Clonal relationships in a shelter-associated outbreak of drug-resistant tuberculosis: 1983-1997

SETTING

An outbreak of tuberculosis caused by Mycobacterium tuberculosis resistant to isoniazid and streptomycin (HS-resistant) was documented in Boston's homeless population in 1984. Isolate relatedness was confirmed at the time by phage typing. In the late 1990s, cases of HS-resistant tuberculosis in the homeless were also documented, confirmed by RFLP typing using IS6110. None of the phage typed isolates from the 1980s were viable for performing RFLP analysis. We attempted to determine, using mixed-linker PCR (M-L PCR) finger-printing, whether or not these cases were all due to the same strain of M. tuberculosis.

DESIGN

Isolates from 10 HS-resistant patients-four non-viable isolates from the 1980s and six viable isolates from 1996-1997-were sent to the Centers for Disease Control and Prevention for M-L PCR fingerprinting. These results were combined with record reviews of older cases and an ongoing epidemiologic investigation.

RESULTS

Eight of 10 of the isolates were clonal, and the other two were strongly suspected matches. Epidemiologic investigation determined that transmission continued to occur after the initial outbreak in 1984-1985, and that a streptomycin-monoresistant variant of the strain was also circulating.

CONCLUSION

M-L PCR fingerprinting combined with epidemiology was able to document links between cases across 15 years.

Comparison of a whole-blood interferon gamma assay with tuberculin skin testing for detecting latent Mycobacterium tuberculosis infection

CONTEXT

Identifying persons with latent tuberculosis infection (LTBI) is crucial to the goal of TB elimination. A whole-blood interferon gamma (IFN-gamma) assay, the QuantiFERON-TB test, is a promising in vitro diagnostic test for LTBI that has potential advantages over the tuberculin skin test (TST).

OBJECTIVES

To compare the IFN-gamma assay with the TST and to identify factors associated with discordance between the tests.

DESIGN AND SETTING

Prospective comparison study conducted at 5 university-affiliated sites in the United States between March 1, 1998 and June 30, 1999.

PARTICIPANTS

A total of 1226 adults (mean age, 39 years) with varying risks of Mycobacterium tuberculosis infection or documented or suspected active TB, all of whom underwent both the IFN-gamma assay and the TST.

MAIN OUTCOME MEASURE

Level of agreement between the IFN-gamma assay and the TST.

RESULTS

Three hundred ninety participants (31.8%) had a positive TST result and 349 (28.5%) had a positive IFN-gamma assay result. Overall agreement between the IFN-gamma assay and the TST was 83.1% (kappa = 0.60). Multivariate analysis revealed that the odds of having a positive TST result but negative IFN-gamma assay result were 7 times higher for BCG-vaccinated persons compared with unvaccinated persons. The IFN-gamma assay provided evidence that among unvaccinated persons with a positive TST result but negative IFN-gamma assay result, 21.2% were responding to mycobacteria other than M tuberculosis.

CONCLUSIONS

For all study participants, as well as for those being screened for LTBI, the IFN-gamma assay was comparable with the TST in its ability to detect LTBI, was less affected by BCG vaccination, discriminated responses due to nontuberculous mycobacteria, and avoided variability and subjectivity associated with placing and reading the TST.

Surgery for bronchiectasis

OBJECTIVE

The incidence of bronchiectasis has declined markedly in developed countries. However, a reasonable number of patients still need surgery, despite aggressive physiotherapy and antibiotic therapy. We have reviewed our patients to clarify the benefits from surgery and to analyse the complications.

MATERIAL AND METHODS

Between 1988 and 1999, we have operated on 119 patients with bronchiectasis, 71 female and 48 male, with a mean age of 42.2 years (range 11--77 years). Surgery was indicated because of unsuccessful medical therapy in 66 patients (55%), 31 (26%) had haemoptysis, 11 (9.2%) had lung abscess, 10 (8.4%) had lung masses, and three (2.5%) had pneumothorax. The most common manifestations were cough with sputum in 90 patients (76%), haemoptysis in 45 (38%) and recurrent infections in 57 (48%). The mean duration of the symptoms was 4 years (range 1--40 years). The lower lobes were diseased in 61 patients and bilateral disease was found in ten. The mean number of involved pulmonary segments was five (range 1-15). A lobectomy was performed in 75 patients (62%), a segmentectomy in 12 (10%), a pneumonectomy in nine (7.4%) and a bilobectomy in four (3.3%). Complete resection of the disease was achieved in 108 cases (91%).

RESULTS

There was no operative mortality and perioperative morbidity occurred in 15 patients (15%), including temporary broncho-pleural fistulae in 7 (5.8%), and post-operative haemorrhage and atrial arrhythmias in four (3.3%) each. After a mean follow-up was 4.5 years, 73 patients (68%) of this group were asymptomatic, and 31 (29%) had meaningful clinical improvement, while only four (3.7%) maintained or worsened prior symptoms. The best clinical improvement occurred in patients with complete resection of the disease (P=0.008). There were no differences in the respiratory function, comparing pre- and post-operative data, with a 2-year of minimum interval. The VC was 91 and 89% and the FEV1 was 83% and 81% of expected, respectively before and after surgery, (P=NS).

CONCLUSION

Surgery of pulmonary bronchiectasis has few complications and markedly improves symptoms in the great majority of patients, especially when complete resection of the disease is achieved. Pulmonary resection of bronchiectasis does not alter respiratory function.

Excision of pulmonary metastases of osteogenic sarcoma of the limbs

OBJECTIVE

The combination of surgery and chemotherapy improves the prognosis of patients with osteogenic sarcoma of the limbs without detectable metastases at presentation. However, lung metastases are a frequent complication. To evaluate the role of the resection of pulmonary metastases of osteogenic sarcoma of the limbs, we have reviewed our experience with this type of surgery, combined with a multidrug chemotherapy protocol.

PATIENTS AND METHODS

From January 89 to December 97, 198 patients operated on for osteogenic sarcomas of the limbs were followed in our centre. Of these, 31 patients (15.7%), with a mean age of 25 years (range 10-54 years), developed lung metastases and had undergone 45 thoracotomies. All patients received chemotherapy, followed by resection of metastatic lesions and additional chemotherapy. The mean time interval between resection of the primary tumour and the diagnosis of lung metastases was 22 months (4-122 months). Eight patients (25.8%) needed more than one (2-4) thoracotomy. The mean time interval between the first and second thoracic surgeries was 9.2 months (2-14 months).

RESULTS

There was no operative mortality or major morbidity. During the 45 thoracotomies, five lobectomies and 40 wedge resections were necessary. The mean number of metastases resected per thoracotomy was 3.4 (range 1-10). The degree of necrosis was evaluated by seriated sections for a histologic study. In the end the mean necrotic volume was calculated. A strong correlation was found between the degree of necrosis of the metastases and the need for reoperation for new metastatic lesions, because all the patients who needed more than one operation had less than 80% of necrosis of metastases. The patients were followed for a mean period of 28 months (6-72 months). Ten patients (32.2%) died of related causes at a mean of 19.4 months after thoracic surgery, three of whom had more than one operation. The 3-year survival after metastasectomy was 61%. Patients without pulmonary metastases had a 3-year survival of 79%.

CONCLUSIONS

In patients with lung metastases of an osteogenic sarcoma, the combination of chemotherapy and surgery improves the outcome. In our series the mortality was not influenced by the number or thoracotomies required.

Cardiac lymphatic dynamics after ischemia and reperfusion--experimental model

ABSTRACT. The aim of the present study was to investigate the lymphatic cardiac circulation in an experimental model of ischemia plus reperfusion in mongrel dogs (Canis familiaris L). As radiotracer we used 0.2-0.25 ml (111 MBq) of 99mTc-Re2S7 colloid (+/-10 microm), injected subcapsullary below the second diagonal of the descending anterior ligated coronary artery with a special needle. A gamma-camera/Starport + DecStation were used for data acquisition. Four experimental groups with five animals each were established: G I = controls; G II = immediately after acute myocardial infarction (AMI); G III = late infarction (5 days after AMI); G IV = ischemia (90 min) + reperfusion. Four regions of interest (ROIs) were chosen: injection area (ZA), above (ZB), near right (ZD), and far right (ZC) from ZA. Mean disappearance times in ZA and dynamic parameters in the other ROIs were determined from activity/time curves drawn in each area, using homemade software. The results obtained seem to indicate that the methodology is appropriate to a detailed study of lymphatic drainage in pathological situations in animal models.

Differential responses of human mononuclear phagocytes to mycobacterial lipoarabinomannans: role of CD14 and the mannose receptor

CD14 is a signaling receptor for both gram-negative bacterial lipopolysaccharide (LPS) and mycobacterial lipoarabinomannan (LAM) that lacks terminal mannosyl units (AraLAM). In contrast, terminally mannosylated LAM (ManLAM) binds the macrophage mannose receptor (MMRc), although the ability of the MMRc to serve as a signaling receptor has not been previously reported. We compared the abilities of AraLAM and ManLAM to induce distinct responses in two monocytic cell populations, freshly isolated human peripheral blood monocytes (PBM) and monocyte-derived macrophages (MDM). The responses examined were chemotaxis and transient changes in free cytosolic calcium ([Ca2+]in). We found that AraLAM but not ManLAM was chemotactic for both PBM and MDM. Migration of these cells in vitro to AraLAM was specifically blocked by an anti-CD14 monoclonal antibody, suggesting that CD14 mediates the chemotactic response to AraLAM. Subsequently, we found that AraLAM induced a transient rise in [Ca2+]in levels within a subpopulation of PBM but not MDM. This response was blocked by anti-CD14 antibodies. In contrast, ManLAM induced a transient rise in [Ca2+]in levels within a subpopulation of MDM but not PBM. This response was blocked by either anti-CD14 or anti-MMRc antibodies. These data suggest that the MMRc can serve as a signaling receptor and that coligation of both CD14 and the MMRc is required to elicit a specific response. Thus, one response to LAM (chemotaxis) can be elicited solely by engaging CD14, whereas a different response (changes in [Ca2+]in levels) depends on both the differentiation state of the cells and concomitant engagement of CD14 and the MMRc.

Adherence-dependent calcium signaling in monocytes: induction of a CD14-high phenotype, stimulus-responsive subpopulation

Isolation of monocytes by plastic adherence alters cell morphology and function. In order to study the effects of cell isolation procedures and subsequent culture on monocyte function, we examined cytoplasmic calcium concentration changes (delta[Ca2+]in) in human monocytes isolated by either negative (magnetic bead) or positive (plastic adherence) selection then stimulated with formyl-Met-Leu-Phe (fMLP), either immediately after isolation, or after 48 h in culture. We have previously shown that fresh adherence-isolated monocytes respond to fMLP with small delta[Ca2+]in and oxidative burst responses, exhibiting larger responses following 48 h of incubation. We now demonstrate that fresh monocytes, prevented from adhering by negative selection, exhibit an even smaller fMLP-induced delta[Ca2+]in, which does not increase during 48 h in culture if cells are kept nonadherent, in Teflon. Calcium responses of adherent, fresh monocytes do not increase if cells are subsequently placed into suspension and maintained nonadherent, but increase if nonadherent cells are permitted to adhere to plastic. Furthermore, augmented fMLP-[Ca2+]in and oxidative burst responses in plastic-adherent cells are restricted to a CD14-high phenotype subpopulation. The CD14-high phenotype also describes a subpopulation of cells that responds to CD4 crosslinking with a rapid delta[Ca2+]in. Induction of a subpopulation of CD14-high expressing cells by adherence may explain in part maturation-induced response changes observed in macrophage but not in monocyte in vitro systems.

Endotracheal reintubation: a closer look at a preventable condition

We designed a prospective study of endotracheal intubations and reintubations in our inner city Level 1 Trauma Center, to determine the frequency and causes of reintubation and evaluate the impact of an educational intervention aimed at minimizing unplanned extubations (UEs). After an initial 3-month phase, efforts were instituted to educate healthcare providers to the causes of reintubation noted. An identical 3-month period was then studied to evaluate the efficacy of the interventions. There were 862 patients, all adults, in the initial phase of the study, with 40 reintubation events in 22 patients; of the 808 in the second phase, there were 16 reintubations in 13 patients. The reintubation rate decreased from 4.4% to 1.9% (p = 0.005). Reintubations after UEs decreased from 14% to 5.2% (rate ratio, 0.374; 95% confidence interval = 0.141, 0.990). Multiple reintubation events decreased from 45% to 18.8% (p = 0.07). Increased provider education and protocol changes were associated with lower reintubation rates.

[The implantable cardioverter-defibrillator: the Portuguese experience]

OBJECTIVE

The aim of this study was to review the Portuguese experience with implantable cardioverter-defibrillator therapy (ICD), in order to evaluate the increase in the number of ICD implanted, the main indications for this kind of therapy, the technical evolution of the procedure and the results of the follow-up of these patients during the last five years.

PATIENT SELECTION

The study group consists of 58 patients, 53 male and 5 female, mean age 54 +/- 14 years with ICD implanted in our country since 1992. The ICDs were implanted in 4 Hospitals, namely, Santa Cruz Hospital with 36 patients, Santa Maria Hospital with 11, Santa Marta Hospital with 8 and Coimbra University Hospital with 3 patients. Twenty six patients were resuscitated from cardiac arrest and the other 32 had ventricular tachycardia (VT) not tolerated haemodynamically and refractory to therapy. The diagnosis was coronary artery disease in 31 patients, dilated cardiomyopathy in 8, valvular disease in 4, congenital cardiopathy in 3, right ventricular dysplasia in 2, congenital long QT syndrome in 1, hypertrophic cardiomyopathy in one. Seven patients had idiopathic ventricular fibrillation without structural heart disease and one patient had isolated right ventricular dilatation.

METHODS

All patients underwent electrophysiological study before ICD implantation. In 2 patients epicardial leads were used and in the remaining 56 patients a transvenous approach was used. The device was implanted in an abdominal position in 36 patients and in a pectoral position in 22. Defibrillation and pacing thresholds were measured during the implantation procedure and whenever necessary. Patients were followed up on an outpatient basis with evaluation of the number of arrhythmic episodes, therapy efficacy with reprogramming of the device when required.

RESULTS

The number of implantations has increased, from 4 devices implanted in 1992, to 32 in 1996. The implantation was successful and without mortality or complications in all patients. Defibrillation threshold was 16 +/- 3 J, with an electrode impedance of 48 +/- 9 Ohms. During a mean follow-up time of 18 +/- 15 months (1 to 56) 5 patients died, one of sudden death and 4 of non cardiac deaths, 15 patients were re-admitted to hospital and in 8 patients the device was replaced due to exhaustion. In this period, 37 patients (64%) had arrhythmic episodes detected by the device, 32 patients (55%) had shocks and 9 (16%) were treated with anti-tachycardia pacing. Inappropriate shocks were observed in 10 patients (17%). The ICD were reprogrammed in 11 patients.

CONCLUSIONS

Portuguese experience with IC implantation is increasing and has shown to be a safe procedure with no operative mortality or morbidity. The incidence of appropriate shocks was high with a good efficacy in sudden death reduction.

Rifampin preventive therapy for tuberculosis in Boston's homeless

An epidemic of isoniazid (INH)- and streptomycin (SM)-resistant tuberculosis began among Boston's homeless population in 1984. Individuals with skin test conversions who agreed to preventive therapy received either INH, rifampin, or a combination of INH and rifampin. A total of 204 individuals with documented tuberculin skin test conversions who did not have active tuberculosis at the time of the clinical evaluation for their positive skin test were eligible for preventive therapy. Data on type and length of preventive therapy were obtained from the Tuberculosis Clinic and the Boston Tuberculosis Registry records at Boston City Hospital. The individuals were followed for development of active tuberculosis. Six of 71 (8.6%) individuals who received no therapy, 3 of 38 (7.9%) in the INH group, and none in the rifampin or rifampin plus INH groups (49 and 37 persons, respectively) developed active tuberculosis. Patients in the rifampin group were significantly less likely to develop tuberculosis than patients in the no therapy group (p = 0.04; odds ratio [OR] = 0.00, 95% confidence interval [CI] = 0.00-0.91). Treatment with any rifampin-containing preventive therapy (rifampin or rifampin plus INH) was effective (p < 0.01 ) in preventing development of active disease. The three INH failures were with organisms that were resistant to INH.

Neutrophil functional responses depend on immune complex valency

Ligand-induced cross-linking of Fc gamma receptors (Fc gamma R) on neutrophils plays a significant role in their stimulation, shown here by contrasting the responses induced by low valency immune complexes (LICs) and high valency immune complexes (HICs) and by cross-linking LICs in situ (L/Ab) after their addition to the cells. Multiparameter flow cytometry was used to measure immune complex (IC)-elicited changes in cytoplasmic Ca2+ concentration and initiation of the oxidative burst simultaneously in the same cell and to correlate these with Fc gamma R occupancy. We have previously shown that subpopulations of neutrophils respond maximally to subsaturating concentrations of HIC; saturating dosages stimulate the entire population. This discrepancy was not due to differences in receptor occupancy. The magnitude of the transient Ca2+ increase was independent of the dose of HIC but depended on the dose when an LIC was used. As shown here, L/Ab cross-linking elicited Ca2+ responses similar to those observed in HIC-stimulated cells. In contrast, LIC elicited only minimal intracellular delta pH and no oxidative burst or membrane potential changes at all unless Fc gamma R was cross-linked, accomplished by HIC or by L/Ab. However, azurophilic degranulation, as determined by elastase release, was not observed in cells stimulated by the in situ cross-linking method, whereas the HIC preparation triggered azurophilic degranulation. Thus, some Fc gamma R-mediated neutrophil effector functions such as azurophilic degranulation and oxidative burst initiation have an absolute requirement for Fc gamma R cross-linking, whereas signaling functions such as changes in membrane potential, intracellular pH, and intracellular Ca2+ concentration can occur, albeit more slowly and to a lesser extent, if single Fc gamma R are occupied.

Role of the Fc gamma R subclasses Fc gamma RII and Fc gamma RIII in the activation of human neutrophils by low and high valency immune complexes

Two Fc gamma receptor (Fc gamma R) subclasses on human neutrophils, Fc gamma RII and Fc gamma RIII, activate different cellular functions. To examine the involvement of each receptor subtype in polymorphonuclear leukocyte activation, Fab and F(ab')2 fragments of subclass-specific monoclonal antibodies ([mAbs] mAb IV.3 against Fc gamma RII and mAb 3G8 against Fc gamma RIII, respectively) were used to block the binding of low valency immune complexes (LICs) and high valency immune complexes (HICs). Flow cytometry then permitted the simultaneous quantitation of antibody and ligand binding, the elicited intracellular Ca2+ concentration (delta[Ca2+]int), initiation of the oxidative burst, and/or the phospholipase A activation in the same cell. We have previously demonstrated that subsaturating dosages of HIC bind uniformly to all the cells but elicit an "all-or-none" (i.e., dose independent) maximal delta[Ca2+]int in a dose-dependent subpopulation of the cells. In contrast, both the proportion of cells responding and the magnitude of the delta[Ca2+]int transient depend on the subsaturating dose of LIC, even though it too binds uniformly to all the cells, nonresponding as well as responding. These earlier findings have here been extended by single cell flow cytometric analysis to demonstrate that F(ab')2 Fc gamma RIII is the major Fc gamma R involved in HIC binding (and [Ca2+]int mobilization), as well as in oxidative burst and phospholipase A activation. In contrast, both receptor subclasses must be available for LIC-elicited delta[Ca2+]int, as blockage by either of the mAb Fab or F(ab')2 fragments abrogates this response, even though LIC binding to the receptors is not decreased. Furthermore, LIC elicited little oxidative burst activity and failed to activate phospholipase A but cross-linking to achieve multivalency, previously shown to induce [Ca2+]int and oxidative burst responses, elicited phospholipase A activity via Fc gamma RIII. Fc gamma RII's role appears to be modulation of the small, late Ca2+ influx observed at > 1 min, whereas Fc gamma RIII modulates all the earlier larger events. Thus, simultaneous observation of receptor identity, receptor occupancy, and consequent activation parameters in the same cell by flow cytometry permits use to demonstrate that Fc gamma RII is necessary for the small signal transduction elicited by LIC; it plays a relatively small role in polymorphonuclear leukocyte stimulation by HIC. Fc gamma RIII is the main receptor responsible for immune complex-elicited polymorphonuclear leukocyte responses; its efficacy is greatly enhanced when the receptors are cross-linked, either by preequilibrated multivalent complexes or by in situ cross-linking of bound LIC with excess antibody.

Cytokine binding to CD4+ inflammatory cells: implications for asthma

While LCF is present in BAL early after antigen challenge, we know little about its other potential effects beyond CD4+ T cell, monocyte, and eosinophil chemotaxis and monocyte and CD4+ T cell activation. The work described here focuses on the hypothesis that the secreted protein products of T cells participate in the airway inflammatory process that underlies human asthma, and in particular that LCF could play an early role because of the unusual responsiveness of LCF-producing T to histamine. To date, most studies have addressed the measurement of cytokines derived from CD4+ T cells (e.g., IL-2, IL-3, IL-4, IL-5, and GM-CSF) in the airways of asthmatics, and attempted to correlate the presence of protein or mRNA with the complexion of the inflammatory infiltrate. These studies have been based upon the reports that there are increased numbers of CD4+ T cells in the airways of asthmatics, and that the presence of eosinophils might correlate with the secretion of TH2-type cytokines like IL-3, -4, and -5. Using this information as a background, our work has approached the problem in an entirely different way. We have focused our attention on the early events in antigen-induced asthma that are responsible for CD4+ cell accumulation in the lung, including CD4+ T cells, eosinophils, and monocytes. We have attempted to identify mechanisms by which mast cell mediators, in particular histamine, might play a role in the secretion of chemotactic lymphokines that are selective for CD4+ cells by using CD4 itself as a chemotactic factor receptor.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of pulmonary systemic blood flow using ECG gated acquisition

We propose a functional parametric analysis method using ECG-gated 99mTc-labeled red blood cell (RBC) imaging for detection and characterization of periodic variations in local blood activity in the lungs during cardiac cycle. We validated in animal experiments that such count variations correlate with cyclical pulmonary blood flow and may be used for evaluation of systemic-to-pulmonary shunts. Clinical studies were performed in 48 patients. After labeling the RBC pool with 99mTc, ECG-gated gamma camera images of both lung fields were acquired and processed to obtain Fourier transforms of time/activity functions in selected regions. The first harmonic parametric images of amplitude and phase were derived. There was an excellent correlation (r = 0.92) between activity variations and pulsatile flow measured by our method with that obtained by the thermodilution method in dog experiments (n = 10) after implantation of a systemic-to-pulmonary shunt. Patient studies showed the technique to be sensitive in detecting and quantifying abnormal systemic-to-pulmonary blood flow. Lung pulsatile flow can thus be noninvasively measured from functional parametric phase and amplitude images; the technique may be useful for detecting and quantifying abnormal systemic-to-pulmonary blood flow in man.

Chemotactic peptide-induced cytoplasmic pH changes in incubated human monocytes

Stimulation of phagocytic leukocytes with chemotactic factors results in transient acidification, followed by alkalinization of the cytosol. Human monocytes are known to alter their functional responses to the chemotactic peptide N-formylmethionyl-leucyl-phenylalanine (fMLP) in a complex fashion as they mature in vitro to macrophages. To examine the evolution of the cytoplasmic pH (pHi) response of monocytes to fMLP as they mature into macrophages, we incubated cells for 0, 24, 48, and 96 h (Medium-199 + 10% fetal bovine serum; 37 degrees C) and examined pHi using the fluorescent probe 2',7'-bis(carboxyethyl)-5(6)-carboxyfluorescein (BCECF; 1 microM) and a Perkin-Elmer 650/10 spectrofluorimeter (lambda em = 530 nm, lambda ex = 500, 450 nm) as previously described. The resting pHi of fresh (0 h) monocytes was 7.07 +/- 0.16 (SD) and was unchanged after incubation for 24, 48, or 96 h (7.09, 7.11, 7.05, respectively). Cells exhibited an fMLP dose-dependent cytoplasmic acidification, with maximal delta pHi occurring 30-60 s after exposure to 10(-7) M fMLP. The response to fMLP did not change with the duration of incubation and, as with neutrophils, cytoplasmic realkalinization was blocked by dimethylamiloride (20 microM). Incubation with 2-deoxyglucose (10 min, 5 mM), sufficient to inhibit by more than 90% the formyl peptide-stimulated superoxide generation by monocytes, slowed fMLP-induced acidification and abrogated the alkalinization. In addition, monocytes isolated from the blood of a patient with X-linked chronic granulomatous disease (CGD) underwent fMLP-induced acidification that was unmasked further by coincubation with dimethylamiloride, in a manner quantitatively similar to that of normal monocytes, despite the inability of the CGD cells to produce superoxide. The chemotactic factor-induced cytoplasmic pH responses of monocytes/macrophages remained constant as the cells matured in vitro and exhibited a dimethylamiloride-independent acidification and dependent alkalinization, as did the response in neutrophils. The cytoplasmic acidification of these cells thus did not correlate with the cells' production of superoxide and with the concomitant hexose monophosphate shunt activation, as has been suggested for other leukocyte types.

Flow cytometric kinetic measurements of neutrophil phospholipase A activation

The interrelationships between activation of phospholipases and neutrophil stimulus-induced Ca2+ responses remain unclear. We report here that immune complexes activate a phosphatidylcholine-specific phospholipase A in a neutrophil only after the cytoplasmic Ca2+ transient has been initiated in the same cell, while chemotactic peptide activation does not proceed via such a phospholipase A-mediated mechanism. Measurements of [Ca2+] changes and of phosphatidylcholine-specific phospholipase A activity were made by flow cytometry, using Indo-1 for Ca2+ indication, and a new fluorescent probe, bis-BODIPY-phosphatidylcholine, localized in the inner leaflet of the plasma membrane, to measure phospholipase A activation. Both 100 nM formyl-methionyl-leucyl-phenylalanine (with or without cytochalasin B) and 60 micrograms/ml insoluble immune complexes elicited cytoplasmic Ca2+ transients, but only insoluble immune complexes stimulated phospholipase A activation in a subpopulation of cells exhibiting an elevation of [Ca2+]in. Phospholipase A activation followed the Ca2+ transient, starting, in each cell, after [Ca2+]in had begun to decrease as Ca2+ redistributed in the activated cell. The products of this phospholipase activation were confirmed by thin layer chromatography. We conclude that neutrophils respond to immune complexes with an elevated cytoplasmic Ca(2+)-requiring phosphatidylcholine-specific phospholipase A activation and to chemotactic peptides by a different mechanism.

Tuberculosis: a disease of the 1990s

In the United States, the decades preceding the 1980s were characterized by a decline in the incidence of tuberculosis. More recently, the trend has undergone a significant reversal: Case rates have been increasing by 3% to 6% annually. In 1990, more than 25,700 cases were reported to the Centers for Disease Control. In a sense, tuberculosis is adapting to the '90s. The recent increase in its incidence tends to affect populations with identifiable characteristics. Among the most important of these groups are the populations at high risk for infection by the human immunodeficiency virus. The increase is also fueled by cases in populations that are medically underserved, including foreign-born persons from high-prevalence countries, persons with low incomes, and persons living in long-term-care facilities--especially persons with previous tuberculosis infection. Thus, factors such as homelessness, chronic alcohol or drug abuse, malnutrition, and crowded living conditions continue to favor development and transmission of disease. The increase in the incidence of tuberculosis appears to be greatest when subpopulations in such circumstances are also at high risk for HIV infection. Complex issues in the diagnosis and treatment of tuberculosis arise from these epidemiologic patterns. HIV infection is associated with unusual presentations of tuberculosis. Thus, the clinician must maintain a high index of suspicion for the disease in the setting of HIV infection or risk of the infection. The populations at greatest risk are likely to be mistrustful of the medical system, making the long-term administration of potentially toxic chemotherapy more difficult than it already is. Chronic substance abuse may complicate compliance and add further difficulties to the monitoring of chemotherapy. At the same time, the monitoring becomes even more important in the physician's effort to minimize adverse effects of the medications. Outbreaks of drug-resistant disease have recently occurred, complicating the selection of drugs and affecting the duration of treatment. Despite all of these problems, it is essential to establish a diagnosis and initiate treatment rapidly, both to arrest the disease process and to limit its transmission. Since Mycobacterium tuberculosis is spread to uninfected persons in aerosols generated by coughing or sneezing, the infectiousness of a patient with active disease can be related, at least in part, to the number of organisms seen on sputum smears. Initiation of therapy is followed by a rapid decline in infectivity.

Effect of salt supplementation on amphotericin B nephrotoxicity

It has been suggested that salt loading protects against amphotericin B-induced nephrotoxicity. The influence of saline loading on the nephrotoxic response to amphotericin B (50 mg/dose given i.v. over 4 hr 3 X/week for 10 weeks) was assessed in two groups of ten patients each who were diagnosed with mucocutaneous leishmaniasis. Patients were randomized to receive either 1 liter of 0.9% saline or 1 liter of 5% dextrose in water, administered i.v. over one hour in a double-blinded manner, directly prior to amphotericin B administration. Renal function was monitored on a weekly basis two days after the last dose of amphotericin B. Baseline characteristics were similar in both groups except for a slightly higher serum creatinine concentration (Cr) in the saline group (0.8 +/- 0.05 vs. 0.6 +/- 0.04 mg/dl). Baseline sodium (Na) excretion was relatively high (262 +/- 23 mmol/day in the dextrose group and 224 +/- 17 mmol/day in the saline group). None of the patients sustained an increase in Cr to values greater than 1.7 mg/dl. Although mean Cr remained within normal, there was a significant difference between the two groups over the ten week period, with the dextrose group sustaining a significant increase in Cr and the saline group remaining unchanged. Serum potassium (K) levels fell in both groups necessitating oral K supplementation. The saline group required significantly greater amounts of K supplementation to maintain a normal serum K. Amphotericin B caused a rapid reduction in the acidification ability of the kidney in response to an ammonium chloride load. Under these conditions, the saline group had a poorer ability to acidify the urine.(ABSTRACT TRUNCATED AT 250 WORDS)