Multiplatform analyses reveal distinct drivers of systemic pathogenesis in adult versus pediatric severe acute COVID-19

The pathogenesis of multi-organ dysfunction associated with severe acute SARS-CoV-2 infection remains poorly understood. Endothelial damage and microvascular thrombosis have been identified as drivers of COVID-19 severity, yet the mechanisms underlying these processes remain elusive. Here we show alterations in fluid shear stress-responsive pathways in critically ill COVID-19 adults as compared to non-COVID critically ill adults using a multiomics approach. Mechanistic in-vitro studies, using microvasculature-on-chip devices, reveal that plasma from critically ill COVID-19 adults induces fibrinogen-dependent red blood cell aggregation that mechanically damages the microvascular glycocalyx. This mechanism appears unique to COVID-19, as plasma from non-COVID sepsis patients demonstrates greater red blood cell membrane stiffness but induces less significant alterations in overall blood rheology. Multiomics analyses in pediatric patients with acute COVID-19 or the post-infectious multi-inflammatory syndrome in children (MIS-C) demonstrate little overlap in plasma cytokine and metabolite changes compared to adult COVID-19 patients. Instead, pediatric acute COVID-19 and MIS-C patients show alterations strongly associated with cytokine upregulation. These findings link high fibrinogen and red blood cell aggregation with endotheliopathy in adult COVID-19 patients and highlight differences in the key mediators of pathogenesis between adult and pediatric populations.

A-131 Measuring the Effect of CPT-3 Administration on Regional Cerebral Blood Flow with Single-Photon Emission Computed Tomography (SPECT) in ADHD

Objective: The aim of this study is to investigate the effect of the administration of the Conners Continuous Performance Test (CPT-3) on cerebral blood flow (CBF) in children with ADHD.

Methods: The data for this study was derived from a large - database. Participants in the ADHD group (n = 1853, Mage = 12.01) were similar to those in the healthy control group (n = 38, Mage = 11.70). All participants were assessed for cerebral blood flow levels before and after CPT-3 administration.

Results: Multiple 2-by-2 ANOVAs with repeated measures were conducted with sphericity assumed. The overall effect of CPT-3 administration on CBF levels was significant in the right cingulate left and right sides of the frontal lobe left and right sides of the occipital, left and right sides of the parietal lobe, left and right sides of the subcortical region. Post hoc analysis with a Bonferroni adjustment revealed that there was a statistically significant increase in CBF levels from baseline to following CPT-3 administration in both the ADHD and control groups. The interaction between CPT-3 administration and ADHD diagnosis was not significant. The overall effect of ADHD diagnosis on CBF levels was not significant.

Conclusions: All individuals had higher levels of CBF following the administration of CPT-3. Without an interaction, we can infer that ADHD diagnosis does not change the effect of CPT-3 administration on CBF levels. This is counterintuitive considering that CPT-3 is a test of sustained attention, a common challenge for children with ADHD. These findings need to be replicated.

Multistate Outbreak of Melioidosis Associated with Imported Aromatherapy Spray

Melioidosis, caused by the bacterium Burkholderia pseudomallei, is an uncommon infection that is typically associated with exposure to soil and water in tropical and subtropical environments. It is rarely diagnosed in the continental United States. Patients with melioidosis in the United States commonly report travel to regions where melioidosis is endemic. We report a cluster of four non-travel-associated cases of melioidosis in Georgia, Kansas, Minnesota, and Texas. These cases were caused by the same strain of B. pseudomallei that was linked to an aromatherapy spray product imported from a melioidosis-endemic area.

Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multicenter Randomized Clinical Trial

OBJECTIVE

The aim of this study was to determine which initial surgical treatment results in the lowest rate of death or neurodevelopmental impairment (NDI) in premature infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP).

SUMMARY BACKGROUND DATA

The impact of initial laparotomy versus peritoneal drainage for NEC or IP on the rate of death or NDI in extremely low birth weight infants is unknown.

METHODS

We conducted the largest feasible randomized trial in 20 US centers, comparing initial laparotomy versus peritoneal drainage. The primary outcome was a composite of death or NDI at 18 to 22 months corrected age, analyzed using prespecified frequentist and Bayesian approaches.

RESULTS

Of 992 eligible infants, 310 were randomized and 96% had primary outcome assessed. Death or NDI occurred in 69% of infants in the laparotomy group versus 70% with drainage [adjusted relative risk (aRR) 1.0; 95% confidence interval (CI): 0.87-1.14]. A preplanned analysis identified an interaction between preoperative diagnosis and treatment group (P = 0.03). With a preoperative diagnosis of NEC, death or NDI occurred in 69% after laparotomy versus 85% with drainage (aRR 0.81; 95% CI: 0.64-1.04). The Bayesian posterior probability that laparotomy was beneficial (risk difference <0) for a preoperative diagnosis of NEC was 97%. For preoperative diagnosis of IP, death or NDI occurred in 69% after laparotomy versus 63% with drainage (aRR, 1.11; 95% CI: 0.95-1.31); Bayesian probability of benefit with laparotomy = 18%.

CONCLUSIONS

There was no overall difference in death or NDI rates at 18 to 22 months corrected age between initial laparotomy versus drainage. However, the preoperative diagnosis of NEC or IP modified the impact of initial treatment.

Sudden death in an adolescent due to undiagnosed classic Hodgkin lymphoma

Few cases of natural sudden death presenting as an undiagnosed lymphoma have been reported in the literature, especially in adolescents. Herein we provide a report of sudden death caused by undiagnosed classic Hodgkin lymphoma (cHL). We describe an 18-year-old female who collapsed after several weeks of weight loss, decreased appetite, and dyspnea. At autopsy, a bulky mass arising in the mediastinum and neck compressed the esophagus and trachea, surrounded the great vessels, obliterated the pericardial sac, and infiltrated the myocardium. The lungs were collapsed and large pleural effusions were present. The tumor burden, which weighed at least 2710 g in aggregate, was entirely above the diaphragm. Microscopic examination of the masses showed features typical for nodular sclerosis cHL including large bands of sclerosis, numerous Hodgkin/Reed-Sternberg (HRS) cells, and an eosinophil-rich mixed inflammatory cell infiltrate. Immunohistochemical stains showed the HRS cells to be uniformly positive for CD30 and CD15 and negative for CD3, CD20, CD45, and PAX5. This case exemplifies a rare sudden natural death due to previously undiagnosed cHL in a young patient.

The prognostic importance of polypharmacy in older adults treated for acute myelogenous leukemia (AML)

We retrospectively evaluated the prognostic significance of polypharmacy and inappropriate medication use among 150 patients >60 years of age receiving induction chemotherapy for acute myelogenous leukemia (AML). After adjustment for age and comorbidity, increased number of medications at diagnosis (≥ 4 versus ≤ 1) was associated with increased 30-day mortality (OR=9.98, 95% CI=1.18-84.13), lower odds of complete remission status (OR=0.20, 95% CI=0.06-0.65), and higher overall mortality (HR=2.13, 95% CI=1.15-3.92). Inappropriate medication use (classified according to Beers criteria) was not significantly associated with clinical outcomes. Polypharmacy warrants further study as a modifiable marker of vulnerability among older adults with AML.

Lymphadenectomy for renal cell carcinoma and urothelial carcinoma of the upper urinary tract: analysis of evidence in the minimally invasive era

Although lymphnode dissection (LND) provides staging and therapeutic benefit in bladder cancer, the role of lymphadenectomy in renal cell carcinoma (RCC) and urothelial cancer of the upper urinary tract (UCUUT) remains undefined. The aim of this paper was to examine the staging and therapeutic role of LND in RCC and UCUUT with emphasis on applicability to modern minimally invasive approaches. A Pubmed search was conducted to identify literature published between January 1, 2008 and March 11, 2013 addressing the role of lymphadenectomy in renal and upper urinary tract cancer. Key words included "lymphadenectomy", lymphnode dissection", "lymphnode excision", "lymphatic metastasis", "renal cancer", "renal neoplasm", "renal cell carcinoma", "kidney cancer", "kidney neoplasm", "upper urinary tract", "urothelial carcinoma", "kidney pelvis", "ureteral neoplasm", "transitional cell", "ureter, and upper tract urothelial neoplasm". The staging benefit of LND in RCC and UCUUT remains controversial although lymphnode metastasis is an important prognostic factor in both disease processes. It is not well established whether LND improves survival in RCC and UCUUT. There is no consensus regarding the optimal lymphnode yield or template. Much of the current literature is derived from studies of open surgery. Patients with higher grade and stage may derive the most benefit from LND. LND may provide both staging and survival benefit in select patients undergoing surgery for treatment of either RCC or UTUUC. Patients with clinical stage T2 or higher, those with aggressive histologic subtypes and features, and those with clinically enlarged nodes should undergo LND. Simple LND templates based on tumor location should be used and are amenable to both open and minimally invasive approaches.

Aprotinin in cardiac surgery patients: is the risk worth the benefit?

BACKGROUND

Aprotinin is the only Food and Drug Administration-approved agent to reduce haemorrhage related to cardiac surgery and its safety and efficacy has been extensively studied. Our study sought to compare the efficacy, early and late mortality and major morbidity associated with aprotinin compared with e-aminocaproic acid (EACA) in cardiac surgery operations.

METHODS

Between January 2002 and December 2006, 2101 patients underwent coronary artery bypass grafting (CABG), valve surgery or CABG and valve surgery in our institution with the use of aprotinin (1898 patients) or EACA (203 patients). Logistic regression and propensity score analysis were used to adjust for imbalances in the patients' preoperative characteristics. The propensity score-adjusted sample included 570 patients who received aprotinin and 114 who received EACA (1-5 matching).

RESULTS

Operative mortality was higher in the aprotinin group in univariate (aprotinin 4.3% vs EACA 1%, p=0.023) but not propensity score-adjusted multivariate analysis (4% vs 0.9%, p=0.16). In propensity score-adjusted analysis, aprotinin was also associated with a lower rate of blood transfusion (38.8% vs 50%, p=0.04), a lower rate of haemorrhage-related re-exploration (3.7% vs 7.9%, p=0.04) and a higher risk of in-hospital cardiac arrest (3.7% vs 0%, p=0.03) and a marginally but not statistically significantly higher risk of acute renal failure (6.8% vs 2.6%, p=0.09). In Cox proportional hazards regression analysis, the risk of late death was higher in the aprotinin compared to EACA group (hazard ratio=4.33, 95% confidence interval (CI)=1.60-11.67, p=0.004).

CONCLUSION

Aprotinin decreases the rate of postoperative blood transfusion and haemorrhage-related re-exploration, but increases the risk of in-hospital cardiac arrest and late mortality after cardiac surgery when compared to EACA. Cumulative evidence suggests that the risk associated with aprotinin may not be worth the haemostatic benefit.

Quality improvement in cardiac critical care

Our quality improvement program began in 2004 to improve cardiac surgery outcomes. Early tracheal extubation in the cardiovascular intensive unit was utilized as a multidisciplinary driver for the quality improvement program. Continuous improvement in the rate of early extubation to drive multidisciplinary quality improvement in cardiac critical care correlated with decreased mortality, morbidity, and improved operational efficiency. Supportive educational efforts included, but were not limited to, principles of change, trust, competing values, crew resource management, evidence based medicine, and quality improvement.

Can timing of tracheal extubation predict improved outcomes after cardiac surgery?

INTRODUCTION

Early tracheal extubation is a common goal after cardiac surgery. Our study aims to examine whether timing of tracheal extubation predicts improved postoperative outcomes and late survival after cardiac surgery. We also evaluated the optimal timing of extubation and its association with better postoperative outcomes.

METHODS

Between 2002 and 2006, 1164 patients underwent early tracheal extubation (<6 hours after surgery) and 1571 had conventional extubation (>6 hours after surgery). Propensity score adjustment and multivariable logistic regression analysis were used to adjust for imbalances in the patients' preoperative characteristics. Receiver operating characteristic curves (ROC) were used to identify the best timing of extubation and improved postoperative outcomes. Cox regression analysis was used to identify whether early extubation is a risk factor for decreased late mortality.

RESULTS

Results - Early extubation was associated with lower propensity score-adjusted rate of operative mortality (Odds Ratio =0.55, 95% Confidence Intervals =0.31-0.98, p=0.043). Extubation within 9 hours emerged as the best predictor of improved postoperative morbidity and mortality (sensitivity =85.5%, specificity =52.7%, accuracy =64.5%). Early extubation also predicted decreased late mortality (Hazard Ratio =0.45, 95% Confidence Intervals 0.31-0.67, p<0.001).

CONCLUSIONS

Early extubation may predict improved outcomes after cardiac surgery. Extubation within 9 hours after surgery was the best predictor of uncomplicated recovery after cardiac surgery. Those patients intubated longer than 16 hours have a poorer postoperative prognosis. Early extubation predicts prolonged survival up to 16 months after surgery.

Continuous quality improvement program and major morbidity after cardiac surgery

The aim of this study was to investigate how a continuous quality improvement (CQI) program affected major morbidity and postoperative outcomes after cardiac surgery. Patients were divided into 2 groups: those who underwent surgery (coronary artery bypass grafting, isolated valve surgery, or coronary artery bypass grafting and valve surgery) after the establishment of a CQI program (from January 2005 to December 2006, n = 922) and those who underwent surgery beforehand (from January 2002 to December 2003, n = 1,289). Patients who had surgery in 2004, when the system and processes were reengineered, were not included in the analysis. Outcomes compared between the 2 groups included (1) acute renal failure, (2) stroke, (3) sepsis, (4) hemorrhage-related reexploration, (5) cardiac tamponade, (6) mediastinitis, and (7) prolonged length of stay. Logistic regression analysis and propensity score adjustment were used to adjust for imbalances in the patients' preoperative characteristics. After propensity score adjustment, CQI was found to decrease the rate of sepsis (odds ratio [OR] 0.5, 95% confidence interval [CI] 0.3 to 0.9, p = 0.02) and cardiac tamponade (OR 0.2, 95% CI 0.04 to 0.8, p = 0.02) but to only marginally decrease the rate of acute renal failure (OR 0.7, 95% CI 0.5 to 1.0, p = 0.07). CQI did not emerge as an independent risk factor for hemorrhage-related reexploration, prolonged length of stay, mediastinitis, or stroke in either multivariate logistic regression analysis or propensity score adjustment. In conclusion, the systematic implementation of a CQI program and the application of multidisciplinary protocols decrease sepsis and cardiac tamponade after cardiac surgery.

Cloretazine is an effective induction therapy in elderly patients (pts) with poor-risk de novo AML

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Background: The incidence of AML increases with age with a median of 68 years in the US. The treatment of elderly pts (≥60 years) with AML poses challenges related to pt characteristics (age, performance status (PS), comorbidities) and adverse biological features. The majority of elderly pts are not considered for standard induction therapies that incorporate araC + anthracycline, and complete remission rates (CR+CRp), leukemia-free (LFS) and overall survival (OS) are significantly lower than in younger pts. As a result, NCCN guidelines recommend investigational therapy for this population. Cloretazine (C) is a novel DNA alkylating agent that selectively targets the O-6 position in guanine and has been developed in AML, based on phase I data demonstrating activity in refractory hematologic malignancies with acceptable toxicity. Methods: A multi-center trial in elderly pts with untreated poor-risk AML and high risk MDS was performed. Pts received C (600 mg/m2) as a single 30–60 minute infusion. Retreatment for induction was permitted for pts who showed improvement. A consolidation course of C at 400 mg/m2 was an option for pts who achieved a CR. Results: 105 pts were treated, of whom 45 pts (median age 72, range 60–84) had de novo AML, 44 had secondary AML, and 16 had high-risk MDS. Considering only de novo AML pts, pt characteristics are the following: M/F=25/20; favorable/intermediate/poor/NA cytogenetics =0/28(62%)/15(33%)/2; and PS 0/1/2=8(18%)/21(47%)/16(36%). The CR rate was 49% (N=22). CR was 50% for pts with intermediate cytogenetics and 53% for pts with poor risk cytogenetics. CR remained consistent despite increasing PS (PS0=50%, PS1=48%, PS2=50%). For responders, the median time for ANC≥1000 cells/dl was 31 days (range 27–44) and for plt≥20,000/dl was 22 days (range 14–29). There was no significant non-hematologic toxicity; the early death rate was 20%. Of the 22 pts who achieved CR, 8 remain alive and disease-free at a median of 337 days (range 137–546). At one year, the LFS is 27% and the OS is 22%. Conclusion: C is very well tolerated and has demonstrated impressive response results as a single agent in an elderly pt population with poor risk AML.

[Table: see text]

Poor risk assessment in the elderly receiving cloretazine induction for AML or MDS

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Background: Elderly patients (pts) ≥60 years with acute myelogenous leukemia (AML) have lower response rates, and higher morbidity and mortality than younger pts when treated with cytotoxic induction therapy. Common disease-related factors that predict poor response in the elderly are adverse cytogenetics and secondary leukemia (following antecedent hematologic disorder or exposure to chemotherapy). Pt-related factors such as ECOG performance status (PS) and organ dysfunction affect treatment decisions due to poor tolerability and early death. Cloretazine, a novel alkylating agent has significant activity in AML and MDS with a favorable safety profile. A Phase II study of monotherapy induction was conducted in elderly pts with AML or high risk MDS (N = 105, median age 72, range 60–88), with a 31% complete response rate and minimal non-hematologic toxicity. To describe the pts in this study considered “unfit” for 7+3 induction, disease-related and pt-related information was obtained. The Hematopoietic Cell Transplantation Comorbidity Index (Sorrer et al, 2005) (HCT-CI) is a modification of the Charlson Comorbidity Index (Charlson et al.1987), for pts considered for stem cell transplant. Seventeen medical conditions are included with weighted values predicting non-relapse mortality (NRM). Methods: Baseline demographic and pt-related data was obtained from case report forms. In addition to disease-related prognostic indicators, pt-related data was scored by the HCT-CI. Pts were grouped in risk categories for NRM by HCT-CI scores (low = 0, intermediate = 1 or 2; high ≥3). Results: Either or both disease-related poor risk factors were present in 68 pts (65%): 42 pts (40%) had unfavorable cytogenetics and 45 pts (43%) had secondary AML. No pt had favorable cytogenetics. Ninety-four (89%) pts had at least one HCT-CI comorbidity. The most common were cardiac (46%), psychiatric (28%); hepatic (25%) and controlled infection (24%). By HCT-CI, the risk for NRM was low in 10%, intermediate in 32%, and high in 57% of pts. Conclusions: The majority of these elderly pts were poor-risk by disease-related criteria or comorbidities measured by the HCT-CI. This index warrants further testing for determining NRM risk of induction regimens for elderly pts with AML.

[Table: see text]

G-scan--mobile multiview 3-D measuring system for the analysis of the face

The development of optical 3-D measuring techniques and their use in industrial quality assurance, in design, and for rapid prototyping has experienced strong growth. A large number of optical 3-D measuring methods and systems are on the market in dentistry. CAD/CAM production has become firmly established in dental medicine, not least due to the systematic introduction of the Cerec technique and the digiDent method. The scanners on which these technologies are based are designed for a relatively small measuring area. To be able to measure and three-dimensionally assess the face--and the numerous changes in the face/forehead/neck region--it was necessary to design and develop a self-calibrating measuring system with gray code for clinical use: the G-Scan measuring system. Objects up to a size of 500 x 500 x 400 mm can be acquired three-dimensionally with it, with a measuring inaccuracy of 10 to 70 microm in a typical measuring time of 15 s. The present article describes the measuring principle, the system parameters, and the features of the new measuring system, and illustrates the measuring results on 3-D displays of the face in static occlusion and in functional occlusion positions.

Safety and immunogenicity of a recombinant Borrelia burgdorferi outer surface protein A vaccine against lyme disease in healthy children and adolescents: a randomized controlled trial

OBJECTIVE

A recombinant lipoprotein outer surface protein A (OspA) Lyme disease (LD) vaccine (LYMErix) has been shown to be safe and effective in preventing LD in adults and in adolescents 15 years of age and older. Children are at risk for developing LD. This clinical study was conducted to address the safety and immunogenicity of LD vaccine in children 4 to 18 years of age.

METHODS

A randomized, placebo-controlled clinical trial was conducted at 17 investigational sites in Lyme-endemic areas in the United States. Immunogenicity data from this study also were compared with data obtained from the adult efficacy study. A total of 4090 healthy children and adolescents (age range: 4-18; mean age: 10.4 years) were randomized; 4087 were vaccinated, and a subset of 301 children participated in the immunogenicity analysis. Children were randomized to receive either 30 microgram of LD vaccine (N = 3063) or placebo (N = 1024) on a 0, 1, 12-month schedule. Safety assessments evaluated both solicited (local: redness, swelling, and pain; general: fever, headache, fatigue, arthralgia, and rash) and unsolicited adverse events. Serum specimens were collected at month 0 or month 2, and months 6, 12, and 13.

RESULTS

Solicited reactogenicity data revealed a higher incidence of local injection site reactions and general symptoms (fever, headache, fatigue, and arthralgia) in vaccine than placebo recipients. The majority of events were limited in duration (mean: 2-3 days) and were mild to moderate in severity. The total IgG anti-OspA geometric mean titer (GMT) in the pediatric vaccine recipients at month 13 was as good as and statistically higher than the GMT in the adult cohort at month 13 (27 485 enzyme-linked immunosorbent assay units [EL.U]/mL vs 8216 EL.U /mL). All of the pediatric vaccine recipients attained a level of antibody concentration >/=1400 EL.U/mL (proposed seroprotective level) compared with 90% of adults attaining levels >/=1400 EL.U/mL in the efficacy trial.

CONCLUSIONS

LD vaccine administered on a 0, 1, 12-month schedule generally is well tolerated and immunogenic in children 4 to 18 years of age. The safety profile consists of mild to moderate local injection site reactions and flu-like symptoms of limited duration and did not worsen with subsequent injections. IgG GMT at month 13 was threefold higher than the month 13 GMT obtained in the adult efficacy study. This higher immune response in children should provide protection against LD.

Safety and efficacy of a continuous infusion, patient controlled anti-emetic pump to facilitate outpatient administration of high-dose chemotherapy

We evaluated the combination of diphenhydramine, lorazepam, and dexamethasone delivered as a continuous i.v. infusion via an ambulatory infusion pump with patient-activated intermittent dosing (BAD pump) for prevention of acute and delayed nausea/vomiting in patients receiving high-dose chemotherapy (HDC) for peripheral blood progenitor cell (PBPC) mobilization (MOB) or prior to autologous PBPC rescue. The BAD pump was titrated to patient response and tolerance, and continued until the patient could tolerate oral anti-emetics. Forty-four patients utilized the BAD pump during 66 chemotherapy courses, 34 (52%) for MOB and 32 (48%) for HDC with autologous PBPC rescue. The median number of days on the BAD pump during MOB and HDC was 3 (1-6) and 9 (2-19) days, respectively. Complete overall or complete emesis control occurred on 94% of MOB and 89% of HDC treatment days during chemotherapy administration and 72% and 43%, respectively, following chemotherapy administration. Eighty-three percent of MOB and 55% of HDC treatment days were associated with no nausea. While on the BAD pump, no patient experienced severe toxicity or required hospitalization for management of nausea/vomiting. The BAD pump was safe and effective in minimizing nausea and vomiting associated with HDC, and thus, eliminated the need for hospitalization for management of chemotherapy-induced nausea and vomiting.

Isolation and characterization of fluconazole- and amphotericin B-resistant Candida albicans from blood of two patients with leukemia

Infections with fluconazole-resistant Candida albicans isolate have rarely been described in clinical settings other than oropharyngeal candidiasis in patients with late-stage AIDS. We report on two patients with leukemia who developed fungemia caused by fluconazole-resistant C. albicans after receiving fluconazole prophylaxis (400 mg/day) and empiric amphotericin B therapy (0.5 mg/kg of body weight per day). The fluconazole MICs for the isolates were > or = 64 micrograms/ml, and the isolates were resistant to other azoles and had membrane sterol changes consistent with a mutation in the delta 5,6-sterol desaturase gene. The lack of ergosterol in the cytoplasmic membrane of the fluconazole-resistant strains also imparted resistance to amphotericin B. Both patients were successfully treated with high-dose amphotericin B (1 to 1.25 mg/kg/day) and flucytosine (150 mg/kg/day).

Diagnostic yield of the autopsy in a university hospital and a community hospital

To determine the extent to which autopsies yield unexpected findings that are relevant to the patient's death and whether cases with a high yield of such findings can be identified selectively, we studied a total of 233 autopsies at a university hospital and at a community hospital. The rates at which autopsies detected major unexpected findings whose premortem diagnosis would probably have improved survival were 11 percent at the university hospital and 12 percent at the community hospital. Major unexpected findings whose premortem diagnosis would not have prolonged survival were found in another 12 and 21 percent of cases, respectively. Pulmonary embolism and fungal infections in immuno-compromised hosts were the most common major unexpected findings. Neither we nor the patients' physicians were able to identify from the clinical data the autopsies likely to have high yields. Furthermore, the physicians' estimates of an autopsy's expected yield were similar for patients evaluated by autopsy and for matched patients who were not. We conclude that the autopsy continues to yield clinically relevant findings at a high level and that it is not currently possible to predict which cases will have high yields. Autopsies are vital to ensure the quality of medical care, and autopsy rates must be increased substantially if this role is to be fully realized.

Renal failure in dogs with experimental acute pancreatitis: role of hypovolemia

The factors causing a decline in renal perfusion were studied in anaesthetized dogs with acute pancreatitis 4 h after the forceful injection of bile into the pancreatic duct. In 11 such dogs, glomerular filtration rate (GFR) decreased by 40.4% from the control state (P less than 0.05), whereas the clearance of para-aminohippurate (CPAH) declined by 50.2%. These changes were associated with a 15.3% decline in cardiac output (P less than 0.05) and a 26.2% fall in plasma volume. Glomerular morphology was entirely normal. When hypovolemia was prevented by infusing homologous plasma over the 4-h period of observation, the normally observed decline in GFR, CPAH, and cardiac output was prevented. The decline in plasma volume, associated with a rising hematocrit and declining plasma protein concentration, and the associated decrement in renal perfusion, could be entirely duplicated by the infusion of trypsin, chymotrypsin, elastase, and phospholipase A2 (but not lipase or amylase) into normal dogs. These perturbations also were prevented by the concurrent infusion of 4% albumin in saline. At 24 h, however, the renal failure became unresponsive to volume replenishment. We conclude that the decline in renal perfusion in dogs at 4 h with acute pancreatitis is entirely due to hypovolemia, induced by the release of specific enzymes from the inflamed gland, which causes the loss of protein-rich plasma from the vascular space.

Regional mapping of human chromosome 19: organization of genes for plasma lipid transport (APOC1, -C2, and -E and LDLR) and the genes C3, PEPD, and GPI

We report the regional mapping of human chromosome 19 genes for three apolipoproteins and a lipoprotein receptor as well as genes for three other markers. The regional mapping was made possible by the use of a reciprocal whole-arm translocation between the long arm of chromosome 19 and the short arm of chromosome 1. Examination of three separate somatic cell hybrids containing the long arm but not the short arm of chromosome 19 indicated that the genes for apolipoproteins CI, CII, and E (APOC1, APOC2, and APOE, respectively) and glucose-6-phosphate isomerase (GPI) reside on the long arm, whereas genes for the low density lipoprotein receptor (LDLR), complement component 3 (C3), and peptidase D (PEPD) reside on the short arm. When taken together with previous studies, our results suggest the following physical gene map: pter-LDLR-C3-p13.2-PEPD-centromere-(APOE, APOC1, APOC2, GPI)-qter. In addition, we have isolated a single lambda phage carrying both APOC1 and part of APOE. These genes are tandemly oriented and are separated by about 6 kilobases of genomic DNA. Since previous family studies indicate tight linkage of APOE and APOC2, the apolipoprotein genes APOC1, APOC2, and APOE form a tight complex on the long arm of chromosome 19, suggesting the possibility of coordinate regulation.

Plasmapheresis in thyroxine overdose: a case report

Thyrotoxicosis from an overdose of medicinal thyroid is a condition which may be associated with a significant delay in onset of toxicity. We report a case treated with plasmapheresis, and conclude that the amount of thyroid hormone removed was insignificant compared to the total ingestion. We also note that the plasma half-life of thyroxine is apparently reduced in an acute massive ingestion.

Nutritional support in an inpatient rehabilitation unit

Twenty-four patients with protein-calorie malnutrition were treated with intensive dietary support to improve nutritional status. Sixteen patients were able to ingest a mean of 1,945kcal and 77gm protein per 24 hours. Eight patients were unable to consume sufficient protein (11 gm) and kcal (311 gm) per 24 hours; these patients were treated with enteral tube feeding. Patients supported on tube feeding increased serum albumin levels by 0.5gm/100ml and were eventually able to consume 2,170kcal and 87gm of protein per 24-hour period after tube feeding was discontinued. Treatment of patients with protein-calorie malnutrition may require a multiple-modality nutritional support system in a rehabilitation unit.

Nutritional assessment in a rehabilitation unit

Forty-nine consecutive patient admissions to a rehabilitation unit were evaluated by a nutritional assessment team. Measured parameters included serum albumin, height, weight, 24-hour protein and calorie intake, and response to 4 antigens (purified protein derivative, streptokinase/streptodornase, trichophyton, candida) administered by intradermal injections. Patients were classified normal (albumin greater than or equal to 3.5 gm%, positive skin tests, normal weight), Kwashiorkor (albumin less than 3.5gm%, anergic skin tests, no weight loss), marasmus (albumin greater than or equal to 3.5gm%, anergic skin tests, weight loss greater than 101lb (4.54kg) or obesity (greater than 130% ideal body weight). Protein-calories malnutrition (marasmus or kwashiorkor) was found in 34 (67%) of the patients. Only 15 patients (33%) satisfied criteria for normal nutritional status at the time of admission. Four subjects satisfied the criteria for both obesity and kwashiorkor. Because of the increased morbidity and mortality associated with protein-calorie malnutrition, all patients admitted to a rehabilitation unit should have a nutritional assessment. If the assessment demonstrates malnutrition, a program of metabolic support should be initiated to increase protein levels and restore immune competence.

Significance of the cell cycle in commitment of murine erythroleukemia cells to erythroid differentiation

The relationship between differentiation of murine erythroleukemia cells (MEL) induced by DMSO and the cell division cycle has been analyzed. We demonstrate that incubation in the presence of DMSO increases the length of the G1 phase of the cell cycle. A method of synchronization of MEL cells by unit gravity sedimentation has been developed and characterized. Using this method, a series of synchronized cell populations covering the entire cell division cycle can be generated simultaneously. Cells synchronized by this technique were challenged with DMSO and analyzed for kinetics of commitment to the differentiation program. Our results indicate that populations of cells in G1 or G2 at the time of addition of inducer give rise to a greater proportion of committed cells than an unfractionated population, while cells in S phase result in a lower percentage of committed cells than the unfractionated population when cultured in DMSO.

Anemia in primary hyperparathyroidism

Although anemia has not been widely appreciated as a complication of primary hyperparathyroidism, 5.1% of the individuals with this disorder seen at the Massachusetts General Hospital since 1962 had a normochromic, normocytic anemia that could not be related to blood loss,a deficiency state, or uremia. The anemic group had more advanced bone disease and higher levels of serum calcium, alkaline phosphatase, and parathyroid hormone than the nonanemic group. Results of bone marrow biopsies performed in five patients showed variable degrees of myelofibrosis. However, none of the patients had hepatosplenomegaly, a myelophthisic peripheral blood smear, leukopenia, or thrombocytopenia. Removal of the abnormal parathyroid glands led to improvement or correction of the anemia.

Commitment to erythroid differentiation by friend erythroleukemia cells: a stochastic analysis

A method for the clonal analysis of murine erythroleukemia cells has been developed which allows the precise characterization of the number of progeny produced by each cell and the degree of differentiation of each progeny cell. The potential of almost every cell in the culture can be monitored because a plating efficiency close to 100% has been achieved. The effects of treatment with an inducer of differentiation (DMSO) on the proliferative capacity of the treated cells have been studied with this technique. Cells from a mass culture treated with inducer give rise to colonies of differentiated progeny when subsequently cloned in the absence of inducer. Colonies exhibiting this phenotype represent the progeny of cells committed to the differentiation pathway by treatment with inducer. We observe that the commitment decision limits the subsequent proliferative capacity of the cell to four additional cell divisions. A quantitative analysis suggests that the commitment decision for each cell is made in a stochastic manner. Irreversible commitment to the expression of differentiated functions occurs with discrete probability per cell generation for many cell generations. The value for this probability is a function of the concentration of inducer (DMSO). A correlative biochemical study suggests that an irreversible commitment decision by a significant proportion of the population precedes or accompanies increases in cytoplasmic globin mRNA levels, one of the earliest detectable biochemical markers for erythroid differentiation in this system. A specific kinetic model based on these considerations has been developed to predict clonal phenotypes as a function of time and probability of commitment. Quantitative predictions based on this model are in excellent agreement with experimental observations. The effectiveness of a stochastic model in predicting the behavior of this system is discussed in relation to the stochastic behavior of normal hematopoiesis and the biochemical mechanisms which control these differentiation programs.