Ciprofloxacin during upper respiratory tract infections to reduce Pseudomonas aeruginosa infection in paediatric cystic fibrosis: a pilot study.

OBJECTIVES: Acute viral respiratory illnesses are associated with acquisition of Pseudomonas aeruginosa infection in cystic fibrosis (CF) patients. This study aimed to pilot a protocol for a randomized controlled trial to determine whether oral antipseudomonal antibiotics used at the onset of such episodes might delay onset of infection with this organism. METHODS: A total of 41 children with CF aged 2-14 years, without chronic Pseudomonas infection, were randomized to receive ciprofloxacin (n = 28) or placebo (n = 13) at the onset of acute viral respiratory infections on an intention to treat basis, during a study period of up to 32 months. RESULTS: There were no unexpected adverse events believed related to the use of the study medication. The rate of withdrawal from the study was low (approximately 7%) and did not differ between groups. Randomization was effective and acceptable to participants. Primary and secondary outcome measures all favoured active treatment, but there were no significant between group differences. The median rate of Pseudomonas isolates was 0/patient/year (interquartile range 0-0.38) in both the active and placebo groups. Kaplan-Meier survival curves showed no significant difference in time to first Pseudomonas isolate between groups. CONCLUSIONS: This study demonstrated the clinical feasibility of using oral ciprofloxacin in CF patients at times of viral infection. Within this sample size, no significant association was found between active treatment and decreased growth of Pseudomonas in follow-up microbiological samples. A definitive study would require at least 320 children to demonstrate significant differences in the rate of pseudomonal isolates.

Characterizing the ultrastructure of primary ciliary dyskinesia transposition defect using electron tomography.

Primary ciliary dyskinesia is an autosomal recessive disorder affecting the motility of cilia. There are a range of ultrastructural ciliary defects that lead to associated clinical symptoms including ineffective mucus clearance, reduced lung function, infertility, and left-right isomerism. Mutations in radial spoke head proteins are a known cause of primary ciliary dyskinesia. Ultrastructually these defects are identified by a portion of cilia lacking a central pair and transposed outer microtubular doublets. We have repeatedly observed an intermittent loss of the central pair in patients with a transposition defect. To further understand the central pair changes in these radial spoke head mutations we employ electron tomography, a high resolution electron microscope technique, to elucidate in three dimensions the ultrastructural arrangements caused by mutation of the RSPH4A gene. We thereby provide an explanation of the structures observed by conventional electron microscopy studies. We demonstrate that the central pair can be present within the cilium. In some cilia, the central pair rotates at the base of the axoneme. We propose that it is this rotation that gives rise to an intermittent appearance of the central pair when viewed under conventional electron microscopy. We discuss the potential causes and consequences of these findings. © 2014 Wiley Periodicals, Inc.

Mutations in CCDC39 and CCDC40 are the major cause of primary ciliary dyskinesia with axonemal disorganization and absent inner dynein arms.

Primary ciliary dyskinesia (PCD) is a genetically heterogeneous disorder caused by cilia and sperm dysmotility. About 12% of cases show perturbed 9+2 microtubule cilia structure and inner dynein arm (IDA) loss, historically termed "radial spoke defect." We sequenced CCDC39 and CCDC40 in 54 "radial spoke defect" families, as these are the two genes identified so far to cause this defect. We discovered biallelic mutations in a remarkable 69% (37/54) of families, including identification of 25 (19 novel) mutant alleles (12 in CCDC39 and 13 in CCDC40). All the mutations were nonsense, splice, and frameshift predicting early protein truncation, which suggests this defect is caused by "null" alleles conferring complete protein loss. Most families (73%; 27/37) had homozygous mutations, including families from outbred populations. A major putative hotspot mutation was identified, CCDC40 c.248delC, as well as several other possible hotspot mutations. Together, these findings highlight the key role of CCDC39 and CCDC40 in PCD with axonemal disorganization and IDA loss, and these genes represent major candidates for genetic testing in families affected by this ciliary phenotype. We show that radial spoke structures are largely intact in these patients and propose this ciliary ultrastructural abnormality be referred to as "IDA and microtubular disorganisation defect," rather than "radial spoke defect."

Quantification of periciliary fluid height in human airway biopsies is feasible, but not suitable as a biomarker.

The "low volume hypothesis," stating that imbalanced ion movement across the cystic fibrosis (CF) airway epithelium leads to a reduction in periciliary fluid (PCL) and consequently impaired mucociliary clearance, has been the prevailing theory explaining CF pathophysiology, and has been supported by animal models and ex vivo cell culture systems. However, studies in freshly obtained human tissue have not yet been performed. Methods to quantify PCL height in freshly obtained airway biopsies may be useful to assess efficacy of new treatments aimed at restoring PCL height. Here, we established methods to quantify PCL height in freshly obtained CF and non-CF human lower airway biopsies. More than 90% of biopsies contained ciliated epithelium, and PCL height measurements were feasible in approximately 50% of these. Although the mean PCL height was reduced in CF tissue (non-CF, 5.60 ± 0.28 µm; CF, 4.52 ± 0.47 µm), this did not reach statistical significance (P = 0.06). To strengthen the data, we performed similar studies in wild-type and CF knockout mice, and confirmed the results (non-CF, 4.70 ± 0.13; CF, 4.10 ± 0.09 µm; P < 0.05). PCL height measurements in freshly obtained human airway biopsies are feasible, and PCL height appears reduced in subjects with CF, thereby further supporting the "low volume hypothesis." However, power calculations indicate that this assay can only be considered as a biomarker in large, late-phase clinical trials, because sample sizes required to achieve sufficient power are comparatively large.

Limitations of the murine nose in the development of nonviral airway gene transfer.

A clinical program to assess whether lipid GL67A-mediated gene transfer can ameliorate cystic fibrosis (CF) lung disease is currently being undertaken by the UK CF Gene Therapy Consortium. We have evaluated GL67A gene transfer to the murine nasal epithelium of wild-type and CF knockout mice to assess this tissue as a test site for gene transfer agents. The plasmids used were regulated by either (1) the commonly used short-acting cytomegalovirus promoter/enhancer or (2) the ubiquitin C promoter. In a study of approximately 400 mice with CF, vector-specific CF transmembrane conductance regulator (CFTR) mRNA was detected in nasal epithelial cells of 82% of mice treated with a cytomegalovirus-plasmid (pCF1-CFTR), and 62% of mice treated with an ubiquitin C-plasmid. We then assessed whether CFTR gene transfer corrected a panel of CFTR-specific endpoint assays in the murine nose, including ion transport, periciliary liquid height, and ex vivo bacterial adherence. Importantly, even with the comparatively large number of animals assessed, the CFTR function studies were only powered to detect changes of more than 50% toward wild-type values. Within this limitation, no significant correction of the CF phenotype was detected. At the current levels of gene transfer efficiency achievable with nonviral vectors, the murine nose is of limited value as a stepping stone to human trials.

Expression of blood dendritic cell antigens (BDCAs) by CD1a+ human pulmonary cells.

BACKGROUND: Myeloid and plasmacytoid dendritic cell (DC) subsets have been recently identified in the human lung based on their differential expression of Blood DC Antigens 1-3 (BDCAs). We investigated the expression of these antigens by isolated human pulmonary CD1a(+) DCs, namely Langerhan's cells. METHODS: Using an in vitro cell culture system we successfully isolated a population of relatively pure (>70%) CD1a(+) cells from human lung tissue (n=5 subject samples) and stained these with antibodies against the myeloid DC markers BDCA1 (CD1c) and BDCA3 (CD303), the plasmacytoid DC marker BDCA2 (CD141), the Langerhan's cell marker Langerin and the maturation marker CD83. RESULTS: Among different subject samples, the isolated CD1a(+) cells showed variable expression of Langerin, BDCAs and CD83. Interestingly, in two subject samples, which contained >70% CD83(+) mature CD1a(+) cells, >50% of the cells were positive for all of the BDCAs. CONCLUSIONS: We conclude that isolated pulmonary CD1a(+) DCs in vitro have the capacity to express both myeloid and plasmacytoid BDCA markers and that rather than subset restriction in pulmonary DCs, a significant degree of flexibility/plasticity can be induced, albeit experimentally.

Role of the cystic fibrosis transmembrane conductance regulator in internalization of Pseudomonas aeruginosa by polarized respiratory epithelial cells.

Pseudomonas aeruginosa is an important human pathogen, producing lung infection in individuals with cystic fibrosis (CF), patients who are ventilated and those who are neutropenic. The respiratory epithelium provides the initial barrier to infection. Pseudomonas aeruginosa can enter epithelial cells, although the mechanism of entry and the role of intracellular organisms in its life cycle are unclear. We devised a model of infection of polarized human respiratory epithelial cells with P. aeruginosa and investigated the role of the cystic fibrosis transmembrane conductance regulator (CFTR) in adherence, uptake and IL-8 production by human respiratory epithelial cells. We found that a number of P. aeruginosa strains could invade and replicate within cells derived from a patient with CF. Intracellular bacteria did not produce host cell cytotoxicity over a period of 24 h. When these cells were transfected with wild-type CFTR, uptake of bacteria was significantly reduced and release of IL-8 following infection enhanced. We propose that internalized P. aeruginosa may play an important role in the pathogenesis of infection and that, by allowing greater internalization into epithelial cells, mutant CFTR results in an increased susceptibility of bronchial infection with this microbe.

Age-related changes in the protective effect of chronic administration of L-arginine on post-ischemic recovery of endothelial function.

OBJECTIVE: The aim of this study was to assess the effect of chronic administration of L-arginine (LA) on vascular functions as well as its age-related changes. METHODS: Male Sprague-Dawley rats aged 1, 4, 8 and 16 months were divided into control and LA groups, which were administered LA (4 mg/ml) for 6 weeks. Isolated heart perfusion was performed, followed by cardioplegic arrest for 4h at 4 degrees C and reperfusion. Vascular functions were assessed through observations of pre-/post-ischemic coronary flow response to 5-hydroxytryptamine (5-HT) and glyceryl trinitrate (GTN). Ultrastructure was studied after the same ischemia-reperfusion. RESULTS: A significant improvement of percentage recovery (post-/pre-ischemic value) of response to 5-HT were seen in 4 and 8 months LA group when compared to the control (84.2+/-14.0 vs. 33.9+/-12.5 (P<0.05) and 97.0+/-23.2 vs. 21.5+/-9.7 (P<0.05), respectively). Furthermore, 8 months LA group had better percentage recovery of response to GTN (124.5+/-41.6 vs. 47.7+/-6.3, P<0.05). Ultrastructural study showed no significant differences between the groups in any age. CONCLUSIONS: Chronic oral administration of LA enhanced the post-ischemic recovery of vascular function in the young adult and adult hearts, but not in the infant and elderly.

PECAM-1 (CD31) homophilic interaction up-regulates alpha6beta1 on transmigrated neutrophils in vivo and plays a functional role in the ability of alpha6 integrins to mediate leukocyte migration through the perivascular basement membrane.

Platelet-endothelial cell adhesion molecule (PECAM)-1 has been implicated in leukocyte migration through the perivascular basement membrane (PBM) though the mechanisms involved are unclear. The present results demonstrate that the ability of alpha(6) integrins to mediate neutrophil migration through the PBM is PECAM-1 dependent, a response associated with PECAM-1-mediated increased expression of alpha(6)beta(1) on transmigrating neutrophils in vivo. An anti-alpha(6) integrins mAb (GoH3) inhibited (78%, P < 0.001) neutrophil migration through interleukin (IL)-1beta-stimulated cremasteric venules, primarily at the level of the PBM, as analyzed by intravital and electron microscopy. In PECAM-1-deficient mice (KO), a reduced level of neutrophil transmigration elicited by IL-1beta (4-h reaction) was observed in both the cremaster muscle (55% inhibition, P < 0.05) and in the peritoneum (57% inhibition, P < 0.01) but GoH3 had no additional inhibitory effect on these responses. FACS((R)) analysis of neutrophils demonstrated increased expression of alpha(6)beta(1) on transmigrated peritoneal neutrophils, as compared with blood neutrophils, in wild-type but not KO mice even though neutrophils from both strains of mice exhibited comparable levels of intracellular expression of alpha(6) as observed by immunofluorescent staining and confocal microscopy. Furthermore, mice deficient in either leukocyte or endothelial cell PECAM-1, as developed by bone marrow transplantation, demonstrated a similar level of reduced neutrophil transmigration and expression of alpha(6)beta(1) on transmigrated neutrophils as that detected in KO mice. The results demonstrate a role for PECAM-1 homophilic interaction in neutrophil transmigration and increased expression of alpha(6)beta(1) on the cell surface of transmigrated neutrophils in vivo, a response that could contribute to the mechanism of PECAM-1-mediated neutrophil migration through the PBM.

The effect of chronic L-arginine administration on vascular recovery following cold cardioplegic arrest in rats.

OBJECTIVE: Acute administration of L-arginine (LA), the physiological substrate of nitric oxide, has been used as a strategy for myocardial protection during ischemia-reperfusion. The aim of this study was to assess the effects of chronic oral LA administration on vascular functions and morphology after prolonged cold cardioplegic arrest. METHODS: Adult male Sprague-Dawley rats (600-650 g) were divided into control and LA groups, which received LA (4 mg/ml) for 6 weeks. Two experimental protocols were carried out. (1) Isolated rat heart perfusion was performed and hearts were subjected to ischemia for 4 h at 4 degrees C using cold crystalloid cardioplegia (n=8 in LA, n=7 in control). Endothelial and vascular smooth muscle functions were assessed through observations of pre- and post-ischemic coronary flow response to 5-hydroxytryptamine (5-HT) and glyceryl trinitrate (GTN) (%5-HT and %GTN, respectively). (2) Semi-quantitative assessment of tissue morphology was conducted after the same ischemia-reperfusion protocol (n=4 in each group). RESULTS: The LA group showed significantly better recovery (post-/pre-ischemic value) of %5-HT (97.0+/-65.6 versus 21.5+/-25.7%, P=0.015) and %GTN (124.5+/-117.6 versus 47.7+/-16.6%, P=0.021). The histological assessment showed no significant differences between the two groups. CONCLUSIONS: Chronic oral administration of LA significantly ameliorated the postischemic recovery of endothelial and vascular smooth muscle functions after cold cardioplegic arrest in rats.