Neuropathological and biochemical investigation of Hereditary Ferritinopathy cases with ferritin light chain mutation: Prominent protein aggregation in the absence of major mitochondrial or oxidative stress

AIMS

Neuroferritinopathy (NF) or hereditary ferritinopathy (HF) is an autosomal dominant movement disorder due to mutation in the light chain of the iron storage protein ferritin (FTL). HF is the only late-onset neurodegeneration with brain iron accumulation disorder and study of HF offers a unique opportunity to understand the role of iron in more common neurodegenerative syndromes.

METHODS

We carried out pathological and biochemical studies of six individuals with the same pathogenic FTL mutation.

RESULTS

CNS pathological changes were most prominent in the basal ganglia and cerebellar dentate, echoing the normal pattern of brain iron accumulation. Accumulation of ferritin and iron was conspicuous in cells with a phenotype suggesting oligodendrocytes, with accompanying neuronal pathology and neuronal loss. Neurons still survived, however, despite extensive adjacent glial iron deposition, suggesting neuronal loss is a downstream event. Typical age-related neurodegenerative pathology was not normally present. Uniquely, the extensive aggregates of ubiquitinated ferritin identified indicate that abnormal FTL can aggregate, reflecting the intrinsic ability of FTL to self-assemble. Ferritin aggregates were seen in neuronal and glial nuclei showing parallels with Huntington's disease. There was neither evidence of oxidative stress activation nor any significant mitochondrial pathology in the affected basal ganglia.

CONCLUSIONS

HF shows hallmarks of a protein aggregation disorder, in addition to iron accumulation. Degeneration in HF is not accompanied by age-related neurodegenerative pathology and the lack of evidence of oxidative stress and mitochondrial damage suggests that these are not key mediators of neurodegeneration in HF, casting light on other neurodegenerative diseases characterized by iron deposition.

The Design and Evaluation of a Burn Wound Covering

A burn wound covering based on an acrylonitrile-dimethylaminoethyl methacrylate copolymer membrane is described. The requirements for a burn wound covering are discussed and a particular requirement, that of adequate water vapour permeability, is considered in detail. The effects on membrane water vapour permeability of contacting the membrane with ethylene oxide gas and of incorporating plasticizers are reported.

A qualitative study to develop a tool to examine patients’ perceptions of NHS orthodontic treatment

OBJECTIVE

To identify issues of importance to adolescent patients surrounding the delivery of orthodontic treatment under the National Health Service (NHS), which can form the basis of a tool to examine patients' perceptions of NHS orthodontic treatment.

DESIGN

Study using qualitative research methods.

SETTING

Patients were recruited from the orthodontic departments at Derriford Hospital and Bristol Dental Hospital, and from Specialist Orthodontic Practices in Plymouth and Solihull.

SUBJECTS

A rolling sample of patients from a list of orthodontic patients under treatment at each site was selected. Twenty-six patients took part in five focus group meetings. Three patients took part in semi-structured telephone interviews.

METHODS

Participants were invited to participate in either a focus group meeting or a telephone interview. The transcripts of these meetings were analysed by two researchers working independently. Issues of importance to patients regarding the delivery of orthodontic treatment under the NHS were identified.

RESULTS

The issues identified included being treated with respect by the clinician and being included in discussions about treatment. Participants tended to rely on their peers for advice about what to expect from treatment. The patients also discussed the benefits to them of undergoing orthodontic treatment. These included an improved appearance and increased self-confidence.

CONCLUSION

This qualitative research has identified issues that are important to adolescent orthodontic patients. These issues will be used to form the basis of a patient-centred measure for auditing patients' perceptions of orthodontic treatment under the NHS.

Images of the terminal ileum are more convincing than cecal images for verifying the extent of colonoscopy

BACKGROUND AND STUDY AIMS

Independent verification of colonoscopy completion is important for quality assurance. Cecal photographs aimed at showing key landmarks, including the ileocecal valve (ICV) and appendiceal orifice are the currently recommended standard, but are often perceived as unreliable. Images of the terminal ileum demonstrating villi may provide more robust evidence of completion. We sought to prospectively evaluate the ease of routine intubation of the terminal ileum and to compare the effectiveness of terminal ileum and cecal photographs in convincing independent reviewers that total colonoscopy had been accomplished.

PATIENTS AND METHODS

A prospective, observational study evaluated 216 consecutively completed colonoscopies performed in routine clinical practice. Cecal and terminal ileum photographs were evaluated and scored by independent reviewers. Frequency of terminal ileum intubation, time required, and safety parameters were recorded.

RESULTS

The terminal ileum was intubated and photographed in 188/216 (87%) of cases. Median time taken to intubate, or attempt to intubate the terminal ileum was 1 min 24 s, and was achieved without complications or requirement for additional sedation. Terminal ileum images were significantly more likely to be considered convincing than cecal images ( P<0.0001 for all reviewers). There was excellent interobserver agreement amongst the opinion of reviewers regarding terminal ileum photographs (kappa=0.91).

CONCLUSION

Terminal ileum intubation is achievable rapidly and safely in the majority of patients undergoing colonoscopy. Terminal ileum images provide more convincing evidence of complete examination of the colon than cecal images, even when attempts to capture images specifically of the ICV and appendiceal orifice are made.

Health-related quality of life and survival in the 2 years after surgery for gastric cancer

BACKGROUND

This prospective study examined health-related quality of life (HRQL) and survival in patients with potentially curable gastric cancer.

METHODS

Consecutive patients (n=58) selected for curative surgery completed a validated questionnaire (EORTC QLQ-C30) and site-specific module (QLQ-STO22) before surgery and regularly for 2 years afterwards. Changes of 10 or more points on a 0-100 scale were considered clinically significant.

RESULTS

Some 30 patients were alive after 2 years (52%). In the first 3 months after surgery, HRQL was significantly reduced across all dimensions except emotional and cognitive functioning (mean reduction of 10 or more points). Functional aspects of HRQL recovered by 6 months in patients who subsequently were alive at 2 years, although at least a third of patients experienced specific symptoms, even 6 months after surgery, especially diarrhoea. For those dying within 2 years, some postoperative functional HRQL recovery occurred, but many symptoms were common.

CONCLUSIONS

Potentially curative gastrectomy for cancer has a detrimental impact on HRQL that mostly recovers in patients surviving some 2 years. Patients who die within 2 years may experience limited postoperative recovery. It is recommended that patients receive HRQL information about the outcomes of surgery for gastric cancer.

Reversibility of cerebral symptoms in severe hypertension in relation to acute antihypertensive therapy. Danish Multicenter Study

Cerebral symptoms were registered in a multicenter study including 64 patients with severe hypertension, diastolic blood pressure (DBP) greater than or equal to 135 mmHg, and more or less pronounced hypertensive encephalopathy. The symptoms were: headache (70%), dizziness (35%), consciousness disturbances (28%), nausea (27%), paresis (23%), blurred vision (22%), paraesthesia (21%) and vomiting (14%). None had convulsions or coma. Initial treatment was furosemide i.v., and if DBP was greater than or equal to 125 mmHg after one hour, patients were randomized to treatment with either i.v. diazoxide (bolus injections of 75-150 mg) or i.m. dihydralazine (bolus injections of 6-12.5 mg). A gradual fall in blood pressure (BP) was obtained in all three groups. Along with BP reduction a substantial regression of neurological symptoms was registered. After 5 hours only minor cerebral symptoms were present without significant difference between diazoxide and dihydralazine. None developed cerebral complications. The study failed to show a significant correlation between BP reduction and regression of neurological symptoms graded semiquantitatively. Reduction of BP by titration using small repeated bolus injections is recommended, but oral treatment should be considered in the patients who are able to ingest peroral medication in spite of neurological symptoms.

Severe hypertension with cerebral symptoms treated with furosemide, fractionated diazoxide or dihydralazine. Danish Multicenter Study

Emergency treatment of acute, severe hypertension defined as diastolic blood pressure (DBP) greater than or equal to 135 mmHg combined with cerebral symptoms was prospectively monitored in a randomized multicenter study including 64 patients. Treatment was divided into two periods. In the first hour the patients were observed in the supine position after being given 40 mg furosemide intravenously. If DBP remained greater than 125 mmHg (n = 52), the patients were put on fractionated diazoxide administered intravenously (n = 28) or dihydralazine administered intramuscularly (n = 24). Blood pressure (BP) decreased with diazoxide from an average of 241/149 mmHg to 180/111 mmHg after 5 hours and with dihydralazine from 237/149 to 161/101 mmHg. The inter-individual BP response varied considerably. A clear and identical regression in neurological symptoms was observed on both drug regimens. No new neurological symptoms were seen to develop. It is concluded that a gradual fall in BP can be obtained after fractionated dosage of diazoxide (i.v.) as well as after dihydralazine (i.m.). The indication of acute parenteral therapy compared to less aggressive oral treatment is discussed.

The antihypertensive effect of prazosin on mild to moderate hypertension, changes in plasma volume, extracellular volume and glomerular filtration rate

Changes in blood pressure, plasma volume (PV) (125I-albumin space), extracellular volume (ECV) (82Br-space) and glomerular filtration rate (GFR) (51Cr-EDTA clearance) were measured in 12 patients with mild to moderate essential hypertension on placebo and during long-term treatment with prazosin. During the study, BP decreased from an average of 172/107 to 166/102 mmHg (n.s.). PV increased from 3278 to 3324 ml (n.s.) and ECV from 18360 to 18639 ml (n.s.). GFR was almost unchanged, 95 and 93 ml/min, prespectively. An inverse significant correlation was found between the changes in mean BP and changes in ECV, i.e. fluid retention was demonstrated in patients with the smallest BP reduction. It is concluded that inadequate BP response during treatment with prazosin may in part be due to fluid retention. It is therefor suggested that prazosin should in principle be used together with a diuretic in order to prevent fluid retention.

A follow-up study of hypertensive patients after operative treatment of unilateral renovascular or renal disease

A study of 44 hypertensive patients with unilateral renovascular or renal parenchymal disease is presented. All patients underwent corrective surgery. Out of the 44 operated patients, five did not participate in the follow-up examination. The remaining 39 patients constitute the study population. The effects of surgery on the hypertensive state could be evaluated in 35 patients, whereas four died less than two months after the operation. Follow-up studies were carried out at 8-60 months after the operation. The average period of observation was 32 months; 24 patients were observed for more than two years. As a group, the patients had severe hypertension with extensive target organ damage and widespread atherosclerosis. A fairly rigorous selection process was applied, and an unsatisfactory response to medical management was considered a point of major importance. In the majority of cases, renovascular lesions were atherosclerotic, with only two cases of fibromuscular dysplasia. Unilateral nephrectomy was performed in 32 patients, whereas seven underwent reconstructive vascular surgery. Out of 35 patients, 22 (63%) were cured, 8 (23%) improved and 5 (14%) unaltered. A gratifying regression of hypertensive lesions in target organs was observed in patients who were cured or improved by surgery. The frequency and severity of postoperative complications were related to the presence of extrarenal vascular disease.

The role of health-related quality of life outcomes in clinical decision making in surgery for esophageal cancer: a systematic review

BACKGROUND

Esophagectomy for cancer offers a chance of cure but is associated with morbidity, at least a temporary reduction in health-related quality of life (HRQL), and a 5-year survival of approximately 30%. This research evaluated how and whether HRQL outcomes contribute to surgical decision making.

METHODS

A systematic review identified randomized trials and longitudinal and cross-sectional studies that assessed HRQL after esophagectomy with multidimensional validated questionnaires. Articles were independently evaluated by two reviewers, and the value of HRQL in clinical decision making was categorized in three ways: (1) the assessment of the quality of HRQL methodology according to predefined criteria; (2) the influence of HRQL outcomes on treatment recommendations and/or informed consent; and (3) the HRQL after esophagectomy for cancer in methodologically robust studies.

RESULTS

Eighteen publications were identified, of which 16 (89%) were categorized as having robust HRQL design. Of these studies, 3 concluded that HRQL influenced treatment recommendations and 11 (including the former 3) informed patient consent. The remaining five papers were well designed, but the authors did not use HRQL to influence treatment recommendations or informed consent. After esophagectomy, patients report major deterioration in most aspects of HRQL with slow recovery.

CONCLUSION

HRQL outcomes are relevant to surgical decision making. Methods to communicate HRQL outcomes to patients are required to inform consent and clinical practice.

Prolonged cholestasis following successful removal of common bile duct stones: Beware patients on estrogen therapy

There are various well described forms of chronic cholestatic jaundice in adults, such as autoimmune cholangitis, drug-induced cholangitis and intrahepatic cholestasis of pregnancy. We present two cases of prolonged cholestasis following removal of gallstones at endoscopic retrograde cholangiopancreatography (ERCP) and subsequent clear cholangiography. Both patients were taking oral estrogens at the time of presentation, which were subsequently withdrawn. The first case responded rapidly to corticosteroid treatment, and the second case had a much slower resolution with ursodeoxycholic acid. Both cases highlighted the significance of estrogen-induced cholestasis in female patients with protracted jaundice following ERCP and removal of intra-ductal stones. After oral estrogens are discontinued, a short course of steroids needs to be considered.

A role for HNF-3 in the regulation of the HNF-1 gene of the Atlantic salmon

Hepatocyte nuclear factors -1 (HNF-1) and -3 (HNF-3) are hepatocyte-enriched transcription factors that are central to the establishment and maintenance of the liver phenotype in vertebrates. In the present study we demonstrate that, in the Atlantic salmon, asHNF-3 regulates the expression of the gene for asHNF-1. Multiple putative binding sites for asHNF-3 were identified within the 5' flanking region of the HNF-1 gene using a computer-based algorithm, and these were confirmed to be functional by electrophoretic mobility shift assays. In transient transfection assays it was shown that co-expression of asHNF-3 leads to a decrease in the promoter activity of the 5' flanking region of the asHNF-1 gene.

Synergistic activation of the Atlantic salmon hepatocyte nuclear factor (HNF) 1 promoter by the orphan nuclear receptors HNF4 and chicken ovalbumin upstream promoter transcription factor I (COUP-TFI)

Hepatocyte nuclear factor 1 (HNF1) is a liver-enriched transcription factor that plays an important role in transcriptional networks involved in liver function. The promoters of mammalian HNF1 genes contains a single binding site for another liver-enriched transcription factor, the nuclear hormone receptor HNF4. A transcriptional hierarchy involving HNF4-mediated activation of the HNF1 promoter has been proposed to be of crucial importance in maintaining the differentiated hepatocyte phenotype. Here we present evidence that the Atlantic salmon HNF1 promoter contains three nuclear-hormone-receptor-binding sequences. Gel-shift assays showed that these motifs are recognized with different affinities by HNF4 and the orphan nuclear receptors chicken ovalbumin upstream promoter transcription factors COUP-TFI and COUP-TFII. In hepatoma cells, the site showing highest affinity for HNF4 appears to be crucial for promoter activity. Transfection experiments in non-hepatic cells indicated that the salmon HNF1 promoter was activated by both HNF4 and COUP-TFs. We also identified a promoter fragment encompassing the two more distal nuclear-hormone-binding sites that was activated by HNF4, unaffected by COUP-TF and showed a strong synergistic activation by HNF4/COUP-TF. Results are presented detailing these interactions in relation to the salmon HNF1 promoter architecture.

A prospective, randomized comparison of the ease and safety of variceal ligation using a multiband vs. a conventional ligation device

BACKGROUND AND STUDY AIMS

Recent advances in endoscopic technology have led to the development of multiple-banding devices which avoid the use of an overtube in endoscopic variceal ligation. In the present study we prospectively examined the safety and efficacy of one such device compared with the conventional single-band ligator.

PATIENTS AND METHODS

A total of 45 patients undergoing band ligation were randomly assigned to receive ligation using conventional techniques (n = 22), or multiband ligation (n = 23).

RESULTS

The use of the multiband device was associated with a significant reduction in sedation requirements (midazolam 7.1 mg vs. 9.9 mg, P < 0.01, multiband vs. conventional, respectively), less discomfort (4% vs. 23% severe discomfort, P < 0.05). The total time of the endoscopic session was reduced in the multiband group (8 minutes 25 seconds vs. 12 minutes 21 seconds, P < 0.01), as was the time required for application of all the bands (2 minutes 22 seconds vs. 5 minutes 34 seconds, P < 0.001), and average time taken per individual band application (36 seconds vs. 1 minute 36 secs, P < 0.01). In three patients who underwent ligation using the conventional method, the procedure was stopped because of trauma secondary to overtube application.

CONCLUSIONS

Multiband ligation is safer, quicker, and associated with less patient discomfort and morbidity when compared with conventional ligation.

Atlantic salmon HNF-3/forkhead: cDNA sequence, evolution, expression, and functional analysis

We report the isolation and characterization of a cDNA encoding an HNF-3 family member (as HNF-3) from Atlantic salmon (Salmo salar L). The important functional domains of HNF-3 proteins that have been characterized previously are revealed by segments of high identity along the alignment of the asHNF-3 with winged helix/forkhead amino acid sequences isolated from other species. A comparison of asHNF-3 cDNA and genomic DNA indicated that there were no introns present in the asHNF-3 gene. Expression of asHNF-3 protein in adult salmon tissues was not exclusive to liver but was also present in the pancreas and intestine. An RT-PCR analysis performed on salmon development showed that asHNF3 expression is detectable before gastrulation at the mid blastula transition stage. Functional analysis of the asHNF-3 protein using a characterized HNF-3 consensus binding site demonstrated that the protein can recognize and bind to specific HNF-3 consensus sequences. We also report the identification of a novel HNF3 binding site in the promoter of the Atlantic salmon transferrin gene.

Thrombin is effective in arresting bleeding from gastric variceal hemorrhage

Gastric variceal hemorrhage is associated with a high morbidity and mortality. We report the efficacy and safety of bovine thrombin in the treatment of bleeding gastric varices. At endoscopy 52 patients with hematemesis were diagnosed with bleeding gastric varices. Patients were treated by intravariceal injection with bovine thrombin and underwent further endoscopy at 72 hr and then at two-week intervals. Initial hemostasis was achieved in 49/52 patients (94%). Bleeding-related mortality at 72 hr after the index bleed was 3/52 (6%). The mean amount of thrombin used to achieve initial hemostasis was 1070 IU (range 400-2000 IU) and no adverse drug effects were observed. The median number of treatment sessions required to achieve gastric variceal ablation was 2 (range 1-3). At six weeks, 9 of 49 surviving patients (18%) rebled and one further patient died. The six-week mortality in patients treated with thrombin was 4/52 (8%). In conclusion, safe and effective hemostasis of bleeding gastric varices can be achieved by intravariceal injection with thrombin.

Thrombin is effective in arresting bleeding from gastric variceal hemorrhage

Gastric variceal hemorrhage is associated with a high morbidity and mortality. We report the efficacy and safety of bovine thrombin in the treatment of bleeding gastric varices. At endoscopy 52 patients with hematemesis were diagnosed with bleeding gastric varices. Patients were treated by intravariceal injection with bovine thrombin and underwent further endoscopy at 72 hr and then at two-week intervals. Initial hemostasis was achieved in 49/52 patients (94%). Bleeding-related mortality at 72 hr after the index bleed was 3/52 (6%). The mean amount of thrombin used to achieve initial hemostasis was 1070 IU (range 400-2000 IU) and no adverse drug effects were observed. The median number of treatment sessions required to achieve gastric variceal ablation was 2 (range 1-3). At six weeks, 9 of 49 surviving patients (18%) rebled and one further patient died. The six-week mortality in patients treated with thrombin was 4/52 (8%). In conclusion, safe and effective hemostasis of bleeding gastric varices can be achieved by intravariceal injection with thrombin.

The clinical diversity and role of chemotherapy in lymphoproliferative disorder in liver transplant recipients

BACKGROUND/AIMS

Post-transplant lymphoproliferative disorder is a well-documented complication with an incidence ranging from 2 to 10%, depending on the organ transplanted. Yet despite our increased understanding of the pathophysiology of this disease and the various treatments available, the mortality remains high at 60-80%. We present the clinical and histological features of ten adult liver transplant recipients with post-transplant lymphoproliferative disorder presenting over a 15-year period and review the therapeutic options.

METHODS

CD20/CD45RO immunostaining was used for T/B-cell markers; polymerase chain reaction and in-situ hybridisation for Epstein-Barr virus genome detection; kappa/lambda immunostaining and gene rearrangement analysis for clonality.

RESULTS

There were six females and four males (age range 24-56) with onset of post-transplant lymphoproliferative disorder-symptoms ranging from 3 to 72 months post transplant. Sites of post-transplant lymphoproliferative disorder included liver (n=4), lymph nodes (n=5), bone marrow (n=2), lungs (n=2), kidneys (n=2), brain, ovaries,: and pancreas (n=1). All lesions were classified as high-grade lymphoma, of B-cell lineage (9 tested); Epstein-Barr virus genome was detected in 7/10 cases. Three tumours were monoclonal; four were polyclonal and three undetermined. Treatment included immunosuppression reduction, antiviral therapy with acyclovir and/or chemotherapy (CHOP or VAPEC-B). Survival times for those patients not treated with chemotherapy were from 9 days to 30 months, whereas those receiving chemotherapy had remission times of 4 to 48 months.

CONCLUSIONS

Longer-term remissions can be achieved in patients treated with systemic chemotherapy, although not without morbidity. Clonality assessment is important but treatment decisions should be based primarily on clinical features of progression, as polyclonal tumours can behave as aggressively as monoclonal tumours.

Hepatocyte nuclear factor 4 (HNF4) binding sites in the salmon HNF1 promoter

We report the isolation and sequencing of a 1100-bp DNA fragment containing the salmon Hepatocyte Nuclear Factor 1 gene (sHNF1) promoter. The sHNF1 promoter cloned upstream of the chloramphenicol acetyl transferase (CAT) encoding gene is shown to be active in two cell lines of hepatic origin. DNasel footprint analysis of the proximal 400 bp reveals several protein-binding sites, including a CCAAT box, a potential site for Sp1, and three potential HNF4 binding sites. The sequence does not contain any canonical TATA box or initiator and sHNF1 transcription is initiated at four different sites spanning a region of 56 bp. Sequence comparison with the Xenopus laevis HNF1 promoter sequence did not show any significant similarity except in the region overlapping two of the potential HNF4 binding sites.

Schistosoma mansoni: interaction of nuclear extracts with the CCAAT-binding site revealed by the gel shift assay

Analysis of the 5'-flanking region of the gene encoding the 28-kDa glutathione S-transferase of Schistosoma mansoni (Sm28GST) indicated the presence of motifs identical to AP-1 and CCAAT-family transcription factor recognition sequences. Gel retardation experiments showed that nuclear extracts from adult S. mansoni bound to an oligodeoxynucleotide containing at CCAAT box. A DNA fragment corresponding to the region of Sm28GST containing the CCAAT motif was demonstrated to interact with schistosome nuclear proteins. This binding was dependent on the presence of the CCAAT pentanucleotide motif. Nuclear factor Y (NF-Y) is a member of the CCAAT transcription factor family that has absolute requirement for the CCAAT sequence and that is highly conserved throughout evolution. The results of a PCR-based strategy aimed at cloning the NF-YA protein of S. mansoni are presented.

Tissue expression of the Schistosoma mansoni 28 kDa glutathione S-transferase

The expression of the Schistosoma mansoni 28 kDa glutathione S-transferase (Sm28) was studied using molecular (PCR, in situ hybridization), and immunocytochemical techniques. The presence of Sm28 was demonstrated in all developmental stages of the parasite except the intra-uterine immature egg. In the parenchyma of male and female adult worms the distribution of Sm28 was limited to a subpopulation of parenchymal cells and to the dorsal tubercles of the male. The tegument, the muscles, the digestive tract, the neural mass, the vitelline glands, and mature gametes were not immunoreactive. Immature germinal cells in both sexes, and the ootype in the female genital system, were found to express Sm28. Deposits of immunoreactive material on host skin following cercarial penetration, exfoliation from the male tubercles, and especially emission of Sm28 from eggs in hepatic granulomas are suspected to be a source of antigen during the parasite infection. The reduction in worm fecundity previously observed in immunization experiments may result from an antibody response directed against Sm28 present in the ootype. There was no cross-reactivity observed, under the experimental conditions used, between the anti-Sm28 sera and either vertebrate or invertebrate host tissue.

[Spirapril and nitrendipine in arterial hypertension. A comparison of therapeutic effects and tolerance]

In a double-blind, randomized parallel-group investigation, a new angiotensin-converting enzyme-inhibitor, spirapril, was compared with a calcium antagonist, nitrendipine, in 266 patients with mild to moderate hypertension (diastolic blood pressure 96-119 mmHg). The object was to reduce the diastolic blood pressure measured 24 hours after intake of medicine to less than or equal to 90 mmHg. After monotherapy for four weeks with either 20 mg nitrendipine once daily or 12 mg spirapril once daily, the dosages were doubled in the patients in whom the desired blood pressure had not been obtained. After treatment for eight weeks, 12.5 mg hydrochlorthiazide daily was employed as a supplement in patients who had not yet obtained satisfactory blood pressures. Both methods of treatment resulted a lower number of patients who responded and lesser decreases in blood pressure than anticipated. No differences were found in the decreases in blood pressure resulting from the two therapeutic methods. The effect of supplementary hydrochlorthiazide to spirapril treatment was as anticipated while the combination with nitrendipine only resulted in a marginally extra decrease in blood pressure. Nitrendipine resulted in significantly more side effects and more patients defected from the investigation on account of side effects in the nitrendipine group (27%) than in the spirapril group (7%). This investigation had documented the abilities of nitrendipine and spirapril to reduce blood pressure and the side effects associated with this but does not predict whether the preparations can be employed to prevent the complications of hypertension which constitute the indications for treatment. Supplementing nitrendipine therapy with hydrochlorthiazide is not recommended.

Treatment of renovascular hypertension by unilateral nephrectomy. A follow-up study in patients above 60 years of age

The long term results of surgical intervention in 26 elderly patients with renovascular hypertension are presented. All patients were above 60 years of age at the day of operation. The majority of the patients had atherosclerotic renovascular disease with only one case of fibromuscular dysplasia. Several patients had severe extrarenal atherosclerotic disease. The diagnosis of renovascular hypertension was based upon the results of isotope renography, renal arteriography and renal vein catheterization. All patients underwent unilateral nephrectomy. Notably, no deaths or complications occurred in relation to surgery. At the follow-up study, blood pressure was lowered and the requirement for antihypertensive drugs reduced in 86% of the patients. We conclude that unilateral nephrectomy in elderly high risk patients with renovascular hypertension is a safe and efficient procedure.

Immediate central hemodynamic effects of five different beta-adrenoceptor-blocking agents, acebutolol, atenolol, pindolol, practolol, and propranolol, in patients with ischemic heart disease

The hemodynamic effects of acebutolol were studied in six patients with ischemic heart disease. The changes in heart rate, cardiac output, and arterial blood pressure were determined after intravenous administration of six increasing doses of acebutolol to a cumulative dose of 0.64 mg/kg. After the sixth dose of acebutolol, cardiac output and heart rate were reduced 15% and 8%, respectively. Pulmonary artery pressure was increased by 4 mm Hg. Arterial blood pressure was not changed significantly. The effects of graded doses of acebutolol on heart rate and cardiac output were compared with earlier obtained results after atenolol (0.19 mg/kg), pindolol (0.025 mg/kg), practolol (0.64 mg/kg), and propranolol (0.19 mg/kg). The effects of increasing doses of acebutolol and practolol were very similar and significantly different from the effects of the other three drugs in spite having been administered at equipotent doses. The hemodynamic effects of acebutolol support the hypothesis that the hemodynamic response to beta-adrenoceptor antagonist drugs at rest is determined primarily by the degree of intrinsic sympathomimetic activity, whereas beta-1 selectivity does not modify the central hemodynamic response.

Acute hemodynamic effects of pinacidil and hydralazine in essential hypertension

In a double-blind, randomized, crossover study, the effects of intravenous pinacidil, 0.2 mg/kg, were compared with those of hydralazine, 0.3 mg/kg, before and after beta-adrenoceptor blockade in six subjects with hypertension. Both drugs equally reduced total peripheral resistance by about 40%. Pinacidil reduced mean blood pressure by an average of 30 mm Hg, while the reduction after hydralazine was 10 mm Hg. The difference in antihypertensive effect resulted from greater increases in heart rate, cardiac contractility (systolic time intervals), and cardiac index (thermodilution) after hydralazine. These effects after hydralazine could not be fully abolished by beta-blockade, as could the effects after pinacidil. Pinacidil decreased pulmonary blood pressure, whereas there was a slight rise in pulmonary blood pressure after hydralazine. Forearm blood flow (venous occlusion strain gauge plethysmography) increased equally after both drugs; thus pinacidil decreased forearm vascular resistance more than hydralazine did. Serum concentrations of both drugs were within the therapeutic range and correlated with the fall in mean blood pressure. Five subjects complained of side effects after hydralazine, but none were reported after pinacidil. Hydralazine increased myocardial oxygen consumption (as estimated from the rate-pressure product) by 35%; there was no change after pinacidil. It is suggested that hydralazine has direct cardiostimulatory effects that limit its antihypertensive effectiveness. These effects increase myocardial oxygen consumption and may be responsible for the common and sometimes severe cardiovascular side effects of hydralazine.

Antihypertensive effect of diazoxide given intravenously in small repeated doses

Seven patients with acutely elevated diastolic blood pressure (DBP greater than or equal to 135 mmHg) were treated with repeated injections of diazoxide 1 mg/kg body weight i.v. at 10-min intervals. If the DBP was not reduced to 110 mmHg or less after 5 injections, a dose of 5 mg/kg was given. Serum diazoxide (total and unbound) was determined by high pressure liquid chromatography. In all the patients it was possible to reduce the blood pressure to a satisfactory level (i.e. DBP less than 110 mmHg). The individual plasma diazoxide concentrations necessary to achieve the desired response ranged from 20 to 85 micrograms/ml. A significant correlation was found between the initial venous concentration and the initial reduction in blood pressure (p less than 0.02). A high initial concentration in venous blood was associated with high protein binding ("transport function", p less than 0.05), and so were the elimination half-lives, which ranged from 14.7 to 61.3 h ("depot function", p less than 0.05). It is concluded that the previously recommended therapy of injection of 5 mg/kg as a bolus should be given only to patients who do not respond to small repeated doses.

A comparison of the acute haemodynamic effects of propranolol and pindolol at rest and during supine exercise in man

1. Dose-response curves for heart rate, cardiac output, arterial blood pressure and pulmonary artery pressure were obtained in 16 male patients after intravenous administration of three increasing doses of pindolol, propranolol or placebo. All patients had an uncomplicated acute myocardial infarction 6-8 months earlier. 2. The dose-response curves were obtained at rest and during repeated bouts of supine bicycle exercise. The cumulative dose amounted to 0.024 mg/kg body weight for pindolol and to 0.192 mg/kg body weight for propranolol. 3. At rest propranolol significantly reduced heart rate and cardiac output by 12% and 15% respectively. Arterial mean blood pressure was reduced by 9.2 mmHg. Mean pulmonary artery pressure increased significantly by 2 mmHg. Statistically significant changes in these variables were not seen after pindolol or placebo. 4. During exercise pindolol and propranolol both reduced cardiac output, heart rate and arterial blood pressure to the same extent. After propranolol mean pulmonary artery pressure was increased significantly by 3.6 mmHg. Pindolol and placebo did not change pulmonary artery pressure significantly. 5. The study suggests that pindolol may offer haemodynamic advantages over beta-receptor-blocking agents without intrinsic sympathomimetic activity during low activity of the sympathetic nervous system, and may be preferable in situations where the beta-receptor-blocking effect is required only during physical or psychic stress.