BCG immunization induces CX3CR1hi effector memory T cells to provide cross-protection via IFN-γ-mediated trained immunity

After a century of using the Bacillus Calmette-Guérin (BCG) vaccine, our understanding of its ability to provide protection against homologous (Mycobacterium tuberculosis) or heterologous (for example, influenza virus) infections remains limited. Here we show that systemic (intravenous) BCG vaccination provides significant protection against subsequent influenza A virus infection in mice. We further demonstrate that the BCG-mediated cross-protection against influenza A virus is largely due to the enrichment of conventional CD4+ effector CX3CR1hi memory αβ T cells in the circulation and lung parenchyma. Importantly, pulmonary CX3CR1hi T cells limit early viral infection in an antigen-independent manner via potent interferon-γ production, which subsequently enhances long-term antimicrobial activity of alveolar macrophages. These results offer insight into the unknown mechanism by which BCG has persistently displayed broad protection against non-tuberculosis infections via cross-talk between adaptive and innate memory responses.

Interleukin-3 coordinates glial-peripheral immune crosstalk to incite multiple sclerosis

Glial cells and central nervous system (CNS)-infiltrating leukocytes contribute to multiple sclerosis (MS). However, the networks that govern crosstalk among these ontologically distinct populations remain unclear. Here, we show that, in mice and humans, CNS-resident astrocytes and infiltrating CD44hiCD4+ T cells generated interleukin-3 (IL-3), while microglia and recruited myeloid cells expressed interleukin-3 receptor-ɑ (IL-3Rɑ). Astrocytic and T cell IL-3 elicited an immune migratory and chemotactic program by IL-3Rɑ+ myeloid cells that enhanced CNS immune cell infiltration, exacerbating MS and its preclinical model. Multiregional snRNA-seq of human CNS tissue revealed the appearance of IL3RA-expressing myeloid cells with chemotactic programming in MS plaques. IL3RA expression by plaque myeloid cells and IL-3 amount in the cerebrospinal fluid predicted myeloid and T cell abundance in the CNS and correlated with MS severity. Our findings establish IL-3:IL-3RA as a glial-peripheral immune network that prompts immune cell recruitment to the CNS and worsens MS.

Monocytes re-enter the bone marrow during fasting and alter the host response to infection

Diet profoundly influences physiology. Whereas over-nutrition elevates risk for disease via its influence on immunity and metabolism, caloric restriction and fasting appear to be salutogenic. Despite multiple correlations observed between diet and health, the underlying biology remains unclear. Here, we identified a fasting-induced switch in leukocyte migration that prolongs monocyte lifespan and alters susceptibility to disease in mice. We show that fasting during the active phase induced the rapid return of monocytes from the blood to the bone marrow. Monocyte re-entry was orchestrated by hypothalamic-pituitary-adrenal (HPA) axis-dependent release of corticosterone, which augmented the CXCR4 chemokine receptor. Although the marrow is a safe haven for monocytes during nutrient scarcity, re-feeding prompted mobilization culminating in monocytosis of chronologically older and transcriptionally distinct monocytes. These shifts altered response to infection. Our study shows that diet-in particular, a diet's temporal dynamic balance-modulates monocyte lifespan with consequences for adaptation to external stressors.

Human alveolar macrophage metabolism is compromised during Mycobacterium tuberculosis infection

Pulmonary macrophages have two distinct ontogenies: long-lived embryonically-seeded alveolar macrophages (AM) and bone marrow-derived macrophages (BMDM). Here, we show that after infection with a virulent strain of Mycobacterium tuberculosis (H37Rv), primary murine AM exhibit a unique transcriptomic signature characterized by metabolic reprogramming distinct from conventional BMDM. In contrast to BMDM, AM failed to shift from oxidative phosphorylation (OXPHOS) to glycolysis and consequently were unable to control infection with an avirulent strain (H37Ra). Importantly, healthy human AM infected with H37Ra equally demonstrated diminished energetics, recapitulating our observation in the murine model system. However, the results from seahorse showed that the shift towards glycolysis in both AM and BMDM was inhibited by H37Rv. We further demonstrated that pharmacological (e.g. metformin or the iron chelator desferrioxamine) reprogramming of AM towards glycolysis reduced necrosis and enhanced AM capacity to control H37Rv growth. Together, our results indicate that the unique bioenergetics of AM renders these cells a perfect target for Mtb survival and that metabolic reprogramming may be a viable host targeted therapy against TB.

Sleep exerts lasting effects on hematopoietic stem cell function and diversity

A sleepless night may feel awful in its aftermath, but sleep's revitalizing powers are substantial, perpetuating the idea that convalescent sleep is a consequence-free physiological reset. Although recent studies have shown that catch-up sleep insufficiently neutralizes the negative effects of sleep debt, the mechanisms that control prolonged effects of sleep disruption are not understood. Here, we show that sleep interruption restructures the epigenome of hematopoietic stem and progenitor cells (HSPCs) and increases their proliferation, thus reducing hematopoietic clonal diversity through accelerated genetic drift. Sleep fragmentation exerts a lasting influence on the HSPC epigenome, skewing commitment toward a myeloid fate and priming cells for exaggerated inflammatory bursts. Combining hematopoietic clonal tracking with mathematical modeling, we infer that sleep preserves clonal diversity by limiting neutral drift. In humans, sleep restriction alters the HSPC epigenome and activates hematopoiesis. These findings show that sleep slows decay of the hematopoietic system by calibrating the hematopoietic epigenome, constraining inflammatory output, and maintaining clonal diversity.

Brain motor and fear circuits regulate leukocytes during acute stress

The nervous and immune systems are intricately linked¹. Although psychological stress is known to modulate immune function, mechanistic pathways linking stress networks in the brain to peripheral leukocytes remain poorly understood². Here we show that distinct brain regions shape leukocyte distribution and function throughout the body during acute stress in mice. Using optogenetics and chemogenetics, we demonstrate that motor circuits induce rapid neutrophil mobilization from the bone marrow to peripheral tissues through skeletal-muscle-derived neutrophil-attracting chemokines. Conversely, the paraventricular hypothalamus controls monocyte and lymphocyte egress from secondary lymphoid organs and blood to the bone marrow through direct, cell-intrinsic glucocorticoid signalling. These stress-induced, counter-directional, population-wide leukocyte shifts are associated with altered disease susceptibility. On the one hand, acute stress changes innate immunity by reprogramming neutrophils and directing their recruitment to sites of injury. On the other hand, corticotropin-releasing hormone neuron-mediated leukocyte shifts protect against the acquisition of autoimmunity, but impair immunity to SARS-CoV-2 and influenza infection. Collectively, these data show that distinct brain regions differentially and rapidly tailor the leukocyte landscape during psychological stress, therefore calibrating the ability of the immune system to respond to physical threats.

Mitochondrial cyclophilin D promotes disease tolerance by licensing NK cell development and IL-22 production against influenza virus

Severity of pulmonary viral infections, including influenza A virus (IAV), is linked to excessive immunopathology, which impairs lung function. Thus, the same immune responses that limit viral replication can concomitantly cause lung damage that must be countered by largely uncharacterized disease tolerance mechanisms. Here, we show that mitochondrial cyclophilin D (CypD) protects against IAV via disease tolerance. CypD-/- mice are significantly more susceptible to IAV infection despite comparable antiviral immunity. This susceptibility results from damage to the lung epithelial barrier caused by a reduction in interleukin-22 (IL-22)-producing natural killer (NK) cells. Transcriptomic and functional data reveal that CypD-/- NK cells are immature and have altered cellular metabolism and impaired IL-22 production, correlating with dysregulated bone marrow lymphopoiesis. Administration of recombinant IL-22 or transfer of wild-type (WT) NK cells abrogates pulmonary damage and protects CypD-/- mice after IAV infection. Collectively, these results demonstrate a key role for CypD in NK cell-mediated disease tolerance.

Astrocytic interleukin-3 programs microglia and limits Alzheimer's disease

Communication within the glial cell ecosystem is essential for neuronal and brain health1-3. The influence of glial cells on the accumulation and clearance of β-amyloid (Aβ) and neurofibrillary tau in the brains of individuals with Alzheimer's disease (AD) is poorly understood, despite growing awareness that these are therapeutically important interactions4,5. Here we show, in humans and mice, that astrocyte-sourced interleukin-3 (IL-3) programs microglia to ameliorate the pathology of AD. Upon recognition of Aβ deposits, microglia increase their expression of IL-3Rα-the specific receptor for IL-3 (also known as CD123)-making them responsive to IL-3. Astrocytes constitutively produce IL-3, which elicits transcriptional, morphological, and functional programming of microglia to endow them with an acute immune response program, enhanced motility, and the capacity to cluster and clear aggregates of Aβ and tau. These changes restrict AD pathology and cognitive decline. Our findings identify IL-3 as a key mediator of astrocyte-microglia cross-talk and a node for therapeutic intervention in AD.

M. tuberculosis Reprograms Hematopoietic Stem Cells to Limit Myelopoiesis and Impair Trained Immunity

A greater understanding of hematopoietic stem cell (HSC) regulation is required for dissecting protective versus detrimental immunity to pathogens that cause chronic infections such as Mycobacterium tuberculosis (Mtb). We have shown that systemic administration of Bacille Calmette-Guérin (BCG) or β-glucan reprograms HSCs in the bone marrow (BM) via a type II interferon (IFN-II) or interleukin-1 (IL1) response, respectively, which confers protective trained immunity against Mtb. Here, we demonstrate that, unlike BCG or β-glucan, Mtb reprograms HSCs via an IFN-I response that suppresses myelopoiesis and impairs development of protective trained immunity to Mtb. Mechanistically, IFN-I signaling dysregulates iron metabolism, depolarizes mitochondrial membrane potential, and induces cell death specifically in myeloid progenitors. Additionally, activation of the IFN-I/iron axis in HSCs impairs trained immunity to Mtb infection. These results identify an unanticipated immune evasion strategy of Mtb in the BM that controls the magnitude and intrinsic anti-microbial capacity of innate immunity to infection.

Cyclophilin D Regulates Antiviral CD8+ T Cell Survival in a Cell-Extrinsic Manner

CD8+ T cell-mediated immunity is critical for host defense against viruses and requires mitochondria-mediated type I IFN (IFN-I) signaling for optimal protection. Cyclophilin D (CypD) is a mitochondrial matrix protein that modulates the mitochondrial permeability transition pore, but its role in IFN-I signaling and CD8+ T cell responses to viral infection has not been previously explored. In this study, we demonstrate that CypD plays a critical extrinsic role in the survival of Ag-specific CD8+ T cell following acute viral infection with lymphocytic choriomeningitis virus in mice. CypD deficiency resulted in reduced IFN-I and increased CD8+ T cell death, resulting in a reduced antiviral CD8+ T cell response. In addition, CypD deficiency was associated with an increase in pathogen burden at an early time-point following infection. Furthermore, our data demonstrate that transfer of wild-type macrophages (expressing CypD) to CypD-deficient mice can partially restore CD8+ T cell responses. These results establish that CypD plays an extrinsic role in regulating optimal effector CD8+ T cell responses to viral infection. Furthermore, this suggests that, under certain circumstances, inhibition of CypD function may have a detrimental impact on the host's ability to respond to viral infection.

Regulation of protein kinase Cδ Nuclear Import and Apoptosis by Mechanistic Target of Rapamycin Complex-1

Inactivation of the protein complex ‘mechanistic target of rapamycin complex 1’ (mTORC1) can increase the nuclear content of transcriptional regulators of metabolism and apoptosis. Previous studies established that nuclear import of signal transducer and activator of transcription-1 (STAT1) requires the mTORC1-associated adaptor karyopherin-α1 (KPNA1) when mTORC1 activity is reduced. However, the role of other mTORC1-interacting proteins in the complex, including ‘protein kinase C delta’ (PKCδ), have not been well characterized. In this study, we demonstrate that PKCδ, a STAT1 kinase, contains a functional ‘target of rapamycin signaling’ (TOS) motif that directs its interaction with mTORC1. Depletion of KPNA1 by RNAi prevented the nuclear import of PKCδ in cells exposed to the mTORC1 inhibitor rapamycin or amino acid restriction. Mutation of the TOS motif in PKCδ led to its loss of regulation by mTORC1 or karyopherin-α1, resulting in increased constitutive nuclear content. In cells expressing wild-type PKCδ, STAT1 activity and apoptosis were increased by rapamycin or interferon-β. Those expressing the PKCδ TOS mutant exhibited increased STAT1 activity and apoptosis; further enhancement by rapamycin or interferon-β, however, was lost. Therefore, the TOS motif in PKCδ is a novel structural mechanism by which mTORC1 prevents PKCδ and STAT1 nuclear import, and apoptosis.

Tolerogenic signaling of alveolar macrophages induces lung adaptation to oxidative injury

BACKGROUND

Inhaled oxidative toxicants present in ambient air cause airway epithelial injury, inflammation, and airway hyperresponsiveness. Effective adaptation to such environmental insults is essential for the preservation of pulmonary function, whereas failure or incomplete adaptation to oxidative injury can render the host susceptible to the development of airway disease.

OBJECTIVE

We sought to explore the mechanisms of airway adaptation to oxidative injury.

METHODS

For a model to study pulmonary adaptation to oxidative stress-induced lung injury, we exposed mice to repeated nose-only chlorine gas exposures. Outcome measures were evaluated 24 hours after the last chlorine exposure. Lung mechanics and airway responsiveness to methacholine were assessed by using the flexiVent. Inflammation and antioxidant responses were assessed in both bronchoalveolar lavage fluid and lung tissue. Using both loss or gain of function and genomic approaches, we further dissected the cellular and molecular mechanisms involved in pulmonary adaptation.

RESULTS

Repeated exposures to oxidative stress resulted in pulmonary adaptation evidenced by abrogation of neutrophilic inflammation and airway hyperresponsiveness. This adaptation was independent of antioxidant mechanisms and regulatory T cells but dependent on residential alveolar macrophages (AMs). Interestingly, 5% of AMs expressed forkhead box P3, and depletion of these cells abolished adaptation. Results from transcriptomic profiling and loss and gain of function suggest that adaptation might be dependent on TGF-β and prostaglandin E₂.

CONCLUSION

Pulmonary adaptation during oxidative stress-induced lung injury is mediated by a novel subset of forkhead box P3-positive AMs that limits inflammation, favoring airway adaptation and host fitness through TGF-β and prostaglandin E₂.

The heme-regulated inhibitor is a cytosolic sensor of protein misfolding that controls innate immune signaling

Multiple cytosolic innate sensors form large signalosomes after activation, but this assembly needs to be tightly regulated to avoid accumulation of misfolded aggregates. We found that the eIF2α kinase heme-regulated inhibitor (HRI) controls NOD1 signalosome folding and activation through a process requiring eukaryotic initiation factor 2α (eIF2α), the transcription factor ATF4, and the heat shock protein HSPB8. The HRI/eIF2α signaling axis was also essential for signaling downstream of the innate immune mediators NOD2, MAVS, and TRIF but dispensable for pathways dependent on MyD88 or STING. Moreover, filament-forming α-synuclein activated HRI-dependent responses, which suggests that the HRI pathway may restrict toxic oligomer formation. We propose that HRI, eIF2α, and HSPB8 define a novel cytosolic unfolded protein response (cUPR) essential for optimal innate immune signaling by large molecular platforms, functionally homologous to the PERK/eIF2α/HSPA5 axis of the endoplasmic reticulum UPR.

Dissecting host cell death programs in the pathogenesis of influenza

Influenza A virus (IAV) is a pulmonary pathogen, responsible for significant yearly morbidity and mortality. Due to the absence of highly effective antiviral therapies and vaccine, as well as the constant threat of an emerging pandemic strain, there is considerable need to better understand the host-pathogen interactions and the factors that dictate a protective versus detrimental immune response to IAV. Even though evidence of IAV-induced cell death in human pulmonary epithelial and immune cells has been observed for almost a century, very little is known about the consequences of cell death on viral pathogenesis. Recent study indicates that both the type of cell death program and its kinetics have major implications on host defense and survival. In this review, we discuss advances in our understanding of cell death programs during influenza virus infection, in hopes of fostering new areas of investigation for targeted clinical intervention.

RIPK3 interacts with MAVS to regulate type I IFN-mediated immunity to Influenza A virus infection

The type I interferon pathway plays a critical role in both host defense and tolerance against viral infection and thus requires refined regulatory mechanisms. RIPK3-mediated necroptosis has been shown to be involved in anti-viral immunity. However, the exact role of RIPK3 in immunity to Influenza A Virus (IAV) is poorly understood. In line with others, we, herein, show that Ripk3-/- mice are highly susceptible to IAV infection, exhibiting elevated pulmonary viral load and heightened morbidity and mortality. Unexpectedly, this susceptibility was linked to an inability of RIKP3-deficient macrophages (Mφ) to produce type I IFN in the lungs of infected mice. In Mφ infected with IAV in vitro, we found that RIPK3 regulates type I IFN both transcriptionally, by interacting with MAVS and limiting RIPK1 interaction with MAVS, and post-transcriptionally, by activating protein kinase R (PKR)-a critical regulator of IFN-β mRNA stability. Collectively, our findings indicate a novel role for RIPK3 in regulating Mφ-mediated type I IFN anti-viral immunity, independent of its conventional role in necroptosis.

Unravelling the networks dictating host resistance versus tolerance during pulmonary infections

The appearance of single cell microorganisms on earth dates back to more than 3.5 billion years ago, ultimately leading to the development of multicellular organisms approximately 3 billion years later. The evolutionary burst of species diversity and the “struggle for existence”, as proposed by Darwin, generated a complex host defense system. Host survival during infection in vital organs, such as the lung, requires a delicate balance between host defense, which is essential for the detection and elimination of pathogens and host tolerance, which is critical for minimizing collateral tissue damage. Whereas the cellular and molecular mechanisms of host defense against many invading pathogens have been extensively studied, our understanding of host tolerance as a key mechanism in maintaining host fitness is extremely limited. This may also explain why current therapeutic and preventive approaches targeting only host defense mechanisms have failed to provide full protection against severe infectious diseases, including pulmonary influenza virus and Mycobacterium tuberculosis infections. In this review, we aim to outline various host strategies of resistance and tolerance for effective protection against acute or chronic pulmonary infections.

Lipoxygenase-derived lipid mediators effectively regulate influenza-induced immunopathology

Despite the worldwide application of vaccination and other antiviral interventions, influenza A virus (IAV) infection still remains a serious threat to humans. The success of IAV infection is linked to its ability to cause lower airways infections, which activates alveolar macrophages and often leads to a cytokine storm, pneumonia and respiratory failure. At this stage, uncontrolled host inflammatory response is the major cause of death. Therefore, understanding the mechanisms of immune regulation during IAV infection is critical in preventing IAV-induced immunopathology and mortality. Although cytokines have been extensively studied in immunity to IAV infection, little is known about the role of eicosanoids. We have recently demonstrated that cyclooxygenase-derived PGE2 plays a deleterious role in protection against IAV infection by inhibiting antiviral type I interferon (IFN). Herein, we aimed to investigate the potential contribution of lipoxygenase (LOX)-derived lipid mediators in IAV-immunity using the 5-LOX (Alox5−/−) deficient mice. Our data indicate that despite reduced pulmonary IAV titers, Alox5−/− mice are more susceptible to infection and exogenous administration of stable lipoxin A4 restore protection to IAV in Alox5−/− mice. This increased susceptibility was coupled with enhanced immunopathology and decreased pulmonary function. Remarkably, the production of type I IFN and IL-10 were significantly reduced in the lungs of IAV-infected Alox5−/− mice as well as IAV-infected Alox5−/− macrophages. Collectively these findings identified a protective role of the LOX-derived lipids against IAV-induced immunopathology and may pave the way for novel anti-influenza treatments using stable bioactive lipids.

Annexin1 regulates DC efferocytosis and cross-presentation during Mycobacterium tuberculosis infection

The phagocytosis of apoptotic cells and associated vesicles (efferocytosis) by DCs is an important mechanism for both self tolerance and host defense. Although some of the engulfment ligands involved in efferocytosis have been identified and studied in vitro, the contributions of these ligands in vivo remain ill defined. Here, we determined that during Mycobacterium tuberculosis (Mtb) infection, the engulfment ligand annexin1 is an important mediator in DC cross-presentation that increases efferocytosis in DCs and intrinsically enhances the capacity of the DC antigen-presenting machinery. Annexin1-deficient mice were highly susceptible to Mtb infection and showed an impaired Mtb antigen-specific CD8+ T cell response. Importantly, annexin1 expression was greatly downregulated in Mtb-infected human blood monocyte-derived DCs, indicating that reduction of annexin1 is a critical mechanism for immune evasion by Mtb. Collectively, these data indicate that annexin1 is essential in immunity to Mtb infection and mediates the power of DC efferocytosis and cross-presentation.

Drosophila male courtship behavior is modulated by ecdysteroids

Temperature-dependent induction of ecdysteroid deficiency in the ecdysoneless mutant ecd(1) adult Drosophila melanogaster results in altered courtship behavior in males. Ecdysteroid deficiency brings about significantly elevated male-male courtship behavior including song production resembling that directed toward females. Supplementation with dietary 20-hydroxyecdysone reduces male-male attraction, but does not change motor activity, courtship patterns or attraction to females. These observations support the hypothesis that reduced levels of ecdysteroids increase the probability that male fruit flies will display courtship behaviors to male stimuli.

Epidemiology of influenza-associated hospitalization in adults, Toronto, 2007/8

The purpose of this investigation was to identify when diagnostic testing and empirical antiviral therapy should be considered for adult patients requiring hospitalization during influenza seasons. During the 2007/8 influenza season, six acute care hospitals in the Greater Toronto Area participated in active surveillance for laboratory-confirmed influenza requiring hospitalization. Nasopharyngeal (NP) swabs were obtained from patients presenting with acute respiratory or cardiac illness, or with febrile illness without clear non-respiratory etiology. Predictors of influenza were analyzed by multivariable logistic regression analysis and likelihoods of influenza infection in various patient groups were calculated. Two hundred and eighty of 3,917 patients were found to have influenza. Thirty-five percent of patients with influenza presented with a triage temperature >or=38.0 degrees C, 80% had respiratory symptoms in the emergency department, and 76% were >or=65 years old. Multivariable analysis revealed a triage temperature >or=38.0 degrees C (odds ratio [OR] 3.1; 95% confidence interval [CI] 2.3-4.1), the presence of respiratory symptoms (OR 1.7; 95% CI 1.2-2.4), admission diagnosis of respiratory infection (OR 1.8; 95% CI 1.3-2.4), admission diagnosis of exacerbation of chronic obstructive pulmonary disease (COPD)/asthma or respiratory failure (OR 2.3; 95% CI 1.6-3.4), and admission in peak influenza weeks (OR 4.2; 95% CI 3.1-5.7) as independent predictors of influenza. The likelihood of influenza exceeded 15% in patients with respiratory infection or exacerbation of COPD/asthma if the triage temperature was >or=38.0 degrees C or if they were admitted in the peak weeks during the influenza season. During influenza season, diagnostic testing and empiric antiviral therapy should be considered in patients requiring hospitalization if respiratory infection or exacerbation of COPD/asthma are suspected and if either the triage temperature is >or=38.0 degrees C or admission is during the weeks of peak influenza activity.

The use of hand held mobile phones by drivers

The use of mobile phones by drivers has been shown to be associated with an increased risk of motor vehicle crashes. The aim of this study was to identify the use of hand held mobiles phones by drivers in Ireland. Their use was investigated by a direct observation survey of drivers. The study showed that 3.6% of drivers were using hand held mobile phones while driving. This rate is high compared to other studies. Van drivers were three times more likely than other drivers to use a mobile phone whilst driving. Legislation needs to be introduced to ban their use and thereby reduce the risk of crashes.

The burden of alcohol misuse on emergency in-patient hospital admissions among residents from a health board region in Ireland

AIMS

To identify in-patient emergency admissions to acute hospitals of residents from a health board region in the Republic of Ireland with an acute alcohol intoxication diagnosis; to profile the admissions and to assess whether the increase in alcohol consumption in Ireland has been mirrored by an increase in alcohol related emergency admissions over the same time period.

DESIGN

A retrospective review of hospital admissions using Hospital In-Patient Enquiry (HIPE) data and alcohol consumption trends using data from the Central Statistics Office (CSO).

SETTING

Acute hospitals in the Republic of Ireland.

PARTICIPANTS

All residents from a health board region admitted with a recorded alcohol intoxication emergency admission to non-private acute hospitals in Ireland.

MEASUREMENTS

All in-patient emergency admissions for which an acute alcohol intoxication diagnosis (ICD Codes 303.0 and 305.0) was recorded of residents from one health board region were extracted from the HIPE system for years 1997-2001 inclusive. Pearson's chi2 test was used to compare proportions in groups of categorical data and chi2 test for trend was used to identify linear trends. Age standardized rates were calculated for each year and trend analysis carried out. Demographic data on the patients were also extracted from the database.

FINDINGS

There were 3289 acute alcohol intoxication admissions to acute hospitals of residents from the study region recorded for years 1997-2001 inclusive. There were 777 acute alcohol intoxication admissions in 2001 compared to 432 admissions in 1997, an increase of 80%. Age standardized rates showed a significant increasing linear trend (P < 0.001). Over half the admissions occurred on weekends. The average length of stay was 2.7 days (95% CI 2.5-2.8) with just under a quarter (24.3%) of these admissions being discharged on the same day. The majority of these patients were male (71.5%), 40.9% were under 30 years old and over half (59.4%) were single.

CONCLUSIONS

This study shows that alcohol intoxication accounted for a substantial number of emergency in-patient admissions to acute hospitals in one health board region in Ireland and that the age standardized recorded acute alcohol related emergency admission rate increased significantly over the 5-year period, 1997-2001. This increase mirrored the national increase in alcohol consumption over the same time period.

A randomized placebo-controlled multicentre study to evaluate the safety and efficacy of finasteride for male chronic pelvic pain syndrome (category IIIA chronic nonbacterial prostatitis)

OBJECTIVE

To determine if finasteride can reduce symptoms in men with a clinical diagnosis of chronic nonbacterial prostatitis (National Institutes of Health, NIH, category IIIA chronic pelvic pain syndrome, CPPS) compared with placebo.

PATIENTS AND METHODS

Men (76) with category IIIA CPPS enrolled in four North American prostatitis research centres were randomized after a 2-week placebo run-in to finasteride or placebo for 6 months. The primary efficacy variable was a subjective overall assessment (SOA); the secondary efficacy variables included the NIH chronic prostatitis symptom index (NIH-CPSI) and safety data. Patients were assessed at screening, baseline (after the 2-week placebo run-in), 3 and 6 months.

RESULTS

Sixty-four patients had at least one assessment on medication (31 placebo, 33 finasteride); 75% of the finasteride and 54% of the placebo group had at least a mild improvement (defined as > 25% improvement in SOA), and 44% and 27%, respectively, a moderate or marked improvement (>50% improvement in SOA). The trend was similar in the NIH-CPSI scores. Five patients in the finasteride and seven in the placebo group reported medication-related adverse events.

CONCLUSION

This randomized placebo-controlled pilot study suggests that finasteride was of benefit for some men with category IIIA CPPS, but the results do not justify recommending finasteride as monotherapy, except for men who also have benign prostatic hyperplasia. A larger, properly powered study, possibly evaluating combination with other therapies or specifically in men with prostatitis and benign prostatic hyperplasia, is required to confirm any clinical benefit.

Predictors of patient response to antibiotic therapy for the chronic prostatitis/chronic pelvic pain syndrome: a prospective multicenter clinical trial

PURPOSE

To our knowledge antibiotics are the most popular choice of therapy for all categories of the chronic prostatitis/chronic pelvic pain syndrome. We determine if culture, leukocyte and/or antibody status of prostate specific specimens predicts patient response to antibiotic therapy.

MATERIALS AND METHODS

Patients clinically diagnosed with the chronic prostatitis/chronic pelvic pain syndrome according to the National Institutes of Health (NIH) definition had a lower urinary tract evaluation that included standard microscopy and culture of prostate specific specimens, and determination of the ratio of voided bladder 3 and voided bladder 2 antibody levels against a panel of identified prostate pathogens (enzyme linked immunosorbent assay methodology). Symptom evaluation consisted of the NIH chronic prostatitis symptom index (derived) pain scale 0 to 21, symptom severity index scale 0 to 100, symptom frequency questionnaire scale 0 to 50 and quality of life scale 0 to 6. Patients were stratified according to microscopy, culture and immune status, were treated with 12 weeks of ofloxacin, and were assessed at 4, 12 and 24 weeks with symptom scores as well as global assessments.

RESULTS

Based on leukocyte and culture results, 102 evaluable patients were stratified into categories II (14%), IIIA (48%) and IIIB (38%) of the chronic prostatitis/chronic pelvic pain syndrome. Of the cases 23% were categorized as antibody positive and 77% as antibody negative. Average age was 42 +/- 10 years and 92% of patients were white. Of the patients 57% believed that they had moderate to marked improvement. All categories of the chronic prostatitis/chronic pelvic pain syndrome and patients in whom antibody was positive or negative had significant improvement in the NIH chronic prostatitis symptom index, symptom severity index, symptom frequency questionnaire and quality of life scores compared with baseline (p <0.001). There was no significant difference in patient response to the stratification based on culture, leukocyte, that is categories II, IIIA and IIIB had same beneficial response, or antibody status.

CONCLUSIONS

Culture, leukocyte and antibody status of prostate specific specimens does not predict antibiotic response in patients with the chronic prostatitis/chronic pelvic pain syndrome. The perceived beneficial effect of antibiotics needs to be evaluated in a randomized placebo controlled trial.

Prevalence of prostatitis-like symptoms in a population based study using the National Institutes of Health chronic prostatitis symptom index

PURPOSE

The National Institutes of Health (NIH) chronic prostatitis symptom index was used to determine the prevalence of prostatitis-like symptoms among men (age 20 to 74 years) at risk in a community based study.

MATERIALS AND METHODS

The study was a cross-sectional postal survey of men age 20 to 74 years in Lennox and Addington counties, which included a large rural area, 1 major town and a suburban area with a stable population of men representative of Canadian demographics. The questionnaire collected information on 2 domains of chronic prostatitis identified in the NIH chronic prostatitis symptom index, including pain (location, severity and frequency), voiding function (irritative, obstructive), demographics, quality of life, general health and health seeking behavior. The self-reported pain score was used to identify prostatitis-like symptoms in the most discriminating domain. Based on analysis of the index final validation study comparing patients with prostatitis to normal controls and those with benign prostatic hyperplasia, the 2 questions most specific for prostatitis, including perineal and/or ejaculatory pain/discomfort, and a total pain score (0 to 21) 4 or greater were used to identify men with significant prostatitis-like symptoms.

RESULTS

A total of 2,987 eligible men received the survey, and it was completed by 868 (29%). Of the men 84 (9.7%) were identified as having chronic prostatitis-like symptoms (mean NIH chronic prostatitis symptom index pain score 9.1 +/- 0.3). The average age of the prostatitis population was 50 years compared with 52 years for men without prostatitis-like symptoms. Prevalence was 11.5% in men younger than 50 years and 8.5% in men 50 years or older. Of the sampled population 57 (6.6%) men had prostatitis-like symptoms and an index pain score 8 or greater (moderate to severe). The index voiding score (0 to 10) was 4.1 +/- 0.5 in men younger than 50 years compared with 1.5 +/- 0.1 for normal controls, and 4.7 +/- 0.4 in those 50 years or older compared with 1.9 +/- 0.1 for normal controls. Of the prostatitis group 60% sought medical help for their symptoms.

CONCLUSIONS

In our opinion this community based study using the new prostatitis symptom index confirms that chronic prostatitis-like symptoms are common.

Pentosan polysulfate therapy for chronic nonbacterial prostatitis (chronic pelvic pain syndrome category IIIA): a prospective multicenter clinical trial

OBJECTIVES

Chronic nonbacterial prostatitis/chronic pelvic pain syndrome (CPPS) has clinical and perhaps etiologic characteristics similar to interstitial cystitis. Pentosan polysulfate sodium (PPS), an oral medication indicated for the treatment of interstitial cystitis, has shown moderate benefit in reducing chronic pelvic pain and voiding symptoms in patients with interstitial cystitis. We undertook a prospective open-label, multicenter Phase II pilot study to examine the potential efficacy of PPS in the treatment of CPPS in men, using outcome tools validated for CPPS in men.

METHODS

Patients with a diagnosis consistent with National Institutes of Health (NIH) CPPS category IIIA (inflammatory) were treated with PPS, 100 mg three times daily, for 6 months. The evaluation at baseline, 3 months, and 6 months consisted of the Symptom Severity Index, a Symptom Frequency Questionnaire, the NIH-Chronic Prostatitis Symptom Pain Index (NIH-CPSI), a quality-of-life assessment, and a subjective global assessment.

RESULTS

Thirty-two patients (mean age 45.5 +/- 11 years; duration of symptoms 9.2 +/- 12 years) were enrolled in five centers; 28 patients were available for evaluation. Seven patients experienced drug-related side effects, including hair loss (n = 2), headache (n = 2), mild nausea (n = 1), mild weight gain (n = 1), and skin flushing (n = 1). The decrease in frequency (Symptom Frequency Questionnaire 28.1 to 17.9), severity (Symptom Severity Index 53.6 to 36.3), and combined location/frequency/severity of pain (NIH-CPSI pain 14.5 to 9.2) symptom scores at 6 months compared with baseline was significant. The decrease was associated with a significant improvement in patients' quality of life (quality-of-life assessment 5.3 to 3.8). Forty-three percent of the patients had a greater than 50% improvement in the Symptom Frequency Questionnaire, Symptom Severity Index, and NIH-CPSI (rated as clinically significant improvement). At 6 months, mild, moderate, and marked improvement was noted (subjective global assessment) by 33%, 19%, and 15% of the patients, respectively.

CONCLUSIONS

PPS is well tolerated and appears to have efficacy in reducing the severity and frequency of general symptoms, reducing specific pain symptoms, and improving the quality of life in many male patients with CPPS. The results of this study justify the initiation of a randomized controlled trial comparing the safety and efficacy of PPS to placebo.

Asymptomatic inflammation and/or infection in benign prostatic hyperplasia

OBJECTIVE

To determine the extent, pattern and clinical significance of asymptomatic histological inflammation and latent infection (National Institute of Health Category IV prostatitis) in benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

The study included 80 patients (from a cohort of 100 consecutive potentially eligible subjects) with a diagnosis of BPH, but no history or symptoms of prostatitis. Histological sections were obtained from specimens collected prospectively at transurethral resection of the prostate (TURP), immunostained for leukocyte common antigen and scanned using a computerized image-analysis system. Foci of inflammation were categorized as glandular, periglandular, stromal or peri-urethral, and the inflammatory cell density graded from 1 to 3. Relationships and correlations were calculated between the volume, degree and type of inflammation, presence and type of bacteria (culture of deep prostatic biopsies), the use of catheters and prostate specific antigen (PSA) levels.

RESULTS

Inflammation was identified in all patients but the mean tissue surface area involved was only 1.1% of the total specimen, with periglandular inflammation being the predominant pattern (0.5%). Of the prostate specimens, 44% showed bacterial growth (in 67% of the catheterized patients and 28% of those uncatheterized; 42% of patients were catheterized before TURP). There was no significant difference between any combination of inflammation pattern, volume or grade of inflammation in those catheterized or not (P=0.15) or culture-positive (pathogenic or not) and culture-negative cases (P=0.06). Neither total PSA or PSA density was significantly correlated (P>0.05) with the amount, degree or distribution of inflammation.

CONCLUSION

Prostatic inflammation is an extremely common histological finding in patients with symptoms of BPH who have no symptoms of prostatitis. There was no correlation between the degree and pattern of inflammation, catheterization, presence of bacteria, serum PSA or PSA density. The clinical significance of asymptomatic Category IV chronic prostatitis associated with BPH has yet to be determined.

Repetitive prostatic massage therapy for chronic refractory prostatitis: the Philippine experience

Patients frustrated with failure of traditional therapy for prostatitis have traveled to the Philippines and elsewhere for repetitive prostatic massage combined with antibiotic therapy. The aim of our study was to evaluate prospectively the response of patients who traveled to Manila to undergo this treatment. Twenty-six patients consented and were registered by the Prostatitis Foundation (B.H.) and subsequently evaluated (J.C.N., J.D.) prior to and following treatment (A.E.F.). Evaluation at baseline and after treatment consisted of standardized history and previously validated prostatitis-specific Symptom Frequency Questionnaire (SFQ) and Symptom Severity Index (SSI), International Prostate Symptom Score (I-PSS) and Quality of Life (QoL) questionnaire, the O'Leary Sexual Function Inventory (SFI), and a Subjective Global Assessment (SGA). Treatment in Manila consisted of triweekly prostatic massage combined with specific culture directed and/or empirical antimicrobial therapy for 6 to 12 weeks. Twenty-two patients completed at least one follow-up assessment and 12 patients completed 2-year assessment (average follow-up of 17 months in 22 patients). There was a significant decrease in average symptom severity (SSI) by 4 months that continued for 2 years, but less improvement in symptom frequency (SFQ) and quality of life (QoL), and no significant improvement in voiding symptoms (I-PSS) or sexual function (SFI) at time of last assessment. Forty-six percent of the 22 evaluable patients had >60% decrease (significant improvement) in symptom severity (SSI), whereas 27% had similar significant improvement in frequency of symptoms (SFQ) when last assessed. Thirty-three percent reported marked subjective improvement (SGA) at last evaluation. Of the 12 patients who completed the 2-year follow-up, 5 of the original 26 had a significant and sustainable improvement in objective and subjective measurements of frequency and severity of symptoms. The combination of prostatic massage and antibiotics for treating difficult refractory cases of prostatitis may be promising, but its ultimate value needs to be confirmed. Studies in patients with less refractory and shorter duration disease may allow us to predict who will respond to this therapeutic approach.

Relative efficacy of various exogenous glycosaminoglycans in providing a bladder surface permeability barrier

PURPOSE

To investigate the relative efficacy of heparin (H), pentosanpolysulfate (PPS) and hyaluronic acid (HA) in preventing the absorption of 14C labeled urea in protamine pretreated bladders compared with saline pretreated control bladders.

MATERIALS AND METHODS

Control Group - Rabbit bladders were pretreated with phosphate buffered saline (PBS) followed by instillation of 14C-urea. Radioactivity was determined in blood, bladder and fluid drained from the bladder. Protamine Group - Bladders were pretreated with of PBS followed by protamine sulfate. The bladders were then treated with 14C-urea and radioactivity determined as above. GAG Groups - Bladders were pretreated with saline and protamine as described above followed by instillation of: Group 3A - HA, Group 3B - H and Group 3C - PPS. The bladders were then treated with 14C-urea and radioactivity determined as described above.

RESULTS

Protamine treated bladders demonstrated significantly more radioligand uptake in bladder tissue compared with control bladders. There was no significant difference in radioligand uptake in bladders treated with PPS and H compared with control. While not significantly different, there was considerably more radioligand concentration in the blood of rabbits with bladders treated with protamine and protamine-HA compared with those of control rabbits and those treated with protamine-PPS and protamine-H.

CONCLUSIONS

Exogenous GAG's are effective in providing an epithelial permeability barrier in protamine pretreated bladders. There is a difference in the relative efficacy of the various GAG's in producing this effect.

Cervical spine degenerative diseases: an evaluation of clinical and imaging features in surgical decisions

In clinically severe cervical spondylosis, imaging plays a vital role in surgical decisions. A prime factor is acquired canal stenosis with cord compression. To validate this concept, the clinical and imaging features of 20 patients with spondylotic myelopathy and 24 with radiculopathy were retrospectively reviewed. All had computed tomographic myelography (CTM) as part of their clinical work-up. The patients' clinical severity was graded as mild, moderate and severe; the age, length of illness and a history of eventual surgery or otherwise were recorded. At the level of maximum compression the following parameters were obtained from the axial CTM images: surface area and ratio of the anteroposterior to the transverse diameter of the cord; subarachnoid space and vertebral canal areas. Data were statistically analysed. A significant association exists between surgery and increasing severity of symptoms (P = 0.04), and advancing age (P = 0.01). These associations hold true for myelopathy and radiculopathy. A strong association is present between surgery and the surface area of the cord (P = 0.01), being applicable to myelopathy only. The other parameters show no association with surgical decisions. It is concluded that with myelopathy a narrow cord area at the level of maximum compression, and moderate--severe functional impairment are indicators for surgical intervention.

Deriving respiration from pulse wave: a new signal-processing technique

Investigations of autonomic nervous system activity using spectral analysis of heart rate (HR) and blood pressure (BP) variability is very popular in many scientific disciplines, and yet only half of all studies involving spectral analysis control for respiration. Because respiration modulates HR and BP variability, knowledge of the respiratory rate is necessary for the proper interpretation of HR and BP power spectra. We devised and validated a new signal-processing technique to derive respiration from the blood pressure wave. This technique is based on the relationship between oscillations in the area under the dicrotic notch of the pulse wave and respiration. The results of our view signal-processing technique yielded significant correlations between protocols of the actual number of respiratory cycles and our blood pressure-derived respiratory cycles and their respective spectra for a number of standard autonomic tests (P < 0.05). Our method will allow retrospective extraction of the respiratory wave and as such afford a more precise interpretation of HR and BP spectra.

The psychological effects of multifetal pregnancy reduction

OBJECTIVE

To study the psychological effects of multifetal pregnancy reduction.

DESIGN AND SETTING

Hour-long semistructured telephone interviews with both multifetal pregnancy reduction patients and control subjects.

PATIENTS

Forty-two multifetal pregnancy reduction patients were contacted within 1 year of undergoing the procedure. Forty-four control subjects had become pregnant after infertility evaluation or treatment but conceived only a single fetus or twins and thus did not consider fetal termination.

MAIN OUTCOME MEASURES

Standardized measures of depressive disorder and current psychiatric symptoms, as well as questions about emotional reactions to multifetal pregnancy reduction.

RESULTS

Reduction patients who were pregnant or postpartum at the time of the interview (n = 34) were no more likely than pregnant or postpartum controls (n = 34) to report episodes of depression or high psychiatric symptom levels. The same proportion (14.7%) of both reduction patients and controls with a successful pregnancy outcome met criteria for an episode of major depressive disorder occurring during the 9 months before the interview. In contrast, the 8 reduction patients who spontaneously aborted the entire pregnancy and the 10 controls who spontaneously aborted reported significantly higher rates of the full depressive syndrome.

CONCLUSIONS

Multifetal pregnancy reduction is experienced as stressful and distressing. However, when pregnancy outcome is successful, the medical intervention does not put women at significant risk for affective illness or elevated levels of psychiatric symptoms.

Immunotherapy of an experimental adenocarcinoma of the prostate

We have developed and tested a fractionated, purified and deproteinized emulsion of a mycobacterial cell wall (MCW) and report on a controlled study of this compound in the treatment of the experimental R3327-H adenocarcinoma of the prostate. The intraperitoneal route of administration was found ineffective at the weekly dose of 500 micrograms. The intratumoral administration of 1000 micrograms of MCW exhibited significant antitumor activity. Tumors larger than 2.2 cm.3 in volume showed evidence of temporary regression, but no cures were recorded in these animals. Complete tumor regression was found in 50% of the rats with tumor volumes less than 2.2 cm.3 at the onset of treatment. The animals in this group not responding initially were treated with a second 3-week course of MCW which resulted in complete tumor regression in one-half of the animals, for a total cure rate, in the smaller tumor cohort, of 75%. Mycobacterial cell wall is an effective biological response modifier in the Dunning R3327-H adenocarcinoma of the prostate in Copenhagen rats. Additional studies to elucidate the effect of the compound in relation to dose and tumor volume are underway.

Adenosine-induced vasodilation: receptor characterization in pulmonary circulation

Adenosine mediates vascular smooth muscle relaxation in the pulmonary circulation. The A2 receptor has been suggested to mediate adenosine-induced vasodilation (AIV). In this study, the effect(s) of selective adenosine agonist and antagonist on the hypoxic pressor response (HPR) was assessed in the isolated blood-perfused rat lung. Adenosine (0.075-7.5 mM) infusion (0.125 ml/min) into the pulmonary artery dose dependently attenuated the HPR. AIV was mimicked by 10 microM 5'-(N-ethylcarboxamido)adenosine (NECA), a nonselective adenosine agonist. Adenosine- and NECA-induced vasodilation were attenuated by 67 microM 8-(p-sulfophenyl)theophylline. In contrast, NECA-induced vasodilation was not attenuated by the A1 antagonist 8-cyclopentyl-1,3-dipropylxanthine (1 microM). At 10 microM, a minimal vasodilatory effect was seen with the nonselective adenosine agonists CV-1808 and N6-(2-phenylisopropyl)adenosine (R-PIA) compared with NECA. The highly selective A2a agonist 2-[p-(2-carboxyethyl)phenyl amino]-5'-N-ethyl carboxamido adenosine (CGS-21680C, 10 microM) and A1 agonist 2-chloro-N6-cyclopentyladenosine (CCPA, 10 microM) had no vasodilatory effect. Neither the K+ channel blockers tetraethylammonium chloride (10 mM) and glibenclamide (100 microM) nor the NO synthase inhibitor N omega-nitro-L-arginine methyl ester attenuated NECA-induced vasodilation. These findings suggest that AIV is mediated via the A2b receptor and that AIV occurs via an NO-independent mechanism.

Antibiotic pharmacokinetics in the inflamed prostate

We hypothesized that altered pharmacokinetics in the inflamed prostate gland might account for the treatment failure of clinically diagnosed chronic bacterial prostatitis. We employed a rat model of chronic bacterial prostatitis to investigate any pharmacokinetic differences that may exist between uninflamed and inflamed prostate glands. Four groups of animals were studied (treated and untreated control and prostatitis groups). Seven days of norfloxacin therapy cured 60% of the animals with well-established bacterial prostatitis compared with a spontaneous cure rate of 10% in the nontreated prostatitis animals. Norfloxacin levels did not change significantly between the infected and noninfected prostate glands. We conclude that failure of antibiotic therapy in chronic bacterial prostatitis is not due to significantly altered norfloxacin pharmacokinetics in the chronically inflamed prostate gland but rather to the difficulty of eradicating protected bacterial microcolonies within an infection-induced altered microenvironment deep within the prostate gland.

Psychoanalysis, psychobiology, and homosexuality

The potential role of biological influences in human sexual orientation was considered more seriously during the early phases of psychoanalysis than in the years since World War II. Recently studies of homosexuality and heterosexuality in the neurosciences have attracted widespread attention both in the scientific and lay communities. The salience of these new data for psychoanalytic theory and practice is just beginning to be explored. In this article, we review research on sexual orientation in the following areas: genetics, crosscultural studies, studies of development in individuals with abnormal prenatal hormone exposure, childhood play patterns, and brain studies in both nonhumans and humans. Differences between male and female homosexuality are explored. We propose that psychoanalytic theory can grow and profit from a careful consideration of new findings in the psychobiology of sexuality, and that the interaction between mind and body is the appropriate purview of psychoanalysis.

Neurobiology and sexual orientation: current relationships

Despite great progress in the neurosciences, our understanding of the determinants of sexual orientation is incomplete. The authors review for the clinician/neuropsychiatrist studies pertaining to the formation of sexual orientation in the following areas: hormone effects on sexual behavior (animal and human); the complicated relationship between gender identity, gender role, and sexual orientation in humans; cross-cultural studies of homosexuality; behavioral observations in pseudohermaphrodites and offspring of mothers treated with hormones during pregnancy; brain studies of homosexual and heterosexual individuals; and genetic studies. The authors conclude that human sexual orientation is complex and diversely experienced and that a biopsychosocial model best fits the current state of knowledge in the field.