Enzyme level changes in the cerebrospinal fluid of patients with acute stroke.

Creatine kinase (CK), brain CK (CKBB), lactate dehydrogenase (LD), and aspartate aminotransferase (ASAT) levels were determined in cerebrospinal fluid (CSF) obtained from 35 patients with acute stroke. In patients with transient, minor neurological disturbances, only LD levels increased; in those who remained comatose and died, the levels of all the enzymes, except ASAT, increased. Patients who remained with focal motor defects had increased CK and LD levels, while CKBB and ASAT levels were variable. In most of the CSF samples, muscle CK activity was also detectable, suggestive of a leakage from blood to CSF. The pattern of the enzyme increase could be related to the causative mechanisms for the strokes. The study suggests that CSF enzyme determinations may provide supplementary information as to the extent and severity of brain damage and the recovery potentials of selected patient groups with strokes.

Unlabeled antibody peroxidase-antiperoxidase method combined with direct immunofluorescence.

Paired staining with the unlabeled antibody peroxidase-antiperoxidase (PAP) method and direct immunofluorescence (DIF) differentiated distinctly between gastrin- and somatostatin-producing cells in the human gastric antrum. Similar paired staining of complexed lambda and alpha chains in immunoglobulin (Ig)A myeloma cells, of kappa and free J chains in IgG myeloma cells, and of secretory IgA and its epithelial transport protein, the free secretory component (SC), in colonic crypt cells, demonstrated that PAP staining inhibits subsequent DIF staining of an antigenic determinant present on the same molecule as the antigen revealed by the brown color of diaminobenzidine (DAB) or present or an unassociated molecule in the same cell. A quenching effect of the DAB reaction product was noted for both fluorescein (green) and rhodamine (red) emissions. In addition, a blocking effect of the DAB deposits has been demonstrated and is assumed to be the principal methodological basis for the paired PAP-DIF staining approach omitting intermediate antibody elution, as well as for the more time-consuming sequential PAP staining with DAB substrate for the first and 4-chloro-1-naphthol (CN) for the second antigen. The quenching and blocking effects limit in practice the paired PAP-DIF method to the localization of antigens present in separate cells.

Comparison of paired immunofluorescence and paired immunoenzyme staining methods based on primary antisera from the same species.

Evaluation of sequential paired staining with the unlabeled antibody peroxidase-antiperoxidase (PAP) method showed that the brown reaction product of diaminobenzidine (DAB) concealed both enzyme and antigen-antibody sites in the reagent sequence. The blue reaction product of the alternative substrate, 4-chloro-1-naphthol (CN), exerted no such blocking effect. Hence, to avoid interactions between the two PAP sequences, DAB had to be used for the first and CN for the second antigen. Complete blocking required that the DAB color reaction be of sufficient strength. When two antigens were present in the same cell, the DAB deposits inhibited staining of the second antigen unless the brown color was decreased by progressive dilution of the initial primary antibody. A mixture of brown and blue could thus reflect either concomitant staining of the two antigens or unwanted interactions between the two PAP sequences. Double staining of individual cells was, therefore, equivocal and conclusions had to be based on comparative single staining results in adjacent tissue sections. Tests carried out in several model systems showed that paired direct immunofluorescence with fluorochrome conjugates of contrasting colors (green and red) was much less time-consuming, more reliable, and of higher detection sensitivity for analyses of unbalanced mixtures of two antigens in the same cell.

Selective inhibition of nonspecific eosinophil staining or identification of eosinophilic granulocytes by paired counterstaining in immunofluorescence studies.

Nonspecific staining of eosinophilic granulocytes produced by nonimmune rabbit IgG conjugates, highly labeled with fluorescein isothiocyanate (FITC) or tetramethylrhodamine isothiocyanate (MRITC), was efficiently inhibited by pretreatment of tissue sections with diaminobenzidine and hydrogen peroxide; the brown reaction product developed in the presence of this substrate by the endogenous peroxidase of the granulocytes sheltered these cells from subsequent nonspecific staining without interfering with specific immunofluorescence staining of other tissue elements. Similar results were obtained with the alternative noncarcinogenic peroxidase substrate, p-phenylenediamine-pyrocatechol. Alternatively, the eosinophils could be identified by their nonspecific staining with FITC-labeled bovine serum albumin when this conjugate was combined with an MRITC conjugate used for specific staining; optical conditions selective for green and red fluorescence discriminated distinctly between double-stained eosinophils and purely red specifically stained cells.

Retardation of immunofluorescence fading during microscopy.

Polyvinyl alcohol (PVA) mounting medium containing paraphenylenediamine (PPD), n-propyl gallate (NPG), or 1,4-diazobicyclo(2,2,2)-octane (DABCO) was compared with PVA alone or buffered glycerol with regard to capacity for preservation of immunofluorescence preparations. The results were based on staining of an artificial substrate with homogeneous antigen distribution followed by microphotometric determination of the initial light emission from bound fluorescein isothiocyanate (FITC)-labeled antibody and the subsequent fluorescence fading during 3-min exposure to blue excitation light. At a concentration of 0.2-2.0 g/liter and 6 g/liter, respectively, PPD and NPG were shown to effectively retard fluorescence fading without notably decreasing the initial emission intensity; two requisites were that the modified PVA used must be rather fresh and that the mounted preparations be examined within a few days. Although addition of DABCO (6 g/liter) afforded a mounting medium that tolerated storage before use better, but both PPD and NPG were more advantageous in practice. The retarding effect of PPD on fading of FITC emission was confirmed by performance testing on human tissue sections. Remounting in PVA alone is recommended for prolonged storage of sections that have been mounted in PVA modified with one of the above-mentioned compounds.

Doxazosin treatment and peroxidation of low-density lipoprotein among male hypertensive subjects: in vitro and ex vivo studies.

Doxazosin is an antihypertensive drug that gives rise to 6- and 7-hydroxydoxazosin during hepatic metabolism. The structures of the hydroxymetabolites suggest that they may possess antioxidative properties. The aim of the present study was to examine whether doxazosin and 6- and 7-hydroxydoxazosin were able to scavenge free radicals and whether these compounds might protect low-density lipoprotein (LDL) against in vitro and ex vivo oxidation. Both 6- and 7-hydroxydoxazosin showed radical scavenging capacity as assessed by measuring scavenging of 1,1-diphenyl-2-picrylhydrazyl radicals. In vitro incubation with 10 microM 6- and 7-hydroxydoxazosin significantly reduced human mononuclear cell-mediated oxidation of LDL, measured as the formation of lipid peroxides and the relative electrophoretic mobility of LDL (to 10 and 6% of the control, respectively). Furthermore, formation of conjugated dienes in LDL during Cu2+-induced oxidation was significantly reduced in the presence of 5 microM 6- and 7-hydroxydoxazosin (to 28% of tmax [time to maximum] of control). However, treatment of hypertensive patients with increasing doses of doxazosin (from 1 to 8 mg/day) for 8 weeks altered neither Cu2+-catalyzed, 2,2'azobis-(2-amidinopropane hydrochloride)-initiated, nor cell-mediated oxidation of patient LDL ex vivo. Furthermore, the total antioxidative capacity of plasma was unaffected by treatment. In conclusion, the present study shows that 6- and 7-hydroxydoxazosin have radical scavenging properties and protect LDL against in vitro oxidation. However, treatment of hypertensive male subjects with increasing doses of doxazosin for 8 weeks did not affect ex vivo oxidation of LDL.

Calf blood flow and systolic blood pressure in patients with hyperviscosity of the blood.

The calf blood flow and the ankle blood pressure at rest and during post-ischemic reactive hyperemia were measured by an airfilled rubber segment plethysmograph in 5 patients with hyperviscosity of the blood. The patients had no signs of peripheral arterial disease. A normal flow and pressure pattern was obtained. It is concluded that hyperviscosity does not contribute significantly to the peripheral resistance during reactive hyperemia in the patients studied. The importance of hyperviscosity for peripheral resistance in patients with atherosclerosis obliterans is discussed.

Trimipramine and duodenal ulcer.

The gastric acid secretion, fasting serum gastrin and serum concentration of trimipramine were studied in 20 patients with duodenal ulcer during a 6 weeks treatment with trimipramine. Ulcer healing was examined endoscopically. In the group of 11 patients with healed ulcers the gastric acid secretion decreased significantly at 3 and 6 weeks in contrast to the 9 patients in whom ulcers did not heal, indicating a different antisecretory response in the two groups. The serum concentration of trimipramine was similar in both groups during treatment. Possible mechanisms of action of trimipramine in peptic ulcer disease and problems concerning clinical response and dose are discussed.

The human gastrointestinal secretory immune system in health and disease.

The main function of secretory IgA is to exert immune exclusion; that is, by intimate cooperation with innate non-specific defence mechanisms, it dampens down penetration of soluble antigens and inhibits epithelial colonisation of bacteria and viruses. Secretory IgM may exert a similar protective function in the gut as its local synthesis sometimes is markedly increased, especially in selective IgA deficiency. IgG should not be considered a secretory immunoglobulin because its external translocation depends on passive intercellular diffusion. By activating complement, antibodies of this isotype may cause increased mucosal permeability and tissue damage. IgG may thus contribute to persistent immunopathology in mucosal lesions. The same is true for IgE antibodies which, in atopic individuals, may be carried into the gut mucosa by mast cells and cause their degranulation with histamine release. Secretory IgA and secretory IgM are the products of two cell types: plasma cells synthesise IgA dimers and IgM pentamers which, by non-covalent association, become complexed with the secretory component (SC) which is synthesized by serous-type glandular cells. The adsorption of the Ig polymers to the SC-expressing epithelial cells depends on J chain-determined binding sites. This fact gives biological significance to the striking J chain expression shown by mucosal immunocytes regardless of the Ig class they produce. The immunocytes populating the gut mucosa apparently belong to relatively early memory B cell clones. The obvious functional goal of J chain expression at this stage of clonal differentiation is local generation of SC-binding IgA and IgM polymers. In various gut diseases, altered immune regulation results in a disproportionately increased number of J chain-negative IgG-producing cells in the mucosa. Such altered immunological homeostasis may contribute to perpetuation of inflammatory bowel diseases.

Trimipramine in the treatment of duodenal ulcer. A multicenter, open study.

Sixty patients with endoscopically confirmed duodenal ulcers were treated with 50 mg of trimipramine daily. After the end of the treatment 45 patients showed healed ulcers. Ulcer healing was not related to serum concentration of trimipramine, but seemed to be influenced by smoking habits and duration of the total and actual disease history.

Subclass distribution of mucosal IgG-producing cells in gastritis.

IgG-mediated immune reactions are probably involved in the maintenance of gastritis and glandular atrophy; the mucosal IgG-subclass pattern may therefore influence the effect of local hypersensitivity mechanisms. In this study the proportions of IgG1-, IgG2-, IgG3-, and IgG4-producing immunocytes were determined by paired immunofluorescence staining in specimens from simple gastritis, gastritis after Billroth II (BII) resection, and gastritis associated with dermatitis herpetiformis (DH). The results were related to histopathological degree of inflammation and atrophy. Generally, IgG1 immunocytes predominated (48-60%) in all types of gastritis. With increasing severity of inflammation, the IgG2-cell proportion was significantly increased from 4-6% to 26-34% in simple and BII gastritis, whereas the ratio of IgG1 immunocytes was correspondingly decreased from 58-69% to 38-43%. In the same types of gastritis the proportion of IgG3 cells was increased in association with severe (35-38%) compared with mild (15-23%) atrophy, whereas the proportion of IgG1 cells was correspondingly decreased. In severe gastritis associated with DH, the proportion of IgG1 cells was relatively high (60%) and that of IgG2 cells relatively low (13%), and severe atrophy did not seem to influence significantly the subclass proportions.

Paired indirect immunoenzyme staining with primary antibodies from the same species. Application of horseradish peroxidase and alkaline phosphatase as sequential labels.

Paired indirect immunoenzyme staining based on primary antisera from the same species was performed sequentially without intermediate antibody elution. The first antigen was labelled brown by an immunoperoxidase procedure (either the two-stage indirect method, the unlabelled antibody peroxidase-antiperoxidase method, or the avidin-biotin bridge method using diaminobenzidine (DAB) and hydrogen peroxide as the substrates. The second antigen was labelled blue by applying a two-stage indirect immuno-alkaline phosphatase procedure using naphthol AS phosphate and Fast Blue BB salt as the substrate. In this way, polyclonal mucosal immunocytes were revealed in distinctly contrasting colours when stained for kappa and lambda light chains. Glucagon and somatostatin (D) cells in human pancreatic islets, and gastrin and D cells in human gastric antral glands, were likewise clearly differentiated. Conversely, a mixed colour appeared in some immunocytes after staining for alpha and kappa chains. However, unbalanced colour mixing was sometimes difficult to interpret, and additional experiments demonstrated that unwanted interactions could take place between the two sequences of reagents if the density of the DAB deposits was insufficient. These pitfalls were incompatible with unequivocal double staining in the same cell. Nevertheless, paired staining could be conveniently applied with the described procedures when prior knowledge had established that the antigens in question were located in separate cells.

[A user evaluation of software programs in family practice]. / En brukerundersøkelse av dataprogrammer i legepraksis.

Software for electronic patient journals was evaluated. A questionnaire was sent to a total of 551 general practitioners working on contract, salaried general practitioners and specialist practitioners. Among the 345 respondents, 63% used electronic journals. Three programs dominated. Legeservice (n = 94) was exclusively used by salaried general practitioners, Profdoc (n = 88) and Infodoc (n = 34) were preferred by general practitioners working on contract and by specialists. In the latter group only 40% used electronic journals. In general, the users of Profdoc and Infodoc were satisfied with the central functions of the software and the service provided by the suppliers. The users of Legeservice were significantly less satisfied. In conclusion, some of the existing software for patient journals in Norway can safely be recommended.

Trimipramine in the treatment of gastric ulcer.

Forty patients with endoscopically confirmed gastric ulcers, completed a double-blind study comparing trimipramine with placebo during 4 weeks' treatment. The daily dose of trimipramine was 50 mg given before bedtime. No serious side-effects occurred. After four weeks' treatment 12 of the 20 patients receiving trimipramine had endoscopically completely healed ulcers, while in the placebo group only 4 of the 20 ulcers were healed (P = 0.025). With regard to the patients' complaints, a distinct and statistically significant improvement was also observed in the patients receiving trimipramine (P = 0.025). It is assumed that the previously shown antisecretory effect of the drug, together with the sedative and anti-depressive effect, make trimipramine a valuable drug in the treatment of peptic ulcer disease.

Computed tomography and angiography in pancreatic apudomas and cystadenomas.

During a 4-year period 17 patients with pancreatic apudoma and 3 patients with cystadenoma of the pancreas were admitted to this hospital. Computed tomography correctly located 3 of 4 insulinomas examined, while angiography revealed 4 of 8, which indicates that CT may replace angiography as the primary examination of these tumors, and possibly also other types of apudomas. When CT fails angiography may demonstrate a pancreatic tumor, suggesting angiography as a supplementary examination. In cystadenoma sufficient information was obtained at CT.

Local immune defence in relation to gastritis in Billroth-II-resected stomachs.

Biopsy specimens from Billroth-II-resected stomachs obtained endoscopically 28-32 years after the operation were subjected to an immunohistochemical study by two-colour immunofluorescence staining. The epithelial distribution of immunoglobulin A (IgA), secretory component (SC), lysozyme (Ly), and lactoferrin (Lf) was evaluated, and IgA-, IgM-, and IgG-producing cells were quantified in the lamina propria. Gastric body mucosa excised from resected stomachs obtained from patients with duodenal ulcer was used as control and showed considerably less extensive gastritis than the stump mucosa. Both specimen categories showed enhanced expression of epithelial IgA, SC, Ly, and Lf associated with severe gastritis, except for areas with intestinal metaplasia, which lacked Ly and Lf. The number of IgA-, IgM-, and IgG-producing cells was significantly increased with increasing degree of gastritis, particularly so for IgG cells on a relative basis. After partial gastrectomy, therefore, the stump mucosa generally responds with activation of local immune mechanisms; this response is principally similar to that seen in simple gastritis of comparable severity.

Quantitative distribution of immunoglobulin-producing cells in gastric mucosa: relation to chronic gastritis and glandular atrophy.

Immunoglobulin (Ig)-producing immunocytes were quantified by paired immunofluorescence staining in specimens of gastric antral (n = 52) and body (n = 117) mucosa obtained from 45 patients with various gastrointestinal disorders. Enumerations were carried out in a 500 micron wide zone from the muscularis mucosae to the lumen ('tissue unit'). The specimens were divided into three categories according to the degree of inflammation, and each specimen received a grade for atrophy (0-2). The total number of IgA-, IgM- and IgG-producing cells per tissue unit increased strikingly with increasing degree of inflammation, both in antral and body mucosa. IgA immunocytes predominated (61-91%) in all specimens, but the IgG isotype showed the largest relative increase (four to 17-fold), particularly in the basal part of the mucosa. In this layer of the gastric body the proportion of IgG cells was also significantly raised in association with atrophy, irrespective of degree of inflammation. Locally produced IgG may be of protective significance in terms of internal (or 'second line') defence but may at the same time maintain immunopathological mechanisms contributing to the chronicity of gastritis.

Sensitivity and efficiency of four immunohistochemical methods as defined by staining of artificial sections.

Direct (DIF) and indirect (IIF) immunofluorescence, indirect immunoperoxidase conjugate (IPC) and unlabelled antibody peroxidase antiperoxidase (PAP) staining was performed on sections of artificial substrate containing different concentrations of human immunoglobulin (Ig)A or IgG. Detection sensitivity, in terms of the lowest amount of discernible antigen, was evaluated by direct microscopy and by microphotometry. Staining efficiency (signal-to-noise ratio) was evaluated by microphotometry. Only minor differences in antigen detection sensitivity were found when IPC and PAP were compared with DIF and IIF under appropriate conditions. The sensitivity of DIF was only marginally improved by raised conjugate concentration and prolonged incubation time. Microphotometry of DIF on ethanol-fixed IgA substrate revealed that the staining intensity increased proportionally with the antigen concentration whereas on formaldehyde-fixed substrate a progressive masking of the antigen was indicated which, however, could be overcome by applying raised conjugate concentration and prolonged incubation time. Such antigenic self masking was of relatively little importance to IPC and PAP staining, probably because of the inherent amplification in these methods. An additional masking effect due to extraneous protein was revealed by DIF when ethanol-fixed sections had been soaked in bovine serum albumin and postfixed with formaldehyde; unmasking was achieved by proteolytic treatment of the sections.

Efficacy and tolerability of a combination tablet of candesartan cilexetil and hydrochlorothiazide in insufficiently controlled primary hypertension--comparison with a combination of losartan and hydrochlorothiazide.

This randomized, double-blind study compared the antihypertensive effect, safety and tolerability of a candesartan cilexetil/hydrochlorothiazide (candesartan/HCT; 16/12.5 mg) combination tablet with that of a losartan/HCT (50/12.5 mg) combination tablet in patients with mild-to-moderate primary hypertension insufficiently controlled on previous monotherapy. Men and women, aged 20-80 years, with a sitting diastolic blood pressure (DBP) > or = 90 and < or = 110 mmHg and sitting systolic blood pressure (SBP) < or = 200 mmHg during treatment with any kind of antihypertensive monotherapy for at least 4 weeks were randomized to candesartan/HCT or losartan/HCT once daily for 12 weeks. All BP measurements were performed 24 h after previous dose. Mean values and standard deviations (SD) or confidence intervals (CI) are given. A total of 340 patients were enrolled, of whom 299 (144 women and 155 men, mean age 59.5 [10.5] years) were randomized to candesartan/HCT (n = 151) or losartan/HCT (n = 148). BPs at randomization were 159.5 (15.4)/98.4 (5.8)mmHg and 160.5 (16.1)/98.5 (5.4)mmHg, respectively. There was a greater reduction in BP with candesartan/HCT than with losartan/HCT: DBP -10.4 (-11.8; -8.9) vs -7.8 (-9.3; -6.3) mmHg, difference between treatments -2.6 (-4.7; -0.5) mmHg (p = 0.016); SBP -19.4 (-22.1; -16.7) vs - 13.7 (-16.5; - 10.9) mmHg, difference between treatments -5.7 (-9.6; -1.8) mmHg (p = 0.004). The proportion of patients achieving a DBP < or = 90 mmHg was greater in the candesartan/HCT group: 60.9 (53.1; 68.7) vs 49.3 (41.3; 57.4)% (p = 0.044). There were 12 withdrawals in the candesartan/HCT group, of which 8 were due to adverse events, and 17 and 12, respectively in the losartan/HCT group. We conclude that the combination of candesartan and HCT reduces BP effectively and is well tolerated. BP was normalized in 61% of these patients who had insufficient response to previous monotherapy. The reduction in BP and the proportion of patients with normalized BP were greater with the candesartan/HCT 16/12.5 mg combination than with the losartan/ HCT 50/12.5 mg combination.