Alveolar Hemorrhage in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Results of an International Randomized Controlled Trial (PEXIVAS)

Rationale: Diffuse alveolar hemorrhage (DAH) is a life-threatening manifestation of antineutrophil cytoplasmic antibody-associated vasculitis (AAV). The PEXIVAS (Plasma Exchange and Glucocorticoids in Severe Antineutrophil Cytoplasmic Antibody-Associated Vasculitis) (NCT00987389) trial was the largest in AAV and the first to enroll participants with DAH requiring mechanical ventilation. Objectives: Evaluate characteristics, treatment effects, and outcomes for patients with AAV with and without DAH. Methods: PEXIVAS randomized 704 participants to plasma exchange (PLEX) or no-PLEX and reduced or standard-dose glucocorticoids (GC). DAH status was defined at enrollment as no-DAH, nonsevere, or severe (room air oxygen saturation of ⩽ 85% as measured by pulse oximetry, or use of mechanical ventilation). Measurements and Main Results: At enrollment, 191 (27.1%) participants had DAH (61 severe, including 29 ventilated) and were younger, more frequently relapsing, PR3 (proteinase 3)-ANCA positive, and had lower serum creatinine but were more frequently dialyzed than participants without DAH (n = 513; 72.9%). Among those with DAH, 8/95 (8.4%) receiving PLEX died within 1 year versus 15/96 (15.6%) with no-PLEX (hazard ratio, 0.52; confidence interval [CI], 0.21-1.24), whereas 13/96 (13.5%) receiving reduced GC died versus 10/95 (10.5%) with standard GC (hazard ratio, 1.33; CI, 0.57-3.13). When ventilated, ventilator-free days were similar with PLEX versus no-PLEX (medians, 25; interquartile range [IQR], 22-26 vs. 22-27) and fewer with reduced GC (median, 23; IQR, 20-25) versus standard GC (median, 26; IQR, 25-28). Treatment effects on mortality did not vary by presence or severity of DAH. Overall, 23/191 (12.0%) with DAH died within 1 year versus 34/513 (6.6%) without DAH. End-stage kidney disease and serious infections did not differ by DAH status or treatments. Conclusions: Patients with AAV and DAH differ from those without DAH in multiple ways. Further data are required to confirm or refute a benefit of PLEX or GC dosing on mortality. Original clinical trial registered with www.clinicaltrials.gov (NCT00987389).

Impact of surgical lung biopsy on lung function and survival in patients with idiopathic pulmonary fibrosis in a multi-centre registry cohort

BACKGROUND AND OBJECTIVE

Establishing an accurate and timely diagnosis of idiopathic pulmonary fibrosis (IPF) is essential for appropriate management and prognostication. In some cases, surgical lung biopsy (SLB) is performed but carries non-negligible risk. The objective of this retrospective study was to determine if SLB is associated with accelerated lung function decline in patients with IPF using the Canadian Registry for Pulmonary Fibrosis.

METHODS

Linear mixed models and Cox proportional hazards regression models were used to compare decline in forced vital capacity (FVC)%, diffusion capacity of the lung (DLCO%) and risk of death or lung transplantation between SLB and non-SLB patients. Adjustments were made for baseline age, sex, smoking history, antifibrotic use, and lung function. A similar analysis compared lung function changes 12 months pre- and post-SLB.

RESULTS

A total of 81 SLB patients and 468 non-SLB patients were included. In the SLB group, the post-biopsy annual FVC% decline was 2.0% (±0.8) in unadjusted, and 2.1% (±0.8) in adjusted models. There was no difference in FVC% decline, DLCO% decline, or time to death or lung transplantation between the two groups, in adjusted or unadjusted models (all p-values >0.07). In the pre-post SLB group, no differences were identified in FVC% decline in unadjusted or adjusted models (p = 0.07 for both).

CONCLUSION

No association between SLB and lung function decline or risk of death or lung transplantation was identified in this multi-centre study of patients with IPF.

Treatment of rheumatoid arthritis-associated interstitial lung disease in a multi-center registry cohort

Background

Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is challenging to manage, with a paucity of robust data to guide treatment. Our aim was to characterize the pharmacologic treatment of RA-ILD utilizing a retrospective design in a national multi-center prospective cohort, and to identify associations between treatment and change in lung function and survival.

Methods

Patients with RA-ILD and a radiological pattern of non-specific interstitial pneumonia (NSIP) or usual interstitial pneumonia (UIP) were included. Unadjusted and adjusted linear mixed models and Cox proportional hazards models were used to compare lung function change and risk of death or lung transplant by radiologic patterns and treatment.

Results

Of 161 patients with RA-ILD, UIP pattern was more common than NSIP (55.9% vs. 44.1%). Only 44/161 (27%) patients were treated over median follow-up of 4 years with medication choice appearing unrelated to patient-specific variables. Decline in forced vital capacity (FVC) was not associated with treatment. Patients with NSIP had lower risk of death or transplant, compared to UIP (P=0.0042). In patients with NSIP, there was no difference in time to death or transplant comparing treated to untreated in adjusted models [hazard ratio (HR) =0.73; 95% confidence interval (CI): 0.15-3.62; P=0.70]. Similarly, in patients with UIP, there was no difference in time to death or lung transplant between treated and untreated in adjusted models (HR =1.06; 95% CI: 0.49-2.28; P=0.89).

Conclusions

Treatment of RA-ILD is heterogeneous, with most patients in this cohort not receiving treatment. Patients with UIP had worse outcomes compared to NSIP, similar to other cohorts. Randomized clinical trials are needed to inform pharmacologic therapy in this patient population.

Sputum quantitative cytometry in patients with interstitial lung disease and chronic cough

BACKGROUND

Chronic cough frequently occurs in patients with diffuse interstitial lung diseases (ILDs), and can have negative effects on quality-of-life. While there are multiple possible contributors to cough in this setting, the contribution and consequences of airway inflammation have not been previously measured. We aimed to estimate the prevalence of airway cellular inflammation in patients with chronic cough and ILD, and examine the interaction between airway inflammation and changes in lung function.

METHODS

We examined all patients with physician-diagnosed ILD and chronic cough who had sputum quantitative cytometry ordered between 2004 and 2018. The prevalence of airway inflammation was estimated by applying previously established criteria for bronchitis. FEV₁ and FVC were compared between individuals based on the presence of airway inflammation. The changes in FEV₁ and FVC were compared between individuals who had their treatment tailored to their sputum result, and those who did not.

RESULTS

Airway inflammation was present in 50% of patients (n = 173), and was associated with lower FEV₁ (1.87 vs 2.05 L, p = 0.043) and FVC (2.39 vs 2.71, p = 0.024). Sputum-guided management of airway eosinophilia was associated with improvements in FEV₁ (+120 vs -205mL, p < 0.0001) and stability of FVC (+13 vs -284mL, p = 0.003).

CONCLUSIONS

Airway inflammation is common in patients with chronic cough and ILD, and its presence may negatively affect lung function. Further research is required to understand if there is a role for quantitative sputum cytometry in this population, particularly if sputum-guided management of airway inflammation could lead to improvements in cough and other ILD outcomes.

Sputum Eosinophilia and Magnetic Resonance Imaging Ventilation Heterogeneity in Severe Asthma

RATIONALE

Inflammation and smooth muscle dysfunction are integral components of severe asthma that contribute to luminal obstruction causing airflow limitation, ventilation heterogeneity, and symptoms. This is important for guiding treatment decisions directed at the inflammatory (e.g., anti-T-helper cell type 2 monoclonal antibodies) and noninflammatory, smooth muscle-mediated (e.g., bronchial thermoplasty) components of severe asthma.

OBJECTIVES

To investigate the contribution of eosinophilic bronchitis and smooth muscle dysfunction to magnetic resonance imaging (MRI) ventilation heterogeneity in patients with severe asthma.

METHODS

We measured the inhaled hyperpolarized gas MRI response to salbutamol as a marker of smooth muscle dysfunction, and sputum eosinophils as a marker of airway inflammation, and their contributions to ventilation heterogeneity (quantified as the ventilation defect percent [VDP]) in 27 patients with severe asthma. Spirometry and forced oscillation airway resistance measurements were also acquired pre- and postsalbutamol. Patients were dichotomized on the basis of sputum eosinophilia, and pre- and postsalbutamol VDP and physiological measurements were evaluated.

MEASUREMENTS AND MAIN RESULTS

MRI VDP improved with salbutamol inhalation in patients in whom sputum eosinophilia was uncontrolled (≥3%, n = 16) (P = 0.002) and in those in whom it was controlled (<3%, n = 11) (P = 0.02), independent of improvements in FEV₁, indicating smooth muscle response. In those patients in whom sputum eosinophilia was uncontrolled, greater VDP persisted postsalbutamol (P = 0.004). Postsalbutamol VDP correlated with sputum eosinophils (r = 0.63; P = 0.005).

CONCLUSIONS

In patients with severe asthma, MRI regionally identifies the inflammatory and noninflammatory components of airway disease. Ventilation heterogeneity persists postsalbutamol in patients with uncontrolled eosinophilic bronchitis, which may be the functional consequence of airway inflammation.

The impact of digging on craniodental morphology and integration

The relationship between the form and function of the skull has been the subject of a great deal of research, much of which has concentrated on the impact of feeding on skull shape. However, there are a number of other behaviours that can influence craniodental morphology. Previous work has shown that subterranean rodents that use their incisors to dig (chisel-tooth digging) have a constrained cranial shape, which is probably driven by a necessity to create high bite forces at wide gapes. Chisel-tooth-digging rodents also have an upper incisor root that is displaced further back into the cranium compared with other rodents. This study quantified cranial shape and upper incisors of a phylogenetically diverse sample of rodents to determine if chisel-tooth-digging rodents differ in craniodental morphology. The study showed that the crania of chisel-tooth-digging rodents shared a similar place in morphospace, but a strong phylogenetic signal within the sample meant that this grouping was nonsignificant. It was also found that the curvature of the upper incisor in chisel-tooth diggers was significantly larger than in other rodents. Interestingly, most subterranean rodents in the sample (both chisel-tooth and scratch diggers) had upper incisors that were better able to resist bending than those of terrestrial rodents, presumably due to their similar diets of tough plant materials. Finally, the incisor variables and cranial shape were not found to covary consistently in this sample, highlighting the complex relationship between a species' evolutionary history and functional morphology.

Finite element analysis of stress in the equine proximal phalanx

REASONS FOR PERFORMING STUDY

To improve understanding of the internal structure of the proximal phalanx (P1), response of the bone to load and possible relation to the pathogenesis of fractures in P1.

OBJECTIVES

To model the P1 and replicate the loads experienced by the bone in stance, walk, trot and gallop using finite element analysis.

METHODS

The geometry of the P1 was captured using micro-computed tomography (μCT) and was reconstructed in 3 dimensions. Values for material properties and forces experienced at stance, walk, trot and gallop were taken from the literature and were applied to the reconstructed model. Using the same total load across the proximal articular surface, the model was solved with and without loading of the sagittal groove. Biomechanical performance was then simulated with finite element analysis and evaluated in terms of von Mises stress maps.

RESULTS

Compared with the lowest force simulation equivalent to stance, the effects of the gallop force showed higher levels of stress along the sagittal groove and on the palmar surface just distal to the sagittal groove in both models, with and without the sagittal groove loaded. The results highlighted an area of bone on the dorsal aspect of P1 that experiences lower stress compared with the rest of the dorsal surface, an effect that was much more apparent when the sagittal groove was not loaded. Qualitative comparison of the models revealed minimal difference in the pattern of von Mises stress between the loaded and unloaded groove models.

CONCLUSIONS

The study demonstrates a finite element model of P1 that produces results consistent with clinical observation. The simulated high stress levels associated with the sagittal groove correspond to the most common site for fractures in the equine P1.

POTENTIAL RELEVANCE

With refinement of the model and further investigation, it may be possible to improve understanding of the behaviour of P1 under loading conditions that more closely simulate those experienced in the living animal, leading to a more solid understanding of fractures of P1.

Finite element modelling of squirrel, guinea pig and rat skulls: using geometric morphometrics to assess sensitivity

Rodents are defined by a uniquely specialized dentition and a highly complex arrangement of jaw-closing muscles. Finite element analysis (FEA) is an ideal technique to investigate the biomechanical implications of these specializations, but it is essential to understand fully the degree of influence of the different input parameters of the FE model to have confidence in the model's predictions. This study evaluates the sensitivity of FE models of rodent crania to elastic properties of the materials, loading direction, and the location and orientation of the models' constraints. Three FE models were constructed of squirrel, guinea pig and rat skulls. Each was loaded to simulate biting on the incisors, and the first and the third molars, with the angle of the incisal bite varied over a range of 45°. The Young's moduli of the bone and teeth components were varied between limits defined by findings from our own and previously published tests of material properties. Geometric morphometrics (GMM) was used to analyse the resulting skull deformations. Bone stiffness was found to have the strongest influence on the results in all three rodents, followed by bite position, and then bite angle and muscle orientation. Tooth material properties were shown to have little effect on the deformation of the skull. The effect of bite position varied between species, with the mesiodistal position of the biting tooth being most important in squirrels and guinea pigs, whereas bilateral vs. unilateral biting had the greatest influence in rats. A GMM analysis of isolated incisor deformations showed that, for all rodents, bite angle is the most important parameter, followed by elastic properties of the tooth. The results here elucidate which input parameters are most important when defining the FE models, but also provide interesting glimpses of the biomechanical differences between the three skulls, which will be fully explored in future publications.

X-ray spectroscopy of Cu impurities on NSTX and comparison with Z-pinch plasmas

X-ray spectroscopy of mid-Z metal impurities is important in the study of tokamak plasmas and may reveal potential problems if their contribution to the radiated power becomes substantial. The analysis of the data from a high-resolution x-ray and extreme ultraviolet grating spectrometer, XEUS, installed on NSTX, was performed focused on a detailed study of x-ray spectra in the range 7-18 Å. These spectra include not only commonly seen iron spectra but also copper spectra not yet employed as an NSTX plasma impurity diagnostic. In particular, the L-shell Cu spectra were modeled and predictions were made for identifying contributions from various Cu ions in different spectral bands. Also, similar spectra, but from much denser Cu plasmas produced on the UNR Z-pinch facility and collected using the convex-crystal spectrometer, were analyzed and compared with NSTX results.

Impact of cigarette smoke on T and B cell responsiveness

Although its direct effects cannot be discounted, tobacco's effects on the immune system have been proposed to play a key role in mediating its deleterious health impact. Studies in rats using high levels of smoke exposure have suggested that tobacco smoke exhausts cellular signal transduction cascades, making lymphocytes unresponsive to stimulation. In the present study, we show that purified B or T cells, and total lymphocytes from the lungs, lymph nodes and spleens of smoke-exposed mice fluxed calcium, proliferated, and secreted immunoglobulin or IFN-gamma similarly to control mice when stimulated with ligands including anti-IgM, and anti-CD3. Importantly, we recapitulated these findings in PBMCs from human smokers; cells from long-term smokers and never-smokers proliferated equivalently when stimulated ex vivo. Previous reports of lymphocyte unresponsiveness in rats are inconsistent with these findings, and may reflect a phenomenon observed only at levels of smoke exposure well above those seen in actual human smokers.

The effects of leptin on airway smooth muscle responses

Obesity is associated with asthma and airway hyperresponsiveness. Leptin modulates some of the proinflammatory effects observed in obesity. The objective of this study was to determine the effects of leptin on airway smooth muscle responses. The effect of leptin (0.1-100 ng/ml) on migration (toward platelet-derived growth factor [PDGF], 10 ng/ml, across collagen-coated membrane in Transwell culture plates), proliferation (by BrDU incorporation), and cytokine production (by Bioplex bead assay) of cultured human airway smooth muscle cells from nine nonasthmatic donors was assessed. Effects of leptin on the contractile responses were studied in bovine tracheal smooth muscle rings. Leptin receptor expression and activation of STAT-3, Src kinase, Suppressor of Cytokine Signaling-3 (SOCS-3), and COX were evaluated by Western blotting and PCR. PGE(2) levels in supernatant were assessed by enzyme immunoassay. Human airway smooth muscle cells express leptin receptor, which, when engaged, phosphorylated STAT-3. Leptin inhibited PDGF-induced human airway smooth muscle migration and proliferation and IL-13-induced eotaxin production. Leptin did not stimulate cytokine synthesis and did not evoke contractile responses or inhibit isoproterenol-induced relaxation of carbachol-induced contraction of bovine tracheal rings. The inhibitory effects on migration and eotaxin production are not due to activation of SOCS-3 but are partly due to increased production of PGE(2) because they were attenuated by indomethacin. In conclusion, leptin inhibited human airway smooth muscle proliferation, migration toward PDGF, and IL-13-induced eotaxin production. This is partly mediated by PGE(2) secretion from smooth muscle cells induced by leptin. The association between obesity and asthma is unlikely to be due to a direct effect of leptin on airway smooth muscle.

Modulation of human airway smooth muscle migration by lipid mediators and Th-2 cytokines

Cysteinyl leukotrienes and the T helper (Th)-2 cytokines IL-5 and IL-13 directly modulate human airway smooth muscle functions such as contraction and proliferation. We studied the effects of other lipid mediators involved in asthma pathophysiology such as prostaglandin D(2) (PGD(2)), lipoxin, and isoprostanes, and the cytokines, IL-5, IL-4, and IL-13 on human airway smooth muscle cell migration. Chemotaxis and chemokinesis of cultured airway smooth muscle cells from humans without asthma (second to fifth passages, n = 6) were studied using collagen-I-coated polycarbonate membranes in Transwell culture plates. Receptor expression and kinase activation were studied by flow cytometry, polymerase chain reaction, and Western blotting techniques. In contrast to LTE(4)- stimulated (10(-6) M) chemokinesis and LTE(4)-primed migration toward platelet-derived growth factor (PDGF), isoprostane 15-F(2t)-IsoP, and IL-5 were neither chemotactic nor chemokinetic. PGD(2) (10(-10)-10(-6) M) was a chemoattractant and primed migration toward PDGF through the DP(2)/CRTh(2) receptor. Although airway smooth muscle cells did not express the lipoxin A(4) cognate receptor, LTE(4)-primed migration toward PDGF was blocked by lipoxin A(4) (10(-6) M), suggesting that this is mediated through CysLT(1)R antagonism. IL-13 (10 ng/ml), but not IL-4 (0.1-100 ng/ml), augmented migration toward PDGF. This was associated with increased Src-kinase phosphorylation and up-regulation of PDGF-alpha and -beta receptors, and was attenuated by IL-13Ralpha- and IL-4Ralpha-neutralizing antibodies, an Src-kinase antagonist (PP1, 3 muM), a CysLT(1)R antagonist, montelukast (10(-6) M), and by lipoxin A(4) (10(-6) M). PGD(2) and IL-13 promote human airway smooth muscle migration. IL-13 can promote airway smooth muscle migration through Src-kinase and leukotriene-dependent pathways. This may contribute to the accumulation of smooth muscle cells in remodeled airway submucosa.

A randomized clinical trial of lung volume reduction surgery versus best medical care for patients with advanced emphysema: a two-year study from Canada

BACKGROUND

We present a summary report evaluating the efficacy of lung volume reduction surgery (LVRS) in patients with advanced emphysema in the Canadian setting.

METHODS

Quality of Life measures assessed the efficacy of adding LVRS to best medical care including rehabilitation in this blinded randomized multicentered controlled trial with 2 years of follow-up. Health utility and quality-adjusted life years (QALY) were outcomes central to our economic assessment.

RESULTS

None of the 32 patients randomized to the LVRS arm or 30 patients in the best medical care (BMC) arm crossed-over and no patients were lost to follow-up. Overall surgical mortality was 16% at 2 years while the overall medical mortality was 13% (p = 0.914). There were no 30-day postoperative deaths but 2 deaths (6%) occurred within 90 days of randomization. Surgery reduced the residual volume measured at 6 months by 23% (5,385 mL to 4,322 mL, p = 0.007). There was an increase in forced expiratory volume in 1 second (FEV1) of 30% (265 mL, p = 0.013) from baseline, an improvement in the six minute walk test (6MWT) of 78 meters (p = 0.045), and an increase in Health Utility Index 3 (HUI3) which peaked at 6 months with a difference of 0.16 (p = 0.129). There was a gain in QALYs of 0.21 (p = 0.19) in the LVRS-arm over the BMC-arm. The LVRS costs an additional 28,119 Canadian dollars (CAD) compared with BMC or 133,900 CAD/QALY gained.

CONCLUSIONS

The addition of LVRS to best medical care including pulmonary rehabilitation improves pulmonary function, exercise activity, and quality of life in selected patients with advanced emphysema. Cost is high but in keeping with other treatment modalities currently available.

Extracellular matrix regulates human airway smooth muscle cell migration

Extracellular matrix proteins regulate the survival and proliferation of smooth muscle cells. Their effect on airway smooth muscle cell migration is not known. Their role in leukotriene-primed (0.1 microM leukotriene E4) chemotaxis of cultured human airway smooth muscle cells towards platelet-derived growth factor BB (1 ng.mL(-1)) was investigated. Migration of cells was greater on membranes coated with collagens III and V and fibronectin compared to collagen I, elastin and laminin (all 10 microg.mL(-1)). Concentration-dependent promotion of migration was observed on collagen I (1,000>10 microg.mL(-1)), which was associated with increased phosphorylation of Src kinase. This was not observed on laminin or elastin. The role of Src kinase was further confirmed by demonstrating that its inhibitor, PP1 analogue (1 microM), inhibited chemotaxis. Collagen I itself was not a chemoattractant; however, haptokinesis was observed when cells were primed with leukotriene E4, and haptotaxis when cells were primed with platelet-derived growth factor. The priming effect of leukotrienes on chemotaxis was not elicited by promoting adhesion, increasing surface expression of beta1, alphav and alpha5 integrin, or Src kinase phosphorylation. These experiments demonstrate that the extracellular matrix, along with growth factors and cysteinyl leukotrienes, can regulate human airway smooth muscle cell migration. This may be relevant in the remodelling process in chronic airway diseases, such as asthma.

Radiofrequency ablation of airway smooth muscle for sustained treatment of asthma: preliminary investigations

Bronchial thermoplasty is a procedure now being tested in humans for the treatment of asthma. Current studies focusing on safety are encouraging. The procedure, which causes extensive ablation of airway smooth muscle (ASM), is well tolerated, and there is a sustained reduction in airway responsiveness to methacholine. Two assumptions underlie the development of this procedure: 1) ASM is a vestigial tissue; and 2) that treatment directed at ASM alone will provide sustained symptomatic and physiological improvement in asthmatic humans. Even if this procedure is efficacious, it must be safe in the long-term. Current studies in animals and humans suggest that this is very likely to be the case. While bronchial thermoplasty may have a broad application, especially for patients who wish for a permanent amelioration of their symptoms or have difficulty adhering to medical regimens, the compelling use of this procedure is for patients who are inadequately controlled on current drug therapy or who cannot adhere to therapeutic regimens. The application of this procedure for the treatment of asthma is currently being considered by regulatory agencies, and study centres are currently disseminated throughout North America and Europe. Within the next 1-2 yrs, a profile of the potential role of this therapy in human asthma should be developed fully.

Reduction in airway hyperresponsiveness to methacholine by the application of RF energy in dogs

We delivered controlled radio frequency energy to the airways of anesthetized, ventilated dogs to examine the effect of this treatment on reducing airway narrowing caused by a known airway constrictor. The airways of 11 dogs were treated with a specially designed bronchial catheter in three of four lung regions. Treatments in each of the three treated lung regions were controlled to a different temperature (55, 65, and 75 degrees C); the untreated lung region served as a control. We measured airway responsiveness to local methacholine chloride (MCh) challenge before and after treatment and examined posttreatment histology to 3 yr. Treatments controlled to 65 degrees C as well as 75 degrees C persistently and significantly reduced airway responsiveness to local MCh challenge (P < or = 0.022). Airway responsiveness (mean percent decrease in airway diameter after MCh challenge) averaged from 6 mo to 3 yr posttreatment was 79 +/- 2.2% in control airways vs. 39 +/- 2.6% (P < or = 0.001) for airways treated at 65 degrees C, and 26 +/- 2.7% (P < or = 0.001) for airways treated at 75 degrees C. Treatment effects were confined to the airway wall and the immediate peribronchial region on histological examination. Airway responsiveness to local MCh challenge was inversely correlated to the extent of altered airway smooth muscle observed in histology (r = -0.54, P < 0.001). We conclude that the temperature-controlled application of radio frequency energy to the airways can reduce airway responsiveness to MCh for at least 3 yr in dogs by reducing airway smooth muscle contractility.

Vasoconstrictor actions of isoprostanes via tyrosine kinase and Rho kinase in human and canine pulmonary vascular smooth muscles

1. We examined the effects of several E-ring and F-ring isoprostanes on mechanical activity in pulmonary artery and vein. 2. 8-iso PGE(2) and 8-iso PGF(2 alpha) were powerful spasmogens in human vasculature and in canine pulmonary vein. 8-iso PGE(1) and 8-iso PGF(2 beta) also exhibited moderate spasmogenic activity in canine pulmonary vein; 8-iso PGF(1 alpha), 8-iso PGF(1beta), and 8-iso PGF(3 alpha) were generally ineffective. Canine pulmonary arteries did not exhibit excitatory responses to any of the isoprostanes. 3. The spasmogenic effects of 8-iso PGE(2) were markedly attenuated by the TP-receptor blocker ICI 192605 and by the EP-receptor blocker AH 6809 (-log K(B)=8.4 and 5.7, respectively). PGE(2) was a very weak agonist ( approximately 100 fold less so than 8-iso PGE(2)). 4. In the presence of ICI 192605 (10(-6) M), 8-iso PGE(1) evoked modest dose-dependent relaxations in human and canine pulmonary vein, and in canine pulmonary artery, but not in the human pulmonary artery. The other isoprostanes were generally ineffective as vasodilators in the pulmonary vasculature of both species. 5. The spasmogenic effects of 8-iso PGE(2) and 8-iso PGF(2 alpha) did not involve elevation of [Ca(2+)](i). 6. 8-iso PGE(2)-evoked contractions were blocked by inhibitors of tyrosine kinase (genistein) and Rho kinase (Y 27632 and HA 1077), but not by inhibitors of protein kinase C (calphostin C or chelerythrine), mitogen-activated protein kinase kinase (PD 98059) or p38-kinase (SB 203580). 7. The actions of 8-isoprostanes in the lungs are compound-, species- and tissue-dependent. Several isoprostanes evoke vasoconstriction: in the case of 8-iso PGE(2), this involves activation of TP-receptors, tyrosine kinases and Rho kinases. 8-iso PGE(1) is also able to cause vasodilation.

A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma

BACKGROUND

Chiropractic spinal manipulation has been reported to be of benefit in nonmusculoskeletal conditions, including asthma.

METHODS

We conducted a randomized, controlled trial of chiropractic spinal manipulation for children with mild or moderate asthma. After a three-week base-line evaluation period, 91 children who had continuing symptoms of asthma despite usual medical therapy were randomly assigned to receive either active or simulated chiropractic manipulation for four months. None had previously received chiropractic care. Each subject was treated by 1 of 11 participating chiropractors, selected by the family according to location. The primary outcome measure was the change from base line in the peak expiratory flow, measured in the morning, before the use of a bronchodilator, at two and four months. Except for the treating chiropractor and one investigator (who was not involved in assessing outcomes), all participants remained fully blinded to treatment assignment throughout the study.

RESULTS

Eighty children (38 in the active-treatment group and 42 in the simulated-treatment group) had outcome data that could be evaluated. There were small increases (7 to 12 liters per minute) in peak expiratory flow in the morning and the evening in both treatment groups, with no significant differences between the groups in the degree of change from base line (morning peak expiratory flow, P=0.49 at two months and P=0.82 at four months). Symptoms of asthma and use of 3-agonists decreased and the quality of life increased in both groups, with no significant differences between the groups. There were no significant changes in spirometric measurements or airway responsiveness.

CONCLUSIONS

In children with mild or moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit.

Accumulation of salicylic acid and indomethacin in isolated proximal tubular cells of the rat kidney

The handling and accumulation of salicylic acid (SA) and indomethacin was examined in freshly isolated proximal tubular (PT) cells of the rat kidney in order to determine whether these cells provide a useful tool for studying accumulation of nonsteroidal anti-inflammatory drugs. A PT cell suspension was prepared by collagenase digestion, followed by filtration and isopycnic centrifugation. SA uptake was concentration-dependent and could be inhibited by probenecid. SA accumulated in the PT cells, and therefore, uptake is probably an active process. In the presence of probenecid, no SA accumulation was observed. Indomethacin uptake increased with time up to 2 min. Thereafter, a sharp decrease occurred, probably caused by inhibition of the oxidative phosphorylation. In the presence of probenecid, uptake was significantly reduced and no longer time-dependent. Indomethacin accumulated in the PT cells by a factor of more than 25. In the presence of probenecid, accumulation was decreased but was still considerable (approximately 10), probably as a result of binding to cellular protein. We conclude that as a result of carrier-mediated transport which is probenecid-sensitive, SA and indomethacin accumulate in the PT cells. The observed accumulation values are in accordance with previously observed values in the isolated perfused rat kidney. Therefore, freshly isolated PT cells appear to be a simple and useful model for studying the accumulation process of drugs like SA and indomethacin.

Renal handling and effects of S(+)-ibuprofen and R(-)-ibuprofen in the rat isolated perfused kidney

1. The renal handling and effects of S(+)- and R(-)-ibuprofen have been studied in the isolated perfused kidney (IPK) of the rat. 2. Both ibuprofen enantiomers were extensively reabsorbed and accumulated in the kidney in a concentration-dependent manner. No pharmacokinetic differences were observed between the two enantiomers. 3. S(+)-ibuprofen concentrations ranging from 0.25 to 25 micrograms ml-1 (1.2 to 120 microM) caused a decrease in urinary flow, glomerular filtration rate (GFR) and electrolyte excretion. Urinary pH and excretion of glucose were not influenced. R(-)-ibuprofen concentrations ranging from 2.5 to 25 micrograms ml-1 (12 to 120 microM) also decreased urinary flow and electrolyte excretion. This decrease, however, was less than observed with S(+)-ibuprofen. GFR, urinary pH and glucose excretion were not affected by R(-)-ibuprofen. Prostaglandin E2 (PGE2) concentrations of 133 ng ml-1 reversed the effects on renal function of both enantiomers. 4. Very high S(+)- and R(-)-ibuprofen concentrations (greater than 400 micrograms ml-1) resulted in an increase in urinary flow and fractional excretion of sodium, chloride, potassium, glucose and calcium. 5. It is concluded that the pharmacokinetic behaviour of ibuprofen in the kidney is not stereoselective. Relatively high concentrations of both enantiomers increased the urinary flow and electrolyte excretion in a nonstereoselective manner. Lower concentrations of S(+)-ibuprofen decreased urinary flow and electrolyte excretion. The pharmacologically inactive R(-)-ibuprofen was also able to affect renal function in a similar way, but at different concentrations. These effects on renal function are probably caused by inhibition of PGE2 synthesis.

Renal handling and effects of salicylic acid in the isolated perfused rat kidney

The renal handling of salicylic acid (SA) and its effects on renal function were studied in the isolated perfused rat kidney (IPK). The renal handling of SA is dominated by reabsorption and only a small fraction of the filtered SA is excreted into the urine. Reabsorption is a passive process and is dependent on urinary pH. Because of the extensive reabsorption, no decrease in perfusate concentration can be observed in the course of the IPK experiment. SA accumulated slightly in the IPK and this accumulation is concentration dependent. Small amounts of SA were converted to salicyluric acid (SU), the glycine conjugate of SA. SA concentrations higher than 100 micrograms/ml caused an immediate increase in urinary flow and in fractional excretion of sodium, potassium, chloride and calcium. Fractional excretion of glucose increased gradually. Glomerular filtration rate, renal perfusion flow, renal pressure and fractional excretion of magnesium were not affected by SA. The effects were dependent on the SA concentration. Although SA is a classical non-steroidal antiinflammatory drug (NSAID), its influence on renal function appears to be different from other NSAIDs which are usually associated with a reduction in urinary flow and salt excretion.

Indometacin: renal handling and effects in the isolated perfused rat kidney

We investigated renal handling and effects of indometacin on renal function in the isolated perfused rat kidney (IPK). Indometacin concentrations less than 2.5 ng/ml did not influence renal function, while higher concentrations caused a decrease in urinary flow and electrolyte excretion. The presence of 133 ng/ml prostaglandin E2 (PGE2) in the perfusate fully opposed these effects on kidney function. Only a small fraction of the filtered indometacin is excreted into the urine, indicating extensive reabsorption of the compound. This is probably a passive process, dependent on the tubular load, urinary pH and urinary flow. Indometacin accumulates extensively in the IPK, causing a kidney to perfusate ratio between 5 and 9. Accumulation decreased with increasing perfusate concentration. This can be explained by active secretion: increasing the perfusate concentration leads to a saturation of the active secretion and a decrease in the relative accumulation. We conclude that indometacin accumulates extensively in the IPK, that it affects kidney function and that this influence is probably caused by the inhibition of PGE2 synthesis.

Renal disposition and effects of naproxen and its l-enantiomer in the isolated perfused rat kidney

Renal handling, metabolism and effects on kidney function of naproxen and its l-enantiomer were examined in the isolated perfused rat kidney (IPK). Urinary excretion rate of naproxen was much lower than the filtration rate, indicating extensive reabsorption. Naproxen is accumulated considerably in the IPK. This accumulation is concentration-dependent and is probably the result of active secretion of naproxen. Considerable amounts of desmethyl-naproxen were formed in the IPK. The kinetic behavior of the l-enantiomer of naproxen did not differ from naproxen. Addition of 37.5 to 3750 micrograms naproxen caused a decrease in urinary flow, glomerular filtration rate and fractional excretion of sodium, chloride, potassium, magnesium and calcium. The presence of prostaglandin E2 in the perfusate fully opposed the effects of naproxen on kidney function. Addition of 375 micrograms l-enantiomer of naproxen did not influence kidney function. Addition of very high doses (1 x 10(5) micrograms) of naproxen and its l-enantiomer to the IPK caused diuresis and increased the fractional excretion of sodium, chloride, potassium, glucose and calcium. We conclude that the pharmacokinetic behavior and the metabolism of naproxen in the IPK is probably not stereoselective; that relatively low doses of naproxen exert a specific, stereoselective effect on kidney function caused by inhibition of the prostaglandin E2 synthesis and that high doses of naproxen exert a nonstereoselective effect on kidney function.

Isolated perfused rat kidney as a tool in the investigation of renal handling and effects of nonsteroidal antiinflammatory drugs

An isolated perfused rat kidney (IPK) preparation is described in which renal perfusion flow, perfusion pressure, urinary flow, urinary pH, and glomerular filtration rate (GFR) are recorded continuously during the perfusion experiment. The usefulness of this IPK system in studying the renal handling and the effects of non-steroidal antiinflammatory drugs (NSAIDs) is shown using salicyluric acid (SU), salicylic acid (SA), and naproxen (NA). Excretion of SU involves glomerular filtration, active secretion, and passive reabsorption. The excretion rates of SA and NA were both much lower than their filtration rate, indicating extensive reabsorption. All three drugs accumulate in the IPK but at different levels. SU accumulates much more than either SA or NA. The effects on renal function were different for the three drugs studied. SU had no effect on kidney function. SA perfusate concentrations greater than 100 micrograms/mL caused diuresis and natriuresis, while SA concentrations less than 100 micrograms/mL did not influence kidney function. NA perfusate concentrations ranging from 0.16 to 25 micrograms/mL caused a decrease in urinary flow and sodium excretion. Very high NA concentrations (greater than 500 micrograms/mL) caused an increase in urinary flow and sodium excretion. We conclude that the IPK is a suitable preparation for characterizing and comparing renal handling and effects of NSAIDs.

Renal handling of salicyluric acid in the isolated perfused rat kidney: evidence for accumulation in tubular cells

The renal handling of salicyluric acid (SU) was studied over a broad concentration range (0-400 micrograms/ml) in the isolated perfused rat kidney (IPK). The accumulation of SU was determined by difference calculations between the SU dose given and the SU amount present in the perfusate and excreted into the urine. SU accumulates highly in the IPK and this accumulation is concentration-dependent. At low perfusate concentrations (5-20 micrograms/ml) there is a sharp increase in the accumulation (100-400 micrograms/g), whereas at higher concentrations (20-100 micrograms/ml) a small increase (400-500 micrograms/g) is seen. The largest part of the accumulation is probably caused by accumulation of SU in the tubular cells. This is a result of the active uptake of SU over the basolateral membrane followed by facilitated diffusion over the brush-border membrane. As a result of the saturation of the active SU uptake, accumulation reaches a maximal value. Excretion of SU in the IPK involves glomerular filtration, active secretion and reabsorption. Reabsorption is probably a passive process, dependent on the urinary flow and pH. The apparent Michaelis-Menten constant of the excretion is 18.7 +/- 1.8 micrograms/ml and the maximum transport capacity is 69.8 +/- 1.4 micrograms/min. The pharmacokinetic parameters of the excretion of SU were in good agreement with previously reported in vivo values.

Substituent effects during the rat liver aldehyde dehydrogenase catalyzed oxidation of aromatic aldehydes

The influence of the steric hindrance of halogen substituents was investigated in vitro by measuring the activity of yeast aldehyde dehydrogenase (aldehyde: NAD(P)+ oxidoreductase, EC 1.2.1.5) and of aldehyde dehydrogenases in subcellular rat liver fractions with a series of ortho- and para-halo-substituted benzaldehydes as substrates. Upon an increase in the size of the halogen substituent (F, Cl, Br), the reactivity of yeast aldehyde dehydrogenase to ortho-substituted benzaldehydes decreased drastically. The same phenomenon was observed with the unspecific aldehyde dehydrogenases in three rat liver fractions; cytoplasm, mitochondria and microsomes. The corresponding para-halobenzaldehydes (F, Cl, Br, I) did not reveal large differences in reactivity to the various rat liver aldehyde dehydrogenases. The aldehyde dehydrogenases in the rat liver microsomal fraction exhibited most clearly the regiospecificity. Enzymatic oxidation of 4-bromobenzaldehyde was more than 30-times faster then the ortho-isomer. The findings in this investigation confirm the suggestion that the steric hindrance of bulky ortho-substituents of benzaldehydes account for the slowing down of the aldehyde dehydrogenase-catalyzed oxidation of benzaldehydes to corresponding benzoic acids. The enzymatic oxidation of microsomal aldehyde dehydrogenase is strongly influenced by steric effects of benzaldehydes, bearing a halogen in ortho-position. We think that the microsomal aldehyde dehydrogenase might be the principal enzyme responsible for oxidation of halobenzaldehydes in rat liver.

Electron-microscopic and radioiron studies of iron uptake in newborn rat myocardial cells in vitro

In vitro cultured myocardial cells from newborn rats were shown to be a good model system for the study of iron uptake and iron metabolism. Ferric ammonium citrate was readily taken up by cells, and about 50% of it was sequestered in ferritin. The rate of iron uptake and/or accumulation in the cells was proportional to its concentration in the medium at 30, 60, and 90 microM but was reduced at 180 microM. At 360 microM iron both the rate of uptake and the total iron taken up was less than at 90 microM iron. Electron-microscopic examination showed endocytotic vesicles and lysosomes containing iron-filled ferritin molecules, as well as normal morphology. In both control and experimental cultures there was an increase with time in the number of lysosomes; however, in the control cultures there were considerably fewer molecules of ferritin seen per lysosome than in experimentals. The number of ferritin molecules apparent in lysosomes increased with time and with increasing concentrations of iron in the medium.

Vertebrate regeneration system: culture in vitro

With standard tissue-culture techniques and media, various components of the lizard tail regenerate have been maintained in culture for 8 months. Differentiation of two cell types, melanophores and striated muscle, has been obtained. Myoblast proliferation and fusion can be selectively controlled by altering the culture medium.