Length of Stay and Hospital Cost Reductions After Implementing Bedside Percutaneous Ultrasound Gastrostomy (PUG) in a Critical Care Unit

Background: Critical care patients receive 50% of gastrostomy tubes placed in the United States. Several gastrostomy placement methods exist, however care processes remain variable and often lack health system cost effectiveness. No data exists on efficiency or cost impact of performing bedside percutaneous ultrasound gastrostomy (PUG) on patients with ventilator-dependent respiratory failure. This study's objective was to determine if implementing bedside PUG would positively impact efficiency and cost outcomes in intensive care unit (ICU) patients compared to usual care gastrostomy. Design and Methods: This is a retrospective cohort study of patients with ventilator-dependent respiratory failure who received a gastrostomy consult or procedure in the ICU. Patients received PUG or usual care gastrostomy, determined by the presiding attending's skillset, and both groups were compared across patients' demographics, clinical characteristics and outcomes. Primary outcomes were length of stay (LOS) and total hospital costs. Results: A total of 88 patients were included in the analysis, 45 patients in the PUG group and 43 in the usual care gastrostomy group. No differences were observed in demographic and clinical characteristics. Patients who received PUG had a significantly shorter mean ICULOS and hospital LOS, with reductions of 5.0 and 8.7 days, respectively. Total hospital costs were significantly reduced in the PUG group, with a cost savings of US $26,621 per patient. No differences in mortality or discharge disposition were observed. PUG patients received concomitant percutaneous dilatation tracheostomy (PDT) and PUG ("TPUG") 70% of the time, whereas no usual care patients received concomitant procedures. Off-hour procedures occurred in 53.3% of PUG and 4.6% of usual care gastrostomy. Conclusions: This study demonstrates bedside PUG leads to decreased LOS and total hospital costs in patients with ventilator-dependent respiratory failure. Hospital costs were significantly reduced with a per patient savings of $26,621 compared to usual care gastrostomy.

Performance of low-cost monitors to assess household air pollution

Exposure to household air pollution is a leading cause of morbidity and mortality globally. However, due to the lack of validated low-cost monitors with long-lasting batteries in indoor environments, most epidemiologic studies use self-reported data or short-term household air pollution assessments as proxies of long-term exposure. We evaluated the performance of three low-cost monitors measuring fine particulate matter (PM_2.5) and carbon monoxide (CO) in a wood-combustion experiment conducted in one household of Spain for 5 days (including the co-location of 2 units of HAPEX and 3 units of TZOA-R for PM_2.5 and 3 units of EL-USB-CO for CO; a total of 40 unit-days). We used Spearman correlation (ρ) and Concordance Correlation Coefficient (CCC) to assess accuracy of low-cost monitors versus equivalent research-grade devices. We also conducted a field study in India for 1 week (including HAPEX in 3 households and EL-USB-CO in 4 households; a total of 49 unit-days). Correlation and agreement at 5-min were moderate-high for one unit of HAPEX (ρ = 0.73 / CCC = 0.59), for one unit of TZOA-R (ρ = 0.89 / CCC = 0.62) and for three units of EL-USB-CO (ρ = 0.82-0.89 / CCC = 0.66-0.91) in Spain, although the failure or malfunction rate among low-cost units was high in both settings (60% of unit-days in Spain and 43% in India). Low-cost monitors tested here are not yet ready to replace more established exposure assessment methods in long-term household air pollution epidemiologic studies. More field validation is needed to assess evolving sensors and monitors with application to health studies.

Mitochondrial dysfunction and pulmonary hypertension: cause, effect, or both

Pulmonary hypertension describes a heterogeneous disease defined by increased pulmonary artery pressures, and progressive increase in pulmonary vascular resistance due to pathologic remodeling of the pulmonary vasculature involving pulmonary endothelial cells, pericytes, and smooth muscle cells. This process occurs under various conditions, and although these populations vary, the clinical manifestations are the same: progressive dyspnea, increases in right ventricular (RV) afterload and dysfunction, RV-pulmonary artery uncoupling, and right-sided heart failure with systemic circulatory collapse. The overall estimated 5-yr survival rate is 72% in highly functioning patients, and as low as 28% for those presenting with advanced symptoms. Metabolic theories have been suggested as underlying the pathogenesis of pulmonary hypertension with growing evidence of the role of mitochondrial dysfunction involving the major proteins of the electron transport chain, redox-related enzymes, regulators of the proton gradient and calcium homeostasis, regulators of apoptosis, and mitophagy. There remain more studies needed to characterize mitochondrial dysfunction leading to impaired vascular relaxation, increase proliferation, and failure of regulatory mechanisms. The effects on endothelial cells and resulting interactions with their microenvironment remain uncharted territory for future discovery. Additionally, on the basis of observations that the "plexigenic lesions" of pulmonary hypertension resemble the unregulated proliferation of tumor cells, similarities between cancer pathobiology and pulmonary hypertension have been drawn, suggesting interactions between mitochondria and angiogenesis. Recently, mitochondria targeting has become feasible, which may yield new therapeutic strategies. We present a state-of-the-art review of the role of mitochondria in both the pathobiology of pulmonary hypertension and potential therapeutic targets in pulmonary vascular processes.

A Woman in Her 60s With Lung Adenocarcinoma Presents With Copious Watery Sputum and Respiratory Failure

CASE PRESENTATION

A woman in her 60s presented with 1 month of progressive dyspnea, watery rhinorrhea, and paroxysmal cough productive of clear, watery sputum. She was diagnosed with epidermal growth factor receptor (EGFR) mutation-positive lung adenocarcinoma at another institution 1 week prior to presentation and 3 weeks after the onset of symptoms. She was a never-smoker. She denied fevers and had completed a course of antibiotics for presumed pneumonia, without clinical improvement. She presented to the hospital due to increasing severity of her shortness of breath.

Complexity of macrophage migration inhibitory factor (MIF) and other angiogenic biomarkers profiling in pulmonary arterial hypertension

Macrophage migration inhibitory factor (MIF) and 22 a priori selected biomarkers were measured from pulmonary arterial hypertension (PAH) patients. Significant positive correlations were found between MIF and several angiogenic factors suggesting a possible MIF regulation role in PAH angiogenesis and pathobiology, but simultaneously highlighting the biomarkers profiling complexity in PAH.

Seasonality and nitrogen supply modify carbon partitioning in understory vegetation of a boreal coniferous forest

Given the strong coupling between the carbon (C) and nitrogen (N) cycles, there is substantial interest in understanding how N availability affects C cycling in terrestrial ecosystems, especially in ecosystems limited by N. However, most studies in temperate and boreal forests have focused on the effects of N addition on tree growth. By comparison, less is known about the effects of N availability on the cycling of C in understory vegetation despite some evidence that dwarf shrubs, mosses, and lichens play an important role in the forest C balance. In this study, we used an in situ 13CO2 pulse-labeling technique to examine the short-term dynamics of C partitioning in understory vegetation in three boreal Pinus sylvestris forest stands exposed to different rates of N addition: a low and high N addition that receive annual additions of NH4NO3 of 20 and 100 kg N/ha, respectively, and this is a typo. It should be an unfertilized control. Labeling was conducted at two distinct periods (early vs. late growing season), which provided a seasonal picture of how N addition affects C dynamics in understory vegetation. In contrast to what has been found in trees, there was no obvious trend in belowground C partitioning in ericaceous plants in response to N additions or seasonality. Increasing N addition led to a greater percentage of 13C being incorporated into ericaceous leaves with a high turnover, whereas high rates of N addition strongly reduced the incorporation of 13C into less degradable moss tissues. Addition of N also resulted in a greater percentage of the 13C label being respired back to the atmosphere and an overall reduction in total understory carbon use efficiency. Taken together, our results suggest a faster cycling of C in understory vegetation with increasing N additions; yet the magnitude of this general response was strongly dependent on the amount of N added and varied seasonally. These results provide some of the first in situ C and N partitioning estimates for plants growing under the complex web of resource limitations in the boreal understory.

Degeneration and plasticity of the optic pathway in Alström syndrome

BACKGROUND AND PURPOSE

Alström syndrome is a rare inherited ciliopathy in which early progressive cone-rod dystrophy leads to childhood blindness. We investigated functional and structural changes of the optic pathway in Alström syndrome by using MR imaging to provide insight into the underlying pathogenic mechanisms.

MATERIALS AND METHODS

Eleven patients with genetically proved Alström syndrome (mean age, 23 years; range, 6-45 years; 5 females) and 19 age- and sex-matched controls underwent brain MR imaging. The study protocol included conventional sequences, resting-state functional MR imaging, and diffusion tensor imaging.

RESULTS

In patients with Alström syndrome, the evaluation of the occipital regions showed the following: 1) diffuse white matter volume decrease while gray matter volume decrease spared the occipital poles (voxel-based morphometry), 2) diffuse fractional anisotropy decrease and radial diffusivity increase while mean and axial diffusivities were normal (tract-based spatial statistics), and 3) reduced connectivity in the medial visual network strikingly sparing the occipital poles (independent component analysis). After we placed seeds in both occipital poles, the seed-based analysis revealed significantly increased connectivity in patients with Alström syndrome toward the left frontal operculum, inferior and middle frontal gyri, and the medial portion of both thalami (left seed) and toward the anterior portion of the left insula (right and left seeds).

CONCLUSIONS

The protean occipital brain changes in patients with Alström syndrome likely reflect the coexistence of diffuse primary myelin derangement, anterograde trans-synaptic degeneration, and complex cortical reorganization affecting the anterior and posterior visual cortex to different degrees.

Alström syndrome is associated with short stature and reduced GH reserve

INTRODUCTION

Alström syndrome (ALMS) is a rare autosomal recessive monogenic disease included in an emerging class of genetic disorders called 'ciliopathies' and is likely to impact the central nervous system as well as metabolic and endocrine function. Individuals with ALMS present clinical features resembling a growth hormone deficiency (GHD) condition, but thus far no study has specifically investigated this aspect in a large population.

MATERIAL AND METHODS

Twenty-three patients with ALMS (age, 1-52 years; 11 males, 12 females) were evaluated for anthropometric parameters (growth charts and standard deviation score (SDS) of height, weight, BMI), GH secretion by growth hormone-releasing hormone + arginine test (GHRH-arg), bone age, and hypothalamic-pituitary magnetic resonance imaging (MRI). A group of 17 healthy subjects served as controls in the GH secretion study. Longitudinal retrospective and prospective data were utilized.

RESULTS

The length-for-age measurements from birth to 36 months showed normal growth with most values falling within -0·67 SDS to +1·28 SDS. A progressive decrease in stature-for-age was observed after 10 years of age, with a low final height in almost all ALMS subjects (>16-20 years; mean SDS, -2·22 ± 1·16). The subset of 12 patients with ALMS tested for GHRH-arg showed a significantly shorter stature than age-matched controls (154·7 ± 10·6 cm vs 162·9 ± 4·8 cm, P = 0·009) and a mild increase in BMI (Kg/m(2) ) (27·8 ± 4·8 vs 24·1 ± 2·5, P = 0·007). Peak GH after GHRH-arg was significantly lower in patients with ALMS in comparison with controls (11·9 ± 6·9 μg/l vs 86·1 ± 33·2 μg/l, P < 0·0001). Severe GHD was evident biochemically in 50% of patients with ALMS. The 10 adult ALMS patients with GHD showed a reduced height in comparison with those without GHD (149·7 ± 6·2 cm vs 161·9 ± 9·2 cm, P = 0·04). MRIs of the diencephalic and pituitary regions were normal in 11 of 12 patients. Bone age was advanced in 43% of cases.

CONCLUSIONS

Our study shows that 50% of nonobese ALMS patients have an inadequate GH reserve to GHRH-arg and may be functionally GH deficient. The short stature reported in ALMS may be at least partially influenced by impairment of GH secretion.

Hippocampal tissue of patients with refractory temporal lobe epilepsy is associated with astrocyte activation, inflammation, and altered expression of channels and receptors

Temporal lobe epilepsy (TLE) is the most common form of focal epilepsy. Previous research has demonstrated several trends in human tissue that, undoubtedly, contribute to the development and progression of TLE. In this study we examined resected human hippocampus tissue for a variety of changes including gliosis that might contribute to the development and presentation of TLE. The study subjects consisted of six TLE patients and three sudden-death controls. Clinicopathological characteristics were evaluated by H&E staining. Immunohistological staining and Western blotting methods were used to analyze the samples. Neuronal hypertrophy was observed in resected epileptic tissue. Immunohistological staining demonstrated that activation of astrocytes was significantly increased in epileptic tissue as compared to corresponding regions of the control group. The Western blot data also showed increased CX43 and AQP4 in the hippocampus and downregulation of Kir4.1, α-syntrophin, and dystrophin, the key constituents of AQP4 multi-molecular complex. These tissues also demonstrated changes in inflammatory factors (COX-2, TGF-β, NF-κB) suggesting that these molecules may play an important role in TLE pathogenesis. In addition we detected increases in metabotropic glutamate receptor (mGluR) 2/3, mGluR5 and kainic acid receptor subunits KA1 (Grik4) and KA2 (Grik5) in patients' hippocampi. We noted increased expression of the α1c subunit comprising class C L-type Ca(2+) channels and calpain expression in these tissues, suggesting that these subunits might have an integral role in TLE pathogenesis. These changes found in the resected tissue suggest that they may contribute to TLE and that the kainic acid receptor (KAR) and deregulation of GluR2 receptor may play an important role in TLE development and disease course. This study identifies alterations in number of commonly studied molecular targets associated with astrogliosis, cellular hypertrophy, water homeostasis, inflammation, and modulation of excitatory neurotransmission in hippocampal tissues from TLE patients.

Sedimentological control on Mn, and other trace elements, in groundwater of the Bengal delta

To reveal what controls the concentration and distribution of possibly hazardous (Mn, U, Se, Cd, Bi, Pb) and nonhazardous (Fe, V, Mo, PO(4)) trace elements in groundwater of the Bengal delta, we mapped their concentrations in shallow groundwater (<60 mbgl) across 102 km(2) of West Bengal. Only Mn is a potential threat to health, with 55% of well water exceeding 0.3 mg/L, the current Indian limit for drinking water in the absence of an alternate source, and 75% exceeding the desirable limit of 0.1 mg/L. Concentrations of V are <3 μg/L. Concentrations of U, Se, Pb, Ni, Bi, and Cd, are below WHO guideline values. The distributions of Fe, Mn, As, V, Mo, U, PO(4), and δ(18)O in groundwater reflect subsurface sedimentology and sources of water. Areas of less negative δ(18)O reveal recharge by sources of evaporated water. Concentrations of Fe, As, Mo, and PO(4) are high in palaeo-channel groundwaters and low in palaeo-interfluvial groundwaters. Concentrations of U, V, and Mn, are low in palaeo-channel groundwaters and high in palaeo-interfluvial groundwaters. Concentrations of Fe and Mn are highest (18 and 6 mg/L respectively) at dual reduction-fronts that form strip interfaces at depth around the edges of palaeo-interfluvial aquifers. The fronts form as focused recharge carries dissolved organic carbon into the aquifer margins, which comprise brown, iron-oxide bearing, sand. At the Mn-reduction front, concentrations of V and Mo reach peak concentrations of 3 μg/L. At the Fe-reduction front, concentrations of PO(4) and As reach concentrations 3 mg/L and 150 μg/L respectively. Many groundwaters contain >10 mg/L of Cl, showing that they are contaminated by Cl of anthropogenic origin and that organic matter from in situ sanitation may contribute to driving reduction.

Adaptation of continuous-flow cavity ring-down spectroscopy for batch analysis of δ13C of CO2 and comparison with isotope ratio mass spectrometry

Measurements of δ(13)C in CO(2) have traditionally relied on samples stored in sealed vessels and subsequently analyzed using magnetic sector isotope ratio mass spectrometry (IRMS), an accurate but expensive and high-maintenance analytical method. Recent developments in optical spectroscopy have yielded instruments that can measure δ(13)CO(2) in continuous streams of air with precision and accuracy approaching those of IRMS, but at a fraction of the cost. However, continuous sampling is unsuited for certain applications, creating a need for conversion of these instruments for batch operation. Here, we present a flask (syringe) adaptor that allows the collection and storage of small aliquots (20-30 mL air) for injection into the cavity ring-down spectroscopy (CRDS) instrument. We demonstrate that the adaptor's precision is similar to that of traditional IRMS (standard deviation of 0.3‰ for 385 ppm CO(2) standard gas). In addition, the concentration precision (±0.3% of sample concentration) was higher for CRDS than for IRMS (±7% of sample concentration). Using the adaptor in conjunction with CRDS, we sampled soil chambers and found that soil-respired δ(13)C varied between two different locations in a piñon-juniper woodland. In a second experiment, we found no significant discrimination between the respiration of a small beetle (~5 mm) and its diet. Our work shows that the CRDS system is flexible enough to be used for the analysis of batch samples as well as for continuous sampling. This flexibility broadens the range of applications for which CRDS has the potential to replace magnetic sector IRMS.

Evidence for Molecular Heterogeneity of the Specific Antigen (Fraction-1) of Pasteurella pestis

Fraction-I (F-I) protein, the specific antigen of Pasteurella pestis, appears to be a series of molecular aggregates of identical subunits, all of which have serological reactivity with specific F-I antiserum.

Assimilation of xylem-transported 13C-labelled CO2 in leaves and branches of sycamore (Platanus occidentalis L.)

Previous reports have shown that CO(2) dissolved in xylem sap in tree stems can move upward in the transpiration stream. To determine the fate of this dissolved CO(2), the internal transport of respired CO(2) at high concentration from the bole of the tree was simulated by allowing detached young branches of sycamore (Platanus occidentalis L.) to transpire water enriched with a known quantity of (13)CO(2) in sunlight. Simultaneously, leaf net photosynthesis and CO(2) efflux from woody tissue were measured. Branch and leaf tissues were subsequently analysed for (13)C content to determine the quantity of transported (13)CO(2) label that was fixed. Treatment branches assimilated an average of 35% (SE=2.4) of the (13)CO(2) label taken up in the treatment water. The majority was fixed in the woody tissue of the branches, with smaller amounts fixed in the leaves and petioles. Overall, the fixation of internally transported (13)CO(2) label by woody tissues averaged 6% of the assimilation of CO(2) from the atmosphere by the leaves. Woody tissue assimilation rates calculated from measurements of (13)C differed from rates calculated from measurements of CO(2) efflux in the lower branch but not in the upper branch. The results of this study showed unequivocally that CO(2) transported in xylem sap can be fixed in photosynthetic cells in the leaves and branches of sycamore trees and provided evidence that recycling of xylem-transported CO(2) may be an important means by which trees reduce the carbon cost of respiration.

Molecular analysis and long-term clinical evaluation of three siblings with Alström syndrome

Alström syndrome is a rare, autosomal recessive disorder characterized by a wide spectrum of clinical features including early-onset retinal degeneration leading to blindness, sensorineural hearing loss, short stature, obesity, type 2 diabetes, hyperlipidemia and dilated cardiomyopathy. Renal, hepatic and pulmonary dysfunction may occur in the later phases of the disease. The three affected sisters, from a consanguineous Turkish family, with the characteristic features of Alström syndrome, were clinically diagnosed in 1987 and followed for 20 years. DNA sequence analysis of ALMS1, the causative gene in Alström syndrome, identified a novel homozygous disease-causing mutation, c.8164C>T, resulting in a premature termination codon in exon 10 in each of the three affected sisters. Furthermore, we describe the longitudinal disease progression in this family and report new clinical findings likely associated with Alström syndrome, such as pes planus and hyperthyroidism.

Promotion of physical activity by Canadian Registered Dietitians in daily practice

BACKGROUND

Dietitians are in an opportunistic position to promote healthy eating and active living. The purpose of this study was to determine counselling strategies of dietitians 1 year after attending a workshop designed to strengthen dietitians' self-efficacy for promoting physical activity (PA) as an adjunct to regular nutrition practice.

METHODS

A convenience sample of Registered Dietitians (RDs) in Alberta, Canada (n=103) responded to an invitation via an electronic newsletter to complete a web-based survey that asked about counselling practices related to PA.

RESULTS

Thirty-seven workshop attendees (n=37) were compared with a group of dietitians (n=66) who completed the survey but who did not attend the workshop. Nearly all (91%) respondents reported promoting PA in daily practice. Those who attended the workshop were more likely to refer clients to PA professionals (chi2=12.68, P<0.05) than those who were not workshop attendees.

CONCLUSIONS

Despite a relatively modest response rate, there were clear suggestions that RDs in Alberta, Canada promote PA in daily practice and attending a workshop designed to facilitate the use of specific tools and strategies for promoting PA in daily practice resulted in increased referral of their clients to exercise specialists.

A multi-species comparison of delta13C from whole wood, extractive-free wood and holocellulose

The stable carbon (C) isotope composition (delta13C) of tree rings is a powerful metric for reconstructing past physiological responses to climate variation. However, accurate measurement and interpretation are complicated by diagenesis and the translocation of compounds with distinct isotopic signatures. Isolation and analysis of cellulose minimizes these complications by eliminating variation due to biosynthetic pathways; however, isolation of cellulose is time-consuming and has no clear endpoint. A faster and better-defined analytical method is desirable. Our objectives were to determine if there is a direct relationship between the isotopic compositions of whole wood (WW), whole wood treated with solvents to remove mobile extractives (extractive-free wood; EF) and holocellulose (HC) isolated by extractive removal and subsequent bleaching. We also determined if total C concentration could explain the isotopic composition and variation among these three wood components of each sample. A set of wood samples of diverse phylogeny, anatomy and chemical composition, was examined. The mean offset or difference between HC and EF delta13C was 1.07 +/- 0.09 per thousand and the offset between HC and WW was 1.32 +/- 0.10 per thousand. Equivalence tests (with alpha = 0.05) indicated that the relationship between EF delta13C and HC delta13C had a slope significantly similar to 1 +/- 5.5%, whereas for the WW delta13C: HC delta13C relationship, the slope was significantly similar to 1 +/- 10.08%. A regression model using EF delta13C to predict HC delta13C had a slope of 0.97, which was not significantly different from unity (P = 0.264), whereas the regression for WW had a slope of 0.92 which was significantly different from unity (P = 0.0098). Carbon concentration was correlated with HC:WW offset and cellulose:EF offset (P = 0.0501 and 0.007, respectively), but neither relationship explained much of the variation (r2 = 0.12 and 0.14, respectively). We suggest that HC extraction is unnecessary for most analyses of tree-ring delta13C; a simple solvent extraction is a suitable alternative for many applications.

Familial variable expression of dilated cardiomyopathy in Alström syndrome: A report of four sibs

Alström syndrome is an autosomal recessive disorder comprised of progressive vision loss (nystagmus, photophobia, and pigmentary retinopathy), progressive sensorineural hearing loss, morbid obesity, male hypogonadism, insulin resistant diabetes, renal failure, and dilated cardiomyopathy. We report on four sibs with Alström syndrome with intra-familial variability in onset, severity, and spectrum of manifestations; the most serious manifestation being dilated cardiomyopathy. This report emphasizes the difficulty of recognizing this constellation of symptoms as Alström syndrome at an early age, the seriousness of cardiac involvement, and the intra-familial variability of phenotypic expression.

Apparent respiratory discrimination is correlated with growth rate in the shoot apex of sunflower (Helianthus annuus)

The literature offers no consensus as to whether the delta(13)C of respired CO(2) is identical to that of the respiratory substrate, perhaps because of differences in measurement technique and growth conditions. To address this issue, the delta(13)C of respired CO(2) from growing sunflower shoot apices was measured and compared with that of soluble carbohydrates extracted from the respiring tissues. Shoot apices were studied because any influence of growth and biosynthesis was expected to be maximally expressed in these rapidly growing tissues. The two most probable substrates, starch and soluble sugars, were similar in delta(13)C (P=0.46). The delta(13)C of respired CO(2) was enriched in (13)C compared with these putative substrates (P<0.0001). This apparent enrichment ranged from 2.2 per thousand-5.7 per thousand, and decreased with relative growth rate (P<0.0001). The respiratory enrichment was counterbalanced by a depletion in the tissue constructed from the residual carbohydrates. The depletion varied from 2.2 per thousand to 3.0 per thousand relative to soluble carbohydrates (P<0.05), as predicted from mass-balance arguments. These results support the idea that respired CO(2) is enriched relative to its substrates. Variation in growth rates may help to explain the variable amounts of respiratory discrimination described in the literature.

Responses of foliar delta13C, gas exchange and leaf morphology to reduced hydraulic conductivity in Pinus monticola branches

We tested the hypothesis that branch hydraulic conductivity partly controls foliar stable carbon isotope ratio (delta13C) by its influence on stomatal conductance in Pinus monticola Dougl. Notching and phloem-girdling treatments were applied to reduce branch conductivity over the course of a growing season. Notching and phloem girdling reduced leaf-specific conductivity (LSC) by about 30 and 90%, respectively. The 90% reduction in LSC increased foliar delta13C by about 1 per thousand (P < 0.0001, n = 65), whereas the 30% reduction in LSC had no effect on foliar delta13C (P = 0.90, n = 65). Variation in the delta13C of dark respiration was similar to that of whole-tissues when compared among treatments. These isotopic measurements, in addition to instantaneous gas exchange measurements, suggested only minor adjustments in the ratio of intercellular to atmospheric CO2 partial pressures (ci/ca) in response to experimentally reduced hydraulic conductivity. A strong correlation was observed between stomatal conductance (gs) and photosynthetic demand over a tenfold range in gs. Although ci/ca and delta13C appeared to be relatively homeostatic, current-year leaf area varied linearly as a function of branch hydraulic conductivity (r2 = 0.69, P < 0.0001, n = 18). These results suggest that, for Pinus monticola, adjustment of leaf area is a more important response to reduced branch conductivity than adjustment of ci/ca.

Time-series analysis of delta13C from tree rings. I. Time trends and autocorrelation

Univariate time-series analyses were conducted on stable carbon isotope ratios obtained from tree-ring cellulose. We looked for the presence and structure of autocorrelation. Significant autocorrelation violates the statistical independence assumption and biases hypothesis tests. Its presence would indicate the existence of lagged physiological effects that persist for longer than the current year. We analyzed data from 28 trees (60-85 years old; mean = 73 years) of western white pine (Pinus monticola Dougl.), ponderosa pine (Pinus ponderosa Laws.), and Douglas-fir (Pseudotsuga menziesii (Mirb.) Franco var. glauca) growing in northern Idaho. Material was obtained by the stem analysis method from rings laid down in the upper portion of the crown throughout each tree's life. The sampling protocol minimized variation caused by changing light regimes within each tree. Autoregressive moving average (ARMA) models were used to describe the autocorrelation structure over time. Three time series were analyzed for each tree: the stable carbon isotope ratio (delta(13)C); discrimination (delta); and the difference between ambient and internal CO(2) concentrations (c(a) - c(i)). The effect of converting from ring cellulose to whole-leaf tissue did not affect the analysis because it was almost completely removed by the detrending that precedes time-series analysis. A simple linear or quadratic model adequately described the time trend. The residuals from the trend had a constant mean and variance, thus ensuring stationarity, a requirement for autocorrelation analysis. The trend over time for c(a) - c(i) was particularly strong (R(2) = 0.29-0.84). Autoregressive moving average analyses of the residuals from these trends indicated that two-thirds of the individual tree series contained significant autocorrelation, whereas the remaining third were random (white noise) over time. We were unable to distinguish between individuals with and without significant autocorrelation beforehand. Significant ARMA models were all of low order, with either first- or second-order (i.e., lagged 1 or 2 years, respectively) models performing well. A simple autoregressive (AR(1)), model was the most common. The most useful generalization was that the same ARMA model holds for each of the three series (delta(13)C, delta, c(a) - c(i)) for an individual tree, if the time trend has been properly removed for each series. The mean series for the two pine species were described by first-order ARMA models (1-year lags), whereas the Douglas-fir mean series were described by second-order models (2-year lags) with negligible first-order effects. Apparently, the process of constructing a mean time series for a species preserves an underlying signal related to delta(13)C while canceling some of the random individual tree variation. Furthermore, the best model for the overall mean series (e.g., for a species) cannot be inferred from a consensus of the individual tree model forms, nor can its parameters be estimated reliably from the mean of the individual tree parameters. Because two-thirds of the individual tree time series contained significant autocorrelation, the normal assumption of a random structure over time is unwarranted, even after accounting for the time trend. The residuals of an appropriate ARMA model satisfy the independence assumption, and can be used to make hypothesis tests.

Immunostimulatory sequence DNA linked to the Amb a 1 allergen promotes T(H)1 cytokine expression while downregulating T(H)2 cytokine expression in PBMCs from human patients with ragweed allergy

BACKGROUND

Recent studies have demonstrated that bacterially derived immunostimulatory sequences (ISSs) of DNA can activate the mammalian innate immune system and promote the development of T(H)1 cells. Promotion of T(H)1 immunity by means of immunotherapy in allergic patients has led to the alleviation of symptoms that result from allergen-specific T(H)2 responses.

OBJECTIVE

Our purpose was to investigate whether the T(H)1-enhancing properties of ISSs could be used to alter the T(H)2-dominated immune response of allergic PBMCs in vitro.

METHODS

Ragweed protein-linked ISS (PLI) was generated from a specific, highly active 22-base ISS and Amb a 1, the immunodominant allergen in ragweed pollen, to combine the T(H)1-enhancing properties of ISSs with allergen selectivity, and its activity was investigated in PBMC cultures from subjects with ragweed allergy.

RESULTS

PLI was markedly successful at reversing the dominant allergen-induced T(H)2 profile while greatly enhancing IFN-gamma production. Delivering ISSs in a linked form proved to be much more effective at modulating the resulting cytokine profile than delivering free ISSs in a mixture with unlinked Amb a 1. PLI also demonstrated cytokine-modulating properties, even when used to stimulate cells that had already been primed for 6 days with Amb a 1. The antigen specificity of the action of PLI was confirmed by the observations that PLI enhances Amb a 1--specific T-cell proliferation.

CONCLUSION

These data indicate that delivery of ISSs within an antigen-specific context exhibits potent cytokine-modulating activity and, combined with its reduced allergenicity, makes this molecule a strong candidate for use in improved immunotherapy applications.

Family differences in height growth and photosynthetic traits in three conifers

We investigated variation in height growth, gas exchange, chlorophyll fluorescence and leaf stable carbon isotope ratio among wind-pollinated progenies of Douglas-fir (Pseudotsuga menziesii (Mirb.) Franco var. glauca), ponderosa pine (Pinus ponderosa Dougl. ex Laws.) and western white pine (Pinus monticola Dougl. ex D. Don) from a small group of contiguous stands on the Priest River Experimental Forest in northern Idaho. Photosynthetic variables differed between height classes in the pines, but not in Douglas-fir. Among species and families, tall families of ponderosa pine regained photosynthetic capacity earliest in the spring and maintained it latest in the growing season. Tall families of western white pine had higher instantaneous water-use efficiencies and lower photosynthetic rates than short families on warm days in August.

Expression and function of IL-12 and IL-18 receptors on human tonsillar B cells

IL-12 activates murine and human B cells, but little information is available as to the expression and function of IL-12R on human B lymphocytes. Here we show that the latter cells, freshly isolated from human tonsils, expressed the transcripts of both beta1 and beta2 chains of IL-12R and that beta2 chain mRNA was selectively increased (4- to 5-fold) by incubation with Staphylococcus aureus Cowan I bacteria or IL-12. B cell stimulation with IL-12 induced de novo expression of the transcripts of the two chains of IL-18R, i.e., IL-1 receptor-related protein and accessory protein-like. Functional studies showed that both IL-12 and IL-18 signaled to B cells through the NF-kappaB pathway. In the case of IL-12, no involvement of STAT transcription factors, and in particular of STAT-4, was detected. c-rel and p50 were identified as the members of NF-kappaB family involved in IL-12-mediated signal transduction to B cells. IL-12 and IL-18 synergized in the induction of IFN-gamma production by tonsillar B cells, but not in the stimulation of B cell differentiation, although either cytokine promoted IgM secretion in culture supernatants. Finally, naive but not germinal center or memory, tonsillar B cells were identified as the exclusive IL-12 targets in terms of induction of NF-kappaB activation and of IFN-gamma production.

Carbon and nitrogen allocation to male and female reproduction in Rocky Mountain Douglas-fir (Pseudotsuga menziesii var. glauca, Pinaceae)

We measured carbon (respiration, photosynthesis, and production) and nitrogen allocation to male and female cones of Rocky Mountain Douglas-fir (Pseudotsuga menziesii var. glauca) to quantify gender-specific: (1) resource allocation to reproduction, and (2) contribution to carbon costs of reproduction via photosynthesis. We also measured foliar photosynthesis and nitrogen concentration ([N]) near and far from female cones to examine the relationship between reproduction and foliar physiology. Over one growing season, male cones required only 8% of all carbon allocated to reproduction, with females consuming the remaining 92%. Female cones, however, had maximum instantaneous refixation rates of 54%, which, integrated over the season, offset 6% of their total carbon requirements, while male cones were completely dependent on vegetative tissues for carbon. Male cones received 22% of all nitrogen allocated to reproduction and female cones received the remaining 78%. Foliage near female cones had elevated photosynthesis during the early stages of cone development and consistently lower [N] than foliage far from cones. Although female cones may photosynthesize, the annual sum of carbon fixed by reproductive structures is minor in comparison to the total carbon allocated to production and respiration.

On-line nitrate-delta(15)N extracted from groundwater determined by continuous-flow elemental analyzer/isotope ratio mass spectrometry

Nitrate-delta(15)N from groundwater samples is determined on an inorganic nitrate derivative using automated, continuous-flow elemental analyzer/isotope ratio mass spectrometry (EA/IRMS). Nitrate is extracted and concentrated based on a recently published ion-exchange resin method. Freeze-dried AgNO(3) (0.5-1.5 mg) is packed in silver-foil cups and combusted within the reactor of an NC2500 elemental analyzer (CE Instruments, Milan, Italy) using its existing reaction scheme for nitrogen and carbon analysis. delta(15)N is determined using a Finnigan MAT DELTA(plus) isotope ratio mass spectrometer (Bremen, Germany). Results are drift-corrected to a AgNO(3) working standard that has been calibrated against known AgNO(3). Despite high concentrations of carbonate, the precision for all runs is better than 0.10 per thousand. The combination of this extraction procedure with commercially available delta(15)N analysis instrumentation offers a precise on-line alternative to existing methods, with considerable reduction in labor and analysis time.

Alström syndrome: further evidence for linkage to human chromosome 2p13

Alström syndrome is a rare autosomal recessive disorder characterized by retinal degeneration, sensorineural hearing loss, early-onset obesity, and non-insulin-dependent diabetes mellitus. The gene for Alström syndrome (ALMS1) has been previously localized to human chromosome 2p13 by homozygosity mapping in two distinct isolated populations - French Acadian and North African. Pair-wise analyses resulted in maximum lod (logarithm of the odds ratio) scores of 3.84 and 2.9, respectively. To confirm these findings, a large linkage study was performed in twelve additional families segregating for Alström syndrome. A maximum two-point lod score of 7.13 (theta = 0.00) for marker D2S2110 and a maximum cumulative multipoint lod score of 9.16 for marker D2S2110 were observed, further supporting linkage to chromosome 2p13. No evidence of genetic heterogeneity was observed in these families. Meiotic recombination events have localized the critical region containing ALMS1 to a 6.1-cM interval flanked by markers D2S327 and D2S286. A fine resolution radiation hybrid map of 31 genes and markers has been constructed.

Rifapentine pharmacokinetics in adolescents

OBJECTIVE

Determination of rifapentine pharmacokinetics in healthy adolescent children.

DESIGN

Prospective Phase II clinical trial.

SETTING

Clinical research center within a university children's hospital.

PATIENTS

Twelve subjects ranging in age from 12 to 15 years, male and female.

INTERVENTIONS

A single oral dose of rifapentine was administered to healthy adolescent volunteers, 450 mg if <45 kg or 600 mg if > or =45 kg. Blood was collected at serial intervals (0, 2, 3, 4, 5, 6, 8, 12, 18, 24, 48 and 72 h postdose). Subjects were observed for adverse effects during the period of study.

MEASUREMENTS

High pressure liquid chromatography was used to measure the plasma concentration of rifapentine and 25-desacetyl rifapentine in each blood sample. For each subject a plot of mean plasma concentration vs. time data for rifapentine and its metabolite (i.e. 25-desacetyl rifapentine) were created. Subsequently model-independent methods were used to determine the pharmacokinetic profiles for each subject.

RESULTS

All subjects tolerated rifapentine without adverse effects. The 2-h postdose plasma concentrations of rifapentine (6.59 to 9.05 microg/ml) and 25-desacetyl rifapentine (0.57 to 2.64 microg/ml) far exceeded the MIC of Mycobacterium tuberculosis to rifapentine (approximately 0.12 microg/ml). The combination of a high Cmax (rifapentine, 9.95 to 18.63 microg/ml; 25-desacetyl rifapentine, 3.73 to 7.46 microg/ml) and lengthy terminal elimination phase t1/2 (rifapentine, 10 to 23 h; 25-desacetyl rifapentine, 14 to 35 h) resulted in potentially effective plasma concentrations of both compounds that persisted for at least 48 h in most subjects.

CONCLUSIONS

A well-tolerated oral rifapentine dose produced rapid and sustained plasma drug concentrations in adolescents that should effectively treat infections caused by M. tuberculosis. Rifapentine pharmacokinetics appears to be similar in adolescent and adult populations.

The interleukin-12-mediated pathway of immune events is dysfunctional in human immunodeficiency virus-infected individuals

Interleukin-12 (IL-12) is a potentially critical factor in the immune response against human immunodeficiency virus (HIV) because it is important for regulating proliferation and interferon-gamma (IFN-gamma) production by T cells and natural killer (NK) cells, antigen presentation and accessory cell function by macrophages and dendritic cells, and cytolytic activities of cytotoxic T-lymphocyte cells and NK cells, which are all functions known to be dysfunctional in patients with acquired immune deficiency syndrome. Peripheral blood mononuclear cells (PBMC) from HIV-infected patients have been previously shown to be deficient in the ability to produce IL-12 in response to the bacterial pathogen Staphylococcus aureus Cowan. In this study, impaired IL-12 production in cells from PBMC of HIV-infected patients compared with healthy donors was observed across a broad panel of stimuli derived from infectious pathogens with or without priming with cytokines such as IFN-gamma and IL-4, which amplify the IL-12 induction signal. Analysis of p40 and p35 mRNA accumulation showed that reductions in both subunits contribute to the lower IL-12 secretion of cells from HIV-infected individuals. PBMC from HIV-infected donors also failed to upregulate the IL-12 receptor beta2 chain (IL-12Rbeta2) in response to mitogenic stimuli. The expression of the IL-12Rbeta2 gene could, however, be restored by in vitro exposure to rIL-12. Thus, it is possible that a primary IL-12 defect may lead to secondary deficiencies in expression of the genes for IL-12Rbeta2 and IFN-gamma, thus amplifying immune deficiency during HIV infection.

Developmental pharmacodynamics of cyclosporine

OBJECTIVE

To determine the relationship between human development and in vitro cyclosporine (INN, ciclosporin) pharmacodynamics.

METHODS

Fifty-six subjects ranging in age from 3 months to 39 years were studied in this prospective laboratory investigation at a university children's hospital and clinical pharmacology laboratory. Peripheral blood monocytes were separated from whole blood and cultured with phytohemagglutinin A (5 microg/mL) and cyclosporine (0, 6.25, 12.5, 25, 50, 100, 500, 1000, 2500, and 5000 ng/mL). Peripheral blood monocytes cultures were assayed for cell proliferation and supernatant interleukin-2 concentration with use of radionuclide DNA tagging and enzyme-linked immosorbent assay, respectively. After concentration-effect modeling, summary pharmacodynamic parameters, including the maximal drug effect (Emax) and cyclosporine concentration at which 50% of maximal effect (IC50) and 90% of maximal effect (IC90), were determined. These parameters were compared between four consecutive subject age groups: infants (0-1 years), children (>1-4 years), preadolescents (>4-12 years), and adults (>12 years).

RESULTS

The peripheral blood monocytes of the infants showed a twofold lower mean IC50 (peripheral blood monocyte proliferation) and sevenfold lower mean IC90 (interleukin-2 expression) than peripheral blood monocytes from older subjects. The three older age groups were similar with respect to mean IC50 and Emax (peripheral blood monocyte proliferation). Lymphocyte subtype proportions measured in peripheral blood monocytes preparations from each age group were generally similar. The experimental conditions (eg, general anesthesia and cyclosporine solvents) did not affect peripheral blood monocytes proliferation, but the highest experimental cyclosporine concentration (ie, 5000 ng/mL) was associated with decreased peripheral blood monocytes viability.

CONCLUSIONS

Cyclosporine pharmacodynamics in vitro are related to age. This factor, if neglected, may be a source of iatrogenic risk during pediatric immunosuppressive therapy.

Single-dose pharmacokinetics of a pleconaril (VP63843) oral solution in children and adolescents. Pediatric Pharmacology Research Unit Network

Pleconaril is an orally active, broad-spectrum antipicornaviral agent which demonstrates excellent penetration into the central nervous system, liver, and nasal epithelium. In view of the potential pediatric use of pleconaril, we conducted a single-dose, open-label study to characterize the pharmacokinetics of this antiviral agent in pediatric patients. Following an 8- to 10-h period of fasting, 18 children ranging in age from 2 to 12 years (7.5 +/- 3.1 years) received a single 5-mg/kg of body weight oral dose of pleconaril solution administered with a breakfast of age-appropriate composition. Repeated blood samples (n = 10) were obtained over 24 h postdose, and pleconaril was quantified from plasma by gas chromatography. Plasma drug concentration-time data for each subject were fitted to the curve by using a nonlinear, weighted (weight = 1/Ycalc) least-squares algorithm, and model-dependent pharmacokinetic parameters were determined from the polyexponential parameter estimates. Pleconaril was well tolerated by all subjects. A one-compartment open-model with first-order absorption best described the plasma pleconaril concentration-time profile in 13 of the subjects over a 24-h postdose period. Pleconaril pharmacokinetic parameters (means +/- standard deviations) for these 13 patients were as follows. The maximum concentration of the drug in serum (Cmax) was 1,272.5 +/- 622.1 ng/ml. The time to Cmax was 4.1 +/- 1.5 h, and the lag time was 0.75 +/- 0.56 h. The apparent absorption rate constant was 0.75 +/- 0.48 1/h, and the elimination rate constant was 0.16 +/- 0.07 1/h. The area under the concentration-time curve from 0 to 24 h was 8,131.15 +/- 3,411.82 ng.h/ml. The apparent total plasma clearance was 0.81 +/- 0.86 liters/h/kg, and the apparent steady-state volume of distribution was 4.68 +/- 2.02 liters/kg. The mean elimination half-life of pleconaril was 5.7 h. The mean plasma pleconaril concentrations at both 12 h (250.4 +/- 148.2 ng/ml) and 24 h (137.9 +/- 92.2 ng/ml) after the single 5-mg/kg oral dose in children were higher than that from in vitro studies reported to inhibit > 90% of nonpolio enterovirus serotypes (i.e., 70 ng/ml). Thus, our data support the evaluation of a 5-mg/kg twice-daily oral dose of pleconaril for therapeutic trials in pediatric patients with enteroviral infections.

Regulation of human IL-18 mRNA expression

As virtually nothing is known about the pattern of expression of human IL-18, we investigated certain factors that may contribute to the regulation of IL-18 mRNA accumulation and compared this with regulation of the human gene encoding the p40 chain of IL-12, a cytokine that shares similar biologic activity with IL-18. IL-18 mRNA was expressed constitutively in unstimulated PBMC or monocytes, unlike p40, which required induction by a stimulus. Upon stimulation, IL-18 transcript accumulation was enhanced with an earlier and more transient pattern of expression than IL-12 p40 mRNA. Bacteria-derived stimuli and priming with IFN-gamma or IL-4 also upregulated IL-18 mRNA in a fashion similar to that of IL-12 p40. IL-10 exerted an inhibitory effect on IL-18 mRNA accumulation, though not as markedly as in the suppression of IL-12 p40 by IL-10. Finally, unlike IL-12 p40 mRNA, the constitutive accumulation of IL-18 transcripts by unstimulated cells was amplified in the presence of the translational blocker cycloheximide, which also caused a superinduction of IL-18 expression after Staphylococcus aureus stimulation.

Human DCTN1: genomic structure and evaluation as a candidate for Alström syndrome

The human dynactin 1 gene (DCTN1) is positioned on chromosome 2p13, the candidate region for various diseases including Alström syndrome, limb-girdle muscle dystrophy, and Miyoshi myopathy. Here, we report the exon-intron structure of DCTN1 along with characterization of the 5' upstream sequence and alternative splice variants previously identified by Tokito et al. (1996), Mol. Biol. Cell 7: 1167-1180). Knowledge of the genomic structure of DCTN1allowed us to design intronic primers necessary for analyzing mutations in families segregating for diseases linked to this gene. These primers were tested on a French Acadian kindred segregating for Alström syndrome. No mutations were observed within the coding region of DCTN1 in this family. However, the intronic primers should allow for the rapid amplification of the coding region for mutational analysis of additional Alström families and other diseases tightly linked to the DCTN1locus on chromosome 2p13.

Pharmacokinetics and pharmacodynamics of bumetanide in critically ill pediatric patients

This prospective, open-label, clinical trial was conducted to describe the pharmacology of bumetanide in pediatric patients with edema. Nine infants, children, and young adults with edema who were selected for diuretic therapy were studied. After a brief baseline period, each patient received parenteral bumetanide 0.2 mg/kg divided into two equal doses and administered every 12 hours. Urine excretion rate, fractional and total excretion of Na+, Cl-, and K+, creatinine clearance, and plasma and urine concentrations of bumetanide were measured at multiple intervals after drug administration. Bumetanide caused significant increases in the excretion rate of urine and each measured electrolyte. Unexpectedly, creatinine clearance increased dramatically after each dose. Adverse effects, including hypokalemia and hypochloremic metabolic alkalosis, were evident by the end of the treatment period. The plasma pharmacokinetics of bumetanide revealed mean +/- standard deviation values for total clearance and apparent volume of distribution of 3.9 +/- 2.4 mL/min/kg and 0.74 +/- 0.54 L/kg, respectively. Patients excreted an average of 34% of each dose unchanged in the urine over 12 hours. Plasma concentrations of bumetanide accurately predicted several renal effects using a link model with similar pharmacodynamic parameters in each case. Parenteral bumetanide 0.1 mg/kg administered every 12 hours produced significant beneficial and adverse effects in these critically ill pediatric patients with edema. Pharmacokinetic parameters are similar to those previously reported for infants. Plasma concentrations of bumetanide can predict effect-compartment pharmacodynamics.

Genealogy, natural history, and phenotype of Alström syndrome in a large Acadian kindred and three additional families

We describe a large Acadian kindred including 8 Alstrom Syndrome (AS) patients, with an age range of 4 to 26 at the time of clinical assessment. The affected subjects come from 5 nuclear families within this kindred. The phenotype includes early childhood retinopathy, progressive sensorineural hearing loss, truncal obesity, and acanthosis nigricans. In addition, hyperinsulinemia and hypertriglyceridemia with normal cholesterol levels were observed in most affected individuals tested. Non-insulin dependent diabetes mellitus and growth retardation appear to be age-related manifestations that occur post-adolescence. Younger affected children are not overtly hyperglycemic and are normal or above average height for age. Although the AS patients in kindred 1 presumably carry the same mutation, many manifestations of the disease are variable. For example, of the 8 children in the Acadian kindred, 4 have scoliosis, 2 have had infantile cardiomyopathy, 2 are hypothyroid, 1 has had hepatic dysfunction and is hypertensive, and 4 have developed asthma. Seven subjects described in this kindred exhibit developmental delay. One additional manifestation not described widely in the literature, advanced bone age, was observed in all subjects tested. The clinical data from this large Acadian kindred, together with information obtained from 4 additional AS patients in 3 unrelated kindreds, confirm and extend clinical observations previously described. In addition, the Acadian kindred with multiple affected individuals, probably arising from a common founder, should allow for identification of the chromosomal localization of a gene causing AS.

Priming with IL-4 and IL-13 during HIV-1 infection restores in vitro IL-12 production by mononuclear cells of HIV-infected patients

The production of proinflammatory cytokines can be regulated by several factors that exert activating or inhibitory effects. IL-4, IL-10, IL-13, TGF-beta, and PGE2 have demonstrated a very wide range of potent macrophage-deactivating activities and, specifically, down-regulation of the production of many proinflammatory monokines. IL-12 plays a key role during immune response by providing a link between natural resistance and adaptive immunity. We and others have previously shown an impairment in IL-12 production by PBMC from HIV-1-infected individuals in response to various stimuli, but defining the mechanism responsible remains elusive. In this study, we observed that pretreatment of PBMC from patients with IL-4 or IL-13 for 24 h primes the cells for enhanced production of IL-12 in response to Staphylococcus aureus, and almost completely restores their deficient IL-12 production when compared with healthy controls. Although this priming effect was completely abrogated by IL-10 and PGE2, IL-10 was produced equivalently by untreated and IL-4- or IL-13-pretreated PBMC from both patients and controls. Additionally, indomethacin, which shuts off PGE2 synthesis, and cAMP-blocking reagents failed to restore or enhance IL-12 production. The priming effect of IL-4 and IL-13 is at the transcription level for both p40 and p35 genes. This complete restoration of IL-12 production by Th2-associated cytokines was unexpected in light of the mutually antagonistic roles of IL-12 and IL-4 in promoting Th1 or Th2 immune responses.

Priming with IL-4 and IL-13 during HIV-1 infection restores in vitro IL-12 production by mononuclear cells of HIV-infected patients

The production of proinflammatory cytokines can be regulated by several factors that exert activating or inhibitory effects. IL-4, IL-10, IL-13, TGF-beta, and PGE2 have demonstrated a very wide range of potent macrophage-deactivating activities and, specifically, down-regulation of the production of many proinflammatory monokines. IL-12 plays a key role during immune response by providing a link between natural resistance and adaptive immunity. We and others have previously shown an impairment in IL-12 production by PBMC from HIV-1-infected individuals in response to various stimuli, but defining the mechanism responsible remains elusive. In this study, we observed that pretreatment of PBMC from patients with IL-4 or IL-13 for 24 h primes the cells for enhanced production of IL-12 in response to Staphylococcus aureus, and almost completely restores their deficient IL-12 production when compared with healthy controls. Although this priming effect was completely abrogated by IL-10 and PGE2, IL-10 was produced equivalently by untreated and IL-4- or IL-13-pretreated PBMC from both patients and controls. Additionally, indomethacin, which shuts off PGE2 synthesis, and cAMP-blocking reagents failed to restore or enhance IL-12 production. The priming effect of IL-4 and IL-13 is at the transcription level for both p40 and p35 genes. This complete restoration of IL-12 production by Th2-associated cytokines was unexpected in light of the mutually antagonistic roles of IL-12 and IL-4 in promoting Th1 or Th2 immune responses.

IL-15 enhances immune functions during HIV infection

IL-15, a new cytokine primarily produced by macrophages, has been shown to exhibit several functional properties shared with IL-2. Treatment of PBMC from HIV-infected patients with IL-15 resulted in an increase in NK cell cytotoxicity to levels similar to those of untreated PBMC from healthy donors. This effect is independent of several well-characterized regulatory cytokines, as it is not prevented by Abs that neutralize IFNs, TNF-alpha, IL-2, or IL-12. Enhanced cytotoxicity was accompanied by a significant increase in expression of cytotoxic granules. IL-15 enhanced the proliferative ability in both controls and HIV-seropositive in response to mitogen and recall Ags. Although the addition of IL-15 has a preventive effect on the appearance of spontaneous cell death, this effect was not seen during mitogen-induced apoptosis. The production of IL-15 by PBMC from patients in response to Staphylococcus aureus Cowan strain 1 appeared heterogeneous and was not negatively regulated by cytokines that inhibited IL-12 production. No correlation was found between in vitro HIV infection and IL-15 production, as viral infection had no effect on the ability of monocytes to produce IL-15 in response to S. aureus. Interestingly IL-15 restored the deficient production of IL-12 by PBMC from HIV+ people and had no major effect on modulating viral expression in latently infected cell lines or PBMC from naturally infected people. Taken together, these results suggest a potent immunoregulatory role of IL-15 during HIV infection.

IL-15 enhances immune functions during HIV infection

IL-15, a new cytokine primarily produced by macrophages, has been shown to exhibit several functional properties shared with IL-2. Treatment of PBMC from HIV-infected patients with IL-15 resulted in an increase in NK cell cytotoxicity to levels similar to those of untreated PBMC from healthy donors. This effect is independent of several well-characterized regulatory cytokines, as it is not prevented by Abs that neutralize IFNs, TNF-alpha, IL-2, or IL-12. Enhanced cytotoxicity was accompanied by a significant increase in expression of cytotoxic granules. IL-15 enhanced the proliferative ability in both controls and HIV-seropositive in response to mitogen and recall Ags. Although the addition of IL-15 has a preventive effect on the appearance of spontaneous cell death, this effect was not seen during mitogen-induced apoptosis. The production of IL-15 by PBMC from patients in response to Staphylococcus aureus Cowan strain 1 appeared heterogeneous and was not negatively regulated by cytokines that inhibited IL-12 production. No correlation was found between in vitro HIV infection and IL-15 production, as viral infection had no effect on the ability of monocytes to produce IL-15 in response to S. aureus. Interestingly IL-15 restored the deficient production of IL-12 by PBMC from HIV+ people and had no major effect on modulating viral expression in latently infected cell lines or PBMC from naturally infected people. Taken together, these results suggest a potent immunoregulatory role of IL-15 during HIV infection.

Frequency and cytokine profile of HPRT mutant T cells in HIV-infected and healthy donors: implications for T cell proliferation in HIV disease

It has been postulated that HIV-infected patients undergo an active production of virus and CD4+ T cell destruction from the early stages of the disease, and that an extensive postthymic expansion of CD4+ T cells prevents a precipitous decline in CD4+ T cell number. Based on the rebound of the CD4+ T cell number observed in patients undergoing antiretroviral therapy with protease inhibitors, it has been calculated that, on average, 5% of T cells are replaced every day in HIV-infected patients. To obtain an independent estimate of the recycling rate of T cells in the patients, we measured the frequency of cells carrying a loss-of-function mutation at the hypoxanthine guanine phosphoribosyl transferase (hprt) locus. Assuming a recycling rate of 5%/d, an accumulation of 2.6 mutations/10(6)/yr over the physiological accumulation was predicted. Indeed, we observed an elevated frequency of HPRT mutants in the CD4+ T cells of most patients with < 300 CD4+ T cells/mm3 of blood and in the CD8+ T cells of most patients with < 200 CD4+ T cells/mm3, consistent with an elevated and protracted increased division rate in both subsets. However, in earlier stages of the disease the mutant frequency in both CD4+ and CD8+ T cells was lower than in healthy controls. The cytokine production profile of most HPRT mutant CD4+ T cell clones from both healthy and HIV-infected patients was typical of T helper cells type 2 (high IL-4 and IL-10, low IFN-gamma), whereas the cytokine production pattern of wild-type clones was heterogeneous. The cytokine profile of CD8+ clones was indistinguishable between HPRT mutants and wild type. Our data provide evidence of increased CD4+ and CD8+ T cell recycling in the HIV-infected patients.

Homozygosity mapping at Alström syndrome to chromosome 2p

Alström syndrome is a rare autosomal recessive disorder characterized by pigmentary retinal degeneration, sensorineural hearing loss, childhood obesity, non-insulin-dependent diabetes mellitus, hyperlipidemia and chronic nephropathy. Features occasionally observed include acanthosis nigricans, hypogonadism, hypothyroidism, alopecia, short stature and cardiomyopathy. We report here the results of a linkage study in a large French Acadian kindred, as a first step in identifying the molecular basis of Alström syndrome. Evidence of a founder effect made if feasible to use a homozygosity mapping strategy to identify the chromosomal location of the Alström gene. In a genome-wide screen, haplotype sharing for a region on chromosome 2 was observed in all affected individuals. Two point linkage analysis resulted in a maximum lod score of 3.84 (theta = 0.00) for marker D2S292. By testing additional markers, the disease gene was localized to a 14.9 cM region on chromosome 2p.

Body dissatisfaction and drive for thinness in high performance field hockey athletes

The prevalence of eating disordered tendencies and its relationship to body composition was examined in elite female field hockey players. Eating Disorder Inventory (EDI) and body composition (skinfold) data were collected from 111 (92.5%) athletes from 12 teams at the 1994 Indoor Canadian National Tournament. Athletes at risk for developing frank eating disorders were identified using cutoff scores of clinically diagnosed patients with eating disorders. 19/111 (17.1%) demonstrated increased body dissatisfaction (BD), and 4/111 (3.6%) an elevated drive for thinness, suggesting that concern for body shape and size is a greater issue in field hockey than preoccupation with weight. Compared to athletes not at risk, those with elevated BD scores were significantly heavier, fatter, and had higher BMIs. Although it appears that these athletes may have reason to be dissatisfied, they may be at increased risk for initiating and sustaining weight controlling behaviours associated with eating disorders. Special care must be taken in any intervention strategy.

Cross-linking of the CD40 ligand on human CD4+ T lymphocytes generates a costimulatory signal that up-regulates IL-4 synthesis

Although there is good evidence that the induction of IL-4 synthesis in CD4+ T lymphocytes is favored by Ag presentation by B cells and not macrophages, the precise molecular signals provided by B cells to T cells that enhance IL-4 synthesis are not clear. To examine this issue, we established an APC-independent system to activate highly purified T cells and induce cytokine synthesis, using immobilized mAbs against several T cell surface molecules, including CD3, CD28, and the CD40 ligand (CD40L). The counter-receptors for all three of these molecules are expressed on B cells, and include CD40, which is expressed primarily on B cells, but also on dendritic cells and thymic epithelium. We found that IL-4 synthesis was greatly enhanced by triggering of CD40L on the T cell surface in conjunction with ligation of CD3/TCR and CD28, whereas ligation of CD3/TCR and CD28 in the absence of CD40L triggering resulted in little or no IL-4 synthesis. CD40L costimulation greatly enhanced IL-4 synthesis both in T cells from normal nonallergic adult subjects as well as in naive T cells from cord blood. Furthermore, we demonstrated that IL-4 synthesis was optimally enhanced when the strength of the CD3/TCR signal was limiting, while IL-4 synthesis was inhibited when CD3/TCR stimulation was maximal. These studies confirm that IL-4 synthesis can be induced in normal T lymphocytes in the absence of exogenous IL-4, and demonstrate that CD40L costimulation is of fundamental importance in regulation of IL-4 production. In addition, these findings provide a mechanism by which B cells preferentially enhance IL-4 synthesis in T cells at low Ag concentrations.

Cross-linking of the CD40 ligand on human CD4+ T lymphocytes generates a costimulatory signal that up-regulates IL-4 synthesis

Although there is good evidence that the induction of IL-4 synthesis in CD4+ T lymphocytes is favored by Ag presentation by B cells and not macrophages, the precise molecular signals provided by B cells to T cells that enhance IL-4 synthesis are not clear. To examine this issue, we established an APC-independent system to activate highly purified T cells and induce cytokine synthesis, using immobilized mAbs against several T cell surface molecules, including CD3, CD28, and the CD40 ligand (CD40L). The counter-receptors for all three of these molecules are expressed on B cells, and include CD40, which is expressed primarily on B cells, but also on dendritic cells and thymic epithelium. We found that IL-4 synthesis was greatly enhanced by triggering of CD40L on the T cell surface in conjunction with ligation of CD3/TCR and CD28, whereas ligation of CD3/TCR and CD28 in the absence of CD40L triggering resulted in little or no IL-4 synthesis. CD40L costimulation greatly enhanced IL-4 synthesis both in T cells from normal nonallergic adult subjects as well as in naive T cells from cord blood. Furthermore, we demonstrated that IL-4 synthesis was optimally enhanced when the strength of the CD3/TCR signal was limiting, while IL-4 synthesis was inhibited when CD3/TCR stimulation was maximal. These studies confirm that IL-4 synthesis can be induced in normal T lymphocytes in the absence of exogenous IL-4, and demonstrate that CD40L costimulation is of fundamental importance in regulation of IL-4 production. In addition, these findings provide a mechanism by which B cells preferentially enhance IL-4 synthesis in T cells at low Ag concentrations.

Pharmacokinetics and pharmacodynamics of famotidine in children

The pharmacokinetics and pharmacodynamics of intravenous famotidine were studied in 12 children (1.1-12.9 years of age; mean weight +/- standard deviation = 27.6 +/- 21.2 kg) who were given the drug for prophylactic management of stress ulceration. After a 0.5-mg/kg infusion of famotidine, timed blood (n = 10) and urine (n = 6) samples and repeated evaluations of intragastric pH (n = 13) were obtained from each subject. Pharmacokinetic parameters were determined from curve fitting of serum concentration data. The mean (+/- SD) maximum serum concentration (Cmax) was 527.6 +/- 281.2 ng/mL, the elimination half-life (t1/2) was 3.2 +/- 3.0 hours, and the apparent steady-state volume of distribution (Vdss) was 2.4 +/- 1.7 L/kg. Plasma clearance (Cl) and renal clearance (ClR) were 0.70 +/- 0.34 L/hr/kg and 0.43 +/- 0.24 L/hr/kg, respectively. Over 24 hours, 73.0 +/- 27.3% of the dose was excreted unchanged in the urine (Fel). Pharmacodynamic analysis of gastric pH data using the sigmoid Emax model predicted that 50% of the maximal effect of famotidine (EC50) occurs at a serum concentration of 26.0 +/- 13.2 ng/mL. Children who did not have an initial intragastric pH < or = 4 did not have a significant response in pH after receiving famotidine. Although Vdss and Cl were higher in these children than those seen in adults, statistically significant relationships between these parameters and age were not observed in the study population. The pharmacodynamics and pharmacokinetics of famotidine in children older than one year of age appear to be similar to those noted in adults.

IL-12 inhibits the production of IL-4 and IL-10 in allergen-specific human CD4+ T lymphocytes

IL-12 influences cytokine synthesis in unprimed CD4+ T cells by enhancing IFN-gamma synthesis and enhancing the development of Th1 cells, but its effects upon Ag-primed T cells, which are thought to have relatively fixed cytokine profiles, is less clear. We investigated the capacity of IL-12 to modify cytokine synthesis in allergen-specific human CD4+ T lymphocytes from allergic donors after in vitro stimulation. CD4+ T cells were obtained from the peripheral blood of subjects with allergic rhinitis, depleted of activated T cells, and cultured with APCs and allergen. IL-12 dramatically inhibited the development of IL-4 and IL-10 synthesis, while it enhanced T cell secretion of IFN-gamma and IL-2, and enhanced Ag-specific T cell proliferation. The inhibitory effect of IL-12 on IL-4 synthesis was not dependent on the presence of IFN-gamma, was greatest when IL-12 was added at the initiation of culture, and was minimal when added late, indicating that resting memory CD4+ T cells were more sensitive than activated CD4+ T cells to the effects of IL-12. The effect of IL-12 on IL-4 and IL-10 synthesis was not dependent on the APC type, because IL-12 decreased IL-4 synthesis when either B cells or monocytes served as APCs. These results indicate that IL-12 may be therapeutically beneficial in the treatment of allergic diseases in which allergen-specific T cells characteristically produce enhanced quantities of IL-4 and IL-10.

IL-12 inhibits the production of IL-4 and IL-10 in allergen-specific human CD4+ T lymphocytes

IL-12 influences cytokine synthesis in unprimed CD4+ T cells by enhancing IFN-gamma synthesis and enhancing the development of Th1 cells, but its effects upon Ag-primed T cells, which are thought to have relatively fixed cytokine profiles, is less clear. We investigated the capacity of IL-12 to modify cytokine synthesis in allergen-specific human CD4+ T lymphocytes from allergic donors after in vitro stimulation. CD4+ T cells were obtained from the peripheral blood of subjects with allergic rhinitis, depleted of activated T cells, and cultured with APCs and allergen. IL-12 dramatically inhibited the development of IL-4 and IL-10 synthesis, while it enhanced T cell secretion of IFN-gamma and IL-2, and enhanced Ag-specific T cell proliferation. The inhibitory effect of IL-12 on IL-4 synthesis was not dependent on the presence of IFN-gamma, was greatest when IL-12 was added at the initiation of culture, and was minimal when added late, indicating that resting memory CD4+ T cells were more sensitive than activated CD4+ T cells to the effects of IL-12. The effect of IL-12 on IL-4 and IL-10 synthesis was not dependent on the APC type, because IL-12 decreased IL-4 synthesis when either B cells or monocytes served as APCs. These results indicate that IL-12 may be therapeutically beneficial in the treatment of allergic diseases in which allergen-specific T cells characteristically produce enhanced quantities of IL-4 and IL-10.

Diarrhea associated with enteral benzodiazepine solutions

Diarrhea occurred in an infant given large enteral doses of benzodiazepine solutions that contained the carriers propylene glycol and polyethylene glycol. This adverse drug effect may be avoided by prescribing the tablet formulations appropriately prepared for enteral administration.