Pneumonia

Despite antibiotic therapy, pneumonia remains a significant worldwide cause of morbidity and mortality. The term pneumonia covers several distinct clinical entities, and correct classification is vital as the aetiology, infective organism, antibiotic management and outcome are determined by how and where pneumonia was contracted. Early recog-nition and appropriate treatment improve outcome. Critical care physicians must be familiar with all aspects of pneumonia, as they will be expected to advise on and manage severe community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP) and opportunistic pneumonias in immuno-compromised patients in the wards, high depend-ency units (HDUs) and intensive care units (ICUs). Differences in the recently published antibiotic guidelines between the British and American Tho-racic Societies are highlighted in this chapter.

Placental angiogenesis markers sFlt-1 and PlGF: response to cigarette smoke

OBJECTIVE

Excess soluble vascular endothelial growth factor receptor, fms-like tyrosine kinase-1 (sFlt-1), and reduced placental growth factor (PlGF) mediate the genesis of preeclampsia. Cigarette smoking reduces the risk of preeclampsia. We hypothesized that placental secretion of sFlt-1 and PlGF was affected by exposure to cigarette smoke extract.

STUDY DESIGN

Term placental villous explants were cultured with cigarette smoke extract. Media were analyzed for sFlt-1 and PlGF. Apoptosis was measured by TUNEL staining. Results are reported as sFlt-1 or PlGF picogram/milliliter/milligram wet weight of explant.

RESULTS

Exposure to cigarette smoke extract reduced secretion of sFlt-1 in a dose-dependent manner. There was no difference in apoptosis. In contrast with sFlt-1, PlGF did not decline when incubated with cigarette smoke extract.

CONCLUSION

Exposure of placental villous explants to cigarette smoke extract results in a proangiogenic state with reduced sFlt-1 and relative abundance of PlGF. This is the reverse of changes that are seen in preeclampsia and may explain the reduction of preeclampsia in smokers.

Antemortem diagnosis of new york human rabies case and review of u.s. Cases

To help elucidate rabies disease patterns and control issues, a full assessment of a human case of dog-variant rabies was undertaken. In 2000, a 54-year-old man presented to a New York hospital with lower back discomfort four days after arrival from Africa. Rabies was first suspected 8 days after hospitalization based on clinical signs, specimens were collected on the same day, and rabies infection was confirmed the following day (fluorescence antibody testing on nuchal skin biopsy specimen). By the 12(th) day after illness onset, he was unresponsive, and life support was removed on day 15. Subsequently, an African dog variant was confirmed by nucleic acid sequence analysis of rabies viral RNA extracted and amplified from the patient's saliva. Management of human concerns about exposure to the patient kept the number of persons receiving postexposure prophylaxis to 26. With less than half of the U.S. human rabies cases being diagnosed antemortem, this case emphasizes the need to routinely include rabies in the differential diagnosis of any unexplained encephalitis to ensure early confirmation and triage of human contacts to reduce associated healthcare costs.

Obesity and the Metabolic Syndrome: The Stress on Society

The problem of obesity was only accepted by the World Health Organization as of major public health importance in 1997 when the criteria for the specification of the metabolic syndrome were also being sought. Then the risk factor analyses of the determinants of global ill health at the start of the millennium showed that an excessive body mass index (BMI) above the optimum of 21 was one of the top 10 contributors. No analyses could be related to abdominal obesity because of the absence of systematic representative surveys of waist circumferences but the ill health attributable to excess weight included the risk factors specified in the metabolic syndrome and showed that the co-morbidities in Asia were far greater than those predicted from simply an excess weight. The recent proposed definition of the metabolic syndrome includes these different criteria specified on an ethnic basis but there is now a need to recognize that abdominal obesity is more common on the developing world and linked to childhood stunting and early deprivation. The importance of intrauterine and postnatal epigenetic and altered organ function needs to be recognized. Thus the co-morbidities associated with weight gain and the development of the metabolic syndrome dominate in the developing world where the majority of the population is proving more susceptible to the effects of weight gain than Caucasians now living in affluent societies. This therefore presents a major challenge in both research and public policy terms.

FGF Ligand Family mRNA Expression Profile for Mouse Preimplantation Embryos, Early Gestation Human Placenta, and Mouse Trophoblast Stem Cells

Signaling by fibroblast growth factor (FGF) is essential is for trophoblast stem (TS) cells and preimplantation embryos. FGF4 provides essential signaling, but the expression of the complete set of 23 FGF family members has not been analyzed. Here, semi-quantitative RT-PCR and microarray analyses were used to define expression of all FGF ligand mRNA. RT-PCR was done for developmentally important FGF subfamilies, FGF10/FGF22 and FGF8/FGF17/FGF18 as well as FGF11. FGF4 and FGF18 are detected at highest levels by RT-PCR and microarrays. FGF10 was detected at low levels in both assays. FGF11 was detected at moderate levels by microarray, but not by RT-PCR. FGF17 was detected at low levels by array and moderate levels by RT-PCR. FGF8 and FGF22 were detected by RT-PCR, but not by microarrays during late cleavage divisions. FGF8, FGF5, and FGF9 were detected in the oocyte by microarray. FGF2, FGF3, and FGF7 were not detected by RT-PCR or microarrays and FGF13, FGF14, and FGF23 were not detected by microarray. Since a major role of FGF is to maintain TS cells, we tested human and mouse placental cell lines and early gestation human placenta for expression of FGF ligands. Expression in mouse TS cells was compared with preimplantation embryos, and human placental cell line expression was compared with human placenta, to infer which ligands are expressed in placental lineage vs. other cell lineages. The data suggest that human and mouse placenta share FGF18 and its high expression suggests preimplantation and early placental function.

SAPKgamma/JNK1 and SAPKalpha/JNK2 mRNA transcripts are expressed in early gestation human placenta and mouse eggs, preimplantation embryos, and trophoblast stem cells

OBJECTIVE

To test early-gestation human placenta, a human trophoblast cell line, mouse eggs, preimplantation embryos, and a mouse trophoblast cell line for the expression of mRNA transcripts for stress-activated protein kinase/c-Jun N-terminal kinase (SAPKgamma/JNK1, SAPKalpha/JNK2, and SAPKbeta/JNK3).

DESIGN

Whole RNA was isolated from the tissue sources listed above and control tissues, and reverse transcription-polymerase chain reaction (RT-PCR) was performed to assay for the qualitative and semiquantitative presence of SAPKgamma/JNK1, SAPKalpha/JNK2, and SAPKbeta/JNK3.

SETTING

None.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The presence and magnitude of amplimer amounts in gels or gene hybridization on Affymetrix cDNA arrays of RT-PCR products of reactions for SAPKgamma/JNK1, SAPKalpha/JNK2, and SAPKbeta/JNK3.

RESULT(S)

SAPKgamma/JNK1 and SAPKalpha/JNK2 mRNA transcripts are present in early-gestation human placenta, a human trophoblast cell line, mouse eggs, preimplantation embryos, and a mouse trophoblast cell line at levels similar to positive control levels. SAPKalpha/JNK2 is expressed at the highest level of the three transcripts in the family. SAPKbeta/JNK3 is present at levels that are 1/100-1/1,000 those of the positive control and in some cases at the apparent level of the negative control (previously measured by the less-sensitive Northern blot analysis). Analysis with an Affymetrix cDNA array suggested that SAPKalpha/JNK2 and 38 kDa mitogen-activated protein kinase had the highest mRNA expression measured for each of three family members.

CONCLUSION(S)

Mitotic placental trophoblast cell lines and primary conceptus/embryo samples containing early placental trophoblasts express SAPKalpha/JNK2 at higher levels than SAPKgamma/JNK1, but not (only low background levels of) SAPKbeta/JNK3 mRNA transcripts. This suggests that SAPKgamma/JNK1 and SAPKalpha/JNK2 may be important mediators of stress-induced responses in early implanting conceptuses that could mediate embryo loss.

Effects of ACh and adenosine mediated by Kir3.1 and Kir3.4 on ferret ventricular cells

The inotropic effects of ACh and adenosine on ferret ventricular cells were investigated with the action potential-clamp technique. Under current clamp, both agonists resulted in action potential shortening and a decrease in contraction. Under action potential clamp, both agonists failed to decrease contraction substantially. In the absence of agonist, application of the short action potential waveform (recorded previously in the presence of agonist) also resulted in a decrease in contraction. Under action potential clamp, application of ACh resulted in a Ba(2+)-sensitive outward current with the characteristics of muscarinic K+ current (I(K,ACh)); the presence of the muscarinic K+ channel was confirmed by PCR and immunocytochemistry. In the absence of agonist, on application of the short ACh action potential waveform, the decrease in contraction was accompanied by loss of the inward Na(+)/Ca(2+) exchange current (I(NaCa)). ACh also inhibited the background inward K+ current (I(K,1)). It is concluded that ACh activates I(K,ACh), inhibits I(K,1), and indirectly inhibits I(NaCa); this results in action potential shortening, decrease in contraction, and, as a result of the inhibition of I(K,1), minimum decrease in excitability.

Contraception of women with intellectual disability: prevalence and determinants

The contraception of women with intellectual disability (ID) is a major concern for caregivers. However, the prevalence of contraception and the frequency of use of different methods (e.g. sterilization) remain generally unknown. Moreover, indications specific to women with ID are controversial. The present authors conducted a population-based study among 97% of the women with ID aged between 18 and 46 years attending government-funded facilities in Brussels and the nearby province of Walloon Brabant in Belgium. Out of 397 subjects, 40.8% did not use any contraceptive method, 22.2% were sterilized, 18.4% used an oral contraceptive agent, 17.6% used depotmedroxyprogesterone acetate and 1% used an intrauterine device. These figures differ widely from those of the general Belgian population. Binary logistic regression for 'contraceptive utilization' showed the strong influence of institutional factors such as sleeping environment (i.e. institutional or parental), sexual relationship policy and contraception policy. Having or having had a boyfriend is also correlated with a stronger probability of contraceptive use. Other factors have a smaller influence (e.g. a milder level of ID). Very few factors, none of which are medical, are correlated with an increased use of a specific method. The present results are discussed in the light of the general medical application of contraception and the commonly assumed specific indications for women with ID.

The worldwide obesity epidemic

The recent World Health Organization (WHO) agreement on the standardized classification of overweight and obese, based on body mass index (BMI), allows a comparable analysis of prevalence rates worldwide for the first time. In Asia, however, there is a demand for a more limited range for normal BMIs (i.e., 18.5 to 22.9 kg/m(2) rather than 18.5 to 24.9 kg/m(2)) because of the high prevalence of comorbidities, particularly diabetes and hypertension. In children, the International Obesity Task-Force age-, sex-, and BMI-specific cutoff points are increasingly being used. We are currently evaluating BMI data globally as part of a new millennium analysis of the Global Burden of Disease. WHO is analyzing data in terms of 20 or more principal risk factors contributing to the primary causes of disability and lost lives in the 191 countries within the WHO. The prevalence rates for overweight and obese people are different in each region, with the Middle East, Central and Eastern Europe, and North America having higher prevalence rates. In most countries, women show a greater BMI distribution with higher obesity rates than do men. Obesity is usually now associated with poverty, even in developing countries. Relatively new data suggest that abdominal obesity in adults, with its associated enhanced morbidity, occurs particularly in those who had lower birth weights and early childhood stunting. Waist measurements in nationally representative studies are scarce but will now be needed to estimate the full impact of the worldwide obesity epidemic.

Isolation of vascular smooth muscle cells from a single murine aorta

The vascular smooth muscle cell plays a significant role in many important cardiovascular disorders, and smooth muscle biology is therefore important to cardiovascular research. The mouse is critical to basic cardiovascular research, largely because techniques for genetic manipulation are more fully developed in the mouse than in any other mammalian species. We describe here a technique for isolating smooth muscle cells from a single mouse aorta. This technique is particularly useful when material is limiting, as is frequently the case when genetically modified animals are being characterized.

Residues and mechanisms for slow activation and Ba2+ block of the cardiac muscarinic K+ channel, Kir3.1/Kir3.4

Mechanisms and residues responsible for slow activation and Ba(2+) block of the cardiac muscarinic K(+) channel, Kir3.1/Kir3.4, were investigated using site-directed mutagenesis. Mutagenesis of negatively charged residues located throughout the pore of the channel (in H5, M2, and proximal C terminus) reduced or abolished slow activation. The strongest effects resulted from mutagenesis of residues in H5 close to the selectivity filter; mutagenesis of residues in M2 and proximal C terminus equivalent to those identified as important determinants of the activation kinetics of Kir2.1 was less effective. In giant patches, slow activation was present in cell-attached patches, lost on excision of the patch, and restored on perfusion with polyamine. Mutagenesis of residues in H5 and M2 close to the selectivity filter also decreased Ba(2+) block of the channel. A critical residue for Ba(2+) block was identified in Kir3.4. Mutagenesis of the equivalent residue in Kir3.1 failed to have as pronounced an effect on Ba(2+) block, suggesting an asymmetry of the channel pore. It is concluded that slow activation is principally the result of unbinding of polyamines from negatively charged residues close to the selectivity filter of the channel and not an intrinsic gating mechanism. Ba(2+) block involves an interaction with the same residues.

Cs+ block of the cardiac muscarinic K+ channel, GIRK1/GIRK4, is not dependent on the aspartate residue at position 173

Cs+ block of GIRK1/GIRK4 expressed in Xenopus oocytes has been investigated. It has been reported that a negatively charged aspartate residue at position 172 in IRK1 is responsible for Cs+ block of the channel. IRK1, a homotetramer, has four aspartate residues at this position. GIRK1/GIRK4 is a heterotetramer and has two aspartate residues at the equivalent position (GIRK1-D173) and, consequently, it should be less sensitive to Cs+. Cs+ caused voltage-dependent block of GIRK1/GIRK4 current (measured with the two-microelectrode voltage-clamp technique). The apparent fraction of the electrical field through which Cs+ moves in order to reach its site of block (delta approximately equals 1.66) is comparable to that in IRK1, suggesting that Cs+ binds to a similar site in the two channels. GIRK1/GIRK4 was less sensitive than IRK1 to Cs+ -the Kd was 3.0-8.5 times greater and at potentials more negative than approximately or = to 130 mV there was voltage-dependent relief of block of GIRK1/GIRK4 (not the case with IRK1). However, the mutations GIRK1-D173A and GIRK1-D173Q increased the sensitivity of the channel to Cs+, while adding a negatively charged aspartate residue to GIRK4 at the equivalent position (GIRK4-N 79D) decreased Cs+ sensitivity. GIRK1-D173 cannot be the site of Cs+ block of GIRK1/GIRK4.

Inhibition of the K+ channel kv1.4 by acidosis: protonation of an extracellular histidine slows the recovery from N-type inactivation

1. Acidosis alters the transient outward current, ito, in the heart. We have studied the mechanism underlying the effect of acidosis on one of the K+ channels, Kv1.4 (heterologously expressed in Xenopus laevis oocytes), known to underlie ito. 2. At pH 6.5, wild-type Kv1.4 current was inhibited during repetitive pulsing, in part as a result of a slowing of recovery from N-type inactivation. 3. Acidosis still caused slowing of recovery after deletion of just one (either the first or second) of the N-terminal inactivation ball domains. However, deletion of both the N-terminal inactivation ball domains greatly reduced the inhibition. 4. As well as the N-terminus, other parts of the channel are also required for the effect of acidosis, because, whereas the transfer of the N-terminus of Kv1.4 to Kv1.2 conferred N-type inactivation, it did not confer acidosis sensitivity. 5. Replacement of an extracellular histidine with a glutamine residue (H508Q) abolished the slowing of recovery by acidosis. Reduction of C-type inactivation by raising the bathing K+ concentration or by the mutation K532Y also abolished the slowing. 6. It is concluded that binding of protons to H508 enhances C-type inactivation and this causes a slowing of recovery from N-type inactivation and, thus, an inhibition of current during repetitive pulsing.

Molecular and fetal tissue biopsy capabilities are needed to maximize prenatal diagnosis of junctional epidermolysis bullosa: fetal skin biopsy using a 1-mm microendoscope

OBJECTIVE

To describe a minimally invasive micro-endoscopic technique for fetal skin biopsy and direct examination for a lethal skin condition.

MATERIALS AND METHODS

Direct fetoscopic examination of a fetus was undertaken along with full thickness skin biopsies at 19 weeks' gestation.

RESULTS

No phenotypic expressions of the lethal condition were visualized and six full thickness skin biopsies were collected. Pathological examination revealed normal skin structures not consistent with junctional epidermolysis bullosa (JEB).

CONCLUSION

Minimally invasive examination with the 1 mm endoscope allows direct fetal phenotypic evaluation, full thickness skin biopsies, with risks similar to amniocentesis.

Effect of extracellular cations on the inward rectifying K+ channels Kir2.1 and Kir3.1/Kir3.4

The effects of Ba2+, Mg2+, Ca2+ and Na+ as blocking ions were investigated in 90 and 10 mM extracellular K+ solutions on the cloned inward rectifying K+ channel Kir2.1 expressed in Xenopus oocytes. Some data were also obtained using another inward rectifying K+ channel Kir3.1/Kir3.4. The addition of Ba2+ caused a concentration-, voltage- and time-dependent block of both channels. Decreasing the extracellular K+ concentration augmented the block. The data suggest that Ba2+ blocks the channels by binding to a site within the channel pore and that the electrical binding distance, delta, of the site is significantly different for Kir2.1 and Kir3. 1/Kir3.4 (0.38 and 0.22, respectively). Mg2+ and Ca2+ caused an instantaneous concentration- and voltage-dependent block of both channels. With Kir2.1, decreasing the K+ concentration augmented the block. The voltage dependence of the block was less than that of Ba2+ ([delta], 0.1), indicating a more superficial binding site for these ions within the channel pore. The affinity of the channels for Mg2+ and Ca2+ was 1000-fold lower than that for Ba2+. Addition of Na+ resulted in a concentration-, voltage- and time-dependent block of Kir2.1, similar to that observed with Ba2+. The competition between the blocking cations (for Kir2.1: Ba2+, Mg2+, Ca2+; for Kir3. 1/Kir3.4: Ba2+) and extracellular K+ suggests that the binding sites for the blocking cations may be sites to which K+ binds as part of the normal passage of K+ through the channels. It is possible that under normal physiological conditions naturally occurring extracellular cations may partly block the two inward rectifying K+ channels.

Lysyl oxidase transcripts in peritoneal adhesions and incisional scars

OBJECTIVE

To evaluate the role of lysyl oxidase in postsurgical adhesion formation and incision wound repair.

STUDY DESIGN

Female New Zealand rabbits underwent a pelvic-peritoneum adhesion-inducing operation under sterile conditions. In brief, the uterine horns were removed from the abdomen and abraded with surgical gauze and a scalpel blade. The horns were then replaced into the abdominal cavity, the incision was sutured, and the animals were allowed to recover. The animals were killed before lesion development and after 2, 4, 8, and 14 days of postsurgical recovery. The abraded uterine horns, abdominal wall incisional wound and a portion of the sidewall peritoneum were then removed. Total RNA was extracted using the guanidinium thiocyanate-phenol-chloroform method. Northern blot analysis was performed with an [alpha-32P]-labeled lysyl oxidase probe.

RESULTS

Lysyl oxidase was expressed during abdominal wall incision repair on days 2 and 4 of postsurgical recovery, declining thereafter (days 8 and 14). In contrast, no increase in lysyl oxidase expression was noted in the uterine horns as compared to the control sidewall peritoneum.

CONCLUSION

Lysyl oxidase plays a differential role in the early stages of abdominal wall and uterine horn repair.