"Shake hands"; diagnosing a floppy infant--myotonic dystrophy and the congenital subtype: a difficult perinatal diagnosis.

Myotonic dystrophy is a multi-organ disease inherited in a complicated way. Congenital myotonic dystrophy is a distinct entity with severe symptoms leading to a high rate of perinatal morbidity and mortality. The occurrence of congenital myotonic dystrophy often allows a subsequent diagnosis in the mother with important implications for her life, her further pregnancies and offspring. Genetic principles of anticipation and somatic mosaicism are involved and hamper the prenatal diagnostic possibilities. A family is presented in which maternal myotonic dystrophy and congenital myotonic dystrophy were diagnosed after the third pregnancy. The key features leading to the diagnosis were obstetric history, neonatal hypotonia and asphyxia, facial abnormalities in the mother together with the inability to bury eyelashes and delayed release of grip after shaking hands. The disorder is reviewed with respect to clinical symptoms, pathogenesis and genetics.

Evaluation of the immunogenicity of polymerized hemoglobin solutions in a rabbit model.

Chemical modification of proteins carries the risk that neo-antigens are introduced. To investigate the potential immunogenicity of human glutaraldehyde-polymerized hemoglobin (polyHbX1), we analyzed the antibody responses of rabbits after hyperimmunization with complete Freund's adjuvant. In view of the species difference, we also tested rabbit hemoglobin that was modified in the same way as human polyHbX1. Thereafter, we studied the antibody response after weekly intravenous infusion of clinically relevant doses of polyHbX1 to evaluate whether an immune response is likely to occur when modified hemoglobin is used as blood substitute. The occurrence of an antibody response was tested by using an enzyme immunoassay (ELISA). To find out whether antibodies were directed against neo-epitopes on human polyHbX1 we used a competitive ELISA. The results showed that polymerized hemoglobin may weakly activate the immune system in special conditions, but is unlikely to do so when it is used as blood substitute.

Function of isolated rabbit hearts perfused with erythrocyte suspension is not stable but improvement may be feasible with hemoglobin solution.

In the present study isolated rabbit hearts were perfused with erythrocyte suspensions (hematocrit 21.5 +/- 0.5%) or hemoglobin solutions according to Langendorff with a constant flow at 37 degrees C. In preliminary experiments three types of stroma-free hemoglobin were used: unmodified, but carefully purified, stroma-free hemoglobin (SFHb), HbNFPLP which is a chemically modified Hb molecule and polyHbNFPLP which is a polymer of HbNFPLP. In hearts perfused with erythrocyte suspensions left ventricular developed pressure and oxygen consumption decreased and perfusion pressure increased steadily from the beginning of the perfusion. Dark spots appeared on the surfaces of these hearts, which were the result of extravasation of erythrocytes. As a consequence capillaries probably became obstructed, leading to reduced cardiac function. Hearts perfused with stroma-free hemoglobin solutions showed an initial increase in left ventricular developed pressure after switching from Tyrode perfusion to perfusion with hemoglobin solutions. Left ventricular developed pressure and perfusion pressure were stable for about 2 hours in hearts perfused with SFHb and were reasonable for 2 hours when the heart was perfused with HbNFPLP or more than 4 hours with polyHbNFPLP. More extensive experiments with stroma-free hemoglobin solutions when these become available in sufficient quantities have, according to the results from preliminary experiments, the potential of showing good oxygen supply resulting in reasonable cardiac function.

Prevention of side effects by hemoglobin solutions; the selection of optimal test models, especially concerning thrombogenicity.

Modification of hemoglobin (Hb) by crosslinking and polymerization results in an improved oxygen release capacity and a prolonged vascular retention time. Modification improves the efficacy and prevents certain side effects. It eliminates leakage of Hb through the kidneys and accumulation in the tubuli. Another important issue is the degree of purification of Hb solutions. Traces of membrane fragments may cause immunogenic and thrombogenic side effects. To determine the contamination with erythrocyte membrane fragments, we developed assays for glycophorin-alpha and phospholipids. Special models were evaluated for testing the maximum allowable level of membrane contamination. As an in vitro model for thrombogenicity we used confluent monolayers of human umbilical vein endothelial cells. These cells were incubated with Hb solutions and subsequently tested on tissue factor (TF) procoagulant activity. TF was tested by the factor VII-catalyzed activation of factor X. The lower detection limit of this assay for endotoxin was 0.5 ng/ml. Hb did not cause any tissue factor expression even after prolonged incubation. No cooperation was found within endotoxin. As an in vivo test on thrombogenicity we developed a guinea pig model in which we can follow the generation of fibrinopeptide A (FPA). This is one of the most sensitive markers for thrombin activation in vivo. When slightly contaminated Hb solutions (phospholipid content 2 nmol/ml) were infused in the presence of factor Xa at a dose (9 micrograms/kg) which in itself did not induce FPA generation, we observed an increase in FPA levels in the plasma from 1.2 +/- 0.4 ng/ml to 5.2 +/- 0.7 ng/ml. Factor Xa is used to mimic a stressed clinical condition with activated coagulation.(ABSTRACT TRUNCATED AT 250 WORDS)

Measurement of interleukin-6 production by monocytes for in vitro safety testing of hemoglobin solutions.

Induction of interleukin-6 (IL-6) production by isolated human mononuclear blood cells was taken as in vitro model for the induction of inflammatory reactions. The model was very sensitive to bacterial endotoxin (detection limit < 10pg/ml). Hemoglobin (Hb) solutions, prepared under non-sterile conditions also induced IL-6 production, which correlated with a positive reaction in the Limulus assay. Purification of the Hb solutions with a detergent prevented IL-6 production, showing that pure Hb itself does not activate the monocytes. We conclude that this assay is a useful and sensitive test of contamination with components that can induce inflammatory reactions, especially microbial products.

Detection of erythrocyte membrane components in hemoglobin-based blood substitutes.

Two methods for the detection of membrane components in human stroma-free hemoglobin solutions are described. The first is a phospholipid assay with a detection limit of 0.5-1 nmol phospholipid/ml hemoglobin-solution. For the detection of membrane proteins an immunoassay with a monoclonal antibody against glycophorin alpha was developed (detection limit 0.01% of the original amount). These methods were used to determine the purity of Hb solutions prepared in two different ways. Hb solutions prepared by filtration of red blood cells, gradually swollen in hypotonic buffer, contained 0.25% of the original amount of phospholipid and no detectable glycophorin alpha. For Hb solutions prepared in a similar way from red blood cells lysed in water, the values for phospholipid and glycophorin alpha were 2.5% and 0.06%, respectively. The determination of both glycophorin alpha and phospholipid gives a useful indication of the purity of Hb solutions.

Preparation and characterization of crosslinked and polymerized hemoglobin solutions.

In 1982 we synthesized 2-Nor-2-formylpyridoxal 5'-phosphate (NFPLP) and subsequently showed that coupling of the beta chains of hemoglobin (Hb) by this organic phosphate compound according to Benesch et al. (1) lowers the oxygen affinity and prolongs the retention time in the circulation of rats and rabbits with a factor 3 by prevention of excretion via the kidneys. Optimal conditions for the purification of HbNFPLP either by ion-exchange chromatography or by heat treatment were established with recoveries of 70% and 85%, respectively. By extrapolation from the data in rats and rabbits a half life of about 8 hours can be expected in the circulation of humans. However, under some conditions a further prolongation is required. The aim of further modification of HbNFPLP was to achieve a retention time of about 24 hours. Polymerization with glutaraldehyde to polyHbNFPLP resulted in a mixture of polymers of different size. We determined the optimal degree of polymerization with respect to the effects on vascular retention time, oncotic activity, viscosity and oxygen affinity. Depending on the degree of polymerization we found in rats a 5- to 7- fold increase in vascular half-life compared to native Hb. The change in oxygen affinity was found to be independent of the polymer size (P50 = 18-22 mmHg). A limiting factor for polymerization is the increase in viscosity, which was dramatic when large polymers (greater than 300 kD) were present in the preparation.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of membrane fragments in hemoglobin solutions.

Two methods for the detection of membrane components in human stroma-free hemoglobin (SFHb) solutions are described. The first method is a phospholipid assay with a detection limit of 0.5-1 nmol phospholipid/ml SFHb. For the detection of membrane proteins an immunoassay with a monoclonal antibody against glycophorin alpha was developed (detection limit 0.01% of the original amount). The determination of both glycophorin alpha and phospholipid yields useful information on the purity of SFHb solutions, as was shown by determination of the purity of two SFHb solutions prepared in different ways.

Intravascular reduction of methemoglobin in plasma of the rat in vivo.

The formation and reduction of extracellular methemoglobin (metHb) in plasma was studied in vivo in conscious rats after isovolemic exchange transfusions with polymerized hemoglobin solutions. After exchange transfusions of 40 and 70% of the blood volume with hemoglobin solutions, containing less than 6% methemoglobin, the methemoglobin level remained below 15%, whereas exchange transfusions of greater than 90% resulted in an increase in the metHb level to about 30% after 24 hours. The reduction of metHb was studied after exchange transfusions with fully oxidized hemoglobin. A gradual decrease in the metHb level to 20% was observed after exchanges of 5 or 40%. A higher exchange transfusion (70%) resulted also in a decrease in the metHb level but only to approximately 40% in 24 hours. In another series of experiments the reduction of metHb was studied in vitro with isolated human erythrocytes. Incubation of the erythrocytes in the presence of oxidized polymerized hemoglobin (3 g%) resulted in a decrease in the percentage of metHb from 91% to 64%. In the presence of 0.2 mM ascorbic acid the metHb level declined to 22%, suggesting a synergistic effect. These results indicate (1) that there is a potent reducing mechanism present in blood that can reduce extracellular oxidized polymerized hemoglobin and (2) that isolated erythrocytes have a large capacity to reduce extracellular metHb, and may also play an important role in the reduction of extracellular metHb in vivo.

Effects of modified hemoglobin solutions on the isolated rabbit heart.

The effects of modified hemoglobin (Hb) solutions on the coronary vasculature were studied. Hearts were perfused according to Langendorff with constant flow of Tyrode solution. The solutions studied were stroma- free Hb, prepared by lysis of red blood cells in water (SFHb-lys), or prepared by swelling of red blood cells in hypotonic phosphate buffer (SFHb). The increase in coronary vascular resistance at a dose of 200 mg Hb/dl was 68% for SFHb-lys and 13% for SFHb, respectively. Addition of the modified Hb solutions HbNFPLP and polyHbNFPLP produced an increase in coronary resistance of 11% and 8%, respectively. The left ventricular developed pressure (LVDP) (control value 72 +/- 12 mm Hg) increased by 18 and 12 mm Hg, respectively, for a dose of 250 mg Hb/dl. When HbNFPLP was converted to its met-Hb form the increase in LVDP was reduced to 3 mmHg and the increase in perfusion pressure to 6 mm Hg. We conclude that elimination of stromal contamination from Hb solutions can diminish vasoconstrictor effects. The increase in cardiac pressure development and in coronary vascular resistance found for dilute modified Hb solutions is partly due to an improved oxygen transport to the heart.

Effect of polymerization on clearance and degradation of free hemoglobin.

In the present study we investigated the mechanism of prolongation of the plasma retention of free hemoglobin by polymerization. Polymerization of intramolecularly crosslinked hemoglobin with glutaraldehyde yields a mixture of large polymers, small polymers and monomers. In exchange transfusion experiments in rats we analyzed plasma samples by gel filtration to determine the clearance of polymers of different size. A positive correlation was found between polymer size and vascular retention. Furthermore, the clearance of large polymers appeared to be highly dose-dependent: after 20% and 70% exchange transfusions, we observed for large polymers a plasma half-life of 12 and 26 hours, respectively, whereas the half-life for 64 kD monomers was 4 hours in both cases. The degradation of hemoglobin was followed by measuring the bilirubin excretion. The infused heme was recovered as bilirubin within 72 hours. The delay between the disappearance of free hemoglobin from the plasma and the recovery as bilirubin was about six hours and was not affected by polymerization or dose. We conclude that polymerization prevents the operation of certain clearance mechanisms, while still allowing a route of clearance that is easily saturated. The intracellular degradation of heme into bilirubin is not affected by the modifications of hemoglobin and is not easily saturated.

Biophysical characteristics of hemoglobin intramolecularly cross-linked and polymerized.

Hemoglobin modified by intramolecular cross-linking with 2-nor-2-formylpyridoxal 5'-phosphate (NFPLP) has potential application as an oxygen-carrying plasma expander with improved vascular retention time (threefold) and oxygen-transporting properties compared to native hemoglobin. Under some conditions a further prolongation is required. In this study polymerization of the purified modified hemoglobin (HbNFPLP) with glutaraldehyde was investigated. The influence of the degree of polymerization on the iso-oncotic concentration and the viscosity of the polymerized Hb-NFPLP (polyHbNFPLP) was investigated with three products polymerized to an increasing extent. Exchange transfusions in rats followed by gel filtration analyses of plasma samples provided information on the vascular retention time of four separate polymer fractions (i.e., monomers, dimers, trimers/tetramers, and polymers). The vascular retention time of these fractions correlated with their size. For lightly and highly polymerized HbNFPLP we found fivefold and sevenfold increases, respectively, compared to the retention time for native hemoglobin. This finding and the different shapes of the clearance curves suggested a different clearance mechanism from the vascular system for the monomer and polymer fractions. By polymerizing HbNFPLP the oxygen affinity was enhanced (oxygen half-saturation pressure shifted from 45 to 22 mm Hg), and it appeared to be independent of the degree of polymerization. Because hemoglobin was undetectable in the urine of the rats after the exchange transfusions, no accumulation of polyHbNFPLP will occur in the tubules of the kidney.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of intraperitoneal administration of two different batches of albumin solutions on peritoneal solute transport in CAPD patients.

The effects of intraperitoneal administration of two different batches of human albumin (batch A and batch B) on peritoneal solute transport and dialysate white cell count were studied in 16 CAPD patients. The studies were done on two separate days during a 4-h dwell, one day without and one day with the intraperitoneal administration of 10 g/l human albumin. Marked differences were found between the two batches. The transport of all measured solutes increased during administration of batch A compared to the control experiments: urea 78% +/- 62%, lactate 51% +/- 38%, creatinine 96% +/- 54%, glucose 67% +/- 55%, inulin 27% +/- 33% IgG 126% +/- 80%, mean +/- SD; P less than 0.02). In the experiments with batch A the white cell count of the test bag was greater than that of the effluent ('night bag') before the test (13 +/- 5 vs 194 +/- 61 mm3/l; P less than 0.02). These effects were also observed when the dialysate was buffered to pH = 7.4 before inflow. Albumin batch B showed no effect on solute transport and white cell count. The effects of solute transport and white cell count are probably caused by the greater concentration of prekallikrein activator in batch A when compared to batch B (30.1 vs 0 U/l). Caution is warranted when human albumin is used for simultaneous measurement of peritoneal fluid and solute kinetics.

Neonatal pneumothorax drainage systems: in vitro evaluation.

We studied, in vitro, different commercially available components for pneumothorax drainage, i.e. drainage tubes, Heimlich flutter valve and vacuum control units. The drainage of a pneumothorax by a drainage tube was, as expected, directly dependent on Poiseuille's law and was influenced more by diameter than length. Of practical importance, a size 6 French gauge tube, used for the very small newborn, may not efficiently evacuate a pneumothorax due to a large air leak. The Heimlich flutter valve, though useful clinically, adds to the resistance of the system especially if fluids accumulate in the valve. All vacuum control units, adaptations of the basic three- or four-bottle pleural drainage system, functioned adequately but simple changes in construction may increase the safety of some of these systems.

Key role of macrophages in hypotensive side effects of immunoglobulin preparations. Studies in an animal model.

Intravenous administration of certain immunoglobulin preparations may cause severe adverse reactions, especially in hypogammaglobulinaemic patients. Because the exact mechanism of the adverse reactions is still unknown, we investigated the severe, prolonged hypotension induced in anaesthetized rats on rapid i.v. infusion of standard immunoglobulin preparations. The hypotensive response was previously shown to be associated with IgG aggregates in the preparations but independent of complement activation. We found that the hypotension could be prevented by treating the rats with a specific receptor antagonist of platelet-activating factor; or by depletion of the macrophages of the rats; or by pretreatment with monomeric IgG. This provided evidence that the hypotension is initiated by interaction of IgG-aggregates with Fc-receptors on macrophages, leading to the production of platelet-activating factor. We conclude that the rat model provides a sensitive and reproducible test system for macrophage-activating properties of immunoglobulin preparations for i.v. administration which may lead to vasoactive side effects.

In vivo distribution and elimination of hemoglobin modified by intramolecular cross-linking with 2-nor-2-formylpyridoxal 5'-phosphate.

Modified hemoglobin solutions have potential application as plasma expanders with oxygen-transporting capacity. In a previous study it was found that modification of hemoglobin by intramolecular cross-linking with 2-nor-2-formylpyridoxal 5'-phosphate (NFPLP) improves the vascular retention time by a factor of three, and it also improves the oxygen-transporting properties. In the present study we investigated in rats how, after exchange transfusion of a clinically relevant dose, the modified hemoglobin (HbNFPLP) was distributed in the body compared with how the unmodified hemoglobin was distributed. By using a new technetium 99m labeling technique, we found in a scintigraphic study that accumulation of hemoglobin in the kidneys was greatly diminished by the intramolecular cross-linking with NFPLP. These findings were confirmed by light-microscopic observations after diaminobenzidine staining. It was concluded that the impairment of kidney function caused by blockade of the tubuli is not to be expected from HbNFPLP. In the liver and spleen, where the free HbNFPLP is possibly eliminated, some accumulation of 99mTc label was observed, but the major part of the extravascular label was diffusely spread throughout the body. This led to the conclusion that important accumulation of undegraded HbNFPLP does not occur in the liver and spleen. Rapid appearance of both hemoglobin and HbNFPLP in the lymph showed that cross-linking with NFPLP does not prevent the distribution of hemoglobin over the interstitial space in the first hours after administration. However, pharmacokinetic analysis demonstrated that transcapillary transfer contributes only to a limited extent to the disappearance from the circulation. During 24-hour infusions of HbNFPLP, a steady state with a constant plasma concentration was easily reached. The latter experiment indicated that the eliminating system does not become saturated during prolonged administration of large doses of HbNFPLP.

Hemoglobin radiolabeling: in vitro and in vivo comparison of iodine labeling with iodogen and a new method for technetium labeling.

Radiolabeled hemoglobin may be a useful tool in the study of the body distribution of hemoglobin solutions developed as plasma expanders with oxygen-transporting capacity. The present investigation compares the suitability of two radiolabeling techniques for hemoglobin. 125I labeling of hemoglobin with Iodogen as iodinating agent caused major changes in the chromatographic behaviour and an accelerated plasma clearance of the labeled hemoglobin in rats. A recently developed two-step procedure for 99mTc labeling gave better results. The label had only minimal influence on the chromatographic behaviour of hemoglobin. In vivo, no free label occurred in the circulation and no transfer of the label to other plasma proteins took place. The plasma clearance of 99mTc-labeled hemoglobin in rats was slowed. However, this could be explained entirely by diminishing glomerular filtration, probably by inhibition of the dissociation of the hemoglobin molecule into dimers. The plasma clearance of hemoglobin modified by intramolecular cross-linking, which prevents dissociation of the molecule into dimers and thus excretion by the kidney, was not influenced by the label. We conclude that the 99mTc labeling procedure is suitable for in vivo distribution studies of hemoglobin when it is taken into account that the urinary excretion is underestimated. For cross-linked hemoglobin, which is more promising as plasma expander, no such restriction exists.

Purification and physical characteristics of a hemoglobin solution modified by coupling to 2-nor-2-formylpyridoxal 5'-phosphate (NFPLP).

Human stroma-free hemoglobin (Hb) was crosslinked with 2-nor-2-formylpyridoxal 5'-phosphate (NFPLP), purified over crosslinked dextran, and eluted with a linear salt gradient. The oxygen dissociation curve of this crosslinked hemoglobin appeared to be shifted to the right with a standard P50 of 49 torr (PO2 for 50% saturation with oxygen at a pH of 7.40, a PCO2 of 40 torr, and a temperature of 37 degrees C) compared with a P50 of 12 to 15 torr for the unmodified Hb. The Hill coefficient n of HbNFPLP was 2.1, versus 2.8 for Hb. The proton Bohr factor of HbNFPLP, calculated from P50 values in the pH range of 7.1 to 7.7, was found to be -0.19, versus -0.29 for unmodified Hb. The oxygen capacity of HbNFPLP was not affected by the crosslinking and was found to be 1.410 ml of O2 per g of HbNFPLP, versus 1.407 ml of O2 per g of Hb for unmodified Hb. Four derivatives of HbNFPLP, i.e., deoxyhemoglobin, oxyhemoglobin, carboxyhemoglobin, and methemoglobin, were prepared, and the light adsorption spectra were recorded in the region of 480 to 680 nm. No differences were detected in comparison with the spectra of unmodified Hb. The alpha and beta chains of the tetramer were separated by reverse-phase chromatography. Comparison of the elution patterns of the chains of Hb and HbNFPLP revealed a retardation of the beta chains due to crosslinking with NFPLP. This indicates that the binding of NFPLP to Hb occurred only between the beta chains.(ABSTRACT TRUNCATED AT 250 WORDS)

Preparation and physical characteristics of a hemoglobin solution modified by coupling to 2-nor-2-formylpyridoxal 5'-phosphate.

Stroma-free hemoglobin (Hb) solutions were prepared on a 20-I scale. In 3-I batches, the beta chains of hemoglobin were crosslinked with 2-nor-2-formylpyridoxal 5'-phosphate (NFPLP) that was synthesized on a gram scale. The coupling efficiency was 60 to 80 percent. The oxygen dissociation curve of these Hb/HbNFPLP mixtures was shifted to the right with P50 (PO2 for 50% saturation with oxygen) values of 26 to 38 torr versus values of 12 to 16 torr for the nonmodified hemoglobin solutions. Both the H+ Bohr factor and the Hill coefficient were lower for the Hb/HbNFPLP mixture than for the original hemoglobin solution. The oxygen-binding coefficient beta was the same for both types of Hb solutions. The viscosity and the colloid osmotic pressure of both solutions were also the same. During storage at 4 degrees C for 18 months, no precipitation or denaturation of hemoglobin was detectable in either solution. There was also no conversion of the modified hemoglobin molecules, HbNFPLP, to the native hemoglobin tetramers, dimers, or monomers. The percentage of methemoglobin remained at 5 percent for about 6 months; it increased to 26 percent over the next 12 months. The results indicate that intramolecular coupling of hemoglobin with NFPLP yields a stable product with physiologic oxygen-carrying properties.