Delusional disorder and tuberculosis: A clinical case

Introduction

Tuberculosis is still a challenging disease, infecting around a third of the world’s population. As comorbidity with mental disorder is common, it is relevant to associate them at a diagnostic, therapeutic and prognostic level.

Objectives

We present a clinical case describing a patient with psychosis, further diagnosed with tuberculosis during psychiatric treatment. Moreover, we present a summarized revision of the state of the art.

Methods

Revision of the state of the art, drawing from PubMed and using the keywords “mental health”, “psychosis” and “tuberculosis”, in the last 10 years.

Results

Male, 61 years old, heavy smoker and alcohol drinker. Admitted for allegedly feeling “worms” in his body. After medical examination, a weight loss of 13 kg in five months and symptoms compatible with tenesmus stood out. Following diagnostic tests, the patient was diagnosed with Ekbom Syndrome and Ganglionar Tuberculosis; he was then medicated with the adequate antipsychotic and tuberculostatic agents, which resulted in overall clinical improvement.

Conclusions

This case illustrates the relationship between tuberculosis and mental disorders, in a patient with a low literacy level and a precarious socioeconomic background, known risk factors for mental disorder in patients with tuberculosis and are often associated with poor therapeutic adherence. Although proper treatment of the mental disorder is key to reducing the risk of tuberculostatic dropout, the stigma of mental disorder and tuberculosis decreases the probability of these patients seeking proper treatment. Thus, we alert the medical community for the possibility of psychiatric comorbidity in patients with diagnosed tuberculosis – and vice-versa –, allowing for an early intervention,

Disclosure

No significant relationships.

When does diabetes start? Early detection and intervention in type2 diabetes mellitus

Type 2 diabetes mellitus (DM2) is a progressive disease whose pathophysiological changes occur several years before its detection. An approach based on the pathophysiological development of DM2 and its complications emphasises the importance of early and intensive intervention, not only to prevent beta-cell dysfunction but also to act on the potential associated cardiovascular risk factors before reaching the blood glucose thresholds currently set for diagnosing DM2. In the field of recently diagnosed DM2, the VERIFY study has shown that early treatment combined with metformin-vildagliptin provides relevant improvements in long-term glycaemic control and can positively affect the disease's progression.

Atopic Dermatitis Host and Environment Model: Revisiting Therapeutic Options

Summary

Atopic Dermatitis affects both children and adults and is a serious health concern in many countries. AD is a complex disease with host and environmental factors underlying its pathology. Its treatment is multidimensional reflecting the diverse nature of its triggers and includes emollients, topical steroids and calcineurin inhibitors among others. Immunological dysfunction can be addressed broadly with systemic immunosupressors and specifically with monoclonal antibodies. Dupilumab, which targets IL-4 and IL-13 was granted approval for treatment of moderate-to-severe AD. Biologics targeting IgE/Th2 pathways may have its role in patients with overlapping AD and asthma. Psychological distress can exacerbate symptoms and is associated with increased severity of AD. Environmental triggers, such as, allergens can be addressed in selected cases with allergic immunotherapy. In this paper, we discuss AD treatment and propose a new step-by-step approach aiming at maintaining disease control and improving quality of life.

Short and extended provocation tests have similar negative predictive value in non-immediate hypersensitivity to beta-lactams in children

INTRODUCTION AND OBJECTIVES

Drug provocation tests (DPTs) are the gold-standard method to diagnose non-immediate hypersensitivity reactions (NIHSR) to beta-lactam antibiotics (BL) in children. Our aim was to compare the negative predictive value (NPV) of one-day (short) DPT versus 3-7 days (extended) DPT for the diagnosis of NIHSR to BL in paediatric age. A secondary aim was to compare confidence on drug re-exposure after short and extended negative DPTs.

METHODS

The occurrence of HSR on drug re-exposure and drug refusal after negative diagnostic DPTs were evaluated in children/adolescents with a history of NIHSR to BL using a questionnaire performed six months to ten years after DPT. Patients were divided into two groups according to the protocol performed: short DPT vs. extended DPT.

RESULTS

We enrolled 212 children and adolescents (86 females, 126 males, mean age at DPT 5.52 years, p25=3 years, p75=7.25 years): 69 tested with short DPT, and 143 with extended DPT. The NPV of both types of DPT together was 95.2%. The NPV of short DPT was 97.5% and the NPV of extended DPT was 93.8% (p=0.419). After negative DPT, beta-lactams were refused by carers in 14.75% of the children requiring subsequent treatment, 6.98% in the short DPT group and 18.99% in the extended DPT group (p=0.074).

CONCLUSIONS

In our paediatric sample, prolonging drug administration did not increase the NPV of diagnostic DPT for NIHSR to BL or reduce drug refusal. Altogether, the data here reported suggest that, however intuitive, prolonging DPT is not beneficial in the parameters analysed.

The Reference Site Collaborative Network of the European Innovation Partnership on Active and Healthy Ageing

Seventy four Reference Sites of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) have been recognised by the European Commission in 2016 for their commitment to excellence in investing and scaling up innovative solutions for active and healthy ageing. The Reference Site Collaborative Network (RSCN) brings together the EIP on AHA Reference Sites awarded by the European Commission, and Candidate Reference Sites into a single forum. The overarching goals are to promote cooperation, share and transfer good practice and solutions in the development and scaling up of health and care strategies, policies and service delivery models, while at the same time supporting the action groups in their work. The RSCN aspires to be recognized by the EU Commission as the principal forum and authority representing all EIP on AHA Reference Sites. The RSCN will contribute to achieve the goals of the EIP on AHA by improving health and care outcomes for citizens across Europe, and the development of sustainable economic growth and the creation of jobs.

Galactose-α-1,3-galactose allergy: a rare syndrome and an atypical presentation

Summary

Allergies to red meat associated with galactose-α-1,3-galactose, commonly known as α-gal, are rare and have only recently been described. At this time, the literature reports only one case documented in Portugal. In this study, we report the case of a 76-year-old male with an immediate reaction following the ingestion of red meat. Rigorous diagnostic exams, including prick test, prick-to-prick tests, serum specific IgE and SDS-PAGE IgE-immunoblotting, were performed. The α-gal epitope IgE re-turned a value of 35.3 kUA/L, leading the authors to believe that this is an atypical case of α-gal allergy.

Incidence, recurrence and cost of hyperglycaemic crises requiring emergency treatment in Andalusia, Spain

AIMS

Hyperglycaemic crises (diabetic ketoacidosis and hyperosmolar hyperglycaemic state) are medical emergencies in people with diabetes. We aimed to determine their incidence, recurrence and economic impact.

METHODS

An observational study of hyperglycaemic crises cases using the database maintained by the out-of-hospital emergency service, the Healthcare Emergency Public Service (EPES) during 2012. The EPES provides emergency medical services to the total population of Andalusia, Spain (8.5 million inhabitants) and records data on the incidence, resource utilization and cost of out-of-hospital medical care. Direct costs were estimated using public prices for health services updated to 2012.

RESULTS

Among 1 137 738 emergency calls requesting medical assistance, 3157 were diagnosed with hyperglycaemic crises by an emergency coordinator, representing 2.9 cases per 1000 persons with diabetes [95% confidence intervals (CI) 2.8 to 3.0]. The incidence of diabetic ketoacidosis was 2.5 cases per 1000 persons with diabetes (95% CI 2.4 to 2.6) and the incidence of hyperosmolar hyperglycaemic state was 0.4 cases per 1000 persons with diabetes (95% CI 0.4 to 0.5). In total, 17.7% (n = 440) of people had one or more hyperglycaemic crisis. The estimated total direct cost was €4 662 151, with a mean direct cost per episode of €1476.8 ± 217.8.

CONCLUSIONS

Hyperglycaemic crises require high resource utilization of emergency medical services and have a significant economic impact on the health system.

Serum YB-1 (Y-box binding protein 1) as a biomarker of bone disease progression in patients with breast cancer and bone metastases

YB-1 (Y-box binding protein 1) is a multifunctional cold-shock protein that has been implicated in all hallmarks of cancer. Elevated YB-1 protein level was associated with poor prognosis in several types of cancers, including breast cancer (BC), where it is a marker of decreased overall survival (OS) and distant metastasis-free survival across all subtypes. YB-1 is also secreted by different cell types and may act as an extracellular mitogen; however the pathological implications of the secreted form of YB-1 (sYB-1) are unknown. Our purpose was to retrospectively evaluate the association between YB-1 measured by ELISA in serum and disease characteristics and outcomes in patients with BC and bone metastases (BM). In our cohort, sYB-1 was detected in the serum of 22 (50%) patients, and was associated with the presence of extra-bone metastases (p=0.044). Positive sYB-1 was also associated with faster bone disease progression (HR 3.1, 95% CI 1.09–8.95, P=0.033), but no significant differences were observed concerning OS, and time to development of skeletal-related events. Moreover, patients with positive sYB-1 also had higher levels of IL-6, a known osteoclastogenic inducer. Therefore, detection of sYB-1 in patients with BC and BM may indicate a higher tumor burden, in bone and extra-bone locations, and is a biomarker of faster bone disease progression.

Non-steroidal anti-inflammatory drug hypersensitivity in children

INTRODUCTION

There are rather few publications about hypersensitivity reactions to non-steroidal anti-inflammatory drugs (NSAID) in the paediatric age. In this study, we aimed to assess the frequency of confirmed NSAID hypersensitivity in children with a previous reported reaction to NSAID in order to investigate the role of the drug provocation test (DPT) in the diagnostic workup and to explore the factors associated with confirmed NSAID hypersensitivity.

METHODS

We conducted a retrospective analysis of the clinical files from every patient under 18 years old who attended two Portuguese paediatric allergy outpatient clinics, from January 2009 to August 2014, due to a suspected NSAID hypersensitivity.

RESULTS

We included 119 patients, with a median age of nine years (P₂₅-P₇₅: 5-14). Ibuprofen was the commonest implicated NSAID in the patients' reports (n=94-79%). After DPT, NSAID hypersensitivity was confirmed in nine (7.6%) patients, excluded in 93 (78.2%) and was inconclusive in 17 (14.3%). In the majority (n=95-79.8%), the reaction occurred in the first 24h after intake. Eighty-four patients (70.6%) reported only cutaneous manifestations and 18 (15.1%) had systemic symptoms. Anaphylaxis represented a relative risk to NSAID hypersensitivity confirmation. No association was found for atopy and the number of previous reactions.

CONCLUSION

In our study, NSAID hypersensitivity was confirmed in a small proportion of the patients with a previous reported reaction. Ibuprofen was the most implicated drug with urticaria/angio-oedema as the commonest manifestation. Anaphylaxis was associated with confirmed drug hypersensitivity. The drug provocation test was essential to establish the diagnosis.

Building Bridges for Innovation in Ageing: Synergies between Action Groups of the EIP on AHA

The Strategic Implementation Plan of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) proposed six Action Groups. After almost three years of activity, many achievements have been obtained through commitments or collaborative work of the Action Groups. However, they have often worked in silos and, consequently, synergies between Action Groups have been proposed to strengthen the triple win of the EIP on AHA. The paper presents the methodology and current status of the Task Force on EIP on AHA synergies. Synergies are in line with the Action Groups' new Renovated Action Plan (2016-2018) to ensure that their future objectives are coherent and fully connected. The outcomes and impact of synergies are using the Monitoring and Assessment Framework for the EIP on AHA (MAFEIP). Eight proposals for synergies have been approved by the Task Force: Five cross-cutting synergies which can be used for all current and future synergies as they consider overarching domains (appropriate polypharmacy, citizen empowerment, teaching and coaching on AHA, deployment of synergies to EU regions, Responsible Research and Innovation), and three cross-cutting synergies focussing on current Action Group activities (falls, frailty, integrated care and chronic respiratory diseases).

Recommendations for Vaccination in Adult Patients with Systemic Inflammatory Rheumatic Diseases from the Portuguese Society of Rheumatology

BACKGROUND

Serious infections are a major cause of morbidity and mortality in systemic inflammatory rheumatic disease (SIRD) patients. Although vaccination may prevent numerous infections, vaccination uptake rates are low in this group of patients.

OBJECTIVES

To develop evidence-based recommendations for vaccination in SIRD patients.

METHODS

We searched MEDLINE (until 31 October 2014) and EMBASE (until 14 December 2014) databases, as well as the ACR and EULAR congress abstracts (2011-2014). Patients with any systemic inflammatory rheumatic disease were included and all vaccines were considered. Any safety and efficacy outcomes were admitted. Search results were submitted to title and abstract selection, followed by detailed review of suitable studies. Data were subsequently pooled according to the type of vaccine and the SIRD considered. Results were presented and discussed by a multidisciplinary panel and systematic literature review (SLR)-derived recommendations were voted according to the Delphi method. The level of agreement among rheumatologists was assessed using an online survey.

RESULTS

Eight general and seven vaccine-specific recommendations were formulated. Briefly, immunization status should routinely be assessed in all SIRD patients. The National Vaccination Program should be followed and some additional vaccines are recommended. To maximize the efficacy of vaccination, vaccines should preferably be administered 4 weeks before starting immunosuppression or, if possible when disease activity is controlled. Non-live vaccines are safe in SIRD, including immunosuppressed patients. The safety of live attenuated vaccines in immunosuppressed patients deserves further ascertainment, but might be considered in particular situations.

DISCUSSION

The present recommendations combine scientific evidence with the multidisciplinary expertise of our taskforce panel and attained desirable agreement among Portuguese rheumatologists. Vaccination recommendations need to be updated on a regular basis, as more scientific data regarding vaccination efficacy and safety, emergent infectious threats, new vaccines as well as new immunomodulatory therapies become available.

Abstract P4-09-06: The prognostic role of RANK single nucleotide polymorphisms in breast cancer patients with bone metastases

Background: Receptor activator of NF-kB (RANK) pathway regulates bone remodeling and is involved in breast cancer (BC) progression. RANK over-expression in primary BC associates with poor prognosis and metastasis development. In patients with BC, RANK and RANK-ligand (RANKL) single nucleotide polymorphisms (SNPs) have also been associated with BC risk and bone metastasis (BM)-free survival , respectively. Here we analyze the association of five RANK missense SNPs with prognosis of patients with BM from BC.

Methods: Missense RANK SNPs (rs34945627, rs12721431, rs35184120, rs35993683, rs61751992) were genotyped in germline DNA from a retrospective cohort of 76 patients with BM from BC, under bisphosphonates; and a cohort of 80 healthy volunteers (samples from Biobanco-IMM, Lisbon, Portugal). Genotypic allelic frequencies were assessed using TaqMan assays (Applied Biosystems). SNP rs34945627 was analyzed with regard to clinicopathological characteristics, skeletal-related events (SRE), bone progression-free interval (BPFi), and overall survival (OS). Univariate association with clinicopathological characteristics was performed using Fisher's exact test and Wilcoxon rank-sum test; univariate differences between survival rates were tested for significance using the log-rank test, while multivariate analysis for survival was tested using Cox proportional hazards models.

Results: SNP rs34945627 had a minor allele frequency of 11.84% (n=9) in BC patients versus 1.25% (n=1) in healthy individuals, whereas the remaining SNPs had a minor allele frequency of 2.60% (n=2) in BC patients. Therefore, for inferential analysis only SNP rs34945627 was considered. No differences between alleles were observed regarding clinicopathological characteristics, including treatment. Homozygous patients (CC) had increased OS when compared to heterozygous patients (CT) controlling for age at diagnosis, visceral involvement, radiographic pattern of BM and baseline urine NTX (adjusted HR 5.76, 95% CI 2.10-15.81; p<0.001). No association could be seen with regard to SREs (adjusted HR 1.43, 95% CI 0.46-4.46; p=0.54) or BPFi (adjusted HR 0.26, 95% CI 0.06-1.17; p=0.08).

Conclusions: RANK SNP rs34945627 seems to be a marker of poor prognosis in patients with BC and BM. Further studies are required to characterize the biological and clinical significance of this finding.

Citation Format: Casimiro S, Ferreira A, Alho I, Melo M, Brás R, Costa AL, Sousa AR, Mansinho A, Abreu C, Pulido C, Macedo D, Pacheco TR, Costa L. The prognostic role of RANK single nucleotide polymorphisms in breast cancer patients with bone metastases. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-09-06.

Incidence and care-related costs of severe hypoglycaemia requiring emergency treatment in Andalusia (Spain): the PAUEPAD project

AIMS

Hypoglycaemia is a serious medical emergency. The need for emergency medical service care and the costs of hypoglycaemic emergencies are not completely known.

METHODS

This was a retrospective observational study using Public Company for Health Emergencies (EPES) data for hypoglycaemia in 2012. The EPES provides emergency medical services to the entire population of Andalusia, Spain (8.5 million people). Data on event type, onsite treatments, emergency room visits or hospitalization were collected. Medical costs were estimated using the public rates for healthcare services.

RESULTS

From a total of 1 137 738 emergency calls that requested medical assistance, 8683 had a primary diagnosis of hypoglycaemia (10.34 per 10 000 person-years). The incidence of severe hypoglycaemic episodes requiring emergency treatment in the estimated population with diabetes was 80 episodes per 10 000 person-years. A total of 7479 episodes (86%) required an emergency team to visit the patient's residence. The majority of cases (64%) were addressed in the residence, although 1784 (21%) cases were transferred to hospital. A total of 5564 events (65%) involved patients aged > 65 years. Overall mortality was 0.32% (28 cases). The total annual cost of attending a hypoglycaemic episode was €6 093 507, leading to an estimated mean direct cost per episode of €702 ± 565. Episodes that required hospital treatment accounted for 49% of the total costs.

CONCLUSIONS

Hypoglycaemia is a common medical emergency that is associated with high emergency medical service utilization, resulting in a significant economic impact on the health system.

Asthma control and exacerbations in patients with severe asthma treated with omalizumab in Portugal

The analysis of outcomes from patients with severe asthma treated with omalizumab, using real-life prospective data, should contribute to future informed decisions about this treatment in Portugal. The aim of this study was to assess the clinical effect of omalizumab in Portuguese patients with severe persistent allergic asthma, considering specifically asthma control and exacerbations. This was an observational, prospective, multicentre study. Data were collected at routine care over a 12-month period. Disease control was defined by Control of Allergic Rhinitis and Asthma Test (CARAT) global score >24. All asthma patients already under treatment with omalizumab in 7 departments from 6 Portuguese hospitals were included (n=48). Most (77%) patients were female and the mean (SD) age was 51.9 (10.2) years old. During the study period, asthma was controlled in 34% of the visits and the 12-month exacerbation rate was 1.7 per patient (0.6 with unscheduled medical care). One-third of the patients needed unscheduled medical care because of asthma and 29% had to start or increase oral corticosteroid. There was still a 41% reduction in the total sum of oral corticosteroids usage from the first to the last trimester of the study. During routine treatment with omalizumab, Portuguese patients with severe asthma achieved asthma control in 1/3 of the visits and only 1/3 needed unscheduled or Emergency Room care because of asthma exacerbations. These outcomes support the maintenance of the clinical effect during treatment with omalizumab in routine care in Portugal.

Relationship between thyroid-stimulating hormone and insulin in euthyroid obese men

BACKGROUND/AIMS

Obesity has been associated with hypothyroidism and impaired insulin sensitivity. However, few studies have specifically addressed the association between insulin sensitivity and thyroid function. Our aim was to look for a relation between these 2 factors in a sample of obese males.

METHODS

One hundred and forty-four euthyroid male obese patients--mean age 42.6 years, mean body mass index (BMI) 41.8--were enrolled in this cross-sectional study. The hospital study protocol at entrance included baseline serum thyroid-stimulating hormone (TSH), insulin and glucose concentrations. Data were studied using an age-adjusted simple and multivariate linear regression analysis with TSH as the dependent and insulin and BMI as the independent variables.

RESULTS

Mean TSH and insulin were 1.6 and 21.2 mU/l, respectively. It was found that their relationship follows a regression model: TSH=1.725-0.019 (age) + 0.003 (insulin) + 0.017 (BMI). Further data showed a positive correlation between BMI and TSH (r= 0.22; p<0.05), as well as between serum baseline insulin (>10 mU/l) and TSH concentration (r=0.27; p<0.05). This association was stronger in patients with higher insulin values (>21.2 mU/l; r=0.40; p<0.01). However, negative correlations between age and insulin (r= -0.14; not significant) and age and TSH (r= -0.35; p<0.05) were observed.

CONCLUSIONS

In obese males, insulin resistance is significantly related with impairment of thyroid function, and this situation seems to be attenuated with age.

Lack of association between androgen receptor polymorphisms and bone mineral density or physical function in older men

Individuals whose androgen receptors have short polyglutamine tracts (resulting from CAG repeats) may have greater receptor signaling activity of the androgen receptor. We evaluated the association between bone mineral density (BMD) and CAG repeats in 91 older men with normal (control) and low femoral neck (EN) BMD (OP) or a history of femoral fracture (FX). Bioavailable testosterone (BioT) and physical performance, including composite score (EPESE) and physical activity (PASE), were also measured. Comparing FX, OP, and control subjects, we observed BMD Tscores of -2.16 +/- 1.08, -2.26 +/- 0.74, and -0.20 +/- 0.40 (p < 0.001); CAG repeat lengths of 21.9 +/- 2.7, 22.5 +/- 2.4, and 22.3 +/- 2.9 (p = 0.63); BioT levels of 2.29 +/- 1.25, 2.19 +/- 1.11, and 3.99 +/- 1.25 nmol/L (p < 0.001); EPESE scores of 8.0 +/- 3.0, 9.7 +/- 2.0, and 11.3 +/- 0.9 (p < 0.001); and PASE scores of 91 +/- 66, 122 +/- 66, and 200 +/- 55 (p < 0.001), respectively. There were no significant correlations between CAG repeats and BioT or physical performance. Men with osteoporosis or fracture had lower BioT, physical performance, and physical activity than controls. This study found no association between CA G repeats and FN BMD in older men with normal or low BMD or FX.

Crenarchaeota and Euryarchaeota in temperate estuarine sediments

AIMS

Application of molecular techniques to ecological studies has unveiled a wide diversity of micro-organisms in natural communities, previously unknown to microbial ecologists. New lineages of Archaea were retrieved from several non-extreme environments, showing that these micro-organisms are present in a large variety of ecosystems. The aim was therefore to assess the presence and diversity of Archaea in the sediments of the river Douro estuary (Portugal), relating the results obtained to ecological data.

METHODS AND RESULTS

Total DNA was extracted from sediment samples obtained from an estuary deprived of vegetation, amplified by PCR and the resulting DNA fragments cloned. The archaeal origin of the cloned inserts was checked by Southern blot, dot blot or colony blot hybridization. Recombinant plasmids were further analysed by restriction with AvaII and selected for sequencing. Phylogenetic analyses of 14 sequences revealed the presence of members of the domain Archaea. Most of the sequences could be assigned to the kingdom Crenarchaeota.

CONCLUSION

Most of these sequences were closely related to those obtained from non-extreme Crenarchaeota members previously retrieved from diverse ecosystems, such as freshwater and marine environments.

SIGNIFICANCE AND IMPACT OF THE STUDY

The presence of archaeal 16S rDNA sequences in temperate estuarine sediments emerges as a valuable contribution to the understanding of the complexity of the ecosystem.

[Kaposi sarcoma associated with HIV infection]

Kaposi's sarcoma is the most common neoplasm in AIDS patients. In a 12-year period, 45 (8%) cases were diagnosed in 552 patients with AIDS. Epidemiological and clinical aspects are reviewed. The disease occurred predominantly in males and homosexuals. In 30 (67%) patients it was the first manifestation of AIDS. Skin and/or oral disease was the most frequent manifestation observed in our patients; 13 (29%) had visceral involvement. Previous or concommitant opportunistic diseases, systemic illness and severe immunosuppression were present in the majority of the patients. Opportunistic infections were the cause of death in 30 patients; in five others, Kaposi's sarcoma was responsible for death. Advances in antiretroviral therapy were of benefit for patients submitted to chemotherapy and may contribute to a reduction in morbidity with this neoplasm.

Prostaglandins regulate the expression of fibroblast growth factor-2 in bone

We examined the effect of PGs, particularly PGF2alpha, on basic fibroblast growth factor-2 (FGF-2) messenger RNA (mRNA) and protein in the rat osteoblastic cell line Py1a and in fetal rat calvariae. Py1a cells expressed multiple FGF-2 mRNA transcripts. PGF2alpha dose-dependently increased the 6-kb transcript at 6 h. The selective PGF2alpha agonist, fluprostenol (Flup), was more potent than PGF2alpha. Phorbol myristate acetate (10(-6) M) also increased a 6-kb mRNA at 6 h. By immunofluorescence microscopy, Flup increased perinuclear staining for FGF-2 protein at 6 h and nuclear labeling at 24 h. Immunogold labeling of calvariae revealed that treatment with Flup for 3 h caused a transition of FGF expression from matrix to cells and an increase in cytoplasmic labeling for FGF-2 protein in periosteal cells and in osteoblasts. After treatment with Flup for 24 h, nuclear labeling was marked in periosteal cells and in osteoblasts, and a further increase in cytoplasmic labeling for FGF-2 was noted in osteocytes, periosteal cells, and osteoblasts. We conclude that PGs can increase FGF-2 mRNA and protein in bone cells. Because the effect of Flup was mimicked by phorbol myristate acetate, we hypothesize that PGs' regulation of FGF-2 is mediated by a PGF2alpha-selective receptor acting through protein kinase C. Hence, effects of PGs on bone remodeling may be mediated, in part, by endogenous FGF-2.

Signal transduction by basic fibroblast growth factor in rat osteoblastic Py1a cells

Basic fibroblast growth factor (bFGF) is a potent mitogen for bone. In this study, we utilized the clonal rat osteoblastic cell line, Py1a, to examine signal transduction by bFGF and to determine the role of mitogen activated protein kinases (MAPK) and induction of c-fos mRNA in the mitogenic response to bFGF. Stimulation of [3H]thymidine incorporation (TDR) into DNA by bFGF was determined in the presence of phorbol myristate acetate of (PMA) to down-regulate the protein kinase C (PKC) pathway, genistein, an inhibitor of tyrosine kinase and H-7, a PKC inhibitor, bFGF 10(-8) M and PMA 10(-7) M increased TDR by 242 and 245%, respectively. Treatment with bFGF or PMA for 5 or 30 minutes increased tyrosine phosphorylation of multiple proteins, and immunoblotting with MAPK-specific antibody revealed that two of these bands were the 42 and 44 kD isoforms of MAPK. PMA and bFGF induced c-fos mRNA expression at 30 minutes. Genistein at 10 micrograms/ml blocked the mitogenic effect of bFGF and partially inhibited the mitogenic effect of PMA. Genistein at 100 micrograms/ml also blocked both bFGF- and PMA-induced increases in c-fos mRNA. A 24 h pretreatment with PMA at 10(-7) M inhibited the mitogenic response, tyrosine phosphorylation of MAPK, and induction of c-fos mRNA subsequent to the addition of PMA, but not bFGF. H-7 at 50 microM blocked bFGF-induced mitogenesis and c-fos induction, but did not inhibit bFGF-induced tyrosine phosphorylation of MAPK. In this study, we show that the signaling pathway of bFGF and PMA are similar in that they both induce tyrosine phosphorylation of MAP kinases and activate c-fos. However, the signaling pathways ultimately diverge in that once the PKC pathway is down-regulated by PMA pretreatment or blocked by the PKC inhibitor H-7, tyrosine phosphorylation of MAP kinase, c-fos induction, and the mitogenic effect of PMA is blocked. In contrast, down-regulation of the PKC pathway inhibits c-fos and the mitogenic response to bFGF, but not bFGF's effects on tyrosine phosphorylation of MAP kinase.

Regulation of NFIL-6 and IL-6 expression by basic fibroblast growth factor in osteoblasts

We determined whether basic fibroblast growth factor (bFGF) regulated the expression of IL-6 and NFIL-6 in osteoblasts. In mouse osteoblastic MC3T3-E1 cells, bFGF (10(-8) M) increased NFIL-6 mRNA 2-fold at 30 minutes and 3-fold at 2 h. IL-6 mRNA was increased by bFGF 10(-8) M after 1 h. IL-6 protein was detectable in control cultures but was significantly increased by bFGF (10(-8) M) at 4 h. Immunofluorescence analysis of MC3T3-E1 cells showed primarily cytoplasmic and perinuclear NFIL-6 staining in control cultures while bFGF-treated cells showed increased NFIL-6 staining at 2 and 4 h. Western blotting revealed that bFGF increased NFIL-6 protein at 2 h. In calvarial mouse osteoblasts, bFGF 10(-8) M induced IL-6 mRNA as early as 1 h and significantly increased IL-6 protein levels as early as 2 h. In conclusion, bFGF stimulates IL-6 and NFIL-6 mRNA in osteoblasts. The increase in NFIL-6 mRNA was associated with increased NFIL-6 protein. The increase in IL-6 mRNA was also associated with increased IL-6 protein. We propose that activations of NFIL-6 and IL-6 may be important mediators of the effects of bFGF on bone cells.

Intact insulin-like growth factor binding protein-5 (IGFBP-5) associates with bone matrix and the soluble fragments of IGFBP-5 accumulated in culture medium of neonatal mouse calvariae by parathyroid hormone and prostaglandin E2-treatment

We examined the distribution of insulin-like growth factor binding proteins (IGFBPs) in cultured neonatal mouse calvariae. IGFBP-3 and -4 were predominantly found in the conditioned medium. IGFBP-2 was partitioned between conditioned medium and bone and extracellular matrix (BECM), while intact (31-kDa) IGFBP-5 was most abundant in BECM extracts. After treatment with parathyroid hormone (PTH, 10(-8) M) or prostaglandin E2 (PGE2, 10(-6) M), immunoreactive IGFBP-5 accumulated in the conditioned medium in a 21-kDa form which did not bind IGF-I on Western ligand blots. PTH and PGE2 did not alter the level of steady-state IGFBP-5 mRNA, nor markedly stimulate IGFBP-5 synthesis in the calvariae, and thus accumulation of 21-kDa IGFBP-5 was largely due to release from BECM. This accumulation of truncated IGFBP-5 in the conditioned medium was not dependent on osteoclastic bone resorption, since it was not blocked by calcitonin or a bisphosphonate which inhibited PTH- and PGE2-stimulated 45Ca-release. The conditioned medium from PTH- or PGE2-treated cultures degraded recombinant human IGFBP-5 into lower molecular weight fragments. Addition of IGF-1 at 10(-8) M into the culture resulted in accumulation of native 31-kDa IGFBP-5. However, even in the presence of IGF-1, the native IGFBP-5 was degraded and the 21-kDa product accumulated in the culture medium. These results suggested a possible proteolytic mechanism for 21-kDa IGFBP-5 accumulation, responsive to PTH and PGE2. Aprotinin, leupeptin, cystatin, and bestatin did not inhibit the effects of PTH and PGE2 in the cultures. The localization of IGFBP-5 in BECM and its release and proteolysis induced by PTH and PGE2 could play a role in the local regulation of bone metabolism.

Transcriptional regulation of the collagenase gene by basic fibroblast growth factor in osteoblastic MC3T3-E1 cells

Recent studies have shown that Basic Fibroblast Growth Factor increases bone resorption and increases interstitial collagenase mRNA and protein in osteoblasts. We examined the effect of bFGF on a 1.8-kb fragment of the rabbit collagenase promoter linked to a chloramphenicol acetyl transferase CAT construct stably transfected into mouse osteoblastic MC3T3-E1 cells. Treatment with bFGF (10(-8)M) for 24 h caused a 3-fold increase in collagenase-CAT activity. CAT activity in a construct without the collagenase promoter was not regulated by 48 h treatment with bFGF (10(-8)M). Neither indomethacin nor staurosporine blocked the effect of bFGF on collagenase-CAT activity in these cells. However, the stimulatory effect of bFGF on collagenase-CAT activity was inhibited by genistein and herbimycin A, which are tyrosine kinase inhibitors. These data show for the first time that bFGF transcriptionally regulates collagenase gene expression in osteoblasts through a protein tyrosine kinase-dependent pathway.

Transcriptional induction of prostaglandin G/H synthase-2 by basic fibroblast growth factor

In serum-free mouse osteoblastic MC3T3-E1 cells, basic fibroblastic growth factor (bFGF) induced mRNA and protein for prostaglandin G/H synthase-2 (PGHS-2), the major enzyme in arachidonic acid (AA) conversion to prostaglandins. mRNA accumulation peaked at 1 h with bFGF 1 nM. In cells stably transfected with a 371-bp PGHS-2 promoter-luciferase reporter, bFGF stimulated luciferase activity, which peaked at 2-3 h with bFGF 1-10 nM. In the presence of exogenous AA, bFGF stimulated PGE2 production, which paralleled luciferase activity. In serum-free neonatal mouse calvarial cultures, bFGF stimulated PGE2 production in the absence of exogenous AA. bFGF stimulated PGHS-2 mRNA accumulation, which peaked at 2-4 h and then decreased; there were later mRNA elevations at 48 and 96 h that were inhibited by indomethacin. In both MC3T3-E1 cells and neonatal calvariae, bFGF produced smaller and slower increases in PGHS-1 mRNA levels than for PGHS-2. bFGF stimulated bone resorption in mouse calvariae with a maximal increase of 80% at 1 nM. Stimulation was partially inhibited by nonsteroidal anti-inflammatory drugs. We conclude that bFGF rapidly stimulates PGE2 production in osteoblasts, largely through transcriptional regulation of PGHS-2, and that prostaglandins mediate some of bFGF's effects on bone resorption.

Update on the use of cefotaxime for pediatric meningitis in Portugal

We treated 256 children who had identified bacterial meningitis with cefotaxime. Causative organisms were: Neisseria meningitidis in 108 cases, Streptococcus pneumoniae in 61, Haemophilus influenzae in 60, enteric Gram-negative bacilli in 21, and Staphylococcus spp. in six. Daily doses of cefotaxime were 150-200 mg/kg. A total of 240 patients (93.7%) were cured. In the cured patients, sterilization of cerebrospinal fluid was obtained in the first 72 h of treatment in 214 (80.0%). Cefotaxime is an effective and safe drug for the treatment of childhood bacterial meningitis.