[Effect of Inhalation of Tobramycin for 12 Months on Reduction of Hospitalisation Rate in Severe COPD]. / Inhalation von Tobramycin über 12 Monate zur Senkung der Hospitalisationsrate bei schwerer COPD mit gehäuften Hospitalisationen.

INTRODUCTION: Bacterial colonisation in stable disease of severe COPD and bronchiectasis can cause recurrent hospital treatment, which has a negative impact on the patient's prognosis. A multicentre study has investigated if daily inhalation of tobramycin for one year would lower the number of hospitalisations in severe COPD. METHODS: 44 patients with severe COPD [FEV1 % of predicted value: 42.8 ± 7,1 tobramycin group (T) and 33.5 ± 10.3 placebo group (P)] and a minimum of two hospitalisations in the year before inclusion were randomly assigned to inhale twice daily for 12 months 80 mg tobramycin or isotonic saline (placebo). Concomitant therapy was according to the GOLD guidelines. Primary end point was the number of hospitalisations in the period of study, secondary end points were pulmonary function test and 6 MWD. RESULTS: Inhalation of T changed the number of hospitalisations from 2.8 ± 0.5 per year to 3.5 ± 2.7, P from 3.0 ± 1,4 to 2.3 ± 2.2. These differences and the results for secondary endpoints did not reach significance. The dropout rate was high, only 6 patients (T) and 14 patients (P) finished the study per protocol. CONCLUSION: Inhalation with 160 mg tobramycin by means of a nebuliser over a 12-month period did not reduce the number of hospitalisations for patients with severe COPD and a minimum of two hospitalisations compared to placebo. The severity of the disease was the main reason for the high dropout rate.

A phase II study on safety and efficacy of high-dose N-acetylcysteine in patients with cystic fibrosis.

OBJECTIVE: We conducted a single-centre, randomised, double-blinded, placebo-controlled phase II clinical study to test safety and efficacy of a 12-week therapy with low-dose (700 mg/daily) or high-dose (2800 mg/daily) of NAC. METHODS: Twenty-one patients (DeltaF508 homo/heterozygous, FEV1>40% pred.) were included in the study. After a 3-weeks placebo run-in phase, 11 patients received low-dose NAC, and 10 patients received high-dose NAC. Outcomes included safety and clinical parameters, inflammatory (total leukocyte numbers, cell differentials, TNF-alpha, IL-8) measures in induced sputum, and concentrations of extracellular glutathione in induced sputum and blood. RESULTS: High-dose NAC was a well-tolerated and safe medication. High-dose NAC did not alter clinical or inflammatory parameters. However, extracellular glutathione in induced sputum tended to increase on high-dose NAC. CONCLUSIONS: High-dose NAC is a well-tolerated and safe medication for a prolonged therapy of patients with CF with a potential to increase extracellular glutathione in CF airways.

[The effects of physical training on the body composition of patients with COPD]. / Die Auswirkungen von Sport auf die Körperzusammensetzung von COPD-Patienten.

AIM: The following controlled trial was conducted to determine the positive effects of exercise on the body composition of patients suffering from COPD. METHODS: A group consisting of 23 COPD patients who regularly participated in a guided exercise programme was compared with a control group consisting of 19 COPD patients who did not exercise. The relative changes of body mass index (BMI), body cell mass in % [BCM-(%)], extra cellular mass/body cell mass index (ECM/BCM index) and phase angle (angle between sinus current and sinus voltage) after 6 months and after one year were analysed for statistical differences. The values of BMI, BCM-(%), ECM/BCM index and phase angle at the beginning of the study were compared with the results during the course of the 18 months training merely within the exercising group. The body composition of the patients was determined with the help of the bioelectric impedance analysis (BIA) using the system "Nutriguard M" produced by "Data Input". RESULTS: Significantly raised phase angle values as well as significantly increased BCM-(%) values and a decreased ECM/BCM index were found in the group of patients who exercised compared with the COPD patients who did not exercise. While there were no differences concerning the BMI value, significant increases in BCM-(%) and phase angle and a significant decrease of the ECM/BCM index could be detected within the group that had been exercising. The best values were recorded after 6 months of exercising. The differences of the group responses resulted from a worsening of the body composition in the control group rather than from improvements in the exercise group. CONCLUSION: Physical exercise can improve or at least stabilise the body composition of COPD patients and should be recommended.

Down-regulation of cystic fibrosis transmembrane conductance regulator gene expression by agents that modulate intracellular divalent cations.

In cystic fibrosis (CF), epithelial cells are unable to normally up-regulate apical membrane Cl- secretion in response to agents which increase cyclic AMP, but they do increase Cl- secretion in response to increases in intracellular Ca2+. Since intracellular divalent cations regulate the expression of many genes, we hypothesized that mobilization of intracellular Ca2+ and/or other divalent cations might modulate not only Ca(2+)-dependent Cl- channels but also cystic fibrosis transmembrane conductance regulator (CFTR) gene expression. To evaluate this concept, HT-29 human colon carcinoma cells were cultured under various conditions designed to manipulate intracellular divalent cation concentrations and CFTR gene expression was quantified at the levels of transcription, mRNA accumulation, mRNA half-life, and protein. Exposure to the divalent cation ionophores A23187 and ionomycin (agents which increase intracellular divalent cation concentrations) caused dose- and time-dependent reductions of CFTR mRNA levels, which could be blocked by the use of Ca(2+)- and Mg(2+)-free media. Ionophore-induced CFTR gene modulation was also observed with T84 human colon carcinoma cells and freshly isolated normal human bronchial epithelial cells. Incubation of HT-29 cells with thapsigargin, an agent that releases Ca2+ from intracellular stores, or in medium containing increased extracellular concentrations of Ca2+ or Mg2+ also caused down-regulation of CFTR mRNA levels. Transcription run-on analysis showed that, parallel with the decrease in CFTR mRNA levels, A23187 reduced the rate of transcription of the CFTR gene, while CFTR mRNA transcript half-life was unaffected. Consistent with the down-regulation of CFTR gene expression, CFTR protein levels also decreased after exposure to A23187. Thus, despite the independence of Ca(2+)-dependent Cl- channels and cyclic AMP-dependent CFTR-related Cl- channels in epithelial cells, increases in intracellular divalent cation concentrations down-regulate the expression of the CFTR gene at the transcriptional level, with consequent decreases in CFTR mRNA and protein.

[Retroperitoneal bronchogenic cyst]. / Retroperitoneale bronchogene Zyste.

We describe a 35-year-old female patient who underwent surgery because of a coincidentally occurring cryptic tumour near the left adrenal gland and a right renal carcinoma (pT1, N0, G2, R0). The left-sided tumour was intraoperatively identified as a cystic structure filled with secretion. Histopathological analysis provided the diagnosis of a bronchogenic cyst.

[Villous adenoma of the renal pelvis and ureter]. / Villöses Adenom des Nierenbeckens und Ureters.

Villous adenomas of the urinary tract are extremely rare tumours belonging to the adenoepithelial metaplasias. They can be associated with other neoplasias, especially with carcinomas. We describe the case of an 85-year-old female patient suffering from a villous adenoma of the renal pelvis and ureter.

Expression of human beta-defensin-1 promotes differentiation of keratinocytes.

Epithelial cells have been shown to express the antibiotic peptides human beta-defensins-1 and 2. While beta-defensin-2 is known to be up-regulated by bacterial factors and proinflammatory mediators, the expression of beta-defensin-1 does not appear to be affected by these mediators. To determine the regulation and function of beta-defensin-1 we analyzed its expression upon stimulation of inflammatory mediators in vitro and ex vivo. In immortalized human cell lines (HaCaT) and nasal polyps beta-defensin-1 was not induced upon incubation with bacteria or proinflammatory mediators, suggesting that the inertness of beta-defensin-1 expression levels is not the result of the shortcoming of HaCaT cells. As proliferation and regeneration play an important role at sites of inflammation, we examined the expression level of beta-defensin-1 in relation to the differentiation and proliferation of HaCaT cells. beta-defensin-1 mRNA levels remained low during proliferation but were highly induced upon differentiation. In contrast, beta-defensin-2 expression was unaffected under these conditions. To examine the function of beta-defensin-1 in cellular proliferation and differentiation processes beta-defensin-1 was overexpressed in keratinocytes. Protein expression analysis of the differentiation marker keratin 10 revealed that its expression is highly induced in the presence of increased concentrations of beta-defensin-1. Hence our data indicate that high expression of beta-defensin-1 promotes cell differentiation processes of keratinocytes.

Epithelial defensins impair adenoviral infection: implication for adenovirus-mediated gene therapy.

Epithelial cells have been to participate actively in host defense by producing small cationic peptides called defensins. To investigate the biological activity of epithelial defensins in more detail, we expressed two defensins, hBD-1 and HD-5, in eukaryotic cell lines. Defensins were localized in the cytoplasm and in cell culture medium and exhibited strong microbicidal activity toward Escherichia coli, Pseudomonas aeruginosa, and Staphylococcus aureus. Moreover, our data indicate that the presence of defensins protected the cells from adenoviral infection. The presence of HD-5 or hBD-1 reduced the infectivity of Av1CF2 three- to fivefold. These results imply that defensins must be considered a serious obstacle whenever adenovirus is used to deliver genes to epithelial cells.

Expression of human alpha-defensin 5 (HD5) mRNA in nasal and bronchial epithelial cells.

BACKGROUND/AIMS: Human defensins are antibiotic peptides expressed in myeloid and epithelial cells. Human alpha-defensin 5 (HD5) has been detected in Paneth cell granules in the crypts of Lieberkühn and has recently been identified in the female reproductive tract. The aim of this study was to investigate the presence of HD5 mRNA in nasal and bronchial epithelial cells. METHODS/RESULTS: Semiquantitative reverse transcription polymerase chain reaction (RT-PCR) analysis showed that HD5 mRNA was expressed infrequently and to varying degrees in bronchial and nasal epithelial cells. In situ hybridisation resulted in a positive signal in the epithelial layer of nasal polyps. HD5 mRNA was locally restricted to a specific area of epithelial cells and also occurred in submucosal glands. CONCLUSIONS: HD5 mRNA expression in nasal and bronchial epithelial cells is rare and seemed to be locally induced. The results indicate that HD5 might play a role in innate defence in nasal and bronchial epithelia.

A time-resolved PHIP-NMR method applied to the asymmetric homogeneous hydrogenation of ß-dehydroamino acids.

A new NMR technique based on parahydrogen-induced polarisation (PHIP) is presented, that allows the catalytic enantioselective hydrogenation of prochiral substrates to be monitored (see scheme, the left-hand side arises from the hydrogenation of a prochiral alkene). The approach takes into consideration the kinetics of hydrogenation as well as the relaxation of polarisation. The use of parahydrogen temporarily generates diastereomers which can be monitored as a function of time where otherwise only enantiomers are formed.

Detection of ppm quantities of gaseous SO2 by o9rganoplatinum dendritic sites immobilised on a quartz microbalance.

Sensor devices for the detection of low quantities of SO2 gas have been constructed which comprise organoplatinum receptor sites for the selective recognition of SO2 and a quartz crystal microbalance for the detection of small mass changes at the receptor sites.

Glutathione and glutathione peroxidase in sputum samples of adult patients with cystic fibrosis.

BACKGROUND: Reduced glutathione (GSH) is a major antioxidant in the lung. In cystic fibrosis (CF) patients, extracellular GSH levels of lower airways, obtained by bronchoalveolar lavage (BAL), were reported to be lower than non-CF individuals. METHODS: Upper airway secretions of stable adult CF patients (29 spontaneous and 13 induced sputum) and non-CF individuals (14 healthy and 12 asthmatics; all induced sputum) were analyzed for total glutathione (i.e. the sum of reduced, GSH, and oxidized, GSSG, forms), GSH and GSSG levels by enzymatic kinetic assay. RESULTS: In CF, both spontaneous and induced sputum samples were comparable in total glutathione levels which were surprisingly high (median concentration of 9.2 (range 1.4-65.2) and 11.6 (1.1-69.8) microM, respectively). In non-CF individuals, total glutathione levels were significantly lower (healthy 2.8 (1.0-12.3), asthmatics (5.3 (1.3-19.2) microM; p<0.001, both vs. CF). In CF, more than 90% of total glutathione was represented by GSH, whereas in non-CF controls, GSH made up less than 50% of total glutathione (p<0.001). CONCLUSIONS: In contrast to BAL, CF sputum contains high levels of GSH. Sputum induction is a potentially useful procedure to monitor antioxidant levels in upper airways of CF patients.

Prophylactic antibiotic therapy is associated with an increased prevalence of Aspergillus colonization in adult cystic fibrosis patients.

Aspergillus colonization is a common phenomenon in adult cystic fibrosis (CF) patients. The clinical significance of Aspergillus for the pathogenesis of CF lung disease remains unclear and factors predisposing to such colonization are still completely unknown. We investigated the prevalence of Aspergillus colonization in 104 adult CF patients who attended our outpatient clinic in 1997. With respect to demographic and clinical data, and antibiotic therapy received, we further examined which factors were associated with Aspergillus colonization in these patients. Repeated investigations of CF sputum samples revealed Aspergillus species in 43/104 (41.3%; 95% confidence interval 30.2-52.5%) of the patients. We found no significant relationship between Aspergillus colonization and age (P > 0.4), gender (P = 0.4), colonization with pseudomonas species (P > 0.6), lower lung function values (P > 0.9), or worse chest radiography (P > 0.1). Surprisingly, the prevalence of Aspergillus colonization was higher in CF patients receiving prophylactic antibiotic therapy (oral antibiotics: P = 0.05; inhalative antibiotics: P = 0.035; both antibiotics: P = 0.048). Prophylactic antibiotics are widely used to eradicate or decrease chronic bronchopulmonary infection in CF. Our results indicate that long-term antibiotic therapy may predispose CF patients to Aspergillus colonization.

Eosinophilic cationic protein as a marker of nasal inflammation in patients with cystic fibrosis.

OBJECTIVES: Evaluation was made of eosinophilic cationic protein (ECP) in nasal secretion for measuring the degree of nasal inflammation and monitoring response to therapy in cystic fibrosis (CF) patients with chronic rhinosinusitis. Symptoms and findings in regard to ECP levels before and after treatment were described. STUDY DESIGN: Study was prospective, with 21 CF patients aged 4 to 19 years; 20 healthy volunteers served as controls. Collection of nasal secretion by a sponge was performed, and blood samples were obtained for serum. Cystic fibrosis (CF) patients were classified according to nasal symptoms and findings. METHODS: ECP was measured by fluoroimmunoassay. Age, sex, nasal symptoms, and endoscopic and histological findings were obtained, and examinations were conducted before and after treatment; recurrences were recorded. RESULTS: In CF patients with chronic nasal inflammation, increased nasal levels of ECP were detected when compared with asymptomatic CF patients or healthy nonatopic subjects. ECP concentrations were strongly related to the extent of nasal disease; patients with nasal polyps had higher levels than those without. Checked at 1 and 4 months after treatment, ECP levels declined with regression of symptoms, and in patients with exacerbation of nasal disease, ECP levels rose. CONCLUSIONS: According to our study, there is a relationship between levels of ECP in nasal secretions and the degrees of nasal inflammation. In addition, the measurement of ECP could be useful in monitoring nasal disease in CF patients.

Modulation of cystic fibrosis transmembrane conductance regulator gene - expression by elevation of intracellular cyclic AMP.

Cystic fibrosis (CF) is caused by mutations of the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Its product is a cyclic AMP-dependent Cl- channel, that is defective in CF. Since cAMP regulates the expression of many genes and since the 5'-flanking region of the CFTR gene contains cAMP response elements, we hypothesized that intracellular cAMP might modulate not only the cAMP-dependent Cl- channel CFTR, but also CFTR gene expression in epithelial cells. To accomplish this, we investigated Cl- secretion and CFTR-mRNA levels in HT-29 and T84 colon carcinoma epithelial cells before and after exposure to forskolin and 8-bromo-cAMP for 12 hr. While resting T84 cells increased Cl- secretion in response to forskolin strongly and immediately, HT-29 cells did not, although both cell lines showed highly increased Cl- efflux in response to A23187, a calcium ionophore. Interestingly, prolonged exposure to forskolin (12 hr) induced a clear decrease of CFTR-mRNA levels in T84 cells, but an increase of CFTR-mRNA levels in HT-29 cells, thus demonstrating different behaviour of CFTR gene regulation in different epithelial cells in response to intracellular cAMP. These results suggest that cells with an effective cAMP-dependent Cl- channel (CFTR) respond to prolonged stimulation of this channel with down-regulation of CFTR gene expression, while cells with no effective cAMP-dependent Cl--secretion respond with an up-regulation of CFTR gene expression.

Diabetes mellitus in patients with cystic fibrosis: the impact of diabetes mellitus on pulmonary function and clinical outcome.

In this multicenter study, the impact of CF-related diabetes mellitus (CFRD) on pulmonary function and clinical outcome has been investigated. To better characterize the relationship between insulin deficiency and clinical outcome we prospectively followed a group of 56 CF patients, 28 with CFRD (group 1) and 28 without diabetes (group 2) for 5 years. The clinical course of the patients was registered at each center. Data included were mortality, pulmonary function, body mass index, in-patient treatment, and CF-typical and diabetes typical complications. At the end of the study nearly twice the number of patients had died in group 1 as compared to group 2, however due to the low patient number this did not reach statistical significance. In patients with diabetes FEV1 and FVC declined significantly over the five year study period, whereas patients without diabetes did not show a significant decline during the study period. Retinopathy, nephropathy, and neuropathy were only observed in diabetic patients. In conclusion, the data presented in this prospective, multicenter study give evidence that insulin deficiency leads to a direct decline in pulmonary function suggesting a cause and effect relationship between insulin deficiency and lung disease.

Risk of Pseudomonas aeruginosa cross-colonisation in patients with cystic fibrosis within a holiday camp--a molecular-epidemiological study.

OBJECTIVE: A study on the molecular epidemiology of Pseudomonas aeruginosa in patients with cystic fibrosis (CF) from Germany (N = 18) and Israel (N = 12) is presented. The aim is to provide an answer to the question as to whether or not social contact outside the hospital environment involves a potential risk for person-to-person spread of this pathogen. METHODS: Sputa from German and Israeli patients were obtained while these were attending a holiday camp in Israel. The sputum samples were analysed with regard to Pseudomonas aeruginosa. Strains dissimilar in macroscopic appearance and/or antibiotic resistance patterns were genotyped using pulsed-field gel electrophoresis after digestion of genomic DNA with restriction endonuclease Spel. The genetic polymorphism of DNA fragment patterns of all strains (N = 146) was studied for their overall relatedness using a fingerprint software system. RESULTS: Most of the German patients (77.7%) were colonised persistently by a unique clonal type during the four-week screening period. Isolates obtained from Israeli patients displayed a very close clonal relationship and a higher antibiotic resistance as a result of preceding epidemic spread of certain clones before the camp. Additionally, isolates showing identical PFGE patterns were demonstrated once in a single male Israeli patient and in one female German patient, suggesting previous cross-colonisation. CONCLUSION: The occurrence of person-to-person spread through social contact in patients with CF is supported by our findings, but remains a rare event outside the hospital environment, provided appropriate hygienic measures are applied.

[Cystic fibrosis--initial diagnosis in a 39-year-old patient]. / Zystische Fibrose--Erstdiagnose bei einer 39-jährigen Patientin.

BACKGROUND: Cystic fibrosis is the most common hereditary disorder among Caucasians. Most of the patients are diagnosed as children. However, some cases are going undiagnosed into adulthood and are then often misdiagnosed because the non-pediatricians do not know cystic fibrosis very well and do not consider this diagnosis in adult patients. CASE REPORT: We present the medical history of a woman, who was diagnosed with cystic fibrosis at the age of 39 years, although she had suffered from bronchiectasis, pancreatic insufficiency and liver cirrhosis since many years. Her medical history was long with some diagnosis, but because of her age nobody considered the final diagnosis. CONCLUSION: In adult patients with bronchiectasis, liver cirrhosis and pancreatic insufficiency in combination or with only one of these symptoms, cystic fibrosis should be included into the differential diagnosis.