Infants and young children with cystic fibrosis have high levels of serum sialyl Lewis(a) antigen.

Previous studies suggest that serum levels of the mucin-associated sialyl Lewis(a) (Le(a)) antigen (NeuAC alpha 2-3 Gal beta 1-3 [Fuc alpha 1-4]GlcNAc beta 1...) correlate with the pulmonary status of cystic fibrosis (CF) patients who have Le(a) or Lewis(b) blood types and can form the antigen. However, there is little information on serum sialyl Le(a) antigen levels in CF patients or normal children younger than 9 y. We measured serum antigen levels using the MAb 19-9 in normal term neonates, CF infants and young children, and infants and children who had bronchopulmonary dysplasia or asthma. The mean serum sialyl Le(a) antigen level of the CF patients was 46.7 U/mL, significantly above (p < 0.01) the mean levels of the three other groups. The mean serum sialyl Le(a) levels of the three non-CF groups were not significantly different from one another or from published normal values. We conclude that serum sialyl Le(a) antigen levels are elevated early in CF, but are normal in asthma and bronchopulmonary dysplasia patients.

Isolation and characterization of mucin from the serum of cystic fibrosis patients.

Using monoclonal antibody 19-9, elevated levels of the sialyl Lea antigen (NeuAc alpha 2-3Gal beta 1-3[Fuc alpha 1-4]GlcNac beta 1-3R) are detected in serum from most cystic fibrosis patients. We now report further characterization of the serum antigen and evidence that it is on a mucin glycoprotein and not on glycolipids. The antigen has an apparent molecular weight greater than 2 X 10(6) by gel filtration on Sephacryl S-400. On density gradient centrifugation, the antigen has a density of 1.54 g/ml in cesium chloride and 1.42 g/ml in cesium chloride/4 M guanidine HCl. Immunostaining with monoclonal antibody 19-9 of lipid extracts from cystic fibrosis patient serum and erythrocytes does not detect any antigen on glycolipids. The antigen was purified by gel filtration and density gradient centrifugation. After tritium labeling of the sialic acid residues, sodium dodecyl sulfate gel electrophoresis separates two subunits with apparent molecular weights of 200,000 and 400,000. All of the labeled sialic acid is released as low molecular weight oligosaccharides after mild alkaline borohydride degradation. The purified antigen contains fucose, galactosamine, glucosamine, and galactose but no mannose and is enriched in the amino acids threonine, serine, glycine, proline, and alanine. The purified antigen binds several antibodies recognizing epitopes common to many mucins. Thus, the physical, biochemical, and immunochemical properties of the purified antigen indicate that the sialyl Lea antigen is present on mucins in the serum of cystic fibrosis patients.

Serum mucin-associated antigen levels of cystic fibrosis patients are related to their ages and clinical statuses.

Mucin levels are generally elevated in sera from many cystic fibrosis (CF) patients as measured by radioimmunoassay using monoclonal antibody 19-9, which is directed against the mucin-associated sialyl Lea antigen. Antibody 19-9 can only be used to measure mucin-associated antigen levels in those patients who are genetically able to make detectable levels of mucin-associated sialyl Lea epitope. Serial studies of 20 patients followed over 3-5 y showed that their serum mucin-associated antigen levels varied directly with respect to the severity of their disease and inversely with their Shwachman-Kulczycki clinical scores (p less than 0.001) and Brasfield chest roentgenographic scores (p less than 0.02). Serum mucin-associated antigen levels in samples from 89 CF patients were generally higher in the older patients (p less than 0.025). Serum mucin-associated antigen levels of CF patients who were colonized with Pseudomonas aeruginosa did not significantly differ from those of uninfected CF patients. The mean serum mucin-associated antigen level of CF patients colonized with Pseudomonas was higher than the mean mucin level of six non-CF bronchiectatic patients whose lungs were colonized with Pseudomonas (p = 0.053). Serum mucin-associated antigen levels are thus related to CF patients' ages and clinical statuses.

A serum test for cystic fibrosis using monoclonal antibody 19-9.

Monoclonal antibody 19-9 detects a sialosylated Lea antigen with the following sugar sequence: NeuNAc alpha 2-3Gal beta 1-3[Fuc alpha 1-4]GlcNAc beta 1-3Gal. . . . This antigen is detected as a mucin in the sera of many patients with gastrointestinal and pancreatic cancer. Elevated levels of sialosylated Lea antigen are also detected in serum from 14 of 16 patients with cystic fibrosis (87%). One of the two negative patients belongs to the Le(a-b-) blood group and so is unable to synthesize the sialosylated Lea antigen. The high percentage of cystic fibrosis patients with elevated sialosylated Lea antigen suggests that the 19-9 antibody may be useful for diagnosis of cystic fibrosis. Antibodies to other sialosylated carbohydrates in mucins may also be useful for detection of cystic fibrosis and may allow diagnosis of patients belonging to the Le(a-b-) blood group.

Outcome of home mechanical ventilation in children.

A retrospective study of the outcome of home mechanical ventilation in 54 children with chronic respiratory insufficiency was conducted. The children's ages ranged from 4 months to 18 years. Tracheostomies and positive pressure ventilation were used in 33 patients, and negative pressure ventilation in 21 patients. Nine patients were eventually weaned from the ventilator, including three quadriplegic patients in whom electrophrenic stimulation subsequently was used. Over 20 years, there were 17 deaths, including three from ventilator disconnection. Life table analysis showed 1-year survival to be 84%, and 5-year survival 65%. Home mechanical ventilation, with patients cared for by family and friends, cost less (average less than $1000/mo) than registered nurse or hospital care (average $16,000/mo). There was no significant difference in the number of deaths between patients cared for by registered nurses 24 hours a day and those cared for by family and friends. Home mechanical ventilation may be a reasonably safe and cost-effective alternative to prolonged hospitalization for the ventilator-dependent child.

Home negative pressure ventilation: report of 20 years of experience in patients with neuromuscular disease.

Twenty years of experience using negative pressure devices (NPD) at home to ventilate 40 patients with neuromuscular disease is presented. The purpose of the study was to determine the costs, complications, and clinical outcome of this form of respiratory support, and to ascertain the reasons for failure to institute effective negative pressure ventilation (NPV) in nine patients. Emerson tank respirators, used mainly to rest respiratory muscles at night, and intermittent positive pressure breathing machines were used by 98% of patients at an average equipment cost of +2,700 annually. Patients in whom NPV was initiated on an elective rather than emergent basis saved an average of +12,000 during their initial hospitalization. Life table analysis shows a five-year survival of 76%, and a 10-year survival of 61%. Complications were minor and occurred at an average rate of less than one per year per patient at home on NPV. Failure to achieve satisfactory NPV in nine patients was associated with age (six patients were younger than 3 years of age), or severe thoracocervical scoliosis, which prevented proper fitting of the NPD. For reasons of safety, economy, and quality of life, NPV at home is the preferred treatment for patients having neuromuscular disease who need respiratory assistance.

Selenium responsive myositis during prolonged home total parenteral nutrition in cystic fibrosis.

The need for routine supplementation of total parenteral nutrition solutions with selenium (Se) has not been clearly defined. Although clinical selenium deficiency in patients on prolonged total parenteral nutrition has been reported, it is rarely observed in the United States. We report a 19-year-old woman with cystic fibrosis who developed muscle pain and weakness after 3 months on total parenteral nutrition which was not supplemented with Se. Coincident with her onset of symptoms, markedly elevated serum creatine kinase values were observed compared to baseline levels. Subsequent evaluations revealed undetectable (less than 0.02 microgram/ml) serum and urine Se levels in this patient. In addition, electromyographic evidence of myositis and nonspecific membrane irritability was documented. Therapy with oral Se rapidly reversed her symptoms and normalized with serum creatine kinase values over a 10-day period. Prolonged treatment with Se was required to achieve normal values of Se in the serum. Patients with severe pancreatic insufficiency, such as cystic fibrosis, may be at risk for clinical Se deficiency if on prolonged total parenteral nutrition without supplementation. Elevated creatine kinase levels should alert physicians to the possibility of Se deficiency in such patients.

Home positive-pressure ventilation. Twenty years' experience.

We studied retrospectively 26 adults and 21 children with chronic respiratory failure whose condition was managed at home using positive-pressure ventilators in order to ascertain the outcome, benefits, and complications of this form of management. Twenty-six (55 percent) of the patients had injuries to the spinal cord. Among the 47 patients, nine were eventually weaned from the ventilator, and two died at home because of disconnection from their ventilators. Using life-table analysis, projected three-year survival was 74 percent for patients without spinal injury and 63 percent for patients with spinal injury. Mortality was greater for children than for adults. For a majority of patients, the cost of management at home was significantly less than management in the hospital, depending largely on the level of nursing care required. We suggest that mechanical ventilation at home may be a reasonable alternative to prolonged hospitalization for medically stable ventilator-dependent adults and children.

Mucus glycoproteins secreted by respiratory epithelial tissue from cystic fibrosis patients.

Tracheae, bronchi, nasal epithelial, and nasal polyp tissue slices were incubated in tissue culture with [3H]-glucosamine, and the rate of secretion of labeled mucus glycoproteins was measured. Secretion rates were at least 3- to 6-fold higher for all of the samples from nine patients with cystic fibrosis (CF) who were studied, as compared with values for tissue slices from eight young subjects not affected with this disease. The secreted glycoproteins were further purified into one neutral and three acidic fractions by ion-exchange chromatography on DEAE-cellulose. The glycoproteins secreted by respiratory epithelial tissue from cystic fibrosis subjects contained relatively more of two acidic glycoprotein fractions. Double-label experiments with both [3H]-glucosamine and [35S]-sulfate as mucus glycoprotein precursors further substantiated the shift to more acidic components in the purified mucus glycoproteins and, in addition, suggested a higher level of sulfation of these same two acidic glycoprotein fractions. All four of the labeled glycoprotein fractions secreted by cultured human bronchi cochromatographed with authentic mucus glycoproteins purified from sputum of cystic fibrosis subjects by the same techniques. The differences between mucus glycoproteins from cultured CF airway tissue and mucus glycoproteins from other patients' tissue included relatively increased rates of production, level of sulfation, and greater acidity. Further applications of these in vitro techniques should allow the determination of the enzymatic and biochemical causes of these observed differences in the absence of such potentially confounding variables as concurrent airway infection or of oropharyngeal secretions.

Increased [125I]trypsin-binding in serum from cystic fibrosis patients.

The capacities of normal and cystic fibrosis (CF) sera to bind to exogenous human [125I]trypsin were compared. Sera from eight older CF patients bound significantly more exogenous human [125I]trypsin than did sera from eight normal subjects (p less than 0.001). Disregarding the increased trypsin-binding (TB) of CF sera, serum immunoreactive trypsinogen (SIRT) levels were not detectable in these eight older CF patients. However, when SIRT levels were corrected for TB, four CF patients had normal SIRT concentrations and four had low but detectable SIRT levels. As compared to five normal newborns' sera, serum from a newborn with CF had normal TB and the SIRT levels were very high. In conclusion, increased TB in CF serum lowers results of SIRT assays. Therefore, unless SIRT levels are corrected for TB, results obtained from currently available SIRT kits may be invalid.

Analysis of predictive factors in the assessment of warm-water near-drowning in children.

The records of 42 children hospitalized after a serious fresh-water accident were studied retrospectively. Nine variables thought to be indicative of neurologic outcome in near-drowned patients were analyzed by means of a stepwise discriminant function procedure. The presence of coma and fixed and dilated pupils on examination in the emergency room perfectly predicted those patients who would die (24%) or sustain severe and permanent brain damage (16% of the survivors). All dead or badly brain-damaged patients drowned or nearly drowned in warm water (greater than 20 degrees C). Easily obtained prognostic neurologic findings may be important in assessing the efficacy of resuscitation measures in pediatric near-drowning victims, particularly those who were immersed in warm water.

Hereditary generalized juvenile polyposis associated with pulmonary arteriovenous malformation.

A 28-yr-old mother and her 10-year-old daughter with generalized juvenile gastrointestinal polypsis, arteriovenous (AV) malformations of the lung and severe digital clubbing are described. The AV malformations were documented by pulmonary angiography in both subjects, and generalized juvenile polyposis was confirmed histologically and radiographically. Since pulmonary AV malformations associated with juvenile polyposis has not been previously reported, a new hereditary syndrome is proposed.

High-altitude pulmonary edema in children.

A 15-year-old boy with recurrent high-altitude pulmonary edema had previously been mistakenly treated for asthma and pneumonia. Clinical manifestations of this disorder, its etiology, treatment, and prevention are discussed.