Cardiopulmonary exercise testing excludes significant disease in patients recovering from COVID-19

Objective

Post-COVID-19 syndrome presents a health and economic challenge affecting ~10% of patients recovering from COVID-19. Accurate assessment of patients with post-COVID-19 syndrome is complicated by health anxiety and coincident symptomatic autonomic dysfunction. We sought to determine whether either symptoms or objective cardiopulmonary exercise testing could predict clinically significant findings.

Methods

113 consecutive military patients were assessed in a comprehensive clinical pathway. This included symptom reporting, history, examination, spirometry, echocardiography and cardiopulmonary exercise testing (CPET) in all, with chest CT, dual-energy CT pulmonary angiography and cardiac MRI where indicated. Symptoms, CPET findings and presence/absence of significant pathology were reviewed. Data were analysed to identify diagnostic strategies that may be used to exclude significant disease.

Results

7/113 (6%) patients had clinically significant disease adjudicated by cardiothoracic multidisciplinary team (MDT). These patients had reduced fitness (V̇O226.7 (±5.1) vs 34.6 (±7.0) mL/kg/min; p=0.002) and functional capacity (peak power 200 (±36) vs 247 (±55) W; p=0.026) compared with those without significant disease. Simple CPET criteria (oxygen uptake (V̇O2) >100% predicted and minute ventilation (VE)/carbon dioxide elimination (V̇CO2) slope <30.0 or VE/V̇CO2slope <35.0 in isolation) excluded significant disease with sensitivity and specificity of 86% and 83%, respectively (area under the receiver operating characteristic curve (AUC) 0.89). The addition of capillary blood gases to estimate alveolar–arterial gradient improved diagnostic performance to 100% sensitivity and 78% specificity (AUC 0.92). Symptoms and spirometry did not discriminate significant disease.

Conclusions

In a population recovering from SARS-CoV-2, there is reassuringly little organ pathology. CPET and functional capacity testing, but not reported symptoms, permit the exclusion of clinically significant disease.

Robust anti-obesity and metabolic effects of a dual GLP-1/glucagon receptor peptide agonist in rodents and non-human primates

AIMS

To characterize the pharmacology of MEDI0382, a peptide dual agonist of glucagon-like peptide-1 (GLP-1) and glucagon receptors.

MATERIALS AND METHODS

MEDI0382 was evaluated in vitro for its ability to stimulate cAMP accumulation in cell lines expressing transfected recombinant or endogenous GLP-1 or glucagon receptors, to potentiate glucose-stimulated insulin secretion (GSIS) in pancreatic β-cell lines and stimulate hepatic glucose output (HGO) by primary hepatocytes. The ability of MEDI0382 to reduce body weight and improve energy balance (i.e. food intake and energy expenditure), as well as control blood glucose, was evaluated in mouse models of obesity and healthy cynomolgus monkeys following single and repeated daily subcutaneous administration for up to 2 months.

RESULTS

MEDI0382 potently activated rodent, cynomolgus and human GLP-1 and glucagon receptors and exhibited a fivefold bias for activation of GLP-1 receptor versus the glucagon receptor. MEDI0382 produced superior weight loss and comparable glucose lowering to the GLP-1 peptide analogue liraglutide when administered daily at comparable doses in DIO mice. The additional fat mass reduction elicited by MEDI0382 probably results from a glucagon receptor-mediated increase in energy expenditure, whereas food intake suppression results from activation of the GLP-1 receptor. Notably, the significant weight loss elicited by MEDI0382 in DIO mice was recapitulated in cynomolgus monkeys.

CONCLUSIONS

Repeated administration of MEDI0382 elicits profound weight loss in DIO mice and non-human primates, produces robust glucose control and reduces hepatic fat content and fasting insulin and glucose levels. The balance of activities at the GLP-1 and glucagon receptors is considered to be optimal for achieving weight and glucose control in overweight or obese Type 2 diabetic patients.

A hierarchical model of factors influencing a battery of agility tests

AIM

The aim of this study was to investigate the hierarchical contributions of anthropometry, strength and cognition to a battery of prescriptive and reactive agility tests.

METHODS

Nineteen participants (mean±S.D.; age:22.1±1.9 years; height: 182.9±5.5 cm; body mass: 77±4.9 kg) completed four agility tests: a prescriptive linear sprint, a prescriptive change-of-direction sprint, a reactive change-of-direction sprint, and a reactive linear deceleration test. Anthropometric variables included body fat percentage and thigh girth. Strength was quantified as the peak eccentric hamstring torque at 180, 300, and 60°·s-1. Mean reaction time and accuracy in the Stroop word-colour Test was used to assess perceptual and decision making factors.

RESULTS

There was little evidence of intertest correlation with the strongest relationship observed between 10 m sprint and t-test performance (r2=0.49, P<0.01). Anthropometric measures were not strong predictors of agility, accounting for a maximum 23% (P=0.12) in the prescriptive change-of-direction test. Cognitive measures had a stronger correlation with the reactive (rather than prescriptive) agility tests, with a maximum 33% (P=0.04) of variance accounted for in the reactive change-of-direction test. Eccentric hamstring strength accounted for 62% (P=0.01) of the variance in the prescriptive change-of-direction test. Hierarchical ordering of the agility tests revealed that eccentric hamstring strength was the primary predictor in 3 of the 4 tests, with cognitive accuracy the next most common predictor.

CONCLUSION

There is little evidence of inter-test correlation across a battery of agility tests. Eccentric hamstring strength and decision making accuracy are the most common predictors of agility performance.

Deep vein thrombosis and pulmonary embolism in the military patient

OBJECTIVES

Venous thromboembolism (VTE), encompassing deep vein thrombosis and pulmonary embolism, is a common, potentially lethal condition and a cause of long-term morbidity and functional limitation. This paper is a clinical review focused on military epidemiology, evidence-based recommendations for prevention, diagnosis and management of VTE and occupational considerations in a military population.

METHODS

A literature review was conducted through Pubmed and Embase for systematic reviews, meta-analyses and clinical trials relating to VTE. Guidelines from the National Institute for Health and Care Excellence, British Thoracic Society and the American College of Chest Physicians were reviewed and recommendations considered.

RESULTS

Acute morbidity from VTE can range from limb pain and swelling to life-threatening cardiovascular compromise. Long-term sequelae include postthrombotic syndrome, chronic thrombosis and pulmonary hypertension. Diagnosis should follow a validated pathway depending on the patient's prerest probability. The management of the condition should vary with attention to risk stratification.

DISCUSSION

Prompt initiation of anticoagulation reduces symptoms, rates of recurrent VTE and death but treatment must be balanced against the risk of major haemorrhage. Military operations expose personnel to a unique combination of risk factors for VTE and operating in austere environments can increase the challenge of diagnosis, prognostication and management. Furthermore, there are implications for troop attrition, operational readiness and return to work.

An unusual case of anaemia and lymphadenopathy in a soldier on deployment

We describe the case of a British soldier, originally from southeast Africa, who presented to the British military hospital in Helmand Province, southern Afghanistan, with a history of constitutional upset, profound anaemia and diffuse lymphadenopathy with hepatosplenomegaly. Following evacuation to the UK investigations revealed a rare (and a not so rare) diagnosis. This case raises a number of questions regarding the population at risk, the prevalence of endemic diseases in this population and laboratory capabilities in the deployed setting.

Stereo-selective inhibition of transient receptor potential TRPC5 cation channels by neuroactive steroids

BACKGROUND AND PURPOSE

Transient receptor potential canonical 5 (TRPC5) channels are widely expressed, including in the CNS, where they potentiate fear responses. They also contribute to other non-selective cation channels that are stimulated by G-protein-coupled receptor agonists and lipid and redox factors. Steroids are known to modulate fear and anxiety states, and we therefore investigated whether TRPC5 exhibited sensitivity to steroids.

EXPERIMENTAL APPROACH

Human TRPC5 channels were conditionally expressed in HEK293 cells and studied using intracellular Ca²⁺ measurement, whole-cell voltage-clamp and excised patch techniques. For comparison, control experiments were performed with cells lacking TRPC5 channels or expressing another TRP channel, TRPM2. Native TRPC channel activity was recorded from vascular smooth muscle cells.

KEY RESULTS

Extracellular application of pregnenolone sulphate, pregnanolone sulphate, pregnanolone, progesterone or dihydrotestosterone inhibited TRPC5 activity within 1–2 min. Dehydroepiandrosterone sulphate or 17β-oestradiol had weak inhibitory effects. Pregnenolone, and allopregnanolone, a progesterone metabolite and stereo-isomer of pregnanolone, all had no effects. Progesterone was the most potent of the steroids, especially against TRPC5 channel activity evoked by sphingosine-1-phosphate. In outside-out patch recordings, bath-applied progesterone and dihydrotestosterone had strong and reversible effects, suggesting relatively direct mechanisms of action. Progesterone inhibited native TRPC5-containing channel activity, evoked by oxidized phospholipid.

CONCLUSIONS AND IMPLICATIONS

Our data suggest that TRPC5 channels are susceptible to relatively direct and rapid stereo-selective steroid modulation, leading to channel inhibition. The study adds to growing appreciation of TRP channels as non-genomic steroid sensors.

Cis-isomerism and other chemical requirements of steroidal agonists and partial agonists acting at TRPM3 channels

BACKGROUND AND PURPOSE

The transient receptor potential melastatin-3 (TRPM3) channel forms calcium-permeable, non-selective, cationic channels that are stimulated by pregnenolone sulphate (PregS). Here, we aimed to define chemical requirements of this acute steroid action and potentially reveal novel stimulators with physiological relevance.

EXPERIMENTAL APPROACH

We used TRPM3 channels over-expressed in HEK 293 cells, with intracellular calcium measurement and whole-cell patch-clamp recording techniques.

KEY RESULTS

The stimulation of TRPM3 channels was confined to PregS and closely related steroids and not mimicked by other major classes of steroids, including progesterone. Relatively potent stimulation of TRPM3-dependent calcium entry was observed. A sulphate group positioned at ring A was important for strong stimulation but more striking was the requirement for a cis (beta) configuration of the side group, revealing previously unrecognized stereo-selectivity and supporting existence of a specific binding site. A cis-oriented side group on ring A was not the only feature necessary for high activity because loss of the double bond in ring B reduced potency and loss of the acetyl group at ring D reduced efficacy and potency. Weak steroid stimulators of TRPM3 channels inhibited effects of PregS, suggesting partial agonism. In silico screening of chemical libraries for non-steroid modulators of TRPM3 channels revealed the importance of the steroid backbone for stimulatory effects.

CONCLUSIONS AND IMPLICATIONS

Our data defined some of the chemical requirements for acute stimulation of TRPM3 channels by steroids, supporting the existence of a specific and unique steroid binding site. Epipregnanolone sulphate was identified as a novel TRPM3 channel stimulator.

Upregulated TRPC1 channel in vascular injury in vivo and its role in human neointimal hyperplasia

Occlusive vascular disease is a widespread abnormality leading to lethal or debilitating outcomes such as myocardial infarction and stroke. It is part of atherosclerosis and is evoked by clinical procedures including angioplasty and grafting of saphenous vein in bypass surgery. A causative factor is the switch in smooth muscle cells to an invasive and proliferative mode, leading to neointimal hyperplasia. Here we reveal the importance to this process of TRPC1, a homolog of Drosophila transient receptor potential. Using 2 different in vivo models of vascular injury in rodents we show hyperplasic smooth muscle cells have upregulated TRPC1 associated with enhanced calcium entry and cell cycle activity. Neointimal smooth muscle cells after balloon angioplasty of pig coronary artery also express TRPC1. Furthermore, human vein samples obtained during coronary artery bypass graft surgery commonly exhibit an intimal structure containing smooth muscle cells that expressed more TRPC1 than the medial layer cells. Veins were organ cultured to allow growth of neointimal smooth muscle cells over a 2-week period. To explore the functional relevance of TRPC1, we used a specific E3-targeted antibody to TRPC1 and chemical blocker 2-aminoethoxydiphenyl borate. Both agents significantly reduced neointimal growth in human vein, as well as calcium entry and proliferation of smooth muscle cells in culture. The data suggest upregulated TRPC1 is a general feature of smooth muscle cells in occlusive vascular disease and that TRPC1 inhibitors have potential as protective agents against human vascular failure.

Genome sequence, comparative analysis and haplotype structure of the domestic dog

Here we report a high-quality draft genome sequence of the domestic dog (Canis familiaris), together with a dense map of single nucleotide polymorphisms (SNPs) across breeds. The dog is of particular interest because it provides important evolutionary information and because existing breeds show great phenotypic diversity for morphological, physiological and behavioural traits. We use sequence comparison with the primate and rodent lineages to shed light on the structure and evolution of genomes and genes. Notably, the majority of the most highly conserved non-coding sequences in mammalian genomes are clustered near a small subset of genes with important roles in development. Analysis of SNPs reveals long-range haplotypes across the entire dog genome, and defines the nature of genetic diversity within and across breeds. The current SNP map now makes it possible for genome-wide association studies to identify genes responsible for diseases and traits, with important consequences for human and companion animal health.

The genome sequence of the filamentous fungus Neurospora crassa

Neurospora crassa is a central organism in the history of twentieth-century genetics, biochemistry and molecular biology. Here, we report a high-quality draft sequence of the N. crassa genome. The approximately 40-megabase genome encodes about 10,000 protein-coding genes--more than twice as many as in the fission yeast Schizosaccharomyces pombe and only about 25% fewer than in the fruitfly Drosophila melanogaster. Analysis of the gene set yields insights into unexpected aspects of Neurospora biology including the identification of genes potentially associated with red light photobiology, genes implicated in secondary metabolism, and important differences in Ca2+ signalling as compared with plants and animals. Neurospora possesses the widest array of genome defence mechanisms known for any eukaryotic organism, including a process unique to fungi called repeat-induced point mutation (RIP). Genome analysis suggests that RIP has had a profound impact on genome evolution, greatly slowing the creation of new genes through genomic duplication and resulting in a genome with an unusually low proportion of closely related genes.

The genome of M. acetivorans reveals extensive metabolic and physiological diversity

Methanogenesis, the biological production of methane, plays a pivotal role in the global carbon cycle and contributes significantly to global warming. The majority of methane in nature is derived from acetate. Here we report the complete genome sequence of an acetate-utilizing methanogen, Methanosarcina acetivorans C2A. Methanosarcineae are the most metabolically diverse methanogens, thrive in a broad range of environments, and are unique among the Archaea in forming complex multicellular structures. This diversity is reflected in the genome of M. acetivorans. At 5,751,492 base pairs it is by far the largest known archaeal genome. The 4524 open reading frames code for a strikingly wide and unanticipated variety of metabolic and cellular capabilities. The presence of novel methyltransferases indicates the likelihood of undiscovered natural energy sources for methanogenesis, whereas the presence of single-subunit carbon monoxide dehydrogenases raises the possibility of nonmethanogenic growth. Although motility has not been observed in any Methanosarcineae, a flagellin gene cluster and two complete chemotaxis gene clusters were identified. The availability of genetic methods, coupled with its physiological and metabolic diversity, makes M. acetivorans a powerful model organism for the study of archaeal biology. [Sequence, data, annotations and analyses are available at http://www-genome.wi.mit.edu/.]

Mapping of Myxococcus xanthus social motility dsp mutations to the dif genes

Myxococcus xanthus dsp and dif mutants have similar phenotypes in that they are deficient in social motility and fruiting body development. We compared the two loci by genetic mapping, complementation with a cosmid clone, DNA sequencing, and gene disruption and found that 16 of the 18 dsp alleles map to the dif genes. Another dsp allele contains a mutation in the sglK gene. About 36.6 kb around the dsp-dif locus was sequenced and annotated, and 50% of the genes are novel.

The Alaska Native diabetes program

OBJECTIVES

To provide optimum health care to indigenous people with diabetes, to prevent diabetes, and to monitor the epidemiology of diabetes and selected complications. The purposes of this paper are to describe the program and to present data that highlights the major problems and successes.

STUDY DESIGN

Descriptive epidemiology report of diabetes and population service program based on yearly chart review data.

METHODS

Almost half of Alaska Natives with diabetes have no direct access to physicians or hospitals. Health care delivery is now managed by the tribes themselves. Program emphases include maintenance of a population-based registry, formal training for village health aides, physical activity programs, patient education, primary prevention activities and adherence to standards of care to prevent complications. A centralized registry is maintained to assure that epidemiological data is available and patients are not lost to follow-up. Each year a random sample of charts at each major facility is audited against nationally standardized care guidelines.

RESULTS

The prevalence of diabetes among Alaska Natives increased 80% over the 13 years from 1985 to 1998 (15.7/1000 to 28.3/1000, age adjusted to U.S. 1980 population). For the years 1986-1998 the incidence rates of lower extremity amputation and end stage renal disease were 6.1/1000 and 2.0/1000 respectively. The level of care provided to Alaska Native patients is comparable to that provided to the general diabetic patient population seen in Alaskan urban clinics.

CONCLUSIONS

In spite of logistic challenges, care provided to Alaska Native people with diabetes compares favorably to that provided in other settings. Incidence rates of lower extremity amputation and end stage renal disease also remain comparable to or lower than those in other U.S. populations. Many aspects of our system could be extended to other chronic disease programs serving isolated indigenous populations. Primary prevention of diabetes remains a major challenge as life styles change.

Initial sequencing and analysis of the human genome

The human genome holds an extraordinary trove of information about human development, physiology, medicine and evolution. Here we report the results of an international collaboration to produce and make freely available a draft sequence of the human genome. We also present an initial analysis of the data, describing some of the insights that can be gleaned from the sequence.

The immune response to soluble D10 TCR: analysis of antibody and T cell responses

In order to evaluate the potential of TCR as vaccines for immunomodulation, the immunogenicity of soluble versions of D10 TCR has been investigated in mice. Soluble D10 TCR containing the extracellular domains were produced either as dual chain (dc) TCR lacking transmembrane and cytoplasmic regions or as a TCR-IgG1 chimeric protein. Soluble single chain (sc) D10 TCR contained only the Valpha and Vbeta segments joined by a peptide linker. Syngeneic D10 dcTCR or D10 TCR-IgG1 immunizations of AKR mice induced antibody responses to D10 clonotypic epitopes and to constant region epitopes that are not exposed on D10 cells. Only clonotypic antibodies were produced after D10 scTCR immunizations. Immunization of AKR mice with D10 dcTCR and D10 TCR-IgG1 primed I-Ak- and I-Ek-restricted CD4+ T cells recognizing constant region epitopes, but there was no detectable response to the variable region. Comparison of the in vitro proliferative responses of CD4+ T cells from D10 scTCR-primed H-2 congenic mice revealed that H-2u was a responder haplotype for the variable region. How the immunogenicity of particular regions of the TCR appears to be shaped by tolerance induction in vivo and the implications for immunotherapy with soluble TCR vaccinations are discussed.

Maternal immunization with a soluble TCR-Ig chimeric protein: long term, V beta-8 family-specific suppression of T cells by maternally transferred antibodies

Maternal transfer of TCR clonotypic Ab protected young NOD mice against the adoptive transfer of diabetes by the BDC 2.5 T cell clone. The effect of maternal anti-TCR Vbeta-8 Ab on T cell development and function has now been investigated. SJL/J mice, which lack TCR Vbeta-8, were immunized with soluble, chimeric D10 TCR-IgG1 containing Vbeta-8.2. The (SJL/J x AKR/J) F1 offspring of immunized female SJL/J mice were severely depleted of peripheral T cells bearing Vbeta-8 until 11 to 17 wk of age. The loss of Vbeta-8 expression did not appear to be due to modulation of cell surface TCR. Since the Vbeta-8+ T cell population was unperturbed in the (AKR/J x SJL/J) F1 offspring of D10 TCR-IgG1-immunized AKR/J mothers making D10 clonotypic Ab, the effect was immunologically specific. The deletion of Vbeta-8+ T cells had functional consequences. In the in vitro response to the superantigen, staphylococcal enterotoxin B, the usually observed participation of Vbeta-8.2+ T cells was largely suppressed, whereas the recruitment of Vbeta-3+ T cells remained unaltered. In control mice, T cell responses to the 134- to 146-residue peptide of conalbumin (pCA(134-146)) were biased toward use of Valpha-2/Vbeta-8.2 TCR. In D10 TCR-IgG1 maternally immunized (SJL x AKR/J) F1 mice, the T cell responses to pCA(134-146) were suppressed, and T cell lines derived from these in vitro were devoid of Vbeta-8.2 expression. With an increased understanding of TCR V gene usage in autoimmune diseases, similar strategies for the depletion of autoreactive T cells may become feasible in humans.

Maternal immunization with a soluble TCR-Ig chimeric protein: long term, V beta-8 family-specific suppression of T cells by maternally transferred antibodies

Maternal transfer of TCR clonotypic Ab protected young NOD mice against the adoptive transfer of diabetes by the BDC 2.5 T cell clone. The effect of maternal anti-TCR Vbeta-8 Ab on T cell development and function has now been investigated. SJL/J mice, which lack TCR Vbeta-8, were immunized with soluble, chimeric D10 TCR-IgG1 containing Vbeta-8.2. The (SJL/J x AKR/J) F1 offspring of immunized female SJL/J mice were severely depleted of peripheral T cells bearing Vbeta-8 until 11 to 17 wk of age. The loss of Vbeta-8 expression did not appear to be due to modulation of cell surface TCR. Since the Vbeta-8+ T cell population was unperturbed in the (AKR/J x SJL/J) F1 offspring of D10 TCR-IgG1-immunized AKR/J mothers making D10 clonotypic Ab, the effect was immunologically specific. The deletion of Vbeta-8+ T cells had functional consequences. In the in vitro response to the superantigen, staphylococcal enterotoxin B, the usually observed participation of Vbeta-8.2+ T cells was largely suppressed, whereas the recruitment of Vbeta-3+ T cells remained unaltered. In control mice, T cell responses to the 134- to 146-residue peptide of conalbumin (pCA(134-146)) were biased toward use of Valpha-2/Vbeta-8.2 TCR. In D10 TCR-IgG1 maternally immunized (SJL x AKR/J) F1 mice, the T cell responses to pCA(134-146) were suppressed, and T cell lines derived from these in vitro were devoid of Vbeta-8.2 expression. With an increased understanding of TCR V gene usage in autoimmune diseases, similar strategies for the depletion of autoreactive T cells may become feasible in humans.

Determination of mycotoxins in pet foods sold for domestic pets and wild birds using linked-column immunoassay clean-up and HPLC

A technique referred to as 'linked-column immunoassay clean-up', was developed for the simultaneous determination of aflatoxins and ochratoxin A in a range of dry cereal-based pet foods and wild bird food. In addition a method also based on clean-up using immunoaffinity columns was used for the determination of fumonisin mycotoxins in samples known or suspected to contain maize. One hundred samples of pet foods consisting of 35 samples of domestic bird seeds and 15 samples of wild bird food were examined for aflatoxins B1, B2, G1 and G2 and ochratoxin A. Twenty samples of these samples were also examined for fumonisins B1 and B2. Limits of detection were about 0.5 micrograms/kg for each aflatoxin and ochratoxin A and 3 and 8 micrograms/kg for fumonisins B1 and B2 respectively. Eighty-four percent of the samples contained no measurable concentrations of mycotoxins. A low level of aflatoxin B1 was found in a sample of cat food and a concentration of 370 micrograms/kg aflatoxin B1 in one sample of peanuts marketed for wild birds. Ochratoxin A was detected in 10% of samples but in low concentrations, the highest of 7 micrograms/kg occurring in a sample of bird food. Fumonisins were found in 30% of the 20 samples tested with a maximum of 750 micrograms/kg total fumonisins being found in a sample of cat food. Five samples each of dog and cat foods were examined for mould count and fungal species as received and after storage under controlled simulated damp conditions. Mould counts in all 10 samples examined were very low when received. The samples in which moisture content had been increased contained visible mould after storage. Penicillium, Eurotium and Aspergillus were the predominant species. However, no ochratoxin A or aflatoxins were detected in these spoiled samples.

Two chimaeric transcription units result from an inversion breaking intron 1 of the factor VIII gene and a region reportedly affected by reciprocal translocations in T-cell leukaemia

Analysis of mRNA in two haemophilic monozygotic twins offers novel information on the organisation of expressed sequences distal to the coagulation factor VIII gene. These patients show an inversion that, in contrast to the common inversions responsible for 1/5 of all haemophilia A, affects the first rather than intron 22 of the gene. This displaces the most telomeric of the factor VIII exons (exon 1) by approximately 100 kb towards the telomere, and close to the region of the C6.1A gene. This novel inversion creates two hybrid transcription units: one formed by the promoter and first exon of the factor VIII gene followed by a widely expressed sequence; the other by the promoter and coding region of the C6.1A gene plus most of the factor VIII gene (part of intron 1 and exons 2-26). Investigation of this transcription unit reveals that the C6.1A gene has an unsuspected intron in the region coding for the previously described 3'-untranslated tail of the message. Furthermore, exons located beyond the known C6.1A sequence and present in normal transcripts precede exons 2-26 of the factor VIII gene in the hybrid mRNA of the haemophilic twins. The factor VIII sequences in this hybrid mRNA are not expected to be expressed because they lack the first exon, encoding the prepeptide, and follow a translation stop in the C6.1A gene. Leukaemia-related translocations in the C6.1A region suggest that this region may be somewhat unstable.

Immunization with soluble BDC 2.5 T cell receptor-immunoglobulin chimeric protein:antibody specificity and protection of nonobese diabetic mice against adoptive transfer of diabetes by maternal immunization

The BDC 2.5 T cell clone is specific for pancreatic beta-cell antigen presented by I-Ag7, and greatly accelerates diabetes when injected into 10-21-d-old nonobese diabetic (NOD) mice. The BDC 2.5 T cell receptor (TCR) has been solubilized as a TCR-IgG1 chimeric protein. All NOD mice immunized against BDC 2.5 TCR-IgG1 produced antibodies recognizing TCR C alpha/C beta epitopes that were inaccessible on the T cell surface. 56% of the mice produced antibodies against the BDC 2.5 clonotype that specifically blocked antigen activation of BDC 2.5 cells. We have used the adoptive transfer model of diabetes to demonstrate that maternal immunization with soluble TCR protects young mice from diabetes induced by the BDC 2.5 T cell clone.

Extracellular and intracellular acid-base status in the freshwater crayfish, Austropotamobius pallipes between 1 and 12(o)C

Freshwater crayfish, Austropotamobius pallipes, caught in the winter when water temperature was 5 &deg;C, were acclimated in the laboratory to 5 &deg;C for 1 week and to 1 and 12 &deg;C for 1 month before haemolymph and tissue samples were taken for acid&shy;base analysis. In vivo, haemolymph (extracellular) pH increased by 0.14 units between 5 and 1 &deg;C but remained unchanged between 5 and 12 &deg;C, giving an overall deltapHe/deltat value of -0.009 pH units &deg;C-1 and an [H+] value of +3.3 nmol l-1. Haemolymph withdrawn from crayfish acclimated to 1 &deg;C and warmed anaerobically in vitro to 12 &deg;C had a deltapHe/deltat value of -0.010 pH units &deg;C-1. This was depressed compared with the values of -0.015 and -0.016 pH units &deg;C-1 obtained from haemolymph withdrawn from crayfish held at 5 and 12 &deg;C, respectively, but changes in H+ concentration were similar in all three groups. There was little change in intracellular pH with rise in temperature in either claw muscle (deltapHi/deltat=-0.003 pH units &deg;C-1) or hepatopancreas (deltapHi/deltat=-0.006 pH units &deg;C-1). In the heart, deltapHi/deltat paralleled that in the haemolymph (-0.010 pH units &deg;C-1), but the largest change was found in the abdominal muscle (-0.025 pH units &deg;C-1). In all tissues apart from claw muscle, there was a metabolic acidosis, with an increase in metabolic acid load as temperature rose from 1 to 12 &deg;C. The depressed in vivo deltapHe/deltat value and the differences in deltapHi/deltat between the tissues were attributed to active regulation of pHi, possibly to control enzyme function in the intracellular compartments. Tissues that are functionally important in the winter months, such as abdominal muscle, followed alphastat regulation, whereas tissues that are less active in the winter, such as claw muscle and hepatopancreas, maintained pHi irrespective of temperature, resulting in a relatively acidotic pHi, which may serve to depress the activity of metabolic enzymes.

Characteristic mRNA abnormality found in half the patients with severe haemophilia A is due to large DNA inversions

Surprisingly half of all severe haemophilia A patients have no mutation in the promoter, coding sequences and normal RNA processing signals of the factor VIII gene. Instead they manifest a unique mRNA defect that prevents the amplification of the message across the boundary between exon 22 and 23. This locates the defect to internal regions of intron 22. Novel sequences 3' to exon 22 were isolated from the 9 available patients with the above abnormality by combining RACE and vectorette amplifications on trace amounts of mRNA. This showed that exons 1-22 of the factor VIII mRNA had become part of a hybrid message containing new multi exonic sequences expressed in normal cells. The novel sequences were not located in a YAC covering the whole factor VIII gene. Southern blots from patients probed by novel sequences and clones covering intron 22 showed no obvious abnormalities. This suggested inversions involving intron 22 repeated sequences. Screening of 3 YAC libraries with the novel sequences located them at least 200 kb telomeric (5') to factor VIII and pulsed field gel analysis detected abnormal bands in patients. This demonstrates that the mutations in the patients are inversions of long DNA regions possibly involving the repeated sequences and occurring at the surprising rate of approximately 4 x 10(-6) per gene per gamete per generation.

Analysis of antigen receptor genes in Hodgkin's disease

AIM

To analyse the configuration of the antigen receptor genes in Hodgkin's disease.

METHODS

DNA extracted from 45 samples of Hodgkin's disease was analysed using Southern blotting and DNA hybridisation, using probes to the joining region of the immunoglobulin heavy chain gene, the constant region of kappa immunoglobulin light chain gene, and the constant region of the beta chain of the T cell receptor gene.

RESULTS

A single case of nodular sclerosing disease showed clonal rearrangement of the immunoglobulin heavy and light chain genes, all other samples having germline immunoglobulin genes. The nature of the clonal population in the diseased tissue is uncertain, because the intensity of the rearranged bands did not correlate with the percentage of Reed-Sternberg cells present. The T cell receptor genes were in germline configuration in all the samples.

CONCLUSIONS

Antigen receptor gene rearrangement is a rare finding in unselected cases of Hodgkin's disease.

Inhibition of hematopoietic progenitor colony growth by a monoclonal antibody against the transferrin receptor: comparison of unconjugated antibody with an immunotoxin containing recombinant ricin A chain

We studied an immunotoxin consisting of recombinant ricin A chain (rRA) conjugated to 454A12 MoAb, a monoclonal antibody which recognizes an epitope on the human transferrin receptor, and compared the ability of 454A12 MoAb-rRA immunotoxin to inhibit the growth of erythroid burst-forming units (BFU-e) and myeloid colony-forming units (CFU-c) with unconjugated 454A12 MoAb. A significant reduction in BFU-e colony growth was observed at 0.001 microgram/ml of 454A12 MoAb-rRA versus 0.1 microgram/ml of unconjugated 454A12 MoAb (p = 0.005). Comparison of the effects of 454A12 MoAb-rRA and 454A12 MoAb on myeloid colony development gave markedly different results. Unconjugated antibody had no effect on CFU-c colony growth; in contrast, 0.01 microgram/ml of 454A12 MoAb-rRA reduced the number of colonies from 139 per 1 X 10(5) to 75 per 1 X 10(5) cells plated (p = 0.0005). No myeloid progenitor colonies developed at 0.1 microgram/ml of immunotoxin. These observations suggest that 454A12 MoAb-rRA inhibits growth by a potent, ricin A chain-mediated toxic effect on any proliferating cells expressing transferrin receptors, whereas the 454A12 MoAb exerts a selective inhibitory effect primarily on erythroid progenitors by perturbing the transferrin cycle. While growth factor receptors expressed on hematopoietic cells represent promising targets for immunotoxin therapy, our data indicate that an immunotoxin could inhibit cellular proliferation by a different mechanism than the corresponding unconjugated MoAb. Depending on the antibody used, these differences may be important in trials using immunotoxins for in vivo treatment or in vitro purging of malignant hematopoietic cells.

Left-handedness and myasthenia gravis

In two separate studies comparing the handedness of patients suffering from myasthenia gravis with matched controls, no evidence was found to support the Geschwind Behan hypothesis of an association between autoimmune disease and left-handedness. Counter to prediction both studies found marginally lower incidences of left-handedness in myasthenics, and when combined with the similar result of Cosi et al. (Cortex 24, 573-577, 1988) the difference was highly statistically significant. The personality of myasthenics, as assessed by the Eysenck Personality Questionnaire (EPQ), and in particular the psychoticism scale, which has been postulated to be related to androgen levels, was not significantly different from controls. However, assessment of sex-roles using the Bem Sex Role Inventory suggested that female myasthenics were more masculine than controls.

Identification of immunogenic regions of the major coat protein of human papillomavirus type 16 that contain type-restricted epitopes

We have identified regions of the major capsid protein, L1, of the human papillomavirus (HPV) type 16 (HPV-16 L1), that are recognized by five monoclonal antibodies (MAbs) raised to a bacterial fusion protein containing residues 172 to 375 of HPV-16 L1. All five MAbs recognized HPV-16-infected tissue sections by immunohistochemistry, but not sections infected with HPV-1a (cutaneous warts), HPV-6b or -11 (genital warts). MAbs 3D1, 5A4 and 1D6 also recognized HPV-2-infected sections (cutaneous warts); MAb 8C4 recognized only sections containing HPV-16. Four MAbs (8C4, 3D1, 1D6 and 5A4) recognized a synthetic peptide corresponding to residues 269 to 284 of HPV-16 L1; within this region a minimum antibody binding site was identified, a tripeptide 276 to 278. However the complete epitope appears to extend beyond these residues and beyond HPV-16 L1 (269 to 284). The fifth MAb, 1C6, recognized bacterial fusion proteins containing HPV-6b L1, -16 L1 or -18 L1 using immunoblots, yet appeared HPV-16-specific when tested on infected tissue sections. This MAb recognized five amino acids within a different region of HPV-16 L1 (residues 299 to 313).

Combination of Spigelian and Richter's hernias: a case report

Spigelian and Richter's hernias, individually, are both moderately rare. To encounter a patient having both of these surgical diseases as a single entity is indeed unique. Such a patient with an acute partial enterocele of cecum (Richter's hernia) strangulated in a lateral ventral musculoaponeurotic defect (Spigelian hernia) was successfully treated with wedge cecectomy and simple herniorraphy.

Prevalence of malnutrition in general medical patients

Three, single-day nutritional surveys at weekly intervals were conducted in the general medical wards of an urban municipal teaching hospital. The techniques of nutritional assessment included anthropometric measures (weight/height, triceps skin fold, arm-muscle circumference, serum albumin, and hematocrit). The prevalence of protein-calorie malnutrition was 44% or greater by these criteria (weight/height, 45%; triceps skin fold, 76%; arm-muscle circumference, 55%; serum albumin, 44%; and hematocrit, 48%). These results were reproducible without significant variation between surveys. In 34% of patients, a lymphopenia of 1,200 cells/cu mm or less was found, a level likely to be associated with diminished cell-mediated immunity. Compared with a similar survey among surgical patients, the medical patients were more depleted calorically (weight/height, triceps skin fold) but had better protein status (arm-muscle circumference, serum albumin). Significant protein-calorie malnutrition occurs commonly in municipal hospitals in both medical and surgical services.

Isolation of protective somatic antigen from Vibrio cholerae (Ogawa) ribosomal preparations

Ribosomal preparations from Vibrio cholerae Ogawa and Inaba are protective immunogens for mice challenged with either serotype. Column chromatography of ribosomal fractions separated protective antigen from the ribosomes. The antigen is a heterogeneous colloid which contains protein, lipid, and carbohydrate in the ratio 3:1:1. Amino acid composition is that of a slightly acidic protein with no unusual complement of amino acids. The lipid component consists of several longchain fatty acids and of phosphatidyl ethanolamine. The major sugars identified were glucose and galactose. The colloid can be dissolved by treatment with chelating agents and sodium dodecyl sulfate. Purification of the solubilized material or of the colloid was unsuccessful.

FACTORS CONTROLLING EMBRYO GROWTH AND DEVELOPMENT IN BARLEY (HORDEUM VULGARE L.)

Normal growth and development of barley proembryos occurred in excised intact florets, but not in ovaries from which lemmas and paleas were removed. The lemmas and paleas of the barley floret apparently contained a substance (referred to as "hull factor") which inhibited cell extension and stimulated cell division in the embryo. Evidence was obtained that this stimulation was not due to the provision of a simple energy source such as sucrose. In the absence of the "hull factor", ovaries cultured in vitro were found to contain embryos having nuclei in which the DNA content was equivalent to the tetraploid level, while mitosis was almost completely lacking. A similar embryo growth stimulation was obtained when a single leaf was left on an excised barley spike where lemmas and paleas were removed.

CHOLEDOCHOLITHIASIS-Correlation of Preoperative with Operative and Postoperative Data to Enhance Diagnostic Insight

One hundred cases of common bile duct explorations were reviewed in an attempt to obtain information that might give insight into the diagnosis and definitive treatment of choledocholithiasis. Fifty of the hundred patients had common duct stones. Correlations were made between the incidence of choledocholithiasis as proved at operation, and the following factors: Kind and number of choledochal exploratory criteria used, the clinical diagnosis of common duct stones, and the pathologic features of gallbladders removed. The incidence of stones was statistically related to aging. The most frequent choledochal exploratory criteria were common duct dilatation or thickening (63 cases) and history of jaundice (50 cases). The most reliable single criterion in "diagnosing" common duct stones was palpable common or hepatic duct stones, the diagnosis having been correct in 15 of 17 such cases. The most reliable combination of criteria was a history of jaundice, plus palpable stones, with correct diagnosis in all such cases. The clinical diagnosis of choledocholithiasis was correct in only 17 per cent of cases. The correlation of the incidence of common duct stones with the degree of gallbladder disease-that is, acute or chronic-did not provide information that might be helpful in diagnosing choledocholithiasis. The incidence of proven retained common duct stones was 3 per cent, the non-fatal postoperative complication rate was 21 per cent and operative mortality was 1 per cent.