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Background Mortality during severe acute pancreatitis generally occurs early or late. Early mortality occurs as a consequence of fulminant systemic inflammation, whereas late mortality can be attributed to secondary infection of necrotic pancreatic tissue. Aims of this study were to correlate plasma levels of various cytokines and chemokines to outcome, and secondly, to assess the effect of probiotic modulation of intestinal flora on systemic cytokine levels. Materials and methods Pancreatitis was induced in rats by intraductal infusion of bile salt followed by i.v. cerulein hyperstimulation. Rats were administered a mixture of 6 probiotic strains ( Ecologic ® 641) or placebo for five days prior to and seven days after induction of pancreatitis. Plasma cytokine levels were determined before, and 6 hours, 24 hours and 7 days after induction of pancreatitis. Total bacterial counts were performed by cultivation as well as by cultivation-independent rt-PCR in pancreatic necrosis at day 7.

To determine the role of antibiotics in patients with acute pancreatitis.Literature review.A Medline search for randomised clinical trials (RCTs) during the period 1990-1999 was carried out using the key words 'pancreatitis', 'acute' and 'antibiotics'. Outcome measures were pancreas-related infection, sepsis and death.Four RCTs were identified. Control groups were not given antibiotics. Based on the pooled data, the differences in risk in favour of the groups treated with various antibiotics were as follows: -14% (95% CI: -26(-)-1; p = 0.04) for pancreas infections, -25% (95% CI: -39(-)-12; p = 0.0002) for sepsis and -13% (95%-BI: -22(-)-3; p = 0.007) for death.Administration of antibiotics to patients with severe acute (necrotising) pancreatitis reduces the risk of serious complications.

The intestinal flora is thought to play an important role in regulation of immune responses. We investigated the effects of changing the intestinal flora on the course of adjuvant-induced arthritis (AIA) and on experimental autoimmune encephalomyelitis (EAE) by the use of oral antibiotics.Oral treatment with either vancomycin or vancomycin, tobramycin, and colistin was started after AIA and EAE induction. Clinical symptoms of AIA and EAE were monitored, and microbial analysis of ileal samples was performed.Oral vancomycin treatment after disease induction significantly decreased clinical symptoms of AIA. Simultaneously, increased concentrations of Escherichia coli were detected in the distal ileum of vancomycin-treated rats. Ileal concentrations of E coli were inversely related to disease scores in rats with AIA. Coadministration of colistin/tobramycin to prevent the increase in E coli abrogated the beneficial effect of vancomycin on AIA. Vancomycin treatment also reduced the clinical symptoms of EAE.We propose oral vancomycin as a novel therapeutic strategy in autoimmune diseases.

In this study we examined whether response shift resulting from changes in internal standards occurs in cancer patients undergoing radiotherapy. Ninety-nine newly diagnosed patients undergoing radiotherapy were administered two standardized self-report measures of fatigue prior to receiving radiotherapy. After completion of radiotherapy, patients filled out these questionnaires as a conventional posttest and in reference to how they perceived themselves as they were prior to radiotherapy (a so-called 'thentest'). A transition (direct change) score on fatigue was used as a stratification measure. Patients were subsequently interviewed about their responses. The pattern of mean scores indicative of response-shift effects was found in two distinct subgroups: patients experiencing diminishing levels of fatigue and patients facing early stages of adaptation to increased levels of fatigue. Since response shift may adversely affect the results of self-reported outcomes in clinical trials or other longitudinal research, further research is very much needed.

Monitoring and blunting styles have become relevant concepts regarding their potential impact on patients' and doctors' behaviors. The present study aimed at investigating the relation between cancer patients' coping styles and doctor-patient communication and global affect. Coping styles were assessed by means of the Threatening Medical Situations Inventory (TMSI). Since a shortened version of the TMSI was used, the validity of this instrument was also evaluated. First, it was examined whether the two factor structure of the original TMSI could be confirmed in our version. Then, the relation between coping style and patients' preferences for information and participation in decision-making was evaluated. Second, the relation between monitoring and blunting and patients' age, sex, education, quality of life and prognosis was investigated. Finally, the relation between patients' coping styles and communicative behaviors and global affect of both patients and physicians during the initial oncological consultation was examined. Patients (N = 123) visited their gynaecologist or medical oncologist for an initial discussion of possible treatment. Patients' coping styles, socio-demographics, preference for information and participation in decision-making, quality of life and prognosis were assessed by postal questionnaire prior to the visit to the outpatient clinic. The consultation was audiotaped and analysed according to Roter's Interaction Analysis System, to identify instrumental and affective communicative behaviors of both patients and physicians. The two factor structure of the TMSI could be confirmed. A monitoring style was related to a preference for detailed information (r = 0.23) and participation in medical decision-making (r = 0.23). A monitoring style was also related to patient question-asking (r = 0.25) and patient dominance (r = 0.23). To conclude, the validity of the shortened TMSI is satisfactory. Also, cancer patients' coping styles are not related to other personal and disease characteristics. Further, a monitoring style seems to have an impact on patients' question-asking and dominance during the oncological consultation.

Interdigestive small bowel motility has a regulatory function on the microflora of the upper small bowel. Here we investigate the effects of ABT-229 and octreotide on morphine-induced dysmotility, the accompanying bacterial overgrowth and bacterial translocation.Rats were fitted with jejunal myoelectrodes and a subcutaneous cannula for continuous infusion of saline or morphine. Fasting motility was measured for 6 h on four occasions: one control measurement (day 0) and three measurements on consecutive days (days 1-3) while receiving saline alone (group A), morphine alone (group B), saline + ABT-229 (group C), morphine + ABT-229 (group D), saline + octreotide (group E) or morphine + octreotide (group F). Samples from the mesenteric lymph node complex (MLN), liver, spleen, duodenum and ileum were taken for quantitative microbial culturing on day 4.Neither ABT-229 nor octreotide increased the number of propagated activity fronts during saline infusion. During morphine-induced dysmotility, ABT-229 induced more propagated activity fronts in group D (13.4, 9.8 and 8.8 per 6 h) than in group B (7.0, 4.5, 3.8 per 6 h) on days 1, 2 and 3 (P0.05 for all days) Octreotide did not induce more propagated activity fronts. Disruption of small bowel motility by morphine led to bacterial overgrowth in the duodenum. ABT-229 and octreotide did not reduce the bacterial growth levels. The total incidence of bacterial translocation was significantly higher in the morphine-treated animals than in the saline-treated animals. Neither ABT-229 nor octreotide reduced the bacterial translocation incidence. The number of propagated activity fronts on day 3 and duodenal bacterial growth correlated significantly in groups A, E and F.ABT-229, but not octreotide, reduced morphine induced dysmotility. Small bowel bacterial overgrowth and bacterial translocation were not prevented. Fasting small bowel motility has a regulatory function on the intestinal microflora of the upper small bowel.

One of the most frequently used systems to analyse doctor-patient communication is the Roter Interaction Analysis System (RIAS). However, it has mostly been applied and evaluated in primary care settings. Two studies are presented in which the psychometric properties of the RIAS are investigated in an oncological setting. In the first study (N = 25) the feasibility, inter-rater reliability and content validity of the RIAS was investigated. In the second study, we evaluated the discriminant validity of the RIAS. Results of the first study showed that coding of tapes was more time consuming than indicated by the Roter manual. The inter-rater reliability proved to be high for both physician communication (0.68-1) and patient communication (0.60-1). The content validity proved to be acceptable: all utterances could be classified. However, coding dilemmas regarding affective communication occurred. The RIAS provided no option to classify communication of a third person present. Some communication categories were never or rarely used. Results of the second study indicate that the RIAS was able to discriminate between communicative behaviors in oncological consultations (N = 60) and three different GP-samples (random-GP sample N = 329, hypertension sample N = 103, gynaecology sample N = 65). To conclude, the psychometric properties of the RIAS are satisfactory in an oncological setting.

There are three Anglo-Saxon guidelines for the management of patients with a community-acquired pneumonia: an American, a British and a Canadian one. The guidelines correspond fairly well. There is a subdivision into categories according to whether the patients are treated at home (formerly healthy patients younger than 60 years versus patients with pre-existent disease or aged 60 years and more) or in the hospital (patients not needing intensive care versus those who do need it). For each category the most common causative micro-organisms are listed together with recommended antibiotic treatment. The Canadian guidelines have nursing home patients as a separate category because of slightly different causative organisms due to frequent microaspiration. The guidelines are applicable to the situation in the Netherlands, with a few exceptions: antibiotic resistance is not a major problem in the Netherlands (as yet), and contrary to what the guidelines state an agent with activity against Pseudomonas aeruginosa is not necessary; the same agents as in category III can be prescribed in these patients. A macrolide or azalide antibiotic is advisable for intensive care patients in view of the possibility of infection with Legionella pneumophila or Mycoplasma pneumoniae.

Atherosclerotic lesions have been reported to contain herpes simplex virus 1 (HSV-1) genomic material. This, and other previous evidence, suggests that latent viral infection may be an atherogenic trigger. Moreover, active HSV-1 lesions manifest marked fibrin deposition in microvessels. In this report we show that very early infection of human endothelial cells with HSV-1 appears to alter surface conformation as detected by merocyanine 540 staining. Concomitantly, the efficiency of prothrombinase complex assembly increases, resulting in a 2- to 3-fold accelerated rate of thrombin generation on the cell surface. Increased thrombin generation is probably doubly procoagulant, since we also demonstrate that thrombin-induced platelet accumulation on HSV-infected endothelium (50.7 +/- 9.3%) is increased compared to uninfected endothelium (9.5 +/- 2.1%; P less than 0.002). Associated with HSV infection, prostacyclin secretion in response to thrombin is diminished by a factor of 20, probably explaining the enhanced platelet attachment. We conclude that HSV infection shifts endothelial cell properties from anticoagulant to procoagulant, both by promoting prothrombinase complex formation and function and by increasing platelet binding, well before cell disruption takes place. Virus-induced changes in the endothelial plasma membrane and diminished prostacyclin secretion are suggested as the pathways for this pathophysiologic mechanism, which may be germane to atherosclerotic thrombosis as well as HSV-mediated tissue necrosis.

Some endothelial-injury syndromes, including atherosclerosis, may involve herpes simplex virus (HSV) infection. Examining the mechanism of injury, we found adherence of unstimulated granulocytes to HSV infected endothelium to be twice that to uninfected endothelium (34.8 +/- 1.1 versus 18.8 +/- 0.5%; mean +/- SEM; p less than 0.001) which further increased in the presence of anti-HSV antibodies. Enhanced adhesion was accompanied by excessive granulocyte-mediated lysis of 51Cr-labeled, HSV-infected endothelium (16.4 +/- 0.9%, HSV-infected versus 0.9 +/- 4.5% for uninfected endothelium; p less than 0.01). HSV infection also increased granulocyte-mediated endothelial cell detachment from its substratum (14.7 +/- 1.7% versus 3.3 +/- 0.3% for uninfected endothelium; p less than 0.001), which further increased (p less than 0.01) in the presence of immune complexes (IgG-sensitized erythrocytes). This suggests that neo-Fc receptors of infected endothelium bind IgG-coated particles, which, in turn, attract and stimulate granulocytes. In support, granulocyte-mediated detachment was not enhanced by immune complexes if endothelium was infected with a mutant HSV strain (E3/3) that does not produce glycoprotein E, the viral glycoprotein having Fc-receptor activity. Exaggerated endothelial detachment correlated with poor binding of infected endothelial cells to the substratum matrix protein, fibronectin. Resuspended, virus-infected endothelial cells bound significantly less well to tissue-culture wells coated with both low (p less than 0.001) and high (p less than 0.05) concentrations of fibronectin as compared with uninfected endothelial cells, a dichotomy further worsened in the presence of granulocyte-released elastase. We conclude that HSV-infected human endothelium is vulnerable to granulocyte-mediated injury by opposing alterations in its adhesive properties: its increased binding of granulocytes and its weakened tethering to matrix fibronectin, particularly when exposed to secreted granulocyte proteases, such as elastase.

Intracellular calcium ([Ca++]i) plays an important role in signal transduction and cell activation. The measurement of [Ca++]i in intact monolayers of human umbilical vein endothelial cells with the fluorescent calcium-sensitive probe fura 2 has been evaluated. Monolayers provide a more physiologic cell preparation than suspensions and allow a greater variety of experimental manipulation. Basal [Ca++]i was 117 +/- 5 nmol/L, with a range from 40 to 280 nmol/L that was not affected by cell age (days of primary culture) or degree of confluence. Thrombin in concentrations of 0.005 to 5 NIH units/ml produced a dose-dependent increase in [Ca++]i up to a maximum of 1500 +/- 147 nmol/L; this increase was shown to depend in part on the concentration of extracellular calcium. The presence of antithrombin III at physiologic concentrations abolished responses to 0.5 NIH units/ml thrombin but had no effect on 5 NIH units/ml. The potential of this technique was demonstrated further by our ability to examine [Ca++]i responses in endothelial cells following infection with herpes simplex virus type 1, a virus implicated in vascular injury. After 18 hours' infection, the response to both thrombin and histamine was dramatically reduced despite a normal resting [Ca++]i. It is concluded that this method may be useful for detecting early and subtle changes in endothelial cell function under a variety of physiologic and pathologic conditions.

Human adherent cells, obtained by EDTA reversible adherence to plastic, are potent effectors in cell-mediated cytotoxicity. Spontaneous cytotoxicity in a 2-hr assay against K562 target cells was shown to be largely mediated by contaminating natural killer (NK) cells. Treatment of adherent cells with NK-specific monoclonal antibody anti-Leu-11 plus complement abolished almost completely the spontaneous cytotoxicity. Spontaneous cytotoxicity by adherent cells was also reduced when the phorbol ester PMA was present in the assay. On the other hand, PMA induced a cytotoxic response in NK-cell depleted adherent cells after prolonged 18 hr incubation. The cell population responsible for this dichotomous effect of PMA on adherent cell-mediated cytotoxicity was shown to be monocytes, as revealed by monoclonal antibody treatment. Pure NK cell preparations were not affected by PMA in their cytolytic capacities. Reactive oxygen species are not involved in NK-cell mediated cytotoxicity, while PMA stimulated the monocytes to exert cytolysis and suppressed NK cells by the generation of these highly toxic oxygen products. Hydrogen peroxide especially seemed to be the mediator in this oxygen-dependent monocyte-mediated cytotoxicity and NK-cell suppression.

Herpes simplex virus (HSV) infection may be involved in various endothelial-injury syndromes, including vasculitis and atherosclerosis. In a previous study, it was reported that HSV-infected human umbilical endothelial cells are more vulnerable to detachment mediated by granulocyte-secreted proteases. To elucidate the molecular basis of this observation, the authors examined the interaction of infected endothelial cells with the purified basement membrane proteins, fibronectin, laminin, and type IV collagen. HSV-infected endothelial cells exhibited defects in their ability to adhere, spread, and migrate on all three matrix components. This defective adhesion could be partially overcome by increasing concentrations of fibronectin; in contrast, no abrogation of deficient binding occurs with increased levels of laminin or collagen type IV. This suggests that endothelial cells may use different surface constituents for binding to the three proteins and use multiple "receptors" for adhesion to the fibronectin molecule--"receptors" that are variably affected by HSV infection. The authors investigated this supposition by assaying adhesion of normal and infected endothelial cells to two non-overlapping cell-adhesion promoting fragments of fibronectin: 1) a 75 kd motility-promoting fragment which contains the arginyl-glycyl-aspartylserine (RGDS) adhesion sequence, and 2) a 33 kd carboxyl-terminal heparin binding fragment, which promotes cell adhesion by an RGDS-independent mechanism. Normal endothelial cells adhered and spread on both purified fragments. In contrast, while infected endothelial cells could adhere, albeit rather poorly, to high coating concentrations of the 75 kd fragment, these cells did not bind to the 33 kd heparin binding fragment of fibronectin at all. These results support the concept that endothelial cells adhere to multiple domains of fibronectin, and that HSV infection preferentially abrogates binding to the heparin-binding domain, while leaving relatively intact receptors for the RGDS-containing domain. In support, soluble RGDS significantly blocked fibronectin adhesion of infected, but not control, endothelial cells. It is concluded that HSV infection inhibits the interaction of endothelial cells with basement membrane proteins and weakens their tethering to substratum. This tethering is inadequate for proper cell spreading or movement to occur and may result in both excessive endothelial lift-off and impaired vascular repair in HSV infections.

Systemic viral infection is a known precipitant of vasocclusive crisis in sickle patients, but the mechanism underlying this clinical observation is unknown. In the present studies, human umbilical vein endothelial cells were infected with Herpes simplex virus type 1 (HSV) to model systemic viral disease. The already abnormal adherence of sickle erythrocytes to control endothelium is enhanced 1.8 +/- 0.4-fold to HSV-infected endothelium (P less than 0.001). This component of potentiated adherence is eliminated by maneuvers that block Fc receptors, it is prevented by tunicamycin, and it is not seen using a mutant HSV that is unable to express the Fc receptor glycoprotein. Thus, the incremental adherence seen here occurs due to expression of Fc receptor activity on HSV-infected endothelium and the consequent recognition of abnormal amounts of IgG on sickle erythrocytes. We conclude that systemic viral infection potentially can induce a novel mechanism for enhancement of erythrocyte adherence to endothelium and that this may increase the likelihood of vasocclusion during viral infection.