Activation of extracellular signal-regulated kinase (ERK) and p38 kinase in shock wave-promoted bone formation of segmental defect in rats

Extracorporeal shock waves (ESW) have recently been used in bone repair. Extracellular signal-regulated kinase (ERK) and p38 kinase are found to act as important mediators for osteogenic factor and mechanical-stimulated proliferation and differentiation of bone-forming cells. A previous study reported that ESW promoted healing of segmental defects in rats by inducing bone morphogenetic proteins (Bone 32 (2003) 387-396) and stimulating osteogenic differentiation of mesenchymal stem cells. In this study, we found that ERK and p38 activation was involved in ESW-augmented bone regeneration of segmental defects. ESW treatment (0.16 mJ/mm2, 1 Hz, 500 impulses) rapidly promoted [3H]-thymidine uptake in 1 day and progressively increased alkaline phosphatase activity, collagen I, II, and osteocalcin synthesis in callus organ culture within 14 days after treatment. Results of [gamma-32P]-phosphotransferase activity assay showed that ERK and p38 in calluses were rapidly activated 1 day and 7 days after ESW treatment, respectively. Histological observation showed that segmental defects subjected to ESW treatment underwent typical bone formation (mesenchymal cell aggregation, hypertrophic cartilage, and endochondral/intramembrane ossification). Intensive bone formation coincided with evident expression of phosphorylated ERK and p38. Moreover, expression of phosphorylated ERK persisted in mesenchymal, chondral, and osteoblastic cells at newly developed bone and cartilage, and the expression of activated p38 was evident on chondral cells located at hypertrophic cartilage. Our findings suggest that mitogen-activated protein kinases (MAPK) regulate the stimulation of biophysical ESW, triggering mitogenic and osteogenic responses in the defects. ERK phosphorylation is active throughout the period of ESW-induced bone regeneration. p38 activation most likely plays an important role in signaling cartilage formation in callus.

A model to study neurotropism and persistency of Japanese encephalitis virus infection in human neuroblastoma cells and leukocytes

Japanese encephalitis (JE) is the most common mosquito-borne encephalitis in the Asia-Pacific region. Patients with JE usually present neuronal involvement, but other organ involvement is relatively rare. Employing human neuroblast-derived (NB) cell lines and different blood cells (erythrocytes, lymphocytes, granulocytes and monocytes), the neurotropism and persistency of Japanese encephalitis virus (JEV) in human cells was investigated. It was found that JEV could not replicate in erythrocytes, granulocytes or lymphocytes. Monocytes and NB cell lines could support replication of JEV as demonstrated by expression of viral NS3 antigen and virus plaque-forming units (p.f.u.). JEV could replicate more efficiently in neuroblastoma (HTB-11) cells than in monocytes after infection for 48 h (2.1+/-1.2x10(7) vs 2.8+/-0.7x10(2) p.f.u. ml(-1)). Two different strains of JEV revealed a similar infectivity to different leukocytes and four NB cell lines. In a kinetic study, it was found that JEV-infected monocytes possessed a high viability (90 %) after infection for 5 days, while JEV-infected neuroblastoma cells suffered cell apoptosis in 2 days and decreased viability to less than 1 % in 5 days. Further studies showed that monocytes could take up JEV rapidly, displaying a log scale increase of intracellular JEV titres in 9 h after infection. Significantly, extracellular production of JEV by monocytes started in 12 h, peaked in 3 days and persisted for more than 3 weeks. These results suggest that JEV-infected monocytes may play an important role in harbouring JEV for eventual transmission to NB cells and that modulation of JEV-induced NB cell apoptosis may be useful in treating patients with JE.

Hyposensitization therapy reduced exhaled nitric oxide in asthmatic children with corticosteroid dependency

Measurement of exhaled nitric oxide (FeNO) is a simple and noninvasive method for assessment of airway inflammation severity in asthmatic patients. The aim of this study was to investigate whether hyposensitization with extracts of Dermatophagoides pteronyssinus (Der p) and Dermatophagoides farinae (Der f) could decrease airway inflammation as determined by FeNO levels. Ten asthmatic children with corticosteroid dependency were recruited for the study. Eight subjects completed a ten months mite hyposensitization regimen. FeNO concentrations, asthma symptom scores and peak expiratory flow rates (PEFR) were measured monthly before and after treatment. FeNO levels from asthmatic patients were found to be higher before treatment (65.34+/-31.63 ppb). FeNO levels fell significantly after four months' treatment (39.89+/-21.13 ppb; p<0.05). PEFR increased significantly five months after hyposensitization treatment (214.38+/-49.38 vs 251.25+/-28.00; p<0.05). Asthma symptom scores decreased 5 months after hyposensitization treatment (6.84+/-1.22 vs 5.80+/-0.67, p<0.05). Hyposensitization with extracts of Der p and Der f appears to improve clinical symptoms and reduce airway inflammation as determined by FeNO concentrations in children with mite allergy asthma.

Flashlamp pulsed dye laser (PDL) suppression of keloid proliferation through down-regulation of TGF-?1 expression and extracellular matrix expression

BACKGROUND AND OBJECTIVES

Keloids have been treated with flashlamp pulsed dye lasers (PDLs) with good results. We investigated whether PDL treatments induced keloid regression by decreasing growth factor-beta(1) (TGF-beta(1)) induction, thereby reducing fibroblast proliferation and collagen deposition.

STUDY DESIGN/MATERIALS AND METHODS

Clinical evaluation and photography documented keloid height/texture, erythema, and pliability before and after PDL treatments scheduled at 2-month intervals in 30 patients. Fluence per pulse was 10-18 J/cm(2) (mean 14.0 J/cm(2)). Immunohistochemical (IHC) staining of TGF-beta(1), proliferating cell nuclear antigen (PCNA), and collagen (types I and III) in extra-cellular matrix was performed on 10 intra-lesional or punch biopsies obtained before and 7 days after PDL treatments.

RESULTS

Twelve months after final PDL treatments, keloid regression ( >/= 50%) had occurred in 26/30 patients in whom erythema and surface irregularities had been reduced and pliability had been increased. In 4/30 patients, no changes in keloids had occurred after 12 months. Multiple treatments ( > 6) yielded better results than fewer treatments: 79% versus 50%, respectively. Marked keloid regression ( >/= 90%) occurred in two patients who had received more than 10 treatments. IHC staining indicated that expression of TGF-beta(1), PCNA and collagen type III, but not type I, was significantly reduced in keloid fibroblasts after PDL irradiation.

CONCLUSIONS

Keloids regressed following PDL-induced reduction in TGF-beta(1) expression, fibroblast proliferation, and collagen type III deposition. More than six PDL treatments at 2-month intervals provided the best results.

Shock wave treatment shows dose-dependent enhancement of bone mass and bone strength after fracture of the femur

Shock wave treatment is believed to improve bone healing after fracture. The purpose of this study was to evaluate the effect of shock wave treatment on bone mass and bone strength after fracture of the femur in a rabbit model. A standardized closed fracture of the right femur was created with a three-point bending method in 24 New Zealand white rabbits. Animals were randomly divided into three groups: (1) control (no shock wave treatment), (2) low-energy (shock wave treatment at 0.18 mJ/mm2 energy flux density with 2000 impulses), and (3) high-energy (shock wave treatment at 0.47 mJ/mm2 energy flux density with 4000 impulses). Bone mass (bone mineral density (BMD), callus formation, ash and calcium contents) and bone strength (peak load, peak stress and modulus of elasticity) were assessed at 12 and 24 weeks after shock wave treatment. While the BMD values of the high-energy group were significantly higher than the control group (P = 0.021), the BMD values between the low-energy and control groups were not statistically significant (P = 0.358). The high-energy group showed significantly more callus formation (P < 0.001), higher ash content (P < 0.001) and calcium content (P = 0.003) than the control and low-energy groups. With regard to bone strength, the high-energy group showed significantly higher peak load (P = 0.012), peak stress (P = 0.015) and modulus of elasticity (P = 0.011) than the low-energy and control groups. Overall, the effect of shock wave treatment on bone mass and bone strength appears to be dose dependent in acute fracture healing in rabbits.

Prenatal prediction of infant atopy by maternal but not paternal total IgE levels

BACKGROUND

The atopic history of parents has long been used to predict infant atopy. However, bias from questionnaires of allergic history are also frequently suspected, because a large number of vasomotor rhinitis, intrinsic asthma, and seborrheic dermatitis cases are probably misinterpreted to be atopic diseases.

OBJECTIVE

We attempted to identify a risk factor other than parental atopic history to predict elevated infant IgE levels and infant atopy.

METHODS

A total of 655 core families were prenatally recruited, and finally 545 families completed the study for the prospective analysis of infant atopy at 6 months of age. Atopic history and blood samples of parents were collected in the third trimester during pregnancy. Cord blood (CB) was collected immediately after birth. Infant blood samples and history of infant eczema were collected in the 6-month physical checkup clinic. Blood total IgE and specific IgE levels were determined by use of the Pharmacia CAP system.

RESULTS

In univariate analysis, maternal, but not paternal, atopic history correlated with elevated CB IgE levels and the occurrence of infant eczema. Elevated maternal, but not paternal, total IgE levels (>150 KU/L) significantly correlated with increases of CB IgE levels (median, 0.54 vs 0.17 KU/L, P <.001), infant IgE levels (log-transformed mean values, 1.32 +/- 0.51 vs 1.13 +/- 0.51 KU/L, P <.001), and infant eczema (P =.008). Multivariate logistical regression analysis, however, showed that only maternal total IgE levels correlated with CB and infant IgE levels and the development of infant eczema.

CONCLUSIONS

The maternal, but not paternal, total IgE level correlates with elevated infant IgE levels and infant atopy. This provides a high specificity (83%) and a sensitivity of 34% for prediction of infant atopy. This suggests that maternal factors, placental factors, or both have an impact on perinatal allergic sensitization.

Ras induction of superoxide activates ERK-dependent angiogenic transcription factor HIF-1alpha and VEGF-A expression in shock wave-stimulated osteoblasts

Vascular endothelial growth factor (VEGF) released by osteoblasts plays an important role in angiogenesis and endochondral ossification during bone formation. In animal studies, we have reported that shock waves (SW) can promote osteogenic differentiation of mesenchymal stem cells through superoxide-mediated signal transduction (Wang, F. S., Wang, C. J., Sheen-Chen, S. M., Kuo, Y. R., Chen, R. F., and Yang, K. D. (2002) J. Biol. Chem. 277, 10931-10937) and vascularization of the bone-tendon junction. Here, we found that SW elevation of VEGF-A expression in human osteoblasts to be mediated by Ras-induced superoxide and ERK-dependent HIF-1alpha activation. SW treatment (0.16 mJ/mm(2), 1 Hz, 500 impulses) rapidly activated Ras protein (15 min) and Rac1 protein (30 min) and increased superoxide production in 30 min and VEGF mRNA expression in 6 h. Early scavenging of superoxide, but not nitric oxide, peroxide hydrogen, or prostaglandin E(2), reduced SW-augmented VEGF-A levels. Inhibition of superoxide production by diphenyliodonium, an NADPH oxidase inhibitor, was found to suppress VEGF-A expression. Transfection of osteoblasts with a dominant negative (S17N) Ras mutant abrogated the SW enhancement of Rac1 activation, superoxide synthesis, and VEGF expression. Further studies demonstrated that SW significantly promoted ERK activation in 1 h and HIF-1alpha phosphorylation and HIF-1alpha binding to VEGF promoter in 3 h. In support of the observation that superoxide mediated the SW-induced ERK activation and HIF-1alpha transactivation, we further demonstrated that scavenging of superoxide by superoxide dismutase and inhibition of ERK activity by PD98059 decreased HIF-1alpha activation and VEGF-A levels. Moreover, culture medium harvested from SW-treated osteoblasts increased vessel number of chick chorioallantoic membrane. Superoxide dismutase pretreatment and anti-VEGF-A antibody neutralization reduced the promoting effect of conditioned medium on angiogenesis. Thus, modulation of redox reaction by SW may have some positive effect on angiogenesis during bone regeneration.

Shock wave application enhances pertussis toxin protein-sensitive bone formation of segmental femoral defect in rats

Extracorporeal shock waves (ESWs) elicit a dose-dependent effect on the healing of segmental femoral defects in rats. After ESW treatment, the segmental defect underwent progressive mesenchymal aggregation, endochondral ossification, and hard callus formation. Along with the intensive bone formation, there was a persistent increase in TGF-beta1 and BMP-2 expression. Pretreatment with pertussis toxin reduced ESW-promoted callus formation and gap healing, which presumably suggests that Gi proteins mediate osteogenic signaling.

INTRODUCTION

Extracorporeal shock waves (ESWs) have previously been used to promote bone repair. In our previous report, we found that ESWs promoted osteogenic differentiation of mesenchymal cells through membrane perturbation and activation of Ras protein. In this report, we show that ESWs elicit a dose-dependent effect on the healing of segmental defects and that Gi proteins play an important role in mediating ESW stimulation.

MATERIALS AND METHODS

Rats with segmental femoral defects were subjected to ESW treatment at different energy flux densities (EFD) and impulses. Bone mass (mineral density and calcium content), osteogenic activities (bone alkaline phosphatase activity and osteocalcin content), and immunohistochemistry were assessed.

RESULTS

An optimal ESW energy (500 impulses at 0.16 mJ/mm2 EFD) stimulated complete bone healing without complications. ESW-augmented healing was characterized by significant increases (p < 0.01) in callus size, bone mineral density, and bone tissue formation. With exposure to ESW, alkaline phosphatase activity and osteocalcin production in calluses were found to be significantly enhanced (p < 0.05). After ESW treatment, the histological changes we noted included progressive mesenchymal aggregation, endochondral ossification, and hard callus formation. Intensive bone formation was associated with a persistent increase in transforming growth factor-beta 1 (TGF-beta1) and bone morphogenetic protein-2 (BMP-2) expression, suggesting both growth factors were active in ESW-promoted bone formation. We also found that pertussis toxin, an inhibitor of membrane-bound Gi proteins, significantly reduced (p < 0.01) ESW promotion of callus formation and fracture healing.

CONCLUSION

ESW treatments enhanced bone formation and the healing of segmental femoral defects in rats. It also seems likely that TGF-beta1 and BMP-2 are important osteogenic factors for ESW promotion of fracture healing, presumably through Gi protein-mediated osteogenic signaling.

Implication of serum IgE in childhood nephrotic syndrome

Elevated serum IgE levels have been related to glomerular diseases. We investigated the relationship between serum total and specific IgE levels and their modulating factors [interleukin-4 (IL-4) and sCD23] and the outcome of childhood nephrotic syndrome (NS) after steroid treatment. We found that children with NS had significantly higher serum IgE levels than age-matched allergic patients and normal controls. Patients with steroid-resistant nephrotic syndrome (SRNS) had higher serum IgE levels than patients with steroid-sensitive nephrotic syndrome (SSNS) both pre and post treatment. Elevated initial serum IgE levels appeared to be associated with poor outcome. Although one-half of nephrotic children had detectable specific IgE to common allergens (dust mites or milk), the presence of specific IgE was not correlated with disease outcome. Serum IL-4 levels were not different among normal controls and patients with SRNS or SSNS. However, serum sCD23 levels in NS patients were significantly higher than in normal controls both pre and post treatment. Serum sCD23, but not IL-4, levels were correlated with serum total IgE levels. Our results suggest that regulation of total IgE production correlates with the disease activity and outcome of NS, although the presence of common specific IgE may not be linked to the pathogenesis.

Shock wave therapy induces neovascularization at the tendon-bone junction. A study in rabbits

Despite the success in clinical application, the exact mechanism of shock wave therapy remains unknown. We hypothesized that shock wave therapy induces the ingrowth of neovascularization and improves blood supply to the tissues. The purpose of this study was to investigate the effect of shock wave therapy on neovascularization at the tendon-bone junction. Fifty New Zealand white rabbits with body weight ranging from 2.5 to 3.5 kg were used in this study. The right limb (the study side) received shock wave therapy to the Achilles tendon near the insertion to bone. The left limb (the control side) received no shock wave therapy. Biopsies of the tendon-bone junction were performed in 0, 1, 4, 8 and 12 weeks. The number of neo-vessels was examined microscopically with hematoxylin-eosin stain. Neovascularization was confirmed by the angiogenic markers including vessel endothelial growth factor (VEGF) and endothelial nitric oxide synthase (eNOS) expressions and endothelial cell proliferation determined by proliferating cell nuclear antigen (PCNA) expression examined microscopically with immunohistochemical stains. The results showed that shock wave therapy produced a significantly higher number of neo-vessels and angiogenesis-related markers including eNOS, VEGF and PCNA than the control without shock wave treatment. The eNOS and VEGF began to rise in as early as one week and remained high for 8 weeks, then declined at 12 weeks; whereas the increases of PCNA and neo-vessels began at 4 weeks and persisted for 12 weeks. In conclusion, shock wave therapy induces the ingrowth of neovascularization associated with early release of angiogenesis-related markers at the Achilles tendon-bone junction in rabbits. The neovascularization may play a role to improve blood supply and tissue regeneration at the tendon-bone junction.

Different antigens trigger different Th1/Th2 reactions in neonatal mononuclear cells (MNCs) relating to T-bet/GATA-3 expression

Neonates are known to have poor cellular immunity, especially poor Th1 response. We investigated how neonatal mononuclear cells raised different Th1/Th2 reactions in response to different antigens. Employing Dermatophagoides pteronyssinus (Der p) extract and varicella zoster virus (VZV) as antigens, we assessed Th1/Th2 reactions as demonstrated by IL-4/IFNgamma production and mRNA expression, and transcriptional factors T-bet/GATA-3 mRNA expression in mononuclear cells from human umbilical cord blood (CBMC). Results showed that VZV induced a dramatic increase of IFNgamma production by adult peripheral blood mononuclear cells (PBMC), whereas VZV did not drive CBMC to release significant IFNgamma production (1614.7+/-362.0 vs. 49.0+/-29.3,p<0.005). However, Der p induced higher IFNgamma production by CBMC than VZV (298.1+/-171.8 vs. 49.0+/-29.3, P=0.047). In contrast, VZV did not induce significant IL-4 production either by CBMC or by PBMC. Der p induced a comparative IL-4 production by CBMC and PBMC (2.58+/-0.84 vs. 2.04+/-0.37, p>0.05). A real-time RT-PCR analysis of IL-4 and IFNgamma mRNA expression showed that VZV induced a significantly higher IFNgamma, but not IL-4, mRNA expression in PBMC than CBMC. Der p did not induce significant difference of IFNgamma or IL-4 mRNA expression in PBMC and CBMC. VZV enhanced Th1-related transcription factor T-bet mRNA expression, in association with later down-regulation of Th2-related GATA-3 mRNA expression in PBMC. However, VZV did not up-regulate T-bet or down-regulate GATA-3 expression significantly in CBMC. In contrast, Der p induced an early GATA-3 expression and later T-bet expression in CBMC. These results suggest that different antigens trigger various Th1/Th2 reactions in PBMC and CBMC resulting from kinetic changes of T-bet/GATA-3 expression.

Pertussis toxin-sensitive Gαi protein and ERK-dependent pathways mediate ultrasound promotion of osteogenic transcription in human osteoblasts1

Bone cells respond to mechanical stimulation via mechanoreceptors and convert biophysical stimulation into biochemical signals that alter gene expression and cellular adaptation. Pulsed acoustic energy treatment raises membrane potential and induces osteogenic activity. How membrane-bound osteoblast mechanoreceptors convert physical ultrasound (US) stimuli into osteogenic responses is not fully understood. We demonstrated that low-intensity pulsed US treatment (200-micros pulse, 1 kHz, 30 mW/cm2) elevated Cbfa1/Runx2 mRNA expression and progressively promoted osteocalcin mRNA expression in human osteoblasts. Pretreatment with pertussis toxin (PTX), but not with cholera toxin, suppressed US-augmented osteogenic transcription. This indicated that Gi proteins, but not Gs proteins, were involved in US promotion of osteogenic transcription. Further studies demonstrated US treatment could rapidly increase PTX-sensitive Galphai protein levels and subsequently enhanced phosphorylation of extracellular signal-regulated kinase (ERK). PTX pretreatment significantly reduced US promotion of ERK activation. Moreover, inhibition of ERK activity by PD98059 suppressed US augmentation of Cbfa1/Runx2 and osteocalcin mRNA expression. Membranous Galphai proteins and cytosolic ERK pathways acted as potent mechanosensitive signals in the response of osteoblasts to pulsed US stimulation.

Prediction of elevated cord blood IgE levels by maternal IgE levels, and the neonate's gender and gestational age

BACKGROUND

Elevation of cord blood immunoglobulin E (IgE) is used to predict childhood atopy. In an effort to catch such problems at an earlier time, we sought to identify the impact of parental atopy as well as gestational age, the baby's gender, and the season of delivery on cord blood IgE levels.

METHODS

The allergic history of parents was collected during pregnancy. Blood samples from parents were collected in the third trimester. Cord blood was collected immediately after birth. Total and specific IgE levels were determined using the Pharmacia CAP system.

RESULTS

In total, 437 core family blood samples were collected. Male babies had a significantly higher IgE level (0.535 +/- 0.898 vs. 0.369 +/- 0.565 KU/L, p = 0.021) and a higher frequency of IgE > or = 1.0 KU/L (14.6% vs. 7.5%, p = 0.018) compared to female babies. A cyclic trend in higher cord blood IgE levels was found in babies born in early summer and early winter. Multiple logistic regression analyses revealed that elevation of cord blood IgE levels could be predicted by higher maternal IgE levels (odds ratio [OR] = 6.35; p = 0.000), male baby gender (OR = 2.31; p = 0.021), and increases in gestational age by 1 week (OR = 1.34; p = 0.039). In contrast, neither the allergic history of parents nor elevation of paternal IgE levels could be correlated with elevated cord blood IgE levels of neonates.

CONCLUSION

The baby's gender and gestational age, and maternal IgE levels influence cord blood IgE levels. Avoiding allergens and decreasing allergic activities during pregnancy may be the most important means of preventing the fetus from having allergic sensitization.

Shock wave therapy for calcific tendinitis of the shoulder: a prospective clinical study with two-year follow-up

BACKGROUND

Shock wave therapy is a new modality that has shown efficacy in the treatment of various orthopaedic disorders.

PURPOSE

To determine the effectiveness, at 2- to 3-year follow-up, of shock wave therapy for calcific tendinitis of the shoulder.

STUDY DESIGN

Prospective clinical study.

METHODS

Thirty-seven patients (39 shoulders) with calcific shoulder tendinitis were treated with shock wave therapy (1000 impulses at 14 kV) and observed for 24 to 30 months. The control group, which underwent sham treatment with a dummy electrode, consisted of 6 patients (6 shoulders) with an average follow-up of 6 months. Evaluation included use of the 100-point Constant score system and shoulder radiographs.

RESULTS

The overall results in the study group were 60.6% excellent (20 of 33 shoulders), 30.3% good (10), 3.0% fair (1), and 6.1% poor (2), and those of the control group were 16.7% fair (1 of 6 shoulders) and 83.3% poor (5). The symptom recurrence rate in the study group was 6.5%. Dissolution of calcium deposits was complete in 57.6% of the study group, partial in 15.1%, and unchanged in 27.3%. Fragmentation was seen in 16.7% of the control group patients; in 83.3% deposits were unchanged. No recurrence of calcium deposits was observed during the 2 years that the study group was followed.

CONCLUSIONS

Shock wave therapy is a safe and effective noninvasive treatment for patients with calcific tendinitis of the shoulder.

Temporal and spatial expression of bone morphogenetic proteins in extracorporeal shock wave-promoted healing of segmental defect

Extracorporeal shock wave (ESW) is a noninvasive acoustic wave, which has recently been demonstrated to promote bone repair. The actual healing mechanism triggered by ESW has not yet been identified. Bone morphogenetic proteins (BMP) have been implicated as playing an important role in bone development and fracture healing. In this study, we aimed to examine the involvement of BMP-2, BMP-3, BMP-4, and BMP-7 expression in ESW promotion of fracture healing. Rats with a 5-mm segmental femoral defect were given ESW treatment using 500 impulses at 0.16 mJ/mm(2). Femurs and calluses were subjected to immunohistochemistry and RT-PCR assay 1, 2, 4, and 8 weeks after treatment. Histological observation demonstrated that fractured femurs received ESW treatment underwent intensive mesenchymal cell aggregation, hypertrophic chondrogenesis, and endochondral/intramembrane ossification, resulting in the healing of segmental defect. Aggregated mesenchymal cells at the defect, chondrocytes at the hypertrophic cartilage, and osteoblasts adjunct to newly formed woven bone showed intensive proliferating cell nuclear antigen expression. ESW treatment significantly promoted BMP-2, BMP-3, BMP-4, and BMP-7 mRNA expression of callus as determined by RT-PCR, and BMP immunoreactivity appeared throughout the bone regeneration period. Mesenchymal cells and immature chondrocytes showed intensive BMP-2, BMP-3, and BMP-4 immunoreactivity. BMP-7 expression was evident on osteoblasts located at endochondral ossification junction. Our findings suggest that BMP play an important role in signaling ESW-activated cell proliferation and bone regeneration of segmental defect.

Implications of serum TNF-beta and IL-13 in the treatment response of childhood nephrotic syndrome

The cause of childhood nephrotic syndrome (NS) is unknown and whether it responds to steroid therapy remains unpredictable. In the present study, we measured the Th1/Th2 cytokines, serum tumor necrosis factor-beta (TNF-beta) and interleukin-13 (IL-13), levels in children with NS before and after prednisolone (60 mg/m(2)/day) treatment for 4 weeks, to evaluate their relationships with disease activity and treatment response. Patients with acute NS had higher serum TNF-beta and IL-13 levels than normal controls. After 4 weeks of prednisolone treatment, patients with steroid-resistant NS (SRNS) presented a higher serum TNF-beta level than that before treatment (p=0.008). In contrast, patients with steroid-sensitive NS (SSNS) presented a higher serum IL-13 level than that before treatment (p=0.027). This study demonstrates the significance of serum TNF-beta and IL-13 levels in relation to the disease activity and treatment response of childhood NS. Patients with SRNS appeared to have elevated TNF-beta after steroid therapy, while patients with SSNS tended to have elevated IL-13 after steroid therapy. Thus, an altered Th1/Th2 reaction as demonstrated by TNF-beta/IL-13 imbalance may play a pathophysiologic role in childhood NS.

Expression of CD40 ligand on CD4+ T-cells and platelets correlated to the coronary artery lesion and disease progress in Kawasaki disease

OBJECTIVE

Kawasaki disease (KD) is an acute febrile vasculitic syndrome in children. CD40 ligand (CD40L) has been implicated in certain types of vasculitis. We proposed that CD40L expression might be correlated with coronary artery lesions in KD.

METHODS

Blood samples were collected from 43 patients with KD before intravenous immunoglobulin (IVIG) treatment and 3 days afterward. Forty-three age-matched febrile children with various diseases were studied in parallel as controls. CD40L expression on T-cells and platelets were detected by flow cytometry, and soluble CD40L (sCD40L) levels were measured by enzyme-linked immunosorbent assay.

RESULTS

We found that CD40L expression on CD4(+) T-cells was significantly higher in patients with KD than in the febrile control (FC) group (28.69 +/- 1.17% vs 4.37 +/- 0.36%). CD40L expression decreased significantly 3 days after IVIG administration (28.69 +/- 1.17% vs 13.53 +/- 0.55%). CD40L expression on platelets from patients with KD was also significantly higher than in the FC group (8.20 +/- 0.41% vs 1.26 +/- 0.12%) and decreased after IVIG therapy. sCD40L levels were also significantly higher in KD patients with those of FC (9.69 +/- 0.45 ng/mL vs 2.25 +/- 0.19 ng/mL) but were not affected by IVIG treatment 3 days afterward (9.69 +/- 0.45 ng/mL vs 9.03 +/- 0.32 ng/mL). More interesting, we found that in KD patients, CD40L expression on CD4(+) T-cells and platelets but not on CD8(+) T-cells or sCD40L was correlated with the occurrence of coronary artery lesions.

CONCLUSIONS

CD40L might play a role in the immunopathogenesis of KD. IVIG therapy might downregulate CD40L expression, resulting in decrease of CD40L-mediated vascular damage in KD. This implicates that modulation of CD40L expression may benefit to treat KD vasculitis.

Different proinflammatory reactions in fatal and non-fatal enterovirus 71 infections: implications for early recognition and therapy

AIM

The mechanism of pulmonary oedema, a life-threatening manifestation of enterovirus 71 (EV71) encephalitis, is unclear. Our aim was to assess the relationship of proinflammatory cytokines to EV71-related pulmonary oedema.

METHODS

Proinflammatory responses in 33 EV71 patients with various complications and 21 normal healthy children were measured using an enzyme-linked immunosorbent assay.

RESULTS

EV71 patients with both encephalitis and pulmonary oedema were found to have much higher levels of blood interleukin-6 (IL-6) (947 +/- 1239 vs 4.9 +/- 3.1 pg/ml, p = 0.0003), tumour necrosis factor-alpha (TNF-alpha) (22.4 +/- 29.5 vs 5.3 +/- 1.0 pg/ml, p = 0.0035), interleukin Ibeta (IL-1beta) (48.4 +/- 85.2 vs 4.9 +/- 10.1 pg/ml, p = 0.01), white blood cell count (28.3 +/- 7.6 vs 15.5 +/- 6.8 10(9)/L, p > or = 0.0001) and blood glucose (501 +/- 186 vs 165 +/- 117 mg/dL, p = 0.0009) than patients with EV71 encephalitis alone. In fact, the cytokine levels in patients with encephalitis only or in those without complications were not significantly different from the levels found in normal children. The sensitivity, specificity, positive and negative predictive values of IL-6 > 70 pg/ml for EV71 encephalitis with pulmonary oedema were all 100%.

CONCLUSION

Patients with EV71-related encephalitis combined with pulmonary oedema were found to have significantly elevated levels of proinflammatory cytokines and the best predictor for this complicated condition was found to be the level of serum IL-6.

Mycoplasma pneumoniae-associated Stevens-Johnson syndrome exhibits lymphopenia and redistribution of CD4+ T cells

Erythema multiforme (EM) is an immune-mediated disease categorized into EM minor and EM major, also called Stevens-Johnson syndrome. The presence of mucosal involvement differentiates erythema multiforme major from erythema multiforme minor. Many drugs and agents can induce Stevens-Johnson syndrome. We report a case of Stevens-Johnson syndrome associated with Mycoplasma pneumoniae infection. Lymphopenia with a significant decrease of CD4+ T cells in the blood and predominant CD4+ T cells in the skin vesicular fluid was found. The improvement of lymphopenia was associated with disease recovery. In a retrospective chart review of patients treated in our hospital over the past 3 years, we found that 5 patients with Stevens-Johnson syndrome all had lymphopenia (< 1.50 x 10(9)/L; average 0.99 x 10(9)/L), whereas 13 other patients with erythema multiforme minor demonstrated normal lymphocyte counts (average 3.13 x 10(9)/L), with the exception of one patient with herpes infection showing lymphopenia. These results suggested that an immunopathogenesis involving redistribution of CD4+ T cells might contribute to the development of Stevens-Johnson syndrome. Further studies to investigate the involvement of CD4+ T cells in Stevens-Johnson syndrome may implicate a specific strategy to prevent fatal Stevens-Johnson syndrome.

Reactive thrombocytosis without endothelial damage does not affect the microvascular anastomotic patency

There is still controversy about the correlation of thrombocytosis and thrombosis complication. Using a rodent splenectomy-induced thrombocytosis model and a thrombogenic endothelial damage model (inverted suture resulting in an intraluminal thrombogenic adventitia of divided femoral artery), the authors investigated whether reactive thrombocytosis with or without endothelial damage contributes to the patency of microvascular anastomosis. Four experimental groups were evaluated in this study: 1) sham operation without thrombogenic anastomosis after femoral artery division; 2) sham operation with thrombogenic anastomosis; 3) thrombocytosis alone without thrombogenic anastomosis; 4) thrombocytosis with thrombogenic anastomosis (each subgroup n = 10, total N = 40). Vascular patency was assessed after immediate operation and on the seventh day postoperatively. Platelet counts and platelet activation (CD62P) were studied in correlation to microvascular patency. In rats without thrombogenic anastomosis groups, there were no significant differences in CD62P expression on platelets (p = 0.09), the patency rates (p = 0.561), or perfusion units (p = 0.746) before and after arterial reanastomosis between rats with and without thrombocytosis, respectively. However, the thrombogenic anastomosis of femoral artery in thrombocytosis and control groups showed significantly increased CD62P expression (p < 0.05), decreased the perfusion unit (p < 0.05), and patency rate (p < 0.001), compared with rats without thrombogenic anastomosis of femoral artery in both groups. In summary, this study demonstrates that microvascular anastomosis can be performed safely with reactive thrombocytosis alone without thrombogenic anastomosis. Meticulous microvascular anastomosis without triggering platelet activation is the most important factor to prevent thrombosed vessels in microsurgical anastomosis.

Hyper-IgM syndrome complicated with interstitial pneumonia and peritonitis

Hyper-IgM syndrome (HIM) is a rare disorder resulting from mutation in the CD40 ligand (CD40L) gene. This defect is associated with normal or elevated serum level of IgM and with low to undetectable levels of serum IgG, IgA, IgE. This case of HIM with CD40L deficiency was proven by flow cytometry but initially presented as interstitial pneumonia. Pneumocystis carinii pneumonia was highly suggested. After intravenous immunoglobulin and trimethoprim-sulfamethoxazole treatment, his lung condition improved. However, peritonitis developed and surgical intervention was performed. Ileum perforation and intestinal lymphoproliferation from a pathologic specimen were noted. Although peritonitis is extremely rare in patients with HIM, this report indicates that peritonitis which results from intestinal lymphoproliferation may be a manifestation of HIM.

Neonatal varicella frequently associated with visceral complications: a retrospective analysis

Neonates are very susceptible to varicella, which usually causes high mortality and morbidity rates among that age group. We analyzed the prognosis and complications of neonates with varicella in a retrospective study that assessed the clinical features, laboratory data, and clinical outcomes of twelve neonates who either had the illness or who were at risk. Based on exposure history, twelve babies were separated into prenatal and postnatal infection groups. Seven cases were categorized as having prenatal infections and five had postnatal varicella infection. Results showed that the major complications in the prenatal infection group included three cases of hepatitis, two of pneumonia, one of pyoderma and one of sepsis. The presence of fever was a good indicator for predicting complications among the prenatal infection group. These complications were not found in the postnatal infection group. We found that prenatal varicella infections appear to have a higher visceral complication rate. However, our patients had a much lower mortality rate than those reported in previous studies. This may be attributed to the administration of acyclovir after delivery.

Implications of blood soluble and cell surface tumor necrosis factor receptors in childhood nephrotic syndrome

We investigated whether leukocyte cell surface TNF receptors (cTNFR) and plasma soluble TNF receptors (sTNFR) could serve as predictors of childhood steroid-resistant nephrotic syndrome (SRNS) during the early stage of diagnosis. We recruited 39 nephrotic children for studies correlating plasma sTNFR and leukocyte cTNFR with disease activity and therapeutic response. We found that patients with idiopathic childhood nephrotic syndrome (NS) had higher pre-treatment plasma sTNFR1 ( P<0.001) and sTNFR2 levels ( P<0.001) than controls without NS. In contrast, cTNFR1 ( P<0.001) and cTNFR2 ( P=0.014) expression on granulocytes but not lymphocytes was lower in patients than controls. Patients with SRNS, similar to steroid-sensitive nephrotic syndrome (SSNS), had higher sTNFR1 and sTNFR2 levels pre treatment. However, patients with SRNS revealed higher expression of cTNFR1 ( P<0.001) and cTNFR2 ( P=0.023) than those with SSNS. After 4 weeks of steroid treatment, plasma sTNFR1 and sTNFR2 levels returned to normal in both patients with SRNS and SSNS. Post treatment, the decreased cTNFR1 and cTNFR2 expression on granulocytes in patients with SSNS returned to normal, while patients with SRNS revealed no change before and after treatment. This study suggests that a higher plasma sTNFR level associated with lower cTNFR expression reflects NS disease activity, whereas a higher initial granulocyte cTNFR expression tends to predict steroid resistance. TNFR may play a pathophysiological role in childhood NS.

Decreased nitric oxide production after intravenous immunoglobulin treatment in patients with Kawasaki disease

OBJECTIVE

To assess nitric oxide (NO) production and different displays of NO synthase (NOS) isoforms in patients with Kawasaki disease (KD) before and after intravenous immunoglobulin (IVIG) treatment.

STUDY DESIGN

Blood and urine samples were collected from patients with KD before IVIG treatment and 3 days afterward. Age-matched febrile patients with various diseases served as control patients. Plasma NOx (NO3- + NO2-) levels were measured as NO production. Real-time reverse transcriptase-polymerase chain reaction and immunohistochemical staining were used to detect differential NOS isoform expression in mononuclear leukocytes (MNCs).

RESULTS

Patients with KD (n = 40) had higher levels of NOx than the non-KD febrile control patients. The elevated NOx levels in patients with KD were significantly associated with the occurrence of coronary artery dilation (>3 mm). These elevated NOx levels significantly decreased after IVIG treatment (157.8 +/- 15.9 micromol/L vs 57.0 +/- 4.27 micromol/L, P <.01). However, excretion of urinary NOx levels was not changed after IVIG treatment. Inducible but not constitutive NOS mRNA and protein in MNCs were prominently expressed but significantly decreased after IVIG treatment.

CONCLUSIONS

IVIG may suppress iNOS expression of MNCs in patients with KD, thus decreasing NO-mediated inflammatory responses and coronary artery dilation.

Clinical manifestations and laboratory assessment in an enterovirus 71 outbreak in southern Taiwan

An epidemic of enterovirus 71 (EV71) infection compatible with hand, foot and mouth disease and associated with high morbidity and mortality occurred in Taiwan in 1998. We recruited 90 patients (50 males, 40 females) with definite EV71 infections for clinical and laboratory analysis. The neurological signs and symptoms, all of which occurred during the febrile period, in patients with central nervous system (CNS) involvement (aseptic meningitis, encephalitis or myelitis) were myoclonic jerks (23/33), vomiting (10/33), ataxia (7/33), lethargy (6/33), seizure (4/33) and tremor (2/33). Patients with CNS involvement had longer durations of fever (4.6+/-0.2 vs. 3.1+/-0.3 d; p <0.01) and a higher white blood cell count (12,512+/-658 vs. 10,607+/-409 cells/mm3; p = 0.01) than patients without CNS involvement. The case fatality rate in patients with CNS involvement was 4/33 (12%), whereas no fatalities (0/57) occurred in patients without CNS involvement. Six of 11 patients subjected to MRI showed a high intensity T2-weighted signal in the brainstem. A nested fluorescent RT-PCR for detection of virus in throat and stool specimens showed higher sensitivity than viral culture. Viremia was detectable using RT-PCR in 20% of cases (3/15), whereas no virus was isolated from culture or detected by RT-PCR in cerebrospinal fluid.

Platelet glycoprotein IIb/IIIa receptor antagonist (abciximab) inhibited platelet activation and promoted skin flap survival after ischemia/reperfusion injury

BACKGROUND

Evidence has shown that platelets play an important role in the pathogenesis of flap failure. Employing a rat inferior epigastric artery skin flap as a flap reperfusion injury model, we investigated whether platelet activation was involved in the skin flap failure and whether administration of abciximab (ReoPro, chimeric 7E3 Fab) could decrease platelet activation/aggregation and promote flap survival.

METHODS

Normal saline and abciximab (0.06 mg/kg; 0.2 mg/kg; 1 mg/kg) were injected intravenously into skin flaps 30 min before reperfusion and 1 h after reperfusion (each subgroup n = 6). Platelet activation as demonstrated by P-selectin (CD62P) was analyzed by flow cytometry. P-selectin expression on flap vessels was detected by immunohistochemical staining. Platelet aggregation was induced with adenosine diphosphate (ADP). Laser Doppler flowmetry monitored tissue perfusion. The surviving area was evaluated 7 days postoperatively.

RESULTS

CD62P progressively increased after reperfusion. The peak CD62P occurred after reperfusion for 12 h. Immunohistochemical staining showed CD62P significantly deposited on the endothelium after reperfusion. Administration of abciximab (1 mg/kg) effectively improved flap survival rate (P = 0.003), significantly decreased ADP-induced platelet aggregation (P < 0.001), and suppressed CD62P expression on blood platelets (P = 0.002) and its deposition on the flap vessels.

CONCLUSION

Abciximab promotion of skin flap survival is due to blocked platelet activation/aggregation and decreased activated-platelet deposition on the vascular endothelium. Thus, administration of a platelet glycoprotein IIb/IIIa receptor antagonist such as abciximab may save the skin flap from reperfusion injury after a long period of ischemia.

Reactive thrombocytosis alone does not affect the patency of microvascular anastomosis in the splenectomy rat

Vascular thrombosis is a harbinger of failure in microsurgery. However, there is still controversy regarding the correlation of the complications of thrombocytosis and thrombosis. Some evidence indicates that patients with elevated platelet counts tend to have a higher flap failure rate, and surgeons usually hesitate to operate on patients with thrombocytosis. Nevertheless, the authors have experienced successful free tissue transfer in seven patients with thrombocytosis resulting from traumatic splenectomy or multiple trauma. On the basis of clinical observation, the authors investigated whether reactive thrombocytosis contributes to the patency of a microvascular anastomosis. In a rodent splenectomy-induced thrombocytosis model (n = 40), stable reactive thrombocytosis occurred after postoperative days 5 to 10, with the peak on postoperative day 7. Femoral artery division and reanastomosis was performed in rats with or without splenectomy-induced thrombocytosis, and vascular patency was assessed. Platelet counts and platelet activation were studied in correlation to microvascular patency. Platelet activation as demonstrated by CD62P expression on platelets was not significantly different between rats with and without thrombocytosis (6.41 +/- 0.95 percent versus 4.51 +/- 0.55 percent, respectively; p = 0.089). As immature platelets were not increased (2.86 +/- 0.33 percent versus 1.99 +/- 0.32 percent, p = 0.074), it seems that the splenectomy-induced thrombocytosis is the result of redistribution of platelets instead of an increase in bone marrow production. There were no significant differences in the patency rates or perfusion units of femoral artery after arterial anastomosis between rats with and without thrombocytosis (90 percent and 95 percent, respectively; p = 0.561). In conclusion, this study demonstrates that microvascular anastomosis can be performed safely in patients with reactive thrombocytosis without platelet activation.

Glutamine protects activated human T cells from apoptosis by up-regulating glutathione and Bcl-2 levels

Glutamine is the most abundant amino acid in the body. A decrease of plasma glutamine concentrations is found in catabolic stress and is related to susceptibility to infections. Glutamine is known to modulate lymphocyte activation; however, little is known about glutamine modulation of cell death of activated human T cells. Using Jurkat T cells, we investigated glutamine modulation of T-cell apoptosis activated by PMA plus ionomycin. We found that glutamine at various concentrations significantly enhanced IL-2 production, cell proliferation, and cell viability of Jurkat T cells. Glutamine also decreased the number of apoptotic cells stimulated with PMA plus ionomycin as demonstrated by flow cytometry. Meanwhile, glutamine down-regulated CD95 and CD95L expression, but up-regulated CD45RO and Bcl-2 expression in activated T cells. Further investigation of CD95-mediated caspase activities revealed that supplementation of glutamine significantly decreased caspase-3 and caspase-8 activities in activated T cells. Since oxidative stress is closely associated with induction of lymphocyte apoptosis, we found that glutamine significantly increased glutathione (GSH), but decreased reactive oxygen species levels in activated T cells. Blockade of intracellular GSH formation enhanced, but exogenous GSH supplementation decreased, activated T-cell apoptosis. Studying normal peripheral lymphoproliferation, we also found that the presence of glutamine increased lymphoproliferation as well as Bcl-2 and CD95 expression; but decreased CD95L and activation-induced T-cell death. Taken together, glutamine appeared to augment lymphoproliferation but suppressed activation-induced T-cell death in both Jurkat T cells and human peripheral T lymphocytes.

Extracorporeal shock wave promotes growth and differentiation of bone-marrow stromal cells towards osteoprogenitors associated with induction of TGF-beta1

Extracorporeal shock-wave (ESW) treatment has been shown to be effective in promoting the healing of fractures. We aimed to determine whether ESW could enhance the growth of bone-marrow osteoprogenitor cells. We applied ESW to the left femur of rats 10 mm above the knee at 0.16 mJ/mm2 in a range of between 250 and 2000 impulses. Bone-marrow cells were harvested after ESW for one day and subjected to assessment of colony-forming unit (CFU) granulocytes, monocytes, erythocytes, megakaryocytes (CFU-Mix), CFU-stromal cells (CFU-S) and CFU-osteoprogenitors (CFU-O). We found that the mean value for the CFU-O colonies after treatment with 500 impulses of ESW was 168.2 CFU-O/well (SEM 11.3) compared with 88.2 CFU-O/well (SEM 7.2) in the control group. By contrast, ESW treatment did not affect haematopoiesis as shown by the CFU-Mix (p = 0.557). Treatment with 250 and 500 impulses promoted CFU-O, but not CFU-Mix formations whereas treatment with more than 750 impulses had an inhibiting effect. Treatment with 500 impulses also enhanced the activity of bone alkaline phosphatase in the subculture of CFU-O (p<0.01), indicating a selective promotion of growth of osteoprogenitor cells. Similarly, formation of bone nodules in the long-term culture of bone-marrow osteoprogenitor cells was also significantly enhanced by ESW treatment with 500 impulses. The mean production of TGF-beta1 was 610 pg/ml (SEM 84.6) in culture supernatants from ESW-treated rats compared with 283 pg/ml (SEM 36.8) in the control group. Our findings suggest that optimal treatment with ESW could enhance rat bone-marrow stromal growth and differentiation towards osteoprogenitors presumably by induction of TGF-beta1.

Superoxide mediates shock wave induction of ERK-dependent osteogenic transcription factor (CBFA1) and mesenchymal cell differentiation toward osteoprogenitors

Extracorporeal shock wave (ESW) is an alternative non-invasive method for the promotion of bone growth and tendon repair. In an animal model, we have reported that ESW promoted bone marrow osteoprogenitor growth through transforming growth factor-beta1 induction. We have further explored the mechanism for the ESW promotion of osteogenesis. Results showed that an optimal ESW treatment at 0.16 mJ/mm(2) for 500 impulses rapidly induced a higher O(2)(-) and ONOO(-) production associated with a decrease of nitric oxide level in 1 h, and induced a higher transforming growth factor-beta1 production in 24 h, and a higher colony-forming units-osteoprogenitor formation in 12 days. The colony-forming units-osteoprogenitor colonies revealed positive staining of bone alkaline phosphatase and turned into bone nodules in 21 days. Early scavenging of O(2)(-) but not Ca(2+), H(2)O(2), or prostaglandin E(2) suppressed osteoprogenitor cell growth and maturation. Scavenging of O(2)(-) by superoxide dismutase raised the nitric oxide level back to the basal level and suppressed ESW-promoted osteoprogenitor cell growth, whereas inhibition of ONOO(-) by urate or NO by N-nitro-l-arginine methyl ester did not affect ESW promotion of osteogenesis, indicating that O(2)(-) acted as an early signal for ESW-induced cell growth. Further studies demonstrated that ESW induced ERK activation, and blockage of O(2)(-) production or inhibition of tyrosine kinase, but not protein kinase A and C inhibitors, suppressed ESW-induced ERK activation. In support that O(2)(-) mediated the ESW-induced ERK activation and osteogenic differentiation, we further demonstrated that scavenging of O(2)(-) by superoxide dismutase and inhibition of ERK activation by PD98059 decreased specific osteogenic transcription factor, core binding factor A1 activation, and decreased osteocalcin expression. Taken together, we showed that ESW-induced O(2)(-) production followed by tyrosine kinase-mediated ERK activation and core binding factor A1 activation resulted in osteogenic cell growth and maturation. Thus, an appropriate modulation of redox reaction by ESW may have some positive effect on the bone regeneration.

Reversible phosphatidylserine expression on blood granulocytes related to membrane perturbation but not DNA strand breaks

Exposure of phosphatidylserine (PS) on the outer leaflet of the cell membrane is recognized as an early indicator of programmed cell death (apoptosis) in plant and mammalian cells. Currently, there is no literature describing that PS expression on the surface of white blood cells is reversible. We found that a hypotonic 0.2% NaCl or NH(4)Cl lysing solution used to separate white blood cells from red blood cells induced a reversible PS expression on the cell surface of granulocytes and monocytes but not lymphocytes. This reversible PS expression was associated with change of plasma membrane potential but not degranulation-associated membrane mobilization or DNA fragmentation. In contrast, TNF-alpha induced an irreversible PS expression, associated with apoptotic DNA fragmentation shown on gel electrophoresis. The fact that hypotonic shock induced a reversible PS expression on granulocytes, and TNF-alpha induced an irreversible PS expression associated with apoptotic DNA fragmentation indicate the new insight that expression of PS on the outer cell surface does not always represent cell apoptosis. Also, the reversible PS expression was associated with altered plasma-membrane potential but not DNA strand breaks, indicating that early PS expression may be related to the membrane perturbation but not directly related to DNA fragmentation in certain types of cells.

Physical shock wave mediates membrane hyperpolarization and Ras activation for osteogenesis in human bone marrow stromal cells

Physical shock wave (SW) has shown effectiveness on promotion of bone growth. We have recently demonstrated that SW could promote bone marrow stromal cell differentiation toward osteoprogenitor associated with induction of TGF-beta1. We have further demonstrated that SW-induced membrane hyperpolarization and Ras activation acted an early signal for the osteogenesis in human bone marrow stromal cells. An optimal dose of SW treatment at 0.16 mJ/mm(2) for 500 impulses induced a rapid membrane hyperpolarization in 5 min, activation of Ras in 30 min, and cell proliferation in 2 days. The SW-promoted cell growth was related to osteogenesis as demonstrated by increase of bone alkaline phosphatase activity in 6 days and osteocalcin mRNA expression in 12 days. In support that SW-induced Ras activation mediated osteogenesis of human bone marrow stromal cells, we further demonstrated that transfection of bone marrow stromal cells with a dominant negative Ras mutant (Asn-17 ras(H)) abrogated the SW enhancement of osteogenic transcription factor (CBFA1) activation, osteocalcin mRNA expression, and bone nodule formations. These results suggest that physical SW promotes bone marrow stromal cell differentiation toward osteogenic lineage via membrane hyperpolarization, followed by Ras activation and specific osteogenic transcription factor CBFA1 expression. A link between physical SW and biomembrane perturbation-mediated Ras activation may highlight how noninvasive physical agents could be used to promote fracture healing and to rescue patients with osteoporosis and osteopenic disorders in the future.

A single dose of nebulized budesonide decreases exhaled nitric oxide in children with acute asthma

This study was conducted to investigate whether a single dose of nebulized budesonide effectively decreased airway inflammation as demonstrated by exhaled nitric oxide (eNO) levels. A single dose of nebulized budesonide, but not nebulized terbutaline, rapidly decreased eNO levels in 6 hours. The decrease in eNO levels induced by nebulized budesonide was correlated to an increase in peak expiratory flow rate.

Granulocyte function disorders: aspects of development, genetics and management

The field of phagocytic disorders has attained major biologic and clinical significance in the past 40 years. The development of exciting new techniques in molecular biology and the cellular physiology of signal transduction have made it possible to identify the genetic defects involved in many of these disorders. Moreover through immunopharmacologic intervention, bone marrow or peripheral or cord blood stem cell transplantation along with the prospect of gene therapy, we have begun attempts to at least partially correct genetic defects in cell development and activation pathways in the entire spectrum of phagocyte disorders. Carrier detection and prenatal diagnosis employing with chain reaction techniques or direct nucleotide sequencing in fetal blood have made these diseases potentially preventable or treatable in utero or shortly after birth.

Evaluation of different nebulized bronchodilators on clinical efficacy and hypokalemia in asthmatic children

Acute asthma attack continues to be a major cause for children admitted to the emergency room. Nebulized beta 2-adrenergic agonists are still the first-line drugs for a rapid bronchodilation effect and an easily administered drug during acute asthma attack. The bronchodilator-induced hypokalemia is thought significant in adult group, but is often ignored in children group. In this study, we conducted a randomized study to compare the laboratory and clinical effects between nebulized salbutamol and terbutaline. We found that both salbutamol and terbutaline nebulization induced a significant hypokalemia (p < 0.05). Terbutaline nebulization also significantly improved the peak expiratory flow rate (PEFR) and respiratory rate (RR), but not venous partial pressure of oxygen (PvO2), venous carbon dioxide tension (PvCO2) and O2 saturation in venous blood (SvO2). In contrast, salbutamol improved not only PEFR and RR, but also PvO2, PvCO2, and SvO2 30 minutes of administration. In conclusion, the nebulized salbutamol, although induced a hypokalemic effect which is similar to terbutaline group, has a better effect on improving O2 saturation than nebulized terbutaline with the same dose 30 minutes after administered for children with acute asthma attack.

Effect of shock wave therapy on acute fractures of the tibia: a study in a dog model

The effect of shock wave therapy on acute fractures of the tibia was studied in eight adult dogs. A fracture with a 3-mm gap was created in both tibias and the fractures were fixed internally with a small metallic plate and screws. Each of the right limbs received 2,000 impulses of shock waves at 14 kV whereas the left limbs were used as controls. The evaluations included the callus formations based on serial radiographic examinations at 1, 4, 8, and 12 weeks and histologic examinations at 12 weeks for tissue distribution including bone tissues. Based on radiographic findings, there was no statistically significant difference in the amount of callus formation between the treated and the control groups at 8 weeks or less. However, the radiographic findings at 12 weeks statistically showed more callus formations in the treated group. In histologic examinations, there was significantly more cortical bone formation in the treated group at 12 weeks and the bone tissues were thicker, denser, and heavier. Shock wave therapy enhanced callus formation and induced cortical bone formation in acute fractures in dogs at 12 weeks. The effect of shock wave therapy seemed to be time-dependent at 3 months.

Treatment of nonunions of long bone fractures with shock waves

A prospective clinical study investigated the effectiveness of shock waves in the treatment of 72 patients with 72 nonunions of long bone fractures (41 femurs, 19 tibias, seven humeri, one radius, three ulnas and one metatarsal). The doses of shock waves were 6,000 impulses at 28 kV for the femur and tibia, 3,000 impulses at 28 kV for the humerus, 2,000 impulses at 24 kV for the radius and ulna, and 1,000 impulses at 20 kV for the metatarsal. The results of treatment were assessed clinically, and fracture healing was assessed with plain radiographs and tomography. The rate of bony union was 40% at 3 months, 60.9% at 6 months, and 80% at 12 months followup. Shock wave treatment was most successful in hypertrophic nonunions and nonunions with a defect and was least effective in atrophic nonunions. There were no systemic complications or device-related problems. Local complications included petechiae and hematoma formation that resolved spontaneously. In the authors' experience, the results of shock wave treatment were similar to the results of surgical treatment for chronic nonunions with no surgical risks. Shock wave treatment is a safe and effective alternative method in the treatment of chronic nonunions of long bones.

Chronic granulomatous disease: a case report

Chronic granulomatous disease is one form of the phagocyte function disorder. Unlike most patients with chronic granulomatous disease who develop signs and symptoms of chronic and recurrent pyogenic infections during the first 2 years of life, patients with mild forms of the disease may not present until the teenage years or even adulthood. Thus, the diagnosis in these mild-form patients is often delayed. This paper describes a patient with the mild form of chronic granulomatous disease. A 7-year-old boy was admitted to our ward with intermittent high fever and a left neck mass present for about 1 week. He had a history of persistent infection in the bilateral lower face lasting for about 1 year during his fourth year of life. Family history was unremarkable except that the patient's elder sister had a history of persistent oral mucosal wound infection for about 1 year during the fifth year of life. On physical examination, there were scars over the patient's bilateral lower face. Bacterial culture of pus drained from the neck mass revealed Burkholderia cepacia, a rare species in patients without immunodeficiency. A series of antibiotics, including oxacillin, clindamycin, and piperacillin, was given, and two incision operations for drainage and debridement were performed. The neck mass resolved completely about 1.5 months later. This history indicated that the patient might have chronic granulomatous disease. A definite absence of superoxide activity in the patient's granulocytes detected by chemiluminescence and nitroblue tetrazolium dye test confirmed this diagnosis.

Altered cellular but not humoral reactions in children with complicated enterovirus 71 infections in Taiwan

Enterovirus 71 (EV 71) infections have high neurovirulence and fatality. Immune responses were assessed in 78 patients with EV 71 infection. EV 71 meningoencephalitis occurred more frequently in younger children and in boys. C-reactive protein levels were not elevated, although total leukocyte counts were increased in these patients. The CD40-ligand expression on T cells significantly decreased in children with meningoencephalitis (P=.041). Polymorphism of the cytotoxic T lymphocyte antigen-4 (CTLA-4) at position 49 of exon 1 showed a higher frequency of G/G genotype in patients with EV 71 meningoencephalitis than in those without meningoencephalitis (18/31 vs. 14/47; P=.045) and in control subjects (18/31 vs. 25/93l; P=.007). Specific EV 71 neutralizing antibody titers were detectable but did not differ in children with and without meningoencephalitis in the acute and convalescent stages. Results from this study suggest that younger children with a certain CTLA-4 polymorphism and altered cellular but not humoral response may be linked to EV 71 meningoencephalitis.

Antibody-dependent enhancement of heterotypic dengue infections involved in suppression of IFNgamma production

Antibody-dependent enhancement has been implicated in some outbreaks of epidemic dengue hemorrhagic fever, however, the mechanism of antibody-dependent enhancement is not well known. This study was conducted to investigate the cross-protection and cross-enhancement of dengue-2 virus infections by dengue-1 immune sera. It was found that dengue-1 immune sera at 1:5 dilution (n = 12) could neutralize dengue-2 infections in BHK-21 cells, as assessed by a standard plaque-reduction neutralization assay. Two-thirds of the dengue-1 immune sera at 1:25 dilution demonstrated neutralizing effects for dengue-2 infections, whereas, non-immune sera revealed no neutralization for dengue-2 infections in BHK-21 cells. Human mononuclear leukocytes in response to dengue-2 infections elicited a T cell helper 1 (Th1) response revealing induction of IFNgamma but not IL-4 production. Dengue-1 immune sera did not neutralize dengue-2 infections in mononuclear leukocytes. Subneutralizing titers of dengue-1 immune sera at 1:250, but not at 1:10 dilution, enhanced dengue-2 infections in mononuclear leukocytes (1.2 +/- 0.7 x 10(4) vs. 2.8 +/- 0.3 x 10(2) PFU/ml). The enhancement of dengue-2 infections in mononuclear leukocytes by dengue-1 immune sera at 1:250 was associated with an increase in the lymphocyte proliferation index, and a decrease in IFNgamma production (56 +/- 24 vs. 12 +/- 3 pg/ml). The addition of IFNgamma (0.1 microg/ml) suppressed significantly the antibody-dependent enhancement induced by dengue-1 immune sera, whereas the presence of anti-IFNgamma F(ab)2 antibody augmented the antibody-dependent enhancement effect. Results from this study suggest that suppression of Th1 response may be involved in the antibody-dependent enhancement of heterotypic dengue infections. Better regulation of Th1/Th2 reactions may be useful for prevention of heterotypic immune enhancement of dengue infections.

A model of the real-time correlation of viral titers with immune reactions in antibody-dependent enhancement of dengue-2 infections

We simultaneously assessed dengue-2 virus (DEN-2) titers by real-time quantitative reverse transcription-polymerase chain reaction (RT-PCR) and immune reactions including interleukin-4 (IL-4), interferon-gamma (IFN-gamma) and prostaglandin E(2) (PGE(2)) production by human mononuclear cells (MNLs) in a model of antibody-dependent enhancement (ADE). We found that DEN-1 immune sera at 1:100 and 1:250, but not those at 1:10 or control sera, enhanced DEN-2 infections in human MNLs as assessed by the fluorogenic RT-PCR technique. The enhanced profiles of DEN-2 infections determined by the RT-PCR in 6 h were reproducible by the standard plaque-forming unit (PFU) measurement established after 7 days. The ADE-enhanced DEN-2 titers determined by the RT-PCR were 5.5-33-fold higher than those detected by PFU assay, suggesting that total virions during infections were much higher than the viable ones detected by PFU assay. MNLs in response to DEN-2 infections had higher IFN-gamma and PGE(2) production. However, the enhancement of DEN-2 infections by DEN-1 immune sera in MNLs was not associated with further enhancement of IFN-gamma production. In contrast, the presence of subneutralizing DEN-1 immune sera that enhanced DEN-2 infections also enhanced PGE(2) but not IL-4 production. The results of this study suggest that ADE of DEN-2 infections associated with induction of immunosuppressive mediators such as PGE(2) and IL-4 can be simultaneously assessed in a real-time fashion.

A model to study antioxidant regulation of endotoxemia-modulated neonatal granulopoiesis and granulocyte apoptosis

Neonates with septicemia tend to develop granulocytopenia, which may, in part, be due to septic mediators such as oxygen free radicals and tumor necrosis factor alpha (TNF-alpha). Granulocytopenia may be caused by a decrease in granulocyte growth and/or an increase in granulocyte destruction. In the present study, we investigated antioxidant regulation of endotoxin-modulated neonatal granulopoiesis and granulocyte apoptosis. Using human umbilical cord blood (HUCB), we found that simulating endotoxemia in vitro elicited significant superoxide production within a few minutes. Endotoxin exposure suppressed colony-forming unit-granulocyte and monocyte formation in a dose-dependent fashion. Addition of antioxidants such as N-acetyl-cysteine could reverse the endotoxin suppression of colony-forming unit-granulocyte and monocyte formation (13 +/- 5 versus 75 +/- 5 colony-forming units/mL). Spontaneous in vitro granulocyte apoptosis in 6 h, as reflected by phosphatidylserine expression on the cell surface, was higher in granulocytes from HUCB than in those from adult blood (10.8 +/- 1.0% versus 5.6 +/- 1.2%). The addition of endotoxin or IL-8 to the cells in the in vitro model did not promote granulocyte apoptosis, but TNF-alpha, a major mediator of the effects of endotoxin, significantly induced granulocyte apoptosis in HUCB (control versus TNF-alpha: 8.9 +/- 1.2% versus 35.9 +/- 2.9%). Addition of the antioxidant N-acetyl-cysteine effectively blocked TNF-alpha-induced granulocyte apoptosis as demonstrated by DNA fragmentation. Results from these studies indicate that oxygen radicals are directly involved in endotoxin suppression of granulopoiesis, and indirectly promote granulocyte apoptosis, presumably through TNF-alpha-mediated action. Thus, under certain conditions, modulation of oxygen radical production in the blood may benefit neonates with granulocytopenia.

Childhood asthma: aspects of global environment, genetics and management

The prevalence of asthma in children dramatically increased over the past two decades. In Taiwan, the prevalence of childhood asthma has risen to around 10% in the 1990s, in contrast to a prevalence of about 1% in the 1970s. Currently, Australia and New Zealand have the highest prevalence in the world (> 15%). African and Asian countries have a low prevalence of about 5 to 10%. In general, countries in coastal, temperate and subtropical zones have the highest mite-sensitive asthma prevalence. Countries in the subarctic or in semiarid areas have a lower prevalence. Indoor allergens such as house dust mites, cockroaches and fungi usually cause perennial asthma; outdoor allergens such as grass and tree pollens as well as outdoor fungi induce seasonal asthma. A gene on chromosome 11q13 is significantly linked to maternal inheritance of asthma, and possibly involves polymorphisms in the beta subunit of the high affinity IgE receptor. Cytokine genes in chromosome 5q31-33 are known to regulate IgE production resulting in various severities of allergic diseases. Recent studies suggest that pollutants such as diesel exhaust, O3, NO2, and SO2, together with allergens and susceptible genes are likely to promote IgE production and allergic reactions. As a result, asthma is apparently not a single gene disorder, but a disease determined by the interaction between gene and environment. In practice, immunopharmacological interventions to block IgE-mediated early bronchospasm and late inflammatory reactions are the major regimens for asthma treatments. This makes possible a step-wise self-management based on portable monitoring of airway resistance using the peak expiratory flow rate (PEFR). Early avoidance of allergen exposure in utero as well as early anti-inflammatory therapy in infancy have decreased the prevalence of allergic diseases. A combination of both strategies may bring much more benefit in the prevention of childhood asthma. As progress in therapeutic gene vaccines as well as genetic immunoregulation continues, we expect early environmental avoidance and genetic vaccines may prevent childhood asthma in the near future.

Common variable immunodeficiency with mosaic trisomy 8: report of one case

This case study reported a 17-year-old female of common variable immunodeficiency (CVID) associated with bronchiectasis, pernicious anemia and mosaic trisomy 8. Clinically this patient presented with recurrent sinopulmonary infections, intractable diarrhea, macrocytic anemia, and primary amenorrhea. Immunological tests showed pan-hypogammaglobulinemia and a decrease of peripheral blood B cells (4%) and CD4+ cells (25%). Lymphoproliferative responses to mitogen (PHA) and specific antigen (BCG) were profoundly impaired in the patient in comparison to those in control. Production of interleukin 4 (IL-4) and gamma interferon (IFN-gamma) in the in vitro lymphoproliferation was also profoundly depressed. Pernicious anemia demonstrated by larger MCV (112.9 fl) and hyper-segmental granulocytes on peripheral blood smear responded to parental administration of vitamin B12. Interestingly, she had a mosaic trisomy 8 in peripheral blood mononuclear cells but normal 46XX karyotype in the bone marrow cells. To our knowledge, this is the first case of CVID associated with mosaic trisomy 8 reported in the literature. As the case exemplifies, CVID should be considered when the physicians evaluate the patient presenting with recurrent sinopulmonary infections, diarrhea, malnutrition, and pernicious anemia. It requires further study to explore whether the genes in the chromosome 8 are linked to CVID.

Pentoxifylline synergizes with all-trans retinoic acid to induce differentiation of HL-60 myelocytic cells, but suppresses tRA-augmented clonal growth of normal CFU-GM

All-trans retinoic acid (tRA) has been shown to promote terminal differentiation of promyelocytic leukemia cells, but frequently induce hyperleukocytosis and pulmonary leakage syndrome. Employing pentoxifylline (PTX), a phosphodiesterase inhibitor which could raise intracellular cAMP and modulate leukocyte activation, we sought to investigate if PTX could enhance tRA-induced promyelocytic leukemic cell differentiation but suppress tRA-augmented growth and activation of human granulocytes. tRA could significantly suppress clonal growth of U937 and HL-60 leukemic cells but enhanced the CFU-GM formation of normal bone marrow cells (22 +/- 6 vs. 90 +/- 16 CFU/well). PTX significantly augmented tRA suppression of clonal growth of U937 and HL-60 leukemic cells but suppressed tRA-augmented CFU-GM formation of normal bone marrow cells (90 +/- 16 vs. 25 +/- 9 CFU/well). In addition, PTX enhanced tRA-induced growth inhibition and differentiation of promyelocytic HL-60 leukemic cells, but suppressed respiratory burst activation by the immature granulocytic HL-60 cells and suppressed CD11b adhesion molecule expression by mature granulocytes. PTX similar to dibutyric cAMP promoted HL-60 myelocytic leukemic cell differentiation and growth inhibition, whereas PTX, in contrast to dibutyric cAMP which could augment phorbol myristate acetate (PMA)-elicited respiratory burst activity by immature granulocytes, suppressed the PMA-elicited respiratory burst activity by immature and mature granulocytes. PTX did not raise the intracellular cAMP level of HL-60 cells, but partly suppressed the dibutyric cAMP-elicited elevation of intracellular cAMP level. Results from these studies suggest that PTX might act through different signaling pathways to enhance tRA-induced myelocytic leukemic cell differentiation but prevent from hyperreactive normal granulopoiesis and granulocyte activation.

Potential dengue virus-triggered apoptotic pathway in human neuroblastoma cells: arachidonic acid, superoxide anion, and NF-kappaB are sequentially involved

Direct in vivo evidence for the susceptibility of human neuronal cells to dengue virus has not been reported. In this study, we demonstrated that type 2 dengue (DEN-2) virus infection induced extensive apoptosis in the human neuroblastoma cell line SK-N-SH. Phospholipase A(2) (PLA(2)) was activated by DEN-2 infection, which led to the generation of arachidonic acid (AA). Inhibition of PLA(2) activity by the PLA(2) inhibitors, AACOCF(3) and ONO-RS-082, diminished DEN-2 virus-induced apoptosis. In contrast, the cyclooxygenase inhibitors aspirin and indomethacin, thought to increase AA accumulation by blocking AA catabolism, enhanced apoptosis. Exogenous AA induced apoptosis in a dose-dependent manner. Superoxide anion, which is thought to be generated through the AA-activated NADPH oxidase, was increased after infection. Pretreatment with superoxide dismutase (SOD) protected cells against DEN-2 virus-induced apoptosis. Furthermore, generation of superoxide anion was blocked by AACOCF(3). In addition, the transcription factors, NF-kappaB and c-Jun, were found to be activated after DEN-2 virus infection. However, pretreatment of cells with oligodeoxynucleotides containing NF-kappaB, but not c-Jun, binding sites (transcription factor decoy) strongly prevented dengue virus-induced apoptosis. The finding that AACOCF(3) and SOD significantly block activation of NF-kappaB suggests that this activation is derived from the AA-superoxide anion pathway. Our results indicate that DEN-2 virus infection of human neuroblastoma cells triggers an apoptotic pathway through PLA(2) activation to superoxide anion generation and subsequently to NF-kappaB activation. This apoptotic effect can be either directly derived from the action of AA and superoxide anion on mitochondria or indirectly derived from the products of apoptosis-related genes activated by NF-kappaB.

Atopic cataracts in a child with atopic dermatitis: a case report and review of the literature

Cataracts induced by atopic dermatitis rarely occur in adolescent and young adult patients suffering from this problem. Lenticular opacity is an important ocular complication in atopic dermatitis. Although the cause of atopic dermatitis and its ocular complications are unknown, cataracts have been observed to develop and progress during periods of exacerbation of the dermatitis. We report the case of a 16-year-old boy with atopic dermatitis who abruptly developed cataracts in both eyes while suffering from severe skin itching which began 2 months before the initial examination. His peroxidation test result was very high, and we postulate the retinal peroxidation might play a key role in cataractogenesis. Lens aspiration and intraocular artificial lens implantation were performed smoothly with restoration of visual acuity in both eyes.

Profiles of inflammatory cytokines in bronchoalveolar lavage fluid from premature infants with respiratory distress disease

In view of cytokine's effects in promoting or inhibiting inflammation, the objective of this study was to explore the characteristics of the proinflammatory cytokine, interleukin-8 (IL-8), and the inhibitory cytokine, interleukin-10 (IL-10), in the bronchoalveolar lavage (BAL) fluid of premature infants suffering from respiratory distress disease. Eighteen premature neonates with respiratory distress disease with gestational age (GA) ranging from 24 to 37 weeks were recruited for study. BAL fluids were collected following endotracheal intubation during an episode of hypoxemia or dyspnea. A series of BAL samples were obtained on day 1, 2, 4 and 7 after intubation for measuring IL-8 and IL-10 levels. The results indicate that premature infants with GA ranging from 24 to 32 weeks had a higher level of IL-8 (p = 0.029), but not level of IL-10 (p = 0.109), in the BAL obtained during the first intubation compared to premature infants with GA ranging from 33 to 37 weeks. The administration of exogenous surfactant did not influence the profiles of IL-8 and IL-10, as compared to those in-patients without treatment. Levels of IL-8 were correlated with IL-10 levels (r = 0.613, p = 0.007) in BAL fluid samples obtained on the day of intubation. The level of IL-8, but not IL-10, was significantly correlated with the duration of intubation. IL-8 and IL-10 levels in BAL fluid samples collected on the day of intubation were correlated with the development of chronic lung disease (CLD). The results suggest that extreme prematurity tends to have increased IL-8 and IL-10 levels in BAL fluid compared to premature infants with older GA, and that these increased levels are associated with the development of CLD.