NXF1 and CRM1 nuclear export pathways orchestrate nuclear export, translation and packaging of murine leukaemia retrovirus unspliced RNA

Cellular mRNAs are exported from the nucleus as fully spliced RNAs. Proofreading mechanisms eliminate unprocessed and irregular pre-mRNAs to control the quality of gene expression. Retroviruses need to export partially spliced and unspliced full-length RNAs to the cytoplasm where they serve as templates for protein synthesis and/or as encapsidated RNA in progeny viruses. Genetically complex retroviruses such as HIV-1 use Rev-equivalent proteins to export intron-retaining RNA from the nucleus using the cellular CRM1-driven nuclear export machinery. By contrast, genetically simpler retroviruses such as murine leukaemia virus (MLV) recruit the NXF1 RNA export machinery. In this study, we reveal for the first time that MLV hijacks both NXF1 and CRM1-dependent pathways to achieve optimal replication capacity. The CRM1-pathway marks the MLV full-length RNA (FL RNA) for packaging, while NXF1-driven nuclear export is coupled to translation. Thus, the cytoplasmic function of the viral RNA is determined early in the nucleus. Depending on the nature of ribonucleoprotein complex formed on FL RNA cargo in the nucleus, the FL RNA will be addressed to the translation machinery sites or to the virus-assembly sites at the plasma membrane.

Pump Prime Aprotinin Fails to Limit Proinflammatory Cytokine Release After Coronary Artery Bypass Surgery

BACKGROUND

The purpose of this study was to establish whether pump prime aprotinin could limit the cytokine responses in patients undergoing elective coronary artery bypass surgery.

METHODS

Twenty-one patients admitted for first-time elective coronary artery bypass surgery were randomized into control or aprotinin groups. Patients in the aprotinin group received 280 mg aprotinin in the pump prime. Leukocyte count, creatine kinase cardiac isoenzyme (CK-MB), cytokine production and postoperative blood loss were analyzed perioperatively and compared with preoperative values.

RESULTS

The peak level of leukocyte count was lower in the aprotinin group than in controls (9.3 +/- 0.58 vs 11.2 +/- 0.68 x 10(9)/L, p = 0.01). Interleukin (IL)-6 and IL-8 did not differ significantly between the groups throughout the study period. Plasma IL-10 levels were higher in the controls than in the aprotinin group at 5 min (49.6 +/- 24.9 vs 8.13 +/- 2.8 pg/ml, p = 0.01) after reperfusion.

CONCLUSION

Pump prime aprotinin fails to limit proinflammatory cytokine response in circulating blood.

Serum matrix metalloproteinase‐9 is elevated in men with a history of myocardial infarction

Elevated serum inflammatory markers have been reported in coronary heart disease. Levels of serum matrix metalloproteinase-9 (MMP-9), C-reactive protein (CRP), C3-complement (C3) and autoantibodies against oxidized low-density lipoprotein (oxLDL) in 120 male subjects with a history of myocardial infarction (MI) were compared with those in 250 age-matched controls, both groups from a large cross-sectional population survey, the FINRISK study. The concentrations of serum MMP-9 and autoantibodies against oxLDL were measured by enzyme-linked immunosorbent assay, CRP and C3 by immunonephelometry. MMP-9, CRP and C3 concentrations were higher in the subjects with a history of MI than in the controls (p=0.037, p=0.004, and p=0.006, respectively). There was no difference between the groups in serum levels of autoantibodies against oxLDL. In other background characteristics, men in the MI group had higher body mass index (BMI) and serum triglyceride values and lower serum HDL cholesterol values compared to controls (p=0.009, p=0.001, and p<0.001, respectively). When analyzed by stepwise multiple logistic regression using BMI, HDL cholesterol, triglycerides, CRP, C3 and MMP-9 as independent variables, the significant predictors for MI were HDL cholesterol (p=0.002) and MMP-9 (p=0.015). These results suggest that increased serum MMP-9 may reflect inflammatory pathologic processes that are related to progression of atherosclerosis.

Duodenal diazepam‐binding protein expression and plasma cholecystokinin after alcoholic pancreatitis

OBJECTIVE

After the first acute alcohol-induced pancreatitis (AAIP) episode 46 % of patients will have a recurrent attack, but the pathophysiology is unclear. The hyperstimulation of the pancreas with cholecystokinin (CCK) induces acute pancreatitis. Alcohol induces temporary stimulation of the pancreas and CCK could be a mediator. CCK is regulated by releasing peptides - diazepam-binding protein (DBI) being a possible candidate. The aim of this study was to investigate the possible association between CCK plasma levels and DBI expression in patients with AAIP or its recurrence.

MATERIAL AND METHODS

The study comprised 44 subjects (mean age 42 years): A) Patients with a first episode of AAIP (n = 9); B) patients with three or more episodes of AAIP (n = 11); C) patients with a heavy alcohol consumption, with no detected AAIP (n = 11) and D) healthy controls (n = 13). CCK levels were measured by radioimmunoassay (RIA). Duodenal biopsies were analyzed for DBI mRNA and histology.

RESULTS

There was no significant difference in CCK plasma levels, DBI expression or CCK/DBI ratio between the groups.

CONCLUSIONS

There were no changes in fasting CCK plasma levels or DBI expression. This may suggest that they do not play a major role as risk factors for alcohol-induced pancreatitis.

Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks

BACKGROUND

Esophageal perforations and extensive anastomotic leaks after esophageal resection or gastrectomy are surgical emergencies with high mortality rates. In recent years, the use of self-expanding metallic stents (SEMS) has emerged as a promising treatment alternative for bridging and sealing the damage. This study aimed to evaluate the role of covered SEMS for the management of esophageal perforations and anastomotic leaks.

METHODS

All esophageal stent placement procedures (174 procedures for 157 patients) at the authors' unit between January 1999 and April 2008 were assessed by a retrospective chart review. Of the 157 patients, 10 (6.4%) were treated with SEMS for sealing of an iatrogenic esophageal perforation (n = 4), a spontaneous esophageal rupture in Boerhaave's syndrome (n = 4), or an anastomotic leakage (n = 2).

RESULTS

The median time from perforation or anastomotic leak to stent insertion was 13 days (range, 2 h to 48 days). The esophageal leak was totally sealed for 8 (80%) of 10 patients. The overall mortality rate was 50% (n = 5), and three (30%) of the five deaths were related to the perforation (n = 2) or leakage (n = 1). In both of the perforation cases, the diagnosis and treatment were substantially delayed. One patient with an anastomotic leak after gastrectomy died of the complication despite successful operative and SEMS treatment. Two of the deaths were unrelated to the perforation. In both cases, the cause of death was a disseminated malignant disease.

CONCLUSIONS

Traumatic perforations and anastomotic leaks can be treated effectively with covered SEMS together with adequate drainage of the thoracic cavity even in cases of severely ill patients with inveterate esophageal perforations and leaks.

Job strain as a predictor of disability pension: the Finnish Public Sector Study

OBJECTIVE

To examine whether high job strain (a combination of high job demands and low job control) is a risk factor for disability pension.

SETTING

Ten municipalities and 21 hospitals in Finland.

DESIGN AND PARTICIPANTS

A prospective cohort study of 20 386 female and 4 764 male Finnish public sector employees aged 19-50 using data from two surveys (baseline in 2000-2 and follow-up in 2005) and employers' registers. In addition to self-reported job strain, we computed work unit-aggregated job strain for each participant (the average of scores of all workers of participant's work unit except the participant him/herself).

MAIN RESULTS

93 employees (0.4%) retired because of disability during the follow-up. In multilevel logistic regression analysis adjusted for demographic characteristics and health risk behaviour, odds for disability pension was 2.60 (95% CI 1.26 to 5.34) times higher for employees with high self-assessed job strain than for those with low self-assessed job strain at baseline. The corresponding OR for passive job versus low job strain was 2.82 (95% CI 1.34 to 5.96). Analysis of work unit-aggregated scores replicated the association for high job strain, OR 2.25 (95% CI 1.17 to 4.35), but not that for passive job. The association between work unit job strain and disability pension remained significant after further adjustment for prevalent diseases, psychological distress and perceived health status.

CONCLUSIONS

Job strain is associated with risk of subsequent disability pension. If causal, this association suggests that organisational interventions to reduce job strain may also reduce early exit from work.

Severe and fatal complications after ERCP: analysis of 2555 procedures in a single experienced center

BACKGROUND AND STUDY AIMS

The majority of recent large series on endoscopic retrograde cholangiopancreatography (ERCP) complications have been multicenter studies reflecting varying degrees of experience and ERCP volume; major ERCP complications are associated with low case volume. The aim of this study was to report and analyze the frequency of severe and fatal complications associated with ERCP at a single specialized surgical high-volume referral center (Turku University Central Hospital).

METHODS

All scheduled ERCP procedures (n = 2788) at our unit between January 1997 and December 2005 were included and the procedure-related severe and fatal complications were assessed by retrospective chart review. Complications were classified as severe or fatal according to standardized guidelines.

RESULTS

The number of ERCP procedures performed was 2555, of which 71% were therapeutic and 29% were diagnostic. Seventeen (0.8%) severe complications were identified in 16 patients, of whom 15 underwent a therapeutic endoscopic procedure. Of the 17 severe complications, perforation constituted five cases (0.2%), pancreatitis occurred in five patients (0.2%), bleeding in five cases (0.2%), and two patients suffered from purulent cholangitis (0.1%). Procedure-related mortality was 0.08% (n = 3).

CONCLUSIONS

In our study the rate of severe or fatal complications of ERCP is low in experienced hands at a high-volume center, comparing favorably to corresponding complication rates of multicenter series, which further supports the importance of centralizing ERCP procedures in high-volume advanced centers.

Surgeons' experience with laparoscopic fundoplication after the early personal experience: does it have an impact on the outcome?

BACKGROUND

The adverse outcomes of laparoscopic fundoplication are more likely during the initial 20 cases performed by each individual surgeon. This study aimed to evaluate the impact of substantial surgical experience versus experience beyond the learning curve on the early and late objective and subjective results.

METHODS

The patients were divided into two groups according to the surgeon. In group 1 (n = 230), all the patients underwent surgery by a surgeon with substantial experience in laparoscopic fundoplication. In group 2 (n = 118), the patients were treated by a total of seven surgeons whose personal experience exceeded the individual learning curve, but was distinctively less than that of the group 1 surgeon.

RESULTS

The conversion rate was 2.2% in group 1 and 4.4% in group 2. The median operating time was 65 min in group 1 and 70 min in group 2 (p = 0.0020). The occurrence of immediate complications was 3.5% in group 1 and 7.6% in group 2 (p = 0.0892). At 6 months after surgery, 7.4% of the patients in group 1 and 16.1% of the patients in group 2 reported that dysphagia disturbed their daily lives (p = 0.0115). The late subjective results, including postoperative symptoms and evaluation of the surgical result, were similar in the two groups.

CONCLUSIONS

Substantial experience with the procedure is associated with a shorter operating time and somewhat fewer complications, conversions, and early dysphagia episodes. This supports the provision of expert supervision even after the initial learning phase of 20 individual procedures. The patients' long-term subjective symptomatic outcome was similar in the two groups. Substantial experience does not provide better late results than surgical experience beyond the learning curve.

Needle-knife assisted ERCP

BACKGROUND

During endoscopic retrograde cholangiopancreatography (ERCP), incising through the wall of the major papilla with an electrocautery needle-knife is a method for achieving access into the bile duct. This procedure, often referred to as a "precut," may be used when cannulation attempts via the orifice of the papilla are unsuccessful. Potential complications include hemorrhage, duodenal perforation, and acute pancreatitis.

METHODS

The 172 patients who underwent an attempt of a needle-knife assisted ERCP during the years 1997-2003 at our institution were retrospectively evaluated.

RESULTS

A selective bile duct cannulation was achieved after needle-knife incision in 148 out of 172 patients (86%) at the primary session. In 10 additional patients (6%), a repeated procedure proved successful for cannulation. In the remaining 14 patients (8%), the biliary cannulation failed and was not attempted again. Complications after needle-knife assisted ERCP occurred as follows: three patients (2%) presented with late bleeding after the ERCP and three patients (2%) developed acute pancreatitis. None of the patients required operative treatment for complications. There was no mortality.

CONCLUSION

The use of the needle-knife markedly improves the success rate of selective biliary cannulation in ERCP without increasing the rate of complications.

Circulating oxidized low-density lipoprotein and common carotid artery intima-media thickness in a random sample of middle-aged men

Circulating oxidized low-density lipoprotein (oxLDL) has been suggested to play an important role in atherosclerosis development. According to previous observations, oxLDL correlates with clinically manifest coronary and carotid artery disease. We investigated the association between the oxLDL concentration measured directly in plasma and common carotid artery intima-media thickness (IMT) in a population-based, case-control study in middle-aged men from Southern Finland. oxLDL was determined in 214 men by a commercially available sandwich ELISA test (Mercodia). Carotid artery IMT was measured at 12 standardized segments by B-mode ultrasonography (at the near and far wall of the left and right common carotid arteries, bifurcations and internal carotid arteries), and the overall mean maximum IMT (MMaxIMT) was calculated. The MMaxIMT of the carotid arteries was significantly associated with circulating oxLDL (r(s) = 0.16, p = 0.018). In a stepwise multiple regression model with MMaxIMT as dependent variable and systolic blood pressure, smoking, oxLDL, HDL cholesterol and apolipoprotein B as covariates, systolic blood pressure (beta = 0.22, p < 0.001), oxLDL (beta = 0.15, p = 0.022) and smoking (beta = 0.17, p = 0.014) showed an independent association with IMT (R(2) = 0.10, p < 0.001). Our results show that oxLDL measured directly from plasma is independently associated with subclinical carotid artery atherosclerosis in middle-aged men.

Anti-inflammatory cytokine response and the development of multiple organ failure in severe sepsis

BACKGROUND

The production of proinflammatory cytokines activates the systemic inflammatory response in sepsis. Patients also develop a compensatory anti-inflammatory reaction, which may have an important down-regulatory effect on the overactive inflammation. However, the role of this anti-inflammatory response in sepsis is not completely clarified. In this prospective study, we investigated the relationship between the pro- and anti-inflammatory cytokine profiles in severe sepsis and their role in the development of multiple organ failure (MOF).

METHODS

Thirty-eight patients meeting the criteria for severe sepsis were studied. MOF was defined as a maximum SOFA score of 10 or higher. Serial measurements of the proinflammatory IL-6 and IL-1beta and the anti-inflammatory IL-10 and IL-1ra were used. The cytokine samples were taken at the onset of sepsis and on the third and fifth day during the ICU period.

RESULTS

The initial IL-10 and IL-1ra responses were identical in patients with or without MOF. The anti-inflammatory cytokine levels remained elevated in the MOF patients, whereas in patients without MOF the levels declined. The IL-6/IL-10 ratio was significantly higher in the MOF patients on days 1 and 3 compared with patients without MOF.

CONCLUSIONS

We could not demonstrate overproduction of anti-inflammatory IL-10 in MOF patients. On the contrary, the high IL-6/IL-10 ratio indicates that IL-10 deficiency may contribute to the development of MOF in severe sepsis.

Immunoglobulin G3 and immunoglobulin M isotype plasma levels are influenced by interleukin-1alpha genotype

The immunoglobulin (Ig) plasma levels are known to be, at least partially, genetically regulated, but all the genes involved are not known. Interleukin-1 (IL-1) is a potent proinflammatory cytokine able to serve as an adjuvant for immune responses. IL-1alpha gene is polymorphic, and at least one of the polymorphisms has been identified in the 5' regulatory region of the promoter, a biallelic base exchange (C-->T) at position -889. We set out to study whether the IL-1alpha genotype might contribute to the genetic component seen in the steady-state antibody levels of healthy individuals. Four hundred healthy blood donors (218 males and 182 females) were genotyped, and the plasma levels of IgM, IgG as well as IgG subclasses were measured. An association was found between IgG3 plasma levels and the IL-1alpha genotype; the 1.1 homozygotes had increased IgG3 levels compared with the 1.2 heterozygotes (P < 0.001 in males and P = 0.04 in females, Mann-Whitney U-test). A similar significant association was also found between IgM plasma levels and the IL-1alpha genotype in males, but it was no longer present in females; the 1.1 homozygotes had higher IgM levels than the 2.2 homozygotes (P = 0.03, Mann-Whitney U-test). The data suggest that IL-1alpha-mediated signals are critical for IgG3 and IgM responses, which are induced by thymus-independent antigens and are important in activating complement.

Role of laparoscopy and laparoscopic ultrasound in staging of pancreatic tumours

BACKGROUND AND AIMS

Radiological imaging alone is not reliable enough in staging of pancreatic cancer. Not only because of poor sensitivity but also because there is a tendency to overstage tumours. The aim of the study was to compare the efficiency of spiral computed tomography (CT), transabdominal ultrasound (US), laparoscopy (LAP) and laparoscopic ultrasound (LUS) in staging of pancreatic tumours.

MATERIAL AND METHODS

In this prospective study 27 patients underwent pancreatic tumour staging with CT, US, LAP and LUS. The reference standard was operative evaluation or in case of disseminated disease laparoscopic assessment.

RESULTS AND CONCLUSIONS

Although LAP was hindered by adhesions in 11% of the patients the benefit of LAP staging was evident in detecting peritoneal carcinomatosis. The assessment of the local tumour expansion of a pancreatic carcinoma was difficult for all staging modalities. LUS did not change the decision whether to proceed with laparotomy once. In our experience routine use of laparoscopic staging does not benefit patients with pancreatic tumour but in selected cases it may prevent unnecessary laparotomy.

Early identification of bacteremia by biochemical markers of systemic inflammation

Group II phospholipase A2 (PLA2-II), procalcitonin (PCT) and C-reactive protein (CRP) are useful indicators of the severity of inflammation in various infections. To compare their discriminatory abilities at an early phase of bacteremia, PLA2-II, PCT and CRP were measured upon admission and 24-48 h thereafter in 29 patients with bacteremia, non-bacteremic bacterial or viral infections. The levels of PLA2-II and PCT were higher in bacteremia than in non-bacteremic bacterial or viral infections. PCT was highest upon admission, PLA2-II peaked at 12-24h, whereas CRP peaked one day later. At < or =24h, the AUC(ROC)s of PLA2-II and PCT were superior to those of CRP. Thereafter, the AUC(ROC)s of PLA2-II and PCT decreased and those of CRP increased. PLA2-II at cut-off level of 150 microg/L and PCT at 2-6 microg/L showed high sensitivity and specificity for bacteremia within the first 24h. In conclusion, PLA2-II and PCT are useful markers for early diagnosis of bacteremia. Devising analytical methods suitable for point-of-care testing would further enhance the clinical utility of the measurement of serum PLA2-II and PCT.

Cytokine responses and myocardial injury in coronary artery bypass grafting

OBJECTIVE

Cardiopulmonary bypass is acknowledged to be one of the major causes of a complex systemic inflammatory response after cardiac surgery, and it may contribute to postoperative complications and even multiple organ dysfunction. We here compared the cytokine responses and the degree of myocardial injury after coronary artery bypass grafting with or without cardiopulmonary bypass.

METHODS

Nine patients underwent off-pump revascularization and 13 with cardiopulmonary bypass. Plasma levels of tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-6, IL-8 and IL-10 were measured before anesthesia induction, and 5 min, 1, 4, and 20 h after reperfusion to the myocardium. Levels of the MB isoenzyme of creatine kinase (CK-MB) were also measured after the operation.

RESULTS

Levels of TNF-alpha were low in both groups. A delayed elevation of IL-6 was noted in the off-pump group. IL-8 and IL-10 levels were significantly higher in the CPB than in the off-pump patients after reperfusion (p=0.006 and 0.001 respectively). Postoperative CK-MB levels were significantly higher in the CPB than in the off-pump group (p=0.001). Cytokine levels correlated with CK-MB values.

CONCLUSION

The results indicated that off-pump revascularization was associated with reduced cytokine responses and less severe myocardial injury. The degree of myocardial injury, as defined by CK-MB release, correlated with cytokine release. Intervention designed to reduce cytokine responses in cardiac surgery may be advantageous for patients with severe comorbidity.

Serum adhesion molecules and interleukin-2 receptor as markers of tumour load and prognosis in advanced cutaneous melanoma

Cell adhesion molecules are cell surface glycoproteins that may act as mediators in the metastatic process. Soluble interleukin-2 receptor (sIL-2R) is an immunological marker that may also serve as an indicator of tumour progression. Normal and neoplastic cells are capable of releasing these molecules into circulation. We evaluated the association between pretreatment serum levels of soluble intercellular adhesion molecule 1 (sICAM-1), vascular cell adhesion molecule 1 (sVCAM-1) and sIL-2R and metastases and survival in 50 patients with advanced melanoma. The patients with liver and/or bone metastases had significantly higher sICAM-1 levels than those with soft tissue and/or lung involvement (P=0.002). In addition, there was a trend towards higher sIL-2R levels in patients with more metastatic sites (P=0.07). In univariate analysis, the number of metastatic sites (P=0.0001, odds ratio (OR) 3.0, 95% confidence interval (CI): 1.7-5.3), the metastatic site (P=0.01, OR 2.3, 95% CI: 1.2-4.4) and the levels of sICAM-1 (P=0.011, OR 2.5, 95% CI: 1.2-5.0), sVCAM-1 (P=0.036, OR 2.1, 95% CI: 1.0-4.3) and sIL-2R (P=0.0016, OR 3.0, 95% CI: 1.5-6.0) were found to be statistically significant prognostic factors for survival. In multivariate analysis, the number of metastatic sites was the dominant prognostic indicator. After it was excluded from the analysis, the sIL-2R level and the metastatic site were found to be significant. It can be concluded, that high sICAM-1 levels suggest liver metastases and sIL-2R seems to serve as a marker of tumour load in metastatic melanoma. Furthermore, the sIL-2R level appears to add to clinical data predicting the patient's outcome.

Cardioprotective effect of adenosine pretreatment in coronary artery bypass grafting

OBJECTIVE

There are several reports of the use of adenosine as a cardioprotective agent during cardiac surgery. Adenosine treatment might affect neutrophils and inflammatory mediators. The present prospective randomized study was designed to investigate the effect of adenosine pretreatment on myocardial recovery and inflammatory response in patients undergoing elective coronary artery bypass surgery.

DESIGN

A prospective, randomized, controlled study.

SETTING

Operative unit and ICU in a university hospital in Finland.

PATIENTS

Thirty male patients undergoing primary, elective coronary revascularization.

INTERVENTIONS

Patients in the adenosine group received a 7-min infusion of adenosine (total, 650 microg/kg) before the initiation of cardiopulmonary bypass.

MEASUREMENTS

Postoperative creatine kinase (CK)-MB release and hemodynamics were recorded. Perioperative leukocyte and cytokine release were measured.

RESULTS

Adenosine pretreatment resulted in less CK-MB release and an improved postbypass cardiac index. Similar leukocyte counts and cytokine responses were seen in both groups perioperatively. Neutrophil counts were similar between the groups before and after myocardial ischemia when measured simultaneously in arterial and coronary sinus blood.

CONCLUSIONS

The present results support the hypothesis that adenosine pretreatment is cardioprotective in humans, but the present dose failed to regulate the inflammatory responses after coronary artery bypass grafting.

Inflammatory cytokines and soluble receptors after coronary artery bypass grafting

Much interest has been focused on the overexpression of proinflammatory cytokines, but studies on their soluble receptors are rare. For a comprehensive picture of cytokine activation in cardiac surgery, a combination of cytokines and the corresponding soluble receptor concentration should be determined. Blood samples were collected from the radial artery and coronary sinus perioperatively in ten patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. TNF-alpha, IL-6, sTNFRI, sTNFRII, and sIL-6R levels in the plasma were determined. Systemic TNFRI, TNFRII and IL-6 increased significantly after reperfusion to the myocardium, while perioperative systemic sIL-6r levels were similar. Arterial and sinus levels of TNFRI, TNFRII and sIL-6r were similar before cardiopulmonary bypass. Five minutes after reperfusion to the myocardium, higher sinus TNFRI and TNFRII and lower sinus sIL-6R levels were observed as compared to the arterial levels. The myocardium release of sTNFRI (r=0.57, P=0.089) and sTNFRII (r=0.64, P=0.047) positively correlated with the change of cardiac index after cardiopulmonary bypass. Myocardium releases sTNFRI and sTNFRII after ischaemic-reperfusion injury, and this may be of benefit to cardiac performance. sIL-6R is constantly being produced in areas other than the myocardium, while sIL-6R levels are reduced by consumption in the myocardium after ischaemic-reperfusion injury.

Anti-inflammatory effects of 17beta-estradiol pretreatment in men after coronary artery surgery

OBJECTIVE

To investigate the anti-inflammatory and hemodynamic effects of 17beta-estradiol in men undergoing elective coronary artery bypass graft surgery (CABG).

DESIGN

Prospective, randomized, controlled.

SETTING

Operating room and intensive care unit in a university hospital.

PARTICIPANTS

Twenty-one men undergoing primary, elective CABG surgery.

INTERVENTION

17beta-estradiol, 2mg, was given orally twice in 14 hours before the operation.

MEASUREMENTS AND MAIN RESULTS

Leukocyte counts, plasma myeloperoxidase, tumor necrosis factor-alpha, interleukin (IL)-6, IL-8, and IL-10 were measured perioperatively. Leukocyte counts were lower in the 17beta-estradiol group than in controls at 6 hours (11.4 +/- 2.0 hours v 15.5 +/- 4.7 hours x 10(9)/L) and 20 hours (11.6 +/- 1.9 hours v 13.6 +/- 2.5 hours x 10(9)/L) after reperfusion (p = 0.03). The release of myeloperoxidase was lower in the 17beta-estradiol group than in controls (5 minutes; 634.4 +/- 213.1 microg/mL v 773.1 +/- 209.3 microg/mL; 4 hours, 305.0 +/- 108.0 microg/mL v 441.3 +/- 191.6 microg/mL; p = 0.02). Systemic vascular resistance index was lower just after cardiopulmonary bypass, and cardiac index was higher postoperatively in the 17beta-estradiol group as compared with controls.

CONCLUSION

Pretreatment with 17beta-estradiol can limit leukocyte activation in men after CABG surgery.

Lipid peroxidation is increased in paraoxonase L55 homozygotes compared with M-allele carriers

Human serum paraoxonase (PON) is an antioxidative enzyme, which circulates on high-density lipoproteins and appears to use oxidized phospholipids as physiological substrates. PON M/L55 substitution changes the ability of PON to prevent lipid oxidation. Urinary 8-iso-PGF(2alpha) (one of F2 -isoprostanes) may represent a non-invasive in vivo index of free radical generation and we propose that PON might influence the biosynthesis of 8-iso-PGF(2alpha) in the vasculature. We studied the urinary excretion of 8-iso-PGF(2alpha) and related it to PON M/L55 genotypes in patients with type 2 diabetes mellitus (n = 55) and non-diabetic control subjects (n = 55). Urinary 8-iso-PGF(2alpha) was determined by competitive ELISA and the PON genotype by a PCR based restriction enzyme digestion method. LL homozygotes were compared to M-allele carriers (ML heterozygotes and MM homozygotes). The urinary excretion of 8-iso-PGF(2alpha) among non-diabetic non-smoking LL homozygotes was 3995.5 +/- 3352.8 ng/24-hour and among M-allele carriers 1689.8 +/- 1051.3 ng/24-hour (p = 0.017, ANCOVA; gender, hypertension, total cholesterol, triglycerides and LDL cholesterol as covariates). The excretion of 8-iso-PGF(2alpha), was increased in type 2 diabetes mellitus compared to non-diabetic control subjects. PON may thus protect against oxidative stress by destroying some biologically active lipids. Excretion of 8-iso-PGF(2alpha) is increased in type 2 diabetes, which may reflect oxidant injury.

Cytokine responses in patients undergoing coronary artery bypass surgery after ischemic preconditioning

OBJECTIVE

The release of proinflammatory cytokines has been shown to be associated with the development of complications after coronary artery bypass grafting with cardiopulmonary bypass. The purpose of the present study was to establish whether ischemic preconditioning (IP) could limit inflammatory cytokines release in patients undergoing elective coronary artery bypass surgery.

METHODS

Twenty-two patients with multiple-vessel coronary artery disease and stable angina admitted for first-time elective coronary artery bypass surgery were randomized into control or ischemic preconditioning groups. Patients in the IP group were exposed to two cycles of two-minute myocardial ischemia, followed by three minutes of reperfusion, at the beginning of the revascularization operation, before the cross-clamping and ischemic period used for coronary artery bypass graft anastomosis. Peripheral plasma levels of TNF-alpha, IL-6, IL-8 and IL-10 were measured perioperatively.

RESULTS

Significant elevation of IL-6, IL-8 and IL-10 were observed in both groups after reperfusion. Ischemic preconditioning has no effect on cytokine release in the early stage after reperfusion. Arterial blood IL-6 levels in the preconditioning group were significantly lower than in controls at 20 h after declamping (52.93 +/- 9.79 vs 96.04 +/- 17.56 pg/ml, p < 0.05).

CONCLUSIONS

The results indicate that ischemic preconditioning results in no effect on systemic inflammatory cytokine release in the early stage but a delayed reduction in IL-6 levels at 20 h after reperfusion.

Serum matrix metalloproteinase-2 as a prognostic marker in advanced cutaneous melanoma

The association was studied between serum concentration of matrix metalloproteinase-2 (MMP-2) and metastatic site, survival and disease progression in patients with advanced cutaneous melanoma. The patient population consisted of 50 patients who were treated with chemoimmunotherapy. The median baseline serum concentration of MMP-2 was 724 ng/ml (range 500-2,297 ng/ml). There were no significant differences in MMP-2 levels according to metastatic site. Baseline MMP-2 concentration did not have a prognostic value. The patients with levels below 800 ng/ml survived for 8.8 months and those with higher levels for 9.7 months. On serial measurements, median serum MMP-2 concentration at disease progression in 25 patients was significantly higher than before treatment. Only five samples at response were available, and the levels were not significantly different from baseline levels. In conclusion, serum MMP-2 is not a prognostic marker in advanced melanoma. It also appears to be of limited clinical value in monitoring.

Normal CSF neuron-specific enolase and S-100 protein levels in patients with recent non-complicated tonic-clonic seizures

PURPOSE

Increased concentrations of the nervous-system-specific proteins neuron-specific enolase (NSE) and S-100 protein (S-100) have been measured with lesions in the CNS. Elevated levels of serum NSE (s-NSE) have been found in status epilepticus, but also after single epileptic seizures. Because larger studies addressing cerebrospinal fluid (CSF) levels of NSE or S-100 have not been performed, we measured CSF NSE and S-100 after tonic-clonic seizures to search for evidence of neuronal and glial damage.

METHODS

22 consecutive patients with single, previously undiagnosed and untreated tonic-clonic seizures were studied. Serum and CSF samples were collected within 24 h after seizure. 18 serum and CSF samples were measured from a control group.

RESULTS

The mean CSF NSE was 8.9 ng/ml (range 0-28 ng/ml) and s-NSE 8.2 ng/ml (range 5-15 ng/ml) in the patient group. The mean concentrations in the control group were 13.1 ng/ml (range 3-24 ng/ml) and 8.0 ng/ml (range 5-12 ng/ml) respectively. The mean CSF S-100 was 3.17 microg/l (range 1.45-7.02 microg/l) and serum S-100 0.05 microg/l (range 0-0.32 microg/l), and in controls 3.19 microg/l (range 1.52-5.13 microg/l) and 0.08 microg/l (range 0-0.28 microg/l).

CONCLUSION

There were no significant differences between the mean concentrations of NSE or S-100 in CSF and serum between the epileptic group and controls. These results do not confirm the previous observation of elevated NSE-levels after tonic-clonic seizures, which argues against neuronal or glial damage after uncomplicated tonic-clonic seizures in unmedicated patients.

Antiphospholipid and antinuclear antibodies in patients with epilepsy or new-onset seizure disorders

PURPOSE

The increased prevalence of autoantibodies in patients with epilepsy has been traditionally regarded to be a consequence of antiepileptic drugs. The purpose of this study was to measure autoantibodies in well-defined groups of patients with seizures to determine the effects of epilepsy and antiepileptic medications on the presence of autoantibodies.

PATIENTS AND METHODS

We studied the frequency of antinuclear antibodies, anti-beta2-glycoprotein I antibodies, and anticardiolipin antibodies in 50 patients with therapy-resistant localization-related epilepsy, 50 patients with generalized epilepsy syndromes, 52 patients with a newly diagnosed seizure disorder but no antiepileptic medication, and 83 healthy controls.

RESULTS

Compared with controls, newly diagnosed patients had a significantly greater prevalence of immunoglobulin (Ig) G class anticardiolipin antibodies (21% versus 7%); the prevalence was 14% in patients with localization-related epilepsy and 8% in patients with generalized epilepsy. The prevalence of IgM class anticardiolipin antibodies was significantly greater in all seizure groups (60% in localization-related epilepsy, 42% in generalized epilepsies, and 33% in newly diagnosed patients) compared with controls (7%). Antinuclear antibodies were significantly more common in newly diagnosed patients (21%) and localization-related epilepsy (24%) compared with controls (12%). When patients with generalized epilepsy (8%) were used as the reference group, antinuclear antibodies were also significantly more frequent in localization-related epilepsy (relative risk [RR] = 2.9, 95% confidence interval [CI]: 1.1 to 8.2) and newly diagnosed seizures (RR = 3.4, 95% CI: 1.2 to 9.3). There were no consistent associations between autoantibodies and specific antiepileptic medications.

CONCLUSIONS

The prevalence of autoantibodies is greater in patients with epilepsy, including newly diagnosed seizure disorder. The increased prevalence of autoantibodies is more strongly associated with epilepsy than with antiepileptic drugs, perhaps indicating that immune dysregulation may be commonly associated with epilepsy.

Cholecystokinin in acute alcoholic and biliary pancreatitis

BACKGROUND

Recent studies have shown that cholecystokinin (CCK) agonist, cerulein can induce acute pancreatitis in animals. The role of CCK in the induction of acute pancreatitis in humans is unclear. We investigated plasma CCK levels in alcoholic and biliary pancreatitis on admission and during the episode of acute pancreatitis.

METHODS

Plasma CCK concentrations were determined by a specific and sensitive radioimmunoassay using CCK antiserum (Euro-Diagnostica, Malmö, Sweden) in 35 patients with acute alcoholic pancreatitis, in 27 patients with acute biliary pancreatitis, in 34 patients with nonpancreatic acute abdominal pain, and in 43 healthy subjects. The mean time from the first symptoms to the plasma sample was 31 (+/- 3.7) h in alcoholic pancreatitis patients and 25 (+/- 5.1) h in biliary pancreatitis patients. We also determined CCK levels in 20 patients during the episode of acute pancreatitis. Normal fasting level of CCK is < or = 1.12 pmol/L according to manufacturer.

RESULTS

Basal plasma CCK concentrations were significantly lower both in alcoholic pancreatitis (mean +/- SEM, 0.04 +/- 0.03 pmol/L, p < 0.0001) and biliary pancreatitis patients (0.17 +/- 0.13 pmol/L, p < 0.0001) than in nonpancreatic acute abdominal pain patients (1.23 +/- 0.32 pmol/L) or healthy subjects (1.18 +/- 0.20 pmol/L). Plasma CCK levels also remained low until the patient was well-recovering and had started oral diet.

CONCLUSION

Basal plasma CCK concentrations are significantly decreased in acute alcoholic and biliary pancreatitis after the first day from the beginning of the symptoms until the patient was well-recovering.

The value of serum S-100beta and interleukins as tumour markers in advanced melanoma

Recently serum S-100beta has shown promise as a tumour marker in melanoma; however, its use as a prognostic marker in the advanced stage needs to be confirmed. Interleukins (ILs) may mediate regression or progression of cancer. In order to study their relation to the metastatic profile and survival, we evaluated the association between pretreatment serum levels of S-100beta, IL-6, IL-10 and IL-12 and metastatic site and survival in 50 patients with advanced melanoma who were to receive chemoimmunotherapy. Patients with liver and/or bone metastases had significantly higher median concentrations of S-100beta, IL-6 and IL-10 than those with only skin, nodal and/or lung involvement. The differences in IL-12 levels were unremarkable. Using univariate analysis, the S-100beta level and metastatic profile were found to be statistically significant prognostic factors for survival. Using multivariate analysis the S-100beta level was the most powerful prognostic indicator, while the metastatic profile was found to be significant after exclusion of S-100beta. The findings suggest that elevated serum levels of S-100beta, IL-6 and IL-10 reflect concurrent liver or bone metastases in melanoma. S-100beta is also an independent prognostic marker. Pretreatment IL levels were not associated with outcome.

Defective tumour necrosis factor-alpha production in mother's milk is related to cow's milk allergy in suckling infants

BACKGROUND

The precise role of leucocytes in human milk is still unresolved.

OBJECTIVE

To assist in clarifying the immune mechanisms involved in the development of CMA in suckling infants, we studied the role of immunoregulatory leucocytes and their mediators in human breast milk.

METHODS

The study population consisted of 43 lactating mothers and their infants, aged 0.25-8.0 months, followed-up prospectively from birth. Of these mothers, 27 had an infant with challenge-proven cow's milk allergy manifested with either skin (n = 23), gastrointestinal (n = 2) or skin and gastrointestinal symptoms (n = 3). Sixteen mothers with a healthy infant served as controls. We evaluated the spontaneous and mitogen-induced tumour necrosis factor-alpha (TNFalpha) and interferon-gamma (IFNgamma) production of human milk leucocytes and isolated peripheral blood lymphocytes in vitro with a commercial ELISA kit.

RESULTS

TNFalpha production of breast milk leucocytes was significantly lower in the mothers with a cow's milk-allergic infant, whereas IFNgamma production of these cells was comparable in the two groups.

CONCLUSION

Our results suggest that in the breast milk of mothers having an infant with cow's milk allergy, the number and function of TNFalpha-producing cells is defective. This might lead to a disturbance in the development of oral tolerance and thereby to the development of CMA in suckling infants. These novel results may help in clarifying the etiopathogenesis of CMA.

Cholecystokinin in the early course of acute post-ERCP pancreatitis

BACKGROUND

A high dose of cholecystokinin (CCK) agonist cerulein can induce acute pancreatitis in animals. The role of CCK in the induction of acute pancreatitis in humans is unclear. We investigated basal plasma CCK levels before and after induction of post-ERCP pancreatitis to determine CCK levels in the early course of the disease.

STUDY DESIGN

We determined plasma CCK concentrations in four groups of patients who underwent ERCP: (1) post-ERCP pancreatitis patients (n = 23); (2) patients with post-ERCP hyperamylasemia without pancreatitis (n = 5); (3) patients with post-ERCP abdominal pain without hyperamylasemia (n = 18); and (4) patients with an uneventful post-ERCP period (n = 43). Plasma samples were taken before ERCP, 4 to 8 hours, 10 to 16 hours, and 24 hours after ERCP. Plasma CCK concentrations were determined by a specific and sensitive radioimmunoassay using CCK antiserum (Euro-Diagnostica, Malmö, Sweden).

RESULTS

Plasma CCK levels increased five-fold early in the course in post-ERCP pancreatitis patients, but not in post-ERCP hyperamylasemia patients or in uncomplicated ERCP patients, where CCK levels temporarily decreased after ERCP. In patients with abdominal pain, CCK levels did not change. After the early increase, plasma CCK levels declined to almost unmeasurable levels one day after the onset of symptoms in post-ERCP pancreatitis. In other groups CCK levels were close to the pre-ERCP level.

CONCLUSIONS

It remains to be shown whether CCK is important in the pathogenesis of post-ERCP pancreatitis or merely a secondary phenomenon. There is a rationale to test CCK antagonists in preventing post-ERCP pancreatitis.

Eosinophil protein X and eosinophil cationic protein as indicators of intestinal inflammation in infants with atopic eczema and food allergy

BACKGROUND

The aim of this study was to evaluate the presence of allergic intestinal inflammation in infants with food allergy and atopic eczema before and after elimination diet, and to evaluate the use of eosinophil protein X (EPX) and eosinophil cationic protein (ECP) in the monitoring of inflammatory activity.

METHODS

The study material comprised 25 infants with atopic dermatitis and food allergy. Thirteen healthy infants served as controls. Faecal and serum samples were collected before an elimination diet (on the first visit to the hospital) and approximately 3 months later for the determination of EPX and ECP.

RESULTS

Before the elimination diet, infants with atopic dermatitis demonstrated markedly higher faecal concentrations of EPX and ECP than healthy controls (P = 0. 0003, P < 0.0001, respectively). The faecal concentrations of EPX and ECP showed a distinct decrease as a result of an adequate elimination diet in patients with favourable clinical response (P = 0.0027, P = 0.004, respectively).

CONCLUSIONS

The results indicate the presence of marked intestinal inflammation in patients with atopic dermatitis and food allergy. The determination of faecal ECP and especially of faecal EPX provides a promising noninvasive tool in monitoring intestinal inflammation and disease activity in infants with atopic eczema and food allergy.

Self-determination in nursing students: an empirical investigation

The purpose of this descriptive study was to examine nursing students' perceptions of student self-determination in a Finnish health-care institute and to find out whether background data were in any way associated with these perceptions. To do this we developed a 56-item Students Self-Determination Questionnaire (SSDQ), which was completed by 435 nursing students. The results showed that self-determination is important for nursing students and that they are willing to exercise self-determination in their training. In practice, however, the students were not very active in this respect, nor did they feel that they were getting very much support from teaching staff. The meaning of self-determination increased with age and with increasing experience.

Defective tumor necrosis factor-alpha production in infants with cow's milk allergy

As an aid to clarifying the role of immune mechanisms in the development of cow's milk allergy (CMA) in suckling infants, we studied the capacity of peripheral blood mononuclear cells (PBMC) to produce tumor necrosis factor-alpha(TNF-alpha) in vitro. The study population consisted of 43 infants, aged 0.12-11.2 months; of these, 31 had challenge-proven cow's milk allergy manifested with either skin or gastrointestinal symptoms or both. In addition, 12 healthy infants were studied as controls. The spontaneous, unstimulated and mitogen-induced production of TNF-alpha and interferon-gamma (IFN-gamma) by isolated peripheral blood leukocytes was evaluated. TNF-alpha and IFN-gamma production of PBMC was significantly lower in infants with cow's milk allergy than in healthy children. Our results indicate that, in infants with CMA, the function of TNF-alpha-producing cells is defective. This might disturb the development of oral tolerance and thereby lead to cow's milk allergy. These results may help to clarify the etiopathology of CMA.

Opsonising immunoglobulins and mannan-binding lectin in chronic lymphocytic leukemia

We investigated the influence of plasma concentrations of immunoglobulin G (IgG), IgA, IgM, IgG subclasses and mannan-binding lectin (MBL) on susceptibility to infection in patients with chronic lymphocytic leukemia (CLL). Of 28 patients with CLL, increased susceptibility to infection was recorded in nine. Four of them (44%) had hypogammaglobulinemia as opposed to only one (5%) of the 19 patients without increased susceptibility to infection (OR 14.4; 95% CI, 1.6-130). When the effect of IgG subclasses contributing to hypogammaglobulinemia was studied, only the decreased concentrations of IgG4 and IgG2 were associated with increased susceptibility to infection. They, in turn, were intercorrelated and also highly correlated with the concentration of IgA. In fact, when these parameters were studied by a multivariable model, only the decreased concentration of IgA was shown as an independent risk factor for infection (P = 0.03). The mean concentration of MBL was significantly higher in patients with infections than in those without (6.54 mg/l and 2.75 mg/l, respectively; P = 0.001). The monitoring of its concentrations might be useful in the follow-up of infectious morbidity in CLL.

The significance of IgG subclasses and mannan-binding lectin (MBL) for susceptibility to infection in apparently healthy adults with IgA deficiency

The aim of this study was to investigate the significance of IgG subclasses and MBL for susceptibility to infection in association with IgA deficiency. The study population consisted of 139 apparently healthy adult blood donors with IgA deficiency and normal serum levels of IgG and IgM, and an increased susceptibility to infection demonstrated at a population level. Additionally, 216 controls matched for age and sex were investigated. IgG4 deficiency was more common and the mean level of IgG4 lower in persons with IgA deficiency than in the controls. No significant associations could be demonstrated between overt IgG subclass deficiencies and increased susceptibility to infection. However, when the mean concentrations of IgG subclasses were analysed with regard to medical history, that of IgG1 was lower in persons who reported recurrent viral respiratory infections, that of IgG3 in persons who had episodes of severe infection in their history, and that of IgG4 in persons who had recurrent mild respiratory infections, compared with those who had no particular history of infections. In contrast, MBL deficiency-alone or combined with that of the IgG subclass-was not associated with increased susceptibility to infection in persons with IgA deficiency. The results indicate that the proneness to infections observed in a population of otherwise healthy persons with IgA deficiency can only for a small part be accounted for by concomitant deficiencies of IgG subclasses. Contrary to expectations, no synergism between the deficiencies of IgA and MBL could be demonstrated.

Time-resolved fluorescence in immunocytochemical detection of prostate-specific antigen in prostatic tissue sections

Chelates with fluorescent lanthanides such as europium and terbium are widely used in immunofluorometric assays, e.g. for the measurement of different molecular forms of prostate-specific antigen (PSA) in serum for detection and monitoring of prostate cancer. These chelates have also been introduced as non-radioactive labels in immunocytochemistry and in situ hybridization. In the present study, sections of non-malignant prostate were investigated using monoclonal IgGs against PSA. Detection of specific immunostaining employing time-resolved fluorescence with europium-labeled streptavidin was compared with conventional detection by streptavidin conjugated to horse-radish peroxidase. The high PSA concentration in the tissue produced high intensity, specific time-resolved fluorescence signals in the epithelial cells of the prostate gland without disturbance from non-specific tissue autofluorescense. This allowed short exposure times to be used which resulted in insignificant photobleaching. Two of the three europium-chelates evaluated yielded high signal intensities. Counterstaining was found to be optimal with Gill No. 1-Haematoxylin solution and Merckoglas was the best mounting medium for the europium chelates tested. In conclusion, time-resolved fluorescence imaging is an attractive alternative to conventional detection of streptavidin conjugated to horse-radish peroxidase, as it provides linear, high intensity, specific signals subsequent to the decay of non-specific tissue autofluorescence.

Laparoscopy for chronic abdominal pain

The purpose of this study was to evaluate the usefulness of exploratory laparoscopy in patients with chronic abdominal pain. Forty-six patients underwent diagnostic laparoscopy for abdominal pain of unknown origin during 1992-1996. The average duration of the symptoms was 3.5 years. Patients with known malignancy were excluded. Seventy-two percent of the patients had undergone previous abdominal or groin surgery. An organic disease was found in 68% of the laparoscopies. Adhesions were found in 29 patients, inguinal hernia in 2 patients, and abnormal mesenteric lymph nodes in 1 patient. Adhesiolysis was carried out in 24 patients. Eighty-nine percent of patients could be contacted for follow-up. Mean follow-up time was 19 months. Seventy-seven percent of patients who had undergone adhesiolysis considered the result good or beneficial. Sixty percent of all patients reported a beneficial outcome after laparoscopy. No major complications were noted. This retrospective study suggests that laparoscopy is a safe and useful procedure in the diagnosis and treatment of chronic abdominal pain.

Hematopoietic growth factors stimulate paraprotein isotype production by bone marrow mononuclear cells in an aggressive case of multiple myeloma

We describe a patient with multiple myeloma (MM), whose bone marrow (BM) cells were capable of spontaneous paraprotein isotype secretion, which could be strongly stimulated by hematopoietic growth factors (GFs), such as interleukin-6 (IL-6), granulocyte-macrophage colony-stimulating factor (GM-CSF), G-CSF and IL-3. Ig production by BM cells from another five MM patients and four control patients with non-malignant hematological diseases could not be stimulated by these GFs. The results indicate that GFs, at least in some instances, can activate tumoral plasma cells in patients with MM. This possibility should be taken into account when the utility and effectiveness of GFs in the treatment of MM is evaluated.

Laparoscopic vs conventional Nissen fundoplication. A prospective randomized study

BACKGROUND

Laparoscopic Nissen fundoplication has gained wide acceptance among surgeons, but the results of the laparoscopic procedure have not been compared to the results of an open fundoplication in a randomized study.

METHODS

Some 110 consecutive patients with prolonged symptoms of grade II-IV esophagitis were randomized, 55 to laparoscopic (LAP) and 55 to an open (OPEN) Nissen fundoplication. Postoperative recovery, complications, and outcome at 3- and 12-month follow-up were compared in the two groups.

RESULTS

Five LAP operations were converted to open laparotomy due to esophageal perforation (two), technical difficulties (two), and bleeding (one). In the OPEN group (two) patients underwent splenectomy. There was no mortality. The mean hospital stay was 3.2 days in the LAP group and 6.4 in the OPEN group. Dysphagia and gas bloating were the most common complaints 3 months after the operation in both groups. These symptoms had disappeared at the 12-month follow-up examination. All patients in the LAP group and 86% in the OPEN group were satisfied with the result.

CONCLUSIONS

Laparoscopic Nissen fundoplication is a safe and feasible procedure. Complications are few and functional results are good if not better than those of conventional open surgery.

Laparoscopic appendectomy-is it worthwhile? A prospective, randomized study in young women

BACKGROUND

Clinical diagnosis of acute appendicitis is most difficult in fertile-age women. In this patient group up to 50% of open appendectomies are negative for appendicitis. We conducted a randomized study to compare laparoscopic and open appendectomy in young female patients with suspected acute appendicitis.

METHODS

Fifty female patients between the ages of 16 and 40 years presenting with acute right lower abdominal pain were randomized, 25 to laparoscopy and 25 to an open appendectomy. Diagnostic accuracy, rate of negative appendectomies, safety, and final outcome were compared in the two groups.

RESULTS

Diagnosis was established in 96% of patients in the laparoscopic group and in 72% in the open group. There were 11 (44%) unnecessary appendectomies in the open group, but only one (4%) in the laparoscopic group (p < 0.0005).

CONCLUSIONS

In young women with right lower abdominal pain, laparoscopy can give precise diagnosis and reduce the rate of negative appendectomies.

Pancreatitis associated protein as an early marker of acute pancreatitis

BACKGROUND

Measuring serum pancreatitis associated protein (PAP) in acute pancreatitis has proved valuable to monitoring the course of the disease and the recovery of the patient.

AIMS

The aim was to analyze the utility of PAP on admission as a diagnostic and prognostic marker of acute pancreatitis.

PATIENTS

Values of PAP were prospectively analyzed in 80 healthy volunteers, 164 patients with abdominal pain but without pancreatitis, 109 patients with mild acute pancreatitis, and 38 patients with severe acute pancreatitis.

METHODS

The diagnosis of acute pancreatitis was verified with clinical, laboratory, radiological, and in some cases findings at operation or necropsy.

RESULTS

Mean (95% confidence intervals) serum PAP values were 27 (24 to 29) micrograms/l in healthy volunteers, 78 (59 to 96) micrograms/l in patients with abdominal pain, 191 (134 to 247) micrograms/l, in patients with mild acute pancreatitis, and 599 (284 to 914) micrograms/l in patients with severe acute pancreatitis. Differences between the groups were significant (p = 0.04 - 0.01). Despite the differences in means, the ranges overlapped between the groups. The sensitivity of PAP on admission to detect acute pancreatitis was 38%-53% and the respective specificity 89%-77% depending on the cut off level. The sensitivity of PAP to detect severe acute pancreatitis was 45%-68% and the specificity 74%-59% depending on the cut off level.

CONCLUSIONS

Admission PAP did not distinguish severe from mild acute pancreatitis better than C reactive protein. Measurement of PAP does not give appreciable diagnostic advantages in the early phase of acute pancreatitis.

BMX tyrosine kinase gene is expressed in granulocytes and myeloid leukaemias

The growth and maturation of haemopoietic cells is regulated by signal transduction through tyrosine protein kinases. Recently, a novel cytoplasmic tyrosine kinase gene in chromosome X, called Bmx, was identified in human bone marrow RNA. Bmx belongs to a subfamily of tyrosine kinases which are expressed in various haemopoietic cell lineages. We studied Bmx expression using RT-PCR of RNA from fractionated peripheral blood leucocytes, progenitor-enriched fractions of cord blood and from bone marrow or peripheral blood samples from leukaemia patients. Bmx was strongly expressed in haemopoietic tissues and enhanced in neutrophilic granulocytes. Bmx mRNA was also found in CD34-positive progenitor cells from cord blood. All samples (10/10) of patients with acute myeloid leukaemia and (4/4) with chronic myeloid leukaemia showed expression of Bmx. In contrast, none of the samples of acute lymphoid leukaemia (0/8) and only one out of six samples of chronic lymphoid leukaemia expressed Bmx. In conclusion, Bmx expression seems to be associated with myelopoiesis.

Effect of interferon-alpha on immunoglobulin production by peripheral blood mononuclear cells in multiple myeloma

To test a hypothesis that interferon-alpha (IFN) treatment might restore normal immunoglobulin (Ig) production in multiple myeloma (MM), the effect of IFN on Ig isotype (IgG and IgA) production by peripheral blood (PB) and bone marrow (BM) mononuclear cells (MNCs) in MM patients was analyzed by ELISA. IFN at a concentration of 1000 U/ml was found to enhance IgA production by PB MNCs in IgA-MM and had a trend to stimulate IgG production in IgG-MM. The effect of IFN on nonparaprotein Ig isotype production was more variable, with mostly neutral or inhibitory effects being seen in both the MM subtypes. In contrast to the influences observed in MM patients, IFN at the same concentration inhibited both IgG and IgA production by PB MNCs in healthy controls. In studying BM cells, IFN was found to reduce IgA production in IgA-MM, but had a neutral effect on IgG production in IgG-MM. In the controls, the production of both the IgG and the IgA isotypes by BM MNCs was decreased by IFN. On the basis of these results it seems that the disease itself somehow affects the Ig-producing cells in MM, when measured as different responses of the cells to exogenous IFN in vitro. The results do not support the hypothesis that IFN treatment could restore normal Ig production in MM patients.

Serum levels of interleukins 2, 6 and 8, soluble interleukin-2 receptor and intercellular adhesion molecule-1 during treatment with interleukin-2 plus interferon-alfa

In the present study we evaluated the haematological and immunological changes in 4 patients with advanced melanoma and 6 patients with advanced renal cell carcinoma treated with subcutaneous interleukin (IL)-2 and interferon (IFN)-alfa-2b. Serum samples taken before and during six weeks' courses of IL-2 plus IFN-alfa were assayed for the presence of IL-2, soluble IL-2-receptor (sIL-2R), soluble intercellular adhesion molecule-1 (sICAM-1), IL-6 and IL-8. In addition, whole blood counts were taken. Eosinophilia occurred in all patients, lymphocytosis in 8 patients. The higher maximum level of IL-2 during treatment seemed to be connected to longer survival: it was a median of 578 pg/ml in the patients with a median survival of 7 months, and 1025 pg/ml in the patients who survived a median of 15 months. Conversely, an increase in sIL-2R was an unfavourable sign: it was a median of 8-fold and 3-fold in the patients with a median survival of 7 and 16 months, respectively. During treatment, sICAM-1 levels paralleled with those of sIL-2R. There was major intraindividual and interindividual variation in serum IL-6 and IL-8 levels with no distinctive kinetic pattern. Thus, no definite conclusions could be drawn. However, it seems worthwhile to measure IL-2, sIL-2R and sICAM-1 during immunotherapy; their prognostic value should be further evaluated in a larger patient population.

Intestinal inflammation in children with atopic eczema: faecal eosinophil cationic protein and tumour necrosis factor-alpha as non-invasive indicators of food allergy

BACKGROUND

Food allergy is contemplated in atopic eczema. Early recognition of food allergies is difficult and the diagnosis is often missed because of the non-specificity of symptoms. New non-invasive tests are clearly needed.

OBJECTIVE AND METHODS

We measured the concentrations of tumour necrosis factor-alpha, eosinophil cationic protein and alpha-1 antitrypsin in faeces as indicators of intestinal inflammation induced by double-blind placebo-controlled oral cow's milk challenge in infants and young children with atopic eczema.

RESULTS

An increased alpha-1 antitrypsin concentration (> 2 mg/g) after cow's milk challenge was detected in 43% of the infants positive as compared with 11% of the infants negative to challenge, P = 0.02. The concentration of eosinophil cationic protein in faeces increased after cow's milk challenge in patients positive to challenge (P = 0.02) but not in those negative to challenge (P = 0.79). The concentration of eosinophil cationic protein was enhanced particularly in patients manifesting immediate-type reactions to the cow's milk challenge. The concentration of tumour necrosis factor-alpha increased after cow's milk challenge in patients positive to challenge (P = 0.005) but not in those negative to challenge (P = 0.25). The concentration of tumour necrosis factor-alpha in faeces was enhanced particularly in patients manifesting delayed-type reactions to the cow's milk challenge.

CONCLUSION

We conclude that in children with atopic eczema food allergy is associated with intestinal inflammation indicating that more general immunologic disturbances than previously thought take place in these patients. We further suggest that faecal eosinophil cationic protein, tumour necrosis factor-alpha and alpha-1 antitrypsin distinctly indicate various reaction types of food allergy. Parallel testing with eosinophil cationic protein and tumour necrosis factor-alpha may significantly enhance the accuracy in diagnosis of food allergy in patients with atopic eczema.

Thyroid antibodies in association with thyroid malignancy II: Qualitative properties of thyroglobulin antibodies

Qualitative properties of thyroglobulin (Tg) antibodies, in association with thyroid malignancy, suspected malignancy or other thyroid diseases, were studied in 177 patients. Retrospective clinical analysis revealed 137 patients to have thyroid carcinoma and 40 to have other thyroid diseases. Serum Tg was assayed by an immunoradiometric method. Thyroid microsomal (AMC) and Tg antibodies were measured by the particle agglutination method and the avidity of Tg antibodies by enzyme immunoassay (EIA). Assessment of the qualitative properties of Tg antibodies revealed that the high-avidity antibodies especially seem to bind circulating Tg. Thus any Tg value from a sample with detectable Tg antibodies is unreliable and should be interpreted with caution.

A novel method to quantitate methylation of specific genomic regions

A new solid-phase primer extension method has been developed for the quantitation of methylation differences and is described here. The method is less cumbersome than Southern blot analysis, expresses the results in a numerical format, can be adapted to a microtitration well format, and thus allows the analysis of a large series of samples. The model gene analyzed here is the calcitonin gene, but the method can be adapted to the analysis of methylation alterations in any area of the genome. The primer extension method clearly differentiated hypermethylated samples from normally methylated samples and a range for normal values could be determined. In quantitation experiments the method showed linearity in a range from 2% to 100% malignant blasts diluted with normal leukocytes.