Role of platelet-activating factor in Chinese hamster ovary cell responses to cholera toxin.

Cholera toxin (CT)-induced intestinal secretion and Chinese hamster ovary cell (CHO) elongation involves cyclic adenosine monophosphate and protein synthesis-dependent prostaglandin formation. We previously reported inhibition of CT-induced intestinal secretion and CHO elongation by platelet-activating factor (PAF) receptor antagonists and secretion of PAF by human intestinal epithelial cells exposed to CT. Herein, we show that PAF is involved after cAMP and that PAF, like CT, mediates prostaglandin E2 synthesis in CHO cells. CT-induced CHO elongation was blocked by specific PAF receptor antagonists, BN52021 and SR27417. SR27417 blocked dibutyryl cAMP-induced CHO elongation, but did not alter CHO elongation caused by PGE2. Neither CT-stimulated cAMP accumulation nor PGE2 production was inhibited by SR27417. Both PGE2 and PAF caused significant CHO elongation, but the latter did not stimulate significant cAMP production. In addition, PAF, like CT and dibutyryl cAMP, stimulated significant PGE2 production. Finally, the protein synthesis inhibitor cycloheximide, which completely blocks the effect of CT on prostaglandin synthesis, also blocked that of PAF, suggesting that PAF also mediates protein synthesis-dependent prostaglandin formation. We conclude that PAF is involved in CHO cytoskeletal responses to CT after the accumulation of cAMP and, like CT, PAF stimulates protein synthesis-dependent prostaglandin accumulation.

Extracellular cGMP inhibits transepithelial sodium transport by LLC-PK1 renal tubular cells.

Both atrial natriuretic peptide (ANP) and sodium nitroprusside (SNP) inhibit tubular sodium reabsorption by generation of guanosine 3',5'-cyclic monophosphate (cGMP). To determine the role of extracellular cGMP in this response, monolayers of porcine renal tubular LLC-PK1 cells were incubated for 5 min with ANP, SNP, cGMP, or 8-bromoguanosine 3',5'-cyclic monophosphate (8-BrcGMP) (10 nM to 0.1 mM). Transepithelial sodium transport was measured as amiloride-inhibitable short-circuit current (Isc). Incubation of cell monolayers with 1 microM of ANP, cGMP, or 8-BrcGMP inhibited Isc by > 70%, as did SNP at 100 microM (P < 0.01). Adenosine 3',5'-cyclic monophosphate (0.1 mM) had no significant effect. Incubation of monolayers with 1 microM LY-83583 (an inhibitor of guanylyl cyclase), 10 microM probenecid (an organic anion transport inhibitor), or preincubation with 1 microgram/ml nocodazole (a microtubule disrupter) reduced extracellular accumulation of cGMP (P < 0.05) and abolished the SNP-mediated reduction of Isc. However, addition of these inhibitors did not affect reduction of Isc by exogenous cGMP. We conclude that SNP inhibits sodium transport by LLC-PK1 monolayers through generation of cGMP but that extrusion of cGMP out the cell is necessary for its effect.

Prosthetic valve endocarditis: superiority of surgical valve replacement versus medical therapy only.

The objective of our study was to assess the long-term outcome of patients with prosthetic valve endocarditis. We used a multicenter, prospective, observational study design. Six university teaching hospitals with high volume cardiothoracic surgery participated. Seventy-four patients with prosthetic valve endocarditis as defined by explicit, objective criteria were selected for participation. All patients were followed up prospectively for 1 year. Thirty-one percent and 69% had development of endocarditis within 60 days of valve insertion ("early") and after 60 days ("late"), respectively. The most common causes were Staphylococcus epidermidis (40%), Staphylococcus aureus (20%), streptococcal species (18%), and aerobic gram-negative bacilli (11%). Physical signs of endocarditis (new or changing murmur, stigmata, emboli) were seen in 58%. At 6 months and 12 months, mortality was 46% and 47%, respectively. Surgical replacement of the infected valve led to significantly lower mortality (23%) as compared with medical therapy alone (56%), as assessed by both univariate and multivariate analyses (p < 0.05). Improved outcome was seen for the surgical group even when controlling for severity of illness at time of diagnosis. From these findings we conclude that accurate assessment of outcome in prosthetic valve endocarditis requires long-term follow-up of at least 6 months following diagnosis. Surgical therapy warrants greater scrutiny; evaluation in controlled clinical trials is appropriate.

Community-acquired pneumonia caused by Legionella dumoffii in a patient with hairy cell leukemia.

A case of community-acquired pneumonia caused by Legionella dumoffii in a patient with hairy cell leukemia is described. Diagnosis was confirmed by isolation by culture of sputum and broncho-alveolar lavage specimens, positive direct fluorescent antibody stains, and antibody seroconversion from 1:16 (acute) to 1:4096 (six months). The blue white autofluorescence of the L. dumoffii colonies when viewed under ultraviolet light was particularly useful in preliminary identification. The patient recovered from his pneumonia after administration of erythromycin and rifampin. Legionella have been shown to multiply in monocytes and cell-mediated immunity appears to be the primary mechanism of host defense in man. Hairy cell leukemia is characterized by monocyte dysfunction and such patients have a predilection for infection by microbes that are controlled by cell-mediated defenses. We review other cases of community-acquired L. dumoffii pneumonia as well as other cases of Legionella infection in patients with hairy cell leukemia.

New and emerging etiologies for community-acquired pneumonia with implications for therapy. A prospective multicenter study of 359 cases.

Three hundred fifty-nine consecutive patients with community-acquired pneumonia admitted to university, community, and VA hospitals underwent a standardized evaluation, including specialized tests for Legionella spp. and Chlamydia pneumoniae (TWAR). The most common underlying illnesses were immunosuppression (36.3%), chronic obstructive pulmonary disease (32.4%), and malignancy (28.4%). The most frequent etiologic agents were Streptococcus pneumoniae (15.3%) and Hemophilus influenzae (10.9%). Surprisingly, Legionella spp. and C. pneumoniae were the third and fourth most frequent etiologies at 6.7% and 6.1%, respectively. Aerobic gram-negative pneumonias were relatively uncommon causes of pneumonia despite the fact that empiric broad-spectrum combination antibiotic therapy is so often directed at this subgroup. In 32.9%, the etiology was undetermined. Antibiotic administration before admission was significantly associated with undetermined etiology (p = 0.0003). There were no distinctive clinical features found to be diagnostic for any etiologic agent, although high fever occurred more frequently in Legionnaires' disease. Clinical manifestations for C. pneumoniae were generally mild, although 38% of patients had mental status changes. Mortality was highest for Staphylococcus aureus (50%) and lowest for C. pneumoniae (4.5%) and Mycoplasma pneumoniae (0%). We document that specialized laboratory testing for C. pneumoniae and Legionella spp. should be more widely used rather than reserved for cases not responding to standard therapy. Furthermore, realization that C. pneumoniae and Legionella spp. are common etiologies for community-acquired pneumonia should affect empiric antibiotic prescription.

Prognosis of patients hospitalized with community-acquired pneumonia.

PURPOSE: Our purpose was to determine which clinical features predict short-term mortality in patients with community-acquired pneumonia. PATIENTS AND METHODS: We conducted a prospective multicenter study of 347 patients hospitalized in Pittsburgh (the derivation cohort) and 253 hospitalized and ambulatory patients in Boston (the validation cohort) with clinical and radiographic evidence of pneumonia. Patients in the derivation cohort underwent an extensive microbiologic evaluation including bacteriologic sputum culture, blood cultures, direct fluorescent antibody testing for Legionella species, and serologic testing for Mycoplasma pneumoniae, Legionella species, and Chlamydia TWAR. RESULTS: The overall mortality was 18% in the derivation cohort and 13.2% in the validation cohort. We identified five independent predictors of mortality in the derivation cohort: pleuritic chest pain (risk ratio, 0.4; 95% confidence interval [CI], 0.17 to 0.99), mental status changes (risk ratio, 2.6; 95% CI, 1.4 to 4.6), a severe vital sign abnormality (risk ratio, 2.1; 95% CI 1.2 to 3.6), neoplastic disease (risk ratio, 5.0; 95% CI, 2.7 to 9.1), and "high-risk" pneumonia etiology (risk ratio, 2.8; 95% CI, 1.6 to 5.0). A mortality index based on these factors accurately classified patients into five risk classes of increasing mortality. In the derivation cohort, the 6-week mortality rates were 0% in class I, 2.9% in class II, 13.1% in class III, 32.7% in class IV, and 89.5% in class V. There was little deterioration in the predictive accuracy of the model when tested in the validation cohort: mortality was 2.2% in class I, 0% in class II, 13.5% in class III, 33.3% in class IV, and 55.6% in class V. CONCLUSIONS: This prognostic classification may help direct triage decisions, assess appropriateness of care, and guide the design and analysis of therapeutic trials in patients with community-acquired pneumonia.