Characterization of Codeine Treatment Responders Among Patients with Refractory or Unexplained Chronic Cough: A Prospective Real-World Cohort Study

PURPOSE

Codeine is a narcotic antitussive often considered for managing patients with refractory or unexplained chronic cough. This study aimed to evaluate the proportion and characteristics of patients who responded to codeine treatment in real-world practice.

METHODS

Data from the Korean Chronic Cough Registry, a multicenter prospective cohort study, were analyzed. Physicians assessed the response to codeine based on the timing and degree of improvement after treatment initiation. Follow-up assessments included the Leicester Cough Questionnaire and cough severity visual analog scale at six months. In a subset of subjects, objective cough frequency was evaluated following the initiation of codeine treatment.

RESULTS

Of 305 patients, 124 (40.7%) responded to treatments based on anatomic diagnostic protocols, while 181 (59.3%) remained unexplained or refractory to etiological treatments. Fifty-one subjects (16.7%) were classified as codeine treatment responders (those showing a rapid and clear response), 57 (18.7%) as partial responders, and 62 (20.3%) as non-responders. Codeine responders showed rapid improvement in objective cough frequency and severity scores within a week of the treatment. At 6 months, responders showed significantly improved scores in cough scores, compared to non-responders. Several baseline parameters were associated with a more favorable treatment response, including older age, non-productive cough, and the absence of heartburn.

CONCLUSIONS

Approximately 60% of chronic cough patients in specialist clinics may require antitussive drugs. While codeine benefits some, only a limited proportion (about 20%) of patients may experience rapid and significant improvement. This underscores the urgent need for new antitussive drugs to address these unmet clinical needs.

Skin Test-Guided Strategy to Select Alternative Iodinated Contrast Media in Patients With Immediate Hypersensitivity Reaction: A Prospective Confirmative Study

BACKGROUND

Iodinated contrast media (ICM) are a common cause of drug-induced immediate hypersensitivity reaction (IHR). Repeated use of ICM is often necessary; therefore, a standardized protocol to prevent recurrence of IHR is required.

OBJECTIVE

We aimed to propose an intradermal skin test (IDT)-guided strategy for previous reactors to prevent recurrence of IHR.

METHODS

We conducted a prospective multicenter study from May 2018 to December 2020 and recruited patients who had experienced IHR to ICM. Once enrolled, the participants underwent IDT with a causative ICM. The alternatives for reexposure were selected using the following protocol: (1) if the IDT with the culprit ICM was positive, further skin tests with other available ICM were conducted to choose IDT-negative agents as alternatives, and (2) if the IDT with the culprit ICM was negative, a randomly changed ICM was used without additional skin tests. The recurrence and severity of hypersensitivity were assessed in subsequent computed tomography examinations. Premedication was administered according to the severity of the index event in all cases.

RESULTS

A total of 496 participants were enrolled, and 299 were reexposed to ICM. Among 269 participants who followed the protocol, 228 (84.8%) completed computed tomography examinations without adverse reactions, and IHR recurred in 16 of 30 participants (53.3%) who did not follow the protocol (P < .001). In addition, application of the protocol reduced the severity of IHR in recurred cases (P = 0.003).

CONCLUSIONS

Our IDT-guided strategy not only reduced recurrence of IHR to ICM but also mitigated the severity in recurred cases. This provides evidence for recommending an IDT to diagnose ICM allergy and find safe alternatives.

An Automated Brain Metastasis Detection and Segmentation System from MRI with a Large Multi-Institutional Dataset

PURPOSE/OBJECTIVE(S)

Developments of automated systems for brain metastasis (BM) detection and segmentation from MRI for assisting early detection and stereotactic radiosurgery (SRS) have been reported but most based upon relatively small datasets from single institutes. This work aims to develop and evaluate a system using a large multi-institutional dataset, and to improve both identification of small/subtle BMs and segmentation accuracy of large BMs.

MATERIALS/METHODS

A 3D U-Net system was trained and evaluated to detect and segment intraparenchymal BMs with a size > 2mm using 1856 MRI volumes from 1791 patients treated with SRS from seven institutions (1539 volumes for training, 183 for validation, and 134 for testing). All patients had 3D post-Gd T1w MRI scans pre-SRS. Gross tumor volumes (GTVs) of BMs for SRS were curated by each institute first. Then, additional efforts were spent to create GTVs for the untreated and/or uncontoured BMs, including central reviews by two radiologists, to improve accuracy of ground truth. The training dataset was augmented with synthetic BMs of 3773 MRIs using a 3D generative pipeline. Our system consists of two U-Nets with one using small 3D patches dedicated for detecting small BMs and another using large 3D patches for segmenting large BMs, and a random-forest based fusion module for combining the two network outputs. The first U-Net was trained with 3D patches containing at least one BM < 0.1 cm3. For detection performance, we measured BM-level sensitivity and case-level false-positive (FP) rate. For segmentation performance, we measured BM-level Dice similarity coefficient (DSC) and 95-percentile Hausdorff distance (HD95). We also stratified performances based upon BM sizes.

RESULTS

For 739 BMs in the 134 testing cases, the overall lesion-level sensitivity was 0.870 with an average case-level FP of 1.34±1.92 (95% CI: 1.02-1.67). The sensitivity was >0.969 for the BMs >0.1 cm3, but dropped to 0.755 for the BMs < 0.1 cm3 (Table 1). The average DSC and HD95 for all detected BMs were 0.786 and 1.35mm. The worse performance for BMs > 20 cm3 was caused by a case with 83 cm3 GTV and artifacts in the MRI volume.

CONCLUSION

We achieved excellent detection sensitivity and segmentation accuracy for BMs > 0.1 cm3, and promising performance for small BMs (<0.1cm3) with a controlled FP rate using a large multi-institutional dataset. Clinical utility for assisting early detection and SRS planning will be investigated. Table 1: Per-lesion detection and segmentation performance stratified by individual BM size. N is the number of BMs in each category.

Baseline Cohort Profile of the Korean Chronic Cough Registry: A Multicenter, Prospective, Observational Study

PURPOSE

The Korean Chronic Cough Registry study was initiated to characterize patients with chronic cough (CC) and investigate their outcomes in real-world clinical practice. This report aims to describe the baseline cohort profile and study protocols.

METHODS

This multicenter, prospective observational cohort study included newly referred CC patients and those already being treated for refractory or unexplained chronic cough (RUCC). Cough status was assessed using a visual analog scale, the Leicester Cough Questionnaire (LCQ), and the Cough Hypersensitivity Questionnaire (CHQ).

RESULTS

A total of 610 patients (66.9% women; median age 59.0 years) were recruited from 18 centers, with 176 being RUCC patients (28.9%). The median age at CC onset was 50.1 years, and 94.4% had adult-onset CC (≥ 19 years). The median cough duration was 4 years. Compared to newly referred CC patients, RUCC patients had a longer cough duration (6.0 years vs. 3.0 years) but had fewer symptoms and signs suggesting asthma, rhinosinusitis, or gastroesophageal acid reflux disease. Subjects with RUCC had lower LCQ scores (10.3 ± 3.3 vs. 11.6 ± 3.6; P < 0.001) and higher CHQ scores (9.1 ± 3.9 vs. 8.4 ± 4.1; P = 0.024). There were no marked differences in the characteristics of cough between refractory chronic cough and unexplained chronic cough.

CONCLUSIONS

Chronic cough typically develops in adulthood, lasting for years. Cough severity and quality of life impairment indicate the presence of unmet clinical needs and insufficient cough control in real-world clinical practice. Longitudinal follow-up is warranted to investigate the natural history and treatment outcomes.

Safety and outcomes of "at-home self-provocation tests" in patients with mild nonsteroidal anti-inflammatory drug-induced urticaria/angioedema

BACKGROUND

Nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity is common; however, many patients do not receive an accurate diagnosis and are using unnecessary alternative drugs or have medication restrictions.

OBJECTIVE

To establish a protocol for provocation tests that can be performed safely and effectively at home to give patients an accurate diagnosis, whereas also delabeling NSAID hypersensitivity.

METHODS

We retrospectively analyzed the medical records of 147 patients with NSAID hypersensitivity. All patients had NSAID-induced urticaria/angioedema with less than 10% body surface area skin involvement. One specialist developed the protocol through history taking and chart review. If NSAID hypersensitivity was confirmed, an oral provocation test was performed to confirm the safe alternative medications (group A). If it was undetermined, an oral provocation test was performed to confirm the diagnosis and alternative medications (group B). All oral provocation tests were performed by patients in their homes according to the protocol.

RESULTS

Approximately 26% of group A patients had urticaria or angioedema symptoms with alternative drugs, whereas the remaining 74% was safe. In group B, 34% of the patients were diagnosed with having NSAID hypersensitivity. However, 61% did not respond to the culprit drug; therefore, NSAID hypersensitivity had been misdiagnosed. During this at-home self-provocation test, no severe hypersensitivity reactions occurred.

CONCLUSION

Many patients originally suspected of having NSAID hypersensitivity were confirmed to have been misdiagnosed. We successfully conducted an effective and safe at-home self-provocation test.

Clinical Relevance of Staphylococcus aureus Nasal Colonization and Staphylococcal Enterotoxin-Specific IgE Sensitization in Late-Onset Asthma

This prospective observational study examined whether Staphylococcus aureus (SA) nasal colonization and staphylococcal enterotoxin (SE)-specific IgE sensitization synergistically affect clinical outcomes of adults with late-onset asthma (onset age ≥ 40 years). Nasal swabs were taken to evaluate SA colonization. Serum SE-IgE level was measured. Subjects were classified into 4 groups according to SA colonization and SE-IgE sensitization positivity. Among 181 patients with late-onset asthma recruited, the proportions of SA/SE (‒/‒), SA/SE (+ /‒), SA/SE (‒/ +), and SA/SE (+ / +) were 33.7%, 15.5%, 28.2%, and 22.6%, respectively. Severe asthma was more frequent in the SA/SE (+ / +) group than in the SA/SE (‒/‒) group (41.5% vs. 13.1%). The relationship of SA/SE (+ / +) with severe asthma was significant in multivariate logistic regression (vs. SA/SE (‒/‒); adjusted odds ratio: 4.36; 95% confidence intervals: 1.50‒12.73; p = 0.007), whereas SA/SE (+ /‒) or SA/SE (‒/ +) was not. In conclusion, SA nasal colonization and SE-IgE sensitization may synergistically affect disease severity in late-onset asthmatics.

Chest computed tomography scan utilization and diagnostic outcomes in chronic cough patients with normal chest X-rays: analysis of routinely collected data of a tertiary academic hospital

Background

The role of chest computed tomography (CT) scan is controversial in the management of chronic cough patients with normal chest X-rays. We investigated the utilization pattern and diagnostic outcomes of chest CT scans using institutional routinely collected data (RCD) in South Korea.

Methods

This is a retrospective analysis of adults with chronic cough (>8 weeks in duration) identified from routinely collected electronic health records (EHRs). Structured data were retrieved, including demographics, medical history, symptoms, and diagnostic test results (including chest X-rays and CT scans). Chest CT scan outcomes were classified into major abnormal findings (malignancy, infectious diseases, or other critical conditions that warrant immediate treatment decisions), minor abnormal findings (other abnormal findings), or normal CT.

Results

A total of 5,038 chronic cough patients with normal chest X-rays were analyzed. Chest CT scans were performed in 1,006 patients. Prescription of CT scans was significantly associated with older age, male sex, smoking history, and physician-diagnosed history of lung disease. Only 8 of 1,006 (0.8%) patients had major abnormal findings (4 pneumonia, 2 pulmonary tuberculosis, and 2 lung cancer), while 367 (36.5%) had minor findings, and 631 (62.7%) had normal CT scans. However, no baseline parameters were significantly associated with major CT findings.

Conclusions

Chest CT scans were frequently prescribed for chronic cough patients with normal chest X-rays, and abnormal findings were frequently found (37.3%). However, the diagnostic yield for malignancy or infectious disease were low (<1%). Given the potential radiation harm, a routine chest CT scan may not be warranted in chronic cough patients with normal chest X-rays.

Soluble ACE2 and TMPRSS2 Levels in the Serum of Asthmatic Patients

BACKGROUND

Angiotensin-converting enzyme 2 (ACE2) and transmembrane protease serine subtype 2 (TMPRSS2) are key proteins mediating viral entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Although gene expressions of ACE2 and TMPRSS2 have been analyzed in various organs and diseases, their soluble forms have been less studied, particularly in asthma. Therefore, we aimed to measure circulating ACE2 and TMPRSS2 in the serum of asthmatics and examine their relationship with clinical characteristics.

METHODS

Clinical data and serum samples of 400 participants were obtained from an asthma cohort. The soluble ACE2 (sACE2) and soluble TMPRSS2 (sTMPRSS2) level was measured by enzyme-linked immunosorbent assay, and the values underwent a natural log transformation. Associations between sACE2 and TMPRSS2 levels and various clinical variables were analyzed.

RESULTS

The patients younger than 70 years old, those with eosinophilic asthma (eosinophils ≥ 200 cells/µL), and inhaled corticosteroids (ICS) non-users were associated with higher levels of sACE2. Blood eosinophils and fractionated exhaled nitric oxide levels were positively correlated with serum ACE2. In contrast, lower levels of sTMPRSS2 were noted in patients below 70 years and those with eosinophilic asthma, while no association was noted between ICS use and sTMPRSS2. The level of sTMPRSS2 also differed according to sex, smoking history, coexisting hypertension, and forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio. The proportion of sputum neutrophils was positively correlated with sTMPRSS2, while the FEV1/FVC ratio reported a negative correlation with sTMPRSS2.

CONCLUSION

The levels of ACE2 and TMPRSS2 were differently expressed according to age, ICS use, and several inflammatory markers. These findings suggest variable susceptibility and prognosis of SARS-CoV-2 infection among asthmatic patients.

The role of intraoperative frozen section analysis in joint arthroplasty with CD66b immunohistochemical staining

The preoperative diagnosis of infection during joint arthroplasty is important for clinical management. However, the evaluation of polymorphonuclear leukocytes (PMNs) during frozen section analysis is sometimes difficult due to frozen artifacts. In the present study, we sought to investigate the utility of intraoperative fresh frozen section (FFS) examination for diagnosis of infection and to evaluate whether the neutrophil-specific surface marker CD66b helps to improve the diagnostic accuracy of infection. A consecutive series of 65 original frozen sections at the time of resection arthroplasty was retrospectively reviewed compared with corresponding permanent sections. The presence of PMNs was determined using intraoperative FFS and permanent sections. Furthermore, CD66b staining was performed to identify PMNs clearly. The ratio of male to female patients was 21:42. The mean age was 70 years. Postoperatively, 25 of 65 cases were histologically diagnosed with infection (25/65; 39%). The sensitivity and specificity of intraoperative FFS relative to permanent section histology were 100% (25/25) and 95% (38/40), respectively. Among 40 patients without infection, two showed false-positive results during intraoperative FFS diagnosis (2/40, 5%). In addition, on CD66b staining, six cases (9%) experienced changes in results, which altered the sensitivity and specificity of intraoperative FFS compared with permanent histology only to 87% and 87%, respectively. In conclusion, the diagnostic performance of intraoperative FFS is high and comparable to yields of permanent section histology. Therefore, intraoperative FFS is highly suitable diagnostic method for detection of infection during joint arthroplasty. And CD66b immunostaining facilitates delicate identification of PMNs, especially in equivocal cases.

Epidemiology of adult chronic cough: disease burden, regional issues, and recent findings

Chronic cough is a common medical condition that has a significant impact on patients' quality of life. Although it was previously considered a symptom of other disorders, it is now regarded as a pathologic state that is characterized by a deviation from the intrinsic protective functions of the cough reflex, especially in adults. There are several factors that may underlie the cough reflex hypersensitivity and its persistence, such as age, sex, comorbidities, viral infection, exposure to irritants or environmental pollutants, and their interactions may determine the epidemiology of chronic cough in different countries. With a deeper understanding of disease pathophysiology and advanced research methodology, there are more attempts to investigate cough epidemiology using a large cohort of healthcare population data. This is a narrative overview of recent findings on the disease burden, risk factors, Asia-Pacific issues, and longitudinal outcomes in adults with chronic cough. This paper also discusses the approaches utilizing routinely collected data in cough research.

Whole-exome sequencing and immune profiling of early-stage lung adenocarcinoma with fully annotated clinical follow-up

Background

Lung adenocarcinomas (LUADs) lead to the majority of deaths attributable to lung cancer. We performed whole-exome sequencing (WES) and immune profiling analyses of a unique set of clinically annotated early-stage LUADs to better understand the pathogenesis of this disease and identify clinically relevant molecular markers.

Methods

We performed WES of 108 paired stage I-III LUADs and normal lung tissues using the Illumina HiSeq 2000 platform. Ten immune markers (PD-L1, PD-1, CD3, CD4, CD8, CD45ro, CD57, CD68, FOXP3 and Granzyme B) were profiled by imaging-based immunohistochemistry (IHC) in a subset of LUADs (n = 92). Associations among mutations, immune markers and clinicopathological variables were analyzed using ANOVA and Fisher's exact test. Cox proportional hazards regression models were used for multivariate analysis of clinical outcome.

Results

LUADs in this cohort exhibited an average of 243 coding mutations. We identified 28 genes with significant enrichment for mutation. SETD2-mutated LUADs exhibited relatively poor recurrence- free survival (RFS) and mutations in STK11 and ATM were associated with poor RFS among KRAS-mutant tumors. EGFR, KEAP1 and PIK3CA mutations were predictive of poor response to adjuvant therapy. Immune marker analysis revealed that LUADs in smokers and with relatively high mutation burdens exhibited increased levels of immune markers. Analysis of immunophenotypes revealed that LUADs with STK11 mutations exhibited relatively low levels of infiltrating CD4+/CD8+ T-cells indicative of a muted immune response. Tumoral PD-L1 was significantly elevated in TP53 mutant LUADs whereas PIK3CA mutant LUADs exhibited markedly down-regulated PD-L1 expression. LUADs with TP53 or KEAP1 mutations displayed relatively increased CD57 and Granzyme B levels indicative of augmented natural killer (NK) cell infiltration.

Conclusion(s)

Our study highlights molecular and immune phenotypes that warrant further analysis for their roles in clinical outcomes and personalized immune-based therapy of LUAD.

SATB2-associated syndrome presenting with Rett-like phenotypes

The SATB2-associated syndrome (SAS) was proposed recently, after the SATB2 gene was initially discovered to be associated with isolated cleft palate. This syndrome is characterized by intellectual disability with delayed speech development, facial dysmorphism, cleft or high-arched palate, and dentition problems. Here, we describe two novel SATB2 sequence variants in two unrelated patients presenting with Rett-like phenotypes. We performed trio-based whole-exome sequencing in a 17-month-old girl presenting with severe retardation and Rett-like phenotypes, which revealed a de novo missense variant in SATB2 (p.Glu396Gln). Moreover, targeted sequencing of the SATB2 gene was performed in a 2-year-old girl with severe psychomotor retardation, facial hypotonia, and cleft palate who also exhibited some features of Rett syndrome. A nonsense variant in SATB2 was identified in this patient (p.Arg459*). This study expanded the clinical and genetic spectrum of SAS. SATB2 variants should be considered in cases with psychomotor retardation alone or in any cases with Rett-like phenotypes, regardless of the typical features of SAS such as cleft palate.

Role of second-look ultrasound examinations for MR-detected lesions in patients with breast cancer

PURPOSE

To assess the clinical value of second-look ultrasound (US) examination for the evaluation of additional enhancing lesions detected on magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Between May 2008 and February 2011, 794 consecutive patients with histologically confirmed breast cancer underwent breast MR imaging. We included 101 patients with 132 additional enhancing breast lesions detected on MR imaging who underwent second-look US.  The imaging features and lesion category according to the Breast Imaging and Reporting and Data System (BI-RADS) were assessed with MR and US imaging, respectively.

RESULTS

According to the BI-RADS system, 67 lesions (50.8 %) were classified as category 0, 33 lesions (25.0 %) as category 3, and 32 lesions (24.2 %) as category 4. Of the 67 indeterminate lesions on MR imaging, 34 (50.7 %) were demonstrated on second-look US. 11 of these 34 lesions showed suspicious sonographic features, including 1 lesion that showed malignancy (9.1 %, 1/11). Most of the suspicious lesions on MR imaging (26 of 32 BI-RADS category 4 lesions, 81.3 %) were demonstrated on second-look US, and 17 were malignant (65.4 %, 17/26). Of the 6 BI-RADS category 4 lesions without sonographic correlation, 1 was malignant (16.7 %, 1/6).

CONCLUSION

Second-look US examination was useful for evaluating MR-detected lesions in patients with breast cancer.

The analgesic effect of remifentanil on prevention of withdrawal response associated with the injection of rocuronium in children: no evidence for a peripheral action

Remifentanil pre-treatment has been reported to decrease the incidence of rocuronium injection-associated withdrawal movement. This study was designed to explore the site of action of remifentanil for reducing withdrawal response during rocuronium injection in children. Ninety-six paediatric patients were randomly assigned to three groups. After induction of anaesthesia with 5 mg/kg 2.5% thiopental sodium, 2 ml saline (placebo group) or 0.5 microg/kg remifentanil (group R), was injected intravenously 1 min before 0.6 mg/kg rocuronium. In a third group (group R'), the venous retention of 0.5 microg/kg remifentanil was maintained for 30 s followed by tourniquet release and injection of 0.6 mg/kg rocuronium. Withdrawal response was graded using a four-point scale. The incidence of withdrawal movement after rocuronium administration was 94%, 22% and 81% in the placebo, R, and R' groups, respectively. This study demonstrated that the pre-treatment effect of remifentanil for reducing rocuronium-associated withdrawal response occurs mainly through a central action.

Tyrosine phosphorylation of cofilin at Y68 by v-Src leads to its degradation through ubiquitin-proteasome pathway

Cofilin is a major regulator of actin dynamics involved in the regulation of cell spreading and migration through its actin depolymerizing and severing activities. V-Src is an activated Src tyrosine kinase and a potent oncogene known to phosphorylate a variety of cellular proteins in cell transformation process including altered cell adhesion, spreading and migration. Recently, it has been suggested that cofilin is a potential substrate of v-Src (Rush et al., 2005). Here, we show direct tyrosine phosphorylation of cofilin by v-Src and identify Y68 as the major phosphorylation site. Cofilin phosphorylation at Y68 did not change its activity per se, but induced increased ubiquitination of cofilin and its degradation through the proteosome pathway. Furthermore, the negative effect of cofilin on cellular F-actin contents was inhibited by co-expression of v-Src, whereas that of cofilin mutant Y68F (Y68 mutated to F) was not affected, suggesting that v-Src-mediated cofilin phosphorylation at Y68 is required for degradation of cofilin in vivo. Lastly, inhibition of cell spreading by v-Src was rescued partially by co-expression of cofilin, and to a greater extent by the Y68F mutant which is not subjected to v-Src induced degradation through phosphorylation, suggesting that v-Src mediated changes in cell spreading is, at least in part, through inhibiting the function of cofilin via phosphorylating it at Y68. Together, these results suggest a novel mechanism by which cofilin is regulated by v-Src through tyrosine phosphorylation at Y68 that triggers degradation of cofilin via ubiquitination-proteosome pathway and consequently inhibits cofilin activity in reducing cellular F-actin contents and cell spreading.

Relationships of methacholine and AMP responsiveness with peak expiratory flow variability in children with asthma

BACKGROUND

Both bronchial responsiveness (BR) and peak expiratory flow (PEF) variability are increased in asthma. PEF variability is presumed to reflect the degree of BR in asthma. BR is commonly assessed by bronchial challenges using direct or indirect stimuli.

OBJECTIVE

The aim of this study was to compare methacholine and adenosine 5'-monophosphate (AMP) responsiveness with regard to their relationships with PEF variability in children with asthma.

METHODS

Methacholine and AMP challenge tests were performed in 79 children with mild to moderate asthma, and a provocative concentration causing a 20% decline in forced expiratory volume in 1 s (PC(20)) was calculated for each challenge. Subjects recorded PEF each morning and each evening for 14 consecutive days. PEF variability was expressed as amplitude percentage mean (amp%mean; high PEF minus low PEF on each day, expressed as a percentage of their mean, averaged over 14 days), and as the lowest percentage highest (low%high; the lowest PEF expressed as a percentage of the highest PEF recorded over the period).

RESULTS

Methacholine PC(20) correlated significantly but weakly with both indices of PEF variability (amp%mean: r=-0.285, P=0.011; low%high: r=0.238, P=0.034). However, there was a significant and strong correlation between AMP PC(20) and both amp%mean (r=-0.583, P=0.000) and low%high (r=0.496, P=0.000). For AMP PC(20), the correlations were stronger than for methacholine PC(20) (comparison of correlation coefficients with amp%mean: P=0.021; with low%high: P=0.063).

CONCLUSION

Both methacholine PC(20) and AMP PC(20) correlated significantly with PEF variability. However, the stronger correlations for AMP PC(20) than for methacholine PC(20) suggest that PEF variability may be better reflected by BR assessed by AMP than by methacholine.

Bronchial responsiveness to methacholine and adenosine 5'-monophosphate in young children with asthma: their relationship with blood eosinophils and serum eosinophil cationic protein

BACKGROUND

Bronchial hyperresponsiveness is a characteristic feature of asthma, and is usually measured by bronchial challenges using direct or indirect stimuli. Blood eosinophil numbers and serum levels of eosinophil cationic protein (ECP) are considered as indirect measures of airway inflammation in asthma. The aim of this study was to investigate whether bronchial responsiveness to adenosine 5'-monophosphate (AMP) is more closely associated with blood eosinophil markers, compared with that to methacholine, in young children with asthma.

METHODS

Methacholine and AMP bronchial challenges were performed in 4- to 6-year-old children with asthma (n = 77) and in healthy controls (n = 32), using a modified auscultation method. The end-point was defined as the appearance of wheezing and/or oxygen desaturation. The peripheral blood eosinophil counts and serum ECP concentrations were determined in each subject.

RESULTS

A positive response to methacholine (end-point concentration < or =8mg/ml) and to AMP (end-point concentration < or =200 mg/ml) was observed in 74 (96.1%) and 66 asthmatic children (85.7%), respectively. A majority of controls was unresponsive to both challenges. In the asthma group, there was no significant correlation between methacholine end-point concentration and the eosinophil counts (r = -0.111, P = 0.337) or serum ECP levels (r = -0.126, P = 0.274). In contrast, AMP end-point concentration correlated significantly with the eosinophil counts (r = -0.372, P = 0.001) and with serum ECP levels (r = -0.371, P = 0.001).

CONCLUSIONS

Our results suggest that bronchial responsiveness to AMP is more closely related to airway inflammation, compared with that to methacholine, and support the potential usefulness of AMP challenges in detecting inflammatory changes in young children with asthma.

Bronchial responsiveness to methacholine and adenosine 5'-monophosphate in atopic and non-atopic preschool children with recurrent wheezing

BACKGROUND

It is well known that atopy is a major determinant of bronchial hyper-responsiveness (BHR) in both asymptomatic and asthmatic children. However, the relationship between atopy and BHR has not been well studied in preschool children with wheezing. BHR is usually measured by bronchial challenges using direct and indirect stimuli.

OBJECTIVE

The aim of this study was to investigate whether atopic and non-atopic preschool wheezers display similar or different BHR profiles for direct and indirect stimuli.

METHODS

Methacholine and adenosine 5'-monophosphate (AMP) bronchial challenges were performed in 4 to 6-year-old children with recurrent wheezing, using a modified auscultation method. The end-point was defined as the appearance of wheezing and/or oxygen desaturation. Atopy was determined to be present when a child had at least one positive reaction to a panel of 13 common airborne allergens in the presence of positive and negative controls.

RESULTS

A positive response to methacholine (an end-point concentration < or =8 mg/mL) was observed in 89.3% (50/56) of atopic wheezers and in 83.8% (31/37) of non-atopic wheezers (P=0.44) for the difference. By contrast, the frequency of a positive response to AMP (an end-point concentration < or =200 mg/mL) was significantly higher in the atopic group (47/56, 83.9%) compared with the non-atopic group (12/37, 32.4%; P<0.01).

CONCLUSION

While a majority of both atopic and non-atopic preschool wheezers were hyper-responsive to methacholine, atopic subjects were more hyper-responsive to AMP than non-atopic subjects. These findings suggest that atopic and non-atopic wheeze in preschool children are related to distinctive pathophysiologic pathways.

Bronchial hyperresponsiveness in young children with allergic rhinitis and its risk factors

BACKGROUND

Subjects with allergic rhinitis but no clinical evidence of asthma have greater bronchial hyperresponsiveness (BHR), and several factors have been implicated as its determinants. However, studies in young children are lacking. The aims of this study were to evaluate the prevalence of BHR in young children with allergic rhinitis and to investigate its risk factors.

METHODS

Methacholine bronchial challenges were performed in 4- to 6-year-old nonasthmatic children with allergic rhinitis (n = 83) and in healthy nonatopic controls (n = 32), using a modified auscultation method. The end-point was defined as the appearance of wheezing and/or oxygen desaturation. Subjects were considered to have BHR when they had end-point concentrations of methacholine <or=8 mg/mL. Clinical and laboratory data in allergic rhinitis patients and a history of allergic diseases in their parents were collected.

RESULTS

BHR was observed in 27 subjects with allergic rhinitis (32.5%) and three controls (9.4%). Among subjects with allergic rhinitis, serum total IgE, the number and pattern of skin-prick test responses, blood eosinophil markers, and parental history of allergic rhinitis and atopic dermatitis were not different between the BHR(+) and BHR(-) groups, whereas the persistent type of rhinitis and parental history of asthma were more frequent in the BHR(+) group than in the BHR(-) group. These associations remained significant in a multivariable logistic regression.

CONCLUSIONS

Young children with allergic rhinitis alone showed an increased prevalence of BHR. Both persistent type of rhinitis and parental history of asthma were significant and independent risk factors for BHR in these children.

Methacholine and adenosine 5'-monophosphate challenges in children with post-infectious bronchiolitis obliterans

Airway hyperresponsiveness (AHR) is a characteristic feature of asthma, but is also frequently demonstrated by children and adults with chronic obstructive lung diseases. AHR is usually measured by bronchial challenges using direct or indirect stimuli. The aim of this study was to compare these two types of bronchial challenge in children with post-infectious bronchiolitis obliterans (BO). Methacholine and adenosine 5'-monophosphate (AMP) challenges were used as tools for the evaluation of AHR to direct and indirect stimuli, respectively, in children with post-infectious BO (n = 28). These results were compared with those of asthmatic (n = 30) and control children (n = 25). Altogether, twenty-two patients (78.6%) with post-infectious BO were hyperreactive to methacholine with a provocative concentration causing a 20% fall in forced expiratory volume in one second (PC20) of <16 mg x mL(-1), but only six (21.4%) were hyperreactive to AMP with a PC20 of <200 mg x mL(-1). All patients with asthma responded positively to methacholine, and most (28, 93.3%) also responded positively to AMP. The majority of controls were insensitive to both challenges. Airway hyperresponsiveness to methacholine is a frequent, but by no means universal, finding in children with post-infectious bronchiolitis obliterans, but is usually not accompanied by airway hyperresponsiveness to adenosine 5'-monophosphate. This finding suggests that airway hyperresponsiveness in patients with post-infectious bronchiolitis obliterans has characteristics that differ from those of asthmatic subjects.

Birth month and sensitization to house dust mites in asthmatic children

BACKGROUND

Early exposure to high quantities of allergen has an important role in the incidence of atopic sensitization. In fact, subjects sensitized to house dust mites (HDMs) have a significantly higher proportion of births in the season when HDMs are most abundant.

OBJECTIVE

The aim of this study was to investigate whether birth month patterns differ for asthmatic patients sensitized only to HDMs and for those sensitized to HDMs and other allergen(s).

METHODS

Among 2225 patients with asthma, aged 10-16 years, 1642 sensitized to HDMs were identified by skin prick testing. This group was composed of patients sensitized only to HDMs (n = 715) and patients sensitized to HDMs and other allergen(s) (n = 927). The birth month distributions of the group of HDM-sensitive asthmatics or its subgroups were compared with that of a reference population (total live births in the same years as the studied subjects). The risk ratio of a given birth month in relation to all the other months was calculated as an odds ratio (OR) with the corresponding 95% confidence interval (CI).

RESULTS

A significant difference in birth month distribution was observed for HDM-sensitive asthmatics (chi(2) = 23.6, P = 0.015), with higher rates of birth in August (OR: 1.23, 95% CI: 1.04-1.46) and September (1.24, 1.04-1.46). When the two subgroups were analyzed separately, significantly more births were noted in August (1.34, 1.06-1.71) and September (1.34, 1.05-1.70) for those sensitized only to HDMs, whereas no such birth month preference was observed for those sensitized to HDMs and other allergen(s).

CONCLUSIONS

The HDM-positive asthmatics showed a greater proportion of births in August and September, which correspond to high HDM exposure. However, this birth month pattern was evident in asthmatic-sensitive only to HDMs, but was not observed in those sensitive to HDMs and other allergen(s).

Coincidence of atopy profile in terms of monosensitization and polysensitization in children and their parents

BACKGROUND

Results from epidemiologic studies have shown that childhood atopy is probably a hereditary disorder, because the offspring of affected parents have a higher risk of developing atopy. Among the atopic population, some subjects are sensitized to only one class of allergens (monosensitized), while other subjects are sensitized to more than one class of allergens (polysensitized). The aim of this study was to investigate whether atopy profile (monosensitization/polysensitization) in children is linked to the same conditions in their parents.

METHODS

We evaluated sensitization to five classes of aeroallergens (house dust mites, animal danders, pollens, molds, and cockroach) by skin prick testing in a group of 494 children with suspicious allergic symptoms and in their parents.

RESULTS

The frequency of parental atopy was highest (51.6%) in polysensitized children (n = 189), intermediate (37.1%) in monosensitized children (n = 178), and was lowest (22.4%) in nonsensitized children (n = 127). The proportion of polysensitized subjects among atopic parents was significantly higher for polysensitized children (45.6%) than for monosensitized children (31.1%). Polysensitized children were found to more frequently have one or both parents polysensitized (32.3%, 7.4%) than monosensitized children (18.5%, 2.2%) with odds ratios of 2.09 (95% CI: 1.29-3.40) and 3.48 (1.12-10.78), respectively, whereas the likelihood of having one or two monosensitized parents was not increased for polysensitized children.

CONCLUSION

Our data suggest a familial coincidence of atopy profile in terms of monosensitization and polysensitization, although the relative importance of genetic or environmental influence should be studied further.

Sputum eosinophil counts and eosinophil cationic protein levels in cough-variant asthma and in classic asthma, and their relationships to airway hypersensitivity or maximal airway response to methacholine

BACKGROUND

The aims of this study were to compare the degree of airway inflammation in cough-variant asthma (CVA) with that in classic asthma (CA), and to examine the relationship between airway inflammation and airway hypersensitivity or maximal airway response to methacholine in both conditions.

METHODS

Sputum was induced in 41 CVA patients, in 41 methacholine PC(20)-matched CA patients, and in 20 healthy children. The sputum samples were analyzed for total and differential cell counts, and for eosinophilic cationic protein (ECP). A high-dose methacholine challenge test was performed in CVA and CA patients to determine PC(20) and maximal airway response.

RESULTS

Sputum eosinophil percentages and ECP levels were significantly elevated in CVA and CA vs the control, but no significant differences were found between the two asthma groups. In the two asthma groups, neither sputum parameters correlated significantly with methacholine PC(20). However, the absence of a maximal response plateau or its higher level, when present, was associated with increased eosinophil percentages and ECP levels in the CVA group.

CONCLUSIONS

The degree of eosinophilic inflammation may not be causally related to differences in presented asthma manifestations. The identification of a maximal response plateau and the level of this plateau in patients with CVA may provide information pertinent to airway eosinophilic inflammation.

Sputum eosinophilia in cough-variant asthma as a predictor of the subsequent development of classic asthma

BACKGROUND

A significant proportion of patients diagnosed with cough-variant asthma eventually manifest classic asthma signs, such as wheezing and dyspnoea. The aim of this study was to investigate whether the percentage of eosinophils and/or concentration of eosinophilic cationic protein (ECP) in sputum induced from patients with cough-variant asthma can predict the development of classic asthma.

METHODS

Sixty-two children with cough-variant asthma were prospectively studied for 4 years. At the initiation of the study, sputum was induced with hypertonic saline, and the sputum samples were analysed for total and differential cell counts, and for ECP. Each subject was checked clinically at least every 3 months, and details of classic asthma signs experienced during the intervening periods were taken.

RESULTS

Twenty-four (47.1%) of the 51 subjects available for follow-up developed signs of classic asthma, while 27 did not. The only significant difference in the sputum parameters between these two groups was a higher percentage of sputum eosinophils in subjects who developed classic asthma. A significant association was found between sputum eosinophil percentage and classic asthma development, but not between the concentration of sputum ECP and classic asthma development.

CONCLUSION

Sputum eosinophilia in cough-variant asthma may be a correlate of the later development of classic asthma. This suggests that sputum differential cell counts may be useful in the clinical management of patients with cough-variant asthma, as they may enable the prediction of the subsequent classic asthma development.

Caenorhabditis elegans MES-3 is a target of GLD-1 and functions epigenetically in germline development

The maternal-effect sterile (MES) proteins are maternally supplied regulators of germline development in Caenorhabditis elegans. In the hermaphrodite progeny from mes mutant mothers, the germline dies during larval development. On the basis of the similarities of MES-2 and MES-6 to known transcriptional regulators and on the basis of the effects of mes mutations on transgene expression in the germline, the MES proteins are predicted to be transcriptional repressors. One of the MES proteins, MES-3, is a novel protein with no recognizable motifs. In this article we show that MES-3 is localized in the nuclei of embryos and germ cells, consistent with its predicted role in transcriptional regulation. Its distribution in the germline and in early embryos does not depend on the wild-type functions of the other MES proteins. However, its nuclear localization in midstage embryos and its persistence in the primordial germ cells depend on wild-type MES-2 and MES-6. These results are consistent with biochemical data showing that MES-2, MES-3, and MES-6 associate in a complex in embryos. The distribution of MES-3 in the adult germline is regulated by the translational repressor GLD-1: MES-3 is absent from the region of the germline where GLD-1 is known to be present, MES-3 is overexpressed in the germline of gld-1 mutants, and GLD-1 specifically binds the mes-3 3' untranslated region (3' UTR). Analysis of temperature-shifted mes-3(bn21ts) worms and embryos indicates that MES-3 function is required in the mother's germline and during embryogenesis to ensure subsequent normal germline development. We propose that MES-3 acts epigenetically to induce a germline state that is inherited through both meiosis and mitosis and that is essential for survival of the germline.

A fatality due to injection of tiletamine and zolazepam

A 22-year-old male with more than 28 needle marks on his right arm was found dead. First, he was suspected as a drug abuser. Blood, urine, spleen, and injection-site tissue was collected during autopsy. The blood and urine specimens were screened for drugs. Immunoassay studies did not show any illegal drugs. However, two unidentified peaks were isolated in both of these biological fluids by routine gas chromatography-flame-ionization detection (GC-FID) and thermionic specific detection. Additional gas chromatography-mass spectrometry analysis determined these two peaks to be tiletamine and zolazepam. These two agents are used in combination as veterinary anesthesia. The concentrations of these drugs in blood were quantitated by GC-FID and found to be 0.85 mg/L of tiletamine and 3.3 mg/L of zolazepam. In urine, tiletamine and its metabolite, 2-(ethylamino)-2-(2-thionyl) cyclohexanol, were identified to be present along with zolazepam. The concentrations of tiletamine and zolazepam in spleen were revealed to be 0.92 and 3.5 mg/kg, respectively. Injection-site tissue concentrations were determined to be 25.1 mg/kg tiletamine and 23.3 mg/kg for zolazepam. The cause of death in this case was determined to be due to the multiple drug intoxication of tiletamine and zolazepam.

Image subband coding using context-based classification and adaptive quantization

Adaptive compression methods have been a key component of many proposed subband (or wavelet) image coding techniques. This paper deals with a particular type of adaptive subband image coding where we focus on the image coder's ability to adjust itself "on the fly" to the spatially varying statistical nature of image contents. This backward adaptation is distinguished from more frequently used forward adaptation in that forward adaptation selects the best operating parameters from a predesigned set and thus uses considerable amount of side information in order for the encoder and the decoder to operate with the same parameters. Specifically, we present backward adaptive quantization using a new context-based classification technique which classifies each subband coefficient based on the surrounding quantized coefficients. We couple this classification with online parametric adaptation of the quantizer applied to each class. A simple uniform threshold quantizer is employed as the baseline quantizer for which adaptation is achieved. Our subband image coder based on the proposed adaptive classification quantization idea exhibits excellent rate-distortion performance, in particular at very low rates. For popular test images, it is comparable or superior to most of the state-of-the-art coders in the literature.

Identification of a blue photoluminescent composite material from a combinatorial library

A quaternary combinatorial masking strategy was used in conjunction with photolithography to generate compositionally diverse thin-film phosphor libraries containing 1024 different compositions on substrates 2.5 centimeters square. A parallel imaging system and scanning spectrophotometer were used to identify and characterize compositions in the library with interesting luminescent behavior. Optimal compositions were identified with the use of gradient libraries, in which the stoichiometry of a material was varied continuously. This process led to the identification of an efficient blue photoluminescent composite material, Gd3Ga5O12/SiO2. Experimental evidence suggests that luminescence in this material may arise from interfacial effects between SiO2 and Gd3Ga5O12.

Inhibition of NADH-linked mitochondrial respiration by 4-hydroxy-2-nonenal

During the progression of certain degenerative conditions, including myocardial ischemia-reperfusion injury, mitochondria are a source of increased free-radical generation and exhibit declines in respiratory function(s). It has therefore been suggested that oxidative damage to mitochondrial components plays a critical role in the pathology of these processes. Polyunsaturated fatty acids of membrane lipids are prime molecular targets of free-radical damage. A major product of lipid peroxidation, 4-hydroxy-2-nonenal (HNE), is highly cytotoxic and can readily react with and damage protein. In this study, the effects of HNE on intact cardiac mitochondria were investigated to gain insight into potential mechanisms by which free radicals mediate mitochondrial dysfunction. Exposure of mitochondria to micromolar concentrations of HNE caused rapid declines in NADH-linked but not succinate-linked state 3 and uncoupled respiration. The activity of complex I was unaffected by HNE under the conditions of our experiments. Loss of respiratory activity reflected the inability of HNE-treated mitochondria to meet NADH demand during maximum rates of O2 consumption. HNE exerted its effects on intact mitochondria by inactivating alpha-ketoglutarate dehydrogenase. These results therefore identify a potentially important mechanism by which free radicals bring about declines in mitochondrial respiration.

Evaluation of the efficacy and safety of flumazenil in the treatment of portal systemic encephalopathy: a double blind, randomised, placebo controlled multicentre study

BACKGROUND

Portal systemic encephalopathy (PSE) is a complex neuropsychiatric syndrome associated with hepatic failure. Small scale studies have shown the benzodiazepine receptor antagonist flumazenil to be effective in ameliorating PSE.

AIMS

To determine the efficacy of flumazenil in patients with non-comatous mild to moderate PSE (stages I to III) due to severe chronic liver disease.

PATIENTS

49 male and female adults without symptoms of severe bleeding and sepsis and who screened negative for benzodiazepine in both blood and urine, were included in the study.

METHODS

Patients were randomised to receive either three sequential bolus injections of flumazenil (0.4, 0.8, and 1 mg) or placebo at one minute intervals, followed by intravenous infusions of either flumazenil (1 mg/h) or placebo for three hours. Clinical PSE grading and vital signs were assessed hourly during baseline and post-treatment periods and half hourly during treatment. The main outcome measures were improvement in group average PSE score and reduction of two points in individual PSE score (clinically relevant improvement).

RESULTS

The mean average improvement in the PSE score in the subjects treated with flumazenil was not statistically significantly different from placebo. However, for patients showing clinically relevant improvement, the difference between flumazenil and placebo was statistically significant (seven of 28 v none of 21; p = 0.015). Flumazenil was well tolerated.

CONCLUSIONS

A subgroup of patients with PSE resulting from chronic liver disease may benefit from the administration of flumazenil.

Fatal zipeprol and dextromethorphan poisonings in Korea

Zipeprol and dextromethorphan are abused together by young people in Korea to obtain a stronger hallucinogenic effect. Because large amounts of these drugs are taken for this reason, nine fatal poisonings due to zipeprol and dextromethorphan have been reported since 1993. In this paper, the concentration of drugs in the postmortem blood and gastric contents of these victims is examined. The determination and identification of the drugs in biological fluids were conducted by gas chromatography (GC)-thermionic specific detection and GC-mass spectrometry. Linear calibration curves and high recoveries were obtained. The blood concentrations of zipeprol varied from 1.3 to 28.6 micrograms/mL, and the concentrations of dextromethorphan ranged from 1.1 to 18.3 micrograms/mL. The concentration of zipeprol in the gastric contents ranged from 26.8 to 1384.8 micrograms/g, and dextromethorphan concentrations varied from 2.1 to 243.7 micrograms/g.

Ubiquitination of full-length cyclin

Mitotic cyclins are key cell-cycle regulators that are relatively stable through most of the cell-cycle then rapidly degraded at mitosis. We have detected ubiquitin conjugates of full-length Xenopus cyclin B2 strongly suggesting that ubiquitination rather than a proteolytic cleavage is the initiating event in cyclin destruction. The highest levels of ubiquitin conjugates correlate with the phase of rapid proteolysis. This result supports previous findings that implicate the ubiquitin system in cyclin proteolysis. However, we also observe cyclin-ubiquitin conjugates in both cytostatic factor arrested and interphase extracts where cyclin is more stable. The physiologic role of ubiquitinated cyclin under these conditions is unclear.

Urinary methamphetamine concentration following famprofazone administration

A 37-year-old man had a considerable concentration of methamphetamine in his urine, but he denied taking any abused drug. It was found that he took a pain killer that contains famprofazone, a relatively strong analgesic whose metabolites include methamphetamine and amphetamine. The human urinary metabolism of famprofazone was investigated. Immunoassay was used as a preliminary test, and gas chromatography with flame-ionization detection and gas chromatography-mass spectrometry were used for quantitation and confirmation.