Identification of GP2, the major zymogen granule membrane glycoprotein, as the autoantigen of pancreatic antibodies in Crohn's disease.

BACKGROUND AND AIMS: The aetiopathogenesis of Crohn's disease, an inflammatory bowel disease (IBD), is not yet fully understood. Autoimmune mechanisms are thought to play a role in the development of Crohn's disease, but the target antigens and the underlying pathways have not been sufficiently identified. METHODS: Based on data from immunoblotting and matrix-assisted laser desorption ionisation time-of-flight (MALDI-TOF) mass spectrometry, the major antigenic target of pancreatic autoantibodies (PABs), which are specific for Crohn's disease, was identified. Specificity of autoantibody reactivity was confirmed by enzyme-linked immunosorbent assay (ELISA) and indirect immunofluorescence (IIF) using purified rat and human recombinant GP2 synthesised in transiently transfected mammalian HEK 293 cells. Real-time polymerase chain reaction (rt-PCR) and IIF were used to detect mRNA and antigen localisation in human colon biopsies. RESULTS: The major zymogen granule membrane glycoprotein 2 (GP2) was identified as the autoantigen of PABs in Crohn's disease. PAB-positive sera from patients with Crohn's disease (n = 42) displayed significantly higher IgG reactivity to rat GP2 in ELISA than either PAB-negative sera (n = 31), or sera from patients with ulcerative colitis (n = 49), or sera from blood donors (n = 69) (p<0.0001, respectively). Twenty-eight (66%) and 18 (43%) of 42 PAB-positive sera demonstrated IgG and IgA reactivity to human recombinant GP2 in IIF, respectively. Patients with PAB-negative Crohn's disease (n = 31) were not reactive. GP2 mRNA transcription was significantly higher in colon biopsies from patients with Crohn's disease (n = 4) compared to patients with ulcerative colitis (n = 4) (p = 0.0286). Immunochemical staining confirmed GP2 expression in human colon biopsies from patients with Crohn's disease. CONCLUSION: Anti-GP2 autoantibodies constitute novel Crohn's disease-specific markers, the quantification of which could significantly improve the serological diagnosis of IBD. The expression of GP2 in human enterocytes suggests an important role for anti-GP2 response in the pathogenesis of Crohn's disease.

A novel epitope on the C-terminus of SmD1 is recognized by the majority of sera from patients with systemic lupus erythematosus.

The SmD1 protein is a specific target for the autoantibody response in SLE. To further analyze this reactivity epitope, mapping was performed with cellulose-bound 13-mer peptides overlapping 10 amino acids (aa). In this initial approach, 4 out of 15 SLE sera recognized more than five overlapping peptides of the SmD1 C-terminus. Therefore, longer oligopeptides of up to 37 aa of this region were generated and probed for as antigens by ELISA. For the SmD1 aa 83-119 polypeptide, there was a striking increase of reactivity with 70.0% positive reactions out of 167 SLE sera. In contrast, 105 healthy control sera were negative, and only 8.3% of sera from patients with other inflammatory diseases (n = 267) exhibited a response, which was of low level only. The anti-SmD183-119 reactivity was significantly higher in anti-dsDNA antibody positive vs. negative sera (P < 0.001) and correlated with disease activity. Four of five human monoclonal anti-dsDNA antibodies also reacted with SmD183-119. The specificity for SmD1 was demonstrated by inhibition experiments and immunization of rabbits with SmD183-119 inducing SmD1-specific antibodies. In conclusion, the SmD183-119 peptide was demonstrated to be an important and highly specific target of the autoimmune response in SLE. The high sensitivity of this ELISA probably depends on a conformational epitope, which appears not to be accessible in the full-size SmD1 protein.

Conformation and stability of recombinant HIV-1 capsid protein p24 (rp24).

Conformation and stability of the recombinant protein HIV-1 rp24 were analyzed by circular dichroism, fluorescence spectroscopy and differential scanning calorimetry under different solvent conditions. From circular dichroism measurements, HIV-1 rp24 at pH 5.8 can be classified as an all alpha-helical protein. A fluorescence maximum of about 330 nm indicates a predominantly hydrophobic environment of the five tryptophan residues. The GdnHCl-induced unfolding curves monitored by CD and fluorescence are sigmoidal and single phasic and the midpoints of transitions are independent on the protein concentration. For the calculation of free energy of unfolding delta GuH2O a 'two-state' model was applied. The calculated values are between 18 and 24 kJ/mol and thus on the lower limit of the conformational stability of globular proteins. Melting experiments at pH 5.8 are impaired by a strong irreversible aggregation at higher temperatures. However, at pH 3.0 and in the presence of 0.1% (w/v) ocytl beta-glucopyranoside the melting curves show a large degree of reversibility with a Tm value of 38 degrees C and a molar enthalpy change delta Hm of 218 kJ/mol. At pH < 2.5 HIV-1 rp24 can adopt a new conformation which is characterized by a high alpha-helical content, a strongly decreased CD in the aromatic region, a red-shift of the fluorescence spectrum and a strong binding of ANS. These spectral features of the acid-induced conformational state are similar to those obtained for molten globule-like folding states. HIV-1 rp24 unfolds cooperatively at pH 2.0 in the concentration range of about 1.5-3.0 M GdnHCl. The calculated values delta GuH2O at pH 2.0 of about 12 kJ/mol are significantly decreased in comparison to the delta GuH2O values of the protein at pH 5.8.

Conformation, pH-induced conformational changes, and thermal unfolding of anti-p24 (HIV-1) monoclonal antibody CB4-1 and its Fab and Fc fragments.

Conformation, acid-induced conformational changes and stability of the murine monoclonal antibody CB4-1 directed against the human immunodeficiency virus type 1 capsid protein p24, and its Fab and Fc fragments, were analysed by circular dichroism (CD), fluorescence, and differential scanning calorimetry (DSC) measurements. CD spectra show the characteristics expected for beta-proteins. Lowering the pH to 3.5 reduces the stability, but does not change the conformation. Between pH 3.5 and 2.0 conformational changes and the formation of new structures are indicated. Deconvolution of the bimodal DSC curves of CB4-1 reveals five 'two-state' transitions at pH 7.5. At pH 5 and below, only four transitions are found. Half transition temperatures Tm and molar enthalpy changes DeltaHm gradually decrease at pH 4 and 3.4. At pH 2.1, two low-temperature (Tm=36.9 and 44.1 degrees C) and two high-temperature (Tm=74.6 and 76.8 degrees C) transitions are identified. The Fab and Fc fragments behave similarly. Deconvolution of their monophasic DSC curves yields two 'two-state' transitions for each fragment. Tm and DeltaHm values gradually decrease at pH 4.0 and 3.4; and at pH 2.1 and 2.8 for Fab and Fc, respectively, one of the transitions is found at high temperature (Tm=67.2 and 75.9 degrees C for Fab and Fc, respectively).

Oxidation of a methionine residue in subtilisin-type proteinases by the hydrogen peroxide/borate system--an active site-directed reaction.

Subtilisin-type proteinases (thermitase, subtilisin Carlsberg, alkaline proteinase ZIMET 10911, proteinase K) are partially inactivated by hydrogen peroxide in the alkaline pH range only in the presence of boric acid or phenylboronic acid. A model is presented to describe the inactivation mechanism. Both boric acid and perboric acid existing in equilibrium in the presence of hydrogen peroxide bind competitively at the active site of the enzyme. The inactivation, which is known to be caused by sulfoxide formation from the methionine residue in the active site (Stauffer, C.E. and Etson, D. (1969) J. Biol. Chem. 244, 5333-5338), is due to the enzyme-bound perboric acid species. The dissociation constants for the boric acid-thermitase and perboric acid-thermitase complexes are 36 +/- 7 and 4 +/- 1 mM, respectively. The first-order rate constant of inactivation is k = 0.63 +/- 0.14 min-1. The same mechanism of inactivation holds true for phenylboronic acid in alkaline hydrogen peroxide solutions.

Coronary artery stenosis after radiofrequency catheter ablation of accessory atrioventricular pathways in children with Ebstein's malformation.

BACKGROUND: Complications concerning the coronary arteries that are directly related to radiofrequency catheter ablation procedures have not been reported in children. Coronary artery lesions, however, have been demonstrated after the endocardial application of radiofrequency current in young animals. METHODS AND RESULTS: Two boys with Ebstein's anomaly of the tricuspid valve developed clinically asymptomatic coronary artery stenosis after radiofrequency catheter ablation of right-sided accessory atrioventricular pathways with standard catheter technology. CONCLUSIONS: The complication of coronary artery stenosis demonstrates a substantial risk after right atrial free wall radiofrequency current application in children. The risk of late coronary alterations should be considered when the use of catheter ablation procedures to young patients is proposed.

Structural base of the interaction of a monoclonal antibody against p24 of HIV-1 with its peptide epitope.

The interaction of a murine monoclonal antibody (CB 4-1) against the core protein p24 of HIV-1 with its peptide antigen was studied in detail. The amino acid sequence of the variable regions of the heavy and light chain as derived from DNA sequencing was used to model the structure of the antigen binding region on the basis of reported Fab structures from the Brookhaven Protein Data Base. A linear peptide epitope responsible for the p24 binding to the antibody was determined by peptide scan. Subsequent N- and C-terminal truncation of the corresponding sequence region as well as amino acid substitutions were performed to recognize the epitope and the amino acid residues critical for antibody binding. These data were used to derive a structural model of the peptide-antibody interaction.

Binding kinetics of an antibody against HIV p24 core protein measured with real-time biomolecular interaction analysis suggest a slow conformational change in antigen p24.

The interaction between HIV core protein p24 and the murine monoclonal antibody CB-4/1 or its Fab fragment showed unusual kinetics. Recombinant p24 was immobilised in a hydrophilic carboxymethyldextran matrix. At high concentration of CB-4/1 Fab the association of the antigen-antibody complex proceeds in two phases, while dissociation is mono-exponential. The antigen has a 'memory', i.e. shortly after dissociation of Fab-antigen complex the fast association phase is enhanced. Biphasic association was also found in solution. Experiments suggest a reversible change of binding properties in the epitope region with an overall time constant of about 100 s at room temperature. Intermediate steps with faster time constants must be involved. Slow conformational changes of p24 seem to be the most probable explanation. A simple model that provides a quantitative description of this process could not be found. Real-time analysis of antibody binding by surface plasmon resonance is a powerful method for studying such changes in the time domain of a few seconds to a few minutes.

Tomographic myocardial perfusion scintigraphy in children with Kawasaki disease.

Myocardial infarction and stenotic coronary lesions are serious late complications in children with Kawasaki disease. For the noninvasive assessment of myocardial perfusion, dipyridamole-redistribution 201Tl emission computed tomography (ECT) was performed in seven children (age 2 8/12-8 7/12 yr) 3-20 mo after the acute stage of the disease. In all patients, coronary aneurysms had been demonstrated by cross-sectional echocardiography. The scintigrams of six children showed no significant regional reduction of myocardial thallium uptake. These children had remained asymptomatic since the acute stage of Kawasaki disease. Persistent and transient thallium defects were present in one child with documented myocardial infarction. For this patient, obstruction of corresponding coronary vessels was confirmed by contrast angiography. It is suggested, that 201Tl ECT after dipyridamole-induced vasodilation may be used as a safe alternative to invasive coronary angiography for follow-up investigations in patients with Kawasaki disease.

Coronary angioplasty for coronary stenosis after the arterial switch procedure.

Coronary balloon angioplasty seems to be an adequate therapy for proximal coronary stenoses developing after the arterial switch operation, with adequate medium-term results. Overexpansion of the lesion seems to be necessary.

Transcatheter closure of atrial septal defect with a new flexible, self-centering device (the STARFlex Occluder).

The purpose of this study was to evaluate the short-term safety and efficacy of the STARFlex Occluder for transcatheter closure of atrial septal defects with difficult anatomy. Transcatheter closure of the defect was attempted and successfully performed in 5 patients; the "stretched" defect diameter ranged from 12 to 24 mm and the implanted devices ranged from 23 to 33 mm.

Percutaneous transluminal angioplasty for the treatment of complete arterial occlusion after retrograde cardiac catheterization in infancy.

Nine patients with arterial thrombosis were treated with transcatheter recanalization and subsequent balloon dilation of the occluded vessel. Repeat angiography or duplex sonography 3 to 14 months after intervention showed completely patent arteries without restenosis in 7 patients; there was residual narrowing of the vessel in the remaining 2 patients.

Transcatheter closure of atrial septal defect and patent foramen ovale with ASDOS device (a multi-institutional European trial).

A clinical trial was conducted to assess the feasibility, safety, and efficacy of the atrial septal defect (ASD) occlusion system for transcatheter closure of secundum ASD and patent foramen ovale (PFO) after episodes of cerebral embolism. Occlusion was attempted in 200 patients aged 1 to 74 years (mean 32). The procedure failed in 26 patients (13%); the device was retrieved through a catheter in 20 and through surgery in 6 patients. Procedure-related complications necessitating surgical removal of the device included device embolization in 2, device entrapment within the Chiari network in 1, frame fracture in 1, and perforation of atrial wall in 2. All 6 patients experienced an uneventful postoperative course. An additional 11 patients (6%) underwent surgical removal of the device during follow-up. There were 163 patients (81%) with an implanted ASD occlusion system at follow-up of from 6 to 36 months (mean 17). Thrombus formation around the device was detected by transesophageal echocardiography in 9 patients 1 to 4 weeks after implantation. One of these patients (who had a coagulation factor XII deficiency) suffered a cerebral thromboembolism. Late atrial wall perforation (5, 6, and 8 months after implantation) occurred in 3 adult patients. Infectious endocarditis developed in 2 adult patients (1%). No late device embolization and no atrioventricular valve injury occurred. An asymptomatic device frame fracture was found in 14% and frame deformity in 4% of all patients during the follow-up period of >230 patient-years. Immediately after closure, a moderate/large residual shunt remained in 8% and a small shunt in 29% of patients. After 1 year, a moderate/large shunt was present in 2% and a small one in 26% of patients. During a total follow-up of 49 patient-years, only 1 of 46 patients with PFO had a transient neurologic event after the closure. The study indicates that patients with centrally situated secundum ASD and those with PFO after cerebral embolism can be treated with this system with a high success rate and an acceptable morbidity.

A recombinant human immunodeficiency virus type-1 capsid protein (rp24): its expression, purification and physico-chemical characterization.

An expression system has been established in Escherichia coli to facilitate the preparation of the HIV-1 capsid protein in amounts sufficient for structural analysis. A plasmid vector pTCA5, containing the gene for the recombinant HIV-1 capsid protein rp24 under the control of the lambda-PR-promoter, was constructed which gave an expression product that spanned 234 amino acid residues. It differs at the N-terminus from the authentic sequence in that the residues Pro-Ile- are replaced by Met-Asn-Ser-Ala-Met-. Recombinant p24 was produced, as inclusion bodies in E. coli LE392 containing pTCA5, at a level of approximately 15% of the total cellular protein. After dissolution of the inclusion bodies in the acidic urea system, the protein was easily reconstituted in a soluble state by dialysis. The yield of reconstituted and purified protein was 12 mg per liter in rich medium. Recombinant rp24 consists of about 40% alpha-helix and 10% beta-sheet from circular dichroism measurements and the two cysteine residues, within the rp24 sequence, are bridged by a disulfide bond.

Extending the limits of transcatheter closure of atrial septal defects with the double umbrella device (CardioSEAL).

OBJECTIVE: To report initial findings from a selected group of patients with morphological variations of the atrial septal defect who underwent transcatheter closure with a second generation redesigned double umbrella device. PATIENTS: Two patients with abnormal location of the oval fossa and partial deficiency of the septal rim, three patients with multiple defects, and two patients with a multiperforated aneurysm of the interatrial septum (age range, 3.6-25.5 years). METHODS: Defects were closed with the double umbrella device (CardioSEAL) consisting of two sets of flexible arms (with central and two mid-arm hinges) covered with sewn Dacron patches. The implantation procedure was monitored by transoesophageal echocardiography. RESULTS: The diameter of the defect measured during transoesophageal echocardiography ranged from 7-18 mm and the balloon stretched diameter ranged from 13-21 mm. The size of the devices varied from 28-33 mm and the ratio of device size to defect size varied from 1.6-2.1. Two devices (23 and 28 mm) were chosen in a patient with two separated defects. No complications or serious arrhythmias were observed during implantation or follow up (median, 1.8 months). Residual shunting was trivial in three patients and mild in one patient (inferiorly located additional defect). CONCLUSIONS: To extend the selection critera of an isolated central interatrial defect for transcatheter closure, some modifications of the implantation technique are needed. Using the redesigned double umbrella device, effective closure in patients with multiple or irregularly shaped atrial septal defects was achieved, indicating a broadening of the spectrum of transcatheter closure.

Surgical preconditioning and completion of total cavopulmonary connection by interventional cardiac catheterisation: a new concept.

A new, staged procedure for univentricular repair of "high risk" patients using a combined surgical transcatheter technique is reported. As first step a surgical hemifontan procedure was performed and a multifenestrated patch inserted into the right atrium. For later transcatheter completion of univentricular repair, a subtotal banding just above the cavoatrial junction was performed. Two months later transcatheter completion was performed by balloon dilatation of the banded cavo-atrial junction and additionally either by inserting a covered stent as intracardiac conduit between the superior and inferior vena cava or by inserting a (non-covered) stent into the cavo-atrial junction and occluding the fenestrations in the right atrial patch using Rashkind-PDA occluders. This new technique was successfully applied without mortality in eight patients with a preoperative mean pulmonary pressure of 18 to 23 mm Hg. No complications typical for Fontan-like corrections occurred within the follow up period of 4 to 14 months.

Sequelae after modified Fontan operation: postoperative haemodynamic data and organ function.

OBJECTIVE: To investigate the specific sequelae of the Fontan operation, and particularly the potential sequelae of chronically elevated systemic venous pressure. DESIGN: A retrospective analysis of clinical and haemodynamic data and evaluation of organ function in 80 surviving patients undergoing modified Fontan operation for various forms of underlying functionally univentricular hearts. PATIENTS: 65 patients (81%) who had undergone a total cavopulmonary anastomosis and 15 an atriopulmonary anastomosis. Follow up ranged from 12 to 106 months (mean 54 (SD 23) months). RESULTS: 62 patients underwent postoperative cardiac catheterisation (mean systemic venous pressure 10.5 (2.5) mm Hg and cardiac index 3.1 (0.7) l/min/m2). Older age at operation was significantly correlated with both higher systemic venous pressure and lower cardiac index. Atrial arrhythmia was documented on Holter electrocardiogram in 17%. Protein losing enteropathy (with abnormal alpha 1-antitrypsin clearance) was found in 2/80 patients (2.5%). Ten patients had hypoproteinaemia, with a significantly higher incidence in patients after total cavopulmonary anastomosis and young age at operation. Liver function tests reflecting liver synthesis and metabolism were normal in all, whereas mild cholestasis was found in nearly 30%-predominantly in patients with a cardiac index of < 3 l/min/m2 (P = 0.045). Five patients (6.2%) developed atrial thrombosis. Coagulation factor analysis in 44 patients showed protein C deficiency in 11 (25%); laboratory signs of activation of the coagulation system were found in four of these (9%). None of the abnormal laboratory indices was significantly related to underlying cardiac malformation, postoperative systemic venous pressure, or follow up interval. CONCLUSIONS: A high proportion of clinically asymptomatic patients had abnormal laboratory findings on mid-term follow up. Detailed evaluation of organ function is necessary to detect the need for further diagnostic procedures before clinical symptoms develop.

Transcatheter closure of secundum atrial septal defects with the atrial septal defect occlusion system (ASDOS): initial experience in children.

OBJECTIVE: To report initial experiences with transcatheter occlusion of atrial septal defects using a new occlusion device. SUBJECTS: 10 children aged 1.1 to 14.9 years. INCLUSION CRITERIA: Patients with a body weight above 10 kg, normal pulmonary resistance and an indication for surgical closure of a secundum atrial septal defect, a residual tissue rim of interatrial septum surrounding the defect of more than 5 mm, and a maximum defect diameter of 20 mm. METHODS: The defects were closed by a transcatheter device (ASDOS) consisting of two umbrellas which are introduced over a guidewire loop. Both umbrellas consist of a central body and five arms formed from preshaped nitinol wire covered with a thin polyurethane patch. The central body of the distal umbrella contains a thread, the proximal umbrella contains a bolt. The two umbrellas are connected by screwing the bolt on the thread using a screwdriver catheter. RESULTS: The implantation was performed under echocardiographic guidance; in six of 10 patients, transoesophageal echocardiography was necessary. The "stretched" diameter of the defect evaluated during balloon sizing ranged from 10 to 20 mm, and the pulmonary to systemic blood flow ratio from 1.5:1 to 2.8:1. Transcatheter closure was successfully performed in 9/10 patients using devices with a diameter of 25 mm to 40 mm. No severe complications occurred. However, in one patient with a pre-existing prolonged PR interval brief periods of second and third degree atrioventricular block occurred after the implantation but normalised within 3 d. During a follow up period of 21 to 29 weeks no device embolisation, thromboembolic complications, fractures of the implanted device, atrial perforations, pericardial effusions, obstructions of systemic or pulmonary veins, atrioventricular valve dysfunction, or other complications occurred. CONCLUSIONS: The new device is a promising transcatheter approach for the occlusion of secundum atrial septal defects in children. However, further evaluation and long term data are needed before this transcatheter technique can be recommended.

Animal experimental implantation of an atrial septal defect occluder system.

OBJECTIVE: To establish the implantation technique for the atrial septal defect occluder system (ASDOS) device in an experimental animal model and to determine long term mechanical stability of the device and its in vivo properties in terms of biocompatibility and tissue reaction. MATERIALS AND METHODS: An atrial septal defect was created and the device implanted in 17 pigs (mean weight 30 kg). The implantation technique was refined and modified because of initial technical and anatomical complications during nine acute pilot studies. The technique proved to be feasible in eight subsequent survival studies. Four pigs were electively killed three months after implantation (group 1). The remaining four pigs were killed six months after implantation (group 2). RESULTS: Necropsy showed all devices were embedded in soft tissue three months after implantation. Microscopic examination of atrial septal tissue showed an acute granulomatous inflammatory reaction in group 1 and fibrosis in group 2. The intensity of the inflammatory reaction around the device was clearly milder in group 2, indicating a decline in the inflammatory response with time. Clinical and biochemical investigations indicated acceptable biocompatibility of the device. CONCLUSION: The implantation technique for the ASDOS device in a chronic pig model has been established. Biocompatibility of the device was acceptable.

Supraventricular tachycardia in infants, children and adolescents: diagnosis, and pharmacological and interventional therapy.

Supraventricular tachycardia is the most frequent form of symptomatic tachydysrhythmia in children. Neonates and infants with paroxysmal supraventricular tachycardias generally present with signs of acute congestive heart failure. In school-aged children and adolescents, palpitations are the leading symptom. Chronic-permanent tachycardia results in a secondary form of dilated cardiomyopathy. Therapy for episodes of tachycardia depends on the individual situation. In severe haemodynamic compromise, or if ventricular tachycardia is suspected, tachycardia should immediately be terminated by external cardioversion during deep sedation. Vagal manoeuvres are effective in patients with atrioventricular reentrant tachycardias. Adenosine is the drug of first choice in any age group for tachycardias involving the atrioventricular node; its advantages include short half-life and minimal or absent negative inotropic effects. Adenosine may also be used in patients with wide QRS complex tachycardia. Intravenous verapamil is contraindicated in neonates and infants because of the high risk of electromechanical dissociation. In older children (>5 years) and adolescents, verapamil may be administered with the same restrictions as in adult patients (wide QRS complex tachycardia, significant haemodynamic compromise). Spontaneous cessation of tachycardia can be expected in most neonates and infants during the first year of life. Prophylactic pharmacological treatment in this age group is advisable because recognition of tachycardia is often delayed until the occurrence of symptoms. Withdrawal of drug treatment should be attempted around the end of the first year. However, in older children, spontaneous cessation of tachycardia is rare. Prophylactic drug therapy is performed on an empirical basis. Digoxin may be administered in all forms of supraventricular tachycardia in which the atrioventricular node is involved, except in patients with pre-excitation syndrome aged >1 year. In patients with atrioventricular reentrant tachycardia, class IC drugs such as flecainide and propafenone are effective. Sotalol is also effective in atrioventricular reentrant tachycardia, as well as in primary atrial tachycardia. Although amiodarone has the highest antiarrhythmic potential, it should be used with caution because of its high rate of adverse effects. In school-aged children and adolescents, radiofrequency catheter ablation of the anatomical substrate is an attractive alternative to drug therapy, with a rate of permanent cessation of the tachycardia of up to 90%. Despite the clear advantages of this procedure, it should be performed only with unquestionable indication; the long term morphological and electrophysiological sequelae on the growing atrial and ventricular myocardium are still unknown.