Clinical ethicists' perspectives on organisational ethics in healthcare organisations

BACKGROUND

Demand for organisational ethics capacity is growing in health organisations, particularly among managers. The role of clinical ethicists in, and perspective on, organisational ethics has not been well described or documented in the literature.

OBJECTIVE

To describe clinical ethicists' perspectives on organisational ethics issues in their hospitals, their institutional role in relation to organisational ethics, and their perceived effectiveness in helping to address organisational ethics issues.

DESIGN AND SETTING

Qualitative case study involving semi-structured interviews with 18 clinical ethicists across 13 health organisations in Toronto, Canada.

RESULTS

From the clinical ethicists' perspective, the most pressing organisational ethics issues in their organisations are: resource allocation, staff moral distress linked to the organisation's moral climate, conflicts of interest, and clinical issues with a significant organisational dimension. Clinical ethicists were consulted in particular on issues related to staff moral distress and clinical issues with an organisational dimension. Some ethicists described being increasingly consulted on resource allocation, conflicts of interest, and other corporate decisions. Many clinical ethicists felt they lacked sufficient knowledge and understanding of organisational decision-making processes, training in organisational ethics, and access to organisational ethics tools to deal effectively with the increasing demand for organisational ethics support.

CONCLUSION

Growing demand for organisational ethics expertise in healthcare institutions is reshaping the role of clinical ethicists. Effectiveness in organisational ethics entails a re-evaluation of clinical ethics training to include capacity building in organisational ethics and organisational decision-making processes as a complement to traditional clinical ethics education.

Antimetastatic activity of a cyclooxygenase-2 inhibitor

Cyclooxygenase-2 (COX-2) expression is increased in breast cancer and surgery has been shown to increase the growth of metastatic tumours. We investigated the effect of selective COX-2 inhibition on the growth of metastases in either an experimental metastasis model or following excision of a murine primary breast tumour. 50 000 4T1 mammary carcinoma cells were injected into the mammary fat pad of female BALB/c mice. When the mean TD reached 8±0.4 mm, tumours were excised and the mice were randomised into two groups (n=12 per group) to receive daily intraperitoneal injections of the selective COX-2 inhibitor, SC-236 or drug vehicle for 14 days. Alternatively, experimental metastases were established by tail-vein injection of 50 000 4T1 cells. Mice received either the selective COX-2 inhibitor, SC-236 or drug vehicle for 14 days (n=12 per group). SC-236 treatment significantly reduced tumour burden, the number and size of spontaneous metastases following primary tumour excision. SC-236 treatment also reduced tumour burden, the number and size of experimental metastases. Immunohistochemical staining demonstrated that COX-2 inhibition reduced microvessel density and increased apoptosis within both spontaneous and experimental metastases. These data clearly demonstrate that the selective COX-2 inhibitor, SC-236, has potent antimetastatic activity against both spontaneous metastases arising following primary tumour excision and experimental metastases.

Unusual cause of a perforated stomach

A case of gastric perforation 2 months following insertion of a gastric balloon is reported. The literature is reviewed regarding the complications and success rates inherent in such balloon devices. This is the first case report of an intra-gastric balloon causing gastric perforation.

Lack of prognostic effect of Cox-2 expression in primary breast cancer on short-term follow-up

AIMS

Cyclo-oxygenase (Cox) catalyses the conversion of arachidonic acid into prostaglandins (PG) and other eciosanoids. The prostaglandins, especially PGE(2) are implicated in tumorigenesis via angiogenesis and suppression of immune reactivity. There are two known isoforms of the enzyme, Cox-1, which is constitutively expressed and the inducible isoform, Cox-2. Cox-2 is induced in response to inflammatory mediators, growth factors, oncogenes and mitogens. Non-selective Cox inhibitors may reduce the relative risk of colonic and breast carcinoma.

METHODS

We studied the expression of Cox-2 by immunohistochemistry in 106 primary breast carcinoma specimens collected over a three-year period, using a commercially available polyclonal antibody on formalin-fixed, paraffin-embedded tissue. The slides were examined independently by two pathologists. Tumours were classified according to accepted criteria and an immunohistochemical score (IHS) was calculated for each specimen. The IHS combines the percentage of immunoreactive cells (quantity score) and an estimate of staining intensity (staining intensity score).

RESULTS

All patients were female. The mean age was 53 years, range 28-86 years. Forty percent (n=42) of tumours were node negative and 60% (n=64) node positive. Forty-nine percent (n=52) of tumours were grade 3, a further 49% (n=52) grade 2 and 2% (n=2) grade 1. There was no statistically significant correlation between IHS and tumour size, grade, histology, nodal status, estrogen receptor or progesterone receptor positivity. A trend was observed showing an IHS of zero is associated with prolonged survival compared with an IHS of 9-12.

CONCLUSION

Cox-2 expression in primary breast cancer does not correlate with accepted pathological or biochemical prognostic indicators.

Gastrointestinal stromal tumours

BACKGROUND

Gastrointestinal stromal tumours (GISTs), previously classified as benign or malignant smooth muscle tumours, are the most common mesenchymal tumours of the gastrointestinal tract. GISTs express a growth factor receptor with tyrosine kinase activity, termed KIT. Mutations of KIT are common in malignant GISTs and lead to constitutional activation of tyrosine kinase function, which causes cellular proliferation and resistance to apoptosis. GISTs are notoriously unresponsive to chemotherapy and, until the recent introduction of the KIT inhibitor imatinib, there has been no effective therapy for advanced, metastatic disease.

METHODS

A Medline literature search was preformed to locate all articles relating to gastrointestinal tumours, GISTs, KIT and imatinib.

RESULTS AND CONCLUSIONS

The 5-year survival rate after complete resection of GISTs is approximately 50 per cent. The median duration of survival for patients with a metastatic GIST is approximately 20 months, and 9-12 months for patients with local recurrence. Phase II trials have investigated the effect of imatinib on irresectable or metastatic GISTs. In these trials more than 50 per cent of patients responded to imatinib within a few months and approximately 12 per cent had disease progression. Uptake of [(18)F]fluoro-2-deoxy-D-glucose demonstrated by positron emission tomography has been found to be reduced after starting imatinib. The potential for cure and the optimal length of treatment is currently unknown. Imatinib is the first effective systemic therapy for metastatic and locally irresectable GISTs. Large multi-institutional clinical trials to investigate the efficacy of imatinib as adjuvant or neoadjuvant therapy for GISTs are now required.

A novel treatment for chronic pancreatitis

BACKGROUND

Hereditary pancreatitis is an important cause of chronic pancreatitis, which may result in endocrine and exocrine failure. This may necessitate simultaneous pancreas and kidney transplant (SPK). Bladder drainage of the exocrine secretions may cause problems.

AIM

To report one such case and its surgical correction.

METHODS

A 20-year-old male with insulin-dependent diabetes mellitus secondary to idiopathic chronic pancreatitis had a SPK with bladder drainage. Urological and metabolic complications secondary to the drainage of pancreatic secretions, rich in proteolytic enzymes required convertion from bladder to enteric drainage.

RESULTS

He was able to discontinue his pancreatic enzyme supplements, ceased to have steatorrhoea and gained weight. He was referred to the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer (EUROPAC), hereditary pancreatitis was confirmed by genetic analysis.

CONCLUSION

Enteric-drained pancreas transplantation is a successful treatment for exocrine as well as endocrine pancreatic failure and should be considered as a treatment option in patients with chronic pancreatitis.

Pharmacological induction of HSP27 attenuates intimal hyperplasia in vivo

OBJECTIVES

intimal hyperplasia (IH) is a major cause of re-stenosis post-vascular intervention. Induction of heat shock proteins (HSPs), by thermal pre-conditioning, reduces IH. Our aim was to investigate the effect of the pharmacological HSP inducer herbimycin A on IH in the rat carotid balloon injury model.

MATERIALS AND METHODS

thirty male Sprague-Dawley rats were randomized into three groups. All groups underwent balloon injury to the left carotid artery. Stress proteins were induced 18 h pre-operatively by heat shock or herbimycin A. Two weeks post-operatively, animals were sacrificed and carotid intima/media area ratio (I/M ratio) calculated using computerized planimetry. Neo-intimal proliferation was assessed immunohistochemically with PCNA (proliferating cell nuclear antigen). Western blot and immunohistochemistry for arterial HSP70 and HSP27 were performed.

RESULTS

heat stress and herbimycin significantly reduced the I/M ratio (p < 0.05 vs balloon injury alone). Neo-intimal proliferation was significantly reduced in the heat stress and herbimycin groups (p < 0.05 vs balloon injury alone). Heat stress induced arterial HSP70 and HSP27. Herbimycin A increased arterial HSP27.

CONCLUSION

herbimycin A significantly attenuates IH after balloon injury. HSP27 may be the HSP involved in mediating this response. Pharmacological inducers of HSPs may have a therapeutic role to play in preventing re-stenosis post-vascular intervention.

Cyclo-oxygenase inhibition reduces tumour growth and metastasis in an orthotopic model of breast cancer

The effect of selective and non-selective cyclo-oxygenase inhibition on tumour growth and metastasis in an orthotopic model of breast cancer was investigated. 4T1 mammary adenocarcinoma cells were injected into the mammary fat pad of female BALB/c mice. When tumours reached a mean tumour diameter of 8.4+/-0.4 mm, mice were randomised into three groups (n=6 per group) and received daily intraperitoneal injections of the selective cyclo-oxygenase-2 inhibitor, SC-236, the non selective cyclo-oxygenase inhibitor, Indomethacin, or drug vehicle. Tumour diameter was recorded on alternate days. From 8 days after initiation of treatment, tumour diameter in animals treated with either SC-236 or indomethacin was significantly reduced relative to controls. Both primary tumour weight and the number of lung metastases were significantly reduced in the SC-236 and indomethacin treated mice. Microvessel density was reduced and tumor cell apoptosis increased in the primary tumour of mice treated with either the selective or non-selective cyclo-oxygenase inhibitor. In vitro, cyclo-oxygenase inhibition decreased vascular endothelial growth factor production and increased apoptosis of tumour cells. Our results suggest that cyclo-oxygenase inhibitors will be of value in the treatment of both primary and metastatic breast cancer.

Randomised controlled trial of specialist nurse intervention in heart failure

OBJECTIVES

To determine whether specialist nurse intervention improves outcome in patients with chronic heart failure.

DESIGN

Randomised controlled trial.

SETTING

Acute medical admissions unit in a teaching hospital.

PARTICIPANTS

165 patients admitted with heart failure due to left ventricular systolic dysfunction. The intervention started before discharge and continued thereafter with home visits for up to 1 year.

MAIN OUTCOME MEASURES

Time to first event analysis of death from all causes or readmission to hospital with worsening heart failure.

RESULTS

31 patients (37%) in the intervention group died or were readmitted with heart failure compared with 45 (53%) in the usual care group (hazard ratio=0.61, 95% confidence interval 0.33 to 0.96). Compared with usual care, patients in the intervention group had fewer readmissions for any reason (86 v 114, P=0.018), fewer admissions for heart failure (19 v 45, P<0.001) and spent fewer days in hospital for heart failure (mean 3.43 v 7.46 days, P=0.0051).

CONCLUSIONS

Specially trained nurses can improve the outcome of patients admitted to hospital with heart failure.

Enteric conversion after bladder-drained pancreatic transplantation; a simple and safe salvage procedure

OBJECTIVE

To present our experience with conversion from bladder to enteric drainage after simultaneous pancreatic and renal transplants, so that new transplant centres know that it is both safe and effective.

DESIGN

Retrospective study.

SETTINGS

Teaching hospital, Republic of Ireland.

SUBJECTS

Six patients who had simultaneous pancreatic and renal transplants for insulin-dependent diabetes and who subsequently developed complications of bladder drainage including recurrent episodes of dehydration and metabolic acidosis (n = 3), haematuria (n = 2), and urinary tract infections (n = 1).

INTERVENTION

Conversion to enteric drainage.

MAIN OUTCOME MEASURE

Resolution of symptoms.

RESULTS

All symptoms resolved, but one patient each developed pulmonary oedema, haematuria, and prolonged ileus. All three complications resolved on conservative treatment. All patients are well with surviving grafts a mean of 40 months later (range 19-50).

CONCLUSION

Conversion to enteric drainage is safe and effective in patients with refractory metabolic or urological complications of bladder drainage after simultaneous pancreatic and renal transplantation.

Randomized clinical trial of diathermy versus scalpel incision in elective midline laparotomy

BACKGROUND

Electrocautery is used increasingly for tissue dissection, although fears of excessive scarring and poor wound healing have curtailed its widespread use for skin incision. This study compared electrosurgical incision with traditional scalpel incision.

METHODS

One hundred patients requiring elective midline laparotomy were randomized prospectively to either scalpel or diathermy incision. Parameters measured included incision time, wound size, wound blood loss, total intraoperative blood loss and postoperative wound pain. All wound complications were recorded.

RESULTS

The two groups did not differ significantly in relation to patient or wound characteristics. Laparotomy incisions using diathermy were significantly quicker than scalpel incisions (mean(s. e.m.) 6.1(0.4) versus 7.5(0.5) s/cm2; P < 0.04). There was significantly less blood loss in the diathermy group compared with the scalpel group (0.8(0.1) versus 1.7(0.3) ml/cm2; P = 0.002). Postoperative pain scores were significantly lower in the diathermy group for the first 48 h after operation (P < 0.05). Morphine requirements were also significantly lower over the first 5 postoperative days in the diathermy incision group (P < 0.04). There was no difference between groups in wound complications before discharge and at the 1-month follow-up.

CONCLUSION

Electrosurgical midline incision in elective surgery has significant advantages over scalpel use on the basis of incision time, blood loss, early postoperative pain and analgesia requirements.

Induced and accidental hypothermia

OBJECTIVE

To review human thermoregulation and the pathophysiology and management of induced and accidental hypothermia.

DATA SOURCES

A review of studies reported over ten years from 1990 to 2000 and identified through a MEDLINE search of the English-language literature on thermoregulation and induced and accidental hypothermia.

SUMMARY OF REVIEW

Hypothermia is defined as a core temperature less than 35 degrees C, and may be therapeutic (i.e. induced for clinical benefit) or accidental. Hypothermia induced prior to cardiovascular or neurosurgical procedures (i.e. therapeutic hypothermia) allows for a greater hypotensive operative period with less risk of cerebral or cardiac ischaemic injury. Hypothermia induced following tissue injury (e.g. closed head injury, cerebrovascular accident, adult respiratory distress syndrome) has also been used to reduce ischaemic tissue injury, although significant clinical benefits have not yet been demonstrated. Inadvertent hypothermia (i.e. accidental hypothermia) is classed as mild from 33 degrees C-35 degrees C, moderate from 30 degrees C-33 degrees C and severe if less than 30 degrees C. Treatment includes surface and core warming methods, all of which have a valid basis from experimental studies. However, no prospective, randomised controlled clinical trials exist that have compared the various rewarming methods. Currently, passive rewarming methods (e.g. reflective metalloplastic sheets, blankets) are recommended for patients with mild hypothermia (> 33 degrees C), active surface rewarming (e.g. heated blankets, hot air circulators) for moderate hypothermia (> 30 degrees C), active core rewarming (e.g. heated haemodialysis, haemodiafiltration or peritoneal dialysis) for severe hypothermia (< 30 degrees C), and heated cardiopulmonary bypass for severe hypothermia with cardiopulmonary arrest.

CONCLUSIONS

Operative hypothermia reduces ischaemic injury during cardiac and neurosurgical procedures. Hypothermia induced following tissue injury has not yet been shown to be of benefit. Management of accidental hypothermia requires passive and active warming methods, the indication of each depending on the availability of the method and severity of hypothermia.

Angiography of fluoresceinated anti-vascular endothelial growth factor antibody and dextrans in experimental choroidal neovascularization

OBJECTIVE

To determine if anti-vascular endothelial growth factor antibody and a range of dextrans with varying diffusion radii and molecular weights are permeable through experimental choroidal neovascularization (CNV).

METHODS

Choroidal neovascularization was induced in 10 cynomolgus monkey retinas by means of argon laser injury. Digital fundus fluorescein angiograms were performed with fluorescein sodium, fluoresceinated IgG antibodies (anti-vascular endothelial growth factor and a control antibody), and fluoresceinated dextrans with molecular weights of 4, 20, 40, 70 and 150 kd. The 40- and 70-kd dextrans straddle the effective diffusion radius of IgG. For each reagent, early and late angiograms were performed in a standardized fashion, with follow-up images obtained to monitor residual fluorescence.

RESULTS

Perfusion of retinal vessels and choroidal vasculature was seen with all reagents. Fluorescein and 4- and 20-kd dextran leaked rapidly from the CNV within the first minute. Angiography with the use of 40-kd dextran and fluoresceinated antibody, either anti-vascular endothelial growth factor or control IgG, showed fluorescence within the CNV that increased during the first 1 to 5 hours, with mild leakage from the CNV. By 24 hours, fluorescence in the CNV was minimal, although in some cases persistent fluorescence in the surrounding tissue was evident up to 2 weeks. The 70-kd dextran showed fluorescence within the CNV and leakage in 1 of 3 eyes. The 150-kd dextran showed fluorescence within the CNV but did not demonstrate leakage.

CONCLUSIONS

Fluoresceinated antibodies and dextran with smaller effective diffusion radii showed CNV perfusion and leakage. Dextrans with larger effective diffusion radii (70 kd and 150 kd) perfused into CNV but did not show leakage consistently.

CLINICAL RELEVANCE

Determining the permeablity of antibodies and molecules of similar size through CNV can help ascertain the feasibility of using intravenously administered antibodies against angiogenic growth factors as a future treatment for choroidal neovascularization.

MDMA toxicity presenting with severe hyperpyrexia: a case report

Ingestion of even small amounts of MDMA ('ecstasy') by a small subset of the population may result in a potentially fatal clinical syndrome of severe hyperpyrexia, cardiovascular collapse, coagulopathy, rhabdomyolysis and multiple organ failure. Rapid and aggressive temperature control is of utmost importance in the management of these patients. We report a case of MDMA toxicity presenting with severe hyperpyrexia (43 degrees C) who survived after a rapid reduction in temperature to 36 degrees C within 60 minutes following active surface cooling, cooled (approximately 4 degrees C) intravenous solutions, urinary and gastric lavage solutions and replacement fluids for continuous veno-venous diafiltration.

Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus

Using a computer database, we conducted a retrospective review of all ankle fractures treated at our institution from March 1985 to October 1996. Twenty-one patients with diabetes mellitus and isolated ankle fractures that were treated operatively met all inclusion criteria. Seven had insulin-dependent diabetes, and 14 had non-insulin-dependent diabetes. A randomly selected control group of 46 patients without diabetes who also underwent operative treatment of ankle fractures during this same time period were matched for age, sex, and fracture severity. The complication rate was 43% with 13 complications in nine patients with diabetes. There were seven (15.5%) complications in the control group. Complications in the diabetic group included seven infections (five deep, two superficial) and three losses of fixation. The complications were more severe in our diabetic population, requiring seven additional procedures including two below-knee amputations; a third patient refused an amputation. No additional procedures were required in our control group. All complications in our control group resolved with treatment. The relative risk for postoperative complications in patients with diabetes who sustained ankle fractures that were treated operatively was 2.76 times greater than the control group's (95% confidence interval, 1.57-3.97).

Intravenous magnesium

OBJECTIVE

To review the function and use of intravenous magnesium in magnesium depleted and non-magnesium depleted patients.

DATA SOURCES

A review of studies reported from 1966 to 1998 and identified through a MEDLINE search of the English-language literature on the use of intravenous magnesium.

SUMMARY OF REVIEW

Magnesium is a metalo-coenzyme that participates in numerous enzymatic reactions including all reactions that involve the formation and utilization of ATP. The cardiovascular, neurological and metabolic disorders caused by magnesium deficiency are associated with an increase in morbidity and mortality and can be rapidly corrected by magnesium therapy. There is also evidence that intravenous magnesium alters ion channels, NMDA receptors, and calcium metabolism, causing effects that are beneficial in a range of cardiovascular, respiratory and metabolic disorders, in the absence of magnesium deficiency. In these disorders intravenous magnesium sulphate is usually administered as an initial bolus varying between 8 - 16 mmol over 5 min, followed by an infusion of 2 - 4 mmol/h, to keep the plasma magnesium between 1.5 - 3 mmol/L.

CONCLUSIONS

Magnesium is required in patients who are magnesium depleted and is also of benefit in non-magnesium depleted patients with pre-eclampsia. It may also be of benefit in non-magnesium depleted patients with acute coronary syndromes, arrhythmias, acute asthma, stroke, seizures and spinal cord injury.

Incidence and occupational pattern of leukaemias, lymphomas, and testicular tumours in western Ireland over an 11 year period

STUDY OBJECTIVE

To determine incidence of the following malignancies, testicular tumours, all leukaemias and all lymphomas in the West of Ireland in an 11 year period. Secondly, to examine the relation between disease patterns and available occupational data in male subjects of working age.

DESIGN

A census survey of all cases occurring in the three counties in the Western Health Board (WHB) area, Galway, Mayo and Roscommon, for the 11 year period 1980 to 1990 inclusive. Average annual age standardised incidence rates for the period were calculated using the 1986 census data. Rates for the area are compared with rates from the southern region of Ireland, which had a tumour registry. Trends over the time period are evaluated. All male subjects for whom occupational data were available were categorised using the Irish socioeconomic group classification and incidence rates by occupation were compared using the standardised incidence ratio method. In one of the counties, Galway, a detailed occupational history of selected cases and an age matched control group was also elicited through patients' general practitioners.

SETTING

All available case records in the West of Ireland.

RESULTS

There are no national incidence records for the period. Compared with data from the Southern Tumour Registry, the number of cases of women with myeloid leukaemias was significantly lower. Male leukaemia rates were significantly lower as a group (SIR 84 (95% CI 74, 95) but not when considered as individual categories. Regression analysis revealed an increasing trend in the number of new cases of non-Hodgkin's lymphoma among both men (r = 0.47, p = 0.02) and women (r = 0.90, p = 0.0001) and of chronic lymphocytic leukaemia in men (r = 0.77, p = 0.005) and women (r = 0.68 p = 0.02) in the WHB region over the last decade. Four hundred and fifty six male cases over the age of 15 years were identified and adequate occupational information was available for 74% of these. Standardised incidence ratios of testicular tumours 100, 938) and agriworkers other than farmers (SIR 377, 95% CI 103, 967). There were also significantly increased incidence ratios for both non-Hodgkin's lymphoma (SIR 169, 95% CI 124, 266) and three categories of leukaemias among farmers. Hodgkin's disease and acute myeloid leukaemias were significantly increased among semi-skilled people. Interview data with 90 cases and 54 controls of both sexes revealed that among farmers, cases (n = 31) were significantly less likely than controls (n = 20) to use tractor mounted spraying techniques (OR = 0.19 (95% CI 0.04, 0.80)) and less likely to wear protective masks (OR 0.22 (95% CI 0.05, 0.84)).

CONCLUSIONS

Trends of increase in non-Hodgkin's lymphoma and some leukaemias are consistent with studies elsewhere. The study provides further evidence of the relation between agricultural work and certain lymphoproliferative cancers. The possible carcinogenic role of chemicals used in agricultural industries must be considered as an explanation.

Abnormal regulation of the leptin gene in the pathogenesis of obesity

A subset of obese humans has relatively low plasma levels of leptin. This finding has suggested that in some cases abnormal regulation of the leptin gene in adipose tissue is etiologic in the pathogenesis of the obese state. The possibility that a relative decrease in leptin production can lead to obesity was tested by mating animals carrying a weakly expressed adipocyte specific aP2-human leptin transgene to C57BL/6J ob/ob mice (which do not express leptin). The transgene does not contain the regulatory elements of the leptin gene and is analogous to a circumstance in which the cis elements and/or trans factors regulating leptin RNA production are abnormal. The ob/ob mice carrying the transgene had a plasma leptin level of 1. 78 ng/ml, which is approximately one-half that found in normal, nontransgenic mice (3.72 ng/ml, P < 0.01). The ob/ob animals expressing the leptin transgene were markedly obese though not as obese as ob/ob mice without the transgene. The infertility as well as several of the endocrine abnormalities generally evident in ob/ob mice were normalized in the ob/ob transgenic mice. However, the ob/ob transgenic mice had an abnormal response when placed at an ambient temperature of 4 degreesC, suggesting that different thresholds exist for the different biologic effects of leptin. Leptin treatment of the ob/ob transgenic mice resulted in marked weight loss with efficacy similar to that seen after treatment of wild-type mice. In aggregate these data suggest that dysregulation of leptin gene can result in obesity with relatively normal levels of leptin and that this form of obesity is responsive to leptin treatment.

Identification of a family of zinc transporter genes from Arabidopsis that respond to zinc deficiency

Millions of people worldwide suffer from nutritional imbalances of essential metals like zinc. These same metals, along with pollutants like cadmium and lead, contaminate soils at many sites around the world. In addition to posing a threat to human health, these metals can poison plants, livestock, and wildlife. Deciphering how metals are absorbed, transported, and incorporated as protein cofactors may help solve both of these problems. For example, edible plants could be engineered to serve as better dietary sources of metal nutrients, and other plant species could be tailored to remove metal ions from contaminated soils. We report here the cloning of the first zinc transporter genes from plants, the ZIP1, ZIP2, and ZIP3 genes of Arabidopsis thaliana. Expression in yeast of these closely related genes confers zinc uptake activities. In the plant, ZIP1 and ZIP3 are expressed in roots in response to zinc deficiency, suggesting that they transport zinc from the soil into the plant. Although expression of ZIP2 has not been detected, a fourth related Arabidopsis gene identified by genome sequencing, ZIP4, is induced in both shoots and roots of zinc-limited plants. Thus, ZIP4 may transport zinc intracellularly or between plant tissues. These ZIP proteins define a family of metal ion transporters that are found in plants, protozoa, fungi, invertebrates, and vertebrates, making it now possible to address questions of metal ion accumulation and homeostasis in diverse organisms.

Absence of soluble leptin receptor in plasma from dbPas/dbPas and other db/db mice

The leptin receptor (Ob-R) is alternatively spliced into at least five different RNAs designated Ob-R(a-e). Ob-R(a-d) predict receptors with a single transmembrane domain, and Ob-Re predicts a secreted form of the receptor. The presence of an approximately 120-kDa soluble leptin receptor in mouse plasma was confirmed by precipitation with leptin-Sepharose beads followed by immunobloting with anti-leptin receptor antibodies. The soluble leptin receptor is larger than that predicted by the primary sequence. Deglycosylation of the receptor with peptide N:glycosidase F results in a decrease in molecular mass to a size consistent with that of the primary sequence. The secreted receptor was present in plasma from wild type mice but was truncated in plasma from db3J/db3J and absent in dbPas/dbPas plasma. Although db3J/db3J mice are known to have a frameshift mutation at amino acid 625, the basis for the mutation in dbPas/dbPas mice was not known. Further studies indicated that dbPas/dbPas mice carry a duplication of exons 4 and 5 of Ob-R. This mutation introduces a premature stop codon into the protein at amino acid 281. The absence of Ob-R in db3J/db3J and dbPas/dbPas mice confirm the identify of the 120-kDa plasma protein as Ob-Re.

Complications relating to the urinary tract associated with bladder-drained pancreatic transplantation

OBJECTIVE

To evaluate the incidence and management of the urological complications after bladder-drained pancreatic transplantation.

PATIENTS AND METHODS

A retrospective study was carried out on 24 consecutive bladder-drained pancreatic transplants in 24 patients with type I insulin-dependent diabetes mellitus, 22 with simultaneous kidney transplants and two of pancreas alone, over a period of 53 months.

RESULTS

All 24 patients were alive within a mean follow-up of 26.7 months: 22 patients have functioning pancreatic grafts and are insulin-independent. The overall incidence of urological complications was 83% (20 of 24 patients) and 14 patients had more than one complication. The major non-infective complication was haematuria (eleven), which was treated conservatively, with only two patients requiring enteric conversion. One patient developed a duodeno-vesical fistula and lost the functioning pancreatic graft as a consequence. Other non-infective complications were urethritis (one) and urethral stricture (one), which were managed with catheter drainage and internal urethrotomy, respectively, and vulval ulcers (one) and reflux pancreatitis (one) treated conservatively. The main infective complications were recurrent lower urinary tract infection (nine), asymptomatic persistent bacteriuria (nine), prostatitis and epididymitis (one), and pyelonephritis (one), all managed with appropriate antibiotics. Three patients developed septicaemia from urosepsis and were treated successfully with antibiotics. Two patients developed genital warts and were treated with laser vaporization.

CONCLUSION

Although bladder drainage has significantly contributed to the increasing success of pancreatic transplantation, urological complications are frequent and can be serious and life-threatening. As more of these procedures are performed urologists need to be able to recognize and treat these problems.

Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema

OBJECTIVE

To evaluate whether bilevel positive airway pressure, by actively assisting inhalation, more rapidly improves ventilation, acidemia, and dyspnea than continuous positive airway pressure (CPAP) in patients with acute pulmonary edema.

DESIGN

Randomized, controlled, double-blind trial.

SETTING

Emergency department in a university hospital.

PATIENTS

Twenty-seven patients, presenting with acute pulmonary edema, characterized by dyspnea, tachypnea, tachycardia, accessory muscle use, bilateral rales, and typical findings of congestion on a chest radiograph.

INTERVENTIONS

In addition to standard therapy, 13 patients were randomized to receive nasal CPAP (10 cm H2O), and 14 patients were randomized to receive nasal bilevel positive airway pressure (inspiratory and expiratory positive airway pressures of 15 and 5 cm H2O, respectively) in the spontaneous/timed mode that combines patient flow-triggering and backup time-triggering.

MEASUREMENTS AND MAIN RESULTS

After 30 mins, significant reductions in breathing frequency (32 +/- 4 to 26 +/- 5 breaths/min), heart rate (110 +/- 21 to 97 +/- 20 beats/min), blood pressure (mean 117 +/- 28 to 92 +/- 18 mm Hg), and Paco2 (56 +/- 15 to 43 +/- 9 torr [7.5 +/- 2 to 5.7 +/- 1.2 kPa]) were observed in the bilevel positive airway pressure group, as were significant improvements in arterial pH and dyspnea scores (p < .05 for all of these parameters). Only breathing frequency improved significantly in the CPAP group (32 +/- 4 to 28 +/- 5 breaths/min, p < .05). At 30 mins; the bilevel positive airway pressure group had greater reductions in Paco2 (p = .057), systolic blood pressure (p = .005), and mean arterial pressure (p = .03) than the CPAP group. The myocardial infarction rate was higher in the bilevel positive airway pressure group (71%) compared with both the CPAP group (31%) and historically matched controls (38%) (p = .05). Duration of ventilator use, intensive care unit and hospital stays, and intubation and mortality rates were similar between the two groups.

CONCLUSIONS

Bilevel positive airway pressure improves ventilation and vital signs more rapidly than CPAP in patients with acute pulmonary edema. The higher rate of myocardial infarctions associated with the use of bilevel positive airway pressure highlights the need for further studies to clarify its effects on hemodynamics and infarction rates, and to determine optimal pressure settings.

Conserved promoter elements in the CYP6B gene family suggest common ancestry for cytochrome P450 monooxygenases mediating furanocoumarin detoxification

Despite the fact that Papilio glaucus and Papilio polyxenes share no single hostplant species, both species feed to varying extents on hostplants that contain furanocoumarins. P. glaucus contains two nearly identical genes, CYP6B4v2 and CYP6B5v1, and P. polyxenes contains two related genes, CYP6B1v3 and CYP6B3v2. Except for CYP6B3v2, the substrate specificity of which has not yet been defined, each of the encoded cytochrome P450 monooxygenases (P450s) metabolizes an array of linear furanocoumarins. All four genes are transcriptionally induced in larvae by exposure to the furanocoumarin xanthotoxin; several are also induced by other furanocoumarins. Comparisons of the organizational structures of these genes indicate that all have the same intron/exon arrangement. Sequences in the promoter regions of the P. glaucus CYP6B4v2/CYP6B5v1 genes and the P. polyxenes CYP6B3v2 gene are similar but not identical to the -146 to -97 region of CYP6B1v3 gene, which contains a xanthotoxin-responsive element (XRE-xan) important for basal and xanthotoxin-inducible transcription of CYP6B1v3. Complements of the xenobiotic-responsive element (XRE-AhR) in the dioxin-inducible human and rat CYP1A1 genes also exist in all four promoters, suggesting that these genes may be regulated by dioxin. Antioxidant-responsive elements (AREs) in mouse and rat glutathione S-transferase genes and the Barbie box element (Bar) in the bacterial CYP102 gene exist in the CYP6B1v3, CYP6B4v2, and CYP6B5v1 promoters. Similarities in the protein sequences, intron positions, and xanthotoxin- and xenobiotic-responsive promoter elements indicate that these insect CYP6B genes are derived from a common ancestral gene. Evolutionary comparisons between these P450 genes are the first available for a group of insect genes transcriptionally regulated by hostplant allelochemicals and provide insights into the process by which insects evolve specialized feeding habits.

Cryptosporidiosis in children who visited an open farm

In the summer of 1995, cryptosporidiosis was diagnosed in a child in hospital. This child had taken part in a summer activity project involving 161 children and nine adults. Reports of a similar illness among a number of other participants prompted an outbreak investigation. A cohort study was conducted in two phases. Thirteen children (aged 6 to 15 years) out of 161 respondents to the first questionnaire met the case definition for illness and cryptosporidium was detected in stools from seven of the 13. Illness was significantly associated with child participants who had visited an open farm (p < .000005). Nine of the cases sought medical attention, and two were admitted to hospital. The second phase of the cohort study was conducted among 52 of the 55 people who had visited the open farm. Illness was significantly associated with playing in sand to which animals had access, at the edge of a stream beside a picnic area (p < .005). Contact with various animals was not associated with illness. This outbreak emphasises the risk for children of visiting open farms. Managers of open farms need to be aware of the potential for transmission of infectious diseases to visiting children. Strict implementation of hygiene measures is essential to minimise risk.

Subarachnoid hemorrhage diagnosis: lumbar puncture is still needed when the computed tomography scan is normal

OBJECTIVES

To determine the sensitivity of third-generation CT scanners for diagnosed nontraumatic subarachnoid hemorrhage (SAH) and to assess the impact of symptom duration on sensitivity.

METHODS

A retrospective chart review was performed in a university-affiliated tertiary care hospital with an annual ED volume of > 100,000 patients. The target population was all patients who presented to the ED from January 1991 to September 1994 with symptoms suggestive of SAH and who had a final diagnosis of nontraumatic SAH based on either a positive CT scan or positive spinal fluid analysis. Patients referred from outside facilities were included if they had a CT done at the study site. All CT scans were done using third-generation scanners. Official CT scan reports were used to categorize scans as positive or negative.

RESULTS

There were 140 patients identified with SAH, with a mean age of 56 years (range 10-88). The sensitivity of CT in the diagnosis of nontraumatic SAH when performed at or before 12 hours of symptom duration was 100% (80/80), and 81.7% (49/60) after 12 hours of symptom duration (95% CI 95-100% and 69.5-90.4%, respectively; p < 0.0001). Eleven of the 140 patients had a negative CT and positive spinal fluid analysis, yielding an overall sensitivity of 92.1% (129/140).

CONCLUSION

The sensitivity of third-generation CT scans for SAH decreases with time from the onset of symptoms. In this sample population, CT was able to detect all patients scanned < or = 12 hours after symptom onset. Although the study demonstrated good sensitivity of CT scan reports for SAH when the scan was performed after < or = 12 hours of symptom onset, additional real-time experience is needed to better define the potential risk of a missed SAH should this population not receive the customary lumbar puncture examination in the setting of a negative CT scan.

Intravenous infusion of liposomal benzoporphyrin derivative for photodynamic therapy of experimental choroidal neovascularization

OBJECTIVE

To compare the effectiveness of photodynamic therapy to close experimental choroidal neovascularization using an intravenous infusion of liposomal benzoporphyrin derivative (verteporfin) with previous work using a rapid intravenous injection, before initiating clinical trials.

METHODS

Choroidal neovascularization was induced in cynomolgus monkey eyes using argon laser. Liposomal benzoporphyrin derivative was delivered by an intravenous infusion pump for 10 or 32 minutes at a dose of 0.375 mg/kg. Irradiation was performed with 689- or 692-nm laser light (600-mW/cm2 irradiance and 150-J/cm2 fluence) in 7 normal eyes and 11 eyes with choroidal neovascularization between 30 and 105 minutes after the start of dye infusion. Findings were documented by fundus photography, fluorescein angiography, and light and electron microscopy.

RESULTS

Irradiation within 32 to 50 minutes of the start of the fast (10 minutes) or slow (32 minutes) dye infusion resulted in closure of choroidal neovascularization. In normal eyes, this technique caused choriocapillaris closure and retinal pigment epithelium damage with minimal damage to surrounding tissues.

CONCLUSION

Photodynamic therapy using intravenous infusion of liposomal benzoporphyrin derivative selectively closed experimental choroidal neovascularization. This may be a suitable modality for clinical use.

Professional partnerships in primary care practice

Professional partnerships in pediatric primary care produce opportunities for blending nursing and medical roles to offer optimal health care to children and families. During the Sixth Annual Pediatric Nursing Conference, held October 4-7, 1990 in San Francisco, issues of role delineation, reimbursement or salary schedules, prescriptive authority, on-call status, malpractice coverage, and hospital privileges were discussed among a distinguished panel of PNPs and physicians.

Alpha 1-adrenergic stimulation of Cl- efflux in isolated brown adipocytes

Unidirectional 36Cl- efflux from preloaded isolated brown adipocytes was studied. A norepinephrine-stimulated 36Cl- efflux pathway was found which approximately doubled the rate of 36Cl- efflux from the cells. The response to norepinephrine was fully inhibited by the alpha 1-adrenergic antagonist prazosin, but was unaffected by the beta-adrenergic antagonist propranolol, showing that norepinephrine stimulated the 36Cl- efflux pathway via the alpha 1-adrenoceptor. The stimulation of 36Cl- efflux could not be mimicked by the Ca2+ ionophore A23187, indicating that the effect was not mediated by elevation of the intracellular Ca2+ level. It is concluded that brown fat cells possess a specific mechanism for alpha 1-adrenergic stimulation of Cl- efflux. The possibility is discussed that this Cl- efflux pathway could be the basis for the early alpha-adrenergic depolarization seen in brown fat cells.

Beta-adrenergic modulation of Ca2+ uptake by isolated brown adipocytes. Possible involvement of mitochondria

Rapid, unidirectional Ca2+ influx was examined in isolated brown adipocytes by short incubations (30 s) with 45Ca2+. Ca2+ uptake was found to be large in the resting brown adipocyte, but was markedly inhibited when the cells were presented with norepinephrine. Specific alpha 1-adrenergic stimulation was without effect on Ca2+ uptake. The effect of norepinephrine (which had an EC50 of 140 nM) could be inhibited by beta-adrenergic blockade and could be mimicked by forskolin (an adenylate cyclase activator) and theophylline (a phosphodiesterase inhibitor). Exogenous free fatty acids such as octanoate and palmitate (classical stimulators of respiration in brown adipocytes) were also able to dramatically inhibit Ca2+ uptake by the cells. The artificial mitochondrial uncoupler carbonyl cyanide p-trifluoromethoxyphenylhydrazone (FCCP) induced a large reduction in cellular Ca2+ uptake (even in the presence of the ATPase inhibitor oligomycin), and in the presence of FCCP the inhibitory effect of norepinephrine on Ca2+ uptake was significantly reduced. The effect of beta-adrenergic stimulation on Ca2+ uptake was not directly caused by the large increase in respiration that occurs in response to norepinephrine because the respiratory inhibitor rotenone did not affect the Ca2+ response of the cells to the hormone. The evidence suggests that beta-adrenergic stimulation of brown adipocyte metabolism leads to a partial inhibition of Ca2+ uptake into the mitochondrial Ca2+ pool and we discuss the possibility that this represents the effect of a reduced membrane potential (and thus reduced Ca2+ uniport activity) in the partially uncoupled mitochondria of the thermogenically active brown adipocyte.

Distinction between mechanisms underlying alpha 1- and beta-adrenergic respiratory stimulation in brown fat cells

Experimental conditions are described for selective alpha 1- and beta-adrenergic stimulation of the respiration of brown fat cells. The dual agonist norepinephrine was unsuitable as a selective alpha 1-agonist, since unacceptably high concentrations of propranolol were needed to abolish the beta-response. Phenylephrine at 50 microM, in the presence of 5 microM dl-propranolol, was shown to lead to a maximal, selective alpha 1-stimulation, whereas maximal, selective beta-stimulation was achieved with 1 microM isoproterenol in the presence of 5 microM prazosin. The mitochondrial uncoupler carbonyl cyanide p-trifluoromethoxyphenylhydrazone (FCCP) was able to further increase respiration that was already maximally alpha 1-stimulated, but when added before the alpha 1-stimulation, FCCP totally abolished the response. In contrast, FCCP had no effect on the beta-stimulated response. Similarly, oligomycin (an inhibitor of mitochondrial ATP synthesis) inhibited alpha 1-respiration but had a much smaller effect on beta-respiration. Ouabain (an inhibitor of the Na+-K+-ATPase) halved alpha 1-respiration but only induced a small inhibition of beta-respiration. It is concluded that only a small fraction of thermogenesis from beta-adrenergic processes is due to oxidative phosphorylation, whereas alpha 1-respiration is largely due to the oxygen cost of mitochondrial ATP synthesis, and a large fraction of this ATP is apparently used for the restoration of ion gradients.

Norepinephrine-induced Na+ influx in brown adipocytes is cyclic AMP-mediated

To examine the involvement of Na+ ions in adrenergic responses in brown adipose tissue, a method is described for measuring Na+ influx into isolated brown adipocytes, using short (30 s) incubations with 22Na+, followed by a two-step centrifugation recovery procedure. Using this method, a clear norepinephrine-stimulated accumulation of intracellular 22Na+ was observed, which was enhanced by the addition of ouabain, was insensitive to amiloride (a Na+/H+ exchange blocker), and could not be mimicked by the total removal of oxygen from the incubation medium. The norepinephrine-stimulated Na+ influx was dose-dependent for the hormone with an EC50 of 250 nM, was blocked by the beta-antagonist propranolol but not by the alpha 1-antagonist prazosin, and could be induced by adrenergic agonists with the order of potency: isoproterenol greater than norepinephrine greater than phenylephrine, indicating a beta-receptor-mediated process. The Na+ influx was found to be cAMP-dependent since it could be induced by both theophylline (a phosphodiesterase inhibitor) and forskolin (an adenylate cyclase activator), but it was independent of other known cellular cAMP-dependent responses since neither addition of fatty acid substrates (octanoate or palmitate), nor of the mitochondrial uncoupler carbonyl cyanide p-trifluoromethoxyphenyl-hydrazone could induce the phenomenon, despite having significant stimulatory effects on cellular respiration. Furthermore, total respiratory inhibition with rotenone, or total oxygen depletion of the medium with dithionite, did not prevent the normal norepinephrine-induced Na+ influx. The possibility that this beta-mediated norepinephrine-stimulated Na+ influx plays an important physiological role in brown adipose tissue activity is discussed, perhaps as one of the, as yet undefined, signals initiating tissue growth in the chronically beta-stimulated tissue of animals facing long-term increases in thermogenic demands.

Presence of a Ca2+-dependent K+ channel in brown adipocytes. Possible role in maintenance of alpha 1-adrenergic stimulation

We have previously demonstrated mobilization of Ca2+ in and efflux of Rb+ (K+) from isolated hamster brown adipocytes as a consequence of norepinephrine stimulation. We have now investigated the adrenoceptor subtype specificity of these responses and found them both to be of the alpha 1-subtype. Further, we have found that the Rb+ (K+) efflux was dependent upon a primary Ca2+ mobilization event in response to the alpha 1-adrenergic stimulation, since the Rb+ efflux could also be demonstrated by the addition of the Ca2+ ionophore A23187 to the cells. The norepinephrine- and A23187-stimulated Rb+ effluxes were both inhibited by the Ca2+-dependent K+-channel blocker apamin. Apamin also significantly attenuated Ca2+ mobilization in cells in response to a submaximal concentration of norepinephrine. We conclude that alpha 1-adrenergic stimulation of brown fat cells leads to a mobilization of intracellular Ca2+ which, in itself or via other mechanisms, leads to an increase in cytosolic Ca2+ concentration which, in turn, activates a Ca2+-dependent K+ channel, leading to a K+ release from these cells. A possible role for this channel to sustain and augment the response to alpha 1-adrenergic stimulation is discussed.

Na+-dependent, alpha-adrenergic mobilization of intracellular (mitochondrial) Ca2+ in brown adipocytes

The existence and significance of a hormone-sensitive, rapidly mobilizable intracellular pool of Ca2+ in hamster brown-fat cells was investigated with 45Ca2+-labelling techniques. It was shown that such a pool existed and was probably located within the abundant mitochondria. It was rapidly mobilized by norepinephrine (median effective concentration 50 nM) through alpha-adrenergic mechanisms. The mobilization of Ca2+ from the intracellular stores (mitochondria) required the presence of extracellular Na+, but not of Ca2+, K+ or Mg2+. It is concluded that the experiments are in agreement with a hypothesis linking the mobilization of intracellular Ca2+ pools with an alpha-adrenergically-induced increase in plasma membrane Na+ permeability (observed as a membrane depolarization), and a subsequent activation of the mitochondrial Na+/Ca2+ exchange, leading to mobilization of mitochondrial Ca2+ and the mediation of alpha-adrenergic effects as a result of an elevated cytosolic Ca2+ level.

Possible expression of the obese gene in the brown adipose tissue of lean heterozygote littermates of the genetically obese (ob/ob) mouse

Lean littermates of the genetically obese (ob/ob) mouse of confirmed genotype, +/+ wildtype or ob/+ heterozygous, were fed either stock diet or a high-energy 'cafeteria' diet. Body weights food consumption, and weights and metabolic parameters of the interscapular and dorso-cervical brown adipose tissue sites were examined. Both genotypes showed similar characteristics of food intake and body weight gain on the cafeteria diet. The ob/+ brown adipose tissue was, however, different from the +/+ in that the GDP binding to the mitochondria was lower and the cytoplasmic density of the mitochondria in the tissue was higher in both stock and cafeteria fed groups. It is suggested that the decreased GDP binding is partly compensated for by an increase in the mitochondrial content of the brown adipose tissue of the ob/+ mice, thus normalizing the total thermogenic capacity and allowing the maintenance of lean body weight despite a slight expression of the obese gene in the thermogenic pathway.

Intraoperative neurosurgical ultrasound: transdural and transfontanelle applications

High-resolution real-time ultrasound scanning of 54 patients was performed with a sector scanner during a variety of neurological procedures. Scans obtained at the time of craniotomy were successful in characterizing and localizing tumors, abscesses, arteriovenous malformations, and hematomas within the brain of 15 of 16 adult patients. One attempt to visualize a brain cyst through a 15-mm burr hole was unsuccessful. Scanning of 37 infants and young children was performed through the anterior fontanelle during placement of ventricular shunts. This allowed for the accurate placement of shunts in all patients and resulted in fewer short-term and long-term complications. Intraoperative ultrasound is a practical and highly effective means of providing intraoperative localization of intracranial anatomy and disease.

Responses to cafeteria feeding in mice after the removal of interscapular brown adipose tissue

Feeding a cafeteria diet to mice resulted in an increased energy intake of approximately 30% and this led to increases in the wet weight, total protein content, and total cytochrome oxidase activity of interscapular and dorso-cervical brown adipose tissue. Surgical removal of interscapular brown adipose tissue, followed by cafeteria feeding, gave rise to an elevation in dorso-cervical brown adipose tissue wet weight, total protein content, and total cytochrome oxidase activity, compared to intact cafeteria-fed mice. Cafeteria feeding with or without the removal of interscapular brown adipose tissue did not lead to significant increases in body weight compared to stock-fed control mice, but both cafeteria-fed groups of mice showed significant elevations in body fat content indicating that the induced hyperphagia led to a relative obesity in the cafeteria-fed groups. The results presented are consistent with an increased thermogenic activity in the brown adipose tissue of cafeteria-fed mice, and the effect of the removal of interscapular brown adipose tissue further indicates the quantitative importance of the tissue in the control of body weight.

The effect of interscapular brown adipose tissue removal on body-weight and cold response in the mouse

1. The removal of the interscapular brown adipose tissue (IBAT) led to an increase in body-weight of normal, lean mice as compared to anaesthetized controls. 2. No significant difference in food consumption could be detected between the two groups of mice over the period of the experiment. 3. Fat extraction of the whole carcasses with chloroform:methanol showed a statistically significant increase in fat content in the animals without IBAT. 4. There was no apparent failure in the operated animals to sustain core temperature when exposed to a cold stress situation (4 degrees for 24 h). 5. There was no difference in the wet weight, protein content or cytochrome oxidase content of the dorso-cervical brown adipose tissue (DCBAT) between operated and control mice. This is indicative of a lack of proliferation of other brown adipose tissue sites in the operated mice in response to the removal of the IBAT. 6. It is suggested that brown adipose tissue is implicated in dietary thermogenesis in the mouse.

Primary reticulum cell sarcoma of the brain in a renal transplantation recipient

✓ A case of primary reticulum cell sarcoma of the brain (microgliomatosis) is reported in a kidney transplant recipient treated with immunosuppressants, the second such case seen at this institution. Hypotheses for the mechanism of lymphoma development in this situation are reviewed, and the remarkable predilection for the brain is pointed out.

The use of intra-arterial Urokinase in a case of recurrent arterial occlusion

The present case report describes the use of intraarterial Urokinase in an occlusive episode involving the right radial and ulnar arteries. Details of the case history are given and the choice of thrombolytic therapy, plus its route of administration are discussed.