The primary immune response in mice. I. The enhancement and suppression of hemolysin production by a bacterial endotoxin.

The manner in which a single injection of S. typhosa endotoxin effects the primary hemolysin response to sheep erythrocytes in the mouse has been shown to depend on the dosage, route, and time of administration of the endotoxin, as well as on the route employed for the injection of antigen. The normal production of antibody, following an intravenous or an intraperitoneal injection of red blood cells, is suppressed if the bacterial lipopolysaccharide is given before and by the same route as the antigen. The response to an intraperitoneal injection of sheep red cells is also inhibited if preceded by an intravenous injection of endotoxin. By contrast, hemolysin formation to intravenous antigen is enhanced considerably by a previous intraperitoneal injection of endotoxin, and the response both to intravenous and to intraperitoneal injections of the antigen increases if the endotoxin is given by the same route either simultaneously or shortly after the foreign red cells. These findings are discussed in regard to the physiological action of bacterial endotoxins and the early events in antibody formation.

The primary immune response in mice. II. Cellular responses of lymphoid tissue accompanying the enhancement or complete suppression of antibody formation by a bacterial endotoxin.

The effects of a single injection of a bacterial endotoxin on the cellular changes of a primary immune response to a standard dose of sheep red blood cells were studied in the spleens and mesenteric lymph nodes of mice. Daily histological comparisons of these organs in mice, injected with endotoxin, or with antigen, or both, showed that endotoxin given simultaneously with sheep red blood cells, as antigen, significantly enhanced all of the cellular changes that appear in the mesenteric lymph nodes and spleens of mice that form antibody when that antigen is given alone. First, in the white pulp of the spleens and cortical regions of the nodes, there appeared an early and excessive proliferation of the large pyroninophilic cells which seems to be responsible for the earliest formation of antibody, as judged by this work and that of others cited in the body of the paper. Polymorphonuclear cells invaded the spleens of these animals early after simultaneous challenge with antigen and endotoxin, and in far greater numbers than have ever been seen in mice given the same antigen without endotoxin. "Activated" germinal centers formed in the lymphoid tissue either 1 day before the appearance of antibody in the blood stream or on the same day, and they became larger than in the mice given antigen only. On the other hand, these specific and characteristic cellular changes failed to appear in mice prevented from forming any antibody at all by injections of endotoxin given 2 days before the antigenic challenge. These findings are discussed in the light provided by data from recent reports of others as well as in the light of the accompanying paper (1) which demonstrated not only the enhancement of antibody formation following simultaneous injections of antigen and endotoxin, as already known, but a totally unexpected, complete suppression of its formation when endotoxin was given 2 days before antigen.

Cellular requirements for the primary in vitro antibody response to DNP-ficoll.

The cellular requirements for the primary in vitro IgM and IgG response to dinitrophenyl-substituted Ficoll were examined. Neither thymus-derived lymphocytes nor macrophage-rich splenic adherent cells were required for anti-DNP antibody synthesis. DNP-Ficoll is therefore tentatively classified as a "thymic-independent" antigen.

Hapten-specific delayed hypersensitivity to epsilon-2,4-dinitrophenyl-L-lysine-Ficoll in guinea pigs immunized with 2,4-dinitrophenyl-keyhole limpet hemocyanin.

After active immunization with 2,4-dinitrophenyl-keyhole limpet hemocyanin (DNP-KLH), 2,4-dinitropheynl-L-lysine (DNPL)-Ficoll may elicit indurated, erythematous skin reactions lasting 24-72 h. Histological sections of these reactions, examined by microscope techniques, showed they contained polymorphonuclear leukocytes and perivascularly situated lymphocytes and macrophages, but had very few basophils. Consequently, the reaction was interpreted as having an immediate component and a component typical of delayed hypersensitivity; this indicated that the delayed reaction could be specific for the DNP hapten. Although this delayed type of skin reaction was not transferred to recipients with anti-DNP-KLH serum, one pool of that serum did sensitize guinea pigs so that they could respond with a different skin reaction after challenge with DNPL-Ficoll. This reaction was soft, pale pink, and lasted for 24 h. Histologically, it contained only a few polymorphonuclear leukocytes. It differed from the delayed reaction in actively immunized animals in that it lacked induration, and was devoid of lymphocytes and macrophages.

Vitamin D deficiency is associated with tuberculosis disease in British children.

BACKGROUND: Basic science, epidemiological and interventional research supports a link between vitamin D and tuberculosis (TB) immunity, infection and disease. We evaluated the association between vitamin D levels and TB infection and disease in UK children recruited to the National Institute for Health Research IGRA Kids Study (NIKS).METHODS: Children presenting between 2011 and 2014 were eligible if they had history of exposure to an adult case with sputum smear/culture-positive TB, or were referred and diagnosed with TB disease. Children were assessed at baseline and at 6-8 weeks for immunological evidence of TB infection (interferon-gamma release assay and/or tuberculin skin test) and evidence of TB disease. Some centres routinely measured total 25-hydroxy vitamin D (25-OHD) levels.RESULTS: A total of 166 children were included. The median 25-OHD levels were higher in non-infected children (45.5 nmol/l) than in those with tuberculous infection (36.2 nmol/l) and TB disease (20.0 nmol/l). The difference between TB infection and disease was statistically significant (P < 0.001). By logistic regression, lower vitamin D levels were associated with TB disease among participants with infection or disease, with no evidence of confounding by age, sex, bacille Calmette-Guérin vaccination status, ethnicity, non-contact referral, season or centre.CONCLUSION: Children with TB disease had lower vitamin D levels than children with infection. Implications for prevention and treatment remain to be established.

Native and recombinant human hepatocyte growth factors are highly potent promoters of DNA synthesis in both human and rat hepatocytes.

Human hepatocyte growth factor (hHGF) has recently been expressed as a recombinant polypeptide from Chinese hampster ovary cell transfectants. Using a primary rat hepatocyte bioassay, we have tested the biological activity of recombinant hHGF and compared it with native hHGF. Dose-response curves were almost identical, with half-maximal stimulation of DNA synthesis at 1-2 ng/ml (equivalent to approximately 10 pM). S-phase labeling index was similarly enhanced and numerous mitotic cells were observed. Recombinant and native hHGF also stimulated DNA synthesis and S-phase labeling index in primary adult human hepatocytes. Human cells were more responsive than rat hepatocytes, with recombinant hHGF slightly more potent than native hHGF (half-maximal stimulation 0.3 and 0.6 ng/ml, respectively). Since HGF levels rise in patients with fulminant hepatic failure and in animals after partial hepatectomy or administration of hepatotoxins, situations where liver regeneration occurs, HGF is suggested to play a key role in regulation of hepatic growth. The high potency of the factor on human hepatocytes reinforces its candidacy as a critical mitogen in human liver growth. The availability of a recombinant hHGF opens the way for in vivo experimental studies and to the possibility of using hHGF as a clinical therapeutic agent, either alone or in combination with other factors.

Equitable tuberculosis care in the North West of England: analysis of tuberculosis cohort review data.

BACKGROUND: In the United Kingdom, tuberculosis (TB) predominantly affects the most deprived populations, yet the extent to which deprivation affects TB care outcomes is unknown. METHODS: Since 2011, the North West TB Cohort Audit collaboration has undertaken quarterly reviews of outcomes against consensus-defined care standard indicators for all individuals notified with TB. We investigated associations between adverse TB care outcomes and Index of Multiple Deprivation (IMD) 2010 scores measured at lower super output area of residence using logistic regression models. RESULTS: Of 1831 individuals notified with TB between 2011 and 2014, 62% (1131/1831) came from the most deprived national quintile areas. In single variable analysis, greater deprivation was significantly associated with increased likelihood of the completion of a standardised risk assessment (OR 2.99, 95%CI 5.27-19.65) and offer of a human immunodeficiency virus test (OR 1.72, 95%CI 1.10-2.62). In multivariable analysis, there were no significant associations. CONCLUSIONS: TB patients in the most deprived areas had similar care indicators across a range of standards to those of individuals living in the more affluent areas, suggesting that the delivery of TB care in the North West of England is equitable. The extent to which the cohort review process contributes to, and sustains, this standard of care deserves further study.

Metabolic effects of cyclosporin A and FK 506 in liver transplant recipients.

Postoperative diabetes is a reported feature of the immunosuppressive agents cyclosporin A and FK 506. To date, however, no randomized comparative studies of the metabolic effects of these two drugs have been performed. In this study, extended (300 min) oral glucose tolerance tests (75 g) were performed a median of 8 mo (range 5-9 mo) postoperatively in 20 clinically stable liver transplant recipients randomly allocated to maintenance immunosuppression with either cyclosporin A (with or without azathioprine) or FK 506. None of the patients had clinically overt diabetes antedating transplantation. To avoid the confounding effects of corticosteroids, prednisolone was withdrawn at least 6 wk beforehand in each case. Ten healthy volunteers matched for age and body mass index served as control subjects. Overall blood glucose concentrations after the glucose challenge were significantly elevated in both groups of transplant recipients (P < 0.005 and P < 0.001 for cyclosporin A and FK 506 treatment groups, respectively) compared with the healthy control subjects. Venous whole-blood glucose concentration (mean +/- SE) 120 min after the ingestion of oral glucose was significantly higher in both the cyclosporin A (P < 0.05) and FK 506 (P < 0.01) treatment groups compared with the control subjects (6.6 +/- 0.5 vs. 8.8 +/- 0.9 vs. 5.2 +/- 0.2 mM, respectively). According to 1985 WHO criteria, 4 of 10 cyclosporin A-treated patients had impaired glucose tolerance, whereas 3 of 10 FK 506-treated patients had diabetes with 4 others having impaired glucose tolerance.(ABSTRACT TRUNCATED AT 250 WORDS)

Left ventricular dysfunction after acute myocardial infarction: results of a prospective multicenter study.

In a multicenter prospective study of 866 patients who survived the coronary care unit phase of an acute myocardial infarction, variables reflecting left ventricular function were examined to assess their impact on 2 year survival. Single variables that reflected left ventricular dysfunction before infarction and in the acute and recovery phases were, respectively, history of prior myocardial infarction, rales in the coronary care unit dichotomized at greater than bibasilar and predischarge radionuclide ejection fraction dichotomized at less than 0.40. When combined in a stepwise fashion, patients lacking these three risk characteristics had a 2 year 4.2% mortality rate, whereas patients possessing all three characteristics had a 45% mortality rate. Rales in the coronary care unit and predischarge ejection fraction act independently, and each contributes to mortality. Fifty-two patients with advanced rales but an ejection fraction of 0.40 or greater had a 21% mortality rate. Similarly, 208 patients with few rales but an ejection fraction of less than 0.40 had a 15% mortality rate. These data suggest that the mortality risk imposed by those factors that assess permanent left ventricular damage is independent of and additive to the mortality risk contributed by dynamic, acute phase dysfunction. These data fit the hypothesis that acute phase dysfunction is, in part, due to transient ischemia that, on reversal, can restore function toward normal. The results suggest 1) that assessment of left ventricular function during the acute and recovery phases of myocardial infarction is necessary to define prognostic characteristics of an individual patient, and 2) that of particular importance is the identification of patients whose postinfarction course is consistent with reversible ischemia.

Nonfatal cardiac events and recurrent infarction in the year after acute myocardial infarction.

The occurrence and importance of nonfatal cardiac events in the year after an acute myocardial infarction were studied in 866 patients who were enrolled by nine hospitals with a broad geographic distribution. The extensive clinical data acquired on each patient included special tests, such as radionuclide-determined ejection fraction, 24 hour ambulatory electrocardiogram and a low level exercise tolerance test. Recurrent events were frequent in the first 5 months, and certain events were significant indicators of a poor prognosis. An ejection fraction less than 40% and angina after discharge from the coronary care unit predicted patients at high risk of rehospitalization. Recurrent infarction was similarly predicted by angina, but not by any features of an exercise test. This study demonstrates the considerable morbidity that occurs after an acute myocardial infarction and its relation to and role in subsequent mortality.

Surgical treatment of metastases to the pancreas.

BACKGROUND AND AIMS: Metastases to the pancreas are rare and their surgical treatment is not well reported. We present a considerable experience from a single centre analysing various prognostic factors. METHODS: Data were collected on 13 cases who underwent surgery between 1988 and 2002. Since 1997, data have been recorded prospectively on a dedicated database. Clinical and histopathological factors were reviewed. RESULTS: There were two women and 11 men with a median age of 62 years (range 40-73). There were seven cases of renal cell carcinomas, three colorectal carcinomas, two sarcomas and one lung carcinoma. A prolonged disease-free interval from primary surgery was characteristic for renal cell carcinoma cases (median = 10.8 years). The operative procedures performed included seven pancreatoduodenectomies, four total and two distal pancreatectomies. The operative mortality and morbidity was 7.7% and 46.1% respectively. The overall one- and two-year survival was 78.8% and 54% respectively. Median survival for renal cell carcinoma was 30.5 months and for non-renal cell carcinoma was 26.4 months (p = 0.76). CONCLUSIONS: Pancreatectomy should be considered for metastases to the pancreas in the absence of generalised metastatic disease. However, decision making and experience should be concentrated in centres with significant familiarity of this approach.

New antiarrhythmic agents. 2. Amide alkyl alpha-amino xylidides.

The synthesis of a series of N-alkyl 2-amino 2',6'-xylidides is described. The method involved coupling of the N-alkyl-2',6'-xylidine with the appropriate 2-haloacyl halide, followed by ammonolysis. Alternatively, alkylation of the 2-phthalimido 2',6'-xylidide with NaH and the alkyl halide followed by hydrazinolysis was used. All compounds were evaluated for their ability to protect mice against chloroform-induced ventricular fibrillation. The compounds were generally more potent antifibrillatory agents than the corresponding secondary amides. All were more potent than tocainide and several showed less CNS toxicity. Five compounds were further evaluated in dogs with ventricular arrhythmias resulting from myocardial infarction. N-Ethyl-2-aminoaceto-4'-propoxy-2',6'-xylidide was as potent as lidocaine and produced less CNS toxicity.

New antiarrhythmic agents. 5. alpha-Aminoaceto-2,6-xylidides with functionalized amide alkyl substituents.

The synthesis of aminoaceto-2',6'-xylidides substituted on the amide nitrogen with 2-(diethylamino)ethyl, 2-aminoethyl, 2-hydroxyethyl, and 2-ethoxyethyl groups is described. The 2-aminoethyl derivatives were prepared by treatment of N-(2-phthalimidoethyl)-2',6'-xylidine with chloroacetyl chloride, followed by treatment with either potassium phthalmide or diethylamine. Hydrazinolysis of the phthalimides liberated the free amines. The remaining target compounds were produced by alkylation of lidocaine or of 2-phthalimidoaceto-2',6'-xylidide with the appropriate halide and sodium hydride, followed by hydrazinolysis where necessary. All target compounds were evaluated for antiarrhythmic efficacy against chloroform-induced ventricular tachycardia, as well as for acute CNS toxicity in mice. Most of the target compounds were more potent than the corresponding secondary amides and had improved therapeutic margins toward CNS toxicity. The diamines N-(2-aminoethyl)-2-aminoaceto-2',6'-xylidide (13) and N-(2-aminoethyl)--2-(diethylamino)aceto-2',6'-xylidide (29) are especially promising in this respect. Several compounds were tested as spinal anesthetics.

New antiarrhythmic agents. 6. Quantitative structure-activity relationships of aminoxylidides.

The synthesis and pharmacological evaluation of primary and tertiary aminoxylidides with the amino group in the 2-7 position of the acyl chain are described. 2,6-Xylidine was acylated with haloacyl halides and converted to the target compounds by direct amination or by the Gabriel procedure. Alternatively, 2,6-xylidine was coupled with keto acids, and the ketoxylidides were converted to the amines by reductive amination. The target compounds were evaluated in mice both for antiarrhythmic efficacy against chloroform-induced tachycardia and for central nervous system toxicity. Experimentally determined values of partition coefficients and pKa values were used for quantitative structure-activity analyses. While the antiarrhythmic activity could be described as a function of log P alone, the CNS toxicity was best described as a function of both log P and pKa. The results suggest that antiarrhythmic potency can be increased by increasing lipophilicity, while the therapeutic index can be improved by increasing the pKa.

New antiarrhythmic agents. 3. Primary beta-amino anilides.

The synthesis and pharmacologic evaluation of primary beta-amino anilides, as well as comparisons with tocainide, lidocaine, and its beta homologue, are described. Substituted anilines were acylated with 3-bromoacyl chlorides and converted to the title compounds by direct amination or via 3-phthalimido anilides and subsequent hydrazinolysis. Alternatively, anilines were acylated with substituted acryloyl chlorides and the amines prepared by addition of ammonia to the double bond. The target compounds were evaluated for their ability to protect against chloroform-induced fibrillation in mice. All were found to have some antifibrillatory activity; several were more potent than tocainide, a compound in clinical trials as an oral antiarrhythmic drug. Four compounds were tested for their effects against ventricular arrhythmias in dogs with myocardial infarction. 3-Amino-2',6'-butyroxylidide (38) was found to be more potent and less CNS toxic than tocainide.

New antiarrhythmic agents. 4. 1'-(Aminoalkyl)-1,2,3,4-tetrahydronaphthalene-1-spiro-3'-pyrrolidine-2',5'-dione derivatives.

A series of 33 1'-(Aminoalkyl)-1,2,3,4-tetrahydronaphthalene-1-spiro-3'-pyrrolidine-2',5'-dione derivatives was tested for antiarrhythmic and toxic effects in mice and dogs. In mice, 31 compounds produced some protection against chloroform-induced tachyarrhythmias at subcutaneous doses of 100 mg/kg, and 6 compounds produced no detectable toxicity at doses protecting 80% or more of the animals. Seven of the more potent and nontoxic derivatives were tested in dogs with surgically induced myocardial infarctions. All produced distinct antiarrhythmic effects at doses considerably lower than doses of lidocaine or tocainide producing comparable effects. The principal toxic effects observed in dogs were convulsion and depression of intracardiac conduction; they occurred generally at higher doses than those leading to antiarrhythmic effect. Several compounds also suppressed digitalis-induced arrhythmias in anesthetized dogs. Half-lives and total body clearance in dogs were determined for three compounds; two had half-lives comparable to that of tocainide, a long-acting, orally active antiarrhythmic agent, in clinical trials.

New antiarrhythmic agents. 1. Primary alpha-amino anilides.

Thirty-two alpha-amino anilides with various substituents in the aromatic ring and in the alpha position are described. Their abilities to protect mice against chloroform-induced fibrillation and to elicit toxicity were determined. Substitution of an alkyl or aryl group in the alpha position enhanced the antifibrillatory activity. In most cases, increased potency was accompanied by increased toxicity. Eleven compounds were tested in dogs with surgically induced myocardial infarction; most showed antiarrhythmic activity. 2-Aminopropiono-2',6'-xylidide, tocainide, was chosen for clinical investigation.

Indocyanine green clearance in acute rejection after liver transplantation.

Previous animals studies have demonstrated a fall in liver blood flow associated with acute rejection after liver transplantation. To study the relationship between rejection and liver blood flow in humans after liver transplantation indocyanine green (ICG) clearance was measured serially in 7 patients with clinical and histological features of acute rejection. There was a consistent pattern of satisfactory initial ICG clearance that fell in association with acute rejection and rose with successful treatment of the episode of rejection. In one patient there was no improvement in ICG clearance after treatment with additional immunosuppression, and she subsequently required retransplantation for chronic rejection. The volume of distribution of ICG was also estimated and fell considerably during the first weeks after transplantation. These results show that rejection is associated with a reduction in ICG clearance that may be due to a fall in liver blood flow, and that graft ischemia and rejection may therefore be interrelated, and important in one another's etiology.

Technique of organ removal and fate of kidney grafts from liver donors.

The fate of 42 kidney grafts taken from heart-beating, ventilated donors at the same time as removal of the liver for allografting is reported, and is compared with 50 kidney grafts taken from heart-beating, ventilated donors whose ventilators were electively switched off either during or immediately before kidney removal. The fate of 32 kidney grafts taken from donors classified as "dead on arrival" at the admitting hospital is also reported. Onset of life-supporting graft function was significantly earlier among kidneys from the "liver donor" group. Consequently, immediate postoperative dialysis requirements were significantly less in recipients of this group of kidneys. Early graft survival, the incidence of graft primary nonfunction, failure of first and second kidney grafts, and recipient survival were not significantly different when comparing liver donor and "ventilator switch off" kidneys. No constant relationship was apparent in any donor group between graft fate and the anoxic and ischaemic times the graft was exposed to during organ removal and reimplantation.

Enisoprost in liver transplantation.

Previous human studies in renal transplant recipients have shown a lower incidence of acute rejection and cyclosporine-associated acute nephrotoxicity when prostaglandins are administered in conjunction with standard immunosuppressants. This study evaluates the effects of enisoprost (EP), a synthetic PGE methyl ester analog, in a single-center, prospective, randomized, double-blind, placebo-controlled, parallel group trial in 81 consecutive adult patients undergoing orthotopic liver transplantation (OLT). The subjects received EP 100 mg p.o. t.i.d. (n = 40) or placebo (n = 41) for the first 12 weeks after OLT. Immunosuppression was based on cyclosporine, azathioprine, and corticosteroids. Effective renal plasma flow and glomerular filtration rate were determined at 4 and 12 weeks after OLT. Eighty-one patients entered the study; sixty-six patients completed the 16-week study period. There were no statistically significant differences between EP- and placebo-treated groups at 12 weeks for creatinine clearance, glomerular filtration rate, and effective renal plasma flow. At least 1 episode of cyclosporine nephrotoxicity occurred in 7/40 patients (17.5%) in the EP group compared with 9/41 patients (20.0%) in the placebo group (P = 0.781). There was no significant difference in the incidence of graft rejection episodes in the 2 groups. Enisoprost, as used in this study, does not have any beneficial effect on renal function or incidence of rejection in OLT recipients.