Search

In this article we address the relevance of rare diseases and their peculiarities with respect to pain therapy. Towards this end, four rare diseases (hemophilia, Morbus Fabry, dermatomyositis, and facioscapulohumeral dystrophy (FSHD)) will be presented and fundamental aspects of their pain therapies described. The diseases were chosen to showcase a pain therapy based on the WHO-step-by-step plan (hemophilia), a complex but established pain therapy (M. Fabry), and two less well established, individually adapted pain therapies (dermatomyositis, FSHD).

Basic physics places limits on the mechanics involved in shaking a baby. Fundamental definitions and practical limitations are used to compare shaking with car crashes and low-level falls. First-order mathematical considerations applied to a 6-month-old infant determine an angular velocity limit for head rotation around 75 rad/s and maximum angular acceleration less than 1600 rad/s2 without impact. By comparison, results from a low-level fall of 0.76 m (30 inches) yield values of 83 rad/s and 13,000 rad/s2 in a practical worst-case scenario.

The study explores the possibility of efficiently codelivering DNA vaccines and protein-based vaccines by formulation with aluminum phosphate (AlPO4). When mixed with aluminum adjuvants, plasmid DNA bound tightly onto aluminum hydroxide [Al(OH)3] but not to AlPO4. Different doses of DNA vaccines formulated with AlPO4 [but not Al(OH)3] induced enhanced humoral responses and supported priming of MHC class I restricted cellular immunity. Different proteins mixed with the plasmid DNA vaccine in the AlPO4 formulation did not impair its immunogenicity. Coinjection of two different vaccine-relevant antigens in the same AlPO4 formulation, one as a DNA vaccine and the other as a recombinant protein, elicited polyvalent, humoral, and cellular immune responses to all antigens delivered. The isotype profiles of the induced humoral responses and the cytokine profiles of the specifically primed T cell responses indicated that the combined vaccines supported copriming of Th1- and Th2-biased as well as balanced responses. These findings indicate that the AlPO4 adjuvant, a widely accepted adjuvant in human vaccination practice, can be used to combine protein- and DNA-based vaccination to prime an enhanced and balanced specific immunity.

The small surface antigen of the hepatitis B virus (HB5Ag) was cloned into expression plasmid pCI under either a viral (CMV) promoter;enhancer sequence control (plasmid pCI/S), or a human desmin promoter/enhancer sequence control (plasmid pDes/S). Cells of different species and tissue origin transiently transfected in vitro with pCI/S or pDes/S plasmid DNA expressed readily detectable amounts of HBsAg, either intracellularly (precipitated from cell lysates), or as secreted products (detectable in ELISA). When these plasmids were used in DNA vaccination, both efficiently primed humoral and/or cellular immune responses to HBsAg after a single injection in Balb/c mice. Intramuscular injection of a high dose of DNA (100 rig/mouse) of both plasmids primed MHC-I-restricted cytotoxic T lymphocyte (CTL) responses and Thi serum antibody responses (IgGlIgG2a ratio O.4C0.7) of comparable magnitude in all vaccinated mice. Intradermal injection of low doses of (particle-coated) DNA (1 microgm/mouse) of both plasmids with the gene gun primed Th2 serum antibody responses (IgGl/IgG2a ratio > 100) but no CTL responses. The data indicate that antigens can be efficiently expressed under viral or eukaryotic promoter/enhancer control for immunogenic in vivo presentation, but that the technique, dose and/or route of DNA injection have a decisive role in determining the type of immune response elicited.

Vaccination with either exogenous hepatitis B surface antigen (HBsAg) lipoprotein particles without adjuvants, or plasmid DNA encoding secreted small HBsAg stimulate long-lasting, potent antibody responses in H-2d(BALB/c) and C57Bl/6 (H-2b) mice. Vaccination with exogenous HBsAg primes MHC-I restricted cytotoxic T lymphocyte (CTL) responses to HBsAg in H-2dbut not H-2bmice, while DNA vaccination primes HBsAg-specific CTL responses in both mouse strains. We defined vaccination strategies that could elicit CTL responses to exogenous HBsAg in ‘low responder’ C57Bl/6 mice. We found that the bacterial plasmid DNA itself, synthetic oligodeoxynucleotides containing immunostimulating sequences, or recombinant Th1 cytokines (IL12, IFNγ) efficiently support priming of CTL responses to exogenous HBsAg in ‘low responder’ H-2bmice, but have only minor effects on CTL priming in ‘high responder’ H-2dmice in the high dose range tested. These molecularly well defined adjuvants can thus efficiently support priming of anti-viral T cell responses under ‘low responder’ conditions.

A humanized murine monoclonal antibody directed to the Fc epsilonR1-binding domain of human IgE (rhuMAb-E25) has been shown to inhibit the binding of IgE to mast cells without provoking mast cell activation. To examine the effects of neutralizing IgE on allergic airway responses, we assessed the effects of 9 wk of treatment with rhuMAb-E25 in a parallel group, randomized, double-blind, placebo-controlled study of 19 allergic asthmatic subjects. We found that treatment with rhuMAb-E25 reduced serum IgE, increased the dose of allergen needed to provoke an early asthmatic response, reduced the mean maximal fall in FEV1 during the early response (30 +/- 10% at baseline to 18.8 +/- 8%, versus 33 +/- 8% at baseline to 34 +/- 4% after placebo; p = 0.01), and reduced the mean maximal fall in FEV1 during the late response (24 +/- 20% at baseline to 9 +/- 10% versus 20 +/- 17% at baseline to 18 +/- 17% after placebo; p = 0.047). We conclude that an anti-IgE monoclonal antibody, which inhibits binding of IgE to its receptor, suppresses the early- and late-phase responses to inhaled allergen in allergic asthmatic subjects. Targeting IgE with rhuMAb-E25 might be a useful treatment for allergic asthma.

Aim of this study was to retrospectively compare the image quality and the radiation dose of an ultra high pitch CT scan for the evaluation of pulmonary embolism and visualization of cardiac structures in comparison to our institution's standard pulmonary embolism protocol.The study cohort consisted of 115 consecutive patients, 57 underwent CT pulmonary angiography on a dual source 128 slice scanner (Siemens Somatom Definition FLASH) via an ultra high pitch mode (Pitch 2.8) while 58 were scanned on a dual source 64 slice scanner (Siemens Somatom Definition Dual Source) with standard pitch (Pitch 0.9). Qualitative image assessment was determined by two blinded radiologists with 3 and 15 years' experience in chest and cardiac CT. Quantitative image assessment was determined by the signal to noise ratio (SNR) and contrast to noise ratio (CNR). Effective radiation dose was calculated via the product of the dose length product.For the ultra high pitch protocol, 14% (8/57) were positive for pulmonary embolus compared to 13.7% (8/58) for the standard pitch group. 98.2% of the ultra high pitch scans were diagnostic for pulmonary embolus vs. 94.8% of the standard protocol. Visualization of cardiac structures was significantly improved with the ultra high pitch protocol (p0.0001). Significantly more lung parenchymal motion was observed on the standard protocol (p0.0001). The mean pulmonary vessel attenuation, SNR, and CNR were not significantly different. The mean effective dose was lower for the ultra high pitch studies (4.09mSv±0.78 vs. 7.72mSv±2.60, p0.0001).Ultra high pitch CT imaging for pulmonary embolus is a technique which has potential to assess motion free evaluation of most cardiac structures and proximal coronary arteries at lower radiation doses.

The efficiency of different vaccination techniques to prime in vivo major histocompatibility complex class I-restricted murine cytotoxic T-lymphocyte (CTL) precursors to hepatitis B virus small surface antigen (HBsAg) was investigated. Mice were immunized either by injection of a low dose of recombinant HBsAg protein preparations (native HBsAg particles or denatured HBsAg monomers) without adjuvants, by infection with recombinant vaccinia virus carrying an HBsAg-encoding gene, or by intramuscular transfer of plasmid DNA encoding HBsAg under appropriate promoter control. In H-2d mice, an Ld-restricted, S28-39-specific CTL response was efficiently primed by all alternative vaccination techniques tested, but the most potent priming of class I-restricted CTL to HBsAg in vivo was observed with DNA immunization. Priming of anti-HBsAg CTL in H-2b mice was not detectable after infection with a recombinant vaccinia virus or after injection with exogenous recombinant HBsAg preparations. After DNA immunization, however, both Kb- and Db-restricted CTL reactivity to HBsAg emerged in H-2b mice. Hence, nucleic acid immunization revealed class I-restricted CTL responsiveness to HBsAg in a mouse strain previously considered to be a nonresponder at the CTL level. These results demonstrate that the simple technique of nucleic acid immunization not only is extremely efficient but also reveals an extended spectrum of potentially immunogenic epitopes of protein antigens.

Micronutrients play an important role in function and health maintenance for the eye. Especially lutein, zeaxanthin and omega-3 fatty acids perform remarkable functions: lutein together with zeaxanthin forms the macular pigment, these carotenoids filter out the damaging blue light component from the sunlight as well as the ultraviolet light which leads to improved contrast sensitivity and less problems with screen glare. Furthermore, the macular pigment has antioxidant and anti-inflammatory effects. The omega-3 fatty acids also possess anti-inflammatory effects and, when converted into neuroprotectin, they protect against oxidative induced apoptosis in the retina. They are also responsible for the fluidity and supply to the photoreceptor membrane. These properties are important for the prevention and treatment of degenerative eye diseases like age-related macular degeneration. However, older people are often not sufficiently supplied of micronutrients in their diet. Because the supply of nutrients can hardly be achieved by dietary change, the additional intake in the form of food supplements is useful in this age group. Scientific studies have shown the positive effects of supplementation with micronutrients such as lutein/zeaxanthin, vitamin C, vitamin E, zinc and omega-3 fatty acids, docosahexaenoic acid and eicosapentaenoic acid (DHA and EPA). Currently available nutritional products are based in part on the ingredients of the ARED study (Age Related Eye Disease Study). According to more recent studies formulations containing lutein and omega-3 fatty acids in physiologically meaningful doses without additional beta-carotene should be preferred. 10 to 20 mg of lutein and zeaxanthin represent a safe daily dose Regarding to the context above, beta-carotene in high doses plays a minor role to the eye and is especially critical for the health of smokers. This paper summarises the functions of the presented micronutrients in the eye and can assist ophthalmologists in advising their patients.

SUMMARY We have investigated the effect of a bolus injection of atracurium 0.6mg kg−1 on the cardiovascular system in 16 patients undergoing aortocoronary bypass surgery. H1- and H2-receptor antagonists were administered to eight patients before the neuromuscular blocker. A standard anaesthetic was used comprising fentanyl, flunitrazepam, etomidate and enflurane. After administration of atracurium, haemodynamic changes and plasma histamine concentrations were measured at frequent intervals. In the first group, who received only atracurium, a brief but marked decrease in SVR and MAP occurred, accompanied by an increase in Cl, together with a marked increase in plasma concentration of histamine. In the second group, who received H1 and H2-receptor block, there was no decrease in MAP and only a small increase in plasma histamine concentration. However, there were significant changes in SVR and Cl similar to those in the atracurium group.

The 38-year-old index patient was examined by visual acuity testing, perimetry, dark adaptometry, funduscopy, electroretinogram (ERG), and multifocal ERG. She was screened for mutations in exons 2-5 and exon/intron boundaries of the 11- cis retinol dehydrogenase gene by direct sequencing.Visual acuity was 1.0, but perimetry revealed paracentral scotomas associated with reading problems. The optic discs were normal. After 45 min of darkness there was nearly no increase of light sensitivity. After 30 min of dark adaptation, the scotopic ERG showed reduced amplitudes, but after 60 min a nearly normal level was reached. The 30-Hz flicker response of the cone ERG showed borderline implicit times, but no reduction of amplitudes. However, multifocal ERG clearly disclosed a paracentral amplitude reduction as the reason for the visual field defects. The fundus was typical for fundus albipunctatus. The patient is a compound heterozygote carrying a Ile33Asn and a Arg157Trp mutation.The paracentral visual field defects were due to cone dysfunction. So far the patient exhibits no cone dystrophy.

A 67-year-old man presented with a 6-week history of slowly progressive muscle pain and generalized muscular weakness. Neurological examination showed symmetrical proximal weakness (MRC grade 4/5).Laboratory tests revealed an elevated CK level of 124 U/l (normal80). Needle EMG showed pathological spontaneous activity in proximal muscle groups. A diagnostic muscle biopsy taken from the left deltoid muscle revealed a characteristic infiltrate of PAS-positive and acid phosphatase-positive macrophages. Electron microscopic analysis of muscle tissue failed to demonstrate aluminium hydroxide inclusion. Serological analysis excluded antibodies against HAV and HBV but was compatible with a previous tetanus vaccination (antibody titre of 2.3 IE/ml).A 2-year treatment with steroids and azathioprine led to complete recovery of muscle strength without relapse after discontinuing the immunosuppression.Macrophagic myofasciitis (MMF) is a rare inflammatory muscle disorder characterized by a characteristic infiltration of muscle tissue by PAS-positive macrophages, which is caused by pathological persistence of vaccine-derived aluminium hydroxide. The diagnosis can only be established by an open muscle biopsy from the muscle that was used for intramuscular vaccination.

Mutations of the human telethonin gene have recently been shown to cause limb girdle muscular dystrophy type 2G in three Brazilian families. The mRNA has been shown to be dynamically regulated in animals, however, the fate of the protein in human muscle is unknown. In order to assess the expression of telethonin in more frequently encountered myopathological conditions we generated and characterized a rabbit antiserum raised against the C-terminal end of telethonin by immunoblotting and immunogold EM. Indirect immunofluorescence analysis of a wide variety of neuromuscular disorders including dystrophinopathies, metabolic myopathies, denervation disorders, congenital and inflammatory myopathies revealed that the characteristic Z-band staining of telethonin was preserved in all disease entities included in our study. However, a reduced telethonin immunoreactivity was observed in up to 10% of type II fibers in 10 cases of neurogenic atrophy. A decreased telethonin staining was more frequently observed in early stages of fiber atrophy than in type II fibers displaying normal or highly atrophic fiber diameters. Hence, not only the telethonin transcript is rapidly downregulated in denervated muscle but the protein itself undergoes dynamic changes while its known sarcomeric binding partner titin remains unaltered. Beyond its role as a static component of Z-bands, these findings indicate that telethonin protein levels seems to be at least in part regulated by neuronal activity and is thus linked to the dynamic control of myofibrillogenesis and muscle turnover in human skeletal muscle.

Humoral and cellular immune responses to protein antigens can be efficiently primed by nucleic acid or DNA vaccination. In DNA-based vaccination, immunogenic proteins are expressed with correct posttranslational modification, conformation or oligomerization; this ensures the integrity of epitopes that stimulate neutralizing antibody (B cell) responses. DNA (or RNA) immunization is exceptionally potent in stimulating T cell responses because antigenic peptides are efficiently generated in (endogenous or exogenous) processing pathways (without interference by viral proteins) from intracellular or extracellular protein antigens expressed after transient in vivo transfection. Both features are difficult to achieve with recombinant subunit vaccines produced in eukaryotic or prokaryotic expression systems. The current state of vector designs, strategies for delivery of DNA vaccines, priming humoral and cellular immune responses by DNA vaccines, experimental strategies facilitated by DNA vaccines, unique advantages of DNA vaccination, experience of DNA vaccination in preclinical animal models and clinical trials, and potential risks of DNA vaccination are discussed. Excellent reviews on DNA-based vaccination have been published recently [1-3].

We describe a 52-year-old woman who presented with severe diarrhea, nausea, intermittent abdominal pain and weight loss of 18 kg within ten months. Jejunal and duodenal ulcers were detected by endoscopy and multiple biopsies revealed villous atrophy of the jejunum. However, neither gliadin nor endomysium antibodies were detected and no clinical and histological improvement was achieved after gluten withdrawal. Despite strong clinical suspicion for intestinal lymphoma many unrevealing biopsies were done. The patient developed intermittent septic fever and diagnostic laparotomy revealed jejunal perforation. Partial jejunal resection was performed and histology confirmed the diagnosis of an intestinal T-cell lymphoma without celiac disease. Malabsorption and all intestinal ulcers disappeared during the course of chemotherapy (six cycles CHOP) and the patient recovered remarkably.

CD4+ TCRalphabeta+ T cells from the colonic lamina propria of athymic (nude) mice were adoptively transferred into histocompatible (SCID) mice homozygous for the autosomal recessive mutation scid (severe combined immunodeficiency). Transfer of these extrathymic CD4+ T cells into SCID mice induced a pancolitis in the adoptive host. The histopathology of this inflammatory response was restricted to the colon and closely resembled human UC. CD4+ T cells infiltrating the colonic lamina propria of diseased SCID mice displayed the surface phenotype of mucosa-seeking memory/effector cells, expressed interferon-gamma (IFN-gamma), and lysed targets in a Fas (CD95)/FasL-dependent pathway. Massive accumulation of oligoclonal CD4+ T cells of athymic origin with the phenotype of Th1 memory/effector T cells in the colonic lamina propria of a histocompatible, immunodeficient host elicits a pancolitis that morphologically mimics human UC.

Essential hypertension and gastrointestinal disease are two of the most common diagnoses made in the doctor's office. Since they may occur simultaneously, the differential therapeutic aspects of the respective therapies are of importance for every general practitioner. However, complex interactions between hypertension and gastrointestinal diseases often make the choice of the most suitable drug difficult. The present article provides an overview of the most common therapeutic regimens, identifies possible interactions, and should help the doctor to select the optimal treatment for the individual patient.

H-2d mice generated a major histocompatibility complex (MHC) class I (Ld)-restricted T-cell response of defined restriction and epitope specificity to the hepatitis B virus small surface antigen (HBsAg). Here, we compare different vaccination techniques that prime in vivo class I-restricted, murine cytotoxic T lymphocyte (CTL) precursors and specific serum antibody responses. CTL were efficiently primed by the injection of low doses of recombinant native HBsAg particles without adjuvants, by the injection of low doses of denatured HBsAg monomers without adjuvants, by infection with recombinant vaccinia virus carrying a HBsAg-encoding gene, or by intramuscular transfer of plasmid DNA encoding HBsAg under appropriate promoter control. The observation that the injection of 100 ng to 1 microgram of native HBsAg "virus-like particles' (VLP) without adjuvants is an exogenous antigen preparation that efficiently primes class I-restricted CTL responses was unexpected. It reveals a novel aspect of the immunogenicity of VLP for T cells.

Chronic inflammatory bowel diseases, ulcerative colitis and Crohn's disease, are thought to be distinct clinical entities. The mechanisms involved in the pathogenesis of the diseases are poorly understood, however, it is thought that dysregulation of the immune system, especially of the mucosal immune reactivity, as well as a genetic susceptibility and environmental factors, e.g. bacterial flora, may each contribute to initiation and/or progression and chronicity of the diseases. Experimental animal models are available to study the different components involved in inflammatory bowel disease and to complement our understanding of chronic inflammatory reactions in these organs ultimately leading to effective alternative therapeutic approaches.

Cogan's syndrome is an uncommon disease characterized by ocular inflammation, vestibuloauditory dysfunction and symptoms of systemic disease. The etiology is unknown, however there is evidence for an autoimmune pathogenesis. The "typical" Cogan's syndrome presents as bilateral interstitial keratitis and progressing vestibuloauditory dysfunction. The presence of other inflammatory manifestations in addition of keratitis has been termed as "atypical" Cogan's syndrome.We report on six patients presenting with typical as well as atypical ocular manifestations between 1982 and 1994. Typically, the illness was accompanied by systemic symptoms. Each patient had audiovestibular involvement, that was the initial presentation in 4 cases. Vestibular dysfunction often preceded hearing loss. Five of our patients not only presented with keratitis but also demonstrated signs of ocular inflammation diagnosed as scleritis or episcleritis. In two patients these ocular symptoms were the first signs of Cogan's syndrome, recurred periodically and did not respond to corticosteroids.In 3 patients that were diagnosed early and treatment with corticosteroids was initiated early, hearing could be stabilized, in the remaining patients total bilateral deafness could not be prevented.The importance of being aware that vestibuloauditory dysfunction may occur in patients with ocular inflammation, and the fact that early immunotherapy may prevent the risk of deafness, has to be emphasized.

We developed a model in which full-thickness human genital mucous membranes (fallopian tubes, endometrium) were heterotopically xenografted into the skin of severe combined immunodeficient (SCID) mice. The transplanted tissue retained its human phenotype for at least 4 weeks including the glandular epithelium, the lamina propria, and main parts of the grafted vessels. By using an occlusive chamber filled with covering phosphate-buffered saline we created a system that protected the moist human epithelial surface. This system will allow the study of the interaction of test substances, or of invasive, pathogenic microorganisms, with epithelial cells and other cellular components of the human genital mucosa under in vivo conditions.

New insights into HIV-pathogenesis suggest that the cell mediated immune response might play a crucial role in controlling HIV infection by suppressing HIV-replication in CD4-positive cells by a lymphokine-like soluble factor and by killing HIV-infected cells via classical CTL mediated lysis. This type of a cellular immune response rather than an antibody response seems to be most promising to protect if not from infection, so at least from disease. Therefore rationally designed candidate vaccines should be capable of inducing a cell mediated immunity in addition to a humoral immune response. In order to avoid adverse side effects upon immunization, carefully selected antigens and epitopes should be presented in a favourable manner to the immune system. In previous experiments, we could demonstrate that the gag-polyprotein precursor, known to include a series of T-helper and CTL epitopes, assembles to highly immunogenic, complete noninfectious HIV-1 virus-like particles (VLP). Based on these VLP we developed a novel antigen presentation system, which allows the presentation of selected epitopes derived from HIV reading frames other than gag to the immune system. Alternatively complete derivatives of the HIV-1 external glycoprotein can be presented by the VLP. Immunological analysis of different VLP preparations in a BALB/c mouse model revealed the induction of a strong CTL response. The significance of these observations for future vaccine strategies is discussed.

Many hypertensive patients have other, usually long-term diseases. Antihypertensive therapy may interfere with these diseases and their therapies. In the present study, the possible interactions of the ACE-inhibitor perindopril with several of the most common long-term diseases was evaluated.In a multicenter, double-blind, randomized, placebo-controlled trial, the effect of perindopril was evaluated in 490 patients with mild essential hypertension and any one of the following concomitant diseases: hyperlipidemia, type II diabetes mellitus, ischemic heart disease, cardiac arrhythmia, peripheral arterial occlusive disease, nephropathy with proteinuria, chronic obstructive pulmonary disease, or degenerative joint disease treated with nonsteroidal anti-inflammatory drugs (NSAIDs). After a 3-week single-blind placebo run-in, the patients received either perindopril (4 mg/d) or matching placebo for 6 weeks.Blood pressure was effectively reduced by perindopril irrespective of the associated disease. The rate of spontaneously reported side effects was low. Treatment with perindopril was free from adverse interactions with the concomitant diseases and therapies. Moreover, favorable actions could be observed in patients with ischemic heart disease (reduction of maximal ST-segment depression during peak exercise and decrease in the number of angina attacks), in patients with proteinuria (decrease in albuminuria in patients with normal serum creatinine levels), and in patients with NSAID-treatment (increase in prostaglandin E2 concentration in gastric mucosa suggesting gastric cytoprotection).This trial shows that ACE-inhibition with perindopril represents a simple, safe, and effective short-term therapeutic option for the large proportion of patients with mild essential hypertension and concomitant diseases and therapies.

This study examined the frequency and nature of pregnancy-related dreams in pregnant women in a family practice center and assessed the extent such dreams were discussed with providers of prenatal care.Pregnant women 18 years of age or older who were receiving prenatal care at the University of Missouri-Columbia Family Medical Care Center responded to a two-page self-administered questionnaire. The major variables measured were frequency of pregnancy-related dreams, frequency of frightening dreams, content of dreams, and discussion of dreams. Health professionals providing prenatal care to these women were also surveyed.Eighty-eight pregnant women, 41 family physicians, and 3 nurse practitioners participated in the study. Dreams about their pregnancy or baby were reported by 59 (67 percent) of 88 pregnant women, of whom 22 had experienced at least one frightening dream. Seventeen women reported being upset by a dream. The frequency of dreams increased with advancing gestational age. The content of the most common dream involved conflict with the father of the baby. Most women had talked to another person about their dreams, usually the baby's father. Only 2 women told their physicians about the pregnancy-related dream. One-half of the providers of prenatal care reported discussing pregnancy-related dreams with a pregnant patient at least once during their careers.Dreams about their pregnancy or baby occurred frequently in pregnant women and could be a neglected source of information about the psychological state of the patient.

We treated 11 patients with posterior chamber intraocular lenses that were dislocated into the vitreous cavity. Using a pars plana approach, vitrectomy was performed and in order to facilitate manipulation, half of the bulbus volume was filled by perfluorodecaline. The IOL was grasped with forceps and repositioned with a special technique. In this way the first haptic is fixed in the ciliary sulcus. Fixation of the second haptic with 9 x 0 polypropylene suture was performed with a similar procedure. Finally, prophylactic cryotherapy of the retina is indicated.

Side Effects of Water-Soluble Contrast Agents in Upper Gastrointestinal Tract J. GMEINWIESER;W. ERHARDT;H. REIMANN;R. BABIC;U. SPECK;B. WENZEL-HORA; Investigative Radiology

In patients in a surgical intensive care unit a controlled clinical trial was performed concerned with the pathophysiological functions of histamine in stress ulcer disease and with the influence of cimetidine prophylaxis on this complication. The commonly used organization of a controlled clinical trial was enforced to be changed by considerable theoretical, ethical and practical difficulties in designing and conducting the study: As a surprising and remarkable result of the study clinically manifest stress ulcers occurred exclusively in our patients in the intensive care unit and among them mainly in those with severy polytrauma and postoperative complications. Cimetidine was highly effective in preventing stress ulceration in severe polytrauma patients. But it seems absolutely unnecessary to distribute this drug in all patients of a surgical intensive care unit like from a cornucopia of happiness.

In fourteen patients with food allergy, intragastral provocation under endoscopical control (IPEC) was performed. In all patients positive immediate-type reactions of the gastric mucosa were observed consisting of oedema, erythema and petechial bleeding. Microscopically, mast cell degranulation was observed and measured by mast cell counts using the o-phthaldialdehyde technique. Concomitantly, tissue histamine content in gastric mucosa decreased significantly after allergen provocation, while there was no change in normal volunteers. Plasma histamine concentration increased in most patients; the increases were most evident in four patients showing mild systemic reactions (urticaria and bronchospasm). The technique described might prove to be useful in establishing the diagnosis in doubtful cases of food allergy.

In a double blind crossover experiment in 16 healthy male volunteers, the effects of oral FPL 52694 and a matching placebo upon pentagastrin stimulated gastric acid secretion, gastric mucosal histamine content, and gastric mucosal mast cell count were compared. There was a significant increase in acid secretion, and a fall in tissue histamine and the mast cell count after treatment with the placebo. All these changes were inhibited by FPL 52694, and there was a significant difference between the effects of this compound and the placebo in all three parameters. It is concluded that FPL 52694 caused significant inhibition of acid secretion, and that the likely mechanism of action is by stabilisation of mast cells and inhibition of histamine release.

The hypernephroid carcinoma is the most common tumour of the kidney in adults. Haematuria can occur, even in the early developmental stages. In investigations of 30 patients with-haematuria, radiological examinations were made and the plasma histamine levels were determined in both from the renal artery and vein, the vena cava and the aorta. After nephrectomy, the histamine content of various tissues in different regions of the kidney were investigated. Significant increases of plasma and tissue histamine levels were found in the veins of the tumour-riddled kidney and in the tissue surrounding the tumour. an experimental study on dogs investigated whether or not an injection of histamine into the renal artery would provoke haematuria. Dose-dependent haematuria occurred, which was most pronounced following intra-arterial injection of 25 micrograms/kg of histamine.

Using a specific fluorimetric and biological method, the occurrence and distribution of histamine was investigated in man, various mammals, birds, reptiles, amphibians, bony and cartilaginous fishes, lancelets, tunicates, echinoderms, molluscs, and crustaceans. The amine was identified by the fluorescence spectrum, by specific antihistaminics in the bioassay, by the comparison of the fluorimetric histamine values following three different isolation procedures, and in some tissues also by thin-layer chromatography. Histamine was found in all chordates in considerable concentrations with the exception of the stomachless carp. The distribution of histamine in the body, however, varied largely from species to species. Only the gastric mucosa of all vertebratesinvestigated was relatively rich in histamine. The amine was nearly uniformly distributed in amphibians and fishes, in which only the stomach and partly the intestinum showed higher histamine concentrations than all the numerous other tissues investigated. The distribution of histamine, however, in mammals, birds, and reptiles showed great variations from tissue.to tissue. Organs free from histamine were first found in fishes going backward in the phylogeny. Because of the great variabilities in the distribution of histamine in the body of numerous species which were studied in this investigation, only one hypothesis can be developed with respect to a common physiological significance of histamine: there is a selective accumulation of histamine in the gastric mucosa of all chordates possessing acid-secreting cells and a low concentration of histamine in the gastro-intestinal tract of stomachless fishes. The gastric acid secretion is stimulated by histamine in all vertebrates investigated, whereas in many fishes histamine has no effects on the circulation or on smooth muscles of the gastro-intestinal tract or on the uterus. Thus, stored histamine probably has a specific function in the gastric mucosa, but not a general function, such as the regulation of ubiquitous metabolic processes or the regulation of microcirculation.

In a clinical study the participation of histamine in the allergenic response of patients with food allergy was investigated. The resting levels of gastric tissue and plasma histamines of 10 patients were slightly higher than the respective values of normal volunteers. 5 minutes after local intragastral allergenic provocation a decline of the mucosal histamine content of the allergen-treated area was noticed. Parallel investigations on the mast cell content of the stomach mucosa revealed a parallel decrease of the o-phthaldialdehyde stained cells, whereas the number of toluidine blue stained cells remained unchanged. These data are in accordance with an antigen-induced IgE-dependent liberation of the mast cell histamine stores.

The plasma histamine levels were reported to increase in early hours of the morning in asthmatic patients. It was supposed that this phenomenon would also be observed in normal volunteers. In this study using twelve normal healthy volunteers the plasma histamine levels were examined in a pharmacokinetic manner. It could be shown that plasma histamine levels flow biorhythmic changes with 3 maxima and 3 minima. The acrophases of the maxima are 12.77 +/- 0.61, 19.33 +/- 0.78 and 5.42 +/- 1.83 h. The most important rise in plasma histamine levels was found in the early hours of the morning representing about 55% of the total histamine available in plasma.

Histamine concentrations in plasma, whole blood and various tissues of human subjects, monkeys, pigs and dogs were determined by fluorometric methods before, during and after surgical operations. Following intraabdominal surgery in 6 of 22 patients elevated plasma histamine levels were found several hours after the end of operation. Some of the causes of histamine release in surgery were found to be premedication by atropine, intravenously administered anaesthetics, infusion of plasma substitutes and manipulation on the gut. Acute blood losses were without effect on the plasma histamine levels. Clinical symptoms and pathophysiological reactions, such as tachycardia, hypotension, increased gastric secretion and anaphylactoid reactions could be related to the release of histamine in some circumstances.

Cytotoxic T lymphocytes (CTL) recognize antigen in the context of syngeneic MHC class I gene products. The "learning" of MHC restriction is thought to take place during the early intrathymic development of cytotoxic lymphocyte precursors (CLP). This view does not allow for any significant number of "allorestricted" (as opposed to selfrestricted) T cells to occur among mature, peripheral T cells. Recent evidence indicates, however, that large numbers of antigen-specific, allorestricted CLP can be readily detected among splenic T cell populations from several strains of unprimed normal mice. The frequencies of allorestricted CLP as determined under limiting dilution (LD) culture conditions are in fact in the same order of magnitude as frequencies of selfrestricted CLP. These findings were at the origin of the present study, which was designed to investigate whether antigen-specific, allorestricted CTL populations could also be detected among human peripheral blood T lymphocytes. To address this issue we studied the CTL response to virus-infected allogeneic stimulator cells in two different LD systems. In the first system, peripheral T cells from normal donors were cocultured under precisely defined LD conditions with Epstein-Barr virus (EBV)-transformed allogeneic lymphoblastoid cell lines (LCL). Frequencies of CLP that lysed the stimulating LCL ranged from one in 70 to one in 200, while frequencies of CLP that lysed the respective allogeneic ConA blast targets were 3-40-fold lower. The split-well analysis suggested that a large fraction of developing CTL colonies specifically lysed the stimulating LCL targets but neither the respective ConA blasts nor HLA-mismatched third party LCL targets. CTL generated in this culture system thus displayed allorestricted specificity for LCL membrane antigens. Comparable results were obtained in a second LD system where T cells from normal donors were cocultured with mumps virus-infected allogeneic mononuclear cells (MNC) or ConA blasts. One of 600 to one of 2,800 T cells gave rise to a cytotoxic colony that lysed mumps virus-infected stimulator-derived ConA blast target cells. To assess the lytic specificity of the in vitro expanding CTL populations, individual microcultures were split into three aliquots and tested for cytolytic activity against mumps virus-infected and noninfected specific targets as well as mumps virus-infected, HLA-mismatched third party targets. Clonal CTL populations from four of seven donors lysed virus-infected stimulator targets but did not lyse either noninfected stimulator targets or mumps virus-infected third party targets, i.e., they again showed an antigen-specific allorestricted lytic r

The capacity of various stimulator cell types to present alloantigens or viral antigens to resting human CD8+ cytotoxic lymphocyte precursors (CLP) was analyzed in a limiting dilution culture system. Cell sorter-separated T lymphoblasts of both CD4+ and CD8+ phenotypes but not resting T cells were found to efficiently stimulate the clonal development of allogeneic CD8+ CLP. Thus, 5000 CD4+ T lymphoblasts activated as many (one out of 200 to one out of 300) allogeneic CLP as 50,000 peripheral blood mononuclear stimulator cells. This potent stimulator activity was found in CD4+ and CD8+ T lymphoblasts activated by mitogen, anti-T3 monoclonal antibody, or mixed leukocyte reactions. Cytotoxic T cells generated in this system were highly specific for HLA class I antigens. Furthermore, T lymphoblasts infected with mumps virus efficiently induced development of autologous CLP into CTL clones that were virus specific and self-HLA restricted, as shown by split-well analysis. The possible in vivo significance of antigen-presenting T lymphoblasts is discussed.

Various lymphocyte populations, dendritic cells and macrophages contribute to the intake of antigen. The transportation of antigen in the intestinal wall is possible with the help of receptive endocytosis, including extracellular protein in fluid droplets, bacterial and vegetable toxins, as well as certain viruses, which seem to be able to penetrate the cell membrane and enter directly into the cell. Own investigations: After endoscope controlled allergy-irritation of the gastro-intestinal tract, 20 people used in the clinical test showed acute signs of mucosal reaction with inflammation and swelling of the mucous membrane as well as haemorrhagic lesions. A histamine release from the mastcell was proved.

Tissue histamine determination in the urogenital tract showed that there are significant differences concerning tissue histamine content between intraoperative and postmortem tissue samples. The difference appeared to be most significant in the case of renal pelvis samples, where the decrease was about 90% in the autopsie material compared to intraoperative tissues. In comparing tissue histamine content in special organs of different animal species we discovered considerable differences; e.g. in the ureter of the dog we measured 30 micrograms/g tissue - where as against the values in man amounted to only 6 micrograms/g tissue. The physiological meaning of the different tissue histamine levels is unknown.

Prior to cannulation for extracorporeal circulation, 375 Units of Heparin/kg body weight were applied to 22 patients (group 1) into the right atrium. A few minutes later, characteristic changes in haemodynamics were observed. In a second group of 10 patients, the same amount of heparin was injected directly into the ascending aorta to avoid the passage of an undiluted bolus of heparin through the pulmonary vessels. In this group, the haemodynamic effects of heparin seemed to be slightly weakened. Immediately after administration of heparin, a significant increase of plasma histamine was measured (in 12 patients of group 1). This might be the main reason for the heparin-dependent haemodynamic effects.

Several reports, dealing with typical cardiovascular reactions immediately after injection of heparin during cardiac surgery, have been presented. A possible reason for these reactions is a short-lasting elevation of plasma histamine concentration following heparin injection. As most types of heparin contain antibacterial preservatives such as benzyl alcohol, which can cause adverse reactions, both substances, heparin itself and the preservative, can theoretically be responsible for this reaction. Therefore, this study was carried out in order to measure the effects of preservative-free heparin on plasma-histamine levels and on hemodynamic parameters. It became evident that preservative-free heparin also entails characteristical hemodynamic effects, such as a decrease in arterial mean pressure and peripheral vascular resistance as well as an increase in cardiac output. A significant increase in plasma-histamine concentration could be shown 20-120 seconds after injection of heparin. We conclude that benzyl alcohol is not the major reason for the hemodynamic effects and elevation of plasma-histamine concentration, following heparin injection, but we cannot exclude that benzyl alcohol does in fact play a minor role. The results of this study suggest that the cardiovascular reactions and the elevation of plasma histamine concentration following heparin injection are heparin-specific phenomena.

From a methodological point of view the relevance of clinical-biochemical trials depends on the answers to mainly four complexes of questions: (1) the reliability of the assays in the clinical situation to be tested, (2) the precision and accuracy of sample-taking, (3) the qualification of the design and the protocols in the clinical part of the trial and (4) the usefulness of the time concepts in the trial concerning biorhythms, seasonal influences, psychological trauma of diagnostic procedures and treatment. In this study mainly the second complex of questions was studied intensely. The precision of the fluorometric histamine assay in biopsy specimens from human gastric mucosa depended on several conditions: Biochemical technique, sample preparation and removal of biopsies from gastric mucosa via endoscopy. The CV% of the whole procedure was about 8-times higher than that of the biochemical technique. In clinical-biochemical studies on the significance of histamine or any other hormone (such as gastrin) in any disease (uch as duodenal ulcer) it seems therefore useless to describe the precision of an assay only by the variance of the biochemical technique. Calculation of the histamine content as mean of 3 samples reduced the CV% from 27.2 to 14.9% and should therefore be recommended.

This study demonstrates a very rapid and short-lasting elevation of plasma histamine concentrations after heparin injection prior to cannulation for extracorporeal circulation during cardiac surgery. Plasma histamine concentrations increased significantly for less than 1 min following bolus injection of heparin into the right atrium. Blood samples were taken from the distal pulmonary vascular bed, i.e. the pulmonary vein. The design of the study enabled us to observe the development of plasma histamine concentrations within very short time intervals and to detect the high peak plasma histamine concentration that may occur, primarily in the pulmonary outstream vessels. Therefore, the histamine found here could originate from intrathoracically located mast cells. It is more likely, however, that the histamine was administered together with the heparin in complex binding, due to purification problems. The amount of histamine found in this study was sufficient to produce mild to severe circulatory effects in all patients receiving a high dose of heparin.

Stimulation tests (pentagastrin) induced significant changes in tissue histamine levels in the gastric mucosa within 30 minutes. Acid secretion and a decrease of histamine after application of antacids containing calcium could not be observed in our study; neither was application of antacids over a period of eight days followed by a change in gastric mucosal tissue histamine concentrations. Patients under non-steroidal antiphlogistic medication showed diminished histamine levels. Administration of antacids did not produce changes in histamine levels, but induced a rise of PGE2 levels in the fundal and corpus area of the stomach. This may be due to a cytoprotective effect of antacids containing calcium on the gastric mucosa.

We have investigated the diversity and repertoire of human TCR delta chain variable gene segments in the human peripheral blood CD4- CD8- (double-negative) population, using rearrangement and expression studies and sequence analyses. 20 TCR delta DNA clones were derived from the RNA of bulk-cultured double-negative T cells and their nucleotide sequences determined. These clones can be classified into six different V delta subfamilies. The distribution, however, was uneven in these cells, with 16 of 20 being derived from the V delta 1 (9) and V delta 2 (7) subfamilies. The remaining subfamilies, V delta 3, V delta 4, V delta 5, and V delta 6, were only represented by one clone each. The majority of these subfamilies seem to consist of a single member, in contrast with the closely linked V alpha subfamilies, which, in most cases, consist of multiple members. Our findings suggest that only a limited number of V delta genes are used in human peripheral blood double-negative T cells and that two major V delta subfamilies (V delta 1 and V delta 2) are used more frequently. Sequence comparison of our cDNA clones to V alpha clones indicates that there is no overlap in usage of V alpha and V delta gene segments, except for the V delta 4 (V alpha 6) subfamily. Comparison of the different V delta sequences suggests that the majority of the sequence diversity is concentrated in the junctions between V, D, and J segments and results from extensive N region diversity.

In a retrospective analysis in patients with differentiated thyroid carcinoma, the diagnostic validities of 131I whole-body scans and radioimmunologic determinations of thyroglobulin (hTg) are compared with special regard to late metastases. Metastases were found in 83 out of 311 patients with differentiated thyroid carcinoma. In two thirds of the cases, these were primary metastases while in the remaining third of the cases, metastases developed in later follow-up with a mean time of latency of 3.3 years. While about 70% of the early metastases could bei detected by 131I scintigraphy, this percentage amounted to only 40% in late metastases. With a diagnostic sensitivity of 90%, hTg-RIA was clearly superior in the detection of early as well as of late metastases. hTg was measurable, however, only in iatrogenous hypothyroidism in 4 out of 49 cases. Based on these results and an analysis of the literature, a program for follow-up of differentiated thyroid carcinoma is proposed. The hTg-RIA is thereby used as an alternative to 131I scintigraphy in the late phase of follow-up after complete ablation of any thyroid tissue.