Sudden Death and Staged Therapy for Hemodynamic Stabilization in Patients Enrolled in a Heart Transplantation Program

To investigate the impact of staged therapy for advanced heart failure on therapeutic endpoints, 236 consecutive patients (coronary artery disease/dilated cardiomyopathy in 61/175 patients, left ventricular ejection fraction 14%± 5%, New York Heart Association Class IIl/IIIIV in 102/79/55 patients, respectively) with advanced heart failure were prospectively followed. One hundred thirtyseven patients enrolled from January 1989 to December 1991 were treated conventionally with digoxin, furosemide, and low dose angiotension converting enzyme (ACE) inhibition. Patients refractory to this therapy underwent urgent heart transplantation. Ninetynine patients enrolled from January 1992 to August 1993 underwent staged therapy: stage 1: maximal tolerated ACE inhibition; stage 2: therapy with PGE₁ for preand afterload reduction to achieve hemodynamic stabilization; or stage 3: refractory patients bridged to heart transplantation with continuous outpatient dobutamine. Sudden death was defined as death within 1 hour of symptoms if heart failure symptoms remained stable over the previous 7 days. Conventionally treated patients were followed for 10 ± 9 months; patients who underwent staged therapy for 9 ±5 months. In the group of patients that underwent standard therapy, 39 of 137 (28%) patients died: 5 (13%) deaths occurred suddenly, and death due to progressive pump failure occurred in the remaining 34 (87%) patients. In the group of patients that underwent staged therapy, 25 of 99 (25%) patients died: 13 (52%) deaths occurred suddenly, and 12 (48%) deaths occurred due to progressive pump failure. Thus, patients who underwent staged therapy were at increased risk for sudden death (P = 0.01, relative risk 3.4, 95% confidence interval 1.2–9.7) but were at lower risk for death from pump failure (P = 0.009, relative risk 0.44, 95% confidence interval 0.22–0.84). In patients who underwent therapy with continuous outpatient PGE₁ (n = 7) or dobutamine (n= 21), risk for sudden death (P = NS by log rank test) did not increase. In conclusion, staged therapy significantly reduced death from pump failure; however, patients who could be stabilized and considered too well for heart transplantation were at increased risk for sudden death. Thus, overall survival did not improve. Of note, outpatient dobutamine did not increase the risk for sudden death.     

Characterization of T-Cell Receptor Vβ Repertoire in Ovarian Tumour-Reacting CD3+ CD8+ CD4− CTL Lines

T cells from tumour infiltrating lymphocytes (TIL) cultured in media containing IL-2 were shown to mediate in vitro and in vivo antitumour responses. To characterize the T-cell antigen receptor (TCR) Vβ expression in autologous cytotoxic effectors we isolated CD3⁺ CD8⁺ CD4⁻ cells from cultures of TIL and tumour-associated lymphocytes (TAL) and analysed the TCR Vβ repertoire of CD3⁺ CD8⁺ CD4⁻ lines of known HLA-A, -B and -C phenotype, using polymerase chain reaction (PCR). These lines showed preferential lysis of autologous tumours and lysed, to a much lesser extent, NK and LAK cellsensitive targets. Tumour lysis was inhibited by antibodies to CD3 and MHC class I antigens indicating that they are cytotoxic T lymphocytes (CTL). These CD8⁺ CTL lines expressed a broad distribution of TCR Vβ repertoire which was dominated by particular groups of Vβ families in each CTL line. However, no predominant expression of one or the same Vβ segment in all CTL lines was observed although statistical correlations between Vβ family usage and magnitude of the antitumour cytolytic response were found. These results suggest that certain TCR Vβ families may be selected by antigen in ovarian tumour-reactive T cells and this selection may be affected by Ag expression, and/or host factors. To our knowledge, this is the first documentation of TCR Vβ repertoire of human ovarian tumour-reactive CD3⁺ CD8⁺ CD4⁻ CTL from different individuals of known HLA types.     

Cytotoxic T-Cell Clones Isolated from Ovarian Tumour Infiltrating Lymphocytes Recognize Common Determinants on Non-Ovarian Tumour Clones

CTL-TIL lines have been developed from tumour infiltrating lymphocytes (TIL) from the ascites of patients with ovarian carcinoma, and used to investigate whether common tumour antigens are expressed on allogeneic ovarian tumours epithelial tumour lines derived from colon and pancreatic carcinoma. Three CTL lines expressed preferential cytolytic activity against autologous tumour cells and against certain allogeneic ovarian tumour cells that shared HLA-A2 molecules. Analysis of the target specificity of these CTL lines indicated that they also lysed human colon and pancreatic tumour lines sharing HLA-A2. CTL-TIL clones isolated from these lines were found to lyse HLA-A2⁺ ovarian, colon and pancreatic tumours, and to recognize clonally distributed common epitopes on pancreas and colon tumour clones. These results indicate that shared tumour antigens can he found among tumours of common epithelial cell origin. These results indicate a novel class of T-cell-definable tumour antigens recognized by tumour-reactive CTL on human tumours and may be significant for understanding of cellular immunity in ovarian cancer, identification of CTL-defined tumour antigens and future adoptive specific immunotherapeutic approaches in ovarian cancer.     

Association of acanthosis nigricans with insulin resistance in patients with polycystic ovary syndrome

Summary This study was designed to explore the association of insulin resistance and acanthosis nigricans (AN) in patients with polycystic ovary syndrome (PCOS). Fifty women, 18–37 years old, were included in the study, and divided into five groups consisting of: (I) 10 women with PCOS, abnormal body mass index (BMI) and AN; (II) 10 women with PCOS and abnormal BMI, but without AN; (III) 10 women with PCOS, normal BMI, and no AN: (IV) 10 women with abnormal BMI, but without PCOS or AN; and (V) 10 healthy women with normal BMI. Measurement of fasting glucose and insulin levels before and after oral glucose challenge was performed. Fasting serum insulin levels were found to be significantly lower in groups III. IV and V than in groups I and II, with no significant difference between groups I and II, or between groups III, IV and V. Total insulin response following administration of glucose did not differ significantly between the groups. These findings support the view that obese PCOS patients with AN do not have significantly higher insulin resistance than obese patients without AN. Insulin resistance is a necessary, but not the only, factor leading to the development of AN in patients with PCOS. Other factors should also be considered in the pathogenesis of this cutaneous reaction.     

IL-2-Dependent Murine T-Cell Lines and Clones Expressing Gamma/Delta T-Cell Antigen Receptors. I, Functional and Biochemical Characterization

We have developed two stable IL-2-dependent T-cell lines designated AKV-I and AKV-N from the enlarged spleens, respectively, of an AKV1 and an NFS mouse. Immunofluorescence staining with the appropriate monoclonal antibodies revealed that cells of the AKV-I cell line were alpha beta TCR-CD3+CD4-CD5-CD8+CD25+, whereas cells of the AKV-N cell line were alpha beta TCR-CD3+CD4-CD5+CD8-CD25+. A number of T-cell clones were developed from the AKV-I or AKV-N T-cell lines by limiting dilution and analysed by immunofluorescence. All clones tested were alpha beta TCR-CD3+CD4-CD25+. Certain T-cell clones expressed the CD5 antigen, whereas others expressed the CD8 antigen. The AKV-I cell line responded by proliferation to rIL2, rIL4, phorbol myristate acetate (PMA), PMA plus IL-4 and PMA plus PHA or Con A. In contrast, the AKV-N cell line did not respond to rIL-4 or rIL-4 plus PMA and exhibited only a modest proliferative response to PMA alone. Both AKV-I and AKV-N T-cell lines as well as a large number of T-cell clones examined were able to lyse cells of the PU5-IR murine cell line in the presence of the anti-CD3 (clone 145-2C11) MoAb, demonstrating their ability to mediate cytotoxicity in this system. Biochemical analysis of both AKV lines and a number of clones by immunoprecipitation with the anti-CD3 MoAb, followed by one-dimensional (either non-reducing or reducing) or two-dimensional (non-reducing/reducing) SDS-PAGE, revealed that the AKV lines and clones expressed a disulphide-linked dimer. Under non-reducing conditions, a band in the range of 75-85 kDa was observed and upon reduction it was resolved into two discrete polypeptide chains of 43-44 kDa and 48 kDa in certain AKV-I cells or 38 kDa and 42 kDa in certain AKV-N cells. In other T-cell clones or lines a broad band of 42-47 kDa was observed in AKV-I cells or 38-45 kDa in AKV-N cells. These results suggest the presence of different forms of disulphide-linked dimers on these cells. Northern blotting analysis using probes specific for the constant regions of the alpha-, beta-, gamma- and delta-chains of the T-cell antigen receptor revealed that all the AKV cell lines or clones tested expressed full-length alpha-, gamma- and delta-chain mRNA, whereas beta-chain mRNA was absent.(ABSTRACT TRUNCATED AT 250 WORDS)     

NOCTURNAL PENILE TUMESCENCE AND RIGIDITY MONITORING IN YOUNG POTENT VOLUNTEERS: REPRODUCIBILITY, EVALUATION CRITERIA AND THE EFFECT OF SEXUAL INTERCOURSE

Purpose

We studied the reproducibility of nocturnal penile tumescence, rigidity evaluation criteria and the possible effects of sexual intercourse in young, healthy, potent male volunteers.

Materials and Methods

We recruited 12 male medical students 21 to 24 years old into the study. A disorder-free medical history, availability of a sexual partner and normal erectile function were the inclusion criteria. All subjects completed 3 sessions of 3 nights of recording using the RigiScan* device with at least a 3-day interval between recordings. During the last 3-night recording subjects were asked to have sexual intercourse at least once. Analysis of the recordings was focused on the best erectile event as well as on rigidity and tumescence activity units normalized per hour.*UroHealth Systems, Inc., Laguna Niguel, California.

Results

The subjects completed 36, 3-night recordings. Of the total of 108 sessions 18 occurred after sexual intercourse. We analyzed 562 erectile episodes. All 3-night recordings included at least 1 episode of rigidity at the penile tip greater than 60% and more than 10 minutes in duration. Sexual intercourse did not significantly affect nocturnal penile tumescence and rigidity. When rigidity and tumescence activity unit values were normalized by the hour and expressed as mean values of the 3-night sessions, documented values became reproducible.

Conclusions

At least 2 consecutive nights of recording are necessary to evaluate nocturnal penile tumescence and rigidity recordings. Nocturnal penile tumescence and rigidity with at least 1 erectile episode of tip penile rigidity greater than 60% and 10 minutes in duration may be associated with potency. Mean rigidity and tumescence activity unit values per hour of a recording may be used as objective parameters to measure overall erectile activity. In addition, sexual intercourse seems to decrease nocturnal penile tumescence and rigidity measurements, although not statistically significant. We anticipate that application of these criteria for nocturnal penile tumescence and rigidity evaluation will improve the diagnostic validity of the test. Future research will determine whether these criteria are too strict for the evaluation of aging men.     

TREATMENT OF ORAL PEMPHIGUS VULGARIS

Background. Oral pemphigus is considered to represent either an initial stage of pemphigus vulgaris that should be treated with high doses of immunosuppressive drugs to prevent its spread to the skin or a variety of the disease that does not need aggressive treatment. The absence of a widely accepted therapeutic method and the obscure nature of this disease prompted this study. Methods. Twenty-eight patients with oral pemphigus were randomly divided into three groups. The first group received only steroids at a dose of 40 mg of prednisone equivalent. In the other two groups the same dose of steroids was administered, but combined with either 100 mg of cyclophosphamide or 5 mg/kg of cyclosporine as an adjuvant. Direct immunofluorescence studies were performed on specimens obtained from both buccal mucosa and oral skin. Results. There was no significant difference in the duration of treatment required to achieve remission and in the relapse rate among the three groups. The incidence of complications was higher with combination treatment. Deposited immunoreactants were detected with equal frequency in specimens obtained from the buccal mucosa and normal skin. Conclusions. Oral pemphigus most likely represents an initial stage of a disease that can become generalized. Administration of moderate doses of steroids alone is effective in controlling the disease.