Off-line breath acetone analysis in critical illness.

Analysis of breath acetone could be useful in the Intensive Care Unit (ICU) setting to monitor evidence of starvation and metabolic stress. The aims of this study were to examine the relationship between acetone concentrations in breath and blood in critical illness, to explore any changes in breath acetone concentration over time and correlate these with clinical features. Consecutive patients, ventilated on controlled modes in a mixed ICU, with stress hyperglycaemia requiring insulin therapy and/or new pulmonary infiltrates on chest radiograph were recruited. Once daily, triplicate end-tidal breath samples were collected and analysed off-line by selected ion flow tube mass spectrometry (SIFT-MS). Thirty-two patients were recruited (20 males), median age 61.5 years (range 26-85 years). The median breath acetone concentration of all samples was 853 ppb (range 162-11 375 ppb) collected over a median of 3 days (range 1-8). There was a trend towards a reduction in breath acetone concentration over time. Relationships were seen between breath acetone and arterial acetone (rs = 0.64, p < 0.0001) and arterial beta-hydroxybutyrate (rs = 0.52, p < 0.0001) concentrations. Changes in breath acetone concentration over time corresponded to changes in arterial acetone concentration. Some patients remained ketotic despite insulin therapy and normal arterial glucose concentrations. This is the first study to look at breath acetone concentration in ICU patients for up to 8 days. Breath acetone concentration may be used as a surrogate for arterial acetone concentration, which may in future have a role in the modulation of insulin and feeding in critical illness.

Selenium status and allergic disease in a cohort of New Zealand children.

BACKGROUND: New Zealand has one of the highest rates of asthma and atopy. Selenium has been implicated in the aetiology of asthma, and associations between low selenium status and asthma in New Zealand children have been reported. OBJECTIVE: The aim was to investigate the association between selenium status and allergic disease in a birth cohort of New Zealand children. METHODS: The New Zealand Asthma and Allergy Cohort Study is a prospective birth cohort in Wellington and Christchurch, involving 1105 infants born 1997-2001. During the 6-year assessment (n = 635), associations were investigated between plasma selenium (PlSe) and whole blood glutathione peroxidase activity (WBGPx) and allergy-related health outcomes including asthma, wheeze, hayfever, rhinitis, eczema and rash. RESULTS: Wellington children had greater PlSe and WBGPx than Christchurch children (P < 0.001 for both). PlSe (P = 0.004) and WBGPx (P = 0.03) were lower in children exposed to environmental smoke, but differences were no longer significant after adjustment for study location, current household smoking (5-6 years), maternal smoking during pregnancy, family history (either parent with asthma, eczema or hayfever), prioritized ethnicity (Maori, Pacific peoples, Other, European), gender, season born, number of siblings, New Zealand Deprivation Index and body mass index at 6 years. Analysis of PlSe or WBGPx as continuous variables or of quartiles of PlSe with health outcomes showed no significant associations after adjustment. Univariate analysis of quartiles of PlSe and WBGPx with persistent wheeze showed significant inverse trends (P = 0.005 for both), but these reduced after adjustment. CONCLUSIONS AND CLINICAL RELEVANCE: Our results do not support a strong association between selenium status and the high incidence of asthma in New Zealand. However, there was a modest association between lower PlSe and WBGPx activity and higher incidence of persistent wheeze.

Chromosome 4q31 locus in COPD is also associated with lung cancer.

Chronic obstructive pulmonary disease (COPD) is the single greatest risk factor for lung cancer in smokers and is found in 50-90% of lung cancer cases. The link between COPD and lung cancer may stem in part from the matrix remodelling and repair processes underlying COPD, and the development of epithelial-mesenchymal transition (EMT) that underlies lung carcinogenesis. The Hedgehog-interacting protein (HHIP), which mediates the epithelial response (EMT) to smoking, has been implicated in COPD and lung cancer. Recent genome-wide and candidate gene studies of COPD implicate genetic variants on the chromosomal 4q31 (HHIP/glycophorin A (GYPA)) locus. In a case-control study of smokers with normal lung function, COPD and lung cancer (subphenotyped for COPD), we show the GG genotype of the rs 1489759 HHIP single-nucleotide polymorphism (SNP) and the CC genotype of the rs 2202507 GYPA SNP confers a "protective" effect on COPD (OR 0.59, p = 0.006 for HHIP and OR = 0.65, p = 0.006 for GYPA) and lung cancer (OR = 0.70 (p = 0.05) for HHIP and OR 0.70 (p = 0.02) for GYPA). This study suggests that, in smokers, genetic variants of the 4q31 locus conferring a protective effect for COPD are also protective in lung cancer. We conclude that genetic susceptibility to lung cancer includes COPD-related gene variants.

A gene-based risk score for lung cancer susceptibility in smokers and ex-smokers.

BACKGROUND: Epidemiological and family studies suggest that lung cancer results from the combined effects of age, smoking and genetic factors. Chronic obstructive pulmonary disease (COPD) is also an independent risk factor for lung cancer and coexists in 40-60% of lung cancer cases. METHODS: In a two-stage case-control association study, genetic markers associated with either susceptibility or protection against lung cancer were identified. In a test cohort of 439 Caucasian smokers or ex-smokers, consisting of healthy smokers and lung cancer cases, 157 candidate single nucleotide polymorphisms (SNPs) were screened. From this, 30 SNPs were identified, the genotypes (codominant or recessive model) of which were associated with either the healthy smokers (protective) or lung cancer (susceptibility) phenotype. After genotyping of this 30-SNP panel in a second validation cohort of 491 subjects and using the same protective and susceptibility genotypes from our test cohort, a 20-SNP panel was selected on the basis of independent univariate analyses. RESULTS: Using multivariate logistic regression, including the 20 SNPs, it was also found that age, history of COPD, family history of lung cancer and gender were significantly and independently associated with lung cancer. CONCLUSIONS: When numeric scores were assigned to both the SNP and demographic data, and sequentially combined by a simple algorithm in a risk model, the composite score was found to be linearly related to lung cancer risk with a bimodal distribution. Genetic data may therefore be combined with other risk variables from smokers or ex-smokers to identify individuals who are most susceptible to developing lung cancer.

Lung cancer gene associated with COPD: triple whammy or possible confounding effect?

Recently, several large genome-wide association studies have identified a putative "lung cancer" locus in the nicotinic acetylcholine receptor subunit genes (nAChR) on 15q25. However, these findings may be confounded by the presence of chronic obstructive pulmonary disease (COPD), which is also strongly associated with smoking exposure and lung cancer. This is likely as the prevalence of COPD in lung cancer cohorts is as much as two-fold greater than that reported in smoking control populations (50 versus 20%). The present authors compared the genotype frequencies of the most strongly associated single nucleotide polymorphism (rs16969968) in the alpha5 subunit of the nAChR gene cluster between three matched smoking cohorts. The AA genotype was found to be more frequent and was seen in 437 (16%) lung cancer cases and 445 (14%) COPD cases compared with 475 (9%) healthy smoking controls. More importantly, when 429 lung cancer cases were divided according to spirometry results (performed within 3 months of diagnosis, prior to surgery and in the absence of effusions or collapse), the AA genotype was present in 19 and 11% of cases with and without COPD, respectively. These findings suggest that the association between the alpha5 subunit nicotinic acetylcholine receptor single nucleotide polymorphism and lung cancer may, in part, be confounded by chronic obstructive pulmonary disease.

Non-allergenic antigen in allergic sensitization: responses to the mite ferritin heavy chain antigen by allergic and non-allergic subjects.

BACKGROUND: The majority of house dust mite proteins are non-allergenic. There is, however, no information on the type of immune responses produced to these proteins and if the responses are affected by allergic sensitization. OBJECTIVE: To identify and produce a non-allergenic antigen of the house dust mite and compare antibody and T cell responses with the responses to allergens in sensitized and non-sensitized individuals. RESULTS: Ferritin heavy chain was cloned from a cDNA library as a candidate non-allergen of the house dust mite. It bound IgG but not IgE in the sera of allergic and non-allergic subjects and induced high T cell proliferative responses that correlated highly with the responses to the major allergen Der p 2. The cytokine response to the non-allergen was characterized by the release of high levels of both Th1 and Th2 cytokines from the PBMC of both allergic and non-allergic subjects. In contrast, the response to Der p 2 showed the expected high level of Th2 cytokine release from the PBMC of allergic subjects, while the Th2 cytokine production from PBMC of non-allergic subjects was low and even lower than that induced by ferritin heavy chain. The levels of IFN-gamma release were similar for all groups. Der p 2 induced significantly more IL-10 than ferritin in the non-allergic group. CONCLUSION: The T cell responses to a non-allergenic protein of the house dust mite were high and strongly correlated with the response to the major allergen. The non-allergenic protein induced high levels of Th1 and Th2 cytokine in both allergic and non-allergic subjects, while the allergen induced high levels of Th2 cytokine in allergic subjects and low levels in non-allergic subjects. The responses to the allergen were thus independently up- and down-regulated with no evidence of bystander regulation.

Steroid effects on secretion from subsets of lactotrophs: role of folliculo-stellate cells and annexin 1.

Prolactin secretion is controlled by the hypothalamus, and by circulating steroids; oestrogens stimulate, but glucocorticoids inhibit prolactin release. Lactotrophs express intracellular receptors for oestrogens, but apparently not glucocorticoids. Therefore, a genomic effect of oestrogens could be direct, but that of glucocorticoids appears to be indirect. Lactotrophs are not a homogeneous cell population: some have large irregular dense-cored vesicles, others have small round vesicles, but the functional significance of this inhomogeneity is far from clear. Oestradiol and testosterone can stimulate rapid release of prolactin selectively from type II lactotrophs characterised by small round vesicles. Progesterone and other steroids do not exert this effect, which results from a non-genomic action of oestradiol and testosterone. Glucocorticoid inhibition of secretagogue-induced prolactin secretion is mimicked by annexin 1 (lipocortin 1), a protein induced by glucocorticoids in the pituitary and many other tissues, and can be blocked by annexin 1 immunoneutralisation and antisense. Glucocorticoid inhibition of ACTH and growth hormone secretion also involves annexin 1. Pituitary annexin 1 is located in folliculo-stellate cells; these express glucocorticoid receptors, and glucocorticoids induce annexin-1 synthesis. Annexin 1 is externalised from folliculo-stellate cells in response to glucocorticoids, despite the fact that it lacks a secretory signal sequence and is not packaged in vesicles. Inhibition of annexin 1 externalisation by glyburide suggests involvement of an ABC (ATP-binding cassette) transporter in externalisation. Both oestradiol and glucocorticoids therefore influence the secretion of prolactin by novel direct and indirect mechanisms, in addition to their much better understood effects on transcription via classical intracellular steroid receptors.

T cell cytokine responses to outer membrane proteins of Haemophilus influenzae and the house dust mite allergens Der p 1 in allergic and non-allergic subjects.

BACKGROUND: Haemophilus influenzae are ubiquitous colonizers of the nasopharynx, Little is known about the T cell cytokine responses to the antigens of these bacteria and whether or not the responses may interact with responses to aeroallergen. OBJECTIVE: To measure the T cell cytokine responses to conserved outer membrane protein antigens of Haemophilus influenzae and to house dust mite allergen of subjects allergic to the house dust mite and of subjects without allergic sensitization. METHODS: T cell responses were measured by in vitro proliferation and cytokine release from peripheral blood monocytes (PBMC). The allergen used was Der p 1 and outer membrane proteins were recombinant polypeptides representing the OMP6 and D15 antigens. RESULTS: The PBMC of most subjects had proliferative responses to OMP6 and D15, which were highly correlated. The pattern of cytokine release was Th1 biased with high levels of IFN-gamma and usually little IL-5 or IL-13 although PBMC from a few subjects did release IL-5 independent of allergic status. IL-10 release was readily detected. There was no difference in the anti-OMP cytokine response of PBMC from subjects without any known allergy and the responses of PBMC from subjects who were highly allergic to house dust mite. The responses to the Der p 1 allergen showed the expected Th2 cytokine release. CONCLUSION: The outer membrane protein antigens of the ubiquitous colonizing bacteria Haemophilus influenzae induce Th1 cytokine responses which are similar for PBMC from non-allergic individuals and subjects with a high degree of allergy to the perennial house dust mite allergen and strong Th2 responses to Der p 1.

Sensitisation to the lipid-binding apolipophorin allergen Der p 14 and the peptide Mag-1.

BACKGROUND: The IgE-binding peptides Mag 1 and Mag 3 and the high-molecular-weight protein M-177 have been identified as parts of the apolipophorin-like group 14 house dust mite allergen. By analogy with the homologous insect proteins, apolipophorins are hydrophobic proteins found in lipid bodies and lipid transport particles. This explains why they degrade and are poorly represented in extracts. METHODS: We have examined the T cell stimulation induced by a 341-residue recombinant Der p 14 peptide equivalent to the Mag 1 polypeptide examined by others. RESULTS: Peripheral blood mononuclear cells from both allergic and non-allergic donors responded strongly in in vitro proliferation assays to the Der p 14 peptide to induce markedly more (3)H-thymidine incorporation than Der p 2 and the release of Th2 cytokines. CONCLUSIONS: The apolipophorin-like group 14 allergens, despite their predicted hydrophobicity and lipid-binding activity, can induce high IgE responses and T cell stimulation. They appear to be important mite allergens unsuited to representation by aqueous extracts of mites.

Nosocomial pneumonia in adult general medical and surgical patients at Christchurch Hospital.

AIMS: To determine the incidence, microbial cause, and outcome of nosocomial pneumonia in adult general medical and surgical patients at Christchurch Hospital. METHOD: A one-year prospective study of consecutive patients developing nosocomial pneumonia in a university-affiliated hospital. Expanded diagnostic laboratory testing was undertaken to identify the microbial cause of pneumonia. RESULTS: We recruited 126 patients, which represented an incidence of 6.1 per 1,000 admissions. Only 52 (41%) patients submitted sputum that satisfied the cytological screening criteria for testing. A microbial cause was identified in 47 cases (37%): the most common was Legionella spp. (sixteen cases), followed by Influenza A (six cases) and Staphylococcus aureus (four cases). We did not identify an environmental source of the Legionella species. Fourteen patients (11%) died as a consequence of pneumonia and nearly all of these had significant comorbidity. Renal impairment, alcohol excess, and severity of pneumonia were the most powerful predictors of a fatal outcome by univariate analysis. CONCLUSIONS: In most patients we did not identify a microbial cause of pneumonia; when we did, Legionella species were the most common, although this micro-organism has a long incubation period so some subjects may have acquired it before admission. These results guide preventative efforts, diagnostic testing and selection of antimicrobial therapy for nosocomial pneumonia in our hospital.

High-molecular-weight allergens of the house dust mite: an apolipophorin-like cDNA has sequence identity with the major M-177 allergen and the IgE-binding peptide fragments Mag1 and Mag3.

BACKGROUND: A 349-residue recombinant polypeptide of Dermatophagoides farinae, Mag 3, has been shown to represent part of a larger 177-kD (M-177) allergen with very high IgE-binding activity. METHODS: Cloning and sequencing of cDNA from the house dust mites Dermatophagoides pteronyssinus and Euroglyphus maynei was used to characterise the polypeptide containing the Mag 3 sequence. RESULTS: cDNA clones containing the complete sequence of the E. maynei homologue of the M-177 allergen were isolated and analysed. The translation contained not only an amino acid sequence with 90% identity to the 349-residue Mag-3 fragment but also a further sequence with 90% identity to another IgE-binding recombinant D. farinae polypeptide designated Mag 1. The complete sequence encoded a mature polypeptide of 1,650 residues and a molecular mass of 189.5 kD. cDNA clones from D. pteronyssinus also encoded sequences equivalent to the Mag 1 and 3 polypeptides. The M-177 sequence showed strong similarity to the lipid transport apolipophorins found in insect lipophorins. CONCLUSIONS: cDNA sequence data show that the D. pteronyssinus and E. maynei homologues of the M-177 high-molecular-weight D. farinae allergen contain sequences equivalent to both the Mag 1 and Mag 3 recombinant IgE-binding fragments. The N-terminal sequence of the full-length 1,650 amino-acid allergen showed strong similarity to the insect apolipophorins which are poorly soluble in aqueous extracts and exist in the lipid transport particles in haemolymph. It is proposed that presentation in lipid particles could be a factor which enhances the immunogenicity of this group of allergens.

Functions of the perikaryon and dendrites in magnocellular vasopressin-secreting neurons: new insights from ultrastructural studies.

Magnocellular hypothalamic neurosecretory neurons secreting vasopressin or oxytocin provide a robust model system for the investigation and understanding of many aspects of peptidergic neuronal function. Many of their functions and the cellular organelles involved are well understood. However, recent ultrastructural studies have thrown new light on various aspects of magnocellular neurosecretory function which have not previously received much attention. This review concerns two of these: the effects of mutations in the vasopressin gene on the handling of the translated peptide by the rough endoplasmic reticulum; and the role of the magnocellular dendrites in the production, secretion and localisation of peptides. Investigation of the synthesis of proteins derived from vasopressin genes which have undergone various mutations has at the moment provided more answers than questions: Why do some abnormal products accumulate as masses of peptide in the rough endoplasmic reticulum while others do not? Why do accumulations in humans appear to be damaging to the neurons while those in the rat do not? Investigations of the role of dendrites in the production and release of peptides show that the dendrites have all the machinery needed for protein translation and appear to synthesize locally proteins required for dendritic function. Of particular interest is the possibility that various transmitter receptor proteins could be synthesized in the dendrites close to the synapses in which they become localized. Precisely how such membrane proteins are inserted into the synaptic complex is, however, unclear, because the most part of the dendrites lack any form of the Golgi packaging organelle that can be recognised as such either by immunocytochemistry or electron microscopy. Better established is the ability of magnocellular dendrites to secrete either vasopressin or oxytocin in response to a variety of stimuli including sex steroids. This local release of peptide into the magnocellular nuclei has important but as yet incompletely defined effects on the functioning of the neurons.

Climate and aeroallergen levels in asthma: a 12 month prospective study.

BACKGROUND: There is evidence to suggest that changes in weather and airborne fungal spore and pollen counts may affect asthma symptoms. METHODS: The relationship between climate, airborne fungal spore, and pollen counts and peak expiratory flow rate (PEFR) and asthma symptoms was prospectively investigated in a population of mild to moderate asthmatic subjects in Blenheim, New Zealand. Subjects recorded twice daily PEFR measurements and asthma symptom scores for up to one year. Spore and pollen counts were measured two hourly and meteorological data were measured hourly. Individual, within person, multiple linear regression analyses were conducted, adjusting for auto-correlation. A random effects model was assumed for the individual regression co-efficients and weighted estimates of the mean of these coefficients were obtained by the method of maximum likelihood. RESULTS: One hundred and thirty nine asthmatic patients (60% atopic) aged 17-80 years completed the study. Of the weather variables, only temperature showed a small but consistent association with PEFR. The mean rise in PEFR for an 8.8 degrees C (2 SD) change in temperature was 0.78% (95% CI 0.44% to 1.11%), approximately 3.0 l/min. There was a weak association between days of high basidiospore counts and increased nocturnal wakening and reliever medication use. Pollen counts showed no consistent association with either PEFR or asthma symptoms. CONCLUSIONS: The results of this study suggest that the effects of weather and aeroallergens on PEFR and asthma symptoms in this population are small, and that other causes need to be sought to account for variations in asthma severity and exacerbations.

Community acquired pneumonia: aetiology and usefulness of severity criteria on admission.

BACKGROUND: Community acquired pneumonia remains an important cause of hospital admission and carries an appreciable mortality. Criteria for the assessment of severity during admission have been developed by the British Thoracic Society (BTS). A study was performed to determine the sensitivity and specificity of a severity rule based on a modification of the BTS prognostic rules applied on admission, to compare severity as assessed by medical staff with the modified rule, and to determine the microbiological cause of community acquired pneumonia in Christchurch. METHODS: A 12 month study of all adults admitted to Christchurch Hospital with community acquired pneumonia was undertaken. Three hundred and sixteen consecutive patients with suspected community acquired pneumonia were screened for inclusion. Variables obtained from the history, examination, investigations, and initial treatment were examined for association with mortality. RESULTS: Two hundred and fifty five patients met the inclusion criteria. Their mean age was 58 years (range 18-97). A microbiological diagnosis was made in 181 cases (71%), Streptococcus pneumonia (39%), Mycoplasma pneumoniae (16%), Legionella species (11%), and Haemophilus influenzae (11%) being the most commonly identified organisms. Patients had a 36-fold increased risk of death if any two of the following were present on admission: respiratory rate > or = 30/min, diastolic BP < or = 60 mm Hg, urea > 7 mmol/l, or confusion. The severity rule identified 19 of the 20 patients who died and six of eight patients admitted to the intensive care unit as having life threatening community acquired pneumonia. The sensitivity of the modified rule for predicting death was 0.95 and the specificity 0.71. In 47 cases (21%) the clinical team appeared to underestimate the severity of the illness. CONCLUSIONS: The organisms responsible for community acquired pneumonia in Christchurch are similar to those reported from other centres except for Legionella species which were more common than in most studies. The modification of the BTS prognostic rules applied as a severity indicator at admission performed well and could be incorporated into management guidelines.

An audit of the assessment and management of patients admitted to Christchurch Hospital with chronic obstructive pulmonary disease.

AIM: To audit the assessment and management of patients admitted to hospital with chronic obstructive pulmonary disease (COPD) during three months of the winter of 1992. METHODS: Consensus management guidelines were developed as the basis for the audit. Consecutive cases were audited by review of the case notes. Half were admitted initially under a respiratory physician and half under a general physician. Ninety-five cases were audited. RESULTS: The overall standard of medical assessment was adequate but a number of deficiencies were identified. The mean duration of stay in hospital was nine days. In the emergency department the use of pulse oximetry in preference to arterial blood gas analysis led to failure to diagnose significant ventilatory failure in five cases. Initial assessment by junior medical staff failed to include comment about level of consciousness in 50% of cases and chest hyperinflation in 40%. Oxygen therapy was given in 87% of cases, but was not prescribed in one third and was often not adequately monitored. Peak flow monitoring was performed on admission in 74% of cases and arterial blood gas measurement in 81%. Over 90% of patients were given nebulised bronchodilator therapy with both nebulised ipratropium bromide and salbutamol. Antibiotics were given in 77% of cases. Corticosteroids were given in 95% of cases, usually orally. Sedatives were prescribed inappropriately in six cases where there was acute ventilatory failure. Four patients died in hospital, none unexpectedly. Three patients were mechanically ventilated and all survived to leave hospital. There was no discharge summary in the case records in 29% of cases. CONCLUSIONS: Standards of assessment and treatment were adequate. Several areas were identified where improvements are required, particularly in the prescribing and monitoring of oxygen therapy. Hospital-wide guidelines for the management of COPD are to be developed.

An audit and international comparison of asthma management in the emergency department.

AIMS: 1. To perform an audit of asthma management in the Christchurch Hospital emergency department during the period March 1987 to August 1988. 2. To compare management of asthma in Christchurch with other centres in New Zealand and the United Kingdom. 3. To compare markers of asthma severity on admission with other centres. METHODS: Details of all attendances by adults to the Christchurch Hospital emergency department with acute asthma during the above period were recorded on specially designed asthma treatment sheets. This data was compared with similar studies performed in Wellington (NZ) and Southampton and Leicester (UK). RESULTS: 759 cases were analysed. Most subjects were in the 15-25 year age group. 47% were taking inhaled corticosteroids at presentation. History taking was satisfactory according to guidelines operative at that time. Peak flow rate measurement at presentation was performed in 79% of cases, and in 67% of cases following treatment. Nebulised bronchodilators were given in 88% of cases and parenteral steroids given in 22%. 46% of cases were discharged home and of these 28% received a course of oral prednisone. All management decisions, except the decision to give oral steroids on discharge, showed a relationship to objective indices of asthma severity. CONCLUSION: Comparison with other centres shows that the treatment of acute asthma in Christchurch was of a similar standard. Severity of asthma on presentation, as measured by peak flow and pulse rates showed no difference between Christchurch and Southampton.