BOS is associated with decreased HDAC2 from steroid resistant lymphocytes in the small airways

Immunosuppression therapies including corticosteroids fail to prevent bronchiolitis obliterans syndrome (BOS), primarily a disease of the small airways, following lung transplantation. We reported increases in steroid-resistant proinflammatory lymphocytes and their loss of histone deacetylase 2 (HDAC2), an important mediator of steroid action, in the blood of stable lung transplant recipients. We noted similar increases in the steroid-resistant lymphocytes in both the blood and small airways in BOS compared with the large airways. We hypothesized that these small airway cells would also exhibit a loss of HDAC2, and that these changes could be reversed by treatment with theophylline (HDAC2 activator). Blood, bronchoalveolar lavage and large and small airway brushings were collected from lung transplant patients with BOS (n = 12) or stable lung function (n = 18) and healthy aged-matched controls (n = 13). Intracellular proinflammatory cytokines [interferon (IFN-γ) and tumour necrosis factor (TNF)-α and HDAC2 were measured in CD8⁺ T, natural killer (NK) T-like and NK cells from cultured small airway brushings ± 5 mg/l theophylline ± 1 µM prednisolone using flow cytometry. Increased small airway CD8 T, NK T-like and NK cells were identified in BOS versus stable transplant and controls. In BOS, these cells exhibited increased IFN-γ/TNF-α and a loss of HDAC2. HDAC2 expression by small airway CD8⁺ T cells correlated with forced expiratory volume in 1 s (FEV₁ ) (R = 0·880, P = 0·031). Theophylline and prednisolone synergistically up-regulated HDAC2 in CD8⁺ T cells. BOS is associated with loss of HDAC2 from steroid-resistant proinflammatory CD8⁺ T, NK T-like and NK cells in the small airways. Therapeutically increasing HDAC2 in these lymphocytes may reduce steroid resistance and improve graft survival.

The impact of immunoglobulin in acute HIV infection on the HIV reservoir: a randomized controlled trial

OBJECTIVES

Antiretroviral therapy (ART) during acute HIV infection (AHI) restricts the HIV reservoir, but additional interventions are necessary to induce a cure. Intravenous immunoglobulin (IVIG) is not HIV-specific but is safe and temporarily reduces the HIV reservoir in chronic HIV infection. We present a randomized controlled trial to investigate whether IVIG plus ART in AHI reduces the HIV reservoir and immune activation compared with ART alone.

METHODS

Ten men with AHI (Fiebig II-IV) initiated ART (tenofovir, entricitabine, ritonavir boosted darunavir and raltegravir) at HIV-1 diagnosis and were randomized to ART alone or ART plus 5 days of IVIG, once virally suppressed (week 19). Blood samples were evaluated for viral reservoir, immune activation, immune exhaustion and microbial translocation. Flexible sigmoidoscopy was performed at weeks 19, 24 and 48, and gut proviral DNA and cell numbers determined.

RESULTS

IVIG was well tolerated and no viral blips (> 50 HIV-1 RNA copies/mL) occurred during IVIG therapy. From baseline to week 48, total HIV DNA in peripheral blood mononuclear cells (PBMCs) (cases: -3.7 log₁₀ copies/10⁶ CD4 cells; controls: -3.87 log₁₀ copies/10⁶ CD4 cells) declined with no differences observed between the groups (P = 0.49). Declines were observed in both groups from week 19 to week 48 in total HIV DNA in PBMCs (P = 0.38), serum low copy RNA (P = 0.57) and gut total HIV DNA (P = 0.55), but again there were no significant differences between arms. Biomarkers of immune activation, immune exhaustion and microbial translocation and the CD4:CD8 ratio were similar between arms for all comparisons.

CONCLUSIONS

Although safe, IVIG in AHI did not impact total HIV DNA, immune function or microbial translocation in peripheral blood or gut tissue.

Naloxone-precipitated withdrawal jumping in 11 inbred mouse strains: evidence for common genetic mechanisms in acute and chronic morphine physical dependence

Physical dependence is a widely known consequence of morphine intake. Although commonly associated with prolonged or repeated morphine administration, withdrawal symptoms can be elicited even after a single prior morphine exposure. What remains contentious is the extent to which physical dependence following acute and chronic morphine treatment is mediated by common physiological substrates and, accordingly, represent distinct syndromes. The genetic relationship between acute and chronic morphine dependence was thus presently studied by comparing mice of 11 inbred strains (129P3, A, AKR, BALB/c, C3H/He, C57BL/6, CBA, DBA/2, LP, SJL, and SWR) for naloxone-precipitated withdrawal jumping responses using three subcutaneous morphine administration paradigms: acute (single injection) or chronic (three daily morphine injections for 4 days) injection, or chronic infusion (7 days via implanted osmotic minipumps). Although there were differences in the magnitude of withdrawal jumping between the three different morphine administration paradigms, large and significant strain differences were observed for each. In addition, the same strains were unusually sensitive or, conversely, altogether refractory to withdrawal jumping across all morphine treatment conditions. Overall, strain jumping means between acute and chronic dependence paradigms displayed a high degree of genetic correlation (r=0.87-0.95). The significant correlation between chronic morphine injection and continuous morphine infusion discounts the possible confounding effect of contextual learning and spontaneous withdrawal between chronic injections on the assessment of naloxone-precipitated withdrawal. Substantial heritability was also observed for acute and both paradigms of chronic dependence, with estimates ranging from h(2)=0.53 to 0.70. The present demonstration of a strong genetic correlation between physical dependence to morphine following acute and chronic treatment implies that genes associated with variable sensitivity in the two traits are the same, and is suggestive of shared physiological substrates. The data also demonstrate that the differential genetic liability to morphine physical dependence begins with, and is predicted by, the first morphine exposure.

Assessment of acute and chronic morphine dependence in male and female mice

The present study compared male and female mice for frequency of naloxone-precipitated jumping and naloxone ED(50) values, two common indices of physical dependence, following acute and chronic morphine administration. Both sexes displayed a positive dose-response relationship between acute morphine and naloxone doses and jumping frequency. There was a significant main effect of sex, with mean jumping frequencies greater in males. The naloxone ED(50) estimate was also fourfold lower in males, indicating greater withdrawal sensitivity than females. Jumping frequencies were similar in male and female saline-treated control mice, discounting initial sex differences as a significant factor in the unequal magnitude and sensitivity in acute morphine dependence between sexes. In contrast, males and females displayed similar mean withdrawal jumping frequencies and naloxone ED(50) values after 3 days of morphine injections. Sex difference in withdrawal jumping was also not observed when morphine treatment was increased to 7 days via daily injection or continuous subcutaneous infusion. The present study demonstrates the development of greater physical dependence in male relative to female mice following acute but not chronic morphine administration.

Morphine tolerance after chronic intracerebroventricular injection in male and female mice

We compared morphine analgesia ED(50) values of male and female mice prior to (Day 1) and after (Day 4) 3 days of intracerebroventricular morphine injections. Increases in ED(50) values from Day 1 to Day 4, indicating tolerance, were of similar magnitude in both sexes. The data suggest that spinal opioid analgesic mechanisms, acting alone or in synergy with supraspinal loci, may contribute to pharmacodynamic explanations of sex differences in systemic morphine tolerance.

Morphine tolerance and dependence in nociceptin/orphanin FQ transgenic knock-out mice

It has been hypothesized that morphine tolerance and dependence in mice following chronic exposure may reflect increased compensatory activity of antiopioid systems. The endogenous peptide nociceptin/orphanin FQ has been shown to have anti-opioid effects, for example antagonizing morphine analgesia. Moreover, chronic morphine administration increases synthesis of the peptide, and morphine tolerance and dependence can be attenuated or reversed by antagonists and agonists of the nociceptin/orphanin FQ receptor, respectively. The present study seeks to confirm a role for nociceptin/orphanin FQ in opioid tolerance and dependence by comparing morphine ED(50) values and naloxone-precipitated withdrawal jumping in mice homozygous (knock-out) and heterozygous for a null mutation of the Npnc1 gene encoding the nociceptin/orphanin FQ propeptide, and their wild type littermates, following chronic morphine exposure. Relative to morphine-naive control mice, significant rightward shifts in the morphine dose-response curve, resulting in increased morphine ED(50) values (approximately two to three-fold), was observed for all genotypes following three days of repeated systemic morphine injections. However, no differences between genotypes in the magnitude of tolerance were observed. In contrast, knock-out mice displayed significantly increased naloxone-precipitated withdrawal jumping relative to heterozygous and wild-type mice following implantation with a morphine pellet (25mg) for 72h. Use of nociception/orphaninFQ transgenic knock-out mice thus demonstrate the differential involvement of nociceptin/orphanin FQ in morphine tolerance and dependence.

A comparison of morphine analgesic tolerance in male and female mice

Studies comparing morphine tolerance in males and females are rare, and all studies to date have utilized the rat. To generalize from findings with rats morphine tolerance was investigated in male and female mice using the tail-withdrawal test. Three and 7 days of systemic morphine injections produced significant but unequal rightward shifts in the morphine dose-response curve such that females displayed greater increases in analgesic ED(50) values when compared to males. In a separate experiment, males and females displayed similar reductions in morphine analgesic sensitivity when %MPE (maximum possible effect) and %total (area under the curve) were compared after 3 days of morphine. Differences in initial morphine sensitivity between sexes were not observed in either study. The data demonstrate that, in contrast to rats, female mice undergo greater reductions in morphine analgesia relative to males following chronic morphine, but this sex difference may depend on the method of assessing analgesia. Furthermore, the duration and/or cumulative dose of morphine treatment does not affect the expression of sex differences in morphine tolerance.

Sex differences in thermoregulation after acute and chronic morphine administration in mice

Sex differences in thermoregulation have been reported following acute morphine administration in rats only. This study assessed whether male and female mice also differ in thermoregulatory responses following acute and chronic morphine administration. Females displayed significantly higher baseline colorectal temperature and greater morphine (24mg/kg, s.c.) hypothermia (2. 5-fold) on day 1. Two additional days of morphine treatment did not alter baseline temperature readings on Day 4 in either sex, but significantly reduced the morphine hypothermia relative to Day 1 in a sex-dependent manner. Whereas the morphine hypothermia was completely abolished in males, significant hypothermia was still observed in females. Acute and chronic saline injections had no effect on colorectal temperature. The data demonstrate sex differences in the thermoregulatory responses to acute and chronic morphine administration in mice.

Calcium kinetics in children with osteogenesis imperfecta type III and IV: pre- and post-growth hormone therapy

Children with osteogenesis imperfecta (OI) type III and type IV were studied using a (42)Ca stable isotope technique. Serum dilution kinetics of (42)Ca were studied pre- and post-growth hormone (GH) treatment in 9 OI III (age range 5-9 years) and 8 OI IV patients (age range 5-12 years). Each subject was studied twice: at baseline and following GH therapy (range 1-1.5 years). Isotopic enrichments of (42)Ca were followed over 7 days using thermal ionization mass spectrometry. A binding site model, which describes reversible and irreversible binding of calcium (Ca) ions to postulated short- and long-term binding sites in bone, was used to analyze the kinetic data. In type III patients, GH treatment (1) increased the fraction of short-term binding sites, theta (0.777 +/- 0.112 versus 0.877 +/- 0.05, respectively; P = 0.034); (2) increased the apparent half-life of a Ca ion attached to the long-term binding site by 76% (P = 0. 009); (3) although not statistically significant (P = 0.098), a trend toward an increased growth rate was observed with increasing change in theta (Deltatheta); (4) patients experienced a 75% increase in growth rate during the first 6 months of treatment. In type IV patients, GH treatment increased the apparent half-life of a Ca ion attached to the long-term binding site by 83% (P = 0.048), however, no trend toward an increased growth rate was observed with increasing Deltatheta in these patients. These significant changes in Ca binding to bone may influence growth in type III patients.

A single surgeon's experience with the Delaire palatoplasty

The purpose of this review was to evaluate the clinical outcomes regarding velopharyngeal insufficiency and fistulization in patients with cleft palate who underwent primary repair with the one-stage Delaire palatoplasty. All patients who had a primary Delaire-type palatoplasty performed by the senior surgeon over a 10-year period (1988 to 1998) were studied. During this period, each consecutive patient with an open palatal cleft underwent the same type of repair by the same surgeon. Speech quality and velopharyngeal competence as determined by a single speech pathologist were recorded. A total of 95 patients were included in this series. The average length of follow-up was 31 months (range, 1 to 118 months). Average age at time of surgery was 13.3 months (range, 6 to 180 months). Thirty-one patients (32.6 percent) had significant associated anomalies. The average length of hospital stay was 1.9 days (range, 1 to 8 days) with a trend in recent years toward discharge on postoperative day 1. There were no intraoperative complications, either surgical or anesthetic. Three patients (3.2 percent) developed palatal fistula; none of them required repair. Six patients (6.3 percent) had velopharyngeal incompetence. In patients with more than 1 year of follow-up, the incidence of velopharyngeal incompetence was 9.2 percent (6 of 65). The incidence of fistula after the Delaire palatoplasty was lower than usually reported. The incidence of velopharyngeal incompetence requiring pharyngoplasty was equal to or lower than that seen after other types of palatoplasty, suggesting superior soft-palate muscle function attributable to approximation of the musculus uvulae. The Delaire palatoplasty results in a functional palate with low risk for fistula formation and velopharyngeal incompetence.

Effect of growth hormone treatment on calcium kinetics in patients with osteogenesis imperfecta type III and IV

Using a dual stable isotope technique, the effect of growth hormone (GH) on whole body calcium (Ca) metabolism was studied in children (ages 5-14 years) with type III (n = 9) and IV (n = 8) osteogenesis imperfecta. Each subject was studied twice: at baseline and following a GH (0.1-0.2 U/kg per day) treatment period of 1-1.5 years. Subjects were given 42Ca intravenously and 44Ca orally. The sera and urine 42Ca and 44Ca isotopic enrichments were followed over 7 days using thermal ionization mass spectrometry. The SAAM program was used to fit a three-compartment model to the tracer data. No significant differences were observed between: (1) children with type III and IV disease; or (2) baseline studies of boys and girls within each disease type. However, GH treatment significantly increased: (1) the exchangeable calcium pool (EP) in type III patients (2086 vs. 4422 mg/day, p = 0.02); and (2) the parameter associated with bone calcium accretion in type IV patients (Vo+: 973 vs. 1560 mg/day,p = 0.03) with boys responding with a significantly greater increase than girls (p = 0.008). Although not statistically significant, a trend toward an increase in Vo+ in type III patients and in EP in type IV was observed following treatment. Our observations imply that more Ca was available for bone mineralization following GH treatment in these subjects.

Alterations in swim stress-induced analgesia and hypothermia following serotonergic or NMDA antagonists in the rostral ventromedial medulla of rats

Serotonergic, NMDA, or opioid antagonists in the rostral ventromedial medulla (RVM) reduce morphine analgesia elicited from the periaqueductal gray (PAG). Continuous (CCWS) and intermittent (ICWS) cold-water swims elicit respective naltrexone-insensitive and naltrexone-sensitive analgesic responses. CCWS analgesia is reduced by systemic NMDA receptor antagonism and by systemic, but not intrathecal serotonergic antagonism. ICWS analgesia is reduced by both systemic and intrathecal serotonergic antagonism, but unaffected by systemic NMDA antagonism. The present study evaluated whether serotonergic (methysergide: 5-10 microg) or competitive [AP7 (2-amino-7-phosphonoheptanoic acid): 0.01-0.1 microg] or non-competitive [MK-801 (dizocilipine maleate): 0.3-3 microg] NMDA antagonists in the RVM altered CCWS and ICWS analgesia and hypothermia as well as basal nociceptive latencies. Methysergide in the RVM significantly potentiated CCWS, but not ICWS analgesia. In contrast, AP7 in the RVM significantly potentiated ICWS analgesia. Antagonist-induced changes in either hypothermia or basal nociception failed to account for any alterations in stress-induced analgesia. These data suggest that serotonergic, but not NMDA, receptors in the RVM may mediate collateral inhibition between mesencephalic morphine analgesia and naltrexone-insensitive CCWS analgesia.

Cancer support nurses: a co-ordinating role in cancer care

Cancer support nurses (CSNs) have a key co-ordinating role in the cancer services in North Lancashire and South Lakeland. The working practices of the three CSNs in North Lancashire are described in detail. There was a total cumulative caseload of 604 patients in September 1996, with 397 referrals in the previous 12-month period. There were 267 deaths during this time. CSNs are an essential element of cancer service provision. A ratio of one CSN to 40,000 population gives a manageable workload, provided there is an infrastructure of supportive care to which patients, carers and bereaved can be referred.

Phenotypic comparison of an osteogenesis imperfecta type IV proband with a de novo alpha2(I) Gly922 --> Ser substitution in type I collagen and an unrelated patient with an identical mutation

We examined the type I collagen synthesized by cultured dermal fibroblasts from a patient affected with osteogenesis imperfecta (OI) type IV. Both normal and abnormal trimers were produced. The mutant collagen molecules were excessively modified intracellularly, had a melting temperature 4 degrees C lower than the control, were secreted at a reduced rate, and underwent delayed processing to mature alpha chains.Molecular investigations identified a G --> A transition in one COL1A2 allele, resulting in a Gly922 --> Ser substitution in the alpha2(I) chain. The proband's mutation was demonstrated to arise "de novo" by the absence of the mutant allele restriction enzyme pattern from parental genomic DNA.We analyzed the insoluble extracellular matrix deposited by long-term cultured fibroblasts from our patient and from a previously described unrelated individual who carries an identical substitution. In both cases, the mutant chain constituted 10-15% of the total alpha chains deposited.We also present here the first detailed comparison of phenotype between unrelated OI patients with an identical collagen mutation. These two patients are both Caucasian females, ages 8 and 9 years, each diagnosed as type IV OI by the Sillence classification. They have a similar phenotype including moderate skeletal fragility with several femur fractures, dentinogenesis imperfecta, wormian bone, and reduced height and weight. We conclude that this phenotype is related both to the location of this mutation and to the similar extent of matrix incorporation by the mutant chains. Molecular and biochemical studies of unrelated individuals with identical amino acid substitutions in type I collagen resulting in either similar or dissimilar clinical outcomes will make a significant contribution to identifying the factors involved in the modulation of the OI phenotype.

Sequential compression to treat lymphoedema

There is no consensus on the most appropriate treatment for lymphoedema. Patients are often confused--and may have been misinformed--about treatment options. The breast care specialist nurse should be able to offer a range of treatments, including sequential compression.

The development of clinical leadership through supported reflective practice

The notion of clinical leadership is significant in current nursing practice, particularly since recommendations made by the Department of Health in 'The Strategy for Nursing'. However, while it is a concept that many nurses aspire to implement, in reality the operationalizing of such a concept is fraught with difficulty. This paper aims to explore the issue of clinical leadership through a collegiate model developed in a particular practice area. The development of this collegiate relationship is articulated through the mediums of reflective practice and clinical supervision. A model of collegiality is offered as an approach to the integration of the spheres of clinical leadership. If reflective practice is to be a reality then it is essential that both clinical leaders and practitioners engage in such processes within a supportive culture.

Mechanism of action of SCN in isolated gastric glands

Isolated gastric glands were used to study the mechanism of acid secretory inhibition by thiocyanate (SCN). It was found that SCN does not act as a competitive antagonist of histamine nor does SCN prevent the increase in cellular cAMP associated with histamine stimulation. SCN modifies but does not prevent the expansion of parietal cell canaliculi, indicating that this characteristic morphological transition does not require the actual formation of hydrochloric acid. Low doses (less than 5 mM) of SCN were found to inhibit aminopyrine accumulation, an index of acid formation, but do not inhibit either resting or stimulated respiration. Higher doses (greater than 10 mM) of SCN produce significant inhibition of stimulated but not resting respiration. These results indicate that SCN has two actions, i.e., inhibition of acid formation that requires low doses and inhibition of oxidative metabolism that requires higher doses. Incubation of glands in high-K+ (108 mM) medium leads to formation of an acid gradient in the absence of other secretagogues. The gradient was found to be transient, and its formation does not require oxidative metabolism, indicating that continued proton pumping is not required. Low doses of SCN were found to be more effective in dissipating the high-K+-induced gradient than a similar gradient induced by histamine stimulation. These results support the hypothesis that SCN inhibits acid secretion by increasing the rate of proton-gradient dissipation rather than interfering with a proton-pump mechanism.

Special considerations for minority participation in prenatal diagnosis

Parents who use information from prenatal diagnosis in family planning may be faced with difficult decisions. For a variety of reasons, the communications and decision-making process may be substantially more complex and difficult if the parents are members of a minority group. Unless a number of special considerations are kept in mind when programs of prenatal diagnosis for minorities are developed, such programs may be more harmful than beneficial.

Performance of graduates of foreign medical schools on the examinations of the American Board of Internal Medicine

We investigated the performance of two groups of graduates of foreign medical schools on the 1975 and 1976 certification examinations of the American Board of Internal Medicine. Nearly all their postdoctoral residency training was obtained in the United States. The performance (most of those in this study were born in Asia and Southeast Asia) was much lower than that of graduates of United States medical schools. United States citizens who studied medicine abroad performed no better than alien graduates from foreign medical schools. Approximately half the foreign graduates born in the United States studied in Italy, and 10% in Switzerland, Mexico and Belgium. There were no significant differences in performance associated with the type of postdoctoral training (university, university-affiliated, community or other) undertaken in the United States. A significant inverse relation was observed between the interval from completion of training to first examination and the examination performance.