Prehospital Mortality Due to Hemorrhagic Shock Remains High and Unchanged: A Summary of Current Civilian EMS Practices and New Military Changes

ABSTRACT

Mortality secondary to trauma-related hemorrhagic shock has not improved for several decades. Underlying the stall in progress is the conundrum of effective prehospital interventions for hemorrhage control. As we know, neither pressing hard on the gas nor "stay and play" has changed mortality over the last 20 years. For this reason, when dealing with effective changes that will improve severe hemorrhage mortality outcomes, there is a need for the creation of a hybrid prehospital model. Improvements in mortality outcomes for patients with severe hemorrhage based on evidence for common civilian prehospital procedures such as in-field intubation and immediate fluid resuscitation with crystalloid solution are weak at best. The use of tourniquets, once considered too risky to use, however, has risen dramatically in large part due to success seen during their use in the military. Their use in the civilian setting shows promising results. Recently updated military Advanced Resuscitative Care guidelines propose the use of prehospital whole blood transfusion as well as in-field use of Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta. Several case studies from Europe suggest these strategies are feasible for use in the civilian population, but could they be implemented in the US?

Firearm homicide mortality is influenced by structural racism in US metropolitan areas

INTRODUCTION

Metropolitan cities in the United States suffer from higher rates of gun violence. However, the specific structural factors associated with increased gun violence are poorly defined. We hypothesized that firearm homicide in metropolitan cities would be impacted by Black-White segregation index.

METHODS

This cross-sectional analysis evaluated 51 US metropolitan statistical areas (MSAs) using data from 2013 to 2017. Several measures of structural racism were examined, including the Brooking Institute's Black-White segregation index. Demographic data were derived from the US Census Bureau, US Department of Education, and US Department of Labor. Crime data and firearm homicide mortality rates were obtained from the Federal Bureau of Investigation and the Centers for Disease Control. Spearman ρ and linear regression were performed.

RESULTS

Firearm mortality was associated with multiple measures of structural racism and racial disparity, including White-Black segregation index, unemployment rate, poverty rate, single parent household, percent Black population, and crime rates. In regression analysis, percentage Black population exhibited the strongest association with firearm homicide mortality (β = 0.42, p < 0.001). Black-White segregation index (β = 0.41, p = 0.001) and percent children living in single-parent households (β = 0.41, p = 0.002) were also associated with higher firearm homicide mortality. Firearm legislation scores were associated with lower firearm homicide mortality (β = -0.20 p = 0.02). High school and college graduation rates were not associated with firearm homicide mortality and were not included in the final model.

CONCLUSION

Firearm homicide disproportionately impacts communities of color and is associated with measures of structural racism, such as White-Black segregation index. Public health interventions targeting gun violence must address these systemic inequities. Furthermore, given the association between firearm mortality and single-parent households, intervention programs for at-risk youth may be particularly effective.

LEVEL OF EVIDENCE

Epidemiological level II.

Single Institution Trial Comparing Whole Blood vs Balanced Component Therapy: 50 Years Later

BACKGROUND

Early close ratio transfusion with balanced component therapy (BCT) has been associated with improved outcomes in patients with severe hemorrhage; however, this modality is not comparable with whole blood (WB) constituents. We compared use of BCT vs WB to determine if one yielded superior outcomes in patients with severe hemorrhage. We hypothesized that WB would lead to reduced in-hospital mortality and blood product volume if given in the first 24 hours of admission.

STUDY DESIGN

This was a 1-year, single institution, prospective, observational study comparing BCT with WB in adult (18+y) trauma patients with active hemorrhage who required blood transfusion upon arrival at the emergency department. Primary endpoint was in-hospital mortality. Secondary endpoints included 24-hour transfusion volumes, in-hospital clinical outcomes, and complications.

RESULTS

A total of 253 patients were included; 71.1% received BCT and 29.9% WB. The WB cohort had significantly more penetrating trauma (64.4% vs 48.9%; p = 0.03) and higher Shock Index (1.12 vs 0.92; p = 0.04). WB patients received significantly fewer units of packed red blood cells (PRBCs) (p < 0.001) and fresh frozen plasma (FFP) (p = 0.04), with a lower incidence of ARDS (p = 0.03) and fewer ventilator days (p = 0.03). Kaplan Meier survival analysis revealed no difference in survival between the 2 transfusion strategies (p = 0.80). When adjusted for various markers of injury severity and critical illness in Cox regression analysis, WB remained unassociated with mortality (hazard ratio 1.25; 95% CI 0.60-2.58; p = 0.55).

CONCLUSIONS

There was no difference in survival rates when comparing BCT with WB. In the WB group, the incidence of ARDS, duration of mechanical ventilation, massive transfusion protocol (MTP) activation, and transfusion volumes were significantly reduced. Further research should be directed at analyzing whether there is a true hemorrhage-related pathophysiologic benefit of WB when compared with BCT.

Asthma in COVID-19 patients: An extra chain fitting around the neck?

Introduction

The novel coronavirus disease 2019 (COVID-19) has rapidly spread across the globe. Pre-existing comorbidities have been found to have a dramatic effect on the disease course. We sought to analyze the effect of asthma on the disease progression and outcomes of COVID-19 patients.

Methods

We conducted a multi-center retrospective study of positively confirmed COVID-19 patients. The primary outcome of interest was in-hospital mortality. Secondary outcomes were the Intensive Care Unit (ICU) admission, intubation, mechanical ventilation, and length of hospital stay.

Results

A total of 502 COVID-19 adult patients (72 asthma and 430 non-asthma cohorts) with mean age of 60.7 years were included in the study. The frequency of asthma in hospitalized cohorts was 14.3%. Univariate analysis revealed that asthma patients were more likely to be obese (75% versus 54.2%, p = 0.001), with a higher frequency of intubation (40.3% versus 27.8%, p = 0.036), and required a longer duration of hospitalization (15.1 ± 12.5 versus 11.5 ± 10.6, p = 0.015). After adjustment, multivariable analysis showed that asthmatic patients were not associated with higher risk of ICU admission (OR = 1.81, 95%CI = 0.98–3.09, p = 0.06), endotracheal intubation (OR = 1.77, 95%CI = 0.99–3.04, p = 0.06) or complications (OR = 1.37, 95%CI = 0.82–2.31, p = 0.23). Asthmatic patients were not associated with higher odds of prolonged hospital length of stay (OR = 1.48, 95%CI = 0.82–2.66, p = 0.20) or with ICU stay (OR = 0.76, 95%CI = 0.28–2.02, p = 0.58). Kaplan-Meier curve showed no significant difference in the overall survival of the two groups (p = 0.65).

Conclusion

Despite the increased prevalence of hospitalization in elder asthmatic COVID-19 patients, after adjustment for other variables, it was neither associated with increased severity nor worse outcomes.

•

Asthma is more prevalent in COVID-19 cohort than in the general population.

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Asthma was neither associated with disease severity nor negative outcomes.

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Asthma does not imply a worse outcome as compared to non-asthmatics.

Inappropriateness of fresh frozen plasma for abnormal coagulation tests

BACKGROUND

There is increasing evidence to suggest that the use of fresh frozen plasma (FFP) as a prophylaxis to bleeding is ineffective. However, a high proportion of FFP transfusions still occur in non-bleeding patients despite the high risk of adverse events. The aim of the study was to assess compliance with current prophylactic FFP guidelines at a large tertiary centre.

METHODS

Data were collected retrospectively over a 16-month period from May 2010 to August 2011. Information collected included patient characteristics, indications for and details of FFP use, and the ordering of coagulation screens before and after transfusion.

RESULTS

Over this period, FFP was used in a total of 573 transfusion episodes, 88 of which were prophylactic. This use deviated from the British Committee for Standards in Haematology guidelines in three main areas: indications for FFP use (89%), dose prescribed (49%) and the measurement of prothrombin time (PT) and activated partial thromboplastin time (APTT) after transfusion (66%).

CONCLUSIONS

There were no significant differences in compliance with guidelines between different hospital departments, suggesting a culture of widespread inappropriate FFP use and a general lack of understanding among clinicians. Physician training and increased enforcement of existing guidelines could reduce FFP usage and expenditure.

Growth-inhibition of human-melanoma cells by vitamin-d analogs

The antiproliferative activity of 1,25(OH)(2)-vitamin D-3, and four vitamin D analogs was assessed in RPMI-7951, a human melanoma cell line which expresses the vitamin D receptor. Proliferation assays consisted of a [H-3]-thymidine incorporation assay, and a 6-day growth study. The affinity of vitamin D analogs for vitamin D receptor relative to 125(OH)(2)-vitamin D-3 was determined with a hydroxyapatite-based competitive binding assay. For the proliferation assays, cells were treated with 10(-8) M 1,25(OH)(2)-vitamin D-3, 1,25(OH)(2)-16-ene-23-yne-vitamin D-3 (Ro 23-7553), 1,25(OH)(2)-16-ene-23-yne-26,27-hexafluoro-vitamin D-3 (Ro 24-5531), 1,25(OH),-16,23Z-diene-26,27-hexafluoro-vitamin D-3 (Ro 25-5317), and 1 alpha-fluoro-25(OH)- 16-ene-23-yne-hexafluoro-vitamin D-3 (Ro 24-5583). 1,25(OH)(2)-vitamin D-3 and the four analogs all significantly inhibited melanoma cell growth (P<0.05). Competitive binding of the vitamin D analogs to vitamin D receptor ranged from 51% to 72% that of 1,25(OH)(2)-vitamin D-3, suggesting a receptor-mediated response. These results demonstrate that analogs of 1,25(OH)(2)-vitamin D-3 are potent antiproliferative agents in human melanoma cells in vitro.

A xenogeneic PSMA DNA vaccine for patients (pts) with non-castrate metastatic (NCMPC) and castrate metastatic prostate cancer (CMPC)—A phase I trial of proof of principle

3073

Background: Prostate Specific Membrane Antigen (PSMA) represents a target for both primary and metastatic prostate cancer and an anti-angiogenic approach for other solid tumors. Antitumor effects in PC have been observed using autologous dendritic cells pulsed with PSMA peptides. This is a pilot phase I trial of vaccination with a DNA encoding PSMA in patients with PC. The objective was to determine the safety and immunogenicity of vaccination with the genes encoding for mouse and human PSMA in patients with recurrent disease. The hypothesis was that xenogeneic DNA encoding a xenogeneic homologous antigen was a more potent immunogen than self DNA. Methods: Thirty-six HLA-A0201+ pts with either NCMPC or CMPC were randomly assigned to vaccination with either xenogeneic (mouse) or human (self) PSMA DNA delivered i.m. via a high pressure delivery system at 100μg, 1,500μg or 4,000μg every 3 weeks for 3 immunizations. Those pts randomized initially to receive human PSMA DNA received 3 immunizations with mouse PSMA DNA at three week intervals. Sera and peripheral blood mononuclear cells were analyzed for humoral and T cell responses Results: Twenty-nine of 36 pts were evaluable having received all six vaccines. Nine remain active without disease progression or significant change in PSA logslope. One of 6 pts treated at the 4,000μg cohort has been followed by > 92 weeks; at the 1,500μg cohort 1 of 2 pt has been monitored for > 110 weeks; and 1 pt at the 100μg dose has remained on study for > 169 weeks. No high titer antibodies against PSMA were detected by ELISA or FACS against 3T3 fibroblasts transduced to express PSMA. Conclusions: The vaccine was safe at all dose levels without evidence of autoimmune reactivity. While antibodies against PSMA were not detected, studies are ongoing to examine T cell responsiveness. The majority of pts who remain on study were treated at 4,000μg dose level which appears to be the optimal dose. Supported by The Prostate Cancer Foundation and MSKCC Prostate Cancer SPORE

No significant financial relationships to disclose.

HDM2 protein overexpression, but not gene amplification, is related to tumorigenesis of cutaneous melanoma

We investigated the role of alterations of HDM2, the human homologue of murine mdm2, in the tumorigenesis and progression of cutaneous melanoma. A well-characterized cohort of 172 cases representing different points in the spectrum of melanocyte transformation (16 dysplastic nevi, 11 melanomas in situ, 107 invasive primaries, and 38 metastatic lesions), as well as 11 human melanoma cell lines were examined by immunohistochemistry and Western blotting for HDM2 protein expression, and by either Southern blotting (SB) or fluorescence in situ hybridization for HDM2 gene amplification. HDM2 overexpression, defined as >20% tumor cells showing nuclear immunoreactivity, was observed in 1 of 16 (6%) dysplastic nevi, 3 of 11 (27%) melanomas in situ, and 81 of 145 (56%) invasive primary and metastatic melanomas. Comparable frequencies of HDM2 overexpression were observed among invasive primary cases with differing tumor thicknesses as well as among the metastatic cases: 21 of 40 (53%) at < or =1.5 mm; 31 of 50 (62%) at 1.6-3.9 mm; 10 of 17 (58%) at >4 mm; and 19 of 38 (50%) metastases. HDM2 amplification was observed in 1 of 88 (1%) primary cases using fluorescence in situ hybridization, and in 0 of 12 (0%) metastatic cases that overexpressed HDM2 using SB. Melanoma cell lines expressed HDM2 protein, but there was no evidence of amplification by SB. Our data suggest that HDM2 protein overexpression is common in invasive and metastatic melanoma. Observing HDM2 overexpression in noninvasive melanoma suggests that expression of this oncogene may play an early role in melanocyte transformation. HDM2 amplification occurs infrequently, and other mechanisms that up-regulate HDM2 expression are under investigation.

Src-catalyzed phosphorylation of c-Cbl leads to the interdependent ubiquitination of both proteins

The protooncogene c-Cbl has recently emerged as an E3 ubiquitin ligase for activated receptor tyrosine kinases. We report here that c-Cbl also mediates the ubiquitination of another protooncogene, the non-receptor tyrosine kinase c-Src, as well as of itself. The c-Cbl-dependent ubiquitination of Src and c-Cbl requires c-Cbl's RING finger, Src kinase activity, and c-Cbl's tyrosine phosphorylation, probably on Tyr-371. In vitro, c-Cbl forms a stable complex with the ubiquitin-conjugating enzyme UbcH7, but active Src destabilizes this interaction. In contrast, Src inhibition stabilizes the c-Cbl. UbcH7.Src complex. Finally, c-Cbl reduces v-Src protein levels and suppresses v-Src-induced STAT3 activation. Thus, in addition to mediating the ubiquitination of activated receptor tyrosine kinases, c-Cbl also acts as a ubiquitin ligase for the non-receptor tyrosine kinase Src, thereby down-regulating Src.

Final version of the American Joint Committee on Cancer staging system for cutaneous melanoma

PURPOSE

To revise the staging system for cutaneous melanoma under the auspices of the American Joint Committee on Cancer (AJCC).

MATERIALS AND METHODS

The prognostic factors analysis described in the companion publication (this issue), as well as evidence from the published literature, was used to assemble the tumor-node-metastasis criteria and stage grouping for the melanoma staging system.

RESULTS

Major changes include (1) melanoma thickness and ulceration but not level of invasion to be used in the T category (except for T1 melanomas); (2) the number of metastatic lymph nodes rather than their gross dimensions and the delineation of clinically occult (ie, microscopic) versus clinically apparent (ie, macroscopic) nodal metastases to be used in the N category; (3) the site of distant metastases and the presence of elevated serum lactic dehydrogenase to be used in the M category; (4) an upstaging of all patients with stage I, II, and III disease when a primary melanoma is ulcerated; (5) a merging of satellite metastases around a primary melanoma and in-transit metastases into a single staging entity that is grouped into stage III disease; and (6) a new convention for defining clinical and pathologic staging so as to take into account the staging information gained from intraoperative lymphatic mapping and sentinel node biopsy.

CONCLUSION

This revision will become official with publication of the sixth edition of the AJCC Cancer Staging Manual in the year 2002.

Vaccination of high-risk breast cancer patients with mucin-1 (MUC1) keyhole limpet hemocyanin conjugate plus QS-21

Our objective was to determine whether an immune response can be generated against MUC1 peptide and against tumor cell MUC1 after vaccination with MUC1-keyhole limpet hemocyanin (KLH) conjugate plus QS-21 in breast cancer patients. Nine patients with a history of breast cancer but without evidence of disease were treated with MUC1-KLH conjugate plus QS-21, containing 100 microg of MUC1 and 100 microg of QS-21. s.c. vaccinations were administered at weeks 1, 2, 3, 7, and 19. Peripheral blood was drawn at frequent intervals to assess antibody titers. Skin tests were placed at weeks 1, 3, 9, and 21 to determine delayed type hypersensitivity reactions. Common toxicities included a local skin reaction at the site of the vaccine, usually of 4-5 days' duration, and mild flu-like symptoms usually of 1-2 days' duration. High IgM and IgG antibody titers against synthetic MUC1 were detected. IgG antibody titers remain elevated from a minimum of 106-137 weeks after the first vaccination. Binding of IgM antibody to MCF-7 tumor cells was observed in seven patients, although there was minimal binding of IgG antibody. Two patients developed significant antibody titers post-high-dose chemotherapy and stem cell reinfusion. There was no evidence of T cell activation. This MUC1-KLH conjugate plus QS-21 was immunogenic and well tolerated in breast cancer patients. Additional trials are ongoing to determine the optimal MUC1 peptide for use in larger clinical trials. Further investigation of vaccine therapy in high-risk breast cancer is warranted.

A new American Joint Committee on Cancer staging system for cutaneous melanoma

The Melanoma Staging Committee of the AJCC has proposed major revisions of the melanoma TNM and stage grouping criteria. The committee members represent most of the major cooperative groups and cancer centers worldwide with a special interest in melanoma; the committee also collectively has had clinical experience with over 40,000 patients. The new staging system better reflects independent prognostic factors that are used in clinical trials and in reporting the outcomes of various melanoma treatment modalities. Major revisions include 1) melanoma thickness and ulceration, but not level of invasion, to be used in the T classification; 2) the number of metastatic lymph nodes, rather than their gross dimensions, the delineation of microscopic versus macroscopic lymph node metastases, and presence of ulceration of the primary melanoma to be used in the N classification; 3) the site of distant metastases and the presence of elevated serum LDH, to be used in the M classification; 4) an upstaging of all patients with Stage I,II, and III disease when a primary melanoma is ulcerated; 5) a merging of satellite metastases around a primary melanoma and in-transit metastases into a single staging entity that is grouped into Stage III disease; and 6) a new convention for defining clinical and pathologic staging so as to take into account the new staging information gained from intraoperative lymphatic mapping and sentinel lymph node biopsy. The AJC Melanoma Staging Committee invites comments and suggestions regarding this proposed staging system before a final recommendation is made.

Ligand-induced ubiquitination of the epidermal growth factor receptor involves the interaction of the c-Cbl RING finger and UbcH7

c-Cbl plays a negative regulatory role in tyrosine kinase signaling by an as yet undefined mechanism. We demonstrate here, using the yeast two-hybrid system and an in vitro binding assay, that the c-Cbl RING finger domain interacts with UbcH7, a ubiquitin-conjugating enzyme (E2). UbcH7 interacted with the wild-type c-Cbl RING finger domain but not with a RING finger domain that lacks the amino acids that are deleted in 70Z-Cbl, an oncogenic mutant of c-Cbl. The in vitro interaction was enhanced by sequences on both the N- and C-terminal sides of the RING finger. In vivo and in vitro experiments revealed that c-Cbl and UbcH7 synergistically promote the ligand-induced ubiquitination of the epidermal growth factor receptor (EGFR). In contrast, 70Z-Cbl markedly reduced the ligand-induced, UbcH7-mediated ubiquitination of the EGFR. MG132, a proteasome inhibitor, significantly prolonged the ligand-induced phosphorylation of both the EGFR and c-Cbl. Thus, c-Cbl plays an essential role in the ligand-induced ubiquitination of the EGFR by a mechanism that involves an interaction of the RING finger domain with UbcH7. This mechanism participates in the down-regulation of tyrosine kinase receptors and loss of this function, as occurs in the naturally occurring 70Z-Cbl isoform, probably contributes to oncogenic transformation.

Leucine zipper-mediated homodimerization of the adaptor protein c-Cbl. A role in c-Cbl's tyrosine phosphorylation and its association with epidermal growth factor receptor

The 120-kDa proto-oncogenic protein c-Cbl is a multidomain adaptor protein that is phosphorylated in response to the stimulation of a broad range of cell surface receptors and participates in the assembly of signaling complexes that are formed as a result of the activation of various signal transduction pathways. Several structural features of c-Cbl, including the phosphotyrosine-binding domain, proline-rich domain, and motifs containing phosphotyrosine and phosphoserine residues, mediate the association of c-Cbl with other components of these complexes. In addition to those domains that have been demonstrated to play a role in the binding of c-Cbl to other signaling molecules, c-Cbl also contains a RING finger motif and a putative leucine zipper. In this study, we demonstrate that the previously identified putative leucine zipper mediates the formation of Cbl homodimers. Using the yeast two-hybrid system, we show that deletion of the leucine zipper domain is sufficient to abolish Cbl homodimerization, while Cbl mutants carrying extensive N-terminal truncations retain the ability to dimerize with the full-length Cbl. The requirement of the leucine zipper for the homodimerization of Cbl was confirmed by in vitro binding assays, using deletion variants of the C-terminal half of Cbl with and without the leucine zipper domain, and in cells using Myc and green fluorescent protein (GFP) N-terminal-tagged Cbl variants. In cells, the deletion of the leucine zipper caused a decrease in both the tyrosine phosphorylation of Cbl and its association with the epidermal growth factor receptor following stimulation with epidermal growth factor, thus demonstrating a role for the leucine zipper in c-Cbl's signaling functions. Thus, the leucine zipper domain enables c-Cbl to homodimerize, and homodimerization influences Cbl's signaling function, modulating the activity of Cbl itself and/or affecting Cbl's associations with other signaling proteins in the cell.

The tyrosine phosphatase SHP-1 is a negative regulator of osteoclastogenesis and osteoclast resorbing activity: increased resorption and osteopenia in me(v)/me(v) mutant mice

Naturally occuring inactivating mutations of the Src homology 2 (SH2) domain-containing tyrosine phosphatase 1 (SHP-1) in mice give rise to the motheaten (me) phenotype. me/me mice have multiple hematopoietic abnormalities, suggesting that this phosphatase plays an important role in hematopoiesis. SHP-1 binds to and is activated by several hematopoietic surface receptors, including the colony-stimulating factor type 1 receptor. We have examined the role of SHP-1 in osteoclastogenesis and osteoclast function using mice with the viable motheaten (me(v)/me(v)) mutation, which has markedly decreased SHP-1 activity. Histomorphometric analysis of 6-week-old me(v)/me(v) mice and control littermates showed a marked osteopenia with an increase in bone resorption indices. The number of formed osteoclast-like cells (OCLs) in cocultures of me(v)/me(v) hematopoietic cells with normal osteoblasts was significantly increased. In contrast, the number of OCLs formed in the coculture of normal bone marrow cells with the me(v)/me(v) osteoblasts was not significantly different from controls. The bone-resorbing activity of me(v)me(v) OCLs and authentic osteoclasts was also found to be increased. Finally, Western blotting of proteins from me(v)/me(v) and control OCLs revealed an overall increase in tyrosine phosphorylation in the me(v)/me(v) lysates. These in vivo and in vitro results suggest that SHP-1 is a negative regulator of bone resorption, affecting both the formation and the function of osteoclasts.

Expression of type X collagen and matrix calcification in three-dimensional cultures of immortalized temperature-sensitive chondrocytes derived from adult human articular cartilage

Chondrocytes isolated from normal adult human articular cartilage were infected with a retroviral vector encoding a temperature-sensitive mutant of the simian virus 40 large tumor antigen and a linked geneticin (G418)-resistance marker. G418-resistant colonies were then isolated, ring-cloned, and expanded in serum-containing media. Several immortalized chondrocyte cell lines were established from the clones that survived, some of which have been maintained in continuous culture for over 2 years. Despite serial subcultures and maintenance as monolayers, these cells retain expression of markers specific for cells of the lineage, namely type II collagen and aggrecan, detected immunocytochemically. We also examined the phenotype of three of these immortalized cell lines (designated HAC [human articular chondrocyte]) using a pellet culture system, and in this report, we present evidence that a prototype of these lines (HAC-F cells) expresses markers normally associated with hypertrophic chondrocytes. When HAC-F cells were cultivated in centrifuge tubes, for periods of up to 63 days, at 39 degrees C with mild and intermittent centrifugation they continued to express both lineage markers; total type II collagen/pellet remained stable, whereas there was a temporal decrease in cartilage-specific glycosaminoglycans content. In addition, in the presence of ascorbate but in the absence of a phosphate donor or inorganic phosphate supplement, the cells also begin to express a hypertrophic phenotype characterized by type X collagen synthesis and extensive mineralization of the extracellular matrix in late stage cultures. The mRNA encoding type X collagen was detected in the cell pellets by reverse transcriptase polymerase chain reaction as early as day 2, and anti-type X collagen immunoreactivity was subsequently localized in the matrix. The mineral was characterized by energy-dispersive X-ray microanalysis as containing calcium (Ca) and phosphorus (P) with a Ca:P peak height ratio close to that of mineralized bone tissue. The unexpected phenotype of this human chondrocyte cell line provides an interesting opportunity for studying chondrocyte maturation in vitro.

Prognostic significance of peripheral blood and bone marrow tyrosinase messenger RNA in malignant melanoma

The objectives of this study were to evaluate the prognostic significance of reverse transcription PCR (RT-PCR) detection of tyrosinase mRNA in the peripheral blood (PB) and bone marrow (BM) of patients with stage II-IV malignant melanoma (MM). Seventy-three PB samples and 109 BM aspirates from 123 assessable patients with stage II-IV MM were analyzed for tyrosinase mRNA using nested RT-PCR. Twenty-five controls without MM were also evaluated. The RT-PCR results were correlated with overall survival (OS) and clinical stage. Overall, 23 of the 123 patients with MM (19%) had tyrosinase mRNA in their blood and/or BM. RT-PCR positivity was present in the PB of 9 of 73 patients (12%), whereas 18 of 109 (16.5%) had tyrosinase mRNA in their BM. All controls were tyrosinase PCR negative. There was no correlation between RT-PCR results and clinical stage. Within stage II, BM PCR-positive patients had a shorter median survival (24 months) than BM PCR-negative individuals (median not reached), with a P approaching significance (P = 0.06). There was a statistically significant correlation between blood PCR positivity and decreased overall survival (P = 0.03) in all patients. Blood PCR positivity was associated with a significantly decreased OS in stage II and III (P = 0.01 and 0.02, respectively) and was not a predictor of OS in stage IV. In multivariate analysis, blood RT-PCR for tyrosinase mRNA was found to be an independent predictor of survival (P = 0.03; risk ratio, 2.87). RT-PCR can specifically detect tyrosinase mRNA in the PB and BM of patients with MM. Blood RT-PCR is an independent predictor of overall survival in stage II-III MM. Additional studies are needed to define the potential role of this assay in the management of patients with advanced melanoma.

Fc receptors are required in passive and active immunity to melanoma

Effective tumor immunity requires recognition of tumor cells coupled with the activation of host effector responses. Fc receptor (FcR) gamma-/- mice, which lack the activating Fc gamma R types I and III, did not demonstrate protective tumor immunity in models of passive and active immunization against a relevant tumor differentiation antigen, the brown locus protein gp75. In wild-type mice, passive immunization with mAb against gp75 or active immunization against gp75 prevented the development of lung metastases. This protective response was completely abolished in FcR gamma-deficient mice. Immune responses were intact in gamma-/- mice because IgG titers against gp75 develop normally in gamma-/- mice immunized with gp75. However, uncoupling of the Fc gamma R effector pathway from antibody recognition of tumor antigens resulted in a loss of protection against tumor challenge. These data demonstrate an unexpected and critical role for FcRs in mediating tumor cytotoxicity in vivo and suggest that enhancement of Fc gamma R-mediated antibody-dependent cellular cytotoxicity by inflammatory cells is a key step in the development of effective tumor immunotherapeutics.

Immortalization of human marrow stromal cells by retroviral transduction with a temperature sensitive oncogene: identification of bipotential precursor cells capable of directed differentiation to either an osteoblast or adipocyte phenotype

The etiology of osteoporosis is multifactorial, but there is evidence from both animal and human studies that the volume of marrow adipose tissue increases when bone volume is reduced in osteoporosis. The cell-related mechanism that may account for this inverse relationship between the volume of marrow adipose tissue and bone remains to be clarified, although it is known that both adipocytes and osteoblasts are derived from stromal cells precursors in bone marrow. We report that retroviral transduction with a temperature-sensitive oncogene (SV40 large T antigen) can generate bipotential cell lines from human marrow stroma that are capable of directed differentiation, in vitro, down either an osteogenic or adipocytic lineage pathway. One such clone, designated hOP 7, expresses type alpha 1(I) procollagen and has low alkaline phosphatase (AP) activity under basal culture conditions that is reminiscent of an osteoprogenitor cell. Exposure of hOP 7 cells to dexamethasone upregulates AP activity and enables the cells to mineralize their extracellular matrix. Also, treatment with calcitriol induces osteocalcin expression and both PTH and PGE2 induce/augment cAMP formation. Incubation with normal rabbit serum, however, causes the cells to become adipogenic as demonstrated by histological staining with Oil-red-O, expression of mRNA for the early and late adipocyte markers lipoprotein lipase and glycerol 3-phosphate dehydrogenase, respectively, and loss of type alpha 1(I) procollagen mRNA. The generation of homogeneous populations of these cells, as confirmed by Southern blot analysis, demonstrates the capacity of a human clonal cell line to differentiate in either an osteogenic or adipogenic direction.

Expression of members of a novel membrane linked metalloproteinase family (ADAM) in human articular chondrocytes

Using resting chondrocytes derived from human articular femoral head and a conditionally immortalised human articular chondrocyte cell line we have studied the expression of members of the novel metalloproteinase/disintegrin family termed ADAM. Using RT-PCR we can detect the expression of ADAM-12 a novel family member isolated from myeloma cells [1]. We also find expression of ADAM 10 a functional metalloproteinase/disintegrin first isolated from bovine brain and ADAM-15 a metallodisintegrin isolated from mammary derived epithelial cells. Northern blotting was used to confirm expression. One main transcript is visible for ADAM-12 whereas both ADAM-10 and ADAM-15 have multiple transcripts indicating possible RNA variants potentially derived from alternative splicing or alternative use of polyadenylation sites. Since chondrocytes are proposed as an important source of metalloproteinase enzymes involved in joint pathology the potential relevance of the expression of these molecules to connective tissue disorders is discussed.

Appropriateness of admission and the last 24 hours of hospital care in medical wards in an east London teaching group hospital

OBJECTIVE

To assess the rates of inappropriateness of admission and last day of care on adult medical wards in an east London hospital, to identify associations with any inappropriateness and to assess what services need to be improved or provided if patients assessed as "inappropriate" are to be more appropriately placed in the future.

DESIGN

From the patients' medical notes, nursing notes and ward charts, a trained reviewer with nursing and university qualifications collected concurrent information about each patient's first 24 hours as an in-patient and about the last 24 hours of care preceding discharge. Patients were also interviewed before discharge and 7-10 days after discharge, and their health status and level of satisfaction about the discharge process assessed.

SETTING

The three adult medical wards at the Homerton Hospital in Hackney, east London. This hospital is within the St Bartholomew's Hospital Teaching Hospital Group.

SUBJECTS

The case-notes of a random sample of 625 adult in-patients were reviewed.

END POINTS

Appropriateness of admission and last day of care.

MAIN OUTCOME MEASURES

The main instrument used was the Appropriateness Evaluation Protocol (AEP). This is an instrument devised to assess the appropriateness of adult patient admission to, and specific days of care in, acute hospital beds through case-note review against a structured set of criteria.

RESULTS

The study presented here reported that 31% of in-patient admissions to adult medical wards in an east London hospital were inappropriate, and also that 66% of the last days of stay were inappropriate.

CONCLUSIONS

There is clearly considerable room for improvement in relation to cooperation between service providers in order to maximise efficient bed use. Delays due to waiting for medications from pharmacy, and the combination of more "inappropriate" cases wanting help from social services after discharge with the fact that many of them were still in hospital because they were waiting for these services to be organized, suggest that inappropriateness could be reduced through increased efficiency or increased provision in these areas. The study reported here is unique in its inclusion of patient interview data.

Ruptured diaphragm: the latent phase

Traumatic rupture of the diaphragm is an uncommon injury which can be missed unless there is a high index of suspicion. In the interval between rupture of the diaphragm and herniation of abdominal contents, signs and symptoms are nonspecific and the chest X-ray may be normal.

R24 anti-GD3 ganglioside antibody can induce costimulation and prevent the induction of alloantigen-specific T cell clonal anergy

R24 is a monoclonal antibody directed against the cell surface ganglioside GD3. It can detect GD3 on the surface of a subset of T lymphocytes and can stimulate proliferation and secretion of cytokines in vitro. In the present report, we examined the effects of the R24 antibody upon antigen-specific T cell response, employing an HLA-DR7-specific T cell clonal model. As previously shown, primary stimulation of HLA-DR7-specific alloreactive T cell clones by transfectants expressing HLA-DR7 alone (t-DR7) in the absence of B7 co-stimulation resulted in anergy. Binding of cell surface GD3 on HLA-DR7-specific alloreactive T cell clones with R24 under these anergizing conditions resulted in interleukin-2 (IL-2) accumulation and prevented the induction of alloantigen-specific T cell clonal anergy. Binding of GD3 by R24 also prevented anergy under conditions where B7:CD28 interactions were blocked by CTLA4-Ig. The effect of R24 was abrogated in the presence of a combination of monoclonal antibodies for the alpha and beta chains of the IL-2 receptor (IL-2R) or a neutralizing anti-IL-2 antibody. R24 does not appear to interact directly with the IL-2R since incubation of T cell clones with R24 did not induce early activation of IL-2R associated Jak kinases, Jak1 and Jak3, as was induced following incubation with IL-2. In contrast, incubation of HLA-DR7-specific clones with t-DR7 in the presence of R24 did result in phosphorylation of IL-2R related Jak kinases after 24 h. Our data indicate that the membrane ganglioside GD3 structure recognized by R24 may play an important role in antigen-specific T cell clonal response.

Does a dedicated discharge coordinator improve the quality of hospital discharge?

OBJECTIVE

To evaluate the effectiveness of the role of a discharge coordinator whose sole responsibility was to plan and coordinate the discharge of patients from medical wards.

DESIGN

An intervention study in which the quality of discharge planning was assessed before and after the introduction of a discharge coordinator. Patients were interviewed on the ward before discharge and seven to 10 days after being discharged home.

SETTING

The three medical wards at the Homerton Hospital in Hackney, East London.

PATIENTS

600 randomly sampled adult patients admitted to the medical wards of the study hospital, who were resident in the district (but not in institutions), were under the care of physicians (excluding psychiatry), and were discharged home from one of the medical wards. The sampling was conducted in three study phases, over 18 months.

INTERVENTIONS

Phase I comprised base line data collection; in phase II data were collected after the introduction of the district discharge planning policy and a discharge form (checklist) for all patients; in phase III data were collected after the introduction of the discharge coordinator.

MAIN MEASURES

The quality and out come of discharge planning. Readmission rates, duration of stay, appropriateness of days of care, patients' health and satisfaction, problems after discharge, and receipt of services.

RESULTS

The discharge coordinator resulted in an improved discharge planning process, and there was a reduction in problems experienced by patients after discharge, and in perceived need for medical and healthcare services. There was no evidence that the discharge coordinator resulted in a more timely or effective provision of community services after discharge, or that the appropriateness or efficiency of bed use was improved.

CONCLUSIONS

The introduction of a discharge coordinator improved the quality of discharge planning, but at additional cost.

Acute medical admissions: results of a national audit

The rising number of emergency admissions and the increasing specialisation of medicine sometimes cause problems in the organisation of care for patients admitted as emergencies to medical beds. A multidisciplinary working group from general practice and the hospital sector identified five main areas in which problems occurred-communication, appropriateness of referral, finding beds, waiting by patients, and the organisation of clinical care. Guidelines and standards were suggested. We then carried out an audit of acute care in 42 hospitals with 400 or more acute beds. The most significant problems that emerged were the suboptimal involvement of consultants in acute care, the frequent lack of appropriateness of the admitting specialty to the patient's condition, and confusion about policies for admitting elderly patients.

Phase Ia trial of murine immunoglobulin A antitransferrin receptor antibody 42/6

In preclinical in vitro and in vivo systems, mAbs to human transferrin (Tf) receptors blocked iron uptake from Tf and showed antitumor activity. However, Tf receptors are also displayed by normal tissues, and a large, soluble pool of circulating serum Tf receptors has been detected. We report results of a Phase Ia trial of IgA monoclonal anti-Tf receptor antibody 42/6. Twenty-seven patients with advanced refractory cancer received 33 treatments with 42/6 administered as a 24-h infusion at doses ranging from 2.5 to 300 mg/m2. 42/6 was generally well tolerated, although one patient receiving a second treatment experienced an allergic-type response associated with a human antimouse antibody response. Three patients with hematological cancers showed mixed tumor responses; there were no partial or complete remissions. Peak serum levels of antibody were obtained at the termination of the 24-h infusion. At doses >/=25 mg/m2, there was a linear relationship between the 42/6 dose and average peak serum 42/6 levels ranging from <1 to 36 microgram/ml. Serum Tf receptors showed a dose-dependent decrease during 42/6 infusion to 20-30% of baseline, and remained depressed for at least 48 h after terminating the infusion. Serum 42/6 levels rose in an inverse relationship to the drop in Tf receptors. 42/6 induced an increase in serum iron and Tf saturation consistent with blockade of peripheral iron uptake, and reduced Tf receptor display by bone marrow cells. Human antimouse antibody was detected in nine patients. Anti-Tf receptor antibody was well tolerated and mediated in vivo effects on iron uptake and Tf display. Antibody concentrations capable of inhibiting malignant blood cell growth were obtained without toxicity. This represents the first clinical trial of an IgA mouse mAb, and one of only a few trials in which an antibody reacting with a broad range of normal tissues has been administered. Additional clinical trials of anti-Tf receptor antibodies in blood cell cancers are indicated.

Analysis of weekly complete blood counts in patients receiving standard fractionated partial body radiation therapy

PURPOSE

Hematopoiesis is among the most sensitive systems in the body to radiation. Routine complete blood counts (CBCs) are common in clinical radiotherapy practice. Only a few studies have attempted to characterize the behavior of peripheral blood levels during partial body radiation therapy with field sizes smaller than those used in hemibody or total nodal irradiation. Such information is needed to identify which patients are at risk for cytopenia and require close monitoring.

METHODS AND MATERIALS

In 1993, 412 new patients were seen at Michael Reese Hospital for radiotherapy. A total of 972 weekly CBCs were identified for 155 patients receiving a minimum of 5 weeks of treatment for breast, prostate, lung, gynecological, or head and neck malignancies. Linear regression models were fitted to the weekly CBC values for those patients who had pretreatment CBC values recorded. Factors affecting starting levels, rates of decline, and nadirs during treatment were determined for leukocytes, platelets, and hemoglobin.

RESULTS

Leukocytes declined most dramatically during the first week of treatment (16% from pretreatment to Week 1 levels) and then at a rate of 3.3% per week from Week 1 to Week 7 (p < 0.001). Total mean leukocyte decrease over 7 weeks of therapy was 30%. Platelets declined 9% on average during the first week of therapy and then at a mean rate of 1.4% per week (p < 0.02). A statistically significant decrease in hemoglobin levels could not be detected. No difference in the rate of decrease could be found for different disease sites, age groups, or amount of marrow irradiated. The effects of chemotherapy were variable, depending on blood element and whether therapy was sequential or concomitant. The odds of a nadir < 2000 counts/mm3 for white blood count (WBC), < 50,000 counts/mm3 for platelets, and < 8.0 g/dl for hemoglobin were all well below 5%. A strong correlation existed between starting CBC values and nadirs; patients with lower Week 1 CBC levels were most likely to have the lowest nadirs.

CONCLUSIONS

Low CBC levels during radiation therapy are likely to be the result of other medical problems that cancer patients face. Regional irradiation with small field sizes (< 40% of total body marrow) typically used in clinical radiotherapy is unlikely to be the cause of marrow depression significant enough to warrant medical intervention. Blood levels taken during the first week of treatment (Week 1) can be used to determine risks of developing critical nadirs. Localized breast and prostate cancer patients are unlikely to require routine CBCs if initial levels are normal. Routine CBC levels on all radiation oncology patients without other reasons for hematopoietic depression requires reevaluation, as millions of dollars are spent on unnecessary testing. If weekly CBC blood levels are avoided in localized breast and prostate cancer patients, this alone could potentially result in a savings of as much as $40 million a year nationally.

Crossover trial of partial shift working and a one in six rota system for house surgeons in two teaching hospitals

The objective of this study was to compare an on call rota and partial shift working pattern for house surgeons in two hospitals. The study was conducted using a crossover trial of working both systems for 6 weeks each in two groups of newly appointed house surgeons. Assessment was by questionnaire to house surgeons, consultants, registrars, nursing staff and patients. The study took place at the departments of general surgery at Guy's and Lewisham Hospitals, London. A total of 12 house surgeons attached to four surgical firms and their consultants and registrars were the subject of our study. In addition the permanent nursing staff on designated general surgical wards and those patients of greater than 48 h stay on those wards on the day of assessment took part. Expectations of reduced fatigue levels using the partial shift system were not fulfilled. In contrast, this working pattern led to perceived disruption of the running of the surgical firms and demoralization of the house surgeons. Standards of patient care were, however, equally high using a rota or partial shift system. This comparison of a partial shift working pattern to an on call rota of similar average weekly hours demonstrated a marked preference for an on call rota from both medical and nursing staff although patients found both systems acceptable.

Women who have abortions--are they different?

BACKGROUND

The aim of the study is to test the hypothesis that there is no difference between women who are currently undergoing an abortion and those who are not in an inner London health district.

METHODS

One hundred and thirty-one consecutive attenders at an inner city day-care abortion service were compared, using a self-administered questionnaire, with two other groups: a random sample of 142 women aged between 18 and 45 taken from the local Family Health Services Authority age-sex register, and 149 consecutive attenders at the district's antenatal clinic.

RESULTS

Women in the abortion group were found to be very similar to those in the antenatal sample in terms of social class, obstetric history, ethnic origin and knowledge of contraception. Women in the population survey, however, were found to be older, of higher social class, more likely to be white and of UK origin, and to have higher contraceptive knowledge scores. However, when the results were adjusted for age, the differences in social class and several other variables disappeared, although differences in ethnic origin remained.

CONCLUSION

It was concluded that apart from age and ethnic origin, there were no differences between women who were having abortions and those who were not. The evidence points to abortion rates being a function of fertility rate, which is in turn a function of culture, rather than the results of the activities of individual or sub-groups of women at particular risk.