Carbamazepine therapy in restless legs. Discrimination between responders and non-responders

One hundred and seventy-four patients suffering from restless legs were included in a double-blind trial. Eighty-four patients were treated with carbamazepine (CBZ) and 90 with placebo. Discrimination analysis was carried out in order to characterize the patients who did not benefit from the treatment. Patients treated with CBZ were divided into responders and non-responders. A discriminant function classified 15 out of 19 actual non-responders as non-responders and 60 out of 65 actual responders as responders. By using the "leaving-one-out" technique, 14 of the non-responders and 57 of the responders were still correctly classified. The probability of erroneously classifying a patient increased from about 10 to 15% by this correction. The discriminant function classified approximately 80% of the patients in the placebo group as responders to CBZ.

Correlated trapped bosons and the many-body Efimov effect

We study two-body correlations in systems of identical bosons. We use a Faddeev type of decomposition of the wave function where all pairs of particles are treated equally. At large scattering length appears a series of Efimov-like states, i.e., spatially extended, model-independent many-body bound states inside the trap. They may play a role in the decay of Bose-Einstein condensates.

The human cationic antimicrobial protein (hCAP-18) is expressed in the epithelium of human epididymis, is present in seminal plasma at high concentrations, and is attached to spermatozoa

Innate immunity is important for the integrity of the host against potentially invasive pathogenic microorganisms in the environment. Antibiotic peptides with broad antimicrobial activity are part of the innate immune system. We investigated the presence of the cathelicidin, human cationic antimicrobial protein (hCAP-18), in the male reproductive system. We found strong expression of the hCAP-18 gene by in situ hybridization and hCAP-18 protein, as detected by immunohistochemistry, in the epithelium of the epididymis, but not in the testis. The highest expression in the epididymis was in the caudal part. Western blotting showed a doublet band, the upper part corresponding to the size of hCAP-18 in plasma and neutrophils. Using a specific enzyme-linked immunosorbent assay (ELISA), levels of 86.5 +/- 37.8 microg/ml (mean +/- standard deviation; range, 41.8 to 142.8 microg/ml; n = 10) were detected in seminal plasma from healthy donors, which is 70-fold higher than the level in blood plasma. Flow cytometry and immunocytochemistry revealed the presence of hCAP-18 on spermatozoa. ELISA measurement showed levels of 196 ng/10(6) spermatozoa, corresponding to 6.6 x 10(6) molecules of hCAP-18 per spermatozoon. Our results suggest a key role for hCAP-18 in the antibacterial integrity of the male reproductive system. The attachment of hCAP-18 to spermatozoa may implicate a role for hCAP-18 in conception.

Methods for quantitation of human neutrophil proteins, a survey

Neutrophils contain a variety of proteins that endow the cell with its capacity to migrate towards and eliminate microbial pathogens. Many of these proteins are largely or exclusively localized to neutrophils. It is therefore of interest to quantitate these proteins in a variety of clinical settings as well as in basic research. The aim of this survey is to give an introduction to some of the more commonly used methods for quantitation of neutrophil proteins and to discuss advantages and problems of the different methods and the relevance of quantitating neutrophil proteins in different biological settings.

YKL-40, a matrix protein of specific granules in neutrophils, is elevated in serum of patients with community-acquired pneumonia requiring hospitalization

The serum concentration of YKL-40, a matrix protein of specific granules in neutrophils, was determined by RIA in 90 patients hospitalized with pneumonia of suspected bacterial origin. Of these, 64 were followed prospectively during antibiotic treatment with blood samples taken on day 0 (on admission and the start of treatment) and on days 1, 3, 5, 7, 10, and 21. Serum YKL-40 at admission was increased in patients with Streptococcus pneumoniae pneumonia (median, 893 microgram/L; 95% confidence interval [CI], 704-1560), compared with healthy subjects (median, 102 microgram/L; 95% CI, 64-247 microgram/L; P<.001) and in patients with pneumonia of unknown etiology (median, 448 microgram/L; 95% CI, 334-700; P<.05). Peak YKL-40 serum values were observed on day 1 and thereafter declined steeply to almost normal by day 3. During the first 10 days, there was a close relation between serum YKL-40 and markers of specific granules of neutrophils (serum lactoferrin and neutrophil gelatinase-associated lipocalin), which suggests that serum YKL-40 reflects exocytosis of specific granules of neutrophils in persons with acute bacterial pneumonia.

The human antibacterial cathelicidin, hCAP-18, is bound to lipoproteins in plasma

Cathelicidins are a family of antibacterial and lipopolysaccharide-binding proteins. hCAP-18, the only human cathelicidin, is a major protein of the specific granules of human neutrophils. The plasma level of hCAP-18 is >20-fold higher than that of other specific granule proteins relative to their levels within circulating neutrophils. The aim of this study was to elucidate the background for this high plasma level of hCAP-18. Plasma was subjected to molecular sieve chromatography, and hCAP-18 was found in distinct high molecular mass fractions that coeluted with apolipoproteins A-I and B, respectively. The association of hCAP-18 with lipoproteins was validated by the cofractionation of hCAP-18 with lipoproteins using two different methods for isolation of lipoproteins from plasma. Furthermore, the level of hCAP-18 in delipidated plasma was <1% of that in normal plasma. Immunoprecipitation of very low, low, and high density lipoprotein particles with anti-apolipoprotein antibodies resulted in coprecipitation of hCAP-18. The binding of hCAP-18 to lipoproteins was mediated by the antibacterial C-terminal part of the protein. The binding of hCAP-18 to lipoproteins suggests that lipoproteins may play an important role as a reservoir of this antimicrobial protein.

The human cationic antimicrobial protein (hCAP18), a peptide antibiotic, is widely expressed in human squamous epithelia and colocalizes with interleukin-6

Peptide antibiotics are widespread in nature and, by providing a rapid first line of defense, may be key players in the innate immune system. Although epithelia are the main barriers shielding the internal environment from microorganisms, the role for peptide antibiotics in epithelial protection is unclear. We recently reported that the human cationic antimicrobial protein hCAP18, the precursor of the antimicrobial peptide called LL-37, is not expressed by normal human keratinocytes but is induced in various inflammatory skin disorders. In the present study we demonstrate that hCAP18 is consistently expressed at both mRNA and protein levels in squamous epithelia of the mouth, tongue, esophagus, cervix, and vagina in humans. The gene for hCAP18 contains promoter elements that are potentially regulated by interleukin-6, and our data further show a colocalization between interleukin-6 and hCAP18 expression in these tissues. Our finding that hCAP18 is widely produced in squamous epithelia suggests a role for this peptide in epithelial antimicrobial defense. Furthermore, colocalization with interleukin-6 indicates a potential local mechanism for the upregulation of hCAP18 at the epithelial surfaces.

Timing, targeting and sorting of azurophil granule proteins in human myeloid cells

Biosynthesis of 3 human granule proteins, myeloperoxidase, defensin and lysozyme, all present in azurophil granules, was investigated in normal bone marrow cells and in the promyelocytic cell line HL-60 to see whether differences in timing of biosynthesis could explain the well established differences in their subcellular localization in the mature neutrophil (targeting), and whether differences exist in the efficiencies by which granule proteins are retained in cells (sorting). Normal human bone marrow cells were separated into three bands by density gradient centrifugation. Band 1 contains band and segmented cells, band 2 mainly myelocytes, metamyelocytes and some band cells, and band 3 myeloblasts and promyelocytes in addition to megakaryocytes and proerythroblasts. Cells from these bands, as well as undifferentiated HL-60 cells, were pulsed with radiolabeled cysteine and methionine, and biosynthesis of granule proteins was subsequently evaluated by immunoprecipitation and quantified by phosphorimaging. Myeloperoxidase synthesis was maximal in cells from band 3 while defensin biosynthesis was maximal in cells from band 2. Lysozyme was synthesized in cells from all bands but was maximal in cells from band 2. These results are in agreement with our hypothesis that timing of biosynthesis determines the localization of individual granule proteins. While myeloperoxidase and defensins were efficiently retained in immature cells (band 3), a significant fraction of lysozyme was routed out of the cells, showing that differences exist in the sorting of granule proteins between constitutive and regulated secretion. In addition, defensin was less efficiently retained in cells from band 2 than from band 3, indicating that sorting mechanisms may depend on the stage of cell maturation.

YKL-40, a mammalian member of the chitinase family, is a matrix protein of specific granules in human neutrophils

YKL-40, also called human cartilage glycoprotein-39 (HC gp-39), is a member of family 18 glycosyl hydrolases. YKL-40 is secreted by chondrocytes, synovial cells, and macrophages, and recently it has been reported that YKL-40 has a role as an autoantigen in rheumatoid arthritis (RA). The function of YKL-40 is unknown, but the pattern of its expression in normal and disease states suggests that it could function in remodeling or degradation of the extracellular matrix. High levels of YKL-40 are found in synovial fluid from patients with active RA. Neutrophils are abundant in synovial fluid of patients with RA, and the cells are assumed to play a role in joint destruction in that disorder. Therefore, we examined whether neutrophils are a source of YKL-40. YKL-40 was found to colocalize and comobilize with lactoferrin (the most abundant protein of specific granules) but not with gelatinase in subcellular fractionation studies on stimulated and unstimulated neutrophils. Double-labeling immunoelectron microscopy confirmed the colocalization of YKL-40 and lactoferrin in specific granules of neutrophils. Immunohistochemistry on bone marrow cells showed that neutrophil precursors begin to synthesize YKL-40 at the myelocyte-metamyelocyte stage, the stage of maturation at which other specific granule proteins are formed. Assuming that YKL-40 has a role as an autoantigen in RA by inducing T cell-mediated autoimmune response, YKL-40 released from neutrophils in the inflamed joint could be essential for this response. In RA and other inflammatory diseases, YKL-40 released from specific granules of neutrophils may be involved in tissue remodeling or degradation.

Reduced expression of C5a receptors on neutrophils from cord blood

AIM

To describe further functional deficiencies of neonatal neutrophils by measuring the expression of C5a receptors.

METHODS

C5a uptake was measured using flow cytometry with fluorescein isothiocynate labelled recombinant C5a. The response of neutrophils to stimulation with C5a and fMLP was tested by measuring migration and exocytosis of myeloperoxidase and lactoferrin.

RESULTS

C5a mean fluorescence on neutrophils from neonates was significantly lower (22.4 (SD 3.5)) than in adult controls (31.5 (3.1)). Neutrophils from neonates migrated poorly towards both C5a and fMLP compared with those from adult controls. Exocytosis of myeloperoxidase, but not lactoferrin from neonatal neutrophils stimulated with C5a, was significantly lower than in adult controls. fMLP stimulation, on the other hand, resulted in significantly higher exocytosis in neonates.

CONCLUSION

The lower expression of C5a receptors on neutrophils from neonates could be related to reduced C5a mediated exocytosis of myeloperoxidase.

The human antibacterial cathelicidin, hCAP-18, is synthesized in myelocytes and metamyelocytes and localized to specific granules in neutrophils

hCAP-18 is the only human member of the antibacterial and endotoxin-binding family of proteins known as cathelicidins. The antibacterial and endotoxin binding domains reside in the C-terminal 37 amino acids of the protein (LL-37) and this is believed to be unleashed from the neutralizing N-terminus by proteases from peroxidase positive granules. In human neutrophils, peroxidase positive and peroxidase negative granules can be subdivided into granule subsets that differ in protein content and ability to be exocytosed. To determine the localization of hCAP-18, we performed high-resolution immuno-electron microscopy and subcellular fractionation on Percoll density gradients. Biosynthesis of hCAP-18 was investigated in isolated human bone marrow cells. hCAP-18 was found to colocalize and comobilize with lactoferrin, but not with gelatinase in subcellular fractions. This was confirmed by electron microscopy. hCAP-18 is synthesized at the same stage of myeloid cell maturation as lactoferrin, and is efficiently targeted to granules. Like the peroxidase negative granule's matrix metalloproteinases, collagenase and gelatinase, hCAP-18 is also stored in unprocessed form. hCAP-18 is a major protein of specific granules where it is present in equimolar ratio with lactoferrin.

An ELISA for hCAP-18, the cathelicidin present in human neutrophils and plasma

hCAP-18 is a newly described protein of human neutrophilic granulocytes which belongs to the cathelicidin family of antimicrobial proteins. Members of this protein family share a common N-terminal sequence followed by a highly diverse antimicrobial, cationic C-terminus. The present work describes the production of recombinant hCAP-18, the generation of antibodies to the protein and the development of an accurate, sensitive and specific ELISA for the detection of hCAP-18 in cells, plasma and urine with a detection limit of 0.084 ng/ml. The amount of hCAP-18 in neutrophils is 0.627 microgram protein per 10(6) cells. The plasma level is 1.18 micrograms/ml which is several fold higher than for other neutrophil specific granule proteins. hCAP-18 is present in plasma as high molecular weight complexes. In accordance with this, hCAP-18 is barely excreted in the urine. The bone marrow appears to be the major source of plasma hCAP-18. The high level of hCAP-18 in plasma may provide an important defense against microorganisms and endotoxins.

An ELISA for grancalcin, a novel cytosolic calcium-binding protein present in leukocytes

Grancalcin is a newly discovered cytosolic calcium-binding protein, belonging to the group of EF-hand proteins. Grancalcin is specifically associated with cells originating in the bone marrow. Grancalcin binds reversibly to secretory vesicles and plasma membranes in human neutrophils and might therefore play a role in the regulation of vesicle/granule exocytosis. We describe here the production of recombinant grancalcin, the generation of antibodies to the protein and the development of a specific, accurate and sensitive ELISA for the detection of human leukocytic grancalcin. This ELISA may be useful for monitoring leukocyte infiltration into tissues.

Gamma-aminobutyric acid concentration in lumbar cerebrospinal fluid from patients with febrile convulsions and controls

The cerebrospinal fluid (CSF) concentration of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) was analysed in 41 children with febrile convulsions (FC), 41 febrile controls of similar age (control group 1), and 59 controls, who had no fever and/or were outside the age range for FC (control group 2). A significant correlation between CSF-GABA and age was demonstrated for controls (1 + 2) (r = 0.63, p less than 0.00001), as well as for patients with FC (r = 0.42, p = 0.003). Patients with FC did not differ significantly from control group 1 in respect to CSF-GABA. Duration of FC was related to both CSF-GABA and age (GABA: r = -0.29, p less than 0.05; age: r = -0.32, p less than 0.05). For 56 controls (1 + 2) greater than 1 year of age, a significant negative correlation between CFC-GABA and body temperature was found (r = -0.34, p = 0.01). The low CSF-GABA in the FC-labile age group, the negative correlation of CSF-GABA to body temperature, and the negative correlation of the duration of FC to both CSF-GABA and age, all indicate that GABA could be of importance in the pathophysiology of FC.

Immunomagnetic removal of B-lymphoma cells from human bone marrow: a procedure for clinical use

B-lymphoma cells were purged from human bone marrow by incubating the cell suspension with a cocktail of three different pan-B cell mouse IgG1 monoclonal antibodies, and then with immunobeads charged with sheep anti-mouse antibody, followed by magnetic separation. The primary antibodies used, HD37 (CD19), HD6 (CD22), and HH1 (CD37), bind to a very high percentage of the cells in non-Hodgkin's lymphomas of poor prognosis. The secondary antibody is directed against the Fc portion of the IgG antibodies. In model experiments Burkitt's lymphoma cells (Rael) were admixed to mononuclear bone marrow cells in the ratio 1/9. With a ratio of immunobeads/total antibody-binding B cells of 50/1 in a first treatment cycle and repeating the procedure with the same number of beads in a second cycle, a tumor cell depletion of more than 5 logs was achieved, as judged by a clonogenic assay. The concomitant reduction of CFU-GM and CFU-GEMM was about 20%. The purging procedure has been scaled up to clinical use. Equipment suitable for purging patients' marrow specimens, employing standard transfusion facilities, is described. With this equipment the efficacy of tumor cell removal was the same as in the model experiments, and the whole magnetic separation could be completed in 2 hours.

Cerebral hyperperfusion following carotid endarterectomy

Serial measurements of cerebral blood flow (CBF) were performed in 56 patients before and one to four times after uncomplicated carotid endarterectomy. The findings were related to the ratio between internal carotid artery (ICA) and common carotid artery (CCA) mean pressures. Within the 1st postoperative day CBF increased by a median of 37% in the ipsilateral and 33% in the contralateral hemisphere. Later recordings showed a gradual return of CBF toward the preoperative level. Sixteen patients with an ICA/CCA pressure ratio below 0.7 showed a significantly more pronounced and longer-lasting flow increase than did 40 patients with a ratio above this level. On Day 1, the median CBF increase in the ipsilateral hemisphere was 61% and 24% in the two groups, respectively (p less than 0.01). A significant improvement in side-to-side asymmetry, resulting from a higher gain in the ipsilateral hemisphere, occurred in the low pressure ratio group, while the hemispheric asymmetry on average was unchanged in the high pressure ratio group. This relative hyperemia was most pronounced 2 to 4 days following reconstruction. The marked hyperemia, absolute as well as relative, in patients with a low ICA/CCA pressure ratio suggests a temporary impairment of autoregulation. Special care should be taken to avoid postoperative hypertension in such patients, who typically have preoperative hypoperfusion, to avoid the occurrence of cerebral edema or hemorrhage.

The incidence of cardiac arrhythmias and arterial hypotension subsequent to standardized surgical stimuli in patients undergoing thoracotomy. With reference to enflurane and halothane

A main factor which might cause cardiac arrhythmias and arterial hypotension during thoracic operations is surgical manipulation around the pericardium and the lung hilus. Halothane and enflurane were compared as to the occurrence of arrhythmias and hypotension caused by standardized surgical stimulation. Twenty-eight patients scheduled for thoracotomy were studied. The patients were selected in randomized order, and the anaesthetic agent in use was unknown to the surgeon. ECG, intra-arterial blood pressure and central venous pressure were recorded continuously. Six patients in the halothane group (n = 14) and nine patients in the enflurane group (n = 14) developed premature atrial contractions and nodal rhythm, while nine patients in the halothane group and five in the enflurane group developed a fall in systolic blood pressure of more than 20 mmHg (2.7 kPa). No statistically significant difference in the occurrence of cardiac arrhythmias and hypotension was found between the two anaesthetic groups.

Treatment of the restless legs syndrome with carbamazepine: a double blind study

One hundred and seventy four patients suffering from the restless legs syndrome were examined in a double blind, between patient, placebo controlled study in general practice for five weeks to investigate the effects of carbamazepine and placebo on the syndrome. The syndrome was more common among middle aged women with relatively low systolic blood pressure. The median haemoglobin concentration was about average for the population, but the severity of the symptoms seemed to increase with decreasing concentrations of haemoglobin. Both placebo and carbamazepine showed a significant therapeutic effect (p less than 0.01). Carbamazepine was significantly more effective than placebo (p less than or equal to 0.03). The significant therapeutic effect of placebo in restless legs showed that only double blind controlled trials can confirm the efficacy of suggested treatments.

Haemodynamic effects of intravenous procaine as a supplement to general anaesthesia in patients with valvular heart disease

The effect of intravenous procaine, 2 mg/kg/min, on the cardiovascular function of nine patients scheduled for cardiac valve replacement was studied under enflurane-pancuronium anaesthesia. Procaine infusion was started after intubation during steady-state anaesthesia, and continued until start of cardiopulmonary by-pass. Systemic vascular resistance decreased steadily from 198.2 +/- 28.7 to 133.0 +/- 17.2 kPa X s/l (P less than 0.05). A simultaneous decline in mean arterial pressure from 10.13 +/- 0.68 to 7.47 +/- 0.48 kPa was observed (P less than 0.01). Cardiac index, heart rate, central venous pressure, pulmonary arterial mean pressure and pulmonary capillary wedge pressure were all unaffected by procaine as well as by surgical stimulation. It is concluded that continuous procaine infusion as an adjuvant to general anaesthesia effectively abolishes the hypertensive and tachycardiac response to surgical stimulation. The limiting factor in the amount of infused procaine appears to be the hypotension caused by vasodilation, not myocardial depression or convulsions.

Cardiac effects of atropine and gallamine in patients receiving suxamethonium

Eighty healthy patients were randomly allocated to four groups. Atropine 0.01 mg kg-1 i.v. (group I), gallamine 0.3 mg kg-1 i.v. (group II), atropine 0.01 mg kg-1 i.m. and gallamine 0.3 mg kg-1 i.v. (group III), or atropine 0.01 mg kg-1 i.v. and gallamine 0.3 mg kg-1 i.v. (group IV) were given before operation. After induction of anesthesia with thiopentone, suxamethonium 1 mg kg-1 was given i.v. The lungs were ventilated with halothane in nitrous oxide in oxygen. Five minutes later the same dose of suxamethonium was repeated. E.c.g. was monitored continuously. No serious bradycardia was observed following a second injection of suxamethonium in any group. The results suggest that thiopentone protects against suxamethonium-induced bradycardia during halothane anaesthesia.

Thiopental-nitrous oxide- halothane anesthesia and repeated succinylcholine: comparison of preoperative glycopyrrolate and atropine administration

The effects of glycopyrrolate and atropine given prior to thiopental-N2O-halothane anesthesia on bradyarrhythmias associated with the administration of succinylcholine were studied and compared. Sixty healthy adult patients were allocated at random to one of three groups. Three minutes before induction of anesthesia with thiopental (4 to 5 mg/kg) one group received glycopyrrolate, 0.0045 mg/kg IV, the second group, glycopyrrolate, 0.008 mg/kg IV, and the third group, atropine, 0.009 mg/kg IV. Succinylcholine, 1 mg/kg of body weight, was given 1 minute and 6 minutes after the conclusion of the thiopental injection. ECG monitoring was continuous, and serum K+ levels as well as PaO2 and paCO2 were repeatedly measured. In all three groups patients were adequately and equally protected against serious bradyarrhythmias following the second dose of succinylcholine by atropine and glycopyrrolate in the doses used.

Cimetidine in the prevention of acid aspiration during anesthesia

In a controlled, randomized, double-blind trial, the value of cimetidine as prophylaxis against acid aspiration pneumonitis was studied. Compared to placebo, cimetidine reduced the volume as well as the acidity of the gastric contents significantly. The patients at risk of developing severe pneumonitis after aspiration (pH less than 2.5 and volume greater than 20 ml) were reduced from 55% in the placebo group to 0 in the group having received cimetidine 400 mg the night before and a further 400 mg on the morning of surgery. Premedication with cimetidine may be useful if rapid intubation cannot be anticipated.