Adding an extension piece to the end of the purge side arm of the Impella device can prevent the incidence of the cassette breaking and decrease the Impella device failure rate: Impact of practice change on patient outcome

Background: Impella 5.5® with Smart Assist is a minimally invasive Left Ventricular Assist Devices (LVAD) approved by the Food and Drug Administration (FDA) for treating ongoing cardiogenic shock for up to 14 days. The Impella® intends to reduce ventricular workload and provide the circulatory support necessary for myocardial recovery.Research Question: Compared to standard practice, does adding an extension piece to the purge tube side arm of the Impella® Device decrease the incidence of device failure and positively impact the health outcome of adult patients receiving Impella® support?Study Design and Methods: A retrospective chart review of ICU patients was done at a tertiary care center from August 2018 to August 2022 to assess the differences in patient outcomes related to Impella® Device utilization before and after the implementation of the extension piece to the purge tube sidearm. Among patients reviewed, a total of 20 were included in our review, with seven not having the purge tube side arm extension added, while 13 patients had the extension.Results: The two study groups had no significant difference in patient health outcomes. Additionally, there were no instances of device failure requiring explanation without the extension tubing. However, there were no cases of the purge cassette cracking with the addition of the extension tubing.Conclusion: The addition of extension tubing to the purge cassette of the Impella® Device did not impact patient health outcomes or the incidence of device failure. There was a complete reduction in the incidence of the purge cassette cracking, which could reduce the potential for infection or device failure over a long period of mechanical support. There is a need for long-term prospective studies to confirm the results.

From numbers to medical knowledge: harnessing combinatorial data patterns to predict COVID-19 resource needs and distinguish patient subsets

Background

The COVID-19 pandemic intensified the use of scarce resources, including extracorporeal membrane oxygenation (ECMO) and mechanical ventilation (MV). The combinatorial features of the immune system may be considered to estimate such needs and facilitate continuous open-ended knowledge discovery.

Materials and methods

Computer-generated distinct data patterns derived from 283 white blood cell counts collected within five days after hospitalization from 97 COVID-19 patients were used to predict patient's use of hospital resources.

Results

Alone, data on separate cell types-such as neutrophils-did not identify patients that required MV/ECMO. However, when structured as multicellular indicators, distinct data patterns displayed by such markers separated patients later needing or not needing MV/ECMO. Patients that eventually required MV/ECMO also revealed increased percentages of neutrophils and decreased percentages of lymphocytes on admission.

Discussion/conclusion

Future use of limited hospital resources may be predicted when combinations of available blood leukocyte-related data are analyzed. New methods could also identify, upon admission, a subset of COVID-19 patients that reveal inflammation. Presented by individuals not previously exposed to MV/ECMO, this inflammation differs from the well-described inflammation induced after exposure to such resources. If shown to be reproducible in other clinical syndromes and populations, it is suggested that the analysis of immunological combinations may inform more and/or uncover novel information even in the absence of pre-established questions.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Tracking the dynamic ecological history of a tropical urban estuary as it responds to human pressures

Coastal cities in tropical areas are often low-lying and vulnerable to the effects of flooding and storms. San Juan, Puerto Rico is a good example of this. It is built around a lagoon-channel complex called the San Juan Bay Estuary (SJBE). A critical channel in the estuary, the Caño Martín Peña, has filled in and now frequently floods the surrounding communities with sewage-enriched waters, causing a series of human health and ecological problems. Sediment core analyses indicate that portions of the SJBE now function as settling basins. High urban and sewage runoff to the Caño contributes nitrogen (N), but stable isotope and sediment nutrient analyses indicate that this runoff may also enhance conditions for coupled sulfate reduction-nitrogen fixation. The amount of 'new' bioavailable N created from inert atmospheric N₂ gas may meet or exceed that from the runoff into the Caño Martín Peña. The ecological consequences of this appear to extend beyond the ponded channel, potentially contributing to the poor water quality of the SJBE, greater than contaminated runoff alone.

Fam83d modulates MAP kinase and AKT signaling and is induced during neurogenic skeletal muscle atrophy

Skeletal muscle atrophy is a serious health condition that can arise due to aging, cancer, corticosteroid exposure, and denervation. Previous work comparing gene expression profiles in control and denervated muscle tissue revealed for the first time that Fam83d is expressed in skeletal muscle and is significantly induced in response to denervation. Quantitative PCR and Western blot analysis found that Fam83d is more highly expressed in proliferating myoblasts compared to differentiated myotubes. Characterization of the transcriptional regulation of Fam83d showed that ectopic expression of myogenic regulatory factors inhibits Fam83d reporter gene activity. To assess where Fam83d is localized in the cell, Fam83d was fused with green fluorescent protein, expressed in C₂C₁₂ cells, and found to localize in a punctate manner to the cytoplasm of muscle cells. To assess function, Fam83d was ectopically expressed in cultured muscle cells and markers of muscle cell differentiation, the MAP Kinase signaling pathway, and the AKT signaling pathway were analyzed. Fam83d overexpression resulted in significant repression of myosin heavy chain and myogenin expression, while phosphorylated ERK and AKT were also significantly repressed. Interestingly, inhibition of the 26S proteasome and the MAP kinase signaling pathway both resulted in stabilization of Fam83d during muscle cell differentiation. Finally, Fam83d has a putative phospholipase D-like domain that appears to be necessary for destabilizing casein kinase Iα and inhibiting ERK phosphorylation in cultured myoblasts. The discovery that Fam83d is expressed in skeletal muscle combined with the observation that Fam83d, a potential modulator of MAP kinase and AKT signaling, is induced in response to neurogenic atrophy helps further our understanding of the molecular and cellular events of skeletal muscle wasting.

Care Management to Promote Treatment Adherence in Patients with Cognitive Impairment and Vascular Risk Factors: A Demonstration Project

Dementia prevention is highly important. Improved control of vascular risk factors has the potential to decrease dementia risk, but may be difficult. Therefore, we developed and piloted a care management protocol for Veterans at risk for dementia. We enrolled 32 Veterans with diabetes and hypertension, at least one of which was poorly controlled, and cognitive impairment. Participants were randomly assigned to a 6-month care management intervention or to usual care. At enrollment, 6-months and 12-months, we assessed cognitive performance, mood, and diabetes and hypertension control. At follow-up, diastolic blood pressure was lower in intervention participants at 6 months (p=.041) and 12 months (p=.022); hemoglobin A1c, global mental status and mood did not differ between groups. Recall of a distractor list (p=.006) and logical memory long-delay recall (p=.036) were better at 6 months in the intervention group (p=.006). Care management may contribute to improved control of dementia risk factors.

Phenotype standardization for statin-induced myotoxicity

Statins are widely used lipid-lowering drugs that are effective in reducing cardiovascular disease risk. Although they are generally well tolerated, they can cause muscle toxicity, which can lead to severe rhabdomyolysis. Research in this area has been hampered to some extent by the lack of standardized nomenclature and phenotypic definitions. We have used numerical and descriptive classifications and developed an algorithm to define statin-related myotoxicity phenotypes, including myalgia, myopathy, rhabdomyolysis, and necrotizing autoimmune myopathy.

Reduction of isoniazid bioavailability in normal men by concomitant intake of food

The influence of food intake on the bioavailability of isoniazid (INH) has been examined in nine healthy male volunteers. INH was administered as a single oral dose, both in fasting state and together with a standardized breakfast. Numerous venous blood samples were obtained 5 min-6 hours after the INH ingestion, and the concentrations of unmetabolized INH in serum were assessed by spectrophotometry. The observations indicate that both the peak concentration and the total amount of INH absorbed are greatly reduced when the drug is ingested together with food. Hence it is recommended that, in the treatment of tuberculosis with INH, the drug should be given on an empty stomach. The data may also have some bearing on the use of INH for assessing acetylation rates and estimating dosages of hydralazine and related drugs.

Evaluation of quinidine Lipettes -- a sustained release preparation

A new sustained release preparation (Lipettes) of quinidine has been evaluated with regard to dissolution, absorption, serum concentration and side-effects. The serum levels of quinidine after single oral doses and after long-term treatment have been compared with the serum levels after administration of some other quinidine preparations on the Swedish market. The side-effects of the sustained release preparations have also been studied. Results indicated that this new sustained release quinidine preparation yields more even serum concentrations of quinidine and seemed to cause less troublesome side-effects than the marketed preparations.

Massive doses of procainamide for ventricular tachyarrhythmias due to myocardial infarction

Three patients are described in whom malignant ventricular arrhythmias appeared in connection with a reinfarction some days after hospitalization for an acute myocardial infarction and in whom massive doses of procainamide, up to 7.5 g/day i.v., were necessary to prevent these arrhythmias. The serum concentration of procainamide was 2--4 times higher than the recommended upper level, but no side-effects were observed. With the dose given, one would have expected still higher serum concentrations. Several reasons for this finding are discussed, including the effects of renal function, intestinal leakage, storage of the drug in tissues and hitherto unknown metabolic pathways of procainamide in patients, who are slow acetylators.

Mexiletine in treatment of ventricular arrhythmias. A long-term follow-up

Maxiletine, a new drug effective in the treatment of ventricular arrhythmias, was given to 20 patients for approximately 2 years. The study was designed to investigate the nature and prevalence of side-effects during long-term therapy, and the degree of correlation between such effects and the serum levels of the drug. The methodology used to determine the serum level is described. Mexiletine was well tolerated and serious side-effects were not seen. In particular, antinuclear factor was not detected during the treatment period. The serum level of mexiletine was easily maintained within the therapeutic range, and most side-effects correlated closely with the drug level. Mexiletine appears to be an effective alternative to currently available antiarrhythmic agents.

Mail and phone interventions for weight loss in a managed-care setting: weigh-to-be 2-year outcomes

OBJECTIVE

Evaluate effectiveness of weight-loss interventions in a managed care setting.

METHODS

Three-arm randomized clinical trial: usual care, mail, and phone intervention. Participants were 1801 overweight managed care organization (MCO) members. Measures included baseline height, weight at baseline and 24 months, self-reported weight at 18 months. Intervention and participation in other weight-related programs was monitored across 24 months.

RESULTS

Weight losses were 2.2, 2.4, and 1.9 kg at 18 months in the mail, phone, and usual care groups, respectively. Mail and phone group weight changes were not significantly different from usual care (P<0.35). Weight losses at 24 months did not differ by condition (0.7 kg mail, 1.0 kg phone, and 0.6 kg usual care, P=0.55). Despite treatment availability over 24 months, participation diminished after 6 months. Participation was a significant predictor of outcomes in the mail and phone groups at 18 months and the mail group at 24 months. Cost-effectiveness of phone counseling was $132 per 1 kg of weight loss with mail and usual care achieving similar cost-efficiency of $72 per 1 kg of weight loss.

CONCLUSION

Although mail- and phone-based weight-loss programs are a reasonably efficient way to deliver weight-loss services, additional work is needed to enhance their short- and long-term efficacy.

An exploration of family carers' experience of respite services in one specialist palliative care unit

BACKGROUND

Changing patterns of care for terminally ill people mean that 90% of patients in the UK now spend the majority of their last year of life at home. It is now widely accepted that supporting individuals to die at home relies heavily on the availability of family carers to provide the majority of the care needed. However, one of the most common reasons for unplanned admissions near the end of life is carers' inability to provide continuing care. One strategy to overcome these challenges has been to offer planned respite care. Despite recent studies, in reality little is known about respite services for patients with life limiting illness, in particular how respite is experienced by the caregivers or to what extent respite services address their needs.

METHODS

This prospective study, comprising mixed methods of data collection, explored the experiences of 25 family carers whose relative had been admitted to the local hospice for inpatient respite care. Semi-structured interviews were conducted at two time points: pre- and post-respite. The Relative Stress Scale Inventory was administered at both interviews.

RESULTS

Just over half of the sample were caring for a relative with a diagnosis of cancer (n=13); the majority of the others had a number of neurological conditions (n = 12). The data demonstrate that managing care for relatives with a life limiting illness was perceived to be hard work, both physically and mentally. Inpatient respite care was considered important as it enabled family carers to have a break from the ongoing care-giving responsibilities, as well as being an opportunity to experience 'normal life' independently. The majority of family carers felt that their expectations of respite for themselves had been achieved. The respite service was well evaluated in relation to: standard of nursing care; alternative facilities on offer, atmosphere; and other care homes.

DISCUSSION

Currently, inpatient respite services are provided to two patient groups--those in the last year of life and those with a chronic life limiting illness. However, on closer analysis, the current model of service delivery, a two-week inpatient stay, may not be best suited to those caring for a relative in the last year of life. Similarly, it might be questioned whether an inpatient hospice is the most suitable setting for those patients needing supportive care, rather than specialist palliative care. The study has raised many issues that need to be considered in the support of carers caring for relatives with a life limiting illness with uncertain trajectories.

Defects in cAMP-pathway may initiate carcinogenesis in dividing nerve cells: a review

The mechanisms of carcinogenesis in nervous tissues are not well understood. It is now established that adenosine 3,',5'-cyclic monophosphate (cAMP)-pathway plays a crucial role in initiating differentiation in transformed and embryonic cells of neuronal and glial origin. Therefore, we propose that defects in the cAMP-pathway may initiate the first phase of carcinogenesis (immortalization). Subsequent genetic abnormalities in oncogenes, anti-oncogenes or other cellular genes individually or in combination may lead to transformation (cancer phenotype). This hypothesis is derived from the fact that an elevation of the cAMP level in murine NB cells induces terminal differentiation in many of these cells in spite of the fact that they are highly aneuploid. Additional changes in cAMP-regulated genes responsible for initiating differentiation may make these cells resistant to cAMP or may make the cAMP-effect on differentiation reversible. Indeed, cAMP-resistant cells exist in NB cell populations, and the cAMP-effect on differentiation is reversible in glioma cells. Identification of genes that initiate, promote and maintain terminal differentiation and those which prevent differentiation following elevation of cAMP in NB cells may increase our understanding of the mechanisms of carcinogenesis. This review illustrates the following: (a) historical background leading to the discovery of cAMP as an inducer of differentiation in nerve cells; (b) identification of potential sites in cAMP-pathway that may play a crucial role in initiating the first phase of carcinogenesis (immortalization) and potential gene targets in immortalized cells whose alterations may cause neoplastic transformation of nerve cells. It is interesting to note that the cAMP pathway remains responsive to an elevated cAMP level in inducing differentiation in NB cells in spite of chromosomal anomalies and genetic changes associated with the maintenance of a cancer phenotype.

Evaluation of antigen-specific responses using in vitro enriched T cells

Antigen-specific lymphocytes are important in the immune response to viral infection. Peripheral blood mononuclear cells (PBMC) are traditionally used as a source of effector cells in most immunological studies. We described here the use of the bispecific monoclonal antibodies (BSMAB) anti CD3:CD8 (CD3,8) and anti CD3:CD4 (CD3,4B) to expand and selectively enrich CD4+ and CD8+ T cells populations, respectively. The expanded cells demonstrated >90% CD3+CD4+ or CD3+CD8+ by 14 days. We measured HIV- and CMV-specific responses of these subset-enriched T cell and found that sensitivity and specificity is similar or higher when compared to PBMC in various cellular immunology assays (CMI). Vbeta analysis of BSMAB-enriched cells demonstrated comparable repertoire to the parent PBMC. Although both CD45RA(hi) and CD45RO(hi) cell populations were expanded with the BSMAB, selective subset depletion demonstrated that the antigen-specific T cell responses were restricted to the initial CD45RO(hi) memory effector subgroup. In conclusion, BSMAB in vitro enrichment of T cells allows significant expansion of the cell population without loss of specificity. This technique of cell expansion permits studies of T cell subset function in situations where the initial cell source is scarce, and presents an alternative for viable and functional T cells in immunological assays.

Energy recovery from grass using two-phase anaerobic digestion

Municipal solid wastes are major sources of air, water and soil contamination. There is a need for alternative waste management techniques to better utilize the waste and minimize its adverse environmental impact. A two-phase pilot-scale bio-fermentation system was used to evaluate the feasibility of producing methane from grass waste, a major constituent of solid wastes. The bi-phasic system consists of a solid phase and a methane phase. Leachate is re-circulated through the solid phase until a desired level of volatile fatty acid (VFA) is accumulated in the leachate. The leachate is then transferred to the methane reactor where the VFA is converted to methane. The results showed that 67% of the volatile solids in the waste can be converted into soluble chemical oxygen demand in a period of six months. The system produced an average of 0.15 m3 of methane per kg of grass. The average methane concentration in the produced gas was 71%. A mathematical model was developed to estimate the methane and carbon dioxide concentrations in the gas phase as a function of reactor properties.

Clinical genetics of familial progressive supranuclear palsy

Recent studies have shown that progressive supranuclear palsy (PSP) could be inherited, but the pattern of inheritance and the spectrum of the clinical findings in relatives are unknown. We here report 12 pedigrees, confirmed by pathology in four probands, with familial PSP. Pathological diagnosis was confirmed according to recently reported internationally agreed criteria. The spectrum of the clinical phenotypes in these families was variable including 34 typical cases of PSP (12 probands plus 22 secondary cases), three patients with postural tremor, three with dementia, one with parkinsonism, two with tremor, dystonia, gaze palsy and tics, and one with gait disturbance. The presence of affected members in at least two generations in eight of the families and the absence of consanguinity suggests autosomal dominant transmission with incomplete penetrance. We conclude that hereditary PSP is more frequent than previously thought and that the scarcity of familial cases may be related to a lack of recognition of the variable phenotypic expression of the disease.

International, multicentre, placebo-controlled study to evaluate the effectiveness of ondansetron vs. metoclopramide in the prevention of post-operative nausea and vomiting

Ondansetron 4 mg was compared with metoclopramide 10 mg for prevention of post-operative nausea and emesis in in-patients undergoing major gynaecological surgery in this double-blind, randomized, placebo-controlled, multicentre study. A total of 1044 patients received a single intravenous (i.v.) injection of study medication immediately before induction of anaesthesia. Nausea and emesis were assessed over the 24 h post-operative period. Significantly more patients who received ondansetron experienced no emetic episodes (44%) compared with those who received metoclopramide (37%, P = 0.049) or placebo (25%, P < 0.001). No nausea was experienced by significantly more patients who received ondansetron (32%) than with patients who received metoclopramide (24%, P = 0.009) or placebo (16%, P < 0.001). In addition, fewer emetic episodes, less severe nausea and a reduced need for rescue antiemetics were also observed with ondansetron (P < 0.05 vs. metoclopramide and placebo). Metoclopramide and placebo-treated patients were also 1.5 times (95% Cl 1.5-4.2) and 2.5 times (95% Cl 1.1-2.0) more likely, respectively, to experience nausea post-operatively. Overall, ondansetron was the most effective antiemetic in this patient population.

The 'No Suicide Contract' Helpful or Harmful?

1. Contracting for Safety (CFS) has become an integral part of nursing practice but never has been subjected to scientific scrutiny. 2. Clinical reasons for avoiding the use of contracting with some patient populations exist, including that some patients may construe CFS as a failure of empathy by the caregiver. 3. CFS can, in some instances, be helpful in establishing a therapeutic relationship or aiding in assessment, but never should be the sole basis for determining a patient's lethality.

Radical cations of benzo[a]pyrene and 6-substituted derivatives: reaction with nucleophiles and DNA

1. Oxidation of benzo[a]pyrene (BP) by I2 in the presence of AgClO4 in benzene generates the BP.+ClO4-.AgI complex. This same method was used to produce radical cations from 6-FBP, 6-ClBP, 6-BrBP and 6-CH3BP. 2. Reaction of the BP, 6-FBP, 6-ClBP and 6-BrBP radical cation perchlorates with H2O produced BP 1,6-, 3,6- and 6,12- dione, whereas 6-CH3BP.+ClO4-.AgI yielded 6-CH2OHBP. 3. When BP.+ClO4-.AgI and 6-FBP.+ClO4-.AgI were reacted with NaOAc in H2O/CH3CN (9:1), 6-OAcBP was formed, in addition to the quinones. In the case of 6-ClBP.+ClO4-.AgI, a small amount of 1-OAc-6-ClBP and 3-OAc-6-ClBP was formed in addition to the diones, whereas for 6-BrBP and 6-CH3BP the reaction products were BP diones and 6-CH2OHBP respectively. 4. These results confirm the localization of charge in the BP.+ at C-6, followed by C-1 and C-3. 5. The reaction of BP with NOBF4 in CH2Cl2 produced BP.+BF4-, radical cation free of complexation with inorganic salts. 6. Reaction of BP.+BF4- with DNA produced the depurinating adducts BP-6-C8Gua, BP-6-C8dGua and BP-6-N7Gua.

Microcalorimetric study on myocardial metabolism in a hibernator and two nonhibernators at 20 degrees C and 37 degrees C

Metabolic activity in cardiac tissue slices from the guinea pig (GP), the rat (RT), the nonhibernating summer and winter hedgehog (SH and WH), respectively, was determined at 20 degrees and at 37 degrees C from their rates of heat production, P, (units, W/g tissue) by direct and indirect calorimetry. Energy-linked transport of Na+ and K+ in the tissues was determined from changes in metabolic rate induced by specific inhibition of the Na/K pump, the functional expression of Na/K-ATPase, the pacemaker enzyme in energy production assigned the role of transporting Na+ and K+ out of and into the cell. The results indicate a higher rate of energy production and utilization in the cardiac tissue of the hedgehog than in that of the nonhibernators, the rat and the guinea pig, at both temperatures. At 37 degrees C the rate at which the cardiac tissue from the hedgehog consumed oxygen was as much as six times that registered for the guinea pig. The temperature coefficients of P and of the Na/K pump in the tissues from the two groups of hedgehogs were significantly higher than in the tissues from the rat and the guinea-pig (P < 0.001). The determined metabolic indices, the basal rate of heat production P, the rate of oxygen consumption, P(O2) in thermal units (W/g tissue), and the Na/K-pump capacity (PC) indicate species-specific differences between the animals. Both PC and its variation with temperature, delta PC/delta T(o)C, were in the order WH > SH > RT > GP. These results indicate that the hedgehog's cardiac tissue, in comparison with that of the nonhibernators, has a greater capacity to generate energy in general and for active transport of Na+ and K+ at 37 degrees C after exposure to a lower temperature. A role is suggested for the Na/K-ATPase and some other unique rate-limiting enzymes in the metabolic pathway for the observed differences in temperature tolerance and cardiac performance between hibernators and nonhibernators.

Screening for psychiatric morbidity in a medical outpatient clinic for HIV infection: the need for a psychiatric presence

OBJECTIVE

To ascertain the prevalence and type of psychiatric morbidity present in HIV infected patients presenting for the first time to a specialty HIV medical clinic. Also, to develop a way of screening for psychiatric cases in this setting using established self-report questionnaires.

METHOD

Fifty patients who presented consecutively for medical care at the Johns Hopkins Hospital General HIV Clinic participated in this study. These patients were first screened using the General Health Questionnaire and the Beck Depression Inventory and subsequently underwent a comprehensive neuropsychiatric evaluation.

RESULTS

Fifty-four percent were found to suffer from a psychiatric disorder with an additional 22 percent from an active substance use disorder. These rates are one-and-one-half to two times higher than those reported from other medical clinics. The GHQ and BDI used together as screens could identify psychiatric "cases" with a sensitivity of 81 percent and a specificity of 61 percent, an efficacy similar to that found in other clinics.

CONCLUSIONS

Given the high prevalence of psychiatric disorders in HIV infected patients presenting for medical care, screening, evaluating, and treating for these disorders is crucial and should be pursued systematically. This is best done through the presence of a psychiatric team within HIV medical clinics rather than in affiliation with such clinics.

Surface damage to cobalt-chrome femoral head prostheses

Fifty-four cobalt-chrome alloy femoral heads were retrieved at revision surgery or at post-mortem; 23 came from uncemented, eight from hybrid and 23 from cemented hip arthroplasties. The uncemented and hybrid implants had porous coating, metal backing and modular femoral heads; with one exception none of the cemented implants had any of these. Twenty-five of the 31 heads from uncemented and hybrid arthroplasties, and 11 of the 23 heads from cemented arthroplasties showed surface damage involving more than 25% of the surface. Scanning electron microscopy revealed multidirectional fine scratches 1 micron to 10 microns in depth and width which appeared to have been made by fine, hard particles. There was a higher rate of such damage in the uncemented and hybrid arthroplasties than in the cemented implants, suggesting that the abrasive particles were mainly released from the metal, rather than from the cement or polyethylene components of the implants.

Surface damage to cobalt-chrome femoral head prostheses

Fifty-four cobalt-chrome alloy femoral heads were retrieved at revision surgery or at post-mortem; 23 came from uncemented, eight from hybrid and 23 from cemented hip arthroplasties. The uncemented and hybrid implants had porous coating, metal backing and modular femoral heads; with one exception none of the cemented implants had any of these. Twenty-five of the 31 heads from uncemented and hybrid arthroplasties, and 11 of the 23 heads from cemented arthroplasties showed surface damage involving more than 25% of the surface. Scanning electron microscopy revealed multidirectional fine scratches 1 micron to 10 microns in depth and width which appeared to have been made by fine, hard particles. There was a higher rate of such damage in the uncemented and hybrid arthroplasties than in the cemented implants, suggesting that the abrasive particles were mainly released from the metal, rather than from the cement or polyethylene components of the implants.

Simulated paraphilias: a preliminary study of patients who imitate or exaggerate paraphilic symptoms and behaviors

In a consecutive series of admissions to the Johns Hopkins Sexual Disorders Unit, 4 out of 20 patients appeared to have simulated paraphilic symptoms that further assessment indicated were either exaggerated or not present. The paper presents case histories of these 4 patients. A descriptive comparison is made between these patients and control groups of patients who admitted having paraphilic symptoms and a group of patients accused of having paraphilic symptoms but who denied them. Patients who simulated paraphilias tended to be self-referred (75%) and without current legal charges (100%). None of these patients was referred or sought treatment for pedophilia, in contrast to the other two patient groups, in which pedophilia accounted for 75% of the referrals. Several possible explanations for why patients might simulate paraphilias and implications for therapists who evaluate or treat sex offenders are discussed.

Antibodies to a recombinant glutamate-rich Plasmodium falciparum protein: evidence for protection of individuals living in a holoendemic area of Liberia

A Plasmodium falciparum antigen gene coding for a 220-kD glutamate-rich protein (GLURP) has been cloned, and the 783 C-terminal amino acids of this protein (GLURP489-1271) have been expressed as a beta-galactosidase fusion protein in Escherichia coli. The encoded 783 amino acid residues contain two areas of repeated amino acid sequences. Antibodies against recombinant GLURP489-1271, as well as against a synthetic peptide corresponding to GLURP899-916, and against a synthetic peptide representing the major glutamate rich repeat sequence from the P. falciparum ring erythrocyte surface antigen (Pf155/RESA) (EENV)6 were examined in 423 individuals (age range 30 days-78 years) living in a malaria holoendemic area of Liberia. In the 5-9-year-old age group, subjects with anti-GLURP489-1271 antibody concentrations greater than the mean value of the group had lower parasite densities than those with low antibody concentrations (P = 0.0151). High levels of anti-GLURP899-916 antibodies did not correlate with low parasite densities. However, high levels of anti-(EENV)6 antibodies were associated with significantly lower parasite densities in the 2-4-year-old age group (P = 0.0189). There was no correlation between the anti-GLURP489-1271 and anti-(EENV)6 antibody responses. The data provide indirect evidence for a protective role of antibodies reacting with recombinant GLURP489-1271 as well as with the synthetic peptide (EENV)6 from the Pf155/RESA.

Effects of hemorrhagic shock and retransfusion on catalase and superoxide dismutase activities in rabbits

The effects of hemorrhagic shock and retransfusion on the activities of two endogenous antioxidant enzymes, catalase and superoxide dismutase, were studied in male New Zealand white rabbits. Following instrumentation and stabilization, blood was withdrawn to reduce mean arterial pressure to 35 mmHg (SHOCK). After 60 min of shock, the warmed autologous blood was infused and the animals were allowed to recover for an additional 30 min (RETRANS). CONTROL animals were instrumented but not bled or transfused. A 60 min period of hemorrhagic shock had no significant effect on tissue or plasma activities of catalase or superoxide dismutase. However, transfusion following hemorrhagic shock resulted in an increase in catalase activity of nearly two-fold in the liver and five-fold in the small intestine. In contrast, superoxide dismutase activity remained unchanged after retransfusion in other tissues and in plasma. These results indicate that superoxide dismutase and catalase activities may be preserved or even induced following transfusion for hemorrhagic shock.

Isolation of a simian immunodeficiency virus related to human immunodeficiency virus type 2 from a west African pet sooty mangabey

Two of 25 healthy pet sooty mangabey (SM) monkeys (Cercocebus atys) living in West Africa were seropositive by immunoblot when surveyed for antibody to simian immunodeficiency virus of macaques (SIVmac). SIVsmLIB1 was isolated from one of the pet sooty mangabeys. Nucleotide sequence data showed that this isolate is a member of the SIVsm/human immunodeficiecy virus type 2 (HIV-2)/SIVmac group of primate lentiviruses. Furthermore, sequence comparisons revealed extensive genetic diversity among SIVsm isolates similar to that observed previously in SIV isolates from naturally infected African green monkeys. These observations provide additional evidence for monkey-human cross-species transmission of SIVsm as the source of HIV-2 infection of human.

Inhibition of complement components C3 and C4 by cadralazine and its active metabolite

The effect of cadralazine and its active metabolite CGP 22639 on the covalent binding reaction of C4 and C3 has been studied. Trypsin-Sepharose was used to activate radio-labelled C3 and C4 and binding of the radio-labelled protein to the trypsin-Sepharose was measured. Cadralazine inhibited 50% of the binding of C3 and C4 at concentrations of 19 mmol/l and 15 mmol/l, respectively. Its active metabolite was more potent and inhibited 50% of the C3 and C4 binding at concentrations of 8 and 3.5 mmol/l, respectively. These concentrations are much higher than those found in plasma during therapy. This is consistent with the clinical observation that in patients with normal kidney function cadralazine is not an inducer of SLE.

The value of ear lobe oximetry in the assessment of disability in asbestos-related disease

Thirty-four asbestos workers, with either asbestosis, diffuse pleural thickening, calcified pleural plaques, or with comparable asbestos exposure but no evidence of asbestos-related disease and seven normal controls underwent a progressive exercise test. The subjects were categorized on the basis of lung function tests and PA chest X-rays. During the exercise test oxygen saturation was measured continuously by an ear lobe oximeter. The asbestosis and diffuse pleural thickening groups showed significant oxygen desaturation on exertion, confirming that both these conditions give rise to appreciable respiratory disability.