Control of stress-induced depressive disorders by So-ochim-tang-gamibang, a Korean herbal medicine

ETHNOPHARMACOLOGICAL RELEVANCE

So-ochim-tang-gamibang (SOCG) is a Korean herbal medicine formula that has been applied to treat depressive moods and depression associated somatoform pain. This decoction consists of Cyperus rotundus L. (Cyperi Rhizoma), Lindera aggregata (Sims) Kosterm. (Linderae Radix), Aquilaria agallochum (Lour.) Roxb. ex Finl. (Aquilariae Resinatum Lignum), Glycyrrhiza uralensis Fisch. (Glycyrrhizae Radix) Platycodon grandiflorum (Jacq.) A. DC. (Platycodi Radix), and Citrus aurantium L. (Aurantii Fructus). The aim of this study is to assess antidepressant-like effects of SOCG and to investigate its possible cellular and molecular mechanisms.

MATERIAL AND METHODS

Using chronic restraint stress animal model, effects of SOCG on depressive-like behaviors, corticosterone, and hippocampal expressions of a neurotrophic factor and an apoptotic marker, were investigated. Mice were exposed to restraint stress 6h per day over a period of two weeks, and orally administrated either SOCG (30, 100, or 300mg/kg/day). The depressive-like behaviors were analyzed by forced swimming test and open field test. The serum levels of corticosterone were measured by enzyme-linked immunosorbent assay. Expressions of caspase-3 and BDNF in the hippocampus were analyzed by immunofluorescence. Further, effects of SOCG were examined in corticosterone-treated PC12 cells. Cellular toxicity was determined by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide and lactate dehydrogenase assays. Real-time PCR was applied to investigate the cellular expression levels of Bax, Bcl-2, and BDNF. The levels of caspase-3 and BDNF were examined by Western blotting.

RESULTS

Administration of SOCG not only reduced immobility time of restraint-stressed mice in a dose-dependent manner, but also significantly increased the distance mice moved and the number of crossings in the open field test. Further, SOCG significantly reduced the serum level of corticosterone and expression of caspase-3, while increased expression of BDNF in vivo. SOCG increased cell viability in corticosterone treated PC12 cells, which was accompanied by decreased caspase-3 expression and the ratio of Bax/Bcl-2 mRNA expression as well as increased BDNF expression in vitro.

CONCLUSIONS

Taken together, our data suggested that SOCG may have potential as an antidepressant agent controlling depressive behaviors and corticosterone-induced neuronal damage caused by chronic stress.

The comparative clinical study of efficacy of Gamisoyo-San (Jiaweixiaoyaosan) on generalized anxiety disorder according to differently manufactured preparations: multicenter, randomized, double blind, placebo controlled trial

ETHNOPHARMACOLOGICAL RELEVANCE

Gamisoyo-San (GSS) is a well-known Traditional Korean Medicine shown to be effective on mood disorders.

AIM OF THE STUDY

The purpose of this research is to examine the effect of Gamisoyo-San on generalized anxiety disorder by its differently manufactured preparations.

MATERIALS AND METHODS

Multicenter, randomized, double-blinded, placebo-controlled study was set for 147 patients with generalized anxiety disorder recruited from November 1st 2009 to December 16th 2010. They were given Gamisoyo-San individual extract mixture (extraction done for each crude materia medica separately) or Gamisoyo-San multi-compound extract (extraction done for whole materia medica at once) or controlled medication. Hamilton Rating Scale for Anxiety (HAM-A), Korean State-Trait Anxiety Inventory (K-STAI), Penn State Worry Questionnaire (PSWQ), Korean Beck Depression Inventroy (K-BDI), Symptom Checklist-90-Revised (SCL-90-R), and Korean WHO Quality of Life Scale Abbreviated Version (WHOQOL-BREF) were evaluated. We also applied Pattern Identification tool for 'JingJi and ZhengChong (, Traditional Korean Medicine term which correlates with generalized anxiety disorder)' to patients to evaluate different responses among 9 patterns.

RESULTS

HAM-A scores of Gamisoyo-San multi-compound extract group showed greater decrease compared to Gamisoyo-San individual extract mixture group and placebo group, but the difference was insignificant. WHOQOL-BREF scores of Gamisoyo-San multi-compound extract group showed significant increase compared to Gamisoyo-San individual extract mixture group and placebo group. In Heart blood deficiency pattern, the Gamisoyo-San multi-compound extract group showed significant decrease in K-BDI compared to the Gamisoyo-San individual extract mixture group.

CONCLUSION

Gamisoyo-San did not improve anxiety level of GAD patients. However, it can be useful to improve quality of life, and reduce depressive, obsessive-compulsive, somatic symptoms of generalized anxiety disorder. Gamisoyo-San multi-compound seemed more effective than Gamisoyo-San individual extract mixture, especially in Heart blood deficiency pattern.

Multiple receptor tyrosine kinases converge on microRNA-134 to control KRAS, STAT5B, and glioblastoma

Receptor tyrosine kinases (RTKs) are co-deregulated in a majority of glioblastoma (GBM), the most common and most deadly brain tumor. We show that the RTKs MET, EGFR, and PDGFR regulate microRNA-134 (miR-134) in GBM. We find that miR-134 is downregulated in human tumors and cancer stem cells and that its expression inversely correlates with the activation of MET, EGFR, and PDGFR. We demonstrate that miR-134 inhibits cancer cell and stem-cell proliferation, survival, and xenograft growth, as well as cancer stem-cell self-renewal and stemness. We identify KRAS and STAT5B as targets of miR-134, and establish molecular and functional links between RTKs, miR-134, KRAS/STAT5B and malignancy in vitro and in vivo. We show that miR-134 induction is required for the anti-tumor effects of RTK inhibitors. We also uncover the molecular pathways through which RTKs regulate miR-134 expression and demonstrate the involvement of MAPK signaling and the KLF4 transcription factor. We therefore identify miR-134 as a novel RTK-regulated tumor-suppressive hub that mediates RTK and RTK-inhibitor effects on GBM malignancy by controlling KRAS and STAT5B.

Image-guided, direct convective delivery of glucocerebrosidase for neuronopathic Gaucher disease

OBJECTIVE

To determine if convection-enhanced delivery (CED) of glucocerebrosidase could be used to treat targeted sites of disease progression in the brain and brainstem of a patient with neuronopathic Gaucher disease while monitoring enzyme distribution using MRI.

METHODS

A CED paradigm in rodents (n = 8) and primates (n = 5) that employs co-infusion of a surrogate MRI tracer (gadolinium diethylenetriamine penta-acetic acid [Gd-DTPA]) with glucocerebrosidase to permit real-time monitoring of distribution was developed. The safety and feasibility of this delivery and monitoring paradigm were evaluated in a patient with type 2 Gaucher disease.

RESULTS

Animal studies revealed that real-time, T1-weighted, MRI of Gd-DTPA accurately tracked enzyme distribution during CED. Targeted perfusion of clinically affected anatomic sites in a patient with neuronopathic Gaucher disease (frontal lobe and brainstem) with glucocerebrosidase was successfully performed. Real-time MRI revealed progressive and complete filling of the targeted region with enzyme and Gd-DTPA infusate. The patient tolerated the infusions without evidence of toxicity.

CONCLUSIONS

Convection-enhanced delivery can be used to safely perfuse large regions of the brain and brainstem with therapeutic levels of glucocerebrosidase. Co-infused imaging surrogate tracers can be used to monitor and control the distribution of therapeutic agents in vivo. Patients with neuronopathic Gaucher disease and other intrinsic CNS disorders may benefit from a similar treatment paradigm.

Proteomic profiling distinguishes astrocytomas and identifies differential tumor markers

Methods to permit more precise delineation of astrocytomas of different grades may have therapeutic utility. The authors selectively microdissected pure populations of cells from normal brain and astrocytomas. They performed two-dimensional protein gel electrophoresis (2DGE) followed by protein sequencing. Differential expression was confirmed immunohistochemically. 2DGE identified proteomic patterns and proteins that differentiated normal brain from tumor and distinguished astrocytomas of increasing grade.

C-fos expression in rat brain nuclei following incisor tooth movement

In the rat experimental model, molar tooth movement induced by Waldo's method is known to cause a temporally and spatially defined pattern of brain neuronal activation. Since orthodontic correction usually involves the entire dental arch, we used a spring-activated appliance to extend the investigation to incisors, and we included brain regions related to antinociception. Adjustment of the non-activated appliance on incisors resulted in c-fos expression in the dorsal raphe, peri-aqueductal gray matter, and the locus coeruleus, in addition to trigeminal sensory subnuclei and the parabrachial nucleus, where neuronal activation has already been detected in previous studies on molar tooth movement. Appliance activation with a 70-g force resulted in a further increase in Fos-immunoreactive neurons in the trigeminal sensory subnucleus caudalis and in the dorsal raphe. This result suggests that there is a recruitment of neurons related to nociception and to antinociception when tooth movement is increased.

Direct muscle neurotization in rat soleus muscle

An experimental study was conducted using rat soleus muscles to characterize reinnervation of the denervated muscles by direct muscle neurotization. Also studied was whether there is any difference in the regeneration process between original (tibial) and foreign (peroneal) nerve neurotization. For functional evaluation, an electrophysiologic study was carried out by analyzing pattern, latency, amplitude, and duration of compound motor action potential. In a histochemical study, both hematoxylin-eosin stain and nicotineamide adenin dehydrogenase stain were used to identify the morphology and the change in the type of muscle fiber. Combined silver-acetylcholinesterase stain was utilized to identify reinnervated motor endplates and axonal sprouting. Evidence of regeneration of the denervated muscle by direct muscle neurotization could be confirmed. Regenerating muscles showed type grouping of muscle fibers. The newly-formed ectopic motor endplate was connected with axonal sprouting. The giant motor endplate composed of mature axon sprouting and several new ectopic motor endplates appeared in the neurotization group. There was no specific difference in the regeneration process between original and foreign nerve neurotization.

Direct muscle neurotization in rat soleus muscle

The authors carried out an experimental study using rat soleus muscles to evaluate reinnervation of the denervated muscles by direct muscle neurotization. They also attempted to determine whether there is any difference in the regeneration process between original (tibial) and foreign (peroneal) nerve neurotization. For functional evaluation, they did an electrophysiologic study by analyzing pattern, latency, amplitude, and duration of compound motor action potential. For histochemical studies, both hematoxyline-eosin stain and nicotineamide adenin dehydrogenase stainings were used to identify the morphology and the change of the type of muscle fiber. Combined silver-acetylcholinesterase stain was performed to identify reinnervated motor endplate and axonal sprouting. They confirmed evidence of regeneration of the denervated muscle by direct muscle neurotization. Regenerating muscles showed type groupings of muscle fibers. The newly-formed ectopic motor endplate was connected with axonal sprouting. The giant motor endplate composed of mature axon sprouting and several new ectopic motor endplates, appeared in the neurotization group. There was no significant difference in the regeneration process between original and foreign nerve neurotization.

Lamotrigine monotherapy in newly diagnosed untreated epilepsy: a double-blind comparison with phenytoin

PURPOSE

Lamotrigine is an effective add-on therapy against a range of epileptic seizure types. Comparative studies with carbamazepine (CBZ) as monotherapy in newly diagnosed epilepsy suggest similar efficacy. In this study, lamotrigine (LTG) and phenytoin (PHT) are compared.

METHODS

In a double-blind parallel-groups study, 181 patients with newly diagnosed untreated partial seizures or secondarily or primary generalised tonic-clonic seizures were randomised to two treatment groups. One group (n = 86) received LTG titrated over 6 weeks from a starting dose of 100 mg/day. The other (n = 95) received PHT titrated from 200 mg/day. Treatment continued for < or =48 weeks.

RESULTS

The percentages of patients remaining on each treatment and seizure free during the last 24 and 40 weeks of the study, and times to first seizure after the first 6 weeks of treatment (dose-titration period), did not differ significantly between the treatment groups. These were measures of efficacy. Time to discontinuation, a composite index of efficacy and safety, likewise did not distinguish between treatments. Adverse events led to discontinuation of 13 (15%) patients from LTG and 18 (19%) from PHT. The adverse-event profile for LTG was dominated by skin rash [discontinuation of 10 (11.6%) patients compared with five (5.3%) from PHT] rather than central nervous system side effects: asthenia, somnolence, and ataxia were each significantly more frequent in the PHT group. The high rate of rash with LTG was probably due to the high starting dose and may be avoidable. A quality-of-life instrument, the SEALS inventory, favoured LTG. Patients taking PHT showed the biochemical changes expected of an enzyme-inducing drug, whereas those taking LTG did not.

CONCLUSIONS

LTG and PHT monotherapy were similarly effective against these seizure types in patients with newly diagnosed epilepsy. LTG was better tolerated, more frequently causing rash, but with a lower incidence of central nervous system side effects.

How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting

BACKGROUND

Mistakes are an inevitable part of the practice of medicine. While the frequency and severity of medical errors are documented, little is known about patients' attitudes toward physician mistakes.

OBJECTIVE

To examine patient attitudes about physician errors.

DESIGN

A survey instrument assessed attitudes to 3 levels of physician mistakes (minor, moderate, and severe) and 2 fundamental physician responses: disclosure or nondisclosure. One hundred forty-nine study subjects were randomly selected from an academic general internal medicine outpatient clinic.

RESULTS

Virtually all patients (98%) desired some acknowledgment of even minor errors. Patient's desire for referral to another physician ranged from 14% following a minor mistake to 65% following a severe mistake. For both moderate and severe mistakes, patients were significantly more likely to consider litigation if the physician did not disclose the error. In the moderate mistake scenario, 12% of patients would sue if informed by the physician vs 20% if the physician failed to disclose the error and they discovered it by some other means (P < .001).

CONCLUSIONS

Patients desire an acknowledgment from their physicians of even minor errors, and doing so may actually reduce the risk of punitive actions. These findings reinforce the importance of open communication between patients and physicians.

Botulinum toxin--a possible new treatment for axillary hyperhidrosis

The inhibitory action of botulinum toxin is not limited to the neuromuscular junction. The toxin also blocks the autonomic cholinergic fibres, including the sympathetic fibres to sweat glands. We have previously demonstrated that the toxin produces localized anhidrosis. To determine the dosage, pattern and duration of the anhidrotic effect of botulinum toxin and to test the efficacy of axillary injections, we further studied seven healthy volunteers. Two individuals had subcutaneous injections of botulinum toxin (20 mouse units, Dysport-Porton Products) in the dorsum of the hand. Five healthy volunteers had 15-50U of botulinum toxin A (Botox) injected in one axilla. A circular area of complete anhidrosis on the dorsum of the hand was evident on day 2 and persisted for 11 months. By day 3, two of the axillae (injected with 50 U each) were totally dry and in one (injected with 30 U) the sweating was substantially reduced. The effect persisted for 6-8 months before wearing off. No effect was appreciated in two axillae (injected with 15 and 20 U). No significant side-effects were encountered. Subcutaneous injections of botulinum toxin causes chemodenervation of the sweat glands. In normal individuals axillary sweating can be abolished by 50 U of botulinum toxin A (Botox). The results offer a possible novel treatment for severe cases of axillary hyperhidrosis.

Botulinum toxin and sweating

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Scales for rating motor impairment in Parkinson's disease: studies of reliability and convergent validity

Study 1 examined the reliability of the ratings assigned to the performance of five sign-and-symptom items drawn from tests of motor impairment in Parkinson's disease. Patients with Parkinson's disease of varying severity performed gait, rising from chair, and hand function items. Video recordings of these performances were rated by a large sample of experienced and inexperienced neurologists and by psychology undergraduates, using a four point scale. Inter-rater reliability was moderately high, being higher for gait than hand function items. Clinical experience proved to have no systematic effect on ratings or their reliability. The idiosyncrasy of particular performances was a major source of unreliable ratings. Study 2 examined the intercorrelation of several standard rating scales, comprised of sign-and-symptom items as well as activities of daily living. The correlation between scales was high, ranging from 0.70 to 0.83, despite considerable differences in item composition. Inter-item correlations showed that the internal cohesion of the tests was high, especially for the self-care scale. Regression analysis showed that the relationship between the scales could be efficiently captured by a small selection of test items, allowing the construction of a much briefer test.

Botulinum toxin in treating spasticity

The value of locally injected botulinum toxin is emphasised. The toxin was injected directly into the skeletal muscles of eight patients with severe spasticity due to stroke-related hemiplegia. It produced both subjective and objective improvement. The toxin injections were well tolerated and no significant side effects were noted.

Effect of treatment with botulinum toxin on spasticity

Botulinum toxin, a product of Clostridium botulinum, produces presynaptic neuromuscular block by preventing release of acetylcholine from nerve endings. The toxin was injected directly into the skeletal muscles of six patients with severe spasticity due to stroke-related hemiplegia. It produced both subjective and objective improvement. The toxin injections were well tolerated and no significant side effect was reported.

EEG characteristics of epileptic pattern sensitivity and their relation to the nature of pattern stimulation and the effects of sodium valproate

Seven patients with pattern-sensitive epilepsy were examined repeatedly over a period of 4-12 months during which the dose of sodium valproate was adjusted. Patterns were presented in series in which the size of successive patterns was progressively increased until paroxysmal activity appeared, or until the largest pattern (radius 24 degrees visual angle) had been presented. As valproate dose increased, paroxysmal activity was less likely to occur. When it did occur it was less likely to include a spike; it had a lower voltage, involved fewer electrodes, and lasted a shorter time. The size of the pattern just sufficient to induce paroxysmal activity showed relatively little change with valproate dose. The degree to which the various electrodes were involved in the discharges showed considerable stability. The paroxysmal response to patterns presented in one visual half-field was almost invariably maximal over the contralateral posterior quadrant, usually at the posterior temporal electrode.

A comparison of phenytoin and pheneturide in patients with epilepsy: a double-blind cross-over trial

A double-blind cross-over trial between pheneturide and phenytoin in ninety-four outpatients with epilepsy is described. There was no significant difference between the frequency of seizures in the two groups. The difficulties in comparing two anticonvulsants of similar efficacy are discussed particularly in relation to ethical problems, the selection of patients and trial design.

Nomifensine: effect in Parkinsonian patients not receiving levodopa

A clinical trial using the anti-depressant nomifensine in Parkinsonism is reported. Eighteen subjects not receiving levodopa participated. The drug had a small, but significant anti-Parkinsonian effect. No troublesome side effects were encountered. In the treatment of Parkinsonism, nomifensine may be considered as an alternative to amantadine or anticholinergics, especially where depression is an added feature.

Exercise and hormonal secretion

The effect of graded exercise on the secretion of cortisol, testosterone, prolactin, growth hormone, thyroid stimulating hormone (TSH), luteinizing hormone and follicle stimulating hormone (FSH) is reported. While cortisol, prolactin, growth hormone and testosterone rise during the period of exercise, a rise in luteinizing hormone becomes evident only after rest. Levels of FSH and TSH remained unchanged.

Nomifensine in parkinsonism

1. The effect of nomifensine was compared with that of placebo in a double-blind crossover study in patients with parkinsonism. 2. Of the 29 patients who entered the study, three were previously untreated and 26 continued their L-DOPA or other antiparkinsonian therapy, or both, during the trial. 3. Clinical assessments were made at fortnightly intervals throughout the study. 4. The most noticeable improvement during active treatment--namely, tremor, facial expression and finger flexion were moderate in extent. 5. When placebo was substituted for active drug a significant deterioration of physical signs and functional disability occurred (P less than 0.001). 6. Elderly patients fared less well than younger patients, and the most common adverse effect was involuntary movements.

Nomifensine in parkinsonism

Nomifensine, a tetrahydroisoquinolone antidepressant which facilitates dopaminergic and noradrenergic transmission, was studied in 28 Parkinsonism patients most of whom were also receiving conventional medications. Double-blind evaluations revealed a moderate therapeutic action at a mean dose level of 150 mg daily. Adverse reactions were encountered, similar to those identical by levodopa.

Uptake and release of hormones and metabolites by tissues of exercising leg in man

To examine release of insulin from tissues of the exercising llin, growth hormone, cortisol, and circulating metabolites were studied in five men before, during, and after exercise on a bicycle ergometer at 60% of their maximum work capacity. At rest, insulin, growth hormone, and cortisol were taken up by leg tissues. During exercise arterial plasma insulin concentration fell, but cortisol and growth hormone levels rose; there was net release of insulin into venous blood but little change in uptake of cortisol and growth hormone. Insulin release persisted after exercise for 15-30 min. During exercise arterial concentrations and uptake of glucose and free fatty acids (FFA) increased. Examination of the changes in hormones and metabolites failed to identify any single hormonal or metabolic factor causing the observed reversal of insulin uptake with exercise.

Differences in the metabolic and hormonal response to exercise between racing cyclists and untrained individuals

1. Six well-trained cyclists and six untrained subjects were studied during and immediately after four successive 7 min periods of exercise at 30, 45, 60 and 75% of their maximal work capacity. 2. Venous blood samples were taken at rest, at the end of each exercise period and 5 min following the end of exercise, for estimation of metabolites in blood and plasma insulin, growth hormone, cortisol and catecholamines. 3. The results showed significant differences in the mobilization and utilization of muscle fuels between the athletically fit cyclists and the untrained group. In the cyclists, glucose, glycerol and free fatty acid concentrations were higher, but lactate, pyruvate and alanine were lower than in the untrained subjects during exercise. 4. Plasma catecholamines rose in both groups during exercise but the rise was significantly less in the racing cyclists. Plasma insulin was depressed to a greater extent in the untrained subjects during exercise and plasma glucagon rose to a greater extent during strenuous exercise and remained elevated after the end of exercise in the untrained group. Plasma human growth hormone rose to a greater extent during exercise and remained elevated after the end of exercise in the untrained group. Plasma cortisol fell at low and moderate exercise rates in both groups, but to a smaller extent in the cyclists. Cortisol values rose at higher workloads and were significantly higher in the cyclists at the end of exercise. 5. It is concluded that there are significant differences in the metabolic and hormonal responses to exercise between athletically trained and untrained individuals, even when the physically fit subjects work at the same percentage of their maximal capacity as the unfit subjects.

Raised intracranial pressure and cerebral blood flow. 5. Effects of episodic intracranial pressure waves in primates

The effects of episodic waves of intracranial pressure on cerebral blood flow were studied in primates. Six pressure waves each of 20 minutes' duration and ranging from 50 to 100 mmHg in magnitude were induced in baboons, at intervals of 30 minutes, in an attempt to simulate clinical plateau waves. With pressure waves up to 75 mmHg, cerebral blood flow remained at control levels despite falling cerebral perfusion pressures. Between the initial pressure waves a marked hyperaemia developed, with cerebral blood flow increasing by as much as 100%, and this appeared to be a means whereby adequate flow was maintained during pressure waves. Later pressure waves, up to 100 mmHg, eventually reduced blood flow below control levels, although moderately high flows were maintained during periods of very low perfusion pressure. Brain metabolism was affected by eht episodic pressure waves, although no consistent change was seen.

Effect of change of posture on blood pressure and plasma renin concentration in men with spinal transections

1. Blood pressure, heart rate and changes of plasma renin concentration (PRC) have been studied in nineteen patients with traumatic transection of the spinal cord, in relation to change of posture from supine to upright.

2. When supine, subjects with cervical-cord transection had a normal blood pressure, a low heart rate and a high plasma renin concentration. On change of posture to the vertical, orthostatic hypotension developed, heart rate rose and PRC increased. Orthostatic hypotension was not a feature with change of posture in patients with transection of the thoracic spinal cord and PRC rose to a much smaller extent.

3. It is concluded that release of renin on change of posture can occur in patients with spinal-cord transection. Release of renin in man does not depend therefore upon an intact autonomic nervous system, though it is possible that reflex sympathetic pathways in the isolated spinal cord may be involved.

Intermittent hypothermia. Independence of central and reflex thermoregulatory mechanisms

Three patients who had suffered episodes of spontaneous hypothermia are described. Circulatory control was normal for their age but there was evidence of a persistent defect of thermoregulatory mechanisms. In all patients vascular thermoregulatory reflexes dependent upon peripheral receptors were active and in two patients reflex shivering could be obtained. There appeared, however, to be a failure of central thermoregulation as the vascular reflexes were active at abnormally low central temperatures and a fall in central temperature did not initiate shivering. It is concluded that in patients who have suffered spontaneous hypothermia there may be a persistent defect of central mechanisms subserving vasomotion and shivering, although thermoregulatory reflexes dependent upon peripheral receptors can be active. The reflex pathways for thermoregulation in man therefore have a separate integrity, physiologically independent of the central thermoregulatory mechanisms.

Recurrent hyperkalaemia due to selective aldosterone deficiency: correction by angiotensin infusion

A patient with recurrent weakness and blurring of consciousness associated with hyperkalaemia due to aldosterone deficiency is reported. The plasma concentrations of renin, angiotensin II, and aldosterone were low and did not increase during sodium deprivation. Blood angiotensin I was also low while renin-substrate concentration was normal. Infusion of angiotensin produced a distinct rise in plasma aldosterone. The patient was treated successfully with fludrocortisol.The results support the concept that the renin-angiotensin system is an important regulator of aldosterone secretion and that in the syndrome of acquired selective hypoaldosteronism the primary abnormality may be a deficiency of renin. It is suggested that a selective lack of aldosterone should be considered in all cases of otherwise unexplained hyperkalaemia.

Plasma renin in idiopathic orthostatic hypotension: differential response in subjects with probable afferent and efferent autonomic failure

1. The changes of peripheral venous plasma renin concentration (PRC) induced by head-up tilting were studied in four patients with orthostatic hypotension.

2. Two of the patients had the Holmes—Adie syndrome and tests of autonomic function suggested that they had an afferent block from baroreceptors with intact efferent pathways; the others had no evidence of the Holmes—Adie syndrome and investigations suggested that they had interruption of efferent sympathetic pathways.

3. In the two patients in whom lesions of the afferent side of baroreceptor reflexes were suspected, a marked increase in PRC occurred with upright tilting, whereas no change in PRC occurred in the two patients thought to have an efferent sympathetic block.

4. During repeated tilting, supine blood pressure and PRC increased progressively in the two patients with suspected afferent block, but not in the two patients with suspected efferent block.

5. It is suggested that an increase in plasma renin may contribute to the supine hypertension sometimes observed in patients with orthostatic hypotension.

6. It is also suggested that renin release does not require intact autonomic reflexes although certain components of efferent sympathetic pathways, not dependent on baroreceptor reflexes, may be important.

The conformation of an atypical IgG myeloma protein and its papain fragments

An immunoglobulin IgG (Sackfield) which is known to have polypeptide chains shorter than those of typical proteins of its class has been subjected to fragmentation by papain in the presence of cysteine. One fragment was recovered which was indistinguishable from normal Fc fragment. The other fragment was related to normal Fab fragment but differed from it in several of its properties. The molecular weight was only one-half that of normal Fab. The optical rotatory dispersion spectrum of IgG (Sackfield) had features which differed from those of typical IgG myeloma proteins. The optical rotatory dispersion spectrum of Fc (Sackfield) was identical with those of other myeloma proteins, while the Fab (Sackfield) spectrum reflected the differences observed in the parent protein.