COVID-19 Vaccination in Patients with Inborn Errors of Immunity Reduces Hospitalization and Critical Care Needs Related to COVID-19: a USIDNET Report

BACKGROUND

The CDC and ACIP recommend COVID-19 vaccination for patients with inborn errors of immunity (IEI). Not much is known about vaccine safety in IEI, and whether vaccination attenuates infection severity in IEI.

OBJECTIVE

To estimate COVID-19 vaccination safety and examine effect on outcomes in patients with IEI.

METHODS

We built a secure registry database in conjunction with the US Immunodeficiency Network to examine vaccination frequency and indicators of safety and effectiveness in IEI patients. The registry opened on January 1, 2022, and closed on August 19, 2022.

RESULTS

Physicians entered data on 1245 patients from 24 countries. The most common diagnoses were antibody deficiencies (63.7%). At least one COVID-19 vaccine was administered to 806 patients (64.7%), and 216 patients received vaccination prior to the development of COVID-19. The most common vaccines administered were mRNA-based (84.0%). Seventeen patients were reported to seek outpatient clinic or emergency room care for a vaccine-related complication, and one patient was hospitalized for symptomatic anemia. Eight hundred twenty-three patients (66.1%) experienced COVID-19 infection. Of these, 156 patients required hospitalization (19.0%), 47 required ICU care (5.7%), and 28 died (3.4%). Rates of hospitalization (9.3% versus 24.4%, p < 0.001), ICU admission (2.8% versus 7.6%, p = 0.013), and death (2.3% versus 4.3%, p = 0.202) in patients who had COVID-19 were lower in patients who received vaccination prior to infection. In adjusted logistic regression analysis, not having at least one COVID-19 vaccine significantly increased the odds of hospitalization and ICU admission.

CONCLUSION

Vaccination for COVID-19 in the IEI population appears safe and attenuates COVID-19 severity.

The Impact of Caregiver Depression on Child Asthma Outcomes: Pathways and Mechanisms

BACKGROUND

Depression is common in caregivers of children with asthma and is associated with poor outcomes in their child. No prior studies have longitudinally examined caregiver depression remission as a predictor of improvement in child asthma control.

OBJECTIVE

This 2-site study examined whether the proportion of time a caregiver was in depression remission predicted subsequent child asthma control at exit.

METHOD

Caregivers (n = 205) with current major depressive disorder and their children, ages 7 to 17, with persistent asthma were observed every 4 weeks for 52 weeks. Caregiver depressive symptoms were measured using the 17-item Hamilton Rating Scale for Depression (HRSD). Child asthma was assessed with the (Childhood) Asthma Control Test (cACT/ACT) and spirometry, and depression with the Children's Depression Inventory (CDI). Linear regression analyses were conducted with change in cACT/ACT, CDI, and forced expiratory volume in 1 second (FEV₁)% predicted as outcomes and proportion of time the caregiver was in remission (HRSD score ≤ 7) as the predictor. Multilevel mediation analyses examined the role of child depressive symptoms and asthma controller medication adherence.

RESULTS

Children were, on average, 54.1% female and 11 years old. Caregiver proportion of time in HRSD-assessed remission of depression was a significant predictor of improvement in cACT/ACT, CDI, and FEV₁% predicted. Child CDI score, but not medication adherence, mediated the relationship between caregiver HRSD scores and child asthma control scores.

CONCLUSIONS

Improvement in caregiver depression positively influences child asthma outcomes partially through improvement in child depressive symptom severity. Caregiver depression screening and treatment might lead to improvement in child asthma outcomes.

Egg Introduction during Infancy is Associated with Lower Fat Mass Index in Females at Early Adolescence

BACKGROUND

Egg consumption may play an important role in early-life growth given their high-quality protein, essential fatty acids, and micronutrients.

OBJECTIVES

Study objectives were to examine the longitudinal associations of infant age at egg introduction with obesity outcomes in early childhood, middle childhood (mid-childhood), and early adolescence.

METHODS

We used existing data from 1089 mother-child dyads from Project Viva to estimate age at egg introduction through a questionnaire completed by mothers at ∼1 y postpartum (mean ± SD, 13.3 ± 1.2 mo). Outcome measures included height and weight (early childhood, mid-childhood, and early adolescence), body composition including total fat mass, trunk fat mass, and lean mass (mid-childhood and early adolescence), and plasma adiponectin and leptin (early and mid-childhood and early adolescence). We defined childhood obesity as sex- and age-specific BMI ≥ 95th percentile. We estimated the associations of infant age at egg introduction with risk of obesity using multivariable logistic regression and multivariable linear regression models for BMI-z-score, body composition measures, and adiposity hormones; adjusted for maternal prepregnancy BMI and sociodemographics.

RESULTS

Among females, those introduced to egg by the 1-y survey had a lower total fat mass index (confounder-adjusted mean difference, -1.23 kg/m2; 95% CI: -2.14, -0.31), and trunk fat mass index (confounder-adjusted mean difference, -0.57 kg/m2; 95% CI: -1.01, -0.12) in early adolescence compared to those not introduced (reference group). However, no associations between infant age at egg introduction and risk of obesity were observed among males (confounder-adjusted odd ratio [aOR], 1.97; 95% CI: 0.90, 4.30) or females (aOR, 0.68; 95% CI: 0.38, 1.24) across all ages. Egg introduction in infancy was associated with lower plasma adiponectin among females (confounder-adjusted mean difference, -1.93 μg/mL; 95% CI: -3.70, -0.16) in early childhood only.

CONCLUSIONS

Egg introduction during infancy among females is associated with lower total fat mass index in early adolescence and plasma adiponectin in early childhood. This trial was registered at clinicaltrials.gov as NCT02820402.

Delayed egg introduction beyond infancy and increased egg allergy risk in childhood

AIM

Egg is a major food allergen in childhood. Recent studies suggest that early introduction of allergenic foods can decrease the risk of developing egg allergy. The impact of early egg introduction in the general population is unclear. We examined associations between age of infant egg introduction and childhood egg allergy outcomes in a general population.

METHODS

The study population consisted of 1217 neonates from Project Viva, a longitudinal pre-birth cohort in eastern Massachusetts area, USA. Mothers reported age of infant egg introduction and child egg allergy using questionnaires and specific IgE to egg white was assayed. We estimated associations between age of infant egg introduction and egg allergy outcomes using Log-binomial regression models, adjusting for socio-demographics and health confounders.

RESULTS

Egg allergy at 2 years was significantly higher (8.0% vs. 1.4%, P < 0.0001) in children who had delayed egg introduction beyond infancy, compared with children who were introduced to egg during infancy (adjusted relative risk or aRR 7.58; 95% CI 3.08, 18.61). At 12 years, the risk of egg allergy remained significantly higher (3.9% vs. 1.1%, P = 0.048) in children with delayed egg introduction compared with children introduced to egg during infancy (aRR 4.07; 95% CI 1.20, 13.87).

CONCLUSIONS

Infants with delayed introduction of eggs after 12 months had increased risk of egg allergy in childhood (2 years) and the relationship persisted in early adolescence (12 years). Our findings suggest that introduction to eggs before 12 months could contribute to the prevention of egg allergy.

Infant age at egg introduction and malnutrition‐related child growth in the United States

To evaluate the relationship between infant age of egg introduction and malnutrition‐related growth outcomes in the United States, we analysed secondary data of 1716 mother–child dyads in the Infant Feeding Practices Study II and its Year 6 Follow‐Up Study. Malnutrition‐related growth outcomes included body mass index z‐score (BMIZ), obesity (weight‐for‐height z‐score [WHZ] ≥3 or BMIZ ≥ 2), WHZ, wasting (WHZ < −2), height‐for‐age z‐score (HAZ), and stunting (HAZ < –2). Infant age at egg introduction was analysed as a continuous variable. We used generalised estimating equations to estimate the mean difference in continuous outcomes and relative risk [RR]) for binary outcomes, adjusting for related maternal and child confounders. We also explored interactions with child sex, maternal race/ethnicity, maternal educational level, ever breastfeeding, and formula feeding. In the total sample, a later infant age at egg introduction was associated with a lower mean difference in HAZ (confounder‐adjusted mean difference = −0.08, 95% confidence interval [CI]: −0.12 to −0.03 per month) and a higher risk of stunting (confounder‐adjusted RR = 1.17, 95% CI: 1.03–1.33 per month) at 6 years. The associations between infant age at egg introduction and 12‐month growth outcomes differed by child sex. Among females but not among males, later introduction of eggs was associated with a lower mean WHZ (−0.06 [−0.12 to 0.00] per month) at 12 months. Later egg introduction during infancy was associated with a lower mean HAZ and a higher risk of stunting in 6‐year‐old children. Besides this, it was associated with a lower WHZ among females at 12 months.

This secondary data analysis evaluated the relationship between infant age at egg introduction and malnutrition‐related growth outcomes among young US children within the Infant Feeding Practices Study II and its Year 6 Follow‐up Study.

In the total sample, a later infant age at egg introduction was associated with a lower mean 6‐year height‐for‐age z‐score and a higher risk of stunting at 6 years.

The associations between infant age at egg introduction and 12‐month growth outcomes differed by child sex. Later introduction of eggs was associated with a lower mean weight‐for‐height z‐score among females. However, this association was not observed among males.

Practical guidance for the diagnosis and management of secondary hypogammaglobulinemia: A Work Group Report of the AAAAI Primary Immunodeficiency and Altered Immune Response Committees

Secondary hypogammaglobulinemia (SHG) is characterized by reduced immunoglobulin levels due to acquired causes of decreased antibody production or increased antibody loss. Clarification regarding whether the hypogammaglobulinemia is secondary or primary is important because this has implications for evaluation and management. Prior receipt of immunosuppressive medications and/or presence of conditions associated with SHG development, including protein loss syndromes, are histories that raise suspicion for SHG. In patients with these histories, a thorough investigation of potential etiologies of SHG reviewed in this report is needed to devise an effective treatment plan focused on removal of iatrogenic causes (eg, discontinuation of an offending drug) or treatment of the underlying condition (eg, management of nephrotic syndrome). When iatrogenic causes cannot be removed or underlying conditions cannot be reversed, therapeutic options are not clearly delineated but include heightened monitoring for clinical infections, supportive antimicrobials, and in some cases, immunoglobulin replacement therapy. This report serves to summarize the existing literature regarding immunosuppressive medications and populations (autoimmune, neurologic, hematologic/oncologic, pulmonary, posttransplant, protein-losing) associated with SHG and highlights key areas for future investigation.

Respiratory Infections in Patients with Primary Immunodeficiency

Recurrent and life-threatening respiratory infections are nearly universal in patients with primary immunodeficiency diseases (PIDD). Early recognition, aggressive treatment, and prophylaxis with antimicrobials and immunoglobulin replacement have been the mainstays of management and will be reviewed here with an emphasis on respiratory infections. Genetic discoveries have allowed direct translation of research to clinical practice, improving our understanding of clinical patterns of pathogen susceptibilities and guiding prophylaxis. The recent identification of inborn errors in type I interferon signaling as a basis for life-threatening viral infections in otherwise healthy individuals suggests another targetable pathway for treatment and/or prophylaxis. The future of PIDD diagnosis will certainly involve early genetic identification by newborn screening before onset of infections, with early treatment offering the potential of preventing disease complications such as chronic lung changes. Gene editing approaches offer tremendous therapeutic potential, with rapidly emerging delivery systems. Antiviral therapies are desperately needed, and specific cellular therapies show promise in patients requiring hematopoietic stem cell transplantation. The introduction of approved therapies for clinical use in PIDD is limited by the difficulty of studying outcomes in rare patients/conditions with conventional clinical trials.

A pilot school-based health center intervention to improve asthma chronic care in high-poverty schools

OBJECTIVE

To test the feasibility and effectiveness of a multifaceted intervention administered through school-based health centers (SBHCs) to improve asthma control for children in high-poverty schools with not well controlled asthma.

METHODS

Students 4-14 years old with persistent asthma were enrolled from three SBHCs. The centers' advanced practice providers received training on evidence-based asthma guidelines. Students randomized to the intervention received directly observed therapy of their asthma controller medication, medication adjustments as needed by the centers' providers, and daily self-management support. Students randomized to usual care were referred back to their primary care provider (PCP) for routine asthma care.

RESULTS

We enrolled 29 students. Students in the intervention group received their controller medication 92% of days they were in school. Ninety-four percent of follow-up assessments were completed. During the study, 11 of 12 intervention students had a step-up in medication; 2 of 15 usual care students were stepped up by their PCP. Asthma Control Test scores did not differ between groups, although there were significant improvements from baseline to the 7 month follow-up within each group (both p < .01). Both FEV₁% predicted and FEV₁/FVC ratio significantly worsened in the usual care group (both p = .001), but did not change in the intervention group (p = .76 and .28 respectively).

CONCLUSIONS

Our pilot data suggest that a multifaceted intervention can be feasibly administered through SBHCs in communities with health disparities. Despite the small sample size, spirometry detected advantages in the intervention group. Further study is needed to optimize the intervention and evaluate outcomes.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT03032744.

Eosinophilic Esophagitis

Eosinophilic esophagitis is a recently defined condition that has dramatically increased in prevalence in the last several decades. It may occur at any age, but the clinical presentation in young children is often more vague than the classic solid food dysphagia and food impacting that are the major presenting symptoms of eosinophilic esophagitis in adults and adolescents. Successful therapies exist, including medications and dietary modifications, but disease typically recurs when the intervention is discontinued.

Comorbid Obesity and Depressive Symptoms in Childhood Asthma: A Harmful Synergy

BACKGROUND

Overweight/obesity (OV/OB) and depression have each been separately associated with worsened childhood asthma severity and control. Pathways by which these factors may jointly affect childhood asthma have not been elucidated.

OBJECTIVE

To examine the interrelationship of OV/OB and depressive symptoms with childhood asthma and explore associated psychobiologic pathways. The present study investigated whether comorbid OV/OB and depressive symptoms are associated with impaired baseline lung function and increased airway resistance during emotional stress, and to assess whether such effects may be mediated by autonomic nervous system (ANS) dysregulation, specifically through predominance of vagal over sympathetic reactivity (vagal bias).

METHODS

A total of 250 children with asthma, aged 7 to 17, were assessed for OV/OB using body mass index, depressive symptoms using the Children's Depression Inventory (CDI), and asthma severity using National Asthma Education and Prevention Program Expert Panel Report 3 criteria. Baseline pulmonary function (forced expiratory volume in 1 second [FEV₁]) was assessed. The film "E.T. the Extra-Terrestrial" was used in a laboratory paradigm to evoke emotional stress/arousal. Airway resistance (R_int) was measured before and after the film to determine changes in airway function. ANS reactivity was assessed by measuring parasympathetic/vagal and sympathetic reactivity throughout the film.

RESULTS

In OV/OB children with asthma, depressive symptoms predicted lower baseline FEV₁ (β = -0.67, standard error [SE] = 0.24, P = .008), CDI predicted vagal bias under emotion stress/arousal (β = 0.27, SE = 0.09, P = .009), and vagal bias predicted increased R_int (β = 3.55, SE = 1.54, P = .023).

CONCLUSION

This study is the first to link OV/OB and depressive symptoms in their relationship to childhood asthma. In OV/OB children with asthma, depression may potentiate airway compromise, mediated by vagal bias. Use of antidepressant and anticholinergic therapies should be studied in this subgroup of patients.

The role of neutrophils in host defense and disease

Neutrophils, the most abundant circulating leukocyte, are critical for host defense. Granulopoiesis is under the control of transcriptional factors and culminates in mature neutrophils with a broad armamentarium of antimicrobial pathways. These pathways include nicotinamide adenine dinucleotide phosphate oxidase, which generates microbicidal reactive oxidants, and nonoxidant pathways that target microbes through several mechanisms. Activated neutrophils can cause or worsen tissue injury, underscoring the need for calibration of activation and resolution of inflammation when infection has been cleared. Acquired neutrophil disorders are typically caused by cytotoxic chemotherapy or immunosuppressive agents. Primary neutrophil disorders typically result from disabling mutations of individual genes that result in impaired neutrophil number or function, and provide insight into basic mechanisms of neutrophil biology. Neutrophils can also be activated by noninfectious causes, including trauma and cellular injury, and can have off-target effects in which pathways that typically defend against infection exacerbate injury and disease. These off-target effects include acute organ injury, autoimmunity, and variable effects on the tumor microenvironment that can limit or worsen tumor progression. A greater understanding of neutrophil plasticity in these conditions is likely to pave the way to new therapeutic approaches.

Eosinophilic Esophagitis

Eosinophilic esophagitis is a recently defined condition that has dramatically increased in prevalence in the last several decades. It may occur at any age, but the clinical presentation in young children is often more vague than the classic solid food dysphagia and food impacting that are the major presenting symptoms of eosinophilic esophagitis in adults and adolescents. Successful therapies exist, including medications and dietary modifications, but disease typically recurs when the intervention is discontinued.

The effects of caregiver depression on childhood asthma: Pathways and mechanisms

OBJECTIVE

To review the literature regarding the effects of caregiver depression on childhood asthma and integrate the findings into a multilevel model of pathways by which these effects occur to further the understanding of the complex biopsychosocial nature of childhood asthma and the key role that is played by caregiver depression.

DATA SOURCES

PubMed was searched for articles published from 2007 to the present (10-year search), and Google Scholar was searched for articles published in 2017 and 2018 to identify the most recent publications.

STUDY SELECTIONS

Studies selected were recent, empirical, or meta-analytic, conducted in humans, and had specific relevance to one or more of the identified pathways. Articles published before 2007 were included if deemed essential because they addressed key pathways, for which there were no more recent articles.

RESULTS

Review of the literature substantiates that caregiver depression plays a key role in the socioeconomic, familial, psychological, and biological cascade of effects on childhood asthma. Childhood asthma outcomes are affected indirectly by socioeconomic status and family stress mediated by caregiver depression, which affects disease management, and/or stress and depression in the child, which, in turn, affect asthma through alterations in immune modulation and autonomic regulation.

CONCLUSION

Findings indicate that future research should concentrate on mediators and moderators to further clarify the complex interplay of these factors that affect childhood asthma. The findings also have substantial translational implications. Given that child stress and depression contribute to asthma disease activity and that treating caregiver depression improves child stress and depression, there is strong rationale for treating depressed caregivers of children with asthma as a component means of improving childhood asthma control.

Autoimmunity and Immune Dysregulation in Primary Immune Deficiency Disorders

Primary immune deficiencies are often associated with autoimmune disease due to the dysregulation of the immune system as a whole. In many immune deficiencies, lymphocytes may be present but dysfunctional, allowing for the development of excessive autoreactivity and resultant autoimmune disease. Autoimmune polyendocrinopathy candidiasis and ectodermal dystrophy, autoimmune lymphoproliferative syndrome, immunodyregulation polyendocrinopathy enteropathy X-linked, IL-10/IL-10 receptor deficiencies, and PLCG2-associated antibody deficiency and immune dysregulation are disorders in which autoimmunity is a hallmark of the clinical disease presentation. In contrast, adaptive and innate immune deficiencies, which are typically defined by their infectious susceptibilities, can be associated with variable rates of autoimmune manifestations, predominantly autoimmune cytopenias. This review describes the immune dysregulation and autoimmune manifestations that may be encountered in various immune deficiencies.

Review of family relational stress and pediatric asthma: the value of biopsychosocial systemic models

Asthma is the most common chronic disease in children. Despite dramatic advances in pharmacological treatments, asthma remains a leading public health problem, especially in socially disadvantaged minority populations. Some experts believe that this health gap is due to the failure to address the impact of stress on the disease. Asthma is a complex disease that is influenced by multilevel factors, but the nature of these factors and their interrelations are not well understood. This paper aims to integrate social, psychological, and biological literatures on relations between family/parental stress and pediatric asthma, and to illustrate the utility of multilevel systemic models for guiding treatment and stimulating future research. We used electronic database searches and conducted an integrated analysis of selected epidemiological, longitudinal, and empirical studies. Evidence is substantial for the effects of family/parental stress on asthma mediated by both disease management and psychobiological stress pathways. However, integrative models containing specific pathways are scarce. We present two multilevel models, with supporting data, as potential prototypes for other such models. We conclude that these multilevel systems models may be of substantial heuristic value in organizing investigations of, and clinical approaches to, the complex social-biological aspects of family stress in pediatric asthma. However, additional systemic models are needed, and the models presented herein could serve as prototypes for model development.

Human ovarian tumor ascites fluids rapidly and reversibly inhibit T cell receptor-induced NF-κB and NFAT signaling in tumor-associated T cells

Human memory T cells present in ovarian tumor ascites fluids fail to respond normally to stimulation via the T cell receptor (TCR). This immunosuppression is manifested by decreases in NF-κB and NFAT activation, IFN-γ production, and cell proliferation in response to TCR stimulation with immobilized antibodies to CD3 and CD28. The anergy of the tumor-associated T cells (TATs) is mediated by soluble factors present in ovarian tumor ascites fluids. The non-responsiveness of the T cells is quickly reversed when the cells are assayed in the absence of the ascites fluid, and is rapidly reestablished when a cell-free ascites fluid is added back to the T cells. Based upon the observed normal phosphorylation patterns of the TCR proximal signaling molecules, the inhibition of NF-κB, and NFAT activation in response to TCR stimulation, as well as the ability of the diacylglycerol analog PMA and the ionophore ionomycin to bypass the ascites fluid-induced TCR signaling arrest, the site of the arrest in the activation cascade appears to be at or just upstream of PLC-γ. An identical TCR signaling arrest pattern was observed when T cells derived from normal donor peripheral blood were incubated with either malignant or nonmalignant (cirrhotic) ascites fluids. The immunosuppressive activity of ascites fluids reported here suggests that soluble factors acting directly or indirectly upon T cells present within tumors contribute to the anergy that has previously been observed in T cells derived from malignant and nonmalignant inflammatory microenvironments. The soluble immunosuppressive factors represent potential therapeutic targets for ovarian cancer.

Memory T cells in the chronic inflammatory microenvironment of nasal polyposis are hyporesponsive to signaling through the T cell receptor

A majority of T cells from chronic inflammatory tissues derived from patients with nasal polyposis were found to express an effector memory phenotype. We report here that these memory T cells failed to activate NF-κB in response to TCR stimulation but responded normally when the proximal TCR signaling molecules were bypassed with PMA and ionomycin. The dysfunction of these cells was associated with a decrease in the phosphorylation of several TCR proximal signaling molecules including ZAP70, Lck and SLP-76. In addition to the disruption in the TCR signaling pathway, the nasal polyp-associated T cells were shown to have a defect in their ability to translocate LAMP-1 to the cell surface. The results presented here establish that the phenotype and anergy of the T cells in the nasal polyp are similar to those which is seen in memory T cells derived from human tumors and other sites of chronic inflammation.

Human nasal polyp microenvironments maintained in a viable and functional state as xenografts in NOD-scid IL2rgamma(null) mice

OBJECTIVES

The objective was to develop a model with which to study the cellular and molecular events associated with nasal polyp progression. To accomplish this, we undertook to develop a system in which nondisrupted human nasal polyp tissue could be successfully implanted into severely immunocompromised mice, in which the histopathology of the original nasal polyp tissue, including inflammatory lymphocytes, epithelial and goblet cell hyperplasia, and subepithelial fibrosis, could be preserved for prolonged periods.

METHODS

Small, non-disrupted pieces of human nasal polyp tissues were subcutaneously implanted into NOD-scid IL2rgamma(null) mice. Xenografts at 8 to 12 weeks after implantation were examined histologically and immunohistochemically to identify human inflammatory leukocytes and to determine whether the characteristic histopathologic characteristics of the nasal polyps were maintained for a prolonged period. The xenografts, spleen, lung, liver, and kidneys were examined histologically and immunohistochemically and were evaluated for changes in volume. The sera of these mice were assayed for human cytokines and immunoglobulin.

RESULTS

Xenografts of human nasal polyp tissues were established after their subcutaneous implantation into NOD-scid IL2rgamma(null) mice. The xenografts were maintained in a viable and functional state for up to 3 months, and retained a histopathologic appearance similar to that of the original tissue, with a noticeable increase in goblet cell hyperplasia and marked mucus accumulation in the submucosal glands compared to the original nasal polyp tissue. Inflammatory lymphocytes present in the polyp microenvironment were predominantly human CD8+ T cells with an effector memory phenotype. Human CD4+ T cells, CD138+ plasma cells, and CD68+ macrophages were also observed in the xenografts. Human immunoglobulin and interferon-gamma were detected in the sera of xenograft-bearing mice. The polyp-associated lymphocytes proliferated and were found to migrate from the xenografts to the spleens of the recipient mice, resulting in a significant splenomegaly. A progressive increase in the volume of the xenografts was observed with little or no evidence of mouse cell infiltration into the human leukocyte antigen-positive human tissue. An average twofold increase in polyp volume was found at 3 months after engraftment.

CONCLUSIONS

The use of innate and adaptive immunodeficient NOD-scid mice homozygous for targeted mutations in the interleukin-2 receptor gamma-chain locus NOD-scid IL2rgamma(null) for establishing xenografts of nondisrupted pieces of human nasal polyp tissues represents a significant improvement over the previously reported xenograft model that used partially immunoincompetent CB17-scid mice as tissue recipients. The absence of the interleukin-2 receptor gamma-chain results in complete elimination of natural killer cell development, as well as severe impairments in T and B cell development. These mice, lacking both innate and adaptive immune responses, significantly improve upon the long-term engraftment of human nasal polyp tissues and provide a model with which to study how nasal polyp-associated lymphocytes and their secreted biologically active products contribute to the histopathology and progression of this chronic inflammatory disease.

Initiation of maintenance antiinflammatory medication in asthmatic children in a pediatric emergency department

BACKGROUND

Despite National Asthma Education and Prevention Program guidelines recommending the use of daily controller medication in patients with persistent asthma, less than half of children requiring emergency department treatment for asthma exacerbations are receiving antiinflammatory therapy.

OBJECTIVE

The purpose of this study was to evaluate a pediatric emergency department-based intervention designed to affect the prescribing practices of primary care physicians to better comply with national asthma guidelines. The intervention involved initiating maintenance antiinflammatory therapy in children with an asthma exacerbation who met guidelines for persistent disease but were not on antiinflammatory medications.

METHODS

Guardians of children 2 to 18 years of age presenting to the pediatric emergency department with an asthma exacerbation were asked to complete an asthma survey. Patients were classified into severity categories. Those with persistent disease not on antiinflammatory medications were given a 2-week supply of medication and were instructed to follow-up with their primary care physicians to obtain a prescription for the antiinflammatory medication. Patient adherence information was obtained through telephone calls, pharmacy claims data, and physician office records.

RESULTS

Forty-seven of 142 patients met criteria and were enrolled in the intervention. Seven patients were lost to follow-up. Of the remaining 40 patients, 28 followed-up with their primary care physician. Of these patients, 75% were continued on an antiinflammatory medication. Primary care physicians were significantly more likely to continue an antiinflammatory prescription in patients with severe persistent asthma (88.9% vs 68.4% of mild- or moderate-persistent asthmatics). Of the 28 patients who followed-up with their primary care physician, 13 had a prescription written, dispensed, and reported using the medication at the time of follow-up.

CONCLUSIONS

Pediatric emergency department physicians can successfully partner with primary care physicians to implement national guidelines for children requiring maintenance antiinflammatory asthma therapy. Patient nonadherence continues to be a significant barrier for asthma management.

Steroid regulation of octopamine expression during metamorphic development of the moth Manduca sexta

Octopamine (OA), a biogenic amine similar to norepinephrine, has profound and well-documented actions on the nervous systems of invertebrates. In the insect, Manduca sexta, we examined the developmental plasticity of OA synthesis, studied its endocrine regulation, and observed previously undescribed OA-immunoreactive (ir) neurons. We found that levels of tyramine beta-hydroxylase (TbetaH), an essential enzyme for the biosynthesis of OA, increase during metamorphosis. Based on the established and influential roles of the steroid hormone 20-hydroxyecdysone (20-HE) during development, we tested the hypothesis that increases in TbetaH levels and OA immunoreactivity are regulated by the rise in 20-HE occurring during pupal-adult development. We determined that the levels of TbetaH in the terminal abdominal ganglion (neuromeres 6-9) remain at a constant level during pupal development and the early stages of adult development. Beginning at ca. pupal stage 8, however, the levels of TbetaH begin to rise, reaching a maximum level by pupal stage 12. By removing the source of ecdysteroid hormone through ligation, and by subsequent replacement of 20-HE via infusion, we found evidence indicating that the preadult rise of 20-HE is both necessary and sufficient for the increased levels of TbetaH. During the course of our study, we also identified previously unreported OA-ir neurons. In particular, adult-specific OA-ir lateral cells were found, as were relatively small OA-ir dorsal median pairs that doubled in size during adult development. Abdominal ganglia not exposed to the preadult rise in 20-HE possessed neither the OA-ir lateral neurons nor the somatic growth of the smaller OA-ir median neurons. These newly described OA-ir neurons probably contribute to the steroid-induced elevations of TbetaH observed at the end of metamorphosis.

Characterization and developmental regulation of tyramine-beta-hydroxylase in the CNS of the moth, Manduca sexta

Octopamine (OA) is present in insect nervous tissue, but little is known about its biosynthesis. In the CNS of Manduca sexta, OA levels increase markedly during postembryonic adult development. To study this increase, we developed an assay for tyramine-beta-hydroxylase, the putatively rate-limiting enzyme for OA biosynthesis. Tyramine-beta-hydroxylase activity in extracts of M. sexta CNS tissue: (1) was time- and protein-dependent, and with protein concentrations up to 2 microg/microl, was linear for 20 min; (2) had a pH optimum of 7.0 for conversion of tyramine to OA; (3) required ascorbate, copper, and catalase; and (4) had an apparent K(M, tyramine) of 0.22+/-0.04 mM. These characteristics resemble those of the mammalian enzyme dopamine-beta-hydroxylase, suggesting that these two enzymes are functionally related. During adult development, tyramine-beta-hydroxylase activity increased 11-fold in the brain and 9-fold in the abdominal ganglia, paralleling increases in OA levels in those CNS structures during metamorphosis. The apparent kinetic constants of tyramine-beta-hydroxylase suggested that the amount of this enzyme present in the tissues increases. The increase in OA levels during adult development thus appears to be due to an increase in the level of enzyme available for OA synthesis and may reflect an increase in the number of octopaminergic neurons.

Characterization of crustacean cardioactive peptide-like immunoreactivity in the horseshoe crab, Limulus polyphemus

The localization of crustacean cardioactive peptide-like immunoreactivity in the horseshoe crab Limulus polyphemus was investigated with enzyme-linked immunosorbent assay and fluorescence microscopy. Immunoreactivity was quantified in the opisthosomal nervous system (67.7 +/- 11.4 ng/g), cardiac ganglion (45.0 +/- 10.3 ng/g), prosomal nervous system (28.5 +/- 6.6 ng/g), and midgut (24.6 +/- 6.7 ng/g). In the brain, immunoreactive somata were observed in ganglion cells of the central body, in the medullary group and within the ventral medial group. Clusters of immunoreactive cells were found in each of the circumesophageal, pedal ganglia, and in the opisthosomal, abdominal ganglia. In the periphery, immunoreactive varicose fibers were observed in branches of the intestinal nerves, and near longitudinal and circular muscle fibers of the midgut. Immunoreactivity was observed in the cardiac ganglion and myocardium of the neurogenic heart. Synthetic crustacean cardioactive peptide had slight excitatory effects on the cardiac rhythm at doses up to 10(-6) M. This peptide had excitatory effects on the midgut at nanomolar doses. Ventral nerve cord extracts were partially purified with reverse phase high performance liquid chromatography. Two regions of immunoreactivity were detected, one of which coeluted with the authentic peptide. The distribution of crustacean cardioactive peptide immunoreactivity is compared with other transmitter systems in the Limulus nervous system, and myotropic actions of this peptide are discussed with respect to peptidergic modulation of intestinal motility.

Crustacean cardioactive peptide in the sphinx moth, Manduca sexta

The isolation, identification, and actions of crustacean cardiactive peptide (CCAP) have been examined in the sphinx moth Manduca sexta. A sensitive and specific enzyme-linked immunosorbent assay (ELISA) was used to quantify CCAP-like immunoreactivity in the nervous system. The CCAP-like immunoreactivity from the abdominal CNS was then purified, and its sequence was ascertained by amino acid analysis, mass spectral analysis, and HPLC. These studies showed that the nervous system of M. sexta contains a peptide with the sequence Pro-Phe-Cys-Asn-Ala-Phe-Thr-Gly-Cys-NH2, identical to CCAP originally isolated and sequenced from the shore crab Carcinus maenas. The actions of CCAP on the isolated heart of M. sexta and the extensor-tibia muscle of Schistocerca americana were tested. Crustacean cardioactive peptide had excitatory actions on both preparations: a dose-dependent increase in the rate of contractions was observed on the heart, and an increase in the rate of the myogenic rhythm was observed in the leg muscle. Moreover, purified and synthetic CCAP had identical effects on the isolated heart. We conclude that CCAP occurs in M. sexta and exerts potent neurotransmitter or neurohormonal actions on a variety of muscles.

Immunoreactivity in Limulus: III. Morphological and biochemical studies of FMRFamide-like immunoreactivity and colocalized substance P-like immunoreactivity in the brain and lateral eye

FMRFamide-like immunoreactivity (FLI) and the colocalization of FMRFamide and substance P-like (SPLI) immunoreactivities were examined in the brain and lateral eye of the horseshoe crab with FITC- and TRITC-labeled secondary antibody techniques. In the brain, fibers with FLI were localized in the neuropils of the lamina, medulla, central body, corpus pedunculatum, optic tract, circumesophageal connective, and central neuropil. An extensive network of reactive fibers innervatives the brain's vascular sheath. Somata with FLI were found in the dorsal medial group, dorsal lateral posterior groups #1 and #2, and ventral posterior lateral groups #1 and #2. Several distinct subgroups of reactive somata were noted in both the medullar and ventral medial groups. The distribution of fibers in the brain with colocalized FLI and SPLI includes those which innervate the vascular sheath and widespread populations of small-diameter beaded fibers in the central neuropil and circumesophageal connective. Somata with colocalized FLI and SPLI constitute minority populations in the medullar and dorsal medial groups but form the majority population of a subgroup in the ventral medial group. Overall localization of SPLI was reevaluated and is reported here according to the nomenclature of the new Chamberlain and Wyse brain atlas. In addition to those previously reported, somata with SPLI were found in the dorsal lateral posterior groups #1 and #2, the ventral lateral posterior groups #1 and #2, and several distinct subgroups of the medial and ventral medial groups. In the retina of the lateral eye, fibers with both FLI and SPLI ramify in the lateral plexus and ultimately innervate the corneal epidermis. Brain homogenates were examined for immunoreactive (ir) FMRFamide and ir-substance P with radioimmunoassay techniques. Ir-FMRFamide and ir-substance P eluted in different fractions from both gel filtration chromatography and HPLC. Furthermore, the binding curves for both substances were similar to those of the corresponding synthetic compounds. Brain homogenates were also bioassayed on the lateral eye. Three gel filtration fractions mimic natural circadian activity by increasing the sensitivity of the lateral eye, but they were not coincident with ir-FMRFamide or ir-substance P. Although it is not completely resolved what the active molecules in these fractions are, it is clear that neither ir-FMRFamide nor ir-substance P is a possible candidate.

Localization of FMRFamide-like peptides in the snail Helix aspersa

The distribution of FMRFamide-like material in the gastropod mollusc, Helix aspersa, was studied by radioimmunoassay (RIA) and immunocytochemistry. Most of the RIA activity was concentrated in the central nervous system, the male reproductive tract, the tentacles and the posterior digestive system (Table 1). The density of FMRFamidergic perikarya, nerves and nerve varicosities in the muscle tissue of all these regions, as indicated immunocytochemically (Fig. 2), was well correlated with the distribution as determined by RIA. Gel chromatography of each extract resolved two peaks of FMRFamide-like immunoreactivity (Fig. 3). The first of these was further analysed by high-pressure liquid chromatography (HPLC), and the components included two major immunoreactive peaks identifiable, both by their retention times and their effects on the radula protractor muscle of Busycon contrarium, as the known peptides FMRFamide and pQDPFLRFamide (Figs 4–6). The second peak from gel chromatography gave only a single peak, distinct from that of FMRFamide and pQDPFLRFamide, in two HPLC systems (Fig. 7), but it did not behave like a competitive ligand in the FMRFamide RIA. Moreover, its immunoreactivity, unlike any peptides we tested, was not affected by carboxypeptidase Y (Fig. 8), and it was not active on the radula protractor muscle. Thus, it is certainly not an FMRFamide-like peptide. We conclude that Helix aspersa contains at least two FMRFamide-like peptides, FMRFamide and pQDPFLRFamide. These peptides appear to act both as neurohormones and as neurotransmitters or modulators in the central ganglia, reproductive, digestive, muscular and circulatory systems.

The actions of FMRFamide-like peptides on visceral and somatic muscles of the snail Helix aspersa

Phe-Met-Arg-Phe-NH2 (FMRFamide) and pyroGlu-Asp-Pro-Phe-Leu-Arg-Phe-NH2 (pQDPFLRFamide) occur in the ganglia and tissues of the snail, Helix aspersa. This report describes the effects of these two neuropeptides on five visceral organs or somatic muscles isolated from the snail (Table 1). The epiphallus, as well as the rest of the male reproductive tract, was contracted by both FMRFamide and pQDPFLRFamide, and the threshold was usually below 5 X 10(−9) mol l-1 (Fig. 1). Both peptides also reduced the resting tone of the crop and decreased the force and frequency of its rhythmic activity; FMRFamide is about 10 times more potent (Fig. 4). In contrast, pQDPFLRFamide was about 100 times more potent than FMRFamide as a cardioexcitatory agent (Fig. 5). The actions of the peptides on the pharyngeal and tentacle retractor muscles were markedly different: FMRFamide primarily contracted these muscles; and pQDPFLRFamide usually had no effect alone, but relaxed or diminished contractions induced by FMRFamide and acetylcholine (ACh) (Figs 6, 8, 9). Other analogues of FMRFamide were tested, but none was as effective a relaxing agent as pQDPFLRFamide. The effects of FMRFamide and pQDPFLRFamide on all of the preparations could be distinguished from those produced by ACh and 5-hydroxytryptamine (5-HT); thus the actions of the neuropeptides were not mediated by cholinergic or serotonergic neurones. The stimulation of the musculature in the male reproductive tract and the inhibition of motility of the digestive system by FMRFamide and pQDPFLRFamide implicate these peptides in the control of reproductive behaviour. The effectiveness of pQDPFLRFamide in relaxing the retractor muscles and as a cardioexcitatory agent led to the hypothesis that this heptapeptide and FMRFamide, acting at distinct receptors, cooperate to regulate the excitability and contractility of the snail's musculature between the extremes of aestivation and active locomotion.

Cross-phyletic bioactivity of arthropod neurohormones and molluscan ganglion extracts: evidence of an extended peptide family

Two structurally related arthropod neuropeptides, red pigment concentrating hormone (RPCH) and adipokinetic hormone (AKH), are potent excitors of the heart of the clam Mercenaria mercenaria. The response is bimodal: whereas the threshold for affected hearts is 1-3 X 10(-9) M, about 40% of the preparations are virtually unresponsive. Aqueous extracts of Mercenaria ganglia contain a substance which concentrates the red pigment in the erythrophores of intact destalked Uca pugilator and even of its isolated legs. This substance is retained on Sephadex G-15 and co-elutes with synthetic shrimp RPCH. The active fractions also concentrate the erythrophores and the leucophores of destalked shrimp (Penaeus). Neither dopamine nor the molluscan neuropeptide FMRFamide had any chromatophorotropic effect in these assays. The activity of the ganglion extracts was abolished by digestion with chymotrypsin. In conclusion, molluscan ganglion extracts contain a peptide factor, possibly an analog of RPCH, that concentrates the pigments of crustacean chromatophores by a direct action on the cells.

THE FMRFamide-LIKE NEUROPEPTIDE OF APLYSIA IS FMRFamide

The head ganglia from 350 Aplysia brasiliana were extracted and purified by gel (Sephadex G-15) and cation exchange (CM-Sephadex) chromatography; the fractions were examined with radioimmunoassays (RIA) for the molluscan neuropeptides, FMRFamide and SCP_B. Immunoreactive (ir-) FMRFamide (but not ir-SCP_B) coeluted with authentic FMRFamide from both chromatographic columns. The amino acid composition of the purified peptide was: Phe 2: Arg 1: Met 1. Digestion of purified ir-FMRFamide with carboxypeptidase Y indicated that the four residues were in the same sequence as occurs in FMRFamide. The dose-response curves for purified and synthetic FMRFamide on the radula protractor muscle of Busycon contrarium were coincident, as were their inhibition binding curves in the FMRFamide RIA. The highest concentrations of ir-FMRFamide were in the pedal and pleural ganglia; but SCP_B was concentrated in the buccal ganglion. Synthetic SCP_B has no effect on the radula protractor muscle of Busycon or the isolated heart of Mercenaria. In conclusion, the FMRFamide-like peptide in the gastropod Aplysia is FMRFamide, so this peptide has now been identified in two molluscan classes. Moreover, the proposed structural relationship between FMRFamide and SCP_B is fortuitous, and these two peptides should have different physiological functions in Aplysia.

The molluscan neurosecretory peptide FMRFamide: comparative pharmacology and relationship to the enkephalins

The molluscan neuropeptide FMRFamide (Phe-Met-Arg-Phe-NH2) has diverse actions on excitable tissues of molluscs, including hearts, noncardiac muscles, complex organs, and neurons. The intracellular transducing mechanisms are also diverse and are not readily correlated with particular responses. FMRFamide increases cyclic AMP levels concomitant with both cardioexcitation and inhibition, but not with muscle contraction. In the same tissues, the effects of 5-hydroxytryptamine are dissimilar and are always accompanied by a cyclic AMP increase. FMRFamide and acetylcholine cause similar tonic contractions of the Busycon radula protractor muscle and identical catch contractures of the mytilid anterior byssus retractor muscle, but the ionic basis of excitation and the sources of activator calcium for contraction are not the same for the two agonists. A comparative study of structure-activity relations showed that FMRFamide receptors are heterogeneous. Helix aspersa ganglia contain no FMRFamide, but a close analog occurs and has been tentatively identified. Evidence supporting a proposed homology between FMRFamide-like and opioid peptides is summarized. The effects of the amphiactive heptapeptide Tyr-Gly-Gly-Phe-Met-Arg-Phe-NH2 on the venus clam rectum support this hypothesis.

Aspects of copulatory behavior and peptide control of egg laying in Aplysia

The atrial gland of the marine mollusc Aplysia is associated with the large hermaphroditic duct of the reproductive system and contains several peptides capable of inducing egg laying. The structure and function of these peptides are briefly reviewed. It has been hypothesized that during copulation the atrial gland of the female is stimulated by penile insertion to release its peptides, which in turn initiate events leading to egg deposition. To test this hypothesis we monitored reproductive activity over periods of weeks in individual, paired, and grouped A. brasiliana. It was found that copulation is not a necessary stimulus for egg laying, because individually housed Aplysia lay more eggs than when they are paired and allowed to copulate. Nor is copulation a sufficient stimulus, because the vast majority of copulations are not followed by egg laying. Simultaneous egg laying and female copulatory behavior were often observed with grouped and paired animals, but these events are probably not causally related. It is concluded that although the atrial gland contains at least three peptides that can induce egg laying, stimulation of this gland during copulation does not normally serve to initiate egg laying.

Competitive inhibition by dimethylsulfoxide of molluscan and vertebrate acetylcholinesterase

Anticholinesterase-like effects of dimethylsulfoxide (DMSO) were demonstrated on a variety of invertebrate muscles. The excitatory effects of acetylcholine (ACh) on the isolated preparations of the Geukensia demissa heart and anterior byssus retractor muscle (ABRM), and of the Busycon contrarium radula protractor muscle, were potentiated by DMSO (1-5 microliters/ml; 1 microliter/ml = 14 mM). The negative chronotropic effects of ACh, but not of 4-ketoamyltrimethylammonium, were potentiated by DMSO (1-5 microliters/ml) on the isolated heart of the oyster Crassostrea virginica. These four muscles have acetylcholinesterase enzymes of high activity. In contrast, Mercenaria mercenaria hearts have weak cholinesterase activity, and the effects of ACh on this isolated myocardium were not potentiated by DMSO (2-20 microliters/ml). DMSO (0.1-15 microliters/ml) was a competitive inhibitor of both a crude preparation of oyster heart acetylcholinesterase (AChE) (the Km increased 24-fold with DMSO at 15 microliters/ml; the I50 was 1.3 microliters/ml DMSO when [ACh] = Km) and a purified Electrophorus AChE (the Km increased 4.5-fold when DMSO was 10 microliters/ml; the I50 was 10 microliters/ml DMSO near [ACh] = Km). The same doses of DMSO were needed to potentiate the pharmacological effects of ACh on the oyster heart, as to inhibit the AChE of this tissue.

Effects of sevin on development of experimental estuarine communities

The composition of animal communities developing from planktonic larvae in aquariums. A marked increase in the abundance of the annelid Polydora ligni in aquariums containing sand and flowing estuarine water was altered in the presence of the carbamate insecticide Sevin (carbaryl). Treatments were control and concentrations of Sevin that averaged 1.1, 11.1, and 103 micrograms/l; each treatment was replicated 8 times. Animals that colonized aquarium sand were collected in a 1-mm mesh sieve after 10 wk of exposure. Mollusks' arthropods, annelids, and nemerteans were the numerically dominant phyla. The average number of species per aquarium was significantly less (alpha = 0.05) in aquariums containing 11.1 or 103 micrograms/l than in those containing 1.1 micrograms/l or in control aquariums. The abundant clam Ensis minor grew significantly less in length at the higher concentrations of Sevin. The amphipod Corophium acherusicum was particularly affected; significantly fewer were found at all concentrations than in the control aquariums containing 103 micrograms/l corresponded to a marked decrease in the number of other annelids and to a significant absence of nemerteans.