P-191 Differences in morphokinetic patterns and clinical outcomes between fresh and frozen oocytes; a retrospective analysis

Study question

Is there a difference in morphokinetics and clinical outcomes between embryos from fresh and vitrified oocytes?

Summary answer

Embryos from vitrified versus fresh oocytes showed a delay at the cellular stage, but no impact on time to blastulation or clinical outcomes was evident.

What is known already

Oocyte vitrification has greatly impacted assisted reproduction, with the number of treatments cycles using frozen oocytes more than doubling in the UK since 2013. Studies of thawed vitrified oocytes have shown similar success rates and outcomes compared to fresh, allowing the technique to be considered safe and effective. However, vitrification and thawing subjects the oocyte to stress and osmotic changes that may be evident in alterations in the timing of their morphological events. Analysis of morphokinetic markers using time-lapse incubators was performed to investigate this.

Study design, size, duration

Matched cohort study. A total of 823 embryos were analysed, 414 embryos from fresh oocytes and 409 from vitrified. The embryos were from the 288 ICSI treatment cycles performed at LWC in 2019. Fresh oocytes were from women less than 35 years old undergoing fertility treatment and vitrified oocytes were from egg donors under 35.

Participants/materials, setting, methods

Embryos graded AA, BB, BA, AB, were selected and annotated retrospectively on the Embryoscope for the following events: pronuclei appearance (tPNa) and disappearance (tPNf), time until two (t2), four (t4) and eight cells (t8), compaction initiation (tSC), the start of blastulation (tSB) and time to expanded blastocyst (tEB). PN duration, second and third embryo cell cycle (ECC), compaction and blastulation duration were also calculated as well as differences in clinical outcomes.

Main results and the role of chance

Embryos derived from vitrified oocytes (EVO) were observed to have a statistically significant delay in 4/8 morphokinetic events studied: t4 (p = 0.03), t8 (p < 0.01), tSC (p < 0.01) and tSB (p = 0.01). A mean delay of 1h50min was observed when compared to embryos from fresh oocytes (EFO). ECC duration showed a statistically significant difference with a delay of 48 minutes in the vitrified group. However, compaction occurred on average just 84min faster in this group, meaning no differences were observed in the time needed to achieve a full expanded blastocyst.

Regression analysis revealed a correlation between the age of the oocyte and morphokinetic timings. Oocytes from older women demonstrated slower development, with age having a statistically significant impact in the following categories: tPNa, tPNf, t2 and t4.

No differences found between fresh and vitrified groups in fertilization rate (80% EFO vs 79% EVO) (p = 0.841), embryo utilization rate (60% EFO and 61% EVO) (p = 0.432), implantation rate (54% EFO vs 52% EVO) (p = 0.837) and clinical pregnancy rates (49% EFO vs 42% EVO) (p = 0.502).

Limitations, reasons for caution

Limitations of the present study include the retrospective analysis, small sample size and the lack of adjustment for potential contributory/confounding factors such as semen quality, body mass index (BMI), antimüllerian hormone (AMH) levels, type of ovarian stimulation or type of infertility which are known possible influencers of embryo morphokinetics.

Wider implications of the findings

The delay observed at the cellular stage by EVO had no impact on the time the embryos needed to achieve full expansion. While vitrification affects embryo morphokinetics, it does not seem to impact the ability of the oocyte to be fertilized, activated, or to produce a viable blastocyst and pregnancy.

Trial registration number

Not applicable

Interprofessional health education and its impact on integral healthcare

Background

Interprofessionality is a tool for optimizing the human resources available towards the consolidation of a resolutive healthcare. However, applying it is a challenge due to the fragmented training of health professionals.

Objective

to describe the experience of planning and executing an interprofessional health education activity.

Methods

An educational workshop was developed aiming at interprofessional health practice. A clinical case was distributed, which addressed the story of an elderly person who suffered a stroke and lived with the sequels of this episode in addition to emotional trauma from the experience. Each professional was asked to define a therapeutic proposal for the case and one of them was invited to present his proposal and complement it based on the suggestions of the other members.

Results

the workshop enabled the perception that, in isolation, no profession would be able to fully contemplate the patient's needs. Therefore, it encouraged the use of integrated action between different professionals by demonstrating that punctual and disjointed actions would not be sufficient to act effectively in the care and needs related to the individual's health.

Conclusions

the final product of this workshop resulted in a consistent activity contemplated by multiple perspectives, experiences and knowledges which would not be so successful if planned in isolation by a single professional group.

Key messages

Due to its low cost, interprofessional action responds to the new health needs of contemporary times and its implementation is of great value in combating the fragmented trend in health training. The interprofessional view is a common ground to health not only where the study took place but worldwide, consolidating itself as a valuable asset to the construction of integral healthcare.

Psychophysiological stress responses during training and competition in young female competitive tennis players

This study sought to compare the psychophysiological stress responses during an actual competitive game and a training session in a group of high-level young female tennis players. 12 players were monitored during one match and a training day (i.e., simulated match play). Measurements included salivary cortisol (SC), the revised Competitive Sport Anxiety Inventory, heart rate (HR), and rate of perceived exertion (RPE). Match day elicited higher SC levels for losers at all points in time when compared to winners. All players showed significantly lower SC levels during training when compared to the match at all points in time except during the evening for winners. Winners of match and training situations had significantly higher self-confidence and lower cognitive anxiety and somatic anxiety scores than losers. Heart rate and RPE were significantly higher for losers only during the match (158.9±8.3 vs. 168±6.7 bpm; 12.9±1.2 vs. 15±0.8, for losers and winners, respectively). There were moderate to strong correlations between SC, self-confidence and anxiety scores, and match workload (i.e., HR and RPE) only during the match day. These results indicate that the interplay between psychophysiological responses, match workload and outcome was evident only under real competitive situations.

Thiopurine methyl-transferase activity and azathioprine metabolite concentrations do not predict clinical outcome in thiopurine-treated inflammatory bowel disease patients

BACKGROUND

Low thiopurine-methyl-transferase (TPMT) activity and high 6-thioguanine-nucleotide (6TGN) concentrations have been linked to therapeutic success in inflammatory bowel disease patients treated with thiopurines; however, this has not been implemented in clinical practice.

AIM

To identify a therapeutic threshold value for TPMT or 6TGN concentrations, and their capability to predict treatment safety and efficacy.

METHODS

Prospective multicentre study including steroid-resistant/dependent patients starting thiopurines. The TPMT activity was determined at inclusion (>5 U/mL required). Azathioprine metabolites [6TGN, 6-methyl-mercaptopurine ribonucleotides (6MMP), and 6TGN/6MMP and 6TGN/TPMT ratios] were periodically monitored during steroid tapering and after withdrawal for 6 months or until a new flare occurred.

RESULTS

A total of 113 patients were analysed (62% clinical response). Areas under the receiver operating characteristic (ROC) curve (AUC) relating clinical response and metabolite levels at 2, 4 and 6 months after steroid withdrawal were less than 0.7. The AUCs relating final response and initial TPMT activity or metabolite concentrations at 2, 4, 8 and 16 weeks after starting thiopurines were less than 0.7. No cut-off point with worthwhile sensitivity/specificity was found. Eight (7%) patients developed thiopurine-related toxicity that could not be linked to TPMT activity or 6TGN levels.

CONCLUSIONS

Our results do not support determination of TPMT activity or 6TGN concentrations to predict treatment outcome, and no useful serum metabolites threshold value to adjust the drug's dose was identified.

Decrease in viral load at weeks 12 and 24 in patients with chronic hepatitis B treated with lamivudine or adefovir predicts virological response at week 48

AIM

The aim of our study was to evaluate the decrease in viral load (VL) that is able to predict antiviral treatment response at one year in patients with chronic hepatitis B.

METHODS

The clinical records of 66 patients, 31 treated with lamivudine (LAM) and 35 treated with adefovir (ADF), were retrospectively reviewed. We measured viral DNA at months 1, 3 and 6.

RESULTS

The LAM group showed virological response (VR) in 51.6% of patients. Baseline VL was higher in non responders (5.37 +/- 1.16 vs. 7.01 +/- 1.05; p < 0.001). Responders showed a higher percentage of VL decrease at month 3 from baseline (49.2 vs. 38.3%; p = 0.03). We designed a ROC curve and established a cutoff point for decrease of 30% that had 80% of negative predictive value (NPV).The ADF group showed VR in 57.1% of patients. Baseline VL was higher in nonresponders (4.67 +/- 1.22 vs. 5.78 +/- 1.34; p = 0.01). We observed a significant decrease in VL (log) at months 3 (2.6 +/- 1.1 vs. 1.3 +/- 1.3; p = 0.03) and 6 (2.6 +/- 1.2 vs. 1.3 +/- 1.2; p = 0.006). The percentage of decrease of VL from baseline was also statistically significant. We created ROC curves at months 3 and 6, and established the best cutoff points. At month 6 a decrease of 1 log in VL had a NPV of 80%, and a decrease of 20% in VL from baseline had 100% NPV.

CONCLUSION

The decrease in viral DNA at weeks 12 and 24 can predict VR at one year in patients with chronic hepatitis B treated with LAM or ADF. This could optimize treatment.

Predictors of response to infliximab in patients with fistulizing Crohn's disease

OBJECTIVE

To evaluate the efficacy and toxicity of infliximab for the treatment of fistulizing Crohn's disease.

METHODS

Consecutive patients with fistulizing Crohn's disease receiving infliximab were prospectively enrolled. Partial response was defined as a reduction of 50% or more from base-line in the number of draining fistulae. Complete response was defined as the closure of all fistulae. The influence of different variables on the efficacy of infliximab was evaluated.

RESULTS

108 patients were included. The disease was inflammatory plus fistulizing in 18% and only fistulizing in 82%. After the third infusion of infliximab the response was partial in 26% and complete in 57%. Response (%) rates (partial/complete) depending on fistula location were: enterocutaneous (25/68%), perianal (35/60%), rectovaginal (36/64%), and enterovesical (20/40%). None of the studied variables (including concomitant immunosuppressive therapy) correlated with efficacy of infliximab in the multivariate analysis. Incidence of adverse effects (21%) depending on the dose of infliximab was: first dose (5.6%), second (7.4%), and third (11.1%).

CONCLUSIONS

Infliximab is an efficacious treatment for fistulizing Crohn's disease. Partial response was achieved in approximately one third of the patients, and complete response in more than half. No studied variable was predictive of response. Adverse effects were relatively infrequent and mild.

Treatment of Crohn's disease with recombinant human interleukin 10 induces the proinflammatory cytokine interferon gamma

BACKGROUND

Interleukin 10 (IL-10) exerts anti-inflammatory actions by counteracting many biological effects of interferon gamma (IFN-gamma).

AIMS

To investigate this in humans, we studied the effects of human recombinant IL-10 administration on IFN-gamma production by patient leucocytes. Furthermore, we assessed the IFN-gamma inducible molecule neopterin and nitrite/nitrate serum levels, which are indicative of endogenous nitric oxide formation.

METHODS

As part of two placebo controlled double blind studies, we analysed patients with chronic active Crohn's disease (CACD) who received either subcutaneous recombinant human IL-10 (n=44) or placebo (n=10) daily for 28 days, and patients with mild to moderate Crohn's disease (MCD) treated with either subcutaneous IL-10 (n=52) or placebo (n=16) daily for 28 days. Neopterin and nitrite/nitrate concentrations were measured in serum, and ex vivo IFN-gamma formation by lipopolysaccharide or phytohaemagglutinin (PHA) stimulated whole blood cells were investigated before, during, and after IL-10 therapy.

RESULTS

In patients with CACD, the highest dose of 20 microg/kg IL-10 caused a significant increase in serum neopterin on days +15 and +29 of therapy compared with pretreatment levels. No changes were observed for nitrite/nitrate levels under either condition. In MCD, treatment with 20 microg/kg IL-10 resulted in a significant increase in PHA induced IFN-gamma production.

CONCLUSIONS

High doses of IL-10 upregulate the production of IFN-gamma and neopterin. This phenomenon may be responsible for the lack of efficacy of high doses of IL-10 in the treatment of CACD and MCD.

Heme biosynthesis and oogenesis in the blood-sucking bug, Rhodnius prolixus

We have previously shown that the pathway of porphyrin synthesis operates in the blood feeding triatomine bug Rhodnius prolixus but not in the cattle tick Boophilus microplus. In the present paper we studied the correlation between heme synthesis and egg development in Rhodnius. There is a sharp increase heme biosynthetic capability in the fat body (160%) and in the ovaries (360%) in response to a blood meal, as evaluated from the activity of the enzyme delta-aminolevulinate dehydratase (EC 4.2.1.24). The in vivo inhibition of ALA-D by succinyl acetone results in a dose dependent decrease of oviposition. Oviposition is recovered when porphobilinogen, the product of the impaired reaction, is added to the succinyl acetone enriched blood. Taken together, these results show that heme biosynthesis is a fundamental event to vitellogenic females. The demand for heme in this metabolic juncture cannot be supplied by the heme eventually absorbed during blood digestion and associated with Rhodnius heme binding protein (RHBP), which is then incorporated into growing oocytes. Inhibition of heme biosynthesis results in lower levels of RHBP in the hemolymph, suggesting that the synthesis of this protein is controlled by heme availability.

[Purgatory, mercy and charity: structural conditions of care in Portugal (15th to 19th centuries)]

The aim of this article is to show how the Portuguese welfare system was organized and how it survived for several centuries. It was rebuilt by the monarchy in the late 15th century, a process that coincided with the birth of the Misericordias under the protection of the King. After the Council of Trent, these fraternities ran the health system, which was financed by people who believed in the power of perpetual Masses to evade Purgatory. These institutions were run by the political elite, who exploited them for their own benefit. The article also analyses the main measures taken by the state in the 18th century to change the old and weak system of public care. These laws were ineffectual and unable to change the real situation: the Misericordias were alone--the elite had run away when money was short--and they received no support from the public purse or from the faithful, who at that time had less faith in the perpetual Mass.

Impaired mitogenic response of peripheral blood T cells in ulcerative colitis is not due to apoptosis

An abnormal immune response may play a pathogenic role in ulcerative colitis (UC). Animal models suggest that T-cell regulation may be of central importance in the inflammatory process. Our aims were the characterization of the phenotype and functional status of circulating T-cells in ulcerative colitis patients and to determine if activation-induced cell death in CD4 and CD8 lymphocytes in patients differs from healthy controls. Forty-eight patients (24 women and 24 men) fulfilling the histopathological, clinical, and immunological criteria for UC were studied. T-cell phenotype and function were studied in blood lymphocytes from patients with ulcerative colitis and healthy donors by flow cytometric analysis, as well as [3H]thymidine incorporation. There were no significant differences in the percentage of T-cell subpopulations (CD3, CD4, CD8) and NK cells in the different groups. The percentage of cells in growth phase S+G2M at two and three days of phytohemagglutinin (PHA) stimulation was significantly decreased in UC patients, but the percentage of CD4+ and CD8+ cells in UC patients that showed apoptosis was not significantly different than that in the control group. Proliferative responses to IL-4 also suggested that a reduced responsiveness to this cytokine may be involved in UC. In conclusion, the impaired proliferative response to PHA of T lymphocytes from UC patients is not associated with an in vitro increase in the apoptotic response in CD4+ or CD8+ cells. A reduced IL-4 response may be involved in this peculiar mitogenic response. These changes may be pathogenic or a favorable adaptive mechanism.

Isolation of an aspartic proteinase precursor from the egg of a hard tick, Boophilus microplus

An aspartic proteinase precursor, herein named BYC (Boophilus Yolk pro-Cathepsin) was isolated from eggs of the hard tick, Boophilus microplus. As judged by electrophoresis on sodium dodecyl sulfate polyacrylamide slab gel (SDS-PAGE), purified BYC presented 2 bands of 54 and 49 kDa, bearing the same NH2-terminal amino acid sequence. By Western blot analysis, BYC was also found in the haemolymph, indicating an extraovarian site of synthesis. Several organs were incubated in culture medium with [35S]methionine, and only the gut and fat body showed synthesis of BYC polypeptides. Protein sequencing of both the NH2-terminal and an internal sequence obtained after cyanogen bromide (CNBr) cleavage of BYC revealed homology with several aspartic proteinase precursors. Incubation at pH 3.5 resulted in autoproteolysis of BYC, which produced the mature form of the enzyme, that displayed pepstatin-sensitive hydrolytic activity against haemoglobin. Western blot analysis using anti-BYC monoclonal antibodies showed proteolytic processing of BYC during embryogenesis and suggested activation of the enzyme during development. A role of BYC in degradation of vitellin, the major yolk protein of tick eggs, is discussed.

Arterioportal fistula and hemobilia with associated acute cholecystitis: a complication of percutaneous liver biopsy

Complications attributable to percutaneous liver biopsy, including hemobilia and arterioportal fistula, are uncommon. In this report, we present the case of a patient who underwent percutaneous liver biopsy and, as a consequence of this procedure, developed an arterioportal fistula and hemobilia with associated acute cholecystitis. The diagnosis of hemobilia was possible with abdominal ultrasound and upper endoscopy, but the patient required cholecystectomy. Hepatic angiography was performed, demonstrating the arterioportal fistula and hemobilia. Transcatheter embolization occluded the fistula, resolving the hemobilia. We recommend ultrasound and upper endoscopy as initial diagnostic procedures, but angiography and selective embolization must not be delayed if arterioportal fistula and/or hemobilia is suspected since these measures may help to prevent further complications.

Expanded CD4+CD45RO+ phenotype and defective proliferative response in T lymphocytes from patients with Crohn's disease

BACKGROUND & AIMS

An abnormal immune response may play a pathogenic role in Crohn's disease. The aim of this study was to determine the role of regulatory T cells in Crohn's disease.

METHODS

T-cell phenotype and function were studied in blood lymphocytes from patients with Crohn's disease and a control group consisting of healthy donors and patients with ulcerative colitis.

RESULTS

Flow cytometric studies showed a significant increase in the percentage of CD3+DR+ and CD4+CD45RO+ T cells in patients with Crohn's disease. T cells from patients with Crohn's disease and ulcerative colitis showed a defective proliferative response after stimulation with surface mitogenic ligands (phytohemagglutinin and anti-CD28 or anti-CD3 antibodies). Soluble interleukin-2 receptor alpha was augmented in the Crohn's disease and ulcerative colitis groups. In the Crohn's disease group, impairment of T-lymphocyte proliferation was normalized by exogenous interleukin 2, although endogenous interleukin-2 production and interleukin-2 receptor alpha expression were normal.

CONCLUSIONS

An in vivo expansion of CD4+ T lymphocytes with memory phenotype and impaired T-cell proliferation that can be restored by pharmacological amounts of interleukin 2 was found in patients with Crohn's disease. There is a severe immunodisturbance in the T-cell compartment of patients with either clinically active or inactive Crohn's disease.

Interferon and prednisone therapy in chronic hepatitis C with non-organ-specific antibodies

BACKGROUND/AIMS

The relationship between hepatitis C virus and autoimmunity is controversial. The issue is particularly relevant in those patients with hepatitis C virus infection and serum autoantibodies in whom steroids can exacerbate viral replication and interferon can lead to decompensated liver disease. The aim of this study was to evaluate the response to a course of prednisone or interferon-alpha 2b.

METHODS/RESULTS

The 12 study patients had biopsy-proven chronic hepatitis, serum HCV-RNA (by nested polymerase chain reaction) and non-organ-specific antibodies (eight with liver and kidney microsomal antibodies and four with antinuclear antibodies). Eight of these 12 patients received a 4-month course of prednisone (0.5 mg/kg per day), which increased alanine aminotransferase (mean +/- SE) (174 +/- 31 vs 252 +/- 18 U/l, p < 0.05) and bilirubin levels (0.96 +/- 0.17 vs 1.42 +/- 0.18 mg/dl, p = 0.09), without changing liver histology (Knodell index, 13.6 +/- 0.4 vs 13.1 +/- 0.3). Subsequent treatment with interferon in the 12 patients reduced serum alanine aminotransferase levels (170 +/- 20 vs 41 +/- 7 U/l, p < 0.0001) and portal and lobular inflammation (Knodell index, 13.8 +/- 0.5 vs 8.4 +/- 0.2, p < 0.001). A complete response to interferon was observed in ten of these patients (83%), eight of whom had previously been treated with prednisone. Serum HCV-RNA level decreased in interferon responders. A sustained response 1 year after withdrawal of interferon was seen in only five patients (41%).

CONCLUSIONS

Patients with chronic hepatitis C and autoantibodies show a favorable response to interferon, but not to prednisone. The latter regimen can exacerbate liver necrosis in these subjects. The presence of autoantibodies in hepatitis C patients does not modify the response to interferon.

Enhanced endothelium-dependent vasodilation in patients with cirrhosis

Experimental evidence indicates that an increased production of nitric oxide could play a role in the peripheral vasodilation of portal hypertension. To test this hypothesis in humans, we studied basal serum NO(2-) + NO3- levels and the response of forearm resistance vessels to increasing concentrations of methacholine chloride, sodium nitroprusside, and phenylephrine infused into the brachial artery of 12 cirrhotic patients and 10 controls. Forearm vascular resistance (FVR) was calculated from mean arterial pressure and forearm blood flow (FBF). Cirrhotics showed higher NO(2-) + NO3- levels (P < 0.05), higher FBF (P < 0.01), and lower FVR (P < 0.01) than controls. The reduction of FVR in response to every dose of methacholine was greater in cirrhotics than in controls; this was significant (P < 0.05) at the 3 and 10 micrograms/min doses. This response to methacholine was not modified by blockade of vascular prostacyclin. The response to nitroprusside was similar in both groups. The increase in FVR in response to every dose of phenylephrine was significantly (P < 0.01) lower in cirrhotics than in controls. In cirrhotics, a significant correlation (r = -0.81, P < 0.01) was found between the FVR response to the highest doses of methacholine and phenylephrine. In conclusion, cirrhotic patients show an enhanced endothelium-mediated vasodilation, which suggests an increased synthesis of nitric oxide. This defect may mediate the peripheral vasodilation and hyporeactivity to vasopressors of these patients.

Deficient interleukin 2 dependent proliferation pathway in T lymphocytes from active and inactive ulcerative colitis patients

There is increasing evidence that ulcerative colitis is associated with an abnormality of the immune system. Although the aetiology remains unknown, it has been suggested that the immune system of these patients is implicated in the pathogenesis of their disease. T cell function was investigated in ulcerative colitis patients and defective phytohaemagglutinin induced T cell mitogenesis was found. The DNA synthesis induced by stimulation with phorbol esters plus ionophore (ionomycin), however, was normal. These changes cannot be ascribed to either decreased interleukin 2 synthesis or to a defective interleukin 2 receptor expression after cellular activation. Moreover, this defective proliferative response of the T lymphocytes was observed even in the presence of saturated concentrations of exogenous interleukin 2. These results emphasise that the interleukin 2 dependent proliferation pathway is deficient in T lymphocytes from ulcerative colitis patients.

T lymphocytes from alcoholic cirrhotic patients show normal interleukin-2 production but a defective proliferative response to polyclonal mitogens

T lymphocyte proliferation is a complex process involving intra- and extracellular molecules. T cell activation was studied in T lymphocytes from patients with alcoholic cirrhosis. A defective phytohemagglutinin (PHA)-induced T cell mitogenesis was observed in 60% of these patients. Likewise, their blastogenic response to anti-CD3 was also depressed (p < 0.05). However, the DNA synthesis induced by stimulation with phorbol esters (12-O-tetradecanoil-phorbol-13-acetate) + ionomycin was normal (p > 0.05). These alterations cannot be ascribed either to decreased interleukin-2 synthesis or to a defective interleukin-2 receptor expression after cellular activation. Moreover, supplementation of the PHA-stimulated T cell cultures with saturant concentrations of recombinant interleukin-2 did not normalize the hypoproliferative response of T cells from alcoholic++ cirrhotic patients. These results provide evidence that a generalized alteration in the interactions between either mitogens or interleukin-2 and their receptors can explain the T lymphocyte-defective blastogenesis found in patients with alcoholic cirrhosis.

Increased IgM B cell differentiation lymphokine production by T lymphocytes from patients with primary biliary cirrhosis

Hypergammaglobulinemia, mainly due to increased serum immunoglobulin M concentrations, is a common and distinctive feature of primary biliary cirrhosis. T-B cell cooperation plays a pivotal role in the regulation of immunoglobulin secretion. In this paper, the production of regulatory B lymphokines by T cells, as well as the functional response of B lymphocytes to these molecules, was investigated in patients with primary biliary cirrhosis. T cells from patients with primary biliary cirrhosis have an enhanced ability to produce lymphokines that regulate the proliferation of B cells and their differentiation to immunoglobulins G- and M-secreting cells. In contrast, the cellular production of lymphokines involved in the induction of immunoglobulin A-secreting cells was normal. Simultaneously, the proliferation and differentiation of purified B cells in response to stimulation with surface immunoglobulin ligands and lymphokines were normal. These results suggest that the elevated serum levels of immunoglobulins M and G found in patients with primary biliary cirrhosis could be ascribed to an enhanced lymphokine-mediated T-B cooperation.

Deficient interleukin-2 responsiveness of T lymphocytes from patients with primary biliary cirrhosis

There is increasing evidence that primary biliary cirrhosis is associated with an alteration of the immune system. Although the cause remains unknown, it has been suggested that the immune system of patients with primary biliary cirrhosis is involved in the pathogenesis of their disease. We have investigated the T-cell function in patients with primary biliary cirrhosis and have found defective phytohemagglutinin-induced T-cell mitogenesis. Likewise, their blastogenic response to CD3 monoclonal antibody was also depressed, although the DNA synthesis induced by stimulation with phorbol esters (12-O-tetradecanoil-phorbol-13-acetate) plus ionophore (ionomycin) was normal. These alterations could not be ascribed either to a decreased synthesis of interleukin-2 or to a defective expression of interleukin-2 receptor after cellular activation. Moreover, this defective proliferative response of T lymphocytes was observed even in the presence of saturating concentrations of exogenous interleukin-2. These results represent evidence of the deficiency in the interleukin-2-dependent pathway found in T lymphocytes from patients with primary biliary cirrhosis.

Increased spontaneous and lymphokine-conditioned IgA and IgG synthesis by B cells from alcoholic cirrhotic patients

Immunoglobulin secretion by B lymphocytes is a complex process in which lymphokines secreted by T lymphocytes play an important regulatory role. Increased serum levels of IgA and IgG have been characteristically detected in patients with alcoholic cirrhosis. We have studied the functional alterations of T and B lymphocytes implicated in the physiopathology of this common immunoglobulin abnormality. After activation with phytohemagglutinin, purified T cells from alcoholic cirrhotic patients showed significantly enhanced secretion of B-cell differentiation factors for IgG and IgA with respect to those secreted by T cells from healthy controls (p less than 0.05). Simultaneously, normal secretion of B-cell differentiation factor for IgM was demonstrated in T lymphocytes from these patients. The pattern of secretion of the lymphokines involved in the regulation of the B-cell differentiation pathway found in alcoholic cirrhotic patients was different from that of the primary biliary cirrhotic patients studied. Purified B cells from patients with alcoholic cirrhosis secreted significantly higher amounts of IgA and IgG than did those found in healthy controls, both spontaneously (p less than 0.05) and after sequential activation with immunoglobulin ligands (Staphylococcus aureus Cowan I) and a standard B-cell differentiation factor preparation (p less than 0.05). By contrast, the IgM secretion and regulatory pathway were normal in alcoholic cirrhotic patients. These results support a physiopathological explanation for the characteristic hyperimmunoglobulinemia found in patients with alcoholic cirrhosis.

Functional impairment of natural killer cells in active ulcerative colitis: reversion of the defective natural killer activity by interleukin 2

We have studied the functional characteristics and clinical importance of the natural killer (NK) cytotoxicity of peripheral blood mononuclear cells (PBMNC) from patients with ulcerative colitis. Normal NK activity was observed in PBMNC from patients with inactive disease, but a pronounced decrease was found in those with active disease. Clinical change from active to inactive disease was associated with enhancement of the depressed NK activity. The impairment of NK cytotoxicity found in patients with active disese could not be ascribed to a deficient number of NK cells as the amounts of HNK-1+, CD16+ (Leu 11), and CD11b (OKM1) cells in PBMNC were within normal ranges. This defective cytotoxic PBMNC activity was normalised by short term (18 hour) incubation with recombinant interleukin 2 (rIL-2). Moreover, long term (5 day) incubation of these effector cells with rIL-2 induced strong cytotoxic activity against NK resistant and NK sensitive target cells in patients with active and inactive disease. We also found that both precursors and effectors of cytotoxic activity promoted by short term and long term incubation with rIL-2 of PBMNC from the patients showed the phenotype of NK cells (CD16+, CD3-). Taken together, these results show that active ulcerative colitis is associated with a defective function of NK cells that is found to be normal in the inactive stage of the disease. The possible pathogenic and therapeutic implications of these findings are discussed.

Different HCl and pepsinogen I secretion patterns in anatomically defined gastric ulcer subsets

Anatomically, functionally, and clinically, peptic ulcer patients are a heterogeneous group of subjects. These patients can be classified according to the anatomic localization of the niche. The functional state of the gastric mucosa was studied in 30 gastric ulcer patients, 25 duodenal ulcer patients, and 10 normal controls. The classification of the first group was based on Johnson's criteria, with the following results: 10 individuals were type I, 10 were type II, and 10 were type III. Pepsinogen I levels and gastric acid secretion were measured in all 65 subjects under basal conditions and after subcutaneous pentagastrin stimulation. Both basal and stimulated serum pepsinogen I values were significantly higher (p less than 0.05) in gastric ulcer type III patients than in the other four groups. These values in gastric ulcer type I were similar to those of the controls. Gastric ulcer type II patients showed an intermediate functional state similar to that of duodenal ulcer patients. In both gastric ulcer type II and duodenal ulcer patients, the basal and stimulated pepsinogen I levels were significantly higher (p less than 0.05) than those found in controls, whereas the basal serum gastrin levels were similar in the five groups. In conclusion, different HCl and pepsinogen I secretory patterns, with functional heterogenicity of the gastric mucosa, are shown here for the anatomically defined gastric ulcer subsets.

[Extracorporeal biliary lithotripsy: results in 60 cases of single calculus]

The outcome of 60 cases of single biliary stone with a maximum diameter of 25 mm was evaluated. The patients were symptomatic, with functioning gallbladder, and were selected from a group of 180 to evaluate the effects of electrohydraulically generated shockwaves on a priori ideal cases for this procedure. In seven patients fragmentation was not achieved, probably because of the pigmentary character of the stone, that was later verified at cholecystectomy. In 20 out of the 53 in whom fragmentation was satisfactory (38%), fragments were not observed after 24 hours. 32 patients (54%) had a stone-free gallbladder 3 months afterwards; at six months, the number had increased to 40 (66%). This rate becomes 77% if only the cases with fragmentation are considered. In 29% of patients episodes of colicky biliary pain developed as complication. No case of pancreatitis or stuck in gallstone were observed. We conclude that shock waves appear as an excellent therapeutic alternative in single gallstones up to 25 mm in size.

Atypical hepatic tuberculosis presenting as obstructive jaundice

A 78-yr-old female with a short history of malaise, anorexia, mild pyrexia, and obstructive jaundice is presented. A diagnosis of tuberculosis of the liver and gallbladder was established at laparotomy. In spite of anti-tuberculous therapy, the patient died on the 5th postoperative day. Widespread miliary tuberculosis affecting the lung, kidneys, spleen, and mesenteric lymph nodes was observed in postmortem studies, with strikingly severe involvement of the intrahepatic bile ducts. Saccular dilatation of the bile ducts alternating with areas of stenosis and narrowed intrahepatic bile ducts was seen. A correlation of the radiological and hepatic postmortem findings is discussed. The atypical presentation of tuberculosis in present times and the causes of jaundice in atypical cases of hepatic tuberculosis are discussed. The rarity of gallbladder tuberculosis is pointed out.

Study of the secretion of pepsinogen I in cirrhotic humans with and without portacaval shunt

Thirty-nine subjects have been studied: 14 with hepatic cirrhosis who had not been subjected to surgery, 13 cirrhotic patients in whom portacaval shunt had been performed, and 12 normal controls. In all of them, we performed serum determinations of pepsinogen I, both basal and after pentagastrin stimulation, and of basal gastrin levels, as well as analyses of basal and stimulated gastric acid secretion (basal acid output and maximal acid output). The values for pepsinogen I, basal or post-stimulation, were higher (p less than 0.001) in patients with cirrhosis who had not undergone surgical shunt than in those in the control group. However, there were no statistically significant differences when these two groups were compared with the patients who had been subjected to portacaval shunt. In this last group of patients, seven had levels similar to those of the controls, and six presented higher values. Likewise, the values for gastric acid secretion were similar in the three groups of patients, and the basal gastrin level was lower (p less than 0.001) among patients with liver cirrhosis, whether or not they had undergone surgery, than among the control population. In conclusion, the functional alterations of the gastric mucosa in patients with hepatic cirrhosis are not significantly different from those found in cirrhotic patients with portacaval shunt.

In vitro immune cell function in six cases of immunoproliferative small intestinal disease after long term remission

We have studied several parameters of in vitro immune cell function in peripheral blood mononuclear cells from six patients with immunoproliferative small intestinal disease after long term remission. We have observed two groups of patients with different patterns of response. (a) After stimulation with pokeweed mitogen (PWM) and Staphylococcus aureus, three patients showed a significant reduction of the Ig synthesis (A, G and M) and the proliferative response. In two of them, we found increased spontaneous suppressor T cell activity. In the third case, the diminished response could not be attributed, according to our assays, either to suppressor T cells, lack of T helper activity (although the number of OKT4+ cells was diminished) or an intrinsic B cell defect. The three patients showed normal or augmented NK activity and an inversion of the OKT4+/OKT8+ ratio was detected in two of them. (b) The remaining three patients showed a normal Ig synthesis after stimulation with PWM and a slightly depressed IgM synthesis in response to S. aureus. They expressed a normal T helper cell function and did not show increased spontaneous suppressor T cell activity. They had low levels of natural killer cytotoxicity and the OKT4+/OKT8+ ratio was not significantly altered. Taken together, our data indicate that significant alterations of the in vitro immune response can be found in peripheral blood mononuclear cells of some immunoproliferative small intestinal disease patients after long term remission.

The direct agglutination test for chronic Chagas's disease. The effect of pre-treatment of test samples with 2-mercaptoethanol

The relative sensitivity and relative specificity of the direct agglutination (DA) test for the diagnosis of human Trypanosoma cruzi infection were studied in human serum samples, with and without previous treatment with 2-mercaptoethanol (2-ME), which were obtained from different areas of Brazil. Results obtained with these tests were related to those obtained with the indirect immunofluorescence (IIF) and indirect haemagglutination (IHA) tests. The DA test results from the sample not previously treated with 2-ME did not agree with those from the IIF and IHA tests. On the other hand, the DA test results from the sample previously treated with 2-ME agreed significantly (99.22%) with those from the IIF and IHA tests.