Local governments and community-based rehabilitation for developmental disabilities: leaving no one behind

SETTING

The BUDS (not an acronym) institutions comprise a community-based rehabilitation initiative for children and families affected by developmental disabilities in Kerala, India.

OBJECTIVE

To explore the role of local governments in the establishment and functioning of BUDS institutions.

DESIGN

We used qualitative approaches comprising document review and in-depth interviews with trainers, parents of children with developmental disabilities and elected representatives.

RESULTS

BUDS was created by Kudumbasree, a decentralised women empowerment and poverty alleviation initiative. Our findings illustrate the role of local governments in facilitating expansion through the establishment of infrastructure, therapy equipment, transportation and financial allocation for these, as well as through the development of human resources, assistance with enrolment for financial assistance and insurance programmes, and coordination with education and health sectors. Programme implementation varied considerably regarding available infrastructure, staffing and services among the institutions studied. The institutions were physically closed during the COVID-19 pandemic but continued to function in alternative ways.

CONCLUSION

Despite variable implementation, local governments have supported the expansion of BUDS institutions, thereby creating more spaces for inclusive and integrated education and rehabilitation of persons with disabilities in Kerala. The expansion over the past two decades and measures during the COVID-19 pandemic suggest resilience and sustainability of the model.

Effects of Renal Denervation vs Sham in Resistant Hypertension After Medication Escalation: Prespecified Analysis at 6 Months of the RADIANCE-HTN TRIO Randomized Clinical Trial

Importance

Although early trials of endovascular renal denervation (RDN) for patients with resistant hypertension (RHTN) reported inconsistent results, ultrasound RDN (uRDN) was found to decrease blood pressure (BP) vs sham at 2 months in patients with RHTN taking stable background medications in the Study of the ReCor Medical Paradise System in Clinical Hypertension (RADIANCE-HTN TRIO) trial.

Objectives

To report the prespecified analysis of the persistence of the BP effects and safety of uRDN vs sham at 6 months in conjunction with escalating antihypertensive medications.

Design, Setting, and Participants

This randomized, sham-controlled, clinical trial with outcome assessors and patients blinded to treatment assignment, enrolled patients from March 11, 2016, to March 13, 2020. This was an international, multicenter study conducted in the US and Europe. Participants with daytime ambulatory BP of 135/85 mm Hg or higher after 4 weeks of single-pill triple-combination treatment (angiotensin-receptor blocker, calcium channel blocker, and thiazide diuretic) with estimated glomerular filtration rate (eGFR) of 40 mL/min/1.73 m2 or greater were randomly assigned to uRDN or sham with medications unchanged through 2 months. From 2 to 5 months, if monthly home BP was 135/85 mm Hg or higher, standardized stepped-care antihypertensive treatment starting with aldosterone antagonists was initiated under blinding to treatment assignment.

Interventions

uRDN vs sham procedure in conjunction with added medications to target BP control.

Main Outcomes and Measures

Six-month change in medications, change in daytime ambulatory systolic BP, change in home systolic BP adjusted for baseline BP and medications, and safety.

Results

A total of 65 of 69 participants in the uRDN group and 64 of 67 participants in the sham group (mean [SD] age, 52.4 [8.3] years; 104 male [80.6%]) with a mean (SD) eGFR of 81.5 (22.8) mL/min/1.73 m2 had 6-month daytime ambulatory BP measurements. Fewer medications were added in the uRDN group (mean [SD], 0.7 [1.0] medications) vs sham (mean [SD], 1.1 [1.1] medications; P = .045) and fewer patients in the uRDN group received aldosterone antagonists at 6 months (26 of 65 [40.0%] vs 39 of 64 [60.9%]; P = .02). Despite less intensive standardized stepped-care antihypertensive treatment, mean (SD) daytime ambulatory BP at 6 months was 138.3 (15.1) mm Hg with uRDN vs 139.0 (14.3) mm Hg with sham (additional decreases of -2.4 [16.6] vs -7.0 [16.7] mm Hg from month 2, respectively), whereas home SBP was lowered to a greater extent with uRDN by 4.3 mm Hg (95% CI, 0.5-8.1 mm Hg; P = .03) in a mixed model adjusting for baseline and number of medications. Adverse events were infrequent and similar between groups.

Conclusions and Relevance

In this study, in patients with RHTN initially randomly assigned to uRDN or a sham procedure and who had persistent elevation of BP at 2 months after the procedure, standardized stepped-care antihypertensive treatment escalation resulted in similar BP reduction in both groups at 6 months, with fewer additional medications required in the uRDN group.

Trial Registration

ClinicalTrials.gov Identifier: NCT02649426.

695 Analgesic Ladder Compliance by Junior Doctors on Surgical Wards

Introduction

Analgesia makes up an integral part of the management of the surgical patient. The World Health Organisation “analgesic ladder” details the escalation of analgesics from paracetamol through to opiates. Over the past decade, opiate prescriptions in the UK have increased by 22% to 40.5 million a year.

Method

Drug charts were reviewed on the surgical wards prior to presentation of the trust guidelines to surgical juniors. Inclusion criteria was non-cancerous adults who were not on chronic pain medications and had no known allergy or contraindication to NSAIDs. F1/2s were also surveyed on their knowledge of the trust guidelines

Results

Compliance improved in weak opioids (10.6%) and oramorph (19.1%) but fell in NSAIDs (-2.9%). Paracetamol was prescribed appropriately in 100%. 78% of doctors admitted to not having read the trust guidelines and 89% to not following them despite 100% being aware of the concept of the analgesic ladder.

Conclusions

We saw a tangible improvement in opiate prescribing by surgical juniors. However, the overall compliance to the analgesic ladder is still relatively poor given the doctors are all aware of the concept of the analgesic ladder, suggesting appropriate analgesic prescribing does not rank as highly in importance as it should.

Six-Month Results of Treatment-Blinded Medication Titration for Hypertension Control After Randomization to Endovascular Ultrasound Renal Denervation or a Sham Procedure in the RADIANCE-HTN SOLO Trial

BACKGROUND

The multicenter, international, randomized, blinded, sham-controlled RADIANCE-HTN SOLO trial (A Study of the ReCor Medical Paradise System in Clinical Hypertension) demonstrated a 6.3 mm Hg greater reduction in daytime ambulatory systolic blood pressure (BP) at 2 months by endovascular ultrasound renal denervation (RDN) compared with a sham procedure among patients not treated with antihypertensive medications. We report 6-month results after the addition of a recommended standardized stepped-care antihypertensive treatment to the randomized endovascular procedure under continued blinding to initial treatment.

METHODS

Patients with a daytime ambulatory BP ≥135/85 mm Hg and <170/105 mm Hg after a 4-week discontinuation of up to 2 antihypertensive medications, and a suitable renal artery anatomy, were randomized to RDN (n=74) or sham (n=72). Patients were to remain off antihypertensive medications throughout the first 2 months of follow-up unless safety BP criteria were exceeded. Between 2 and 5 months, if monthly measured home BP was ≥135/85 mm Hg, a standardized stepped-care antihypertensive treatment was recommended consisting of the sequential addition of amlodipine (5 mg/d), a standard dose of an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and hydrochlorothiazide (12.5 mg/d), followed by the sequential uptitration of hydrochlorothiazide (25 mg/d) and amlodipine (10 mg/d). Outcomes included the 6-month (1) change in daytime ambulatory systolic BP adjusted for medications and baseline systolic BP, (2) medication burden, and (3) safety.

RESULTS

A total of 69/74 RDN patients and 71/72 sham patients completed the 6-month ambulatory BP measurement. At 6 months, 65.2% of patients in the RDN group were treated with the standardized stepped-care antihypertensive treatment versus 84.5% in the sham group (P=0.008), and the average number of antihypertensive medications and defined daily dose were less in the RDN group than in the sham group (0.9±0.9 versus 1.3±0.9, P=0.010 and 1.4±1.5 versus 2.0±1.8, P=0.018; respectively). Despite less intensive standardized stepped-care antihypertensive treatment, RDN reduced daytime ambulatory systolic BP to a greater extent than sham (-18.1±12.2 versus -15.6±13.2 mm Hg, respectively; difference adjusted for baseline BP and number of medications: -4.3 mm Hg, 95% confidence interval, -7.9 to -0.6, P=0.024). There were no major adverse events in either group through 6 months.

CONCLUSIONS

The BP-lowering effect of endovascular ultrasound RDN was maintained at 6 months with less prescribed antihypertensive medications compared with a sham control.

CLINICAL TRIAL REGISTRATION

URL: https://www.

CLINICALTRIALS

gov. Unique identifier: NCT02649426.

Autonomic dysfunction independently predicts poor cardiovascular outcomes in asymptomatic individuals with type 2 diabetes in the DIAD study

Objective:

The primary aim of this secondary analysis was to determine whether cardiac autonomic neuropathy independently predicted adverse cardiac outcomes in asymptomatic individuals with type 2 diabetes. Additional aims include the determination of the correlation of standard autonomic testing measures and power spectral analysis of heart rate variability, and the association of diabetes-related and cardiac risk factors with cardiac autonomic neuropathy measures.

Methods:

Cardiac autonomic neuropathy was assessed at the study entry into the Detection of Ischemia in Asymptomatic Diabetics study, using autonomic heart rate and blood pressure testing, and power spectral analysis of heart rate variability. All participants were prospectively followed for the composite clinical outcome of cardiac death, acute coronary syndromes, heart failure, or coronary revascularization.

Results:

Over 5 years of follow-up, 94 of 1119 (8.4%) subjects developed symptomatic cardiac disease. In unadjusted bivariate analyses, abnormalities in several cardiac autonomic neuropathy tests, including lower Valsalva and Standing Heart Rate Ratios, higher resting Heart Rate, greater systolic blood pressure decrease on standing, and lower low-frequency power, were predictive of symptomatic disease. Independent predictors of poor cardiac outcome were a lower Valsalva Heart Rate Ratio, non-Black ethnicity, longer diabetes duration, higher glycated hemoglobin (HbA1c), insulin use, reported numbness in the extremities, higher pulse pressure, family history of coronary artery disease, and higher waist-to-hip ratio. Clinical factors independently associated with a lower Valsalva Heart Rate Ratio were insulin use, clinical proteinuria, higher pulse pressure, use of angiotensin-converting enzyme inhibitor and non-Black ethnicity.

Conclusion:

Cardiac autonomic neuropathy predicted adverse cardiac outcomes in asymptomatic type 2 diabetes without known cardiac disease. Clinical variables may help to identify patients who might have cardiac autonomic neuropathy and warrant consideration for autonomic testing.

Comparison of the prognostic value of the 6th and 7th editions of the Union for International Cancer Control TNM staging system in patients with lower esophageal cancer undergoing neoadjuvant chemotherapy followed by surgery

Carcinoma of the esophagus is classified according to the Union for International Cancer Control (UICC) TNM staging system. The 7th edition of the UICC TNM staging system was published in 2009. This is the first study to compare the prognostic value of the TNM 6th and 7th editions in patients with esophageal carcinoma treated with chemotherapy followed by surgery. Two hundred forty-three patients with esophageal carcinoma were retrospectively selected from two referral centers. All patients received chemotherapy before surgery. Histopathologic data from the resection specimens were retrieved and restaged according to the TNM 7th edition. Disease-specific survival curves were plotted for depth of tumor invasion (ypT), lymph node status (ypN), and ypTNM stage and then compared. Median follow-up after surgery was 2.5 years (range 0.2-9 years). Survival analysis using the log-rank method revealed that there was a significant difference in survival between ypT4 disease and ypT3 disease (P= 0.003), but no difference between ypT0, ypT1, ypT2, and ypT3 categories irrespective of TNM edition used. Survival probability was significantly different between ypN0 and ypN1 (P= 0.001 for TNM 6th and 7th edition), as well as ypN2 and ypN3 (TNM 7th edition, P= 0.004), but not between ypN1 and ypN2 (TNM 7th edition, P= 0.89). Neither the TNM 6th nor 7th edition T staging provides accurate survival probability stratification. However, the advantage of the 7th edition is the introduction of a third tier in survival stratification for patients with nodal involvement.

Rhinoentomophthoromycosis

A sixty year old patient presented with a slowly progressive swelling of the nose, of one year duration, suggesting a clinical diagnosis of subcutaneous zygomycosis. On investigation, the tissue fungal culture grew Conidiobolus coronatus, confirming the diagnosis as rhinoentomophthoromycosis. He was treated with a combination of oral fluconazole and oral potassium iodide for a total period of 5 months. His symptoms subsided completely. Serial CT scanning of paranasal sinuses showed the gradual resolution of the swelling, in response to the treatment. Early detection of the disease and combination therapy gave rapid and good results. This is the first case of its kind to be reported from Kerala, the southern state of India.

Increase in Creatinine and Cardiovascular Risk in Patients with Systolic Dysfunction after Myocardial Infarction

Baseline renal function is a potent independent risk factor for adverse events after acute myocardial infarction (MI). Worsening renal function (WRF) has been shown to influence outcomes in the heart failure population, but its impact on cardiovascular risk in the post-MI period has not been well defined. For assessment of the prognostic importance of WRF, 2231 patients who had left ventricular dysfunction and were enrolled in the Survival and Ventricular Enlargement (SAVE) trial were studied. Patients were randomly assigned between 3 and 16 d (average 11 d) after acute MI to receive captopril or placebo; those with a serum creatinine of >2.5 mg/dl were excluded from SAVE. WRF was defined as an increase in creatinine of >0.3 mg/dl measured from baseline to 2 wk after randomization. The predictive value of WRF on cardiovascular morbidity and mortality was examined during 42 mo of follow-up. Paired serum creatinine measurements at baseline and 2 wk were available in 1854 patients. WRF occurred in 223 (12.0%) patients and was a stronger predictor of death (hazard ratio [HR] 1.46; 95% confidence interval [CI] 1.05 to 2.02) than baseline creatinine (HR 1.31; 95% CI 1.01 to 1.70). WRF also showed an increased risk for cardiovascular death (HR 1.62; 95% CI 1.14 to 2.30) and the composite end point (HR 1.32; 95% CI 1.03 to 1.70). When stratified by treatment, 104 (5.7%) and 116 (6.4%) patients with WRF in the placebo and captopril groups had no significant association between treatment group and WRF (P = 0.38). The risk for death associated with WRF was HR 1.63 (95% CI 1.05 to 2.52) in the placebo group compared with HR 1.33 (95% CI 0.81 to 2.21) in the captopril group (P = 0.49 for interaction). WRF as early as 2 wk after MI was not uncommon (12.0%) and was associated with increased mortality in patients without renal dysfunction at baseline. Patients who received captopril did not demonstrate more WRF than patients who received placebo. Monitoring serum creatinine in patients during the first few weeks after MI may help to identify those who are at highest risk and guide effective long-term therapeutic choices.

Renal function and effectiveness of angiotensin-converting enzyme inhibitor therapy in patients with chronic stable coronary disease in the Prevention of Events with ACE inhibition (PEACE) trial

BACKGROUND

Patients with reduced renal function are at increased risk for adverse cardiovascular outcomes. In the post-myocardial infarction setting, angiotensin-converting enzyme (ACE) inhibitors have been shown to be as effective in patients with impaired renal function as in those with preserved renal function.

METHODS AND RESULTS

We assessed the relation between renal function and outcomes, the influence of ACE inhibition on this relation, and whether renal function modifies the effectiveness of ACE inhibition in patients with stable coronary artery disease and preserved systolic function enrolled in the Prevention of Events with ACE inhibition trial (PEACE). Patients (n=8290) were randomly assigned to receive trandolapril (target, 4 mg/d) or placebo. Clinical creatinine measures were available for 8280 patients before randomization. The estimated glomerular filtration rate (eGFR) was calculated with the 4-point Modification of Diet in Renal Disease equation. Renal function was related to outcomes, and the influence of ACE-inhibitor therapy was assessed with formal interaction modeling. The mean eGFR in PEACE was 77.6+/-19.4, and 1355 (16.3%) patients had reduced renal function (eGFR <60 mg.mL(-1).1.73 m(-2)). We observed a significant interaction between eGFR and treatment group with respect to cardiovascular and all-cause mortality (P=0.02). Trandolapril was associated with a reduction in total mortality in patients with reduced renal function (adjusted HR, 0.73; 95% CI, 0.54 to 1.00) but not in patients with preserved renal function (adjusted HR, 0.94; 95% CI, 0.78 to 1.13).

CONCLUSIONS

Although trandolapril did not improve survival in the overall PEACE cohort, in which mean eGFR was relatively high, trandolapril reduced mortality in patients with reduced eGFR. These data suggest that reduced renal function may define a subset of patients most likely to benefit from ACE-inhibitor therapy for cardiovascular protection.

Proteinuria, impaired kidney function, and adverse outcomes in people with coronary disease: analysis of a previously conducted randomised trial

OBJECTIVES

To determine whether data on proteinuria are useful for refining estimates of risk based on kidney function alone, and whether the results of kidney function tests can be a useful adjunct to data on proteinuria.

DESIGN

Analysis of data from a randomised trial. Impaired kidney function was defined as low glomerular filtration rate (< 60 ml/min/1.73 m2) and proteinuria (> or = 1+ protein) on dipstick urinalysis.

SETTING

Study of cholesterol and recurrent events: a randomised trial of pravastatin 40 mg daily versus placebo.

PARTICIPANTS

4098 men and women with previous myocardial infarction.

MAIN OUTCOME MEASURES

All cause mortality and cardiovascular events.

RESULTS

371 participants died in nearly 60 months of follow-up. Compared with participants without proteinuria or impaired kidney function, patients with both characteristics were at high risk (hazard ratio 2.39, 95% confidence interval 1.72 to 3.30), and those with only proteinuria or only impaired kidney function were at intermediate risk (1.69, 1.32 to 2.16; 1.41, 1.12 to 1.79, respectively) of dying from any cause. The results were similar for cardiovascular outcomes, including new cases of heart failure, stroke, and coronary death or non-fatal myocardial infarction. A graded increase in the risk of all cause mortality was seen for severity of renal impairment and degree of proteinuria by dipstick.

CONCLUSIONS

The presence or absence of proteinuria on dipstick urinalysis may be used to refine estimates of risk based on kidney function alone.

Diagnosis of CAD in patients with diabetes: who to evaluate

Effective diagnosis and treatment of coronary artery disease (CAD) are key to the management of patients with diabetes. Although the use of specialized cardiac testing for CAD screening in asymptomatic patients varies widely and is the source of current controversy, evidence is emerging on the prevalence and predictors of asymptomatic ischemia in diabetic patients. Accurate diagnosis and risk stratification are essential in symptomatic patients with known or suspected CAD. Noninvasive cardiac testing has an important role in these patients, although evaluation for revascularization with cardiac catheterization is warranted in high-risk circumstances. This article reviews recent information that may help guide the clinician in the appropriate use of cardiac testing in diabetic patients.

Epitope-specific antibodies to the beta(1C) integrin cytoplasmic domain variant

The beta(1C) integrin is an alternatively spliced variant of the beta(1) subunit that contains a unique 48-amino-acid sequence in its cytoplasmic domain. We have shown previously that beta(1C) is a potent inhibitor of cell proliferation and that in vivo its expression is downregulated in prostate and breast carcinoma. In this study, we describe a panel of specific monoclonal antibodies that react with the beta(1C) cytodomain. We show by immunoblot analysis that the newly generated monoclonal antibodies specifically recognize the beta(1C) cytodomain expressed as glutathione S-transferase fusion protein. The specificity of the antibodies to beta(1C) was confirmed in competition studies by immunoblotting using beta(1C)-specific synthetic peptides. These monoclonal antibodies reacted, in enzyme-linked immunosorbent assays, with the beta(1C) 785-808 peptide but failed to bind the beta(1C) 778-794, beta(1C) 805-825, or beta(1A) 765-798 peptides. Thus, the epitope recognized by the antibodies is located within the Q(795)-F(804) beta(1C) cytoplasmic sequence; this region overlaps the previously described Q(795)-Q(802) domain necessary for beta(1C) to inhibit cell proliferation. To our knowledge, these are the first monoclonal antibodies specific for a beta(1) cytoplasmic isoform. The monoclonal antibodies described here will be useful tools for dissecting functional differences, among beta(1) integrin variants, as well as for the study of the role of beta(1C) in prostate and breast epithelial cell proliferation.

Effects of dietary salt intake on plasma arginine

Because L-arginine is degraded by hepatic arginase to ornithine and urea and is transported by the regulated 2A cationic amino acid y(+) transporter (CAT2A), hepatic transport may regulate plasma arginine concentration. Groups of rats (n = 6) were fed a diet of either low salt (LS) or high salt (HS) for 7 days to test the hypothesis that dietary salt intake regulates plasma arginine concentration and renal nitric oxide (NO) generation by measuring plasma arginine and ornithine concentrations, renal NO excretion, and expression of hepatic CAT2A, and arginase. LS rats had lower excretion of NO metabolites and cGMP, lower plasma arginine concentration (LS: 83 +/- 7 vs. HS: 165 +/- 10 micromol/l, P < 0.001), but higher plasma ornithine concentration (LS: 82 +/- 6 vs. HS: 66 +/- 4 micromol/l, P < 0.05) and urea excretion. However, neither the in vitro hepatic arginase activity nor the mRNA for hepatic arginase I was different between groups. In contrast, LS rats had twice the abundance of mRNA for hepatic CAT2A (LS: 3.4 +/- 0.4 vs. HS: 1.6 +/- 0.5, P < 0.05). The reduced plasma arginine concentration with increased plasma ornithine concentration and urea excretion during LS indicates increased arginine metabolism by arginase. This cannot be ascribed to changes in hepatic arginase expression but may be a consequence of increased hepatic arginine uptake via CAT2A.

[The role of chemokines in nasal polyps]

Nasal polyposis is an inflammatory condition of the nose and the sinuses characterised by a marked infiltration of eosinophils in addition to lymphocytes, mast cells and macrophages. The selective recruitment of eosinophils to inflammatory sites is mediated by CC chemokines such as Eotaxin and Eotaxin-2. In the present study histology, immunohistochemistry and ELISA were performed. The levels of Eotaxin and Eotaxin-2 and for comparison other chemokines RANTES and IL-8 were measured in nasal polyp tissue and in control nasal tissue. On histological examination 6 polyps showed an oedematous structure, one was glandular and one had a fibromatous pattern, while all showed a marked eosinophil infiltration. Immunohistochemistry of the polyps showed that epithelial cells were strongly positive for Eotaxin and IL-8, whereas endothelial cells stained positive for Eotaxin-2. Significantly higher amounts of Eotaxin, Eotaxin-2 and IL-8 were detected in polyp tissue when compared with control middle turbinates. The increased levels of eosinophil-stimulating chemokines, such as Eotaxin and Eotaxin-2 in nasal polyps suggest that they may be important regulators of eosinophil recruitment in this inflammatory disease.

Successful management of benign paroxysmal positional vertigo with the epley manoeuvre

Benign paroxysmal positional vertigo is a recurrent, disabling disorder characterized by transient vertigo induced by changes in head position. Several non-surgical and surgical treatment procedures have been recommended as definitive treatment in this condition. Recent reports indicate a favourable response to a variety of non-invasive, easy to perform liberatory manoeuvres, often with a single treatment session. We report our experience with the Epley manoeuvre in which we obtained a 90% overall success rate which is comparable with results of similar recent studies.

Inhaled corticosteroids increase interleukin-10 but reduce macrophage inflammatory protein-1alpha, granulocyte-macrophage colony-stimulating factor, and interferon-gamma release from alveolar macrophages in asthma

We determined the effect of inhaled corticosteroid, budesonide, on the release of the anti-inflammatory cytokine, interleukin-10 (IL-10), and of pro-inflammatory cytokines, macrophage inflammatory protein-1alpha (MIP-1alpha), interferon-gamma (IFN-gamma), and granulocyte-macrophage colony-stimulating factor (GM-CSF), from blood monocytes and alveolar macrophages of mild asthmatic subjects in a double-blind, cross-over, placebo-controlled study. Budesonide reduced bronchial hyperresponsiveness and improved baseline FEV1. Alveolar macrophages were obtained by bronchoalveolar lavage performed at the end of each treatment phase. IL-10 from blood monocytes was not altered, but both IL-10 mRNA and protein expression from alveolar macrophages stimulated by lipopolysaccharide and IL-1beta were increased after corticosteroid therapy. By contrast, alveolar macrophages released significantly less MIP-1alpha, IFN-gamma, and GM-CSF after steroid treatment. In comparison to alveolar macrophages from normal nonasthmatic volunteers, those from asthmatic patients released more MIP-1alpha, IFN-gamma, and GM-CSF but lower amounts of IL-10 particularly at baseline and after IL-1beta stimulation. The ability of steroids to inhibit pro-inflammatory cytokines but to enhance the anti-inflammatory cytokine such as IL-10 may contribute to their beneficial actions in asthma. Asthma is characterized by alveolar macrophages exhibiting both an enhanced capacity to release pro-inflammatory cytokines and a reduced capacity to produce IL-10.

Kidney extracts from spontaneously hypertensive rats (SHR) have greater dopamine 1A receptor RNA-binding activity than extracts from normotensive Wistar-Kyoto (WKY) rats

Rat kidney extracts contain a 52 kDa protein that binds to the 3' untranslated region of the dopamine 1A (D1A) receptor mRNA at a 243 base-long cis element starting at the stop codon and ending approximately 220 bases upstream of an AUUUA-rich region. The D1A receptor RNA-binding protein (D1A-BP) is redox-sensitive; free sulfhydryl groups on the protein are required for binding. Kidney extracts from SHR have significantly more D1A-BP activity than extracts from WKY rats. When kidney extracts were tested for binding to an 80-base RNA containing four AUUUA repeats, there was also greater binding activity in extracts from SHR. These increases are at least partly specific because there was no difference in catalase RNA-binding protein activity between the two rat strains. These data suggest D1A-BP and AUUUA-binding protein may play a role in posttranscriptional regulation of the D1A receptor in the hypertensive rat.

Interleukin 13 inhibits macrophage inflammatory protein-1 alpha production from human alveolar macrophages and monocytes

Interleukin 13 (IL-13) is a recently described protein secreted by activated T cells and is a potent in vitro modulator of human monocyte and B-cell functions. IL-13 shares some biologic properties as well as structural similarities with IL-4. Macrophage-inflammatory protein 1 alpha (MIP-1 alpha) is a product of activated monocytes and macrophages and an important activator of T cells, monocytes, and macrophages. We determined the effect of human recombinant IL-13 on lipopolysaccharide (LPS)- and IL-1 beta-induced MIP-1 alpha mRNA and protein expression from peripheral blood monocytes (PBM) and alveolar macrophages (AM). In PBM, basal MIP-1 alpha protein was 20 +/- 7 pM and increased following LPS and IL-1 beta to 1,520 +/- 193 (P < 0.001) and 233 +/- 50 (P < 0.003) pM. IL-13 (25 ng/ml) reduced these values by 55 +/- 10% [not significant (NS)], 43 +/- 9% (P < 0.03), and 44 +/- 15% (NS), respectively. LPS- and IL-1 beta-induced MIP-1 alpha mRNA expression was reduced by 43 +/- 5% (P < 0.01) and 41 +/- 4% (NS). In AM, IL-13 reduced LPS-induced MIP-1 alpha protein release of 2,030 +/- 242 pM by 32 +/- 8% (P < 0.05) and MIP-1 alpha mRNA by 27 +/- 1% (NS). For both PBM and AM, the inhibitory effect of IL-13 on MIP-1 alpha protein was maximal at 24 h, was dose dependent with a maximal effect at 100 ng/ml, and was similar to, although slightly less potent than, that seen with IL-4. In PBM, the inhibitory effect of IL-13 required de novo protein synthesis and was not due to enhanced mRNA decay. Thus, IL-13 has inhibitory effects on the transcription of MIP-1 alpha from monocytes and macrophages, and as is the case with IL-4 and IL-10, may be an important mediator for suppressing inflammatory responses.

A study of in vivo immune complex formation and clearance in man

C and CR1 have been shown to participate in the clearance of injected, preformed, immune complexes in humans and in non-human primates. Their role in the physiologic disposal of immune complexes formed in vivo in humans was investigated in three patients receiving radioimmunotherapy for ovarian carcinoma. On day 0 each patient received, by intraperitoneal injection, 10 mg of 131I-mouse anti-tumor mAb (10 mCi/mg). On days 1 and 2, 18 mg of trace-labeled, 125I-human anti-mouse IgG was administered by i.v. infusion over 15 min, to accelerate the clearance of the 131I-anti-tumor antibody from the circulation and reduce the radiation dose to the marrow. Sequential blood samples were obtained after the injection of the second (anti-mouse) antibody, to monitor clearance. Immune complexes (shown by sucrose gradient centrifugation to be 19 to 40 S in size) formed within 5 min, and were cleared with a half-life of 11 +/- 1.7 min in the liver. Complexes were measured by 4% polyethylene glycol precipitation, and by solid phase C3d- and C1q-binding assays. Between 8 and 11% of the total available complexed material bound to CR1 on E. Peak binding of immune complexes to red cells occurred 10 min after the maximal complex load was detected by precipitation with polyethylene glycol. At that time, immune complexes bound to E constituted one-fifth of the total circulating pool of complexes. Coincident with immune complex formation and clearance, a 47% fall in serum C4, C3, and CH50 was measured, with the deposition of up to 1230 molecules of C4, and 2590 molecules of C3 on the surface of red cells. During 20 min after immune complex formation there was a mean loss of 32% of erythrocyte CR1. The changes in complement and CR1 on E and in serum observed in these patients resembled those seen in patients with SLE: i.e., a reduction in CR1 and an increase in C3 and C4 on E, and reduced serum C.

A study of in vivo immune complex formation and clearance in man

C and CR1 have been shown to participate in the clearance of injected, preformed, immune complexes in humans and in non-human primates. Their role in the physiologic disposal of immune complexes formed in vivo in humans was investigated in three patients receiving radioimmunotherapy for ovarian carcinoma. On day 0 each patient received, by intraperitoneal injection, 10 mg of 131I-mouse anti-tumor mAb (10 mCi/mg). On days 1 and 2, 18 mg of trace-labeled, 125I-human anti-mouse IgG was administered by i.v. infusion over 15 min, to accelerate the clearance of the 131I-anti-tumor antibody from the circulation and reduce the radiation dose to the marrow. Sequential blood samples were obtained after the injection of the second (anti-mouse) antibody, to monitor clearance. Immune complexes (shown by sucrose gradient centrifugation to be 19 to 40 S in size) formed within 5 min, and were cleared with a half-life of 11 +/- 1.7 min in the liver. Complexes were measured by 4% polyethylene glycol precipitation, and by solid phase C3d- and C1q-binding assays. Between 8 and 11% of the total available complexed material bound to CR1 on E. Peak binding of immune complexes to red cells occurred 10 min after the maximal complex load was detected by precipitation with polyethylene glycol. At that time, immune complexes bound to E constituted one-fifth of the total circulating pool of complexes. Coincident with immune complex formation and clearance, a 47% fall in serum C4, C3, and CH50 was measured, with the deposition of up to 1230 molecules of C4, and 2590 molecules of C3 on the surface of red cells. During 20 min after immune complex formation there was a mean loss of 32% of erythrocyte CR1. The changes in complement and CR1 on E and in serum observed in these patients resembled those seen in patients with SLE: i.e., a reduction in CR1 and an increase in C3 and C4 on E, and reduced serum C.

Interaction of campylobacter species with antibody, complement and phagocytes

The opsonisation of four different campylobacter species for human neutrophils was studied using a chemiluminescence system and electron microscopy. Opsonisation of Campylobacter fetus, Campylobacter coli, and Campylobacter jejuni was mediated by antibody and enhanced by complement. Antibody was not, however, required for the phagocytosis of Campylobacter pylori because it activates the classical pathway of complement directly. This unusual property may be important in the pathogenesis of C pylori associated gastritis and duodenal ulcer.

Nonoliguric acute renal failure in the newborn: a prospective evaluation of diagnostic indexes

Fifteen newborn babies with azotemia without oliguria were studied. Group A infants had increased BUN levels and decreased creatinine clearance (Ccr) for gestational and postnatal age, and were compared with group B infants, who had increased BUN levels and normal Ccr. The Ccr was 0.35 mL/min in group A and 0.76 mL/min in group B. Urine volume during the same period was 2.45 mL/kg/hr in group A and 4.66 mL/kg/hr in group B. No significant differences in fractional sodium excretion; urine to plasma ratios of creatinine, osmolality, and sodium; and renal failure index were present between the two groups. The results suggest that nonoliguric acute renal failure is a diagnostic entity in the newborn. The Ccr is the most useful indicator for defining renal function in the presence of azotemia and normal urine volume.

The glomerular basement membrane in benign familial hematuria

A total of nineteen children were studied because of asymptomatic hematuria. all had normal renal function, and immunologic and urologic studies. Renal tissue was obtained by percutaneous biopsy and examined by light, immunofluorescence and electron microscopy. On electron microscopy, thickness of the glomerular basement membrane (BGM) was found to distinguish benign familial hematuria (BFH - 10 cases) from non familial idiopathic recurrent hematuria (IRH - 9 cases). Measurements were taken in areas of peripheral glomerular capillary loops (minimum of five) where both cell membranes could be resolved to insure tht determinations were uniform and represented ideal cross sections. The mean thickness +/- SE of GBM in IRH of 303.3 +/- 16.9 nM was greater than that noted in BFH of 207.1 +/- 11.99 nM (P less than .002). The mean thickness +/- SE of the lamina densa in IRH of 236 +/- 15.36 nM was significantly greater than that observed in BFH of 128.5 +/- 11.7 nM (P less than .001). In both BFH and IRH the GBM and LD were uniform in thickness (CV = 20%) and qualitatively normal. The uniform attenuation observed in BFH can be used to distinguish this condition from IRH.

Ontogeny of single nephron filtration distribution in canine puppies

The ontogeny of single nephron filtration distribution was studied in 29 canine puppies two hr to 42 days old using the [14C] ferrocyanide method as modified by Coehlo (9). The ratio of 14C counts in outer cortical nephrons (OC) to counts in juxtamedullary nephrons (JM) were plotted against age for each puppy. This ratio (OC:JM) provided an index for comparing the single nephron glomerular filtration between regions. A four-fold increase in OC:JM occurred from two days to four wk. The youngest puppy, two hr old, showed a ratio of zero because no counts were detected in OC at that age. The most rapid increase occurred in the first 8 days of life. By the fourth wk, the mean OC:JM ratio was 0.72 +/- 0.06, approaching values reported by other laboratories for adult dogs. In contrast to age-related changes in OC:JM ratio, the ratio of middle cortical to JM counts showed no age-related increase. Cortical blood flow distribution was determined by the microsphere method. The ratio of blood flow to outer and inner cortex increased from 0.43 at one-half a day to a mean of 2.93 after one wk. The ratio of OC:JM single nephron filtration of OC/inner cortical nephron renal blood flow was 0.36 from 3 days to 26 days (n = 12) and did not change significantly with age, indicating that changes in zonal filtraion matched the alterations in cortical blood flow distribution.

The effects of theophylline on renal function in the premature newborn

The effects of aminophylline on renal function in 10 premature infants with idiopathic apnea are evaluated. The percent increases in creatinine clearance (128 +/- 339%, mean +/- SD) and sodium clearance (196 +/- 304%, mean +/- SD) are variable while the percent increase in fractional sodium excretion (69 +/- 109%, mean +/- SD) is significant. This effect is postulated to be at the proximal tubule and may be modified by the effects of postnatal age and infusion of albumin. Gestational age, birth weight, heart disease, water and sodium intake and ventilatory support did not appear to influence the results. Hyponatremia is a potential consequence of theophylline therapy for apnea.

Angiotensin-I-converting enzyme activity in term and premature infants

Cord blood angiotensin-I-converting enzyme (ACE) activity was examined in 21 term and 21 premature infants. Values were significantly higher in premature infants than in term infants. Cord blood ACE activity was found to have a significant negative correlation with birth weight and gestational age. ACE activity measured from peripheral blood during the first 24 h of life was higher in premature than term infants but similar to levels in maternal and adult controls. It was not possible to predict those premature infants who would develop respiratory distress syndrome on the basis of cord blood ACE activity. However, ACE may serve as a marker for maturation of the pulmonary vascular endothelial cell.

Degradation of porstaglandin F2alpha in the human pulmonary circulation

Degradation of prostaglandins (PGs) during passage through the human pulmonary circulation was investigated by measuring the transpulmonary plasma PGF2 alpha difference during continuous intravenous infusion of PGF2 alpha (5-10 mug/min). Seven patients with cardiological disorders and two patients with extensive pulmonary abnormalities were investigated during diagnostic cardiac catheterization. PGF2 alpha levels were measured by radioimmunoassay. The seven cardiac patients were found to have transpulmonary PGF2 alpha differences of 47-88%, indicating metabolism of the PG in the lungs. A patient with extensive bronchiectasis had an apparently normal transpulmonary PGF2alpha difference despite gross abnormalities in routine lung function tests. A patient with primary pulmonary arterial hypertension showed no metabolism of PGF2alpha in the pulmonary circulation. The results show that PG degradation is an aspect of normal lung function and suggest that it becomes imparied when extensive pulmonary vascular damage exists.

Intracortical distribution of renal blood flow in hemorrhagic shock in dogs

The effect of acute hypotensive hemorrhage on the intracortical distribution of renal blood flow was studied in anesthetized mongrel dogs with radioactive microspheres. In the early stages of shock, when carotid artery manipulation was avoided, outer cortical blood flow fell drastically and juxtamedullary flow was relatively well preserved. Carotid artery cannulation caused a redistribution of blood flow within the kidney even before hemorrhage, presumably by stimulating the carotid sinus reflex. Subsequently, with hemorrhage there was a parallel reduction in outer cortical and juxtamedullary blood flow. 138 Xe washout curves agreed with the microsphere findings. It was concluded that when the carotid artery was not disturbed, juxtamedullary blood flow was selectively preserved in the early stages of acute hypotensive hemorrhage.

Microsphere measurement of intrarenal circulation of the dog

Distribution of cortical blood flow was measured in the dog by a technique based on radionuclide-labeled microspheres. Initially it was necessary to test possible pitfalls of this technique. Completeness of trapping in the kidney, the effect on renal function, and the notion that microsphere distribution reflects blood flow distribution in the kidney cortex were studied. Renal vein blood contained less than 0.2% of the microspheres (16.8µ diameter) found in the renal artery after an aortic injection. No impairment of C PAH (control 167±4; postinjection 179±31 ml/min), C In (control 39.3%6; postinjection 37.6±2 ml/min), and T m glucose (control 90.8±13; postinjection 102±24) was found using doses adequate to measure renal blood flow (5 mg/injection x 4 injections). After 4 injections of 50 mg each significant impairment of renal function was observed. Intrarenal blood flow distribution was determined during hemorrhagic hypotension. 169 Yb-labeled microspheres were injected into the root of the aorta before, and 85 Sr-labeled microspheres after, acute hemorrhage. Radioactivity was measured in the outer two thirds and inner one third of kidney slices. Tissue blood flow was calculated and expressed as the ratio of outer cortex to inner cortex counts. Renal blood flow was redistributed to the inner cortex after hemorrhage (ratio before, 3.00; after 1.30, P < 0.01). Finally, the results of this technique were compared to a widely used method of measuring intrarenal blood flow distribution, 133 Xe washout. The first component of the washout technique correlated fairly well with total cortical flow but it was not possible to match the second component with any single anatomical area of the kidney. Limitations of the 133 Xe washout are discussed.