Interleukin-8 messenger ribonucleic acid expression correlates with tumor progression, tumor angiogenesis, patient survival, and timing of relapse in non-small-cell lung cancer

Tumor-associated angiogenesis is important for tumor growth and metastasis. Interleukin (IL)-8 was recently reported to be an important angiogenic factor both in vitro and in vivo. In this study we evaluated, for the first time, IL-8 messenger RNA (mRNA) expression in non-small-cell lung cancer (NSCLC), using real-time quantitative reverse-transcription-polymerase chain reaction, and correlated IL-8 mRNA expression in tumor and nontumor lung samples from 58 patients with NSCLC (29 with squamous cell carcinoma and 29 with adenocarcinoma, of whom 20 had Stage I, 10 had Stage II, and 28 had Stage III disease) with these patients' clinicopathologic characteristics, angiogenesis, and outcome. IL-8 protein expression and tumor microvessel count (MC) were assessed immunohistochemically. IL-8 mRNA expression was significantly greater in tumor tissue; high expression was highly associated with tumor in advanced stages (p = 0.03), distant lymph node metastasis (p = 0.02), high tumor MC (> 123) (p = 0.00003), short survival (< 26 mo) (p < 0.00001), and early relapse (< 16 mo) (p < 0.00001). Tumor MC correlated strongly with IL-8 mRNA expression (r = 0.56, p < 0.001). Multivariate analysis showed IL-8 mRNA expression and intratumor MC to be the most important predictors of patient survival and relapse. Thus, in NSCLC, IL-8 mRNA expression is strongly associated with tumor progression, tumor angiogenesis, survival, and time to relapse, suggesting its use as a prognostic indicator.

Clinical spectrum of acute respiratory distress syndrome in a tertiary referral hospital: etiology, severity, clinical course, and hospital outcome

BACKGROUND AND PURPOSE

The clinical picture of patients with acute respiratory distress syndrome (ARDS) in Taiwan has seldom been reported, although new definitions of ARDS have been introduced over the past years. The purpose of this study was to investigate the clinical characteristics, modalities of management, and outcomes in patients with ARDS treated in a tertiary referral hospital.

METHODS

Case records were selected through a computerized search of diagnosis codified at discharge during the period from January 1995 to June 1997. Patients who met the criteria of the American-European Consensus Conference definition of ARDS were included and their medical records were retrospectively reviewed.

RESULTS

A total of 145 patients (91 men, 54 women; mean age, 58 years) who fulfilled the criteria for ARDS were identified. Malignancy (n = 53) and diabetes mellitus (n = 23) were the most common co-morbid conditions. Pneumonia (n = 90), including community-acquired pneumonia in 45 (31%) patients, was the most common risk factor. The lung injury score at the time of ARDS diagnosis was 2.89 +/- 0.40 (mean +/- standard error, SE). The worst value of PaO2/FIO2 was 86.8 +/- 3.8 mm Hg (mean +/- SE). Among the 145 patients, 130 (90%) received mechanical ventilation and 118 (81%) were treated in the intensive care unit. In-hospital mortality was 87%. Seventy (48%) patients received intensive treatment for ARDS, among whom 52 (74%) died; the most common causes of death were multiple organ failure (54%) and respiratory failure (23%).

CONCLUSIONS

The mortality in patients with ARDS was high in this tertiary referral institution. Our findings suggest that aggressive ventilatory, pharmacologic, and supportive therapy may be important to achieve a higher survival rate.

Characterization of Pen n 13, a major allergen from the mold Penicillium notatum

Penicillium notatum is a well-known indoor aeroallergen and is frequently included in skin test panels for allergic diagnosis. On two-dimensional immunoblotting using patients' sera containing IgE and monoclonal antibody D7B8 specific for Pen c 1 of P. citrinum, two allergens with a molecular mass of 33 kDa but different isoelectric points were identified. A novel cDNA coding for Pen n 13 was cloned and sequenced. The nucleotide sequence codes for a protein 397 amino acids including a putative signal peptide of 25 amino acids and a propeptide of 90 amino acids. The allergen is an alkaline serine protease that shares more than 39% identical residues with other kinds of mold allergens. The coding cDNA of Pen n 13 was cloned into vector pQE-30 and expressed in E. coli M15 as a His-tag fusion protein and purified to homogeneity. The fusion protein reacted with monoclonal antibodies of Pen c 1 and with IgE from Penicillium-allergic patients. Furthermore, it also cross-reacted strongly with IgE specific for the natural Pen c 1, indicating that similar IgE binding epitopes may exist in the allergens of P. notatum and P. citrinum. Antigenicity index plots indicated that there are several similar epitope regions of high antigenic indices in Pen c 1 and Pen n 13, corroborating that mold allergens belonging to the alkaline serine protease family possess similar protein structure and strong antigenic cross-reactivity.

Identification and expression of an allergen Asp f 13 from Aspergillus fumigatus and epitope mapping using human IgE antibodies and rabbit polyclonal antibodies

The Aspergillus genus of fungi is known to be one of the most prevalent aeroallergens. On two-dimensional immunoblotting using patients' sera containing IgE specific for Asp f 13, an allergen with a molecular mass of 33 kDa and a pI of 6.2 was identified. This allergen was also present in A. fumigatus culture filtrates. Furthermore, the sequence of the Asp f 13 cDNA was identical to that for alkaline protease isolated from A. fumigatus and showed 42-49% identity of amino acids with two proteases from P. cyclopium and T. album and with the Pen c 1 allergen from P. citrinum. Asp f 13 coding sequences were expressed in Escherichia coli as a [His](6)-tagged fusion protein which was purified by Ni(2+)-chelate affinity chromatography. Recombinant Asp f 13 was recognized by rabbit polyclonal antibodies against Asp f 13 and by IgE antibodies from subject allergic to A. fumigatus. To identify and characterize the linear epitopes of this allergen, a combination of chemical and enzymatic cleavage and immunoblotting techniques, with subsequent N-terminal sequencing and mass spectrometry, were performed. At least 13 different linear epitopes reacting with the rabbit anti-Asp f 13 antiserum were identified, located throughout the entire molecule. In contrast, IgE from A. fumigatus-sensitive patients bound to three immunodominant epitopes at the C-terminal of the protein.

Disseminated cytomegalovirus disease in a patient with systemic lupus erythematosus not undergoing immunosuppressive therapy

We describe a case of cytomegalovirus (CMV) infection in a 25-year-old woman with a 3-year history of systemic lupus erythematosus (SLE) with persistently high disease activity, who had not received immunosuppressive therapy. Disseminated CMV infection presented with upper gastrointestinal bleeding, high fever, respiratory distress, leukopenia, and thrombocytopenia. The CMV infection was successfully treated with combined antiviral and immunoglobulin therapy, and the SLE activity decreased concomitantly. CMV disease is closely related to host immunosuppression, primarily T-lymphocyte dysfunction. This case should highlight the relationship between clinically significant CMV disease and compromised immunity in patients with active SLE who are not receiving immunosuppressive therapy.

Newly identified missense mutation reduces lipoprotein lipase activity in Taiwanese patients with hypertriglyceridemia

Lipoprotein lipase (LPL) plays a crucial role in the regulation of lipoprotein metabolism by hydrolyzing the core triglycerides of circulating chylomicrons and very low-density lipoprotein. Deficiency in this enzyme usually results in disturbances in lipid levels. To understand the molecular defect that leads to a functional deficiency of LPL in patients with hypertriglyceridemia, we looked for mutations of the LPL gene by means of single-strand conformation polymorphism (SSCP) analysis and direct DNA sequencing in 24 patients. A single base C-->G substitution in codon 252 of the LPL gene, encoding a change of a leucine to a valine residue in the mature protein, was found in three women who had hypertriglyceridemia and recurrent pancreatitis. Two of these patients, who were homozygous for the L252V mutation, had variable and occasionally severe hypertriglyceridemia with undetectable or very low LPL activities, respectively. The third woman was heterozygous for this mutation. All three patients had poor post-heparin LPL activity. Site-directed mutagenesis experiments provided in vitro evidence that the mutation of codon 252 was responsible for the loss of LPL activity. In conclusion, we identified a novel LPL mutation that results in decreased LPL activity in Taiwanese patients with hypertriglyceridemia. The assessment of a causative link between the mutation and hyperlipidemia awaits further studies.

Characterization of a novel allergen, a major IgE-binding protein from Aspergillus flavus, as an alkaline serine protease

Aspergillus species of fungi have been known to be one of the most prevalent aeroallergens. One important A. flavus allergen (Asp fl 1) was identified by means of immunoblotting with a serum pool of allergic patients on a two-dimensional electrophoretic gel. The cDNA coding for Asp fl 1 was cloned and sequenced. The clone encodes a full-length protein of 403 amino acid precursors of 42 kDa. After cleavage of a putative signal peptide of 21 amino acids and a prepeptide of 100 amino acids, a mature protein of 282 amino acids was obtained with a molecular mass of 33 kDa and a pI of 6.3. A degree of identity was found in a range of 27 to 84% among related allergens derived from bacteria allergen subtilisin, mold allergen Pen c 1, and virulence factor of A. fumigatus. Recombinant Asp fl 1 (rAsp fl 1) was cloned into vector pQE-30 and expressed in E. coli M15 as a histidine-tag fusion protein and purified to homogeneity. The IgE binding capacity of rAsp fl 1 was tested by immunoblotting using a serum pool of Aspergillus-allergic patients. Recombinant allergen cross-reacted strongly with IgE specific for natural Asp fl 1 and Pen c 1, indicating that common IgE epitopes may exist between allergens of A. flavus and P. citrinum.

High dose tamoxifen plus cisplatin and etoposide in the treatment of patients with advanced, inoperable nonsmall cell lung carcinoma

BACKGROUND

Tamoxifen sensitizes cancer cells to chemotherapeutic agents. High dose tamoxifen has been tested in the treatment of patients with melanoma and other cancers. The authors conducted a Phase II study of high dose tamoxifen plus cisplatin and etoposide for patients with advanced, inoperable nonsmall cell lung carcinoma.

METHODS

Patients with Stage IIIB, Stage IV, or recurrent disease; good performance status; measurable lesions; and good organ function were eligible. Tamoxifen 150 mg/m2/day, divided into 4 doses, was given for 8 days. Cisplatin 60 mg/m2 was given on Day 4. Etoposide 60 mg/m2/day was given on Days 4-8. Patients were allowed to remain in the study until either intolerable toxicity was observed or disease progression occurred.

RESULTS

Forty patients were accrued and received a total of 191 cycles of treatment. All patients were evaluable for response and toxicity. One patient had a complete remission and 14 had a partial remission (overall response rate, 37.5%). The median survival was 47 weeks. One-year survival was 44%. Increased thrombotic episodes were noted; all were clinically manageable.

CONCLUSIONS

High dose tamoxifen can be administered safely in combination with cisplatin and etoposide to patients with advanced nonsmall cell lung carcinoma. Favorable response rates and survival times were obtained. The value of high dose tamoxifen in the treatment of patients with nonsmall cell lung carcinoma can be evaluated further in randomized Phase III studies.

Identification and expression of Pen c 2, a novel allergen from Penicillium citrinum

The mould genus, Penicillium, is known to be a significant source of environmental aero-allergens. One important allergen from Penicillium citrinum, Pen c 2, has been identified by means of two-dimensional immunoblotting using IgE-containing patients' sera. This novel allergen was cloned, sequenced and expressed in Escherichia coli. The cloned cDNA encodes a large 457-amino acid protein precursor containing a 16-amino acid signal peptide, a 120-amino acid propeptide and the 321-amino acid mature protein. Comparison of the Pen c 2 sequence with known protein sequences revealed shared high sequence similarities with two vacuolar serine proteases from Aspergillus niger and Saccharomyces cerevisiae. Asp-46, His-78 and Ser-244 were found to constitute the catalytic triad of the 39-kDa Pen c 2. The DNA coding for Pen c 2 was cloned into vector PQE-30 and expressed in E. coli as a His-tag fusion protein that bound serum IgE from Penicillium-allergic patients on immunoblots. Recombinant Pen c 2 could therefore be used effectively for diagnosis and also potentially for the treatment of mould-derived allergic disorders.

Pen c 1, a novel enzymic allergen protein from Penicillium citrinum. Purification, characterization, cloning and expression

A 33-kDa alkaline serine protease secreted by Penicillium citrinum strain 52-5 is shown to be an allergenic agent in this fungus. The protein, designated Pen c 1, was purified by sequential DEAE-Sepharose and carboxymethyl (CM)-Sepharose chromatographies. Pen c 1 has a molecular mass of 33 kDa and a pI of 7.1. The caseinolytic enzyme activity of this protein was studied. The protein binds to serum IgE from patients allergic to Penicillium citrinum. The cDNA encoding Pen c 1 is 1420 bp in length and contains an open reading frame for a 397-amino-acid polypeptide. Pen c 1 codes for a larger precursor containing a signal peptide, a propeptide and the 33-kDa mature protein. Sequence comparison revealed that Pen c 1 possesses several features in common with the alkaline serine proteases of the subtilisin family. The essential Asp, His, and Ser residues that make up the catalytic triad of serine proteases are well conserved. Northern blots demonstrated that mRNAs transcribed from this gene are present at early stages of culture. The allergen encoded by Pen c 1 gene was expressed in Escherichia coli as a fusion protein bearing an N-terminal histidine-affinity tag. The protein, purified by affinity chromatography with a yield of 130 mg of pure protein per liter of culture, was able to bind to both a monoclonal anti-Pen c 1 antibody and IgE from the serum of patients allergic to Penicillium. Recombinant Pen c 1 can therefore be expressed in E. coli in large quantities and should prove useful as a standardized specific allergen for immuno-diagnosis of atopic disorders. In addition, full caseinolytic enzyme activity could be generated in the purified recombinant protein by sulfonation and renaturation, followed by removal of the affinity tag, indicating that the refolded protein can assume the same conformation as the native protein.

Diagnosis of pulmonary arteriovenous malformations by colour Doppler ultrasound and amplitude ultrasound angiography

BACKGROUND

The clinical value of colour Doppler ultrasound and amplitude ultrasound angiography in the diagnosis and follow up of pulmonary arteriovenous malformations (PAVM) was investigated.

METHODS

Six consecutive patients suspected by clinical appearance and abnormal chest radiographic findings of having PAVM were included in the study. Ultrasonography was performed first by real time grey scale imaging then by colour Doppler imaging and amplitude ultrasound angiography in a random order. All were later proved by angiography to have PAVM.

RESULTS

The ultrasound study was successfully performed in all six patients. A total of eight lesions was detected. The real time grey scale image of PAVM revealed well defined hypoechoic subpleural nodules with strong posterior acoustic enhancement. Colour Doppler ultrasound of PAVM showed turbulent flow, manifest as an area of intense colour with high and mixed velocities (reticulated or mosaiclike pattern). Anatomical continuity was demonstrated in some PAVM. Amplitude ultrasound angiography can delineate a tangled vascular structure with a clear vessel wall and anatomical continuity as well as conventional angiography. Spectral wave analysis showed a relatively low impedance flow presenting with high peak systolic velocity (mean 44.4 cm/s) and relatively high diastolic velocity (mean 19.3 cm/s). The mean pulsatility index (PI) and resistive index (RI) were 1.80 and 0.49, respectively. In two patients who received embolotherapy the colour Doppler ultrasound scan obtained after the procedure showed that the previous focal areas of colour flow signals disappeared or diminished in size. This was compatible with the decrease in, or absence of, blood flow demonstrated by angiography after embolotherapy.

CONCLUSIONS

Combined colour Doppler ultrasound and amplitude ultrasound angiography are useful non-invasive techniques for diagnosis PAVM and provide an alternative approach to angiography in evaluating the efficacy of embolotherapy.

Quantitative analysis of mRNA encoding MUC1, MUC2, and MUC5AC genes: a correlation between specific mucin gene expression and sialomucin expression in non-small cell lung cancer

The expression of mucins is important for tumor invasiveness and metastasis. In our previous report (Am. J. Respir. Crit. Care Med. 1997; 155:1419-1427), non-small cell lung cancers bearing sialomucin expression tended to relapse earlier than those without sialomucin. However, it remained unclear whether the expression of sialomucin in lung cancer is caused by an abnormal glycosylation process or by the expression of a specific mucin gene product. To address this problem, we established a modified quantitative competitive polymerase chain reaction (QC-PCR) analysis. RNA internal standards of MUC1, MUC2, and MUC5AC non-tandem repeat sequences were constructed, and known copy numbers of mucin RNA internal standards were introduced into reverse transcription-polymerase chain reactions (RT-PCR) for each mucin gene in order to compete with native mucin gene RNA during the reaction. The RNA of Gbeta-like gene (a housekeeping gene) was used as internal control for the RNA analysis. Twenty-five lung cancer tissues (13 adenocarcinomas and 12 squamous cell carcinomas) were used for analysis. Mann-Whitney rank sum test was applied to compare the expression amounts of different mucin genes in tissues. The results revealed that adenocarcinoma expressed higher amounts of MUC5AC gene than did squamous cell carcinoma (P = 0.03). The expression amount of MUC5AC correlated positively with the expression status of sialomucin (P = 0.012). Further studies are anticipated to elucidate the underlying mechanism contributing to this phenomenon.

PKC activation is required by EGF-stimulated Na(+)-H+ exchanger in human pleural mesothelial cells

Epidermal growth factor (EGF) stimulates the Na(+)-H+ exchanger, leading to enhanced cell proliferation. In human pleural mesothelial cells (PMCs), the intracellular signaling mechanism mediating the EGF-induced stimulation of the Na(+)-H+ exchanger has not yet been identified. Using a pH-sensitive fluorescent probe, 2',7'-bis(2-carboxyethyl)-5(6)-carboxyfluorescein, to measure changes in intracellular pH (pHi), we found that 1) EGF and 12-O-tetradecanoylphorbol 13-acetate (TPA; a phorbol ester) both stimulate the ethylisopropyl amiloride-sensitive Na(+)-H+ exchanger; 2) TPA-induced alkalosis can be blocked by protein kinase C (PKC) inhibitors (chelerythrine and staurosporine) or by PKC down-regulation, indicating that PKC activation is involved in the stimulation of the Na(+)-H+ exchanger. However, TPA-induced alkalosis is not blocked by tyrosine kinase inhibitors; and 3) the stimulatory effect of EGF on the Na(+)-H+ exchanger acts via stimulation of tyrosine kinase-receptor activity because it is inhibited by tyrosine kinase inhibitors (genistein, lavendustin A, and herbimycin A). It also involves PKC activation because EGF-induced alkalosis was blocked by PKC inhibitors. These results suggest that PKC activation is one of the downstream signals for EGF-induced activation of the Na(+)-H+ exchanger in primary cultures of human pleural mesothelial cells.

Ethanol, stroke, brain damage, and excitotoxicity

The N-methyl-d-aspartate (NMDA)-glutamate receptor could contribute to stroke, trauma, and alcohol-induced brain damage through activation of nitric oxide formation and excitotoxicity. In rat primary cortical cultures NMDA was more potent at activating nitric oxide formation than triggering excitotoxicity. Ethanol dose dependently inhibited both responses. In contrast, treatment of neuronal cultures with ethanol (100 mM) for 4 days significantly increased NMDA stimulated nitric oxide formation and excitotoxicity. These findings suggest that ethanol acutely inhibits but chronically causes supersensitivity to NMDA-induced excitotoxicity in neuronal cultures. To investigate ethanol's interaction with stroke induced damage models of global cerebral ischemia were studied. Transient global ischemia resulted in a loss of hippocampal CA1 pyramidal neurons over a 3- to 5-day period. Determinations of the NMDA receptor ligand binding stoichiometry or postischemic receptor binding changes did not show differences between neurons that undergo delayed neuronal death following ischemia and those that show no toxicity, for example, CA1 and dentate gyrus, respectively. Acute ethanol (3 g/kg) was found to protect against ischemia-induced CA1 hippocampal damage by lowering body temperature, but not under temperature controled conditions. These studies indicate that the factors contributing to stroke-induced brain damage are complex, although they are consistent with chronic ethanol increasing stroke-induced brain damage by increasing NMDA excitotoxicity.

Sonographic imaging of the trachea

We evaluated the feasibility of ultrasonography for imaging of the trachea and its effectiveness in the diagnosis and follow-up of patients with tracheal stenosis due to various diseases. Twenty normal volunteers and six adult patients with tracheal stenosis were included in the study group. Subjects were examined with ultrasonography in a supine position with the neck hyperextended or in a sitting position. At the level of the thyroid isthmus, the anterior tracheal wall thicknesses imaged by ultrasonography were 1.54 +/- 0.22 mm (mean +/- SD) and 1.22 +/- 0.18 mm for normal male and female volunteers, respectively. Ultrasonography could reveal the intrinsic tracheal wall lesions and extrinsic lesions compressing the trachea in patients with tracheal stenosis. These ultrasonographic images correlated with CT images. In conclusion, ultrasonography may be useful in imaging of the trachea.

Estrogens may reduce mortality and ischemic damage caused by middle cerebral artery occlusion in the female rat

The present study was undertaken to determine if estrogens protect female rats from the neurodegenerative effects of middle cerebral artery (MCA) occlusion. The rats were ovariectomized and 7 or 8 days later various estrogen preparations were administered before or after MCA occlusion. Pretreatment with 17beta-estradiol (17beta-E2) or a brain-targeted 17beta-E2 chemical delivery system (CDS) decreased mortality from 65% in ovariectomized rats to 22% in 17beta-E2-treated and 16% in 17beta-E2 CDS-treated rats. This marked reduction in mortality was accompanied by a reduction in the ischemic area of the brain from 25.6+/-5.7% in the ovariectomized rats to 9.8+/-4% and 9.1+/-4.2% in the 17beta-E2-implanted and the 17beta-E2 CDS-treated rats, respectively. Similarly, pretreatment with the presumed inactive estrogen, 17alpha-estradiol, reduced mortality from 36 to 0% and reduced the ischemic area by 55 to 81%. When administered 40 or 90 minutes after MCA occlusion, 17beta-E2 CDS reduced the area of ischemia by 45 to 90% or 31%, respectively. In summary, the present study provides the first evidence that estrogens exert neuroprotective effects in an animal model of ischemia and suggests that estrogens may be a useful therapy to protect neurons against the neurodegenerative effects of stroke.

Elevated serum levels of mucin-associated antigen in patients with acute respiratory distress syndrome

Increased serum levels of mucin-associated antigen have been previously demonstrated in patients with cystic fibrosis (CF) and interstitial pneumonia, and in lung-transplant recipients. The present study assessed the serum airway mucin levels in patients with acute respiratory distress syndrome (ARDS). An enzyme-linked immunosorbent assay (ELISA) method with a human-airway-mucin-specific monoclonal antibody (17Q2) was used to measure serum mucin levels in normal subjects, chronic smokers, patients with chronic bronchitis and other pulmonary diseases, patients with acute cardiogenic lung edema, and patients with ARDS. The serum mucin levels measured 9.9 +/- 0.8 ng/ml (mean +/- SEM, n = 59) in normal subjects, 12.7 +/- 1.6 ng/ml (n = 29) in chronic smokers, 21.8 +/- 1.9 ng/ml (n = 28) in patients with chronic bronchitis and other pulmonary diseases, 9.0 +/- 3.1 ng/ml (n = 5) in patients with acute cardiogenic lung edema. The serum mucin level was 53.8 +/- 6.6 ng/ml (n = 13) in patients with ARDS (p < 0.05, as compared with the four other groups). Serial measurements of serum mucin levels were obtained in patients with ARDS. Statistical analysis showed an inverse correlation of serial measurements of serum mucin with static respiratory-system compliance (p = 0.021), an inverse correlation of sequential serum mucin levels and log(Pa(O2)/Fl(O2)) (p = 0.016), and a positive correlation of sequential serum mucin levels and lung injury score (LIS) (p = 0.019). Gel-filtration analysis showed that mucin-associated antigens in ARDS sera were polydispersed and smaller than the antigens in normal sera. This study indicates that an increasing amount of degraded mucin occurs in patients with ARDS.

Comparison of inflammatory cytokine concentration and physiologic parameters in septic shock

Cytokine-related systemic intravascular inflammation may represent a common pathogenic link between initial insult and multiple organ failure in septic shock patients. We conducted a prospective study with controls in the National Taiwan University Hospital intensive care unit to compare plasma levels of tumor necrosis factor alpha (TNF-alpha), interleukin 6 (IL-6), and circulating intercellular adhesion molecule 1 (cICAM-1) with clinical physiologic parameters in the outcome of patients with septic shock. Healthy volunteers (n = 37) and patients with septic shock admitted to the unit from January to December 1994 (n = 31) were enrolled. Clinical data, APACHE (Acute Physiology and Chronic Health Evaluation) III scores, multiple organ failure scores, the presence of acute respiratory distress syndrome, and outcome were evaluated. The plasma levels of TNF-alpha, IL-6, and cICAM-1 were measured using enzyme-linked immunosorbent assay. Subgroups of survivors and nonsurvivors were compared for plasma levels of these factors or days 1, 2, 3, 7, and 14 after diagnosis of septic shock. Of the patients with septic shock, 20 survived and 11 died. The initial plasma levels of IL-6 were significantly higher in nonsurvivors (p < 0.05). There was a significant inverse correlation between plasma IL-6 level and survival in the first week (r = 0.4297-0.7242, p < 0.05). APACHE III score (r = 0.4335, p = 0.015), acute respiratory distress syndrome (r = 0.5913, p < 0.001), and multiple organ failure score (r = 0.736, p < 0.001) were more strongly (negatively) correlated with survival than the concentrations of TNF-alpha and cICAM-1 by Spearman's rank sum test. Our results showed that in patients with septic shock, of the inflammatory cytokines, only IL-6 showed significantly higher plasma levels in the nonsurvivor group. Inflammatory cytokine levels were not more strongly correlated with the outcome of patients with septic shock than physiologic parameters.

Serodiagnosis of tuberculosis. A study comparing three specific mycobacterial antigens

To compare the efficacy of different mycobacterial specific antigens and to assess the applicability of the combination of several different antigens in the diagnosis of tuberculosis, three ELISA tests derived by Antigen 60, 38kda, and Kp90 were evaluated in 594 Chinese patients (312 patients with active pulmonary tuberculosis and 282 control subjects). Quantified levels of sensitivity and specificity were compared with those in the nontuberculous control groups. Antigen 60 IgG (sensitivity and specificity, 80.77 and 88.4%) was more antigenic and more effective in its determination than was 38kda IgG (sensitivity and specificity, 64.21 and 80.74%) and Kp90 IgA (sensitivity and specificity, 62.58 and 66.3%). The clinical significance of the difference, however, was not striking: negative predictive value of Antigen 60, 38kda, and Kp90 was 93, 86 and 83%, respectively; positive predictive value of Antigen 60, 38kda, and Kp90 was 71, 54, and 39%, respectively. Combination of different antigens could improve the sensitivity and specificity by no more than 10%, with the sacrifice of the opposite parameter by no less than 20%. The same improvement in sensitivity could be easily achieved by adjusting the cutoff values in the ELISA test by a single antigen. We conclude that the sensitivity and specificity of presently available antigens for serodiagnosis of tuberculosis still remains limited at around 80%, which makes it a poor diagnostic tool for disease confirmation. In low incidence areas, its clinical value may be useful in disease exclusion. A combination of several different antigens provides no more improved diagnostic yield than what can be provided by cutoff value adjustment in a single antigen serologic test.

Sialomucin expression is associated with erbB-2 oncoprotein overexpression, early recurrence, and cancer death in non-small-cell lung cancer

Mucin production, when heavily sialylated, can promote cancer cell invasion and metastasis, and modulate the immune recognition system of the host. To explore the prognostic implication of sialomucin expression in lung cancer, we studied 116 patients with non-small-cell lung cancer (NSCLC). Tumor specimens were stained immunohistochemically with monoclonal antibodies (mAbs) against mucin glycoprotein (17Q2, HMFG2, SM3), and histochemically with periodic acid-Schiff/alcian blue to differentiate neutral mucin from acid mucin, and with high-iron diamine/alcian blue to differentiate sialomucin from sulfomucin. The expression status of two established molecular prognostic factors, the p53 and erbB-2 oncoproteins, were evaluated immunohistochemically. The staining was performed on two separately archived, paraffin-embedded tumor blocks for each patient, with normal lung as a control. Correlations were subsequently made among stains and various clinicopathologic factors. All analyses were blinded, and included Kaplan-Meier survival estimates with Cox proportional hazards regression modeling. Associations were established among adenocarcinoma histotype and erbB-2 overexpression, sialomucin expression, and 17Q2 and HMFG2 immunohistochemical positivity (p < 0.05). Sialomucin expression was closely linked to erbB-2 overexpression (p = 0.01). Significant univariate predictors (p < 0.05) of recurrence and cancer death were surgical stage, p53 expression, erbB-2 overexpression, and sialomucin expression. These four factors remained as independent predictors of early recurrence (p < 0.05) after multivariate analysis. For cancer death prediction, p53 and sialomucin expression had a marginal effect. We concluded that sialomucin expression is also a poor indicator of prognosis, which is associated with erbB-2 oncoprotein overexpression, early postoperative recurrence, and cancer death in NSCLC.

Life-threatening scrub typhus with meningoencephalitis and acute respiratory distress syndrome

A 21-year-old man presented with fever, rash, seizure, stiff neck and rapidly progressive bilateral pulmonary infiltrates. Cerebrospinal fluid (CSF) study revealed pleocytosis with predominant polymorphonuclear cells, and hypo-glycorrhachia. Status epilepticus occurred, followed by acute respiratory distress syndrome with respiratory failure. Blood and CSF cultures for bacteria were negative, but an indirect immunofluorescence assay revealed a fourfold rise in antibody to Rickettsia tsutsugamushi in paired serum and a 1:2560 (+) IgM antibody titer. Severe scrub typhus with meningoencephalitis and extensive pneumonitis was diagnosed. The patient survived after intravenous minocycline therapy and intensive care, including aggressive seizure control, supportive mechanical ventilation and avoidance of fluid overloading. He had a nearly complete recovery. Practicing physicians in Taiwan should be aware of this reportable disease and its potentially serious complications if not promptly diagnosed and treated.

Intracellular pH regulation in cultured human pleural mesothelial cells

The human pleural space is lined by a single layer of mesothelial cells, the intracellular pH (pH(i)) of which has never been investigated. In the present study, the intrinsic buffering power of H+ ions (beta(i)) and the pH(i) regulatory systems were investigated in primary cultures of human pleural mesothelial cells (PMCs) with microspectrofluorimetry. We found: (1) that at the resting pH(i), the beta(i) was low and increased as the pH(i) decreased; (2) that the pH(i) recovery was largely inhibited either with Na+-free medium or nominally HCO3 free medium containing ethyl-isopropyl amiloride (EIPA); (3) a 4-4'-diisothiocyanatostilbene-2,2'-disulfonic acid (DIDS)-sensitive, Na+/HCO3-dependent, but Cl(-)-independent acid extrusion mechanism in CO2/HCO3 buffer; and (4) that in the same buffer, a DIDS- sensitive but Na+-independent alkalosis was induced by intracellular Cl- depletion. We therefore conclude that at least three membrane pH(i) regulators are involved in regulating the pH(i) in PMCs, these being the EIPA-sensitive Na+-H+ exchanger; a novel electroneutral, DIDS-sensitive Na+-HCO3 cotransporter; and the DIDS-sensitive Cl(-)-HCO3 exchanger. Furthermore, under physiologic conditions, the Na+-HCO3 cotransporter plays a more important role in extrusion of excess intracellular H+ ions than does the Na+-H+ exchanger.

Overexpression of MUC5 genes is associated with early post-operative metastasis in non-small-cell lung cancer

Mucin glycoprotein can promote tumor-cell invasion metastasis and modulate the immune recognition of cancer. This study aimed to elucidate the clinical significance of mucin gene overexpression in lung cancer. We collected 60 lung cancer samples and paired non-tumorous lung portions of varying types and stages. Slot-blot analysis with specific anti-sense oligonucleotide probes derived from tandem repeat sequence of MUC1, -2, -3, -4, 5B and 5AC were utilized to compare the amount of mucin gene mRNA in tumor samples with that of the non-tumorous counterparts. A ratio higher than 1.5 for each specific mucin mRNA amount was considered to indicate mucin gene overexpression in tumors. Immunohistochemical staining of monoclonal antibodies against mature airway mucin (17Q2) and MUC1 mucin protein (HMFG2) were also used to analyze mucin protein. The study showed that overexpression of mucin genes frequently occurred in lung cancer (25 out of 60, 41.7%), but that there was no preferential expression of a particular mucin gene or a combination of mucin genes in these tumors. The overexpression of mucin genes and mucin protein had no correlation with tumor stage, nodal stage, histology or pathological differentiation grade. Tumors of smokers had higher MUC5B and MUC5AC mRNA expression ratios than those of non-smokers. Tumors with increased expression of mucin genes tended to be associated with post-operative relapse, especially when MUC5B and MUC5AC genes were overexpressed (p = 0.015 and 0.025, respectively). The study suggests that overexpression of novel tracheobronchial mucin genes may result in an increased likelihood of post-operative lung-cancer recurrence or metastases.

Efficacy of tracheal gas insufflation in acute respiratory distress syndrome with permissive hypercapnia

This study was conducted to assess the CO2-elimination efficiency of tracheal gas insufflation (TGI) in 20 patients with acute respiratory distress syndrome and to compare its efficacy during volume-controlled (VCV) and pressure-controlled ventilation (PCV). TGI was initially applied as an adjunct to VCV, with continuous flows (Vcath) of 4 and 6 L/min delivered through a catheter positioned 2 cm above the carina. Total effective tidal volume (VTeff) was held constant. The percent reductions in PaCO2 (% delta PaCO2) were 13.3 +/- 2.1 and 16.7 +/- 2.7% at Vcath 4 and 6 L/min, respectively, which correlated well with the percent reduction in the end-tidal PCO2 from baseline (% delta PETCO2) (r = 0.75, p < 0.001). An inverse relationship (r = -0.65, p < 0.001 and r = -0.59, p < 0.01 at Vcath 4 and 6 L/min, respectively) was found between the % delta PaCO2 and the baseline ratio of artery to PETCO2 difference to PaCO2, which was determined as the fraction of alveolar dead space (VDalv) relative to total alveolar ventilation. Twelve patients were subsequently switched to PCV combined with Vcath 6 L/min, which provided a % delta PaCO2 of 16.1 +/- 3.0% (p = NS versus 17.1 +/- 2.6% during VCV). These data suggest that in patients with ARDS the change in PETCO2 may be helpful in predicting the decrement in PaCO2 during TGI, and the existence of a high VDalv tends to limit its effectiveness. Further, the efficacy of TGI with VCV is equivalent to that with PCV.

Tuberculosis antigen A60 serodiagnosis in tuberculous infection: application in extrapulmonary and smear-negative pulmonary tuberculosis

An ELISA diagnostic test for tuberculosis antigen A60 (TBA60) IgG/IgM was used in a tertiary referral hospital in Taiwan. From June 1992 to December 1993, serum samples obtained from 907 patients were analyzed for TBA60 IgG and IgM titres. The final diagnosis of these patients was confirmed by microbiological study and clinical follow up for 18-24 months. Among 147 patients with active pulmonary tuberculosis, IgG was positive in 112 (76.2%), IgM was positive in 14 (9.52%). Among 90 patients with active extrapulmonary tuberculosis, IgG was positive in 53 (58.9%), IgM was positive in 9 (10%). Among 153 patients with inactive tuberculosis, IgG was positive in 28 (18.3%), IgM was positive in 1 (1.6%). Among 517 patients with nontuberculous disease, IgG was positive in 50 (9.7%), IgM was positive in 3 (0.6%). In this study population with 26% (237/907) active tuberculous infection rate, the TBA60 ELISA IgG had a diagnostic sensitivity of 69.6% and a specificity of 92.1%. These results indicate a positive predictive value of 67.9% and a negative predictive value of 89.2%. The sensitivity of IgM was 10.5% and specificity, 99.4%. The serum IgG tire had good correlation with the extent of pulmonary TB had a higher percentage of IgG seropositivity (83.9%) than those with smear-negative pulmonary TB (70.6%) and extrapulmonary TB (58.9%). In 50 cases with active tuberculosis, follow-up examinations were carried out one month after treatment. In 18 cases with initially negative IgG and IgM titres, 13 showed elevation of serum IgG titres into positive level, one had positive seroconversion of IgM which was the only serological marker indicating active infection. Therefore, 77.8% (14/18) gained diagnostic benefit from follow-up serological examination. It was concluded that TBA60 IgG and IgM ELISA is a useful test when diagnosing tuberculosis. This test also assists in the clinical judgement of tuberculosis when used as an adjunct to symptoms and sputum smear, and for monitoring therapeutic response at the commencement of treatment.