Efficacy of beta2-agonists in bronchiolitis: a reappraisal and meta-analysis

OBJECTIVE

To evaluate the efficacy of beta2-agonists in bronchiolitis.

DESIGN

Critical review and meta-analysis of randomized controlled trials of inhaled beta2-agonists.

RESULTS

Three inpatient and five outpatient studies were identified. Inpatient studies (82 patients) were characterized by wide variability in therapeutic regimens and measurement of outcomes. Several problems were identified in the selection and specification of patients, such as failure to assess the prestudy duration of illness or to exclude patients already taking bronchodilators. Meta-analysis was not possible for inpatient trials due to the great variability in study outcomes, timing of outcome assessment, and drug regimens. Results of inpatient trials were contradictory: one found significant reductions in the clinical score and a shorter hospital stay with treatment, whereas two others found only significant oxygen desaturations. Outpatient studies (251 patients) examined immediate changes in physiologic measures and clinical scores after two treatments, but have not examined the effects of the longer-term regimen customarily used by clinicians. Meta-analysis revealed that short-term beta2-agonist therapy had no impact on the hospitalization rate or respiratory rate, and had a statistically significant but clinically insignificant impact on oxygen saturation and heart rate. The diversity of scoring systems precluded pooling of clinical score data.

CONCLUSIONS

Despite eight clinical trials, conclusive evidence for the efficacy of beta2-agonist therapy for bronchiolitis remains unavailable. Well-designed inpatient trials are needed. Meta-analysis of outpatient studies does not support the use of beta2-agonist therapy for bronchiolitis, but investigators have not studied the outcomes and the long-term outpatient regimen customarily used by clinicians.

Effect of chemotherapy on thyroid hormone concentration in patients with malignant hematologic diseases

Malignant hematologic diseases are severe illnesses for which complex forms of treatment are used and to which a great variety of metabolic changes are anticipated. Both lymphomas and leukemias, as well as chemotherapy, can induce abnormalities in thyroid hormone metabolism without overt disease, thus leading to what is known as euthyroid sick syndrome (ESS). In the present report, 25 patients with lymphomas and leukemias were studied to evaluate the effect of chemotherapy on thyroid hormone concentration. After chemotherapy, the most frequent and significant alteration was a decrease in serum triiodothyronine concentration.

Enhanced amphetamine sensitivity and increased expression of dopamine D2 receptors in postpubertal rats after neonatal excitotoxic lesions of the medial prefrontal cortex

Functional and structural abnormalities in the medial prefrontal cortex (MPFC) and overactive dopamine (DA) neurotransmission are thought to be the key pathologies in schizophrenia. To understand the role of MPFC in the pre- and postpubertal development of the subcortical DA system, the effects of neonatal [postnatal day 7 (PD7)] MPFC excitotoxic lesions on locomotor behaviors and the expression of DA receptor subtypes and DA transporter were investigated in Sprague Dawley rats at PD35 and PD56, respectively. No significant differences in the novelty of d-amphetamine-induced locomotion were observed between sham-operated and ibotenic acid-lesioned rats at PD35. Postpubertally (at PD56), however, the locomotor activity of lesioned rats in the novel environment and after d-amphetamine administration was enhanced significantly compared with controls. The expressions of DA D1, D2, D3, and D4 receptors and DA transporter were then estimated in MPFC-lesioned and sham-operated rats at PD59 and PD60. The levels of DA D2 receptors, measured using [3H]-YM-09151-2 binding, and its mRNA by in situ hybridization, were observed to be significantly increased at PD60 in striatal and limbic areas of lesioned rats. Levels of other DA receptor subtypes were not significantly affected at any time points. Lesioned rats at PD39 show a small increase in DA transporter level in the shell of nucleus accumbens; however, this effect seems to wear off at PD60. The data suggest that neonatal MPFC lesions may alter the functional development and maturation of mesolimbic/nigrostriatal DA systems in that neonatally lesioned rats grow into a behavioral/neurochemical deficit.

Muscarinic antagonists microinjected into the subthalamic nucleus decrease muscular rigidity in reserpinized rats

The ability of anticholinergic agents microinjected into the subthalamic nucleus to reduce reserpine-induced muscular rigidity was assessed in rats. The electromyographical activity of the gastrocnemius-soleus muscle was used as a parameter of muscular rigidity. Reserpine (5 mg/kg i.p.) produced the appearance of electromyographical activity. The muscarinic antagonists M3 (1.27 nmol of 4-DAMP) and M1 (2.36 nmol of pirenzepine) markedly reduced the reserpine-induced electromyographical activity, whereas the M2 antagonist AFDX-116 (2.37 nmol) had no effect. These results suggest that a high cholinergic tone in the subthalamic nucleus is associated with the reserpine-induced muscular rigidity. Moreover, the M3 muscarinic antagonist is more effective than the M1 muscarinic antagonist in reducing the muscular rigidity in reserpinized rats, a model of Parkinson's disease, by blocking the high cholinergic tone in the subthalamic nucleus.

Ionic effects of angiotensin II and their role in the activation of the Na+/H+ antiporter

The possible interdependence of the effects of angiotensin II (Ang II) on intracellular pH (pHi), free cytosolic calcium (Cai2+) and free cytosolic sodium (Nai+) was studied in cultured vascular smooth muscle cells (VSMC) from rat aorta. Cells were loaded with either BCECF/AM, SBFI/AM or Fura-2 for measurement of pHi, Nai+ or Cai2+, respectively. Superfusing with a HEPES solution containing Ang II (1 microM) caused a progressive increase in Nai+. Concurrent pHi changes measured in parallel experiments showed that Ang II caused a brief cell acidification followed by a delayed alkalinization, which is due to activation of the Na+/H+ antiporter. Concurrent Cai2+ changes measured in parallel experiments showed that Ang II caused a prompt rise in Cai2+ with a peak response at approximately 30 seconds followed by a rapid recovery. Obliteration of the Ang II-induced rise in Cai2+ using a Ca2+ chelator (BAPTA), prevented the initial cell acidification but did not prevent the delayed rise in pHi, which reflects stimulation of the Na+/H+ antiporter. Our data thus show that in cultured VSMC neither the rise in Cai2+ nor the fall in pHi caused by Ang II is a total prerequisite for activation of the Na+/H+ antiporter by this agonist.

Circling behavior elicited by cholinergic transmission in the substantia nigra pars compacta: involvement of nicotinic and muscarinic receptors

The influence of cholinergic transmission within the substantia nigra pars compacta on circling behavior was assessed in male rats. Microinjection of physostigmine (6-37 nmol) into the caudal part of the substantia nigra pars compacta elicited a dose-dependent contralateral circling. The circling was inhibited 93 +/- 3% by the dopamine antagonist haloperidol (53 nmol) injected into the neostriatum 90 min before the injection of physostigmine (37 nmol) into the ipsilateral substantia nigra pars compacta. The effect of haloperidol was reversible, since the circling behavior was fully restored when physostigmine was applied to the same animals 24 h later. The circling was completely blocked when physostigmine (37 nmol) was applied simultaneously with the muscarinic M1 antagonist pirenzepine (2 nmol). The M2 antagonist AF-DX 116 (2 nmol) only partially blocked the circling induced by a lower dose of physostigmine (12 nmol). The nicotinic antagonist mecamylamine (5 nmol) also inhibited the circling, but only during the 5 min following co-injection of the drugs. These results indicate that endogenous acetylcholine stimulates muscarinic and nicotinic receptors of nigrostriatal dopaminergic neurons which, in turn, increase their firing rate and cause the circling behavior. We conclude that the pedunculopontine cholinergic neurons, which innervate the substantia nigra pars compacta, modulate the motor behavior by increasing the activity of dopaminergic nigrostriatal pathway.

Decreased binding of dopamine D3 receptors in limbic subregions after neonatal bilateral lesion of rat hippocampus

Neonatal, bilateral lesion of the ventral hippocampus (VH) in rats recently has been proposed as a model of schizophrenia because these animals show postpubertal hypersensitivity to stress and to dopamine (DA) agonists that can be reversed by neuroleptic treatment. In search of the mechanisms of postpubertal emergence of hyperdopaminergic behavior in this model, we investigated developmental expressions of DA D1, D2, and D3 receptors in various striatal and limbic subregions of rats that had received bilateral ibotenic acid lesion of the VH at postnatal day 7 (PD7). D-Amphetamine-, apomorphine-, and stress-induced changes in locomotor activity were measured and, in accordance with previous reports, we observed an increased locomotor activity at PD56 in the hippocampal-lesioned group. The expression of DA D1, D2, and D3 receptors was then estimated in these rats by ligand autoradiography at PD41 and PD62. We observed that the levels of DA D3 receptors, as measured by tritiated 7-hydroxy-N,N-di-n-propyl-2-amino-tetralin ([3H]7-OH-DPAT) binding, are markedly reduced at PD62 in the limbic areas of lesioned rats compared with sham controls particularly in the nucleus accumbens, olfactory tubercles, and islands of Calleja. A small but significant increase in D1 receptors was also seen in the caudate-putamen of the lesioned animals at PD62, whereas no significant change in the overall expression of D2 receptors ([3H]spiperone binding) was noted. In view of the inhibitory role of D3 receptors on locomotion and, presumably, other DA-mediated behaviors, it is suggested that behavioral changes in the neonatally hippocampal-lesioned rats may be mediated by altered D3 receptor levels.

The preparedness of pediatricians for emergencies in the office. What is broken, should we care, and how can we fix it?

OBJECTIVES

To determine the frequency of emergencies in pediatric practices, assess office emergency preparedness, and explore practitioner's reasons for levels of preparedness.

DESIGN AND SETTING

Telephone survey of pediatric offices in Fairfield County, Connecticut.

SAMPLE

Fifty-one (98%) of 52 offices participated, representing 481 staff.

RESULTS

More than 2400 emergencies are seen each year in the pediatric offices, with a median of 24 emergencies per practice annually. Forty-two (82%) of the practices averaged at least one emergency per month, 13 (25%) experienced more than 50 emergencies annually, and seven (14%) experienced more than 100 emergencies annually. Of all eligible staff, 14% were certified in basic life support and 17% in pediatric advanced life support. The following emergency equipment was missing from offices: oxygen, 14 (27%); intravenous catheters, 14 (27%); bag-valve-mask, 15 (29%); nebulizers, 17 (33%); epinephrine 1:10 000, 27 (53%); and intravenous fluids, 28 (55%). Thirty-seven (73%) of offices had the minimum recommended equipment and training for status asthmaticus management; only 17 (33%) of offices had similar preparation for each of the six other emergencies. High-level emergency preparedness was rare. The perceptions of office pediatricians are that office emergencies are rare, and emergency preparedness is difficult to achieve because practices are too busy and the expense and time commitment are too great.

CONCLUSIONS

Emergencies are common in pediatric practices, but problems in the emergency preparedness of practices persist despite previous studies with similar findings, and publication of guidelines. Perceptions of practitioners suggest that not enough effort has been devoted to increasing practitioner awareness of these problems. Greater awareness might result by emphasizing practical instruction in residency and continuing medical education courses, and by publication of guideline summaries.

M3 muscarinic receptors mediate cholinergic excitation of the spontaneous activity of subthalamic neurons in the rat

The effect of the muscarinic antagonist on carbachol-induced increase in spontaneous activity of neurons of the subthalamic nucleus was examined by recording the extracellular unitary activity in an in vitro slice preparation. Carbachol produced (98% of the 263 neurons tested) an increase (twofold of the basal at 500 nM) of the discharge frequency. The EC50 for the carbachol-induced effect was 375 +/- 8.7 nM (mean +/- SEM). The response was blocked by muscarinic antagonists in a dose dependent manner. However, the IC50 (94 +/- 3 nM) for the M3 antagonist 4-diphenyl acetoxy-N-methyl piperidine methobromide (4-DAMP) was considerably less than the other muscarinic antagonists (M1 antagonist pirenzepine, IC50 1340 +/- 110 nM; M2 antagonist AF-DX-116, IC50 6780 +/- 690 nM). These results suggest that the cholinergic input to the rat subthalamic nucleus exerts a postsynaptic excitatory action and this effect is likely mediated via muscarinic receptor type 3.

Angiotensin II and angiotensin-(1-7) effects on free cytosolic sodium, intracellular pH, and the Na(+)-H+ antiporter in vascular smooth muscle

The aim of the present study was to define the effects of angiotensin II (Ang II) and Ang-(1-7) on free cytosolic Na+ (Na+i), intracellular pH (pHi), and the Na(+)-H+ antiporter in cultured vascular smooth muscle cells from rat aorta. Cells were loaded with either BCECF-AM or SBFI-AM for measurement of pHi and Na+i, respectively. Ang II (10(-6) mol/L) caused a rapid rise in Na+i followed by a progressive increase that peaked at about 10 minutes (from 11 +/- 1.5 to 16 +/- 1.5 mmol/L, P < .001), whereas Ang-(1-7) (10(-6) mol/L) did not affect Na+i significantly (from 11.5 +/- 1.1 to 11.8 +/- 0.07 mmol/L). The effect of Ang II on Na+i was concentration dependent (delta Na+i, 5.1 +/- 0.9, 3.8 +/- 0.6, 1.6 +/- 0.6, and 0.14 +/- 0.18 mmol/L with decreasing concentrations of 10(-6), 10(-7), 10(-8), and 10(-9) mol/L, respectively). Ang II caused a brief acidification followed by an increase in pHi (from 7.34 +/- 0.03 to 7.43 +/- 0.03 after 10 minutes, P < .005), and Ang-(1-7) had no significant effect on pHi (from 7.23 +/- 0.03 to 7.23 +/- 0.03). To investigate whether pHi and Na+i changes induced by Ang II were due to cell Na+ entry via stimulation of the Na(+)-H+ antiporter, we pretreated cells with EIPA (25 mumol/L) or ouabain (2.0 mmol/L). Ang II in the presence of ouabain caused a greater increase than that seen with ouabain alone (delta Na+i, 13 +/- 1.5 versus 6.3 +/- 1.2 mmol/L, P < .0025). EIPA by itself decreased Na+i and pHi. After EIPA, Ang II failed to increase both Na+i and pHi, demonstrating that the Na(+)-H+ antiporter is responsible for the rises in Na+i and pHi during stimulation with Ang II. To further characterize the mechanism of Ang II action, we exposed cells to an Ang II type I receptor antagonist (L-158,809, 10(-6) mol/L) or two different type 2 receptor antagonists (PD 123177 and CGP 421112A, 10(-6) mol/L). L-158,809 completely blocked the rise in pHi caused by Ang II, whereas PD 123177 and CGP 421112A did not. We conclude that Ang II increases both Na+i and pHi, and both effects are mediated by stimulation of the Na(+)-H+ antiporter. Ang-(1-7), by contrast, has no significant effect on Na+i, pHi, or the Na(+)-H+ antiporter. Stimulation of this antiporter by Ang II is exerted through the type 1 receptor.

5-Hydroxytryptamine increases spontaneous activity of subthalamic neurons in the rat

The effect of 5-hydroxytryptamine on the spontaneous activity of neurons of the subthalamic nucleus was examined by recording the extracellular unitary activity in an in vitro slice preparation. The most frequent response to 5-hydroxytryptamine (84% of 57 neurons tested) was an increase (twofold of basal at 10 microM) of the discharge frequency. The EC50 for the 5-hydroxytryptamine-induced effect was 1.8 +/- 0.5 microM (mean +/- SEM). The response was dose-dependently blocked by the serotoninergic antagonist mianserin and was not prevented by removal of calcium ions from the perfusing buffer. These results indicate that the serotoninergic input to the rat subthalamic nucleus exerts a postsynaptic excitatory action on most neurons of the nucleus.

Intracellular acidification associated with changes in free cytosolic calcium. Evidence for Ca2+/H+ exchange via a plasma membrane Ca(2+)-ATPase in vascular smooth muscle cells

The purpose of this study was to define the mechanism whereby agonists that increase free cytosolic calcium (Cai2+) affect intracellular pH (pHi) in smooth muscle. Rat aortic vascular smooth muscle cells grown on coverslips were loaded with BCECF/AM or fura-2/AM for continuous monitoring of pHi or Cai2+, respectively, in a HCO3-/CO2- containing medium. Recovery from rapid increases in Cai2+ produced by 1 microM angiotensin (Ang) II (delta Cai2+ -229 +/- 43 nM) or 1 microM ionomycin (delta Cai2+ -148 +/- 19 nM) was accompanied by a fall in pHi (delta pHi, -0.064 +/- 0.0085 P < 0.01, and -0.05 +/- 0.012 pH units, P < 0.01, respectively). Neither the fall in pHi nor the rise in Cai2+ elicited by Ang II was prevented by pretreatment with agents which block the action of this agonist on pHi via the stimulation of the Cl/HCo3 exchangers (DIDS, 50 microM) or the Na+/H+ antiporter (EIPA, 50 microM). In the presence of DIDS and EIPA, Ang II produced a fall in pHi (delta pHi, -0.050 +/- 0.014, P < 0.01) and a rise in Cai2+ (delta Ca2+ 252 +/- 157 nM, P < 0.01). That the change in pHi was secondary to changes in Cai2+ was inferred from the finding that, when the rise in Cai2+ elicited by Ang II was prevented by preincubation with a Ca2+ buffer, BAPTA (60 microM), the fall in pHi was abolished as well (delta pHi, 0.0014 +/- 0.0046). The pHi fall produced by Ang II and ionomycin was prevented by cadmium at a very low concentration (20 nM) which is known to inhibit plasma membrane Ca(2+)-ATPase activity (delta pHi -0.002 +/- 0.0006 and -0.0016 pH units, respectively). Cadmium also blunted Cai2+ recovery after Ang II and ionomycin. These findings suggest that the fall in pHi produced by these agents is due to H+ entry coupled to Ca2+ extrusion via the plasma membrane Ca(2+)-ATPase. Our results indicate that agonists that increase Cai2+ cause intracellular acidification as a result of Ca2+/H+ exchange across the plasma membrane. This process appears to be mediated by a plasma membrane Ca(2+)-ATPase which, in the process of extruding Ca2+ from the cell, brings in [H+] and thus acidifies the cell.

Activation of subthalamic neurons produces NMDA receptor-mediated dendritic dopamine release in substantia nigra pars reticulata: a microdialysis study in the rat

Here we have studied whether the activation of the subthalamic neurons induces the release of dopamine (DA) from dopaminergic dendrites in the pars reticulata of the substantia nigra. Subthalamic neurons were activated by carbachol microinjected into the subthalamic nucleus. A microdialysis probe was implanted in the medial aspect of the pars reticulata to collect samples of the perfusate. Carbachol (1 microgram/0.25 microliter saline) enhanced (58 +/- 8% over basal values) nigral DA release. The enhancement was fully blocked by the NMDA antagonist AP5 added to the microdialysis medium perfusing the pars reticulata. Perfusion of the pars reticulata with NMDA also increased (125 +/- 25% over basal) nigral DA release. Again, AP5 reversed the effect. These results suggest that activation of the glutamatergic subthalamonigral pathway enhances dendritic DA release by activating NMDA receptors present on dopaminergic dendrites.

Neurotransmitter levels in cerebrospinal fluid in relation to severity of symptoms and response to medical therapy in Parkinson's disease

Determinations of biopterin (BP), homovanilic acid (HVA), glutamic acid (GTA), and glutamine (GT) levels in cerebrospinal fluid (CSF) obtained through a lumbar tap were performed in 20 parkinsonian patients in different stages of evolution and without medication. In patients with motor symptoms not related to Parkinson's disease (dystonia, dyskinesia and essential tremor) (n = 4). In 7 other neurological patients subjected to spinal tap for diagnostic procedures neurotransmitters were also determined and taken as control groups. In 14 of the patients with Parkinson's disease, the symptoms were evaluated using conventional scales (UPDS, NYPDS, NWPDS, Schwab and England, and Hoehn and Yahr scale). The amplitude and the frequency of tremor were quantitatively evaluated through a single plane accelerometer Grass SP-1, akinesia was measured through reaction time to auditory stimuli, and rigidity through the speed of lineal movement. Evaluations were performed with the patient not on any medication for 1 week and repeated 1 h after the intake of 250 mg of 200/50 L-dopa/carbidopa preparation (Sinemet) and on a different day after the intake of biperiden (Akineton) 6 mg/day. Differences in neurotransmitter or metabolites levels between Parkinson's disease and control groups were determined through an independent Student's t test. Correlation between severity of symptoms in the scales and for each individual symptom measured through the quantitative tests and the levels of neurotransmitters in CSF were evaluated through the Pearson correlation analysis test. Modifications in the motor performance after administration of Sinemet and Akineton, and the levels of neurotransmitters were indirectly determined. RESULTS. (1) There were significant differences between the levels of BP and GT in patients with Parkinson's disease and control groups, (2) lower GTA levels correlated with more severe rigidity and akinesia, and with the best response to the administration of L-dopa and may be an important marker for prognosis, and (3) lower levels of GT correlated with least akinesia, but not with tremor, which may indicate that the akinesia depends on other biochemical abnormalities besides dopamine depletion.

Efficacy of intravenous immunoglobulin in the treatment of autoimmune hemolytic anemia: results in 73 patients

To determine whether warm-antibody autoimmune hemolytic anemia (AIHA) responds to treatment with intravenous gammaglobulin (IVGG), we conducted separate pilot studies at three institutions enrolling a total of 37 patients. We combined these results with a review of 36 cases of AIHA treated with IVGG reported in the literature. Sixteen clinical variables were examined to determine associations with response to IVGG. Overall, 29 of 73 patients (39.7%) responded to IVGG therapy. Two variables were strongly related to a good response to IVIG: the presence of hepatomegaly (with and without splenomegaly) and a low pre-treatment hemoglobin. A trend towards a better response was observed in the 11 children. Overall, IVGG provided acute benefit in only 1/3 of patients and therefore cannot be recommended as standard therapy for AIHA. It may, however, be useful as adjunctive treatment in selected cases, such as in those with a pre-treatment hemoglobin < 6-7 gm/dl or those with hepatomegaly, and in clinical settings where the toxicity of other treatments may be an important consideration.

Appearance of EMG activity and motor asymmetry after unilateral lesions of the dopaminergic innervation to the subthalamic nucleus in the rat

The effects of unilateral injections of 6-hydroxydopamine into the subthalamic nucleus on muscular rigidity and on motor behavior were examined. Muscular rigidity was judged by the appearance of electromyographical activity in the gastrocnemius-soleus muscle and motor behavior by the turning induced by DL-methamphetamine. The unilateral injection of 6-hydroxydopamine produced the appearance of electromyographical activity ipsilateral to the injected side and ipsilateral turning in response to systemic administration of DL-methamphetamine. These results suggest that the dopaminergic innervation exerts a tonic inhibitory action on the spontaneous activity of the subthalamic neurons. The loss of this action would cause muscular rigidity and motor asymmetry.

Bacteremia due to Pseudomonas aeruginosa in children with AIDS

Six episodes of Pseudomonas aeruginosa bacteremia in five children with AIDS were reviewed to characterize further the disease caused by this pathogen. Hypotension occurred in five episodes, and two children died. Bacteremia was associated most frequently with new pulmonary infiltrates and skin lesions, but additional sites of infection were also observed (the middle ear, an abdominal abscess, and the CNS). None of the children had catheter-associated infection, and only three were neutropenic. P. aeruginosa should be considered as a cause of sepsis in children with AIDS.

Activation of D1 receptors stimulates accumulation of gamma-aminobutyric acid in slices of the pars reticulata of 6-hydroxydopamine-lesioned rats

D1 dopamine receptors are present on terminals of striatal neurons to the pars reticulata of the substantia nigra in the rat. Here we have studied the effect of the activation of these receptors on the synthesis of gamma-aminobutyric acid (GABA) in slices of the pars reticulata of the substantia nigra isolated from 6-hydroxydopamine-lesioned rats. The synthesis was judged by the accumulation of GABA after inhibiting GABA transaminase with aminooxyacetic acid. Both dopamine and SCH 23390, a D1 agonist, stimulated the synthesis. The effect of both compounds was blocked by SCH 23390, a D1 antagonist, but not by sulpiride, a D2 antagonist. In the absence of receptor activation, the synthesis was very slow. The results suggest a trophic influence of dopamine upon the synthesis of GABA via D1 receptors.