A real-world evaluation of an herbal treatment for infantile colic reported by 1218 parents in Israel

PURPOSE

Infantile colic (IC) or fussing and crying behavior of unknown cause, affects up to 20% of the infant population and is one of the major reasons for parents to seek medical advice. Therapeutic options are limited and the key component for IC management is parental support. Fennel-based herbal treatments were shown to significantly reduce crying time. The current study was designed to evaluate the parent perception of effectiveness of a fennel-based commercially-available herbal treatment for IC (BabyCalm, Hisunit Ltd., Israel) using a retrospective online survey.

DESIGN AND METHODS

This was a real-world observational, case-control retrospective study. Parents of babies with IC symptoms, who either used the herbal product for their baby or did not use any product were invited to participate in an online survey during August-December 2019. The primary outcome was the perceived level of treatment success and symptom improvement.

RESULTS

1218 parents of IC babies (48% females, 90% up to 3 months of age, 58% exclusively breast-fed) responded to the survey of whom 771 used the treatment. Significantly fewer IC-related symptoms were reported by parents who used the product compared to those that did not. Parents perceived the treatment as successful in 65% of the cases, reporting meaningful improvements within 30 min for 69%-79% of the symptoms.

CONCLUSIONS

The majority of parents perceived the herbal treatment as effective in rapid symptom reduction suggesting that this may provide a satisfactory solution for IC in the community.

Wastewater-derived organic contaminants in fresh produce: Dietary exposure and human health concerns

Irrigation with reclaimed wastewater is a growing practice aimed at conserving freshwater sources, especially in arid and semiarid regions. Despite the apparent advantages to water management, the practice of irrigation with reclaimed wastewater exposes the agroenvironment to contaminants of emerging concern (CECs). In this report, we estimated the unintentional dietary exposure of the Israeli population (2808 participants) to CECs from consumption of produce irrigated with reclaimed wastewater using detailed dietary data obtained from a National Health and Nutrition Survey (Rav Mabat adults; 2014-2016). Human health risk analyses were conducted based on acceptable daily intake (ADI) and threshold of toxicological concern (TTC) approaches. The highest unintentional exposure to wastewater-borne CECs was found to occur through the consumption of leafy vegetables. All analyzed CECs exhibited hazard quotients <1 for the mean- and high-exposure scenarios, indicating no human health concerns. However, for the extreme exposure scenario, the anticonvulsant agents lamotrigine and carbamazepine, and the carbamazepine metabolite epoxide-carbamazepine exhibited the highest exposure levels of 29,100, 27,200, and 19,500 ng/person (70 kg) per day, respectively. These exposure levels exceeded the TTC of lamotrigine and the metabolite epoxide-carbamazepine, and the ADI of carbamazepine, resulting in hazard quotients of 2.8, 1.1, and 1.9, respectively. According to the extreme estimated scenario, consumption of produce irrigated with reclaimed wastewater (leafy vegetables in particular) may pose a threat to human health. Minimizing irrigation of leafy vegetables using reclaimed wastewater and/or improving the quality of the reclaimed wastewater using an advanced treatment would significantly reduce human dietary exposure to CECs.

Continuous monitoring of advanced hemodynamic parameters shows early cardiovascular changes in a cohort of 492 COVID-19 hospitalized patients

Background

COVID-19 exerts deleterious cardiopulmonary effects, leading to worse prognosis in the most effected.

Purpose

The aim of this retrospective multi-center observational cohort study was to analyze the trajectories of key advanced hemodynamic parameters amongst hospitalized COVID-19 patients according to different risk populations using a chest-patch wearable providing continuous remote patient monitoring.

Methods

The study was conducted in five COVID-19 isolation units. Patients admitted to the units were connected to a photoplethysmography based noninvasive remote advanced hemodynamic monitor after completing a basic risk factor survey. Physiological parameters were measured every 15 minutes during the hospitalization, including cardiac output (CO), cardiac index (CI), systemic vascular resistance (SVR), heart rate, blood pressure (BP), respiratory rate, blood oxygen saturation (SpO2), and body temperature.

Results

492 COVID-19 patients (179 females, average age 58.7 years) were included in the final analysis, with more than 3 million measurements collected during an average of 75.3 hours. Overall, within the first five days of hospitalizations we found a significant increase in SVR, and a significant decrease in SpO2, DBP, CO and CI (p&lt;0.01 for all). The changes were more prominent in high risk populations- males, older age and obesity and had a temporal correspondence to changes in respiratory parameters.

Conclusions

This is the first comprehensive continuous advanced hemodynamic profiling of COVID-19 patients. Worse hemodynamic status was prominent in high risk populations.

Funding Acknowledgement

Type of funding sources: None.

Hair growth-promotion effects at the cellular level and antioxidant activity of the plant-based extract Phyllotex™

Hair loss and predominantly female hair loss is a common dermatologic condition with serious psychosocial consequences. Effective treatments remain scarce mainly due to the multifactorial elements involved in the onset of this chronic condition. The approved drugs available are based on molecules designed towards a single pharmacological target and do not interact with the various biochemical mechanisms involved in alopecia. Phytochemical compounds and their derivatives represent a plethora of biologically active agents, which act in synergism and simultaneously activate different biochemical pathways. Here we present an herbal formulation composed of herbs, vitamins, and minerals acting on hair regrowth and hair micro vascularization.

This study aimed at evaluating the potential of Phyllotex™ to treat multifactorial androgenetic alopecia (AGA) in males and females, as well as delving into its molecular mechanisms of action. In vitro studies showed that the herbal formula stimulates cell proliferation of both dermal papilla and HaCaT cells and increases the phosphorylated form of the extracellular signal-regulated kinase 1 and 2 (ERK1/2), a well-known marker for cell proliferation. Surprisingly, expression of TGF-β1 was significantly suppressed without blocking DHT production. Additionally, the formula was able to rescue cells from the oxidative stress conditions generated by 2,2′-Azobis (2-amidinopropane) dihydrochloride (AAPH), a high oxidative agent. This data supports the potential use of this formulation as a hair growth-promoting agent for the treatment of both male and female AGA due to its multifactorial composition, which grants it the ability to cope with the different mechanisms involved in alopecia.

Bioaccessibility of Shore Magic® collagen, a low-molecular-weight collagen supplement, in different in vitro barrier models

Hydrolyzed collagen consists of peptides, which exert important biological functions in different body systems. This study aimed at testing the biological effects of a low molecular weight collagen (LMWC), namely Shore Magic® Collagen (SMC), in a series of in vitro assays and three different in vitro barrier models with translational significance. We also compared SMC's biological activities with its trypsinized form (TSMC). SMC enhanced migration in both epithelial and endothelial cells; and increased the adhesion of epithelial cells, but surprisingly not of endothelial cells. It also diminished the tightness in the gut and blood-brain barriers in vitro while TSMC did not. SMC induced both neurogenesis and BJ epithelial cell proliferation of cells growing below the in vitro barriers. In conclusion, the intact form of SMC shows enhanced bioavailability and efficiency compared with TSMC.

Importance of ABC Transporters in Drug Development

ATP-binding cassette (ABC) transporters are a huge family of ATP-dependent transmembrane proteins whose main function is exporting or importing substances or molecules through the cell membranes, plasma cell membrane, or inner membranes in organelles. They fulfill these functions by maintaining cell integrity, metabolism, and homeostasis. They are expressed in a variety of tissues as they transport numerous essential compounds including lipids and other signaling molecules. ABC transporters became widely studied since the discovery of their ability to carry a multitude of xenobiotics, including therapeutic drugs, and in light of the fact that they represent a hurdle for the treatment of resistant cancers. In contrast, the role of ABC transporters in neurological diseases like Alzheimer`s and Parkinson`s, depression, schizophrenia, and epilepsy remains controversial and their mechanism of action in these pathologies remains elusive, thus hindering the implementation of therapies aimed at modulating the functions of these transporters. To date, a number of natural and synthetic compounds are known to act as inhibitors, substrates, and even inducers of these transporters, being able to modulate their expression and/or function; however, their implication as therapeutic agents is far from reaching wide clinical utilization. This review highlights the importance of overcoming the challenges posed by ABC transporters in drug development.

Severe hepatocytotoxicity linked to denosumab

OBJECTIVE

Denosumab (Prolia, Amgen, Thousand Oaks, CA, USA) is a fully human antibody to the receptor activator of nuclear factor-KB ligand (RANKL). We present a case of submassive hepatic necrosis with evidence implicating cytokine induction resulting from an immune reaction to denosumab.

CASE REPORT

A 72-year-old lady presented with elevated liver enzymes. One month previously, she received a s/c administration of 60 mg of denosumab. Viral hepatitis A, B and C and human herpes viruses 6-7 were negative as were routine autoimmune serology. Transaminases reached more than 50 x ULN, and gamma-glutamyl-transpeptidase (GGT) increased to more than 30 x ULN. Serum bilirubin reached 13.8 mg/dL. The serum albumin level decreased to 2.8 g/L. Prednisone (40 mg) and ursodeoxycholic acid (900 mg) were administered. The Naranjo Adverse Drug Reaction probability score was 6, consistent with a probable adverse drug reaction. A liver biopsy revealed sub-massive hepatic necrosis consistent with drug-induced liver injury (DILI). During steroid tapering, there was a slow decline in the levels of both the transaminases and the GGT, and a concomitant increase in the serum albumin. A month after stopping prednisone and ursodeoxycholic acid, there was an acute increase in the level of the transaminases and a decrease in the serum albumin. Steroid reintroduction resulted in normalization of the liver enzymes and synthetic capacity. A lymphocyte toxicity assay to denosumab was demonstrated a hypersensitivity reaction to denosumab resulting in 31% toxicity. The control patient showed no toxicity to denosumab. Cytokine levels (pg/mL) were as follows: Interleukin (IL)1 was 1193 (normal-24.5), IL8 357 (20-60), RANKL 224 (60-80), RANTES 215 (15-50), TNF-a 850 (25-50), TGF-b 546 (20-40), VEGF 735 (25-30). Serum RANKL was markedly reduced in the presence of denosumab (16 pg/mL). The elevated markers of apoptosis ccK18(M-30)(68-132) 140 IU and K18 apoptosis+ necrosis (M65) (62-213) 322 U/L implicate necrosis.

CONCLUSIONS

We suggest that RANKL inhibition can produce severe hepatic necrosis together with an increase in proinflammatory cytokines.

Human Exposure to Wastewater-Derived Pharmaceuticals in Fresh Produce: A Randomized Controlled Trial Focusing on Carbamazepine

Fresh water scarcity has led to increased use of reclaimed wastewater as an alternative and reliable source for crop irrigation. Beyond microbiological safety, concerns have been raised regarding contamination of reclaimed wastewater by xenobiotics including pharmaceuticals. This study focuses on carbamazepine, an anticonvulsant drug which is ubiquitously detected in reclaimed wastewater, highly persistent in soil, and taken up by crops. In a randomized controlled trial we demonstrate that healthy individuals consuming reclaimed wastewater-irrigated produce excreted carbamazepine and its metabolites in their urine, while subjects consuming fresh water-irrigated produce excreted undetectable or significantly lower levels of carbamazepine. We also report that the carbamazepine metabolite pattern at this low exposure level differed from that observed at therapeutic doses. This "proof of concept" study demonstrates that human exposure to xenobiotics occurs through ingestion of reclaimed wastewater-irrigated produce, providing real world data which could guide risk assessments and policy designed to ensure the safe use of wastewater for crop irrigation.

Possible evidence of systemic lupus erythematosus and periodontal disease association mediated by Toll-like receptors 2 and 4

Toll-like receptors (TLRs) participate in the innate immune response and trigger the immune responses of the body. Systemic lupus erythematosus (SLE) is an autoimmune disease of unknown aetiology, characterized by an excessive autoimmune response in the body affecting the connective tissues. The disease is possibly triggered by both environmental aetiological factors and pathological organic processes such as exposure to sunlight, chronic infectious processes and genetic factors. Conversely, periodontal disease is an infectious disease caused by microorganisms in the oral cavity, resulting in a chronic inflammatory process which continuously stimulates the immune response, thus causing damage to the periodontal tissues. The expression of both TLR-2 and TLR-4 receptors are increased in both SLE and periodontal disease. Periodontitis might trigger excessive activation of immune response occurring in SLE by maintaining a high expression of TLRs, leading in turn to the acceleration of the onset and progression of autoimmune reactions. In addition, periodontal treatment is able to reduce the expression of these receptors and therefore the symptoms of SLE. Here we discuss the possible interaction between SLE and periodontitis, and suggest further studies evaluating common features in both factors that could explored, due to morbidity and mortality of SLE and the high incidence of periodontal infections around the world.

Effect of a new insulin treatment regimen on glycaemic control and quality of life of Muslim patients with type 2 diabetes mellitus during Ramadan fast - an open label, controlled, multicentre, cluster randomised study

We performed a non-inferiority trial comparing insulin detemir (Levemir) and biphasic insulin (NovoMix70) to standard care during Ramadan fast in insulin treated type 2 diabetes mellitus (T2DM) patients. This was an open label, controlled, multicentre, cluster randomised non-inferiority study. Insulin treated T2DM patients from 12 randomly selected primary clinics received Levemir and NovoMix 70 (intervention, n = 127) or standard care according to the American Diabetes Association recommendations (control, n = 118). Insulin dose (intervention) was 60% of the usual, of this 40% was dosed as Levemir at sunrise and 60% as NovoMix 70 before dinner. Insulin was titrated according to daily 4 point self-measured blood glucose (4P-SMBG) levels. The primary outcome was the difference in mean daily 4P-SMBG during days 23-30 of treatment. Mean age was 60.1 (SD 8.9) and 59.4 (SD 10.1) years in the intervention and control respectively. Mean HbA1c was 8.38% (68 mmol/mol) (SD 0.96) and 8.45% (69 mmol/mol) (SD 1.08). Mean BMI was 32.99 (SD 7.05) and 33.08 (SD 7.24), respectively. The intervention was non-inferior to standard care as assessed by mean 4P-SMBG during days 23-30 of treatment [155 (SD 30.76) mg% and 159 (SD 33.24) mg% respectively, p = 0.269]. Adverse event rate was significantly lower in the intervention group [0.04 (SD 0.06) vs. 0.07 (SD 0.11), p = 0.010]. In particular, hypoglycaemia event rate was lower in the intervention group [0.00 (SD 0.01) vs. 0.01 (SD 0.03), p ≤ 0.001]. To conclude, treatment with Levemir and NovoMix 70 was non-inferior to standard care in this heterogeneous group of patients and was associated with less adverse events.

Carryover Effects of Acute DEHP Exposure on Ovarian Function and Oocyte Developmental Competence in Lactating Cows

We examined acute exposure of Holstein cows to di(2-ethylhexyl) phthalate (DEHP) and its carryover effects on ovarian function and oocyte developmental competence. Synchronized cows were tube-fed with water or 100 mg/kg DEHP per day for 3 days. Blood, urine and milk samples were collected before, during and after DEHP exposure to examine its clearance pattern. Ovarian follicular dynamics was monitored through an entire estrous cycle by ultrasonographic scanning. Follicular fluids were aspirated from the preovulatory follicles on days 0 and 29 of the experiment and analyzed for phthalate metabolites and estradiol concentration. The aspirated follicular fluid was used as maturation medium for in-vitro embryo production. Findings revealed that DEHP impairs the pattern of follicular development, with a prominent effect on dominant follicles. The diameter and growth rate of the first- and second-wave dominant follicles were lower (P < 0.05) in the DEHP-treated group. Estradiol concentration in the follicular fluid was lower in the DEHP-treated group than in controls, and associated with a higher number of follicular pathologies (follicle diameter >25 mm). The pattern of growth and regression of the corpus luteum differed between groups, with a lower volume in the DEHP-treated group (P < 0.05). The follicular fluid aspirated from the DEHP-treated group, but not the controls, contained 23 nM mono(2-ethylhexyl) phthalate. Culturing of cumulus oocyte complexes in the follicular fluid aspirated from DEHP-treated cows reduced the proportion of oocytes progressing to the MII stage, and the proportions of 2- to 4-cell-stage embryos (P < 0.04) and 7-day blastocysts (P < 0.06). The results describe the risk associated with acute exposure to DEHP and its deleterious carryover effects on ovarian function, nuclear maturation and oocyte developmental competence.

166 IN VIVO MODEL TO EXAMINE THE LONG-LASTING EFFECTS OF ACUTE DI-(2-ETHYLHEXYL) PHTHALATE (DEHP) EXPOSURE ON OVARIAN FUNCTION IN BOVINE

Di-(2-ethylhexyl) phthalate (DEHP) is a commonly used plasticizer. Its metabolites have been shown to have adverse effects on reproduction and development in laboratory animals. However, the mechanisms by which they induce infertility remain elusive. We established an experimental model in which lactating Holstein cows were synchronized (GnRH–PG–GnRH) and tube-fed with DEHP (100 mg kg–1 per day; n = 4) or water (n = 5), for 3 days. Urine and plasma samples were collected before (Day 0), during (Days 2 and 4), and after (Days 11, 19, and 24) treatment initiation. For each group, and on each day, samples were pooled and analysed to determine DEHP metabolite concentrations (MEHP, 5OH-MEHP, 5oxo-MEHP, 2cx-MMHP, 5cx-MEPP) by liquid chromatography–mass spectrometry/mass spectrometry. Incorporation of DEHP resulted in relatively high metabolite concentrations on the exposure days (acute phase; Days 1–4), which decreased dramatically through the subsequent period (chronic phase; Days >5). For example, the average plasma MEHP concentration in the control group was 0.012 ± 0.0017 µM throughout the experimental period. In the treated group, it increased to 47.7 ± 8.9 µM in the acute phase, then decreased to 0.045 ± 0.02 µM. To examine the effects on ovarian function, cows were resynchronized during the chronic phase, and monitored by ultrasonography scanner (SSD-900, Aloka, Tokyo, Japan; 7.5 MHz) to classify ovarian follicular dynamics. Follicular fluids of the dominant follicles were aspirated with an ultrasonic scanner connected to a vaginal sector transducer (Pie Medical Imaging BV, Maastricht, the Netherlands; 7.5 MHz). Data were analysed using JMP-7 software (SAS Institute Inc., Cary, NC, USA, 2004). Differences among treatments were analysed by one-way ANOVA followed by Student's t-test. Findings revealed the pronounced effect of DEHP on the dominant follicles. The diameter (15.7 ± 1.8 v. 10.4 ± 1.8 mm) and growth rate (0.88 ± 0.15 v. 0.43 ± 0.17 mm day–1) of the first-wave dominant follicle were higher in the control cows (P < 0.05). The developmental pattern of the second-wave dominant follicle differed between groups, with a higher growth rate during the follicular phase (1.99 ± 0.19 v. 0.46 ± 0.29 mm day–1; P < 0.02) and a larger diameter of the preovulatory follicle (14.48 ± 0.35 v. 9.67 ± 1.85 mm; P < 0.01) in the control group. The pattern of corpus luteum growth and regression also differed between groups, expressed by higher volume (4.37 × 103 ± 0.27 v. 2.91 × 103 ± 0.31 mm3; P < 0.05) in the control group. The proportion of dominant follicles that developed to follicular cysts (> 25 mm) tended to be higher (75 v. 20%; P < 0.09) in the treated group. The average oestradiol concentration in the follicular fluid of the preovulatory follicle was lower in the DEHP-treated group (361.6 ± 130.5 v. 832.6 ± 109.7 ng mL–1; P < 0.05). However, the average progesterone concentration in the plasma during the luteal phase were normal (4.5–5.0 ng mL–1) and did not differ between groups. The findings reveal the potential risk of DEHP exposure and its long-lasting effects on bovine ovarian function. These impairments are suggested to adversely affect fertility.

Irrigation of root vegetables with treated wastewater: evaluating uptake of pharmaceuticals and the associated human health risks

To meet mounting water demands, treated wastewater has become an important source of irrigation. Thus, contamination of treated wastewater by pharmaceutical compounds (PCs) and the fate of these compounds in the agricultural environment are of increasing concern. This field study aimed to quantify PC uptake by treated wastewater-irrigated root crops (carrots and sweet potatoes) grown in lysimeters and to evaluate potential risks. In both crops, the nonionic PCs (carbamazepine, caffeine, and lamotrigine) were detected at significantly higher concentrations than ionic PCs (metoprolol, bezafibrate, clofibric acid, diclofenac, gemfibrozil, ibuprofen, ketoprofen, naproxen, sulfamethoxazole, and sildenafil). PCs in leaves were found at higher concentrations than in the roots. Carbamazepine metabolites were found mainly in the leaves, where the concentration of the metabolite 10,11-epoxycarbamazepine was significantly higher than the parent compound. The health risk associated with consumption of wastewater-irrigated root vegetables was estimated using the threshold of toxicological concern (TTC) approach. Our data show that the TTC value of lamotrigine can be reached for a child at a daily consumption of half a carrot (∼60 g). This study highlights that certain PCs accumulated in edible organs at concentrations above the TTC value should be categorized as contaminants of emerging concern.

Liver injury induced by anticancer chemotherapy and radiation therapy

Cytotoxic chemotherapy prolongs survival of patients with advanced and metastatic tumors. This is, however, a double-edged sword with many adverse effects. Since the liver has a rich blood supply and plays an active role in the metabolism of medications, it is not surprising that there can be hepatic injury related to chemotherapy. In addition, radioembolization may affect the parenchyma of normal and cirrhotic livers. We review chemotherapy-associated liver injury in patients with colorectal liver metastases, including downsizing chemotherapy and neoadjuvant chemotherapy. We discuss the mechanism of the hepatic injury, secondary to reactive oxygen species, and the spectrum of hepatic injury including, steatosis, steatohepatitis, hepatic sinusoidal injury and highlight the pharmacogenomics of such liver insults. Methods for reducing and treating the hepatotoxicity are discussed for specific agents including tamxifen and the newly introduced targeted antibodies.

Genetic polymorphism of IL28B in hepatitis C-infected haemophilia patients in Israel

Single-nucleotide polymorphisms (SNPs) near the IL28B gene were identified as major predictors of treatment response (sustained virologic response--SVR) and spontaneous clearance of HCV. Haemophilia patients have the highest prevalence of HCV, and are a unique target for genetic studies. The Israeli population is ethnically heterogeneous; therefore, genetic variability is anticipated. To determine the IL28B haplotypes in HCV-infected haemophilia patients and association with SVR and spontaneous viral clearance. IL28B polymorphism at SNPs rs12979860 and rs8099917 was determined in sera obtained from 130 HCV-infected haemophilia patients. The frequency of the various haplotypes was analysed according to treatment response, spontaneous HCV clearance, viral load and degree of fibrosis. The CC haplotype at SNP rs12979860 was found in 31% of patients, whereas the TT genotype at SNP rs8099917 was detected in 57% of cases. SVR was achieved in 70% of patients carrying the CC haplotype (P = 0.0196 vs. CT/TT), and 50% of the TT genotype at SNP rs8099917 (P = 0.0227 vs. TG/GG). Thirty-five percent of patients carrying the CC haplotype and 26% with the TT genotype at SNP rs8099917 showed spontaneous clearance of HCV infection (P = 0.00262 vs. CT/TT; and P = 0.00371 vs. TG/GG respectively). The C-allele frequency was exceptionally high (71%) in immigrants from the Asian republics of Russia. In HCV-infected haemophilia patients, SVR was more commonly achieved among patients who had the CC (rs12979860) or TT (rs8099917) genotype. Likewise, patients who possess harbour the CC or TT genotypes were more likely to clear HCV infection spontaneously. A unique distribution of the CC genotype was observed in some ethnic groups.

Cannabidiol inhibits growth and induces programmed cell death in kaposi sarcoma-associated herpesvirus-infected endothelium

Kaposi sarcoma is the most common neoplasm caused by Kaposi sarcoma-associated herpesvirus (KSHV). It is prevalent among the elderly in the Mediterranean, inhabitants of sub-Saharan Africa, and immunocompromised individuals such as organ transplant recipients and AIDS patients. Current treatments for Kaposi sarcoma can inhibit tumor growth but are not able to eliminate KSHV from the host. When the host's immune system weakens, KSHV begins to replicate again, and active tumor growth ensues. New therapeutic approaches are needed. Cannabidiol (CBD), a plant-derived cannabinoid, exhibits promising antitumor effects without inducing psychoactive side effects. CBD is emerging as a novel therapeutic for various disorders, including cancer. In this study, we investigated the effects of CBD both on the infection of endothelial cells (ECs) by KSHV and on the growth and apoptosis of KSHV-infected ECs, an in vitro model for the transformation of normal endothelium to Kaposi sarcoma. While CBD did not affect the efficiency with which KSHV infected ECs, it reduced proliferation and induced apoptosis in those infected by the virus. CBD inhibited the expression of KSHV viral G protein-coupled receptor (vGPCR), its agonist, the chemokine growth-regulated protein α (GRO-α), vascular endothelial growth factor receptor 3 (VEGFR-3), and the VEGFR-3 ligand, vascular endothelial growth factor C (VEGF-C). This suggests a potential mechanism by which CBD exerts its effects on KSHV-infected endothelium and supports the further examination of CBD as a novel targeted agent for the treatment of Kaposi sarcoma.

The decline of anti-drug antibody titres after discontinuation of anti-TNFs: implications for predicting re-induction outcome in IBD

BACKGROUND

Anti-drug antibodies can be elicited by infliximab and adalimumab, but the rate of their decay after therapy is stopped is unknown.

AIM

To investigate the decline of anti-drug antibody titre after anti-TNF cessation, and to evaluate the clinical utility of anti-drug antibody measurement before anti-TNF re-induction.

METHODS

Inflammatory bowel disease (IBD) patients who stopped anti-TNF therapy and had measurable anti-drug antibodies were prospectively followed up by serial blood measurements of antibodies levels. The clinical outcome of a second cohort of patients who received re-induction by infliximab or adalimumab after a drug holiday >4 months was determined vis-à-vis their anti-drug antibodies status before re-induction.

RESULTS

The first cohort included 22 patients with anti-drug antibodies who were prospectively followed up after cessation of anti-TNF. Sixteen had antibodies-to-infliximab (ATI) and six had antibodies-to-adalimumab (ATA). ATI titres declined within 12 months to below detection levels in 13/16 infliximab-treated patients, whereas ATA titres became undetectable in only 2/6 adalimumab-treated patients (P = 0.04). The second cohort comprised 27 patients who resumed anti-TNFs (24 infliximab, 3 adalimumab). Of these, 3/5 patients with measurable anti-drug antibodies before re-induction experienced severe hypersensitivity reaction and/or nonresponse mandating drug-discontinuation, compared to 11/22 patients who were re-induced without measurable anti-drug antibodies (OR = 1.5, 95% CI 0.2-11, P = 0.7).

CONCLUSIONS

Antibodies to infliximab titres decline to undetectable levels within one year of cessation of infliximab in the majority of patients, whereas antibodies to adalimumab seem to persist longer after adalimumab discontinuation. Measuring antibodies to infliximab prior to infliximab re-induction is probably of little clinical utility, especially if more than a 12-month drug-holiday has elapsed.

Nonpsychotropic cannabinoids, abnormal cannabidiol and canabigerol-dimethyl heptyl, act at novel cannabinoid receptors to reduce intraocular pressure

The objective of our study was to examine the pharmacology of the intraocular pressure (IOP)-lowering actions of the behaviorally inactive cannabinoids, abnormal cannabidiol (abn-CBD), and a cannabigerol analog, cannabigerol-dimethyl heptyl (CBG-DMH), in comparison to that of the nonselective cannabinoid 1 receptor (CB(1)R) and CB(2)R agonist, WIN55,212-2, in Brown Norway rats. The IOP was measured noninvasively using a hand-held tonometer in nonanesthetized animals. The IOP measurements were taken every 15 min for a period of 2 h after drug administration. All drugs were administered via intraperitoneal (i.p.) injections, and abn-CBD and CBG-DMH were also given topically. Both abn-CBD and CBG-DMH reduced IOP when administrated i.p. at doses of ≥2.5 mg/kg or topically at concentrations of 1%-2%. The IOP-lowering effects of abn-CBD and CBG-DMH were reduced by i.p. administration of O-1918 (2.5 mg/kg), a selective antagonist of the abn-CBD-sensitive cannabinoid-related receptor (CBx), but were unaffected by the CB(1)R antagonist, AM251 (2.5 mg/kg), or the CB(2)R antagonist, AM630 (2.5 mg/kg). In contrast, the IOP-lowering action of WIN55,212-2 was completely blocked by the CB(1)R-selective antagonist, AM251, and was unaffected by the CBx receptor antagonist, O-1918. However, similar to the nonpsychotropic cannabinoids, the ocular hypotensive actions of WIN55,212-2 were also insensitive to block by the CB(2)R antagonist, AM630. Consistent with this, the selective CB(2)R agonist, HU-308 (2 mg/kg) failed to reduce IOP in Brown Norway rats. Concurrent application of a dose of WIN55,212-2 that was subthreshold to reduce IOP (0.25 mg/kg), together with a topical dose of either abn-CBD (0.5%) or CBG-DMH (0.25%), respectively, potentiated the ocular hypotensive effect of either compound applied alone. This study demonstrates that the atypical cannabinoid, abn-CBD, and the cannabigerol analog, CBG-DMH, decrease IOP in the normotensive Brown Norway rat eye independent of CB(1)R or CB(2)R activation, via activation of CBx receptors. The enhanced decrease in IOP seen after coapplication of the CB(1)R agonist, WIN55,212-2, together with either abn-CBD or CBG-DMH, respectively, further suggests that the ocular pharmacodynamics of abn-CBD and CBG-DMH are mediated by receptor targets distinct from CB(1)R. These results indicate that both CBG-DMH and abn-CBD have the potential for further investigation as novel ocular hypotensive cannabinoids devoid of CB(1)R-mediated side-effects.

Outcome of carbapenem resistant Klebsiella pneumoniae bloodstream infections

The aim of this study was to evaluate the impact of carbapenem-resistant K. pneumoniae bloodstream infections on mortality. During the study period 42, 68 and 120 patients were identified with carbapenem-resistant, extended-spectrum β-lactamase producers (ESBL) and susceptible K. pneumoniae bloodstream infections, respectively. Patients with carbapenem-resistant K. pneumoniae had higher rates of prior antimicrobial exposure, other nosocomial infections, and use of invasive devices. Infection-related mortality was 48% for carbapenem-resistant, 22% for ESBL producers and 17% for susceptible K. pneumoniae. Independent risk factors for infection-related mortality were Pitt bacteraemia score, Charlson score and carbapenem resistance.

Endocannabinoid-like N-arachidonoyl serine is a novel pro-angiogenic mediator

BACKGROUND AND PURPOSE

N-arachidonoyl serine (ARA-S) is a recently identified endocannabinoid-like lipid with weak affinity for the fully characterized cannabinoid receptors (CB(1) and CB(2)) and the transient receptor potential vanilloid receptor 1 (TRPV-1). ARA-S induces vasodilatation and shows vasoprotective potential via activation of key signalling pathways in endothelial cells. Based on these findings, the effect of ARA-S on endothelial functions was further studied.

EXPERIMENTAL APPROACH

Primary human dermal microvascular endothelial cells (HMVEC) were used to investigate effects of ARA-S (0-10 microM) on certain endothelial functions, using cell proliferation, migration and wound repair models in vitro, and angiogenesis assays in vitro and ex vivo. Selective CB receptor antagonists and specific siRNAs were deployed to block individual CB receptors.

KEY RESULTS

We found that ARA-S stimulated angiogenesis and endothelial wound healing through induction of vascular endothelial growth factor C and its cognate receptor expression in primary HMVEC. Moreover, knock-down of G protein-coupled receptor 55 (GPR55) partly inhibited ARA-S-induced signal transduction and endothelial functions.

CONCLUSIONS AND IMPLICATIONS

Our results indicate that ARA-S is a pro-angiogenic factor in addition to a vessel dilator. The GPR55 receptor may serve as one target of ARA-S.

Non-invasive biomarkers of liver fibrosis in haemophilia patients with hepatitis C: can you avoid liver biopsy?

Liver biopsy remains the gold standard for the evaluation of fibrosis despite its risks and limitations, especially in haemophilia patients. Recently, non-invasive biomarkers have been used to assess histological features. The most thoroughly evaluated biomarker is the FibroTest (FT) (AUROC 0.80 for fibrosis stages F2F3F4 vs. F0F1). To estimate liver fibrosis in haemophilia patients infected with hepatitis C (HCV) using non-invasive biomarkers without liver biopsy. One hundred and thirty-two haemophilia patients (124 male, mean age 38 +/- 14 years) with anti-HCV antibodies were evaluated. These patients were stratified into several groups: patients with features of advanced liver disease - seven, persistently HCV RNA-negative - 21, persistently normal liver function tests (LFTs)- 24, HCV/HIV co-infected - 27. The following biomarkers of fibrosis were used: FT, AST-to-platelet ratio index (APRI), Forns index, age-platelet index and hyaluronic acid. The obtained scores were correlated with the clinical features of the patients. Estimated by the FT, the distribution of the stage of fibrosis in the 132 patients was F0F1 = 65% (86/132), F2 = 5% (7/132), F3 = 13% (17/132) and F4 = 17% (22/132). Using FT, all patients with clinical suspicion of advanced liver disease were classified as F3F4, whereas patients with persistently HCV RNA-negative were all classified as F0F1. Twenty-one per cent (5/24) of the patients with persistently normal LFTs had fibrosis stage F3F4. The proportion of F3F4 among HCV/HIV co-infected patients was significantly higher than among HCV mono-infected (52% vs. 33%; P = 0.05). Concordance of three or more biomarkers was present in 43% (57/132) of the patients. Liver biopsy could be avoided in 70% (92/132) using a practical assumption that if FT is in concordance with APRI and/or Forns, then we may confidently rely on the biomarker. Concordance rate for patients with presumably advanced or minimal liver disease was excellent (100% and 95% respectively). In our HCV-infected haemophilia patients, FT correctly identified clinically advanced or minimal liver disease. Discordance among the various biomarkers of fibrosis was considerate; nevertheless, practical combination of FT, APRI, and Forns may predict stage of fibrosis with accuracy, potentially avoiding liver biopsy in the majority of the patients.

N-arachidonoyl L-serine, an endocannabinoid-like brain constituent with vasodilatory properties

The endocannabinoid N-arachidonoyl ethanolamine (anandamide), found both in the CNS and in the periphery, plays a role in numerous physiological systems. One might expect that the chemically related N-arachidonoyl-L-serine (ARA-S) could also be formed alongside anandamide. We have now isolated ARA-S from bovine brain and elucidated its structure by comparison with synthetic ARA-S. Contrary to anandamide, ARA-S binds very weakly to cannabinoid CB1 and CB2 or vanilloid TRPV1 (transient receptor potential vanilloid 1) receptors. However, it produces endothelium-dependent vasodilation of rat isolated mesenteric arteries and abdominal aorta and stimulates phosphorylation of p44/42 mitogen-activated protein (MAP) kinase and protein kinase B/Akt in cultured endothelial cells. ARA-S also suppresses LPS-induced formation of TNF-alpha in a murine macrophage cell line and in wild-type mice, as well as in mice deficient in CB1 or CB2 receptors. Many of these effects parallel those reported for abnormal cannabidiol (Abn-CBD), a synthetic agonist of a putative novel cannabinoid-type receptor. Hence, ARA-S may represent an endogenous agonist for this receptor.

Hepatitis C at the Israeli National Hemophilia Center

Haemophilia patients who received non-virucidally treated large pool clotting factors before 1987 have a high rate of chronic hepatitis C viral infection (HCV). Some patients are coinfected with HIV. Haemophilia patients and other coagulation disorders were treated at one centre since the beginning of the 1970, and the Israeli National Hemophilia Center (INHC) was officially founded in 1987. To characterize patients with HCV as well as patients with HCV/HIV coinfection at the INHC. Patients with haemophilia and other coagulation disorders positive for HCV antibodies were evaluated between 2001 and 2004. Demographic data, type and severity of coagulation disorder, frequency of coagulation factor usage and treatment with concentrated clotting factors prior to 1987 were recorded. Liver enzymes, viral load, genotype and data supporting advanced liver disease were evaluated. About 179 of 239 haemophilia patients (75%) tested positive for anti-HCV antibodies. Our cohort consisted of 165 patients in whom clinical, biochemical and virological data were available. About 117 patients had active HCV infection with HCV-RNA-positive, and 27 were HCV/HIV coinfected. Twenty-one patients (13%) persistently tested HCV-RNA-negative, hence were considered to clear their HCV infection. There was no former USSR immigrants among HCV/HIV coinfected compared with HCV-infected or HCV-RNA-negative groups (0 vs. 30% and 38%, respectively; P < 0.001). HCV-RNA-negative patients used concentrated coagulation factor less frequently than HCV or HCV/HIV-infected patients (48% vs. 73%; P = 0.023, and 48% vs. 74%; P = 0.043, respectively). The use of concentrated clotting factors before 1987 was significantly more frequent in HCV/HIV than in either HCV-infected or HCV-RNA-negative patients (96% vs. 49% and 48%, respectively; P < 0.001). Compared with HCV/HIV subjects, patients with HCV monoinfection were characterized by a higher proportion of infection with genotype 1 (80% vs. 61%; P = 0.027). The rate of persistently normal liver enzymes in these patients was higher (24% vs. 7%; P = 0.05) than in the HCV/HIV-coinfected patients. Advanced liver disease was significantly more common in patients with HCV/HIV-coinfection than in HCV-monoinfected patients (11% vs. 3%; P = 0.045). The majority of haemophilia patients are infected with HCV. Viral clearance occurred in a minority of these patients. HCV monoinfected and HCV/HIV coinfected differ clinically and prognostically.

Evidence that (-)-7-hydroxy-4'-dimethylheptyl-cannabidiol activates a non-CB(1), non-CB(2), non-TRPV1 target in the mouse vas deferens

Previous experiments showed that R-(+)-WIN55212-induced inhibition of electrically-evoked contractions of mouse vasa deferentia could be antagonized by cannabidiol in a manner that appeared to be competitive but not to involve direct competition for established cannabinoid receptors. We have now discovered that (-)-7-hydroxy-4'-dimethylheptyl-cannabidiol (7-OH-DMH-CBD) inhibits electrically-evoked contractions of the vas deferens (EC(50)=13.3 nM). This it appeared to do by acting on prejunctional neurones as 100 nM 7-OH-DMH-CBD did not attenuate contractile responses to phenylephrine or beta,gamma-methylene-ATP. Although 7-OH-DMH-CBD was antagonized by SR141716A, it was less susceptible to antagonism by this CB(1) receptor antagonist than R-(+)-WIN55212. 7-OH-DMH-CBD was also antagonized by cannabidiol (1 microM; apparent K(B)=222.2 nM) but not by the CB(2) receptor antagonist, SR144528 (32 nM), or by naloxone (300 nM), ruthenium red (1 microM) or capsazepine (10 microM). Yohimbine (100 nM) enhanced the ability of 7-OH-DMH-CBD to inhibit electrically-evoked contractions. R-(+)-WIN55212 was also potentiated by 100 nM yohimbine, possibly reflecting ongoing sequestration of G(i/o) proteins from CB(1) receptors by alpha(2)-adrenoceptors. Our results suggest that 7-OH-DMH-CBD may activate a neuronal target in the vas deferens that is not a CB(1), CB(2), TRPV1, opioid or alpha(2)-adrenergic receptor but do not exclude the possibility that it also activates CB(1) receptors.

A comparison of three measures

We investigated the correlation between descriptive and valuational measures of health-related quality of life (HRQL) and assessed determinants affecting these measures. Our suspicion was that there is little similarity in the content of descriptive and valuational measures of HRQL. We thus conducted a cross-sectional observational study of 56 hemodialysis patients. All underwent structured interviews. Dependent variables were patients utilities [time trade-off (TTO)], global rating of HRQL and generic HRQL (SF-36). Independent variables were socioeconomic details, disease severity, comorbidity, symptoms, depression, social support, and laboratory data. The correlation between TTO and global HRQL was -0.33 (P = .0178) and between TTO and the SF-36 physical and mental summary scores -0.16 (P = .2383) and -0.20 (P = .1443), respectively. The regression models for the SF-36 physical and mental summary scores explained 75% and 64% of the variance, and for global HRQL 29% of the variance. The independent variables had no effect on the TTO. This confirmed our suspicion that a qualitative difference exists between TTO and descriptive quality of life tools. The TTO content could not be explained by the variables that entail the content of HRQL instruments.

The relation between objective and subjective impairment in cognitive function among multiple sclerosis patients--the role of depression

OBJECTIVE

To evaluate the relations between perceived cognitive function and objective cognitive deficit and to assess variables affecting perceived cognitive function among multiple sclerosis (MS) patients.

METHODS

A cross sectional study of patients with MS. All patients were interviewed and the Expanded Disability Status Scale (EDSS) score was determined. The dependent variables were four items assessing perceived concentration and thinking, attention, memory, and whether others have noticed memory or concentration problems. The explanatory variables were age, sex, duration of disease, number of relapses in the last 2 years, EDSS score, depressive symptoms score (CES-D) and the domains of the Neurobehavioral Cognitive Status Examination (NCSE) assessing cognitive performance. Bivariate and then multivariate analysis were performed.

RESULTS

One hundred and sixty-one MS patients were included. Mean age was 44.2 years (s.d. 11.3 years), mean EDSS score was 4.86 (s.d. 1.93). Seventy-two per cent of the patients had objective cognitive impairment and 51% reported decreased perceived cognitive function. In all models assessing perceived cognitive function we could explain only a small part of the variance (R2 ranged between 18-26%). In all these models depressive symptoms explained the highest portion of the variance (partial R2 ranging between 13-26%). The only domain of the NCSE that entered some of the models was calculation (partial R2 ranging between 3-7%).

CONCLUSIONS

These findings emphasize the gap between objective and subjective assessment of cognitive function and the high correlation between perceived cognitive deficit and depressive symptoms.

Cyclosporin for severe ulcerative colitis

BACKGROUND

About one-third of patients with severe ulcerative colitis do not respond to conventional therapy and require urgent colectomy. It was recently shown that cyclosporin is effective in some of these patients.

OBJECTIVES

To review the current experience of six hospitals in central Israel that used cyclosporin in patients with severe ulcerative colitis.

METHODS

The files of all 32 patients treated with cyclosporin for corticosteroid-resistant ulcerative colitis were reviewed. Activity of disease was measured by a clinical activity, index colonoscopy and laboratory tests.

RESULTS

The average duration of treatment with intravenous cyclosporin was 12.7 days (range 9-28) after which the disease activity index dropped from an average of 14.22 to 4.74. The mean time for response was 7.5 days (4-14). Twelve patients (40%) required surgery within 6 months and another 6 patients (18.8%) were operated on after more than 6 months. Twelve patients (37%) maintained remission for at least 6 months and did not require surgery. In one patient treatment was stopped because of non-compliance and one was lost to follow-up. There were numerous side effects, but in only one case with neurotoxicity was treatment withdrawn.

CONCLUSIONS

Cyclosporin is a relatively safe and effective treatment for severe ulcerative colitis. It induced long-term remission in 37% of the patients, and in those who required surgery the treatment resulted in an improved clinical condition before the operation.

Factors associated with health indicators in patients undergoing coronary artery bypass surgery

BACKGROUND

The main goals of coronary artery bypass graft (CABG) surgery for most patients are to relieve angina, to improve functional capacity, to return to work, and to improve health. A limited amount of information is available regarding the various attributes that are associated with achieving these goals.

STUDY OBJECTIVES

To investigate different patient attributes affecting these outcomes.

DESIGN

Prospective data collection.

SETTING

Fourteen medical centers that perform CABG surgery in Israel.

PATIENTS

The 4,012 patients who underwent CABG surgery during 1994.

MEASUREMENTS

Trained nurses collected data using structured questionnaires prior to and 4 to 5 months after the operation. Using logistic regression, four risk models were created to the following health indicators: recurrence of angina, functional capacity, return to work, and perception of health. Candidate variables were sociodemographic details, major comorbidities, risk factors for cardiac disease, and severity of cardiac disease.

RESULTS

The mean age of the patients was 63.8 years old, 79.3% were men, 59.9% were elective operations, and left main disease was found in 17.3%. Multivariate logistic regression revealed that the variables that significantly contributed to three or more of the models were Sephardic Jewish origin, female gender, left ventricular dysfunction, and diabetes mellitus.

CONCLUSIONS

There is a similarity between risk factors of various health indicators in CABG surgery patients. Thus, it is possible to define a population at high risk that may not benefit from the procedure.

The competing effects of disease states on quality of life of the elderly: the case of urinary symptoms in men

During the period 1993-1994 we conducted a study in Israel on a national-based sample of 960 men to examine the relationships between urinary symptoms and various domains of quality of life (QoL). Regression analyses were performed for each of the eight SF-36 domains, separately for the entire population and for those--without any co-morbidity. The dependent variable was the SF-36 domain scores. The independent variables included age, origin, education, employment and economic status, the degree of disturbance caused by urinary symptoms and the existence of co-morbidities. There was a significant difference between the entire population and the population without co-morbidities. In the entire population we found that severely bothersome urinary symptoms were related to scores on three QoL domains (social function, role-emotional and mental health) but there was no association with physical functioning and general health perceptions. In men without co-morbidity, urinary symptoms were substantially related to physical functioning and general health perceptions. These findings indicate that the relative weight of the impact of a symptom or disease on QoL domains is changed by the presence of other competing factors, such as co-morbidities or sociodemographic attributes.

Do we know what global ratings of health-related quality of life measure?

Information is lacking about the public's perception of the term health-related quality of life (HRQL). Specifically, what are the relations between the domains included in the operational definition of HRQL tools and global health ratings. The purpose of this analysis was to identify factors associated with global rating of HRQL. We conducted a survey of a representative sample of 2,030 Israeli adults, aged 45-75 years. Multiple linear regression analysis was used to identify associations between the dependent variable, the global rating, and socio-economic details, presence of disease states, and each of the domains of the SF-36. The results demonstrate that the model explains only 52% of the variance of the global rating score. The general health domain of the SF-36 explains the vast majority of the variance, 38.5%. Another important explanatory variable was physical functioning domain, which explains 7.0% of the variance and to a lesser extent vitality. The other domains of the SF-36, socio-economic details and presence of disease states contribute only small percentages to the total explained variance of the global ratings of HRQL. It seems that there is a considerable difference between the operational definition of the research community of HRQL and the public perception of this term.

Comparing medical centers treating hip fractures in the elderly: the importance of multi-outcome measurements

The objective of this study was to assess the merit of multi-outcome measurements on the evaluation of quality of care, comparing different health care providers. We performed a cross-sectional study in 3 medical centers. Three hundred three patients undergoing surgical repair of traumatic femoral neck fracture were included. Trained nurses gathered data by patient and proxy interview and by chart abstraction. Multivariate analysis was performed to obtain an explanatory model for each outcome. Then, the additional contribution of each of the centers to the explanatory power of the model was examined. The outcomes were mortality, functional capacity, post-operative complications, and length of stay. Explanatory variables included were sociodemographic details, comorbidity indices, preoperative functional capacity, depression, and cognition. The results demonstrated that center A was a "good" outlier for mortality rate but, in contrast, was a "bad" outlier for complication rate and length of stay. Center B was a "bad" outlier for functional capacity but a "good" outlier for length of stay. We conclude that outcome studies for quality assurance programs should include all relevant outcomes, as the assumption that one major outcome may be representative for quality of care assessment may be misleading.

The importance of laboratory data for comparing outcomes and detecting 'outlier' wards in the treatment of patients with pneumonia

OBJECTIVES

To evaluate whether routine laboratory data can improve the ability to compare risk-adjusted outcomes of different medical wards, and to detect 'outlier' wards with significantly better or worse outcome.

METHODS

Patient data were taken from the Combined Patient Database Systematic Management and Research Tool, a database created by merging different computerized sources at a tertiary care hospital. All patients admitted to internal wards with the diagnosis of pneumonia during the years 1991-1995 were included (n = 2734). The outcome variable was mortality 30 days post-admission. We used three comorbidity measures based on ICD-9-CM codes as possible predictors of mortality: secondary diagnoses; the Health Care Financing Administration severity index; and the Charlson comorbidity index. Models were created using logistic regression. To each model, laboratory data gathered in the first 48 hours after admission were added. To identify 'outlier' services we determined whether the patients' ward was an independent predictor of mortality. The area under the receiver operator curve (ROC) of the models was used for comparisons.

RESULTS

The area under the ROC was 0.65-0.72 for the models based on age and comorbid diagnoses. The addition of laboratory data improved markedly the discriminatory ability of each of the models, as reflected by an increase in the area under the ROC to 0.83-0.84. An 'outlier' ward with a higher risk-adjusted mortality rate was identified only by the models that included laboratory data.

CONCLUSION

Basic, automated, routinely gathered laboratory data added significantly to the discriminatory power of risk models based on administrative data with abstracted diagnoses. Addition of laboratory data improved the ability to identify providers with possible exceptional quality of care.

Hyperprolactinemia in postmenopausal women

OBJECTIVE

To study the clinical cause and course of hyperprolactinemia in postmenopausal women.

DESIGN

Retrospective case-note study.

SETTING

Tertiary care hospital.

PATIENT(S)

Six postmenopausal women with hyperprolactinemia.

MAIN OUTCOME MEASURE(S)

Clinical history and physical examination, serum levels of PRL, LH, FSH, computed tomography (CT) of the pituitary gland before and after treatment with bromocriptine.

RESULT(S)

At presentation, the mean age was 57.5 +/- 7.5 SD years. The mean level of PRL was 1,427 +/- 1,599 ng/mL (1,427 +/- 1,599 micrograms/L). All women suffered from secondary amenorrhea for a mean duration of 31.8 +/- 5.6 years. Five of six had galactorrhea at some time in the past. Pituitary imaging revealed a pituitary macroadenoma in four women, an enlarged sella suggestive of a pituitary macroadenoma in one woman, and a microadenoma in one. After treatment with bromocriptine, the PRL level decreased in all women to within normal limits. Five of six women developed hot flushes after the PRL level returned to normal.

CONCLUSION(S)

Most cases of hyperprolactinemia in postmenopausal women are due to macroadenoma rather than microadenoma, the common finding in younger women. The clinical course is suggestive of a prolonged disease that was not detected earlier, although clinical signs were present. These findings are suggestive of an enlargement of microadenomas to macroadenomas as time passes.

High levels of soluble p55-TNF receptors in seminal and prostatic fluids of normal and infertile men

PURPOSE

To study the role of tumor necrosis factor (TNF) in the male reproductive systems by examining the occurrence, source, and possible functional significance of soluble TNF receptors in seminal fluids of normal and infertile men.

MATERIALS AND METHODS

Concentrations of soluble TNF receptors (p55-sTNF-R and p75-sTNF-R) were measured by ELISA in human sera, seminal fluids, prostatic fluid and fluid obtained from an epididymal spermatocele.

RESULTS

The level of p55-sTNF-R in seminal fluids of normospermic men was approximately equal to 20-fold higher than in normal serum (13.9 +/- 6.9 ng./ml. versus 0.7 +/- 0.2 ng./ml.). In contrast, p75-sTNF-R, which occurs in serum at amounts higher than p55-sTNF-R, was almost indiscernible in the seminal fluids (<0.18 +/- 0.28 ng./ml. versus 1.9 +/- 0.6 ng./ml. in sera). Concentrations of p55-sTNF-R in seminal fluids of oligoasthenospermic and azoospermic men were similar to those of normospermic men (15.6 +/- 8.5 ng./ml. and 14.9 +/- 6.5 ng./ml., respectively). Higher p55-sTNF-R concentrations were found in prostatic fluids and first split ejaculates (39.8 +/- 1.2 ng./ml. and 32 +/- 1.7 ng./ml., respectively), while second split ejaculates and the fluid from an epididymal spermatocele were found to contain p55-sTNF-R at lower levels (10.8 +/- 1 ng./ml. and 1 ng./ml., respectively).

CONCLUSIONS

These findings suggest intense local biosynthesis of p55-sTNF-R in the prostate occurring independently of spermatogenesis. Possible functional implications are: 1) shielding of spermatozoa from the inhibitory effect of TNF in the female reproductive tract; 2) a role for TNF in the normal physiology of the prostate; and 3) blocking TNF-mediated immune response in the prostate, which may have bearings on the development of prostatic hypertrophy or cancer.

How often should infertile men have intercourse to achieve conception?

OBJECTIVE

To clarify how often infertile men should have intercourse to achieve conception, the effect of sequential ejaculation on total motile sperm counts was investigated.

DESIGN

Case-control study.

SETTING

Infertility and IVF unit, tertiary care center.

PARTICIPANTS

Five hundred seventy-six men who produced two closely spaced sequential ejaculates.

MAIN OUTCOME MEASURE

The total motile sperm counts of the second ejaculates were compared with the total motile sperm counts of the first ejaculates.

RESULTS

In normospermic men (n = 359), the total motile sperm counts decreased significantly from 93 (18 to 601) (median [minimum to maximum] x 10(6)) in the first ejaculate to 42 (1.2 to 387) in the second ejaculate, produced 24 hours later. In contrast to the normospermic men, in the asthenospermic group (24 hours difference, n = 81) and in both oligospermic groups, (1 to 4 hours difference, n = 27; and 24 hours difference, n = 45), there were no significant changes in the total motile sperm counts (24 [5.9 to 229] versus 30 [0.8 to 150], 6 [0.8 to 18] versus 3.6 [0.1 to 63] and 13 [2.5 to 32] versus 10 [0.1 to 66], respectively). Moreover, in both oligoasthenospermic groups (1 to 4 hours difference, n = 23; and 24 hours difference, n = 41) the total motile sperm counts increased significantly (3.2 [0.6 to 7.9] versus 8 [0.4 to 48] and 4 [0.2 to 13] versus 4 [0.1 to 101], respectively). In all groups, pooling sequential ejaculates significantly increased the total motile sperm counts, over and above that of the first ejaculate, by 49% in the normospermic group, 95% in the asthenospermic group, 67% and 75% in the oligospermic groups (1 to 4 hours and 24 hours difference, respectively), and 233% and 139% in the oligoasthenospermic groups (1 to 4 hours and 24 hours difference, respectively).

CONCLUSIONS

Sequential ejaculation may overcome the impaired sperm transport causing low total motile sperm counts observed in some oligospermic and/or asthenospermic men. Most of these infertile men may significantly increase their fertility potential, assessed by the total motile sperm counts, either by pooling sequential ejaculates for IUI, GIFT, and IVF, or by having intercourse every day or even twice a day, at the time of ovulation.

Interleukin-6 inhibits the proliferation of B-chronic lymphocytic leukemia cells that is induced by tumor necrosis factor-alpha or -beta

Tumor necrosis factor (TNF-alpha) acts as a growth stimulatory factor on leukemic B lymphocytes from many patients with chronic lymphocytic leukemia (CLL). Because TNF induces production of interleukin-6 (IL-6), which has been shown to be a growth factor for myeloma and other transformed B cells, we examined the possibility that IL-6 mediates the growth-stimulatory effect of TNF on B-CLL cells. In fact, we found that IL-6 is an inhibitor of B-CLL growth. The addition of recombinant human IL-6 markedly decreased the TNF-induced B-CLL growth, and this decrease was even greater when soluble IL-6 receptor, known to act as IL-6 agonist, was added with recombinant IL-6. Conversely, neutralizing monoclonal antibodies to IL-6 and to the IL-6 receptor potentiated the growth stimulation of TNF on B-CLL cells, in line with the possibility that IL-6 functions as a negative feedback regulator of an autocrine TNF action on these B-leukemic cells. Evidence is presented that production of IL-6 by monocytes and B cells of CLL patients is low, suggesting that administration of IL-6 may be beneficial in CLL to reduce the eventual growth stimulation by TNF and, possibly, also the deficiency in platelets and Ig production in this disease.

Stabilization of the bioactivity of tumor necrosis factor by its soluble receptors

The receptors for tumor necrosis factor (TNF) exist in cell-associated as well as soluble forms, both binding specifically to TNF. Since the soluble forms of TNF receptors (sTNF-Rs) can compete with the cell-associated TNF receptors for TNF, it was suggested that they function as inhibitors of TNF activity; at high concentrations, the sTNF-Rs indeed inhibit TNF effects. However, we report here that in the presence of low concentrations of the sTNF-Rs, effects of TNF whose induction depend on prolonged treatment with this cytokine are augmented, reflecting an attenuation by the sTNF-Rs of spontaneous TNF activity decay. Evidence that this stabilization of TNF activity by the sTNF-Rs follows from stabilization of TNF structure within the complexes that TNF forms with the sTNF-Rs is presented here, suggesting that the sTNF-Rs can affect TNF activity not only by interfering with its binding to cells but also by stabilizing its structure and preserving its activity, thus augmenting some of its effects.

Hypercalciuric rickets: metabolic studies and pathophysiological considerations

Extensive metabolic studies were performed in a 14-year-old boy suffering from the rare clinical entity known as childhood idiopathic hypercalciuria associated with dwarfism, renal tubular abnormalities and bone lesions. The salient features were: hyperphosphaturia with hypophosphatemia, hypercalciuria with normocalcemia, elevated serum 1,25-dihydroxycholecalciferol[1,25(OH)2D3] levels, marked intestinal hyperabsorption of calcium and phosphorus, with low serum parathyroid hormone (PTH) and urinary adenosine 3':5'-cyclic monophosphate (c-AMP). Bone biopsy confirmed the clinical and radiological diagnosis of rickets. It appears that the following pathophysiological sequence is operating: primary renal phosphate leak with hypophosphatemia, increased 1,25(OH)2D3 synthesis, enhanced intestinal calcium absorption which in turn inhibits release of PTH and c-AMP. Hypercalciuria is seen to be secondary to both avid intestinal calcium absorption and depressed PTH activity, and rickets the result of phosphate depletion. Treatment with oral phosphorus only resulted in an acceleration of growth rate, cure of rickets, and return of urinary calcium excretion to normal values.