A Prospective Study on Deep Inspiration Breath Hold Thoracic Radiation Therapy Guided by Bronchoscopically Implanted Electromagnetic Transponders

BACKGROUND

Electromagnetic transponders bronchoscopically implanted near the tumor can be used to monitor deep inspiration breath hold (DIBH) for thoracic radiation therapy (RT). The feasibility and safety of this approach require further study.

METHODS

We enrolled patients with primary lung cancer or lung metastases. Three transponders were implanted near the tumor, followed by simulation with DIBH, free breathing, and 4D-CT as backup. The initial gating window for treatment was ±5 mm; in a second cohort, the window was incrementally reduced to determine the smallest feasible gating window. The primary endpoint was feasibility, defined as completion of RT using transponder-guided DIBH. Patients were followed for assessment of transponder- and RT-related toxicity.

RESULTS

We enrolled 48 patients (35 with primary lung cancer and 13 with lung metastases). The median distance of transponders to tumor was 1.6 cm (IQR 0.6-2.8 cm). RT delivery ranged from 3 to 35 fractions. Transponder-guided DIBH was feasible in all but two patients (96% feasible), where it failed because the distance between the transponders and the antenna was >19 cm. Among the remaining 46 patients, 6 were treated prone to keep the transponders within 19 cm of the antenna, and 40 were treated supine. The smallest feasible gating window was identified as ±3 mm. Thirty-nine (85%) patients completed one year of follow-up. Toxicities at least possibly related to transponders or the implantation procedure were grade 2 in six patients (six incidences, cough and hemoptysis), grade 3 in three patients (five incidences, cough, dyspnea, pneumonia, and supraventricular tachycardia), and grade 4 pneumonia in one patient (occurring a few days after implantation but recovered fully and completed RT). Toxicities at least possibly related to RT were grade 2 in 18 patients (41 incidences, most commonly cough, fatigue, and pneumonitis) and grade 3 in four patients (seven incidences, most commonly pneumonia), and no patients had grade 4 or higher toxicity.

CONCLUSIONS

Bronchoscopically implanted electromagnetic transponder-guided DIBH lung RT is feasible and safe, allowing for precise tumor targeting and reduced normal tissue exposure. Transponder-antenna distance was the most common challenge due to a limited antenna range, which could sometimes be circumvented by prone positioning.

Feasibility of shape-sensing robotic-assisted bronchoscopy for biomarker identification in patients with thoracic malignancies

OBJECTIVE

Molecular diagnostic assays require samples with high nucleic acid content to generate reliable data. Similarly, programmed death-ligand 1 (PD-L1) immunohistochemistry (IHC) requires samples with adequate tumor content. We investigated whether shape-sensing robotic-assisted bronchoscopy (ssRAB) provides adequate samples for molecular and predictive testing.

METHODS

We retrospectively identified diagnostic samples from a prospectively collected database. Pathologic reports were reviewed to assess adequacy of samples for molecular testing and feasibility of PD-L1 IHC. Tumor cellularity was quantified by an independent pathologist using paraffin-embedded sections. Univariable and multivariable linear regression models were constructed to assess associations between lesion- and procedure-related variables and tumor cellularity.

RESULTS

In total, 128 samples were analyzed: 104 primary lung cancers and 24 metastatic lesions. On initial pathologic assessment, ssRAB samples were deemed to be adequate for molecular testing in 84% of cases; on independent review of cellular blocks, median tumor cellularity was 60% (interquartile range, 25%-80%). Hybrid capture-based next-generation sequencing was successful for 25 of 26 samples (96%), polymerase chain reaction-based molecular testing (Idylla; Biocartis) was successful for 49 of 52 samples (94%), and PD-L1 IHC was successful for 61 of 67 samples (91%). Carcinoid and small cell carcinoma histologic subtype and adequacy on rapid on-site evaluation were associated with higher tumor cellularity.

CONCLUSIONS

The ssRAB platform provided adequate tissue for next-generation sequencing, polymerase chain reaction-based molecular testing, and PD-L1 IHC in >80% of cases. Tumor histology and adequacy on intraoperative cytologic assessment might be associated with sample quality and suitability for downstream assays.

Brief Report: Chylothorax and Chylous Ascites During RET Tyrosine Kinase Inhibitor Therapy

INTRODUCTION

Spontaneous chylous effusions are rare; however, they have been observed by independent investigators in patients treated with RET tyrosine kinase inhibitors (TKIs).

METHODS

This multicenter, retrospective study evaluated the frequency of chylous effusions in patients treated with RET TKIs. Clinicopathologic features and management of patients with chylous effusions were evaluated.

RESULTS

A pan-cancer cohort of 7517 patients treated with one or more multikinase inhibitor or selective RET TKI and a selective TKI cohort of 96 patients treated with selpercatinib or pralsetinib were analyzed. Chylous effusions were most common with selpercatinib (7%), followed by agerafenib (4%), cabozantinib (0.3%), and lenvatinib (0.02%); none were observed with pralsetinib. Overall, 12 patients had chylothorax, five had chylous ascites, and five had both. Time from TKI initiation to diagnosis ranged from 0.5 to 50 months. Median fluid triglyceride level was lower in chylothoraces than in chylous ascites (397 mg/dL [interquartile range: 304-4000] versus 3786 mg/dL [interquartile range: 842-6596], p = 0.035). Malignant cells were present in 13% (3 of 22) of effusions. Chyle leak was not identified by lymphangiography. After initial drainage, 76% of patients with chylothorax and 80% with chylous ascites required additional interventions. Selpercatinib dose reduction and discontinuation rates in those with chylous effusions were 47% and 0%, respectively. Median time from diagnosis to disease progression was not reached (95% confidence interval: 14.5-undefined); median time from diagnosis to TKI discontinuation was 11.4 months (95% confidence interval: 8.2-14.9).

CONCLUSIONS

Chylous effusions can emerge during treatment with selected RET TKIs. Recognition of this side effect is key to prevent potential misattribution of worsening effusions to progressive malignancy.

Chylothorax and chylous ascites during RET tyrosine kinase inhibitor therapy

9080

Background: Spontaneous, atraumatic chylous effusions are rare. Investigators have observed a higher than anticipated incidence of chylothorax and chylous ascites in patients (pts) treated with RET tyrosine kinase inhibitors (TKIs). A systematic analysis of the occurrence of chylous effusions during RET TKI therapy and management strategies was thus performed. Methods: In this multicenter, retrospective study, the frequency of biochemically confirmed chylothorax or chylous ascites in pts treated with multikinase inhibitors (MKIs) with anti-RET activity or selective RET TKIs was determined. Clinicopathologic features and management of pts with chylous effusions were assessed. Results: A pan-cancer cohort of 7517 pts treated with at least 1 of 17 MKIs and selective RET TKIs and an independent cohort of 96 pts treated with the selective RET TKIs, selpercatinib or pralsetinib, were identified. Across cohorts, chylous effusions were identified in 22 pts and were most common with selpercatinib (7%; 15/217), followed by the MKIs agerafenib (4%; 1/24), cabozantinib (0.3%; 3/918), and lenvatinib (0.3%; 3/1185). Chylous effusions were not noted in 28 pts treated with pralsetinib. The distribution of malignancies included lung adenocarcinoma (54%) medullary thyroid carcinoma (23%), renal cell carcinoma (19%), and desmoplastic small round cell tumor (4%). Of the 22 pts, 12 had chylothorax, 5 had chylous ascites, and 5 had both. The cumulative incidence of chylous effusions from TKI initiation at 12 months was 3.09%. Median fluid triglyceride level was lower in chylothorax than in chylous ascites [397 mg/dL (IQR 282-4000) vs. 3786 mg/dL (IQR 676-6596), p = 0.035]. Median pleural fluid triglyceride level was higher with selpercatinib compared to MKIs [4,000 mg/dL (IQR 356-4425) vs. 287 mg/dL (IQR 216-395); p = 0.017]. Malignant cells were identified in the effusions from 12% (2/17) and 10% (1/10) of pts with chylothoraces and chylous ascites, respectively. Median time to disease progression from radiographic index and biochemical index across the full cohort was 1.5 years (IQR: 0.6-2.4) and 1.0 year (IQR: 0.1-1.2), respectively. Anatomic chyle leak was not identified in 6 pts who underwent lymphangiography. After initial drainage, additional drainage procedures were required in all cases with chylothorax and 50% of cases with chylous ascites. Chylous effusions prompted TKI dose reduction in 47% (7/15) of pts treated with selpercatinib and 14% (1/7) treated with MKI; none discontinued TKI due to chylous effusions. Conclusions: Chylous effusions can emerge on treatment with certain MKIs or selective RET TKIs. Recognition of this potential side effect is key to prevent misattribution of worsening effusions to progressive malignancy and to motivate a better understanding of its biology and management.

Four-Dimensional Computed Tomography-Based Correlation of Respiratory Motion of Lung Tumors With Implanted Fiducials and an External Surrogate

Purpose

Our purpose was to assess the suitability of airway-implanted internal fiducial markers and an external surrogate of respiratory motion for motion management during radiation therapy of lung tumors.

Methods and Materials

We analyzed 4-dimensional computed tomography scans acquired during radiation therapy simulation for 28 patients with lung tumors who had anchored fiducial markers bronchoscopically implanted inside small airways in or near the tumor in a prospective trial. We used a linear mixed model to build population-based correlative models of tumor and surrogate motion. The first 24 of the 28 patients were used to build correlative models, and 4 of the 28 consecutive patients were excluded and used as an internal validation cohort. Of the 24 patients from the model building cohort, all were used for the models based on the internal fiducial. The external surrogate was completely visualized in 11 patients from the model building cohort, so only those were used for the models based on the external surrogate. Furthermore, we determined the predicted residual error sum of squares for our correlative models, which may serve as benchmarks for future research.

Results

The motion of the internal fiducials was significantly associated with the tumor motion in the anterior-posterior (P < .0001) and superior-inferior (SI) directions (P < .0001). We also observed a strong correlation of the external surrogate anterior-posterior motion to the tumor dominant SI motion (P < .0001). In the validation cohort, the internal fiducial SI motion was the only reliable predictor of lung tumor motion.

Conclusions

The internal fiducials appear to be more reliable predictors of lung tumor motion than the external surrogate. The suitability of such airway-implanted internal fiducial markers for advanced motion management techniques should be further investigated. Although the external surrogate seems to be less reliable, its wide availability and noninvasive application support its clinical utility, albeit the greater uncertainty will need to be compensated for.

Can bronchoscopically implanted anchored electromagnetic transponders be used to monitor tumor position and lung inflation during deep inspiration breath-hold lung radiotherapy?

PURPOSE

To evaluate the efficacy of using bronchoscopically implanted anchored electromagnetic transponders (EMTs) as surrogates for 1) tumor position and 2) repeatability of lung inflation during deep-inspiration breath-hold (DIBH) lung radiotherapy.

METHODS

41 patients treated with either hypofractionated (HF) or conventional (CF) lung radiotherapy on an IRB approved prospective protocol using coached DIBH were evaluated for this study. Three anchored EMTs were bronchoscopically implanted into small airways near or within the tumor. DIBH treatment was gated by tracking the EMT positions. Breath-hold cone-beam-CTs (CBCTs) were acquired prior to every HF treatment or weekly for CF patients. Retrospectively, rigid registrations between each CBCT and the breath-hold planning CT were performed to match to 1) spine 2) EMTs and 3) tumor. Absolute differences in registration between EMTs and spine were analyzed to determine surrogacy of EMTs for lung inflation. Differences in registration between EMTs and tumor were analyzed to determine surrogacy of EMTs for tumor position. The stability of the EMTs was evaluated by analyzing the difference between inter-EMT displacements recorded at treatment from that of the plan for the CF patients, as well as the geometric residual (GR) recorded at the time of treatment.

RESULTS

219 CBCTs were analyzed. The average differences between EMT centroid and spine registration among all CBCTs were 0.45±0.42cm, 0.29±0.28cm, and 0.18±0.15cm in superior-inferior (SI), anterior-posterior (AP) and lateral directions, respectively. Only 59% of CBCTs had differences in registration <0.5cm for EMT centroid compared to spine, indicating that lung inflation is not reproducible from simulation to treatment. The average differences between EMT centroid and tumor registration among all CBCTs were 0.13±0.13cm, 0.14±0.13cm and 0.12±0.12cm in SI, AP and lateral directions, respectively. 95% of CBCTs resulted in <0.5cm change between EMT centroid and tumor registration, indicating that EMT positions correspond well with tumor position during treatments. Six out of the 7 recorded CF patients had average differences in inter-EMT displacements to be ≤0.26cm and average GR ≤0.22cm, indicating that the EMTs are stable throughout treatment.

CONCLUSIONS

Bronchoscopically implanted anchored EMTs are good surrogates for tumor position and are reliable for maintaining tumor position when tracked during DIBH treatment, as long as the tumor size and shape are stable. Large differences in registration between EMTs and spine for many treatments suggest that lung inflation achieved at simulation is often not reproduced. This article is protected by copyright. All rights reserved.

An evolving role for endobronchial ultrasonography in the intensive care unit

Endobronchial ultrasound (EBUS) bronchoscopy is an established minimally-invasive modality for visualization, characterization, and guidance of sampling of paratracheal and parabronchial structures and tissues. In the intensive care unit (ICU), rapidly obtaining an accurate diagnosis is paramount to the management of critically ill patients. In some instances, diagnosing and confirming terminal illness in a critically ill patient provides needed closure for patients and their loved ones. Currently available data on feasibility, safety, and yield of EBUS bronchoscopy in critically ill patients is based on single center experiences. These data suggest that in select ICU patients convex and radial probe-EBUS bronchoscopy can serve as useful tools in the evaluation of mediastinal lymphadenopathy, central airway obstruction, pulmonary embolism, and peripheral lung lesions. Barriers to the use of EBUS bronchoscopy in the ICU include: (I) requirement for dedicated equipment, prolonged procedure time, and bronchoscopy team expertise that may not be available; (II) applicability to a limited number of patients and conditions in the ICU; and (III) technical difficulty related to the relatively large outer diameter of the convex probe-EBUS bronchoscope and an increased risk for adverse cardiopulmonary consequences due to intermittent obstruction of the artificial airway. While the prospects for EBUS bronchoscopy in critically ill patients appear promising, judicious patient selection in combination with bronchoscopy team expertise are of utmost importance when considering performance of EBUS bronchoscopy in the ICU setting.

MI Paste Plus to prevent demineralization in orthodontic patients: a prospective randomized controlled trial

INTRODUCTION

Enamel demineralization is a problem in orthodontics. Fluoride is partially effective in addressing this problem, but additional treatment options are needed. The objective of this prospective randomized controlled trial was to determine the effectiveness of a new product, MI Paste Plus (GC America, Alsip, Ill), in the prevention or reduction of white spot lesions in orthodontic patients.

METHODS

Sixty patients who were undergoing routine orthodontic treatment were recruited for this prospective randomized clinical trial. A double-blind method of randomization was used to determine whether each patient received the MI Paste Plus or a placebo paste (Tom's of Maine, Salisbury, United Kingdom). Each patient was asked to administer the paste by using a fluoride tray for a minimum of 3 to 5 minutes each day at night after brushing. Photographic records obtained in a light-controlled environment were used to record the presence or absence of white spot lesions in both groups. The enamel decalcification index was used to determine the number of white spot lesions per surface at each time interval. Patients were followed at 4-week intervals for 3 months. A scoring system from 0 to 6 was used to determine the level of caries or cavitations. This system was also used for each tooth at each time interval.

RESULTS

Fifty patients (26 using MI Paste Plus, 24 using the placebo paste) completed the study. The enamel decalcification index scores for all surfaces were 271 and 135 at the start of treatment and 126 and 258 at the end of treatment for the MI Paste Plus and placebo paste groups, respectively. The enamel decalcification index scores in the MI Paste Plus group reduced by 53.5%, whereas the placebo group increased by 91.1% during the study period. A 3-way analysis of variance (ANOVA) was done for the average enamel decalcification index scores. The surface type, the product/time interactions, and the product/surface interactions of the mean enamel decalcification index scores were significant (P <0.05).

CONCLUSIONS

MI Paste Plus helped prevent the development of new white spot lesions during orthodontic treatment and decreased the number of white spot lesions already present. The placebo paste had no preventive action on white spot development during orthodontic treatment; the number of lesions actually increased. MI Paste Plus reduced white spots on the gingival surfaces; the placebo paste had the opposite effect. The incisal surface effect on the mean enamel decalcification index scores over time and between products was highly significant. The incisal enamel decalcification index scores were consistently higher than those for the other surfaces (mesial, distal, and gingival).

A Comparison of the Accuracy of Linear Measurements Obtained from Cone Beam Computerized Tomography Images and Digital Models

The purpose of this study was to determine whether cone beam digital models are as accurate as OrthoCAD (Cadent, Inc, Carlstadt, NJ) digital models for the purposes of orthodontic diagnosis and treatment planning. Digital records of 30 subjects were retrospectively reviewed, and the digital models were obtained as OrthoCAD and InVivoDental (San Jose, CA) digital models. Seven parameters indicating linear measurements from predetermined landmarks were measured and analyzed. The analysis of variance and Bland and Altman Analysis were used to compare and evaluate measurements made from the study models generated from cone beam computed tomography (CBCT) and InVivoDental software. The mean difference between the maxillary InVivoDental models and the maxillary OrthoCAD models ranged from -0.57 to 0.44 mm. The analysis of variance for repeated measures (P < 0.001) was applied to all data obtained from the CBCT and OrthoCAD models. The results indicated a mean score of 35.12 and 35.12 mm, respectively. The mean difference of all values was -7.93 × 10^-3 mm. The range of these values at the 95% confidence interval was -0.14 and 0.12 mm for the lower and upper limits, respectively. The results were not statistically significant for both groups. The Bland and Altman analysis was also applied to the data. In the maxilla, the results indicated that the mean difference between InVivoDental and OrthoCAD was -0.01 ± 1.24 mm. The range of the analysis indicated a spread of -2.40 mm and +2.40 mm. In the mandible, the results indicated that the mean difference between InVivoDental and OrthoCAD was -0.01 ± 1.21 mm. The range of the analysis indicated a spread of -2.36 mm and +2.37 mm. The results showed that the linear measurements obtained from CBCT image casts indicated a good level of accuracy when compared with OrthoCAD models. The accuracy was considered adequate for initial diagnosis and treatment planning in orthodontics.

Cone beam computed tomography analysis of dentoalveolar changes immediately after maxillary expansion

AIM

Rapid maxillary expansion (RME) splits the midpalatal suture to correct maxillary transverse discrepancies and increase the arch perimeter. The goal of this paper is to evaluate the immediate effects of RME with Hyrax appliances on the dentoalveolar complex using cone beam computed tomography (CBCT).

METHODS

Twenty-eight patients (19 females and 9 males) requiring maxillary expansion therapy were included (mean age, 14.1 years; range, 13 to 20 years). CBCT images were taken at T1 (before maxillary expansion) and T2 (immediately after expansion) as part of clinical records. Maxillary arch width, posterior segment angulation, and buccal bone thickness at the level of the first premolar and first molar were evaluated. Paired t tests determined statistical significance (P < .05).

RESULTS

The mean ± SD amount of expansion achieved was 4.7788 ± 2.8474 mm for the maxillary premolars and 4.6943 ± 3.2198 mm for the molars. Significant tipping of the palatal roots of the maxillary right and left premolars as well as that for the maxillary left molar was observed. When present, the thickness of the buccal plate decreased on all observed roots.

CONCLUSION

There is a significant increase in interpremolar and intermolar distance with RME. The increase in root angulation suggests that the movement is more tipping than translation. The thickness of the buccal plate decreases immediately after RME. Therefore, the level of inflammation should be closely monitored to avoid periodontal destruction. There is a need to define standardized reference planes and comparable methodology to achieve compatible results among studies.

Force relaxation between latex and non-latex orthodontic elastics in simulated saliva solution

The aim of this study was to compare the force relaxation between traditional latex elastics to different brands of non-latex elastics in a simulated saliva solution. The force relaxation of 6.35 mm (0.25 inch), 99 g (3.5 oz), non-colored latex elastics from Ormco Corp. and non-latex elastics from Phoenix Orthodontics, ClassOne Orthodontics, and Glenroe was tested. The elastics were stretched to 40 mm (1.57 inch) and the force produced by the elastics was then measured using a Mini 44 Instron machine.

RESULTS

The latex elastics had an initial relaxation of 15 percent after 1 hour of incubation and maintained their reduced force after 24 hours of incubation. Non-latex elastics lost approximately 20 percent of their force after the first hour and continued to lose force after up to 24 hours of incubation resulting in as much as 48 percent force relaxation.

CONCLUSION

Latex elastics should be used whenever possible; however, when non-latex elastics are warranted, the clinician should take into account their greater initial forces, significant force relaxation, and variability among brands.

Evidence-based evolution of the high stakes postgraduate intensive care examination in Australia and New Zealand

The fellowship examination for intensive care medicine in Australia and New Zealand, first held in 1979, has undergone four major periods of development and change since inception. These periods are characterised as: 1. 1979 to 1996--initiation and establishment of the exam as a relevant and comprehensive assessment process for a new specialty. 2. 1997 to 2001--revision to increase breadth of coverage, increase reliability for a growing number of candidates and ensure that each candidate received the same exam: Expansion: to incorporate assessment of CanMEDS skills (including communication, procedures and professional qualities). Lengthening: to increase the number of exposures, to ensure reliability. Quarantining of candidates: to allow the provision of a similar exam for each candidate. 3. 2002 to 2006--increasing emphasis on examiner training, standard setting and increasing feedback to candidates to improve the educational experience and guide exam preparation. Blueprinting of questions to maintain validity. 4. 2008 onwards--logistic revision to ensure feasibility for a rapidly growing number of candidates and refinement to apply modem standard setting and quality control. The exam has been regarded as a 'tough but fair' assessment in its 30 years of existence and the committee overseeing its development has aimed to continually review the process to maintain those qualities as well as reliability, validity and feasibility. The increasing number of candidates has allowed accumulation of usable statistics but has tested the feasibility of running such a labour intensive exam. To date, there have been 800 presentations to the exam with 498 successful candidates.

Long-Term Treatment Effectiveness of Molding Helmet Therapy in the Correction of Posterior Deformational Plagiocephaly: A Five-Year Follow-Up

Objective:

To evaluate the long-term effectiveness of helmet therapy in the correction of deformational plagiocephaly and to assess the early occlusal abnormalities seen in these patients.

Design:

A prospective study with blinded measurements.

Patients:

Twenty-eight patients with deformational plagiocephaly who were treated with molding helmet therapy with at least 5 years of follow-up.

Interventions:

The average length of molding helmet treatment was 6.2 months. At the time of this follow-up evaluation, the mean interval since completing the molding helmet therapy was 5.6 years.

Main Outcome Measures:

Anthropometric measurements of cranial asymmetry included cranial vault asymmetry (CVA), orbitotragial depth asymmetry (OTDA), and cranial base asymmetry (CBA). A dental examination was also performed.

Results:

At the completion of therapy, the most improvement was seen in the measurement of CBA, followed by CVA and OTDA. However, in evaluating the long-term stability of molding treatment, OTDA tended to continue improving after the initial treatment, while CBA and CVA appeared to regress, although none of the changes reached statistically significant levels. In dental measurements, all the dental midline and chin deviations were toward the unaffected side with respect to occipital deformation.

Conclusion:

This study demonstrated that helmet remodeling with the dynamic orthotic cranioplasty band is effective in the correction of cranial asymmetry, with some nonstatistically significant changes in long-term cranial vault symmetry. Dental observations indicated the possibility of occlusal abnormalities that may affect dental, especially orthodontic, diagnosis and teatment planning.

The Effects of Salivary Gland Extracts from Boophilus microplus Ticks on Mitogen-stimulated Bovine Lymphocytes

The effect of salivary gland extract (SGE) from the tick Boophilus microplus was examined in mitogen-stimulated lymphocytes in vitro. SGE was added to lymphocytes of seven cattle together with the mitogens concanavalin A (ConA), phytohaemagglutinin (PHA) and pokeweed mitogen (PWM). Semi-purified B cells from another seven cattle were stimulated with the mitogen lipopolysaccharide (LPS). PHA and ConA stimulated proliferation of lymphocytes to the same extent, but the inhibition due to SGE of Boophilus microplus on the proliferative response stimulated by PHA (39.0% +/- 9.3%) was less than the inhibition of proliferative response stimulated by ConA (75.4% +/- 6.9%). In contrast, SGE of B. microplus stimulated the proliferation of B cells in the presence of LPS in a dose-dependent manner. Enhanced stimulation of B cells by SGE at >4 microg in culture was greater than twice that observed when B cells were stimulated by LPS alone. SGE does not have a direct suppressive effect on bovine B cell proliferation; however, in vivo the effectiveness of B cell responses might be influenced by other immune factors, such as cytokine profiles.

The relationship between hypertension and anxiety or depression in Hong Kong Chinese

BACKGROUND

Psychosocial stress can be the cause or the consequence of hypertension.

OBJECTIVE

To study the association between hypertension and anxiety or depression in adults from Hong Kong, China.

SUBJECTS AND METHODS

Patients with diagnosed hypertension (n=197) were recruited to complete the Hospital Anxiety and Depression Scale (HADS) questionnaire. The control group comprised 182 normotensive subjects recruited using random telephone numbers.

RESULTS

The score in the anxiety subscale (HADS-A) of the HADS correlated with age (r= -0.23, P<0.001) and sex (r=0.11, P=0.042), and was found to be higher in women. The score in the depression subscale (HADS-D) correlated with age (r=0.17, P=0.003) and hypertension (r=0.12, P=0.039), but not with sex (r=0.02, P=0.68). When the control subjects were matched for sex and age with the subjects with hypertension, the mean HADS-A score was 5.51+/-0.41 in 113 hypertensive subjects and 4.38+/-0.39 in 113 normotensive subjects (P=0.047). The mean HADS-D score was 5.56+/-0.39 in the hypertensive and 4.76+/-0.32 in the normotensive subjects (P=0.11). Multiple regression analysis using data from both groups indicated that the HADS-A score was related to the HADS-D score (beta=0.49, P<0.001), age (beta= -0.25, P<0.001) and sex (beta=0.12, P=0.01) (R(2)=0.28), whereas the HADS-D score was related to the HADS-A score (beta=0.48, P<0.001), age (beta=0.30, P<0.001), positive smoking status (beta=0.13, P=0.004) and lack of exercise habit (beta=0.12, P=0.008) (R(2)=0.31). Hypertension was related to waist circumference, history of parental hypertension and age (R(2)=0.38, P<0.001). Anxiety and depression scores were rejected as independent variables.

CONCLUSIONS

Hypertension was associated with anxiety but not depression; however, age, history of parental hypertension and central obesity appeared to have a stronger association with hypertension in adults from Hong Kong.

A comparison of the immunosuppressive effects of salivary gland extracts from two laboratory strains of Boophilus microplus

This study addresses three questions related to the immune response of cattle to tick salivary gland extracts. Firstly, is there a difference in the inhibition of proliferation of Concanavalin A (ConA) stimulated bovine lymphocytes induced by salivary gland extracts of the N and Y strains of Boophilus microplus? Second, is there a difference in the development rate of the Y and N tick strains? Third, does the host affect the inhibitory effect of salivary gland extract on the proliferation of ConA stimulated lymphocytes from the two tick strains? Salivary gland extract of the Y strain inhibited in vitro proliferation of lymphocytes stimulated by ConA significantly more than that of the N strain, when each strain was raised on different animals. A difference in the development rate was observed between the tick strains when raised on the same animal, with female ticks of the Y strain developing faster and reaching a greater fully engorged weight than ticks of the N strain. The difference in their rate of development did not appear to contribute to a difference in inhibitory effects of the salivary gland extracts and there was no difference between the inhibitory effects of salivary gland extracts from both strains. However, when Y strain ticks were raised on different animals, there was a significant difference in the inhibition of lymphocyte proliferation between the two salivary gland extracts. Therefore, it was concluded that there is no difference between the inhibitory effects of the two tick strains and that the host has an influence on salivary gland extract composition of B. microplus and its inhibitive properties.

Early invasive revascularisation for patients critically ill after acute myocardial infarction: impact on outcome and ICU resource utilisation

OBJECTIVE

To assess the value of early invasive revascularization for the initial management of critically ill patients after acute myocardial infarction in the daily practice of a University-affiliated referral hospital and to gauge the impact of such a strategy on the intensive care unit.

PATIENTS AND METHODS

A prospective observational study on all patients admitted to the Royal North Shore hospital who had acute pulmonary oedema and/or shock prior to acute angiography for acute myocardial infarction from January 1(st), 1998 to December 31, 2001.

RESULTS

During the study period 846 patients with acute myocardial infarction had coronary artery angiography, 139 had acute pulmonary oedema and/or shock prior to angiography. The average age was 70 years, 65% of whom were male. Approximately 70% of these patients were admitted to the intensive care unit and coronary artery bypass surgery was performed on 38%. Of those patients admitted to the intensive care unit, 95% required mechanical ventilation, 81% required inotropic support and 50% required intra-aortic Balloon counterpulsation. In-hospital mortality was 32%, 6 weeks mortality was 38% and 6 month mortality was 42%.

CONCLUSIONS

Our results confirm the benefit of early invasive revascularisation for critically ill patients after acute myocardial infarction although a substantial amount of intensive care unit resources and cardiothoracic surgical expertise were required.

Pathological and immunological changes after challenge infection with Pasteurella multocida in naive and immunized calves

Challenge infections of calves with Pasteurella multocida were established to characterize the local inflammatory response and determine the effect of previous exposure to live bacteria on the post-challenge immune response. Experimental infections were established by intratracheal inoculation of P. multocida in both naive calves and calves that had been previously vaccinated with two subcutaneous (s.c.) injections of live bacteria. Histological, immunohistological and cytokine expression studies were performed on bronchoalveolar lavage (BAL) samples, lung parenchymal tissues and lung lymph nodes (LN). In comparison to uninfected control animals in which no lung lesions were observed, a patchy to confluent bronchopneumonia was observed following infection of naive calves, characterized by abscess formation, haemorrhage, oedema and suppurative consolidation. Cellular analysis following infection of naive animals was characterized by an influx of neutrophils in the BAL, with macrophages and dendritic cells observed in the lesion perimeter. A significant increase in the number of CD8(+) blasts expressing MHC (major histocompatibility) II was also observed in the BAL of infected calves. Decreased expression of interleukin (IL)-1 beta and increased expression of IL-8 compared to naive unchallenged controls was apparent in lung LN. In comparison, a more limited pathology was observed in vaccinated animals post-challenge, indicating partial protection conferred by the s.c. immunization with live bacteria. Studies of vaccinated animals showed the presence of bronchial-associated lymphoid tissue (BALT) in the lung tissue and an increase in the number of B-cells and CD4(+) T-cells expressing MHCII in the lung LN after challenge. In contrast to primary infection, there was no significant influx of neutrophils in the BAL. Instead, a population of newly recruited monocytes/macrophages was observed. Increased IL-2 expression and decreased IL-8 expression was observed in the LN, while IL-1 beta expression was not detected. The reduced neutrophil and increase monocyte response in the vaccinated calves may be associated with significant changes in the gamma delta T lymphocyte population in the BAL.

The protective effect of niacinamide on ischemia-reperfusion-induced liver injury

Reperfusion of ischemic liver results in the generation of oxygen radicals, nitric oxide (NO) and their reaction product peroxynitrite, all of which may cause strand breaks in DNA, which activate the nuclear enzyme poly(ADP ribose)synthase (PARS). This results in rapid depletion of intracellular nicotinamide adenine dinucleotide and adenosine 5'-triphosphate (ATP) and eventually induces irreversible cytotoxicity. In this study, we demonstrated that niacinamide, a PARS inhibitor, attenuated ischemia/reperfusion (I/R)-induced liver injury. Ischemia was induced by clamping the common hepatic artery and portal vein of rats for 40 min. Thereafter, flow was restored and the liver was reperfused for 90 min. Blood samples collected prior to I and after R were analyzed for methyl guanidine (MG), NO, tumor necrosis factor (TNF-alpha) and ATP. Blood levels of aspartate transferase (AST), alanine transferase (ALT) and lactate dehydrogenase (LDH) which served as indexes of liver injury were measured. This protocol resulted in elevation of the blood NO level (p < 0.01). Inflammation was apparent, as TNF-alpha and MG levels were significantly increased (p < 0.05 and p < 0.001). AST, ALT and LDH were elevated 4- to 5-fold (p < 0.001), while ATP was significantly diminished (p < 0.01). After administration of niacinamide (10 mM), liver injury was significantly attenuated, while blood ATP content was reversed. In addition, MG, TNF-alpha and NO release was attenuated. These results indicate that niacinamide, presumably by acting with multiple functions, exerts potent anti-inflammatory effects in I/R-induced liver injury.

The protective effect of niacinamide on ischemia-reperfusion-induced liver injury

Reperfusion of ischemic liver results in the generation of oxygen radicals, nitric oxide (NO) and their reaction product peroxynitrite, all of which may cause strand breaks in DNA, which activate the nuclear enzyme poly(ADP ribose)synthase (PARS). This results in rapid depletion of intracellular nicotinamide adenine dinucleotide and adenosine 5'-triphosphate (ATP) and eventually induces irreversible cytotoxicity. In this study, we demonstrated that niacinamide, a PARS inhibitor, attenuated ischemia/reperfusion (I/R)-induced liver injury. Ischemia was induced by clamping the common hepatic artery and portal vein of rats for 40 min. Thereafter, flow was restored and the liver was reperfused for 90 min. Blood samples collected prior to I and after R were analyzed for methyl guanidine (MG), NO, tumor necrosis factor (TNF-alpha) and ATP. Blood levels of aspartate transferase (AST), alanine transferase (ALT) and lactate dehydrogenase (LDH) which served as indexes of liver injury were measured. This protocol resulted in elevation of the blood NO level (p < 0.01). Inflammation was apparent, as TNF-alpha and MG levels were significantly increased (p < 0.05 and p < 0.001). AST, ALT and LDH were elevated 4- to 5-fold (p < 0.001), while ATP was significantly diminished (p < 0.01). After administration of niacinamide (10 mM), liver injury was significantly attenuated, while blood ATP content was reversed. In addition, MG, TNF-alpha and NO release was attenuated. These results indicate that niacinamide, presumably by acting with multiple functions, exerts potent anti-inflammatory effects in I/R-induced liver injury.

The lung is the major site that produces nitric oxide to induce acute pulmonary oedema in endotoxin shock

1. The present study was undertaken to determine the locus of nitric oxide (NO) production that is toxic to the lung and produces acute pulmonary oedema in endotoxin shock, to examine and compare the effects of changes in lung perfusate on endotoxin-induced pulmonary oedema (EPE) and to evaluate the involvement of constitutive and inducible NO synthase (cNOS and iNOS, respectively). 2. Experiments were designed to induce septic shock in anaesthetized rats with the administration of Escherichia coli lipopolysaccharide (LPS). Exhaled NO, lung weight (LW)/bodyweight (BW) ratio, LW gain (LWG) and lung histology were measured and observed to determine the degree of EPE 4 h following LPS. The EPE was compared between groups in which LPS had been injected either into the systemic circulation or into the isolated perfused lung. The lung perfusate was altered from whole blood to physiological saline solution (PSS) with 6% albumin to test whether different lung perfusions affected EPE. Pretreatment with various NOS inhibitors was undertaken 10 min before LPS to investigate the contribution of cNOS and iNOS to the observed effects. 3. Endotoxin caused profound systemic hypotension, but little change in pulmonary arterial pressure. The extent of EPE was not different between that induced by systemic injection and that following administration to isolated lungs preparations. Replacement of whole blood with PSS greatly attenuated (P < 0.05) EPE. In blood-perfused lungs, pretreatment with NOS inhibitors, such as Nomega-nitro-L-arginine methyl ester, aminoguanidine and dexamethasone, significantly prevented EPE (P < 0.05). 4. The major site of NO production through the whole blood is in the lung. The NO production mediated by the iNOS system is toxic to the endothelium in the pulmonary microvasculature. Inhalation of NO for patients with sepsis may be used with clinical caution. Therapeutic consideration of lung extracorporeal perfusion with PSS and pharmacological pretreatment with iNOS inhibitors may be warranted.

Involvement of CYP2E1 and carboxylesterase enzymes in vinyl carbamate metabolism in human lung microsomes

Previous studies have shown that CYP2E1 and carboxylesterase enzymes contributed to vinyl carbamate (VC) metabolism in murine lung. Moreover, these studies have implicated CYP2E1 and the carboxylesterases in bioactivation and detoxication, respectively. Here we have tested the hypothesis that CYP2E1 and carboxylesterase enzymes are involved also in VC metabolism in human lung. Demethylation of N-nitrosodimethylamine (NDMA) is an enzyme activity associated with CYP2E1, and was used as a catalytic marker for this P450 in human lung microsomes. NDMA demethylase activity in lung microsomes from 10 patients ranged from 36.9 +/- 1.0 to 82.4 +/- 2.4 pmol/mg protein/min. Significant decreases (40-65%) in demethylase activity were detected in lung microsomes incubated with VC and NADPH, compared with the controls in which incubations were performed with only VC or only NADPH. Preincubation with the CYP2E1 inhibitor diallyl sulfone also significantly decreased demethylase activity, and abrogated the VC-induced effect. Similarly, preincubation of lung microsomes with a human CYP2E1 inhibitory monoclonal antibody ameliorated the VC-induced reduction in demethylase activity. Microsomal carboxylesterase activity in lung microsomes from 10 patients ranged from 19.02 +/- 2.28 to 48.18 +/- 4.34 nmol/mg protein/min, and was significantly decreased (25-45%) in microsomes incubated with phenylmethylsulfonyl fluoride, an inhibitor of the carboxylesterase enzyme. Preincubation of lung microsomes with phenylmethylsulfonyl fluoride and subsequent incubation with VC and NADPH exacerbated the reduction (60-80%) in demethylase activity evoked by reaction with VC and NADPH. These results are consistent with a role for the CYP2E1 enzyme and microsomal carboxylesterases in VC metabolism.

Elevated anti-parasitic activity in peripheral blood monocytes and neutrophils of cattle infected with Babesia bovis

The innate immune response to bovine Babesia bovis infection in vivo has not previously been established. We used assays measuring phagocytosis and oxidative burst to investigate the immune response because they are indicative of the innate antimicrobial capacity of monocytes and neutrophils. Monocyte and neutrophil phagocytosis is thought to be non-specific in nature and so the phagocytosis of either opsonised Zymosan or Escherichia coli was used to indicate the non-specific phagocytic capacity of monocytes and neutrophils ex vivo. The kinetics of both phagocytic and oxidative burst activity in monocytes and neutrophils were followed twice weekly from pre-inoculation (day 0) through to 31 days after inoculation. Peripheral blood monocytes were found to display a pronounced oxidative burst, but a suppressed capacity to phagocytose during a primary infection. On the other hand, neutrophils exhibited an increased phagocytic capacity and reduced oxidative activity during a primary infection. These findings identified considerable antimicrobial activity evident in peripheral blood monocytes and neutrophils from cattle exposed to B. bovis as a primary exposure. This elevated antimicrobial activity was coincident with the time that parasite numbers peaked in the circulation and occurred prior to parasite clearance. These results suggest that peripheral blood monocytes and neutrophils are active mediators in the innate immune response to a primary B. bovis.

Opposition of rapid baroreceptor resetting by prostanoids in rabbits

Arterial baroreceptors reset rapidly within minutes during acute hypertension; baroreceptor pressure threshold (Pth) is increased and the pressure-baroreceptor activity relation is shifted to the right. The purpose of the present study was to determine if prostacyclin (PGI2) or other prostanoids, released during acute hypertension modulate the magnitude of baroreceptor resetting. Baroreceptor activity was recorded from the vascularly-isolated carotid sinus during distension of the sinus with slow pressure ramp in rabbits anesthetized with chloralose. Pressure-activity curves were generated after holding carotid sinus pressure for 10-15 min from 30 to 100 mmHg. In control, the elevation of holding pressure increased Pth from 44+/- to 65+/-5 mmHg (p < 0.05, n = 12). In the presence of PGI2 (20 microM), Pth averaged 43+/-4 and 45+/-3 mmHg (n = 12) after holding pressure at 30 and 100 mmHg, respectively. In the control group before exposing the carotid sinus to indomethacin, an elevation of holding pressure increased Pth from 49+/-2 to 71+/-3 mmHg (p < 0.05, n = 12). After inhibition of the endogenous formation of prostanoids with indomethacin (20 microM), Pth increased by a significantly greater extent from 61+/-2 to 90+/-3 mmHg (p < 0.05, n = 12) with the increase in holding pressure. The slope of the pressure-activity curve (baroreceptor gain) was not influenced by the change in holding pressure. It was increased significantly by PGI2, while decreased by indomethacin. Neither the change in holding pressure nor PGI2 affected the circumferential wall strain of carotid sinus over a wide range of pressure alteration. The results suggest that PGI2 or other prostanoids released during acute hypertension sensitizes baroreceptors and provides a negative feedback mechanism that opposes and limits the magnitude of rapid baroreceptor resetting.

Putative salivary allergens of the cat flea, Ctenocephalides felis felis

The cat flea, Ctenocephalides felis felis, is the major initiator of flea bite hypersensitivity in dogs. Previous analyses of whole extracts of the flea and flea salivary secretions have failed to identify the allergens responsible. We dissected >2000 salivary glands from adult female fleas, extracted them into buffered saline containing protease inhibitors and fractionated the extract using gel permeation HPLC. Dogs were classified as hypersensitive to fleas (flea-feeding positive, FF+) or insensitive (flea-feeding negative, FF-) using a provocative test with live fleas. The allergenicity of the components of the salivary gland extract was tested by intradermal injection of samples of the column eluates. Dogs were also injected intradermally with a sample of whole salivary gland extract, and with histamine as a positive control. Negative control injections consisted of eluate from the column collected prior to fractions containing any protein. The skin of FF- dogs either did not respond or had a minimal response (a bleb approximately 2 mm larger than the injection blebs at the negative control injection sites) to all fractions and to the whole extract; histamine control injections produced positive responses (defined as wheals 5 mm greater than the blebs at the negative control injection sites) in all dogs. The skin of three of the nine FF+ dogs reacted positively to injection of a fraction containing protein/s with apparent MW 40k. Five other FF+ dogs reacted positively to the fractions containing proteins with apparent MW 12-8k. A single dog responded with very large, red wheals to injection of both the approximately MW 40k and MW12-8k fractions. These findings suggest that proteins with apparent MW 40k and MW 12k-8k are important in flea bite hypersensitivity. This work also supports a previous finding that mice which had been exposed to flea bites had antibodies to proteins with approximately MW 40k that were detected in salivary secretions of the flea.

Detection and measurement of canine alpha-macroglobulins by enzyme immuno-assay

The alpha-macroglobulins are broad-specificity protease inhibitors important in the regulation and clearance from circulation of biologically active proteases. Inappropriate protease activation may be a feature of canine acute pancreatitis and the ability of the animal to clear these proteases may be important in determining survival. An enzyme immunoassay for the detection and measurement of canine alpha-macroglobulins in plasma samples was developed. A reference range for the canine alpha-macroglobulins of 1.20-2.72 mg ml-1 was established from a panel of canine plasma samples, and the stability of the alpha-macroglobulins in plasma samples stored at 4 degrees C was investigated. Changes in the level of the alpha-macroglobulins during disease states involving increased endogenous protease activity can now be investigated using a rapid, repeatable and quantifiable assay.

Anti-immunoglobulin antisera used in an ELISA to detect antibodies in barramundi Lates calcarifer to Cryptocaryon irritans

Immunoglobulins (Ig) in serum from barramundi vaccinated with bovine serum albumin (BSA) were purified by ammonium sulphate precipitation and affinity chromatography using BSA as the ligand. The BSA-binding activity of eluted putative Ig fractions was assessed by enzyme-linked immunosorbent assay (ELISA) before being pooled and characterised by sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE). Double affinity purification did not improve the purity of the Ig preparation compared to single affinity purification. Barramundi Ig were injected into sheep to produce anti-Ig antisera which were assessed in an indirect ELISA as the secondary antibody to detect serum Ig in barramundi vaccinated with Cryptocaryon irritans theronts. Affinity-purified Ig induced a more specific reagent for use as secondary antibody in ELISA than did normal whole-barramundi sera. The heavy (H) chain of barramundi Ig had an apparent molecular weight of 70 kDa while that of the light (L) chain was 27 kDa in SDS-PAGE studies. Under non-reducing conditions 2 putative populations of Ig were identified, at 768 and 210 kDa. The N-terminal sequence of the barramundi Ig H chain showed 78% homology with channel catfish Ictalurus punctatus Ig H chain sequence.

Inactivation of cytochrome P-450 (CYP2E1) and carboxylesterase (hydrolase A) enzymes by vinyl carbamate in murine pulmonary microsomes

We tested the hypothesis that vinyl carbamate (VC) is metabolized in vitro by cytochrome P-450 and carboxylesterase enzymes in murine lung. Incubations with VC and an NADPH-generating system produced a 50% decrease in N-nitrosodimethylamine (NDMA) demethylation and a corresponding loss in the amounts of immunodetectable CYP2E1. Preincubation of microsomes with a CYP2E1 inhibitory antibody or the CYP2E1-selective inhibitor diallyl sulfone (DASO2) inhibited demethylase activity; no alterations were detected upon subsequent exposure to VC. Carboxylesterase-mediated hydrolysis of p-nitrophenyl acetate was reduced by 22% in microsomes incubated with VC. Decreased carboxylesterase activity also was detected in microsomes incubated with phenylmethylsulfonyl fluoride (PMSF), an inhibitor of hydrolase A, a carboxylesterase isozyme. No change in enzyme activity was detected when microsomes were subsequently incubated with VC. The loss in carboxylesterase activity correlated with decreased immunodetectable hydrolase A in microsomes incubated with VC, PMSF, or PMSF and VC. The reduction in VC-induced NDMA demethylase activity was increased to 85% of the control in microsomes previously incubated with PMSF, and this corresponded with a marked decrease in CYP2E1 immunoreactivity in the immunoblots. Covalent binding of VC to proteins was detected in microsomes incubated with VC and an NADPH-generating system. Binding was inhibited in microsomes preincubated with either an inhibitory CYP2E1 antibody or DASO2. In contrast, binding levels were augmented in microsomes preincubated with PMSF. These data supported VC metabolism by CYP2E1 and hydrolase A in murine lung microsomes and is consistent with involvement of CYP2E1 and hydrolase A in the activation and detoxication of VC, respectively.

Sustained-release delivery systems and their application for endoparasite control in animals

A solid formulation of a potent anthelmintic macrocyclic lactone, moxidectin, was administered using a non-degradable delivery device to discharge the agent into the subcutaneous tissues of sheep. In vivo release was monitored in sheep indirectly using faecal egg counts. Using a dose of 0.2 mg moxidectin/kg body weight when applied in the form of a solid pellet, protection of sheep against Haemonchus contortus challenge was conferred to a level greater than that of sheep which received Cydectin, the commercial liquid injectable form delivered at the same dosage. The anthelmintic efficacy of the solid formulation was assessed at four dosage levels in sheep and it was demonstrated that the dosage of anthelmintic agent could be reduced to 1/6 of the present recommended injectable dose. When two pellets containing the recommended dose of moxidectin were loaded into a non-degradable delivery device, the period of H. contortus control was extended from 42 to 183 days. Antibody levels of sheep receiving repeated infections of H. contortus L3 larvae and treated with moxidectin-loaded devices were reduced significantly compared to the levels observed in sheep treated with Cydectin (p < 0.0005). This implies that the group treated with the moxidectin-loaded devices was exposed to a reduced antigenic load compared to sheep treated with placebo devices, and sheep treated with Cydectin. The antibody levels generated in the sheep treated with placebo devices were no different to those treated with Cydectin. Application of this sustained release device may allow the control of nematode diseases in livestock throughout an entire season with a single administration.

Isozyme-selective metabolism of ethyl carbamate by cytochrome P450 (CYP2E1) and carboxylesterase (hydrolase A) enzymes in murine liver microsomes

Cytochrome P450 and carboxylesterase enzymes have been implicated in the metabolism of the carcinogen ethyl carbamate (EC). In this study, we have used a murine liver microsomal system to investigate the relative contributions of P450 and carboxylesterase isozymes to hepatic metabolism of EC. N-Nitrosodimethylamine (NDMA) demethylation and p-nitrophenyl acetate (PNA) hydrolysis were used as catalytic markers of CYP2E1 and carboxylesterase enzymes, respectively. Incubation of liver microsomes with EC (1 mM) produced slight but significant decreases in NDMA demethylation and PNA hydrolysis activities. Incubation of microsomes with paraoxon (PAX), a general carboxylesterase inhibitor, or phenylmethylsulfonyl fluoride (PMSF), a specific inhibitor of hydrolase A, produced decreases of 85 and 45%, respectively, in carboxylesterase activities; neither of the inhibitors elicited alterations in levels of NDMA demethylation. Reaction of microsomes with either PAX or PMSF and then with EC exacerbated the reduction (285%) of NDMA demethylation, and this loss corresponded to decreases in immunodetectable CYP2E1 content. The reduction in PNA hydrolysis activity induced by PAX, PMSF, or EC correlated with decreased immunodetectable hydrolase A in liver microsomes; however, reaction with PAX and not PMSF or EC resulted in loss of immunoreactivity for hydrolase B. These data correlated with levels of covalent binding of [ethyl-14C]EC to liver microsomes, which were significantly elevated in incubations conducted with PAX or PMSF. Antibody inhibition of the CYP2E1 enzyme significantly reduced levels of binding to microsomal proteins, compared with control levels. These results are consistent with the premise that EC is metabolized by CYP2E1 and hydrolase A in liver microsomes of mice.

Metabolism of ethyl carbamate by pulmonary cytochrome P450 and carboxylesterase isozymes: involvement of CYP2E1 and hydrolase A

The lung is highly susceptible to ethyl carbamate (EC)-induced tumorigenesis. Our goal in this study was to investigate the in vitro isozyme-selective metabolism of EC in lung microsomes by cytochrome P450 and carboxylesterase enzymes. Our results showed that incubations with EC produced significant reduction in p-nitrophenol (PNP) hydroxylation and N-nitrosodimethylamine (NDMA) demethylation; there were no alterations in 7-pentoxyresorufin- and 7-ethoxyresorufin O-dealkylase activities. Reaction of microsomes with an inhibitory CYP2E1 antibody and subsequent reaction with EC abolished the EC-induced diminution in NDMA demethylase activity. Carboxylesterase activity, as assessed by hydrolysis of p-nitrophenyl acetate, was significantly decreased in microsomes incubated with EC. Reactions with EC in conjunction with the carboxylesterase inhibitors, paraoxon (PAX) or phenylmethylsulfonyl fluoride (PMSF), abolished the EC-induced decrease in carboxylesterase activity; PAX is a broad-spectrum carboxylesterase inhibitor, whereas PMSF is a specific inhibitor of hydrolase A, a carboxylesterase isozyme. Incubations of EC in combination with either PAX or PMSF exacerbated the EC-induced reduction in PNP hydroxylase and NDMA demethylase activities. Alterations in immunodetectable CYP2E1 protein levels were not apparent in microsomes incubated with EC alone, but the amounts were decreased in reactions with EC in conjunction with either PAX or PMSF. Immunoblotting with antibodies for the carboxylesterase isozymes, hydrolase A and B, revealed loss of immunodetectable hydrolase A in microsomes incubated with EC, PAX, or PMSF. However, immunodetectable hydrolase B was only decreased in microsomes reacted with PAX but not with PMSF or EC. These findings correlated with our covalent binding data, which showed that levels of binding of [14C-ethyl]EC to lung microsomes were significantly higher in incubations conducted in conjunction with PAX or PMSF, compared with control levels. Antibody inhibition of the CYP2E1 enzyme significantly reduced the extent of binding. Our results demonstrated that EC metabolism in lung microsomes, as estimated from magnitudes of covalent binding, is mediated by the P450 isozyme CYP2E1 and the carboxylesterase isozyme hydrolase A.

Characterization of cytokine profiles and double-positive lymphocyte subpopulations in normal bovine lungs

OBJECTIVE

To characterize cytokine profiles and lymphocyte subpopulations in lung parenchyma and bronchoalveolar lavage (BAL) fluid from normal bovine lungs.

ANIMALS

Eight 12- to 18-month-old cattle.

PROCEDURE

Cell populations in BAL fluid and collagenase-digested lung parenchyma were analyzed by flow cytometry and monoclonal antibodies. Proportions of total cell populations were determined, using Giemsa-stained cytospots. Distribution of lymphocytes within the lung parenchyma was analyzed by immunohistochemistry, and cytokine mRNA species in the parenchyma were characterized by use of reverse transcriptase-polymerase chain reaction analysis.

RESULTS

Cytokine profiles indicated high amounts of mRNA for interleukins 6 and 10 and transforming growth factor beta. In the BAL fluid and lung parenchyma, macrophages were the predominant cell type, although the proportion was lower in the parenchyma. Lymphocytes made up approximately 3% of both cell populations. Common to both lung compartments was the predominance of CD2+ and gamma delta T cells over B lymphocytes. There were more CD8+ T cells than CD4+ T cells in both compartments. The gamma delta cells made up approximately 9% of the lymphocyte populations. Two-color flow cytometry revealed CD8+ gamma delta T cell and CD8+CD5- populations that were unique to BAL fluid. In the BAL fluid and parenchyma, most CD4+ and CD8+ T cells expressed high amounts of CD44, a characteristic of memory T cells. The gamma delta T cells were CD44(10), as were B cells in the lung parenchyma. The B cells from BAL fluid expressed high amounts of CD44. Immunohistologic analysis of lung tissue revealed bronchus-associated lymphoid tissue structures with distinctive germinal center organization of B cells encompassed by CD4+ T cells.

CONCLUSIONS

Results provided normal values for comparison with those of other species and with the bovine respiratory tract response to disease.

Differential formation of 1,1-dichloroethylene-metabolites in the lungs of adult and weanling male and female mice: correlation with severities of bronchiolar cytotoxicity

The bronchiolar Clara cell cytotoxicant, 1,1-dichloroethylene (DCE), is selectively metabolized by CYP2E1 to metabolites including 2,2-dichloroacetaldehyde and DCE-epoxide. We have performed comparative studies in the lungs of adult and weanling male and female mice to determine their relative capacities to metabolize DCE. Levels of activities of p-nitrophenol hydroxylase, N-nitrosodimethylamine demethylase and NADPH-cytochrome P450 reductase were all significantly higher in adult female mice than in either adult male or weanling mice of both sexes. The quantities of 2,2-dichloroacetaldehyde (identified as its hydrolysis product, acetal) and the DCE-epoxide (identified as the GSH conjugates, 2-(S-glutathionyl) acetyl glutathione [B] and 2-S-glutathionyl acetate [C]) formed were significantly higher in lung microsomes from adult female mice than in those from either adult male or weanling mice of both sexes. Also, the metabolite levels formed in weanling mice were significantly higher than in adult male mice. The amounts of DCE-metabolites produced correlated with the relative severities of DCE-induced bronchiolar damage. The severities of bronchiolar injury were in the rank order adult female > weanling male and female > adult male mice, and coincided with the rank order of DCE-epoxide formation in these experimental groups of mice. In comparison with adult male and weanling male and female mice, adult female mice expressed highest levels of activities of CYP2E1-selective and reductase enzymes, formed most of the DCE-epoxide and were most susceptible to DCE-induced pneumotoxicity. These findings demonstrated sex-related differences in expression of activating enzymes and DCE metabolism in lung, and only in the adult female vs. female weanling mice were there age-related effects in regard to formation of both DCE-metabolites and cytotoxicity.

Purification of hydrophobic integral membrane proteins from Mycoplasma hyopneumoniae by reversed-phase high-performance liquid chromatography

A general and practical approach for isolating, fractionating and purifying large quantities of outer membrane hydrophobic proteins is described as applied to membrane proteins of Mycoplasma hyopneumoniae. Outer membrane proteins were extracted with Triton X-114 detergent and were precipitated from the detergent phase with 90% ethanol. Precipitated proteins were dissolved in 65% formic acid and separated by RP-HPLC using a formic acid-acetonitrile gradient. A M(r) 48 000 protein was obtained in high yield and at greater than 90% purity by optimisation of parameters for RP-HPLC. The combination of Triton X-114 extraction followed by high resolution RP-HPLC is a novel and rapid procedure for the isolation and purification of hydrophobic proteins. Proteins purified by this approach were suitable for subsequent characterisation by direct sequencing of the amino terminus as well as generation of peptides by digestion with cyanogen bromide.

Protection from 1,1-dichloroethylene-induced Clara cell injury by diallyl sulfone, a derivative of garlic

Bronchiolar Clara cell damage ensues after treatment of mice with 1,1-dichloroethylene (DCE). The cytotoxicity is mediated by CYP2E1, a cytochrome P450 isozyme that is highly localized in the Clara cells. Bioactivation of DCE produces the primary metabolites 2,2-dichloroacetaldehyde, which hydrolyzes to the acetal, and DCE epoxide, which reacts with glutathione to form the conjugates 2-(S-glutathionyl) acetyl glutathione [B] and 2-S-glutathionyl acetate [C]. In this study, we investigated the potential of diallyl sulfone (DASO2) to inhibit CYP2E1, to suppress the bioactivation of DCE to reactive intermediates and to abrogate DCE-induced Clara cell cytotoxicity. Our results showed that treatment of mice with DASO2 (100 mg/kg p.o.) produced decreases in CYP2E1-dependent p-nitrophenol hydroxylation that were apparent at 1 h. Enzyme activity plummeted to about 20% of the control by 2 h and remained at this low level from 3 to 8 h. Recovery of activity was evident at 16 h and returned to the control level by 24 h. Immunoreactivity of the CYP2E1 protein was decreased in immunoblots of lung microsomes from DASO2-treated mice. Treatment with DASO2 did not cause any structural alterations in lung tissue; in contrast, treatment with DCE (75 mg/kg) produced Clara cell damage. This lesion was not manifested in mice treated with DASO2 in conjunction with DCE. The lack of cytotoxicity observed in vivo correlated with a reduction of about 45% in the levels of both the acetal and the DCE epoxide-derived conjugates [B] and [C] in vitro. These results demonstrated that DASO2 significantly inhibited the CYP2E1 enzyme, decreased the production of DCE metabolites and protected Clara cells from DCE-induced cytotoxicity.

Predictors of mortality in severe malaria: a two year experience in a non-endemic area

Management of severe malaria is an increasing problem worldwide. This paper reviews the pathophysiology and management documenting two years' experience of admissions of severe malaria to an ICU in a non-endemic area. Clinical and laboratory features of severe malaria were analysed for predictors of mortality Twenty-eight patients had clinical or laboratory features compatible with the WHO criteria for severe malaria and, despite treatment with intravenous quinine and supportive ICU care, mortality was 28.5% (8/28). The three pregnant patients died with 100% foetal mortality and the four paediatric patients survived. Of the non-survivors, 8/8 developed ARDS (defined by worst ALI score > 2.5), 7/8 developed shock requiring inotropic support and 7/8 developed acute renal failure requiring CVVHD. Admission haemoglobin, platelet count, parasite count, and lowest Glasgow Coma Score in the first 24 hours were shown not to be predictors of mortality.

Pulmonary CYP2E1 bioactivates 1,1-dichloroethylene in male and female mice

Pulmonary cytotoxicity induced by 1,1-dichloroethylene (DCE) has been linked to the generation of reactive intermediates through a cytochrome P450-dependent pathway. In the present studies, our objectives were to investigate and compare cytochrome P450 isozyme-selective bioactivation of DCE in vitro in the lungs of male and female mice. Our results showed that CYP2E1-dependent p-nitrophenol hydroxylation was significantly higher in microsomes from female (0.45 +/- 0.01 nmol/mg protein/min) than from male (0.38 +/- 0.02 nmol/mg protein/min) mice. Lung microsomes from male mice incubated in the presence of an NADPH-generating system and increasing amounts of DCE (5-20 mM) exhibited corresponding decreases in p-nitrophenol hydroxylase activity (19%-50%); however, greater decreases (26%-70%) were observed in lung microsomes from female mice incubated under the same conditions. In contrast, alterations in CYP2B1-dependent 7-pentoxyresorufin O-dealkylation and CYP1A1-dependent 7-ethoxyresorufin O-dealkylation were not detected in any microsomal preparation incubated with DCE. Reaction with an anti-CYP2E1 antibody abolished the inhibition of p-nitrophenol hydroxylation by DCE. Protein immunoblotting revealed significant decreases in the intensity of the bands of microsomal samples incubated previously with DCE; in contrast, alterations in heme content were not evoked by reaction with DCE. Our results have demonstrated that CYP2E1, and not CYP2B1 or CYP1A1, mediated the bioactivation of DCE. Furthermore, this bioactivation occurred to a greater extent in lung microsomes from female than from male mice, which suggests that females may be at slightly greater risk for DCE-induced pneumotoxicity.

Antigens identified by monoclonal antibodies in tissue sections of Boophilus microplus

A panel of monoclonal antibodies (mAbs) raised against midgut antigens of Boophilus microplus were used to probe various stages and organs of the tick. One of the monoclonal antibodies in this panel (QU13) has previously been shown to recognize protective antigens. Of the 18 mAbs tested, all except two (QU5 and QU12) reacted with sections of adult midgut and Malpighian tubules using an avidin-biotin alkaline phosphatase method for immunostaining. MAbs QU1, QU2, QU3, QU4, QU12, QU13, and QU18 reacted specifically with the lumenal surfaces of type III acini of the salivary gland. These seven mAbs also stained the midgut in larval sections indicating that the antigens recognized were not stage specific. However, none of the seven mAbs tested recognised antigens in either the adult ovary or the developing egg. Antigens which were immunogold labelled by mAbs QU1, QU4, QU11, QU13, and QU15 in electron microscopy were located either on or near the surface of the microvilli of digestive cells from the midgut of the adult tick. We conclude that common antigens are present on the lumenal surfaces of the adult midgut, type III acini of the salivary gland, and the Malpighian tubules and that these antigens are also located in the larval gut.

Anti-idiotypic antibodies as surrogate antigens for vaccinating against the cattle tick, Boophilus microplus

QU13, a monoclonal antibody (mAb) raised against midgut (GM) antigens from Boophilus microplus and shown to recognise antigens which protect cattle from tick challenge was used to immunise cattle and rabbits to produce anti-idiotypic antibodies (AIA). Polyclonal antisera against mAb QU13 were produced in rabbits and cattle. AIA were purified from these antisera by affinity chromatography procedures. These purified AIA were found to block mAb QU13 binding to GM in enzyme-linked immunosorbent assay (ELISA). AIA purified from bovine antiserum elicited an immune response in cattle to antigens extracted by detergent from the midgut of B. microplus (TXGM) after the fourth vaccination (P = 0.06) compared with the bovine immunoglobulin (Ig) control. The mean antibody level in the group of experimental cattle vaccinated with AIA purified from rabbit antisera was significantly higher (P < 0.03) than that of bovine Ig control cattle after the fourth vaccination and an anamnestic response (P < 0.11) occurred in the rabbit AIA vaccinated group of cattle when a single booster dose of 300 micrograms of TXGM was given after the first tick challenge. The positive control group of cattle vaccinated with TXGM were significantly protected (P < 0.05) against tick infestation after the booster dose of 300 micrograms of TXGM. The AIA vaccinated groups of cattle were not protected against challenge with 20,000 larval ticks either before or after the booster injection of 300 micrograms of TXGM.

In vitro biotransformation of 1,1-dichloroethylene by hepatic cytochrome P-450 2E1 in mice

1,1-Dichloroethylene (DCE) is hepatotoxic in mice and its cytotoxic effects are associated with cytochrome P-450 (P450)-dependent formation of metabolite(s) that bind covalently to tissue macromolecules. Our goal was to investigate effects of DCE on P450 in liver microsomes. Specific objectives were to examine 1) inactivation of P450 by DCE and to determine if during this inactivation the heme and/or apoprotein moieties are destroyed and 2) isozyme-selective biotransformation of DCE by P450. Our results showed significant reduction of P450 content in reactions containing DCE and microsomes from untreated (30%) or phenobarbital-treated (20%) mice. Maximal reduction (50%) of P450 was evoked by DCE in reactions catalyzed by microsomes from acetone-treated mice. Alterations in heme levels were not detected in any microsomal preparation incubated in the presence of DCE. Significant inhibition of p-nitro-phenol hydroxylation was found in microsomes incubated previously with DCE and was most pronounced in acetone-treated mice, as compared to control and phenobarbital-treated mice. DCE did not cause inhibition of 7-pentoxyresorufin-O-dealkylation in any microsomal preparation. Immunoinhibition with an anti-2E1 antibody abolished the observed inhibition of p-nitrophenol hydroxylation. Densitometric scanning of protein immunoblots using an anti-2E1 antibody revealed a 40% decrease in microsomes reacted with DCE, whereas no change was observed in immunoblots prepared with an anti-2B antibody. These results showed that 1) biotransformation of DCE is catalyzed by the 2E1 and not by the 2B enzyme and 2) DCE inactivates P450 by destruction of the apoprotein rather than the heme moieties.

Mesenteric panniculitis presenting as a multilocular cystic mesenteric mass: CT and MR evaluation

Mesenteric panniculitis is a non-neoplastic, inflammatory process affecting the adipose tissue of the mesentery in adults with slight male predilection. Typical computed tomography (CT) or magnetic resonance imaging (MRI) findings are of either diffuse mesenteric infiltration or nodular mesenteric masses. We encountered a case of mesenteric panniculitis in a 26-year-old woman with the left upper quadrant pain and fullness, in which CT and MRI disclosed a large, ill-defined, multilocular cystic mesenteric mass. After surgery, the diagnosis of mesenteric panniculitis was made. The cystic components were dilated lymphatics due to lymphatic and venous obstruction by the mesenteric panniculitis.

Immune responses of cattle to biochemically modified antigens from the midgut of the cattle tick, Boophilus microplus

Treatment of membrane antigens of the midgut (GM) of the cattle tick, Boophilus microplus with sodium metaperiodate (periodate), pronase and lipase significantly inhibited the reactivity of the GM with antibodies in the sera of 57 cattle vaccinated with GM. Treatment of GM with periodate only removed the correlation between antibody reactivity of sera and protection against infestation with ticks. A monoclonal antibody (MoAb QU13), which recognises protective antigens solubilized from GM (Lee + Opdebeeck 1991), did not react with GM treated with periodate. Cattle vaccinated with GM extracts were significantly protected against infestation with cattle ticks (P less than 0.05), whereas cattle vaccinated with either GM extracts treated with periodate or with antigens precipitated from GM extracts with MoAb QU13 and also treated with periodate, were not protected against infestation. These studies provide preliminary evidence that protective antigens in the tick midgut membrane either are carbohydrate or are dependent on carbohydrate for their specificity.

CPAP, effective respiratory support in patients with AIDS-related Pneumocystis carinii pneumonia

Human Immunodeficiency Virus (HIV) related Pneumocystis carinii pneumonia (PCP) associated with severe respiratory failure is an increasingly common problem in major centres and is associated with a high mortality in previous and recent studies. Early in the epidemic, alternatives to invasive intensive care treatment were utilized in our institution and found to be successful. When respiratory failure developed, mask CPAP was used instead of intubation and ventilation. A retrospective review of 175 cases of HIV infected patients with confirmed first presentation PCP was undertaken. Treatment with our protocol resulted in an overall hospital mortality of 9%. Those patients who did not require supplemental oxygen or respiratory support had no in-hospital mortality. The group who required supplemental oxygen had a mortality of 10%. If respiratory failure supervened (severe respiratory distress, PaO2 less than 50 mmHg, SaO2 less than 90% on mask oxygen), CPAP was introduced. The mortality in this group was 22%. Only two patients were admitted to the intensive care unit for respiratory support after failure of CPAP. Both patients were intubated and received intermittent positive pressure ventilation (IPPV). Both patients died.

Isolation of protective antigens from the gut of Boophilus microplus using monoclonal antibodies

Monoclonal antibodies (mAb) were produced against midgut membrane (GM) antigens of Boophilus microplus. The isotypes of these mAb were established and their specificity characterized using double diffusion and Western blotting. GM antigens solubilized by Triton X-100 were precipitated by mAb QU13, and the precipitate was then injected into cattle to test for the presence of protective antigens. Vaccinated cattle challenged with 10-day-old larval ticks showed evidence of protection with a 62% reduction in eggs produced by ticks from vaccinated cattle compared to tick eggs from control cattle. In a second vaccine-challenge experiment, the dose of precipitate was increased and greater than 99% protection was provided to these vaccinated cattle following challenge (calculated from tick egg weights compared to the control group). The solubilized antigen(s) precipitated by QU13 were subjected to SDS-PAGE separation and the calculated sizes of these molecules were greater than 200,000, 80,000, 74,000, 62,000 57,000 and less than 30,000 MW.