Placebo response in phase 2 and 3 trials of systemic and biological therapies for atopic dermatitis-a systematic review and meta-analysis.

A growing number of clinical trials of biological and systemic therapies have been conducted within adult atopic dermatitis (AD). No study has yet examined and meta-analysed the pooled placebo response in AD. We performed a systematic review and meta-analysis to examine the placebo response in clinical trials evaluating the effect of systemic and biological therapies in adult AD and compared it to results from clinical trials in psoriasis. Two screeners independently searched the databases ClinicalTrials.gov, Embase, Pubmed and Web of Science. A total of 2058 articles were identified, of which 78 were full-text reviewed. Overall, 25 trials were included in the qualitative analysis, of which 24 were further included in the quantitative analysis. At 12-week follow-up, EASI50, EASI75 and EASI90 placebo responses were 39.9% [95% confidence interval (CI), 36.7-43.2], 20.9% (95% CI, 18.2-23.8) and 9.0% (95% CI, 6.7-11.6), respectively. At week 12, the pooled proportion of placebo-treated AD patients that obtained EASI50, EASI75 and EASI90 was significantly higher than the pooled proportion of placebo-treated psoriasis patients obtaining PASI50, PASI75 and PASI90 (P < 0.05). Our findings emphasize the fluctuating nature of AD and show that correct and consistent use of topical treatments strongly reduces disease severity.

Pregnancy protects against antiangiogenic and fibrogenic effects of angiotensin II in rat hearts.

AIM: To investigate the difference between physiological and pathological cardiac remodelling induced, respectively, by pregnancy and angiotensin (Ang) II, and to test the hypothesis that pregnancy protects against Ang II effects. METHODS: Female Wistar rats, pregnant (n = 12) and non-pregnant (n = 12), were implanted with mini-pumps containing saline (sham) or 150 ng kg(-1) min(-1) Ang II. Ten days later echocardiography and blood pressure measurement were performed. Expression of 22 genes was assessed using RT-PCR. Microscopic sections of LV were prepared to determine collagen content (Sirius Red staining), vessel density (ß-actin immunolabelling) and myocytes diameter (Toluidine Blue). RESULTS: Heart weight (HW) was increased in Ang II treated groups compared with their controls. Furthermore, HW of Ang II treated pregnant rats (1.0 ± 0.03 g) was higher than that in non-pregnant sham (0.7 ± 0.02 g), pregnant (0.8 ± 0.01 g) and Ang II treated non-pregnant (0.8 ± 0.02 g) rats. Relative LV wall thickness showed similar pattern. Aortic pressure was significantly increased in Ang II groups. Collagen content was increased in Ang II (4.0 ± 0.5%) compared with sham (1.5 ± 0.1%) but reduced again when treated rats were pregnant (2.8 ± 0.4%). Vessel density was reduced by 47.8% after Ang II treatment in non-pregnant and by only 13.9% in pregnant rats. Gene expression analysis showed increased expression of atrial natriuretic factor (ANF), brain natriuretic peptide (BNP), anykrin repeat domain-containing protein 1 (Ankrd-1), protein kinase C-α and -δ and tumour suppressor gene TP53 (p53) in Ang II treated groups and upregulation of ANF, BNP and Ankrd-1 remained when pregnancy was combined with Ang II. Pregnancy reduced expression of: α-myosin heavy chain, tumour necrosis factor-α, p53, endothelial nitric oxide synthase and inducible nitric oxide synthase. CONCLUSION: Pregnancy seems to counteract the detrimental effects of Ang II on fibrosis and angiogenesis in heart. In addition, pregnancy and Ang II lead to partly opposite changes in the expression of some genes important for heart function.

Gene expression, function and ischemia tolerance in male and female rat hearts after sub-toxic levels of angiotensin II.

To examine the response to chronic high-dose angiotensin II (Ang II) and a proposed milder response in female hearts with respect to gene expression and ischemic injury. Female and male litter-matched rats were treated with 400 ng kg(-1) min(-1) Ang II for 14 days. Hearts were isolated, subjected to 30-min ischemia and 30-min reperfusion in combination with functional monitoring and thereafter harvested for gene expression, WB and histology. Ang II-treated hearts showed signs of non-hypertrophic remodeling and had significantly higher end diastolic pressure after reperfusion, but no significant gender difference was detected. Ang II increased expression of genes related to heart function (ANF, ß-MCH, Ankrd-1, PKC-α, PKC-δ TNF-α); fibrosis (Col I-α1, Col III-α1, Fn-1, Timp1) and apoptosis (P53, Casp-3) without changing heart weight but with 68% increase in collagen content. High (sub-toxic) dose of Ang II resulted in marked heart remodeling and diastolic dysfunction after ischemia without significant myocyte hypertrophy or ventricular chamber dilatation. Although there were some gender-dependent differences in gene expression, female gender did not protect against the overall response.

Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans.

LEARNING OBJECTIVES: After studying the article, the participant should be able to: 1. Describe the most common bacteriology of necrotizing fasciitis and purpura fulminans. 2. Describe the "finger test" in the diagnosis of necrotizing fasciitis. 3. Discuss the three presentation patterns of necrotizing fasciitis. 4. Discuss the pathophysiology of acute infectious purpura fulminans. 5. Discuss the treatment strategies for necrotizing fasciitis and purpura fulminans, including the use of artificial skin substitutes. Necrotizing fasciitis and purpura fulminans are two destructive processes that involve skin and soft tissues. The plastic and reconstructive surgeon may frequently be called on for assistance in the diagnosis, treatment, and/or reconstruction of patients with these conditions. Understanding the natural history and unique characteristics of these processes is essential for effective surgical management and favorable patient outcome. A comprehensive review of the literature pertaining to these two conditions is presented, outlining the different pathophysiologies, the patterns of presentation, and the treatment strategies necessary for successful management of these massive infectious soft-tissue diseases.

Glucose and fatty acid oxidation by the in situ dog heart during experimental cooling and rewarming.

BACKGROUND: Reduced myocardial function after hypothermia may be metabolic in origin, but the relationship between myocardial metabolism and the various components of hypothermia-mediated dysfunction has not been thoroughly investigated. METHODS: In the present study we measured myocardial uptake and oxidation of glucose and oleate in mongrel dogs undergoing cooling to 25 degrees C followed by rewarming to 37 degrees C, using radiolabeled substrates. RESULTS: Segment work index declined from 39.3 +/- 5.1 to 15.1 +/- 2.4 mm Hg in response to cooling from 37 degrees to 25 degrees C and did not recover completely on rewarming (27.2 +/- 4.2 mm Hg, p < 0.05). Oleate uptake declined from 3,251 +/- 619 to 1,043 +/- 356 nmol.min-1.100 g-1 (p < 0.05) when the dogs were cooled from 37 degrees to 25 degrees C. Simultaneously, oxidation rate fell from 1,089 +/- 158 to 354 +/- 83 nmol.min-1.100 g-1 (p < 0.05). On rewarming, oleate uptake was restored to prehypothermic values, whereas its rate of oxidation remained depressed (480 +/- 129 nmol.min-1.100 g-1; p < 0.05). Uptake and oxidation of glucose also declined significantly during cooling. However, both uptake and oxidation of glucose recovered fully on rewarming. CONCLUSIONS: The results of the present study demonstrate a reduced capacity to oxidize fatty acids by the myocardium during rewarming after hypothermia.

Lipid peroxidation, arachidonic acid and products of the lipoxygenase pathway in ischaemic preconditioning of rat heart.

OBJECTIVE: Preconditioning with brief intermittent periods of ischaemia is known to provide protection against ischaemic injury. It has been suggested that myocardial ischaemia also activates phospholipase A2, which releases arachidonic acid from phospholipids. In the present study the possible role of phospholipid peroxidation, arachidonic acid and products of the lipoxygenase pathway in cellular mechanisms of ischaemic preconditioning was examined. METHODS: Isolated, buffer-perfused rat hearts were freeze-clamped at the end of preconditioning (a cycle of 5 min global ischaemia +5 min reperfusion) and at the end of 30 min global ischaemia and analysed for non-esterified fatty acids and fatty acids in the 2-position of phospholipid. In a separate set of experiments, hearts pretreated with a lipoxygenase inhibitor, nordihydroguaiaretic acid (NDGA), were subjected to 30 min regional ischaemia and 120 min reperfusion. Infarct size was determined by tetrazolium staining and the ischaemic risk zone with fluorescent particles. RESULTS: Myocardial levels of arachidonic as well as of linoleic and docosahexaenoic acid were significantly elevated by preconditioning. Also, the level of peroxidized polyunsaturated fatty acids (measured as hydroxy conjugated dienes) in myocardial phospholipid was significantly increased: 101.4 +/- 16.8 nmol/g versus 51.2 +/- 7.3 nmol/g tissue dw in the control group, p < 0.05. Pre-treatment of hearts with 5 microM NDGA blocked the infarct limiting effects of preconditioning: infarct size was 37.4 +/- 6.4% of risk zone in control, 9.0 +/- 0.9% in the preconditioning group and 27.7 +/- 3.8% in the preconditioning + NDGA group (p < 0.05 vs. i.p., n.s. vs. control). CONCLUSION: Our findings provide evidence for the involvement of phospholipase A2 and lipoxygenase derived lipid second messengers in ischaemic preconditioning of the isolated rat heart.

Mepacrine protects the isolated rat heart during hypoxia and reoxygenation--but not by inhibition of phospholipase A2.

Mepacrine (quinacrine) has in a number of studies been shown to protect the heart from ischemic injury, a protection commonly claimed to be due to inhibition of phospholipase A2. The aim of the present study was to investigate the effect of mepacrine 1 microM on isolated, buffer perfused rat hearts subjected to 60 min hypoxia and 30 min reoxygenation. We also wanted to clarify whether any cardioprotective effect was due to inhibition of phospholipase A2 or to other effects of the drug. Mepacrine led to a substantial fall in left ventricular developed pressure (LVDP) and coronary flow (CF) during normoxic perfusion. Treated hearts showed less increase in LVEDP and less fall in LVDP during the hypoxic period, and significantly fewer hearts stopped beating compared to untreated controls. Release of CK during hypoxia and reoxygenation was reduced in treated hearts compared to controls (19.9 +/- 3.8 vs. 73.1 +/- 13.3 IU, p < 0.05). Lipid analyses of the myocardium showed a significant increase in the total amount of non esterified fatty acids (NEFA) in both untreated and mepacrine treated hypoxic hearts compared to normoxic controls, but to a significantly lower level in the mepacrine treated hearts. However, contribution of polyunsaturated NEFAs to total NEFAs did not differ between the groups. Also, neither total amount of fatty acids nor amount of polyunsaturated fatty acids obtained from the 2-position of the phospholipid fraction differed between the treated and untreated groups. In an enzyme assay, mepacrine 1 microM did not inhibit phospholipase A2 activity. We conclude that in our model mepacrine protects the heart from hypoxic injury, but probably by another mechanism than inhibition of phospholipase A2 induced membrane damage.

Myocardial substrate oxidation during warm continuous blood cardioplegia.

BACKGROUND: Although long-chain fatty acids are a major energy substrate utilized by the myocardium, changes in the substrate balance toward a predominating fatty acid utilization could jeopardize the myocardium during cardiac operative procedures. METHODS: In the present study myocardial substrate utilization was examined during warm continuous blood cardioplegia (4 hours, 37 degrees C), using pigs undergoing cardiopulmonary bypass. Hearts were perfused antegradely in a closed extracorporeal circuit in which cardioplegic donor blood (hematocrit, 22%) containing 14C-glucose and 3H-oleate was delivered to the heart. Arterial and coronary sinus blood samples were taken at intervals for determination of plasma concentrations of energy substrates, as well as glucose and oleate oxidation rates (14CO2 and 3HOH production). RESULTS: The concentration of fatty acids in the cardioplegic perfusate did not change significantly during the cardiac arrest period. The mean concentration of glucose showed a 30% decline (not significant), whereas the lactate concentration increased from a starting value of 3.12 +/- 0.27 to 6.31 +/- 0.72 mmol/L at the end (mean +/- standard error of the mean; n = 8; p < 0.05). Only fatty acid levels showed a significant (positive) arterial-coronary sinus difference. Myocardial oxidation of oleate varied between 302 +/- 71 and 650 +/- 66 nmol.min-1.heart-1, whereas the range of variation for glucose oxidation was 144 +/- 64 to 355 +/- 107 nmol.min-1.heart-1. However, the changes in fatty acid levels and glucose oxidation rates during the cardiac arrest period were not statistically significant. We calculated that overall glucose oxidation accounted for less than 5% of the total aerobic energy production. CONCLUSIONS: The present results demonstrate overreliance on fatty acids as a source of energy during warm continuous blood cardioplegia, consistent with a condition of myocardial insulin resistance.

Hemodynamic variations between end-to-side and end-organ flap systems.

This study aimed to evaluate microcirculatory differences between anatomic arrangements of the intact side flow and the end flow systems. The cremaster muscle tube-flap model was employed. Fifty male Sprague-Dawley rats were studied in two experimental groups of 25 animals each. The end-to-side vascular system was compared with end-organ flaps during acute (6 hours) and chronic (1, 3, 7, and 14 days) observation periods. Standard microcirculatory measurements were taken in all groups including vessel diameters, red blood cell velocities, and capillary densities. End-to-side flaps presented with stable flow hemodynamics over a 14-day period. In end-organ flaps we found acute venous congestion, alterations in arterial and venous flow velocities, and a significant decline in capillary perfusion.

Microcirculatory response to surgical trauma in composite-tissue transfer.

A rat cremaster muscle-flap model for direct in vivo microcirculatory studies was combined with a rat hind-limb amputation/replantation model, to evaluate changes related to transfer trauma. Forty-eight inbred Sprague-Dawley rats were studied in two experimental groups. In a control group, the cremaster muscle was dissected as an island tube flap, transposed into the hind limb, and anchored at ankle level. No amputation was performed. In a second composite-limb-cremaster-graft group, the limb, with the inserted cremaster muscle flap, was amputated at mid-thigh level, and transferred to a recipient animal. In both groups, at follow-up periods of 1, 24, 48, and 72 hr, the cremaster flap was withdrawn from the limb and prepared for microcirculatory studies. The following parameters were measured: vessel diameters, RBC velocities, capillary density, and leukocytes in the postcapillary venules. Arteriolar and venular diameters, as well as RBC velocity values, were comparable in both groups. However, the composite isografts presented 50 percent more leukocytes sticking to the lumen of the postcapillary venules (p < 0.05) immediately following transfer. In addition, a significant decrease (12 percent) in the number of perfused capillaries was observed in the composite grafts throughout 72 hr. In this study on composite tissue transfer, trauma alone compromised the microcirculatory integrity of the tissue and proved to act as an independent factor. This should be considered during allotransplantations, where the addition of a rejection factor can further compromise graft survival.

Effect of muscle flap denervation on flow hemodynamics: a new model for chronic in vivo studies.

The purpose of this study was to evaluate microcirculatory dynamics following muscle flap denervation. A modification of standard cremaster muscle flap was used. Fifty male Sprague-Dawley rats were studied in two experimental groups of 25 rats each, as follows: Group I (control), after flap isolation, the neurovascular pedicle was left intact; group II (denervation), following muscle isolation at 1 cm segment of genitofemoral nerve was excised and denervated muscle was preserved in the medial border of rat hind limb. For chronic evaluation the cremaster was withdrawn from the leg and prepared for in vivo observations after days 1, 3, 7, and 14. The following measurements were taken: vessel diameters, red blood cell velocities, and number of perfused capillaries. In group II a 15% increase in arteriolar diameter was observed. Throughout the entire 14 day period denervated flaps presented 27% more perfused capillaries. Flap denervation proved to increase capillary perfusion significantly (P < 0.05). The cremaster muscle tube-flap model introduced in this study allows for chronic observation of the microcirculation.

P-57 is a neural specific calmodulin-binding protein.

P-57 is a novel calmodulin-binding protein which has recently been isolated from bovine cerebral cortex (Andreasen, T. J., Luetje, C. W., Heideman, W., and Storm, D. R. (1983) Biochemistry 22, 4615-4618). In contrast to all other calmodulin-binding proteins characterized thus far, P-57 has equivalent or higher affinity for calmodulin in the absence of free Ca2+ compared to the presence of Ca2+. In this study, the distribution of P-57 in other tissues and within brain was examined using a radioimmune assay and photoaffinity labeling with azido-125I-calmodulin. P-57 was not found in tissues other than brain, retina, and spinal cord. Within brain, P-57 levels varied from 0.1% of the total protein in white matter regions to about 0.5% in cell body-rich fractions. The protein was found in both membrane and soluble fractions. P-57 is the most abundant calmodulin-binding protein in brain and appears to be neural specific. The concentrations of P-57 in brain and its affinity for calmodulin in the absence of Ca2+ are sufficient to complex a significant fraction of the total calmodulin present.

Purification of a novel calmodulin binding protein from bovine cerebral cortex membranes.

A new calmodulin (CaM) binding protein, designated P-57, has been purified to apparent homogeneity from bovine cerebral cortex membranes. In contrast to other calmodulin binding proteins, P-57 has higher affinity for calmodulin in the absence of bound Ca2+ than in its presence. The protein was purified by DEAE-Sephacel chromatography and two CaM-Sepharose affinity column steps. The first CaM-Sepharose column was run in the presence of Ca2+; the second was run in the presence of chelator in excess of Ca2+. P-57 was adsorbed by CaM-Sepharose only in the absence of bound Ca2+ and was eluted from the second column by buffers containing Ca2+. Sodium dodecyl sulfate (SDS)-polyacrylamide gels of the purified protein showed only one band at Mr 57 000. The major form of the protein on Bio-Gel A-1.5m and native polyacrylamide gradient gel electrophoresis ran with an apparent Stokes radius of 41 A. Photoaffinity labeling of P-57 with azido[125I]calmodulin yielded one cross-linked product on SDS gels with an Mr of 70 000. This interaction occurred only when excess ethylene glycol bis(beta-aminoethyl ether)-N,N,N',N'-tetraacetic acid was present and was inhibited by the presence of Ca2+ in excess of chelator. It appears that P-57 has novel binding properties for calmodulin distinct from all other calmodulin binding proteins described thus far.

Prostaglandin E-induced heterologous desensitization of hepatic adenylate cyclase. Consequences on the guanyl nucleotide regulatory complex.

Prostaglandin E (PGE) receptor density in hepatic plasma membranes can be down-regulated by in vivo exposure to the 16,16-dimethyl analog of PGE2, and this is associated with desensitization of PGE-sensitive adenylate cyclase. These studies examined adenylate cyclase response to other agonists in membranes whose PGE receptor density was 51% decreased and whose maximal PGE-stimulated adenylate cyclase activity was 31% decreased. Down-regulated membranes had a 37% decrease in their maximal response to glucagon, indicating that treatment with the PGE analog had induced both homologous and heterologous desensitization. To determine whether adenylate cyclase had been affected, stimulation with NaF, guanyl 5'-yl imidodiphosphate (GppNHp), and forskolin was examined in both intact and solubilized membranes. Intact membranes had decreased adenylate cyclase responses to all three stimulators (NaF, -41%; GppNHp, -25%; forskolin, -41%) as did solubilized membranes (NaF, -51%; GppNHp, -50%; forskolin, -50%), suggesting alterations in adenylate cyclase rather than indirect membrane effects. Cholera toxin activation and labeling were examined to more directly assess whether the guanine nucleotide (G/F) regulatory component of adenylate cyclase had been affected. Cholera toxin activation was 42% less in down-regulated membranes, and these membranes incorporated less label when the incubation was performed in the presence of [32]NAD. Solubilized G/F subunit activity from down-regulated membranes was less effective in reconstitution of adenylate cyclase activity from cyc- cell membranes than G/F activity from control membranes. These data indicate that in vivo exposure to the PGE analog causes both homologous and heterologous desensitization of adenylate cyclase as well as an apparent quantitative decrease in G/F.

Photoaffinity labeling of brain adenylate cyclase preparations with azido[125 I]iodocalmodulin.

A partially purified calmodulin-sensitive adenylate cyclase from bovine cerebral cortex was photoaffinity labeled with azido[125 I]iodocalmodulin. Sodium dodecyl sulfate gel electrophoresis followed by autoradiography revealed several cross-linked polypeptides ranging in molecular weight from 37000 to 200000. The calmodulin-sensitive enzyme was submitted to a number of purification steps to determine if any of the calmodulin binding polypeptides copurified with adenylate cyclase activity. Fractionation procedures used included Bio-Gel A5M and Ultragel AcA 34 gel chromatography, isoelectric focusing, and native gradient gel electrophoresis. One cross-linked peptide having a molecular weight of 170000 correlated with adenylate cyclase activity through all purification steps. Native gradient gel electrophoresis in the presence of 0.03% deoxycholate gave one peak of adenylate cyclase activity with a Stokes radius of 40 A, consistent with a molecular weight of 140000-150000. It is proposed that the molecular weight of the adenylate cyclase catalytic subunit is 150,000 and that each catalytic subunit interacts with one calmodulin.

Calcium-independent stimulation of Bordetella pertussis adenylate cyclase by calmodulin.

Bordetella pertussis produces an extracellular adenylate cyclase activity that is present in the culture medium of exponentially growing cells. We have determined that calmodulin (CaM) stimulates this enzyme both in the presence and in the absence of free Ca2+. In the presence of 90 micron Ca2+ half-maximal stimulation of the enzyme occurred at 95 pM calmodulin. Comparable levels of calmodulin stimulation were observed when free Ca2+ levels were minimized by using EGTA-containing buffers. However, the concentration of CaM required for half-maximal stimulation of B. pertussis adenylate cyclase in the presence of 1 nM free Ca2+ was 24 nM. The apparent affinity of the enzyme for calmodulin was also significantly enhanced by Mn2+. In addition, troponin I inhibited calmodulin stimulation of the bacterial adenylate cyclase. Photoaffinity cross-linking experiments using azido[125I]calmodulin and B. pertussis adenylate cyclase revealed only one major cross-linked product having a molecular weight of 97000. It is proposed that the catalytic subunit of the calmodulin-sensitive adenylate cyclase is 77000.

Photochemical cross-linking of azidocalmodulin to the (Ca2+ + Mg2+)-ATPase of the erythrocyte membrane.

The calmodulin (CaM)-binding proteins present in the human red blood cell membrane were examined through photoaffinity labeling. Two different membrane preparations were used: white ghosts and inside-out vesicles. These were incubated with azido-125I-CaM, a photoactivatable derivative of calmodulin, and photolyzed. Cross-linked products were identified by autoradiography of dried sodium dodecyl sulfate slab gels and quantitated by counting gel slices for 125I. The major product formed with each membrane type had an apparent Mr of 168,000. No other product was common to both membrane types; however, a few other products unique to each vesicle type were detected. The formation of the 168,000-dalton product correlated with an increased basal (Ca2+ + Mg2+)-ATPase activity in white ghosts and with an increased basal Ca2+ transport in inside-out vesicles. This suggests that the 168,000-dalton product represents a cross-link between azido-125I-CaM and the Ca2+ pump ATPase. The ATPase appears to be a single protein of about 150,000 daltons, which can bind a single calmodulin. No evidence was found to indicate anything other than a 1:1 binding stoichiometry between calmodulin and the (Ca2+ + Mg2+)-ATPase.