Reduced effect of inhaled beta 2-adrenergic agonists on lung mucociliary clearance in patients with cystic fibrosis

STUDY OBJECTIVE

It has been suggested that the defective cyclic AMP-dependent Cl- secretion and the increased Na+ absorption from airway epithelia in cystic fibrosis (CF) may lead to dehydrated secretions and impaired mucociliary clearance. Beta 2-adrenergic agonists are unable to stimulate the Cl- transport in the airways in CF while being able to do so in normal airways. Thus, we questioned whether the beta 2-adrenergic agonist, terbutaline, would improve mucociliary clearance in patients with CF as it does in healthy subjects.

DESIGN

A double-blind, randomized cross-over trial.

SETTING

Whole lung and regional mucociliary clearance of a radioaerosol was measured for 3 h by gamma camera. One minute of cough clearance was measured at 3 h. Pulmonary function was measured before and after the gamma camera study.

PATIENTS

Ten young patients with CF were studied; three were heterozygous for deletion of the phenylalanine at position 508 (delta F508), and seven were delta F508 homozygous.

INTERVENTIONS

Inhalation of 1 mg of terbutaline (4 puffs) and placebo via a metered-dose inhaler by spacer.

MEASUREMENTS AND RESULTS

The largest differences in tracheobronchial retention (percent) in the whole lung and regional lung zones were generally observed within 1 h after terbutaline and placebo treatment: whole lung (mean +/- SD), 60 +/- 22 percent and 63 +/- 20 percent; central zone, 41 +/- 19 percent and 50 +/- 25 percent; midzones, 65 +/- 27 percent and 63 +/- 19 percent; and peripheral zones, 77 +/- 28 percent and 72 +/- 28 percent, respectively [p > 0.1]. Whereas none of these differences was statistically significant, subanalyses suggested an improvement in mucociliary clearance by terbutaline in the three delta F508 heterozygous patients but not in the seven delta F508 homozygous patients. One minute of voluntary coughing resulted in clearance of less than 8 percent of the initial radioactivity, with a trend of more peripheral zone clearance after terbutaline compared with placebo. A small significant decrease in airway resistance was detected 3 h after terbutaline.

CONCLUSIONS

We conclude that 1 mg of terbutaline did not improve mucociliary clearance significantly in the patients with CF. Also, the effect of terbutaline was much less than demonstrated earlier in healthy subjects. This is consistent with earlier findings of a lack of beta-adrenergic modulation of Cl- transport in CF. Thus, no rehydration of the dry mucus in CF is expected, and a possible beta 2-agonist-induced increase in ciliary beating would have only a minor effect on overall mucociliary clearance.

The cost of not wearing seat belts. A comparison of outcome in 3396 patients

Data from the North Carolina Trauma Registry were analyzed to determine the effect of seat belt usage on outcome in motor vehicle accidents. Of 6237 persons involved in motor vehicle accidents, data on seat belt usage were available for 3396. Of these, 1916 were not and 1480 were wearing seat belts. The mean hospital charge in belted patients was $10,500 +/- $18,200; and in unbelted patients, $15,250 +/- $26,300 (p < 0.001). The total hospital charges were $23 million for the 1508 patients not wearing seat belts. If the unbelted patients had outcomes similar to belted patients, the charges resulting from caring for the 1508 patients would have been $15.8 million, a potential savings of $7.2 million. There were 135 deaths among the unbelted patients (7.0%) and 47 deaths among the belted patients (3.2%) (p < 0.001). A similar projection of belted outcome for unbelted patients suggests that seat belt usage could have reduced the unbelted mortality rate by over one half. Patients wearing seat belts also had significantly shorter hospital stays, fewer days in the intensive care unit, and fewer days on the ventilator (p < 0.001). Seat belt usage is associated with a significant decrease in mortality rate, hospital charges, length of stay, intensive care unit stay, and ventilator requirements. Seat belts could have saved at least 74 lives and 7.2 million dollars during the period from October 1, 1987 to July 1, 1989 in patients seen in the seven trauma centers in North Carolina.

Hippocampal kindling in the rat is associated with time-dependent increases in the concentration of glial fibrillary acidic protein

The effect of hippocampal kindling on the regional brain concentration of total glial fibrillary acidic protein (GFAP), a marker of reactive astrocytes, was studied in partially kindled rats, and in fully kindled rats after a post-kindling period of 24 h, 1 week, and 2 months. GFAP concentration was measured in arbitrary units by dot-blots. In the hippocampus, dentate gyrus, basolateral amygdala, pyriform cortex, and entorhinal cortex, limbic structures which are known to be involved in the kindling process, there was an increase in GFAP concentration which was maximal in the fully kindled animals studied after 24 h. In most brain areas, GFAP concentration was still elevated 1 week post-kindling, but had declined to control level 2 months post-kindling. A significant increase in GFAP was also found in septum, ventral pallidum/accumbens nucleus, and primary motor cortex of kindled rats with a post-kindling period of 24 h, whereas in several other brain regions GFAP was unchanged. These results suggest that astrocyte activation, indicative of degenerative changes in nearby neurons, is a transient and regional phenomenon in kindling occurring only during the development of the kindled state.

[Amyloidosis diagnosed from changes in the oral cavity mucosa]

A patient with lesions of the oral mucosa is presented. Biopsy of the lesions showed deposits of amyloid, which lead to further examination of the patient, revealing a generalized amyloidosis.

Complete nucleotide and deduced protein sequence of CMP-NeuAc: poly-alpha-2,8 sialosyl sialyltransferase of Escherichia coli K1

Poly-alpha-2,8 N-acetylneuraminic acid (polySia) is an important virulence factor in infections caused by Escherichia coli K1 and Neisseria meningitidis B. In E. coli K1 a membranous CMP-NeuAc: poly-alpha-2,8 sialosyl sialyltransferase (polysialyltransferase) complex catalyses the synthesis of linear polySia chains. The complex also elongates sialyl oligomers that serve as exogenous acceptors. The gene encoding a polysialyltransferase of E. coli has been identified by subcloning and DNA sequence analysis. The subcloned DNA fragment codes for a polypeptide with a molecular mass of 47 kDa catalysing the in vitro synthesis of polySia by elongation of exogenous acceptors.

Immunoreactive endometritis

A benign polyclonal lymphoid proliferation of the endometrium which bears morphological resemblance to the malignant lymphoma is found among women with bleeding disturbances. Seven previous cases have so far been reported in the literature. A retrospective examination of 11,648 endometrial specimens revealed 287 examples of chronic endometritis (2.5%) of which 29 displayed lymphoid proliferation. We found no evidence of malignant haematologic disorder after a median observation of 68 months and no positive association with prior or present infectious disease. Histological follow-up of ten patients showed that changes could persist for up to 12 months. We name this benign condition 'immunoreactive endometritis'.

Spectroscopic studies of the DNA binding site of the GAL4 "zinc finger" protein

The yeast GAL4 protein, a transcriptional activator of genes involved in galactose metabolism, binds as a dimer to several closely related seventeen base pair upstream activation sequences (UASGs) that are nearly symmetric about a central dT-dA base pair. A previous study of a GAL4-UASG complex (Carey, M., Kakidani, H., Leatherwood, J., Mostashari, F. and Ptashne, M. (1989) J. Mol. Biol. 209, 423-432) elucidated a pattern of contacts consistent with the protein partially wrapping itself around the helical cylinder, assuming a B-form conformation for the DNA. Alternatively, both monomers could sit on one face of the cylinder if the DNA exists in an underwound conformation such as A-form. Spectroscopic studies that distinguish between these models are reported here. Oligonucleotides containing the consensus UASG or a nine base pair "half site" both exhibit circular dichroism (CD) spectra characteristic of B-form DNA. Two-dimensional NMR studies of the half-site also indicate a B-form conformation. When a GAL4 protein fragment containing the entire DNA-binding and dimerization domains (amino acids 1-140) is bound to the UASG, the CD spectrum above 240 nm changes only slightly, and not in a manner consistent with DNA unwinding. Our studies suggest that the UASG does not adopt an unusual underwound conformation in the absence or presence of the GAL4 protein, and favor the model in which the dimer partially wraps around the helix cylinder.

Human hybridomas derived from CD5+ B lymphocytes of patients with chronic lymphocytic leukemia (B-CLL) produce multi-specific natural IgM (kappa) antibodies

Great numbers of CD5+ B lymphocytes were detected in the peripheral blood of patients with B-CLL. To study the antibody repertoire of this immune cell subpopulation on a monoclonal level, we fused the lymphocytes derived from five different donors to a highly efficient HAT-sensitive heteromyeloma line (CB-F7). A fusion frequency of up to 10(-5) allowed us to analyse hundreds of initial hybridoma lines per fusion. In all culture supernatants in three out of five fusions IgM lambda antibodies were detected, in two experiments only IgM kappa was measured, suggesting monoclonality of the primary hybridoma cell lines. The later fusions resulted in hybridomas producing multi-specific antibodies against both an autoantigen and an infectious agent: (i) dsDNA/influenza virus haemagglutinin; (ii) dsDNA/class V outer membrane protein type C from Neisseria meningitidis. However, no antibodies of the described specificity were detected in blood sera of patients, indicating a 'switch-on' of the immunoglobulin secretion capacity of malignant B cells during fusion to a myeloma partner. We discuss the results as further evidence for the natural multi-reactive antibody repertoire of CD5+ B cells.

Hippocampal kindling alters the concentration of glial fibrillary acidic protein and other marker proteins in rat brain

The effect of hippocampal kindling on neuronal and glial marker proteins was studied in the rat by immunochemical methods. In hippocampus, pyriform cortex and amygdala there was an increase in glial fibrillary acidic protein (GFAP), indicating reactive gliosis, and an increase in the glycolytic enzyme NSE, suggesting increased anaerobic metabolism. Neuronal cell adhesion molecule (NCAM) decreased in pyriform cortex and amygdala of kindled rats, indicating neuronal degeneration.

[Propofol and 3-in-1 block in ambulatory varix surgery]

A method of anaesthesia for surgical treatment of varicose veins is presented. This consists of a combination of propofol and three-in-one blockade. In a non-blind, non-randomised series, this method was accepted just as well as epidural analgesia or general anaesthesia. The method is recommended for outpatient surgical treatment of varicose veins on account of rapid waking of the patients, reduced need for observation after anaesthesia and reduced pollution with anaesthetic gases in the operation theatre.

AgNOR counts in intraendometrial neoplasia

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[Parental reactions after the death of their newborn infant]

A questionnaire was sent to the parents of 57 infants who died in 1985 while hospitalized in the Neonatal Department, Rigshospitalet. These questionnaires were sent 10-22 months after the death of the infant. 76% reacted to this contact. Information was obtained about how the parents experienced the immediate situation on the death of the infant, how the practical problems were solved, how follow-up and supportive measures were given and how this loss influenced marital relationships. Proposals are given as to how hospital staff can support parents by providing adequate practical advice, establishing contact with supportive persons outside hospital and establishing well-structured offers of talks in the hospital during the first weeks after the death of the infant and again in the case of a new pregnancy. Midwives, doctors and nurses should be particularly aware of the problems which these parents experience in subsequent pregnancies and deliveries.

[Phyllodes tumor]

This very rare breast tumour has been diagnosed in five cases, four females and one male, at our hospital during the last two years. The females all presented tumours with a diameter ranging from 5 to 15 cm. Age at diagnosis ranged from 21 to 54 years. We focus on diagnostic challenges, since 3 of our patients were recently treated by removal of a breast tumour diagnosed morphologically as fibroadenomatosis. Our patients underwent different surgical therapy, and we focus on local treatment modalities advocated in recent literature. Systemic chemotherapy, endocrine treatment and/or radiation therapy, in the adjuvant setting or in advanced disease, do not increase survival in patients with malignant phyllodes tumour.

Differential regulation of membrane receptors sensitive to histamine (H2-type), isoproterenol (beta 2-type) and glucagon-like peptides by the somatostatin analogue Sandostatin in rat gastric glands

The potential use of somatostatin-14 and its long lasting analogue Sandostatin as antiulcer agents led us to study the functional properties of these peptides on the histamine H2-receptor H2R adenylate cyclase system in gastric glands isolated from the rat fundus. The action of the two peptides has also been compared on membrane receptors sensitive to isoproterenol and the truncated glucagon-like peptide TGLP-1. The data indicate that somatostatins inhibit selectively H2R and TGLP-1 receptor activity with similar potencies and kinetics, suggesting that the two peptides share the same receptor pool coupled with the Gi subunits of adenylate cyclase. Somatostatin-14 and Sandostatin have no evident action on the beta 2-type adrenergic receptor beta 2R. Therefore, the higher potency of Sandostatin compared to somatostatin-14 in inhibiting acid secretion is probably related to an increased stability of the analogue in vivo.

Evaluation of a needle pH electrode for continuous tissue-pH monitoring during labor. Characteristics during acidosis in the rat

A prototype of a needle tissue-pH (t-pH) electrode designed for continuous t-pH monitoring of the human fetus during labor is described and evaluated in vitro and in vivo in the rat. Respiratory acidosis was induced by ventilation with 5% carbon dioxide, and t-pH measured by the needle electrode compared to simultaneous t-pH measured by the Kontron-Roche electrode and to arterial blood pH. A close correlation between the two t-pH electrodes was demonstrated (r = 0.80, P < 0.001). Furthermore, a close correlation was found between t-pH and arterial blood pH during the first 15 min of acidosis (r = 0.82, P< 0.001). It is concluded that the needle electrode fulfils nearly all theoretical demands to a t-pH electrode for clinical use.

Differential synthesis in vitro of barley aleurone and starchy endosperm proteins

To widen the selection of proteins for gene expression studies in barley seeds, experiments were performed to identify proteins whose synthesis is differentially regulated in developing and germinating seed tissues. The in vitro synthesis of nine distinct barley proteins was compared using mRNAs from isolated endosperm and aleurone tissues (developing and mature grain) and from cultured (germinating) aleurone layers treated with abscisic acid (ABA) and GA(3). B and C hordein polypeptides and the salt-soluble proteins beta-amylase, protein Z, protein C, the chymotrypsin inhibitors (CI-1 and 2), the alpha-amylase/subtilisin inhibitor (ASI) and the inhibitor of animal cell-free protein synthesis systems (PSI) were synthesized with mRNA from developing starchy endosperm tissue. Of these proteins, beta-amylase, protein Z, and CI- 1 and 2 were also synthesized with mRNA from developing aleurone cells, but ASI, PSI, and protein C were not. CI-1 and also a probable amylase/protease inhibitor (PAPI) were synthesized at high levels with mRNAs from late developing and mature aleurone. These results show that mRNAs encoding PAPI and CI-1 survive seed dessication and are long-lived in aleurone cells. Thus, expression of genes encoding ASI, PSI, protein C, and PAPI is tissue and stage-specific during seed development. Only ASI, CI-1, and PAPI were synthesized in significant amounts with mRNA from cultured aleurone layers. The levels of synthesis of PAPI and CI-1 were independent of hormone treatment. In contrast, synthesis of alpha-amylase (included as control) and of ASI showed antagonistic hormonal control: while GA promotes and ABA reduces accumulation of mRNA for alpha-amylase, these hormones have the opposite effect on ASI mRNA levels.

Premedication before day surgery. A double-blind comparison of diazepam and placebo

Premedication with diazepam 0.25 mg kg-1 by mouth was compared with placebo in a double-blind trial in patients undergoing day-case surgery under general anaesthesia. Diazepam decreased significantly preoperative discomfort and apprehension. The patients were discharged on time regardless of the type of premedication, and complaints at the time of discharge and on the following day could be related only to the length of anaesthesia and not to the type of premedication. Premedication given early in the morning remained effective for up to 6 h.