Ureterocystoneostomy (UCN) and subureteral collagen injection (SCIN): combined one-stage correction of high-grade bilateral vesicoureteral reflux (VUR) in children.

The treatment of vesicoureteral reflux (VUR) is still a controversial issue. The efficacy of medical treatment appears to be equal to that of operative procedures in avoiding new formation of renal scars. However, there are generally accepted indications for operative procedures including bilateral high-grade VUR, especially in young patients. Ureteral reimplantation (UCN) is the operative treatment of choice in cases with high-grade VUR. Alternatively in cases with lower-grade VUR, injection of bulking agents under the refluxive orifice can be performed. It is also generally accepted that UCN with extravesical preparation of the ureter and the bladder should not be done bilaterally in a one-stage procedure. Postoperative bladder dysfunction may result due to detrimental neurogenic effects. In this study we report on our operative procedure in cases with bilateral high-grade VUR, during which we perform intra/extravesical UCN (mod. Leadbetter-Politano) of the higher-grade refluxive ureter, and (open) subureteral collagen injection (SCIN) of the lower-grade refluxive orifice as a combined one-stage procedure. In this study 50% of the patients had no VUR on either side after the first combined procedure. 15% of the patients showed significant down-grading of VUR of the injected side. These patients underwent a 2nd endoscopic SCIN. 35% of the patients showed no change of VUR of the injected side after the first procedure; these patients underwent reimplantation of this side in another operation. Accordingly, 50% of patients with bilateral high-grade VUR required a 2nd operative procedure under full anesthesia to achieve loss of VUR on both sides. None of the patients showed bladder dysfunction postoperatively. Mean follow-up after the last operative correction was 29.9 months (6 - 84 months).

Hyperoxia upregulates the NO pathway in alveolar macrophages in vitro: role of AP-1 and NF-kappaB.

The inducible nitric oxide (NO) synthase gene in alveolar macrophages (AMs) is a stress response gene that may contribute to tissue injury in the lung after respiration with high O(2) concentrations through extensive production of NO. In this study, we investigated the influence of hyperoxia on the NO pathway in rat AMs in vitro, its regulation by the transcription factors nuclear factor (NF)-kappaB and activator protein (AP)-1, and the role of reactive oxygen species (ROS). AMs were treated with lipopolysaccharide (LPS) and/or interferon (IFN)-gamma and incubated under 21 or 85% O(2). Stimulation with LPS and IFN-gamma led to induction of the NO pathway that was further upregulated by hyperoxia. The binding activity of NF-kappaB, in contrast to that of AP-1, was activated on stimulation with LPS and IFN-gamma, and both were further increased under hyperoxia. The antioxidants pyrrolidine dithiocarbamate and N-acetyl-L-cysteine inhibited intracellular ROS production and the NO pathway under both normoxic and hyperoxic conditions but had diverse effects on the transcription factors. The results presented here indicate that hyperoxia can upregulate the NO pathway in stimulated AMs through increased production of intracellular ROS and activation of NF-kappaB and AP-1.

Dense bodies of human cytomegalovirus induce both humoral and cellular immune responses in the absence of viral gene expression.

Infection of fibroblast cell cultures with human cytomegalovirus (HCMV) leads to the production of significant amounts of defective enveloped particles, termed dense bodies (DB). These noninfectious structures contain major antigenic determinants which are responsible for induction of both the humoral and the cellular immune response against HCMV. We tested the hypothesis that, by virtue of their unique antigenic and structural properties, DB could induce a significant immune response in the absence of infectious virus. Mice were immunized with gradient-purified DB, which were either left untreated or subjected to sequential rounds of sonication and freeze-thawing to prevent cellular entry. Titers of neutralizing antibodies induced by DB were in a range comparable to levels present in convalescent human sera. The virus-neutralizing antibody response was surprisingly durable, with neutralizing antibodies detected 12 months following primary immunization. The HCMV-specific major histocompatibility complex class I-restricted cytolytic T-cell (CTL) response was assayed using mice transgenic for the human HLA-A2 molecule. Immunization with DB led to high levels of HCMV-specific CTL in the absence of de novo viral protein synthesis. Maximal total cytolytic activity in mice immunized with DB was nearly as efficient as the cytolytic activity induced by a standard immunization with murine cytomegalovirus. Furthermore, DB induced a typical T-helper 1 (Th1)-dominated immune response in mice, as determined by cytokine and immunoglobulin G isotype analysis. Induction of humoral and cellular immune responses was achieved without the concomitant use of adjuvant. We thus propose that DB can serve as a basis for the future development of a recombinant nonreplicating vaccine against HCMV. Finally, such particles could be engineered for efficient delivery of antigens from other pathogens to the immune system.

Frequency of CD8(+) T lymphocytes specific for lytic and latent antigens of Epstein-Barr virus in healthy virus carriers.

We investigated CD8(+) T cell frequencies of five different Epstein-Barr virus-specific cytotoxic T lymphocyte epitopes located within proteins of the replicative cycle and the latent state in healthy long-term virus carriers with IFN-gamma enzyme-linked immunospot assay. Frequencies of the HLA-A3-restricted epitope RVRAYTYSK (RVR) whose minimal length was mapped in this study to amino acid position 148-156 of the immediate-early protein BRLF1 were compared with those of a further known HLA-A3-restricted epitope within EBNA3A, RLRAEAQVK (RLR). Determination of frequencies of CD8(+) T lymphocytes directed against lytic antigen epitope RVR revealed that only one of eight donors recognized this epitope. Frequency was calculated to be 65 RVR-specific CD8(+) T lymphocytes per 10(6) PBMC. None of the HLA-A3-positive donors exhibited IFN-gamma release after antigenic stimulation with the EBNA3A-specific peptide epitope RLR. Furthermore, we chose three known HLA-B8-restricted epitopes, RAKFKQLL (RAK), FLRGRAYGL (FLR), and QAKWRLQTL (QAK), of the lytic protein BZLF1 and the latent protein EBNA3A. Examination of eight HLA-B8-positive virus carriers revealed that the BZLF1-specific epitope RAK was recognized by all donors with a median frequency of 233 RAK-specific CD8(+) T lymphocytes per 10(6) PBMC. Only 50% of these donors reacted against EBNA3A-specific epitope FLR and a minority (25%) reacted against EBNA3A-specific epitope QAK.

Immediate-early transactivator Rta of Epstein-Barr virus (EBV) shows multiple epitopes recognized by EBV-specific cytotoxic T lymphocytes.

We analyzed the immediate-early transactivator Rta of Epstein-Barr virus (EBV) for its role as a target for specific cytotoxic T lymphocytes (CTL). Panels of overlapping peptides covering the entire amino acid sequence of Rta were synthesized and used to induce and analyze specific CTL responses in EBV-positive donors. Using peptide-pulsed target cells, we found nine different CTL epitopes that are distributed over the entire protein sequence. One epitope restricted by HLA-A24 could be mapped to the decameric sequence DYCNVLNKEF between amino acid positions 28 and 37 of the Rta protein. A second epitope could be assigned to the same region of Rta (residues 25 to 39) and was shown to be restricted by HLA-B18. Another, minimal epitope could be mapped to the nonameric sequence ATIGTAMYK between amino acid positions 134 and 142; this peptide was restricted by HLA-A11. Another four epitopes were proven to be restricted by HLA-A2, -A3, -B61, and -Cw4 and were located between Rta residues 225 and 239, 145 and 159, 529 and 543, and 393 and 407, respectively. For two other epitopes, only the location within the Rta protein is known so far (residues 121 to 135 and 441 to 455); their exact HLA restriction patterns have not yet been identified. Using target cells infected with recombinant vaccinia virus containing the gene for Rta, we showed that six of eight Rta-specific CTL lines recognized the corresponding peptides also after endogenous processing. These data suggest that Rta comprises an important target for EBV-specific cellular cytotoxicity. Together with recent findings of other immediate-early and early proteins also acting as CTL targets, they reveal the role of proteins of the lytic cycle in the immune recognition of EBV-infected cells.

Salivary epidermal growth factor plays a role in protection of ileal mucosal integrity.

The role of salivary epidermal growth factor (EGF) in the maintenance of ileal mucosal integrity was studied by evaluating the effects of sialoadenectomy on luminal EGF levels, ileal tissue resistance (Rt), and unidirectional flux of [51Cr]EDTA. Mice in groups 1 (SLX) and 2 (SLX + EGF) were subjected to sialoadenectomy, while mice in groups 3 (Sham) and 4 (Sham + EGF) underwent a sham procedure. All animals received normal diet and water, except that EGF (100 ng/ml) was added to water for SLX + EGF and Sham + EGF mice. At seven days after surgery, luminal EGF levels in gastrointestinal segments and ileal Rt were significantly reduced by sialoadenectomy, which was prevented by EGF supplementation. Unidirectional flux of [51Cr]EDTA was 6- to 22-fold greater in the ileum of sialoadenectomized mice, which was prevented by EGF administration. Results suggest that salivary EGF may be the major source of intestinal EGF, and it may play a role in maintenance of ileal mucosal integrity.

[Costs of drug treatment of neurologic diseases: Parkinson disease, dystonia, epilepsy]. / Kosten der medikamentösen Behandlung neurologischer Erkrankungen: Morbus Parkinson, Dystonie, Epilepsie.

AIM: The costs of drug treatment were evaluated for Parkinson's disease, focal dystonias and epilepsy. METHODS: Retrospective analysis over a period of 12 months of 785 patients who visited regularly a neurological out-patient department. RESULTS: Drug treatment caused a mean annual expenditure of DM 3,920.- (US-($) 2590, pounds 1690) for Parkinson's disease (n = 409), DM 3,620.- (US-($) 2390; pounds 1550) for focal dystonias (n = 140) and DM 660.- (US-($) 435, pounds 280) for hemifacial spasm (n = 35) per patient.- In Parkinson's disease costs are dependent on the extent of the disease, the type involved and the presence or absence of motor fluctuations. In Hoehn and Yahr stage I we calculated costs of DM 2,230.- (US-($) 1470; pounds 960), in contrast to DM 11,870.- (US-($) 7830; pounds 5100) in Hoehn and Yahr stage V. The occurrence of fluctuations in motor ability increased annual costs to DM 6,010.- (US-($) 3970, pounds 2580); patients' treatment without motor fluctuations was cheaper (DM 2,700.-; US-($) 1780, pounds 1160).- The annual treatment costs of focal dystonias and facial hemispasm varied due to the location of the involuntary movement and the extent of symptoms: DM 4,900.- (US-($) 3300; pounds 2100) were calculated for the treatment of cervical dystonias, DM 1,480.- (US-($) 930; pounds 600) for the treatment of blepharo-spasm (oromandibular dystonia: DM 1,710.-; US-($) 1200; pounds 800) and DM 600.- (US-($) 470; pounds 300) for the treatment of facial hemispasm.- The drug treatment of epilepsy caused mean costs of DM 1,740.- (US-($) 1160; pounds 750) per year. There were marked differences concerning the different epileptic syndromes and types of seizure. CONCLUSION: Costs of drug treatment varied considerably in the three diseases depending on the course, the type and the different forms of the respective disease.

Tonic suppression of gastric acid secretion by endogenous peptides in neonatal rats.

Stimulation of gastric acid secretion by secretagogues was measured in developing rats by in vivo and in vitro techniques. Basal acid outputs in vivo were very low in 8- and 14-day-old rats compared with those in 20- and 30-day-old rats. In 20-day-old rats, all secretagogues increased acid output in vivo, whereas only carbachol, pentagastrin, and sulfated cholecystokinin octapeptide (CCK-8S) were active in 14-day-old rats. In contrast, basal acid output in vitro and stimulation by secretagogues did not differ significantly with age. CCK-8S-stimulated acid output in vitro in 14-day-old rats was blocked by L-365,260, L-364,718, tetrodotoxin, and atropine, but not by hexamethonium, whereas gastrin-stimulated acid output was blocked only by L-365,260. Furthermore, acid output in vivo was elevated three- to fourfold by subcutaneous naloxone-methiodide or L-364,718, but not by L-365,260, in 14-day-old rats; none of these antagonists produced an effect in 20-day-old rats. These studies show that low basal gastric acid output in neonatal rats is caused by tonic inhibitory regulation by endogenous regulatory peptides.