"Venous congestion" as a cause of subcortical white matter T2 hypointensity on magnetic resonance images.

Subcortical T2 hypointensity is an uncommon finding seen in very limited conditions such as multiple sclerosis, Sturge-Weber syndrome, and meningitis. Some of the conditions such as moyamoya disease, severe ischemic-anoxic insults, early cortical ischemia, and infarcts are of "arterial origin." We describe two conditions in which "venous congestion" plays a major role in T2 hypointensity - cerebral venous sinus thrombosis (CVST) and dural arteriovenous fistula (dAVF). The third case is a case of meningitis, showing T2 hypointensity as well, and can be explained by the "venous congestion" hypothesis. The same hypothesis can explain few of the other conditions causing subcortical T2 hypointensity.

Off-axis integrated cavity output spectroscopy with a mid-infrared interband cascade laser for real-time breath ethane measurements.

Cavity-enhanced tunable diode laser absorption spectroscopy is an attractive method for measuring small concentrations of gaseous species. Ethane is a breath biomarker of lipid peroxidation initiated by reactive oxygen species. A noninvasive means of quickly quantifying oxidative stress status has the potential for broad clinical application. We present a simple, compact system using off-axis integrated cavity output spectroscopy with an interband cascade laser and demonstrate its use in real-time measurements of breath ethane. We demonstrate a detection sensitivity of 0.48 ppb/Hz(1/2).

Ultrasensitive nonlinear measurements of femtosecond pulses in the telecommunications band by aperiodically poled LiNbO3 waveguides.

We have used aperiodically poled lithium niobate waveguides to perform intensity autocorrelation and frequency-resolved optical gating (FROG) measurements for ultraweak femtosecond pulses at 1.5 microm wavelength. The required pulse energies for intensity autocorrelation and FROG are as low as 52 aJ and 124 aJ, respectively. The corresponding sensitivities are 3.2 x 10(-7) mW(2) and 2.7 x 10(-6) mW(2), about 3-5 orders of magnitude better than the previous records. The high nonlinear conversion efficiency is attributed to the long waveguide structure, and the needed broad phase-matching bandwidth is realized by chirping the poling period. We discuss the theory of intensity autocorrelation and FROG measurements in the presence of different phase-matching bandwidths, and we show, for the first time to our knowledge, that the distorted intensity autocorrelation trace due to a delta-like phase-matching spectrum is described by a modified field autocorrelation function. We also report new experimental results comparing autocorrelation traces measured with chirped and unchirped waveguide samples and demonstrating high-quality FROG measurements for cubic phase waveforms generated in a programmable pulse shaper.

Sputum neutrophilia can mask eosinophilic bronchitis during exacerbations.

BACKGROUND: Exacerbations of airway disease are eosinophilic, neutrophilic, both or neither. The primary objective of the present study was to identify whether the treatment of a neutrophilic bronchitis can unmask an associated eosinophilia. METHODS: A retrospective survey of 2160 consecutive sputum cell counts from 1343 patients with airway disease was conducted to identify patients with an isolated neutrophilic bronchitis, which was defined as a sputum total cell count of greater than or equal to 12 x 10(6) cells/g of sputum and a proportion of neutrophils of 80% or greater. The characteristics of the patients who subsequently demonstrated sputum eosinophilia (3% or greater) within eight weeks of resolving the neutrophilia were compared with the patients who subsequently did not have sputum eosinophilia. RESULTS: Two hundred thirty-seven patients had 273 neutrophilic exacerbations. The sputum was re-examined within eight weeks in 65 patients (27.4%), of whom 38 (58.5%) had resolution of the neutrophilic bronchitis after treatment with an antibiotic. Of these 38 patients, 13 (34%) showed eosinophilia. CONCLUSIONS: A neutrophilic exacerbation of airway disease was observed to mask sputum eosinophilia in one-third of patients who had sputum cell counts available before and after antibiotic therapy. Hence, the absence of sputum eosinophilia during an infective exacerbation should not be used as an indication to reduce the dose of corticosteroids. To optimize therapy, repeat sputum cell count measurements are recommended after antibiotic treatment before changing corticosteroid treatment.

Ventilation and perfusion lung scintigraphy of allergen-induced airway responses in atopic asthmatic subjects.

BACKGROUND: Both ventilation (V) and perfusion (Q) of the lungs are altered in asthma, but their relationships with allergen-induced airway responses and gas exchange are not well described. METHODS: The effects of aerosolized allergen provocation of V/Q abnormalities in nonsmoking, male atopic asthmatics (six dual responders and two isolated early responders) were compared with measurements of airflow limitation (forced expiratory volume in 1 s [FEV(1)]), gas exchange (arterial oxygen saturation, arterial oxygen partial pressure and alveolar-arterial oxygen gradient) and airway reactivity (provocative concentration of histamine causing a decrease of 20% in FEV(1)). V and Q lung scans at 30 min and 6 h following allergen challenge and changes in all variables were compared with prechallenge data. Digital image data were registered to baseline scans, and quantitative comparisons of changes made were supported by qualitative assessments of the images. RESULTS: All subjects showed evidence of impaired gas exchange, as reflected by lowered arterial oxygen tension and widened alveolar arterial oxygen gradients. Baseline V/Q scans were abnormal, and there were allergen-induced changes in V and Q at 30 min, with scans at 6 h showing additional changes in Q, particularly in dual responders. Allergen-induced gas trapping was evident at 30 min and was sustained at 6 h. CONCLUSIONS: Regional patterns of V and Q derived from lung scintigraphy showed a wider range of disturbances than were indicated by the magnitude of airflow limitation and arterial hypoxemia following allergen provocation, and they remained abnormal despite normalization of FEV(1). Imaging of regional abnormalities of gas exchange may be relevant in the evaluation of patients with asthma.

Changing pattern of sputum cell counts during successive exacerbations of airway disease.

BACKGROUND: Exacerbations of airway disease are eosinophilic, neutrophilic, both or neither, and this determines the treatment needed. We examined changes in the cellular nature of airway inflammation between consecutive exacerbations and their predictors in individual patients. METHODS: In a retrospective survey of 1786 consecutive sputum cell counts from 1139 patients with airway disease, we identified 79 patients with two or more exacerbations at an interval of >or=6 weeks. The patients were divided into those who demonstrated a change in the type of airway inflammation and those who did not. RESULTS: There were 186 exacerbations of airway disease over 22 months. The cellular nature of inflammation was eosinophilic in 43%, neutrophilic in 40%, combined eosinophilic and neutrophilic in 5% and unclassified in 12%. A change in the type of airway inflammation was seen in 38 patients (48%). Patients, whose previous exacerbation was eosinophilic or neutrophilic were twice or nearly three times more likely, respectively, to have a subsequent exacerbation of the same type. There was no significant difference in the time to the second exacerbation or the inflammatory type of the second exacerbation in relation to the first exacerbation, irrespective of the cellular nature of the first exacerbation. CONCLUSIONS: Quantitative sputum cell counts during successive exacerbations identify that they are commonly of different type, reflecting different causes and the need for different treatment. Their use, when available, helps to optimize therapy.

Liver X receptor stimulates cholesterol efflux and inhibits expression of proinflammatory mediators in human airway smooth muscle cells.

Human (h) airway smooth muscle (ASM) cells are important mediators of the inflammatory process observed in asthma and other respiratory diseases. We show here that primary hASM cells express liver X receptor (LXR; alpha and beta subtypes), an oxysterol-activated nuclear receptor that controls expression of genes involved in lipid and cholesterol homeostasis, and inflammation. LXR was functional as determined by transient assays using LXR-responsive reporter genes and by analysis of mRNA and protein expression of endogenous LXR target genes in cells exposed to LXR agonists. LXR activation induced expression of the ATP-binding cassette transporters ABCA1 and ABCG1 and increased efflux of cholesterol to apolipoprotein AI and high-density lipoprotein acceptors, pointing to a role for hASM cells in modulating cholesterol homeostasis in the airway. Under inflammatory conditions, hASM cells release a variety of chemokines and cytokines that contribute to inflammatory airway diseases. Activation of LXR inhibited the expression of multiple cytokines in response to proinflammatory mediators and blocked the release of both granulocyte macrophage colony-stimulating factor and granulocyte colony stimulating factor. LXR activation also inhibited proliferation of hASM cells and migration toward platelet-derived growth factor chemoattractant, two important processes that contribute to airway remodeling. Our findings reveal biological roles for LXR in ASM cells and suggest that modulation of LXR activity offers prospects for new therapeutic approaches in the treatment of asthma and other inflammatory respiratory diseases.

Modulation of human airway smooth muscle migration by lipid mediators and Th-2 cytokines.

Cysteinyl leukotrienes and the T helper (Th)-2 cytokines IL-5 and IL-13 directly modulate human airway smooth muscle functions such as contraction and proliferation. We studied the effects of other lipid mediators involved in asthma pathophysiology such as prostaglandin D(2) (PGD(2)), lipoxin, and isoprostanes, and the cytokines, IL-5, IL-4, and IL-13 on human airway smooth muscle cell migration. Chemotaxis and chemokinesis of cultured airway smooth muscle cells from humans without asthma (second to fifth passages, n = 6) were studied using collagen-I-coated polycarbonate membranes in Transwell culture plates. Receptor expression and kinase activation were studied by flow cytometry, polymerase chain reaction, and Western blotting techniques. In contrast to LTE(4)- stimulated (10(-6) M) chemokinesis and LTE(4)-primed migration toward platelet-derived growth factor (PDGF), isoprostane 15-F(2t)-IsoP, and IL-5 were neither chemotactic nor chemokinetic. PGD(2) (10(-10)-10(-6) M) was a chemoattractant and primed migration toward PDGF through the DP(2)/CRTh(2) receptor. Although airway smooth muscle cells did not express the lipoxin A(4) cognate receptor, LTE(4)-primed migration toward PDGF was blocked by lipoxin A(4) (10(-6) M), suggesting that this is mediated through CysLT(1)R antagonism. IL-13 (10 ng/ml), but not IL-4 (0.1-100 ng/ml), augmented migration toward PDGF. This was associated with increased Src-kinase phosphorylation and up-regulation of PDGF-alpha and -beta receptors, and was attenuated by IL-13Ralpha- and IL-4Ralpha-neutralizing antibodies, an Src-kinase antagonist (PP1, 3 muM), a CysLT(1)R antagonist, montelukast (10(-6) M), and by lipoxin A(4) (10(-6) M). PGD(2) and IL-13 promote human airway smooth muscle migration. IL-13 can promote airway smooth muscle migration through Src-kinase and leukotriene-dependent pathways. This may contribute to the accumulation of smooth muscle cells in remodeled airway submucosa.

Pharmacological management of mild or moderate persistent asthma.

Patients with mild persistent asthma rarely see their doctor with symptoms of the disease. Partly as a result of this situation, mild asthma is generally undertreated. Findings of several large randomised clinical trials have shown benefits for this population of regular treatment with low doses of inhaled corticosteroids. Additional drugs are rarely needed, and although leukotriene modifiers are effective, they are less so than inhaled corticosteroids. People with moderate persistent asthma are not well controlled on low doses of inhaled corticosteroids. A combination of this drug and long-acting inhaled beta2 agonists provides improved control compared with doubling of the maintenance dose of inhaled corticosteroids. The combination of budesonide and formoterol has been assessed as both maintenance and reliever treatment. This approach further reduces the risk for severe exacerbations. With these strategies, most individuals can achieve good control of their asthma. For patients who do not achieve asthma control despite taking drugs, measurement of the inflammatory response in the airway in induced sputum could provide further information to guide treatment.

Altered respiratory physiology in obesity.

The major respiratory complications of obesity include a heightened demand for ventilation, elevated work of breathing, respiratory muscle inefficiency and diminished respiratory compliance. The decreased functional residual capacity and expiratory reserve volume, with a high closing volume to functional residual capacity ratio of obesity, are associated with the closure of peripheral lung units, ventilation to perfusion ratio abnormalities and hypoxemia, especially in the supine position. Conventional respiratory function tests are only mildly affected by obesity except in extreme cases. The major circulatory complications are increased total and pulmonary blood volume, high cardiac output and elevated left ventricular end-diastolic pressure. Patients with obesity commonly develop hypoventilation and sleep apnea syndromes with attenuated hypoxic and hypercapnic ventilatory responsiveness. The final result is hypoxemia, pulmonary hypertension and progressively worsening disability. Obese patients have increased dyspnea and decreased exercise capacity, which are vital to quality of life. Decreased muscle, increased joint pain and skin friction are important determinants of decreased exercise capacity, in addition to the cardiopulmonary effects of obesity. The effects of obesity on mortality in heart failure and chronic obstructive pulmonary disease have not been definitively resolved. Whether obesity contributes to asthma and airway hyper-responsiveness is uncertain. Weight reduction and physical activity are effective means of reversing the respiratory complications of obesity.

Eosinophilic bronchitis in asthma: a model for establishing dose-response and relative potency of inhaled corticosteroids.

BACKGROUND: Newer generations and formulations of inhaled corticosteroids have necessitated the development of a clinically relevant model to compare their clinical potency. OBJECTIVE: We evaluated whether sputum eosinophil counts could demonstrate a dose-response to inhaled corticosteroids, and compared the response with other inflammatory markers. METHODS: Fourteen steroid-naive patients with asthma with an initial sputum eosinophilia of > or = 2.5% entered a 6-week sequential, placebo-controlled, patient-blinded, cumulative dose-response study. After 7 days of placebo, they received incremental doses of fluticasone propionate (FP), 50, 100, 200, and 400 microg/d, each for 7 days. Measurements were made of sputum and blood eosinophils, exhaled nitric oxide, spirometry, airway responsiveness to methacholine (methacholine PC20), and symptom scores before and after each dose. RESULTS: Sputum eosinophils and exhaled nitric oxide were extremely sensitive to the effects of FP, and exhibited significant dose-dependent reductions of 99.4% and 99.8 parts per billion, respectively, where each variable was expressed per 100 microg/d FP. This compared with a 0.5 doubling dose increase of airway responsiveness to methacholine and a 0.3 decrease in symptom scores. Airway responsiveness to methacholine was the only variable that increased throughout the study. CONCLUSION: These results suggest that the model of eosinophilic bronchitis could be used to compare the effect of cumulative doses of an inhaled corticosteroid delivered by different types of delivery systems or preparations using a relatively small number of patients. CLINICAL IMPLICATIONS: Future clinical studies based on this model will allow clinicians to make informed decisions regarding the relative potencies of different inhaled corticosteroids.

Predictors of loss of asthma control induced by corticosteroid withdrawal.

BACKGROUND: Asthma guidelines recommend reducing the dose of inhaled corticosteroids after establishing control. OBJECTIVE: To identify predictors of loss of control and the kinetics of symptoms, and inflammatory and physiological measurements when inhaled corticosteroids are reduced in patients with stable asthma. PATIENTS AND METHODS: In a single-blind study, the daily dose of inhaled corticosteroid was reduced by one-half at intervals of 20+/-2 days in 17 adults with controlled asthma until loss of asthma control occurred or until the corticosteroid was replaced with placebo for 20 days. The patients recorded symptoms and peak expiratory flow each day, and forced expiratory volume in 1 s (FEV1), the provocative concentration of methacholine causing a 20% fall in FEV1 (PC20), exhaled nitric oxide, and eosinophils in sputum and blood were measured every 10 days. A loss of asthma control was defined as a worsening of the symptoms score of at least 20%, and either a decrease in FEV1 of at least 15% or a decrease in PC20 of at least fourfold. RESULTS: Two patients had a respiratory infection and were withdrawn from the study. In eight patients, asthma became uncontrolled after a mean of 33 days (range 13 to 48 days). This was accurately reflected by a worsening of all parameters. The first parameter to change was the sputum eosinophil percentage (20 days before the loss of asthma control). Significant changes in exhaled nitric oxide, FEV1 and methacholine PC20 were observed only when the symptoms became uncontrolled. A high blood eosinophil count at baseline (risk ratio of 2.5, 95% CI 1.0 to 6.5) and an increase in sputum eosinophil count after the reduction of corticosteroids were predictors of loss of asthma control. CONCLUSION: In patients whose asthma is controlled on inhaled corticosteroid, it is prudent not to reduce the dose further if the blood eosinophils are increased or if the sputum eosinophils increase by as little as 1% after the reduction of corticosteroids.

Role of extracellular matrix and its regulators in human airway smooth muscle biology.

Altered extracellular matrix (ECM) deposition contributing to airway wall remodeling is an important feature of asthma and chronic obstructive pulmonary disease (COPD). The molecular mechanisms of this process are poorly understood. One of the key pathological features of these diseases is thickening of airway walls. This thickening is largely to the result of airway smooth muscle (ASM) cell hyperplasia and hypertrophy as well as increased deposition of ECM proteins such as collagens, elastin, laminin, and proteoglycans around the smooth muscle. Many growth factors and cytokines, including fibroblast growth factor (FGF)-1, FGF-2, and transforming growth factor (TGF)-beta1, that are released from the airway wall have the potential to contribute to airway remodeling, revealed by enhanced ASM proliferation and increased ECM protein deposition. TGF-beta1 and FGF-1 stimulate mRNA expression of collagen I and III in ASM cells, suggesting their role in the deposition of extracellular matrix proteins by ASM cells in the airways of patients with chronic lung diseases. Focus is now on the bidirectional relationship between ASM cells and the ECM. In addition to increased synthesis of ECM proteins, ASM cells can be involved in downregulation of matrix metalloproteinases (MMPs) and upregulation of tissue inhibitors of metalloproteinases (TIMPs), thus eventually contributing to the alteration in ECM. In turn, ECM proteins promote the survival, proliferation, cytokine synthesis, migration, and contraction of human airway smooth muscle cells. Thus, the intertwined relationship of ASM and ECM and their response to stimuli such as chronic inflammation in diseases such as asthma and COPD contribute to the remodeling seen in airways of patients with these diseases.

All-optical half adder using an SOA and a PPLN waveguide for signal processing in optical networks.

We demonstrate an all-optical half adder for bit-wise addition of two serial data streams that simultaneously generates Sum and Carry outputs. The module performs the required XOR and AND operations using only two nonlinear optical elements. Difference Frequency Generation in a periodically poled lithium niobate waveguide serves as the AND gate and cross-gain modulation in a semiconductor optical amplifier is employed to generate the XOR output. Error free operation for RZ data is reported.

Ultrasensitive second-harmonic generation frequency-resolved optical gating by aperiodically poled LiNbO3 waveguides at 1.5 microm.

We retrieve intensity and phase profiles of 280 fs, 50 MHz optical pulses with 124 aJ coupled pulse energy (960 photons) by second-harmonic generation (SHG) frequency-resolved optical gating, using aperiodically poled LiNbO3 waveguides. The strong nonlinear interaction that is due to confinement within the micrometer-sized waveguide structure and the linearly chirped poling period contribute, respectively, to high SHG efficiency and broad phase-matching bandwidth. The achieved sensitivity is 2.7 x 10(-6) mW2, improving on the previous record for self-referenced complete pulse characterization by 5 orders of magnitude.

400-photon-per-pulse ultrashort pulse autocorrelation measurement with aperiodically poled lithium niobate waveguides at 1.55 microm.

We demonstrate ultrasensitive intensity autocorrelation measurements of subpicosecond optical pulses in the telecommunication band by using aperiodically poled lithium niobate (A-PPLN) waveguides. The tightly confined optical beam in the waveguides and the chirped poling period facilitate simultaneous high second-harmonic generation (SHG) efficiency and broad phase-matching (PM) bandwidth. The resulting measurement sensitivity is 3.2 x 10(-7) mW2, approximately 500 times better than the previous record for intensity autocorrelations. We also show that chirped A-PPLN waveguides retain nearly the same SHG efficiency as the unchirped guide as long as the PM bandwidth is not significantly broader than the input spectrum.

Role for cysteinyl leukotrienes in allergen-induced change in circulating dendritic cell number in asthma.

BACKGROUND: Dendritic cells are important antigen-presenting cells. After an allergen inhalation, their numbers rapidly decrease in circulation and increase in the airway mucosa. OBJECTIVE: To investigate whether allergen-induced changes in the number of circulating dendritic cells are mediated by cysteinyl leukotrienes. METHODS: In a randomized, double-blind, crossover study, we examined the effects of 2 weeks of treatment with pranlukast (a cysteinyl leukotriene 1 [CysLT1] receptor antagonist) 300 mg twice daily and placebo on allergen-induced changes in airway responses and circulating dendritic cells in 15 subjects with mild asthma. We examined by flow cytometry, before and at 3 hours and 24 hours after allergen inhalation, the proportion of myeloid (CD33+) and plasmacytoid (CD123+) dendritic cells (HLA-DR+, CD14-, CD16-) among all peripheral blood mononuclear cells. The fraction of dendritic cells expressing CysLT1 receptor was also determined. RESULTS: Compared with placebo, pranlukast significantly attenuated both the maximum early (by 55%) and the late (by 39%) asthma responses, the allergen-induced methacholine airway hyperresponsiveness, and the increase in macrophage inflammatory protein 1alpha and 3alpha in induced sputum. A significantly greater proportion of CD33+ cells (55%) expressed CysLT1 receptor compared with CD123+ cells (11%). Consistent with this, pranlukast prevented the allergen-induced decrease in CD33+ dendritic cells at 3 hours postallergen (mean Delta from baseline, +4.4%) compared with placebo (mean Delta, -8.4; P <.05), but not CD123+ cells. CONCLUSION: Pretreatment with pranlukast attenuated allergen-induced airway responses and the decrease in circulating myeloid dendritic cells, demonstrating a novel role of cysteinyl leukotrienes in dendritic cell trafficking.