Cutaneous lymphangitis carcinomatosa: a unique presentation of a rare disease

A 75-year-old man with a three-year history of metastatic lung adenocarcinoma was diagnosed with cutaneous lymphangitic carcinomatosa of unique morphology. He was admitted to our hospital for right neck swelling, erythema, and failure to thrive. Skin examination demonstrated an indurated, thickened, firm, hyperpigmented plaque extending from the right neck and chest to the right ear, cheek, and eyelids. Skin biopsy demonstrated poorly differentiated adenocarcinoma, morphologically consistent with metastasis from the patient's known pulmonary adenocarcinoma and showed dermal invasion, perineural invasion, and involvement of dermal lymphatics. The diagnosis was an atypical presentation of cutaneous lymphangitis carcinomatosa from metastatic lung adenocarcinoma. This case presentation affirms that cutaneous lymphangitis carcinomatosa has a variety of atypical presentations, so physicians must maintain a high index of suspicion when evaluating cutaneous lesions in patients with known or suspected internal malignancy.

Use of Factor VIII in the Treatment of Hemophilia

This publication describes the results obtained by treatment of haemophiliacs with factor VIII preparations isolated from Cohn fraction I by use of tannic acid, FI-O-Ta.

The authors stress the rapidity of the disappearance of factor VIII after injection. Transfusions are generally well tolerated. One reaction of the pyrogen type has been observed and also a case of activation of the fibrinolytic system.

A second purification method by means of chromatography on DEAE-cellulose is described.

Formation of covalent di-tyrosine dimers in recombinant α-synuclein

Parkinson's disease is associated with fibril deposition in the diseased brain. Misfolding events of the intrinsically disordered synaptic protein α-synuclein are suggested to lead to the formation of transient oligomeric and cytotoxic species. The etiology of Parkinson's disease is further associated with mitochondrial dysfunction and formation of reactive oxygen species. Oxidative stress causes chemical modification of native α-synuclein, plausibly further influencing misfolding events. Here, we present evidence for the spontaneous formation of covalent di-tyrosine α-synuclein dimers in standard recombinant protein preparations, induced without extrinsic oxidative or nitrative agents. The dimers exhibit no secondary structure but advanced SAXS studies reveal an increased structural definition, resulting in a more hydrophobic micro-environment than the highly disordered monomer. Accordingly, monomers and dimers follow distinct fibrillation pathways.

Transformational supply chains and the 'wicked problem' of sustainability: aligning knowledge, innovation, entrepreneurship, and leadership

Supply chains are increasingly asked by consumers, policy makers, and other stakeholders to deliver product attributes that range far beyond the experience and search attributes of classical consumer demand. One name given these attributes is credence attributes (e.g. place-of-origin, organic, locally-grown). Sustainability as an attribute is an interesting emerging case. Sustainability is an example of a 'wicked problem': complex, ill-defined, messy and unsolvable in any traditional sense. Sustainability's lack of tractability raises the interesting question as to how a supply chain or network produces a thing that is beyond conventional notions of definition and structure. The paper develops a general framework for linking supply chain performance to types of knowledge and supply chain governance. The framework draws from knowledge management theory, the resource based theory of the firm, and transactions cost economics. Various types of knowledge are argued to have different levels of strategic value – explicit knowledge has limited strategic value, tacit knowledge has moderate strategic value, and new knowledge has high strategic value. Managing wicked problems requires a type of supply chain governance that creates new knowledge in the context of a broad stakeholder network. This type of governance is called transformational and is contrasted with exchange governance and learning governance. Once developed, the framework is applied to the wicked problem of sustainability, including a case study on one empirical structure being used to manage it. For supply chains and networks, future economic value is likely to demand delivery of more and more complex attributes that will take businesses increasingly into the realm of wicked problems.

Resrad-recycle: a computer model for analyzing radiation exposures resulting from recycling radioactively contaminated scrap metals or reusing radioactively surface-contaminated materials and equipment

RESRAD-RECYCLE is a computer code designed by Argonne National Laboratory (ANL) to be used in making decisions about the disposition of radioactively contaminated materials and scrap metals. It implements a pathway analysis methodology to evaluate potential radiation exposures resulting from the recycling of contaminated scrap metals and the reuse of surface-contaminated materials and equipment. For modeling purposes, it divides the entire metal recycling process into six steps: (1) scrap delivery, (2) scrap melting, (3) ingot delivery, (4) product fabrication, (5) product distribution, and (6) use of finished product. RESRAD-RECYCLE considers the reuse of surface-contaminated materials in their original forms. It contains representative exposure scenarios for each recycling step and the reuse process; users can also specify scenarios if desired. The model calculates individual and collective population doses for workers involved in the recycling process and for the public using the finished products. The results are then used to derive clearance levels for the contaminated materials on the basis of input dose restrictions. The model accounts for radiological decay and ingrowth, dilution and partitioning during melting, and distribution of refined metal in the various finished products, as well as the varying densities and geometries of the radiation sources during the recycling process. A complete material balance in terms of mass and radioactivity during the recycling process can also be implemented. In an international validation study, the radiation doses calculated by RESRAD-RECYCLE were shown to agree fairly well with actual measurement data.

Ascorbic acid enhances 17 beta-estradiol-mediated inhibition of oxidized low density lipoprotein formation

Postmenopausal women who use estrogen appear to be protected from coronary heart disease (CHD). Studies have demonstrated that estrogen can lower low-density lipoprotein (LDL) levels and the antioxidant activity of 17 beta-estradiol can prevent the oxidation of this LDL. Ascorbic acid is regarded as a major hydrophylic antioxidant, however, its impact on the prevention of CHD has yet to be clearly demonstrated. Modified low density lipoprotein (LDL(-)) is an important marker of LDL oxidation in vivo, since it contributes to the oxidative susceptibility of low density lipoprotein, and at physiological levels displays pro-inflammatory and cytotoxic properties. Previously we showed that women taking estrogen replacement therapy have lower LDL(-) levels along with lower predisposition of the LDL to oxidize. In this study, we evaluated the potential action of 17 beta-estradiol (E(2)) in combination with ascorbic acid (AA) measured on the basis of LDL oxidative susceptibility in vitro and in the presence of cultured cells. High concentrations of E(2) were able to inhibit LDL oxidation, whereas in the presence of ascorbic acid nano- to picomolar levels of E(2) were sufficient to suppress LDL oxidation (P<0.05). Preconditioning male aortic endothelial cells (RAEC) with 5 ng/ml of E(2) (E(2)RAEC) reduced the formation of LDL(-) (P<0.005), and a more extensive inhibition was found in the presence of AA (P<0.0001). Interestingly, E(2) enhanced the uptake of LDL in the absence or presence of AA, however, this was not seen for the uptake of LDL(-). These results provide the first evidence that ascorbic acid can enhance the antioxidant effect of E(2) by preventing LDL oxidation by copper ions or cells. The cytoprotective and antiatherogenic effect of E(2) appears to involve a reduction in the extent of oxidized LDL formation and uptake. The enhanced activity of E(2) in the presence of ascorbate indicates that the antioxidant and antiatherosclerosis activity of E(2) may occur at concentrations within the physiological range.

Non-ignorable missing covariates in generalized linear models

We propose a likelihood method for estimating parameters in generalized linear models with missing covariates and a non-ignorable missing data mechanism. In this paper, we focus on one missing covariate. We use a logistic model for the probability that the covariate is missing, and allow this probability to depend on the incomplete covariate. We allow the covariates, including the incomplete covariate, to be either categorical or continuous. We propose an EM algorithm in this case. For a missing categorical covariate, we derive a closed form expression for the E- and M-steps of the EM algorithm for obtaining the maximum likelihood estimates (MLEs). For a missing continuous covariate, we use a Monte Carlo version of the EM algorithm to obtain the MLEs via the Gibbs sampler. The methodology is illustrated using an example from a breast cancer clinical trial in which time to disease progression is the outcome, and the incomplete covariate is a quality of life physical well-being score taken after the start of therapy. This score may be missing because the patients are sicker, so this covariate could be non-ignorably missing.

Arterial injury by cholesterol oxidation products causes endothelial dysfunction and arterial wall cholesterol accumulation

Cholesterol oxidation products (ChOx) have been reported to cause acute vascular injury in vivo; however, the pharmacokinetics of ChOx after administration and the mechanisms by which they cause chronic vascular injury are not well understood. To further study the pharmacokinetics and atherogenic properties of ChOx, New Zealand White rabbits were injected intravenously (70 mg per injection, 20 injections per animal) with a ChOx mixture having a composition similar to that found in vivo during a 70-day period. Total ChOx concentrations in plasma peaked almost immediately after a single injection, declined rapidly, and returned to preinjection levels in 2 hours. After multiple injections, the ChOx concentrations rose gradually to levels 2- to 3-fold above baseline levels, increasing mostly in the cholesteryl ester fraction of LDL and VLDL. Rabbit serum and the isolated LDL/VLDL fraction containing elevated ChOx concentrations were cytotoxic to V79 fibroblasts and rabbit aortic endothelial cells. At the time of killing, cholesterol levels in the aortas from ChOx-injected rabbits were significantly elevated despite the fact that plasma cholesterol levels remained in the normal range. In addition, aortas from the ChOx-injected rabbits retained more 125I-labeled horseradish peroxidase, measured 20 minutes after intravenous injection. Transmural concentration profiles across the arterial wall also showed increased horseradish peroxidase accumulation in the inner half of the media from the thoracic aorta in ChOx-injected rabbits. In conclusion, ChOx injection resulted in accumulation of circulating ChOx and induced increased vascular permeability and accumulation of lipids and macromolecules. This study reveals that even under normocholesterolemic conditions, ChOx can cause endothelial dysfunction, increased macromolecular permeability, and increased cholesterol accumulation, parameters believed to be involved in the development of early atherosclerotic lesions.

Psychotherapy in primary care: the BATHE technique

The family physician occupies a front-line position in the detection and treatment of emotional problems and psychiatric illnesses. The practice pattern of the family physician necessitates an efficient, effective model of psychotherapy The BATHE technique is a brief psychotherapeutic method that addresses the patient's background issues, affect and most troubling problem. The emphasis of the interview then shifts to how the patient is handling the problem and a demonstration of empathy by the physician. Some of the challenges in psychotherapy are presented, and cases in which the BATHE technique was used are described.

Correlation between self-reported cocaine use and urine toxicology in an inner-city prenatal population

To determine the prevalence of recent cocaine use and the accuracy of self-reported use, the results of a urine assay for the major cocaine metabolite benzoylecgonine were compared with self-reported cocaine use in an inner-city prenatal population offered routine voluntary urine toxicology screening at the time of registration for prenatal care. During a 1-year period, 6866 women registered for prenatal care and 5200 (76%) consented to urine assays for cocaine metabolites. Of the women consenting to urine assays, 253 (5%) had positive assays for benzoylecgonine. Women with positive assays were significantly more likely than those with negative assays to be older (mean [SD] 27 [5] versus 23 [6] years), black, single, and unemployed. In addition, women with positive assays were significantly more likely to be multiparous, report > two sexual partners in the previous year, and acknowledge a history of a sexually transmitted disease (STD). Forty-seven percent of women with positive assays acknowledged cocaine use in the 6 months prior to sampling. Women with positive assays who denied cocaine use were significantly more likely than those who admitted use to be younger (mean [SD] 26 [5] versus 28 [4] years), to report > or = two sexual partners in the past year, and acknowledge a history of an STD. This analysis revealed a poor correlation between self-reported cocaine use and the results of urine assays for cocaine metabolites among women seeking prenatal care in an inner-city institution.

Development of a standardized format for archiving and exchange of electronic patient records in Sweden

This paper describes an effort to standardize the long term archiving format of the electronic patient record. A format is given in SGML (Standard Generalized Markup Language) and also tested as a prototype in a production system.

Factors affecting medical students' selection of Canadian psychiatric residency programs: Part II-Some contemporary issues

OBJECTIVE

The presence of a national cohort of trainees entering psychiatric residency allowed an assessment of contemporary factors influencing their particular program choices. Factors of specific interest included the effect on program choice of relationships with significant others and government attitudes to fiscal restraint, mental health care reform, and licensure.

METHOD

A self-administered questionnaire was sent to 110 trainees identified in the 16 Canadian university departments of psychiatry who began training in July 1994.

RESULTS

While a committed relationship was a primary determinant of program choice, government policies attempting to influence patterns of care had little effect.

CONCLUSION

A strong commitment to undergraduate teaching will improve the attractiveness of psychiatry as a career. This must include exposure of students to teachers who mentor practice patterns attuned to provincial mental health reforms, since government initiatives alone, developed to promote desired transitions in psychiatric care, will not influence training program choice.

Factors affecting medical students' selection of Canadian psychiatric residency programs: Part I--A comparison with American peers

OBJECTIVE

The introduction of a national process to match Canadian medical students to postgraduate year-one (PGY-1) positions in psychiatry created for the first time a cohort of subjects whose choices of a particular training program could be evaluated and compared with American peers. The primary goal of this study was to determine the factors affecting the students' selection of the specific postgraduate programs in which they would train and to compare the findings with those in the American literature.

METHOD

A self-administered questionnaire was sent to 110 trainees who began training in July 1994 identified in the 16 Canadian university departments of psychiatry.

RESULTS

Canadian trainees, like their American counterparts, relied heavily on nonprogrammatic factors in program choice, but differed in emphasizing vocational prospects after residency.

CONCLUSION

When competing for enrollment within a reduced pool of applicants, program directors need to recognize how programs are evaluated, what factors are controllable, and how best to market the individual assets of their programs.

Effect of linoleic acid hydroperoxide on endothelial cell calcium homeostasis and phospholipid hydrolysis

The relationship between intracellular free calcium ion concentrations ([Ca2+]i) and release of arachidonic acid from membrane phospholipids following peroxidation was examined in rabbit aortic endothelial cells treated with linoleic acid hydroperoxide (LOOH). LOOH (0.1-0.4) mumol/10(6) cells) caused a rapid and dose-dependent transient increase in [Ca2+]i in the presence of extracellular Ca2+ that remained elevated over baseline for 15 to 30 s. In the absence of extracellular Ca2+, LOOH also evoked a transient increase in [Ca2+]i of lesser magnitude which immediately returned to basal (or below basal) levels. In this regard, the rise in intracellular Ca2+ after LOOH or vasopressin (AVP) treatments involved, at least in part, related intracellular pools that in each case was followed by influx of extracellular Ca2+. The intracellular membrane sources known to be affected by vasopressin were not directly involved. Most notably, the LOOH evoked rise in [Ca2+]i was not associated with release of IP3, suggesting that the source of intracellular Ca2+ is not IP3-sensitive pools. However, pretreatment with LOOH strongly inhibited the rise in [Ca2+]i upon subsequent addition of AVP or LOOH and the extent of such inhibition was dependent on the availability of free intracellular Ca2+ and presence of extracellular Ca2+. These findings suggest that reuptake of Ca2+ into intracellular membrane pools is reduced in the presence of LOOH and/or the availability of Ca2+ from agonist-sensitive sites is inhibited by LOOH. An increase in free 20:4 levels was found after LOOH treatment that was only partly prevented using intracellular Ca2+ chelators which maintained [Ca2+]i at basal levels after LOOH treatment. These findings suggest that LOOH induction of phospholipid hydrolysis proceeds following small transients in [Ca2+]i that are considerably less than that evoked by agents such as AVP, approximating basal Ca2+ concentrations. Inhibition of LOOH-induced lipid peroxidation by vitamin E also prevented the rise in [Ca2+]i and 20:4 release indicating that phospholipid hydrolysis is dependent, at least in part, on membrane lipid peroxidation. Inhibition of protein kinase C (PKC) completely blocked LOOH-induced release of 20:4 but had little effect on the LOOH-induced rise in [Ca2+]i, suggesting an indirect relationship between LOOH-induced membrane Ca2+ signalling events, with intervention via PKC-mediated induction of phospholipid hydrolysis. A rapid and progressive translocation of PKC to the membrane fraction was evident after LOOH addition over the time course corresponding to the maximal release of 20:4 which was also inhibited by vitamin E.(ABSTRACT TRUNCATED AT 400 WORDS)

Characterization of endothelial cell injury by cholesterol oxidation products found in oxidized LDL

The present study describes the toxicity of oxidized LDL towards rabbit aortic endothelial cells in terms of its lipid components with specific attention to the cholesterol oxidation products (ChOx) found in oxidized LDL isolated from human plasma. Measurements of the major ChOx associated with freshly isolated unmodified LDL, those found in oxidized LDL isolated from human plasma and LDL subjected to oxidation in vitro are described. We have confirmed previous findings that most of the cytotoxicity of freshly isolated human LDL may be attributable to a minor fraction that appears to be oxidatively modified by several criteria. Moreover, this plasma-derived oxidized LDL (referred to as LDL) is highly enriched in ChOx, whereas the content of lipid peroxides or derived products (measured as conjugated dienes and thiobarbituric acid reacting products) are much lower, particularly when compared to copper-induced LDL oxidation. Much of the ChOx found in plasma are associated with LDL, however, the levels and proportions of the various ChOx found in LDL differ from those produced after extensive copper-induced oxidation but resemble those produced after moderate oxidation with copper. The species and concentrations of ChOx found in LDL when applied as a mixture exhibit considerably more toxicity than any individual ChOx alone. At non-toxic levels this ChOx mixture causes an increased influx of several ions, including calcium, an effect not seen with individual ChOx at comparable doses. Perturbations in ionic homeostasis, and particularly the sustained increase in intracellular calcium concentrations, are associated with much of the cytotoxicity, an effect attributable to the membrane disruptive action of ChOx leading to altered ion transporter activity. The effect of the ChOx mixture (but not any individual ChOx) on sodium and potassium flux appears to be due to enhanced Na+/K(+)-ATPase activity based on the complete inhibition produced by ouabain under all treatment conditions. These findings also show that the levels of cholesterol oxidation products found in normal LDL are not cytotoxic whereas those present in oxidized LDL exceed the toxic threshold for endothelial cells and account for most of the cytotoxicity produced by this modified lipoprotein.

Linoleic acid hydroperoxide-induced peroxidation of endothelial cell phospholipids and cytotoxicity

Peroxidation of endothelial cell phospholipids was examined following treatments with linoleic acid hydroperoxide. The treatment effects were analyzed over a range of toxicities and exposure intervals as determined by cell plating efficiencies and survival. Over the concentration ranges where lipid peroxidation was evident (20-40 microM treatments in complete medium), significant cytotoxicity was apparent after 1 h of exposure. The extent of toxicity was dependent on the time interval between the end of peroxide treatment and replating of cells. Maximum toxicity was found when cells were replated 1-3 h after treatment. When cells were replated 4 h after treatment a linear increase in cell survival was found as a function of replating time following peroxide exposure. Analysis of cell phospholipids by HPLC after 1 h of exposure to linoleic acid hydroperoxide revealed that peroxidation (evidenced by conjugated diene content) had taken place among a number of phospholipid species with the most marked increases in phosphatidylcholine. Analysis of the fatty acyl composition of phospholipids also showed that the proportions of polyunsaturated fatty acids were reduced relative to saturated fatty acids, indicating peroxidative damage to phospholipids. Pretreatment of cells with vitamin E prevented the peroxidation of all phospholipids and blocked the cytotoxic action of linoleic acid hydroperoxide. These findings indicate that an immediate cytotoxic action of lipid hydroperoxide is associated with peroxidation of membrane phospholipids. This cytotoxicity is a transient effect, and cells surviving the acute injury display a time-dependent increase in plating efficiency representing a period of repair.

Biochemical and cytotoxic characteristics of an in vivo circulating oxidized low density lipoprotein (LDL-)

Using ion exchange high pressure liquid chromatography, total plasma low density lipoprotein (LDL) from 30 hypercholesterolemic and 10 normocholesterolemic cynomolgus monkeys was subfractionated into unmodified LDL (n-LDL) and more negatively charged LDL (LDL-). In hypercholesterolemic monkeys, the absolute LDL-cholesterol level was 16.54 +/- 2.82 mg/dl (mean +/- SE) whereas in normocholesterolemic monkeys it was 2.39 +/- 0.12 mg/dl (P < 0.0001); the percentage of LDL- was 5.2 +/- 0.71% and 4.9 +/- 0.19% of the total LDL for hypercholesterolemic versus normocholesterolemic monkeys, respectively. LDL- averaged 5% and n-LDL 95% of the total plasma LDL cholesterol. To confirm and further elucidate the oxidative nature of LDL-, cholesterol and cholesterol oxide contents of LDL- and n-LDL were determined by capillary gas chromatography; 53.98 +/- 2.24% (mean +/- SE) of the LDL- cholesterol was oxidized whereas in n-LDL only 10.70 +/- 1.06% of the cholesterol was oxidized (P < 0.00001). The spectrum of oxysterols identified, which was similar for LDL- and n-LDL, suggested a free radical-mediated process for cholesterol oxidation. The principal oxysterols identified were: cholest-5-ene-3 beta, 7 alpha-diol, cholesta-3,5-diene-7-one, cholest-5-ene-3 beta, 7 beta-diol, 5,6 beta-epoxy-5 beta-cholestan-3 beta-ol, 5,6 alpha-epoxy-5 alpha-cholestan-3 beta-ol, 5 alpha-cholestan-3 beta,5,6 beta-triol, 3 beta-hydroxycholest-5-ene-7-one, and cholest-5-ene-3 beta,25-diol. To model one of the steps in the possible mechanism of atherogenesis, the cytotoxicity of LDL- was demonstrated to be greater against subconfluent than confluent aortic endothelial cells.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective cohort study on breast-feeding and otitis media in Swedish infants

This study analyzed the effect of breast-feeding on the frequency of acute otitis media. The protocol was designed to examine each child at 2, 6 and 10 months of age. At each visit nasopharyngeal cultures were obtained, the feeding pattern was recorded and the acute otitis media (AOM) episodes were documented. The analysis was based on 400 children from whom complete information was obtained. They represented 83% of the newborns in the study areas. By 1 year of age 85 (21%) children had experienced 111 AOM episodes; 63 (16%) had 1 and 22 (6%) had 2 or more episodes. The AOM frequency was significantly lower in the breast-fed than in the non-breast-fed children in each age group (P < 0.05). The first AOM episode occurred significantly earlier in children who were weaned before 6 months of age than in the remaining groups. The frequency of nasopharyngeal cultures positive for Haemophilus influenzae, Moraxella catarrhalis and Streptococcus pneumoniae was significantly higher in children with AOM. At 4 to 7 and 8 to 12 months of age, the AOM frequency was significantly higher in children with day-care contact and siblings (P < 0.05 and < 0.01, respectively). The frequency of upper respiratory tract infections was increased in children with AOM but significantly reduced in the breast-fed group.

Eldercare: more than company kindness

Employees caring for aging family members could be costing your company money. Eldercare benefits could be the solution. Relatively inexpensive programs can make a difference in how employees see their company.

Quality of life measures for patients receiving adjuvant therapy for breast cancer: an international trial. The International Breast Cancer Study Group

Serial quality of life (QL) assessments are being obtained every 3 months for 2 years from patients with operable breast cancer in two ongoing International Breast Cancer Study Group (IBCSG) randomised clinical trials of adjuvant treatment. The QL-assessments include patient-derived perceived coping (PACIS, personal adjustment to chronic illness scale), well-being (Bf-S, Befindlichkeitsskala von Zerssen), mood, physical well-being and appetite (LASA, linear analogue self assessments). The first assessment within 6 weeks of surgery was performed by 70% of the patients. The analysis of serial assessments for 265 patients with each of the first four assessments completed showed that all measures improved with increasing time from study entry; that the degrees of improvement for the four major language groups were similar; and that measures were sensitive to treatment difference. In conclusion, measurement of QL related aspects in a multicultural clinical trial is feasible and possibly relevant for the evaluation of treatment results.

Uptake, metabolism, and cytotoxicity of isomeric cholesterol-5,6-epoxides in rabbit aortic endothelial cells

The isomeric cholesterol-5,6-epoxides represent two common cholesterol autoxidation products and along with their principal metabolic product, 3 beta,5 alpha,6 beta-cholestane triol, are purportedly angiotoxic. The uptake and cytotoxic action of these compounds was examined in cultured rabbit aortic endothelial cells emphasizing mechanisms of uptake and metabolic fate. The isomeric cholesterol epoxides are incorporated with equal facility and in a dose-dependent manner. The pattern of uptake, which is markedly influenced by media serum concentration and by temperature, suggests that these compounds are partly incorporated through association with serum lipoproteins. After incorporation, both epoxide isomers are rapidly converted to cholestane triol which readily exits the cells. Cholestane triol is further metabolized to an ester-type product representing up to 10% of the added cholesterol epoxides by 24 h of incubation. The order of cytotoxic potency of these cholesterol oxides is: cholestane triol greater than cholesterol-beta-epoxide greater than cholesterol-alpha-epoxide, with LD50 concentrations ranging from 23 to greater than 150 microM in confluent cells. Cholestane triol and cholesterol-beta-epoxide are twice as cytotoxic to subconfluent cells as compared to confluent cells, whereas cholesterol-alpha-epoxide is essentially equitoxic to confluent and subconfluent cells. Cholesterol epoxide cytotoxicity is significantly reduced by treatments in the absence of serum in accord with substantial reduction in uptake when incubations are performed in serum-free media. Our findings show that these cytotoxic cholesterol oxides are incorporated by endothelial cells through a combination of receptor-mediated and nonspecific or passive mechanisms; however, the efficacy of uptake and resulting toxicity is substantially influenced by serum lipoproteins.

Cutaneous vasculitis associated with pheochromocytoma

We describe a patient who presented with constitutional symptoms, severe hypertension, and purpuric lesions over the knees, thighs, and penis. The patient was eventually diagnosed as having multiple endocrine neoplasia type II, with cutaneous leukocytoclastic vasculitis. The cutaneous vasculitis persisted despite treatment with high-dose systemic corticosteroids, but rapidly resolved after the removal of bilateral pheochromocytomas. This case demonstrates cutaneous leukocytoclastic vasculitis in association with pheochromocytoma.

Induction of cytotoxicity and mutagenesis is facilitated by fatty acid hydroperoxidase activity in Chinese hamster lung fibroblasts (V79 cells)

The metabolic activation of benzo[a]pyrene and 7,8-dihydroxy-7,8-dihydrobenzo[a]pyrene was studied in V79 Chinese hamster fibroblasts after supplementations with arachidonic acid or treatments with linoleic acid hydroperoxide. The extent of metabolic activation was estimated using cytotoxicity and mutagenesis as endpoints. Pretreatment of cells with arachidonic acid for 24 h resulted in significant elevations in the content of this fatty acid in cell phospholipids and increased prostaglandin synthesis. Arachidonic acid and linoleic acid hydroperoxide facilitated 7,8-dihydroxy-7,8-dihydrobenzo[a]pyrene cytotoxicity and mutagenesis, and to a lesser extent increased the cytotoxicity and mutagenicity of benzo[a]pyrene. No other compounds tested were mutagenic under these conditions, however, linoleic acid hydroperoxide markedly increased their cytotoxicity. Arachidonic acid-facilitated toxicity and mutagenesis was inhibited by indomethacin, whereas no inhibition was seen when linoleic acid hydroperoxide was used. Nordihyroquairaretic acid abolished the cytotoxicity and mutagenesis facilitated by arachidonic acid and linoleic acid hydroperoxide. Our findings demonstrate that induction of cytotoxicity and mutagenesis following treatment of V79 cells with carcinogens may be limited by low levels of arachidonic acid in these cells. A peroxidatic mechanism is proposed, with limited substrate specificity, for the metabolic activation of chemicals in V79 cells.

Incorporation of arachidonic, dihomogamma linolenic and eicosapentaenoic acids into cultured V79 cells

The uptake and distribution of three common dietary polyunsaturated fatty acids was studied using Chinese hamster lung fibroblasts (V79 cells). Treatment of V79 cells with arachidonic (20:4), eicosapentaenoic (20:5) and dihomogammalinolenic (20.3) acids for 24 hr produced a marked uptake of 20:3 and 20:4, both of which were assimilated to a considerably greater degree than 20:5. All polyunsaturated fatty acids were incorporated primarily into phospholipids; however, there were considerable differences in their distribution into individual phospholipid species. Although 20:4 was incorporated primarily into phosphatidylcholine, 20:3 entered largely into phosphatidylethanolamine and phosphatidylglycerol, and 20:5 was distributed about equally between phosphatidylcholine, phosphatidylethanolamine and phosphatidylinositol. A marked conversion of 20:3 to 20:4 was found after 24 hr and, in several phospholipids, there was as much derived-radiolabeled 20:4 as there was radiolabeled 20:3. There was little evidence of 20:4 and 20:5 metabolism. V79 cells undergo substantial changes in phospholipid fatty acid composition following supplementation with these polyunsaturated fatty acids; however, these fatty acids are assimilated to different degrees and their distribution among cellular phospholipids is distinct, suggesting incorporation via independent mechanisms.

Impact of Medicare prospective reimbursement system on nutritional support service patients: the importance of pass throughs

The financial data of all patients (535) admitted to the Nutritional Support Service (NSS) during 1985, including charges, true care costs, and actual reimbursement including pass-through payments (which are Medicare funds given directly to hospitals for education and capital equipment, and vary significantly from hospital to hospital), were analyzed. The NSS Medicare patients fell into 98 diagnostic related groups (DRGs). All 3,939 Medicare patients admitted in 1985 with the same DRGs as the NSS patients were also identified and their financial data analyzed. The NSS patients lost $999,643 because of the 266 medicare reimbursed NSS patients sustained high losses which overwhelmed the modest profits of the 269 non-Medicare patients. When data from all Medicare patients (which includes both NSS and non-NSS patients) with the same DRGs are analyzed, large profits are realized. These profits are totally due to pass-through payments received. Without pass throughs the loss for all 3,939 Medicare patients in these 98 DRGs would have been $1,641,273. The impact of eliminating pass throughs in the next few years needs to be determined. NSS patients represent a group that generates high financial losses under the federal prospective reimbursement system. However, present Medicare reimbursement of other less seriously ill patients with similar DRGs more than compensate these losses if pass throughs are used in determining reimbursements.

Mutagenic characterization of cholesterol epoxides in Chinese hamster V79 cells

The uptake, metabolism and alkylating properties of the diastereomeric cholesterol epoxides were studied using Chinese hamster lung fibroblasts (V79 cells). Specific emphasis is given to the comparative cyto- and geno-toxic effects of cholesterol 5 beta,6 beta-epoxide (beta CE) and cholesterol 5 alpha,6 alpha-epoxide (alpha CE) and data are provided for the first time indicating that beta CE can induce more 6-thioguanine-resistant cells than alpha CE. Cholesterol 5 beta,6 beta-epoxide induced colonies of cells resistant to 6-thioguanine at 2-3-fold the frequencies observed with the alpha-isomer, but neither compound produced ouabain-resistant colonies. The cytotoxicity (LD50) of alpha CE was estimated to be 45-50 microM whereas beta CE displayed an LD50 of 25-29 microM. Inhibition of DNA synthesis (IC50) was observed over the same dose ranges as the LD50 for each epoxide isomer. The epoxides were assimilated by cells to an equal extent, however, beta CE was metabolized to cholestane 3 beta,5 alpha-6 beta-triol twice as rapidly as the alpha-isomer. Both epoxides reacted with 4-(4'-nitrobenzyl)-pyridine to a similar extent, and with identical nucleophilic selectivity at pH 7.4, but their alkylating activity was estimated on this basis to be two orders of magnitude less than methyl methanesulfonate. Binding experiments with the DNA or cultured V79 cells or with calf-thymus DNA indicated that interactions were noncovalent and DNA binding did not correlate with the potency of the epoxides to induce the 6-thioguanine-resistant phenotype. Our results could be interpreted as indicating that both cholesterol epoxide isomers are weak mutagens or that they might induce some epigenetic event repressing the hypoxanthine guanine-phosphoribosyltransferase gene. The similarity of the epoxides' alkylating activity and their DNA-binding properties are inconsistent with their different potencies in inducing the 6-thioguanine-resistant phenotype, suggesting that the mechanism leading to this phenotype is not necessarily the result of DNA alkylation.

Growing pains

In the investigation of children with leg aches, it is essential to identify any underlying organic disease. Growing pain is a poorly named, nebulous entity that can be diagnosed only by exclusion. The greatest diagnostic error is to make a diagnosis of growing pains while overlooking some serious underlying condition.

Poly(ADP-ribose) synthesis and inhibition of DNA synthesis in Chinese hamster cells treated with methylating agents and thymidine

A possible role of poly(ADP-ribose) synthesis in modulating the response of V79 cells to DNA damage induced by N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) and methyl methanesulfonate (MMS) was investigated. Inhibition of [3H]thymidine (dThd) incorporation into DNA and lowering of NAD+ levels in intact cells were employed as parameters of DNA-synthesis inhibition and poly(ADP-ribose) synthesis, respectively. Dose responses of these parameters were studied in cells 2 and 24 h after treatment with the methylating agents in medium with or without dThd. The initial inhibition of DNA synthesis was uniformly associated with stimulation of poly(ADP-ribose) synthesis whether the cells were treated with MNNG or MMS, incubated with or without 20 microM dThd which did not inhibit poly(ADP-ribose) synthesis, or incubated with 3 mM dThd which did inhibit the latter synthesis. By contrast, the DNA-synthesis inhibition detected 24 h after treatment with MNNG was not associated with poly(ADP-ribose) synthesis. These data suggest that (i) the mechanism of this later inhibition of DNA synthesis is different from that of the initial inhibition, (ii) DNA-synthesis inhibition does not stimulate poly(ADP-ribose) synthesis, and (iii) single-strand breaks, resulting from N-methylation of the DNA, stimulate poly(ADP-ribose) synthesis, which may produce the initial inhibition of DNA synthesis. The initial inhibition of DNA synthesis was not uniformly associated with mutagenesis and dThd facilitation of MNNG-induced cytotoxicity and mutagenesis. This indicates that O-methylation of DNA does not stimulate poly(ADP-ribose) synthesis. Our data suggest that, in V79 cells treated with methylating agents, poly(ADP-ribose) synthesis is stimulated by single-strand breaks, inhibits DNA synthesis, and thereby serves to allow time for repair of the DNA prior to replication.

Primary pulmonary lymphoma. A clinical and immunohistochemical study of six cases

Six patients with lymphomatous lesions primarily involving the pulmonary parenchyma were studied. In these patients, both the history and physical findings were vague and minimal. The laboratory findings also were nonspecific, although the findings of large multiple lesions in the lungs and pleural adhesion or effusion were more consistent with lymphoma. Histologic examination revealed lymphocytic infiltration of the pulmonary parenchyma in all six patients and presence of germinal or growth centers in some areas of the lesions in four. The hilar or mediastinal lymph nodes were not involved in five patients so examined. Immunocytochemical study of cytoplasmic immunoglobulin revealed monoclonal lymphocytic proliferation in five patients and negative staining in one patient. Clinical, histologic, or immunohistochemical studies alone may not be sufficient to detect all of the lymphomatous lesions. The combined use of all of these parameters is more advantageous for accurate diagnosis of these lesions. Treatment is surgical resection. Radiotherapy or chemotherapy are used when residual disease is present after surgery. Three patients died of disseminated lymphoma 96, 42, and 8 months after diagnosis, respectively, and three patients are still alive at 18, 24, and 4 months, respectively.

Deoxyribonucleoside-induced selective modulation of cytotoxicity and mutagenesis

Treatment of Chinese hamster V79 cells with dThd, dCyd, or dThd plus dCyd increased MNNG-induced AGr-, TGr-, and Ouar-mutant frequencies but did not significantly increase background mutant frequencies. All the AGr colonies that were isolated possessed phenotypes characteristic of HGPRT-deficient mutants, and the deoxyribonucleosides did not selectively affect the growth of the mutants, nor the selecting efficiency of AG, and did not significantly enhance background mutagenesis. These data show that both dThd and dCyd facilitated MNNG-induced mutagenesis. This facilitation was maximal when cells were exposed to the deoxyribonucleosides throughout the first doubling time (24 h) after treatment with MNNG and for 4 more doubling times prior to mutant selection with AG. This indicates that one round of DNA replication was sufficient for mispairing of methylated bases in the DNA with the C and T provided by the deoxyribonucleosides, and that 4-6 doublings prior to mutant selection with AG were necessary to deplete pre-existing hypoxanthine: guanine phosphoribosyl transferase in newly mutated cells. The dCyd facilitated mutagenesis by FdUrd, which was not mutagenic without dCyd, indicating that increased dCTP:dTTP ratios were mutagenic. Treatment with FdUrd plus dCyd also induced FdUrdr cells, suggesting that inhibition of dCyd utilization may prevent the development of FdUrd-resistance in cancer chemotherapy. Although dCyd and dThd facilitated mutagenesis in cells treated with monofunctional alkylating agents that methylate DNA oxygens, facilitation of mutagenesis did not occur in cells treated with BCNU, which cross links DNA, nor with benzo(a)pyrene and aflatoxin B1, which are frame shift mutagens, nor with MMS, which produces barely detectable levels of O-methylation in DNA. Virtually non toxic concentrations of dThd potentiated the cytotoxicity of MNNG more than 10-fold but that of MMS was potentiated only about 2-fold showing that O-alkylation of DNA was associated not only with the facilitation of mutagenesis but also with the potentiation of cytotoxicity. The potentiation of MNNG-induced cytotoxicity was maximal in V79 and L1210 cells after only 2 h treatment with dThd, showing that not even one round of DNA replication was necessary for this potentiation. Moreover, dCyd abolished the potentiation, and, at equitoxic concentrations, MNNG induced higher mutant frequencies than did MMS. These data show that the mechanisms by which methylating agents plus dThd induce mutagenesis are fundamentally different from their mechanisms of cytotoxicity.(ABSTRACT TRUNCATED AT 400 WORDS)

Objective, quantitative measurement of severity of illness in critically ill patients

Severity of illness must be quantitated in critically ill patients if studies of outcome and therapeutic efficacy are to be meaningful. Objective physiologic indicators of critical illness, such as pertinent laboratory values, can be quantitated using the Therapeutic Intervention Scoring System--TISS. TISS data were obtained for 199 consecutive Class IV critically ill surgical ICU patients and compared to the same data obtained in less critically ill Class II and III ICU patients who served as the control group. For the physiologic indicators of critical illness, a wide range of normal values was established prospectively. The actual values generated by Class IV patients were compared to values of the same indicators as measured in Class II and III ICU patients. Of all objective indicators of critical illness, 55% were either outside the normal range or more than 2 SD away from the mean value of objective indicators for Class II and III ICU patients; 49% were beyond the normal range or more than 3 SD away. Of all TISS indicators, 73% were abnormal, and 36% of all physiologic indicators were still abnormal despite massive therapeutic support when compared to Class II or III ICU patients. Those patients who had more than 40% of their physiologic indicators abnormal were more likely to die. However, the percentage of abnormal TISS indicators did not discriminate between patients who died and those who lived, because almost all patients received massive support.(ABSTRACT TRUNCATED AT 250 WORDS)

Mortality among young black women using contraceptives

Data on the risk of death associated with various contraceptive methods are incomplete. Therefore, we analyzed the mortality rates for young, black inner-city women who used one of four methods of contraception--oral contraceptives, depomedroxyprogesterone acetate, intrauterine (contraceptive) devices, and barrier methods. The subjects were 30,580 15- to 44-year-old women who enrolled at a family planning clinic between 1967 and 1972 and who were observed by monitoring death certificates through the end of 1977. Forty percent of the 218 deaths observed were from accidents and violence. Use of this family planning clinic greatly reduced the risk of death from childbearing; only two deaths were associated with pregnancy and childbirth, compared with the 24 deaths expected. Overall, users of the four methods died at similar, low rates. Given that this study involves considerable loss to follow-up, possible acute effects of contraceptives (eg, infections or thrombosis) are more accurately estimated than possible long-term effects (eg, cancer).

Results, charges, and benefits of intensive care for critically ill patients: update 1983

Objective and quantitative methods were used to measure severity of illness and outcome of intensive care in critically ill patients, in terms of success or failure of therapy within the ICU, survival or death at 1 yr, quality of life in survivors, and utilization of resources. One hundred ninety-nine consecutive Class IV critically ill surgical patients hospitalized between 1977 and 1978 at the Massachusetts General Hospital comprised the study population. Although the mortality rate of 69% was close to the 73% rate we recorded for 1972-1973, the survivors' quality of life was significantly better. Hospitalization costs increased from $15,000 to $22,000 per patient, almost consistent with the inflation rate between 1973 and 1978. Survival rates and quality of life in survivors did not vary with age. The disease process for which the patient was hospitalized was an important determinant of outcome. Intensive care medicine for critically ill surgical patients does prolong life and enable some patients to return to a productive lifestyle; however, the costs of these benefits are extremely high.

Sleep studies in the subject's home

Because the ambient environment affects sleep duration and sequence, sleep in the subject's home may be more valid than in a laboratory. Telephone polysomnogram transmission (TPSM) and portable electromagnetic tape recordings offer recordings in the subject's bedroom. Ten subjects were recorded in the laboratory and at home by TPSM and portable recording. Overall sleep patterns were similar with all three techniques, but sleep and REM latency were much shorter and REM duration much longer, and time awake after sleep onset was longer with laboratory recordings. These data show that sleep patterns in the home differ from recordings in the laboratory. Portable recordings provide the additional benefit of monitoring daytime cycles. TPSM affords seven or eight channels for more precise recording and sleep staging.

Induction of mutations by 5-fluorodeoxyuridine: a mechanism of self-potentiated drug resistance?

In medium containing concentrations of deoxycytidine that occur in vivo, 5-fluorodeoxyuridine induced mutation frequencies 6-90 fold greater than spontaneous mutant frequencies at two genetic loci in Chinese hamster cells. In medium lacking deoxycytidine, 5-fluorodeoxyuridine was more cytotoxic but induced no mutants. Hence, the effectiveness of cancer therapy with 5-fluorodeoxyuridine may be limited by self potentiated development of 5-fluorodeoxyuridine-resistant mutants and enhanced and prolonged by manipulating deoxycytidine metabolism.