SARS-CoV-2 caused a surge in antibiotic consumption causing a silent pandemic inside the pandemic. A retrospective analysis of Italian data in the first half of 2022

BACKGROUND

The phenomenon of antibiotic resistance shows no sign of stopping, despite global policies to combat it that have been in place for several years. The risk of forms of pathogenic microorganisms that are increasingly resistant to common antibiotics has led health authorities around the world to pay greater attention to the phenomenon. The worrying situation, has led to further recommendations from the World Health Organization (WHO) and national recommendations in Italy through the new National Plan against Antibiotic Resistance 2022-2025 (PNCAR 2022-2025).

AIM

This manuscript aims to raise the awareness of all health professionals to follow what is suggested by regulatory agencies and scientific societies.

METHOD

We conducted a retrospective study of antibiotic pharmacoutilization in Italy, in the Campania region at the Azienda Sanitaria Locale (ASL) Napoli 3 Sud, on consumption in the first half of 2022 in a population of more than 1 million people.

RESULT

The results indicate that consumption, based on defined daily doses (DDDs), is above the national average. Probably the COVID-19 pandemic has influenced this growth in prescriptions.

CONCLUSIONS

Our study suggests an informed and appropriate use of antibiotics, so as to embark on a virtuous path in the fight against antibiotic resistance.

A systematic review on the efficacy and safety of IL-6 modulatory drugs in the treatment of COVID-19 patients

The pandemic caused by the new SARS-CoV2 coronavirus has led to an effort to find treatments that are effective against this disease that the World Health Organization calls COVID-19. In severe cases of COVID-19, there is an increase in cytokines, among which IL-6 seems to play an important role. A search has been performed for studies using IL-6 blocking drugs (tocilizumab, siltuximab, and sarilumab) in PubMed, Web of Science, and Scopus. Also, a search of ongoing trials registered at clinicaltrials.gov was performed. We found very little published clinical experience with these drugs, consisting mainly of case reports or case series with few patients. The results of clinical trials are necessary to clarify the role of these drugs in patients with COVID-19.

Role of imaging techniques in the diagnosis and follow-up of muscle-invasive bladder carcinoma

INTRODUCTION

Muscle-invasive bladder malignancies represent 20-30% of all bladder cancers. These patients require imaging tests to determine the regional and distant staging.

OBJECTIVE

To describe the role of various imaging tests in the diagnosis, staging and follow-up of muscle-invasive bladder cancer. To assess recent developments in radiology aimed at improving the sensitivity and specificity of local staging and treatment response.

ACQUISITION OF EVIDENCE

We conducted an updated literature review.

SYNTHESIS OF THE EVIDENCE

Computed tomography and magnetic resonance imaging (MRI) are the tests of choice for performing proper staging prior to surgery. Computed tomography urography is currently the most widely used technique, although it has limitations in local staging. Ultrasonography still has a limited role. Recent developments in MRI have improved its capacity for local staging. MRI has been suggested as the test of choice for the follow-up, with promising results in assessing treatment response. Positron emission tomography could improve the detection of adenopathies and extrapelvic metastatic disease.

CONCLUSIONS

Imaging tests are essential for the diagnosis, staging and follow-up of muscle-invasive bladder cancer. Recent technical developments represent important improvements in local staging and have opened the possibility of assessing treatment response.

Expression of Genes Related to Activity of Oxaliplatin and 5-Fluorouracil in Endoscopic Biopsies of Primary Esophageal Cancer in Patients Receiving Oxaliplatin, 5-Flourouracil and Radiation: Characterization and Exploratory Analysis with Survival

With a goal of identifying relations between gene expression and response (mucosal or pathological) or survival in esophageal cancer patients (stages II to IV) receiving oxaliplatin, 5-fluorouracil (5FU) and radiation, we measured in endoscopic primary tumor biopsies from 38 patients, the expression of seven genes (gammaGCS, gammaGT, MRP-2, ERCC-1, XPA, TS and DPD) prior to treatment, 1 week following oxaliplatin alone and at the end of the combined radio-chemotherapy cycle using real time QRT-PCR. A higher pretreatment level of XPA was related to shorter survival with a hazard ratio of 2.43 (90% confidence interval 1.09 to 5.43) using Cox regression modeling. However, multivariate analysis with a Cox model indicated low expression of XPA or TS and combined stages II and III had a higher probability of survival (for XPA: hazard ratio 3.0 and 90% C.I. of 1.3 to 6.9, with adjustment for stage included; for TS: hazard ratio is 1.98 with 90% C.I. of 0.94 to 4.20. The expression of TS, gammaGCS, ERCC-1 and MRP-2 declined from D 1 to the end of the cycle (p<0.05, sign test). A validation and further understanding of the findings need to be carried out in a larger study with a more homogeneous population of patients.

Independence of sleep-wakefulness cycle in an implanted head 'encephale isole'

A quantitative study was carried out on the sleep-wakefulness cycle by means of EEG recordings taken simultaneously from a dog's implanted head and its host. During survival (108 h), neurological activities of the implanted head were similar to those of classic 'encéphale isolé' preparations. In spite of a common circulation, the sleep-wakefulness cycles of the implanted head and host animal were independent. Independence was manifested by: (1) differing percentages of respective phases of their cycles; (2) periods of coincident phases in both heads, only occasionally beginning and/or stopping simultaneously; and (3) the implanted 'encéphale isolé' showed a monotonous cycle with numerous periods of short duration throughout night or day. The host presented a nycthemeral rhythm.

[Evaluation of patients' satisfaction of home care services]

The satisfaction level of a patient that receives home care, is an indicator that is rarely ever evaluated. This is also due to the fact that it is objectively difficult to gather data concerning this issue and there are a countless number of variables that could influence an evaluation. The objective of this study is to quantify the satisfaction level of those that use the Home Care Services of the Trento District. A validated questionnaire with 30 questions was used to explore the organizational, relational and professional aspects, communication, information and patient education in addition to the satisfaction level of certain aspects that concerned the availability/delivery of medical supplies and aids. Together with this information, data was also gathered concerning the patient's formal and informal social network. 122 patients, that received care by the nursing services of the territory and that received home care at least twice a week, were enrolled in the survey. The responses that emerged from this sample of patients, concerning the satisfaction level, were very positive. Each aspect had a high satisfaction percentage that was always beyond 75%. This survey must be used within the trust's continuous quality improvement plan, by addressing the needs that have been expressed and not, by empowering human and organizational resources and by integrating the numerous health care operators that work within the territory to improve citizens' health.

Dose distributions in phantoms irradiated in thermal columns of two different nuclear reactors

In-phantom dosimetry studies have been carried out at the thermal columns of a thermal- and a fast-nuclear reactor for investigating: (a) the spatial distribution of the gamma dose and the thermal neutron fluence and (b) the accuracy at which the boron concentration should be estimated in an explanted organ of a boron neutron capture therapy patient. The phantom was a cylinder (11 cm in diameter and 12 cm in height) of tissue-equivalent gel. Dose images were acquired with gel dosemeters across the axial section of the phantom. The thermal neutron fluence rate was measured with activation foils in a few positions of this phantom. Dose and fluence rate profiles were also calculated with Monte Carlo simulations. The trend of these profiles do not show significant differences for the thermal columns considered in this work.

Preliminary evaluations of the undesirable patient dose from a BNCT treatment at the ENEA-TAPIRO reactor

Boron neutron capture therapy (BNCT) is an experimental technique for the treatment of certain kinds of tumors. Research in BNCT is performed utilizing both thermal and epithermal neutron beams. Epithermal neutrons (0.4 eV-10 keV) penetrate more deeply into tissue and are thus used in non-superficial clinical applications such as the brain glioma. In the last few years, the fast reactor TAPIRO (ENEA-Casaccia Rome) has been employed as a neutron source for research into BNCT applications. Recently, an 'epithermal therapeutic column' has been designed and its construction has been completed. The Monte Carlo code MCNPX was employed to optimize the design of the column and to evaluate the dose profiles and the therapeutic parameters in the cranium of the anthropomorphic phantom ADAM. In the same context, some preliminary evaluations of the undesirable doses to the patient were performed with MCNPX. A hermaphrodite phantom derived from ADAM and EVA was employed to evaluate the energy deposition in some organs during a standard BNCT treatment. The total dose consists of the contributions from the primary neutron beam, the neutron interactions with boron and the neutron induced photons generated in the epithermal column structures and in the patient's tissues. The paper summarizes the computational procedure and provides a general dosimetric framework of the patient radiological protection aspects related to a BNCT treatment scenario at the TAPIRO reactor.

Monte Carlo optimisation of a BNCT facility for treating brain gliomas at the TAPIRO reactor

An epithermal boron neutron capture therapy facility for treating brain gliomas is currently under construction at the 5 kW fast-flux reactor TAPIRO located at ENEA, Casaccia, near Rome. In this work, the sensitivity of the results to the boron concentrations in healthy tissue and tumour is investigated and the change in beam quality on modifying the moderator thickness (within design limits) is studied. The Monte Carlo codes MCNP and MCNPX were used together with the DSA in-house variance reduction patch. Both usual free beam parameters and the in-phantom treatment planning figures-of-merit have been calculated in a realistic anthropomorphic phantom ('ADAM').

The TRADE experiment: shielding calculations for the building hosting the subcritical system

The TRADE project (TRiga Accelerator Driven Experiment), to be performed at the existing TRIGA reactor at ENEA Casaccia, has been proposed as a validation of the accelerator-driven system (ADS) concept. TRADE will be the first experiment in which the three main components of an ADS--the accelerator, spallation target and sub-critical blanket--are coupled at a power level sufficient to encounter reactivity feedback effects. As such, TRADE represents the necessary intermediate step in the development of hybrid transmutation systems, its expected outcomes being considered crucial--in terms of proof of stability of operation, dynamic behaviour and licensing issues--for the subsequent realisation of an ADS Transmutation Demonstrator. An essential role in the feasibility study of the experiment is played by radioprotection calculations. Such a system exhibits new characteristics with respect to a traditional reactor, owing to the presence of the proton accelerator. As beam losses always occur under normal operating conditions of an accelerator, shielding studies need to be performed not only around the reactor but also along the beam line from the accelerator to the spallation target. This paper illustrates a preliminary evaluation, using Monte Carlo methods, of the additional shielding to be located around the reactor structures, the beam transport line and the existing reactor building to allow access into the reactor hall and to restrict the doses outside to their legal limits.

An epithermal facility for treating brain gliomas at the TAPIRO reactor

An epithermal facility for treating patients with brain gliomas has been designed and is under construction at the fast reactor TAPIRO at ENEA Casaccia (Italy). The calculational design tools employed were the Monte Carlo codes MCNP/MCNPX together with the DSA in-house variance reduction patch. A realistic anthropomorphic phantom ("ADAM") was included to optimise dose profiles and in-phantom treatment-planning figures-of-merit. The adopted approach was to minimise the treatment time whilst maintaining a reasonable therapeutic ratio. It is shown that TAPIRO, in spite of its low power of 5 kW, is able to provide an epithermal beam that is of good quality and of sufficient intensity to allow a single beam patient irradiation, under conservative assumptions, of 50 min.

Characterisation of the TAPIRO BNCT thermal facility

Dosimetry and spectrometry measurements have been carried out in the thermal column of the research fast reactor RSV-TAPIRO (ENEA-Casaccia, Rome) in order to investigate its suitability for irradiation of cells or mice, with a view to research in the interests of boron neutron capture therapy (BNCT). The thermal column consists of a graphite moderator (40 cm thick) containing a lead shield (13 cm thick) in order to shield reactor background. The irradiation volume, inside this structure, has cubic shape (18 x 18 x 18 cm3). Besides measurements of fluence and dose rates in air or in phantom performed with thermoluminescence dosemeters (TLDs) and using the activation technique, dose and fluence profiles have been generated using a method based on gel dosemeters analysed with optical imaging. To check the consistency of the results, spectrometry measurements in the same irradiation volume have been performed by means of bubble detectors.

The nitric oxide pathway in the cardiovascular system

The present review analyzes the role nitric oxide (NO) plays in the homeostasis of the cardiovascular system. By regulating vascular smooth muscle cell and myocyte contractility, myocardial oxygen consumption and renal tubular transport, this simple molecule plays a central role in the control of vascular tone, cardiac contractility and short and long term regulation of arterial pressure. Fifteen years ago, all we knew about NO is that it had very similar properties as those of endothelium-derived relaxing factor and that its action was probably mediated by cGMP. An enormous amount of knowledge has since been amassed on the biochemical pathways that NO follows from the moment it is synthesized from L-arginine until the physiological or pathological actions take place in the effector cells. This review intends to organize this knowledge in a fashion that is easy to understand. We will dissect the NO pathway in different steps, focusing on the physiological and pathophysiological actions of the isoenzymes which synthesize NO, the molecules involved in this synthesis such as caveolins, protein kinases and cofactors, the situations in which endogenous inhibitors of NO synthase are formed from L-arginine instead of NO, the way in which NO exerts its physiological actions through cGMP-dependent protein kinases and finally, the pathological routes NO may follow when the oxidative status of the cell is high.

[Assessment of nociceptive suppression in laparoscopic postoperative status: prospective, randomized and comparative study with a control group]

In recent years endoscopic surgery has became a highly demanded procedure because it is an easy method for diagnosis and treatment in gynecological field. Post-operative pain is considered as a condition in the morbidity status. The objective of this study was to evaluate the nociceptive suppression in laparoscopic surgery. A prospective randomized trial was performed in order to evaluate this condition. A total of 45 patients were included. Three groups were randomized using two different anesthetics applied in the cult-de-sac and uterine-bladder union. Group A (n-15) received bupivacaine, group B (n = 15) ropivacaine and group C (control) saline solution was instilled. The pain was scored using the visual analog scale as same as blood pressure and heart rate in a 15 minute intervals in the recovery room. For study design there were no differences in age, weight, height and body mass index (EMI). The surgical and anesthetic times were similar among groups. However there were significant differences when pain was evaluated. For a less toxic effects and good preventive analgesia we recommend to use ropivacaine in the postoperative status.

Discrimination of various contributions to the absorbed dose in BNCT: Fricke-gel imaging and intercomparison with other experimental results

A method is described for the 3D measurements of absorbed dose in a ferrous sulphate gel phantom, exposed in the thermal column of a nuclear reactor. The method, studied for Boron Neutron Capture Therapy (BNCT) purposes, allows absorbed dose imaging and profiling, with the separation of different contributions coming from different secondary radiations, generated from thermal neutrons. In fact, the biological effectiveness of the different radiations is different. Tests with conventional dosimeters were performed too.

Release of nitric oxide after acute hypertension

We have shown that NO production, assessed by measuring changes in plasma nitrate concentration, is down-regulated when blood pressure falls. This study intended to determine first, whether NO-derived plasma nitrate varies in response to increases in blood pressure induced by different mechanical and pharmacologic stimuli, including angiotensin II and catecholamines; and second, specifically to study the interaction between angiotensin II and NO production. An intravenous infusion (4-10 min) of norepinephrine (7.5 microg/kg/min), phenylephrine (30 microg/kg/min), or angiotensin II (0.3 and 3 microg/kg/min) caused hypertension accompanied by an increase in plasma nitrate, as assessed by high-performance capillary electrophoresis. Mechanical hypertension elicited by aortic occlusion also was accompanied by an increase in plasma nitrate. Angiotensin II (0.03, 0.3, and 3 microg/kg/min, 10 min) dose-dependently increased blood pressure. The intermediate and high dose, but not the low dose, of angiotensin II increased plasma nitrate concentration. N(G)-nitro-L-arginine methyl ester (L-NAME) lowered the basal concentration of plasma nitrate, abolished the increase in plasma nitrate elicited by angiotensin II and norepinephrine, and potentiated the pressor effect of the low dose of angiotensin II, although this dose did not increase NO production. L-NAME also potentiated the pressor effects of the intermediate dose of angiotensin II. This study demonstrates that an augmented systemic production of NO, measured as an increase in plasma nitrate, takes place after acute hypertension. The results of this study suggest that an increase in NO generation occurs when angiotensin II hypertension exceeds a certain limit, below which the basal production of NO is sufficient to compensate the vasoconstriction.

Depletion of liver glutathione potentiates the oxidative stress and decreases nitric oxide synthesis in a rat endotoxin shock model

OBJECTIVE

To verify the effects of liver glutathione depletion on redox status and nitric oxide system in a rat endotoxic shock model.

DESIGN

Prospective, randomized, controlled study on rats.

SETTING

A cardiocirculatory research laboratory.

SUBJECTS

A total of 28 Sprague-Dawley male rats (200-250 g body weight) were divided into four experimental groups.

INTERVENTIONS

Arterial blood, liver, and lung samples were taken from each animal under sodium pentobarbital (40 mg/kg i.p.) anesthesia 4 hrs after lipopolysaccharide (LPS group: 5 mg/kg i.p.; n = 7) or vehicle (control group: isotonic NaCl sterile solution i.p.; n = 7) treatments. Phorone (250 mg/kg i.p.) was injected to deplete glutathione in another two experimental groups of rats 30 mins before LPS (phorone+LPS group; n = 7) or vehicle (phorone group; n = 7) treatments, and 4 hrs later the same samples as in LPS and control groups were taken under anesthesia.

MEASUREMENTS AND MAIN RESULTS

Compared with the control group, the LPS group presented higher plasma concentration of end products of nitric oxide metabolism nitrites/nitrates, higher lung activity of inducible nitric oxide synthase, and oxidative stress defined by increased plasma concentration of the lipid peroxides malonaldehyde and 4-hydroxynonenal, and decreased plasma total antioxidant capacity. Treatment with phorone depleted liver glutathione (80% to 90%). In the liver glutathione-depleted animals, the oxidative stress induced by LPS was potentiated and blunted the increases in inducible nitric oxide synthase and plasma nitrites/nitrates.

CONCLUSION

These results show that depletion of the liver glutathione increases the oxidative stress and decreases nitric oxide synthesis of LPS-induced shock in rats.

Detection of microcalcifications by means of multiscale methods and statistical techniques

The detection of clustered microcalcifications can help the radiologist to detect early breast cancer. Microcalcifications exhibit some important characteristics, such as small size and high luminosity. Use of a computer-aided diagnosis (CAD) method can prevent them being overlooked. In this report, a multiresolution analysis is performed based on a multilevel wavelet transformation. Decomposition produces sub-band images which become visible only as details of the different scales. Thereafter, all the images will be combined in a final image, in order to obtain an image that contains all the interest details at the scale where microcalcifications tend to appear. Once the image, called detail image, is obtained, it is necessary to determine which details correspond with microcalcifications. Statistical analysis of the histogram permits classification of the zones likely to contain microcalcifications. Applying this statistical techniques over the whole image and representing the results in a two-dimensional map, clustered microcalcification regions are clearly distinguishable.

Neutron measurements in the stray field produced by 158 GeV c(-1) per nucleon lead ion beams

This paper discusses measurements carried out at CERN in the stray radiation field produced by 158 GeV c(-1) per nucleon 208Pb82+ ions. The purpose was to test and intercompare the response of several detectors, mainly neutron measuring devices, and to determine the neutron spectral fluence as well as the microdosimetric (absorbed dose and dose equivalent) distributions in different locations around the shielding. Both active instruments and passive dosimeters were employed, including different types of Andersson-Braun rem counters, a tissue equivalent proportional counter, a set of superheated drop detectors, a Bonner sphere system, and different types of ion chambers. Activation measurements with 12C plastic scintillators and with 32S pellets were also performed to assess the neutron yield of high energy lead ions interacting with a thin gold target. The results are compared with previous measurements and with measurements made during proton runs.

Role of nitric oxide and prostaglandins in the long-term control of renal function

Previous studies have reported evidence of an important interaction between nitric oxide (NO) and prostaglandins in the acute regulation of renal function. The objective of this study was to determine in conscious dogs whether the renal effects of the prolonged administration of a cyclooxygenase inhibitor are enhanced when NO synthesis is reduced. Meclofenamate infusion (5 microg x kg(-1) x min(-1)) during 4 consecutive days (n=8) elicited a continuous decrease (P<0.05) in renal blood flow and plasma renin activity and a transitory decrease in sodium excretion. NG-Nitro-L-arginine methyl ester (L-NAME) infusion (5 microg x kg(-1) x min(-1)) during 6 days (n=8) produced a significant increase in arterial pressure and a transitory decrease (P<0.05) in both renal blood flow and plasma renin activity. The simultaneous inhibition of NO and prostaglandin synthesis (n=7) led to an increase in arterial pressure and a decrease in renal blood flow similar to those observed during the administration of either L-NAME or meclofenamate. In contrast, this simultaneous inhibition produced a decrease in glomerular filtration rate, which was not observed in the previous groups, and also induced an increase in renal vascular resistance and a decrease in sodium excretion greater (P<0.05) than those found during the inhibition of either NO or prostaglandins. Only a transitory decrease in plasma renin activity was found during meclofenamate infusion in this group. The results of this study present new evidence that the renal vasoconstrictor and antinatriuretic effects induced by the prolonged infusion of a cyclooxygenase inhibitor are significantly enhanced when NO synthesis is reduced. These results suggest that renal function may be more sensitive to the prolonged administration of a cyclooxygenase inhibitor in situations where NO production is reduced.

Alterations to the nitric oxide pathway in the spontaneously hypertensive rat

OBJECTIVES

To examine the role of nitric oxide in the cardiovascular system in spontaneous hypertension. In particular, we wanted to know whether the production of nitric oxide in the cardiovascular system of the spontaneously hypertensive rat is different from that of the normotensive Wistar-Kyoto rat and whether nitric oxide is biologically effective in this system.

DESIGN

We studied various aspects of the L-arginine-nitric oxide pathway in the cardiovascular system of spontaneously hypertensive rats and Wistar-Kyoto rats.

METHODS

To address the first objective we analysed the expression of endothelial nitric oxide synthase in the heart by Western blotting and the activity of constitutive nitric oxide synthase in resistance microvessels obtained from the mesenterium, both from spontaneously hypertensive rats and Wistar-Kyoto rats aged 14-18 weeks. We also analysed the concentration of the oxidative product of nitric oxide, nitrate, in plasma from these rats. To address the second objective, that is, to assess the bioactivity of nitric oxide, we studied the accumulation in tissue of cyclic guanosine 3',5'-monophosphate (GMP), as well as the acute and chronic effects of withdrawing the nitric oxide vasodilatory tone with the inhibitor of nitric oxide synthesis NG-nitro-L-arginine methyl ester on Wistar-Kyoto rats and spontaneously hypertensive rats.

RESULTS

We found that the expression of endothelial nitric oxide synthase in the heart, the activity of constitutive nitric oxide synthase in resistance microvessels and the concentration of nitrate in plasma were all significantly higher in the spontaneously hypertensive rats. In contrast, neither cyclic GMP levels nor the effects of NG-nitro-L-arginine methyl ester were greater in the spontaneously hypertensive rat than they were in the Wistar-Kyoto rat.

CONCLUSIONS

The nitric oxide pathway is upregulated in the resistance circulation and the heart of the spontaneously hypertensive rat by a mechanism involving induction of the constitutive nitric oxide synthase and overproduction of nitric oxide. However, nitric oxide is not sufficiently bioactive to stimulate the formation of cyclic GMP and to maintain an adequate nitric oxide-dependent vasodilatory tone.

Renal changes induced by nitric oxide and prostaglandin synthesis reduction: effects of trandolapril and verapamil

The benefits of the simultaneous administration of low doses of a calcium antagonist and a converting enzyme inhibitor in the treatment of hypertension and renal vasoconstriction are well established. The objective of this study was to evaluate whether the administration of low doses of a calcium antagonist and a converting-enzyme inhibitor have beneficial effects in treating the renal alterations induced by the acute administration of a cyclooxygenase inhibitor when nitric oxide synthesis is reduced. These effects were examined in anesthetized dogs before and during an acute sodium load. It was found that the intrarenal infusion of meclofenamate (5 microg x kg[-1] x min[-1]), simultaneously with a low dose of NG-nitro-L-arginine methyl ester (1 microg x kg[-1] x min[-1]), produced a 40% decrease of renal blood flow and glomerular filtration rate and a reduction in the renal excretory response to the sodium load. In a second group of dogs, intrarenal verapamil (0.5 microg x kg[-1] x min[-1]) was effective in blocking the effects of nitric oxide and prostaglandin synthesis inhibition on sodium excretion and glomerular filtration rate but did not modify the effects on renal blood flow. An intrarenal infusion of trandolapril (0.3 microg x kg[-1] x min[-1]) was effective in a third group of dogs in reducing the renal hemodynamic effects but not in preventing the antinatriuretic effect observed in the first group. Finally, in a fourth group, the simultaneous administration of verapamil and trandolapril was effective in treating all the renal changes induced by the cyclooxygenase inhibitor when nitric oxide synthesis was reduced. These results suggest that the combination of low doses of trandolapril and verapamil has additive effects in treating the renal vasoconstriction and antinatriuresis induced by the acute administration of a cyclooxygenase inhibitor, when nitric oxide synthesis is reduced.

Endothelium and high blood pressure

Due to its strategic anatomical position, the endothelium is constantly exposed to the different risk factors for atherosclerosis. During the last decade it has become clear that hypertension profoundly affects endothelial function. Depending on the form of hypertension, endothelium-dependent relaxation is impaired in most vascular beds. In spontaneous hypertension, the production of nitric oxide, which in endothelial cells is formed from L-arginine via the constitutively expressed enzyme endothelial nitric oxide synthase, represents the main mediator of endothelium-dependent vasodilation and seems to be enhanced. On the other hand, the release of endothelium-dependent contracting factors such as prostaglandin H2 and thromboxane A2 have been demonstrated in this model of hypertension. Similar results have been obtained in the forearm circulation of patients with essential hypertension. In contrast, in models of salt-sensitive hypertension no release of vasoconstrictor prostanoids can be found indicating a decreased production of nitric oxide. Thus, in spontaneous hypertension an increased production of nitric oxide seems to occur, which is ineffective due to either the simultaneous release of endothelium-dependent vasoconstrictors and/or inactivation of nitric oxide, or due to anatomical changes such as hypertension-induced intimal thickness which inhibits its action on vascular smooth muscle cells. In summary, in hypertension, endothelium-dependent vasodilation is blunted and the endothelial L-arginine nitric oxide pathway is altered. These changes seem to represent a consequence rather than a cause of hypertension.

Comparative effects of nitric oxide synthesis inhibition and catecholamine treatment in a rat model of endotoxin shock

Catecholamines and volume repletion are currently used for the treatment of septic shock. However, the prognosis of patients suffering from this condition is very poor. An overproduction of nitric oxide (NO) seems to be related to the hypotension and tissue damage of endotoxin shock. Thus, treatment with NO synthase inhibitors has been proposed. Using a rat model of septic shock we have studied the effects of noradrenaline or the NO synthase inhibitor, NG-nitro-L-arginine methylester (L-NMMA) on arterial pressure, tissue damage and NO production. Anaesthetized rats treated with Salmonella typhosa showed a decrease in blood pressure accompanied by an increase in the plasma concentration of cytosolic enzymes (transaminases and lactate dehydrogenase, markers of cell disruption) and nitrite plus nitrate (NO2-/NO3-, markers of NO production). A large proportion of these animals (40%) died before the end of the experiment. Co-treatment with noradrenaline resulted in temporary maintenance of arterial pressure followed by a decline, despite the dose being increased progressively. No differences were observed in plasma cytosolic enzymes, NO2-/NO3- or mortality compared with animals treated with lipopolysaccharide (LPS) alone. In contrast, administration of L-NMMA (10 mg kg-1) to septic animals prevented the fall in blood pressure and death caused by endotoxin. This treatment markedly diminished cell disruption, as measured by the plasma levels of necrosis enzymes, and partially, but significantly, reduced the production of NO as assessed by plasma NO2-/NO3-. We conclude that tissue damage in septic shock is related to the overproduction of NO and not exclusively to the hypotension that follows this increased production. Thus, maintenance of blood pressure with catecholamines fails to improve cellular damage. Instead, partial inhibition of NO generation is sufficient to ameliorate the haemodynamic and tissue-damaging effects of septic shock and improves survival in this model of endotoxaemia.

Role of angiotensin II in the renal effects induced by nitric oxide and prostaglandin synthesis inhibition

The objective of this study was to examine the renal effects of changes in intrarenal angiotensin II levels during the administration of a cyclooxygenase inhibitor, when nitric oxide synthesis is reduced. In the first group of dogs, the administration of meclofenamate and a subpressor dose of L-NAME induced an increase (P < 0.05) in arterial pressure (14 +/- 2 mm Hg), a decrease (P < 0.05) in RBF (180 +/- 13 to 111 +/- 10 mL/min) and GFR (37 +/- 3 to 24 +/- 5 mL/min), and a reduction in the renal excretory response to a sodium load. In the second group, the administration of a converting enzyme inhibitor prevented the increase in arterial pressure, the renal vasoconstriction, and the increase in the proximal but not the distal tubular sodium reabsorption induced by the inhibition of prostaglandins and nitric oxide synthesis. In the third group, it was found that a small increase in the intrarenal angiotensin II levels, which does not produce changes in renal function in control conditions, induced a significant decrease in RBF (183 +/- 14 to 71 +/- 12 mL/min) and GFR (36 +/- 3 to 13 +/- 4 mL/min) when meclofenamate was administered and nitric oxide synthesis was slightly reduced. The results of this study suggest that renal vasoconstriction and increased proximal sodium reabsorption during the reduction of nitric oxide and prostaglandin synthesis are produced by endogenous angiotensin II levels. These results also suggest that endogenous intrarenal nitric oxide and prostaglandins may serve as homeostatic mediators of angiotensin II effects when the intrarenal levels are inappropriately elevated, as occurs in salt-sensitive hypertension.

Nitric oxide synthase activity in renal cortex and medulla of normotensive and spontaneously hypertensive rats

The medullary portion of the kidney plays a crucial role in the control of sodium and water excretion and arterial pressure. This control is anomalous in hypertension and may be related to an impaired renal nitric oxide (NO) production. We have measured the activity of NO synthase (NOS) in the renal medulla, renal cortex, heart, and aorta from normotensive Wistar Kyoto rats (WKY) and spontaneously hypertensive rats (SHR). Enzyme activity was determined by measuring the conversion of 14C-L-arginine to 14C-L-citrulline. Ca2+-dependent NOS activity was considerably higher in the renal medulla than in the other tissues studied, both in WKY and SHR. The medulla and heart of the SHR displayed a higher Ca2+-dependent NOS activity compared to that of WKY. No differences were found in the Ca2+-independent NOS activity, except for the renal cortex of the SHR, which was higher than in the rest of the tissues. These observations indicate that the renal medulla has a high relative capacity to synthesize NO and suggest that the impaired renal medullary control of arterial pressure of genetic hypertension is not due to a reduced NO production by the kidney.

Changes in nitric oxide release in vivo in response to vasoactive substances

1. Changes in the release of nitric oxide (NO) in vivo were studied in rats following the administration of endothelium-dependent and -independent vasodilators as well as the NO synthesis inhibitor, NG-nitro-L-arginine methyl ester (L-NAME). NO production was assessed by measuring variations of nitrate in plasma by capillary ion analysis. 2. Intravenous administration of the endothelium-dependent vasodilators, bradykinin (2 and 10 micrograms kg-1 min-1) or substance P (0.3-3 micrograms kg-1 min-1) caused a transient dose-dependent hypotension followed by an increase in plasma nitrate concentration (maximal increments: 33 +/- 5% and 38 +/- 6%, for bradykinin and substance P, respectively). Prior administration of L-NAME (10 mg kg-1 min-1) inhibited the hypotension and increase in plasma nitrate caused by these substances. Intravenous administration of sodium nitrate (200 micrograms kg-1) also produced a transitory elevation in plasma nitrate which was similar in magnitude as that caused by the vasodilators. A rapid and transitory increment in plasma nitrate was observed after i.v. administration of authentic NO (400 micrograms kg-1). 3. Rats receiving the endothelium-dependent vasodilators, prostacyclin (0.6 micrograms kg-1 min-1) or adenosine (3 mg kg-1 min-1) intravenously showed a drop in blood pressure paralleled by a decrease in plasma nitrate (maximal decreases: 34 +/- 5% and 24 +/- 4%, for prostacyclin and adenosine, respectively). A similar effect on the plasmatic concentration of nitrate was observed when L-NAME (10 mg kg-1 min-1, i.v.) was administered to the animals. 4. This study demonstrates that (i) changes in plasma nitrate can be detected in vivo after stimulation or inhibition of NO synthase, (ii) an increased production of NO, measured as plasma nitrate, is related to the hypotension caused by bradykinin and substance P and (iii) a diminished concentration of plasmatic nitrate is associated to the hypotension induced by adenosine or prostacyclin (endothelium-independent vasodilators), suggesting that the L-arginine: NO pathway is capable of rapid down-regulation in response to a fall in blood pressure.

Spontaneous calcium-independent nitric oxide synthase activity in porcine ciliary processes

In the cornea, iris, retina, and ciliary processes of porcine eyes the nitric oxide synthase (NOS) activity was assayed by measuring the transformation of L-[U-14C]-arginine into L-[U-14C]-citrulline: (1) in the absence or presence of the calcium-chelator, ethylene glycol tetra acetic acid (EGTA), and (2) in the presence of EGTA and the false precursor of L-arginine, NG-nitro-L-arginine methyl ester (L-NAME). In the retina and the iris a high calcium-dependent NOS activity was present, while in the cornea the activity was relatively low. In these three tissues no significant calcium-independent NOS activity was detected. In contrast, a marked calcium-independent NOS activity, but no calcium-dependent NOS activity, was found in the ciliary processes. The presence of a spontaneous calcium-independent NOS activity in the ciliary processes suggests that nitric oxide (NO) production is highly regulated in this tissue.

Cyclic guanosine 3',5' monophosphate concentrations in pre-eclampsia: effects of hydralazine

OBJECTIVE

To elucidate the role of the L-arginine:nitric oxide pathway in pregnancy and pre-eclampsia.

PARTICIPANTS

Pregnant women (nulliparous, age <25 years). Normotensive pregnancy (n=22) was defined when blood pressure remained at levels of <120/80 mmHg and there was no proteinuria. Women with pre-eclampsia (n=22) had blood pressure measurements of >140/90 mmHg and proteinuria of >300 mg/l. Nonpregnant normotensive women (n=22) were studied as controls.

STUDY DESIGN

Blood samples were taken for measurements of ionised calcium, atrial natriuretic factor, cyclic guanosine 3'5' monophosphate (GMP),arginine and asymmetric dimethylarginine. Urine samples were collected for determination of cyclic GMP excretion. Cyclic GMP concentrations were also determined in 12 women with severe pre-eclampsia before and after treatment with hydralazine.

RESULTS

L-arginine, asymmetric dimethylarginine and atrial natriuretic factor were not different in any group. Cyclic GMP concentrations in plasma [0.94 (SD 0.23) nM] as well as in urine [50.1 (SD 15.7) microM] were increased significantly (P<0.05) in normal pregnancy compared to nonpregnant controls [plasma mean 0.46 (SD 0.12) nM and urine mean 18.4 (SD 10.3) microM], but not in the pre-eclampsia group [plasma mean 0.48 (SD 0.10) nM and urine mean 24.1 (SD 14.5) microM]. Concentrations of cyclic GMP in plasma and urine increased significantly (P<0.05) in women treated with hydralazine.

CONCLUSIONS

The differences in cyclic GMP concentrations may reflect differences in nitric oxide production. Hydralazine increases cyclic GMP concentrations in severely pre-eclamptic women. This action could explain the antihypertensive effect of hydralazine.

Antihypertensive therapy prevents endothelial dysfunction in chronic nitric oxide deficiency. Effect of verapamil and trandolapril

The objective of this study was to examine the effects of long-term antihypertensive therapy on blood pressure and vascular responses of resistance arteries during prolonged inhibition of nitric oxide synthesis. Four groups of 6-week-old Wistar-Kyoto rats were treated with either placebo as controls or N omega-nitro-L-arginine methyl ester (L-NAME) alone or in combination with verapamil or with trandolapril. Drugs were given orally for 6 weeks or short-term in vitro to vessels obtained from untreated rats. Endothelium-dependent and -independent relaxations as well as contractions were studied in isolated perfused mesenteric and renal arteries with an arteriograph. Kidney nitric oxide synthase activity was also evaluated. Verapamil and trandolapril prevented the increase in systolic blood pressure and the blunted acetylcholine-induced relaxations that occurred with L-NAME treatment without improving the nitric oxide synthase activity. Both antihypertensive regimens also normalized sensitivity to sodium nitroprusside, which was enhanced by L-NAME. In contrast, short-term in vitro preincubation with verapamil or trandolaprilat in the presence of L-NAME did not improve the impaired relaxations to acetylcholine. Long-term but not short-term therapy with a calcium antagonist or angiotensin-converting enzyme inhibitor improved the blunted endothelium-dependent relaxations in nitric oxide-deficient hypertension. These findings strongly suggest that the role of other vasodilator systems, which normally do not regulate vascular tone, is enhanced with long-term but not short-term treatment with these drugs. These observations emphasize the potential importance of these treatments in the management of hypertension in which nitric oxide production is diminished.

Expression of nitric oxide synthase isoforms in the thyroid gland: evidence for a role of nitric oxide in vascular control during goiter formation

The thyroid gland is a highly vascular tissue, and its blood flow changes dramatically in various pathological conditions. Although the mechanisms regulating these changes in vascularity and blood flow are not well understood, candidate mediators include endothelin-1 (ET-1) and nitric oxide (NO). In the present study, we used a reverse transcriptase-polymerase chain reaction assay to determine which components of these vasoregulatory pathways are present in the thyroid and to analyze changes in gene expression in an experimental model of goiter formation and involution. Expression of messenger RNAs (mRNAs) encoding ET-1, ET receptors (ETA and ETB), ET-converting enzyme, and the three nitric oxide synthase (NOS) isoforms (NOS I, NOS II, and NOS III) was readily detected in the rat thyroid. After goiter formation was induced by thiouracil and a low iodine diet, there was increased expression of the genes encoding ET-related proteins (ET-1, 3.2-fold; ETA, 2.9-fold; ETB, 3.5-fold) as well as two of the three NOS isoforms (NOS I, 2.7-fold; NOS III, 4.9-fold). During iodide-induced involution, the ET-related mRNA levels remained elevated, whereas those of the two NOS isoforms returned to basal values. ET-converting enzyme, NOS II, and thyroglobulin mRNAs were minimally affected in this model, providing evidence for selective regulation of these genes. To assess whether NO plays a role in vascular changes during goiter formation, animals were treated with a NOS inhibitor, N-nitro-L-arginine methyl ester (NAME). NOS activity in the thyroid was inhibited by more than 75% after treatment with NAME. Thyroid hormone and TSH levels were unchanged. Although NAME had little effect on overall thyroid size, vascular expansion during goiter formation was decreased by 36%. We conclude that the thyroid gland expresses a complex network of vasoactive genes whose expression is regulated dynamically during thyroid goiter formation and involution. NO production and probably other locally produced vasoactive substances are involved in changes in thyroid vascularization.

[Radiology of nonpalpable breast lesions]

The authors reviewed 619 consecutive cases of breast nonpalpable lesions detected with mammography in which wire-directed open biopsy or stereotaxic biopsy was performed from 1984 to 1993. The ratio of benign to malignant biopsy findings was 4:1 for the whole series. The positive predictive value (PPV) of different radiologic pattern was determined. Biopsy is advised in the presence of patterns such as strongly suspect microcalcifications (granular or branching morphologic features), stellate masses, parenchimal distortion, opacities with undefined borders and asymmetric density, which yielded higher PPVs (26%, 93%, 92%, 35%, 42% and 19% respectively). However, follow-up with mammography is advised in probably benign lesions (opacity with regular borders and clusters of round or oval particles of calcifications), which yielded lower PPVs (1.5% and 3%). By decreasing the number of biopsies of probably benign lesions and thereby substantially reducing costs, this approach may help to widespread use of mammographic screening.

[Hepatic veno-occlusive disease associated with ingestion of Senecio tephrosioides]

A case of hepatic veno-occlusive disease (HVOD) in a 38 year-old woman is reported. She had occasionally consumed "Huamanrripa" (Senecio tephrosioides) as a cough remedy for many years. She was hospitalized because she had presented abdominal pain, jaundice and anasarca during 10 weeks. The histological studies of hepatic biopsy showed pronounced congestion to centrilobulillar predominance, focus of necrosis and a reversed lobulation pattern in some areas. In the next 13 months she was hospitalized four times due to complications of portal hypertension. This is the first reported case of HVOD associated with S tephrosioides ingestion. It is very probable that this plant used in peruvian traditional medicine contains pyrrolizidine alkaloids, hepatic and nephrotoxic substances that are present in other species of Senecio genus. Due to present popularity of alternative medicine, an increment in HVOD incidence is expected.

Endothelium-derived vasoactive factors in hypertension: nitric oxide and endothelin

ENDOTHELIUM-DERIVED NITRIC OXIDE: The endothelium is a source of vasoactive factors among which the most relevant are nitric oxide and endothelin. Nitric oxide is synthesized from L-arginine by a family of nitric oxide synthases and is a widespread biological mediator. It is implicated in many physiological and pathophysiological processes, including a variety of cardiovascular diseases like hypertension. NITRIC OXIDE AND HYPERTENSION: The release of nitric oxide seems to be modulated by changes in blood pressure. However, the role of nitric oxide in hypertension is still controversial and seems to vary depending on the stage of the disease and the model studied. In spontaneous hypertension, the production of nitric oxide is increased but inefficacious, probably because of increased inactivation or scavenging. In the heart the production of nitric oxide seems to be increased, probably as a compensatory mechanism against hypertension. In salt-induced hypertension, nitric oxide production may be impaired. In human hypertension, pharmacological experiments reveal an impaired nitric oxide dilator mechanism. In pulmonary hypertension, the use of nitric oxide gas inhalation has been proposed as a future therapy for this condition. ENDOTHELIN: Endothelin-1 is a potent vasoconstrictor peptide produced and released from endothelial cells. In isolated blood vessels, endothelin causes profound contraction. The hemodynamic effects of endothelin can be explained by the activation of two endothelin receptors, ETA and ETB. The relationship between endothelin and hypertension is not clear. Although plasma endothelin levels are normal in most patients with essential hypertension, the hypertensive blood vessel wall may contract more profoundly in response to the peptide; hence, endothelin antagonists may have antihypertensive effects in patients with hypertension.

Nitric oxide in cardiovascular diseases

Nitric oxide (NO), synthesized from L-arginine by a family of NO synthases (NOS), is a widespread biological mediator implicated in many physiological and pathophysiological processes, including a variety of cardiovascular diseases. Endothelium-derived NO, synthesized by a constitutive NOS, is involved in hypertension, atherosclerosis and certain heart diseases. In hypertension and atherosclerosis the role of NO is still controversial and seems to vary depending on the stage of the disease and model studied. In spontaneous hypertension, the production of NO is increased, but inefficacious, probably because of increased inactivation. In salt-induced hypertension NO production may be impaired. In atherosclerosis, an enhanced degradation of NO by superoxide radicals may explain the reduced endothelium-dependent relaxations. In pulmonary hypertension, the use of NO gas inhalation has been proposed as a future therapy for this condition. In the heart, NO regulates coronary flow and myocardial function; both functions are altered in coronary artery disease and cardiomyopathy. Nitric oxide synthesized by the inducible NOS takes part in several immunopathological diseases, such as endotoxin shock, which can particularly affect the heart. In endotoxaemia inducible NOS is overexpressed and the excess in NO production may account for the impaired cardiac performance of this condition. The overproduction of NO occurring in endotoxin shock is also responsible for the hypotension, catecholamine resistance and tissue damage characteristic of this disease. Treatment with inhibitors of NO synthesis is a promise for the future.

Increased activity of constitutive nitric oxide synthase in cardiac endothelium in spontaneous hypertension

BACKGROUND

We analyzed the activity of nitric oxide synthase in the rat heart to study whether this activity is affected by high blood pressure. Hearts from young (3 to 4 weeks old) and adult (15 to 25 weeks old) Wistar-Kyoto (WKY) rats and spontaneously hypertensive rats (SHR) were excised and frozen in liquid nitrogen. The activities of Ca(2+)-dependent (cNOS) and Ca(2+)-independent (iNOS) were determined in homogenized tissues by measuring the conversion of [14C]-L-arginine to [14C]-L-citrulline in the presence or absence of either EGTA (1 mmol/L) or EGTA plus NG-nitro-L-arginine methyl ester (L-NAME, 1 mmol/L each).

METHODS AND RESULTS

Arterial pressure was higher in adult SHR than in young SHR and WKY rats of both ages (P < .01). The cNOS activity was two to three times higher in hypertensive than in normotensive hearts (P = .01 to P = .04). No significant activity of iNOS was detected in any tissue. Studies of the right and left ventricles demonstrated a higher cNOS activity in the left sides of the hearts of adult SHR (P < .05). No differences were found in hearts from WKY rats. Selective removal of endocardial or coronary endothelial cells in hearts of SHR and WKY rats substantially reduced cNOS activity (P < .01).

CONCLUSIONS

The cNOS activity is upregulated in cardiac endothelial cells of genetically hypertensive rats. The high activity of cardiac cNOS is related to increased arterial pressure of these animals. We propose that in the heart, endothelial cells respond with a higher production of nitric oxide as a compensatory mechanism against high blood pressure and its damaging effects in this organ.

Simplification of the polymerase chain reaction for detection of Mycobacterium tuberculosis in the tropics

It has been suggested that the technical complexities, the expense of equipment and consumables, and problems associated with contamination make the polymerase chain reaction (PCR) inappropriate for use in developing countries. These problems were addressed using a novel one-tube nested PCR, small reaction volumes and a 'three room' system for the detection of Mycobacterium tuberculosis. The PCR of sputum samples dried on small filter paper disks was also investigated. Using this strategy 5 smear-positive and 15 smear-negative specimens were correctly identified by PCR. This method of sample collection has the advantage that samples can be sent by post and stored in a minimum of space, and remain viable for PCR for at least 4 years after collection. These and future modifications to the PCR protocol will make the assay more suitable for use in the tropics.

Receptor-mediated effect of a synthetic thromboxane-analogue on cytosolic calcium in isolated proximal tubules

The aims of this study were to measure cytosolic calcium concentration -[Ca2+]i- under resting conditions in isolated renal proximal tubules and to analyze the effect of U-46619 (stable analogue of thromboxane A2/PGH2 on [Ca2+]i in a mammalian epithelium. Proximal tubules were dissected out from male New Zealand rabbits (2.5 to 3.0 kg). After isolation they were washed twice and resuspended in 2 ml phosphate buffer solution (PBS). Tubules were loaded with Quin 2-AM (25 microM) for 15 min. After washing with PBS to eliminate the excess of extracellular Quin 2, fluorescence was measured at 340 nm excitation and 490 emission, under resting conditions and after stimulation. U 46619 (from 10 nm to 10 mM) increased [Ca2+]i in a concentration-dependent pattern. Exposure to an antagonist of the thromboxane receptor (S-145) blocked the response to U-46619. Removal of external calcium abolished the response to U-46619. Change of PBS for Ringer-choline blunted the response to thromboxane analogue. Our results indicate that U-46619 increases cytosolic calcium through a receptor-mediated mechanism that requires external calcium to operate. Blockade of the response in the absence of external sodium suggests that Na+/Ca2+ exchanger participates in this response.

The role of nitric oxide in endotoxic shock: effects of NG-monomethyl-L-arginine

The role of nitric oxide (NO) in the changes in blood pressure and plasma levels of nitrate and nitrite (NOx) and alanine aminotransferase (ALT) were determined over a 5-h period in anesthesized rats after intravenous administration of S. typhosa endotoxin (LPS, 4 mg/kg). Rats treated with LPS showed a sustained fall in blood pressure accompanied by an increase in plasma NOx and ALT. Forty percent of these rats died during the experiment. There was no change in blood pressure in rats treated with dexamethasone (1 mg/kg) 1 h before and 2 h after LPS and the increase in NOx and ALT was significantly inhibited. None of the rats in this group died. Administration of 10 mg/kg of NG-monomethyl-L-arginine (L-NMMA) prevented the fall in blood pressure and partially prevented the increase in NOx and ALT. None of the animals in this group died. In contrast, 300 mg/kg of L-NMMA caused an initial increase in blood pressure followed by a rapid fall and enhanced the increase in ALT while abolishing the elevation of NOx. All of these animals died before the end of the experiment. However, when rats treated with high doses of L-NMMA were given a continuous infusion of S-nitroso-N-acetylpenicillamine (SNAP, 300 micrograms/kg/h), the blood pressure was maintained at control levels and no mortality was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Induction and potential biological relevance of a Ca(2+)-independent nitric oxide synthase in the myocardium

1. We have investigated whether the myocardium and isolated cardiac myocytes can express a Ca(2+)-independent NO synthase after treatment with endotoxin or cytokines. Nitric oxide synthesis was measured in cytosols from the left ventricular wall from rats treated with endotoxin, or from freshly isolated myocytes from adult rats treated in vitro with cytokines. 2. Cytosols from the ventricle of saline-treated control animals showed only Ca(2+)-dependent NO synthesis. After treatment with endotoxin, the expression of an inducible, Ca(2+)-independent NO synthase was observed. The activity of this enzyme was maximal at 6 h and returned towards control levels by 18 h; no alterations occurred in the Ca(2+)-dependent NO synthase activity. Parallel to this enzyme induction there was an increase in myocardial guanosine 3':5'-cyclic monophosphate (cyclic GMP) and plasma nitrite and nitrate (NOx-). All these changes were prevented by pretreatment of the rats with dexamethasone. 3. Myocytes possessed Ca(2+)-dependent NO synthase activity and expressed, after treatment with tumour necrosis factor-alpha (TNF-alpha) and interleukin-1 beta (IL-1 beta), a Ca(2+)-independent NO synthase, the induction of which was prevented by dexamethasone and cycloheximide. 4. Since increases in cyclic GMP levels in the heart are associated with reduced myocardial contractility, it is possible that the enhanced production of NO by a Ca(2+)-independent enzyme accounts, at least in part, for the depression of myocardial contractility seen in septic shock, cardiomyopathies, allograft rejection, burn trauma, as well as during anti-tumour therapy with cytokines.