Effect of non-steroidal anti-inflammatory drugs on neutrophil chemotaxis--an in vitro and in vivo study

We have studied the effects of the two non-steroidal anti-inflammatory drugs (NSAIDs), nabumetone and indomethacin, on neutrophil chemotaxis in vitro and in vivo. When used in therapeutic concentrations in vitro, neither agent had any effect on the chemotactic response of neutrophils isolated from healthy volunteers. This was true for the three chemotactic agents studied: FMLP, zymosan activated serum and purulent sputum. Nabumetone and indomethacin decreased neutrophil chemotaxis over a period of 2 weeks in 12 normal subjects in vivo. The average chemotactic response to 10(-8) mol/l FMLP for all 12 during the control period was 42.1 +/- 6.1 cells per high power field and this fell to 26.1 +/- 4.9 (P less than 0.025) after 7 days and to 15.6 +/- 2.5 (P less than 0.005) after 14 days. The results were similar for both drugs analysed independently. The results suggest that NSAIDs have no effect on the chemotactic response of mature cells in vitro, but suppress chemotaxis progressively when given in vivo. This may be explained by an effect of NSAIDs on maturing cells prior to release into the circulation.

Levels of neutrophil elastase and cathepsin B activities, and cystatins in human sputum: relationship to inflammation

Sputum samples from 25 patients with bronchiectasis were assayed enzymatically for myeloperoxidase, neutrophil elastase and cathepsin B, and immunologically for cystatin A, cystatin B, cystatin C, cystatin S and kininogen. High myeloperoxidase and neutrophil elastase levels were found in those sputum samples that were assessed visually to be purulent. These samples were also found to contain high levels of cathepsin B activity and cystatin A, but low levels of cystatin S and of the most effective cathepsin B inhibitor, cystatin C. In contrast, sputum samples that were low in myeloperoxidase and neutrophil elastase activities had low levels of cathepsin B and cystatin A, but high cystatin C and S levels. It is concluded that cathepsin B activity in sputum is positively correlated with the degree of inflammation and neutrophil recruitment. Although this may be due in part to reduced amounts of cathepsin B inhibitors, particularly cystatin C, theoretical considerations suggest that factors other than the gross level of inhibitors must be involved in the control of cathepsin B activity.

Primary sclerosing cholangitis: the emerging role for liver transplantation

Primary sclerosing cholangitis is a progressive liver disease for which orthotopic liver transplantation is the only curative procedure. Questions exist regarding the role of temporizing procedures and the timing of transplantation. During the past 4 yr, we have performed liver transplants in 177 adult recipients. Twenty-six patients (14.6%) with primary sclerosing cholangitis received 30 transplants including 12 men and 14 women. The recipients were examined for a number of preoperative and postoperative variables. The 4-yr actuarial survival in patients with primary sclerosing cholangitis after transplantation was 88%. Patients were segregated according to preoperative risk variables. Twenty patients were low and medium risk, with one death (95% survival). Three patients were high risk, with two deaths (33% survival). In conclusion, orthotopic liver transplantation is safe and effective therapy for primary sclerosing cholangitis. Early referral for transplantation is recommended to reduce the mortality associated with this procedure in those with advanced hepatic failure.

Neutrophil activation--an important cause of tissue damage during liver allograft rejection?

Although neutrophils have been implicated as mediators of tissue damage in a variety of conditions, their role in graft rejection has not previously been studied. Peripheral neutrophil activation was assessed sequentially in 16 patients following liver transplantation by measuring the ability of neutrophils to respond to the chemotactic peptide FMLP, to release superoxide radicals, and to cause extracellular proteolysis. All three functions increased 1-2 days before episodes of acute rejection and only returned to normal after treatment with high-dose corticosteroids. Three patients who did not develop rejection showed no increase in neutrophil function. Lymphocytes isolated from patients with acute rejection produced factors that were both chemotactic for and capable of activating normal neutrophils. This study shows that neutrophil activation occurs during acute liver allograft rejection, possibly in response to lymphokine secretion, and suggests an important, and hitherto unrecognized, mechanism of graft damage during rejection.

A survey of drugs of abuse testing by clinical laboratories in the United Kingdom. Steering Committee for the UK-External Quality Assessment Scheme for Therapeutic Drug Assays

An external quality assessment survey of testing facilities in UK clinical laboratories for the detection of drugs of abuse was made with nine freeze-dried samples of urine containing representative drugs with their metabolites from the following seven classes; amphetamines and stimulants, barbiturates, cannabinoids, cocaine, minor tranquillisers, opiates and non-opiate narcotics. Reports were received from 120 laboratories. Thirty six per cent of laboratories reported on all seven drug classes and 71% on the five classes excluding cannabinoids and cocaine. A single drug screening technique was used by 32% of laboratories whilst 46% were able to perform tests by both immunological and chromatographic techniques. There was a mean level of false positive reporting of 4.3% and an observed level of false negative reports of 8.4%, the latter underestimating the true frequency. The minor tranquillisers, cocaine and benzoyl ecgonine were the most frequently missed analytes. Several false reports had important potential implications for patient care.

Changes in the expression of elastase and cathepsin B with differentiation of U937 promonocytes by GMCSF

The human promonocytic cell line, U937, when treated for up to 72h with 12,O,tetradecanoyl-phorbol-13-acetate or granulocyte-macrophage colony-stimulating factor, exhibited increased phagocytic activity and expression of the marker p150/95. There was an associated increase in the monocyte proteinase cathepsin B and its mRNA but decreased cellular levels of neutrophil elastase and elastase mRNA. Granulocyte-macrophage colony-stimulating factor therefore causes differentiation of U937 cells, with appropriate effects on the synthesis of leukocyte proteinases.

Inhibition of human leukocyte elastase bound to elastin: relative ineffectiveness and two mechanisms of inhibitory activity

Human leukocyte elastase (HLE) has been demonstrated on lung elastic fibers in areas of pulmonary emphysema. In vitro studies in our laboratory have shown that HLE-elastin complexes may be remarkably stable. We tested the possibility that elastin-bound HLE may retain catalytic activity in the presence of inhibitors that are effective against free HLE and found: (1) alpha-1-proteinase inhibitor (alpha 1PI), antileukoprotease (ALP), and eglin C inhibited free HLE on an approximately 1:1 molar basis, measured with either 3H-elastin or a synthetic peptide substrate; (2) the ability of each inhibitor to control catalytic activity of HLE when complexed with elastin was impaired (e.g., in a 24-h assay, a 70-fold molar excess of alpha 1PI gave only 93% inhibition of HLE); and (3) a chloromethyl ketone inhibitor of HLE gave qualitatively similar results, although at the low enzyme concentrations used it was a less effective inhibitor of free and elastin-bound enzyme than were the polypeptide inhibitors. Further, we found evidence for two distinct mechanisms of inhibition of elastin-bound HLE. alpha 1PI and eglin C prevented elastin solubilization largely by enhancing net dissociation of HLE from the complexes; enzyme remaining bound to the substrate retained essentially full activity. In contrast, ALP and the chloromethyl ketone prevented elastin solubilization by binding to the complexes and inhibiting the enzyme in situ. These results may have implications regarding progressive elastin solubilization in vivo and should stimulate further investigation of enzyme activity in heterogeneous systems in which one or more reactants are insoluble.

IgA subclasses in sputum from patients with bronchiectasis

The concentrations of IgA1 and IgA2 were measured in the serum and sputum from 27 clinically stable patients with bronchiectasis. Of the 27 patients, nine were regularly producing mucoid secretions, nine mucopurulent and nine purulent secretions. No significant differences were observed in serum IgA2 concentrations between the patient groups, although IgA1 concentrations were higher in the serum from the patients producing mucopurulent sputum than those producing mucoid or purulent sputum. The sputum concentrations of both IgA1 and IgA2 increased significantly with purulence. Furthermore, there was a significant increase in the proportion of IgA2 as the secretions became more purulent. The sputum concentrations of both IgA subclasses indicated significant local synthesis, with increased production (especially of IgA2) in the presence of inflammation due to infection.

Effect of alpha-1-proteinase inhibitor on neutrophil chemotaxis

Factors that modulate neutrophil migration into the lung are poorly understood. However, there is evidence that neutrophil activation by formylmethionylleucylphenylalanine (FMLP) depends upon a surface proteinase with chymotrypsin-like activity. This suggests that chymotrypsin inhibitors such as alpha-1-proteinase inhibitor (alpha 1PI) could modify neutrophil migration in response to FMLP. We have studied neutrophil chemotaxis using the multiple blind well assay system. This article presents evidence that alpha 1PI is an inhibitor of neutrophil migration in response to FMLP. The effect is related to the inhibitory function of the protein. Alpha-1-antichymotrypsin is more potent than alpha 1PI as an inhibitor of this movement, whereas antileukoprotease is less potent. The results suggest that a cell membrane-bound serine proteinase (perhaps cathepsin G) is necessary for the enhancement of cell movement after receptor binding of FMLP. Oxidized alpha 1PI or a 4,000-D peptide cleaved from alpha 1PI by porcine pancreatic elastase or human neutrophil elastase are capable of enhancing cell motility. The results suggest that alpha 1PI may play a role in cell migration into the lung during acute inflammatory process.

Developmental regulation of the human cathepsin G gene in myelomonocytic cells

Cathepsin G is a neutral serine protease that is found in the azurophil granules of neutrophils and monocytes. Previous experiments had demonstrated that cathepsin G is actively produced by the promonocytic U937 cell line, and that 12-O-tetradecanoylphorbol-13-acetate (TPA)-induced differentiation of these cells toward macrophages resulted in a reduction of cathepsin G activity. In this study, we have analyzed the mechanism of this TPA-induced down-regulatory event. Using in situ hybridization techniques, we demonstrated that cathepsin G mRNA is detectable only at the promyelocytic stage of myeloid development. Using U937 promonocytic cells as a model, we demonstrated; 1) cathepsin G protein levels decline in TPA-treated cells; 2) this decline was due to a nearly complete loss of cathepsin G mRNA in cells treated with TPA for 24 h; and 3) the rate of cathepsin G mRNA loss with TPA treatment was similar to that with actinomycin D. These results suggested that cathepsin G transcription was down-regulated within several hours of TPA addition. This was directly tested by performing nuclear run-off assays of TPA-treated U937 cells; cathepsin G transcription was shown to be strand-specific, and declined within 4 h of TPA addition. Cathepsin G transcription was essentially undetectable 8 or more hours after TPA treatment, suggesting that down-regulation is predominantly transcriptional. Cycloheximide treatment of U937 cells resulted in a partial block of TPA-mediated cathepsin G down-regulation, indicating that continuous protein synthesis is required for down-regulation to occur. A newly synthesized protein or proteins may therefore be required for the transcriptional down-regulation of cathepsin G during the normal development of promyelocytes or promonocytes.

Inflammatory indices for chronic bronchitis and COAD. Proteases and antiproteases

The study of lung secretion proteinases and their inhibitors, both functionally and quantitatively, provide information concerning the degree of inflammation in the lung. Interpretation of individual parameters may be difficult in isolation. However, a general pattern of response provides supportive evidence of a reduction in lung inflammation, including 1) reduction in plasma inhibitor concentrations, 2) increase in local inhibitor concentrations, 3) increase in enzyme inhibition, and 4) reduction in enzyme activity. Thus such changes provide an objective basis for the assessment of drug therapy.

Role of beta-lactamases in the response of pulmonary infections to amoxycillin/clavulanate

Lung secretions from patients with bronchiectasis have been studied before and during treatment with amoxycillin/clavulanate (Augmentin 750 mg tds). beta-Lactamase activity was usually present in the sputum sol phase and originated from organisms not usually considered to be the major pathogen. The presence of beta-lactamase was related to inactivation of amoxycillin in the lung secretions. Extensive bacteriological investigation of the sputum before therapy showed several organisms to be present in each sample. Six of eight patients showed a good clinical and biochemical response to therapy with amoxycillin/clavulanate. This, however, could not be predicted or explained by the results of bacterial investigation although Haemophilus influenzae was eradicated in three of these responders. beta-Lactamase activity did not change during treatment, and this investigation thus failed to produce indirect evidence of penetration of clavulanate into the secretions.

Patterns of leukocyte chemotaxis to bile after liver transplantation

The role of chemotactic factors in the recruitment of leukocytes to human liver allografts was assessed by studying the effect of bile from transplant recipients on the chemotaxis of cells from normal subjects. Bile samples taken 2-3 days before clinical rejection were more chemotactic for lymphocytes than samples taken during rejection (p less than 0.01), during stable graft function (p less than 0.001), and from nontransplant patients (p less than 0.007). During clinical rejection there was an increase in bile chemotactic activity for both monocytes and neutrophils compared with samples from stable patients (monocytes: p less than 0.001; neutrophils: p less than 0.001) and nontransplant patients (monocytes: p less than 0.001; neutrophils: p less than 0.001). In serial studies chemotactic activity for lymphocytes reached a peak 1-3 days before the onset of clinical rejection, whereas maximum chemotactic activity for monocytes and neutrophils occurred at the time of rejection, when lymphocyte chemotaxis was decreasing. These results suggest that chemotaxis may be important in the recruitment of inflammatory cells to liver allografts and that chemotactic factors for lymphocytes, which appear in bile before clinical rejection, may be critical in the pathogenesis of rejection.

Use of external shock-wave lithotripsy and adjuvant ursodiol for treatment of radiolucent gallstones. A national multicenter study

A prospective multicenter trial was performed to evaluate the use of external shockwave lithotripsy (ESL) and adjuvant medical therapy for the treatment of gallstones. A Medstone STS lithotripter was used together with ursodiol. Two hundred twenty-three patients were treated under general anesthesia (75%) or with intravenous analgesia (25%). Initial treatments were on an inpatient basis, but as centers gained experience, outpatient treatments became more common. Stone fragmentation and clearance were greatest in patients with solitary gallstones less than 2 cm in diameter. In this group of patients, stone fragmentation occurred in 97% of patients, and the cumulative stone-free rates at three and six months were 54% and 90%, respectively. These results indicate that fragmentation of gallstones can be achieved by a dry shock-wave lithotripter and that stone clearance is induced more rapidly by external shock-wave lithotripsy and adjuvant ursodiol therapy than by ursodiol therapy alone.

Effects of plasma, tumour necrosis factor, endotoxin and dexamethasone on extracellular proteolysis by neutrophils from healthy subjects and patients with emphysema

1. Neutrophils from patients with chronic obstructive bronchitis and emphysema or age-matched control subjects were cultured on a substrate of 125I-fibronectin. The neutrophils from patients with lung disease digested significantly more fibronectin and released more elastase into the culture supernatant than did cells from control subjects. Preincubation of neutrophils from emphysematous patients with plasma from control subjects significantly inhibited fibronectin digestion by the patients' neutrophils by, on average, 10%. Preincubation of control subjects' neutrophils with plasma from emphysematous patients had no effect on fibronectin digestion. 2. Tumour necrosis factor increased fibronectin digestion in a dose-dependent manner when the cytokine was added to the adherent cells but not when preincubated with the polymorphonuclear leucocytes in suspension. Bacterial endotoxin in concentrations above 6 micrograms/ml significantly increased fibronectin digestion by neutrophils, but leukotriene B4, interferon-gamma and interleukin-1 alpha had no significant effects. 3. Dexamethasone inhibited fibronectin digestion by neutrophils in a dose-dependent manner, from 11% at 10(-10) mol/l to 68% at 10(-3) mol/l.

Activities and sources of beta-lactamase in sputum from patients with bronchiectasis

beta-Lactamase activity was measured in secretions from patients with bronchiectasis. Of 28 sputum samples, 23 contained measurable amounts of activity; values were significantly higher (P less than 0.01) in purulent samples than in mucoid or mucopurulent samples. beta-Lactamase activity was usually present in saliva collected before and between sputum expectorations, although values for sputum were higher than for either group of saliva samples (P less than 0.025 and P less than 0.005, respectively). This difference suggests that at least part of sputum beta-lactamase activity originates in the bronchial tree. Detailed microbiological study of a further eight specimens (seven were beta-lactamase positive) led to the isolation of Haemophilus influenzae from six, although only two of these isolates were beta-lactamase positive. Several other beta-lactamase-producing organisms were also isolated, including Staphylococcus aureus (n = 3), Escherichia coli (n = 1), Proteus spp. (n = 1), and Bacteroides spp. (n = 3). Size-exclusion high-performance liquid chromatography of the sputum showed several peaks of beta-lactamase activity which usually coeluted in fractions similar to those of their beta-lactamase-positive isolates. Therefore, sources of sputum beta-lactamases are often bacteria not considered truly pathogenic or not isolated during routine bacteriological assessment. These observations should be considered when embarking on antimicrobial therapy in bronchiectatic patients and suggest that increased dosages of penicillins are indicated.

Theophylline assay on Kodak Ektachem DTSC--performance and interference by structurally-related compounds and salicylate

Theophylline was measured with a Kodak Ektachem DTSC using its property of uncompetitive inhibition of alkaline phosphatase. Within- and between-batch reproducibility was satisfactory. Agreement with consensus mean values on quality assessment samples was good as was agreement on patients' samples with a high performance liquid chromatography reference method and an automated fluorescence polarisation immunoassay. At therapeutic theophylline concentrations, no interference was seen with caffeine, theobromine, 1,7-dimethylxanthine, 1,3-dimethyluric acid or 3-propylxanthine. 3-methylxanthine (a theophylline metabolite) gave a positive bias but the concentrations of this metabolite found in serum are such that the clinical significance of this finding is questionable. Salicylate at concentrations which might be found during therapy for paediatric rheumatoid arthritis also gave a positive bias.

Evidence for lipid-associated serine proteases and metalloproteases in human bronchoalveolar lavage fluid

1. We have investigated the nature of elastase activity in bronchoalveolar lavage samples from healthy cigarette smokers and subjects with emphysema. 2. Initial experiments with pure human leucocyte elastase showed this enzyme to be inhibited by high concentrations (greater than 10 mmol/l) of ethylenediaminetetra-acetate, indicating that results of previous studies of 'metalloelastase' activity in bronchoalveolar lavage were ambiguous. 3. We have nevertheless demonstrated the presence in bronchoalveolar lavage of an elastase with the characteristics of a metalloproteinase, although samples also contained a substantial amount of activity that was sensitive to serine proteinase inhibitors. 4. Fractionation of lavage fluid supernatant by size-exclusion chromatography demonstrated most of the elastase activity to be of molecular mass greater than 300 kDa. Treatment of samples with lipase or detergent caused a reduction in metalloelastase activity and the generation of lower-molecular-mass components (90-100 kDa and 40 kDa) which were predominantly serine elastases. This suggested that the enzymes were associated with lipid.

Biliary beta 2-microglobulin in liver allograft rejection

beta 2-Microglobulin, which is associated with HLA class 1 antigens, was assayed in bile and serum from 19 patients following 22 liver transplants. Serum levels were elevated in all posttransplant patients irrespective of the presence of rejection. In contrast, biliary levels were significantly higher during episodes of acute rejection compared with posttransplant cholangitis (p less than 0.01), stable graft function (p less than 0.0001) and nontransplant samples (p less than 0.0001). When bile/serum ratios were studied, the difference between the rejection and the other groups was even more significant, and if a ratio of 0.2 was considered diagnostic of rejection, the test had a sensitivity of 96%, a specificity of 87% with an accuracy of 90%. Therefore, these results suggest that the measurement of bile/serum ratios of beta 2-microglobulin following liver transplantation may be useful in diagnosing acute rejection. When bile/serum ratios of beta 2-microglobulin were compared with those for other proteins, there was strong evidence to suggest that local release accounted for most of the increased biliary beta 2-microglobulin during rejection. These results provide further evidence that HLA class 1 antigens on the biliary epithelium may be important in liver allograft rejection.

A catalytically active high-Mr form of human cathepsin B from sputum

A cysteine proteinase from purulent sputum was partially purified by a method involving affinity chromatography on Sepharose-aminohexanoylphenylalanylglycinaldehyde semicarbazone. It was immunologically related to lysosomal cathepsin B from human liver and was similar in many, but not all, other aspects. It was catalytically active, as demonstrated by active-site-directed radioiodination, and hydrolysed three cathepsin B substrates, two with Km values similar to those of lysosomal cathepsin B. In addition, the rates of inactivation of the sputum and lysosomal forms of the enzyme by L-3-carboxy-2,3-transepoxypropionyl-leucylamido(4-guanidino) butane (Compound E-64) were very similar. However, the sputum enzyme differed from lysosomal cathepsin B in the following respects. Inhibition by chicken cystatin was much weaker for sputum cathepsin B than for the lysosomal enzyme. Sputum cathepsin B had greater stability at pH 7.5 and a higher apparent Mr, even after deglycosylation, than lysosomal cathepsin B. We conclude that the form of cathepsin B found in sputum is probably a truncated form of human procathepsin B, with some differences in properties that could be of physiological importance.

The assessment of alpha 1 proteinase inhibitor form and function in lung lavage fluid from healthy subjects

The form and function of alpha 1 proteinase inhibitor in lung lavage fluid from healthy smoking and non smoking individuals has been accurately assessed using critically appraised techniques. The present study demonstrated that it is possible to accurately assess alpha 1 PI function in unconcentrated lavage fluid but that sample collection, storage and subsequent processing may all affect the results. Absolute levels of alpha 1 PI were elevated in subjects who smoke and a substantial quantity of inactive protein was found in both smokers and non smokers. The proportion of inactive alpha 1 PI was similar for both groups, which by inference implies that normal smoking subjects do not have decreased protection by this inhibitor at the bronchoalveolar level. Physicochemical analysis of the alpha 1 PI in these normal subjects showed that it was different from alpha 1 PI previously reported from patients with established disease and this may have important implications regarding the pathogenesis of their condition. Western immunoblotting of bronchoalveolar lavage fluid (BALF) showed that all of the alpha 1 PI was present in the native molecular mass form (54,000 Da). Pre-incubation of samples with methionine sulphoxide peptide reductase restored alpha 1 PI function only by approximately 10% suggesting the presence of little reversibly oxidised alpha 1 PI in either group. Anion exchange HPLC of BALF revealed the presence of two alpha 1 PI species, one of which co-eluted with native, oxidised or proteolyzed forms and the other which was more cationic and did not inhibit porcine pancreatic elastase. Finally, thirteen out of sixteen BALF samples inhibited more neutrophil elastase than could be accounted for by the amounts of functional alpha 1 PI present, suggesting that the presence of other inhibitors is a feature of normal lavage fluids.