Physiologic implications of the autonomic aberrations in cystic fibrosis

Cystic fibrosis patients and their parents have increased alpha-adrenergic sensitivity, increased cholinergic sensitivity, and reduced beta-adrenergic sensitivity. This combination of autonomic aberrations has been associated with increased airway reactivity in other disease populations. Although studies of airway reactivity are difficult to interpret in the cystic fibrosis patients themselves, the parents have no apparent pulmonary infection or inflammation, and one-third of these people have increased airway reactivity. Moreover, parents of children with cystic fibrosis have increased prevalence of wheezing and lung disease in childhood. Airway reactivity has been associated in other populations, with increased risk of obstructive pulmonary disease. Further studies are required to test the hypothesis that heterozygosity for CF is a risk factor for development and progression of obstructive pulmonary disease.

Office encounters in general practice in the Hamilton Health District I: social class patterns among employed males, 15-64

Recent epidemiological research indicates that a strong inverse relationship exists between social class and mortality for almost every cause of death among employed males in the age group 15-64. On such epidemiological evidence higher levels of health service use among lower socio-economic strata might be expected. Data from a survey of office encounters in general practices in the Hamilton health district reveal social class differences in the expected direction--especially for severe conditions--but the differentials recorded are not substantial. It is suggested that this shortfall in predicted class differentials in office encounters is explained by social class variations in patterns of symptom recognition and help-seeking and in access to care. Such differences mean that lower class men receive less medical attention than their experience of ill-health might warrant.

Mortality among New Zealand Maori and non-Maori Mormons

Mortality rates for New Zealand Maori and non-Maori Mormons in the period 1970-77 have been compared with those for non-Mormons in the census year 1976 to measure the impact of the Mormon lifestyle on differences in mortality between Maoris and non-Maoris. Maori mortality was much lower among Mormons than non-Mormons suggesting that environmental, rather than genetic factors, play a predominant role in the relatively high overall Maori mortality. However the prevalence of smoking among Maori Mormons was not much lower than for the general Maori population. Reasons for the relative mortality advantage of Maori Mormons were therefore not clear, although attitudes to health and health services utilization, and the influence of strong social support networks, might be involved. Paradoxically, non-Maori Mormon mortality rates were similar to those for non-Mormons. A combination of factors appeared to contribute to this finding including the fact that 26% of non-Maori Mormons were of Pacific Island origin, non-Maori Mormons were of lower socioeconomic status than other non-Maoris, and part Maoris probably constitute a high, but unknown, proportion of Mormons classified as non-Maoris.

Bronchiectasis and oligospermia: two families

Five patients from two families had a bronchiectasis syndrome; the men also had oligospermia with poor progressive sperm motility. None of the patients had cystic fibrosis, alpha 1 antitrypsin deficiency, immunoglobulin deficiency, structural abnormalities of the bronchi, or abnormalities of ciliary ultrastructure. Onset of pulmonary symptoms was in the neonatal period or infancy, and bronchitis and bronchiectasis were most severe in the middle and lower lobes. Two patients had sinusitis and two otitis. The two men old enough to be studied had 2-10 X 10(6) sperm/ml of ejaculate with less than 10% progressively motile. There were no other associated anomalies. These patients probably had a distinct genetic error predisposing to pulmonary infection leading to bronchiectasis and, in men, oligospermia with poor progressive motility.

Social class, ethnic group, and male mortality in New Zealand, 1974-8

Social class mortality differences in New Zealand males aged 15 to 64 were investigated for the period 1974-8 using the Registrar-General's classification. The mortality gradient was similar to that previously found in England and Wales, but the New Zealand pattern was non-linear with particularly high mortality in class V. Smoking patterns accounted for much of the increased risk for classes III and IV but did not appear to explain the high mortality in class V. The patterns for the major disease groupings also paralleled those previously found in England and Wales, coronary heart disease and neoplasms displaying weaker gradients than accidents, respiratory diseases, digestive diseases, and infectious diseases. Maori and non-Maori males had comparable social class mortality gradients, but the Maori mortality rates were approximately 50% higher than the non-Maori rates in each class.

The alpha 2-adrenergic system of the platelet in cystic fibrosis

The ability of norepinephrine to inhibit prostaglandin E1 (PGE1)-stimulated accumulation of adenosine 3':5' cyclic monophosphate (cyclic AMP) in intact washed platelets was determined in 12 patients with cystic fibrosis, 6 parents of patients with cystic fibrosis, and a total of 21 healthy age-matched controls. Patients with cystic fibrosis and their parents did not differ from their age-matched controls in basal or PGE1-stimulated levels of cyclic AMP, nor in the dose dependent inhibition of cAMP accumulation by norepinephrine. Moreover, binding sites for [3H]-dihydroergocryptine were present in normal numbers and had normal ligand affinity in platelet membranes from patients with cystic fibrosis. In all measures tested, the alpha 2-adrenergic system in the platelet was normal in cystic fibrosis.

Effects of alpha-tocopherol on platelet membrane function in cystic fibrosis

Patients with cystic fibrosis and their parents were reported to have abnormal platelet aggregation responses to prostaglandin E1. To determine whether this is a property of the platelets, we studied the adenosine 3':5'-cyclic monophosphate (cAMP) response of washed platelets to prostaglandin E1. The cAMP response to prostaglandin E1 was the same in platelets from obligate heterozygotes for cystic fibrosis and from those of healthy controls. Patients with cystic fibrosis who had deficient vitamin E levels (plasma alpha-tocopherol, less than 500 micrograms/dl) had significantly (p less than 0.01) reduced platelet cAMP response to prostaglandin E1 compared with patients who had sufficient vitamin E, and supplementation with water-miscible vitamin E in these patients resulted in significant increases in plasma alpha-tocopherol levels (p less than 0.01) and in cAMP response to prostaglandin E1 (p less than 0.05). Plasma alpha-tocopherol levels correlated significantly with platelet cAMP response to prostaglandin E1 in patients with cystic fibrosis (r = 0.58, p less than 0.05). However, plasma alpha-tocopherol level was unrelated to the lymphocyte and granulocyte cAMP response to prostaglandin E1 or to the platelet cAMP response to alpha 2-adrenergic stimulation. Our data suggest that patients with cystic fibrosis have no inherited defect in platelet cAMP response to prostaglandin E1. In patients who have sufficient vitamin E, cAMP responses to prostaglandin E1 are normal in all the formed elements of the blood.

Diagnosis and treatment of cystic fibrosis. An update

Cystic fibrosis is the most common fatal inherited disease of Caucasians. At present, cystic fibrosis accounts for most cases of chronic progressive pulmonary disease and for many other clinical features in the first three decades of life. Thus, it is a challenge to both pediatricians and internists, particularly chest physicians. The diagnosis is based on the triad of chronic obstructive pulmonary disease, pancreatic insufficiency, and increased levels of electrolytes in the sweat. The cardinal test for confirmation of the diagnosis is the "sweat test," which is an excellent discriminant for cystic fibrosis, even in adults. Ancillary features of cystic fibrosis may be of diagnostic assistance (eg, nasal polyposis, Pseudomonas aeruginosa in sputum, azoospermia, and others). Treatment of the pulmonary disease must be emphasized. Choice of antibiotics should be based on the results of sputum culture, but P aeruginosa is the most common pathogen. Removal of secretions by regular postural drainage and percussion is an integral part of the program. Pneumothorax, massive hemoptysis, cor pulmonale, and other complications may be encountered. Sinusitis is almost universal, and nasal polyposis is frequently present. Pancreatic insufficiency occurs in over 80 percent of the patients with cystic fibrosis and may result in intestinal malabsorption. Massive salt loss through the sweat in hot weather, a distinctive type of biliary cirrhosis without jaundice, gallbladder abnormalities, cholelithiasis, and diabetes mellitus also may be found. Of special importance are intestinal obstructive complications (meconium ileus in newborn infants with cystic fibrosis and intestinal obstruction due to fecal accumulation or intussusception in adults). Azoospermia is present in 95 percent of men and there is reduced fertility in women; however, pregnancy does occur in cystic fibrosis. This chronic and ultimately fatal disease produces a predictable set of psychosocial complications.

Autonomic and airway reactivity in obligate heterozygotes for cystic fibrosis

Obligate heterozygotes for cystic fibrosis, like the patients themselves, have significantly increased pupillary alpha-adrenergic and cholinergic sensitivity and significantly decreased lymphocyte beta-adrenergic responses. The parents of patients with cystic fibrosis also have a high prevalence of airway reactivity: one third have a fall in forced expiratory volume in one second (FEV1) of more than 20% (PD20 FEV1) to less than 3 mg/ml methacholine, compared with 4% in control subjects (p = 0.01, chi-square). Airway reactivity (PD20 FEV1) is significantly correlated with the lymphocyte adenosine 3':5' cyclic monophosphate response to isoproterenol (Rs = 0.54, p less than 0.05). Abnormal autonomic and airway reactivity cannot be ascribed to medication usage, preexisting pulmonary disease, or atopy in these subjects. We conclude that the autonomic abnormalities in cystic fibrosis are inherited and may contribute to the development and progression of pulmonary disease by predisposing to increased airway reactivity.

Mortality and social class in New Zealand. III: male mortality by ethnic group

Social class differences in male mortality in New Zealand were investigated separately for Maori, Pacific Island and other New Zealand males aged 15-64. All three groups displayed strong social class mortality gradients but, for each class, the Maori mortality rates were approximately 50% higher than the rates for the "other" category, while the Pacific Islander rates generally occupied an intermediate position. The Maori mortality rates were particularly high for the disease groupings of respiratory diseases, infectious diseases, genito-urinary diseases, endocrine, nutritional and metabolic disorders and diseases of the circulatory system other than coronary heart disease and cerebrovascular disease--even when the data were adjusted for age and social class factors. The Pacific Islander rates were high for the same disease groupings except for endocrine, nutritional and metabolic disorders. Overall, there were substantial social class differences and ethnic differences in mortality and these were largely independent so that only about one-fifth of the Maori mortality excess was attributable to social class factors. Four-fifths of the Maori excess was not attributable to such factors indicating that interventions aimed specifically at lower socio-economic groups will not eliminate the current mortality differences between Maoris and non-Maoris.

Induction of sister-chromatid exchanges by alcohol and alcoholic beverages after metabolic activation by rat-liver homogenate

Samples of alcohol and alcoholic beverages induced SCEs in Chinese hamster ovary cells in the presence of rat-liver homogenate for metabolic activation. SCE tests with acetaldehyde, and measurement of acetaldehyde concentration in tests with alcohol, indicate that SCE induction by alcohol is caused by formation of acetaldehyde.

Mortality and social class in New Zealand II: male mortality by major disease groupings

Social class differences in male mortality in New Zealand were investigated for each major disease grouping. The patterns found were similar to those for England and Wales with the lower social classes having mortality rates significantly higher than those of the upper social classes for each major cause of death. The strongest social class mortality gradients were found for deaths from accidents, poisonings and violence; diseases of the respiratory system; endocrine, nutritional and metabolic diseases; diseases of the genito-urinary system; and diseases of the digestive system. The gradients for coronary heart disease and neoplasms were weaker, but in the same direction as those found for other disease groupings.

Sweat chloride concentration in adults with pulmonary diseases

In order to determine whether a high proportion of adults with pulmonary diseases have sweat chloride concentrations in the range usually considered diagnostic for cystic fibrosis (greater than 60 mEg/L), we performed the standard diagnostic "sweat test" of Gibson and Cooke prospectively on 187 subjects 18 to 85 yr of age who did not have cystic fibrosis (166 of them had some pulmonary or allergic disorder, and 21 were healthy). In this group, 99% had sweat chloride concentration less than 70 mEq/L, and 96%, less than 60 mEq/L. Those taking steroids had sweat chloride concentration slightly but significantly lower than those who did not take steroids, probably because of the mineralocorticoid effect. Six patients had pancreatitis, and 2 of those had sweat chloride concentration greater than 60 mEq/L, a distribution of values significantly different (p less than 0.005) from the rest of the population. Our results suggest that a very small proportion of adults with pulmonary diseases have sweat chloride concentrations in the range usually considered diagnostic for cystic fibrosis, and that the sweat test is a good discriminant for cystic fibrosis even in the adult age group.

Beta adrenergic receptors in lymphocytes and granulocytes from patients with cystic fibrosis

Intact lymphocytes from patients with cystic fibrosis (CF) produce significantly (P less than 0.001) less adenosine 3':5' cyclic monophosphate (cAMP) than normal lymphocytes in response to isoproterenol (10(-8)-10(-4) M), although the basal cAMP content and the response to prostaglandin E1 are normal. Obligate heterozygotes for CF have significantly (P less than 0.005) reduced cAMP response to isoproterenol as well, suggesting a genetic component in the beta adrenergic deficiency in CF. The number of beta adrenergic receptors, as determined by equilibrium binding of [3H]dihydroalprenolol to lymphocyte particulates, is the same in normal lymphocytes (969 +/- 165 receptors/cell) and lymphocytes from patients with CF (1,333 +/- 263 receptors/cell). Binding properties of the receptor for both antagonist and agonist, as assessed by KD for dihydroalprenolol and Ki for (-)-isoproterenol, are also normal in the CF lymphocytes. Similarly, in granulocytes from patients with CF, the cAMP response to isoproterenol (10(-8)-10(-4) M) is significantly reduced compared with healthy controls (P less than 0.03), as is the response of granulocytes from obligate heterozygotes (P less than 0.05). Again, the basal cAMP levels and the response to prostaglandin E1 are normal. The number of beta adrenergic receptors, as determined by equilibrium binding of [3H]dihydroalprenolol to granulocyte particulates, was the same in normal (1,462 +/- 249 receptors/cell) and CF (1,621 +/- 221 receptors/cell) preparations. Binding properties of the receptor for both agonist and antagonist, as assessed by KD for dihydroalprenolol and Ki for isoproterenol, are normal in CF granulocyte particulates. The lymphocyte and granulocyte beta adrenergic defect in CF cannot be explained by abnormalities of the beta adrenergic receptor or of adenylate cyclase itself. Receptor-cyclase coupling is the most likely site of the heritable beta adrenergic defect in CF.

Mortality and social class in New Zealand. I: overall male mortality

Social class differences in New Zealand male mortality are investigated using two different systems of social class classification. In each case it is found that the lower social classes have mortality rates significantly higher than those of the upper social classes with the mortality rate of the lowest class being approximately twice that of the highest class on a six-category scale. The relative risk is higher in the younger age-groups. When the British Registrar-General's scale is used New Zealand exhibits a social class mortality gradient similar to that previously found in England and Wales, but the lowest social class experiences a particularly high mortality rate.

Autonomic nervous system abnormalities in cystic fibrosis

The basic defect in cystic fibrosis, the most common lethal genetic diseases of white Americans, is unknown, but the character of the generalized exocrinopathy suggests some disorder of the regulation and control of the process of glandular secretion. Definite abnormalities in all branches of the autonomic nervous system have been demonstrated in patients with cystic fibrosis, including increased sensitivity to alpha-adrenergically stimulated pupillary dilation; increased responsiveness to cholinergic stimulation of pupillary constriction, parotid saliva secretion, and eccrine sweat secretion; and decreased responsiveness to beta-adrenergic stimulation of the cardiovascular system as well as circulating lymphocytes and granulocytes. Since these abnormalities also occur in asymptomatic heterozygotes for cystic fibrosis (parents of patients), they are likely to be inherited characteristics and not secondarily acquired. This constellation of inherited autonomic abnormalities--alpha-adrenergic and cholinergic hyperresponsiveness and beta-adrenergic resistance--may contribute to the pathophysiology of cystic fibrosis and may also be an important clue to the nature of the basic defect.

Induction of sister chromatid exchanges in Chinese hamster ovary cells by 5-bromodeoxyuridine

Sister chromatid exchange (SCE) induction in established cell lines has become a widely used criterion for the assessment of genotoxicity. Detection of SCE is only possible if a base-analogue such as bromodeoxyuridine (BrdU) is incorporated into the DNA; it is not known to what extent the observed background level of SCE is a consequence of the presence of the base-analogue, and to what extent it represents a 'natural' background. In this paper, experiments are described in which a number of different BrdU incorporation schemes are compared. The results suggest that under the normal SCE-test conditions, e.g. 5-10 microM BrdU the majority of the spontaneous SCE are of the natural (non-BrdU) origin. The remaining (BrdU-dependent) SCE seems to be a consequence of greater number of spontaneous lesions in the BrdU-containing DNA.

Autonomic nervous system abnormalities and allergy

Abnormal autonomic nervous system responsiveness may contribute to the pathogenesis of asthma and other allergic diseases. Therefore, we measured alpha- and beta-adrenergic and cholinergic responsiveness in allergic subjects. Allergic asthmatic subjects had an abnormal adrenergic (alpha = hyperresponsive; beta = hyporesponsive) and cholinergic (hyperresponsive) profile. However, subjects with allergic rhinitis and preallergic subjects (those with positive allergen skin tests without any disease manifestation) had equivalent beta-adrenergic and cholinergic abnormalities. Thus, all allergic subjects showed abnormal beta-adrenergic hyporeactivity and cholinergic hypersensitivity whereas allergic asthma was singularly associated with excessive alpha-adrenergic responsiveness. Autoantibodies against beta-receptors were found predominantly in subjects with beta-adrenergic hyporeactivity. The presence of these autoantibodies and the physiologic abnormalities associated with their presence suggests a causitive relationship.

Normal alpha 2-adrenergic responses in platelets from patients with asthma

recent in vivo studies suggest that alpha-adrenergic responses are exaggerated in asthmatic subjects. We studied alpha 2-adrenergic responses in platelets from 12 healthy subjects and 10 patients with asthma who had taken no medication for at least 9 days prior to study except low-dose (less than 600 micrograms daily) beclomethasone diproprionate. Alpha 2-adrenergic inhibiton of prostaglandin E1-stimulated adenosine 3':5; cyclic monophosphate (cAMP) accumulation was normal in platelets from subjects with asthma. The time course of inhibition, the extent of inhibition, and the dose-response relationship did not differ between the groups. Results from allergic and nonallergic patients did not differ, and alpha 2-adrenergic responses were not correlated with age, sex, peak flow rated, or total eosinophil counts. Platelet alpha 2-adrenergic cAMP responses are normal in subjects with asthma.

Low sweat electrolytes in a patient with cystic fibrosis

A patient with the clinical syndrome of cystic fibrosis characterized by chronic pulmonary disease, infection with mucoid Pseudomonas aeruginosa, sinusitis, nasal polyposis, abnormal pancreatic bicarbonate response to secretin stimulation, but normal levels of trypsin and chymotrypsin in the duodenal drainage, and a sibling with autopsy-documented cystic fibrosis, is described. Sweat chloride ranged from 20 to 44 meq/liter and sweat sodium from 36 to 55 meq/liter. Immunoglobulin deficiency, alpha 1-antitrypsin deficiency, tuberculosis and abnormalities of ciliary ultrastructure were excluded. Review of sweat electrolytes in 213 patients with cystic fibrosis revealed that patients with normal pancreatic enzyme release have significantly lower sweat sodium and chloride concentrations (p < 0.0005) than do patients with pancreatic insufficiency. Chronic pulmonary disease, pancreatic insufficiency and elevated levels of sweat electrolytes comprise the classic diagnostic triad for cystic fibrosis. The expression of these features may be variable, but the sweat test remains the cardinal laboratory confirmation of the diagnosis. Over 98 percent of patients with cystic fibrosis have sweat chloride values greater than 60 meq/liter, 1 to 2 percent between 50 and 60 meq/liter, and only about one in 1,000, like our patient, less than 50 meq/liter. Patients with cystic fibrosis with borderline sweat chloride values frequently have chronic pulmonary disease but intact pancreatic enzyme release. In such patients, family history, ancillary clinical features and systemic exclusion of other syndromes assume special diagnostic importance.

Hormone-stimulated cyclic AMP production by skin fibroblasts cultured from healthy persons and patients with cystic fibrosis

The experiments reported here illustrate a few of the factors apart from genes which can influence hormone-responsive generation of cyclic adenosine 3':5'-monophosphate in human fibroblasts. For both normal and cystic fibrosis fibroblasts, the isoproterenol stimulation ratio was maximal 2 to 3 days after subculture and declined thereafter; prostaglandin E1 stimulation ratio was maximal 7 to 10 days after subculture. Cells dislodged from the plate by either scraping or typsinization had reduced isoproterenol or prostaglandin E1 stimulation ratios compared to cells studied in situ. Fibroblasts from healthy controls and cystic fibrosis patients plated simultaneously and grown in three different culture conditions responded similarly to the change in growth conditions. Addition to the incubation medium of polyamines, calcium, magnesium, or guanosine triphosphate did not alter the stimulation ratios for isoproterenol or prostglandin E1. Repeated measures analysis indicates that cellular content of cyclic adenosine 3':5'-monophosphate is not a reliable measure for comparing cell lines; isoproterenol stimulation ratio is a reliable measure, but there is large variation from cell line to cell line. Isoproterenol stimulation ratio was the same for normal and cystic fibrosis fibroblasts in each of the three culture conditions tested at both three and ten days after subculture.

Adenylate cyclase in leukocytes from patients with cystic fibrosis

Lymphocytes from patients with cystic fibrosis produce significantly less cAMP in response to beta-adrenergic stimulation than do cells from healthy persons (p less than 0.0005) or patients with bronchiectasis (p less than 0.005). Adenylate cyclase in the basal state or stimulated by GMPPNP or PGE1 is normal, but isoproterenol-stimulated adenylate cyclase activity is significantly (p less than 0.005) reduced in lymphocyte membrane preparations from patients with cystic fibrosis. Granulocytes from patients with cystic fibrosis also produce significantly less cAMP in response to beta-adrenergic stimulation than do cells from healthy subjects (p less than 0.0005) or subjects with bronchiectasis (p less than 0.05). Adenylate cyclase activity in granulocyte homogenates from patients with cystic fibrosis is normal in the basal state or when stimulated by GMPPNP or PGE1 but is significantly (p less than 0.05) reduced compared to normal when stimulated by isoproterenol. These data suggest that the defect is not related to adenylate cyclase itself or to availability of substrate or cofactor to adenylate cyclase, and they may be indicative of a more generalized membrane defect in cystic fibrosis.