Dispersive-cohesive viscoelastic soft shell technique

The binding of iralukast to plasma (or serum) proteins and to erythrocytes was studied in vitro, at +37 degrees C, using the erythrocyte partitioning method (EPM) and/or ultrafiltration (UF) with 14C-labelled iralukast. Iralukast was highly bound in human and animal serum (>99%). Similar bound fraction values were obtained with the two methods: in whole human plasma (or serum) 99.8% (EPM) and 99.9% (UF), in albumin solution 99.8% (EPM and UF), in high density lipoprotein solution 97.3% (EPM) and 98.3% (UF), and in low density lipoprotein solution 97.2% (EPM) and 98.8% (UF). Moreover, the erythrocyte partitioning method allowed the evaluation of other binding parameters. The binding capacity (l/micromol) of proteins equalled 35 for low density lipoproteins, 3.6 for high density lipoproteins, 1.0 for albumin, 0.78 for alpha-1-acid glycoprotein, and 0.03 for gamma globulins. In whole blood, iralukast was distributed between plasma and erythrocytes in the proportion (%) 90/10. At physiological protein concentrations, iralukast was primarily bound to albumin (79%).     

Dose-dependent plasma clearance of MK-826, a carbapenem antibiotic, arising from concentration-dependent plasma protein binding in rats and monkeys

After intravenous administration of MK-826, a new carbapenem antibiotic, the compound exhibited nonlinear pharmacokinetics in rats and monkeys. In both species, time-averaged plasma clearance (based on total concentrations) increased about 5-fold over the 10- to 180-mg/kg dose range. MK-826 was extensively plasma protein bound in rat and monkey plasma, and the extent of binding was concentration dependent at plasma concentrations achieved after administration of these doses. Rosenthal analysis of the plasma protein binding indicated that there were two classes of binding sites. The binding capacity of the primary site was comparable to the plasma albumin concentration, which suggested that this primary site consisted of a single site on albumin. The extent of binding of MK-826 to rat albumin was similar to that in whole plasma. Clearance values based on unbound concentrations appeared independent of dose from 10 to 180 mg/kg, which is consistent with saturation of protein binding as the primary cause of the nonlinear pharmacokinetic behavior.     

Protein binding of 2-chloro 2'-deoxyadenosine (cladribine) in healthy subjects and in patients with leukaemia

The plasma protein binding of 2-chloro-2'-deoxyadenosine (CdA) at 37 degrees C was studied by ultrafiltration in 5 healthy volunteers, in 11 patients with haematological malignancies and in purified protein preparations. In the patients, the binding of CdA to plasma proteins was 25.0% and in healthy subjects it was 21.1%. In a solution of human serum albumin (40 g.l-1), 24.3% CdA was bound, but less than 5% was bound in a solution of alpha 1-acid-glycoprotein (0.7 g.l-1). No dependence of binding on the concentration of CdA was found within a range 25-1000 nmol.l-1. In conclusion, due to its limited binding to plasma proteins, any change in the binding of CdA is unlikely to have a major influence on its pharmacological effect.     

Disposition of the selective alpha1A-adrenoceptor antagonist tamsulosin in humans: comparison with data from interspecies scaling

Tamsulosin-HCl is an alpha1A-adrenoceptor antagonist that is mainly eliminated by metabolism in animals and humans and is highly bound to alpha1-acid glycoprotein in blood plasma. The disposition of the compound (0.4 mg as modified-release granules in a capsule) was determined in male volunteers, using intravenous (iv) infusion of tamsulosin-HCl (0.125 mg over 4 h) as reference treatment for the assessment of absolute oral bioavailability. Disposition parameters of iv tamsulosin in humans was compared with data predicted from animal data by interspecies scaling techniques. Levels after iv dosing in humans showed a biexponential decline, with mean half-lives (+/-SD) of 1.2 +/- 0.6 and 6.8 +/- 3.5 h, respectively. The mean systemic clearance (+/-SD) was low (viz., 48 +/- 24 mL/min). The mean volume of distribution (+/-SD) was rather small (21 +/- 6 L), and was estimated at 16 +/- 4 L in the steady state. The mean absolute oral bioavailability (+/-SD) was approximated at 100 +/- 19%. Systemic clearance in humans was poorly predictable from a logarithmic clearance versus body weight relation of rat, rabbit, and dog data. The prediction improved dramatically (accuracy 213%) when scaling was done with systemic clearance values of unbound drug, and it improved further (accuracy 59%) with the product of unbound clearance and maximum life-span potential. Also, the prediction of volume of distribution improved dramatically (accuracy 81%) after correction for differences in extent of protein binding between species. The terminal disposition half-life of 7.0 h, as predicted after integrating maximum life-span potential and protein binding in scaling of clearance, was very close to the value of 6.8 h established experimentally in humans. The present results with tamsulosin underline the importance of correction for extent of protein binding in allometric scaling of clearance and distribution volume.     

Dry polyacrylamide batch method for studying drug protein binding

The validity of a new technique for studying drug protein binding is tested. By this gel diffusion or batch method using dry polyacrylamide, sulfadiazine and sulfafurazole are bound by human plasma proteins to the same extent as reported by other authors with different techniques. The binding of warfarin to fresh human plasma was quantitatively less than expected. This might be due to the possibility that other plasma constituents of non-fasted test persons displace warfarin from protein binding sites, since it is bound more in buffer solutions containing physiological concentrations of human albumin. Phenylbutazone displaced warfarin from its binding sites in diluted human serum albumin concentrations. Quinidine was found to be adsorbed by the otherwise inert polyacrylamide gel and the method is therefore not applicable to quinidine binding studies.     

Interactions of prostaglandin H2 and thromboxane A2 with human serum albumin

The present report describes the interactions of human plasma proteins with the unstable endoperoxide, prostaglandin H2 and thromboxane A2, generated by incubation of platelets with prostaglandin H2 or arachidonic acid. It was found that both compounds reacted very rapidly with plasma proteins to form covalently bound derivatives. The major reacting plasma protein was human serum albumin. Depending on conditions, 20-40% of added prostaglandin H2 and 50-80% of generated thromboxane were bound to proteins. This reaction of both prostaglandin H2 and thromboxane A2 prevents their detection by classical analytical methods. The protein binding of thromboxane was more pH-sensitive than the binding of prostaglandin H2. The reactions cause reduced levels of both endoperoxide and thromboxane B2 in suspensions of washed platelets using human serum albumin as compared to buffer. It was also shown that the half-life of prostaglandin H2 was considerably reduced in the presence of albumin.     

The plasma protein binding and distribution of etomidate in dog, rat and human blood

The interactions of etomidate and its major metabolite (R 28 141) with plasma proteins were studied by equilibrium dialysis with a multiple cell system. A 4% human serum albumin solution was able to bind 78.5% of the etomidate, and 60.5% of R 25 141, whereas a 1.5% human gamma globulin solution bound etomidate for not more than 3% and did not bind R 28 141 at all. The association constants and free binding energies for the binding of etomidate and R 28 141 to human serum albumin were determined. Plasma protein binding of etomidate was 75.4% in the dog and 76.5% in man; in rat plasma 79.5% of the radioactivity was bound to the plasma proteins, however the etomidate was partly hydrolyzed, even in the presence of sodium fluoride. In the rat 29.7% was distributed to the blood cells, 55.9% bound to plasma proteins and 14.4% was present in plasma water; in the dog the distribution percentages were 42.1%, 43.7% and 14.2% respectively, and in man 37.7%, 47.6% and 14.7% respectively. The major metabolite of etomidate was distributed for 26.3% to the human blood cells, 47.4% was bound to plasma proteins and 26.2% was present in the plasma water; its plasma protein binding amounted to 64.3%. Etomidate was bound at or in the blood cells, whereas R 28 141 was not.     

Species-specific binding of sperm proteins to the extracellular matrix (zona pellucida) of the egg

The zona pellucida is an extracellular matrix surrounding the mammalian egg where species-specific gamete recognition and signaling occur. Pig zona pellucida were isolated in large amounts and used as an affinity matrix for detergent-solubilized, biotinylated membrane proteins of pig spermatozoa. On non-reducing SDS-polyacrylamide gel electrophoresis, specifically bound sperm proteins migrated with M(r) 170,000, 150,000, 130,000, 56,000, and 50,000 (p50). Disulfide bond reduction separated each of the M(r) 130,000-170,000 proteins into M(r) 105,000 (p105) and M(r) 45,000 (p45) subunits, indicating that these high M(r) proteins are related. Based on two-dimensional electrophoresis, the M(r) 56,000 band was composed of three to four proteins that migrated with M(r) 56,000-62,000 (p56-62) in the second (reducing) dimension. p50 bound to heterologous zona pellucida (murine, bovine) and to Xenopus laevis oocyte envelopes, demonstrating a lack of species specificity to its binding and was identified as proacrosin/acrosin based on amino acid sequences of two tryptic peptides and its interaction with monospecific antibodies to proacrosin. In contrast, p105/p45 and one or more of the p56-62 proteins bound to pig zona pellucida but not to the egg extracellular matrices of the other species; these proteins therefore exhibited the species-specific binding to the zona pellucida expected for molecules involved in specific gamete adhesion. Amino acid sequences of nine tryptic peptides derived from p105/p45 did not match peptide sequences in existing databases, establishing it as a unique protein. These (p105/p45 and at least one p56-62 protein) are the first sperm membrane proteins to be identified that bind in a species-specific manner to the egg extracellular matrix.     

The interaction between retinol-binding proteins and prealbumins studied by fluorescence polarization

The interaction between retinol-binding proteins and prealbumins of human and chicken was studied by fluorescence polarization techniques. The binding affinity between chicken plasma retinol-binding protein and chicken prealbumin was essentially the same as between the respective human proteins. Human urine retinol-binding protein displayed a similar affinity, though possibly slightly smaller than that of the human plasma protein, toward human prealbumin. Retinol-binding proteins and prealbumins of human and chicken have been found to cross-interact displaying an affinity similar to that displayed by the proteins of the same species. Solution of a binding equation which assumes identical, independent sites, indicated that the number of binding sites on prealbumin for retinol-binding protein is somewhat less than 2 with the human system, and in the neighborhood of 4 with the chicken system. A possible interpretation suggests that prealbumin possesses four identical binding sites for retinol-binding protein, one for each subunit, but that the binding is of a negative cooperative nature. A major share of the negative cooperativity is likely to result from steric hindrance induced by already bound retinol-binding protein molecules, which have a sizable volume compared to the volume of the prealbumin molecule. The cooperativity is likely to be more pronounced with the human system. Rotational relaxation times derived from Perrin plots suggest that 1:1 molecular complexes of retinol-binding proteins with prealbumins have a compact structure.     

Steroid binding by mouse salivary proteins

The goals of this study were to determine the steroid-binding specificity of the mouse salivary androgen-binding protein (ABP) family and to ascertain whether there might be other proteins in mouse saliva capable of binding steroids. The optimal conditions for testosterone binding by mouse salivary proteins were determined using a small-scale chromatography system to separate bound from unbound steroid. Testosterone binding appeared to be biphasic but was directly proportional to saliva concentration, with an optimum temperature of 37 degrees C in the second phase. These results were used to develop a steroid-binding protocol to study the steroid specificity of salivary proteins separated by electrophoresis. The ABP family bound testosterone and progesterone well and HO-progesterone and DHT to a lesser extent but did not bind either cholesterol or estradiol. Steroid structural comparisons suggest that binding by ABP is governed by the A ring of the steroid. Another protein that is not a member of the ABP family bound cholesterol specifically but no protein that specifically bound estradiol was observed.     

High density lipoprotein (HDL), and not albumin, is the major palmitate binding protein in New Zealand long-finned (Anguilla dieffenbachii) and short-finned eel (Anguilla australis schmidtii) plasma

Plasma from two members of the teleost Anguillidae family, the New Zealand long-finned (Anguilla dieffenbachii) and short-finned eels (Anguilla australis schmidtii), were examined. Agarose gel electrophoresis showed both species had a major anionic diffuse protein band migrating at approximately the same position as human albumin, and autoradiography showed this protein bound [14C]palmitic acid, but not 63Ni2+. Cellulose acetate electrophoresis followed by Oil Red O staining suggested that this band was a lipoprotein. Two-dimensional electrophoresis of plasma showed the absence of a significant albumin band at approx. 65 kDa, and that the palmitate binding band appeared to be composed of at least three proteins, with the major protein running at 30 kDa. N-Terminal sequencing of the palmitate binding band indicated major sequences of DAPAPP(S)QLED- for long-finned eel and DAPAPPSQLEHV- for short-finned eel, confirming their identities as apo-AI, the major apolipoprotein of high density lipoprotein (HDL). When ultracentrifugation was used to separate the lipoproteins of each species, the anionic palmitate binding protein was found solely in the lipoprotein fractions. There was no evidence of albumin in plasma from either eel, and it appears that in its absence HDL takes on the role of fatty acid transport.     

Determination of protein binding of gyrase inhibitors by means of continuous ultrafiltration

In order to characterize the protein binding of a drug, it is necessary to have a method which is close to in vivo conditions and fast in the course of measurement. The continuous ultrafiltration fulfils both requirements for substances with a high extent of protein binding. In this study, 18 gyrase inhibitors in clinical practice, characterized by a lower extent of protein binding, were subjected to the titration procedure of the continuous ultrafiltration using bovine and human serum albumin (BSA, HSA), and human plasma. The results of the continuous ultrafiltration were found to be similar to those obtained by means of the 'classical' discontinuous ultrafiltration using plasma (correlation between continuous and discontinuous ultrafiltration r2 = 0.87). In the cases of pipemidic acid, enoxacin and rufloxacin, the continuous method gave approximately 20% lower degrees of protein binding than the discontinuous procedure, which utilizes plasma having the full range of proteins. It is likely that these drugs bind mainly to other proteins in plasma than HSA. This finding proves that this fast method is worthwhile in the whole range of protein binding.     

Cyclic somatostatin analogs bind specifically to pI 6.1 carboxylesterase of rat liver cells

The hydrophobic cyclohexapeptide cyclo(Phe-Thr-Lys-Trp-Phe-DPro) (008), an analog of somatostatin with retro sequence, was previously shown to competitively inhibit the uptake of cholate and taurocholate into isolated rat liver cells. Conversely, the competitive uptake inhibition of 008 into isolated rat hepatocytes by bile acids confirmed the observation of common binding and transport sites by bile acids and cyclosomatostatin. Furthermore the transport characteristics of 008 uptake revealed a significant and rapid binding to cell membranes. In this context it was of special interest to investigate the specificity of the binding component since specific binding of the substrate to membrane proteins could be responsible for the low Km of 008-transport. Therefore, the cyclohexapeptide 008 could be used as the ligand in affinity chromatography in order to isolate such binding proteins. The gel matrix used did not interact non-specifically with octylglucoside-solubilized proteins from isolated rat liver plasma membranes. In affinity chromatography of octylglucoside-solubilized plasma membranes, two dominant proteins with apparent molecular masses of 60 and 58 kDa bound specifically to the 008 ligand. When used as ligands in affinity chromatography, these membrane-associated 60 and 58 kDa proteins bound exclusively to aromatic cyclopeptides, e.g. cyclosomatostatin 008, but not to linear peptides or taurocholate derivatives. The amino acid sequences of tryptic digests of the 008-affinity-purified 58 kDa protein were identical to the sequence of a microsomal pI6.1 carboxylesterase. Immunofluorescence of intact hepatocytes showed that this xenobiotic metabolizing enzyme is also located in sinusoidal rat liver plasma membranes and could therefore account for the extensive and specific binding of the cyclosomatostatin to sinusoidal plasma membranes of rat liver.     

Protein associated with human lens 'native' membrane during aging and cataract formation

Plasma membrane contains extrinsic as well as intrinsic proteins. Changes in the extrinsic proteins of lens membrane during human aging and cataract formation have not been investigated in detail. Unlike previous studies which examined lens membrane after being stripped of extrinsic proteins by treatment with chaotropic agents, we have isolated whole or 'native' lens membrane on a sucrose gradient by ultracentrifugation of the total water-insoluble protein. Essentially all of the water-insoluble protein from young to aged to cataractous human lens appeared membrane associated. In young lens (20-37 years old), most of the membrane banded at the 25/45% sucrose interface fraction. This fraction contained relatively little urea-soluble protein and likely represents fiber-cell plasma membrane with its physiologically associated extrinsic and intrinsic proteins. With aging (62-80 years old), about one-third of the membrane, as judged by the distribution of cholesterol, banded at a much higher density (50/58% sucrose fraction). The higher density was due to a great increase in the membrane's relative protein content (protein/cholesterol). Although this extra protein was composed of both urea-insoluble and -soluble fractions, the urea-soluble protein predominated in all lenses. Cataractous lens differed from aged-clear lens in that much more of the total membrane (70-75%) had shifted to the high density and participated in this massive binding of cytosolic proteins. Although alpha-crystallin was the principal extrinsic-membrane protein in young lens, high molecular weight aggregate of modified (acidic) crystallins accounted for the increased extrinsic protein in aging. The extrinsic proteins bound to both clear-aged and cataractous lens membrane were aggregated. In conclusion, examination of human lens native membrane fractions revealed that the association of crystallins with membrane in both aging and cataracts was much greater than previously recognized and most of this increased protein was non-covalently bound to the membrane. Much more of the lens total membrane from cataractous than clear-aged lens was involved in this massive protein association and the protein bound to cataract membrane appeared more highly aggregated.     

The binding of phytohemagglutinin M to rat spleen lymphocytes. Quantitative studies

Phytohemagglutinin M (PHAM) has been purified from the commercial mixture of proteins produced by Phaseolus vulgaris, using a Sepharose-thyroglobulin column. The protein gave one band on gel electrophoresis and two bands on SDS-gel electrophoresis (mol. wt. 33 700 and 32 100, respectively). Molecular weight determination by ultracentrifugation gave a value of 61 200 +/- 700. The protein had a minimum sugar content of 16%. Binding studies of PHAM to purified rat spleen lymphocytes have been performed at 0, 25, and 37 degrees C. It was shown that the cells bound about the same amount of lectin at 0 and 37 degrees C, but less protein was bound at 25 degrees C. The binding phenomenon showed saturability at all temperatures. Data were analyzed by Scatchard plots and two kinds of binding sites were found. High-affinity sites and low-affinity sites have been characterized in terms of association constants and (apparent) number. It was also shown that cells treated with trypsin or sodium azide bound less lectin. Bound concanavalin A did not appear to affect the amount of bound PHAM, but its influence was reflected in the value of the association constant for the binding of PHAM. Unlabelled PHAM was shown to displace radioactive PHAM from the cells, but could not remove bound concanavalin A. The significance of these results is discussed in terms of the fluid plasma membrane model and cellular metabolism.     

Specificity and determinants of Sam68 RNA binding. Implications for the biological function of K homology domains

Sam68, a specific target of the Src tyrosine kinase in mitosis, possesses features common to RNA-binding proteins, including a K homology (KH) domain. To elucidate its biological function, we first set out to identify RNA species that bound to Sam68 with high affinity using in vitro selection. From a degenerate 40-mer pool, 15 RNA sequences were selected that bound to Sam68 with Kd values of 12-140 nM. The highest affinity RNA sequences (Kd approximately 12-40 nM) contained a UAAA motif; mutation to UACA abolished binding to Sam68. Binding of the highest affinity ligand, G8-5, was assessed to explore the role of different regions of Sam68 in RNA binding. The KH domain alone did not bind G8-5, but a fragment containing the KH domain and a region of homology within the Sam68 subgroup of KH-containing proteins was sufficient for G8-5 binding. Deletion of the KH domain or mutation of KH domain residues analogous to loss-of-function mutations in the human Fragile X syndrome gene product and the Caenorhabditis elegans tumor suppressor protein Gld-1 abolished G8-5 binding. Our results establish that a KH domain-containing protein can bind RNA with specificity and high affinity and suggest that specific RNA binding is integral to the functions of some regulatory proteins in growth and development.     

Evaluation of the Vitatron "AKES" modification for optimal use in routine enzyme analysis

The method investigated used (3H) cortisol as the ligand, diluted human plasma as the binding protein, and florisil to separate free and bound cortisol. The precision and specificity were found to be adequate for routine use. The effects of such factors as delay in separation of plasma, storage of plasma, provenance of the binding protein, venepuncture, and venous occlusion have been studied. The extent and significance of short term, inter-daily, and longer term variation in plasma cortisol level are discussed.     

Binding characteristics of KNI-272 to plasma proteins, a new potent tripeptide HIV protease inhibitor

The binding characteristics of KNI-272, a potent and selective human immunodeficiency virus (HIV) protease inhibitor, were evaluated in rat and human plasma, and in solutions of human alpha 1-acid glycoprotein (AAG) and human serum albumin (HSA). The unbound fractions (Fu) of KNI-272 were 12.13 and 2.24% in rat and human plasma, respectively, at the drug concentration of 1.0 microgram mL-1. Although KNI-272 binds to both AAG and HSA, the Fu of KNI-272 in AAG solution was 1.83%, and only one-quarter of that in HSA solution (Fu = 6.78%). Binding displacing agents, such as disopyramide, warfarin, diazepam, and digitoxin, were used to determine the binding site of KNI-272 on these plasma proteins. The Fu of KNI-272 in AAG solution increased 14-fold when disopyramide was added to the AAG solution. In addition, warfarin, diazepam, and digitoxin were added to HSA solution as representative drugs bound to distinct binding sites on HSA, namely sites I, II, and III, respectively. The Fu values of KNI-272 in HSA solution significantly increased when warfarin and diazepam were added. In particular, with the addition of warfarin to HSA solution, the Fu of KNI-272 increased to 16%. The modified Scatchard plots of KNI-272 binding to AAG and HSA both showed biphasic curves, and the KNI-272 binding sites at low concentration range on AAG and HSA disappeared with the addition of disopyramide and warfarin, respectively. Therefore, it is considered that KNI-272 binds to the identical site as disopyramide on AAG and site I on HSA in the low KNI-272 concentration range. By comparing the KNI-272 binding parameters obtained in human plasma and these protein solutions, we can assume that KNI-272 binding at low concentration in human plasma is mainly concerned with the binding on AAG. As KNI-272 concentration in plasma increases, HSA becomes concerned with KNI-272 binding.     

Hepatitis B virus surface antigen binds to apolipoprotein H

We have previously demonstrated that a plasma membrane-enriched fraction isolated from human liver is capable of binding recombinant hepatitis B surface antigen (rHBsAg) (P. Pontisso, M. A. Petit, M. Bankowski, and M. E. Peeples, J. Virol. 63:1981-1988, 1989). In this study we have separated the plasma membrane proteins by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and used a ligand-blotting technique to identify a 46-kDa rHBsAg-binding protein. This protein could be removed from the membranes with a weakly acidic buffer, implying that it is peripherally bound. Examination of human serum revealed that the 46-kDa binding protein is a serum protein. Isolation of plasma lipoproteins revealed that the binding protein is in part associated with chylomicrons and high-density lipoproteins, both of which are targeted to the hepatocyte during the normal course of lipid metabolism. The binding protein was identified as apolipoprotein H (apo H), also known as beta 2-glycoprotein I, on the basis of copurification of the rHBsAg-binding activity with the apo H protein and the ability of cDNA-expressed apo H to bind rHBsAg. Serum-derived HBsAg also binds to apo H, indicating that binding is not unique to rHBsAg. Binding is saturable, requires only the small S protein of rHBsAg, and is inhibited by excess rHBsAg, antibodies to HBsAg, and antibodies to apo H. The binding activity of apo H is destroyed upon reduction, indicating that 1 or more of its 22 disulfide bonds are required for interaction with rHBsAg. The possibility that an interaction between hepatitis B virus particles and lipoprotein particles may facilitate entry of the virus into hepatocytes is discussed.     

Theoretical analysis of the binding of salicylate by human serum albumin: the relationship between free and bound drug and therapeutic levels

The binding of salicylates by human serum albumin was analyzed by use of a computer program using previously published association constants and binding capacities for the two sets of binding sites on the protein. The analysis consisted of computing free and bound salicylates for a range of therapeutic and toxic concentration from 181 to 7246 mumole/L (25 to 1000 mg/L). At low and therapeutic levels the total amount of bound drug would exceed the amount of free drug. At higher levels, which included therapeutic and toxic ranges, the amount of free drug plasma, up to 2000 mumole/L the high affinity sites (Site 1), would bind most of the drug, but as the concentration of drug increased this site would approach saturation and the low affinity Site 2 would bind increasing amounts of salicylate. At high salicylate levels the amount of drug bound by the low affinity sites. Computation also showed that when the total amount of protein in the analysis was reduced, from 5, 4, 3, to 2 gm%, as in hypoalbuminemia, the total amount of drug bound by the protein would decrease and the quantity of free drug would increase. The amount of drug bound by each of the two sets of sites also fell as the concentration of protein decreased. Some of the possible clinical implications of these findings are discussed.