Task force on chronic interstitial lung disease in immunocompetent children

Chronic interstitial lung diseases in children represent a heterogeneous group of disorders of both known and unknown causes that share common histological features. Despite many efforts these diseases continue to present clinical management dilemmas, principally because of their rare frequency that limits considerably the possibilities of collecting enough cases for clinical and research studies. Through a Task Force conducted by the European Respiratory Society, which comprised respiratory physicians and basic scientists from across Europe, 185 cases of interstitial lung diseases in immunocompetent children were collected and reviewed. The present report provides important clinically-relevant information on the current approach to diagnosis and management of chronic interstitial lung diseases in children. In addition, recommendations for the management of paediatric interstitial lung diseases, as well as new insights into interstitial lung diseases pathophysiology during childhood are discussed.

[Prospective clinical study on new cutaneous melanomas in the Vendée area]

INTRODUCTION

In parallel to an epidemiological study on the new cases of melanoma reported in the Vendée area in 1997, private dermatologists conducted a clinical analysis of the characteristics of melanomas (including Dubreuilh's melanoma) and of the population concerned.

PATIENTS AND METHODS

For each patient in whom a melanoma had been diagnosed, the dermatologists completed a standardized sheet that included the identification, phototype (comparing the distribution with that of the local population, studied in all the consultants during a randomly selected week), the personal and family history of melanoma, the existence of severe sunburn and exposure to artificial ultra-violet rays, the screening method, the time lapse before treatment, the impact of information campaigns, the number of nevi, atypical or not, and the characteristics of the tumor. The exeresis method and the histological characteristics (type, Clark's score and Breslow's index) were also noted.

RESULTS

In 1997, the 16 local dermatologists diagnosed 97 melanomas in 55 women and 42 men with a mean age of 64 years. There was no statistically significant difference between the melanomas of the men and those of the women, other than their localization. Photoype II was significantly more frequent in the population exhibiting a melanoma. Sun exposure was moderate or intensive for three thirds of the patients. Past history of severe sunburn was twofold more frequent in the patients exhibiting a melanoma on the trunk. The association of many nevi was noted in a little more than half of the patients, and with atypical nevi in 5.2 p.cent. The elements that alerted the patients were recorded. The time lapse before diagnosis was calculated in months for nodular and in years for superficial melanomas. Clark's score and Breslow's index are presented in a table.

DISCUSSION

Our study underlines several interesting features: the fairly high mean age on discovery, a high rate of invasive melanomas, and patients less well informed than in the Ile de France area. These results should open the debate on the best way to educate the population concerned so as to reduce the incidence of this malignant tumor.

[Prospective epidemiological study on cutaneous melanomas in the Vendée area]

INTRODUCTION

The aim of this prospective study was to evaluate the incidence of melanoma in the Vendée area, coastal region of Eastern France, in 1997.

PATIENTS AND METHODS

The 16 dermatologists in the Vendée area in 1997, grouped together in a local association, completed a sheet for each patient in whom a new melanoma had been diagnosed. During the same period, the hospital and private pathologists of the Vendée and surrounding areas reported their new cases of melanoma in patients residing at least six months of the year in the area. The data concerning the local population was supplied by the INSEE (French national institute of economic and statistical information) and the CPAM (French health authority) supplied data on the practitioners' activity. The raw and standardized incidence was calculated by the epidemiologist and the statistician of the local Vendée Cancer registry.

RESULTS

One hundred fifteen new melanomas were diagnosed in Vendée in 1997, 97 by a dermatologist and 18 declared by a pathologist. There were 36 in situ and 79 invasive melanomas discovered in 68 women and 47 men (sex ratio: 1.46). The standardized rate of incidence according to the world model was of 98/100,000 for women and 7.8/100,000 for men. The frequency curve revealed two peaks: the first at 40-50 years of age and the second at 70-75. The mean Breslow index of the 79 invasive cancers was of 1.62 mm (range: 0.10-12.5 mm). The only statistically significant difference between the melanomas of the men and the women concerned the topography; there were more melanomas on the trunk in men and more melanomas on the lower limbs in the women. Forty-seven Dubreuilh melanomas were reported: 28 in situ and 19 invasive.

DISCUSSION

This prospective study determined the incidence of melanoma in Vendée in 1997. The figures have been compared with those of the Vendée cancer registry, founded in April 1997, and with those of various published studies. The comparison was difficult because of the difference in study methodology. The only figures obtained in the same conditions are those of the cancer registry and we compared them with those of the Haut-Rhin, area of Eastern France: the incidence was similar for the women in the two areas and greater for the men in the Haut-Rhin with regard to the invasive melanomas. Conversely, 44 in situ melanomas were declared in the Haut-Rhin over a 3 year period versus 37 in Vendée over a period of 1 year. The increase in the incidence of melanoma in Vendée in the years to come should permit the evaluation of the impact of the various preventive campaigns.

Role of cyclins in epithelial response to oxidants

Oxidants are involved in a large variety of pulmonary diseases. Among the various cell types that compose the respiratory system, the epithelial cells appear to be a major target for oxidative stress. When cells are exposed to DNA-damaging agents such as oxidants, a feedback control is activated that acts as a brake on the cell cycle to inhibit entry into the S phase until DNA repair is completed. Progression through the G1 phase and the G1-S transition involves sequential assembly and activation of key regulators of the cell cycle machinery, the cyclin-dependent kinases (CDKs). Activity of the CDKs is regulated by several mechanisms, which include the CDK inhibitors (CKIs). The CKI p21(CIP1) appears to play an important role in the response of epithelial cells to oxidants.

Abnormal central complex is a marker of severity in the presence of partial ciliary defect

BACKGROUND

Ciliary ultrastructural defects with total lack of dynein arms (DA) cause abnormal mucociliary function leading to the chronic infections observed in primary ciliary dyskinesia. The role of partial ciliary ultrastructural defects, especially those involving the central complex, and their relationship with respiratory symptoms have been less thoroughly investigated.

OBJECTIVE

In a pediatric population with partial ciliary defects, we determined the relationship(s) between ultrastructural findings, ciliary motility, and clinical and functional features, and evaluated the outcome of this population.

DESIGN

We analyzed the clinical presentation and pulmonary function of 43 children with chronic bronchitis and partial ultrastructural defects (from 15% to 90%) of their respiratory cilia demonstrated on bronchial biopsies. The study population was divided into 3 groups according to ciliary ultrastructure: the main ultrastructural defect concerned the central complex in 23 patients (CC group), peripheral microtubules in 8 patients (PMT group), and DA in 12 patients (DA group).

RESULTS

The percentage of ciliary defects was lower in the PMT group than in the CC and DA groups. Patients in the PMT group had less severe disease with frequent normal ciliary motility. Patients in the CC group had initially a higher incidence of respiratory tract infections, extensive bronchiectasis frequently requiring surgery, and arguments in favor of a congenital origin (high proportion of sibling form). Partial absence of DA, although of congenital origin, was associated with a good prognosis. In all groups, follow-up showed that the functional prognosis remained good with appropriate treatment.

CONCLUSIONS

In children with chronic respiratory infections, presence of situs inversus, sibling form, obstructive pulmonary syndrome, or bronchiectasis required ultrastructural analysis, regardless of ciliary motility. Detection of CC abnormalities is a marker of severity and required intensive therapy and close follow-up.

Retinoic acid protects against hyperoxia-mediated cell-cycle arrest of lung alveolar epithelial cells by preserving late G1 cyclin activities

The epithelium of the lung alveolus is a major target for oxidant injury, and its proper repair after injury is dependent on the proliferative response of the alveolar epithelial type 2 cells. Recently, we have provided evidence that retinoic acid (RA) stimulates proliferation of type 2 cells. In the present study, we examined the effects of RA on the proliferative response of alveolar type 2 cells exposed to elevated oxygen (O(2)). We showed that pretreatment by RA was able to prevent the growth arrest and cell loss of O(2)-exposed cells. To gain insights into the mechanisms involved, we studied the effects of RA on the cyclin-dependent kinase (CDK) system. The activity of cyclin E-CDK2 complex was found to be decreased in O(2)-exposed cells. Interestingly, this decrease was no longer observed when cells were pretreated with RA. Analysis of p21(CIP1), an inhibitor of CDK, revealed an increased expression in O(2)-exposed cells that was no longer observed in cells treated with RA. These effects were associated with a reduced association of p21(CIP1) with cyclin E-CDK2 complexes in the presence of RA. In addition, studies of Smad activity strongly suggest that the mechanisms through which RA preserves late G(1) cyclin-CDK complex activity may involve interference with the transforming growth factor-beta signaling pathway.

Cystic fibrosis-related diabetes mellitus: clinical impact of prediabetes and effects of insulin therapy

In patients with cystic fibrosis (CF), glucose intolerance preceding diabetes (prediabetes) may have adverse effects on nutritional status and respiratory function, which are reversible after the start of insulin therapy. Respiratory function (forced vital capacity and forced expiratory volume in one second) and body mass index (BMI) were compared retrospectively in a French cohort of 14 patients during the 5 y preceding insulin therapy for diabetes and in 14 age- and sex-matched controls with normal oral glucose tolerance tests. In the diabetic group, all three parameters deviated increasingly from the values in the controls; the differences became statistically different during the 6 mo before insulin therapy. The effect was more important in patients for whom diabetes mellitus was diagnosed on the basis of symptoms of hyperglycaemia than in patients for whom it was diagnosed by systematic screening, but still present in the latter. After insulin was started, respiratory function improved and the BMI returned to normal within 1 y. The annual insulin requirement increased from 0.62 during the first year to 1.25 during the fifth year. Glycosylated haemoglobin (HbAIc) values ranged from 6.6 to 7.8%. Only 2 episodes of severe hypoglycaemia were recorded over 42 patient-years of follow-up. The insulin regimen most often used was two daily injections of a mixture of short- and intermediate-acting insulin (n = 10) given with an insulin pen.

CONCLUSION

The clinical status of CF patients who will need insulin therapy deteriorates before the start of insulin. In patients with CF-related diabetes, with or without fasting hyperglycaemia, insulin therapy improves anabolism and provides good glycaemic control with few severe hypoglycaemic episodes.

Pulmonary sarcoidosis in children: a follow-up study

Progression of pulmonary sarcoidosis in children remains poorly documented. The aim of this work was to gather follow-up information on pulmonary outcomes in children with sarcoidosis and to obtain data of relevance to a discussion of the optimal length and regimen of glucocorticoid therapy. In the present study, the authors experience of pulmonary sarcoidosis in 21 children referred to the paediatric pulmonary department over a 10-yr period is reported with a documented follow-up of at least 4 yr. Evaluation of the disease during the follow-up included analysis of clinical manifestations, chest radiographs, pulmonary function tests with measurements of the vital capacity (VC), dynamic lung compliance (CL,dyn), lung transfer for CO (TL,CO), and arterial blood gases, as well as bronchoalveolar lavage (BAL) with determination of total and differential cell counts. After initial evaluation the decision was a careful observation of four children without therapy. Corticosteroid treatment was initiated in 17 children. Analysis of results indicated that after 6-12 months of treatment most clinical manifestations of the disease and chest radiograph abnormalities disappeared, and beneficial effects on VC and TL,CO were apparent. After 18 months of steroids no benefit on pulmonary function tests could be noticed, with mainly persistence of alterations of CL,dyn. Results of BAL studies documented the presence of an alveolitis with increased lymphocyte populations throughout the follow-up. Relapses were observed in four children during tapering of prednisone; they were not reported after discontinuation of steroid therapy. Taken together data obtained in the presented population can lead to the following suggestions for the management of pulmonary sarcoidosis in children. BAL should be performed at the initial evaluation to document alveolitis; however, nothing seems to be gained from repeating this investigation during follow-up in the absence of specific reasons. Once the decision to initiate glucocorticoid therapy is made, 18 months may be a reasonable treatment duration. Discontinuation of therapy can be decided even if the pulmonary function tests remain abnormal, but the child should then be carefully monitored for a relapse.

NF-kappa B mediates up-regulation of CFTR gene expression in Calu-3 cells by interleukin-1beta

Inflammation of the airways is a major feature of the inherited disease cystic fibrosis. Previous studies have shown that the pro-inflammatory cytokines tumor necrosis factor alpha and interferon gamma reduce the expression of the cystic fibrosis transmembrane conductance regulator (CFTR) gene (CFTR) in HT-29 and T84 cells by acting post-transcriptionally. We have investigated the effect of the pro-inflammatory peptide interleukin 1beta (IL-1beta) on the expression of the CFTR in Calu-3 cells. IL-1beta increased the production of CFTR mRNA in a dose- and time-dependent manner. Its action was inhibited by inhibitors of the NF-kappaB pathway, including N-acetyl-l-cysteine, pyrrolidine dithiocarbamate, and a synthetic cell-permeable peptide containing the NF-kappaB nuclear localization signal sequence. Gel shift analysis showed that IL-1beta activated NF-kappaB in Calu-3 cells, and transfection experiments using p50 and RelA expressing vectors showed that exogenous transfected NF-kappaB subunits increased the concentration of CFTR mRNA. Gel shift analysis with antibody supershifting also showed that IL-1beta caused the binding of NF-kappaB to a kappaB-like response element at position -1103 to -1093 in the CFTR 5'-flanking region. Transfection experiments using -2150 to +52 CFTR reporter gene constructs showed that the activity of the CFTR promoter is enhanced by exogenous transfected NF-kappaB and IL-1beta and that this enhancement is due, at least in part, to the -1103 to -1093 kappaB site. We conclude that the intracellular signaling that leads to increased CFTR mRNA in response to IL-1beta in Calu-3 cells includes the binding of NF-kappaB to the -1103 kappaB element and a subsequent increase in CFTR promoter activity.

Distinct patterns of insulin-like growth factor binding protein (IGFBP)-2 and IGFBP-3 expression in oxidant exposed lung epithelial cells

Oxygen (O(2)) species are involved in a large variety of pulmonary diseases. Among the various cell types that compose the lung, the epithelial cells of the alveolar structure appear to be a major target for oxidant injury. Despite their importance in the repair processes, the mechanisms which regulate the replication of the stem cells of the alveolar epithelium, the type 2 cells, remain poorly understood. Based on the results of several studies which have documented the involvement of the insulin-like growth factor (IGF) system in lung epithelial cell replication, and which have also suggested a role for IGF binding proteins (IGFBPs) in the control of cell proliferation, the aim of the present work was to determine whether IGFBPs could be involved in the modulation of growth of human lung epithelial cells exposed to oxidants. Experiments were performed using a human lung adenocarcinoma cell line (A549) which was exposed for various durations to hyperoxia (95% O(2)). We observed a rapid and reversible growth arrest of the cells after only 24 h of O(2) exposure. When oxidant injury was prolonged, growth arrest was followed by induction of apoptosis with activation of the Fas pathway. These effects were associated with an increased expression of IGFBP-2 and IGFBP-3. In addition, study of localization of these proteins revealed distinct patterns of distribution. IGFBP-3 was mainly present in the extracellular compartment. In comparison, the fraction of IGFBP-2 secreted was less abundant whereas the IGFBP-2 fraction in the intracellular compartment appeared stronger. In addition, analysis of the subcellular localization provided data indicating the presence of IGFBP-2 in the nucleus. Taken together these data support a role for IGFBP-2 and IGFBP-3 in the processes of growth arrest and apoptosis in lung epithelial cells upon oxidant exposure. They also suggest that distinct mechanisms may link IGFBP-2 and IGFBP-3 to the key regulators of the cell cycle.

Improving uncertain nutrient load estimates for Lake Balaton

Annual nutrient loads have been estimated for Lake Balaton over three decades. Tributaries may transport about half of the loads into the lake. The contribution of diffuse sources may reach two thirds of the total load. Biweekly/monthly water quality monitoring on small inflows (0.01 m3/s-0.3 m3/s range) results in a high uncertainty of load estimates. This paper evaluates the degree of uncertainties by using analytical expressions of sampling theory. Load-flow relationships were derived for five streams and annual total phosphorus load was predicted by four load estimation methods. A seasonal regression model, based upon the evaluation of historical set of observed phosphorus loads, appeared best to refine load estimates on small inflows. Correction frequently led to load estimates that exceeded uncorrected loads by a factor of two to three. Since the dynamics of the watercourses determined the errors of load estimates, stratified sampling is needed to decrease the uncertainties.

Genotype analysis and phenotypic manifestations of children with intermediate sweat chloride test results

STUDY OBJECTIVES

Cystic fibrosis (CF) is one of the most common inherited diseases among whites. Since the cloning of the CF transmembrane conductance regulator (CFTR) gene, a number of studies have focused on associations between the genotype and phenotype in CF. This had led to the progressive identification of new groups of patients, including those who have mild lung disease and those who have normal sweat chloride values (< 60 mEq/L). The aim of the present work was to provide information on the genotype and the phenotypic characteristics of children with intermediate-range sweat chloride test results.

PATIENTS AND RESULTS

We focused on children referred to the pulmonary department for various types of pulmonary disease and who had several sweat chloride test results with median values in the range of 40 to 60 mEq/L. Twenty-four patients over a 10-year period were enrolled (mean age, 4.8 years). Respiratory manifestations at initial evaluation included recurrent bronchitis, wheezing, chronic cough, and pneumonia. The duration of the follow-up ranged from 0.5 to 10.5 years. Sputum cultures revealed the presence of Haemophilus influenzae (10 children), Staphylococcus aureus (4 children), and Pseudomonas aeruginosa (3 children). Pancreatic insufficiency was found in two patients. Analysis of the entire coding sequence allowed identification of 16 known mutations in CFTR gene. Fifteen chromosomes (31.2%) carried a mutation in CFTR gene and one allele carried two mutations. Three patients were homozygous or double heterozygous (DeltaF508/DeltaF508, DeltaF508/3849 + 10 kb C-->T, S1235R/G551D). The 5-thymidine allele was identified in four children.

CONCLUSION

These results indicate an higher frequency of CFTR gene mutations in patients with borderline sweat chloride test results, compared to data reported in the general population. They lead to the recommendations for complete pulmonary and GI investigations in this group of patients, as well as assiduous care and medical follow-up.

[Diagnosis and management of cystic fibrosis in children]

Cystic fibrosis is a genetic disease occurring more frequently in Caucasians. The cystic fibrosis gene, cloned in 1999, codes for the cystic fibrosis transmembrane conductance regulator (CFTR) protein. Dysfunction of this protein leads to the clinical manifestations of cystic fibrosis, mainly lung disease and exocrine pancreas disorders. The pathophysiology of the respiratory component is quite complex, basically related to major and excessive inflammatory processes and to early microbial colonization. Respiratory physical therapy is a key element to management of the respiratory disorder. Antibiotic treatments should be adapted to the bacterial ecology, mainly using antistaphylococcal and antihaemophilus drugs initially, then directed against Pseudomonas aeruginosa. Other drugs including inhaled antiinflammatory drugs are currently in the evaluation stage. In addition, nutritional care and correction of pancreas insufficiency are necessary. The diagnosis of this disease must be made early although systematic neonatal screening is not proposed. Early diagnosis is necessary for improved care and prognosis. Currently, median survival is 29 years. This survival time should probably improve with better understanding of the pathophysiological mechanisms and new therapeutic perspectives.

Pyogenic spondylitis with Scheuermann's disease

We present the case of a teenager suffering from dorsal and lumbar pain. Imaging modalities diagnosed a lumbar retro-marginal anterior herniation and thoracic spondylitis. Such association has been reported twice in the literature.

Spatial and temporal variability of foliar mineral concentration in beech (Fagus sylvatica) stands in northeastern France

Foliar mineral concentration may provide a basis for monitoring the consequences of long-term environmental changes, such as eutrophication and acidification of soils, or increase in atmospheric CO(2) concentration. However, analytical drifts and inter-tree and year-to-year variations may confound environmental effects on long-term changes in foliar mineral concentration. We have characterized the relative effects of these potentially confounding factors on foliar carbon, nitrogen, phosphorus, calcium, potassium, magnesium and manganese concentrations in 118 pure beech (Fagus sylvatica L.) stands, sampled in 1969-71 and 1996-97. Interannual fluctuations of these elements were quantified in a subset of six beech stands monitored for 5 years. Intercalibration between the methods used at each sampling period for nitrogen and phosphorus analyses showed significant, but low, relative differences (0.8 and 3.3% for N and P, respectively). Based on inter-tree variability, elements could be arranged in four groups: C (constant), N and P (low variability), K and Ca (medium variability), Mn and Mg (high variability). Inter-tree coefficients of variation were 2, 6, 8, 15, 18, 22 and 27%, respectively. Year-to-year fluctuations increased in the order N, P, Mg, K, Ca, and Mn coefficients of variation of 4, 4, 7, 9, 11, 15 and 29%, respectively). Between the two sampling periods, foliar N concentration increased 12%, whereas decreases were observed for P (-23%), Mg (-38%) and Ca (-16%). Ratios of N/P, N/K and N/Mg increased by 42, 19 and 77%, respectively. These changes were larger than the interannual variations for P, Mg, N/P, N/Mg and Mg/Ca. Decreasing concentrations of P and cations were particularly marked for trees growing on acidic soils, whereas the positive N trend did not depend on soil type. Both increasing atmospheric CO(2) concentrations and acidification of forest soils could contribute to decreasing P and cation concentrations in foliage. The increase in foliar N concentration with time suggests a nitrogen deposition effect. Whatever the causes of these changes, the large shift in element ratios indicates an accelerating imbalance between nitrogen and cation status.

Retinoic acid-induced proliferation of lung alveolar epithelial cells is linked to p21(CIP1) downregulation

Retinoids, including retinol and retinoic acid (RA) derivatives, have been shown to be involved in the processes of lung development as well as of lung repair after injury. Recently, we have provided evidence that RA could stimulate proliferation of lung alveolar type 2 epithelial cells (E. Nabeyrat, V. Besnard, S. Corroyer, V. Cazals, and A. Clement. Am. J. Physiol. Lung Cell. Mol. Physiol. 275: L71-L79, 1998). To gain some insight into the mechanisms involved in the mitogenic action of RA, we focused in the present study on the effects of RA on the expression of G(1) phase cyclins and their cell cycle-dependent kinases (Cdks). Experiments were performed with serum-deprived cells cultured in the absence and presence of RA. The results showed no effects of RA on the expression of either cyclins or Cdks. In contrast, RA treatment was found to prevent the decrease in cyclin E-Cdk2 activity observed when cells were growth arrested by serum deprivation. The observation that changes in cyclin E-Cdk2 activity were not associated with modifications in the amount of complexes formed led to the suggestion that the Cdk inhibitory protein (CKI) was involved. Study of the CKI p21(CIP1) revealed marked differences in its expression in the absence and presence of RA, with a dramatic downregulation observed in RA-treated cells. Interestingly, immunoprecipitation experiments provided evidence that the decreased levels of p21(CIP1) were associated with a reduced interaction of this CKI with cyclin E-Cdk2 complexes. These data together with previous results obtained in various situations of type 2 cell growth arrest emphasize the role of p21(CIP1) in the control of lung alveolar epithelial cell proliferation.