acids derived from a diet of farmed Atlantic salmon fed fish oil (Seierstad et al. 2005). This follow-up study examines these patients for plasma exposure to selected organic and inorganic contaminants found in seafood that may detract from the benefits of eating oily fish.

METHODS

The study design was from Seierstad et al. (2005), where 58 patients were allocated into three groups consuming 700 g week(-1) of differently fed Atlantic salmon (Salmo salar) fillets for 6 weeks: 100% fish oil (FO), 100% rapeseed oil (RO), or 50% of each (FO/RO).

RESULTS

Different fillets showed graded levels (FO > FO/RO > RO) of polychlorinated dibenzo-p-dioxins (PCDDs), polychlorinated dibenzofurans (PCDFs), dioxin-like polychlorinated biphenyls (DLPCBs), indicator PCBs, polybrominated diphenyl ethers (PBDEs), and arsenic (As). Mercury (Hg) and lead (Pb) levels were similar across the three types of fillets. After 6 weeks of consumption, patient levels of PCDDs, DLPCBs, and PCBs in plasma decreased as the dietary intake of these contaminants increased. Plasma PBDEs only showed increases for the FO patients. Levels of inorganic contaminants in plasma showed only slight changes over the study period.

CONCLUSIONS

These results show a reduction in the use of marine oils in fish feed reduces organic contaminant levels in farmed salmon while still providing a good dietary source of marine fatty acids.

Dietary intake of differently fed salmon; the influence on markers of human atherosclerosis

BACKGROUND

Cardioprotective effects of omega-3 polyunsaturated fatty acids (n-3 PUFAs) of marine origin are well recognized. Because of the shortness of marine resources vegetable oils are increasingly used in fish farming. The effects on human health of fish fed on vegetable oils are largely unknown.

METHODS

In a double-blinded intervention study, 60 patients with coronary heart disease (CHD) were randomly allocated to three groups consuming approximately 700 g per week for 6 weeks of differently fed Atlantic salmon: 100% fish oil (FO), 100% rapeseed oil (RO) or 50% of each (FO/RO), resulting in fillets with high, intermediate and low levels of marine n-3 PUFAs. Patient analyses before and after the intervention period included serum fatty acid profile, serum lipoproteins, and markers of vascular inflammation.

RESULTS

The serum fatty acid profiles of the patients after the intervention mirrored those of the corresponding salmon fillets and the respective salmon feeds. Significant differences between the groups were obtained, especially for the levels of total n-3 PUFAs and the n-3/n-6 FA ratio, which were markedly increased in the FO group in contrast to the two other groups (P < 0.02 for all). Additionally, significant reductions of serum triglycerides and of vascular cell adhesion molecule-1 and interleukin-6 were obtained in patients receiving the FO diet when compared with the two other groups (P < 0.05 for all).

CONCLUSIONS

Tailor-made Atlantic salmon fillets very high in n-3 PUFAs of marine origin seem to impose favourable biochemical changes in patients with CHD when compared with ingestion of fillets with intermediate and low levels of marine n-3 PUFAs, when replaced by rapeseed oil.

Human articular chondrocytes express functional leptin receptors

The effects of leptin hormone are mediated by interactions with several physiological regulatory systems and the cytokine network, and by targeting cells directly. The leptin receptor is a member of the class I cytokine receptor family, and its signal transduction resembles that induced by many cytokines. We demonstrated that serially cultured human articular chondrocytes possess the leptin receptor (Ob-R), and that this receptor was present on chondrocytes in native human cartilage. In cultured chondrocytes we detected mRNA for the functional isoform of leptin receptor (Ob-Rb or Ob-R(L)), and it was revealed that ligand binding resulted in phosphorylation of signal transducers and activators of transcription, namely STAT1 and STAT5. Chondrocytes stimulated with leptin exhibited an increased proliferation and an enhanced synthesis of extracellular matrix (proteoglycans and collagen). These results indicate that leptin affects cartilage generation directly, which is a novel role for leptin in skeletal growth and development.

Predictors of restenosis after coronary angioplasty. A study on demographic and metabolic variables

OBJECTIVE

The major concern about percutaneous transluminal coronary angioplasty (PTCA) is the high incidence of restenosis.

METHODS

Demographic, clinical and biochemical data were recorded 2 weeks prior to PTCA in 388 patients fulfilling the criteria for initial stenosis, successful PTCA, and angiographic follow-up after 6 months. Restenosis was evaluated by quantitative coronary angiography.

RESULTS

Variables predictive of restenosis in univariate analysis were diabetes mellitus, male gender, and the levels of high density lipoprotein (HDL) cholesterol, apolipoprotein A1 (Apo A1) and thio-barbituric acid-reactive substances (TBARS). In trend analysis through quartiles TBARS and fasting glucose levels were significantly associated with restenosis (p = 0.016 and 0.044, respectively), whereas the negative predictivity of Apo A1 and HDL-cholesterol were of borderline significance. In multivariate analysis male gender and diabetes mellitus showed predictivity of significance, and a negative predictivity was also apparent for HDL-cholesterol.

CONCLUSION

We conclude that diabetes mellitus, male gender, and low HDL-cholesterol are predictors of restenosis 6 months after PTCA. In addition, TBARS may be a marker for the development of restenosis after PTCA.

Plasma beta-endorphin concentrations are increased in chronic obstructive pulmonary disease patients

The present study is concerned with plasma beta-endorphin and glucose tolerance in patients with chronic obstructive pulmonary disease (COPD). Plasma beta-endorphin, glucagon and insulin concentrations were measured during an oral glucose tolerance test in 20 COPD patients and in 18 age-matched healthy controls (mean age 62 years). Seven patients had a moderate COPD (group I) and seven a severe COPD (group II). The remaining six severe COPD patients received long-term oxygen therapy (group III). We found that fasting levels of beta-endorphin were significantly increased in all patient groups compared to healthy controls (p < 0.01, 0.05 and 0.005, respectively). Six of the 13 severely diseased COPD patients had impaired glucose tolerance. Plasma beta-endorphin levels decreased significantly during OGTT in the COPD patients (p < 0.05). Fasting beta-endorphin levels were higher in patients with impaired glucose tolerance than in those patients with normal OGTT (42.0 pmol/L +/- 11.4 SD versus 34.8 +/- 10.2). However, this difference was not statistically significant. In conclusion, this study showed that beta-endorphin concentrations are increased in COPD patients whether or not they receive oxygen therapy.

Magnetic resonance imaging as a screening procedure to avoid arthroscopy for meniscal tears

The objective of this study was to evaluate the role of magnetic resonance imaging (MRI) as a screening procedure before arthroscopy of meniscal tears. Forty-one knees in 40 patients underwent MRI and arthroscopy. Compared with arthroscopy, the sensitivity, specificity, positive predictive value and negative predictive value for MRI for the nmedial meniscus were 100%, 77%, 71% and 100%, respectively, while the values for the lateral meniscus were 40%, 89%, 33% and 91%, respectively. The overall accuracy for MRI of the medial and lateral menisci combined was 84%. On the basis of the high predictive value of negative MRI, we conclude that MRI is useful to exclude patients from unnecessary arthroscopy.

Comparison of plasma progesterone, transrectal ultrasound and pregnancy specific proteins (PSPB) used for pregnancy diagnosis in reindeer

The study aimed to compare plasma progesterone concentrations, rectal ultrasonography and plasma concentrations of pregnancy-specific protein B (PSPB) used for pregnancy diagnosis in reindeer. A total of 1,595 blood plasma samples were collected between 1991 and 1996 from 3 semidomestic reindeer (Rangifer tarandus tarandus) herds on the Norwegian mainland (Magerøy, Sørøy, Filefjell) and from 92 wild Svalbard reindeer (Rangifer tarandus platyrhynchus). Samples were collected between January and late April. Plasma levels of progesterone and PSPB were measured and used as indicators of pregnancy. In addition, animals from the Filefjell herd and the Svalbard reindeer were investigated using transrectal ultrasound. The results showed that plasma progesterone lower than 7 nmol l-1 rarely occurs in females diagnosed pregnant either by ultrasound or by observing a calf at foot 7 months after blood sampling. A very good agreement was found between plasma progesterone and PSPB when used for pregnancy diagnosis. On the Norwegian mainland, but not to the same extent on Svalbard, a high proportion of females with a high progesterone concentration was diagnosed not pregnant by ultrasound. This probably reflects a high rate of false negative diagnoses by the ultrasound method rather than false positives in the progesterone analysis.

[Misconceptions and tacit learning--a challenge in medical education]

Medical education has undergone several reforms and innovations both in Norway and elsewhere, and the quality of teaching and learning is, and should be, a subject of ongoing discussions and developments. As a contribution to this discussion a teaching experience and a follow-up study of misconceptions among medical students are presented. More than 10% of 48 young medical students answered that the antagonist moved the femur into abduction when asked to choose between two alternatives. According to a constructivistic theory of learning, unexpected and often incorrect understandings may be developed informally either before or parallel to formal teaching. Whereas there has been a vast number of studies into students' misconceptions in school subjects and their tendency to survive formal educational programmes, they have drawn little attention in medical education. The observations are discussed with reference to contemporary theories on learning: some implications for medical education are suggested.

The effect of supplementation with omega-3 fatty acids on soluble markers of endothelial function in patients with coronary heart disease

During progression of atherosclerosis the overlying endothelial cells alter their expression of some surface molecules. Circulating levels of such molecules may be quantified. We investigated the effect of omega-3 fatty acids (n-3 FA) on the levels of tissue plasminogen activator antigen, von Willebrand factor, and the soluble forms of thrombomodulin, P-selectin, E-selectin, and vascular cell adhesion molecule-1 in 54 patients with coronary heart disease. Twenty-three of the patients had taken 5.1 g/d n-3 FA for 6 months (group I) and 31 were given corn oil as placebo (group II). For another 4 weeks ("the study period") they all got 5.1 g/d of n-3 FA. Compliance was confirmed by demonstration of changes in relevant fatty acids in serum phospholipids. At baseline, significant differences between the groups were found with lower median values of von Willebrand factor (128% versus 147%) and soluble thrombomodulin (24.9 versus 32.5 ng/mL) and higher median values of soluble E-selectin (41.4 versus 35.5 ng/mL) and soluble vascular cell adhesion molecule-1 (573 versus 473 ng/mL) in group I. During the study period differences in changes between the groups were found; tissue plasminogen activator antigen and soluble thrombomodulin decreased (P for difference between the groups 0.001 and 0.015, respectively), whereas soluble E-selectin and soluble vascular cell adhesion molecule-1 increased (P for difference between the groups <0.01 for both) in group II relative to group I. Our results indicate that n-3 FA supplementation decreases hemostatic markers of atherosclerosis, whereas markers of inflammation may be increased. The latter may be the result of lipid peroxidation as a simultaneous decrease of vitamin E and increase in thiobarbituric acid-reactive substances were observed.

N-3 fatty acids do not prevent restenosis after coronary angioplasty: results from the CART study. Coronary Angioplasty Restenosis Trial

OBJECTIVES

The aim of the study was to investigate whether omega-3 fatty acids (n-3 FA) reduce the occurrence of restenosis after percutaneous transluminal coronary angioplasty.

BACKGROUND

Meta-analyses have shown significant reduction of restenosis after coronary angioplasty upon supplementation with n-3 FA.

METHODS

In a prospective, placebo-controlled, double-blind study, 500 patients were randomly allocated to treatment with n-3 FA (Omacor, Pronova AS, Oslo, Norway) 5.1 g/day or corn oil (placebo) starting at least two weeks prior to elective coronary angioplasty. The treatment was continued until restenosis evaluation by quantitative coronary angiography after six months. Stenosis was defined as a minimal luminal diameter (MLD) < 40% of the reference diameter. Successful coronary angioplasty was defined as > or = 20% acute gain in MLD and a residual stenosis < 50%. Restenosis was defined as > or = 20% late loss of diameter and stenosis > 50% or an increase in stenosis of > or = 0.7 mm. Three-hundred ninety-two patients fulfilled the criteria for initial stenosis and successful coronary angioplasty, and, except four patients who died, none were lost for follow-up.

RESULTS

Restenosis occurred in 108/266 (40.6%) of the treated stenoses in the Omacor group and in 93/263 (35.4%) in the placebo group (odds ratio [OR] 1.25, 95% confidence interval [CI] [0.87-1.80] p = 0.21). In the Omacor group one or more restenoses occurred in 90/196 (45.9%) patients as compared with 86/192 (44.8%) in the placebo group (OR 1.05, 95% CI [0.69-1.59] p = 0.82).

CONCLUSIONS

Supplementation with 5.1 g n-3 FA/day for six months, initiated at least two weeks prior to coronary angioplasty did not reduce the incidence of restenosis.

Procoagulant activity and cytokine expression in whole blood cultures from patients with atherosclerosis supplemented with omega-3 fatty acids

Omega-3 fatty acids (n-3 FA) may reduce atherogenesis and thrombosis. We investigated the effects of n-3 FAs on procoagulant activity and cytokine expression in whole blood cultures from patients with atherosclerosis. Eleven of the 23 included patients had received 5.1 g n-3 FA daily for 6 months (group I) whereas 12 patients had been on placebo (group II). All patients were then given 5. g n-3 FA daily for another 4 weeks. At baseline significantly lower levels of LPS-induced prothrombin fragment1+2 were found in group I (p = 0.010), this difference being eliminated after 4 weeks. Il-6 and TNFalpha were significantly higher at baseline in group I and the differences in changes from baseline between the groups were statistically highly significant with increasing values in group II(Il-6 p = 0.001, TNF alpha p = 0.002). The present results indicate a reduction in pro-thrombotic potential in patients receiving highly concentrated n-3 FA, whereas some proinflammatory responses might be adverse.

Comparison of plasma progesterone, transrectal ultrasound and pregnancy specific proteins (PSPB) used for pregnancy diagnosis in reindeer

The study aimed to compare plasma progesterone concentrations, rectal ultrasonography and plasma concentrations of pregnancy-specific protein B (PSPB) used for pregnancy diagnosis in reindeer. A total of 1,595 blood plasma samples were collected between 1991 and 1996 from 3 semidomestic reindeer (Rangifer tarandus tarandus) herds on the Norwegian mainland (Magerøy, Sørøy, Filefjell) and from 92 wild Svalbard reindeer (Rangifer tarandus platyrhynchus). Samples were collected between January and late April. Plasma levels of progesterone and PSPB were measured and used as indicators of pregnancy. In addition, animals from the Filefjell herd and the Svalbard reindeer were investigated using transrectal ultrasound. The results showed that plasma progesterone lower than 7 nmol l-1 rarely occurs in females diagnosed pregnant either by ultrasound or by observing a calf at foot 7 months after blood sampling. A very good agreement was found between plasma progesterone and PSPB when used for pregnancy diagnosis. On the Norwegian mainland, but not to the same extent on Svalbard, a high proportion of females with a high progesterone concentration was diagnosed not pregnant by ultrasound. This probably reflects a high rate of false negative diagnoses by the ultrasound method rather than false positives in the progesterone analysis.

Markers of myocardial injury in blood following PTCA: a comparison of CKMB, cardiospecific troponin T and troponin I

In 74 patients undergoing elective PTCA, CKMB, cTnT, cTnI-Access (cTnI-Acc) and cTnI-Abbott (cTnI-Abb) were measured in serum before and days 1 and 4 after the procedure. Two of the patients had pronounced biochemical evidence of AMI. In addition, a minor to moderate increase in CKMB, cTnT, cTnI-Acc and cTnI-Abb were found on day 1 in 13, 22, 18 and 25 patients, respectively. Excluding the two with AMI, cTnT was also increased on day 4 in 16 patients and cTnI-Abb in 15 patients, whereas CKMB and cTnI-Acc levels were essentially normal in all. Thus, an unexpected discrepancy between the two methods for cTnI was revealed on day 4. In these 16 patients, there was no statistically significant relationship between the level of cTnT on day 4 and the levels of CKMB or cTnI-Acc on day 1. This is in contrast to a significant correlation to cTnT and cTnI-Abb on day 1. Based on these results, it is speculated that the marker levels on day 1 are due to reversible as well as irreversible damage, whereas cTnT and cTnI-Abb on day 4 more selectively reflect the degree of myocardial necrosis. cTnT and TnI-Abb on day 4 are therefore proposed as valuable markers for further study of the clinical implications of myocardial damage following PTCA and related interventions.

[Treatment of focal cartilage injuries in the knee]

Chondrocytes in adult human cartilage have little mitotic capacity even after injuries. Deep injuries penetrating the subchondral bone plate lead to the release of pluripotent mesenchymal stem cells which have the potential to differentiate into different types of connective tissue, including bone and cartilage. The release and stimulation of these stem cells can also be achieved by drilling or microfracture of the subchondral bone of cartilage lesions. When stimulated, periosteal cells may also differentiate into chondrocytes. However, non-chondrocyte determined cells seem to induce mainly fibrocartilage. In 1987 autologous chondrocyte implantation was introduced by a team in Gothenburg. This resulted in clinical improvement and the development of hyaline-like cartilage in patients who had undergone treatment. We first used the method in 1996 in a clinical trial. At a 6-month follow-up of our first 12 patients we found reduced symptoms and improved knee function. This method is promising, but further clinical trials are necessary.

A fast responding combined direct and indirect calorimeter for human subjects

The construction and performance of a 5.4 m3 combined direct and indirect calorimeter for human subjects is described. The calorimeter was constructed for studies on human subjects primarily undergoing fast alterations in heat production and heat losses, e.g. after a meal or during physical exercise. A heat sink and a heat substitution principle is used to measure sensible heat losses directly. Evaporative heat losses are determined by measuring water vapour input and output. Indirect calorimetry is performed by measuring output air flow and changes in gas composition of the air entering and leaving the calorimeter. The response times (90%) for sensible heat and evaporative heat were found to be 4 min and 34 min, respectively. Three alcohol combustion tests gave a recovery of CO2 and O2 in the range 92-97%. The recovery of water was found to be in the range 56-89%.

Myocardial damage during percutaneous transluminal coronary angioplasty as evidenced by troponin T measurements

AIM

The present study was undertaken to assess the effect of balloon inflation during percutaneous transluminal coronary angioplasty on markers of myocardial damage.

METHODS AND RESULTS

Seventy-five patients undergoing elective percutaneous transluminal coronary angioplasty were evaluated with serum creatine kinase MB and cardiospecific troponin T before and 1 and 4 days after the procedure. On day 1, 28% of the patients had increased cardiospecific troponin T values and 18% had increased creatine kinase MB values. On day 4, 24% had increased cardiospecific troponin T values, whereas all creatine kinase MB values were normal. A high degree of correlation between creatine kinase MB and cardiospecific troponin T on day 1, as well as between both markers on day 1 and cardiospecific troponin T on day 4 were found. The increased levels of cardiospecific troponin T on day 4 was significantly correlated with the total balloon inflation time (P < 0.001).

CONCLUSION

We conclude that irreversible myocardial damage, as evidenced by increased cardiospecific troponin T values on day 4, occurs in an appreciable number of patients during percutaneous transluminal coronary angioplasty, and that this damage is strongly correlated with the total balloon inflation time.

Plasma magnesium, calcium and inorganic phosphorus in Norwegian semi-domestic female reindeer (Rangifer tarandus tarandus) on winter pastures

Altogether 1645 blood plasma samples were collected from 2 reindeer (Rangifer tarandus tarandus L) herds in northern Norway (Magerøy and Sørøy), and from 2 herds in southern Norway (Filefjell and Lom) during the period from 1992 through 1995. Except for 2 subsets of samples from Lom (N = 51 and 56) all samples were collected on winter pasture between January and early March. The herds were of varying nutritional status, the Lom herd being regarded to be among the best in the country in this regard. Plasma levels of magnesium, calcium and inorganic phosphorus were measured. In addition, plasma progesterone was used as a pregnancy test, a discriminatory level of 7 nmol l-1 being chosen as indicating pregnancy. For the investigated minerals, the analysis of variance included effects for year of sampling, herd, pregnancy status, age and mineral status. Average mineral concentrations varied considerably between herds and year of sampling. The overall average (SD; min-max) concentrations of plasma Ca, Mg and P in samples collected on winter pastures were 2.42 (0.25; 0.9-3.6), 0.83 (0.17; 0.16-1.39) and 1.70 (0.47; 0.2-3.4) mmol l-1, respectively. The overall pregnancy rate was 79.8%. The frequency of subnormal plasma values within herds and years for magnesium (< or = 0.7 mmol l-1) and calcium (< or = 2.2 mmol l-1) varied between 0-61.9% and 1.4-44.9% respectively. Significant positive correlations between calcium and magnesium were found in all herds except in the Lom herd where all animals had plasma Mg values above 0.8 mmol l-1. Generally, the highest correlation coefficients were found in subsets of data with a high frequency of subnormal magnesium concentrations. Plasma magnesium showed the greatest contribution to plasma calcium variance when tested together with herd, year of sampling, pregnancy status, age and plasma inorganic phosphorus. A decrease in plasma magnesium from 1 to < 0.5 mmol l-1 was associated with a decrease in plasma calcium of approximately 15%. Mean plasma magnesium and calcium levels were significantly (p < 0.01) higher in pregnant animals than in barren females, a significant positive relationship being found between pregnancy rate and average concentrations of the same minerals when sets of observations from different herds and different years were compared. The positive correlation between plasma calcium and magnesium in herds with subnormal magnesium minima is consistent with evidence from other species reported in the literature of impaired calcium homeostasis in magnesium deficient animals.

Plasma magnesium, calcium and inorganic phosphorus in Norwegian semi-domestic female reindeer (Rangifer tarandus tarandus) on winter pastures

Altogether 1645 blood plasma samples were collected from 2 reindeer (Rangifer tarandus tarandus L) herds in northern Norway (Magerøy and Sørøy), and from 2 herds in southern Norway (Filefjell and Lom) during the period from 1992 through 1995. Except for 2 subsets of samples from Lom (N = 51 and 56) all samples were collected on winter pasture between January and early March. The herds were of varying nutritional status, the Lom herd being regarded to be among the best in the country in this regard. Plasma levels of magnesium, calcium and inorganic phosphorus were measured. In addition, plasma progesterone was used as a pregnancy test, a discriminatory level of 7 nmol l-1 being chosen as indicating pregnancy. For the investigated minerals, the analysis of variance included effects for year of sampling, herd, pregnancy status, age and mineral status. Average mineral concentrations varied considerably between herds and year of sampling. The overall average (SD; min-max) concentrations of plasma Ca, Mg and P in samples collected on winter pastures were 2.42 (0.25; 0.9-3.6), 0.83 (0.17; 0.16-1.39) and 1.70 (0.47; 0.2-3.4) mmol l-1, respectively. The overall pregnancy rate was 79.8%. The frequency of subnormal plasma values within herds and years for magnesium (< or = 0.7 mmol l-1) and calcium (< or = 2.2 mmol l-1) varied between 0-61.9% and 1.4-44.9% respectively. Significant positive correlations between calcium and magnesium were found in all herds except in the Lom herd where all animals had plasma Mg values above 0.8 mmol l-1. Generally, the highest correlation coefficients were found in subsets of data with a high frequency of subnormal magnesium concentrations. Plasma magnesium showed the greatest contribution to plasma calcium variance when tested together with herd, year of sampling, pregnancy status, age and plasma inorganic phosphorus. A decrease in plasma magnesium from 1 to < 0.5 mmol l-1 was associated with a decrease in plasma calcium of approximately 15%. Mean plasma magnesium and calcium levels were significantly (p < 0.01) higher in pregnant animals than in barren females, a significant positive relationship being found between pregnancy rate and average concentrations of the same minerals when sets of observations from different herds and different years were compared. The positive correlation between plasma calcium and magnesium in herds with subnormal magnesium minima is consistent with evidence from other species reported in the literature of impaired calcium homeostasis in magnesium deficient animals.

Effects of naloxone on glucagon and insulin concentrations after injection of endotoxin in rats

OBJECTIVE

To find out how infusions of endotoxin and endotoxin plus naloxone affected glucose, glucagon, and insulin concentrations in rats.

DESIGN

Random control study.

SETTING

University hospital, Norway.

MATERIAL

27 Male Wistar rats.

INTERVENTIONS

8 Rats were given Escherichia coli endotoxin 0.25 mg in saline; 5 were given a naloxone infusion (0.4 ml of 0.04 mg/ml for the first half hour and continued at a rate of 0.4 ml/hour for a total of 80 minutes) starting 10 minutes before the same dose of endotoxin; 6 were given saline alone for 70 minutes, and 8 saline alone for 10 minutes. Blood was taken for analysis after 70 minutes in the first three groups and at the end of the infusion in the 10 minute group.

MAIN OUTCOME MEASURES

Serum concentrations of glucose, glucagon, and insulin compared with baseline (10 min group).

RESULTS

Median (interquartile) concentrations of all three substances rose significantly 70 minutes after the injection of endotoxin compared to basal values: 9.8 (8.2-10.9) compared with 6.0 (4.8-7.5) mmol/l for glucose (p < 0.01); 53.1 (44.6-56.0) compared with 3.6 (3.1-5.1) ng/l for glucagon; and 39.4 (38-50.4) compared with 16.7 (11.2-25.5) pmol/l for insulin. When naloxone was combined with endotoxin glucagon and insulin concentrations were significantly lower: 24.3 (23.9-37.5) ng/l (p < 0.01), and 30.6 (24.5-31.6 pmol/l (p < 0.05), respectively. The concentration of glucose in venous blood was unchanged.

CONCLUSIONS

The rise in glucagon and insulin concentrations after endotoxin infusions may be partly mediated by opioids. Naloxone in the dose given did not abolish the increase in glucagon after endotoxin. The high glucagon:insulin ratio after both endotoxin alone and endotoxin plus naloxone may be important in the aetiology of the hyperglycaemia seen.

The effects of 'in-use' surgical handwashing on the pre- and postoperative fingertip flora during cardiothoracic and orthopaedic surgery

Two operating teams (25 persons) were followed for two months with fingerprint samples taken preoperatively; before and after 'in-use' surgical handwashing; and immediately postoperatively, with and without surgical gloves. The mean time for handwashing for the cardiothoracic team (CT) was 2 min and for the orthopaedic team (OT) was 3.5 min. A closer observation of 10 persons revealed a great individual variation in washing techniques, in spite of standard guidelines. The CT team performed eight, and the OT team nine sterile operations with an average duration of 3 h and 20 min and 2 h and 40 min, respectively. Surgical handwashing resulted in fingertip sterility in 111/118 (94.1%) cases; in 61/66 (92.4%) samples from the surgeons and in 50/52 (96.2%) samples from the assistants. Postoperative fingerprinting with gloves on showed sterile conditions in 85/91 (93.4%) samples; 57/59 (96.6%) from the surgeons and 28/32 (87.5%) from the assistants. Immediately after removal of the gloves, 43/67 (64.2%) of fingerprint samples from the surgeons and 13/48 (27.1%) from the assistants were still sterile. Coagulase-negative staphylococci (CNS) and Bacillus species predominated in fingerprint samples. Of the 105 CNS strains tested, 11.4% were methicillin resistant. Only five strains of Staphylococcus aureus were isolated; in 4/5 cases from the OT. This study illustrates that in spite of standard guidelines, there is great individual variation in surgical handwashing. However, in most instances, the bacteria are eradicated from the fingertips. Even after surgery for 2-3 h, there may still be a residual effect of the hand disinfecting agent in half of the cases.

Morphine effects on the release of glucagon, insulin and somatostatin from the isolated, perfused rat pancreas

The pancreatic glands from six male Wistar rats weighing between 200 and 250 g were isolated and perfused. After 30-min equilibration and 20-min basal periods, perfusion with 0.2 mg/ml of morphine for 20 min resulted in a significant (P < 0.05) increase in insulin release, with no changes in release of gucagon or somatostatin. After a recovery period of 20 min, a higher morphine concentration of 2 mg/ml was introduced for another 20-min period. With this morphine dose there were significant increases in release of insulin (P < 0.05), glucagon (P < 0.01) and somatostatin (P < 0.05). This shows that morphine induces the release of insulin, glucagon and somatostatin from pancreas in a dose-dependent way, and that release of insulin and glucagon is not primarily affected by regulation of somatostatin levels.

[Stress echocardiography with dobutamine. A new method for diagnosis of ischemia]

Dobutamine stress echocardiography was performed in 24 patients with angiographically defined coronary artery stenosis, before they underwent percutaneous transluminal coronary angioplasty. Ischemia was detected on stress-ECG in 13 patients. In 19 patients ischemia could be detected with dobutamine stress echocardiography. The method was highly sensitive for detecting ischemia in patients with two vessel or three vessel disease and in patients with affection of only the left anterior descending artery. In patients with one vessel disease the method showed low sensitivity. The most common side effects of dobutamine infusion were flushing and palpitations. One patient suffered atrial fibrillation and one patient had a short and self-limiting ventricular tachycardia. The method seems to be a useful and safe supplementary tool for detecting myocardial ischemia. It is also useful for characterizing the physiological effect of coronary artery stenosis.

Haemorrhage-induced increases in glucose, glucagon and insulin levels are blocked by naloxone in rats

OBJECTIVE

To find out if the opioids that are liberated during bleeding influence the concentrations of glucagon, insulin, somatostatin, corticosterone and glucose in rats, and if naloxone has any regulatory effect.

DESIGN

Laboratory study.

SETTING

University hospital.

MATERIAL

56 Male Wistar rats.

INTERVENTIONS

Removal of blood corresponding to 2% of body weight through a catheter in the internal jugular vein. Before bleeding (n = 8), and at 5, 15 and 30 minutes afterwards (n = 16 at each time point, half of which had received naloxone 0.04 mg/ml, 0.7 ml/hour, for 10 minutes before bleeding and up to 30 minutes afterwards) rats were killed and samples of heart blood taken.

MAIN OUTCOME MEASURES

Concentrations of glucose, glucagon, insulin, somatostatin, and corticosterone in heart blood.

RESULTS

In the control group (saline) concentrations of glucose, glucagon and insulin increased significantly after bleeding, and had returned to baseline concentration by 30 minutes. Naloxone blocked the increases in the treated group.

CONCLUSION

Endogenous opioids, possibly endorphin, may be important in the acute regulation of blood glucose, glucagon and insulin concentrations after haemorrhage.

Increased plasma glucose levels after Hypnorm anaesthesia, but not after Pentobarbital anaesthesia in rats

The effects of the fentanyl fluanisone combination (Hypnorm) and pentobarbitone sodium (Pentobarbital) anaesthesia on blood glucose, insulin and glucagon were tested in rats in the fed and fasted state. Blood glucose was measured before and at 10, 20 and 30 min after injection of the anaesthetic agents. At 30 min the rats were sacrificed, and blood was drawn for measurement of glucagon and insulin. Pre-anaesthetic values for insulin and glucagon were established in separate groups of fasted and fed rats. In fasting rats given Hypnorm, blood glucose and plasma insulin were unchanged while there was a non-significant increase in plasma glucagon. The fasted rats given Pentobarbital had unchanged blood glucose and plasma insulin and a non-significant depression of glucagon. The fed rats given Hypnorm had a significant increase in blood glucose at 10 min and nearly a doubling of glucose values at 20 and 30 min (P < 0.001). Glucagon increased far less than in the fasted group, whereas insulin was doubled from preanaesthetic values (P < 0.05). The fed rats given Pentobarbital, had unchanged blood glucose, a slight non-significant depression of glucagon and a significant increase in insulin (P < 0.01). Thus Hypnorm induced hyperglycaemia in fed but not in fasted rats, probably because more glucose was available in the fed state. Fed animals are a modification of the standard fasted animal model, and may be preferable when exploring hyperglycaemic or other reactions to anaesthetic agents.

Nucleosides. III. Investigation of the Electrochemical Synthesis of N4, O5'-Diacetyl-2',3'-dideoxy-2',3'-didehydrocytidine

The influence of the reaction conditions on the yield of N4,O5′-diacetyl-2′,3′-dideoxy-2′,3′-didehydrocytidine (3), by electrochemical synthesis from N4,O2′,O5′-triacetyl-3′-bromo-3′-deoxycytidine (2), has been studied in order to evaluate the potential of this reaction for synthesis on a larger scale. We have characterized the half-wave potentials of the precursor (2) and the product (3) by polarography under various conditions, and found that reduction in the base moiety can easily take place giving by-products. Furthermore, this reduction consumes protons leading to rapid solvolysis in protic solvents. We have demonstrated for the first time that (3) can be formed near quantitatively in both protic and aprotic solvents. The success of the synthesis of (3) as well as of other 2′,3′-dideoxy 2′,3′-didehydro nucleosides also depends to a large extent on how uniform the current density across the working electrode surface can be maintained during electrolysis.

Morphine and morphine/naloxone modification of glucose, glucagon and insulin levels in fasted and fed rats

In rats weighing 200-250 g catheters were placed in the internal jugular vein and carotid artery. After 1 week of accommodation the training for the experimental situation, morphine (10 mg kg-1) was injected intravenously alone or in combination with naloxone (0.04 mg ml-1, 0.8 ml h-1). Otherwise no form of anaesthesia was used during the experiments. In control fed and fasted rats, there were no significant differences in blood glucose. In fed rats, morphine increased blood glucose as compared to control rats (p < 0.001). This was not seen in the fasted rats. The morphine induced increase in blood glucose in the fed rats was abolished by naloxone (p < 0.001). Glucagon was significantly higher in fasted than in fed control rats (p < 0.01). It was significantly increased after morphine in fed (p < 0.05), but not in fasted rats. The morphine induced increase in glucagon in fed rats was abolished by naloxone (p < 0.01). Insulin was significantly higher in fed than in fasted control rats (p < 0.05). Morphine increased insulin levels significantly in fed and fasted rats (p < 0.001), p < 0.01). The morphine induced increase in insulin in the fed rats was abolished by naloxone treatment. It is concluded that morphine stimulates glucose and glucagon release in fed but not fasted rats, and that these increases are caused by opioid action. Insulin increases after morphine were proved to be opioid-mediated only in the fed state.

Comparison of different multielement techniques for analysis of mosses used as biomonitors

Mosses are used as biomonitors on a regular basis to study trends in the atmospheric deposition of trace elements in Norway. In this paper the analytical scheme used so far, based on a combination of instrumental neutron activation analysis and atomic absorption spectrometry (INAA/AAS) is compared with inductively coupled plasma emission spectrometry (ICP-ES) and inductively coupled plasma mass spectrometry (ICP-MS). ICP-ES provided satisfactory data for nearly 20 elements, but detection limits were inadequate for some elements of importance. For ICP-MS quantitative data were obtained for 33 elements including the heavy metals of key interest in air pollution studies. In most cases where comparison was possible the ICP-MS data compared favourably with data obtained by the reference scheme or by ICP-ES. On the basis of this study ICP-MS is considered to be an equivalent alternative to INAA/AAS in multielement studies using mosses as biomonitors. In addition ICP-MS offers some promise for the study of elements such as Be, Ga, Mo, Te, Tl, and Bi, for which very little information exists regarding their behaviour as air pollutants.

Comparison of the modifying effects of somatostatin and propranolol on morphine-induced changes in glucose, glucagon and insulin levels in fed rats

Twenty-eight rats in four different groups were used. Catheters were implanted in the carotid artery and jugular vein one week before the experiments were performed. The rats were trained to the experimental situation daily, and allowed food and water ad libitum. One group of rats was used to establish control values; a second was injected with morphine (10 mg/ml, 1 ml/kg); a third group got morphine injection (10 mg/ml, 1 ml/kg) combined with somatostatin infusion (0.01 mg/ml, 1 ml/h); and the fourth group was injected with morphine (10 mg/ml, 1 ml/kg) combined with propranolol (0.4 ml, 1 mg/ml). Blood samples for venous glucose and arterial insulin and glucagon were drawn 15 min after start of stimulation. Glucose, insulin and glucagon levels were significantly higher in morphine treated than in control rats. When morphine was combined with somatostatin, the increase in glucose, insulin and glucagon was significantly reduced. However, after the morphine and propranolol stimulation the increase in glucose and glucagon was significantly reduced, whereas the insulin levels were as high as when morphine was given alone. The combined reduction of both glucagon and glucose after somatostatin or propranolol treatment in morphine exposed rats, points to glucagon as a potential link between opioid stimulation and hyperglycemia. Beta-receptor stimulation seems to contribute to the glucagon but not to the insulin release after morphine.

Increments in glucose, glucagon and insulin after morphine in rats, and naloxone blocking of this effect

In awake rats adapted to experimental conditions and allowed food ad libitum, hyperglycemia was induced by the administration of morphine 10 mg/kg through indwelling catheters in the external jugular vein. High glucose values were measured at 5, 15 and 25 min. Glucagon values were high at 5 and 15 min, and again at basal level at 25 min. Insulin was increased after morphine both at 5, 15 and 25 min, whereas somatostatin levels did not change after morphine. When morphine was administered together with naloxone after an initial 10 min period of naloxone administration, there was no increment in glucose, insulin or somatostatin values; neither at 5, 15 or 25 min. There was a remarkable glucagon decrease after naloxone and morphine remaining from 5 to 25 min. Then, one of the possible mechanisms for the hyperglycemic response after morphine may be an opioid effect on pancreas, stimulating glucagon and thereby causing hepatic glucose output.

Electrochemical Synthesis of 2',3'-Dideoxy-2',3'-didehydrocytidine and 2',3'-Dideoxycytidine

An improved electrochemical procedure for the synthesis of N4,O5′-diacetyl-′,3′-dideoxy-2′,3′-didehydrocytidine (8) has been established. The compound (8) was used as an intermediate in the syntheses of 2′,3′-dideoxy-2′,3′-didehydrocytidine (9) and 2′,3′-dideoxycytidine (2).

[Birger Malling's pioneer period as an ophthalmologist in Tromsø]

Birger Malling (1884-1989) was professor of ophthalmology at the University of Oslo from 1939 to 1954. He spent his first and very active years as a practicing ophthalmologist in Tromsø from 1913 to 1922. Based on interviews, patient journals, notes and publications, this article presents interesting and entertaining fragments of this pioneer period north of the Polar Circle. Malling regarded reconstructive surgery performed by himself on a severely multilated Lapp woman as one of his greatest triumphs. In a lecture in 1921 Malling described a characteristic membrane on the anterior surface of the lens in the pupillary field in glaucomatous eyes. He wrote to Alfred Vogt (1879-1943) in Zürich about his findings, but never received a reply. Vogt later published this finding as his own discovery, with no reference to Malling.

Effects of insulin on mononuclear leukocyte beta-adrenoceptor density and adenylate cyclase coupling

The effects of insulin on human beta-adrenoceptor density and isoproterenol-induced cyclic AMP (cAMP) accumulation were characterized in mononuclear leukocytes from healthy subjects. In cells equilibrated with theophylline (4 mM) at 37 degrees C, insulin (4 microU/ml) was present in periods from 1 to 35 min prior to stimulation. The basal cAMP levels were not influenced. After 1 min pretreatment with insulin, the (-)-isoproterenol concentration necessary to cause half-maximal stimulation (EC50) decreased from 260 to 170 nM (P less than 0.025) and the maximal (-)-isoproterenol response above basal increased from 44 to 63 pmol/10(6) cells (P less than 0.01). The short exposure to insulin caused an increase in the number of functional beta-adrenoceptors from 1420 to 2160 receptors/cell (P less than 0.01). The increased (-)-isoproterenol responsiveness showed a time-dependent decline. When insulin had been present for 35 min before stimulation, the EC50 value had increased to 600 nM (P less than 0.01 vs. control) and the maximal (-)-isoproterenol response above basal was reduced to 29 pmol/10(6) cells (P less than 0.01 vs. control). The receptor density decreased to the pretreatment value (1480 receptors/cell) after 35 min exposure to insulin. The present study shows that insulin modifies the beta-adrenoceptor density as well as the beta-adrenoceptor coupling to adenylate cyclase, dependent on the duration of exposure.

[Rupture of the medio-patellar plica. One of the many causes of anterior knee pain]

Anterior knee pain is a common syndrome in orthopedic practice. The origin is often obscure, and the attitude towards operative procedures should be reserved. In selected cases arthroscopy is indicated. I describe a patient with rupture of the mediopatellar plica.

[Alcohol and head injuries]

42 patients with epidural haematoma were operated upon in the surgical department of the regional hospital, Tromsø, in the years 1967-1985. Clinical evaluation showed that 17 of these patients (40.5%) were intoxicated by alcohol at the time of trauma. 14 of the intoxicated (82.4%) but only 7 (28%) of the sober patients, had been injured either in the evening or at night. 13 in the intoxicated group (76.5%) and 10 in the sober group (40%) were hurt by falling or as a result of violence. 15 of the sober group (60%) and 4 intoxicated patients (23.5%) arrived less than 4 hours after the accident. We found a significant difference between the two groups as regards the time lag between accident and arrival at Tromsø hospital.

Double-blind study of naproxen vs placebo in the treatment of acute migraine attacks

Naproxen was compared with placebo in a double-blind, crossover trial in classic and common migraine. The trial was terminated at a fixed date; 37 patients had entered, 5 of whom were excluded. Naproxen was given as 750 mg at the first symptom of the attack, a total of 1250 mg per 24 h was allowed. Patients were followed for six attacks or three months in each phase, whichever came first. The severity of the headache was significantly less with naproxen in the first 2 h of the attack (p = 0.047), whereas there was no difference when the whole attack was considered. Significantly more patients preferred naproxen (p = 0.042). Side effects occurred in five patients, causing withdrawal of one patient while on naproxen.