Excitatory action of hypocretin/orexin on neurons of the central medial amygdala.

The neurons of the lateral hypothalamus that contain hypocretin/orexin (hcrt/orx) are thought to promote arousal through the excitatory action they exert on the multiple areas to which they project within the CNS. We show here that the hcrt/orx peptides can also exert a strong action on the amygdala, a structure known for its implication in emotional aspects of behavior. Indeed, the hcrt/orx peptides, applied in acute rat brain slices, excite a specific class of "low threshold burst" neurons in the central medial (CeM) nucleus which is considered as a major output of the amygdala. These excitatory effects are postsynaptic, mediated by Hcrt2/OX2 receptors and result from the closure of a potassium conductance. They occur on a class of neurons that are also excited by vasopressin acting through V1a receptors. These results suggest that the hcrt/orx system can act through the amygdala to augment arousal and evoke the autonomic and behavioral responses associated with fear, stress or emotion.

Age-related changes of the noradrenergic innervation of rat tracheo-bronchial tree and pulmonary vasculature.

Age-related changes of the noradrenergic innervation of the tracheo-bronchial tree and of pulmonary vasculature were investigated in male Wistar rats of 3 months (young), 12 months (adult) and 24 months (old/aged), using catecholamine histofluorescence techniques associated with image analysis and by high pressure liquid chromagraphy with electrochemical detection. In young rats, blue-green fluorescent nerve fibres supply tracheo-bronchial smooth muscle and tracheal and bronchial glands, which are innervated by a delicate network of nerve fibres rich in varicosities. Pulmonary artery and vein are sparsely innervated. They are supplied with nerve fibres distributed in the vasa vasorum or the adventitia and the outer tunica media. The higher noradrenaline concentrations were found in the trachea and extraparenchymal bronchi, followed by pulmonary vein and pulmonary artery. The density and pattern of noradrenergic innervation of the tracheo-bronchial tree, or of the pulmonary vasculature, were similar in young and adult rats. In aged rats, a loss of noradrenergic innervation involving primarily the supply to the smooth muscle of the tracheo-bronchial tree was observed. Histofluorescence techniques demonstrated a higher sensitivity than noradrenaline assay in detecting changes of the sympathetic innervation of the tracheo-bronchial tree and of the pulmonary vasculature. The possible significance of reduced noradrenergic innervation of the tracheo-bronchial tree in aged rats is discussed.

Bone and renal components in hypercalcemia of malignancy and responses to a single infusion of clodronate.

Increased bone resorption (BR) and increased renal tubular reabsorption of calcium (TRCa) may both be involved in the pathogenesis of hypercalcemia of malignancy (HM). We have evaluated the relative importance of these two mechanisms in 33 patients with HM after extracellular volume expansion and after single infusion of clodronate (C12MDP: 500 mg iv over 8 h). The fasting urine Ca/creatinine ratio was taken as an index of BR (BRI). An index of TRCa was calculated (TRCaI) from a nomogram based on the relationship between urine Ca excretion per unit of glomerular filtration rate and plasma Ca (PCa). Mean (+/- SEM) PCa fell from 3.29 +/- 0.07 to 2.69 +/- 0.05 mmol/l three days after C12MDP (n = 33, p less than 0.001), a response similar to that obtained with repeated daily iv injections of 500 to 1000 mg C12MDP. The pathogenesis of hypercalcemia varied according to the type of neoplasm. BRI was the highest in multiple myeloma and breast tumors. TRCaI was markedly increased in squamous-cells lung, bladder, kidney and liver carcinomas, reaching levels observed in primary hyperparathyroidism. TRCaI was normal in most cases of multiple myeloma. Breast tumors appeared to be heterogeneous with respect to TRCaI. The fall in PCa in response to a single infusion of C12MDP was usually most marked in cancer patients with elevated BRI and normal TRCaI. It was very modest in patients with high TRCaI and slightly elevated BRI. In conclusion, this study confirms that stimulation of bone resorption is not the only mechanism of the maintenance of hypercalcemia of malignancy.(ABSTRACT TRUNCATED AT 250 WORDS)

Expression of CCR5 is increased in human monocyte-derived macrophages and alveolar macrophages in the course of in vivo and in vitro Mycobacterium tuberculosis infection.

Human immunodeficiency virus (HIV) replicates more efficiently in Mycobacterium tuberculosis (MTB)-infected macrophages than in uninfected controls. We investigated whether this may be partly explained by changes in expression of CCR5 in the course of mycobacterial infection, as this molecule has been shown to be a coreceptor for HIV entry. Since the lung is the preferential organ of HIV replication in the course of tuberculosis, we preliminarily analyzed beta-chemokine receptor expression in alveolar macrophages from patients with active tuberculosis, using flow cytometry based on an MIP-1alpha ligand-biotin/avidin-FITC detection system. Increased MIP-1alpha receptor (MIP-1alphaR) expression in alveolar macrophages from infected patients was observed whereas no detectable expression could be revealed in uninfected controls. Since MIP-la can also bind CCR1 and CCR4, the presence of CCR5 mRNA was investigated in bronchoalveolar lavage (BAL) cells and detected in alveolar macrophages from tuberculosis patients only. The study was then extended to in vitro MTB-infected macrophages. Monocyte-derived macrophages (MDMs) were left to differentiate for 7 days before MTB H37Rv infection, and CCR5 expression was monitored, by using a specific monoclonal antibody, on days 1, 6, and 11 after infection. Increased CCR5 expression in MTB-infected macrophages was observed, with a peak on day 6 (64% in MTB-infected versus 33% in control cultures) and a decrease by day 11 (25% in MTB infected versus 13% in control cultures). These results show that CCR5 expression is enhanced in the course of in vitro MTB infection and during active pulmonary tuberculosis.

Immunohistologic analysis of mycobacterial antigens by monoclonal antibodies in tuberculosis and mycobacteriosis.

Four monoclonal antibodies (MoAbs), 60.15, 61.3, 105.10, and 2.16, directed to different proteins of Mycobacterium tuberculosis were used by an indirect avidin-biotin complex peroxidase-antiperoxidase method to detect mycobacterial antigens in lung, lymph node, and joint tissue specimens of tuberculous patients. Using MoAb 60.15, which recognizes a broad range of cross-reactive mycobacterial proteins with a molecular mass of 28 kilodaltons (kD), scattered materials (mycobacterial in origin) were observed, many of which were located within phagocyte cytoplasm. With MoAb 61.3, which reacts with a 35 kD protein present in M tuberculosis, Mycobacterium africanum, and Mycobacterium bovis, many clumped particles similar in size and shape to acid-fast bacilli were observed within the phagocyte cytoplasm (lung tissue) and positive macrophages with lysosomes were distributed throughout the cytoplasm (bronchoalveolar lavage). The specificity of this MoAb (61.3) was confirmed by the negative staining of positive lymph node specimens obtained from a patient infected with Mycobacterium kansasii. MoAbs 105.10 and 2.16 bind to the cross-reactive 65 kD heat shock protein that is present in mycobacteria and stain scattered particles and dark clumps of bacilli within the phagocyte cytoplasm. On the basis of this study, immunohistochemical detection of mycobacterial antigens appears to be useful in establishing the mycobacterial etiology of caseating granulomas and in avoiding the false-negative results obtained by traditional staining methods.

Carcinoembryonic antigen, tissue polypeptide antigen and neuron-specific enolase pleural levels used to classify small-cell and non-small-cell lung cancer patients by discriminant analysis.

The classification of lung cancer into small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC) is essential for disease prognosis and treatment. For this purpose, we have tried to optimize the use of three tumour markers determined on pleural effusions, to differentiate SCLC from NSCLC by means of a canonic variable, generated by discriminant analysis, including subjects with histologically proven lung cancer. Discriminant analysis was performed by using carcinoembryonic antigen, neuron-specific enolase and tissue polypeptide antigen pleural levels, determined in 65 consecutive and unselected patients, histologically classified as 49 NSCLC and 16 SCLC. To validate the formula generated, a control group of 37 lung cancer patients (10 SCLC and 27 NSCLC), enrolled subsequently, was employed. Applying the discriminant analysis to SCLC and NSCLC patients a good classification was obtained (92% rate of correct classification). The aforementioned formula, applied to the validation group, showed a 92% rate of correct classification. This method, which is rapid, inexpensive and routinely applicable to malignant pleural effusions, may be reliably used to classify lung cancer patients.

Use of discriminant analysis to assess disease activity in pulmonary tuberculosis with a panel of specific and nonspecific serum markers.

Several cell activation markers, acute phase reactants, enzymes, and antituberculous antibody serum levels have been proposed as possible markers to monitor disease activity in patients with tuberculosis. They have all shown limited sensitivity or specificity. The authors therefore attempted to generate a canonical variable using discriminant analysis, including sensitive and specific parameters, to be a reliable marker in classifying patients correctly during the course of pulmonary tuberculosis. The following parameters were selected: two soluble cell activation markers (soluble interleukin-2 receptor and sCD8); the levels of immunoglobulin (Ig) G and IgM antibodies against the A60 antigen complex; and the presence of specific antibodies directed to eight different A60 components, revealed by Western blot analysis. The tests were performed on sera from three groups of patients with pulmonary tuberculosis. The first group comprised 25 patients with onset tuberculosis, clinically active (OTCA), evaluated at the time of admission. The second group included 28 patients with chemotherapy-treated tuberculosis, clinically active (CTCA), 2 months after therapy had begun. The third group included 20 patients with tuberculosis, nonclinically active (TNCA), who had had at least 1 year of effective therapy. The authors obtained an 80.9% rate of correct classification for the three groups and a rate of 100% when OTCA and TNCA were compared. The patients with CTCA were scarcely differentiated and tended to be distributed into the two other groups. To improve the separation between patients with CTCA and those with OTCA, a second canonical variable was generated with a 91.7% rate of correct classification, as compared with 71% obtained using the sCD8 as the best single variable. The mean values of the last canonical variable were statistically different (Mann-Whitney test, P = .049) when stratified for acid fast bacilli-positive or negative CTCA patients (microscopic detection). Three patients, followed during the entire course their disease, were, as expected, correctly positioned with respect to the subsequent disease phases.

Sarcoidosis in Europe: a cooperative study.

The data on the epidemiologic situation of sarcoidosis from 24 countries of Europe have been reviewed. The new facts seem to demonstrate that the differences between the frequency of this disease in the north and south are not real. The actual situation is dependent on the general knowledge of this disease and on the extent and intensity of the active detection of its asymptomatic stage. A new prospective cooperative study of the yearly incidence of all forms of sarcoidosis in the total population of at least some European countries would be desirable.

Pharmacological characterisation of Ca2+ channels of the L-type in human peripheral blood lymphocytes.

Ca2+ channels of the L-type were characterised in intact human peripheral blood lymphocytes using a radioligand binding technique and the dihydropyridine-type Ca2+ channel antagonist [3H](+)-PN 200-110 (isopropyl-4-(2,1,3-benzoxadiazol-4-yl)1,4-dihydro-5-methoxycarbon yl-2, 6-dimethyl-3-pyridine carboxylate) as a ligand. [3H](+)-PN 200-110 binding to human peripheral blood lymphocytes was time-, temperature-, concentration-dependent and of high affinity. The dissociation constant (Kd) value was 0.4 +/- 0.02 nM and the maximum binding capacity (Bmax) was 33.5 +/- 1.6 fmol/10(6) cells. Pharmacological analysis of [3H](+)-PN 200-110 binding to human peripheral blood lymphocytes was consistent with the labelling of a Ca2+ channel of the L-type. In fact, dihydropyridine derivatives were the most potent competitors of [3H](+)-PN 200-110 binding, whereas phenylalkylamine and benzothiazepine compounds or non-selective Ca2+ channel modulators were weak or ineffective displacers. These findings are the first observation that human peripheral blood lymphocytes express Ca2+ channels of the L-type. The possibility that Ca2+ channel antagonists may interfere with immune system function is discussed.

Aerosolized interferon-alpha treatment in patients with multi-drug-resistant pulmonary tuberculosis.

Multi-drug-resistant tuberculosis (MDR-TB) has emerged as an obstacle to the control of tuberculosis. Recent data however, suggest that interferon-(IFN)-gamma and IFN-alpha may improve disease evolution in subjects affected with pulmonary tuberculosis caused by multi-resistant (IFN-gamma) and sensitive (IFN-alpha) strains. The mechanisms involved are not known, even though it has been reported that IFN-gamma-secreting CD4+ Th cells may possess antitubercular effects. In addition, IFN-alpha can induce IFN-gamma secretion by CD4+ Th cells, and both types of IFN may stimulate macrophage activities. The aim of this study was to explore the possibility that aerosolized IFN-alpha, administered concomitantly with conventional antitubercular chemotherapy, may improve the course of pulmonary tuberculosis. After six months of directly observed therapy (DOT), seven patients who were non-responders to a second line antitubercular therapy were given an IFN-alpha aerosol (3 MU, three times a week) for two months as adjunctive therapy. All strains were resistant to at least two first-line drugs. After IFN-alpha administration, the patients were followed up for a further six months with the same DOT. Sputum samples were collected monthly during the study period, with the exception of the IFN-alpha administration period, when the observations were performed weekly. High resolution computed tomography (HRCT) chest scans were performed before and after IFN-alpha inhalations. The analysis of the results showed that the mean number of Mycobacterium tuberculosis (Mt) had remained statistically unchanged (p = 0.80) during the first 6 months of DOT. During the following 2 months of IFN-alpha administration, 5 patients became negative (p = 0.02). After the end of treatment a progressive increase in Mt number was observed (p = 0. 02). Sputum cultures remained positive for all patients throughout the study period, although a significant decrease (p = 0.02) in the colony number per culture was observed after adjunctive treatment with IFN-alpha. After stopping administration of IFN-alpha, a significant increase (p = 0.03) in the colony number per culture was noted as well as in Mt numbers. HRCT scans were slightly improved in all patients. These preliminary data suggest that aerosolized IFN-alpha may be a promising adjunctive therapy for patients with MDR-TB. Optimal doses and schedules however, require further studies.

Airway stenosis after tracheo-bronchial tuberculosis.

Primary endobronchial localization of tuberculosis without change on chest X-ray is a rare clinical entity, and bronchoscopic examination is most appropriate to reveal such an occurrence. A 38-year-old man and a 52-year-old woman underwent fibre-optic bronchoscopy many months after the onset of cough with poor sputum and dyspnoea on exercise, chest X-ray being normal. In both cases, a widespread granulomatous involvement of the tracheo-bronchial tree was found and cultures of bronchial wash grew Mycobacterium tuberculosis. Patients recovered after 6 months of combined anti-tuberculous and steroid therapy; the granulomatous lesions disappeared but stenoses were found in the trachea and/or main bronchi. In one case, CO2 laser therapy was performed with no improvement.

Evaluation of response to chemotherapy in patients affected with non-small cell lung cancer by means of three tumour markers elaborated by discriminant analysis.

Chemotherapy is the most effective treatment for inoperable patients (70%) affected with non-small cell lung cancer (NSCLC). The early detection of tumour progression is mandative in order to promptly shift these patients towards salvage or supportive therapy. The present authors investigated the clinical value of a panel of tumour markers, elaborated by means of discriminant analysis, as a follow-up indicator for the detection of tumour progression. The serum levels of tissue polypeptide antigen (TPA), CYFRA-21.1, neuron-specific enolase (NSE) and carcino-embryonic antigen (CEA) were determined before chemotherapy and after three cycles of treatment. Discriminant analysis generated a formula (canonic variable) which correctly classified the 87.8% of the 74 subjects (86.1% of the 36 progressive diseases and 89.5% of 38 non-progressive diseases). This approach produces an algorithm able to calculate a progression score in NSCLC patients which can be helpful for following-up care and therapy control of these patients.

Munchausen's syndrome. A case of factitious hemoptysis.

Factitious hemoptysis is the bleeding type of Munchausen's syndrome, rarely reported in the literature (only seventeen cases). After a careful and detailed literature review, the authors report the case of a 22-year-old working-woman, with a history of asthma, Mediterranean anaemia and recurrent hemoptysis, who was admitted several times to the cardiovascular and Respiratory Sciences Department in the Carlo Forlanini Hospital in 1994 for an asthmatic attack and wheeziness at rest. During the admissions the patient underwent laboratory tests (such as the examination of sputum specimens, urinalysis, tuberculin test, cold agglutinins and pneumotropic virus tests) and diagnostic studies (fiberoptic bronchoscopy with bronchoalveolar lavage, computerized tomography and radiography of the chest, bronchial arteriography, bronchography, perfusion and ventilation lung scan), because she continually presented with hemoptysis, in order to spot and discover the nature of the bleeding. Since such examinations failed (a few of them-namely fiberoptic bronchoscopies--were even performed when she was coughing up blood) and psychiatric consultations revealed the presence of psychologically traumatic events in the patient's history which could explain the psychopathic traits of her personality (in fact she was aggressive and unstable in interpersonal relations), a diagnosis of factitious hemoptysis in Munchausen's syndrome was made.

Strongyloides stercoralis hyperinfection in a case of idiopathic pulmonary fibrosis.

The Strongyloides stercoralis infection is a prominent cause of death in many areas of the world. A 64-year-old man with pulmonary fibrosis was admitted to the hospital because of progressive shortness of breath and increasing cough. The patient had been previously admitted for his illness and had a remarkable immunosuppression due to the use of steroids (CD4+ lymphocytes = 200 x 10(6)/l). Repeated sputum and stool studies were diagnostic for strongyloidiasis. The patient died suddenly from severe cardiorespiratory failure while he was under mebendazole treatment (100 mg b.i.d.). Strongyloidiasis occurs mostly in immunocompromised hosts, as in patients with chronic pulmonary diseases on long-term treatment with corticosteroids, oncology patients under treatment and patients with AIDS.

Pulmonary hamartoma. A rare case report.

Pulmonary hamartoma is a rare lung neoformation, usually symptomless and by chance discovered, of a probable dysontogenetic origin with prevailing cartilaginous tissue and adult, onset age. The Authors report a rare case of a 25-year-old student, symptomless and fortuitously found by means of a radiograph of the chest. Many interesting features characterize the case report: histological nature of the pulmonary hamartoma, mainly vascular, so much as to feign an angiosarcoma at the macroscopical examination, and with small peripheral calcifications as shown by lung CT scan; the measures (about 7 cm) plentifully above the parameters usually reported in the literature (from 2 cm to 4 cm); the young onset age (about 10 years old). We may consider a case exceptionally reported in the literature. Besides, on the base of a few studies and of our experience, the results of the pulmonary hamartoma growth rate and doubling time are reported.

Abdominal tuberculosis mimicking Crohn's disease: a difficult diagnosis. Report of a case.

Abdominal involvement by tuberculosis as first site of disease is comparatively rare in industrialized countries. The emergence of new groups of patients at risk arouse a particular and due interest. This report describes a case of abdominal tuberculosis with a first diagnosis of Crohn's disease in an immigrant girl from Peru. The diagnosis can be difficult because extrapulmonary tuberculosis is often paucibacillary and the disease may mimic a variety of gastrointestinal disorders.

Efficacy and tolerability of brodimoprim in respiratory tract infections.

Brodimoprim is a new diaminopyridine derivative suitable for oral therapy which shows good in-vitro activity against most Gram-positive and Gram-negative pathogens. The efficacy and tolerability of brodimoprim in acute lower respiratory tract infections was tested in controlled clinical trials in comparison with different classes of antibiotics. Acute bacterial infections or infective exacerbations of chronic obstructive bronchitis were included in the studies. Brodimoprim in a single dose was compared to different oral treatments which included co-trimoxazole (trimethoprim 160 mg+sulphamethoxazole 800 mg every 12 hours) and erythromycin (600 mg three times a day). In the studies criteria of efficacy such as daily temperature curve, intensity and frequency of cough, degree of dyspnea, intensity of thoracic pain, difficulty of expectoration, sputum production, thoracic semiology were examined. Brodimoprim was more effective than cotrimoxazole and erythromycin at the end of the treatment, induring a more significant and prompt reduction of axillary temperature, daily sputum volume, degree of dyspnea. There was no difference among treatments in the mean period of therapy to obtain the resolution of the infective process (8 days on average). Brodimoprim had a significantly lower percentage of side effects during the treatment in comparison with cotrimoxazole or erythromycin. Hence brodimoprim was better accepted by patients.

Identification of subpopulations of bronchitic patients for suitable therapy by a dynamic rheological test.

The rheological properties of bronchial mucus samples, collected from randomly selected patients with chronic bronchitis by protected expectoration, under steady-state conditions without any exacerbation, were investigated in a double-blind multicentre study before and after five days of treatment with 4.5 g/day carbocysteine or with glucose as a placebo. Viscous and elastic properties of the mucus were measured with a rheometer fitted with coaxial cylinders set up in an oscillating instead of a rotating mode. The shapes of the ellipses obtained characterized the rheological properties of each bronchial mucus sample before and after treatment. Two different rheological patterns were observed. In the group of patients with initial viscosity greater than or equal to 10,000 mPa.s-1, carbocysteine treatment reduced viscosity and elasticity more than those of the placebo-treated patients. In the group of patients with viscosity lower than 10,000 mPa.s-1, the rheological modifications were the same for both groups. These results are discussed in terms of both the efficacy of carbocysteine and the necessity of rheological characterization of the patients before treatment into different groups, according to the rheological properties of their secretions, for better and targetted therapy with mucus modifying drugs.

Sulbactam/ampicillin combination in the treatment of acute and chronic lower respiratory infections.

The clinical and bacteriological efficacy of a sulbactam/ampicillin combination was compared with piperacillin in a group of 50 patients suffering from acute or chronic lower respiratory infections: 26 were treated intravenously with piperacillin and 24 with sulbactam/ampicillin. The treatment was continued for at least 7 days for 24 patients at the dosage of 3 g sulbactam/ampicillin twice daily, for a further 24 patients at the dosage of 6 g piperacillin twice daily and for two patients at the dosage of 8 g piperacillin twice daily. In the patients treated with sulbactam/ampicillin, a rapid decrease in the fever with the concomitant reduction in cough and sputum production was observed, with cure in 18 cases and improvement in six. In the patients treated with piperacillin cure was observed in 14 cases and improvement in 12 cases. In both treatment groups safety was excellent. There was no significant difference, either in effectiveness or tolerability, between the two groups.

[Anergic miliary tuberculosis, with principally splenic localization simulating hemolymphopathy. Report of 4 cases]. / Tubercolosi miliare anergica a principale localizzazione splenica simulante una emolinfopatia. Descrizione di 4 casi.

Four cases of disseminated tuberculosis with prevailing spleen involvement and lack of tuberculin reactivity are described. The atypical clinical picture justified, at the beginning of the disease, the suspect of a lymphoreticular disorder (malignant lymphoma in 3 cases) or of a pulmonary hemosiderosis (in 1 case). The splenectomy and the following anti-tubercular chemotherapy were fully successful in all 4 patients and the skin reactivity was restored. The Authors discuss the pathogenesis of the observed features and the differential diagnosis of the cases of tuberculosis with only extrapulmonary involvement. These cases represent today about 1/6 of the patients with postprimary tuberculosis.