Serum alpha 1-antichymotrypsin level as a marker for Alzheimer-type dementia

Excessive alpha 1-antichymotrypsin (ACT) in brain has been postulated to play a role in the pathogenesis of Alzheimer's disease (AD). We measured serum ACT by radial immunodiffusion in 57 patients with presumed AD, 110 healthy controls (24 children; 86 adults), 67 non-AD patients from a geriatric private practice and a VA nursing home, and 136 asthmatics (56 adults; 80 children) as an inflammatory disease control group. Serum ACT was significantly higher in AD (73.1 +/- 22 mg/dl) than in healthy controls (47.9 +/- 8.1 mg/dl) or non-AD patients (61.8 +/- 23.9 mg/dl). A level of 60 mg/dl best separated AD patients from controls or non-AD patients. Serial measurements served to distinguish elevations of ACT level in AD from non-AD inflammatory conditions; the ACT level in the latter returned to normal with therapy or time, but the levels in AD remained elevated. A measure of serum ACT by radial immunodiffusion can be used to support a diagnosis of AD disease but not necessarily as a screening test due to the potentially large number of false positives (26% in the population studied) should malignancy or inflammatory disease be concurrent.

A vaccinia-gp160-based vaccine but not a gp160 protein vaccine elicits anti-gp160 cytotoxic T lymphocytes in some HIV-1 seronegative vaccinees

Cytotoxic T lymphocytes (CTL) play an important role in the immune response to viral infection by recognizing and destroying infected cells. HIV-1 elicits an unusually strong CTL response in infected individuals and clearance of the viremia of acute infection coincides with the development of HIV-specific CTL. Because HIV-specific CTL may provide protection against de novo viral infection, we compared the CTL response in seronegative volunteers treated with two vaccination approaches. Seven volunteers were immunized with a live recombinant vaccinia virus expressing the HIV envelope protein gp160LAI (HIVAC-1e) and boosted with 640 micrograms recombinant baculovirus-expressed gp160LAI in alum 1-13 months later. In a second study, three volunteers underwent four successive immunizations with 640 micrograms subunit gp160LAI in alum at 0, 1, 6, and 12 months. The first vaccination strategy using a liver vector would be expected to generate gp160-specific CTL, while for the second, using only whole-protein subunit, the generation of specific CTL would be unlikely. Predominantly CD8+ T-cell lines generated from PBMC by nonspecific stimulation with PHA and IL-2 were screened after three to four weeks of culture for cytolytic activity against autologous targets infected with vaccinia vectors encoding envLAI, RT, gag, and lacZ control. A strong gp 160-specific CTL response was detected in two vaccines in the recombinant vaccinia plus subunit boost study. Modest responses were seen in four of the other five live vector-primed vaccinees. No significant gp160-specific CTL were observed in three volunteers given only subunit rgp160 or in five control subjects.

Enhanced susceptibility to human immunodeficiency virus infection in CD4+ T lymphocytes genetically deficient in CD43

CD43 is a cell surface sialoglycoprotein expressed by most cells of hematopoietic origin, including all T lymphocytes. Elimination of CD43 expression by gene targeting in the CEM T cell line results in its increased homotypic adhesion and binding to HIV-1 gp120. Here we report that the CD43-negative CEM cells show increased susceptibility to HIV-1 infection and increased viral replication compared with the parental CD43+ CEM cell line. Increased HIV-1 replication also was observed in CEM cells with diminished CD43 expression secondary to functional inactivation of a single CD43 allele. The CD43- CEM cells were more susceptible to HIV-1-induced cytopathicity than their CD43+ counterparts. HIV-1 replication also was increased in the CD43- CEM cells after transfection with the infectious HIV molecular clone pNL4-3. These data suggest that factors that diminish CD43 expression on T lymphocytes may enhance their susceptibility to HIV-1 infection.

A simple method to selectively expand HIV-1 specific cytotoxic T lymphocytes in vitro

Cytotoxic T lymphocytes (CTL) may play a critical role in controlling the progression of HIV-1 disease. Conventional assays for demonstration of CTL against HIV-1 have used either fresh PBMC or T cell lines and clones generated by non-specific stimulation. These methods are limited in their sensitivity since without specific secondary stimulation in vitro, epitopes recognized at low frequency may not be detected. Moreover, derivation of CTL clones is labor intensive and not practical for studying a large number of patients. We have developed a simple method to enrich HIV-1 specific CTL in vitro. Autologous antigen presenting cells (APC), either adherent macrophages or EBV transformed B-lymphoblastoid cells, are infected with recombinant vaccinia virus encoding individual HIV-1 proteins and after overnight culture the vaccinia virus is inactivated by uv irradiation in the presence of psoralin. The infected APC are then cultured with patient's T cells and CTL activity determined 10-14 days later. We have used this method to stimulate patients' T cells obtained directly from PBMC and also after mitogenic stimulation. In both systems, the HIV-1 specific response could be enhanced up to five to ten fold. This enhancement is comparable to CTL selection by exposure to HIV-1 immunodominant peptide incubated APC. In some patients, viral-specific CTL could be detected after HIV-vaccinia selection even though the mitogen stimulated cultures had no demonstrable antiviral CTL activity. Selective expansion of CTL directed against multiple HIV-1 proteins (env, gag and RT) could be obtained from PBMC as well as from mitogen-stimulated lines from individual patients. As these lines are predominantly CD8+ T cells by flow cytometric analysis and are free of vaccinia virus as ascertained by the lack of cytopathic effect in culture, in vitro vaccinia selection might also be useful to generate CTL lines for adoptive immunotherapy.

Ex vivo expansion of HIV type 1-specific cytolytic T cells from HIV type 1-seropositive subjects

Cytotoxic T lymphocytes that specifically lyse HIV-1-infected cells occur at uncommonly high frequency in the blood of infected individuals. The CTL response is dominated by the recognition of a small number of peptides encoded by HIV-1 structural and regulatory genes. These two facts have enabled us to develop potent HIV-specific CTL lines from the blood of infected patients without AIDS opportunistic infections by ex vivo culture of nonspecifically stimulated T cell lines with autologous antigen-presenting cells (APCs) preincubated with immunodominant HIV-1 peptides. After one selection, HIV-specific cytotoxicity is enhanced 1.4- to sixfold. Frequency analysis of the T cell line from 1 patient revealed that after exposure to peptide-incubated autologous B-LCLs, the frequency of CTLs specific for the gp160-expressing APCs was enhanced 6-fold and, after a second exposure, 11-fold compared to the nonselected T cell line. Because the APCs used for the frequency analysis were EBV-transformed B-LCLs, some of the specific CTLs in the culture recognized the EBV-expressing APCs. HIV-specific cytotoxicity is enhanced without augmentation of EBV-specific cytotoxicity when PBMCs are used as APCs. Because T cell lines enhanced for HIV-1 specificity are highly cytotoxic and can be expanded to approximately 10(9)-10(10) cells/ml of blood, they may be useful for laboratory research or for immunotherapy.

CD43 diminishes susceptibility to T lymphocyte-mediated cytolysis

CD43 is a major membrane sialoglycoprotein expressed by cells of hematopoietic origin. One property of CD43 is its ability to interfere with heterotypic and homotypic cellular adhesion. To determine whether CD43 expression can affect cell functions requiring intercellular adhesion, we compared a CD43-positive human T cell line (CEM) and its CD43-negative counterpart derived by gene targeting for susceptibility to cell-mediated lysis. CD43-negative CEM cells were more susceptible than CD43-positive cells to lysis by allospecific T cell lines derived from several donors. Induction of CD43 expression on transfected HeLa cells also imparted resistance to lectin-mediated lysis by a CD8+ T cell clone. The effect of CD43 expression on reducing susceptibility to lysis was more pronounced in short-term cytotoxicity assays and tended to disappear as the time of contact between the effector cell and its target increased. The enhanced susceptibility of CD43-negative cells to lysis was not associated with increased expression of adhesion molecules known to mediate antigen-independent cellular adhesion. Sialic acid residues on CD43 contributed to the CD43 protective effect. These results suggest that either diminished CD43 expression or incomplete sialylation may render hematopoietic cells more susceptible to T lymphocyte-mediated cytolysis.

CD43 diminishes susceptibility to T lymphocyte-mediated cytolysis

CD43 is a major membrane sialoglycoprotein expressed by cells of hematopoietic origin. One property of CD43 is its ability to interfere with heterotypic and homotypic cellular adhesion. To determine whether CD43 expression can affect cell functions requiring intercellular adhesion, we compared a CD43-positive human T cell line (CEM) and its CD43-negative counterpart derived by gene targeting for susceptibility to cell-mediated lysis. CD43-negative CEM cells were more susceptible than CD43-positive cells to lysis by allospecific T cell lines derived from several donors. Induction of CD43 expression on transfected HeLa cells also imparted resistance to lectin-mediated lysis by a CD8+ T cell clone. The effect of CD43 expression on reducing susceptibility to lysis was more pronounced in short-term cytotoxicity assays and tended to disappear as the time of contact between the effector cell and its target increased. The enhanced susceptibility of CD43-negative cells to lysis was not associated with increased expression of adhesion molecules known to mediate antigen-independent cellular adhesion. Sialic acid residues on CD43 contributed to the CD43 protective effect. These results suggest that either diminished CD43 expression or incomplete sialylation may render hematopoietic cells more susceptible to T lymphocyte-mediated cytolysis.

Absence of recoverable infectious virus and unique immune responses in an asymptomatic HIV+ long-term survivor

We have studied a woman with transfusion-acquired HIV who appears to have contained infectious virus to consistently undetectable levels over a 13-year period without antiviral treatment. She received the infected transfusion for intra- and postpartum blood loss immediately after delivery of her second child in 1981. She had no acute febrile syndrome and has never had HIV-associated clinical signs or symptoms in the 13 years since infection. She was first tested and found positive for HIV antibodies in 1985, and the infected blood donor was diagnosed with AIDS in 1986 and died of AIDS-related complications in 1989. Two other recipients of packed erythrocytes from this donor (in 1980 and 1982) also became infected and were subsequently diagnosed with AIDS. Between January 1986 and April 1994, in the setting of continuous and unambiguous Western blot HIV-specific antibodies and intermittently positive low-level HIV DNA signal after polymerase chain reaction (PCR) amplification, more than 30 separate cell cocultures performed in several independent laboratories failed to yield evidence of infectious virus, despite special efforts to induce and detect HIV replication. Immunologically, a strong in vitro proliferative response to HIV envelope proteins also distinguished this subject from other asymptomatic HIV+ individuals.

Mortality factors in geriatric blunt trauma patients

OBJECTIVE

To examine various clinical factors for their ability to predict mortality in geriatric patients following blunt trauma.

DESIGN

In this retrospective study, trauma registries and medical records from three trauma centers were reviewed for patients 65 years and older who had sustained blunt trauma. The following variables were extracted and examined independently and in combination for their ability to predict death: age, gender, mechanism of injury, admission blood pressure, and Glasgow Coma Scale score, respiratory status, Trauma Score, Revised Trauma Score, and Injury Severity Score.

SETTING

Three urban trauma centers.

PATIENTS

Geriatric trauma patients entering three trauma centers (Stanford [Calif] University Hospital, Vanderbilt University Medical Center, Nashville, Tenn, and Maryland Institute for Emergency Medical Services Systems, Baltimore) following blunt trauma during a 7-year period (1982 to 1989).

RESULTS

The Injury Severity Score was the single variable that correlated most significantly with mortality. Mortality rates were higher for men than for women and were significantly higher in patients 75 years and older. Admission variables associated with the highest relative risks of death included a Trauma Score less than 7; hypotension (systolic blood pressure, < 90 mm Hg); hypoventilation (respiratory rate, < 10 breaths per minute); or a Glasgow Coma Scale score equal to 3.

CONCLUSIONS

Admission variables in geriatric trauma patients can be used to predict outcome and may also be useful in making decisions about triage, quality assurance, and use of intensive care unit beds.

Imaging endogenous dopamine competition with [11C]raclopride in the human brain

This study images dopamine release in response to a neurochemically specific challenge with the psychostimulant drug methylphenidate. Changes in synaptic dopamine induced by methylphenidate were evaluated with positron emission tomography and [11C]raclopride, a D2 receptor radioligand that is sensitive to endogenous dopamine. Methylphenidate significantly decreased striatal [11C]raclopride binding. The decrease was variable and was negatively correlated with age. Mood and anxiety at baseline, were also correlated with methylphenidate-induced DA changes. This strategy provides a tool to investigate the responsiveness of the dopamine system in the normal and diseased human brain and to investigate the neurochemical correlates of behavior.

Popliteal pseudoaneurysm as a complication of an adjacent osteochondroma

A 19-year-old man presented to our institution with a 4-month history of a pulsatile mass in the left popliteal fossa. Evaluation including plain x-ray films, MRI, and arteriography revealed a pseudoaneurysm associated with an underlying exostosis of the distal femur. The pseudoaneurysm was repaired with a saphenous vein patch and the exostosis was excised. This case is reported in conjunction with an extensive review of the literature, which yielded only 25 similar cases reported in the English language since 1953. The majority of cases involved young men (20/26), whose ages ranged from 9 to 45 years (mean 20 years). Fifteen of the 26 cases involved isolated exostoses, and in less than half (12/26), antecedent trauma was identified as a cause of the pseudoaneurysm. The origin of exostoses and their relationship to popliteal pseudoaneurysms are discussed. Repair of the pseudoaneurysm and excision of the involved exostosis are recommended.

Plasma homovanillic acid levels in first-episode schizophrenia. Psychopathology and treatment response

OBJECTIVES

To examine plasma homovanillic acid (pHVA) levels in first-episode schizophrenia, to compare pHVA levels in patients and controls, and to assess the association of pHVA levels with psychopathology and treatment response.

METHODS

Forty-one patients entered the study, and pHVA levels were measured at baseline and on a weekly basis for up to 6 weeks of open standardized neuroleptic treatment. Psychopathology was evaluated with the Schedule for Affective Disorders and Schizophrenia, the Scale for Assessment of Negative Symptoms, and the Clinical Global Impressions scale. Ten healthy controls were used for comparison of baseline pHVA levels.

RESULTS

No differences were observed between patients and controls. Baseline pHVA level was not associated with psychopathology but was associated with time to reach remission. Baseline pHVA levels and week-1 pHVA levels were higher in responders than nonresponders. Regardless of responsiveness, female participants had higher pHVA levels than male participants throughout the study. The pattern of pHVA levels with treatment was similar in all patients with a short-term rise initially and then a decrease toward baseline values.

CONCLUSIONS

These findings suggest that pHVA levels have prognostic significance for response and time to reach remission. Qualitative and quantitative differences between first-episode patients' pHVA levels and studies using a long-term, neuroleptic-exposed population suggest that changes occur with neuroleptic treatment or the progression of the illness.

The resampling method of statistical analysis

Some non-statisticians occasionally use improper statistical methodology due to a lack of appreciation for the model assumptions that underlie a particular technique. The resampling method is a recent attempt to solve statistical problems with a minimum of assumptions. In essence, resampling involves an intuitive approach to inferential statistics that obviates the need for the mathematically derived sampling distribution. The resampling approach takes advantage of readily accessible high-speed computers to do a computationally intensive Monte Carlo experiment on the available data. The resampling approach liberates the user from imposing assumptions that are sometimes dubious. It also directs one away from a black-box attitude toward statistical analysis and instead forces the user to consider the purpose of the inferential process. A particularly user-friendly implementation of resampling methods that addresses some of the problems faced by non-statisticians is found in a simple, yet powerful, computer program called "Resampling Stats," version 3.13.

Methylphenidate decreases regional cerebral blood flow in normal human subjects

To assess the effects of methylphenidate (MP) on cerebral blood flow (CBF), 5 healthy males were studied using 15O-water and positron emission tomography before and after MP (0.5 mg/kg iv). MP significantly decreased whole brain CBF at 5-10 minutes (25 +/- 11%) and at 30 minutes (20 +/- 10%) after its administration. Decrements in CBF were homogeneous throughout the brain (regional decrements 23-30%) and probably reflect the vasoactive properties of MP. The vasoactive properties of MP should be considered when prescribing this drug chronically and/or when giving it to subjects with cerebrovascular compromise.

Relation of plasma fluphenazine levels to treatment response and extrapyramidal side effects in first-episode schizophrenic patients

OBJECTIVE

The aim of this study was to determine the relation between plasma fluphenazine levels and clinical response in first-episode schizophrenic patients.

METHOD

Data from 36 first-episode schizophrenic or schizoaffective inpatients diagnosed according to the Research Diagnostic Criteria were evaluated. The patients received open, standardized treatment with fluphenazine, 20 mg/day, for at least 4 weeks. Psychopathology was assessed biweekly, and plasma fluphenazine levels were ascertained weekly. Patients were classified as responders or nonresponders, and correlations between their neuroleptic levels and ratings of psychopathologic and extrapyramidal symptoms were computed.

RESULTS

Plasma fluphenazine levels for weeks 1 through 4 were significantly correlated with each other but were not correlated with age, gender, diagnosis, or race. Mean neuroleptic levels (weeks 3 and 4) were not different between responders and nonresponders and were not correlated with measures of psychopathology or extrapyramidal symptoms.

CONCLUSIONS

These results do not indicate an association between plasma fluphenazine levels and response to treatment or extrapyramidal side effects in first-episode schizophrenia. The disparity between the results of this study and those of previous studies may be due to methodological differences or to a biologically based difference between first-episode and chronic patients.

Depression in first-episode schizophrenia

OBJECTIVE

Because findings regarding the prognostic significance of depressive symptoms in schizophrenia and their effect on the course and treatment of schizophrenia have been limited by the effects of previous treatment, retrospective evaluations, and differing definitions and criteria, the authors sought to determine the prevalence and prognostic significance of depressive symptoms in first-episode schizophrenia.

METHOD

Thirty-nine men and 31 women experiencing their first episode of schizophrenia were evaluated with behavioral and extra-pyramidal symptom scales before treatment (baseline), biweekly during acute treatment, and then monthly. Extracted scores on the Hamilton Rating Scale for Depression and a "syndromal" definition of depression based on Research Diagnostic Criteria were obtained. Patients were followed prospectively for up to 5 years and received open standardized treatment.

RESULTS

The prevalence of depressive symptoms at baseline ranged from 75% (patients who met extracted Hamilton and/or syndromal criteria) to 22% (patients who met both criteria). Of 808 psychotic ratings given to the 70 patients over a 5-year follow-up period, 210 (26%) were concurrently rated as depressed; of the 1,754 nonpsychotic ratings, only 70 (4%) were concurrently rated as depressed. Of the 210 depressive symptoms that occurred concurrently with psychosis, 206 (98%) resolved as the psychosis remitted. Depressive symptoms were prodromal to a psychotic relapse in only two (7%) of 27 patients who relapsed. Depressive symptoms correlated more with positive and negative symptoms than with extrapyramidal symptoms.

CONCLUSIONS

These findings suggest that depressive symptoms in patients experiencing their first episode of schizophrenia may represent a core part of the acute illness or may occur as a subjective reaction to the experience of psychotic decompensation. Since most of the depressive symptoms resolved as the psychosis remitted, antidepressant therapy should be limited to patients in whom the depression persists.

Serum angiotensin-converting enzyme as a marker for the chronic fatigue-immune dysfunction syndrome: a comparison to serum angiotensin-converting enzyme in sarcoidosis

PURPOSE

To study the reliability of a serum angiotensin-converting enzyme (ACE) assay as a marker for the chronic fatigue-immune dysfunction syndrome (CFIDS), and to compare some enzyme characteristics of ACE in CFIDS with that in sarcoidosis.

PATIENTS AND METHODS

Forty-nine patients with CFIDS and 56 endemic control subjects from Lyndonville, New York, and Charlotte, North Carolina; plus 23 untreated patients with active sarcoidosis, 24 with sarcoidosis receiving corticosteroid therapy, and 32 patient controls without sarcoidosis from California. Serum ACE levels were determined with a spectrophotometric method. The effect of freezing and thawing and the effect of storage at 4 degrees C were compared between CFIDS and sarcoidosis samples.

RESULTS

Serum ACE levels were elevated in 80% of patients with CFIDS and 30% of endemic control subjects as compared with 9.4% of nonendemic California control subjects. The ACE activity in CFIDS differed from that in sarcoidosis because of its lability with storage at 4 degrees C in CFIDS and its partial activation with freezing and thawing. Thus, ACE activity was elevated in the majority of CFIDS patients either upon initial assay or upon a subsequent assay after refreezing. ACE activity was elevated in 87% of patients with active sarcoidosis and was not affected by storage or freezing and thawing.

CONCLUSIONS

Serum ACE elevations may be a useful marker for CFIDS, especially if a method can be developed to distinguish ACE in CFIDS from that in sarcoidosis. The sensitivity for CFIDS was 80%, with 68% specificity in an endemic area. The increased prevalence of serum ACE elevations in endemic controls as compared with nonendemic controls suggests that an ACE increase may be an early manifestation of CFIDS and supports the concept that CFIDS is a definite disease state.

Zalcitabine compared with zidovudine in patients with advanced HIV-1 infection who received previous zidovudine therapy

OBJECTIVE

To evaluate the safety and efficacy of zalcitabine (also known as dideoxycytidine [ddC]) in patients with advanced human immunodeficiency virus (HIV) infection.

DESIGN

Open-label, randomized study.

SETTING

AIDS Clinical Trials Units, university-affiliated medical centers, and private practice groups.

PATIENTS

Patients with the acquired immunodeficiency syndrome (AIDS) or advanced AIDS-related complex who had tolerated zidovudine for 48 weeks or more.

INTERVENTION

Fifty-nine patients received zidovudine (500 to 1200 mg/d) and 52 patients received zalcitabine (2.25 mg/d).

MEASUREMENTS

The primary end points were survival and time to an AIDS-defining event or death.

RESULTS

Because significantly more patients withdrew from zidovudine therapy, the median duration of treatment was greater in the zalcitabine group than in the zidovudine group (279.0 days compared with 174.5 days; P = 0.001). The estimated 12-month, event-free probabilities were 53% for the zalcitabine group and 57% for the zidovudine group (relative risk, 1.02; 95% CI, 0.5 to 2.2). The estimated 12-month survival rates were 81% for the zalcitabine group and 75% for the zidovudine group (relative risk, 1.39; CI, 0.5 to 3.8). The rate of decline in CD4 lymphocyte counts was significantly slower in the zalcitabine group than in the zidovudine group (-0.08 cells/day compared with -0.17 cells/day). Patients in the zalcitabine group had gained an average of 0.5 kg at week 20 and 0.4 kg at week 24, whereas patients in the zidovudine group had lost an average of 1.8 kg at week 20 and 2.4 kg at week 24 (P = 0.04 and P = 0.05, respectively). Moderate to severe peripheral neuropathy and ulcerative stomatitis occurred in 10 and 9 patients, respectively, in the zalcitabine group.

CONCLUSIONS

The sample size for this study was smaller than planned, and no differences in survival and clinical end points were found. Slower rates of decline in CD4 lymphocyte counts and weight, however, were noted for the zalcitabine group.

Time course and biologic correlates of treatment response in first-episode schizophrenia

OBJECTIVE

To examine the course and potential predictors of treatment response in the early phase of schizophrenia.

DESIGN

Prospective study of an inception cohort.

SETTING

Psychiatric division of an academic medical center with a suburban metropolitan catchment area.

PATIENTS AND INTERVENTION

Seventy first-episode patients who had undergone four biologic assessment procedures (brain magnetic resonance imaging, behavioral response to methylphenidate hydrochloride, growth hormone levels, eye tracking) were treated with a standardized antipsychotic drug protocol until recovery. Response was measured in terms of psychopathology and degree of remission.

RESULTS

Using survival analysis, the proportion of patients remitting by 1 year was estimated at 83%. Mean and median times to remission were 35.7 weeks and 11 weeks, respectively. No baseline demographic or psychopathologic measure significantly predicted time to or level of remission. However, males tended to be nonresponders to treatment and have diagnoses of schizophrenia rather than schizoaffective disorder. Brain pathomorphology and abnormal basal growth hormone significantly predicted time to remission.

CONCLUSIONS

These results indicate that the antipsychotic treatment response of first-episode schizophrenics is better than chronic multiepisode patients and suggest that specific pathobiologic markers reflect pathophysiologic processes that mediate antipsychotic treatment response.

Variants of alpha 1-antitrypsin in Puerto Rican children with asthma

A survey of 393 Puerto Rican and 354 non-Hispanic pediatric patients at Beth Israel Hospital, New York, revealed a significantly larger percentage of asthmatic subjects among Puerto Ricans, confirming findings of a study of Puerto Rican adults in New York. Assays of alpha 1-antitrypsin (AAT) concentration and phenotypes in 61 Puerto Rican asthmatic children revealed a significantly larger number with an S or Z variant in AAT phenotype. The AAT concentration was not a significant variable in this relationship, since four of five subjects with intermediate deficient AAT concentrations and a PiM phenotype were among control nonasthmatic Puerto Rican subjects. A family history of asthma was more common among asthmatic than control subjects and was most common for variant AAT phenotypes in either asthmatic or control subjects. We speculate that the S or Z variant of AAT affects the inflammatory response in such a way as to predispose to asthma.