Clinical pathways can be based on acuity, not diagnosis

The standardization of medical practice is gaining acceptance as a technique for controlling length of stay and hospital charges, while maintaining quality. Most clinical pathways address specific diagnoses or procedures, but we have developed a new approach in which pathways for cardiac care are based on acuity. All congenital cardiac surgical care rendered at Columbus Children's Hospital now falls within one of four such clinical pathways. This simplified approach is easy to use and has been well accepted. Our experience in a group of 107 consecutive patients treated in this fashion is described. The results of variance analyses, along with length of stay and charge data, are presented to demonstrate the degree to which resource utilization can be standardized in this widely variable group of patients whose problems were made cohesive by classification according to acuity level. We conclude that the resultant standardization offers considerable advantages for the managed care environment.

Pediatric patients requiring CPR in the prehospital setting

STUDY OBJECTIVE

To determine the outcome of pediatric patients with prehospital cardiopulmonary arrest.

DESIGN

Chart review of all patients with prehospital cardiopulmonary arrest who were subsequently admitted to a pediatric emergency department from January 1988 to January 1993. Cardiopulmonary arrest was considered to have been present if assisted ventilation and chest compressions were performed on an apneic, pulseless patient.

SETTING

Pediatric ED.

PARTICIPANTS

Pediatric patients in prehospital cardiac arrest.

RESULTS

In all, 95 patients were identified. Fifty-six had initial hospital care at the pediatric ED (primary patients). The remaining 39 were transported to the pediatric ED after initial care of another institution (secondary patients). Forty-one percent of patients were younger than 1 year. Most arrests were respiratory in origin; asystole was the most common dysrhythmia. Fifteen patients (27%) survived to discharge. Fourteen of the survivors had return of spontaneous circulation before ED arrival. Thirty-three patients were in arrest on ED arrival; in 16 (48%) of these, return of spontaneous circulation subsequently developed in the ED, and 1 survived to discharge. Two survivors, including the survivor with return of spontaneous circulation in the ED, had severe neurologic sequelae. Ten (26%) of the secondary patients survived. All survivors had return of spontaneous circulation before arrival in the ED. Two survivors had severe neurologic sequelae.

CONCLUSION

Most successfully resuscitated pediatric arrest victims are resuscitated in the prehospital setting and do not suffer severe neurologic injury. Most patients who present to the ED in continued arrest and survive to discharge have severe neurologic injury.

Estimation of TCA cycle flux, aminotransferase flux, and anaplerosis in heart: validation with syntactic model

Weiss et al. (Circ. Res. 70: 392-408, 1992) proposed a model of the citric acid cycle (CAC) in myocytes and a system of 17 differential equations that can be used to describe the changes over time in enrichment of carbons C-2 and C-4 of glutamate under conditions of metabolic steady state. They also proposed an empirical measure (KT) of flux through the CAC, which has been shown to be correlated to O2 consumption in rat hearts perfused with acetate or a mixture of glucose and acetate. We report a new method for estimation of the absolute rate of the flux through the CAC in heart (vTCA), without the numerical solution of differential equations. Unlike KT, our estimate is equal to the rate of flux catalyzed by the alpha-ketoglutarate dehydrogenase complex (vTCA), not merely correlated with it. We also estimate the rate of flux catalyzed by aspartate aminotransferase (vTA) and by NADP(+)-dependent malic enzyme (an anaplerotic reaction). The formula for vTCA during administration of [2-13C]acetate is as follows: vTCA = M[(C-2ssLC-4)/[C-4ss(LC-4-LC-2)]], where C-2ss and C-4ss represent steady-state fractional enrichment, LC-2 and LC-4 represent dominant rate constants of C-2 and C-4 of glutamate, respectively, and M is the sum of concentrations of aspartate, glutamate, and intermediates of the CAC. The assumptions underlying our formula are as follows: 1) metabolic steady state is maintained, 2) exchange of molecules between cytosolic and mitochondrial compartments is rapid, 3) 13C enters pools of the CAC only from acetyl CoA via citrate synthase, 4) [citrate]/[glutamate] < 1 + (vTCA/vTA), and 5) (m-[glutamate])/M < C-2ss/C-4ss.

Hyperosmotic urea increases transcription and synthesis of Egr-1 in murine inner medullary collecting duct (mIMCD3) cells

It was previously shown that when cells of renal epithelial origin are exposed to hyperosmotic urea in concentrations unique to the renal medulla, abundance of mRNA encoding the immediate-early gene product Egr-1 is up-regulated. This phenomenon appears restricted to cells of renal epithelial origin. In the present study, the newly isolated murine renal inner medullary cell line mIMCD3 was used to determine whether the urea-induced increase in Egr-1 mRNA abundance is associated with increased expression of functional protein product, and whether this increase is transcriptionally mediated. In Western analysis, urea (200 mM) increased Egr-1 immunoreactivity 3-fold relative to sham-treated cells. [35S]Methionine pulse-labeling followed by immunoprecipitation confirmed that this increased immunoreactivity was associated with increased de novo Egr-1 protein synthesis. Electrophoretic mobility shift assay demonstrated that urea treatment induced a commensurate increase in specific DNA binding activity for the Egr-1 consensus sequence. In addition, the increase in Egr-1 mRNA expression accompanying urea treatment was a consequence of enhanced transcription, as determined by nuclear run-off assay. Taken together, these data indicate that hyperosmotic urea increases both Egr-1 transcription and new protein synthesis in renal epithelial cells in culture, and that this newly synthesized Egr-1 is a functional DNA-binding protein. To our knowledge, this is the first example of urea-inducible gene transcription. In addition, Egr-1 represents the first eukaryotic transcription factor transcriptionally activated by a hyperosmotic stressor.

Coronary artery fistula in the pediatric age group: a 19-year institutional experience

Ten patients with coronary artery fistulae were identified from records at Columbus Children's Hospital between 1974 and 1993. Clinical presentations of patients were quite variable, from 1 day to 20 years of age. Symptoms ranged from none to severe cardiorespiratory failure requiring extracorporeal membrane oxygenation. Long term follow-up revealed one sudden death and one spontaneous closure of the fistula. This lesion should be ruled out in patients who present as extracorporeal membrane oxygenation candidates. Patients with mild forms of this lesion may be followed up medically if the left to right shunt is inconsequential, because spontaneous closure is a possibility. Because of the risk of sudden death, close long-term follow-up is mandatory even for operated patients, and antiplatelet therapy should be considered for these patients.

Reconstitution of energy-linked activities of the solubilized F1F0 ATP synthase from Bacillus subtilis

The F1F0 ATP synthases from wild-type Bacillus subtilis and an uncoupler-resistant mutant have comparable subunit structures. In accord with an earlier hypothesis, ATP hydrolysis and ATP-Pi exchange by the two synthases were equally stimulated and inhibited by protonophores, respectively, when reconstituted alone in either wild-type or mutant lipids.

Use of cardiac catheterization in pediatric cardiac surgical decisions

Current practice patterns relating to pediatric cardiac catheterization (Cath) have considerable economic implications. The decreased cost and risk of noninvasive methods such as echocardiography (ECHO) and magnetic resonance imaging (MRI) make them attractive alternative diagnostic methods if they can sufficiently define cardiac anatomy and the need for surgical intervention. We reviewed a recent cardiac surgical series of 465 cases in 1.5 years to determine how often a Cath was performed prior to surgery. Overall, 59.4% of the procedures were preceded by a Cath (76% of open heart operations, and 26.7% of closed heart operations). We specify the situations where we feel enough information is available for preoperative decision making from non-invasive testing, and we present some diagnostic pitfalls that have been encountered.

SYNTAX: a rule-based stochastic simulation of the time-varying concentrations of positional isotopomers of metabolic intermediates

We present a new approach to simulation of metabolic pathways. The syntactic approach combines a rule-based description of biochemical reactions with a stochastic model of chemical kinetics. Each syntactic rule describes the location in a product molecule to which a particular carbon of a reactant molecule will be transferred. Using specifically labeled substrates and known rates of chemical reactions, our simulation predicts the time-dependent changes in concentration of positional isotopomers of metabolic intermediates. (A positional isotopomer of a compound is an isomer that is determined by the positions of isotopes within the molecule, e.g., [1,2-13C]glucose and [1,3,5-13C]glucose). For the simulation of the 13C-positional isotopomers of the citric acid cycle in heart cells we require only 39 syntactic rules, compared to the 176 ordinary differential equations required by the traditional approach. Addition of chemical reactions to the simulation does not require changing the program code for the existing reactions. In comparison, addition of a reaction to a system described by differential equations requires altering the equations for all isotopomers of all reactants and products of the new chemical reaction.

Prediction of positional isotopomers of the citric acid cycle: the syntactic approach

We propose a syntactic approach to modeling of biochemical fluxes that combines a rule-based description of atomic transfer in chemical reactions with a structurally oriented, stochastic model of chemical reaction kinetics. This approach avoids the use of differential equations to describe the production and disappearance of each molecule. The computer simulation predicts the changes over time in the abundance of each positional isotopomer of every metabolic intermediate in the citric acid cycle of heart cells, subsequent to administration of [2-13C]acetate (including natural abundance of 13C). (Positional isotopomers are isomers that differ in the positions of isotopes within the molecule.) The 32 positional isotopomers of glutamate fell into four groups with similar intragroup dynamics but with very different amplitudes. From the relative abundance of each isotopomer of glutamate, we calculate the relative area of multiplets of the nuclear magnetic resonance spectrum.

A systematic method for studying the spatial distribution of water molecules around nucleic acid bases

A new method to analyze the distribution of water molecules around the bases in DNA is presented. This method relies on the notion of a "hydrated building block," which represents the joint observed hydration around all bases of a particular type, in structures of a particular conformation type. The hydrated building blocks were constructed using atomic coordinates from 40 structures contained in the Nucleic Acid Database. Pseudoelectron densities were calculated for water molecules in each hydrated building block using standard crystallographic procedures. The electron densities were fitted to obtain "average building blocks," which represent bases with waters only at average or probable positions. Both types of building blocks were used to construct models of hydrated DNA oligomers. The essential features of the solvent structure around d(CGCGAATTCGCG)2 in the B form and d(CGCGCG)2 in the Z form were reproduced.

Urea induces Egr-1 and c-fos expression in renal epithelial cells

The membrane-permeant solute urea, in concentrations present in the mammalian renal medulla, increased expression at the mRNA level of two immediate-early gene (IEG) transcription factors, Egr-1 and c-fos, in a time- and dose-dependent fashion in confluent growth-suppressed Madin-Darby canine kidney (MDCK) cells. This upregulation occurred in the absence of both cytotoxicity and an inhibition of protein synthesis, two potential nonspecific inducers of IEG expression. These findings were of interest because we have previously shown that hyperosmotic stress induced by the functionally membrane-impermeant solute NaCl increased expression of these IEG, whereas hyperosmotic stress induced by the membrane-permeant solute glycerol failed to do so. The urea-induced increase in Egr-1 mRNA expression was not secondary to enhanced message stability as determined by actinomycin D experiments and is therefore likely a consequence of urea-induced transcriptional activation. Augmented Egr-1 expression in response to urea treatment was also observed in another renal epithelial cell line, LLC-PK1, but not in other cell types examined. Therefore cells of renal epithelial origin may be uniquely capable of responding to hyperosmotic urea with increased expression of IEG transcription factors, and this increase is likely transcriptionally mediated.

Urea selectively induces DNA synthesis in renal epithelial cells

Hyperosmotic stress with the functionally impermeant solute NaCl has been shown by us and others to inhibit cell growth and DNA synthesis. Several lines of evidence suggest that urea, the other principal renal medullary solute, may exert a growth-promoting effect on renal epithelial cells. Among these is the finding that urea upregulates expression at the mRNA level of two growth-associated immediate-early genes, Egr-1 and c-fos. In the present study, urea, in concentrations characteristic of the renal medulla, increased [3H]thymidine incorporation approximately threefold in confluent, growth-suppressed Madin-Darby canine kidney (MDCK) cells, whereas another readily membrane-permeant solute, glycerol, did not. Urea also overcame the inhibitory effect of hyperosmotic NaCl on DNA synthesis. The urea-induced increase in [3H]thymidine incorporation was also evident in the renal epithelial LLC-PK1 cell line, but not in renal nonepithelial and epithelial nonrenal cell types examined. In addition, it was associated with a 15% increase in total DNA content measured fluorometrically at 24 h of treatment. There was, however, no associated increase in cell proliferation as measured by cell number, total protein content, or cell cycle distribution. Urea also failed to induce polyploidy or aneuploidy. Therefore cells of renal epithelial origin may be uniquely capable of responding to hyperosmotic urea with increased DNA synthesis through an undefined and potentially novel mechanism.

Primary malignant melanoma of the cervix and review of the literature

Primary malignant melanoma of the cervix was diagnosed in a patient presenting with postmenopausal bleeding. A cervical lesion was biopsied, and diagnosis was established by electron microscopy and staining procedures. After failing radiotherapy, the patient was treated with simple hysterectomy and bilateral salpingo-oophorectomy. The cytology, histology, and electron microscopy of this lesion are presented in addition to a clinical discussion.

Surgical management of congenital heart disease in the 1990s

OBJECTIVE

To provide a broad overview of recent trends in surgical management of congenital heart disease.

DESIGN

Review of recent literature.

SETTING

Major centers for surgical management of congenital heart disease.

SELECTION PROCEDURES

Analysis of important recent clinical publications.

INTERVENTIONS

None.

RESULTS AND CONCLUSIONS

Definitive, corrective surgery was previously reserved for children beyond infancy. Recognition of the complications associated with palliative operations as well as the realization that neonates and infants did not fare worse than older children during open heart surgery provided the impetus for primary corrective surgery at an earlier age. Advances in our understanding of perioperative care, improved diagnostic capability, and increasing experience with corrective surgery in association with several different congenital heart lesions has resulted in an established therapeutic approach to surgical management of congenital heart disease in neonates and infants.

Expression of GLUT-2 cDNA in human B lymphocytes: analysis of glucose transport using flow cytometry

The molecular characterization of transport proteins is often limited by transient functional expression or the need for a simple method to select functional cDNA clones. We used a mammalian expression system to obtain long-term expression of GLUT-2, an isoform of glucose permease. Rat GLUT-2 cDNA was ligated into an EBV vector (pLPP) and transfected into B lymphocytes which lack GLUT-2. Northern and Western analyses confirmed expression of GLUT-2 protein in membranes of transfected cells. Two functional assays using flow cytometry were developed to distinguish GLUT-2 transfectants from control/pLPP transfectants. Uptake of NBD-glucosamine, a fluorescent analogue of glucose, was increased in GLUT-2 transfectants. In addition, when exposed to hypertonic glucose medium, GLUT-2 transfectants and control/pLPP transfectants exhibited a difference in forward-angle light scatter (FALS), an index of cell volume, indicating a difference in glucose permeability. Independent measurements of glucose uptake (isotopic) and cell volume (video microscopy) confirmed the flow cytometry observations. This expression system used in combination with flow cytometry is useful for studying the functional properties of glucose and other solute transporters.

Immediate early gene and HSP70 expression in hyperosmotic stress in MDCK cells

The early genetic response to hyperosmotic stress remains to be elucidated in eukaryotes. We observed that hyperosmotic NaCl in Madin-Darby canine kidney cells increased levels of mRNA encoding the immediate early gene (IEG) transcription factors Egr-1 and c-fos at 2 h of treatment by two- and threefold, respectively. Sham treatment and hyperosmotic glycerol, and ineffective osmole, had no effect. Hyperosmotic NaCl, but not glycerol, also increased the mRNA level of the stress protein HSP70 by four- to fivefold at 2, 6, and 24 h. These changes occurred despite inhibition of total RNA transcription rate and DNA synthesis rate by NaCl. Neither NaCl nor glycerol treatment manifested significant cytotoxicity. NaCl, and to a lesser extent glycerol, suppressed protein synthesis, a phenomenon previously correlated with IEG superinduction. Therefore, hyperosmotic stimuli with different physiological effects result in differential expression of IEGs and the stress protein HSP70; induction of the former may govern the ensuing program of gene expression that culminates in the osmolyte response, while the latter may serve as a temporizing protective measure.

N6-substituted adenosine receptor agonists: potential antihypertensive agents

Adenosine is known to exert a wide range of pharmacological effects including hypotension. This effect of adenosine suggested that modified analogues of adenosine might provide useful antihypertensive agents. Thus, we prepared a series of novel N6-benzocycloalkyladenosines and studied their receptor binding and antihypertensive activity. The structure-activity relationship study shows that the adenosine analogues having the hydrophobic phenyl moiety one carbon away from the C6-nitrogen have modest affinity and selectivity for the A1 receptor, whereas those with the phenyl moiety two carbons away from the C6-nitrogen have excellent affinity and selectivity for the A1 receptor. Many of these analogues showed excellent antihypertensive activity with a wide range of effects on heart rate. There is no direct correlation between the receptor binding affinities and antihypertensive activity; however, it is more closely associated with A1 than A2 affinity. The bradycardic effect of these agonists seems to be due to the A1 affinity. From this set, compound 3 was further evaluated in secondary antihypertensive screens. It lowered the blood pressure dose dependently with effects lasting for over 20 h following administration of a 30 mg/kg dose. Compound 3 was also effective in lowering blood pressure in a renal hypertensive rat model. Thus, appropriately modified N6-substituted adenosines represent a novel class of antihypertensive agents.

Episcleral radioactive plaque therapy: initial clinical experience with 56 patients

Between 1983 and 1987, 56 patients with choroidal melanoma were treated at the University of Southern California with episcleral plaque (RPT). There were 29 female and 27 male patients, with a mean age of 59 years. Tumor stage at diagnosis was T2 in 18 (32%) and T3 in 38 (68%) patients. The tumor height ranged from 2.9 to 15 mm (mean 6.8 mm). Radial dimensions ranged from 5 to 25 mm (mean 13.2 mm), and circumference ranged from 7 to 23 mm (mean 12.3 mm). Most (77%) patients had posteriorly located tumors, including 18% that were juxtapapillary. Custom-designed gold plaques were utilized in this study. Radioactive isotopes used were 125I for 26 procedures or 192Ir for 31 procedures. A total of 56 patients were treated, with one patient having two procedures. Radiation doses at the tumor apex ranged from 29.8 to 165.4 Gy (mean 94.5 Gy), with the dose at 5-mm depth ranging from 70.5 to 430 Gy (mean 161.5 Gy). Follow-up ranged from 29 to 57 months (mean 39 months). The overall 4-year survival was 96%, with a 91% incidence of free-of-disease progression at 4 years. The majority (84%) of patients experienced a decrease in tumor height, with 27 (48%) patients having greater than 50% decrease. Increase in tumor height was noted in 5 (9%) and no change in 4 (7%) patients. Useful vision (greater than 5/200) was observed in 59% of patients, including 21% who had improved vision. Metastatic tumor occurred in 5 (9%) patients, with a mean time to metastases of 14 months. There was a good correlation between radial tumor dimension and metastatic disease, p less than 0.001. Treatment complications were observed in 34 (61%) patients, with cataract and retinopathy being the most common. Enucleation was performed in 11 (20%) patients, with a mean time to enucleation of 14.5 months. Causative factors for enucleation were treatment complications in 6 and tumor progression in 5 patients. Enucleations were required primarily in patients with tumors greater than 8 mm in height (p = 0.009). Improved RPT techniques with three-dimensional dosimetry are needed to reduce the overall incidence of treatment complications. Adjuvant hyperthermia is being investigated in an attempt to improve tumor control in patients with larger tumors.

Randomness in the heparin polymer: computer simulations of alternative action patterns of heparin lyase

Heparin is a mixture of linear polysaccharides of undetermined sequence. Both biosynthetic data and computer simulation studies have established that each heparin polymer chain is comprised of oligosaccharides of defined sequence, representing ordered domains. One such ordered domian is a pentasaccharide corresponding to heparin's antithrombin III binding site. Previous computer simulation studies, performed under the assumption that heparin lyase (heparinase, EC 4.2.2.7), has a random endolytic action pattern, suggested that certain of these ordered oligosaccharide domains may themselves be nonrandomly arranged in the heparin polymer. The present work presents computer simulations of alternative action patterns for heparin lyase while assuming a random distribution of these oligosaccharide units within the heparin polymer. We consider action patterns that are determined solely by the primary structure of the substrate molecules. Results of the simulations are compared to (1) the experimental measurements of product chains formed throughout the reaction and (2) the change in weight average molecular weight Mw as a function of reaction completion as determined by absorbance at 232 nm. From the simulation of 60 action patterns for heparin lyase, we infer that one of the following statements concerning heparin and heparin lyase is true: (1) Heparin is a random arrangement of a small number of structurally defined oligosaccharide units. Heparin lyase changes its action pattern during the depolymerization of heparin (perhaps influenced by the secondary structure of substrate). (2) Heparin contain clusters of oligosaccharide sequences that are present in low concentrations (overall) in the polymer. Heparin lyase has a specificity for cleaving glycosidic linkages either exolytically at the nonreducing terminus of a chain or (endolytically) at the reducing side of these rare oligosaccharide sequence.

An artificial-intelligence technique for qualitatively deriving enzyme kinetic mechanisms from initial-velocity measurements and its application to hexokinase

We have developed a computer method based on artificial-intelligence techniques for qualitatively analysing steady-state initial-velocity enzyme kinetic data. We have applied our system to experiments on hexokinase from a variety of sources: yeast, ascites and muscle. Our system accepts qualitative stylized descriptions of experimental data, infers constraints from the observed data behaviour and then compares the experimentally inferred constraints with corresponding theoretical model-based constraints. It is desirable to have large data sets which include the results of a variety of experiments. Human intervention is needed to interpret non-kinetic information, differences in conditions, etc. Different strategies were used by the several experimenters whose data was studied to formulate mechanisms for their enzyme preparations, including different methods (product inhibitors or alternate substrates), different experimental protocols (monitoring enzyme activity differently), or different experimental conditions (temperature, pH or ionic strength). The different ordered and rapid-equilibrium mechanisms proposed by these experimenters were generally consistent with their data. On comparing the constraints derived from the several experimental data sets, they are found to be in much less disagreement than the mechanisms published, and some of the disagreement can be ascribed to different experimental conditions (especially ionic strength).