Multicenter Validation of Association Between Decline in MRI-PDFF and Histologic Response in NASH

BACKGROUND AND AIMS

Emerging data from a single-center study suggests that a 30% relative reduction in liver fat content as assessed by magnetic resonance imaging-proton density fat fraction (MRI-PDFF) from baseline may be associated with histologic improvement in nonalcoholic steatohepatitis (NASH). There are limited multicenter data comparing an active drug versus placebo on the association between the quantity of liver fat reduction assessed by MRI-PDFF and histologic response in NASH. This study aims to examine the association between 30% relative reduction in MRI-PDFF and histologic response in obeticholic acid (OCA) versus placebo-treated patients in the FLINT (farnesoid X receptor ligand obeticholic acid in NASH trial).

APPROACH AND RESULTS

This is a secondary analysis of the FLINT trial including 78 patients with MRI-PDFF measured before and after treatment along with paired liver histology assessment. Histologic response was defined as a 2-point improvement in nonalcoholic fatty liver disease activity score without worsening of fibrosis. OCA (25 mg orally once daily) was better than placebo in improving MRI-PDFF by an absolute difference of -3.4% (95% confidence interval [CI], -6.5 to -0.2%, P value = 0.04) and relative difference of -17% (95% CI, -34 to 0%, P value = 0.05). The optimal cutoff point for relative decline in MRI-PDFF for histologic response was 30% (using Youden's index). The rate of histologic response in those who achieved less than 30% decline in MRI-PDFF versus those who achieved a 30% or greater decline in MRI-PDFF (MRI-PDFF responders) relative to baseline was 19% versus 50%, respectively. Compared with MRI-PDFF nonresponders, MRI-PDFF responders demonstrated both a statistically and clinically significant higher odds 4.86 (95% CI, 1.4-12.8, P value < 0.009) of histologic response, including significant improvements in both steatosis and ballooning.

CONCLUSION

OCA was better than placebo in reducing liver fat. This multicenter trial provides data regarding the association between 30% decline in MRI-PDFF relative to baseline and histologic response in NASH.

International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction

Background

The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction.

Methods

The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4–8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1–5 years after reconstruction, and repeated this 2–8 weeks later (test–retest reliability). All participants completed debriefing questionnaires.

Results

A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P &lt; 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test–retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test–retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire.

Conclusion

The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

Follow-up of patients who are clinically disease-free after primary treatment for fallopian tube, primary peritoneal, or epithelial ovarian cancer: a Program in Evidence-Based Care guideline adaptation

BACKGROUND

A need for follow-up recommendations for survivors of fallopian tube, primary peritoneal, or epithelial ovarian cancer after completion of primary treatment was identified by Cancer Care Ontario's Program in Evidence-Based Care.

METHODS

We searched for existing guidelines, conducted a systematic review (medline, embase, and cdsr, January 2010 to March 2015), created draft recommendations, and completed a comprehensive review process. Outcomes included overall survival, quality of life, and patient preferences.

RESULTS

The Cancer Australia guidance document Follow Up of Women with Epithelial Ovarian Cancer was adapted for the Ontario context. A key randomized controlled trial found that the overall survival rate did not differ between asymptomatic women who received early treatment based on elevated serum cancer antigen 125 (ca125) alone and women who waited for the appearance of clinical symptoms before initiating treatment (hazard ratio: 0.98; 95% confidence interval: 0.80 to 1.20; p = 0.85); in addition, patients in the delayed treatment group reported good global health scores for longer. No randomized studies were found for other types of follow-up. We recommend that survivors be made aware of the potential harms and benefits of surveillance, including a discussion of the limitations of ca125 testing. Women could be offered the option of no formal follow-up or a follow-up schedule that is agreed upon by the woman and her health care provider. Education about the most common symptoms of recurrence should be provided. Alternative models of care such as nurse-led or telephone-based follow-up (or both) could be emerging options.

CONCLUSIONS

The recommendations provided in this guidance document have a limited evidence base. Recommendations should be updated as further information becomes available.

Dissociations of the Fluocinolone Acetonide Implant: The Multicenter Uveitis Steroid Treatment (MUST) Trial and Follow-up Study

PURPOSE

To describe fluocinolone acetonide implant dissociations in the Multicenter Uveitis Steroid Treatment (MUST) Trial.

DESIGN

Randomized clinical trial with extended follow-up.

METHODS

Review of data collected on the first implant in the eye(s) of participants. Dissociation was defined as the drug pellet no longer being affixed to the strut and categorized as spontaneous or surgically related.

RESULTS

A total of 250 eyes (146 patients) had at least 1 implant placed. Median follow-up time after implant placement was 6 years (range 0.5-9.2 years). Thirty-four dissociations were reported in 30 participants. There were 22 spontaneous events in 22 participants; 6-year cumulative risk of a spontaneous dissociation was 4.8% (95% confidence interval [CI]: 2.4%-9.1%). The earliest event occurred 4.8 years after placement. Nine of 22 eyes with data had a decline in visual acuity ≥5 letters temporally related to the dissociation. Thirty-nine implant removal surgeries were performed, 33 with replacement. Twelve dissociations were noted during implant removal surgeries in 10 participants (26%, 95% CI 15%-48%); 5 of these eyes had a decline in visual acuity ≥5 letters after surgery. The time from implant placement to removal surgery was longer for the surgeries at which dissociated implants were identified than for those without one (5.7 vs 3.7 years, P < .001). Overall, visual acuity declined 15 or more letters from pre-implant values in 22% of affected eyes; declines were frequently associated with complications of uveitis or its treatment.

CONCLUSION

There is an increasing risk of dissociation of Retisert implants during follow-up; the risk is greater with removal/exchange surgeries, but the risk of both spontaneous and surgically related events increases with longevity of the implants. In 22% of affected eyes visual acuity declined by 15 letters. In the context of eyes with moderate to severe uveitis for years, this rate is not unexpected.

Draft consensus guidelines for diagnosis and treatment of Shwachman-Diamond syndrome

Shwachman-Diamond syndrome (SDS) is an autosomal recessive disorder characterized by pancreatic exocrine insufficiency and bone marrow failure, often associated with neurodevelopmental and skeletal abnormalities. Mutations in the SBDS gene have been shown to cause SDS. The purpose of this document is to provide draft guidelines for diagnosis, evaluation of organ and system abnormalities, and treatment of hematologic, pancreatic, dietary, dental, skeletal, and neurodevelopmental complications. New recommendations regarding diagnosis and management are presented, reflecting advances in understanding the genetic basis and clinical manifestations of the disease based on the consensus of experienced clinicians from Canada, Europe, and the United States. Whenever possible, evidence-based conclusions are made, but as with other rare diseases, the data on SDS are often anecdotal. The authors welcome comments from readers.

Accumulation of NFAT mediates IL-2 expression in memory, but not naïve, CD4+ T cells

In contrast to naïve CD4+ T cells, memory CD4+ T cells rapidly express high levels of effector cytokines in response to antigen stimulation. The molecular mechanism for this specific behavior is not well understood. The nuclear factor of activated T cells (NFAT) family of transcription factors plays an important role in the transcription of many cytokine genes. Here we show that memory CD4+ T cells rapidly induce NFAT-mediated transcription upon T cell receptor ligation whereas NFAT activation in naïve CD4+ T cells requires longer periods of stimulation. The difference in kinetics correlates with the low levels of NFATc1 and NFATc2 proteins present in naïve CD4+ T cells and their high levels in memory CD4+ T cells. Accordingly, IL-2 expression requires NFAT activation only in memory CD4+ T cells whereas it is NFAT-independent in naïve CD4+ T cells. Thus, the accumulation of NFATc1 and NFATc2 in memory CD4+ T cells represents a previously uncharacterized regulatory mechanism for the induction of early gene expression after antigen stimulation.

Cystic fibrosis: terminology and diagnostic algorithms

There is great heterogeneity in the clinical manifestations of cystic fibrosis (CF). Some patients may have all the classical manifestations of CF from infancy and have a relatively poor prognosis, while others have much milder or even atypical disease manifestations and still carry mutations on each of the CFTR genes. It is important to distinguish between these categories of patients. The European Diagnostic Working Group proposes the following terminology. Patients are diagnosed with classic or typical CF if they have one or more phenotypic characteristics and a sweat chloride concentration of >60 mmol/l. The vast majority of CF patients fall into this category. Usually one established mutation causing CF can be identified on each CFTR gene. Patients with classic CF can have exocrine pancreatic insufficiency or pancreatic sufficiency. The disease can have a severe course with rapid progression of symptoms or a milder course with very little deterioration over time. Patients with non-classic or atypical CF have a CF phenotype in at least one organ system and a normal (<30 mmol/l) or borderline (30-60 mmol/l) sweat chloride level. In these patients confirmation of the diagnosis of CF requires detection of one disease causing mutation on each CFTR gene or direct quantification of CFTR dysfunction by nasal potential difference measurement. Non-classic CF includes patients with multiorgan or single organ involvement. Most of these patients have exocrine pancreatic sufficiency and milder lung disease. Algorithms for a structured diagnostic process are proposed.

Construction of BAC and BIBAC libraries and their applications for generation of SSR markers for genome analysis of chickpea, Cicer arietinum L

Large-insert bacterial artificial chromosome (BAC) libraries, plant-transformation-competent binary BAC (BIBAC) libraries, and simple sequence repeat (SSR) markers are essential for many aspects of genomics research. We constructed a BAC library and a BIBAC library from the nuclear DNA of chickpea, Cicer arietinum L., cv. Hadas, partially digested with HindIII and BamHI, respectively. The BAC library has 14,976 clones, with an average insert size of 121 kb, and the BIBAC library consists of 23,040 clones, with an average insert size of 145 kb. The combined libraries collectively cover ca. 7.0 x genomes of chickpea. We screened the BAC library with eight synthetic SSR oligos, (GA)10, (GAA)7, (AT)10, (TAA)7, (TGA)7, (CA)10, (CAA)7, and (CCA)7. Positive BACs were selected, subcloned, and sequenced for SSR marker development. Two hundred and thirty-three new chickpea SSR markers were developed and characterized by PCR, using chickpea DNA as template. These results have demonstrated that BACs are an excellent source for SSR marker development in chickpea. We also estimated the distribution of the SSR loci in the chickpea genome. The SSR motifs (TAA)n and (GA)n were much more abundant than the others, and the distribution of the SSR loci appeared non-random. The BAC and BIBAC libraries and new SSR markers will provide valuable resources for chickpea genomics research and breeding (the libraries and their filters are available to the public at http://hbz.tamu.edu).

Dimensions and wall force development capacity of human pial arteries from normotensives is not altered in obesity

OBJECTIVE

The dimensions and maximum wall tension capacity of segments of human pial arteries from normotensive obese and non-obese patients were compared.

DESIGN

Segment size was assessed by quantitative morphometry of fixed sections and wall force by in vitro myography.

SUBJECTS

Twenty normotensive non-obese and 13 normotensive obese humans body mass index (BMI) 22.4+/-0.5 and 33.9+/-1.7 kg/m(2), respectively) were studied.

RESULTS

There was no significant difference in the perimeter of the outer medial border, the smoothed out length of the internal elastic lamina, the ratios of media thickness to area and lumen diameter and the maximum wall force development between the two groups.

CONCLUSION

Obesity per se is not associated with initial dimensional changes nor capacity to develop wall tension that might lead to the emergence of hypertension.

Analysis of oligonucleotides and unincorporated nucleotides from in vitro transcription by capillary electrophoresis in Pluronic F127 gels

Small functional RNAs required for structure studies are often prepared by in vitro transcription. Capillary electrophoresis in liquid crystalline gels of Pluronic F127 was used to analyze unfractionated in vitro transcription reactions and anion-exchange high-performance liquid chromatography (HPLC) fractions from transcription reactions. Guanosine monophosphate (GMP), the four nucleoside triphosphates (NTPs), abortive transcripts, and transcripts with lengths near the desired product length were simultaneously resolved and quantified in a single run. Oligonucleotides up to at least 35 nucleotides were resolved to baseline within 10 min using a moderate field (185 V/cm) and short effective capillary length (7.6 cm) for electrophoresis in 20% Pluronic F127 at pH 8.3 in Tris-borate-EDTA (TBE) buffer (30 degrees C). Nucleotide migration times were 4-5 min, in the order UTP+CTP (unresolved) <ATP<GTP<GMP. A single capillary filling was reused for 40-50 runs with little decrease in performance, and for up to 100 runs with performance acceptable for many applications. Higher electric fields appeared to affect the gel structure and necessitated more frequent capillary refilling. Capillary gel electrophoresis (CGE) of HPLC fractions in Pluronic gels facilitates rapid recovery of RNA products and the large remaining amounts of valuable, isotopically labeled NTPs. In addition, comparison of electrophoretic patterns under denaturing and nondenaturing conditions yields insights into potential conformational heterogeneity of the folded nucleic acid states. CGE in Pluronic gels provides a rapid, highly discriminating means for analyzing in vitro transcription reactions.

Regulation of norepinephrine in the medial preoptic area of Siberian hamsters by gonadal steroids

Photoperiod has profound effects upon the neuroendocrine axis underlying reproductive physiology in seasonally breeding mammals. For long-day (LD) breeders, such as the Siberian hamster, exposure to a short-day (SD) photoperiod results in declines in circulating levels of gonadal steroids, luteinizing hormone (LH), and prolactin (PRL). The current study sought to investigate the effects of photoperiod and steroid levels on norepinephrine (NE), one of the major neurochemical regulators of gonadotropin-releasing hormone (GnRH) function. Since NE release within the medial preoptic area (mPOA) has been shown to stimulate the activity of GnRH cells, it was hypothesized that exposure to a short photoperiod would decrease NE levels. Furthermore, since gonadal steroids show negative feedback on GnRH function, it was hypothesized that gonadectomy would result in increased levels of NE. Adult male and female Siberian hamsters were gonadectomized and implanted with silastic capsules containing either cholesterol (C) or a mixture of estradiol (E) or testosterone (T). Microdialysis sampling within the mPOA was conducted after 8 weeks of exposure to either an LD or an SD photoperiod. Blood samples were analyzed for LH and PRL, while dialysis samples were analyzed for NE and its major metabolite 3-methoxy-4-hydroxyphenylglycol (MHPG). The results revealed significant suppression of LH and PRL by exposure to the SD photoperiod in both males and females. For LH, the steroid implants suppressed circulating hormone levels under both photoperiods, whereas for PRL, steroid treatment facilitated circulating levels. In contrast, there were no significant effects of photoperiod on NE or MHPG release for either males or females, but there was a significant decrease in extracellular levels of these neurochemicals in steroid-treated animals. These data suggest that photoperiodic modulation of GnRH neuronal function by NE is achieved largely through the indirect effects of photoperiod on circulating gonadal steroids.

Relationship between norepinephrine release in the hypothalamic paraventricular nucleus and circulating prolactin levels in the Siberian hamster: role of photoperiod and the pineal gland

The impact of norepinephrine (NE) and its metabolite, 3-methoxy4-hydroxyphenylglycol (MHPG), on circulating prolactin (PRL) was evaluated in the paraventricular region of the hypothalamus as a function of photoperiod and integrity of the pineal gland. In Experiment 1, whole tissue content of NE and MHPG was assessed in male and female hamsters that had been pinealectomized or sham-pinealectomized and exposed to long or short photoperiods for 5 weeks. The results revealed a marginal effect of photoperiod in males, but no overall effects of surgery. Because analysis of whole tissue content can be complicated by concurrent changes in synthesis and storage rates, Experiment 2 was conducted using microdialysis to assess extracellular levels of NE and MHPG in female hamsters. Pinealectomy completely prevented the short-day-induced suppression of luteinizing hormone, but it only partially prevented the effects of short days on PRL. Furthermore, both NE and MHPG levels were significantly elevated in short-day-exposed pinealectomized and sham-operated animals. These results suggest that NE release within the paraventricular nucleus inhibits the circulating PRL levels and is one mechanism by which direct photic information can influence the neuroendocrine axis independently of the pineal melatonin signal.

Recommendations for quality improvement in genetic testing for cystic fibrosis. European Concerted Action on Cystic Fibrosis

These recommendations for quality improvement of cystic fibrosis genetic diagnostic testing provide general guidelines for the molecular genetic testing of cystic fibrosis in patients/individuals. General strategies for testing as well as guidelines for laboratory procedures, internal and external quality assurance, and for reporting the results, including the requirements of minimal services in mutation testing, the nomenclature for describing mutations, procedures to control false-positive amplification reactions and to validate tests, and guidelines to implement a quality system in a molecular diagnostic laboratory are reviewed.

As human pial arteries (internal diameter 200-1000 microm) get smaller, their wall thickness and capacity to develop tension relative to their diameter increase

Pial arteries play a key role in the regulation of human cerebral blood flow. However, many of the features and mechanisms that regulate the tone and diameters of these vessels cannot be studied in situ. One approach is to study in vitro segments of arteries obtained during neurosurgical procedures. The ratios of arterial media thickness to lumen diameter and of the capacity to develop wall force to lumen diameter have important functional consequences and are known to change in disease. Experiments were carried out on pial arteries from normotensive humans to determine the way in which these parameters vary with vessel size. Vessel dimensions--media thickness and lumen diameter were derived from fixed sections using quantitative morphometry. Wall force was measured using a resistance artery myograph. The ratio of media thickness to lumen diameter and of maximum tension developed to lumen diameter both increased as vessel diameter decreased. These ratios do not change over the age range of 15-75 years. These findings show that although in vivo intralumenal pressure falls as human pial arteries become smaller, their media thickness and capacity to develop tone increase.

National Confidential Enquiry into counselling for genetic disorders by non-geneticists: general recommendations and specific standards for improving care

OBJECTIVES

To assess genetic counselling by non-geneticists and to improve clinical practice.

DESIGN

National retrospective review of casenotes.

SETTING

Antenatal, paediatric, medical, and surgical units.

SAMPLE

1293 genetic events were identified, involving potentially avoidable cases of Down's syndrome, neural tube defect, cystic fibrosis, beta thalassaemia major and late onset medullary carcinoma of the thyroid (multiple endocrine neoplasia). Notes were available for review in 888 (69%) of these cases.

OUTCOMES

Documented counselling, offers of relevant genetic screening and prenatal diagnosis.

RESULTS

Clinical audit was frustrated by poor quality hospital records lacking evidence of counselling. Non-geneticist clinicians concentrate on the management of disease, and may overlook the need for counselling and recording data which patients will later need for decisions about reproduction or disease prevention. Counselling, screening and prenatal diagnosis were sometimes impossible because of late booking in pregnancy, or because of delayed diagnosis of an earlier affected child with cystic fibrosis. There are marked regional inequalities of access to genetic services, particularly for minority ethnic groups with increased risks of thalassaemia. Although patients were selected for this enquiry because they had known high risks of genetic disorders, on average less than half were referred to medical geneticists. General recommendations relevant for improvement of care for patients and families with medical genetic needs and those specific for each disorder are given.

CONCLUSIONS

Assessment of the quality of genetic care becomes increasingly important as genetic counselling spreads beyond the narrow confines of specialist genetic services. Even though the events studied in this enquiry largely occurred between 1991 and 1995, there is little reason to believe that clinicians in general have become markedly better trained in medical genetics. The General Medical Council and Medical Royal Colleges should urgently consider the need for a national policy for improving undergraduate and postgraduate medical, nursing and midwifery education in genetics. Commissioners of clinical services should require that genetic management be at least as well-documented as surgical operations, drug records and informed consent, perhaps by using a nationally agreed pro-forma for prenatal diagnosis. Regular audit of counselling provided by non-geneticists is necessary to confirm that clinical improvements are occurring and standards are being met. The Confidential Enquiry provides data for a systematic approach to clinical governance of genetics in all specialities. This sets the scene for multi-speciality NHS genetic services capable of giving patients greater consistency both in access and in quality.

The rhodopsin content of human eyes

PURPOSE

To measure the total amount of rhodopsin in human eyes across the life span and to test the hypothesis that the rhodopsin content of infants' and the elderly's eyes is lower than at other ages.

METHODS

Rhodopsin was extracted from retinal and pigment epithelial fractions of 196 eyes of 102 donors, ages 27 weeks' gestation through 94 years, using quantitative procedures. To recover photopigment bleached by unavoidable light exposure, the fractions from 78 eyes were incubated with 9-cis retinal. The total photopigment (retinal plus pigment epithelial fractions) per eye was examined for significant changes with age, using the higher value from pairs of eyes.

RESULTS

The median rhodopsin content of the higher eye of adults is 6.45 nmoles (range, 3.33-10.84 nmoles) with 8 nmoles or more recovered from 28% of all adult eyes. The rhodopsin content of infants' eyes (< 12 months post-term) is significantly lower than that of older individuals and increases with age. After infancy, no change with age is found. For both infants and adults, 9-cis retinal significantly increases the amount of photopigment recovered without reducing the variance in the amount of photopigment recovered. The rhodopsin content is estimated to be 50% of the median adult amount early in infancy, approximately 5 weeks postterm (95% confidence interval, 0-10 weeks postterm).

CONCLUSIONS

A developmental increase in rhodopsin content occurs during infancy. Thereafter rhodopsin content remains constant. The amount of rhodopsin recovered from human eyes is quite variable. Bleaching alone cannot explain the variability.

Regulation of neuropeptide Y mRNA and peptide concentrations by copper in rat olfactory bulb

Neuropeptide Y is highly abundant in both the peripheral and central nervous systems and is known to have diverse functions including regulation of feeding behavior, blood pressure, circadian rhythms, reproductive behavior and the response to stress. Northern analysis showed that copper deficiency increased brain NPY mRNA abundance particularly in the olfactory bulb (OB). These increases were not accompanied by alterations in food intake or blood pressure. After 4 weeks of a copper-restricted diet, OB copper concentrations decreased to 44% of control and NPY mRNA increased 1.5-fold. Addition of a copper chelator to the restricted diet, resulted in a two-fold increase in OB NPY mRNA over copper adequate controls. These results were confirmed in primary cultures of OB neurons suggesting that the regulation of NPY mRNA is at the level of the bulb rather than by a hormonal or other copper-regulated factor external to the OB. Immunoreactive NPY (IR-NPY) levels were not, however, increased following the 4 weeks of copper deficiency. Addition of the chelator resulted in a 1.4-fold increase in IR-NPY that, while statistically significant, was not proportional to the two-fold increase in NPY mRNA in the same study. This may suggest that copper deficiency inhibits the translational mechanisms responsible for the synthesis of NPY or that NPY is exported from the bulb in copper deficiency.

Responsiveness of human infant cerebral arteries to sympathetic nerve stimulation and vasoactive agents

Responses of segments of basilar and middle cerebral arteries of eight human infants to activation of perivascular nerves and to vasoactive drugs were studied using a resistance artery myograph. The infants ages ranged from 23 wk of gestation to 34 postnatal days. Neurogenic vasoconstriction occurred in all segments and at 8 Hz was 12.7 +/- 3.5% (11%) of tissue maximum and was blocked by phentolamine (10(-6) M). There was no evidence of a neurogenic dilator response. Catecholamine histofluorescence was seen in nerves in the adventitia at all ages studied. Norepinephrine ED50 was 7.6 +/- 1.8 x 10(-7) M, and its maximum effect was 43.1 +/- 5.7% of tissue maximum. Both neural and norepinephrine responses were greater than those of the proximal parts of adult human middle cerebral arteries obtained postmortem and surgically removed adult human pial arteries. Electron microscopy demonstrated that neural density at the adventitiomedial junction in the infant vessels was greater than in the pial arteries. Constrictor responses to serotonin and prostaglandin F2 alpha were minimal in the two infants of 23 and 24 wk of gestation but were clearly present in the older infants. Histamine and acetylcholine were potent vasodilators. Indomethacin potentiated agonist-induced contraction. In a limited number of trials angiotensin II, neuropeptide Y, caused contraction and bradykinin, relaxation. It is concluded that there is a quantitative similarity between the studied responses of infant cerebral artery segments and human pial arteries of similar diameter. However, sympathetic nerves may potentially play a more important role in the regulation of cerebrovascular tone in the infant compared with the adult, and during the gestational period examined these vessels possess an indomethacin-sensitive system that buffers agonist tone.

Gastro-oesophageal reflux in children

Disordered motility of the gastrointestinal tract in children is usually manifest as gastro-oesophageal reflux disease. Reflux is common in infants but usually resolves spontaneously with time. If severe enough to merit investigation, 24-hour ambulant oesophageal pH monitoring is the most widely used investigation, though it does have disadvantages. Upper gastrointestinal endoscopy and biopsy may be required to diagnose oesophagitis. Treatment follows a step-wise approach, progressing from positioning and feed-thickening in infants, through to pharmacological management with prokinetic agents and/or acid-suppression, and surgery for a very small proportion of children whose symptoms do not respond to optimal medical therapy.

Weakness of sympathetic neural control of human pial compared with superficial temporal arteries reflects low innervation density and poor sympathetic responsiveness

BACKGROUND AND PURPOSE

The primary goal of these studies was to understand and investigate the capacity of perivascular nerves to influence the tone of human pial arteries and to compare them with other human cephalic arteries, the superficial temporal and middle meningeal.

METHODS

Responses to electrical activation of intramural nerves and related features of fresh segments of human cephalic arteries-the pial (PA; 478+/-34 microm ID), middle meningeal (MMA; 540+/-41 microm ID), and superficial temporal (STA; 639+/-49 microm ID)-obtained from patients aged 15 to 82 years during surgical procedures were studied on a resistance artery myograph.

RESULTS

The PA segment responses to electrical nerve activation and to norepinephrine (NE; 10[-5] mol/L) were 1% and 21% of tissue maximum, respectively, compared with 6% and 34% for the MMA and 14% and 90% for the STA. Tissue maximum was defined as the force increase to 127 mmol/L KCl plus arginine vasopressin (1 microm). All arteries dilated well to acetylcholine. Possible explanations for the PA marginal neurogenic responses were assessed. NE ED50 was 5.4+/-2.2 X 10(-7) mol/L and did not vary with age or diameter. NE responsiveness did not increase in vessels with spontaneous or raised potassium-induced tone. Relaxation to isoproterenol was variable and propranolol did not increase the neurogenic response. Neither N(G)-monomethyl-L-arginine, N(G)-nitro-L-arginine methyl ester, endothelium removal, nor indomethacin consistently influenced the contractions to NE or neurogenic reactivity. The weak PA neurogenic response is in keeping with its poor innervation. As determined by catecholamine histofluorescence, innervation in the PA is sparse, with density increasing in the order PA, MMA, and STA. The incidence of nerve structures in the PA adventitio-medial junction was only 3% of those in the STA, and these were situated more than 3 microm from the closest smooth muscle cell.

CONCLUSIONS

We conclude that the weak neurogenic response of adult human pial artery reflects its poor innervation and responsiveness to NE, implying that these features are not important in the regulation of its diameter.

Ethyl propionate is more effective and less cytotoxic than methyl tert-butyl ether for topical gallstone dissolution

BACKGROUND & AIMS

Ethyl propionate and isopropyl acetate were identified as gallstone solvents with more favorable physicochemical properties than the currently used solvent methyl tert-butyl ether (MTBE). In this study, their efficacy and toxicity were compared.

METHODS

To compare efficacy, matched stones from 33 patients were subjected to dissolution with each solvent. To evaluate cytotoxicity, jejunal segments of the anesthetized rat were exposed to each solvent or saline; the segments were then perfused with markers for active absorption and passive permeability.

RESULTS

For 23 gallstone sets that dissolved completely with all three solvents, the average dissolution time was shorter with ethyl propionate (38 +/- 8 minutes) than with MTBE (60 +/- 13 minutes) (P = 0.03) or isopropyl acetate (55 +/- 12 minutes) (P < 0.001). Four stones did not dissolve with ethyl propionate, seven with MTBE, and eight with isopropyl acetate. After 2 minutes of exposure to the solvents, the dry weight of the segments decreased by 36% after MTBE but was unchanged after the other two solvents (P < 0.001). MTBE caused more inhibition of active absorption than the other solvents (P < 0.001) and a greater increase in passive permeation (P < 0.03).

CONCLUSIONS

Ethyl propionate and isopropyl acetate are less toxic to the intestinal mucosa than MTBE, and ethyl propionate is more effective for gallstone dissolution.

Rhodopsin in immature rod outer segments

PURPOSE

To test the hypothesis that rhodopsin concentration is low in immature rat rod outer segments (ROS).

METHODS

Microspectrophotometry (MSP) was used to assess rhodopsin absorbances in localized regions of isolated ROS from dark-adapted 13-, 19-, and 34-day-old and adult rats. Photopigment was extracted from the retinas of paired eyes in dark-adapted and light-adapted rats. One retina of each pair was treated with 9-cis retinal before extraction of photopigment. Rhodopsin with native 11-cis retinal was extracted from the fellow retina.

RESULTS

By MSP, rhodopsin absorbance was low in the short ROS of 13-day-old rats. In 19-day-old rats with ROS lengths approximately equal to those of adults, absorbance was low at the tip, but at the base, it was equal to the high absorbance at both the tip and the base in adults. The 9-cis retinal did not add absorbance to the photopigment extracts of dark-adapted retinas at any age, but it did add absorbance to extracts of the light-adapted retinas at every age.

CONCLUSIONS

The MSP results show that the accumulation of rhodopsin in developing rat rods depends on increasing concentrations in localized regions. No evidence of apo-opsin is found in immature rat rods. Thus, in immature ROS regions, the low rhodopsin absorbances suggest that the amount of opsin is also low. Greater disk-to-disk spacing in immature ROS regions than in mature regions could account for these findings.

Uptake of yeast (Saccharomyces boulardii) in normal and rotavirus treated intestine

BACKGROUND

There has recently been a growing interest in the use of the non-pathogenic yeast Saccharomyces boulardii, in the treatment of gastrointestinal disorders, including diarrhoea. The full effects of administration of the yeast are not fully understood.

AIMS

To investigate the morphological effects of inoculated S boulardii on mouse intestinal villi, both in control animals and those treated with rotavirus.

METHODS

Seven day old BALB/c seronegative mice were intubated with either rotavirus (30 microliters orally) or S boulardii (1.5 g/kg) or both rotavirus and S boulardii administered together. Control animals were given saline only. Animals were killed by decapitation 48 hours post-treatment. The middle region of the small intestine was studied using light microscopy and transmission and scanning electron microscopy, including backscattered electron imaging.

RESULTS

Animals treated with rotavirus with or without S boulardii developed severe diarrhoea and showed morphological villous changes such as stromal separation and increased epithelial vacuolation. Specimens treated with S boulardii contained yeast particles within the mucosal tissues.

CONCLUSION

The administration of S boulardii did not influence the changes produced by rotavirus, but yeast particles appeared to be taken up by the villous mucosa, with the predominant route apparently being uptake between adjacent epithelial cells.

Morphological aspects of particle translocation in vivo following ingestion of the yeast Saccharomyces boulardii

Particle translocation in vivo was studied in mice using the non-pathogenic yeast Saccharomyces boulardii (SB). Seven day old BALB/c mice were given either saline (control) or 1.5 g/Kg SB (every six hours, up to 48 hours), by intubation, and killed by decapitation 48 hours post-treatment. Light and scanning electron microscopy (SEM) examination of specimens prepared from the middle intestine revealed the presence of yeast inclusions localised in the cytoplasm of enterocytes.

Wortmannin, a potent and selective inhibitor of phosphatidylinositol-3-kinase

Phosphatidylinositol-3-kinase is an important enzyme for intracellular signaling. The microbial product wortmannin and some of its analogues have been shown to be potent inhibitors of phosphatidylinositol-3-kinase. The 50% inhibitory concentration for inhibition by wortmannin is 2 to 4 nM. Kinetic analysis demonstrates that wortmannin is a noncompetitive, irreversible inhibitor of phosphatidylinositol-3-kinase, with inactivation being both time- and concentration-dependent. Wortmannin has previously been reported to be an inhibitor of myosin light chain kinase but with an inhibitory concentration of 0.2 microM. Wortmannin was found not to be an inhibitor of phosphatidylinositol-4-kinase, protein kinase C, or protein tyrosine kinase. Wortmannin inhibited the formation of phosphatidylinositol-3-phosphates in intact cells. The results of the study suggest that wortmannin and its analogues may have utility as pharmacological probes for studying the actions of phosphatidylinositol-3-kinase.

Chronic bullous disease of childhood and ulcerative colitis

A 12-year-old girl with ulcerative colitis (UC) treated by colectomy with rectal stump preservation, salazopyrin, and systemic steroids developed persistent mouth ulcers, cutaneous targetlike lesions, papulopustules, and bullae. The clinical, histologic, and immunopathologic features were typical of chronic bullous disease of childhood (CBDC). Although resistant to combined immunosuppressive therapy with low-dose prednisolone, cyclosporin, and thalidomide, striking remission of the mucocutaneous symptoms resulted with surgical resection of the diseased rectal stump. An etiologic association between CBDC and UC is postulated.

Role of hiatal hernia in delaying acid clearance

The aim of this study was to assess prospectively the relationship of a hiatal hernia to gastro-oesophageal reflux. Ninety five children with symptoms of gastro-oesophageal reflux in whom reflux was demonstrated radiologically were investigated. Oesophageal pH monitoring for 18 hours and endoscopy were performed in all patients. On the basis of radiology, patients were divided into those with hiatal hernia (n = 37) and those without (n = 58). Both groups had the same number of reflux episodes on pH monitoring. However, the median duration of the longest episode was significantly greater in the hiatal hernia group (30 min v 19 min), as was the number of reflux episodes longer than five minutes (5 v 4). The percentage with a pH < 4 just failed to be significantly different (13% v 8%). Hiatal hernia was also found to correlate with the presence of oesophagitis. The presence of a hiatal hernia delays the clearance of acid from the oesophagus and is associated with an increased incidence of oesophagitis.

The quantity of rhodopsin in young human eyes

The rhodopsin content of 20 eyes of infants and children ages 27 weeks gestation to 8 years (11 donors) was assayed and compared to the rhodopsin content of adults (36 eyes; 19 donors). Infants have significantly lower rhodopsin contents than adults. On average the rhodopsin content of young infants is about a third of adults. Previously reported full-field b-wave sensitivity of young infants is about 0.5 log units, that is about a third, less than adults. Thus, as previously found in infant rats, photon capture by rhodopsin appears to limit the dark adapted sensitivity of young human infants.

The quantity of rhodopsin in human eyes

The content of rhodopsin in the eyes of 15 donors (30 eyes) was determined. Both retinal and pigment epithelial fractions were collected from each globe, extracted using 1% CTAB, and the rhodopsin difference spectrum of each fraction was obtained separately. The total amount of rhodopsin, obtained by summing the amounts recovered from the retinal and PE fractions, ranged from 2.00 to 11.94 (median: 6.40) nmoles/eye. Previously reported mean values of about 3.5 to 4.0 nmoles per retina have been obtained using a variety of methods. The present higher values, perhaps largely dependent on procedural details described herein, appear plausible given the known concentrations of rhodopsin in rod outer segments, rod outer segment volumes, and number of rods in the human retina.

Fecal incontinence in elderly patients

Fecal incontinence is a common and important problem in the care of the elderly. An understanding of the defecation mechanism, appropriate differential diagnosis, and the best choice of treatment method are necessary to control this problem. Establishing a regular bowel program takes time and energy, but when the final result is continence, it is time and energy well spent.

Fatty acids in cystic fibrosis in response to a marathon race

Lipid metabolism was studied in three cystic fibrosis (CF) patients (18 years old) and three healthy controls (35-40 years old) who completed the New York Marathon 1984. Lipase was not detectable in plasma from two of the CF patients, but in one CF patient with a functioning pancreas and in the three controls it increased during and after the run. Cholesterol concentrations were lower in all patients than in the controls. The HDL/total cholesterol ratios increased in all runners throughout the observation period, substantially more in the patients than in the controls. Triglycerides and glycerol values were similar in the two groups. The relative distribution of fatty acids in total plasma, plasma free fatty acid fractions, and total red blood cell membranes, at rest, were similar to those earlier reported both for the CF patients with pancreatic insufficiency and for the controls. Lower relative concentrations of linoleic acid (C18:2n6) and higher relative concentrations of C14:0, C16:0, C16:1, C18:3n6, and C20:3n6 were found in the CF specimens. During and after the race, linoleic acid concentration increased and the other fatty acids decreased, giving a more normalized pattern in the patients. The fatty acid pattern of the CF patient with a functioning pancreas behaved more like the healthy controls. The fatty acid pattern of the red cell membrane did not change during or after the run. Although the observations are few, it is encouraging that both the HDL/total cholesterol ratio and the fatty acid pattern improve in response to prolonged aerobic exercise.