Resolution of multiply recurrent and multifocal diverticulitis after fecal microbiota transplantation.

BACKGROUND: The exact pathophysiology of diverticulitis is not well understood and may be multifactorial. Recent studies highlight dysbiosis as a plausible mechanism. FMT is a safe strategy to restore commensal colon microbiota and has proven to be an effective treatment for gastrointestinal dysbiosis such as Clostridium difficile infection (CDI). There have been no studies reporting the treatment of diverticulitis with FMT. Our aim was to describe the novel application of fecal microbiota transplantation (FMT) for the treatment of recurrent diverticulitis. CASE: We report a case of a 63-year-old woman who had a 13-year history of multiply recurrent and multifocal diverticulitis previously treated with numerous short courses of intravenous and oral antibiotics for acute flares, two segmental colon resections, and suppressive antibiotic therapy for recurrent disease. Secondary to multiple courses of antibiotics , the patient developed CDI. She was treated with a single round of FMT and subsequently stopped all antibiotics at the time of FMT. RESULTS: In 20 months of follow-up, the patient has had no further recurrence of diverticulitis or CDI. CONCLUSIONS: FMT could prove to be a novel therapy for refractory diverticulitis but requires further investigation.

The relationship between pre-operative hypertension and intra-operative haemodynamic changes known to be associated with postoperative morbidity.

Hypertension is not consistently associated with postoperative cardiovascular morbidity and is therefore not considered a major peri-operative risk factor. However, hypertension may predispose to peri-operative haemodynamic changes known to be associated with peri-operative morbidity and mortality, such as intra-operative hypotension and tachycardia. The objective of this study was to determine whether pre-operative hypertension was independently associated with haemodynamic changes known to be associated with adverse peri-operative outcomes. We performed a five-day multicentre, prospective, observational cohort study which included all adult inpatients undergoing elective, non-cardiac, non-obstetric surgery. We recruited 343 patients of whom 164 (47.8%) were hypertensive. An intra-operative mean arterial pressure of < 55 mmHg occurred in 59 (18.2%) patients, of which 25 (42.4%) were hypertensive. Intra-operative tachycardia (heart rate> 100 beats.min-1 ) occurred in 126 (38.9%) patients, of whom 61 (48.4%) were hypertensive. Multivariable logistic regression did not show an independent association between the stage of hypertension and either clinically significant hypotension or tachycardia, when controlled for ASA physical status, functional status, major surgery, duration of surgery or blood transfusion. There was no association between pre-operative hypertension and peri-operative haemodynamic changes known to be associated with major morbidity and mortality. These data, therefore, support the recommendation of the Joint Guidelines of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the British Hypertension Society to proceed with elective surgery if a patient's blood pressure is < 180/110 mmHg.

CO2 embolism can complicate transanal total mesorectal excision.

BACKGROUND: Carbon dioxide (CO2) embolism is a rare but potentially devastating complication of minimally invasive abdominal and retroperitoneal surgery. Characterized by a decrease in end-tidal CO2 (ETCO2) and oxygen saturation (SpO2), CO2 emboli can cause rapid intraoperative hypotension and cardiovascular collapse. Transanal total mesorectal excision (taTME) is a novel surgical approach for rectal resection, which requires high flow CO2 insufflation in a low volume operative field. In this setting, the incidence of CO2 embolism is unknown; we evaluate three cases of intraoperative CO2 embolism that occurred during the transanal portion of the TME dissection. METHODS: All taTME cases from December 2014 to March 2018 at a single institution were reviewed. Cases of CO2 embolism were identified intraoperatively and characterized using the operative reports and anesthesia records. The transanal/pelvic insufflation included a targeted pressure of 15 mm Hg, high flow and high smoke evacuation. Physiologic derangements and management of these instances were analyzed. The postoperative course was evaluated and any complications were noted. RESULTS: A total of 80 taTME were performed for benign and malignant disease. Three patients (4%) developed intraoperative evidence of CO2 embolism. Each instance occurred during the transanal portion of the dissection. Physiologic changes were marked by abrupt decrease in end-tidal ETCO2, SpO2, and blood pressure (BP). Management included immediate release of pneumopelvis, hemodynamic support with crystalloid or vasopressors, and placement of the patient in the Trendelenburg position with left side down. Within 10 min of the acute event, all patients had return of ETCO2, SpO2, and BP to pre-event levels. There were no intraoperative or postoperative sequelae including arrhythmia, myocardial infarction, stroke or death. No cases required conversion to open. CONCLUSIONS: During taTME, rare CO2 emboli may occur in the setting of venous bleeding during pneumopelvis, causing sudden, transient cardiovascular instability. Immediate recognition of rapid decrease in ETCO2, SpO2, and BP should be followed by desufflation of pneumopelvis, patient positioning in Trendelenburg and left lateral decubitus, and hemodynamic support. Increased awareness of this potential complication and maintaining a high index of suspicion will lead to preparedness of the anesthesia and surgery teams.

Objective assessment of minimally invasive total mesorectal excision performance: a systematic review.

INTRODUCTION: Laparoscopy is widely used in colorectal practice, but recent trial results have questioned its use in rectal cancer resections. Patient outcomes are directly linked to the quality of total mesorectal excision (TME) specimen. Objective assessment of intraoperative performance could help ensure competence and delivery of optimal outcomes. Objective tools may also contribute to TME intervention trials, but their nature, structure and utilisation is unknown. AIM: To systemically review the available literature to report on the available tools for the objective assessment of minimally invasive TME operative performance and their use within multicentre laparoscopic TME randomised controlled trials. METHODS: A systematic search of the PubMed and Cochrane databases was performed to identify tools used in the objective intraoperative assessment of minimally invasive TME performance in accordance with the PRISMA guidelines, independently by two authors. The identified tools were then evaluated within reported TME RCTs. RESULTS: A total of 8642 abstracts were screened of which 12 papers met the inclusion criteria; ten prospective observational studies, one randomised trial and one educational consensus. Eight assessment methods were described, which include formative and summative tools. The tools were mostly adaptations of colonic surgery tools based on either operative video review or post-operative trainer rating. All studies reported objective assessment of intraoperative performance was feasible, but only 126 (7%) of the 1762 included laparoscopic cases were TME. No multicentre laparoscopic TME trial reported using any objective surgical performance assessment tool. CONCLUSION: Objective intraoperative laparoscopic TME performance assessment is feasible, but most of the current tools are adaptation of colonic surgery. There is a need to develop dedicated assessment tools for minimal access rectal surgery. No multicentre minimally invasive TME RCT reported using any objective assessment tool.

Defining the anti-inflammatory activity of a potent myxomaviral chemokine modulating protein, M-T7, through site directed mutagenesis.

Viral chemokine modulating proteins provide new and extensive sources for therapeutics. Purified M-T7, a poxvirus-derived secreted immunomodulatory protein, reduces mononuclear cell invasion and atheroma in rodent models of angioplasty injury as well as aortic and renal transplant, improving renal allograft survival. M-T7 is a rabbit species-specific interferon gamma receptor (IFNγR) homolog, but also inhibits chemokine/glycosaminoglycan (GAG) interactions for C, CC and CXC chemokines, with cross-species specific inhibitory activity. M-T7 anti-atheroma activity is blunted in GAG deficient mouse aortic transplants, but not in CC chemokine receptor deficient transplants, supporting M-T7 interference in chemokine/GAG interactions as the basis of the atheroma-inhibitory activity. We have assessed point mutants of M-T7 both in vivo in a mouse angioplasty model and in vitro in tissue culture and binding assays, in order to better define the primary mechanism of anti-atheroma activity. Of these M-T7 mutants, the R(171)E and E(209)I M-T7 mutants lost inhibitory activity for plaque growth in hyperlipidemic ApoE(-/-) mice after angioplasty injury and R(171)E, moreover, greatly exacerbated plaque growth and inflammation. F(137)D retained some inhibitory activity for plaque growth. In contrast, for cell migration assays, M-T7-His6X, F(137)D, R(171)E, and E(209)I all inhibited CC chemokine (RANTES) mediated cell migration. For the ligand binding assays, R(171)E and E(209)I had significantly reduced binding to RANTES and IFNγ, whereas F(137)D retained wild-type binding activity. Heparin treatment further reduced RANTES binding of all three M-T7 mutants. In summary, point mutations of M-T7, R(171)E and E(209)I, exhibited reduced anti-inflammatory properties in vivo after mouse angioplasty with a loss of in vitro binding to RANTES and IFNγ, indicating these point mutations partially disrupt M-T7 ligand-binding activities. Unexpectedly, the M-T7 mutants all retained inhibitory activity for human monocyte THP-1 cell migration ex vivo, suggesting additional inhibitory properties against human monocyte THP-1 cells that are independent of chemokine inhibition.

Impact of extended-course oral nirmatrelvir/ritonavir (Paxlovid) in established Long COVID: Case series and research considerations.

Background: Prior case series suggest that a 5-day course of oral Paxlovid (nirmatrelvir/ritonavir) benefits some people with Long COVID, within and/or outside of the context of an acute reinfection. To the best of our knowledge, there have been no prior case series of people with Long COVID who have attempted longer courses of nirmatrelvir/ritonavir. Methods: We documented a case series of 13 individuals with Long COVID who initiated extended courses (>5 days; range: 7.5-30 days) of oral nirmatrelvir/ritonavir outside (n=11) of and within (n=2) the context of an acute SARS-CoV-2 infection. Participants reported on symptoms and health experiences before, during, and after their use of nirmatrelvir/ritonavir. Results: Among those who took a long course of nirmatrelvir/ritonavir outside of the context of an acute infection, some experienced a meaningful reduction in symptoms, although not all benefits persisted; others experienced no effect on symptoms. One participant reported intense stomach pain that precluded her from continuing her course. Among the two participants who took a long course of nirmatrelvir/ritonavir within the context of an acute reinfection, both eventually returned to their pre-re-infection baseline. Discussion: Long courses of nirmatrelvir/ritonavir may have meaningful benefits for some people with Long COVID but not others. We encourage researchers to study who, how, and why nirmatrelvir/ritonavir benefits some and what course length is most effective, with the goal of informing clinical recommendations for using nirmatrelvir/ritonavir and/or other antivirals as a potential treatment for Long COVID.

A multicentre cross-sectional descriptive study evaluating the cardiovascular risk profile of preoperatively identified patients with hypertension.

BACKGROUND: The prevalence of hypertension in adults in South Africa (SA) is 35%. Hypertension is the most important modifiable risk factor for cardiovascular (CV) and chronic kidney disease (CKD) in sub-Saharan Africa. However, 49% of people are unaware of their blood pressure status. Screening for hypertension prior to surgery provides a unique opportunity to diagnose and treat affected individuals. Furthermore, assessing overall CV risk identifies patients at highest risk for complications, and improves the utilisation of scarce resources. OBJECTIVES: To evaluate the CV risk profile of hypertensive patients in the adult population of the Western Cape Province presenting for elective non-cardiac, non-obstetric surgery. METHODS: This report documents the CV risk profile of patients recruited to the HASS-2 study (Hypertension and Surgery Study 2), which was undertaken in seven Western Cape hospitals. Patients were screened for hypertension and pharmacological treatment was initiated or adjusted in patients with stages 1 and 2 disease. Stage 3 patients were referred to a physician. In the present substudy, patients with stages 1 and 2 hypertension were assessed for associated CV risk factors, the presence of target organ damage, and documented CV or kidney disease; they received an overall risk stratification according to the 2018 European Society of Cardiology and the European Society of Hypertension Guidelines. RESULTS: Sixty-one patients with stage 1 and 12 with stage 2 hypertension were analysed. Established CV disease was present in 13.7% of the study population, and CKD (eGFR <60 mL/min) in 10.8%. Seventy-one percent of the study group had a raised body mass index, and 55.9% underlying metabolic syndrome. Prediabetes and diabetes were present in 16.1% and 14.5%, respectively. According to the 2018 European guidelines, 34.7% were at moderate, 33.3% at high and 16.7% at very high risk for a CV event in the following 10 years. CONCLUSIONS: The perioperative period is a critical time during which surgeons, nurses and anaesthetists can influence patients' CV risk of adverse events. This involves appropriate screening, education and treatment. In this study population, nearly 9 out of 10 elective surgical patients with stage 1 or 2 hypertension had CV risk factors placing them at moderate to very high risk. The simultaneous assessment of these additional CV risk parameters, in addition to diagnosis and management of hypertension, may further decrease the health and financial burden in resource-limited facilities in SA, and improve CV outcomes.

A multicentre prospective observational study of the prevalence of preoperative anaemia and iron deficiency in adult elective surgical patients in hospitals in Western Cape Province, South Africa.

BACKGROUND: Preoperative anaemia has been shown to be an independent risk factor for postoperative morbidity and mortality. Iron deficiency is the leading cause of anaemia globally. There are limited data describing the burden of perioperative anaemia and the relative contribution of iron deficiency in South Africa (SA). OBJECTIVES: To determine the prevalence and severity of preoperative anaemia in adults presenting for elective surgery in Western Cape Province, SA, and to investigate the contribution of iron deficiency as a cause of the anaemia. For this purpose, an investigative protocol from a recent consensus statement on the management of perioperative anaemia was applied. METHODS: We performed a prospective, observational study in adult patients presenting for elective non-cardiac, non-obstetric surgery over a 5-day period at six Western Cape government-funded hospitals. The World Health Organization patient classification was applied, and patients with anaemia were investigated for iron deficiency. RESULTS: The prevalence of preoperative anaemia was 28% (105/375; 95% confidence interval (CI) 23.5 - 32.5); 55/105 patients (52%) had moderate and 11/105 (11%) severe anaemia. Iron deficiency was the cause of anaemia in 37% (32/87; 95% CI 26.6 - 46.9), but only 9% of iron-deficient patients received iron supplementation prior to surgery. CONCLUSIONS: Preoperative anaemia was common in this study, and more than half of the affected patients had moderate to severe anaemia. Iron deficiency was responsible for almost 40% of cases. Iron supplementation was under-utilised in the preoperative period as a means of increasing haemoglobin. The introduction of system-wide policies would empower perioperative physicians to mitigate the risk associated with preoperative anaemia in the Western Cape.

A multicentre prospective observational study of the prevalence and glycaemic control of diabetes mellitus in adult non-cardiac elective surgical patients in hospitals in Western Cape Province, South Africa.

BACKGROUND: Diabetes mellitus (DM) is a common condition. The high burden of undiagnosed DM and a lack of large population studies make accurate prevalence estimations difficult, especially in the surgical environment. Furthermore, poorly controlled DM is associated with an increased risk of perioperative complications and mortality. OBJECTIVES: The primary objective was to establish the prevalence of DM in elective adult non-cardiac, non-obstetric surgical patients in hospitals in Western Cape Province, South Africa. The secondary objectives were to assess the glycaemic control and compliance with treatment of known diabetics. METHODS: A 5-day multicentre, prospective observational study was performed at six government-funded hospitals in the Western Cape. Screening for DM was done using finger-prick capillary blood glucose (CBG) testing. Patients found to have a CBG ≥6.5 mmol/L had their glycated haemoglobin (HbA1c) level measured. DM was diagnosed based on the Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) diagnostic criteria. Patients known to have DM had their HbA1cmeasured and completed a Morisky Medication Adherence Scale (MMAS-4) questionnaire to assess glycaemic control and compliance with treatment. RESULTS: Of the 379 participants, 61 were known diabetics (16.2%; 95% confidence interval (CI) 12.4 - 19.8). After exclusion of 8 patients with incomplete results, a new diagnosis of DM was made in 5/310 patients (1.6%; 95% CI 0.2 - 3.0). The overall prevalence of DM was 17.8% (66/371; 95% CI 13.9 - 21.7). HbA1c results were available for 57 (93.4%) of the 61 known diabetics. Of these, 27 (47.4%; 95% CI 34.4 - 60.3) had an HbA1c level ≥8.5% and 14 (24.6%; 95% CI 13.4 - 35.8) had a level ≤7%. Based on positive responses to two or more questions on the MMAS-4 questionnaire, 12/60 participants (20.0%) were deemed non-compliant. CONCLUSIONS: There is a low rate of undiagnosed DM in our elective surgical population, but in a high proportion of patients with DM the condition is poorly controlled. Poorly controlled DM is known to increase postoperative complications and is likely to increase the burden of perioperative care. Resources should be focused on improvement of long-term glycaemic control in patients presenting for elective surgery.

Bariatric fellowship positively influences early outcomes for laparoscopic Roux-en-Y gastric bypass surgery over seven years of independent practice.

Introduction Laparoscopic Roux-en-Y gastric bypass (LRYGB) is technically demanding and has an associated learning curve. We published previously that bariatric fellowship reduces the learning curve of primary LRYGB and improves patient outcomes after one year of independent practice. However, the long-term effect of fellowship is unknown. We therefore aimed to compare the 30-day outcomes of LRYGB between the first year of a surgeon's independent practice with the subsequent six years. Materials and methods A prospective database of patients undergoing primary LRYGB under a single surgeon from March 2010 until February 2017 was analysed. Two groups were studied: first year (< 1 year) and the subsequent six years (≥ 1 year) of independent practice. Patient demographics, length of hospital stay, conversion to open surgery, perioperative complications and mortality were compared. Results Among 279 eligible patients, 74 (26.5%) were in the < 1 year group and 205 (73.5%) in ≥ 1 year group. The preoperative risk scores, American Society of Anesthesiologists (ASA) grade, P = 0.00; obesity surgery mortality risk score (OS-MRS), P = 0.04) were significantly higher in ≥ 1 year group. There was no significant difference in perioperative outcomes (length of stay, P = 0.38; total complications, P = 0.20; readmissions, P = 1.00; reoperations, P = 0.60) between the two groups. Conclusions Bariatric fellowship reduces the learning curve for LRYGB and helps to achieve excellent outcomes in the first and subsequent years of independent practice. The higher risk profile of ≥ 1 year group did not equate to an increase in complications, suggesting that experience and standardisation may help in handling complex cases. To our knowledge, this represents the only such study in the literature.

Laparoscopic Roux-en-Y gastric bypass is as safe as laparoscopic sleeve gastrectomy. Results of a comparative cohort study.

BACKGROUND: A meta-analysis and six randomized controlled trials show higher 30-day complication rates with laparoscopic Roux-en-Y gastric bypass (LRYGB) than with laparoscopic sleeve gastrectomy (LSG). AIM: To identify any difference in 30-day outcomes of patients treated with LRYGB or LSG when a standardized technique and identical post-operative protocol was followed with all procedures being conducted either by or under the supervision of a single consultant surgeon who had significant experience in bariatric surgery prior to commencing independent practice. METHODS: A prospectively collected database of all patients under primary LRYGB or LSG, between March 2010 and February 2017, was analyzed. Data on demographics, length-of-stay (LOS), conversion to open, 30-day complications and mortality were reviewed. RESULTS: Over a seven-year period, 485 patients (LRYGB-279 and LSG-206) were included. There were no significant demographic differences and no difference in the pre-operative risk scoring [American Society of Anesthesiologists (ASA) and obesity surgery mortality risk score (OSMRS)] between the groups. There was no significant difference between the groups in terms of LOS (p = 0.275), complications (p = 0.920), re-admissions (p = 0.593) or re-operations (p = 0.366) within 30-days. There were no conversions to open or in-patient mortality in either group. CONCLUSIONS: Unlike previous studies, we found no difference in early complication rates between LRYGB and LSG in a comparable cohort when performed by a surgeon with sufficient experience in bariatric surgery.

Reliability and efficiency of three methods of calculating migration percentage on radiographs for hip surveillance in children with cerebral palsy.

PURPOSE: Hip surveillance programmes for children with cerebral palsy (CP) utilize the migration percentage (MP) measurement to initiate referrals and recommend treatment. This study assesses the reliability and efficiency of three methods of MP measurement on anteroposterior (AP) pelvis radiographs. METHODS: A total of 20 AP pelvis radiographs (40 hips) of children with CP were measured by three raters on two occasions using three methods: digital measurement (DM) on a Picture Archiving and Communication System monitor, computer-aided measurement (CA) using a digital templating tool and mobile device application measurement (MA) using a freely available MP measurement tool. For each method, the time required to complete the MP measurement of both hips on each AP pelvis radiograph was measured. Intra-class correlation coefficient (ICC) was used to determine reliability, and analysis of variance was used to compare groups. RESULTS: All three methods of determining MP showed excellent inter-rater and intra-rater reliability (ICC 0.976 to 0.989). The mean absolute difference in MP measurement was not significant between trials for a single rater (DM 2.8%, CA 1.9%, MA 2.2%) or between raters (DM 3.6%, CA 2.9%, MA 3.6%). The mean time to complete MP measurement was significantly different between methods, with DM = 151 seconds, CA = 73 seconds and MA = 80 seconds. CONCLUSION: All three MP measurement methods were highly reliable with clinically acceptable measurement error. The time required to measure a hip surveillance radiograph can be reduced by approximately 50% by utilizing a computer-based or mobile application-based MP measurement tool.

A multicentre, cross-sectional study investigating the prevalence of hypertensive disease in patients presenting for elective surgery in the Western Cape Province, South Africa.

BACKGROUND: Hypertension is common, affecting over one billion people worldwide. In sub-Saharan Africa, hypertensive disease not only affects the older population but is becoming increasingly prevalent in younger individuals. In South Africa (SA), >30% of the adult population has hypertension, making it the single most common cardiovascular risk factor and the predominant contributor to cardiovascular disease and mortality. Elevated blood pressure is the most common perioperative comorbidity encountered in non-cardiac surgical patients, with an overall prevalence of 20 - 25%, and it remains poorly controlled in low- and middle-income countries. Hypertension in the perioperative setting may adversely affect patient outcome. It therefore not only flags possible perioperative challenges to anaesthesiologists, but also identifies patients at risk of long-term morbidity and mortality. OBJECTIVES: To determine the prevalence and severity of hypertension in elective adult surgical patients in the Western Cape Province, SA. RESULTS: The study population included all elective surgical patients from seven hospitals in the Western Cape during a 1-week period. Hypertension, defined as having had a previous diagnosis of hypertension or meeting the blood pressure criteria of >140/90 mmHg, was identified in 51.8% of patients during preoperative assessment. Significantly, newly diagnosed hypertension was present in 9.9% of all patients presenting for elective surgery. Although 98.1% of the known hypertensive patients were on antihypertensive therapy, 36.9% were inadequately controlled. There are numerous reasons for this, but notably 32.1% of patients admitted to forgetting to take their medication, making patient factors the most common reason for treatment non-compliance. CONCLUSIONS: The perioperative period may be an important opportunity to identify undiagnosed hypertensive patients. The perioperative encounter may have a significant public health implication in facilitating appropriate referral and treatment of patients with hypertension to decrease long-term cardiovascular complications in SA.

Characterization of the muscarinic receptor subtype(s) mediating contraction of the guinea-pig lung strip and inhibition of acetylcholine release in the guinea-pig trachea with the selective muscarinic receptor antagonist tripitramine.

1. The muscarinic receptor subtypes mediating contraction of the guinea-pig lung strip and inhibition of the release of acetylcholine from cholinergic vagus nerve endings in the guinea-pig trachea in vitro have previously been characterized as M2-like, i.e. having antagonist affinity profiles that are qualitatively similar but quantitatively dissimilar compared to cardiac M2 receptors. The present study sought to establish definitely the identity of these receptor subtypes by using the selective muscarinic receptor antagonist, tripitramine. Guinea-pig atria and guinea-pig trachea (postjunctional contractile response) were included for reference. 2. It was found that tripitramine antagonized methacholine-induced contractions of the guinea-pig lung strip with pKB value of 8.76 +/- 0.05. Both the parallel shifts of the concentration-response curves and the slope of the Schild plot begin not significantly different from unity (when antagonist preincubation was for 2 h) indicated the involvement of a single population of receptors in the contractile response. From the pKB values obtained with tripitramine and a range of other selective muscarinic receptor antagonists (cf. Roffel et al., 1993), this single population of receptors can only be classified as M2-like. 3. Tripitramine antagonized methacholine-induced chronotropic and inotropic responses in guinea-pig right and left atria with apparent pKB values of 9.4-9.6. However, such values were only obtained when antagonist preincubation was relatively long and/or antagonist concentration relatively high (e.g with 1 h at 100 or 300 nM but 3 h at 30 nM). It thus appears that low concentrations of tripitramine do not readily equilibrate with M2 receptors in guinea-pig atria nor with M2-like receptors in the guinea-pig lung strip. 4. Tripitramine increased electrical field stimulation-induced cholinergic twitch contractions in guinea-pig trachea in concentrations of 0.3-100 nM, by blocking prejunctional muscarinic inhibitory autoreceptors; with higher concentrations, twitch contractions were progressively diminished, as a result of blocking postjunctional M3 receptors (apparent pKB value 6.07 +/- 0.15). The pEC20 value (-log concentration that increases twitch by 20% maximum) was 8.29 +/- 0.08, which would suggest that M4 receptors are involved in this response. 5. Oxotremorine-induced inhibition of the release of prelabelled [3H]-acetylcholine from guinea-pig trachea, under conditions where there is no auto-feedback, was blocked by tripitramine (2 h preincubation) with a pKB value of 8.56 +/- 0.06. The slope of the corresponding Schild plot was not significantly different from unity, which together with the parallel shifts of the concentration-response curves indicated the involvement of a single muscarinic receptor subtype. 6. Since the pKB value for tripitramine at prejunctional receptors in guinea-pig trachea is in between the affinities towards M2 and M4 receptors, correlation plots were constructed to compare the pKB values obtained with tripitramine and a range of other selective muscarinic receptor antagonists (cf. Kilbinger et al., 1995) to reported affinities at M1-M4 receptors. This showed rather similar distribution patterns of the data points around the line of equality in the case of M2 and M4 receptor subtypes. However, the correlation coefficient was markedly better for M2 (0.9667) than for M4 (0.5976). Since recent evidence suggests that M4 receptors are not expressed in cholinergic nerves from guinea-pig trachea, it is concluded that prejunctional muscarinic autoinhibitory receptors in this tissue exhibit an atypical M2 type character, with a pharmacological profile distinct from cardiac M2 receptors.

The effect of graded doses of fission neutrons or X rays on the stromal compartment of the thymus in mice.

The effect of irradiation on the supportive role of the thymic stroma in T cell differentiation was investigated in a transplantation model using athymic nude mice and transplanted irradiated thymuses. In this model, neonatal CBA/H mice were exposed to graded doses of whole-body irradiation with fast fission neutrons of 1 MeV mean energy or 300 kVp X rays. The doses used varied from 2.75 up to 6.88 Gy fission neutrons and from 6.00 up to 15.00 Gy X rays at center-line dose rates of 0.10 and 0.30 Gy/min, respectively. Subsequently, the thymus was excised and a thymus lobe was transplanted under the kidney capsule of H-2 compatible nude mice. One and two months after transplantation, the T cell composition of the thymic transplant was investigated using immunohistology with monoclonal antibodies directed to the cell surface differentiation antigens Thy-1, Lyt-1, Lyt-2, MT-4, and T-200. Furthermore, the stromal cell composition of the thymic transplant was investigated with monoclonal antibodies directed to MHC antigens and with monoclonal antibodies defining different subsets of thymic stromal cells. To investigate the reconstitution capacity of the thymic transplant, the peripheral T cell number was measured using flow cytofluorometric analysis of nude spleen cells with the monoclonal antibodies anti-Thy-1, anti-Lyt-2, and anti-MT-4. The results of this investigation show that a neonatal thymus grafted in a nude mouse has a similar stromal and T cell composition as that of a normal thymus in situ. In addition, grafting of such a thymus results in a significant increase of the peripheral T cell number. Irradiation of the graft prior to transplantation has no effects on the stromal and T cell composition but the graft size decreases. This reduction of size shows a linear dose-response curve after neutron irradiation. The X-ray curve is linear for doses in excess of 6.00 Gy. The RBE for fission neutrons for the reduction of the relative thymic graft size to 10% was equal to 2.1. Furthermore, the peripheral T cell number decreases with increasing doses of irradiation given to the graft prior to transplantation. The present data indicate that the regenerative potential of thymic stromal cells is radiosensitive and is characterized by D0 values equal to 2.45 and 3.68 Gy for neutrons and X rays, respectively. In contrast, the ability of the thymic stromal cells to support T cell maturation is highly radioresistant.

The effect of graded doses of fission neutrons or X rays on the lymphoid compartment of the thymus in mice.

Young adult CBA/H mice were exposed to graded doses of whole-body irradiation with either fast fission neutrons or 300 kVp X rays at center-line dose rates of 0.1 and 0.3 Gy/min, respectively. Dose-response curves were determined at Days 2 and 5 after irradiation for the total thymic cell survival and for the survival of thymocytes defined by monoclonal anti-Thy-1, -Lyt-1, -Lyt-2, and -T-200 antibodies as measured by flow cytofluorometric analysis. Cell dose-response curves of thymocytes show, 2 days after irradiation, a two-component curve with a radiosensitive part and a part refractory to irradiation. The radiosensitive part of the dose survival curve of the Lyt-2+ cells, i.e., mainly cortical cells, has a D0 value of about 0.26 and 0.60 Gy for neutrons and X rays, respectively, whereas that of the other cell types has corresponding D0 values of about 0.30 and 0.70 Gy. The radiorefractory part of the dose-response curves cannot be detected beyond 5 days after irradiation. At that time, the Lyt-2+ cells are again most radiosensitive with a D0 value of 0.37 and 0.99 Gy for neutrons and X rays, respectively. The other measured cell types have corresponding D0 values of about 0.47 Gy. The fission neutron RBE values for the reduction in the thymocyte populations defined by either monoclonal anti-Thy-1, -Lyt-1, -Lyt-2, or -T-200 antibodies to 1.0% vary from 2.6 to 2.8. Furthermore, the estimated D0 values of the Thy-1-, T-200- intrathymic precursor cells which repopulate the thymus during the bone marrow independent phase of the biphasic thymus regeneration after whole-body irradiation are 0.64-0.79 Gy for fission neutrons and 1.32-1.55 Gy for X rays.

Short- and long-term effects of whole-body irradiation with fission neutrons or X rays on the thymus in CBA mice.

Young adult (6 weeks old) female CBA mice were exposed to whole-body irradiation with either 2.5-Gy fast fission neutrons of 1 MeV mean energy or 6.0-Gy 300 kVp X rays at centerline dose rates of 0.1 and 0.3 Gy/min, respectively. The weight of spleen and animal and the weight, cellularity, and histological structure of the thymus were studied at different times after irradiation. Thymic recovery after whole-body irradiation showed a biphasic pattern with minima at 5 and 21 days after irradiation and peaks of regeneration at Days 14 and 42 after X irradiation or at Days 14 and 70 after neutron irradiation. After the second phase of recovery, a marked decrease in relative thymus weight and cellularity was observed, which lasted up to at least 250 days after irradiation. Splenic recovery showed a monophasic pattern with an overshoot on Day 21 after irradiation. After neutron irradiation a late decrease in relative spleen and animal weight was observed. The observed late effects on thymus and spleen weight and thymus cellularity are discussed in terms of a persistent defect in the bone marrow.