Correlational study between psychic symptoms and quality of life among hemodialysis patients older than 55 years of age

BACKGROUND

The loss of renal function and urination with dialysis can produce a strong emotional crisis in a patient. This study explored the correlation between psychic symptoms and quality of life among hemodialysis patients who were older than 55 years of age in relation to demographic characteristics of age, time on dialysis, and education.

PATIENTS AND METHODS

Twenty patients undergoing hemodialysis were included in the study. The psychic symptoms were studied using the Symptom Checklist-90. Revised (SCL-90 R) and the quality of life was studied using the Complete Form Health Survey (SF 36).

RESULTS

The high correlation between psychological sizes investigated through the SCL-90 R test and those for the SF-36 test confirmed the close relationship between physical disorders and mental suffering, and reduced vitality, and lack of socialization.

CONCLUSION

The psychiatrist and psychologist may help hemodialysis patients to improve their quality of life by providing new coping strategies for each of the family, occupational, and social network.

Major postoperative complications and survival for colon cancer elderly patients

Background

Increased life expectancy has led to elevating the mean age of the patients at the time of diagnosis of colon cancer and subsequent treatment. Differences in complication rates and outcome between elderly and younger patients have been investigated.

Methods

We retrospectively analysed a database containing the information of patients who underwent surgery for stage I-III colorectal cancer from January 2004 to January 2012 at our institution and compared demographic, cancer-related, and outcomes data of 235 elderly patients with 211 patients ≤65 years old.

Results

Intraoperative complications did not differ between young and old patients whereas some differences have been found in postoperative and late complications: elderly patients suffered more by ileus (P = 0.024), peritonitis or septic shock (P = 0.017), pelvic abscess (P = 0.028), wound infection (P = 0.031), and incisional/port herniation (P = 0.012) compared with younger patients. Moreover, elderly patients suffered by systemic complications such as cardiovascular (4.7% vs. 1.4%, P = 0.049), renal (4.7% vs. 0.5%, P = 0.006), and respiratory (10.6% vs. 5.2%, P = 0.036). The multivariate analysis assessing the odds of having a complication revealed that older age (Odd Ratio [OR] 2.75, 95% Confidential Interval [CI]: 1.67-4.52) and open surgery (OR 1.63, 95% CI: 1.01-2.62) are significantly and independently associated with having a complication.

Conclusions

In our series, elderly patients have presented a slight higher incidence of comorbidities that may affect the incidence rates of postoperative complications. These results have implications in increasing the hospital stay as well as a higher rate of death.

Laparoscopic-assisted versus open surgery for colorectal cancer: short- and long-term outcomes comparison

BACKGROUND

Despite the theoretical advantages of laparoscopic surgery, it is still not considered the standard treatment for colorectal cancer patients because of criticism concerning oncologic stability. This study aimed at examining the short- and long-term follow-up results of laparoscopic surgery versus open surgery for colorectal cancer and at investigating clinical outcomes, oncologic safety, and any potential advantages of laparoscopic colorectal cancer resection.

SUBJECTS AND METHODS

We retrospectively analyzed a database containing the information about patients who underwent surgery for stage I-III colorectal cancer from January 2004 to January 2012 at our institution.

RESULTS

The patients who underwent the laparoscopic-assisted procedure showed a significantly faster recovery than those who underwent open surgery, namely, less time to first passing flatus (P=.041), time of first bowel motion (P=.04), time to resume normal diet (P=.043), and time to walk independently (P=.031). Laparoscopic colorectal surgery caused less pain for patients, leading to lower need of analgesic (P=.002) and less hospital recovery time (P=.034), compared with patients who underwent open surgery. No differences were found in 3- and 5-year overall and disease-free survival rates.

CONCLUSIONS

Our results suggested that the laparoscopic approach was as safe as the open alternative. Laparoscopic-assisted surgery has been shown to be a favorable surgical option with better short-term outcomes and similar long-term oncological control compared with open resection.

The Charlson comorbidity index as a predictor of outcomes in liver transplantation: single-center experience

Several comorbidity indices, such as the Child-Turcotte-Pugh (CTP) score and the Model for End-Stage Liver Disease (MELD) score, have been used to optimize available organ resources and adjust priorities in diagnosis and allocation of grafts for patients who are candidates for liver transplantation. There have also been various attempts to create instruments to accurately predict outcomes after liver transplantation, but none has proved to be truly applicable, with the exception of the Charlson comorbidity index (CCI). We retrospectively reviewed data of 221 liver recipients, including living-related liver transplantation and multiple organ transplantation performed between January 2006 and September 2009. Survival analysis revealed a significant association of the CCI with decreased posttransplantation patient survival (P = .003). Furthermore, Kaplan-Meier plots and log-rank test showed a significant association between graft survival and the score (P = .039). Our data suggest that the CCI is a simple tool for the evaluation of comorbidity and that increased preoperative patient comorbidity increases the risk of graft loss and patient death after liver transplantation. The CCI should be considered an important tool for improving patient care because of its potential applications for patient management.

Long-term persistence of seroprotection by hepatitis B vaccination in healthcare workers of southern Italy

BACKGROUND

The impact of hepatitis B virus (HBV) vaccination campaigns on HBV epidemiology needs to be evaluated, in order to assess the long-term immunity offered by vaccines against HBV.

OBJECTIVES

To evaluate the current status of anti-HBV vaccine coverage among healthcare workers (HCWs) in Southern Italy, and to determine the long-term persistence of antibodies to hepatitis B surface antigens (anti-HBs) in such a cohort of subjects.

PATIENTS AND METHODS

A longitudinal, retrospective seroepidemiological survey was conducted among 451 HCWs, who were working at or visiting, the Occupational Health Department of a city hospital, in Catania, Italy, between January 1976 and December 2010.

RESULTS

At the 30-year follow-up (mean follow-up 10.15 ± 5.96 years, range 0.74-30), 261 HCWs had detectable anti-HBs titers indicating a persistence of seroprotection of 89.4% (out of 292 anti-HBs positive results, three months after vaccination). An inadequate vaccination schedule was the strongest predictor of antibody loss during follow-up (OR = 8.37 95% CI: 5.41-12.95, P < 0.001). A Kaplan-Maier survival curve revealed that the persistence of anti-HBs 30 years after vaccination, was 92.2% for high responders, while it was only 27.3% for low responders (P = 0.001).

CONCLUSIONS

A good level of seroprotection persisted in 57.9% of the subjects after 30 years. Factors related to this immunization status confirmed the importance of vaccinating HCWs early in their careers and ensuring an adequate vaccination schedule. However, with particular reference to the low rate of hepatitis B vaccine coverage among HCWs in Southern Italy, the implementation of a new educational intervention as part of an active vaccination program is needed.

The role of obesity in kidney transplantation outcome

BACKGROUND

The number of obese kidney transplant candidates has been growing. However, there are conflicting results regarding to the effect of obesity on kidney transplantation outcome. The aim of this study was to investigate the association between the body mass index (BMI) and graft survival by using continuous versus categoric BMI values as an independent risk factor in renal transplantation.

METHODS

We retrospectively reviewed 376 kidney transplant recipients to evaluate graft and patient survivals between normal-weight, overweight, and obese patients at the time of transplantation, considering BMI as a categoric variable.

RESULTS

Obese patients were more likely to be male and older than normal-weight recipients (P = .021; P = .002; respectively). Graft loss was significantly higher among obese compared with nonobese recipients. Obese patients displayed significantly lower survival compared with nonobese subjects at 1 year (76.9% vs 35.3%; P = .024) and 3 years (46.2% vs 11.8%; P = .035).

CONCLUSIONS

Obesity may represent an independent risk factor for graft loss and patient death. Careful patient selection with pretransplantation weight reduction is mandatory to reduce the rate of early posttransplantation complications and to improve long-term outcomes.

Gastroesophageal reflux disease and postlaryngectomy tracheoesophageal fistula

The objective of this study is to evaluate the incidence of pathologic gastroesophageal reflux in laryngectomized patient with phonatory prosthesis, analyzing potential related problems and appraising, at the same time, the effectiveness of a therapeutic protocol. A retrospective study was conducted on 43 phonatory prosthesis patients who had problems with regard to recurrent tracheoesophageal granulations, the need of frequent prosthesis replacement, within a 3-month period, and unsatisfactory vocal results. Such patients underwent physical examination of the fistula region and of the neopharynx and were submitted to esophagogastroduodenoscopy. Moreover the group of patients underwent a therapeutic protocol and were re-evaluated posttreatment, examining fistula region both on the tracheal side and on the esophageal side through videolaryngostroboscopy. Of the 43 recruited patients 13 (30%) presented tracheoesophageal granulations, 20 (46.5%) unsatisfactory vocal results and 10 (23.5%) frequent prosthesis replacement, within a 3-month period, due to abnormal biofilm development. In particular, of the 13 patients who had recurrent granulations, the evaluation results revealed the presence of gastroesophageal reflux disease (GERD) in 6 cases (46%). In the group of patients presenting unsatisfactory vocal results GERD was shown in 13 cases (65%). In the third group of patients GERD was found in two cases (20%). The overall analysis of the data gathered, allowed to identify GERD in 21 (49%) of the 43 patients submitted to the study. The results posttreatment indicated, in the first group, the disappearance or a significant (>75%) volume reduction of such formation in five cases (38%, p = 0.002). In the second group an overall improvement in the quality of voice was displayed at least for 12 patients (60%, p = 0.0001). Finally in the last group an increase of the prosthesis life was recorded in four (40%, p = 0.05) of the ten patients who had the need of prosthesis replacement within 3 months. Also the 22 GERD negative cases (51%) underwent the treatment, therefore representing the control group, whose posttreatment results showed substantial modifications in just two cases (9%). The data obtained suggest a high degree of correlation between the presence of pathologic gastric reflux and the partial or total prosthesis failure. The introduction of a specific therapeutic protocol has allowed to improve the quality of prosthesis (QoP) in 22 of the 43 patients (p < 0.001) who had a pathologic condition of the fistula and of the prosthesis.

Congenital talipes equinovarus: an epidemiological study in Sicily

BACKGROUND AND PURPOSE

Congenital talipes equinovarus (clubfoot) can present in 2 forms: "syndromic", in which other malformations exist, and the more common "idiopathic" form, where there are no other associated malformations. We analyzed the epidemiology of congenital talipes equinovarus in the Sicilian population, looking for potential etiological factors.

PATIENTS AND METHODS

Among the 801,324 live births recorded between January 1991 and December 2004, 827 cases were registered (560 males; M/F sex ratio: 2.1). Control infants were randomly selected from a historical cohort of live births without any major congenital malformations.

RESULTS

A positive family history of clubfoot, gender, and maternal smoking were found to be risk factors for clubfoot. Patients with clubfoot were born most frequently during the period January-March. No association was found between clubfoot and reproductive history, peri-conceptional maternal drug exposure, maternal education, or ethnicity.

INTERPRETATION

Our findings emphasize the importance of birth defects surveillance programs and their usefulness in investigating potential risk factors.

Worldwide epidemiology of liver hydatidosis including the Mediterranean area

The worldwide incidence and prevalence of cystic echinococcosis have fallen dramatically over the past several decades. Nonetheless, infection with Echinococcus granulosus (E. granulosus) remains a major public health issue in several countries and regions, even in places where it was previously at low levels, as a result of a reduction of control programmes due to economic problems and lack of resources. Geographic distribution differs by country and region depending on the presence in that country of large numbers of nomadic or semi-nomadic sheep and goat flocks that represent the intermediate host of the parasite, and their close contact with the final host, the dog, which mostly provides the transmission of infection to humans. The greatest prevalence of cystic echinococcosis in human and animal hosts is found in countries of the temperate zones, including several parts of Eurasia (the Mediterranean regions, southern and central parts of Russia, central Asia, China), Australia, some parts of America (especially South America) and north and east Africa. Echinococcosis is currently considered an endemic zoonotic disease in the Mediterranean region. The most frequent strain associated with human cystic echinococcosis appears to be the common sheep strain (G1). This strain appears to be widely distributed in all continents. The purpose of this review is to examine the distribution of E. granulosus and the epidemiology of a re-emerging disease such as cystic echinococcosis.

Probiotics in the gastrointestinal diseases of the elderly

Changes of the gut microflora in elderly appear to involve a reduction in numbers of healthy bacteria (lactobacilli and bifidobacteria) and an increase in numbers of potentially pathogenic species. These changes are generally described as gastrointestinal disorders and infections. This review analyses benefits of probiotics in old people, with particular interesting for the latest researches relevant to elderly people, e.g. trials examining enteric infections, antibiotic-associated diarrhea and Clostridium difficile associated diarrhea, functional bowel problems (constipation and irritable bowel syndrome), inflammatory bowel diseases, stimulation of the immune system and prevention of cancer. A growing number of researches indicates that some probiotic strains may help to maintain the health in old people, suggesting both health and cost-saving benefits in offering fermented dairy products. These benefits include: establishment of balanced intestinal microflora; improving colonization resistance and or prevention of diarrhea; reduction of fecal enzymes; reduction of serum cholesterol; reduction of potential mutagenes; reduction of lactose intolerance; synthesis of vitamins; predigestion of proteins.

Pattern of antibiotic use in the community: νon-adherence and self-prescription rates in an Italian urban population

The aim of the present study was to assess the pattern of antibiotic use in a community setting of an urban area of Italy and identify factors that affect adherence to their use. By using a questionnaire-based survey, we collected 1,269 interviews and performed analysis on those patients who had their last course of antibiotic within the past 12 months (956 subjects). Among the subjects reporting that they had not followed their last antibiotic course as prescribed, 14.7% stopped therapy early, 5.4% modified the dosage, and 5% changed the prescribed antibiotic. Approximately 23% of the subjects declared that they self-prescribed antibiotics. After adjusting for all covariates, major predictors for the self-prescription of antibiotics were younger age, female gender and higher socioeconomic and educational status. Conversely, both low educational and socioeconomic status were associated with a higher risk of non-adherence to physician indications. The findings of this study assessed the widespread pattern of poor antibiotic-taking behavior and provides important implications for understanding the targets of future educational campaigns to control the use and misuse of antibiotics.

Age is an important predictor of kidney transplantation outcome

BACKGROUND

Donor and recipient age may have an impact on the renal transplant outcome. Kidney transplantation from older donors may result in a worse outcome, and the survival benefit of kidney transplantation compared with dialysis may be reduced. The aim of this study was to evaluate the impact of donor and recipient age on kidney transplant outcome.

MATERIALS AND METHODS

Two hundred and twenty-three recipients of kidney transplants performed at our institution between 2002 and 2007 were analysed. The role of donor and recipient age matching on survival rate were investigated performing the Kaplan-Meier survival time analysis by decades, considering the donor's age of 60 and 70 years. The Cox proportional hazard uni- and multivariate regressions were also performed. Finally, Kaplan-Meier survival time analysis was performed to assess survival rates of patients transplanted stratified by donor age compared with wait-listed renal transplant candidates.

RESULTS

Elderly recipients had a significant lower graft and patient survival as well as a significantly higher risk of graft loss and patient death. Recipients younger and older than 65 years of age were at higher risk of graft loss if they received grafts from donors>65 years [hazard ratio (HR)=2.59, 95% confidence interval (CI): 1.12-6 and HR=5.65, 95% CI: 2.31-13.79, respectively]. Elderly recipients displayed a worse survival compared with transplant candidates on the waiting list.

CONCLUSIONS

Age is an important predictor of kidney transplantation outcome. Kidney transplantation does not offer a significant survival benefit in the intermediate term, compared to the waiting list, to elderly recipients transplanted with grafts from older donors. However, it cannot be excluded that it is still possible that there is a long-term benefit of transplantation over dialysis in this group of patients.

Acetyl-L-carnitine reduces depression and improves quality of life in patients with minimal hepatic encephalopathy

BACKGROUND

Minimal hepatic encephalopathy (MHE) represents a common complication present in well-compensated cirrhotic patients that impairs patients' daily functioning and health-related quality of life (HRQL). Acetyl-L-carnitine (ALC) has been shown to be useful in improving blood ammonia and cognitive functions in cirrhotic patients with MHE.

OBJECTIVE

This study evaluated the effects of ALC treatment on HRQL and depression in patients with MHE.

STUDY DESIGN

This was a randomized, double-blind, placebo-controlled study. Sixty-seven patients with MHE were recruited to the study. They were randomly assigned to two groups and received either 2 g acetyl-L-carnitine twice a day (n = 33) or placebo (n = 34) for 90 days. The primary efficacy measures were changes in aspartate aminotransferase, alanine aminotransferase, γ-glutamyl-transpeptidase, albumin, alkaline phosphatase, prothrombin time, and ammonia. Clinical and laboratory assessments, psychometric tests and automated electroencephalogram (EEG) analysis were performed for all patients.

RESULTS

At the end of the study period, between the two groups, we observed a significant difference in physical function (p < 0.001), role physical (p < 0.001), general health (p < 0.001), social function (p < 0.05), role emotional (p < 0.05), mental health (p < 0.05), Beck Depression Inventory (p < 0.001), TMT-B s (p < 0.001), State Trait Inventory (p < 0.001), urea (p < 0.05), NH(4)(+) (p < 0.001), and bilirubin (p < 0.001).

CONCLUSIONS

This study shows that ALC treatment is associated with significant improvement in patient energy levels, general functioning and well-being. The improvement of quality of life is associated with reduction of anxiety and depression.

[Adherence to antihypertensive and lipid-lowering medications: a problem of public health, not yet resolved]

Assessment of compliance in patients with relevant comorbidity condition, above all those at high cardiovascular risk, is especially relevant because their clinical condition can be considerably mitigated by treatment with concomitant antihypertensive (AH) and lipid-lowering (LL) medications. The aim of the study was to evaluate patterns and predictors of adherence and persistence with concomitant AH and LL therapy. This retrospective cohort study included 363 enrolled from database of 3 physicians who initiated treatment with AH and LL therapy between January 2007 and January 2010. Adherence was measured as the proportion of days covered in 3-month intervals and patients were considered adherent if they had filled prescriptions for at least 80% of the period. Persistence was measured as absence of discontinuation define as > 30 days between a filled prescription and the subsequent claim. A multivariate analysis with a Cox regression model was performed to evaluate potential predictors of adherence and persistence. Finally, patients outcome was evaluated to assess potential association with adherence and persistence with AH and LL therapy. The mean percentage of patients adherent with both AH and LL medications was 39%, declining from 47% to 31%. The mean percentage of persistence was 43%. After adjustment for variables of interest, major predictors of adherence and persistence were the number of concomitant prescriptions, age of patients, gender time between start of AH and LL therapy, and gravity of coronary disease. Finally, adherent and persistent patients had significant lower blood pressure compared to other subjects. Adherence and persistence with concomitant AH and LL therapy was poor and declined over time. Interventions to improve these attitudes and to contain costs affecting a limited health budget are needed.

[Evolution of hospital concept in Italy]

Hospital building trade was born before the origin of Healthcare System and followed the complex development of healthcare during all the past years to present day. At the beginning of 700's, when infective pathology was predominant and hygienic conditions was parameter of quality, pavilions structure took place. These hospitals required wide land to be built on, with a high surface area to volume ratio and a horizontal development. There were about 1200-1500 sleeping accommodations in large rooms (ward) where patients were split up. The typical pavilions structure were used until half 900's when it was replaced with a new concept of building trade, the mono-polibloc. They were buildings with vertical development that minimized horizontal distances and operating costs. Every floor has confinement and service rooms and represent a single and autonomous operating unit. Nowadays hospitals building trade point to use the flat-tower model that enhance the distinction between confinement area (with a vertical development-monobloc) and diagnosis, care and services area (with a horizontal development-flat). The challenge we willface in the future is to convert healthcare buildings to other uses like trading centres and services areas, to improve structures' flexibility, to better include them in the context of the urban and natural setting.

[Project financing in public hospital trusts]

The growing debate in recent years over how to finance public works through private capital has progressively highlighted the role of project finance (PF) and publicprivate partnerships (PPP) in general. More and more European countries are turning to PF to finance their public infrastructure development. The UK, which pioneered the adoption of project finance in this field, has been followed by Italy, Spain, France, Portugal and Germany and more recently by Greece, Czech Republic and Poland. Beginning in the late 1990's, Italy has steadily amplified its use of PF and PPPs in key sectors such as healthcare as an alternative way of funding the modernisation of its health facilities and hospitals. The trend reveal an average annual growth of 10.9% since 2002 with peaks of varying intensity over the five year period. Project finance and PPPs represent an effective response to the country's infrastructure gap and support the competitiveness of local systems and the quality of public services. None of this will transpire, however without energetic new planning efforts and adequate policy at the centre.

[Drug misuse in the community: factors which influence patients to self-prescribe antibiotics]

This study aimed at deepening our knowledge about patients' non-compliance with antibiotic treatment, at determining which patients in our community use antibiotics without consulting a physician and at examining patient characteristics associated with such antibiotic misuse. The study focused on the correlation between self-prescribing antibiotic and socioeconomic and cultural status. Data were obtained by using a questionnaire-based survey and we computed univariate and multivariate analysis using chi-square test and logistic regression model. Of 663 respondents, 18.7% admitted using non-prescribed antibiotics. Multivariate analysis identified four variables associated with self-prescribing antibiotic: age [p= 0.009; for patients aged 25-44 and over 65 OR: 1.87 (95% C.I.: 0.66-5.32) and OR: 0.55 (95% C.I.: 0.17-1.80) respectively], gender [p=0.027; for women OR: 1.67 (95% C.I.: 1.06-2.64)], socioeconomic (p=0.022) and cultural status (p=0.037) where classes associated with high risk are the most elevated [for highest socioeconomic class OR: 3.99 (95% C.I.: 1.47-10.85) and for highest cultural class OR: 1.37 (95% C.I.: 0.65-2.86)]. Our study demonstrates that high socioeconomic and cultural status is associated with self-administering antibiotics. These results can be used to design appropriate interventions and target future educational campaigns to control and correct use of antibiotics.

Clinical and endoscopic presentation of primary gastric lymphoma: a multicentre study

BACKGROUND

Although the stomach is the most frequent site of intestinal lymphomas, few data are available on both clinical endoscopic presentation of gastric lymphoma and possible differences between low-grade and high-grade lymphomas.

METHODS

Clinical, histological and endoscopic records of consecutive patients with primary low-grade or high-grade lymphoma diagnosed were retrieved. Symptoms were categorized as 'alarm' or 'not alarm'. The endoscopic findings were classified as 'normal' or 'abnormal'.

RESULTS

Overall, 144 patients with primary gastric lymphoma were detected, including 74 low-grade and 70 high-grade lymphoma. Alarm symptoms, particularly persistent vomiting and weight loss, were more frequently present in patients with high-grade lymphoma than in those with low-grade lymphoma (54% vs. 28%; P = 0.002). Low-grade lymphomas presented as 'normal' appearing mucosa (20% vs. 0%; P = 0.0004) or petechial haemorrhage in the fundus (9% vs. 0%; P = 0.02) more frequently than high-grade lymphomas, being also more often confined to the antrum (47% vs. 27%, P = 0.03) and associated with Helicobacter pylori infection (88% vs. 52%, P < 0.0001). On the contrary, high-grade lymphomas presented more commonly as ulcerative type (70% vs. 52%; P = 0.03), being also more frequently diagnosed in stage >I when compared with low-grade lymphomas (70% vs. 21%, P < 0.0001).

CONCLUSIONS

The overall prevalence of alarm symptoms is quite low and may be absent in more than 70% of patients with low-grade lymphoma.

Normal human lung fibroblasts differently modulate interleukin-10 and interleukin-12 production by monocytes: implications for an altered immune response in pulmonary chronic inflammation

The ability of lung fibroblasts to modulate the immune response has been evaluated by analyzing the synthesis and release of interleukin (IL)-10 and IL-12 by lipopolysaccharide (LPS)-stimulated peripheral blood monocytes exposed to pulmonary fibroblast conditioned medium (FCM). IL-10 and IL-12 contents and gene expression were markedly modified by treatment with FCM as measured by ELISA (+97.5 +/- 12.8% and -68 +/- 7.3% for IL-10 and IL-12, respectively), immunocytochemistry, and reverse transcriptase-polymerase chain reaction (RT-PCR). These effects appeared to be mediated by prostaglandin E(2) (PGE(2)) as the modified release of both cytokines was reduced by treatment with indomethacin and mimicked by addition of exogenous PGE(2.) As a result of the enhanced production of IL-10, exposure of LPS/interferon (IFN)-gamma-activated monocytes to FCM was also able to reduce the expression of the class II major histocompatibility complex (MHC) molecule, human leukocyte-associated antigen-DR (HLA-DR) (-51.8 +/- 8.7%) and of the costimulatory molecule, CD40 (-53.9 +/- 11.7%). The expression of both molecules was completely restored when monocytes were pretreated with a neutralizing anti-IL-10 monoclonal antibody. The FCM obtained from fibrotic lung fibroblasts was instead less efficacious in potentiating LPS-stimulated IL-10 release and, consequently, in reducing HLA-DR and CD40 expression, suggesting that an impairment of the immune regulation operated by fibroblasts may be involved in the maintenance of chronic pulmonary inflammation.

Role of endogenous nitric oxide in asthma

Endogenous nitric oxide (NO) is an ubiquitous signaling molecule with important regulatory functions such as regulation of blood pressure, neurotransmission, and host and immune defense. In the respiratory tract, NO is formed and released by various sources including endothelial and epithelial cells, nerves, airway smooth muscle, and inflammatory cells. Recent evidence suggests that endogenous NO is the neurotransmitter of the nonadrenergic noncholinergic inhibitory (iNANC) system, the only bronchorelaxant neural pathway of human airways. A number of studies also suggest that in some species epithelium-derived NO accounts for the functional bronchoprotective role of the so-called epithelium-derived relaxing factor. In human airways, endogenous NO counteracts the bronchoconstriction induced by pharmacologic stimuli such as bradykinin, histamine, and methacholine. On the basis of these and other observations, it is suggested that a reduced synthesis and/or activity of endogenous NO may contribute to the pathogenesis of airway hyperresponsiveness that characterizes asthma and other respiratory disorders. This short paper summarizes the activities of endogenous NO in the airways of experimental animals and man, and discusses the evidence supporting the view that NO confers bronchoprotection.

Asthma controller therapy: role of antileukotrienes, a new therapeutic class

Asthma is a chronic disease and should be treated with both controller and reliever drugs. Asthma controller therapy is not used sufficiently widely, probably due to low compliance with inhaled drugs, lack of response in some patients to low-medium doses of inhaled steroids and possible adverse events. This review analyses a new class of antiasthmatic drugs, leukotriene receptor antagonists (antileukotrienes). At present, two antileukotrienes are available in Italy: zafirlukast and montelukast. Antileukotrienes improve symptoms and also inhibit the effects of some of the inflammatory mediators involved in the pathogenesis of asthma; therefore, antileukotrienes may be used in monotherapy. In addition, the oral administration route is an advantage for compliance. Antileukotrienes significantly improve pulmonary function, asthma symptoms and inhaled and oral steroid and short-acting beta 2-agonist use. Moreover, antileukotrienes produce a 50% mean reduction in the incidence of asthma exacerbations compared with placebo. From the economic point of view, asthma controller therapy using antileukotrienes is associated with a > 50% (compared with placebo) reduction in healthcare costs (hospitalization due to asthma exacerbation, healthcare contact and absenteeism from work or school), which globally account for 93% of asthma-related costs. Antileukotrienes are indicated in the treatment of persistent mild-to-severe asthma, seasonal allergic asthma, exercise-induced asthma and aspirin-induced asthma. Antileukotrienes are well tolerated independently of the duration of treatment and the incidence of the observed adverse events is substantially similar to that observed using placebo. Owing to good tolerability and compliance and the economic advantages, these agents may be considered a valid therapeutic option for the control and management of asthma as a chronic disease.

[Guidelines for the treatment of acute asthma. A critical retrospective analysis]

Acute asthma attacks are frequently observed in common medical practice. However a unified and scientifically proven directive which advises objectively on the best management strategy for patients with acute asthma attacks is still lacking. In the present review we have accurately assessed various important points addressed in the recent international guidelines for acute asthma. This work has enabled us to derive precise and documented suggestions of practical importance which may be useful to the physician for a correct and judicious approach to the management of those patients with acute asthma attacks.

Increased prevalence of cardiac arrhythmias and transient episodes of myocardial ischemia in hypertensives with left ventricular hypertrophy but without clinical history of coronary heart disease

To evaluate the behavior of cardiac arrhythmias (CA) and transient episodes of myocardial ischemia (TEMI), in relation to the circadian pattern of blood pressure in patients suffering from arterial hypertension, with or without echocardiographically ascertained left ventricular hypertrophy (LVH), we studied 128 patients, 87 men (M) and 41 women (F), aging from 21 to 76 years, subdivided into two groups: Group I, including 66 patients with LVH (45 M and 21 F; mean age of 53.7 +/- 9.1 years; Group II, including 62 patients without LVH (42 M and 20 F; mean age of 49.7 +/- 9.5 years). Office blood pressure (OBP) as well as nighttime ambulatory blood pressure (ABP) were higher in patients with LVH (P < .05 and P < .01). CA were present in a higher number of patients of Group I (P < .001): premature supraventricular beats (PSVB) 22.7 v 4.8%, supraventricular couplets (SVC) 36.4 v 16.1%, supraventricular tachycardia runs (SVT runs) 27.3 v 12.9%, ventricular ectopic beats (VEB) 25.6 v 8.0%, ventricular couplets (VC) 30.3 v 12.9%, ventricular tachycardia runs (VT runs) 12.1 v 3.2%. The absolute number of ectopic beats was also significantly higher in patients of Group I. Ventricular arrhythmias were significantly related to ASBP (r = 0.83, P < .01), to ADBP (r = 0.74, P < .01) and to heart rate (r = 0.87, P < .01) in patients of Group I. TEMI were more frequent in patients of Group I (73 v 41 episodes, 39.39% v 25.8% of patients, P < .01) and were related to ABP peaks. In fact, in both groups of patients all TEMI without heart rate increase and most TEMI with heart rate increase were registered between 6:00 and midnight, hours in which ABP values were higher. We conclude that hypertensives with LVH, but without clinical history of coronary heart disease, have a higher prevalence of ventricular arrhythmias and of transient episodes of myocardial ischemia in relation to the circadian pattern of ABP.

Time course of changes in adenosine 5'-monophosphate airway responsiveness with inhaled heparin in allergic asthma

BACKGROUND

Recent studies have shown that inhaled heparin exerts a protective effect against various bronchoconstrictor stimuli in asthma, possible through an inhibition of mast cell activation.

OBJECTIVE

Because adenosine 5'-monophosphate (AMP) elicits bronchoconstriction by augmenting mast cell mediator release, we have investigated the effect of inhaled heparin (15,000 units USP/ml, 4 ml) on the bronchoconstrictor response to this agonist and to methacholine in a randomized, double-blind, placebo-controlled study of 10 subjects with asthma. We also carried out a separate randomized, double-blind study in seven additional volunteers with asthma to examine in more detail the time-course of change in bronchial reactivity to inhaled AMP after treatment with nebulized heparin.

RESULTS

Inhaled heparin significantly increased the provocative concentration of AMP causing a 20% decrease in forced expiratory volume in 1 second (PC20 FEV1-AMP) from the postplacebo treatment value of 22.3 mg/ml (range, 5.7 to 68.9 mg/ml) to 48.1 mg/ml (range, 5.1-196.8 mg/ml) (p < 0.01). When compared with placebo, inhaled heparin failed to alter the airway responsiveness to methacholine; the mean (range) PC20 methacholine values were 1.00 mg/ml (0.44 to 4.76 mg/ml) and 1.08 mg/ml (0.46 to 5.08 mg/ml), respectively. After placebo administration, the PC20 AMP values at 15, 60, and 180 minutes did not differ significantly from each other; their geometric mean (range) values were 26.1 mg/ml (5.9 to 85.8 mg/ml), 26.6 mg/ml (6.3 to 87.8 mg/ml), and 24.9 mg/ml (5.2 to 80.2 mg/ml), respectively. When compared with placebo, the PC20 values for AMP after administration of inhaled heparin were significantly increased up to 57.3 mg/ml (14.7 to 176.0 mg/ml) and to 52.7 mg/ml (13.9 to 90.8 mg/ml) at 15 minutes and 60 minutes, respectively. At 180 minutes, inhaled heparin failed to affect AMP airway responsiveness; the PC20 AMP was not significantly different from that of placebo, with a value of 30.6 mg/ml (4.8 to 93.3 mg/ml).

CONCLUSION

Heparin administered by inhalation is effective in attenuating the airway response to AMP but not to methacholine. The time course of change in bronchial reactivity to AMP has a peak effect at 15 minutes and lasts up to 60 minutes. It is possible that the mechanism(s) underlying the protective effects of inhaled heparin in asthma may be related to an inhibitory modulation of mast cell activation.

Purine derivatives in the study of allergic inflammation in respiratory diseases

Adenosine, a naturally occurring purine nucleoside, elicits dose-related bronchoconstriction in asthmatic subjects when administered by inhalation and it is recovered in increased amounts from the bronchial lavage fluid of subjects with active asthma when compared to normal controls. Although the mechanism by which adenosine mediates bronchoconstriction in asthmatic subjects is not clear, recent data indicate an important role for mast cell mediator release. We have recently shown that local airway challenge with adenosine in subjects with asthma and rhinitis provokes an increase in the levels of PGD2, histamine and tryptase. However, airway responsiveness and atopic status are the most important determinants of adenosine-induced responses, regardless of any increases in mast cell mediators in airway fluids. New discoveries suggest that the airway response to adenosine may be an index of mast cell priming and therefore may provide a useful tool to further explore the inflammatory processes in allergic asthma and rhinitis. Therefore adenosine provocation may gain increasing acceptance as an additional measure of disease activity in asthma and rhinitis.

Human lung fibroblasts inhibit tumor necrosis factor-alpha production by LPS-activated monocytes

Mononuclear phagocytes are important regulators of normal immune, inflammatory, and fibrotic responses. These functions are mediated through the production of several cytokines, including tumor necrosis factor-alpha (TNF-alpha), which regulate the activity of inflammatory and tissue structural cells such as fibroblasts. It is increasingly evident that fibroblasts are also capable of releasing a number of cytokines and soluble factors that can, in turn, interact with monocytes and thereby modulate the inflammatory process. In this study we provide evidence that human lung fibroblasts, through the release of soluble factors such as prostaglandin E2 (PGE2), inhibit both TNF messenger ribonucleic acid (mRNA) accumulation and TNF-alpha protein release by lipopolysaccharide (LPS)-activated human peripheral blood monocytes (PBM). Reverse transcriptase-polymerase chain reaction (RT-PCR) results showed that fibroblast-conditioned medium (FCM) caused a 50% reduction of the TNF-alpha transcript accumulation in LPS-stimulated monocytes. Furthermore, FCM induced a significant decrease in the release of TNF-alpha by LPS-activated PBM. This effect was dependent on the concentration of the FCM and the number of fibroblasts producing it. The maximal effect was seen with monocytes cultured in 100% FCM produced by 2 x 10(6) fibroblasts. This indicated that one or possibly more soluble factors released by fibroblasts were responsible for the effect. Considering that exogenous PGE2 can inhibit TNF-alpha production by PBM, and that fibroblasts are a good source of PGE2, we determined the content of PGE2 in the FCM used in our experiments. We found a good correlation (r = 0.949) between the amount of PGE2 produced by fibroblasts and the degree of TNF-alpha inhibition exerted. In addition, the inhibitory effect of FCM was mimicked by the addition to PBM cultures of exogenous PGE2 in amounts similar to those spontaneously released by fibroblasts in FCM. All of these data suggest a molecular and cellular interaction between PBM and fibroblasts that could contribute to those modulatory mechanisms involved in the self-limitation of the fibrotic process.

Randomised double-blind placebo-controlled study of the effect of inhibition of nitric oxide synthesis in bradykinin-induced asthma

BACKGROUND

Bronchoconstriction induced by bradykinin is reduced by the release of nitric oxide (NO) in the airways of guinea pigs. Inhaled NO is known to cause bronchodilatation in asthmatic patients. To find out the role of endogenous NO in airway response to bradykinin in asthma, we examined the effect of the NO synthase inhibitor NG-monomethyl-L-arginine (L-NMMA) on broncho-constriction after bradykinin challenge in ten patients with mild asthma.

METHODS

The study had a randomised, double-blind, placebo-controlled, cross-over design. Participants were studied during two phases, each consisting of 2 study days. After baseline measurements of forced expiratory volume in 1 s (FEV1) participants inhaled an aerosol of L-NMMA or saline (placebo). After 5 min, saline and doubling doses of bradykinin (from 0.25 nmol) were inhaled until FEV1 fell by at least 20% of the post-saline value. The effect of L-NMMA and placebo on airway response to doubling concentrations of methacholine (from 0.03 mg/mL) was then examined. We also assessed the effect of the inactive enantiomer of L-NMMA, D-NMMA, and placebo on bronchoconstriction after bradykinin or methacholine challenge in six of the participants.

FINDINGS

The geometric mean of the provocative dose producing a 20% fall in FEV1 to bradykinin was 138.0 nmol (range 48.2-475.2 nmol) after placebo and 11.2 nmol (range 0.9-51.3 nmol) after L-NMMA (p < 0.01). L-NMMA also caused a decrease in the provocative concentration of methacholine producing a 20% fall in FEV1 from 0.93 mg/mL (range 0.12-2.55 mg/mL) to 0.38 mg/mL (range 0.06-0.92 mg/mL; p < 0.01). In contrast, D-NMMA did not affect airway response to bradykinin or methacholine.

INTERPRETATION

The results suggest that bronchoconstriction after bradykinin inhalation is greatly inhibited by the formation of NO in airways of asthmatic patients and that NO could have a bronchoprotective role in asthma.

Changes in respiratory drive account for the magnitude of dyspnoea during bronchoconstriction in asthmatics

To evaluate whether the interindividual differences in dyspnoea perceived by asthmatic subjects for the same level of airway narrowing could depend on different changes in respiratory drive, we assessed the relationship between changes in airway calibre, changes in neuromuscular output, and dyspnoea rate during progressive bronchoconstriction induced by methacholine. We studied 18 asymptomatic asthmatic subjects (aged 18-36 yrs; 11 males and 7 females) with normal lung function. Dyspnoea (Borg scale), mouth occlusion pressure (P0.1), and forced expiratory volume in one second (FEV1) were measured at baseline and after inhalation of aerosols of doubling concentrations of methacholine (MCh). The progressive bronchoconstriction induced by MCh was associated with a progressive increase both of P0.1 and dyspnoea. Dyspnoea score was linearly related either to the fall in FEV1, or to the increase in P0.1. However, the slope values of the relationship between dyspnoea score and the corresponding percent fall in FEV1 showed a large interindividual variability (0.05-0.32; coefficient of variability (CoV) 43%). By contrast, the slope values of the relationship between dyspnoea score and the corresponding percent increase in P0.1 ranged 0.02-0.05 (CoV = 14%), indicating a more homogeneous response to dyspnoea for the same change in P0.1. At the highest MCh concentration, the dyspnoea score was linearly related to the corresponding change in P0.1 (r = 0.91; p < 0.01), but not to the corresponding percentage fall in FEV1 (r = 0.28). These results show that the interindividual differences in dyspnoea perceived by asthmatic subjects for the same level of airway narrowing are associated with different changes in respiratory drive during bronchoconstriction.

Changes in neurokinin A airway responsiveness with inhaled lysine-acetylsalicylate in asthma

Endogenously released cyclooxygenase products modulate the bronchoconstrictor response to various stimuli in asthma. Little is known of the change in airway responsiveness to neurokinin A (NKA) after cyclooxygenase blockade. In this randomized, double-blind, placebo-controlled study, we have investigated the effect of the potent cyclooxygenase inhibitor, lysine acetylsalicylate (L-ASA) administered by inhalation, on the bronchoconstrictor response both to neurokinin A (NKA) and methacholine in nine asthmatic subjects. Subjects attended the laboratory on four separate occasions to receive nebulized L-ASA (solution of 90 mg.mL-1) or matched placebo (glycine, solution of 30 mg.mL-1) 15 min prior to bronchial challenge with NKA or methacholine, in a randomized, double-blind order. Changes in airway calibre were followed as forced expiratory volume in one second (FEV1) and agonist responsiveness, expressed as the provocative concentration causing a 20% fall in FEV1 from baseline (PC20). L-ASA elicited a significant fall in FEV1 from baseline. When compared with placebo, inhaled L-ASA reduced the airway responsiveness to NKA in 8 of the 9 subjects studied, the geometric mean (range) values for PC20 NKA increasing significantly from 153.2 (52.0-258.9) to 303.1 (83.4-668.5) micrograms.mL-1 after placebo and L-ASA, respectively. However, no significant change in airway responsiveness to methacholine was recorded after L-ASA, their geometric mean (range) PC20 values being 1.60 (0.17-9.59) and 1.53 (0.09-14.01) mg.mL-1 after placebo and L-ASA, respectively. The small decrease in airway responsiveness to neurokinin A after administration of lysine acetylsalicylate by inhalation suggests that endogenous prostaglandins may play a contributory protective role in the airway response to neurokinin A in human asthma.

Inhaled lysine acetylsalicylate (L-ASA) attenuates histamine-induced bronchoconstriction in asthma

When administered by inhalation, histamine provokes dose-related bronchoconstriction in asthmatic subjects mainly by a direct activation of histamine H1-receptors on airway smooth muscle. However, little is known of the change in airway responsiveness to histamine after cyclooxygenase blockade. The aim of the study was to investigate the effect of the potent cyclooxygenase inhibitor, lysine acetylsalicylate (L-ASA), administered by inhalation on histamine-induced bronchoconstriction in a group of 16 asthmatic subjects. The subjects studied attended the laboratory on four separate occasions to receive nebulized L-ASA (solution of 90 mg/ml) or matched placebo (glycine solution of 30 mg/ml) 15 min before bronchoprovocation tests with histamine and methacholine in a randomized, double-blind order. Changes in airway caliber were followed as forced expiratory volume in 1 s (FEV1), and agonist responsiveness was expressed as the provocative concentration causing a 20% fall in FEV1 from baseline (PC20). Administration of both L-ASA and glycine solution caused a small but significant acute fall in FEV1 from baseline, which returned to normal within 15 min. When compared to placebo, inhaled L-ASA reduced the airway responsiveness to histamine in 13 of the 16 subjects studied, the geometric mean (range) values fro PC20 histamine increasing significantly (P < 0.001) from 1.72 (0.13-5.49) mg/ml to 3.31 (0.36-12.00) mg/ml after placebo and L-ASA, respectively. No significant change in airway responsiveness to methacholine was recorded after L-ASA. Acute administration of L-ASA by inhalation protects the asthmatic airways against histamine-induced bronchoconstriction, thus suggesting that endogenous prostaglandins may play a contributory role in the airways response to histamine in human asthma.

Inhaled lysine acetylsalicylate (L-ASA) attenuates the bronchoconstrictor response to adenosine 5'-monophosphate (AMP) in asthmatic subjects

When administered by inhalation, adenosine 5'-monophosphate (AMP) provokes dose-related bronchoconstriction in asthmatic subjects by a mechanism believed to involve mast cell mediator release. However, little is known of the change in airway responsiveness to AMP after cyclo-oxygenase blockade. The aim of this study was to investigate the effect of the potent cyclo-oxygenase inhibitor, lysine acetylsalicylate (L-ASA) administered by inhalation, on AMP-induced bronchoconstriction in a group of nine asthmatic subjects. The subjects studied attended the laboratory on six separate occasions to receive nebulized L-ASA (solution of 90 mg.ml-1) or matched placebo (glycine solution, 30 mg.ml-1) 15 min prior to bronchoprovocation tests with AMP, histamine and methacholine in a randomized, double-blind order. Changes in airway calibre were followed as forced expiratory volume in one second (FEV1) and agonist responsiveness was expressed as the provocative concentration causing a 20% fall in FEV1 from baseline (PC20). Administration of both L-ASA and glycine solution caused a small but significant acute fall in FEV1 from baseline, which returned to normal within 15 min. When compared to placebo, inhaled L-ASA reduced the airway responsiveness to AMP in all the subjects studied, the geometric mean (range) values for PC20 AMP increasing significantly from 36.3 (7.9-250.5) to 101.8 (27.2-1300) mg.ml-1 after placebo and L-ASA, respectively. Moreover, nebulized L-ASA induced a small but significant reduction in airway responsiveness to histamine, the geometric mean (range) PC20 values for histamine increasing from 2.77 (1.05-5.49) to 4.36 (1.69-11.24) mg.ml-1 after placebo and L-ASA, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Inhaled lysine acetylsalicylate (L-ASA) attenuates the bronchoconstrictor response to adenosine 5'-monophosphate (AMP) in asthmatic subjects

When administered by inhalation, adenosine 5'-monophosphate (AMP) provokes dose-related bronchoconstriction in asthmatic subjects by a mechanism believed to involve mast cell mediator release. However, little is known of the change in airway responsiveness to AMP after cyclo-oxygenase blockade. The aim of this study was to investigate the effect of the potent cyclo-oxygenase inhibitor, lysine acetylsalicylate (L-ASA) administered by inhalation, on AMP-induced bronchoconstriction in a group of nine asthmatic subjects. The subjects studied attended the laboratory on six separate occasions to receive nebulized L-ASA (solution of 90 mg.ml-1) or matched placebo (glycine solution, 30 mg.ml-1) 15 min prior to bronchoprovocation tests with AMP, histamine and methacholine in a randomized, double-blind order. Changes in airway calibre were followed as forced expiratory volume in one second (FEV1) and agonist responsiveness was expressed as the provocative concentration causing a 20% fall in FEV1 from baseline (PC20). Administration of both L-ASA and glycine solution caused a small but significant acute fall in FEV1 from baseline, which returned to normal within 15 min. When compared to placebo, inhaled L-ASA reduced the airway responsiveness to AMP in all the subjects studied, the geometric mean (range) values for PC20 AMP increasing significantly from 36.3 (7.9-250.5) to 101.8 (27.2-1300) mg.ml-1 after placebo and L-ASA, respectively. Moreover, nebulized L-ASA induced a small but significant reduction in airway responsiveness to histamine, the geometric mean (range) PC20 values for histamine increasing from 2.77 (1.05-5.49) to 4.36 (1.69-11.24) mg.ml-1 after placebo and L-ASA, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of an inhaled neutral endopeptidase inhibitor, phosphoramidon, on baseline airway calibre and bronchial responsiveness to bradykinin in asthma

BACKGROUND

Bradykinin is a potent vasoactive peptide which has been proposed as an important inflammatory mediator in asthma since it provokes potent bronchoconstriction in asthmatic subjects. Little is known at present about the potential role of lung peptidases in modulating bradykinin-induced airway dysfunction in vivo in man. The change in bronchial reactivity to bradykinin was therefore investigated after treatment with inhaled phosphoramidon, a potent neutral endopeptidase (NEP) inhibitor, in a double blind, placebo controlled, randomised study of 10 asthmatic subjects.

METHODS

Subjects attended on six separate occasions at the same time of day during which concentration-response studies with inhaled bradykinin and histamine were carried out, without treatment and after each test drug. Subjects received nebulised phosphoramidon sodium salt (10(-5) M, 3 ml) or matched placebo for 5-7 minutes using an Inspiron Mini-neb nebuliser 5 minutes before the bronchoprovocation test with bradykinin or histamine. Agonists were administered in increasing concentrations as an aerosol generated from a starting volume of 3 ml in a nebuliser driven by compressed air at 8 1/min. Changes in airway calibre were measured as forced expiratory volume in one second (FEV1) and responsiveness as the provocative concentration causing a 20% fall in FEV1 (PC20).

RESULTS

Phosphoramidon administration caused a transient fall in FEV1 from baseline, FEV1 values decreasing 6.3% and 5.3% on the bradykinin and histamine study days, respectively. When compared with placebo, phosphoramidon elicited a small enhancement of the airways response to bradykinin, the geometric mean PC20 value (range) decreasing from 0.281 (0.015-5.575) to 0.136 (0.006-2.061) mg/ml. In contrast, NEP blockade failed to alter the airways response to a subsequent inhalation with histamine, the geometric mean (range) PC20 histamine value of 1.65 (0.17-10.52) mg/ml after placebo being no different from that of 1.58 (0.09-15.21) mg/ml obtained after phosphoramidon.

CONCLUSIONS

The small increase in bronchial reactivity to bradykinin after phosphoramidon exposure suggests that endogenous airway NEP may play a modulatory role in the airways response to inflammatory peptides in human asthma.

Pulmonary tuberous sclerosis in a woman of child-bearing age with no mental retardation

Tuberous sclerosis is a rare disease characterized by epilepsy, mental retardation and adenoma sebaceum. We describe the case of a 29-year-old woman with a clinical history of tuberous sclerosis who also had severe hypoxaemia, multifocal hamartoma-like lesions of various extrapulmonary organs, massive hypersplenism and coagulation defects. This case emphasizes the value of high resolution computed tomography (HRCT) in patients with pulmonary tuberous sclerosis.

Release of mast-cell-derived mediators after endobronchial adenosine challenge in asthma

Preformed and newly generated mediators released from airway mast cells may play a role in adenosine-induced bronchoconstriction. To investigate the possible role of mast-cell-derived mediator release in mediating bronchoconstriction induced by adenosine 5'-monophosphate (AMP), we have examined the fluid obtained by bronchoalveolar lavage for inflammatory mediators and markers of airway permeability immediately after instillation of AMP directly into an airway segment of 10 asthmatic subjects. Eight subjects completed the protocol. When compared with the saline-challenged segment, the response to endobronchial stimulation with AMP was characterized by a prompt reduction in airway caliber paralleled by a significant rise in PGD2, histamine, and tryptase levels in the lavage fluid. After AMP challenge, the median (range) concentration for PGD2 increased from 36 to 205 pg/ml (p = 0.006), for histamine from 184 to 433 pg/ml (p = 0.018), and for tryptase from 0.30 to 0.54 ng/ml (p = 0.013). In addition, a small but significant rise in albumin levels (from 27.8 to 36.1 micrograms/ml; p = 0.031) was detected after endobronchial challenge with AMP. These findings indicate that adenosine-induced responses may be initiated by the acute release of mast-cell-derived mediators, including PGD2, histamine, and tryptase.

Neutral endopeptidase inhibitor thiorphan increases airway narrowing to inhaled sodium metabisulfite in normal subjects

Possible mechanisms involved in inhaled sodium metabisulfite (MBS)-induced bronchoconstriction include cholinergic reflex and release of tachykinins from sensory nerve endings. Tachykinins are potent bronchoconstrictors cleaved and inactivated by neutral endopeptidase (NEP) in the airways. To investigate the role of tachykinins in airway response to MBS, we assessed the effect of NEP-inhibitor thiorphan on airway response to MBS in nine nonatopic, nonasthmatic subjects. Two inhalational challenges with doubling doses of MBS (0.03 to 16 mumol) were performed 3 d apart. Ten minutes before MBS challenge, subjects randomly inhaled either thiorphan (1.25 mg) or placebo according to a double-blind cross-over design. Airflow at 30% of vital capacity (V30p) from partial expiratory flow-volume curves was measured at baseline, 10 min after thiorphan or placebo, and 2 min after each MBS dose. The dose of MBS causing 40% fall in V30p (PD40V30p) was calculated. Neither thiorphan nor placebo affected baseline airway caliber. Thiorphan caused a leftward shift of the dose-response curve to MBS. After placebo a measurable PD40V30p was obtained in four of nine subjects. In these subjects PD40V30p fell significantly after thiorphan inhalation. Four of five subjects who did not exhibit PD40V30p after placebo showed measurable PD40V30p after thiorphan. Percent fall in V30p caused by highest dose of MBS was significantly greater after thiorphan compared with placebo (55.9 +/- 4.6% versus 30.8 +/- 5.6%; mean +/- SE; p < 0.001). Results of this study demonstrate that the NEP-inhibitor thiorphan increases MBS-induced bronchoconstriction in normal subjects, suggesting that tachykinins are involved in airway responses to inhaled MBS.

Inhibition of neutral endopeptidase potentiates bronchoconstriction induced by neurokinin A in asthmatic patients

The endogenous tachykinins exhibit a range of properties which may be relevant in the pathophysiology of asthma. Their effects on the airways seem to be modulated by a variety of lung peptidases, including neutral endopeptidase (NEP). In order to evaluate the potential role of endogenous NEP activity in modulating tachykinins-induced bronchoconstriction in man in vivo, six atopic asthmatic patients, with a mean FEV1 value of 3.38 +/- 0.76 l, and a histamine PD20 mean value of 0.024 mg, were studied. The influence of inhaled phosphoramidon (a potent NEP inhibitor) was examined against the NKA-induced bronchospasm in a double-blind, placebo-controlled randomized study. Changes in airway calibre were followed as FEV1 and agonists responsiveness expressed as PD20 and PD15 for histamine and NKA respectively. Patients received nebulized phosphoramidon sodium salt (10(-5) M) or a control solution 10 min prior to the bronchoprovocation test with NKA. No significant difference was noticed between any of the study days and after inhaled phosphoramidon on baseline FEV1 values (3.29 +/- 0.90 l) in comparison with the control solution (3.31 +/- 0.79 l). Inhaled NKA produced a dose-dependent fall in FEV1 values in all the subjects studied with a mean PD15 value of 20.91 x 10(-9) mol. Phosphoramidon administered by inhalation elicited a significant (P < 0.01 vs baseline and control solution) potentiation in the airway responsiveness to inhaled NKA, the NKA PD15 value decreasing to 9.45 x 10(-9) mol. The present study confirms that inhaled NKA induces a dose-related bronchoconstriction in asthmatic patients and demonstrates that inhaled phosphoramidon potentiates NKA-induced bronchoconstriction.

Effect of oral terfenadine on bronchoconstrictor response to inhaled neurokinin A and histamine in asthmatic subjects

Neurokinin A (NKA) elicits a potent contractile effect in asthmatic airways. Its mechanism of action in bronchial asthma is still unknown. Recent work supports the view that NKA may stimulate mediator release from mast cells. To investigate the relative contribution of mast cell degranulation to the action of NKA, a randomized, double-blind study has been undertaken, to evaluate the effect of a potent and selective histamine H1-receptor antagonist, terfenadine (180 mg q.d., for three days), on bronchoconstriction provoked by inhaled NKA in six asthmatic subjects. Bronchial provocation tests with histamine were included in this study as control challenge. In the subjects studied, oral terfenadine, when compared to placebo, significantly increased the geometric mean (range) provocation dose of inhaled histamine required to reduce forced expiratory volume in one second (FEV1) by 20% of baseline (PD20) from 0.05 (0.03-0.08) mg (0.16 (0.10-0.26) mumol) to 1.19 (0.63-2.04) mg (3.88 (2.05-6.64) mumol). However, terfenadine failed to increase the airway responsiveness to NKA in all of the subjects studied, the geometric mean (range) PD15 NKA value being 0.94 (0.47-2.49) micrograms (8.36 (4.14-21.9 nmol) and 0.75 (0.48-1.59) micrograms (6.62 (4.23-14.0) nmol) after placebo and terfenadine, respectively. We conclude that NKA is a potent bronchoconstrictor agonist in asthma, being approximately 19 times more potent than histamine in molar terms. In this study on a small number of subjects, pharmacological intervention with oral terfenadine failed to achieve significant protection of the airways against the constrictor effect of NKA.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of oral terfenadine on bronchoconstrictor response to inhaled neurokinin A and histamine in asthmatic subjects

Neurokinin A (NKA) elicits a potent contractile effect in asthmatic airways. Its mechanism of action in bronchial asthma is still unknown. Recent work supports the view that NKA may stimulate mediator release from mast cells. To investigate the relative contribution of mast cell degranulation to the action of NKA, a randomized, double-blind study has been undertaken, to evaluate the effect of a potent and selective histamine H1-receptor antagonist, terfenadine (180 mg q.d., for three days), on bronchoconstriction provoked by inhaled NKA in six asthmatic subjects. Bronchial provocation tests with histamine were included in this study as control challenge. In the subjects studied, oral terfenadine, when compared to placebo, significantly increased the geometric mean (range) provocation dose of inhaled histamine required to reduce forced expiratory volume in one second (FEV1) by 20% of baseline (PD20) from 0.05 (0.03-0.08) mg (0.16 (0.10-0.26) mumol) to 1.19 (0.63-2.04) mg (3.88 (2.05-6.64) mumol). However, terfenadine failed to increase the airway responsiveness to NKA in all of the subjects studied, the geometric mean (range) PD15 NKA value being 0.94 (0.47-2.49) micrograms (8.36 (4.14-21.9 nmol) and 0.75 (0.48-1.59) micrograms (6.62 (4.23-14.0) nmol) after placebo and terfenadine, respectively. We conclude that NKA is a potent bronchoconstrictor agonist in asthma, being approximately 19 times more potent than histamine in molar terms. In this study on a small number of subjects, pharmacological intervention with oral terfenadine failed to achieve significant protection of the airways against the constrictor effect of NKA.(ABSTRACT TRUNCATED AT 250 WORDS)

Cyclooxygenase products mediate the cutaneous vasodilation induced by endothelin-1 in humans

Intradermal injection of endothelin-1 (ET-1) causes vasoconstriction (pallor) at the injection site, surrounded by a larger area of vasodilation (flare) in humans. Some of the vasomotor responses to ET-1 are thought to be mediated by prostaglandins. In the present study, we investigated the involvement of cyclooxygenase-derived products of arachidonic acid metabolism on the cutaneous vasomotor responses to ET-1. Ten normal subjects (25-44 years) were studied after treatment with either indomethacin (50 mg t.i.d.) or placebo according to a double blind cross-over design. Five doses of ET-1 (5 x 10(-5) to 5 x 10(-1) pmol) were injected intradermally 2 h after the last dose of indomethacin or placebo. Pallor and flare areas measured by planimetry 15 min after the injection were analyzed to evaluate cutaneous vasomotor responses to ET-1. ET-1 induced dose-dependent pallor and flare responses that were significant at the dose of 5 x 10(-3) pmol or greater. Indomethacin did not affect the ET-1-induced pallor but significantly shifted to the right the flare dose-response curve to ET-1. The inhibition of the flare response to 5 x 10(-1) pmol ET-1 was 58.9 +/- 8.5%. These results indicate that the cutaneous vasodilation induced by intradermal injection of ET-1 is mediated by the release of vasodilating cyclooxygenase products.

Effect of topical application with capsaicin on skin responses to bradykinin and histamine in man

Pre-treatment with topical capsaicin is known to induce neuropeptide depletion from sensory nerve endings and it is a useful pharmacological tool to evaluate the contribution of these nerves to skin injury and inflammation. To investigate the relative contribution of sensory neural stimulation to the action of bradykinin and histamine, a randomized, double-blind study has been undertaken evaluating the effect of topical capsaicin pre-treatment on the responses to intradermal injections of both agonists in 12 healthy volunteers. Capsaicin pre-treatment caused significant inhibition of the immediate mean flare responses (95% CI) to both bradykinin (from 51.5 [39.7-63.3] mm2 to 16.2 [8.0-24.5] mm2) (P < 0.01) and histamine (from 108.4 [80.4-136.4] mm2 to 52.3 [37.1-67.1] mm2) (P < 0.01). Topical capsaicin elicited a significant inhibition of the weal response induced by histamine, the mean weal area being reduced from 14.8 (12.6-17.0) mm2 to 12.1 (10.1-14.1) mm2 (P < 0.05). In addition, the effect of topical capsaicin was to completely inhibit the bradykinin induced weal response compared to control, the mean weal area (95% CI) being reduced from 13.4 (11.4-15.4) mm2 to 8.2 (5.3-11.0) mm2 (P < 0.01). Our findings show that repeated topical application with capsaicin led to a significant reduction of the skin responses to intradermal injections with both agonists, and particularly with bradykinin. The weal responsiveness to bradykinin may entirely follow neuropeptide release from sensory nerves within the skin and the same applies to the flare response, although this is not completely inhibited by topical application with capsaicin.

Limited clinical usefulness of plasma corticotropin-releasing hormone, adrenocorticotropin and beta-endorphin measurements as markers of lung cancer

We measured plasma corticotropin-releasing hormone (CRH), ACTH, beta-endorphin (beta-EP), and cortisol levels as possible tumor markers in a sequence of 103, randomly selected, patients with lung cancer but without the ectopic Cushing's syndrome and in 72 age- and sex-matched controls. Plasma CRH levels of cancer patients were similar to those of controls both in patients sampled in the morning or in the afternoon. On the other hand, plasma ACTH levels of cancer patients were significantly higher than control patients both in the morning and in the afternoon and showed a preserved circadian rhythm. However, about 35% of cancer patients sampled in the morning and about 60% of those sampled in the afternoon had ACTH levels within the 95% confidence interval (CI) of controls. Also plasma beta-EP levels were more elevated in cancer patients than controls in the morning but about 33% of them and about 80% of those sampled in the afternoon had beta-EP levels within the 95% CI of controls. Despite the higher plasma ACTH levels, cancer patients had cortisol plasma levels similar to controls with preserved circadian rhythm. In conclusion, although mean plasma ACTH and beta-EP were higher in patients affected by lung cancer, their measurements, as well as those of CRH, have practically no diagnostic value. Perhaps measurement of ACTH levels in the bronchial lavage may be more helpful.