Modern Results of Functional Bracing of Humeral Shaft Fractures: A Multicenter Retrospective Analysis.

OBJECTIVES: To evaluate the rate of, and reasons for, conversion of closed treatment of humeral shaft fractures using a fracture brace, to surgical intervention. DESIGN: Multicenter, retrospective analysis. SETTING: Nine Level 1 trauma centers across the United States. PATIENTS: A total of 1182 patients with a closed humeral shaft fracture initially managed nonoperatively with a functional brace from 2005 to 2015 were reviewed retrospectively from 9 institutions. INTERVENTION: Functional brace. MAIN OUTCOME MEASUREMENTS: Conversion to surgery. RESULTS: A total of 344 fractures (29%) ultimately underwent surgical intervention. Reasons for conversion included nonunion (60%), malalignment beyond acceptable parameters (24%), inability to tolerate functional bracing (12%), and persistent signs of radial nerve palsy requiring exploration (3.7%). Univariate comparisons showed that females and whites were significantly (P < 0.05) more likely to be converted to surgery. The multivariate logistic regression identified females as being 1.7 times more likely and alcoholics to be 1.4 times more likely to be converted to surgery (P < 0.05). Proximal shaft as well as comminuted, segmental, and butterfly fractures were also linked to a higher rate of conversion. CONCLUSIONS: This large multicenter study identified a 29% surgical conversion rate, with nonunion as the most common reason for surgical intervention after the failure of functional brace. These results are markedly different than previously reported. These results may be helpful in the future when counseling patients on the choice between functional bracing and surgical intervention in managing humeral shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Circulating progenitor cells in patients with familial hypercholesterolemia.

OBJECTIVE: Familial hypercholesterolemia (FH) is a genetic disease with very high levels of circulating low density lipoprotein cholesterol (LDL-C) levels that leads to accelerated atherosclerosis. Lipoprotein apheresis is an effective treatment option for patients with FH and results in reduced cardiovascular morbidity and mortality. Circulating progenitor cells (CPCs) are markers of overall vascular health and diminished levels have been associated with decreased reparative potential and worse outcomes. We assessed the short-term change in CPC levels following a single lipoprotein apheresis session in FH patients who are already on stable lipoprotein apheresis therapy. We hypothesized that in addition to a reduction in atherogenic lipids, the cardiovascular benefit from lipoprotein apheresis therapy is mediated by enhanced vascular reparative capacity through mobilization of CPCs. METHODS: Eight FH patients (1 homozygous and 7 heterozygous) on stable lipoprotein apheresis therapy for at least three months had CPCs measured at baseline (prior to apheresis) and two hours after apheresis. Results were compared with data from age-matched hyperlipidemic (HLP) patients on statin therapy and healthy volunteers. RESULTS: FH patients had higher baseline circulating levels of CD34+/CD133+ and CD34+/CD133+/CXCR4+ cells compared to HLP and healthy subjects. There was no significant change in CPCs after apheresis in FH patients. CONCLUSIONS: FH patients had higher CPC counts at baseline compared to age-matched HLP and healthy controls, suggesting activation of reparative mechanism in this high risk population. Larger studies are needed to better characterize differences in CPC counts between FH subjects and HLP patients over time.

Economic burden and health-related quality of life associated with Prader-Willi syndrome in France.

BACKGROUND: To date, there has been no published comprehensive estimation of costs related to Prader-Willi syndrome (PWS). Our objective was therefore to provide data on the economic burden and health-related quality of life associated with PWS in France in order to raise awareness of the repercussions on individuals suffering from this syndrome and on caregivers as well as on the health and social care systems. METHOD: A retrospective cross-sectional study was carried out on 51 individuals recruited through the French PWS patient association. Data on their demographic characteristics and resource use were obtained from an online questionnaire, and costs were estimated by a bottom-up approach. The EQ-5D-5L health questionnaire was used to measure the health-related quality of life of individuals suffering from PWS and their caregivers. RESULTS: The average annual cost of PWS was estimated at €58 890 per individual, with direct healthcare accounting for €42 299, direct non-healthcare formal costs €13 865 and direct non-healthcare informal costs €8459. The main contributors to PWS costs were hospitalisations and social services. Indirect costs resulting from loss of productivity in the labour market was €32 542 for adults suffering from PWS. Mean EQ-5D utility scores were 0.4 for individuals with PWS and 0.7 for caregivers. CONCLUSIONS: Prader-Willi syndrome represents a major economic burden from a societal perspective and has a significant impact on health-related quality of life both for individuals suffering from PWS and for their caregivers in France. These results underscore the need to develop tailored policies targeted at improving care. Likewise, a larger study collecting a broader range of medical characteristics should be undertaken to achieve more precise estimations.

Fragile X syndrome: economic burden and health-related quality of life of patients and caregivers in France.

BACKGROUND: Fragile X syndrome (FXS) is the main hereditary cause of intellectual disability. Although the associated burden appears to be considerable, to date no study has comprehensively assessed the cost incurred because of FXS, including its specific impact on health-related quality of life and the burden on caregivers using standardised quantitative tools. The aim of this article is to provide data in order to increase awareness of the repercussions of FXS on patients and caregivers as well as on the health and social care systems in France. METHODS: A retrospective cross-sectional study was carried out on 145 patients recruited through Le Goëland X-Fragile and Mosaïques, the French FXS patient associations. Data on their demographic characteristics and resource use were obtained from an online questionnaire, and costs were estimated by a bottom-up approach. The EQ-5D health questionnaire was used to measure patients' and caregivers' health-related quality of life. Perceived burden of care was measured using the Zarit Caregiver Burden Interview. The Barthel index, a non-utility-based assessment, was used to measure patients' level of dependence. RESULTS: The annual total direct cost of FXS was estimated at €25 800 per patient. The main contributors were informal care provided by the main caregiver (€10 500) and social services (€8400). Healthcare costs, estimated at €2700, represented only a minor share. Mean EQ-5D utility scores were 0.49 for patients and 0.75 for caregivers. The mean burden for caregivers as measured by the Zarit Caregiver Burden Interview was 39.9. CONCLUSIONS: Fragile X syndrome requires significant resources that are mainly of a non-medical nature and are higher for children than for adults. Compared with related diseases, it constitutes a particularly high burden for caregivers. Using a bottom-up approach and a wide range of standardised measures, this study underscores the need for greater awareness of the burden of FXS as well as an assessment of new and existing interventions to address it.

The economic burden and health-related quality of life associated with systemic sclerosis in France.

OBJECTIVES: To provide data on the economic burden and health-related quality of life (HRQoL) associated with systemic sclerosis (SSc) in France and to raise awareness of the repercussions of this disease for patients and caregivers and on the health and social care system. METHOD: A cross-sectional study was carried out on 147 patients recruited through the Association des Sclérodermiques de France (ASF), the French association for SSc patients. Data on the patients' use of resources were obtained retrospectively from an online questionnaire and costs were estimated by a bottom-up approach. The HRQoL patients and caregivers was assessed with the five-level EURQol-5 Dimension (EQ-5D-5L) health questionnaire. RESULTS: The average annual cost of SSc was estimated at EUR 22,459 per patient. Direct healthcare costs amounted to EUR 8452, direct non-healthcare formal costs to EUR 1606, direct non-healthcare informal costs to EUR 1875, and indirect costs resulting from patients' absence from the labour market to EUR 10,526. The main contributors to SSc costs were hospitalizations and early retirement. Mean EQ-5D utility scores were 0.49 for patients and 0.66 for caregivers. CONCLUSIONS: Although SSc is a rare disease, its economic burden from a societal perspective is substantial and the consequences for HRQoL are significant for both patients and caregivers in France, underscoring the need to develop tailored policies targeted at improving patients' care and reducing the long-term impact of SSc.

The diversity of regulation and public financing of IVF in Europe and its impact on utilization.

STUDY QUESTION: How do the different forms of regulation and public financing of IVF affect utilization in otherwise similar European welfare state systems? SUMMARY ANSWER: Countries with more liberal social eligibility regulations had higher levels of IVF utilization, which diminished as the countries' policies became more restrictive. WHAT IS KNOWN ALREADY: Europe is a world leader in the development and utilization of IVF, yet surveillance reveals significant differences in uptake among countries which have adopted different approaches to the regulation and and public financing of IVF. STUDY DESIGN, SIZE, DURATION: A descriptive and comparative analysis of legal restrictions on access to IVF in 13 of the EU15 countries that affirmatively regulate and publicly finance IVF. PARTICIPANTS/MATERIALS, SETTING, METHODS: Using 2009 data from the European Society of Human Reproduction and Embryology study of regulatory frameworks in Europe and additional legislative research, we examined and described restrictions on access to IVF in terms of general eligibility, public financing and the scope of available services. Multiple correspondence analysis was used to identify patterns of regulation and groups of countries with similar regulatory patterns and to explore the effects on utilization of IVF, using data from the most recent European and international IVF monitoring reports. MAIN RESULTS AND THE ROLE OF CHANCE: Regulations based on social characteristics of treatment seekers who are not applicable to other medical treatments, including relationship status and sexual orientation, appear to have the greatest impact on utilization. Countries with the most generous public financing schemes tend to restrict access to covered IVF to a greater degree. However, no link could be established between IVF utilization and the manner in which coverage was regulated or the level of public financing. LIMITATIONS, REASONS FOR CAUTION: Owing to the lack of data regarding the actual level of public versus private financing of IVF it is impossible to draw conclusions regarding equity of access. Moreover, the regulatory and utilization data were not completely temporally matched in what can be a quickly changing regulatory landscape. WIDER IMPLICATIONS OF THE FINDINGS: Whether motivated by cost, eligility restrictions or the availability of particular services, cross-border treatment seeking is driven by regulatory policies, underscoring the extra-territorial implications of in-country political decisions regarding access to IVF. STUDY FUNDING/COMPETING INTEREST(S): There was no funding source for this study. The authors have no conflicts of interest to declare.

Multicenter validation of a simplified score to predict massive transfusion in trauma.

BACKGROUND: Several studies have described predictive models to identify trauma patients who require massive transfusion (MT). Early identification of lethal exsanguination may improve survival in this patient population. The purpose of the current study was to validate a simplified score to predict MT at multiple Level I trauma centers. METHODS: All adult trauma patients treated at three Level I trauma centers from July 2006 to June 2007 who (1) were transported directly from the scene, (2) were trauma activations, and (3) received any blood transfusions during admission were included. Assessment of Blood Consumption (ABC) score developed using the same inclusion criteria for patients admitted to a single trauma center (Vanderbilt University Medical Center [VUMC]-1) between July 2005 and June 2006. ABC score calculated by assigning a value (0 or 1) to each of the four parameters: penetrating mechanism, positive focused assessment with sonography for trauma for fluid, arrival blood pressure <90 mm Hg, and arrival pulse >120 bpm. A score of 2 was used as "positive" to predict MT. Area under receiver-operating characteristic curve was calculated to compare the predictive ability of the score at each institution. RESULTS: There were 586 patients in the developmental (VUMC-1), 513 patients at trauma center 1 (VUMC-2), 372 at trauma center 2 (PMH), and 133 at trauma center 3 (Johns Hopkins Hospital). MT rate was similar between centers: 14% to 15%. Sensitivity and specificity for the ABC score predicting MT ranged from 75% to 90% and 67% to 88%, respectively. Correctly classified patients and area under receiver-operating characteristic curve, however, were 84% to 87% and 0.83 to 0.90, respectively. CONCLUSIONS: The ABC score is a valid instrument to predict MT early in the patient's care and across various demographically diverse trauma centers. Future research should focus on this score's ability to prospectively identify patients who will receive MT.

Exsanguination protocol improves survival after major hepatic trauma.

BACKGROUND: Hepatic injury remains an important cause of exsanguination after major trauma. Recent studies have noted a dramatic reduction in mortality amongst severely injured patients when trauma exsanguinations protocols (TEP) are employed. We hypothesised that utilisation of our institution's TEP at the initiation of hospital resuscitation would improve survival in patients with significant hepatic trauma. PATIENTS AND METHODS: All patients who (1) sustained intra-abdominal haemorrhage with Grades III-V hepatic injury and (2) underwent immediate operative intervention between February 2004 and January 2008 were included in the study. TEP was instituted in February 2006, and all subsequent patients who met inclusion criteria and were treated with TEP constituted the study group. Patients who met inclusion criteria, were treated before introduction of TEP, and received at least 10 units packed red blood cells in the first 24h constituted pre-TEP comparison group. Univariate and multivariate analyses evaluated the effects of TEP on the study population. RESULTS: Seventy-five patients were included in the study: 39 in the pre-TEP cohort (31% 30-day survival) and 36 in the TEP cohort (53% 30-day survival). There were no differences in demographics, extent of hepatic injury, or operative approach between the patient groups (all p > or = 0.27). Injury Severity Scores were significantly higher in the TEP group (41+/-18 vs. 28+/-15, p<0.01). TEP patients received more plasma and platelets during operative intervention and significantly less crystalloid (all p<0.01). Occurrence of cardiac dysfunction and abdominal compartment syndrome was significantly lower in TEP patients who survived 24-h post-injury (both p < or = 0.04). After adjusting for the significant negative effects of Grade V injury and involvement of major hepatic vasculature (both p < or = 0.02), TEP significantly improved 30-day survival: OR=0.22, 95% CI: 0.06-0.81, p=0.02. CONCLUSIONS: TEP allows for an effective use of plasma and platelets during intra-operative management of severe hepatic injury. Utilisation of TEP is associated with significant reductions of cardiac dysfunction and development of abdominal compartment syndrome, as well as, significant improvement in 30-day survival.

Room for (performance) improvement: provider-related factors associated with poor outcomes in massive transfusion.

BACKGROUND: Massive transfusion (MT) protocols improve survival in patients with exsanguinating hemorrhage. Both the increased plasma to red blood cells (RBC) and platelets to RBC ratios, and the "protocolization" of product delivery seem to be critical components of the reduction in mortality. The purpose of this study was to identify the incidence and impact of MT protocol noncompliance and to intervene in provider-related events associated with poor compliance and outcomes. METHODS: A MT protocol was initiated in 2006 at a Level I trauma center. All cases of protocol activation were reviewed by a multidisciplinary performance improvement (PI) group for compliance and the need for "real-time" protocol adjustments. Educational conferences, Grand Rounds presentations, and individual provider education were performed on a quarterly basis. Compliance of seven measures were evaluated as follows: type and screen sent from emergency department (ED), activation of protocol in ED, activation by trauma attending, administration of 2:3 plasma to RBC, administration of 1:5 platelets to RBC, protocol discontinuation on leaving operating room, and no products wasted. Univariate, multivariate, and time-series analyses were performed. RESULTS: All 125 MT protocol activations occurring from February 2006 to January 2008 were reviewed. Full compliance for all PI measures during the entire period was 27%. There were no differences in demographics, injury severity, or physiologic scores between patients for whom activations were compliant and those who were noncompliant. Full compliance was an independent predictor of survival (86.7% vs. 45.0%, p < 0.001). Both activation of the protocol in the ED and achievement of prespecified ratios of plasma: RBC (2:3) and platelets: RBC (1:5) were independent predictors of 24-hour and 30-day survivals. All PI measures demonstrated improved compliance during the study period with the exception of ED activation. Failure to send type and screen from the ED is an independent predictor of wasted blood products. CONCLUSION: Early activation of a MT protocol and achieving predefined ratios was associated with improved survival. ED activation and direct blood bank notification by the trauma attending were associated with a reduction in blood product wastage. A multidisciplinary PI process helps to identify provider/specialty noncompliance and to assess the impact of these factors, and it was associated with improvement in compliance and MT outcomes over time.

Hyperkalemia following massive transfusion in trauma.

BACKGROUND: Large-volume blood transfusions have been implicated in the development of hyperkalemia. The purpose of the current study was to determine whether critically injured patients receiving massive transfusions are at an increased risk of hyperkalemia. METHODS: Massive transfusion (MT) cohort, all trauma patients (02/2004-01/2008) taken directly to the OR and receiving >or=10 units of RBC in first 24h. Comparison cohort (No-RBC), all patients (02/2004-01/2008) transported directly to the OR who received no blood products in the first 24h. Hyperkalemia defined as K+ > 5.5 mEq/L. RESULTS: There were 266 MT patients, 237 No-RBC patients. MT patients were more likely to have hyperkalemia in the immediate postoperative setting (1.8% versus 4.6%, P = 0.049). However, linear regression did not identify intraoperative blood transfusions as a predictor of postoperative K+ values (P = 0.417). Logistic regression identified only preop K+ (OR 1.79, P = 0.021) and postop pH (OR 0.009, P = 0.001), but not MT, as independent risk factors for postop hyperkalemia. CONCLUSIONS: Despite concerns of hyperkalemia following MT, we found less than a 5% incidence of postop K+ (>5.5 mEq/L). After adjusting for the significant effects of preop K+ and postop pH, MT patients were at no higher risk of hyperkalemia than those who received no blood products.

Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications.

INTRODUCTION: Massive transfusion (MT) protocols have been shown to improve survival in severely injured patients. However, others have noted that these higher fresh frozen plasma (FFP):red blood cell (RBC) ratios are associated with increased risk of organ failure. The purpose of this study was to determine whether MT protocols are associated with increased organ failure and complications. METHODS: Our institution's exsanguination protocol (TEP) involves the immediate delivery of products in a 3:2 ratio of RBC:FFP and 5:1 for RBC:platelets. All patients receiving TEP between February 2006 and January 2008 were compared with a cohort (pre-TEP) of all patients from February 2004 to January 2006 that (1) went immediately to the operating room and (2) received MT (>or=10 units of RBC in first 24 hours). RESULTS: Two hundred sixty-four patients met inclusion (125 in the TEP group, 141 in the pre-TEP). Demographics and Injury Severity Score were similar. TEP received more intraoperative FFP and platelets but less in first 24 hours (p < 0.01). There was no difference in renal failure or systemic inflammatory response syndrome, but pneumonia, pulmonary failure, open abdomens, and abdominal compartment syndrome were lower in TEP. In addition, severe sepsis or septic shock and multiorgan failure were both lower in the TEP patients (9% vs. 20%, p = 0.011 and 16% vs. 37%, p < 0.001, respectively). CONCLUSIONS: Although MT has been associated with higher organ failure and complication rates, this risk appears to be reduced when blood products are delivered early in the resuscitation through a predefined protocol. Our institution's TEP was associated with a reduction in multiorgan failure and infectious complications, as well as an increase in ventilator-free days. In addition, implementation of this protocol was followed by a dramatic reduction in development of abdominal compartment syndrome and the incidence of open abdomens.

Optimizing outcomes in damage control resuscitation: identifying blood product ratios associated with improved survival.

BACKGROUND: Despite recent attention and impressive results with damage control resuscitation, the appropriate ratio of blood products to be transfused has yet to be defined. The purpose of this study was to evaluate whether suggested blood product ratios yield superior survival rates. MATERIALS: After IRB approval, a retrospective evaluation was performed on all trauma exsanguination protocol (TEP, n = 118) activations from February 1, 2006 to July 31, 2007. A comparison cohort (pre-TEP, n = 140) was selected from all trauma admissions between August 1, 2004 and January 31, 2006 that (1) underwent immediate surgery by the trauma team and (2) received greater than 10 units of PRBC in the first 24 hours. We then compared those who received FFP:RBC (2:3) and platelet:RBC (1:5) ratios with those who did not reach these ratios. Multivariate analysis was performed for independent predictors of mortality. RESULTS: A total of 259 patients were available for study. Patients receiving FFP:RBC at a ratio of 2:3 or greater (n = 64) had a significant reduction in 30-day mortality compared with those who received less than a 2:3 ratio (n = 195); 41% versus 62%, p = 0.008. Patients receiving platelets:RBC at a ratio of 1:5 or greater (n = 63) had a lower 30-day mortality when compared with those with who received less than this ratio (n = 196); (38% vs. 61%, p = 0.001). Regression model demonstrated that a ratio of FFP to PRBC is an independent predictor of 30-day mortality, controlling for age and TRISS (OR 1.78, 95% CI 1.01-3.14). CONCLUSIONS: Increased FFP:PRBC and PLT:PRBC ratios during a period of massive transfusion improved survival after major trauma. Massive transfusion protocols should be designed to achieve these ratios to provide maximal benefit.

Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization.

BACKGROUND: The importance of early and aggressive management of trauma- related coagulopathy remains poorly understood. We hypothesized that a trauma exsanguination protocol (TEP) that systematically provides specified numbers and types of blood components immediately upon initiation of resuscitation would improve survival and reduce overall blood product consumption among the most severely injured patients. METHODS: We recently implemented a TEP, which involves the immediate and continued release of blood products from the blood bank in a predefined ratio of 10 units of packed red blood cells (PRBC) to 4 units of fresh frozen plasma to 2 units of platelets. All TEP activations from February 1, 2006 to July 31, 2007 were retrospectively evaluated. A comparison cohort (pre-TEP) was selected from all trauma admissions between August 1, 2004 and January 31, 2006 that (1) underwent immediate surgery by the trauma team and (2) received greater than 10 units of PRBC in the first 24 hours. Multivariable analysis was performed to compare mortality and overall blood product consumption between the two groups. RESULTS: Two hundred eleven patients met inclusion criteria (117 pre-TEP, 94 TEP). Age, sex, and Injury Severity Score were similar between the groups, whereas physiologic severity (by weighted Revised Trauma Score) and predicted survival (by trauma-related Injury Severity Score, TRISS) were worse in the TEP group (p values of 0.037 and 0.028, respectively). After controlling for age, sex, mechanism of injury, TRISS and 24-hour blood product usage, there was a 74% reduction in the odds of mortality among patients in the TEP group (p = 0.001). Overall blood product consumption adjusted for age, sex, mechanism of injury, and TRISS was also significantly reduced in the TEP group (p = 0.015). CONCLUSIONS: We have demonstrated that an exsanguination protocol, delivered in an aggressive and predefined manner, significantly reduces the odds of mortality as well as overall blood product consumption.

Identification of the circadian transcriptome in adult mouse skeletal muscle.

Circadian rhythms are approximate 24-h behavioral and physiological cycles that function to prepare an organism for daily environmental changes. The basic clock mechanism is a network of transcriptional-translational feedback loops that drive rhythmic expression of genes over a 24-h period. The objectives of this study were to identify transcripts with a circadian pattern of expression in adult skeletal muscle and to determine the effect of the Clock mutation on gene expression. Expression profiling on muscle samples collected every 4 h for 48 h was performed. Using COSOPT, we identified a total of 215 transcripts as having a circadian pattern of expression. Real-time PCR results verified the circadian expression of the core clock genes, Bmal1, Per2, and Cry2. Annotation revealed cycling genes were involved in a range of biological processes including transcription, lipid metabolism, protein degradation, ion transport, and vesicular trafficking. The tissue specificity of the skeletal muscle circadian transcriptome was highlighted by the presence of known muscle-specific genes such as Myod1, Ucp3, Atrogin1 (Fbxo32), and Myh1 (myosin heavy chain IIX). Expression profiling was also performed on muscle from the Clock mutant mouse and sarcomeric genes such as actin and titin, and many mitochondrial genes were significantly downregulated in the muscle of Clock mutant mice. Defining the circadian transcriptome in adult skeletal muscle and identifying the significant alterations in gene expression that occur in muscle of the Clock mutant mouse provide the basis for understanding the role of circadian rhythms in the daily maintenance of skeletal muscle.

Gene therapy progress and prospects: alpha-1 antitrypsin.

Over the 2 years covered here, there has been one clinical study in which a normal alpha-1 antitrypsin (AAT) gene was delivered to the nasal epithelium of AAT-deficient subjects using plasmid-liposome complexes; a second study using an adeno-associated vector should begin soon. Although progress in clinical studies has been slow, advances in both viral and nonviral vector designs show considerable promise. Strategies that combine liposome technology with imaginative vector design may permit long-term expression of a normal transgene that is sufficient to achieve therapeutic serum AAT concentrations. While reproducing the normal physiology by targeting normal AAT gene expression to the liver is logical, local expression in lung cells may be less demanding of the technology and offers therapeutic benefits that are produced neither by AAT protein therapy nor by AAT gene therapy targeted to the liver. Developing technologies may permit direct correction of the mutant AAT gene using innovative approaches to in vivo gene repair.

Dysregulated cytokine production in human cystic fibrosis bronchial epithelial cells.

Although pulmonary inflammation is an important pathologic event in cystic fibrosis (CF), the relationship between expression of the CF gene and the inflammatory response is unclear. We studied tumor necrosis factor (TNF) alpha and IL-1beta stimulated production of IL-6 and IL-8 by CF, corrected CF, and normal human bronchial epithelial cells in culture. During the first 24 hours of TNFalpha stimulation, CF cells produced significantly more IL-8 than normal or corrected CF cells. In the second 24 hours of TNFalpha stimulation, IL-6 and IL-8 generation ceased in normal and corrected CF cells but accelerated in CF cells, resulting in marked IL-6 and IL-8 accumulation in CF cells. Similar results were found when cells were stimulated with IL-1beta. Finally, when CF cells were grown at 27 degrees C (a culture condition which results in transport of CF transmembrane conductance regulator, CFTR, to the cell membrane and normalization of chloride conductance) TNFalpha-stimulated production of IL-6 and IL-8 reverted to normal. We conclude that dysregulation of cytokine generation by CF bronchial epithelial cells is directly related to expression of mutant CFTR and these observations provide a potential mechanism for persistence of airway inflammation in CF.

CAMPATH-1M T-cell depleted BMT for SCID: long-term follow-up of 19 children treated 1987-98 in a single center.

BACKGROUND: SCID can be cured by BMT. Depletion of mature T cells from BM has enabled HLA non-identical stem-cell transplantation. We report the outcome of 30 patients treated with 37 T-cell depleted BMT procedures using CAMPATH-1M in vitro between 1987-98 in a single center. METHODS: Immune reconstitution and quality-of-life were assessed in 19 longterm survivors. All but two received pre-transplant conditioning. T- and B-cell chimerism, numbers and function were analyzed during a median follow-up of 5.3 years (range 1.33-12). RESULTS: The overall engraftment rate was 59%, six children required repeated BMT and the survival rate was 63%. All have donor T cells, 58% normal T-cell numbers and 74% normal T-cell function. Of 17 evaluated, 16 patients (94%) have normal IgM and IgG levels, and production of specific Abs to protein Ags, but only 5/16 (31%) have a good response to pneumococcal polysaccharide. Early and late post-BMT complications were rare and there were no delayed deaths. Only one child continues on long-term i.v. Ig 4-years post-BMT. Eleven children died (37%). DISCUSSION: CAMPATH-1M T-cell depleted BMT for SCID resulted in 63% survival. Deaths of 11 children were mainly due to pre-existing infections. Seventeen of 19 long-term survivors have normal immune function and good quality-of-life.

Exaggerated activation of nuclear factor-kappaB and altered IkappaB-beta processing in cystic fibrosis bronchial epithelial cells.

In cystic fibrosis (CF), inflammatory mediator production by airway epithelial cells is a critical determinant of chronic airway inflammation. To determine whether altered signal transduction through the nuclear factor (NF)-kappaB pathway occurs in CF epithelial cells and results in excessive generation of inflammatory cytokines, we evaluated tumor necrosis factor (TNF)-alpha-induced production of the NF-kappaB-dependent cytokine interleukin (IL)-8 and activation of NF-kappaB in three different human bronchial epithelial cell lines: (1) BEAS cells that express wild-type CF transmembrane conductance regulator (CFTR), (2) IB3 cells with mutant CFTR, and (3) C38 cells, which are "corrected" IB3 cells complemented with wild-type CFTR. Treatment of cells with TNF-alpha (30 ng/ml) resulted in markedly elevated NF-kappaB activation and production of IL-8 by IB3 cells compared with BEAS and C38 cells. Despite the differences in NF- kappaB activation, no differences in basal levels of IkappaB-alpha or TNF-alpha- induced IkappaB-alpha processing and degradation were detected among the cell lines. In contrast, the basal level of IkappaB-beta was increased in the IB3 cells. Treatment with TNF-alpha resulted in increased formation of hypophosphorylated IkappaB-beta and increased nuclear localization of IkappaB-beta in IB3 cells compared with the other cell types. These findings provide additional evidence of a dysregulated inflammatory response in CF.

Hepatic cryoablation-induced acute lung injury: pulmonary hemodynamic and permeability effects in a sheep model.

HYPOTHESIS: Hepatic cryoablation of 30% to 35% or more of liver parenchyma in a sheep model results in eicosanoid and nuclear factor-kappaB (NF-kappaB)-mediated changes in pulmonary hemodynamics and lung permeability. SETTING: Laboratory. INTERVENTIONS: At initial thoracotomy, catheters were placed in the main pulmonary artery, left atrium, right carotid artery, and efferent duct of the caudal mediastinal lymph node for subsequent monitoring in adult sheep. After a 1- to 2-week period of recovery, animals underwent laparotomy and left-lobe cryoablation (approximately 35% by volume) with subsequent awake monitoring and on postoperative days 1 to 3. MAIN OUTCOME MEASURES: Cryoablation-induced lung permeability and hemodynamic changes were compared with baseline values in sheep that underwent instrumentation. Similarly handled sheep underwent resection of a similar volume of hepatic parenchyma or had pulmonary artery pressure increases induced by mechanical left atrial obstruction. Activation of NF-kappaB was assessed with electrophoretic mobility shift assay, and serum thromboxane levels were measured with mass spectroscopy. RESULTS: Cryoablation resulted in acutely increased mean pulmonary (20 to 35 cm water) and systemic pressures, which returned to baseline at 24 hours with no change in cardiac output. Serum thromboxane levels increased 30 minutes after cryoablation (9-fold) and returned to baseline at 24 hours. Activation of NF-kappaB was present in liver and lung tissue by 30 minutes after cryoablation. Lung lymph-plasma protein clearance markedly exceeded the expected increase from pulmonary pressures alone, and increased lymph-plasma protein ratio persisted after pulmonary artery pressures normalized. Similar changes were not associated with 35% hepatic resection. CONCLUSIONS: This study demonstrates that 35% hepatic cryoablation results in an acute but transient increase in pulmonary artery pressure that may be mediated by increased thromboxane levels. Increases in pulmonary capillary permeability are not accounted for by pressure changes alone, and may be a result of NF-kappaB-mediated inflammatory mechanisms. These data show that cryosurgery causes pathophysiological changes similar to those observed with endotoxin and other systemic inflammatory stimuli.