T helper cells in synovial fluid of patients with rheumatoid arthritis primarily have a Th1 and a CXCR3+Th2 phenotype

Background

The majority of CD4⁺ T helper (Th) cells found in the synovial fluid (SF) of patients with rheumatoid arthritis (RA) express CXCR3, a receptor associated with Th1 cells. In blood, subsets of Th2 and Th17 cells also express CXCR3, but it is unknown if these cells are present in RA SF or how cytokines from these subsets affect cytokine/chemokine secretion by fibroblast-like synoviocytes (FLS) from patients with RA.

Methods

We examined the proportions of Th1, Th2, CXCR3⁺Th2, Th17, CXCR3⁺Th17, Th1Th17, peripheral T helper (TPh) and T follicular helper (TFh) cells in paired SF and blood, as well as the phenotype of TPh and TFh cells in RA SF (n = 8), by the use of flow cytometry. We also examined the cytokine/chemokine profile in paired SF and plasma (n = 8) and in culture supernatants of FLS from patients with chronic RA (n = 7) stimulated with Th-associated cytokines, by the use of cytometric bead arrays and ELISA. Cytokine receptor expression in FLS (n = 3) were assessed by the use of RNA sequencing and qPCR.

Results

The proportions of Th1 and CXCR3⁺Th2 cells were higher in SF than in blood (P < 0.05). TPh and PD-1^highTFh in RA SF were primarily of a Th1 and a CXCR3⁺Th2 phenotype. Moreover, the levels of CXCL9, CXCL10, CCL20, CCL2, CXCL8, IL-6 and IL-10 were higher in SF than in plasma (P < 0.05). Lastly, IL-4, IL-13 and IL-17A induced RA FLS to secrete proinflammatory IL-6, CCL2, CXCL1 and CXCL8, while IFNγ mainly induced CXCL10.

Conclusion

These findings indicate that not only Th1 but also CXCR3⁺Th2 cells may have a pathogenic role in RA synovial inflammation.

The Rheumatoid Arthritis Risk Gene AIRE Is Induced by Cytokines in Fibroblast-Like Synoviocytes and Augments the Pro-inflammatory Response

The autoimmune regulator AIRE controls the negative selection of self-reactive T-cells as well as the induction of regulatory T-cells in the thymus by mastering the transcription and presentation of tissue restricted antigens (TRAs) in thymic cells. However, extrathymic AIRE expression of hitherto unknown clinical significance has also been reported. Genetic polymorphisms of AIRE have been associated with rheumatoid arthritis (RA), but no specific disease-mediating mechanism has been identified. Rheumatoid arthritis is characterized by a systemic immune activation and arthritis. Activated fibroblast-like synoviocytes (FLS) are key effector cells, mediating persistent inflammation, and destruction of joints. In this study, we identified AIRE as a cytokine-induced RA risk gene in RA FLS and explored its role in these pathogenic stroma cells. Using RNA interference and RNA sequencing we show that AIRE does not induce TRAs in FLS, but augments the pro-inflammatory response induced by tumor necrosis factor and interleukin-1β by promoting the transcription of a set of genes associated with systemic autoimmune disease and annotated as interferon-γ regulated genes. In particular, AIRE promoted the production and secretion of a set of chemokines, amongst them CXCL10, which have been associated with disease activity in RA. Finally, we demonstrate that AIRE is expressed in podoplanin positive FLS in the lining layer of synovial tissue from RA patients. These findings support a novel pro-inflammatory role of AIRE at peripheral inflammatory sites and provide a potential pathological mechanism for its association with RA.

Methotrexate inhibits effects of platelet-derived growth factor and interleukin-1β on rheumatoid arthritis fibroblast-like synoviocytes

Background

A key feature of joints in rheumatoid arthritis (RA) is the formation of hyperplastic destructive pannus tissue, which is orchestrated by activated fibroblast-like synoviocytes (FLS). We have demonstrated that the RA risk gene and tumor suppressor Limb bud and heart development (LBH) regulates cell cycle progression in FLS. Methotrexate (MTX) is the first-line treatment for RA, but its mechanisms of action remain incompletely understood. Here, we studied the effects of MTX on mitogen-induced FLS proliferation and expression of cell cycle regulators in vitro.

Methods

Primary FLS from patients with RA or osteoarthritis were stimulated with the mitogen platelet-derived growth factor (PDGF) and the cytokine interleukin-1β (IL-1β) in the presence or absence of MTX. Cells were then subjected to qPCR for gene expression and cell cycle analysis by flow cytometry.

Results

Stimulation with PDGF and IL-1β increased the percentage of FLS in the G2/M phase and shifted the cell morphology to a dendritic shape. These effects were inhibited by MTX. Furthermore, PDGF + IL-1β reduced LBH mRNA expression. However, MTX treatment yielded significantly higher transcript levels of LBH, and of CDKN1A (p21) and TP53 (p53), compared to untreated samples upon mitogen stimulation. The expression of DNA methyltransferase-1 (DNMT1) was also higher in the presence of MTX and there was strong correlation between DNMT1 and LBH expression.

Conclusions

Therapeutic concentrations of MTX abolish the effects of PDGF and IL-1β on tumor suppressor expression and inhibit mitogen-promoted FLS proliferation. These data demonstrate novel and important effects of MTX on pathogenic effector cells in the joint, which might involve epigenetic mechanisms.

An approach for manganese biomonitoring using a manganese carrier switch in serum from transferrin to citrate at slightly elevated manganese concentration

After high-dose-short-term exposure (usually from occupational exposure) and even more under low-dose long term exposure (mainly environmental) manganese (Mn) biomonitoring is still problematic since these exposure scenarios are not necessarily reflected by a significant increase of total Mn in blood or serum. Usually, Mn concentrations of exposed and unexposed persons overlap and individual differentiation is often not possible. In this paper Mn speciation on a large sample size (n=180) was used in order to be able to differentiate between highly Mn-exposed or low or unexposed individuals at low total Mn concentration in serum (Mn(S)). The whole sample set consisted of three subsets from Munich, Emilia Romagna region in Italy and from Sweden. It turned out that also at low total Mn(S) concentrations a change in major Mn carriers in serum takes place from Mn-transferrin (Mn-Tf(S)) towards Mn-citrate (Mn-Cit(S)) with high statistical significance (p<0.000002). This carrier switch from Mn-Tf(S) to Mn-Cit(S) was observed between Mn(S) concentrations of 1.5μg/L to ca. 1.7μg/L. Parallel to this carrier change, for sample donors from Munich where serum and cerebrospinal fluid were available, the concentration of Mn beyond neural barriers - analysed as Mn in cerebrospinal fluid (Mn(C)) - positively correlates to Mn-Cit(S) when Mn(S) concentration was above 1.7μg/L. The correlation between Mn-Cit(S) and Mn(C) reflects the facilitated Mn transport through neural barrier by means of Mn-citrate. Regional differences in switch points from Mn-Tf(S) to Mn-Cit(S) were observed for the three sample subsets. It is currently unknown whether these differences are due to differences in location, occupation, health status or other aspects. Based on our results, Mn-Cit(S) determination was considered as a potential means for estimating the Mn load in brain and CSF, i.e., it could be used as a biomarker for Mn beyond neural barrier. For a simpler Mn-Cit(S) determination than size exclusion chromatography inductively coupled plasma mass spectrometry (SEC-ICP-MS), ultrafiltration (UF) of serum samples was tested for suitability, the latter possibly being a preferred choice for routine occupational medicine laboratories. Our results revealed that UF could be an alternative if methodical prerequisites and limitations are carefully considered. These prerequisites were determined to be a thorough cleaning procedure at a minimum Mn(S) concentration >1.5μg/L, as at lower concentrations a wide scattering of the measured concentrations in comparison to the standardized SEC-ICP-MS results were observed.

Mass screening and treatment on the basis of results of a Plasmodium falciparum-specific rapid diagnostic test did not reduce malaria incidence in Zanzibar

BACKGROUND

Seasonal increases in malaria continue in hot spots in Zanzibar. Mass screening and treatment (MSAT) may help reduce the reservoir of infection; however, it is unclear whether rapid diagnostic tests (RDTs) detect a sufficient proportion of low-density infections to influence subsequent transmission.

METHODS

Two rounds of MSAT using Plasmodium falciparum-specific RDT were conducted in 5 hot spots (population, 12 000) in Zanzibar in 2012. In parallel, blood samples were collected on filter paper for polymerase chain reaction (PCR) analyses. Data on confirmed malarial parasite infections from health facilities in intervention and hot spot control areas were monitored as proxy for malaria transmission.

RESULTS

Approximately 64% of the population (7859) were screened at least once. P. falciparum prevalence, as measured by RDT, was 0.2% (95% confidence interval [CI], .1%-.3%) in both rounds, compared with PCR measured prevalences (for all species) of 2.5% (95% CI, 2.1%-2.9%) and 3.8% (95% CI, 3.2%-4.4%) in rounds 1 and 2, respectively. Two fifths (40%) of infections detected by PCR included non-falciparum species. Treatment of RDT-positive individuals (4% of the PCR-detected parasite carriers) did not reduce subsequent malaria incidence, compared with control areas.

CONCLUSIONS

Highly sensitive point-of-care diagnostic tools for detection of all human malaria species are needed to make MSAT an effective strategy in settings where malaria elimination programs are in the pre-elimination phase.

Autonomic neuropathy in type I diabetes: influence of duration and other diabetic complications

To evaluate the influence of duration on the development of autonomic neuropathy (AN) a group of type I diabetic patients (n = 58) who had been diagnosed between the ages of 15 and 25 years was investigated. The duration of diabetes varied from 2 months to 30 years (mean 13 years). AN tests included a deep breathing test (E/I ratio) and an orthostatic test on tilt table (acceleration and brake indices) and the results were corrected for age. A clear correlation between AN test and duration of diabetes was shown only for the E/I ratio (r = -0.44, p less than 0.001). On the other hand, deteriorations in the brake index were unrelated to the duration of diabetes and occurred early; 35% of the patients with a duration of 10 years or less showed an abnormal brake index. Autonomic test deviations were related to other diabetic complications. The E/I ratio and the acceleration index were especially low in patients with retinopathy as well as in patients with symptoms of AN if combined with peripheral neuropathy (PN). The brake index was low in patients with symptoms of AN independent of PN.

Oral ibandronate is as active as intravenous zoledronic acid for reducing bone turnover markers in women with breast cancer and bone metastases

BACKGROUND

Phase III study comparing the effect of oral ibandronate and intravenous zoledronic acid on bone markers.

PATIENTS AND METHODS

Breast cancer patients with bone metastases received ibandronate 50 mg/day (n = 137) or zoledronic acid 4 mg every 4 weeks (n = 138) for 12 weeks. The primary end point was mean percentage change in serum levels of cross-linked C-terminal telopeptide of type I collagen (S-CTX) at week 12. Urinary CTX (U-CTX), bone alkaline phosphatase (ALP), amino-terminal procollagen propeptide of type I collagen (PINP) and osteocalcin (OC) were also measured and bone pain and safety assessed.

RESULTS

Both bisphosphonates significantly reduced S-CTX (mean ibandronate 76% +/- 29 (SD) versus mean zoledronic acid 73% +/- 47; P < 0.001 for both versus baseline) and U-CTX (ibandronate 78% +/- 50 versus zoledronic acid 86% +/- 17; P < 0.001). The difference in S-CTX between treatments was 0.6% (confidence interval -1.7% to 3.0%), which was within the prespecified noninferiority margin. Bone ALP, PINP and OC decreased by 26%-47% compared with baseline with both bisphosphonates. Compared with zoledronic acid, ibandronate patients reported fewer adverse events overall (65.0% versus 75.9%), and on days 1-3 (8.0% versus 47.5%), including less pyrexia (overall incidence 0% versus 16.8%) and bone pain (5.8% versus 12.4%).

CONCLUSIONS

Oral ibandronate was well tolerated and statistically noninferior to zoledronic acid for percentage change in the bone resorption marker, S-CTX.

Improved quality of life after long-term treatment with the bisphosphonate ibandronate in patients with metastatic bone disease due to breast cancer

Bone metastases occur in most women with advanced breast cancer and can lead to considerable morbidity and a rapid deterioration in the patient's quality of life. It was the aim of the present study to assess changes in quality of life and bone pain due to intravenous (i.v.) ibandronate, a potent third-generation bisphosphonate. In a phase III randomised, double-blind, placebo-controlled trial in patients with bone metastases due to breast cancer, 466 women were randomised to receive placebo, 2 mg ibandronate or 6 mg ibandronate for up to 96 weeks. Treatment was administered i.v. at 3- or 4-weekly intervals. Clinical endpoints included the incidence of adverse events, quality of life (assessed using the European Organisation for the Research and Treatment of Cancer (EORTC) Quality of Life Scale - Core 30 questionnaire (QLQ-C30)), and bone pain (assessed on a 5-point scale from 0=none to 4=intolerable). Ibandronate was generally well tolerated. Compared with baseline measurements, the bone pain score was increased at the last assessment in both the placebo and 2 mg ibandronate groups, but was significantly reduced in the patients receiving 6 mg ibandronate (-0.28+/-1.11, P < 0.001). A significant improvement in quality of life was demonstrated for patients treated with ibandronate (P < 0.05) for all global health status. Overall, at the last assessment, the 6 mg ibandronate group showed significantly better functioning compared with placebo (P = 0.004), and had significantly better scores on the domains of physical, emotional, and social functioning, and in global health status (P < 0.05). Significant improvements in the symptoms of fatigue and pain were also observed in the 6 mg ibandronate group. I.v. ibandronate treatment leads to significant improvements in quality of life, and is an effective and well-tolerated palliative treatment in patients with bone metastases due to breast cancer.

Intravenous ibandronate reduces the incidence of skeletal complications in patients with breast cancer and bone metastases

BACKGROUND

This phase III study compared the efficacy of the new potent bisphosphonate, ibandronate, with placebo as intravenous (i.v.) therapy in metastatic bone disease due to breast cancer.

PATIENTS AND METHODS

A total of 466 patients were randomised to receive placebo (n = 158), or 2 mg (n = 154) or 6 mg (n = 154) ibandronate every 3-4 weeks for up to 2 years. The primary efficacy parameter was the number of 12-week periods with new bone complications, expressed as the skeletal morbidity period rate (SMPR). Bone pain, analgesic use and safety were evaluated monthly. Results SMPR was lower in both ibandronate groups compared with the placebo group; the difference was statistically significant for the ibandronate 6 mg group (P = 0.004 versus placebo). Consistent with the SMPR, ibandronate 6 mg significantly reduced the number of new bone events (by 38%) and increased time to first new bone event. Patients on ibandronate 6 mg also experienced decreased bone pain scores and analgesic use. Treatment with ibandronate was well tolerated.

CONCLUSIONS

These results indicate that 6 mg i.v. ibandronate is effective and safe in the treatment of bone metastases from breast cancer.

Efficacy and safety of ibandronate in the treatment of hypercalcemia of malignancy: a randomized multicentric comparison to pamidronate

GOALS

To compare the efficacy and safety of ibandronate and pamidronate in patients with hypercalcemia of malignancy (HCM).

PATIENTS AND METHODS

Seventy-two patients with HCM [albumin-corrected serum calcium (CSC) >2.7 mmol/l] were treated with a single infusion of ibandronate (2 or 4 mg) or pamidronate (15, 30, 60, or 90 mg) on day 0. The dose was dependent on the severity of hypercalcemia (baseline CSC level). CSC was assessed daily until day 4, then at intervals until day 28. The primary endpoint was lowering of CSC at day 4. Secondary endpoints included the number of patients responding and time to re-increase following response.

MAIN RESULTS

Using the CSC baseline approach, the most frequently administered doses were 4 mg ibandronate (78.4%) and 60 mg pamidronate (50.0%). Mean lowering of CSC at day 4 was 0.6 mmol/l for ibandronate and 0.41 mmol/l for pamidronate. The 95% confidence interval for the difference ibandronate pamidronate had a lower limit of 0.05 mmol/l, indicating that ibandronate was as effective as pamidronate. The number of patients responding to the two agents was also similar; 76.5% of ibandronate patients and 75.8% of pamidronate patients were rated as responders after the first dose of study medication. The median time to re-increase after response was longer for ibandronate (14 days) than pamidronate (4 days) ( P=0.0303). In the subgroup of 17 patients with high baseline CSC (>3.5 mmol/l), ibandronate appeared to be more effective than pamidronate. The safety profile of both agents was similar.

CONCLUSIONS

Ibandronate is at least as effective as pamidronate in the treatment of HCM. Furthermore, in patients with higher baseline CSC ibandronate appears to be more effective than pamidronate. The duration of response is significantly longer with ibandronate than pamidronate.

Hemorrhage in the floor of the mouth during implant placement in the edentulous mandible: a case report

This report describes a life-threatening hemorrhage in the floor of a patient's mouth during routine implant placement in the anterior mandible. Airway obstruction caused by hematoma development resulted in acute nasotracheal intubation and subsequent surgical intervention. Surgical, radiographic, and anatomic considerations to prevent severe bleeding are discussed. An extraoral submental approach in cases with large sublingual hematomas is recommended. An outpatient should be treated in or close to a hospital where these complications can be dealt with promptly and effectively.

A longitudinal study of resin-bonded prostheses

Resin-bonded fixed partial dentures, without definitive tooth preparation and current resinous cements and perceptive treatment, have had an inordinate number of dislodgments in initial restorative efforts. A longitudinal examination of resin-bonded prostheses was performed after a mean observation time exceeding 6 years. To prevent stress fatigue fractures of the cement bondings, one proximal groove was prepared in dentin for each anterior abutment and the inner surfaces of the frameworks were silicoated. Five of 34 prostheses debonded, and the bond strength between resin and high gold alloys was too low to resist fatigue fractures during this study. The results of this study and other reports suggested a need for increased retention and resistance form of the frameworks to improve longevity of resin-bonded prostheses.

Prospective study of autonomic nerve function in type 1 and type 2 diabetic patients: 24 hour heart rate variation and plasma motilin levels disturbed in parasympathetic neuropathy

To clarify the impact of autonomic neuropathy in diabetic patients, we have conducted a prospective study of 58 Type 1 and 51 Type 2 diabetic patients (investigated at baseline, after 4, and after 7 years). In Type 1 diabetic patients, the sympathetic nerve function (orthostatic acceleration and brake indices) and in Type 2 patients, parasympathetic nerve function (R-R interval variation; E/l ratio) deteriorated during 7 years of prospective observation. Symptoms of autonomic neuropathy were associated with signs of autonomic neuropathy (low brake indices) in Type 1 but not in Type 2 diabetic patients. In the latest assessment 24 h ECG recording was performed and blood samples assayed for neuropeptide Y (NPY) and motilin were obtained. Type 1 diabetic patients with parasympathetic neuropathy (abnormal E/l ratio) showed significantly lower SD value (less variation in the R-R intervals; 29 [17] vs 50 [16], [mean (interquartile range)]; p = 0.001) and higher postprandial plasma motilin values (70 [20] pmol l-1 vs 50 [15] pmol l-1; p < 0.01) than patients with normal parasympathetic nerve function. In Type 2 diabetic patients, sympathetic neuropathy (low brake indices) was associated with an increased frequency of ventricular extra systolic beats during 24 h ECG recording (rs = 0.65; p < 0.01). Postprandial plasma NPY levels were not associated with disturbed autonomic nerve function.

Experimental evaluation of the effect of filtration of diesel exhaust by biologic exposure indicators

The airway resistance, compliance of the respiratory system, transfer factor, and alveolar volume of 33 healthy rabbits were studied before and after exposure to diluted diesel exhaust generated in an experimental motor. Three diesel fuels and two particle traps were tested. Subsequent to the post-exposure lung function measurements, the animals were sacrificed and the lungs were processed for morphologic examination. The concentrations of particles, nitrogen dioxide, and formaldehyde were measured. The inflammatory airway changes were most pronounced in animals exposed to exhaust from standard fuel. Small changes were identified in animals exposed to exhaust filtered through the catalytic trap as well or exposed to unfiltered exhaust from fuels intended for densely built-up areas. Increase in compliance of the respiratory system was associated with the concentration of soot particles and formaldehyde. Compliance decreased significantly in animals exposed to exhaust from standard fuel filtered through the particle traps and increased almost significantly in animals exposed to unfiltered exhaust from the same fuel.

Fertility, infertility and child survival of Somali women

The relationship of reproductive patterns, some socio-economic factors and child survival was studied in 766 rural Somali women. A structured questionnaire was the method of data collection. Teenage marriage was the norm for the women, and divorce was very common. The mean number of live births was 5.2, and the mean number of surviving children was 3.7. 2/3 of the women aged 45+ had a parity of 6 or more, about one third had had at least one miscarriage and one fifth had experienced one stillbirth. Primary infertility was observed in 7% of the women aged 45+, while 20% were considered subfertile. Verbal autopsy showed that mortality was highest among infants and accounted for 63% of the child deaths. Major causes of death were neonatal tetanus, diarrhoea and respiratory diseases. Child survival and reproductive outcome ratios were found to be negatively related to the increasing age of the mother and parity. Divorce and widowhood were also found to be associated with low child survival.

Maternal health and child survival in relation to socioeconomic factors

The health of 280 rural Somali women of reproductive age was studied using a structured questionnaire, measuring weight, height, arm circumference and estimations of hemoglobin. Mean height and weight were 159 cm and 53 kg, respectively. 12.7% had a weight below 50 kg and 5.6% had a height below 150 cm. One third of the women had a body mass index of 19 indicating sub/malnutrition. Mean hemoglobin was 105 g/l. Every fourth woman had a hemoglobin level between 85 and 100, while every tenth had a value below 70 g/l. A higher hemoglobin level and better child survival rate were associated with the husband's reading ability, whether the household owned a farm, whether the woman had a second job, whether the woman possessed gold and the household's possession of a radio.

Temporary health effects from exposure to water-borne paints

Temporary health effects of exposure to experimental paints were studied. Ten painters feeling nuisance from water-borne paints and eight painters not feeling such nuisance applied eight experimental water-borne paints according to normal work routines. The effects were a decrease in forced vital capacity, forced expiratory volume in 1 s and peak expiratory flow, an increase in urine excretion, and a decrease in urine density. A small, but statistically highly significant, increase in the mean volume of erythrocytes was observed. The effects were similar in the two groups, but the "nuisance group" reacted with a larger urine excretion and a larger increase in the mean volume of erythrocytes. The effects did not influence physical work capacity. The effects on the lungs and urinary excretion were probably not associated with the organic solvents or ammonia in the paints. Instead, they were probably due to derivatives of isothiazolinone. This assumption needs verification.

Plasma neuropeptide Y (NPY) and galanin before and during exercise in type 1 diabetic patients with autonomic dysfunction

Plasma neuropeptide Y (NPY), plasma galanin and plasma catecholamines were determined before and during an ergometer exercise test in 11 type 1 diabetic patients (age 19-36 years, mean 30; duration of diabetes 2-18 years, mean 9) with autonomic dysfunction and in 13 age-matched healthy controls (age 24-36 years, mean 29). Before exercise, plasma NPY (100 +/- 6 pmol/l vs 144 +/- 7 pmol/l; P less than 0.001) and plasma galanin (54 +/- 3 pmol/l vs 77 +/- 5 pmol/l; P less than 0.005) were significantly lower in patients than in controls. During exercise, plasma NPY, plasma adrenaline, and plasma noradrenaline increased in patients and controls while galanin only increased in patients. Since there was a direct correlation between plasma NPY before exercise and the increment (delta 80%) in noradrenaline during exercise (r = 0.54; P less than 0.01), it is suggested that plasma NPY determined in the basal situation may be a useful marker of sympathetic nerve failure in diabetic patients.

Lung function and precipitating antibodies in low exposed wood trimmers in Sweden

Wood trimmers are exposed to molds that periodically grow on timber that may induce alveolitis and obstructive lung disease. We have evaluated respiratory symptoms, bronchial reactivity, and lung function in 28 wood trimmers at a Swedish sawmill and in 19 unexposed office workers. Eleven (sero-positive) of the wood trimmers had precipitating antibodies in peripheral blood against one or several molds. The exposure to dust (median 0.26 mg/m3), viable mold spores (median 2950 cfu/m3), viable bacteria (median 370 cfu/m3), airborne endotoxins (range 0.0015-0.0025 microgram/m3), and terpenes (range 0.4-23 mg/m3) was lower than levels that earlier have been reported to affect lung function. The wood trimmers reported an increased prevalence of cough and breathlessness. They also showed signs of a mild obstructive impairment with a tendency to increase bronchial sensitivity to metacholine and decreased FEV1 after 2 days free from exposure. FEV1 decreased more during the working week in the sero-positive workers than among the sero-negative workers, and for the whole group the decrease in FEV1 and MEF25 was correlated to the degree of mold exposure.

Impeded lung function in moulders and coremakers handling furan resin sand

A total of 39 moulders and coremakers exposed to furan resin sand and 27 unexposed local controls were examined by lung-function tests before and after a work shift. In all, 28 of the subjects exposed to furan resin sand and the control group were evaluated by dynamic spirometry and nitrogen washout. The remaining 11 subjects exposed to furan resin sand were studied using both static and dynamic spirometry and the CO single-breath technique. The time-weighted average exposure to furfuryl alcohol was about 7 mg/m3, with peak values exceeding the present Swedish short-term exposure limit (40 mg/m3). The exposure to respirable dust and formaldehyde as time-weighted over the shift was less than 2 mg/m3 and 0.4 mg/m3, respectively, in all groups. During the work shift studied, the 28 exposed subjects had more complaints of airway symptoms than did the controls, showing an average decrease of 0.21 in forced vital capacity but no fall in any other lung-function variable. The remaining 11 exposed subjects demonstrated a post-shift decrease in total lung capacity. The results indicate an acute restrictiveness induced by exposure to furan resin sand, but the underlying mechanism is unclear. Chronic impairment of lung function was not observed.

Autonomic nerve antibodies and autonomic nerve function in type 1 and type 2 diabetic patients

Complement-fixing adrenal medulla (CF-ADM), sympathetic ganglion (CF-SG), and vagal (CF-V) nerve antibodies were determined in diabetic patients. Among 74 patients with Type 1 diabetes, CF-ADM was detected in 7 (10%) cases, CF-SG in 14 (19%) cases, and CF-V in 8 (11%) cases. Among 38 patients with Type 2 diabetes, CF-ADM was detected in 5 (13%) cases, CF-SG in 4 (11%) cases, and CF-V in 6 (16%) cases. There were associations between autonomic nerve antibodies and autonomic nerve function. CF-ADM and/or CF-SG were significantly (P less than 0.002) less prevalent in Type 1 diabetic patients with autonomic neuropathy than in those without [5/44 (11%) vs. 14/30 (47%)] and, in agreement with this, the brake index, a sign of parasympathetic and sympathetic autonomic nerve function, was significantly (P less than 0.005) higher (more normal) in these patients (-0.56 +/- 0.13 vs. -1.04 +/- 0.12). In Type 2 diabetic patients, the E/I ratio, an index of parasympathetic nerve function, was significantly (P less than 0.03) lower (more abnormal) in those with CF-V than in those without (-1.81 +/- 0.17 vs. -1.20 +/- 0.11). In conclusion, the frequency of sympathetic nerve antibodies was decreased in Type 1 diabetic patients with autonomic neuropathy, while in Type 2 diabetic patients parasympathetic nerve antibodies were related to severe parasympathetic neuropathy.

Pulmonary function in workers exposed to diesel exhausts: the effect of control measures

To assess the protective effect of exhausts pipe filters or respirators on pulmonary function, 15 workers in a tunnel construction site, truck and loading machine drivers, rock workers, and others were studied. The total and respirable dust, combustible matter in respirable dust, carbon monoxide, nitrogen monoxide and nitrogen dioxide were measured for each subject during entire work shifts. The effect of the exposure on the lung function variables was measured by dynamic spirometry, carbon monoxide single breath technique, and nitrogen single breath wash-out. The exhaust pipe filtering had a protective effect, directly discernible in the drivers on vital capacity and FEV1.0 and for the whole group on FEV% and TLco. The dust respirators had no effect, probably because of the difficulties in correctly using personal protection under the circumstances in the tunnel. In the absence of a true exposure assessment, control measures for diesel exhausts can be tested by medical effect studies. Catalytic particle filters of diesel exhausts are one method of rendering the emissions less irritant, although they will not remove irritant gases. An indicator of diesel exhaust exposure should include the particle fraction of the diesel exhausts, but a discrimination between different sources of organic dust must be possible.

The activity of the renin-angiotensin-aldosterone system before and during submaximal bicycle exercise in relation to circulatory catecholamines in patients with type 1 (insulin-dependent) diabetes mellitus

To evaluate the renin-angiotensin-aldosterone system in relation to circulatory catecholamines, we determined renin activity, angiotensin II, aldosterone, adrenaline, and noradrenaline in plasma before and during a submaximal bicycle exercise test in 23 Type 1 (insulin-dependent) diabetic patients (aged 19-57 years, mean 37; duration of diabetes 2-32 years, mean 16), 17 with signs of cardiac autonomic neuropathy, and in 18 healthy non-diabetic subjects (aged 24-41 years, mean 29). At rest, Type 1 diabetic patients showed significantly lower aldosterone values than control subjects (0.14 +/- 0.02 nmol/l and 0.22 +/- 0.02 nmol/l; p less than 0.01) while renin activity (1.0 +/- 0.1 nmol.l-1.h-1 and 0.9 +/- 0.1 nmol.l-1.h-1) and angiotensin II (14 +/- 1 nmol/l and 18 +/- 2 nmol/l) did not differ significantly between patients and control subjects. During exercise, increments (increase from the resting value to the value at 80% of maximal working capacity) in renin (1.5 +/- 0.4 nmol.l-1.h-1 and 3.7 +/- 0.5 nmol.l-1.h-1; p less than 0.001), angiotensin II (28 +/- 8 nmol/l and 60 +/- 8 nmol/l; p less than 0.001), aldosterone (0.16 +/- 0.04 nmol/l and 0.25 +/- 0.05 nmol/l; p less than 0.05), adrenaline (1.96 +/- 0.49 nmol/l and 2.92 +/- 0.51 nmol/l; p less than 0.05), and noradrenaline (12.01 +/- 1.25 nmol/l and 18.74 +/- 1.45 nmol/l; p less than 0.01) were significantly lower in the patients than in control subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Autonomic neuropathy in non-insulin dependent (type II) diabetes mellitus. Possible influence of obesity

To assess the prevalence of autonomic neuropathy (AN) in non-insulin dependent diabetes mellitus (NIDDM) and its relationships with other diabetic complications, duration of diabetes, and obesity, we evaluated 51 NIDDM patients (age 41-59 years, mean 49 years, duration of diabetes 0-15 years, mean 6.9 years). AN tests included a deep breathing test (E/I ratio) and an orthostatic tilt table test (acceleration and brake (25 of 51, 49%) and the most frequent disturbance was an impaired E/I ratio (18 of 25; 72%). There were no obvious correlations between AN indices and the duration of diabetes, symptoms of AN, peripheral neuropathy or retinopathy. However, an influence of obesity on AN was suggested. Patients with AN showed a significantly higher BMI than patients without AN (31.0 +/- 0.9 vs. 27.5 +/- 0.8; P less than 0.01).

Impaired responses of plasma catecholamines to exercise in diabetic patients with abnormal heart rate reactions to tilt

The plasma catecholamine response to a standardized bicycle exercise test was evaluated in 24 insulin-dependent diabetic (IDDM) patients in whom the heart rate reactions to deep breathing (E/I ratio) and to tilt, the immediate acceleration and the transient deceleration (acceleration and brake indices), had been assessed as tests of autonomic neuropathy. Patients with an abnormal acceleration index (n = 8) showed, compared with non-diabetic (n = 18) controls who had participated in previous studies, an impaired increment in noradrenaline during exercise (80% of maximal working capacity) (MWC) (12.38 +/- 1.46 nmol l-1 vs. 18.74 +/- 1.45 nmol l-1; P less than 0.01) and adrenaline (50% of MWC: 0.25 +/- 0.04 nmol l-1 vs. 0.54 +/- 0.08 nmol l-1; P less than 0.05). Similarly, patients with an isolated abnormal brake index (n = 6), i.e. with a normal acceleration index and a normal E/I ratio, showed compared with controls an impaired increment in noradrenaline (9.53 +/- 1.66 nmol l-1 vs. 18.74 +/- 1.45 nmol l-1; P less than 0.01) and adrenaline (1.41 +/- 0.22 nmol l-1 vs. 2.92 +/- 0.51 nmol l-1; P less than 0.05) during 80% of MWC. IDDM patients with abnormal heart rate reactions to tilt, an abnormal acceleration index or an abnormal brake index show impaired catecholamine responses to exercise, which can be demonstrated also in patients without signs of parasympathetic neuropathy.

Platelet sodium and potassium ATPase [corrected] activity and noradrenaline efflux rate in relation to autonomic and peripheral nerve function in insulin-dependent diabetic patients

Low sodium and potassium adenosine triphosphatase (ATPase) activity has been proposed as a mechanism behind diabetic neuropathy. In this study the platelet ATPase activity and platelet noradrenaline efflux rate were determined in 47 insulin-dependent diabetes mellitus (IDDM) patients and 20 controls. Ulnar motor conduction velocities, tested in a subgroup, were lower in patients than in controls (52.7 +/- 1.3 m s-1 vs. 61.3 +/- 1.4 m s-1; P less than 0.001). Platelet ATPase activity tended to be increased in the patients compared with the controls (29.9 +/- 1.0 x 10(-3) min-1 vs. 26.9 +/- 1.1 x 10(-3) min-1; NS). In ulnar nerve function tested subjects, ATPase activity was higher in patients than in controls (31.2 +/- 1.7 x 10(-3) min-3 vs. 25.9 +/- 1.3 x 10(-3) min-1; P less than 0.01). The platelet noradrenaline efflux rate tended to be higher in patients with lower brake indices, a sign of autonomic neuropathy, than in controls (29.0 +/- 3.0 x 10(-3) min-1 vs. 21.2 +/- 0.9 x 10(-3) min-1; P less than 0.05). The platelet ATPase activity was not decreased in IDDM patients, however, a connection between diabetic autonomic neuropathy and platelet transmittor leakage was indicated.

Diazo-positive metabolites in urine from workers exposed to aromatic nitro-amino compounds

The amount of diazo-positive compounds in urine from workers at a chemical plant producing pharmaceuticals and explosives was determined in samples collected after work and after a holiday. Forty-five persons working with aromatic nitro-amino compounds (ANA) showed a statistically significant (p less than 0.01) increase in the exposed samples (1.21 +/- 1.40 mmol/mol creatinine) compared to the unexposed samples (0.56 +/- 0.31 mmol/mol creatinine). No increase in the level of diazo-positive metabolites was found in the 25 workers not exposed to ANA compounds. In a follow-up study, 32 trinitrotoluene (TNT) workers were divided into three exposure categories and seemed to show a dose-dependent increase in the level of urinary diazo-positive metabolites. However, there was a considerable interindividual variation. The method seems suitable for the biological assessment of exposure to ANA compounds--at least on a group level. This may be valuable, especially in situations where significant dermal uptake is expected.

Evaluation of 294 psychiatric consultations involving in-patients above 70 years of age in somatic departments in a university hospital

The integrated geropsychiatric service of the Psychiatric Department of the University Hospital in Linköping consists of an observation ward, a day unit and an out-patient unit. One of the main tasks of the last-mentioned unit is to provide geropsychiatric consultations for in-patients in the non-psychiatric departments of the hospital. During the first 2 years from October 1982 to October 1984 300 consultations were performed. The consultations included registration of social, medical and psychiatric data, a psychiatric examination, discussions with the staff and a psychiatric report. Out of the total number of 300 consultations 294 could be evaluated completely. They comprised 247 individuals. The evaluation was performed after the first 2 years by screening the patients' psychiatric records and reports and by computer-analysis of 89 variables covering medical as well as social data. The patients' mean age was 78 years and 52% were treated in the Department of Internal Medicine. Fifty-three percent had had previous psychiatric contacts. Many were suffering from serious somatic diseases and 22% from depressive states. Only 9% showed no signs of psychiatric disorders. Twenty-three percent of the patients were transferred to the geropsychiatric observation ward or day unit and only 3% were recommended to be certified and transferred to a mental hospital. Pertinent findings are discussed in the light of international data on geropsychiatric consultations and liaison psychiatry. The study shows the importance of providing special geropsychiatric consultations for in-patients in somatic departments as a part of an integrated geropsychiatric service.

Autonomic nerve function tests. Reference values in healthy subjects

Autonomic nerve function was evaluated by deep breathing (E/I heart rate ratio) and tilt table tests (acceleration index, brake index, and blood pressures) in 56 healthy subjects in order to find reference values. The results showed that the E/I ratio, the acceleration index and the brake index fell with increasing age. There was no influence of age on the systolic and the diastolic blood pressure reactions to tilt. Age-related reference values are needed in the evaluation of autonomic neuropathy indices.

Development of hearing loss during long-term exposure to occupational noise. A 20-year follow-up study

Occupational noise-induced hearing loss is still responsible for the majority of occupational ailments and injuries, with very large sums being paid in compensation. Repeated hearing tests over a 20-year period have been performed on 319 employees of a timber processing firm, working in sawmills and paper pulp production, exposed to mean noise levels of around 95-100 dB (A) and in a chemicals division with mean noise exposure levels of 80-90 dB (A). During the observation period, mean hearing levels deteriorated slowly, especially at 4 kHz, but no dramatic changes from one year to another were seen. We therefore propose 3-year intervals between regular hearing tests in this type of industry where noise exposure is predominantly of the continuous type, thus releasing resources for more active measures against noise-induced hearing loss. Cases of manifest hearing loss or otherwise at risk must of course be followed up at shorter intervals. A remarkably large proportion of the employees in the chemicals division suffered a hearing loss corresponding to 10% disablement according to Swedish criteria, which raises the question of a possible relation between exposure to industrial solvents and hearing loss.

Malleolar fractures: nonoperative versus operative treatment. A controlled study

Ninety-two intra-articular ankle fractures were randomly selected for either open reduction and internal fixation or closed reduction and plaster cast. The patients were followed for an average of seven years. The initial course was more favorable in surgically reduced fractures. However, follow-up examinations showed little difference in results between the two forms of treatment.

Urinary screening for potentially genotoxic exposures in a chemical industry

Mutagenic activity, measured by the bacterial fluctuation assay and thioether concentration in urine from workers at a chemical plant producing pharmaceuticals and explosives, was determined before and after exposure. Of 12 groups only those exposed to trinitrotoluene (n = 14) showed a significant increase in mutagenic activity using Salmonella typhimurium TA 98 without any exogenous metabolic system. The same strain responded only weakly when the S-9 mix was used; with Escherichia coli WP2 uvrA no effect of exposure was observed. Urinary thioether concentration was higher among smokers than among non-smokers, but occupational exposure had no effect. Urinary mutagenicity testing may be a useful tool for screening potentially genotoxic exposures in complex chemical environments.

Late complications after irradiation treatment for cervical adenitis in childhood. A 60-year follow-up study

Irradiation against benign cervical adenitis in children was formerly a widely used form of treatment which has caused a great number of late complications, mostly various benign and malignant tumours in the head and neck area, especially in the thyroid gland. In a follow-up study on 63 individuals irradiated at Karlstad Hospital between 1917 and 1929 we found, in addition to these changes, two hitherto not reported complications. Laryngeal stenoses occurred in 27 cases, 17 of which so severe that they eventually required permanent tracheostomies and 11 had fibrous strictures of the upper esophagus, repeated dilatations have been necessary in many of these cases. These complications were mostly seen in those who had been irradiated at an early age, the laryngeal stenoses appear to be caused by a general retardation or inhibition of the normal growth of the laryngeal cartilages resulting in a microlarynx. One possible explanation for these previously not reported sequelae might be the exceptionally high irradiation doses these persons were exposed to up to 60 years ago.

Glomerular filtration rate, autonomic nerve function, and orthostatic blood pressure in patients with diabetes mellitus

Glomerular filtration rate (GFR) measured by the 51Cr-EDTA clearance method, autonomic nerve function evaluated by the heart rate reaction to deep breathing (E/I ratio) and to tilting (acceleration and brake indices), and orthostatic blood pressures were followed up after 5-7 yr in 43 patients with Type 1 diabetes. At follow up, 20 patients showed a decrease in GFR greater than expected. In the first study, these patients showed low E/I ratios and brake indices indicating vagal neuropathy, while the acceleration index fell, indicating sympathetic denervation, between the studies. Accordingly, vagal neuropathy preceded decreases in GFR and sympathetic denervation favoured deteriorations in GFR. The present report provides evidence that sympathetic denervation might be behind the development of diabetic kidney complications.

Chlorpropamide-alcohol flushing, aldehyde dehydrogenase activity, and diabetic complications

Many diabetics who take chlorpropamide (a sulphonylurea compound) experience facial flushing after drinking even small amounts of alcohol. These flushers have a noticeably lower prevalence of late complications of diabetes (microangiopathy, macroangiopathy, and neuropathy) than non-flushers. This flush reaction is accompanied by increased blood acetaldehyde concentrations, suggesting an inhibition of aldehyde dehydrogenase activity. In the present study the activity of this enzyme in erythrocytes was assessed in the absence of chlorpropamide. Erythrocyte homogenates obtained from flushers and non-flushers were incubated with acetaldehyde and the rate of metabolism studies. Flushers eliminated acetaldehyde more slowly at a low range of concentrations (0--30 mumol/l), suggesting a difference in aldehyde dehydrogenase activity. Further studies are needed to clarify the role of this enzyme in the pathogenesis of diabetic complications.

A case of adult rhabdomyoma in the tonsillar region. A light and electron microscope study

A case of rhabdomyoma in a 71-year-old woman is reported. The lobulated, soft tumour was situated in the left tonsillar region. It was encapsulated, easily removable and of a uniformly greyish-red colour on the cut surface. Both light and electron microscopy showed the classical features of a benign rhabdomyoma of adult type, with large "spider" cells and typical myofilaments, as well as Z-band fragments. To achieve the correct diagnosis in such cases the most important thing is probably to bear the possibility of this rare, but benign tumour in mind.