Elizabeth Fireman

Randomised crossover trial of naltrexone in uraemic pruritus

BACKGROUND Most dialysis patients develop pruritus, for which current treatment is unsatisfactory. Endogenous opioids may be involved in this pruritus. We studied the effect of the opioid antagonist naltrexone on the pruritus of haemodialysis patients. METHODS Naltrexone 50 mg per day by mouth was given to 15 haemodialysis patients with severe resistant pruritus in a randomised, double-blind, placebo-controlled crossover trial. The naltrexone or placebo periods lasted 7 days each with a 7-day washout between the two periods. Pruritus was assessed by the patients on a visual analogue scale from 0 (no pruritus) to 10 (maximum), and mean daily scores were calculated. Plasma histamine and beta-endorphin levels were measured, and spontaneous and stimulated basophil histamine-release were determined. FINDINGS The median pruritus scores at the end of the naltrexone treatment were 2.1 (interquartile range 1.5-2.15) for the naltrexone-placebo sequence and 1.0 (0.4-1.15) for the placebo-naltrexone sequence. The respective values before naltrexone was given were 9.9 (9.85-9.95) and 9.9 (9.3-10.0). Plasma beta-endorphin levels were normal and remained unchanged during the study. Plasma histamine levels were high (mean 2.32 [SD 0.11] ng/mL, normal < 1.0) and decreased after naltrexone (to 1.8 [0.09], p < 0.01). Basophils from haemodialysis patients stimulated by interleukin-3 plus IgE antibodies released high amounts of histamine. The increase was 78.3 (19.3)% compared with 26.6 (16.3)% for five normal controls (p < 0.01). Incubation of the basophils with naloxone, another opioid antagonist, prevented this effect. INTERPRETATION Our data suggest short-term efficacy with few side-effects for the amelioration of uraemic pruritus with naltrexone.

Induced sputum assessment in New York City firefighters exposed to World Trade Center dust.

New York City Firefighters (FDNY-FFs) were exposed to particulate matter and combustion/pyrolysis products during and after the World Trade Center (WTC) collapse. Ten months after the collapse, induced sputum (IS) samples were obtained from 39 highly exposed FDNY-FFs (caught in the dust cloud during the collapse on 11 September 2001) and compared to controls to determine whether a unique pattern of inflammation and particulate matter deposition, compatible with WTC dust, was present. Control subjects were 12 Tel-Aviv, Israel, firefighters (TA-FFs) and 8 Israeli healthcare workers who were not exposed to WTC dust. All controls volunteered for this study, had never smoked, and did not have respiratory illness. IS was processed by conventional methods. Retrieved cells were differentially counted, and metalloproteinase-9 (MMP-9), particle size distribution (PSD), and mineral composition were measured. Differential cell counts of FDNY-FF IS differed from those of health care worker controls (p < 0.05) but not from those of TA-FFs. Percentages of neutrophils and eosinophils increased with greater intensity of WTC exposure (< 10 workdays or ≥ 10 workdays; neutrophils p = 0.046; eosinophils p = 0.038). MMP-9 levels positively correlated to neutrophil counts (p = 0.002; r = 0.449). Particles were larger and more irregularly shaped in FDNY-FFs (1–50 μm; zinc, mercury, gold, tin, silver) than in TA-FFs (1–10 μm; silica, clays). PSD was similar to that of WTC dust samples. In conclusion, IS from highly exposed FDNY-FFs demonstrated inflammation, PSD, and particle composition that was different from nonexposed controls and consistent with WTC dust exposure.

Effect of endothelin-1 on α-smooth muscle actin expression and on alveolar fibroblasts proliferation in interstitial lung diseases

Abstract Endothelin-1 (ET-1) is a potent constrictor and mitogen peptide which is expressed in several pulmonary diseases. To elucidate the involvement of ET-1 in lung interstitial pathologic events, we assessed ET-1 secretion by alveolar macrophages (AM) and fibroblasts recovered from the bronchoalveolar lavage (BAL) of patients with idiopathic pulmonary fibrosis (IPF), sarcoidosis (SA) and from control subjects. We characterized in vitro alveolar fibroblasts of all subjects using monoclonal antibody specific to α-smooth muscle actin (α-SM actin) and human fibroblast marker. We also examined the effect of ET-1 on the fibroblasts’ mitogenesis and on their cytoskeletal phenotype. The AM recovered from IPF patients showed increased spontaneous secretion of ET-1 compared with cells from SA and control subjects. The expression of α-SM actin in the fibroblasts from IPF patients was significantly higher than in SA fibroblasts and normal lung fibroblasts. Assessing alveolar fibroblasts purity revealed a negative staining for α-SM actin in all SA and control fibroblasts, while alveolar fibroblasts recovered from IPF were 100% positive for α-SM actin, a reliable differentiation marker of myofibroblastic cells. Exposure of SA alveolar fibroblasts to ET-1 resulted in an increased expression of α-SM actin. Addition of exogenous ET-1 to alveolar fibroblasts culture stimulated DNA synthesis and proliferation in all groups. Moreover, neutralization of ET-1 by monoclonal antibody was shown to decrease 3 H-thymidine incorporation in fibroblasts cultured with AM supernatants. These results suggest possible interactions between AM, myofibroblasts and fibroblasts in interstitial lung diseases (ILD). By modulating α-SM actin expression and exertion of the mitogenic effect on alveolar fibroblasts, ET-1 might play an important role in the fibrogenesis of ILD.

The Use of Exhaled Nitric Oxide in the Diagnosis of Asthma in School Children

OBJECTIVES To evaluate the yield of the fractional exhaled nitric oxide (FeNO) in the diagnosis of asthma compared with spirometry and induced sputum cytologic study in school-age children. STUDY DESIGN Consecutive children referred for evaluation of possible asthma were included. At referral, all children completed FeNO measurement, sputum induction for eosinophil count (eos%) and spirometry. The diagnosis of asthma was performed after 18 months with conventional criteria. Receiver operating curves were used to determine cutoff points for disease status, and accuracy was calculated. RESULTS A total of 150 children were included: 69 with steroid-naïve asthma, 44 without asthma, and 37 with asthma treated with controllers. FeNO and eos% levels were significantly higher in those with steroid-naïve asthma (P < .0001). The area under the receiver operating curve for FeNO and eos% were very high compared with forced expiratory volume in 1 second (0.906, 0.921, 0.606, respectively). The sensitivity, specificity, and positive and negative predictive values for best cutoff points of FeNO (19 parts per billion) were 80%, 92%, 89%, and 86%, respectively, and were similar to eos% (best cutoff = 2.7%): 81%, 92%, 89%, 85%, respectively. CONCLUSIONS FeNO measurement is useful in early diagnosis of pediatric asthma. We suggest considering FeNO measurement in the evaluation of children suspected of having asthma, especially in cases where the diagnosis is not clear.

The use of induced sputum in the assessment of pulmonary involvement in Crohn’s disease

Abstract OBJECTIVE: Our aim was to evaluate lung involvement in Crohn’s disease (CRD) patients by induced sputum (IS). Extraintestinal manifestations are frequent in CRD, but lung involvement is rare. Induced sputum is a reliable noninvasive method of investigating the pathogenesis, pathophysiology, and treatment of lung disease. METHODS: Twenty-four CRD patients and nine control subjects (all nonsmokers) without respiratory symptoms were tested. Sputum was induced by 20′ inhalation of 3.5% saline using ultrasonic nebulizer. Samples were studied by differential counts of 200 cells on cytopreps stained by Giemsa. T-lymphocyte subset analyses were done by FACS using three monoclonal antibodies: CD3 = total T cells, CD4 = T helper cells, and CD8 = T suppressor-cytotoxic cells. CD4/CD8 >2.5 was considered abnormal. RESULTS: Four patients did not produce sputum. Of the remaining 20 patients, seven had active CRD and 13 were in remission. They were divided into two groups: Group A patients had abnormal CD4/CD8 ratio of 6.7 ± 2.5; Group B (seven patients) had normal CD4/CD8 ratio of 1.7 ± 0.52 (p = 0.0001). The differential counts of IS samples were similar in both groups, but lymphocyte count was significantly higher in CRD patients than in the control group (13.2 ± 11.2 vs 4.8 ± 3.6, p = 0.036). There were no differences in spirometry, treatment, extent, or activity of CRD. CONCLUSION: Using a simple noninvasive method, we found that among CRD patients without respiratory symptoms there was a high (65%) incidence of lung involvement.

Induced sputum compared to bronchoalveolar lavage for evaluating patients with sarcoidosis and non-granulomatous interstitial lung disease

Bronchoalveolar lavage (BAL), an important tool for evaluating interstitial lung diseases (ILDs), has limited utility due to its invasiveness and the difficulty of performing it in clinically contraindicated patients. We compared BAL with the induced sputum (IS) technique to analyse cells and T lymphocytes in patients with sarcoidosis (SA) and non-granulomatous ILD (NG-ILD). Pulmonary function tests and BAL were performed by conventional methods. IS induction was done 20 sec after inhalation of 3.5% saline with an ultrasonic nebulizer. Giemsa-stained cytopreps were differentially counted. T lymphocyte subsets were analysed by flow activated cell sorter (FACS). Patients with NG-ILD had impaired total lung capacity (TLC). Transbronchial biopsy demonstrated lung fibrosis in NG-ILD and non-caseating granuloma in SA. The differential cell count in both groups demonstrated a significantly lower percentage of neutrophils and a significantly higher percentage of macrophages in BAL than in IS. The IS samples of patients with SA were significantly richer in metachromatic cells and eosinophils, but had a lower percentage of lymphocytes, compared to the BAL samples. The profiles of T cell subsets showed the same pattern, in both samples, in both groups. A CD4/CD8 ratio of 2.5 or greater had a sensitivity of 100% and a specificity of 81.2%, with a positive predictive value of 81.2% to distinguish SA from NG-ILD. IS is an effective non-invasive technique to identify CD4+ inflammation which distinguishes sarcoidosis from other NG-ILDs.

Detection of occult lung impairment in welders by induced sputum particles and breath oxidation

BACKGROUND We evaluated particulate matter in combined induced sputum (IS) and oxidation in exhaled breath condensate (EBC) to test whether underlying inflammatory changes are present in asymptomatic welders. METHODS Thirty welders from the Israel Defense Forces exposed to aluminum/iron (Group 1) or to cadmium/chromium/iron/lead/nickel (Group 2, N = 16) and 27 non-exposed administrators were studied. IS was recovered, particle size distribution, hydrogen peroxide and pH were measured, and exhaled breath condensate was collected. RESULTS Group 2 had a higher % neutrophils than all other participants (P = 0.0001) and a higher % particles >2 microm in diameter (P = 0.0017). Percent particles and years of exposure highly correlated (P = 0.051). All welders EBC samples had higher concentrations of hydrogen peroxide than controls (P = 0.0001). pH was lower only for Group 2 (P = 0.0001). CONCLUSIONS Combined IS and EBC measurements detect underlying inflammation in airways of asymptomatic welders. It emerged that airway inflammation is present in asymptomatic welders, and that the particle burden, inflammatory cells, and level of oxidative stress are a function of the type and the duration of welding. Am. J. Ind. Med. 51:503-511, 2008.

Morphological and Biochemical Properties of Alveolar Fibroblasts in Interstitial Lung Diseases

The phenotype of alveolar-associated fibroblasts (Afb) in sarcoidosis (SA) and idiopathic pulmonary fibrosis (IPF) is unclear. In the present study, we characterized the cytoskeletal proteins and the contraction properties in alveolar-associated fibroblasts recovered by bronchoalveolar lavage (BAL) in the two diseases. Afb were studied from BAL cells in eight IPF and seven SA patients. Cytoskeletal proteins were identified by ELISA and immunofluorescent methods. Biochemical measurements were done by dry chemistry. Contraction was performed by a gel contraction assay. Afb alpha-SM actin measured by ELISA was higher in IPF than in SA (p = 0.042). Vimentin, desmin, myosin, and fibroblast markers were expressed equally. Only in IPF did the Afb reveal the myofibroblast phenotype showing alpha-SM actin immunofluorescence labeling and, by electron microscopy, filaments with associated dense bodies with rough endoplasmic reticulum. Gel contraction showed that cells in IPF contracted significantly more than in SA (p = 0.046 IPF versus SA). The addition of ET-1 increased contraction in all groups. Dry chemistry analysis showed higher levels (p = 0.0065) of creatine phosphokinase (CPK), lower levels of glucose (p = 0.0082), and similar levels of Ca(2+) and lactate in the IPF and SA Afb. Dinitrofluorobenzene (DNFB), a potent inhibitor of CPK, completely abolished spontaneous cell contraction. Afb differentiates into myofibroblasts with different biochemical and energetic properties in IPF. Moreover, Afb from IPF patients showed increased contractile properties. This may explain the difference in the behavior patterns and outcomes of the two diseases.

Pulmonary disease in systemic lupus erythematosus and the antiphospholpid syndrome.

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by disturbances in innate and adaptive immune mechanisms. Multiple systems and organs may be involved. Tissue damage and dysfunction are mediated by autoantibodies and immune complex formation. The lungs are among the organ systems commonly involved. The pulmonary manifestations usually occur in patients with multisystem disease and include: pleural involvement, parenchymal disease, pulmonary vascular disease and diaphragmatic dysfunction. Manifestations may range from sub-clinical abnormalities to life threatening disorders. Many of the pulmonary manifestations characteristic of SLE are seen in the antiphospholipid syndrome (APS) as well, in both the primary and secondary syndrome. In this review the diverse pulmonary manifestations are described as well as the diagnostic modalities available, including the use of induced sputum evaluation for early diagnosis and follow up. New treatment modalities are referred to.

Induced sputum‐retrieved matrix metalloproteinase 9 and tissue metalloproteinase inhibitor 1 in granulomatous diseases

Summary Matrix metalloproteinases (MMPs) capable of degrading various components of connective tissue matrices, and tissue inhibitor metalloproteinases (TIMPs) are considered important in lung parenchymal remodeling and repair processes in pulmonary diseases. Induced sputum (IS) is a reliable noninvasive method to investigate pathogenesis, pathophysiology and treatment of lung disease. This study was designed to determine whether IS‐MMP9/TIMP1 levels demonstrate lung parenchymal remodeling in sarcoidosis (SA) and Crohns disease (CRD) patients. Sputum was induced and processed conventionally in 13 SA patients, 18 CRD patients and 9 controls. Two‐hundred cells were counted on Giemsa‐stained cytopreps, and T lymphocytes subsets (CD4 = T helper and CD8 = T suppressor cytotoxic cells) were analysed by FACS using monoclonal antibodies.MMP‐9 and TIMP‐1 were measured using commercial ELISA kits. MMP‐9 concentrations, but not those of TIMP‐1, were significantly greater in the sputum supernatant in SA and CRD patients compared to controls (P = 0·018 and P= 0·0019, respectively). The molar ratio, MMP‐9/TIMP‐1, was significantly higher in SA and CRD patients compared to controls (P = 0·008 and P= 0·024, respectively). Gelatinase species having a molecular weight similar to that of MMP‐9 were demonstrated by zymographic analysis. MMP‐9 levels were highly correlated with the CD4/CD8 ratio and DLCO capacity in SA but less in CRD patients. MMP‐9 levels in IS provide a sensitive marker for pulmonary damage.