Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Evaluating the immediate effects of wearing foot orthotics in children with Joint Hypermobility Syndrome (JHS) by analysis of temperospatial parameters of gait and dynamic balance: A preliminary study

Joint Hypermobility Syndrome (JHS) in children, presents with increased joint range of motion and can lead to altered gait strategies and reduced dynamic balance. Despite limited evidence foot orthoses are sometimes prescribed to patients with JHS with the aim to improve the stability of their gait pattern and theoretically reduce associated symptoms of fatigue and joint pain. The purpose of this study was therefore to analyse the immediate effects of 'off the shelf' orthoses on temporospatial parameters of gait and dynamic balance in this cohort.

METHODS

A total of 21 patients were recruited for the study (13 female) with a median age of 10 years (IRQ = 4.12). Each patient had their gait analysed using the GAITRite walkway in their own footwear and immediately after being prescribed the orthoses. Gait was tested at both the patients' preferred speed and when asked to walk slower to challenge their dynamic balance.

RESULTS

Gait appeared more synchronised, with a reduction in step length and width variability, when participants were provided with orthotics. The variation was greatest when participants were asked to walk slower. Double stance was significantly less at slower speeds when orthotics were added (1.61%, 95% CI = 0.34, 2.89, p = 0.015) CONCLUSION: Results of this study indicate that orthotics have a definite immediate influence on gait patterns in patients with JHS. Future studies should investigate the long-term effects of orthotics in this population and include outcome measures for symptoms such as pain.

Utopia documents: linking scholarly literature with research data

Motivation: In recent years, the gulf between the mass of accumulating-research data and the massive literature describing and analyzing those data has widened. The need for intelligent tools to bridge this gap, to rescue the knowledge being systematically isolated in literature and data silos, is now widely acknowledged.

Results: To this end, we have developed Utopia Documents, a novel PDF reader that semantically integrates visualization and data-analysis tools with published research articles. In a successful pilot with editors of the Biochemical Journal (BJ), the system has been used to transform static document features into objects that can be linked, annotated, visualized and analyzed interactively (http://www.biochemj.org/bj/424/3/). Utopia Documents is now used routinely by BJ editors to mark up article content prior to publication. Recent additions include integration of various text-mining and biodatabase plugins, demonstrating the system's ability to seamlessly integrate on-line content with PDF articles.

Availability:http://getutopia.com

Contact:teresa.k.attwood@manchester.ac.uk

Skill competency development strategies by a contractor

Construction skill is one of the vital aspects of construction work which is growing in importance due to skill gaps and skill shortages during different economic cycles. The aim of this study was to investigate competence development strategies by a traditional construction company within its own pool of skill resources and among its supply chain members. The study was carried out via literature review, empirical studies involving a focus study, analysis of documentary evidence supported by unstructured interviews and a report of skill development/supply chain conference. The study demonstrates how long-term skill development can be achieved through: (a) strategic capacity planning which allows high retention, continuous training, and balanced construction demand and contractor’s supply capacity over the long term; (b) updating and upgrading the knowledge base of the supply chain through conferences and training schemes; (c) strategic investment in the workforce through training, vocational and higher degrees; and (d) acquaintance with different sources of finance. This study will assist small traditional firms in building competencies in skill development and improvement. It will assist an international audience who may face similar issue with their construction firms.

The reproducibility of transcranial Doppler middle cerebral artery velocity measurements: Implications for clinical practice

Use of transcranial Doppler (TCD) to diagnose vasospasm has been criticised. We examined reproducibility of TCD middle cerebral artery (MCA) velocity measurements. Thirty-six healthy adult volunteers were recruited. Four operators, two experienced and two inexperienced, participated. MCA velocity was measured twice by one operator and once by a second operator. Mean (95% limits of agreement) interoperator agreement was 2.4(+/-36.7) cm/s. Experienced vs. inexperienced, inexperienced vs. inexperienced, and experienced vs. experienced operators were -2.8(+/-39.3), -5.6(+/-40.1), 1.8(+/-22.1) cm/s, respectively. Intraoperator agreement across all operators, experienced and inexperienced were -0.5(+/-16.9), -1.6(+/-19.3), 0.7(+/-13.7) cm/s, respectively. Interoperator limits of agreement for experienced operators were almost half that of inexperienced operators. Intraoperator reproducibility was much better, regardless of level of experience, but aberrant results did occur even with experienced operators. If TCD measurements are used to guide management it is essential that operators are adequately trained, and readings repeated before potentially harmful treatments are instituted.

An active registry for bioinformatics web services

Summary: The EMBRACE Registry is a web portal that collects and monitors web services according to test scripts provided by the their administrators. Users are able to search for, rank and annotate services, enabling them to select the most appropriate working service for inclusion in their bioinformatics analysis tasks.

Availability and implementation: Web site implemented with PHP, Python, MySQL and Apache, with all major browsers supported. (www.embraceregistry.net)

Contact:steve.pettifer@manchester.ac.uk

Metastatic breast carcinoma discovered in a dentigerous cyst — a case report

This paper reports a patient with a history of breast cancer, who presented with altered sensation to the right lower lip and chin. An orthopantomogram showed a probable dentigerous cyst associated with an unerupted lower wisdom tooth, which was closely related to the inferior dental canal. The tooth and cyst were enucleated under general anaesthesia. The subsequent histopathology report concluded that the cyst contained metastatic adenocarcinoma from a primary breast tumour.

Antimicrobial susceptibility and genetic relatedness of Salmonella serovars isolated from animal-derived dog treats in the USA

OBJECTIVES

The objectives of this study were to determine the potential risk of dog treats in transmitting Salmonella to humans in the USA, and to characterize genetic relatedness and antimicrobial resistance among the isolates.

METHODS

A total of 158 dog treats derived from pig ears and other animal parts were randomly collected nationwide and assayed for the presence of Salmonella. The Salmonella isolates were characterized using serotyping, pulsed-field gel electrophoresis (PFGE) and antimicrobial susceptibility testing.

RESULTS

Forty-one percent (65/158) of samples were positive for Salmonella. Eighty-four Salmonella isolates, comprising 24 serotypes, were recovered from the 65 positive samples. Fourteen samples were contaminated with more than one Salmonella serotype. PFGE analysis of 78 Salmonella isolates yielded 64 patterns. S. Infantis with PFGE patterns indistinguishable from those of strains identified in Canadian outbreaks in 1999 were recovered in several dog treat products. The majority of Salmonella isolates were susceptible to the antimicrobials tested; however, resistance was observed to tetracycline (26%), streptomycin (23%), sulfamethoxazole (19%), chloramphenicol (8%) and ampicillin (8%). Twenty-eight (36%) Salmonella isolates were resistant to at least one antimicrobial and 10 (13%) isolates displayed resistance to four or more antimicrobials. Two isolates were identified as S. Typhimurium DT104 with the characteristic penta-resistance phenotype (ampicillin, chloramphenicol, streptomycin, sulfamethoxazole and tetracycline). One S. Brandenburg isolate was resistant to eight antimicrobials. Seven Salmonella isolates also contained class I integrons encoding resistance genes to aminoglycosides, beta-lactam and streptothricin antimicrobials.

CONCLUSIONS

The study indicates that animal-derived dog treats in the USA could be a potential source of animal and human infections with Salmonella, including multidrug-resistant Salmonella strains.

A multivariate analysis of the revised Conners' Teacher Rating Scale with low-income, urban preschool children

The present investigation addressed the utility of the revised Conners' Teachers Rating Scale (CTRS-28) with low-income urban preschool children. CTRS-28 ratings for a large sample of preschool children from an urban Head Start program were analyzed using exploratory factor analysis. Analyses yielded a 3-factor structure: Conduct problems, Hyperactivity, and Passivity. Further analyses cross-validated this structure for males and females and supported its integrity. Multimethod, multisource validity analyses substantiated the CTRS-28 dimensions. The Play Disruption factor of the parent and teacher Penn Interactive Peer Play Scales (PIPPS) provided convergent validity for the Conduct and Hyperactivity factors of the CTRS-28, whereas the Play Interaction factor revealed divergent validity. The Play Disconnection factor of the PIPPS validated the CTRS-28 Passivity factor. The Q-Sort Emotional Regulation scale provided divergent validity for the Conduct and Hyperactivity factors and likewise the Q-Sort Autonomy scale provided divergent validity for the Passivity factor. Age and sex differences were assessed across the 3 factors of the derived preschool structure. A main effect was found for sex and age indicating that boys displayed higher levels of Hyperactivity and Passivity problems than girls did. Similarly, 4-year-old children demonstrated higher levels of Passivity problems than did 5-year-old children.

Epithelioid hemangioendothelioma of the parotid salivary gland

Epithelioid hemangioendothelioma is a borderline neoplasm characterized by proliferation of endothelial cells with epithelioid morphology. The tumor, in terms of histology and behavior, occupies an intermediate position between hemangioma and conventional angiosarcoma. It is encountered in a wide variety of sites, such as soft tissues and skin, visceral organs, and bone. This article describes a slowly growing, painful tumor that developed in the parotid gland of a 48-year-old white woman and was treated with a superficial parotidectomy. Microscopically, the lesion consisted of short strands, cords, or small clusters of epithelioid vacuolated cells that exhibited strong immunoreactivity for endothelial cell markers (CD 31, CD 34, and factor VIII-related antigen). Previous reports have presented epithelioid hemangioendotheliomas in the head and neck region but, to our knowledge, this is the first reported case in the parotid salivary gland.

Genetic analysis of the influence of pertussis toxin on experimental allergic encephalomyelitis susceptibility: an environmental agent can override genetic checkpoints

Pertussis toxin (PTX) is a potent ancillary adjuvant used to elicit several different autoimmune diseases, including experimental allergic encephalomyelitis (EAE). To delineate the genetics of PTX effect in EAE, we mapped EAE-modifying (eae-m) loci in cohorts of backcross mice immunized with and without PTX. In this study, we analyzed the genetic basis of EAE susceptibility and severity and the intermediate phenotypes of mononuclear cell infiltration, suppuration, and demyelination. In animals immunized with PTX, one major locus, eae9, controls disease susceptibility and severity. Eae9 also regulates the extent of mononuclear cell infiltration of the spinal cord in male mice. Without PTX, five eae-m loci were noted, including three new loci in intervals on chromosomes 8 (eae14), 10 (eae17), and 18 (eae18). Taken together, these results suggest that eae9 controls the effects of PTX in EAE susceptibility, and is capable of overriding the other genetic checkpoints in the pathogenesis of this disease.

Pharmaceutically-based severity stratification of an asthmatic population

Algorithms designed to precisely identify disease severity for a given patient within a managed care population are helpful in organizing targeted interventions. These algorithms are also attracting considerable attention within the medical research community. Several health risk screening instruments have been developed; however, these involve survey methodologies and have several shortcomings. We present a valid and efficient method for predicting healthcare resource utilization among asthmatics in an Health Maintenance Organization (HMO) population. First, various diagnosis, procedure and pharmacy billing codes were used to identify the asthmatics within the database. The screening algorithm awards points each time one of these codes is identified for an HMO member. By varying the number of points necessary to consider a patient asthmatic, the sensitivity, specificity, positive and negative predictive values of the algorithm can be adjusted. Once identified as asthmatic, subjects were then stratified into severity levels based on pharmacy data. Severity stratification was validated directly by measuring asthma-related bed days utilized during the 12 months following the date of stratification. Our identification algorithm estimated an asthma prevalence of 3.84% within the studied population, with age-specific prevalence estimates that closely mirrored previously published survey data. There was a monotonic relationship between pharmacy severity levels and inpatient resource utilization. For example, asthmatics in severity level 1 used only 92 hospital days per 1000 asthmatics in the year following characterization, while those in levels 2-5 used 133, 156, 277 and 1168 hospital days (P < 0.001), respectively. Results from this model can be used as adjusters in other predictive models or stand alone to represent a patient's severity of illness.

Effect of ED management on ICU use in acute pulmonary edema

Acute pulmonary edema (APE) is a common Emergency Department (ED) presentation requiring admission to an intensive care unit (ICU). This study was undertaken to examine the effect of ED management on the need for ICU admission in patients with APE. ED records of APE patients were abstracted for patient age, prehospital and ED pharmacological treatment, diagnoses, airway interventions, and ICU length of stay (LOS). Statistical analysis was through multiple regression, logistic regression, chi-square, and ANOVA. One hundred eighty-one patients composed the study group. Pharmacological treatment included nitroglycerin (NTG), 147 patients (81%); morphine sulfate (MS), 88 (49%); loop diuretics (LD), 133 (73%); and captopril sublingual (CSL), 47 (26%). Use of CSL and MS were associated with opposing needs for ICU admission. MS use was associated with increased ICU admissions (odds ratio, 3.08; P = .002), whereas CSL use was associated with decreased ICU admissions (odds ratio, 0.29; P = .002). Morphine sulfate use also demonstrated an increased need for endotracheal intubation (ETI) (odds ratio, 5.04; P = .001), whereas CSL demonstrated a decreased need for ETI (odds ratio, 0.16; P = .008). Ninety-three patients required some form of respiratory support. Forty received noninvasive pressure support ventilation (NPSV) from a bilevel positive airway pressure system (BiPAP), and 60 received endotracheal intubation. Some patients received more than 1 form of respiratory support; all other patients received supplemental oxygen only. The ICU-LOS associated with different airway interventions were supplemental oxygen, 0.72 days; BiPAP, 1.48 days; and ETI, 3.70 days (P < .001). Specific ED pharmacological interventions are associated with a decreased need for ICU admission and endotracheal intubation in acute pulmonary edema patients, whereas use of noninvasive pressure support ventilation correlates with a reduction in the ICU length of stay for patients who do require critical care admission.

Protective effect of encapsulated cells producing neurotrophic factor CNTF in a monkey model of Huntington's disease

Huntington's disease is a genetic disorder that results from degeneration of striatal neurons, particularly those containing GABA (gamma-aminobutyric acid). There is no effective treatment for preventing or slowing this neuronal degeneration. Ciliary neurotrophic factor (CNTF) is a trophic factor for striatal neurons and therefore a potential therapeutic agent for Huntington's disease. Here we evaluate CNTF as a neuroprotective agent in a nonhuman primate model of Huntington's disease. We gave cynomolgus monkeys intrastriatal implants of polymer-encapsulated baby hamster kidney fibroblasts that had been genetically modified to secrete human CNTF. One week later, monkeys received unilateral injections of quinolinic acid into the previously implanted striatum to reproduce the neuropathology seen in Huntington's disease. Human CNTF was found to exert a neuroprotective effect on several populations of striatal cells, including GABAergic, cholinergic and diaphorase-positive neurons which were all destined to die following administration of quinolinic acid. Human CNTF also prevented the retrograde atrophy of layer V neurons in motor cortex and exerted a significant protective effect on the GABAergic innervation of the two important target fields of the striatal output neurons (the globus pallidus and pars reticulata of the substantia nigra). Our results show that human CNTF has a trophic influence on degenerating striatal neurons as well as on critical non-striatal regions such as the cerebral cortex, supporting the idea that human CNTF may help to prevent the degeneration of vulnerable striatal populations and cortical-striatal basal ganglia circuits in Huntington's disease.

Dexamethasone therapy for isosexual precocious pseudopuberty caused by generalized glucocorticoid resistance

Generalized glucocorticoid resistance presents with clinical features secondary to excess production of mineralocorticoids and adrenal androgens. It is our hypothesis that these clinical and biochemical features will respond to glucocorticoid therapy. We tested this hypothesis in a boy with generalized glucocorticoid resistance and increased adrenal androgens. Dexamethasone was administered from age 7 6/12 yr until the onset of true puberty at 11 0/12 yr. Serum concentrations of cortisol and adrenal androgens decreased to the normal or near normal range. The accelerated precocity improved. Secondary sex characteristics did not progress; the difference between bone age and chronological age decreased from 3 1/2 yr to 2 yr, and the difference between height age and bone age decreased from 2 yr to 1/2 yr. We conclude that dexamethasone is effective and safe therapy for the sexual precocity of generalized glucocorticoid resistance.

A mutation of the glucocorticoid receptor in primary cortisol resistance

The precise molecular abnormalities that cause primary cortisol resistance have not been completely described. In a subject with primary cortisol resistance we have observed glucocorticoid receptors (hGR) with a decreased affinity for dexamethasone. We hypothesize that a mutation of the hGR glucocorticoid-binding domain is the cause of cortisol resistance. Total RNA isolated from the index subject's mononuclear leukocytes was used to produce first strand hGR cDNAs, and the entire hGR cDNA was amplified in segments and sequenced. At nucleotide 2,317 we identified a homozygous A for G point mutation that predicts an isoleucine (ATT) for valine (GTT) substitution at amino acid 729. When the wild-type hGR and hGR-Ile 729 were expressed in COS-1 cells and assayed for [3H]-Dexamethasone binding, the dissociation constants were 0.799 +/- 0.068 and 1.54 +/- 0.06 nM (mean +/- SEM) (P < 0.01), respectively. When the wild-type hGR and hGR-Ile 729 were expressed in CV-1 cells that were cotransfected with the mouse mammary tumor virus long terminal repeat fused to the chloramphenicol acetyl transferase (CAT) gene, the hGR-Ile 729 conferred a fourfold decrease in apparent potency on dexamethasone stimulation of CAT activity. The isoleucine for valine substitution at amino acid 729 impairs the function of the hGR and is the likely cause of primary cortisol resistance in this subject.

Locomotion of aged rats: relationship to neurochemical but not morphological changes in nigrostriatal dopaminergic neurons

Spontaneous locomotion and motor coordination was evaluated in young (5-6 month old) and aged (24-25 month old) rats. Animals were tested for spontaneous locomotor activity in Digiscan Animal Activity Monitors during the nocturnal cycle. Aged animals exhibited a significant hypoactivity compared to their young counterparts. Evaluation of the time course of activity revealed that the young animals had a cyclical pattern of activity during the 12-hour testing period with clear peaks at 2-4 hours after the initiation of testing and at 8- to 10-hour intervals thereafter. In contrast, the aged animals exhibited a blunted initial activity peak. During the remainder of the test period the aged animals activity was stable with no further peaks in activity. Compared to the young animals the aged animals also (a) remained suspended from a horizontal wire for less time, (b) were unable to descend a wooden pole covered with wire mesh in a coordinated manner, (c) fell more rapidly from a rotating rod and (d) were unable to maintain their balance on a series of wooden beams with either a square or rounded top of varying widths. Histological analysis demonstrated that there was no reduction in the number, area, or length of tyrosine hydroxylase-immunoreactive neurons within the A8, A9, or A10 region of the aged animals. Neurochemical analysis revealed that while DA and HVA levels were not decreased in the aged rats, DOPAC levels, as well as the ratios of DA/DOPAC and DA/HVA, were decreased. These results indicate that neurochemical but not morphological changes within the nigrostriatal dopaminergic system underlie the deficits in motor behavior observed in aged rats.

Characterization of the Fc gamma receptor on human platelets

IgG-containing immune complexes may play a role in the immune destruction of human platelets by interacting with an Fc gamma receptor on the platelet surface. We studied the platelet Fc gamma receptor and characterized its interaction with IgG ligand and anti-Fc gamma receptor monoclonal antibodies. Oligomers of IgG, but not monomeric IgG, bound to platelets and the number of binding sites was significantly increased at low ionic strength. Ligand-binding studies indicated that normal human platelets express a single Fc gamma receptor (Fc gamma RII) with 8559 +/- 852 sites per cell, Kd = 12.5 +/- 1.7 X 10(-8) M using trimeric IgG. Results of studies with bivalent and Fab monoclonal anti-Fc gamma RII were consistent with each Fc gamma receptor expressing two epitopes recognized by the antibody. The number of Fc gamma binding sites and affinity of binding were unchanged by the presence of 2.0 mM Mg2+ or 10 micrograms/ml cytochalasin B. Platelet stimulation with thrombin or ADP in the presence of fibrinogen also did not alter the number of Fc gamma binding sites or the affinity of binding. However, platelets preincubated with 5 microM dexamethasone expressed a decreased number of Fc gamma binding sites as well as decreased IgG-dependent platelet aggregation. Platelets from patients with Glanzmann's thrombasthenia and from patients with the Bernard Soulier syndrome expressed a normal number and affinity of Fc gamma binding sites. The data suggest that platelet Fc gamma RII binding of trimeric IgG occurs independent of actin filament interaction, Mg2+, ADP, or thrombin and does not require GPIIb/IIIa or GPIIb/IIIa-fibrinogen interaction. Furthermore, this receptor appears to be normally expressed on GPIb-deficient platelets and susceptible to modulation by glucocorticoids. Finally, the Fc gamma-binding protein was isolated from whole platelets as a 220-kDa protein which upon reduction dissociates into 50,000 Mr subunits.

Measurement of blood flow to the adrenal capsule, cortex and medulla in dogs after hemorrhage by fluorescent microspheres

Changes in adrenal medullary and total cortical blood flow after hemorrhage have been described using radioactive microspheres. To assess changes in adrenal capsular and in intracortical adrenal blood flow, a method was used based on microscopic detection of non-radioactive microspheres. Injection of microspheres labelled with fluorescent dyes permitted multiple determinations of blood flow. Pentobarbital anesthetized dogs (n = 6) were prepared acutely with left ventricular and aortic catheters for injection and collection of microspheres, respectively. Adrenal denervation was done unilaterally by cutting the thoracic splanchnic nerve. Injections of 16-microns spheres were made prior to and immediately after 18 ml/kg hemorrhage done over 6 min. Dogs were killed with KCl and adrenals were removed, fixed and sectioned at 80 microns. Using fluorescence microscopy, microspheres were counted in the adrenal capsule, zona glomerulosa, inner cortex (zona facsiculata and reticularis), and the medulla. The majority (95%) of microspheres in the adrenal cortex were trapped in the zona glomerulosa, precluding an independent estimate of blood flow to the inner cortex. Thus, total cortical blood flow was determined by summing the number of 16-microns microspheres in the zona glomerulosa and inner cortex. Prior to hemorrhage, blood flow was greater in the capsule (5.4 +/- 1.6 ml/min/g) compared to the cortex (1.8 +/- 0.9 ml/min/g) and the medulla (2.9 +/- 1.8 ml/min/g). Splanchnicotomy did not change blood flow in the resting state. Following hemorrhage, in innervated glands, medullary blood flow increased to 8.6 +/- 3.1 ml/min/g, whereas blood flow to other zones was unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

Monocyte Fc gamma receptor recognition of cell-bound and aggregated IgG

Monocyte and macrophage Fc gamma receptors are important components in the recognition of IgG-coated cells and IgG-containing immune complexes. Two proteins have been identified on human peripheral blood monocytes that can function as Fc gamma receptors, Fc gamma RI (70 Kd) and Fc gamma RII (40 Kd). We studied the role of Fc gamma RI and Fc gamma RII on human monocytes by examining their binding of IgG-sensitized cells (human IgG anti-D-coated RBCs and rabbit IgG-sensitized sheep RBCs) and their binding of human trimeric IgG. To examine the function of monocyte Fc gamma RII, we used an anti-Fc gamma RII monoclonal antibody (MoAb) that competes for the Fc gamma RII ligand binding site. Preincubation of monocytes with saturating concentrations of anti-Fc gamma RII MoAb did not alter the recognition of IgG (anti-D)-sensitized human RBCs by monocytes. Furthermore, ligand-binding studies demonstrated that anti-Fc gamma RII antibody altered neither the number nor the affinity of monocyte-binding sites for human IgG trimer. Anti-Fc gamma RII inhibited monocyte binding of rabbit IgG-sensitized sheep RBCs, but only at low ionic strength or temperature when increased numbers of monocyte Fc gamma RII were expressed. At low ionic strength and 4 degrees C, anti-Fc gamma RII also partially inhibited monocyte binding of human trimeric IgG. Thus, monocyte Fc gamma RII does not appear to recognize IgG-sensitized RBCs or trimeric IgG at physiologic temperatures and ionic strength. The data suggest that Fc gamma RI is the primary Fc gamma receptor on monocytes involved in the binding of IgG (anti-D)-sensitized erythrocytes and low mol wt complexes of IgG.

Regulation of cardiac myosin synthesis: studies of RNA content in cultured heart cells

Contraction regulates the myosin content and the rate of myosin synthesis in cultured neonatal rat heart cells. To further explore the mechanism for this regulation we examined various parameters of RNA content and RNA synthesis in contacting versus noncontracting myocytes. While contraction stimulated myosin heavy chain (MHC) synthesis by 72% compared to that of KCl-arrested cells, simultaneous analyses of polysome profiles were no different under the two culture conditions. Incorporation of [3H]uridine monophosphate into cellular RNA revealed no change in the rate of total RNA or ribosomal subunits synthesis. In vitro translation of cellular RNA yielded similar incorporation of [35S]methionine into trichloroacetic acid precipitable protein. Specific transcription of the MHC gene was examined by dot-blot analysis and was unaltered by contraction. Northern blot analysis of the MHC sequences detected by a cDNA probe revealed an mRNA sequence corresponding to a molecular weight of approximately 30 S. These data suggest that RNA synthesis and RNA content are unaltered by contraction in cultured heart cells and therefore the changes in myosin synthesis may be mediated at a post-transcriptional control level.

Contraction regulates myosin synthesis and myosin content of cultured heart cells

Cultured neonatal rat heart cells are a useful model for studying the regulation of myocyte growth. The myosin content of heart cells increases between days 1 and 4 in culture. To determine if contraction per se can regulate myocyte growth, myosin content and protein synthesis were compared in spontaneously contracting and noncontracting cultured heart cells. Myosin content, assayed as the total myosin ATPase activity per culture dish, was significantly increased in contracting cells after 3, 4, and 5 days in culture. Protein synthesis was measured by incorporation of [14C]lysine into total cell protein and into sodium dodecyl sulfate-polyacrylamide gel electrophoresis resolved myosin. Contraction stimulated both total cell protein content and protein synthesis by day 3 in culture. Compared with heart cells arrested with 50 mM KCl, myosin synthesis was significantly increased by 96, 112, and 46% at days 2, 3, and 4, respectively. Similar results were observed when myosin content and protein synthesis in contracting myocytes were compared with cells arrested with either 25 mM KCl or 10(-5) M verapamil. The present studies suggest that contraction increases the myosin content in cultured heart cells and that this increase is mediated via a stimulation of myosin synthesis in association with cell growth.

Measurement of myosin adenosinetriphosphatase and myosin content in cultured heart cells

An assay specific for myosin ATPase in whole-cell extracts of cultured heart cells has been developed. Myosin ATPase is measured by the production of Pi from ATP in the presence of high ionic strength (0.5 M KCl) at pH 9.1. Enzyme activity is maximal with 10 mM CaCl2 and completely inhibited with 5 mM MgCl2. Spontaneously beating myocytes grown in the presence of 10% newborn calf serum and 0.1 mM 5-bromo-2'-deoxyuridine show a significant rise in myosin ATPase between Days 1 and 4 in culture. The measurement of myosin ATPase allows for the quantitation of cellular myosin content, and can be used to assess changes in myosin content that occur during growth, development, and cellular repair.

The use of allograft bone in revision of total hip arthroplasty

Fifty-two frozen bone allografts have been used on 44 patients undergoing revision hip arthroplasties. The average follow-up time on these patients has been 17 months, with a range of six to 72 months. Both proximal femoral allografts and the allografts for the reconstruction of acetabular deficiencies have been used. To date, most patients experience marked pain relief and improvement in function. Though the results attained to date are short-term, the use of allografts in the revision hip arthroplasties represents a natural progression of the tumor work. However, while the early results are encouraging, it remains to be seen how the proximal femur allografts and the large acetabular allografts will behave over a long period of time.

Human monocyte recognition of complement-coated lymphoblastoid cells

The macrophage system in man plays a significant role in the detection of foreign cells. The mechanisms by which macrophages recognize malignant cells, however, are not well understood. We used human monocytes and four lymphoblastoid cell (LC) lines derived from human acute lymphocytic leukemia to investigate the initial recognition of tumor cells by monocytes. IgM antibody mediated the binding of these cells to monocytes only in the presence of complement. The stepwise addition of complement components to IgM-coated LC indicated that C3 was necessary to monocyte binding. Similarly, monocyte recognition of IgM-coated LC was maximal in the presence of sera from patients with congenital C5 or C6 deficiency, but absent in the presence of sera deficient C4 or from a patient with congenital C2 deficiency. Complement activation was associated with C3 consumption and the deposition of substantial amounts of C3 on to LC. Although 3H-C3 bound to LC appeared stable for 2 hours, approximately 4.0 +/- 2 X 10(5) 3H-C3 per LC was necessary for monocyte recognition, compared to approximately 2.7 +/- 0.5 X 10(3) 3H-C3 per RBC. The data indicate that LC can be recognized by monocytes through complement by mechanisms similar to nonmalignant target cells. However, substantial amounts of C3 are necessary to induce monocyte recognition of IgM-coated LC and, thus, such complement mediated recognition may be inefficient.

Double-contrast examination of the oesophagus: the radiological changes of peptic oesophagitis

A simple method for obtaining double-contrast views of the oesophagus as part of the routine double contrast examination of the upper gastrointestinal tract using high-density low-viscosity barium is described. The typical radiological changes of early peptic oesophagitis (confirmed by endoscopy) which can be readily demonstrated with this technique are illustrated as an example of its practical value. These consist of 'smudged' or 'cobble-stone' mucosa with thickened and distorted longitudinal folds. Superficial erosions and deep ulcers may also be seen. It is suggested that endoscopic confirmation of these characteristic radiological signs of peptic oesophagitis is unnecessary.

Intravenous cholangiography by bolus injection of meglumine iotroxamate and meglumine iodoxamate: a comparative trial of two new contrast media

The meglumine salts of iodoxamic and iotroxamic acids are recently developed intravenous cholangiographic media. In several studies these two media have been shown to be significantly better than meglumine iodipamide and meglumine ioglycamate for opacification of the biliary tree and incidence of adverse effects. As part of a multi-centre double-blind trial 100 patients were given iodoxamate or iotroxamate. Comparisons of opacification, side effects and renal excretion of contrast were made. The results showed no statistically significant difference in biliary tree opacification; more frequent renal excretion of contrast with iodoxamate; and contrary to previous reports a slightly higher incidence of side effects with iotroxamate.

Effect of corticosteroids on the human monocyte IgG and complement receptors

A quantitative in vitro assay was employed to directly assess the effect of corticosteroids on the IgG and complement receptor function of human mononuclear phagocytic cells. In this system corticosteroids were solubilized with cholesterol-phospholipid sonicated dispersions before exposure to mononuclear cells. Solubilized corticosteroids at concentrations between 10(-4) and 10(-3) M inhibited both IgG and complement receptor activity in a dose-response fashion. Inhibition was dependent upon the time of interaction of the mononuclear cells with corticosteroids and was half-maximal by 15 min. The inhibitory effect at all concentrations of hydrocortisone was partially overcome by increasing the number of IgG molecules per erythrocyte. Hydrocortisone also inhibited the binding of erythrocytes coated with both IgG and C3, despite the fact that when both were on the erythrocyte surface a synergistic effect on binding to mononuclear cells was observed. At the steroid concentrations employed, the capacity of mononuclear cells to exclude trypan blue and to take up latex particles and neutral red was unaffected. Mineralocorticoids also inhibited receptor activity, but the sex hormones were less effective. These studies demonstrate an effect of steroid hormones on cell membrane receptor function, and they suggest that an inhibition of the recognition system for IgG and C3 in vivo may explain, in part, the effect of corticosteroids in man.

A Mössbauer study of ferri- and ferrocytochrome c

The Mössbauer spectra of horse heart ferri- and ferrocytochrome c were obtained at room temperature using lyophilized powders. The Mössbauer data indicate that the iron in both lyophilized samples is in a low-spin state. The high quadrupole splittings suggest that the iron atom is in an asymmetric ligand field. Upon reduction the asymmetry increases, suggesting a change in the bonding between the protein moieties and the iron atom.