Exaggerated postprandial GLP-1 secretion following esophagectomy is not associated with gastric emptying and intestinal transit

Esophagectomy causes postprandial symptoms associated with an exaggerated postprandial gut hormone response. This study aimed to compare the gastrointestinal transit time of patients 1 year after esophagectomy with unoperated controls, including its relation to satiety gut hormone release. In this cross-sectional study, consecutive, disease-free patients after esophagectomy with pyloroplasty were compared with unoperated control subjects to assess gastric emptying (GE) and cecal arrival time (CAT). Serial plasma samples were collected before, and for 300 minutes after, a mixed-meal challenge. Body composition was assessed, and symptom scores were calculated. Eleven patients 1 year post-esophagectomy (age: 62.6 ± 9.8, male: 82%) did not show a significantly different GE pattern compared with 10 control subjects (P = 0.245). Rather, patients could be categorized bimodally as exhibiting either rapid or slow GE relative to controls. Those with rapid GE trended toward a higher postprandial symptom burden (P = 0.084) without higher postprandial glucagon-like peptide-1 (GLP-1) secretion (P = 0.931). CAT was significantly shorter after esophagectomy (P = 0.043) but was not significantly associated with GE, GLP-1 secretion, or symptom burden. Neither early nutrient delivery to the proximal small intestine nor to the colon explains the exaggerated postprandial GLP-1 response after esophagectomy. GE varies significantly in these patients despite consistent pyloric management.

Patient-reported outcomes after oesophagectomy in the multicentre LASER study

BACKGROUND

Data on the long-term symptom burden in patients surviving oesophageal cancer surgery are scarce. The aim of this study was to identify the most prevalent symptoms and their interactions with health-related quality of life.

METHODS

This was a cross-sectional cohort study of patients who underwent oesophageal cancer surgery in 20 European centres between 2010 and 2016. Patients had to be disease-free for at least 1 year. They were asked to complete a 28-symptom questionnaire at a single time point, at least 1 year after surgery. Principal component analysis was used to assess for clustering and association of symptoms. Risk factors associated with the development of severe symptoms were identified by multivariable logistic regression models.

RESULTS

Of 1081 invited patients, 876 (81.0 per cent) responded. Symptoms in the preceding 6 months associated with previous surgery were experienced by 586 patients (66.9 per cent). The most common severe symptoms included reduced energy or activity tolerance (30.7 per cent), feeling of early fullness after eating (30.0 per cent), tiredness (28.7 per cent), and heartburn/acid or bile regurgitation (19.6 per cent). Clustering analysis showed that symptoms clustered into six domains: lethargy, musculoskeletal pain, dumping, lower gastrointestinal symptoms, regurgitation/reflux, and swallowing/conduit problems; the latter two were the most closely associated. Surgical approach, neoadjuvant therapy, patient age, and sex were factors associated with severe symptoms.

CONCLUSION

A long-term symptom burden is common after oesophageal cancer surgery.

Effect of neoadjuvant chemoradiation on preoperative pulmonary physiology, postoperative respiratory complications and quality of life in patients with oesophageal cancer

BACKGROUND

It remains controversial whether neoadjuvant chemoradiation (nCRT) for oesophageal cancer influences operative morbidity, in particular pulmonary, and quality of life. This study combined clinical outcome data with systematic evaluation of pulmonary physiology to determine the impact of nCRT on pulmonary physiology and clinical outcomes in locally advanced oesophageal cancer.

METHODS

Consecutive patients treated between 2010 and 2016 were included. Three-dimensional conformal radiation was standard, with a lung dose-volume histogram of V20 less than 25 per cent, and total radiation between 40 and 41·4 Gy. Forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and diffusion capacity for carbon monoxide (DLCO) were assessed at baseline and 1 month after nCRT. Radiation-induced lung injury (grade 2 or greater), comprehensive complications index (CCI) and pulmonary complications were monitored prospectively. Health-related quality of life was assessed among disease-free patients in survivorship.

RESULTS

Some 228 patients were studied. Comparing pulmonary physiology values before with those after nCRT, FEV1 decreased from mean(s.d.) 96·8(17·7) to 91·5(20·4) per cent (-3·6(10·6) per cent; P < 0·001), FVC from 104·9(15·6) to 98·1(19·8) per cent (-3·2(11·9) per cent; P = 0·005) and DLCO from 97·6(20·7) to 82·2(20·4) per cent (-14·8(14·0) per cent; P < 0·001). Five patients (2·2 per cent) developed radiation-induced lung injury precluding surgical resection. Smoking (P = 0·005) and increased age (P < 0·001) independently predicted percentage change in DLCO. Carboplatin and paclitaxel with 41·4 Gy resulted in a greater DLCO decline than cisplatin and 5-fluorouracil with 40 Gy (P = 0·001). On multivariable analysis, post-treatment DLCO predicted CCI (P = 0·006), respiratory failure (P = 0·020) and reduced physical function in survivorship (P = 0·047).

CONCLUSION

These data indicate that modern nCRT alters pulmonary physiology, in particular diffusion capacity, which is linked to short- and longer-term clinical consequences, highlighting a potentially modifiable index of risk.

Changes in gut hormones, glycaemic response and symptoms after oesophagectomy

BACKGROUND

Oesophagectomy is associated with reduced appetite, weight loss and postprandial hypoglycaemia, the pathophysiological basis of which remains largely unexplored. This study aimed to investigate changes in enteroendocrine function after oesophagectomy.

METHODS

In this prospective study, 12 consecutive patients undergoing oesophagectomy were studied before and 10 days, 6, 12 and 52 weeks after surgery. Serial plasma total fasting ghrelin, and glucagon-like peptide 1 (GLP-1), insulin and glucose release following a standard 400-kcal mixed-meal stimulus were determined. CT body composition and anthropometry were assessed, and symptom scores calculated using European Organisation for Research and Treatment of Cancer (EORTC) questionnaires.

RESULTS

At 1 year, two of the 12 patients exhibited postprandial hypoglycaemia, with reductions in bodyweight (mean(s.e.m.) 17·1(3·2) per cent, P < 0·001), fat mass (21.5(2.5) kg versus 25.5(2.4) kg before surgery; P = 0·014), lean body mass (51.5(2.2) versus 54.0(1.8) kg respectively; P = 0·003) and insulin resistance (HOMA-IR: 0.84(0.17) versus 1.16(0.20); P = 0·022). Mean(s.e.m.) fasting ghrelin levels decreased from postoperative day 10, but had recovered by 1 year (preoperative: 621·5(71·7) pg/ml; 10 days: 415·1(59·80) pg/ml; 6 weeks: 309·0(42·0) pg/ml; 12 weeks: 415·8(52·1) pg/ml; 52 weeks: 547·4(83·2) pg/ml; P < 0·001) and did not predict weight loss (P = 0·198). Postprandial insulin increased progressively at 10 days, 6, 12 and 52 weeks (mean(s.e.m.) insulin AUC_{0-30 min} : fold change 1·7(0·4), 2·0(0·4), 3·5(0·7) and 4·0(0·8) respectively; P = 0·001). Postprandial GLP-1 concentration increased from day 10 after surgery (P < 0·001), with a 3·3(1·8)-fold increase at 1 year (P < 0·001). Peak GLP-1 level was inversely associated with the postprandial glucose nadir (P = 0·041) and symptomatic neuroglycopenia (Sigstad score, P = 0·017, R²  = 0·45). GLP-1 AUC predicted loss of weight (P = 0·008, R²  = 0·52) and fat mass (P = 0·010, R²  = 0·64) at 1 year.

CONCLUSION

Altered enteroendocrine physiology is associated with early satiety, weight loss and postprandial hypoglycaemia after oesophagectomy.

Ireland's recent contribution to the radiological literature; a bibliometric analysis

The aim of this study was to identify and analyse all articles published by Irish radiology departments in the medical literature since the year 2000. The PubMed database was searched to identify and review all articles published by radiologists based in the Republic of Ireland or Northern Ireland. Citation counts were then obtained and the top ten most cited articles were identified. There were 781 articles published during the study period. Of these, 558 (71%) were published in radiology journals and the remaining 223 (29%) were published in general medical journals. Abdominal radiology was the most represented sub-specialty (33% of all articles). There was a general trend of increased publications per year. Only 75 (9.6%) of articles were collaborative efforts by more than one radiology department. Irish radiology departments have a considerable research output and this has increased since the year 2000. More collaborative research between Irish radiology departments is encouraged.

The use of ultrasonography and digital mammography in women under 40 years with symptomatic breast cancer: a 7-year Irish experience

BACKGROUND

Breast cancer in women under 40 years of age is rare and typically presents symptomatically. The optimal imaging modality for this patient group is controversial. Most women undergo ultrasonography with/without mammography. Young women typically have dense breasts, which can obscure the features of malignancy on film mammography, however, initial studies have suggested that digital mammography may have a more accurate diagnostic performance in younger women. Ultrasound generally performs well in this age group, although it is poor at detecting carcinoma in situ (DCIS).

AIMS

To evaluate the comparative diagnostic performance of ultrasonography and digital mammography in the initial diagnostic evaluation of women under 40 years of age with symptomatic breast cancer.

METHODS

Retrospective review of all women under the age of 40 years managed at our symptomatic breast cancer unit from January 2009 to December 2015.

RESULTS

There were 120 patients that met the inclusion criteria for this study. The sensitivity of ultrasonography and digital mammography for breast cancer in this patient group was 95.8 and 87.5 %, respectively. The patients with a false negative mammographic examination were more likely to have dense breasts (p < 0.01). Five patients had a false negative ultrasonographic examination, withal of whom were diagnosed with DCIS detected by mammography.

CONCLUSION

This study demonstrates the superior sensitivity of ultrasound for breast cancer in women under the age of 40 years, however, the results show that digital mammography has an important complimentary role in the comprehensive assessment of these patients, particularly in the diagnosis of DCIS.

Cognitive impairment in bipolar disorder in old age: literature review and findings in manic patients

BACKGROUND

Descriptions of aged patients with bipolar (BP) disorder have commented on cognitive impairments. However, the literature regarding cognitive test performance in this population has apparently been scant.

METHOD

1. We reviewed studies reporting cognitive performance in aged BP patients. 2. We compared the performance of elderly BP manic patients and aged community comparison subjects on the Mini-Mental State Examination (MMSE) and the Mattis Dementia Rating Scale (DRS).

RESULTS

1. Seven published studies of cognitive measures in aged BP patients were identified. They utilized different assessment methods and addressed different illness states, but they indicate impairments in these patients. 2. In our sample, the manic patients (n=70) had lower MMSE scores and DRS scores than did the comparison subjects (n=37). In these patients, cognitive scores were not significantly associated with Mania Rating Scale scores.

LIMITATIONS

The patients in our study were assessed cross-sectionally, and they were treated naturalistically.

CONCLUSIONS

Manic or depressed BP elders have impaired cognitive function; in some patients these impairments may persist. Research characterizing these impairments and their clinical implications is warranted.

Establishing human prostate cancer cell xenografts in bone: induction of osteoblastic reaction by prostate-specific antigen-producing tumors in athymic and SCID/bg mice using LNCaP and lineage-derived metastatic sublines

LNCaP lineage-derived human prostate cancer cell lines C4-2 and C4-2B4 acquire androgen independence and osseous metastatic potential in vivo. Using C4-2 and C4-2B4 the goals of the current investigation were 1) to establish an ideal bone xenograft model for prostate cancer cells in intact athymic or SCID/bg mice using an intraosseous route of tumor cell administration and 2) to compare prostate cancer metastasis by administering cells either through intravenous (i.v.) or intracardiac administration in athymic or SCID/bg mice. Subsequent to tumor cell administration, prostate cancer growth in the skeleton was assessed by radiographic bone density, serum prostate-specific antigen (PSA) levels, presence of hematogenous prostate cancer cells and histopathologic evaluation of tumor specimens in the lymph node and skeleton. Our results show that whereas LNCaP cells injected intracardially failed to develop metastasis, C4-2 cells injected similarly had the highest metastatic capability in SCID/bg mice. Retroperitoneal and mediastinal lymph node metastases were noted in 3/7 animals, whereas 2/7 animals developed osteoblastic spine metastases. Intracardiac injection of C4-2 in athymic hosts produced spinal metastases in 1/5 animals at 8-12 weeks post-injection; PC-3 injected intracardially also metastasized to the bone but yielded osteolytic responses. Intravenous injection of either LNCaP or C4-2 failed to establish tumor colonies. Intrailiac injection of C4-2 but not LNCaP nor C4-2B4 cells in athymic mice established rapidly growing tumors in 4/8 animals at 2-7 weeks after inoculation. Intrafemoral injection of C4-2 (9/16) and C4-2B4 (5/18) but not LNCaP (0/13) cells resulted in the development of osteoblastic bone lesions in athymic mice (mean: 6 weeks, range: 3-12 weeks). In SCID/bg mice, intrafemoral injection of LNCaP (6/8), C4-2 (8/8) and C4-2B4 (8/8) cells formed PSA-producing, osteoblastic tumors in the bone marrow space within 3-5 weeks after tumor cell inoculation. A stepwise increase of serum PSA was detected in all animals. Reverse transcription-polymerase chain reaction (RT-PCR) to detect hematogenously disseminated prostate cancer cells could not be correlated to either serum PSA level or histological evidence of tumor cells in the marrow space. We have thus established a PSA-producing and osteoblastic human prostate cancer xenograft model in mice.

Working memory for nonverbal auditory information in dementia of the Alzheimer type

Previous studies have revealed working memory impairments in individuals with dementia of the Alzheimer type (DAT) using visually and auditorily presented verbal materials, and visually presented nonverbal materials. Based on findings from behavioral and neuropathological studies, impairments in working memory for auditorily presented nonverbal materials have been hypothesized as well. Results of a study conducted by Kurylo, Corkin, Allard, Zatorre, and Growden (1993), however, failed to support this hypothesis. In the current investigation, perception and working memory for nonverbal auditory information (tones) were assessed using same-different discrimination tasks. Participants included individuals with no dementia, very mild DAT, and mild DAT. Unlike the findings from the study conducted by Kurylo and colleagues, our results suggest intact tone perception but a progressive decline in working memory for auditory nonverbal information with advancing DAT. A similar decline was also noted on a task assessing working memory for auditorily presented verbal information.

Reliability of the Washington University Road Test. A performance-based assessment for drivers with dementia of the Alzheimer type

OBJECTIVE

To assess the reliability and stability of a standardized road test for healthy aging people and those with dementia of the Alzheimer type (DAT).

DESIGN

A prospective study involving patients with DAT and age-matched healthy controls in which subjects' driving performance was evaluated by several raters in an initial and a follow-up road test.

SETTING

Urban medical school and urban highways and streets.

SUBJECTS

A convenience sample of 58 controls, 36 subjects with very mild DAT, and 29 subjects with mild DAT.

RESULTS

Analysis of road test ability of controls (2 subjects [3%] failed the test), very mild DAT subjects (7 subjects [19%] failed), and mild DAT subjects (12 subjects [41%] failed) disclosed a significant association between driving performance and dementia status (chi 2[4] = 20.65 [N = 123]; P < .001; Kendall tau-b = 0.306). Interrater reliability for assessment of driving performance ranged from kappa = 0.85 to 0.96. One-month test-retest stability on the road test was 0.76 (quantitative scoring) and 0.53 (clinical judgment).

CONCLUSIONS

Dementia adversely affects driving performance even in its mild stages, although some persons with DAT seem to drive safely for some time after disease onset. A traffic-interactive, performance-based road test that examines cognitive behaviors provides an accurate and reliable functional assessment of driving ability.

Environmental cueing may effect performance on a road test for drivers with dementia of the Alzheimer type

This paper examines the impact of environmental cueing on a road test for persons with dementia of the Alzheimer type (DAT). In an earlier study, we demonstrated the reliability and stability of the Washington University Road Test in a sample of 58 healthy elderly controls and 65 subjects with DAT. We found that dementia adversely affects driving performance even in its mild stages. Here were elaborate on the results of a follow-up road test conducted 1 month after the baseline test (n = 63) explore possible reasons why the stability of the follow-up road test was lower than expected. We conclude that environmental cueing may affect performance on a road test in DAT.

Contribution to heart rate variability by mechanoelectric feedback. Stretch of the sinoatrial node reduces heart rate variability

BACKGROUND

Heart rate variability is an important prognostic indicator for sudden death. An increased risk of sudden death and arrhythmia is associated with reduced heart rate variability in heart failure. In heart failure, there is also dilatation of the atria, which raises the prospect that there could be some physiological basis to possibly link heart rate variability with atrial dilatation. We therefore investigated whether sustained atrial stretch could modulate heart rate variability directly.

METHODS AND RESULTS

Pigs were anesthetized and their hearts exposed. A specially built device stretched the sinoatrial node before and after vagal section and then after administration of propranolol. Stretch of the sinoatrial node decreases heart rate variability in the following ways: The standard deviation of the beat-to-beat interval decreases (4.2 to 2.6 ms; P = .004), and the high-frequency components are reduced (control, 6.5 +/- 2.2 ms2, during stretch, 1.4 +/- 0.3 ms2, P = .003). After section of both vagi, the high-frequency components are reduced by stretch of the sinoatrial node (2.8 +/- 0.9 ms2 for control versus 1.2 +/- 0.3 ms2 during stretch; P = .05). Similarly, after both vagal section and beta-blockade, stretch of the sinoatrial node reduces the high-frequency components (10.6 +/- 3.5 ms2 for control verses 3.0 +/- 1.5 ms2 during stretch; P = .01).

CONCLUSIONS

We conclude that stretch of the sinoatrial node reduces high-frequency heart rate variability. This may account in part for the reduced heart rate variability seen in clinical conditions in which the right atrium is dilated, such as congestive cardiac failure.

Cycle length dependence of the electrophysiological effects of increased load on the myocardium

BACKGROUND

Mechanoelectric feedback, the process by which changes in mechanical activity change the electrophysiology of the myocardium, has been linked to the genesis of arrhythmias. We investigated possible arrhythmogenic mechanisms by measuring changes in steady-state action potential duration and, more particularly, electrical restitution on a transiently applied load change, because action potential recovery may provide clues to arrhythmogenesis.

METHODS AND RESULTS

Pigs were anesthetized and their hearts exposed. A snare was placed around the aorta, and the right atrium was paced. Ventricular pressure, monophasic action potential, and segment motion were recorded from the left ventricle. The action potential duration was measured before and during transient aortic occlusion. Electrical restitution curves were constructed from the records obtained during normal loading or during transient aortic occlusion. The degree of shortening of action potential duration on aortic occlusion decreased with decreases in the steady-state beat-to-beat interval (P = .0008). Control restitution curves had the typical configuration, with a rapid initial, usually monotonic, rise toward a plateau. Some curves showed a marginal "supernormal" section. Increased load reduced the action potential duration at the plateau of the restitution curve (9.4 ms, P < .0001) but increased the action potential duration at the start of the restitution curve (8.7 ms, P = .03). Increased loading increased the maximum slope of the electrical restitution curve by 32 ms/100 ms (P = .04). Increased load also increased the supernormal period of the electrical restitution curves.

CONCLUSIONS

Mechanoelectric feedback produces changes in rate-dependent electrophysiology, which could favor a matrix conducive to arrhythmogenesis.

Sympathomimetic modulation of load-dependent changes in the action potential duration in the in situ porcine heart

AIMS

Increased sympathetic stimulation is known to be arrhythmogenic. Likewise increased loading of the myocardium can directly generate arrhythmias. The interaction between the two on the electrophysiology of the myocardium has not been investigated before. We investigated the effect of dobutamine infusion on the shortening of the monophasic action potential duration secondary to increased loading. This was investigated during steady-state pacing and during an alteration in beat-to-beat interval in the form of a restitution curve.

METHODS

Pigs were anaesthetised and their hearts exposed. Monophasic action potentials and segment lengths were recorded from the anterior surface of the left ventricle. The loading of the ventricle was increased by transiently occluding the aorta. Steady-state pacing and a restitution curve were performed. Recordings were taken before and during dobutamine infusion.

RESULTS

At steady state, increased loading of the heart shortened the monophasic action potential duration by a mean (+/- s.e.m.) of 4.0 (+/- 0.5) ms (P < 0.001). During dobutamine infusion this shortening of the monophasic action potential increased. Shortening of the action potential duration increased with the dose of dobutamine up to 10 micrograms/kg/min after which a plateau was reached. By comparison to control, dobutamine depressed the electrical restitution curve at short test pulse intervals did not significantly alter the plateau. Increased loading elevated the initial section of the electrical restitution curve at short test pulse intervals and depressed the plateau in both the control recordings and those taken during dobutamine infusion. Increased loading increased the amplitude of the supernormal phase of the electrical restitution curve in control recordings and those taken during dobutamine infusion. Sympathetic stimulation by dobutamine during the steady state potentiates the effect of mechanoelectric feedback on the myocardium. The effect on the restitution curve varies with test pulse interval. At short test pulse intervals the effect of sympathetic stimulation dominates with only minor antagonistic modification by increased loading. However, at longer test pulse intervals the effect of mechanoelectric feedback is equal to that of sympathetic stimulation and is synergistic with it.

CONCLUSIONS

The mechanically induced changes we describe in the normal pig heart in situ are relatively small. However, they are in the right direction to possibly contribute to arrhythmia under pathological conditions where mechanical as well as electrophysiological inhomogeneity is prominent.

Electrical alternans and the onset of rate-induced pulsus alternans during acute regional ischaemia in the anaesthetised pig heart

OBJECTIVES

Electrical alternans and mechanical alternans are both associated with cardiac ischaemia and in the case of electrical alternans there is a strong link with serious ventricular arrhythmia. We elected to investigate the relationship between electrical and mechanical alternans in control and acutely ischaemic myocardium in the intact porcine heart to determine the nature of their interaction and in particular to determine if abnormal mechanical events play a role in arhythmogenesis as has been suggested in non-ischaemic preparations.

METHODS

We used rapid atrial pacing to induce regional mechanical alternans and pulsus alternans before and then at 5-min intervals after the onset of acute ischaemia induced by a 30-min ligation of a diagonal branch of the left anterior descending artery. Regional mechanical activity is measured with epicardial tripodal strain gauges and regional electrical activity is measured using suction-based monophasic action potential electrodes. To test whether alternate stretching of ischaemic segments during pulsus alternans contributed to electrical alternans we simulated pulsus alternans by clamping the proximal aorta on alternate beats.

RESULTS

In control areas there was a constant discordant relationship between peak systolic pressure during alternans and action potential duration. In contrast, the ischaemic areas showed electromechanical alternans that was most frequently concordant. Clamping the proximal aorta on alternate beats produced an electrical alternans in control areas but not in the ischaemic area.

CONCLUSIONS

Pulsus alternans during acute ischaemia is associated with electrical alternans that can be out of phase in control and ischaemic areas. This could increase electrical dispersion which may be pro-arrhythmic.

Regional alternans in relaxation and the onset of pulsus alternans in the heart of the anaesthetized pig

1. The factors leading to the alternation in myocardial contractility believed primarily responsible for pulsus alternans are not known. We examine regional and global contraction patterns in the in situ heart at stimulation rates just below the threshold for pulsus alternans to determine if events occurring in the transition to alternans can give clues to cellular mechanisms. 2. Twelve pigs were anaesthetized, the chest wall removed and regional contraction measured in three areas of the left ventricle using tripodal strain gauges. We analysed regional and global dynamics during right atrial pacing at cycle lengths 50-150 ms greater than the threshold for pulsus alternans. 3. At pacing cycle lengths 50 ms greater than that required to produce pulsus alternans seven of twelve pigs showed alternans in the maximum rate of ventricular pressure decay but none showed alternans in the maximum rate of pressure rise. Pigs showing alternans in global relaxation were more likely to show alternans in regional contracility (P < 0.05). 4. Twenty-six of the thirty-six areas sampled showed alternans in end-diastolic length at pacing rates below the threshold for pulsus alternans. In fifteen of these areas alternation in end-diastolic length occurred in the absence of alternans in measures of contractility. 5. Alternans in global measures of relaxation may simply be a manifestation of regional alternans in contractility. It is therefore not appropriate, from global haemodynamic data, to suppose that alternans in relaxation is the primary abnormality in the generation of pulsus alternans.(ABSTRACT TRUNCATED AT 250 WORDS)

Regional electromechanical alternans in anesthetized pig hearts: modulation by mechanoelectric feedback

Electrical and mechanical alternans have often been found to coexist. However, the factors controlling their interdependence are not known. In this study we measure regional electrical and mechanical activity during mechanical alternans to investigate this relationship. Mechanical alternans was induced by rapid atrial pacing in 18 anesthetized, open-chest pigs. Regional segmental contraction and monophasic action potential were measured in three areas of left ventricle using epicardial tripodal strain gauges and suction electrodes. Electrical alternans always accompanied pulsus alternans. The phase of electrical alternans was not related to any measure of regional mechanical activity but did show a constant discordant relation to peak ventricular pressure. This suggested that mechanically dependent changes in action potential duration (mechanoelectric feedback) may be important in modulation electrical alternans. In support of this, pulsus alternans simulated by clamping the proximal aorta on alternate beats was associated with electrical alternans comparable to that produced with rapid atrial pacing. Mechanoelectric feedback modulates regional electrophysiology in the intact heart and may be important in the generation of electrical alternans.

Mechanically induced changes in action potential duration and left ventricular segment length in acute regional ischaemia in the in situ porcine heart

OBJECTIVE

The electrophysiological events accompanying early ischaemia are important. The aim of this study was to investigate mechano-electric feedback in acute regional myocardial ischaemia in the intact heart in situ by measuring the change in action potential duration in response to increased ventricular loading imposed by transient aortic occlusion.

METHODS

11 landrace pigs were anaesthetised and their hearts exposed. A pneumatically operated blood pressure clamp was placed around the aorta. Monophasic action potentials and an index of segment motion were recorded from the epicardium in and around the ischaemic area produced by a snare placed around a coronary artery. Ventricular and systemic arterial pressures were measured. An initial aortic clamp was performed during which control recordings were taken. The coronary artery was then tied and the aorta clamped for 5-10 s every 5 min for the duration of the 30 min tie. Recordings were taken from the ischaemic area and non-ischaemic areas.

RESULTS

Aortic clamp before ischaemia increased intraventricular diastolic and systolic pressure and reduced action potential duration in all the areas studied (p < 0.001). During acute regional myocardial ischaemia aortic clamping resulted in significantly more shortening of the action potential in the ischaemic area after 10 min of ischaemia than in the control area (5 ms v 10 ms, p = 0.008). Over the following 20 min the degree of shortening decreased. The greater shortening at 10 min could not be attributed to changes in the end diastolic segment length or peak ventricular pressure and could thus represent a change in the expression of mechano-electric feedback by ischaemic myocardium rather than a change in loading conditions.

CONCLUSIONS

During the first 30 min following a coronary artery occlusion mechano-electric feedback in the ischaemic myocardium varies with time.

Characterisation of regional myocardial dynamics during mechanical alternans in heart of anaesthetised pig

OBJECTIVE

The aim was to investigate the behaviour of regional myocardium during mechanical alternans in a multidirectional manner.

METHODS

Mechanical alternans was induced in 12 anaesthetised open chested pigs by rapid atrial pacing. In contrast to previous studies, regional mechanical activity was simultaneously assessed at up to three different sites on the left ventricle using epicardial measuring devices able to provide multidirectional information on segment motion. Pressure-length loops were plotted to assess different patterns of segmental motion. The integral of pressure and length was calculated to obtain a regional work index for each beat.

RESULTS

Pressure-length loops revealed profound abnormalities in segment motion and work index during regional mechanical alternans. Myocardial segments either performed alternate amounts of positive work on each beat or alternate amounts of positive and negative work on each beat. Alternating segments contracted out of phase with each other and were occasionally stretched during systole.

CONCLUSIONS

The spatio-temporal heterogeneity of regional mechanical behaviour is greatly increased during mechanical alternans.

Characterization of the galactose-specific binding activity of a purified soluble Entamoeba histolytica adherence lectin

We studied galactose (Gal)-specific binding of the soluble purified 260-kDa Entamoeba histolytica adherence protein to glycosylation deficient Chinese hamster ovary (CHO) cell mutants. Our goal was to further define the lectin's functional activity and carbohydrate receptor specificity. The adherence protein was purified by acid elution from an immunoaffinity column; however, exposure of the surface membrane lectin on viable trophozoites to identical acid pH conditions had no effect on carbohydrate binding activity. Saturable Gal-specific binding of soluble lectin to parental CHO cells was demonstrated at 4 degrees C by radioimmunoassay; the dissociation coefficient (Kd) was 2.39 x 10(-8) M-1 with 5.97 x 10(4) lectin receptors present per CHO cell. Gal-specific binding of lectin to Lec2 CHO cell mutants, which have increased N- and O-linked terminal Gal residues on cell surface carbohydrates, was increased due to an enhanced number of receptors (2.41 x 10(5)/cell) rather than a significantly reduced dissociation constant (4.93 x 10(-8) M-1). At 4 degrees C, there was no measurable Gal-specific binding of the adherence protein to the Lec1 and 1dlD.Lec1 CHO mutants, which contain surface carbohydrates deficient in terminal Gal residues. Binding of lectin (20 micrograms/ml) to CHO cells was equivalent at 4 degrees C and 37 degrees C and unaltered by adding the microfilament inhibitor, Cytochalasin D (10 micrograms/ml). Gal-specific binding of the lectin at 4 degrees C was calcium independent and reduced by 81% following adsorption of only 0.2% of the lectin to CHO cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Perceptual asymmetry, plasma cortisol, and response to treatment in depressed outpatients

Perceptual asymmetries as indicated by dichotic listening tasks have been associated with both subtype of depression and response to antidepressant treatment. To examine the association between this relatively new measure and more traditional measures of hypothalamic-pituitary-adrenal axis (HPA) activation in depression, we assessed perceptual asymmetry and basal plasma cortisol in a sample of depressed outpatients undergoing a double-blind, placebo-controlled medication trial. Each measure was examined for its ability to predict response to treatment. Perceptual asymmetry was significantly associated with plasma cortisol levels, and was also a significant predictor of treatment response. The association between plasma cortisol and treatment response did not reach significance. Our findings are limited by relatively small sample sizes but encourage further examination of perceptual asymmetry measures as predictors of treatment response and in relation to HPA activation in depression.

Association of serum antibodies to adherence lectin with invasive amebiasis and asymptomatic infection with pathogenic Entamoeba histolytica

The recognition of the Entamoeba histolytica galactose-inhibitable adherence lectin by antibodies was studied using sera obtained from subjects in South Africa with an amebic liver abscess or asymptomatically pathogenic or nonpathogenic E. histolytica infection and from uninfected regional controls. In addition, sera from healthy American controls or Americans known to be infected with other parasites were studied. Of the 95 sera containing antibodies to total parasite protein, 95% demonstrated antibodies to the 170-kDa heavy subunit but not to the 35-kDa light lectin subunit. All sera (n = 253) were tested by ELISA for antibodies to lectin: 99% from liver abscess patients and all 4 from individuals asymptomatically infected with pathogenic E. histolytica were positive; all from the 40 healthy American controls and the 29 infected with other parasites were negative (P less than .01). The prevalence of serum anti-lectin antibodies was identical (25%) in asymptomatic South Africans with either a nonpathogenic infection or a negative stool culture for E. histolytica. Thus, the presence of serum antibodies to lectin seems to indicate current or prior invasive amebiasis or asymptomatic intestinal infection with pathogenic E. histolytica.

Characterization of cell surface carbohydrate receptors for Entamoeba histolytica adherence lectin

Binding and cytolysis of Chinese hamster ovary (CHO) cells by Entamoeba histolytica trophozoites is inhibitable by galactose (Gal) or N-acetyl-D-galactosamine (GalNAc). To better define the carbohydrate receptor for E. histolytica, we compared the binding and cytolytic target properties of 10 CHO glycosylation mutants. Each mutant expresses a uniquely altered array of N- and/or O-linked cell surface carbohydrates. Amebic adherence was reduced when lactosamine-containing N-linked carbohydrates were essentially absent (Lec1 mutant), almost undetectable when Gal and GalNAc residues were absent on both N- and O-linked carbohydrates (ldlD.Lec1 mutant), and enhanced for mutants with increased terminal Gal residues (Lec2 and Lec3). Parental CHO cells treated with neuraminidase to expose Gal residues behaved like Lec2 mutants. Binding of purified Gal or GalNAc lectin to parental, Lec1, ldlD.Lec1, and Lec2 mutant CHO cells corroborated the adherence results. The suitability of CHO cell mutants as targets for amebic cytolysis correlated with their glycosylation phenotype: the Lec1 mutants were less susceptible than parental CHO cells, the ldlD.Lec1 mutants were highly resistant, and the Lec2 mutants required higher concentrations of Gal for inhibition. The E. histolytica Gal or GalNAc adherence lectin bound preferentially to beta 1-6-branched, N-linked carbohydrates lacking terminal sialic acid or fucose residues. However, amebic lectin binding to either N- or O-linked cell surface carbohydrates was sufficient to initiate parasite cytolytic activity.

Phorbol esters specifically enhance the cytolytic activity of Entamoeba histolytica

Entamoeba histolytica causes invasive amebiasis by lysis of host tissue and inflammatory cells. The in vitro cytolysis of target Chinese hamster ovary (CHO) cells by axenic E. histolytica trophozoites (strain HM1:IMSS) is a calcium- and phospholipase A-dependent event initiated by the binding to the target cell of the galactose-inhibitable surface lectin of the parasite. We utilized phorbol esters as a probe to determine whether an amebic protein kinase C has a role in the cytolytic event. The addition of phorbol 12-myristate 13-acetate (PMA) at 10(-6) or 10(-7) M resulted in a greater than twofold enhancement of amebic killing of target CHO cells over 30 min (P less than 0.01). Prior exposure of only the amebae, but not the CHO cells, to PMA produced a similar effect (P less than 0.01). The inactive analog 4-alpha-phorbol had no effect on amebic killing of CHO cells. The PMA-mediated enhancement of amebic cytolysis persisted for up to 60 min after a 5-min exposure; however, after a 30-min exposure to PMA (10(-6) M) there was no augmentation of amebic killing of CHO cells. PMA (10(-6) M) did not promote adherence of parasites to CHO cells but did enhance amebic cytolysis of previously adherent target cells (P less than 0.01). Sphingosine, a specific inhibitor of protein kinase C, abolished both the PMA-stimulated and the basal cytolytic activity of E. histolytica. PMA enhanced CHO cell cytolysis by the less virulent wild-type strain H-303:NIH (P less than or equal to 0.02) but did not augment the activity of the less virulent strain H-200:NIH or two avirulent clones of HM1 (L6 and C919). In summary, these experiments with the phorbol esters and sphingosine as probes to modulate the activity of protein kinase C indicate participation of a parasite protein kinase C in the cytolytic activity of virulent, axenic E. histolytica trophozoites and thus in the pathogenesis of amebiasis.

The cellular regulation of vesicle exocytosis by Entamoeba histolytica

We studied the cellular regulation of vesicle exocytosis by Entamoeba histolytica utilizing release of endocytosed 125iodine (125I) labeled tyrosine conjugated dextran; 125I-dextran entered the acid pH vesicles of the amebae and was not degraded during these studies. Exocytosis was temperature dependent with 74%, 36%, 4%, and 0% of 125I-dextran released after 120 min at 37 degrees C, 31 degrees C, 25 degrees C, and 4 degrees C, respectively (P less than 0.01 for each). Exocytosis at 37 degrees C was inhibited by cytochalasin D (10 micrograms/ml), EDTA (10 mM), or the putative intracellular calcium antagonist TMB-8 (250 microM) (P less than 0.01 for each at greater than or equal to 60 min). Calcium ionophore A23187 (1 microM) enhanced exocytosis at 5 and 15 min (P less than 0.01). Elevation of vesicle pH with NH4Cl (10 mM) had no effect on release of 125I-dextran; phorbol myristate acetate (10(-6) M) increased exocytosis by 46% at 30 min (P less than 0.01). Centrifugation of amebae with target Chinese hamster ovary cells resulted in decreased 125I-dextran release into the cell supernatant after 30 and 60 min at 37 degrees C (by 40% and 42%, respectively, P less than 0.01); release of 125I-dextran returned to control values with addition of 1.0 g% galactose or GalNac but not with mannose or N-acetyl-D-glucosamine. Amebic phagocytosis of serum-exposed latex beads had no effect on release of dextran by amebae (n = 16). Exocytosis of acid pH vesicles by E. histolytica is temperature-, microfilament-, and calcium-dependent, and stimulated by phorbol esters.

Isolation of the galactose-binding lectin that mediates the in vitro adherence of Entamoeba histolytica

Entamoeba histolytica adheres to human colonic mucus, colonic epithelial cells, and other target cells via a galactose (Gal) or N-acetyl-D-galactosamine (GalNAc) inhibitable surface lectin. Blockade of this adherence lectin with Gal or GalNAc in vitro prevents amebic killing of target cells. We have identified and purified the adherence lectin by two methods: affinity columns derivatized with galactose monomers or galactose terminal glycoproteins, and affinity columns and immunoblots prepared with monoclonal antibodies that inhibit amebic adherence. By both methods the adherence lectin was identified as a 170-kD secreted and membrane-bound amebic protein. The surface location of the lectin was confirmed by indirect immunofluorescence. Purified lectin competitively inhibited amebic adherence to target cells by binding to receptors on the target Chinese hamster ovary cells in a Gal-inhibitable manner.

Recognition of the galactose- or N-acetylgalactosamine-binding lectin of Entamoeba histolytica by human immune sera

Cure of amebic liver abscess is associated with resistance to recurrent invasive amebiasis and the development of a humoral and cell-mediated immune response. We determined whether human immune sera contain blocking antibody for the 170-kilodalton (kDa) galactose or N-acetylgalactosamine (Gal/GalNAc)-binding lectin of Entamoeba histolytica. By Western blot (immunoblot) of whole amebae subjected to sodium dodecyl sulfate-polyacrylamide gel electrophoresis, all eight immune sera studied here prominently recognized a 170-kDa amebic protein. Western blot of the purified Gal/GalNAc lectin with pooled human immune sera (PHIS) confirmed that the 170-kDa band was the adherence lectin. Immunoprecipitation of [35S]methionine-metabolically-labeled amebae with the antilectin monoclonal antibody H8-5 and with PHIS demonstrated that the 170-kDa lectin was the major antigen recognized by PHIS. The in vitro adherence of E. histolytica trophozoites to CHO cells at 4 degrees C was inhibited by prior exposure of amebae to greater than or equal to 1.0% PHIS. The humoral response to the Gal/GalNAc-binding lectin of the parasite may contribute to the development of protective immunity against invasive amebiasis.

Entamoeba histolytica: cytopathogenicity and lectin activity of avirulent mutants

Three clones of Entamoeba histolytica (L-6, C93, C919) were isolated by mutagenesis with ethyl methanesulfonate from the axenic strain HM1:IMSS and were studied for adherence, cytolytic, and soluble galactose inhibitable lectin activity. Avirulent clones adhered to and killed fewer Chinese hamster ovary cells than HM1:IMSS (P less than 0.01). However, only C919 was deficient in adherence to red blood cells. Galactose (1.0 g) completely inhibited adherence of all the mutants to Chinese hamster ovary cells; however, adherence to erythrocytes was only partially inhibitable by galactose. Avirulent mutants were more susceptible to being killed by human neutrophils in vitro (P less than 0.01 compared to HM1:IMSS). Soluble protein preparations from all the avirulent mutants were markedly less mitogenic for human lymphocytes and had lower lectin activity for Chinese hamster ovary cells compared to the HM1:IMSS wild type (P less than 0.01 for each activity with each mutant). Indirect immunofluorescence with a monoclonal antibody (F-14) that recognizes the Gal/GalNAc lectin was positive for L-6 and C919. These findings utilizing avirulent mutants of E. histolytica further support a role for the amebic galactose inhibitable lectin in the in vivo pathogenesis of amebiasis.

Acid intracellular vesicles and the cytolysis of mammalian target cells by Entamoeba histolytica trophozoites

Entamoeba histolytica kills mammalian target cells in a multi-step sequential process with separate adherence, cytolytic, and phagocytic events. In the studies reported here, we used fluorescein isothiocyanate linked to dextran to label the endocytic vesicles of the HM1 strain of E. histolytica and measure vesicle pH (5.1 +/- 0.2 by spectrofluorimetry). Concentrations of NH4Cl (1.0-10.0 mM) sufficient to increase vesicle pH to greater than or equal to 5.7 inhibited amebic killing of target Chinese hamster ovary (CHO) cells as assayed by trypan blue staining, by the release of 3H-thymidine previously incorporated into CHO cell monolayers, and by the release of 111indium oxine from radiolabeled CHO cells. Similar effects were also observed with two other weak bases, primaquine and chloroquine (both 50 microM). In contrast, NH4Cl (10 mM) did not affect either the adherence or phagocytic events, as measured by amebic adherence to CHO cells at 4 degrees C and by the binding and ingestion of 3H-leucine-labeled bacteria. In the presence of NH4Cl and the carbohydrate ligand asialofetuin, there was no evidence of intracellular trapping of the amebic galactose-inhibitable lectin; inhibition of adherence by cycloheximide (10 micrograms/ml for 3 h) suggested rapid turnover of the surface lectin. Prolonged exposure to NH4Cl for 48 h (which had no effect on amebic protein synthesis) or shorter exposure to cycloheximide (10 micrograms for 3 h) produced persistent inhibition of cytolysis. These results indicate that an uninterrupted acid pH in intracellular endocytic vesicles is necessary for the cytolysis of target cells by E. histolytica trophozoites.

Production of mouse monoclonal antibodies which inhibit in vitro adherence of Entamoeba histolytica trophozoites

Adherence by axenic Entamoeba histolytica trophozoites to mammalian cells is mediated by an N-acetylgalactosamine (GalNAc)-inhibitable adhesin on the surface of the parasite. We isolated 35 hybridoma cell lines producing antibodies to E. histolytica as indicated by ELISA with sonicated amebic protein or by immunofluorescence assay with fixed whole trophozoites. Tissue culture supernatants were further screened for subcloning by the ability to bind to Chinese hamster ovary (CHO) cells which were first exposed to a partially purified soluble preparation of the amebic GalNAc-inhibitable lectin. Eight tissue culture supernatants were positive in this assay. Antibodies from four subcloned cell lines (D3-14, H8-5, I12-2, and I1-21) inhibited amebic adherence to CHO cells (P less than 0.01). Of the original 35 tissue culture supernatants, 3 also inhibited amebic adherence (P less than 0.01; F1, F14, and J10); monoclonal antibodies in these supernatants did not bind to lectin-exposed CHO cells. Three purified monoclonal antibodies (H8-5, I12-2, and I1-21) inhibited amebic adherence at greater than or equal to 2 micrograms/10(4) amebae (P less than 0.05). None of these inhibitory monoclonal antibodies immunoprecipitated with a soluble amebic protein preparation following sodium dodecyl sulfate-polyacrylamide gel electrophoresis under denaturing conditions. Monoclonal antibodies which inhibit in vitro adherence by E. histolytica will be useful in purification of the GalNAc-inhibitable lectin.

Patients treated for amebic liver abscess develop cell-mediated immune responses effective in vitro against Entamoeba histolytica

We studied the afferent and efferent cell-mediated immune response in 15 patients treated for amebic liver abscess. Patients had a lower T4 to T8 ratio (1.25 +/- 0.65) compared with age- and sex-matched controls (1.89 +/- 0.44, p less than 0.01) due to a decrease in T4-"helper" cells and an increase in T8-"suppressor" cells (p less than 0.01). The in vitro proliferative response of patient T lymphocytes to the plant mitogen concanavalin A (Con A) was depressed; responses to phytohemagglutinin were not. The proliferative response of patient lymphocytes to an amebic soluble protein preparation (SPP) was greater than the mitogenic response seen in control lymphocytes (mean of 68,300 delta cpm and 22,300 delta cpm, respectively, p less than 0.001), correlated with the T4 to T8 ratio (p less than 0.05) and the duration of time from initiation of antiamebic therapy (p less than 0.01). Supernatants from patient lymphocytes exposed to the amebic SPP activated normal monocyte-derived macrophages to kill virulent axenic E. histolytica trophozoites (p less than 0.001); patient monocyte-derived macrophages activated by Con A-elicited lymphokine could also kill amebae. Finally, when incubated with the amebic SPP for 5 days, T lymphocytes from patients were able to kill virulent amebae (p less than 0.005); patient T lymphocytes not exposed to the amebic SPP or control T lymphocytes incubated for 5 days with the amebic SPP were not cytotoxic to E. histolytica trophozoites. In summary, after cure of amebic liver abscess, specific cell-mediated immune mechanisms develop that are effective in vitro against the parasite.

Patients treated for amebic liver abscess develop cell-mediated immune responses effective in vitro against Entamoeba histolytica

We studied the afferent and efferent cell-mediated immune response in 15 patients treated for amebic liver abscess. Patients had a lower T4 to T8 ratio (1.25 +/- 0.65) compared with age- and sex-matched controls (1.89 +/- 0.44, p less than 0.01) due to a decrease in T4-"helper" cells and an increase in T8-"suppressor" cells (p less than 0.01). The in vitro proliferative response of patient T lymphocytes to the plant mitogen concanavalin A (Con A) was depressed; responses to phytohemagglutinin were not. The proliferative response of patient lymphocytes to an amebic soluble protein preparation (SPP) was greater than the mitogenic response seen in control lymphocytes (mean of 68,300 delta cpm and 22,300 delta cpm, respectively, p less than 0.001), correlated with the T4 to T8 ratio (p less than 0.05) and the duration of time from initiation of antiamebic therapy (p less than 0.01). Supernatants from patient lymphocytes exposed to the amebic SPP activated normal monocyte-derived macrophages to kill virulent axenic E. histolytica trophozoites (p less than 0.001); patient monocyte-derived macrophages activated by Con A-elicited lymphokine could also kill amebae. Finally, when incubated with the amebic SPP for 5 days, T lymphocytes from patients were able to kill virulent amebae (p less than 0.005); patient T lymphocytes not exposed to the amebic SPP or control T lymphocytes incubated for 5 days with the amebic SPP were not cytotoxic to E. histolytica trophozoites. In summary, after cure of amebic liver abscess, specific cell-mediated immune mechanisms develop that are effective in vitro against the parasite.

Effect of antagonists of calcium and phospholipase A on the cytopathogenicity of Entamoeba histolytica

The in vitro mechanisms by which Entamoeba histolytica trophozoites lyse target Chinese hamster ovary (CHO) cells were examined. Calcium chelators ethylenediaminetetraacetate and ethyleneglycol bis (beta-aminoethyl ether)-N,N'-tetraacetate (10 mM) inhibited amebic cytolysis of target CHO cells (P less than .01). A putative antagonist of intracellular calcium flux, 8-(N,N-diethylamino)octyl-3,4,5-trimethoxybenzoate (TMB-8; greater than or equal to 250 microM), inhibited amebic adherence and cytolysis (P less than .001). Quinacrine, Rosenthal's inhibitor (dimethyl-dl-2,3-distearoyloxypropyl-2'-hydroxyethyl ammonium acetate), phosphatidylcholine, and hydrocortisone (greater than or equal to 10(-4) M), all pharmacological antagonists of eukaryotic phospholipase A enzymes, inhibited amebic killing of target CHO cells (P less than .001). At 37 C quinacrine and hydrocortisone reduced amebic adherence to CHO cells, whereas Rosenthal's inhibitor and phosphatidylcholine did not. Phosphatidylcholine and TMB-8 demonstrated a synergistic inhibitory effect on amebic killing of target CHO cells (P less than .001). These studies indicate that extracellular calcium ions, amebic intracellular calcium flux, and amebic phospholipase A activity are required for cytolysis of target cells by E. histolytica.

N-Acetyl-D-galactosamine-inhibitable adherence lectin of Entamoeba histolytica. I. Partial purification and relation to amoebic virulence in vitro

Adherence of axenic Entamoeba histolytica, strain HM1-IMSS, to Chinese hamster ovary (CHO) cells is mediated by an amoebic adhesin that is inhibited by N-acetyl-D-galactosamine (GalNAc). The in vitro virulence for CHO cells and human neutrophils (PMNs) of four strains of axenic amoebae was strain HM1-IMSS greater than H303-NIH = 200-NIH greater than nonvirulent Laredo (P less than .001). The HM1 strain had the greatest sensitivity to GalNAc-mediated inhibition of adherence (P less than .001). GalNAc (1.0 g/100 ml) inhibited the killing of CHO cells and PMNs by HM1 amoebae (P less than .001) and allowed PMNs to kill the amoebae (P less than .0047). Gel filtration chromatography of a soluble fraction of amoebic sonicate demonstrated a GalNAc-inhibitable amoebic lectin of 43,000-67,000 daltons that agglutinated CHO cells, erythrocytes, and PMNs. Strain HM1 contained greater specific lectin activity than did strains 303, 200, and Laredo amoebae (P less than .0016). The in vitro virulence of E. histolytica is associated with a GalNAc-inhibitable amoebic adhesin; this report is the first of a soluble GalNAc-inhibitable amoebic lectin.