Increase in granulocyte-macrophage-colony-stimulating factor secretion and the respiratory burst with decreased L-selectin expression in hyper-IgE syndrome patients

BACKGROUND

The hyper-IgE syndrome is a primary immunodeficiency characterized by severe recurrent abscesses, pneumonia with pneumatocele formation, and elevated serum IgE. Eosinophilia, neutrophil chemotactic defects, and marked tissue damage are frequently present in this syndrome.

OBJECTIVE

To study whether functional changes in cytokines, adhesion molecules, and neutrophils might help explain these clinical observations.

METHODS

The following functions were analyzed in patients with the hyper-IgE syndrome and in controls: (1) production of granulocyte-macrophage-colony-stimulating factor by peripheral blood mononuclear cells by ELISA; (2) respiratory burst and reactive oxygen intermediates production by peripheral neutrophils using the luminol-enhanced chemiluminescense technique; and (3) expression of L-selectin on granulocytes and lymphocytes by flow cytometry.

RESULTS

Patients with hyper-IgE syndrome had significantly increased production of granulocyte-macrophage-colony-stimulating factor by resting or stimulated mononuclear cells, increased generation of reactive oxygen intermediates by neutrophils treated with opsonized zymosan, and reduced L-selectin expression on quiescent and activated granulocytes and lymphocytes.

CONCLUSIONS

Our results suggest that an important feature of the hyper-IgE syndrome is the increased production of granulocyte-macrophage-colony-stimulating factor, which may explain the reduced L-selectin expression, decreased chemotaxis, and increased oxygen radical production and tissue damage in this disease.

Improved outcome for acute lymphoblastic leukemia in children of a developing country: results of the Chilean National Trial PINDA 87

BACKGROUND

The National Chilean Pediatric Oncology Group, PINDA, reports the first prospective, nonrandomized trial for acute lymphoblastic leukemia (ALL), using a modified version of the Berlin-Frankfurt-Munster protocol (ALL BFM 86). The aim of this study was to classify immunophenotypes, to decrease cranial irradiation, and to assess whether this protocol would improve the survival rate.

PROCEDURE

From June, 1987, to June, 1992, 444 unselected children were diagnosed with ALL. Of them, 425 were evaluable. Therapy was stratified by risk. Standard-risk (SR) and high-risk (HR) patients received protocols I, M, II, and maintenance therapy. Very-high-risk (VHR) patients received protocol E instead of protocol M. All patients received a prephase treatment consisting of prednisone and intrathecal methotrexate (MTX). HR and VHR patients received cranial irradiation (12-18 Gy). The following changes were made to the ALL BFM 86 protocol: in protocol M, MTX 1 g/m2 instead of 5 g/m2; in protocol E, citarabine 1 g/m2 instead of 2 g/m2; mithoxantrone and ifosfamide were substituted by teniposide and cyclophosphamide.

RESULTS

Immunophenotypes: pro-B-ALL, 14%; common ALL, 67.4%; pre-B-ALL, 4.3%; T-ALL, 10%; undifferentiated leukemia (AUL), 4.3%. The overall 5-year event-free survival (EFS) rate was 60% +/- 2% (SE). The 5-year EFS rate for each risk group was: SR 75%, HR 62%, VHR 28%, with a median follow-up of 6.5 years (range 4.5-9.5 years). The cumulative incidence of central nervous system (CNS) relapse was 5.4%.

CONCLUSIONS

We have been able successfully to perform a nationwide study. Our strategy to adapt the BFM protocol to our population of patients trial was effective in improving the EFS. The immunophenotype distribution is similar to that in other reported series.

[Esophagogastric varix hemorrhage. Experience with cyanpoacrylate and polidocanol in 68 patients with active hemorrhage]

BACKGROUND

Sclerosis, injection of cianoacrylate and rubber band ligation are the most commonly used endoscopic techniques for the treatment of bleeding esophageal varices.

AIM

To assess the effectiveness of cianoacrylate and polidocanol in the treatment of bleeding esophageal varices.

PATIENTS AND METHODS

Sixty eight patients with active variceal bleeding were studied. Bleeding varices were classified as thin, thick or gastric. Bleeding from thin varices was treated with polidocanol. Bleeding from thick or gastric varices was treated with cianoacrylate. Variceal eradication was done with polidocanol.

RESULTS

Bleeding came from thin esophageal varices in 23% of patients and endoscopic treatment stopped bleeding in 95% of them, from thick esophageal varices in 62% and endoscopic treatment was successful in 94% of these, and from gastric varices in 12% and treatment stopped bleeding in 87% of these (in 3% bleeding was considered subcardial). Twenty-five percent of patients bled again during variceal eradication, 12% died due to uncontrollable bleeding and 20% died due to liver failure. During variceal eradication 59% of patients classified as Child Pugh C, died.

CONCLUSIONS

Treatment of bleeding esophageal varices with cianoacrylate or polidocanol is effective. Patients classified as Child Pugh C have a had prognosis.

Insulin antagonism: a novel role for human serum transferrin

We have purified alpha2-glycoprotein (alpha2-GP), an insulin antagonist from human plasma which is induced by growth hormone (GH), and shown that pure alpha2-GP is a potent antagonist of severe insulin-induced hypoglycemia, producing acute hyperglycemia in intact rats and ketonuria in diabetic rats. The N-terminal amino acid sequence of alpha2-GP and the reactivity of alpha2-GP with an antitransferrin monoclonal antibody show that alpha2-GP is identical to human serum transferrin. Furthermore, pure human serum transferrin and non-glycosylated recombinant human transferrin reproduce the insulin antagonist effects of alpha2-GP in rats, whereas ovotransferrin shows no such effect. The neutralization of the insulin antagonism of human serum transferrin by an anti-transferrin monoclonal antibody shows that transferrin has a new function as a potent insulin antagonist. This novel role for human serum transferrin in the regulation of glucose metabolism provides a reasonable mechanism for the diabetogenic effect of GH, and has important implications for the etiology and progression of diabetes.

A study of granulocyte respiratory burst in patients with allergic bronchial asthma

The respiratory burst of phagocytes plays an important role in the tissue damage that accompanies the inflammatory response. One of these conditions is allergic bronchial asthma, therefore, to evaluate the activation state of peripheral granulocytes the generation of reactive oxygen metabolites was evaluated using Luminol-enhanced chemiluminescence (LCL) and reduction of cytochrome C by superoxide. The resting granulocytes of the asthmatic patients under crisis showed a higher LCL compared to the noncrisis patients and control subjects. The granulocytes stimulated with PMA presented a significant increase in the respiratory burst in both groups of asthmatics. The granulocytes of noncrisis asthmatics challenged with Ops-Zym and with fMLP + Ops-Zym showed a higher metabolic activity, whereas the asthmatics under crisis presented no difference between reactive oxygen generation and that of the control group. The quantitative analysis of superoxide generation by granulocytes of the same patients did not show differences among the groups. Our findings suggest that the granulocytes of crisis and noncrisis asthmatics seem to be in a hyperreactive state and with a higher metabolic response when compared to the control group. However, the patients present a different behavior depending on stimulus used to activate cells. This could indicate that in peripheral blood exist different granulocyte populations depending on the inflammatory response taking place in the respiratory tract.

Spleen-derived stromal cells. Adhesion molecules expression and lymphocyte adhesion to reticular cells

The final steps of lymphocyte differentiation occur in secondary lymphoid organs where B and T lymphocytes interact with the lymphoid microenvironment. Although numerous studies describe the interactions of murine lymphocytes with dendritic, follicular and other antigen presenting cells, little is known on the interactions between lymphocytes and reticular cells, an important cellular component of spleen stroma. In this work we describe the culturing of complete murine spleen stromas and of two cell lines, Sp-1 and Sp-2, identified as of possible reticular origin, and describe the adhesive interactions between murine lymphocytes and human lymphoid cells with murine spleen stromal cells. FACS analysis indicates that the Sp-1 cell line shows a single cell type expressing VCAM-1 and CD44 constitutively. They do not express any of the markers described for follicular cells, interdigitating cells, macrophages or endothelial cells. Our data suggests that these cells represent a population of spleen reticular cells. The Sp-2 cell line shows two phenotypically different cell types that grow in association. FACS analysis demonstrates that both cell types express VCAM-1 and CD44 constitutively, but that they can be differentiated by the expression of CD11b and FcR. These data suggest that the Sp-2 cell line is composed of one type of stromal cell growing over an adherent layer of reticular cells. Furthermore, analysis of the non-B non-T cell fraction prepared from murine spleen shows that approximately 30% of these cells correspond to the CD44/VCAM-1 double positive cells. Murine B and T cells adhere to the complete stromas and to Sp-1 and Sp-2 cell lines. Activation of B cells with LPS had no effect on binding while binding of T cells to complete stromas increased up to threefold after Con-A treatment. Adhesion of human lymphoblastoid Daudi cells to complete spleen stromas is blocked by an anti-(murine) VCAM-1 antibody but not by an antibody to the (human) integrin alpha 4 subunit, while adhesion to the Sp-1 and Sp-2 stromas is blocked by antibodies against both molecules. Also, adhesion of Ramos cells to Sp-2 stromas is inhibited by antibodies to the integrin alpha 4 subunit and to murine VCAM-1. Antibodies to other adhesion receptors such as the integrin beta 2 subunit, ICAM-1 or CD44 have no effect on human cell binding to these stromas. Our results suggest that we have isolated a fraction of splenic reticular cells and that these cells can be cultured as a distinct cell line. The finding that these cells express CD44 and VCAM-1 constitutively and use some of these molecules for lymphocyte binding suggests that spleen reticular cells may be involved in the regulation of normal lymphocyte traffic through the spleen.

[Chronic pancreatitis. A recent national experience with its surgical management]

BACKGROUND

The prevalence of chronic pancreatitis in Chile is not known and there is no local information about the surgical treatment of this disease.

AIM

To review retrospectively the results of surgical treatment of chronic pancreatitis.

MATERIAL AND METHODS

The charts of 17 patients (12 male), aged 7 to 65 years old, with chronic pancreatitis that were operated in three different Chilean regions, were reviewed.

RESULTS

Seven patients had previous endoscopic therapeutic procedures (papillotomy in 4 and stent placing in 3). Seven patients had been subjected to previous biliary surgical procedures. Indications for surgery were severe pain in 14 patients, the suspicion of a pancreatic carcinoma in 4 patients, an infected pseudocyst in one and massive bleeding of multiple pseudo-aneurysms in a pseudocyst in one patient. Twelve patients were subjected to decompressions and 5 to pancreatic resections. There was no operative mortality and one transient pancreatic fistula. After an average follow up of 22 months, pain improved in 94% of cases, pancreatic cancer was diagnosed in one patient and 79% of subjects gained weight. One patient became insulin dependent, one increased his insulin requirements and one had transient steatorrhea, since she could not afford pancreatic enzyme replacement therapy.

CONCLUSIONS

The multidisciplinary approach of patients with chronic pancreatitis, with selective use of surgery, may greatly improve their quality of life.

Incidence of non-fatal workplace assault injuries determined from employer's reports in California

Although fatal work-related assault assault injury rates are routinely reported in the United States, reports of non-fatal injuries are not routinely examined. Non-fatal workplace assault injuries can be reported through many agencies. One of the most common reporting mechanisms in California is the Employer's Report of Occupational Illness and Injury. Employer's Reports filed from October 1, 1994 through January 31, 1995 in the state of California were the source of workplace assault information for this study. All reports indicating an assault-related injury were identified and characterized by gender and occupation of the victim, type of assault and weapon used, and industry. Annual rates were determined based on the number of estimated annual reports and the civilian working population. The estimated annual rate of workplace assault injuries for California based on Employer's Reports is 72.9 per 100,000 workers, which is approximately 50 times the fatal rate. Rates differed by industry, with retail, hospital, transportation and police workers exhibiting the highest rates. Assaults were predominantly Type I, which involve criminal activity, and Type II, which involve an assault by a client, patient, or inmate. The rates of non-fatal work-related assault injury are much greater and have different characteristics than fatal injuries. These non-fatal injury patterns need to be considered when estimating the burden of assault injuries on businesses, and can help identify the most effective prevention strategies.

Comparative analgesic efficacy of patient-controlled analgesia with ketorolac versus morphine after elective intraabdominal operations

We conducted a randomized, double-blind trial to compare analgesia and side effects produced by ketorolac and morphine during postoperative patient-controlled analgesia (PCA). Fifty-one patients (ASA classes I and II) undergoing elective intraabdominal procedures were assigned to one of two groups. When postoperative pain first increased to 4/10 (by visual analog scale [VAS]), patients were randomly assigned to one of two groups. Group 1 (n = 25) received up to two intravenous (IV) boluses of 5 mg of morphine followed by IV morphine PCA, whereas those in Group 2 (n = 26) received up to two IV boluses of 30 mg ketorolac, then IV ketorolac PCA. Up to two rescue doses of morphine (5 mg per dose, subcutaneously) were given in either group when pain during deep inhalation exceeded 5/10 on VAS. Ten patients from Group 1 required rescue doses of morphine compared to 22 patients from Group 2 (P < 0.0011). Two and 16 patients from Groups 1 and 2, respectively, were withdrawn because of inadequate analgesia (P < 0.01). Mean pain scores were less in Group 1 than in Group 2 at each time, but only significantly so at 15 min (P < 0.0021), 30 min (P < 0.0336), and 24 h (P < 0.0358) after starting PCA. Time to acceptance of oral liquids was equivalent in Groups 1 and 2 (22 h and 21 h, respectively). IV ketorolac PCA, although well tolerated, has limited effectiveness as the sole postoperative analgesic after intraabdominal operations.

[Cytogenetic studies of Chilean children with acute lymphoblastic leukemia]

Acute lymphoblastic leukemia (ALL) is the most frequent childhood cancer. The leukemic cells of ALL patients show several well defined numeric and structural chromosomal abnormalities which are universally known for its prognostic implications. We studied a group of 44 children with ALL, to investigate the incidence of chromosome aberrations in ALL, its lymphocyte lineage and some clinical feature associations, and the finding of non previously described aberrations. A high proportion of patients (79.5%) showed chromosomal abnormalities. Most of them had a pseudodiploid karyotype (46 chromosomes), characterized mainly by a translocation. In relation to chromosome number, 27% of them were hyperdiploid with more than 50; 9% hyperdiploid between 47-50 and 7% hypodiploid (less than 46). Among structural aberrations found, were the following recurrent translocations: t (1; 19), t (4; 11), t (9; 22) in 6.8%, 9.1% and 2.3% of cases respectively, all related to an early B immunophenotype. Other translocations found, compromised regions 7q22, 9p21 - 24. Two new translocations in ALL were found: t (1; 5)(q23; q33), apparently balanced, and t (13; 21)(q14; q22), unbalanced. Other recurrent structural changes found were: deletion (6q), (7q), (9p), (11q), (12p), inversion (3q), isochromosome (7q), maker chromosomes and double minutes. The distribution of chromosome abnormalities in this group of patients was in agreement with previous reports from other investigators.

[Value of bronchoalveolar lavage in the diagnosis of pulmonary involvement in storage diseases]

A 17 years old female with hepatosplenomegaly and pulmonary infiltrates since the age of four is presented. Sea-blue histiocyte disease, a sphingolipidosis, was diagnosed by liver biopsy, bone marrow aspirate and bronchoalveolar lavage. The relevance of bronchoalveolar lavage as a diagnostic method in cases of systemic diseases with pulmonary involvement is emphasized.

Induction of peroxisomal fatty acyl-coenzyme A oxidase and total carnitine acetyl-coenzyme A transferase in primary cultures of rat hepatocytes by garlic extracts

Garlic has been proposed as a natural hypolipidemic substance. Most hypolipidemic compounds induce peroxisomal proliferation and increase enzyme activities associated with peroxisomal beta-oxidation in rat liver. Here we report that garlic methanol-extracts behave as hypolipidemic drugs, increasing the activity of peroxisomal fatty acyl-coenzyme A oxidase and of total carnitine acetyl-coenzyme A transferase in primary cultures of rat hepatocytes. Both enzymes are considered markers associated with increased peroxisomal beta-oxidation. As in the case of hypolipidemic peroxisome proliferators, garlic extracts partially prevented the decrease in fatty acyl-coenzyme A oxidase as the culture aged. No changes were observed in the activity of microsomal NADPH cytochrome c reductase or of mitochondrial glutamate dehydrogenase.

Absorption of oral ethinylestradiol is delayed by its eutectic mixture with cholesterol

A solid dispersion of ethinylestradiol-cholesterol (EE & CHOL; eutectic 1:4 W/W) was prepared by melting and rapid cooling. The fused material was then mixed with lactose as vehicle. Soft gelatin capsules were filled with 50 mg of the final mixture to give 0.050 mg of ethinylestradiol. Six female volunteers received, one capsule of the eutectic combination of EE:CHOL or one 50 micrograms tablet of ethinylestradiol (Dianor, Syntex), in a cross-over study and in fasting state. Venous blood samples were drawn at 0, 10, 20, 30, 40, 50, 60, 90, 120, 240, 360, 480, 720, 1440 minutes after dosing. Immunoreactive EE was measured by radioimmunoassay to assess the serum concentration-time course. All subjects exhibited a significant increase in EE levels after oral administration. Mean peak EE levels, 1350 pg/ml vs 91 pg/ml (p less than 0.001), were achieved 360 minutes and 90 minutes (p less than 0.01), after administration of the eutectic and reference formulation, respectively. Eutectic mixture showed a greater area under the serum concentration-time curve, longer mean residence time of the drug in the body, and four times the value of the elimination half-life of the reference formulation. It is concluded that the combination of ethinylestradiol with cholesterol forming an eutectic mixture, when administered orally to normal women, modulates the absorption and the bioavailability of the EE. This approach may be suitable for long-acting oral treatment with sex steroids.

Bradykinin-induced vasoconstriction of rat mesenteric arteries precontracted with noradrenaline

1. Administration of bradykinin caused dose-dependent vasoconstriction in rat isolated perfused mesenteric arteries precontracted with noradrenaline. 2. The vasoconstrictor response was not mediated by BK1-bradykinin receptors. 3. Inhibition of cyclo-oxygenase with indomethacin, aspirin or meclofenamate abolished the vasoconstrictor effect of bradykinin, showing that a member of the arachidonic acid cascade may be involved. 4. Inhibitors of thromboxane synthesis (imidazole and UK 38485) did not affect or only reduced the bradykinin-induced vasoconstriction. 5. The endoperoxide H2/thromboxane A2 receptor antagonist SQ 29548 significantly reduced the vasoconstrictor effect of bradykinin, but did not affect the vasoconstrictor response to noradrenaline, adrenaline, vasopressin, 5-hydroxytryptamine or prostaglandins. 6. The eicosanoid(s) that mediate bradykinin-induced vasoconstriction appear to be synthesized outside the arterial endothelium. 7. The data suggest that the vasoconstrictor effect of bradykinin in the rat isolated mesenteric artery is mediated by vasoconstrictor arachidonic acid metabolites including the cyclic endoperoxides and/or the thromboxanes.

Short-lived suppressor cell activity during normal human pregnancy

Short-lived suppressor cell (SLSC) activity was determined in normal pregnant women. This activity was significantly increased in all three trimesters of pregnancy and during the first week postpartum. When pregnant women were divided into primiparous and multiparous groups, no significant differences were found between the two groups in any of the periods studied. These results suggest that increased SLSC activity may play a role in the materno-fetal tolerance and that parity has no influence on this activity.

[Transient myeloproliferative disorder associated with Down's syndrome in newborn infants]

Four cases of neonatal transient leukemoid reaction associated to Down's syndrome (TLRAD) studied in a Metropolitan Hospital at Santiago, Chile, since 1980 to 1985 are described. Diagnosis was done at the first week of live by blood cell counts in all the patients, and in every case these were characterized by high leukocyte counts (15,000 to 48,000 x mm3 blood), 13 to 25% circulating white blood cell blasts, 25 to 61% blast forms in bone marrow aspirates and normal erythrocyte and blood platelet series. In three cases the lower inferior hepatic border was palpated 3 to 5 cm under the rib's margin at the clavicular mid line. White blood cell blasts disappeared from circulation after 1 to 4 months in coincidence with reduction of liver's size to normal. Two of these patients died after remission of their leukemoid reaction as a result of serious systemic infections, without clinical nor laboratory evidence of leukemoid reaction neither leukemia, even though one of them was submitted to a complete postmortem examination. The other two cases had favourable clinical evolution and their hematologic controls have being normal along the following three years.

[The determination of immunological parameters in splenectomized patients]

We studied 15 patients submitted to splenectomy. Humoral immunity was studied with protein electrophoresis and quantification of immunoglobulins; cellular immunity was studied by total and subpopulation lymphocyte counts and evaluation of phagocytosis. Increased levels of IgG, IgM and IgA, a decrease in circulating T-lymphocytes and an increased phagocytosis was seen after operation. These findings correlated to the presence of viral and parasitic infections postoperatively. Preoperative antipneumococcal vaccination prevented infections by this agent. Thus, appropriate preventive measures must be taken to deal with altered immunological responses after splenectomy.

[Effect of fever on gastric emptying and on serum gastrin levels]

We studied the effect of fever on gastric emptying and serum gastrin 17 levels. 8 patients with fever and normal gastric emptying were selected. Blood samples were obtained for measuring serum gastrin 17. We used Tc99m scintiscanning to measure gastric emptying. Differences between fever and normal temperature were significant. Gastric emptying in fever was 118 +/- 54 minutes and 55 +/- 22 minutes for normal temperature (p less than .01). Serum gastrin was 47.7 +/- 13 pg/ml in normal temperature and with febrile patients was 30 +/- 5.7 pg/ml (p less than .002). We conclude that fever retards gastric emptying, perhaps independently of serum gastrin level.

Inhibition of stress-induced hyperglycemia by tail pinching or intraventricular enkephalin administration in the rat

The tail pinch (t-p) method added to a basal restraint stress produced inhibition of the stress-induced hyperglycemia, an effect that was neutralized with intrathecal anesthesia but not with intracerebroventricular (i.c.v.) naloxone (50, 100, 1000 ng/100 g) or with intraperitoneal naloxone injections (0.1-0.3 mg/100 g). A similar negative result was obtained with i.c.v. administration of 500 and 1000 ng/100 g of beta-endorphin. In contrast, a single i.c.v. injection of 1000 ng/100 g of Met-enkephalin reproduced the t-p inhibitory effect. The latter was not elicited by i.c.v. FK 33824, an enkephalin analogue, a result that supports the specific participation of the delta-opioid receptors. The results obtained with central alpha-adrenoceptor antagonists and central noradrenergic chemical destruction, or central alpha-adrenoceptor agonists, support the production of a reinforcement of the alpha-adrenoceptor stress stimulation by the t-p procedure, probably through noradrenaline and enkephalin mediation.