86 Reducing Inappropriate Readmissions From A Community Hospital—A Quality Improvement Project

Introduction

Quality person-centred care in those approaching the end of life includes consideration and anticipation of their preferred place of death and ceiling of care (CoC). This QI project to reduce inappropriate readmissions was prompted following the transfer of a palliative patient to the acute trust from a community hospital.

Method

Data was collected from the electronic patient record (EPR) at weekly intervals over a six month period, July to December. Electronic documentation of CoC from 507 records from a 24 bed community hospital was reviewed. Data collected included patient age, sex and whether a CoC decision entry had been made on the EPR during the community hospital inpatient stay. The appropriateness of readmissions over the same period was also analy sed. A weekly consultant geriatrician ward round was introduced focusing on advanced care planning with explicit decision making regarding preferred place of care.

Results

There were a total of 16 readmissions during the study period. 3 of these were deemed “inappropriate” following EPR review occurring in August, September and October. Subsequent review of electronic CoC July to October inclusive demonstrated a median completion rate of 20.5%. Following intervention there were no further inappropriate readmissions and the median CoC completion rate was 85%. Qualitatively, the consultant geriatrician managing the community hospital felt there had been a cultural shift where staff felt more comfortable managing complex palliative care.

Conclusions

Introduction of a weekly Consultant Geriatrician ward round in the community setting has led to a sustained improvement in CoC decision-making and documentation. As a result of this there have been no further inappropriate readmissions to the acute trust. This reflects the national guidance in patient centred palliative care. Further work including robust, qualitative assessment of staff attitude towards palliative care is needed to emulate this work at other local community hospitals.

Evidence of patient beliefs, values, and preferences is not provided in osteoporosis clinical practice guidelines

We examined how patient beliefs, values, and preferences (BVPs) were included and conceptualized in international osteoporosis guidelines. The majority of guidelines did not mention BVPs. When mentioned, BVPs were conceptualized as preference for one medication over another. A broader conceptualization and inclusion of BVPs should be incorporated in osteoporosis guidelines.

INTRODUCTION

Our objectives were to determine (1) the extent to which osteoporosis guidelines reflected patients' beliefs, values, and preferences (BVPs); (2) how BVPs were conceptualized; and (3) the methods used to elicit BVPs in the references cited by the guidelines.

METHODS

We conducted a document analysis of English-language international osteoporosis guidelines based on the International Osteoporosis Foundation website. We examined each guideline and extracted all instances of statements pertaining to BVPs. The statements were reviewed by two independent researchers. Discrepancies in data extraction were resolved by the first author. We developed categories based on five common elements that represented the BVP statements.

RESULTS

Twenty-seven of 70 (39%) guidelines included 95 statements about patient BVPs. Of the 95 statements, 32 statements (14 guidelines) were classified under BVP related to the choice of pharmacotherapy or general treatment, 10 (7 guidelines) under BVP related to adherence to pharmacotherapy or treatment in general, 5 (5 guidelines) under BVP related to financial costs and benefits, 43 (19 guidelines) under other BVP mentioned but not supported by a reference to a primary study or systematic review, and 5 (3 guidelines) under other BVP mentioned and supported by at least one reference to a primary study or systematic review. Twenty-nine references were cited to reflect the BVPs mentioned, including an editorial and quantitative studies.

CONCLUSIONS

Twenty-seven (39%) of the guidelines included mention of patients' BVPs. In 19 guidelines, the importance of BVPs was mentioned but these statements were not supported by references to a primary study or systematic review. BVPs were most often (14 guidelines) conceptualized as preference for one medication over another. We suggest that qualitative data be included as evidence of BVPs in guidelines.

Cardiac-gated computed tomography angiography in three alpacas with complex congenital heart disease

BACKGROUND

The prevalence of congenital heart disease is higher in camelids than in other domestic species and complex defects, often involving the great vessels, are more frequently encountered in llamas and alpacas than in other species. Some of these complex defects can be difficult to accurately characterize via echocardiography, the most commonly used diagnostic imaging technique to evaluate the heart in veterinary patients. Contrast-enhanced, electrocardiogram (ECG)-gated computed tomography (CT) has proven utility for the evaluation of human patients with certain congenital heart defects, including those with conotruncal septation defects and other abnormalities involving the formation of the great vessels.

METHODS

Three alpaca crias, 4 days, 5 weeks and 14 months of age were clinically evaluated and subjected to a complete color-flow Doppler echocardiogram and a contrast-enhanced ECG-gated CT.

RESULTS

These alpacas exhibited a variety of clinical findings including lethargy, failure to thrive, exercise intolerance, heart murmur, and/or respiratory difficulty. All three crias were subsequently diagnosed with complex cardiac defects including pulmonary atresia with a ventricular septal defect (VSD), a truncus arteriosus with a large VSD, and a double outlet right ventricle with a large VSD and aortic hypoplasia. In each case, the diagnosis was confirmed by postmortem examination.

CONCLUSION

Color flow echocardiographic evaluation identified all of the intra-cardiac lesions and associated flow anomalies but contrast-enhanced ECG-gated CT permitted more accurate assessment of the morphology of the extracardiac structures and permitted a more precise determination of the exact nature and anatomy of the great vessels.

Impact of a centralized osteoporosis coordinator on post-fracture osteoporosis management: a cluster randomized trial

We conducted a cluster randomized trial evaluating the effect of a centralized coordinator who identifies and follows up with fracture patients and their primary care physicians about osteoporosis. Compared with controls, intervention patients were five times more likely to receive BMD testing and two times more likely to receive appropriate management.

INTRODUCTION

To determine if a centralized coordinator who follows up with fracture patients and their primary care physicians by telephone and mail (intervention) will increase the proportion of patients who receive appropriate post-fracture osteoporosis management, compared to simple fall prevention advice (attention control).

METHODS

A cluster randomized controlled trial was conducted in small community hospitals in the province of Ontario, Canada. Hospitals that treated between 60 and 340 fracture patients per year were eligible. Patients 40 years and older presenting with a low trauma fracture were identified from Emergency Department records and enrolled in the trial. The primary outcome was 'appropriate' management, defined as a normal bone mineral density (BMD) test or taking osteoporosis medications.

RESULTS

Thirty-six hospitals were randomized to either intervention or control and 130 intervention and 137 control subjects completed the study. The mean age of participants was 65 ± 12 years and 69% were female. The intervention increased the proportion of patients who received appropriate management within 6 months of fracture; 45% in the intervention group compared with 26% in the control group (absolute difference of 19%; adjusted OR, 2.3; 95% CI, 1.3-4.1). The proportion who had a BMD test scheduled or performed was much higher with 57% of intervention patients compared with 21% of controls (absolute difference of 36%; adjusted OR, 4.8; 95% CI, 3.0-7.0).

CONCLUSIONS

A centralized osteoporosis coordinator is effective in improving the quality of osteoporosis care in smaller communities that do not have on-site coordinators or direct access to osteoporosis specialists.

The intracellular segment of the sodium channel beta 1 subunit is required for its efficient association with the channel alpha subunit

Sodium channels consist of a pore-forming alpha subunit and auxiliary beta 1 and beta 2 subunits. The subunit beta 1 alters the kinetics and voltage-dependence of sodium channels expressed in Xenopus oocytes or mammalian cells. Functional modulation in oocytes depends on specific regions in the N-terminal extracellular domain of beta 1, but does not require the intracellular C-terminal domain. Functional modulation is qualitatively different in mammalian cells, and thus could involve different molecular mechanisms. As a first step toward testing this hypothesis, we examined modulation of brain Na(V)1.2a sodium channel alpha subunits expressed in Chinese hamster lung cells by a mutant beta1 construct with 34 amino acids deleted from the C-terminus. This deletion mutation did not modulate sodium channel function in this cell system. Co-immunoprecipitation data suggest that this loss of functional modulation was caused by inefficient association of the mutant beta 1 with alpha, despite high levels of expression of the mutant protein. In Xenopus oocytes, injection of approximately 10,000 times more mutant beta 1 RNA was required to achieve the level of functional modulation observed with injection of full-length beta 1. Together, these findings suggest that the C-terminal cytoplasmic domain of beta 1 is an important determinant of beta1 binding to the sodium channel alpha subunit in both mammalian cells and Xenopus oocytes.

Risk factors for suicide attempts among African American women

The aim of this study was to examine psychological and interpersonal risk factors for suicidal behavior in low income, African American women; 285 African American women who reported being in a relationship with a partner in the past year were studied, 148 presented to the hospital following a suicide attempt, and 137 presented for general medical care. Cases were compared to controls with respect to psychological symptoms, alcohol and drug abuse, family violence (intimate partner abuse, childhood trauma), relationship discord, and social support. Psychological risk factors for suicide attempts at the univariate level included psychological distress [Crude Odds Ratio (COR) = 6.5], post traumatic stress disorder (PTSD) symptoms (COR = 3.8), hopelessness (COR = 7.7), and drug abuse (COR = 4.2). Interpersonal risk factors at the univariate level included relationship discord (COR = 4.0), physical partner abuse (COR = 2.5), nonphysical partner abuse (COR = 2.8), childhood maltreatment (COR = 3.2), and low levels of social support (COR = 2.6). A multivariate logistic regression model identified four variables that were strongly and independently associated with an increased risk for suicide attempts: psychological distress, hopelessness, drug abuse, and relationship discord. The model predicted suicide attempt status correctly 77% of the time. The results reveal that African American women who report high levels of psychological distress, hopelessness, drug use, and relationship discord should be assessed carefully for suicidal ideation and referred for appropriate mental health care.

Analysis of Drosophila salivary gland, epidermis and CNS development suggests an additional function of brinker in anterior-posterior cell fate specification

Salivary glands are simple structured organs which can serve as a model system in the study of organogenesis. Following a large EMS mutagenesis we have identified a number of genes required for normal salivary gland development. Mutations in the locus small salivary glands-1 (ssg-1) lead to a drastic reduction in the size of the salivary glands. The gene ssg-1 was cloned and subsequent sequence and genetic analysis showed identity to the recently published gene brinker. The salivary gland placode in brinker mutants appears reduced along both the anterior-posterior and dorso-ventral axis. Analysis of the brinker cuticle phenotype revealed a similar loss of anterior-posterior as well as lateral cell fates. The abdominal ventral denticle belts show a reduced number of setae in the first denticle row. Furthermore, we observed a preferential loss of lateral neuroblasts in the anterior parasegment. Together, these phenotypes suggest that brinker not only plays a role in dorso-ventral but also in anterior-posterior axis patterning.

Effect of gel re-organization and tensional forces on alpha2beta1 integrin levels in dermal fibroblasts

Mechanical forces are known to play an important role in regulating cell function in a wide range of biological systems. This is of particular relevance to dermal fibroblast function, given that the skin is known to be held under an intrinsic natural tension. To understand more about the generation of force by dermal fibroblasts and their ability to respond to changes in it, we have studied the role of the beta1 integrin receptors expressed by dermal fibroblasts in their ability to generate tensional forces within a collagen type I matrix and the effect of altered tensional force on integrin expression by dermal fibroblasts. Using a purpose-built culture force monitor, function-blocking antibodies directed towards the beta1 receptors dramatically reduced the tensional forces generated by dermal fibroblasts in a 3D collagen I matrix. However, the specific involvement of alpha1 or alpha2 subunits could not be demonstrated. Analysis of cellular response demonstrated that cells isolated from contracting collagen gels expressed fourfold higher levels of alpha2 mRNA than cells isolated from fully restrained gels. The levels of beta1 messenger RNA were relatively unaffected by reductions in force. Cells exposed to single reductions in force, however, did not exhibit alterations in either alpha1 or beta1 mRNA levels. We propose, therefore that alpha2beta1 integrin receptor levels in dermal fibroblasts are not altered in response to single reductions of gel tension, but do change following a continual change in force and associated matrix re-organization

Experience with procedural sedation in a pediatric burn center

BACKGROUND

Burn care requires daily debridement, dressing changes, and assessment regarding the need for skin grafting. These procedures are painful and may require an operating room environment.

METHODS

The authors reviewed their experience with 912 consecutive procedural sedations (PS) in 220 pediatric burn patients over a 2-year period to identify what influence PS had on patient care. Median patient age was 32 months, and body surface area burn was 7.2%+/-6%. Pharmacological techniques included oral and intravenous medications and N2O. The authors included all sedations given in the burn treatment area and excluded all treatments given in the intensive care unit or emergency unit.

RESULTS

PS allowed for early aggressive wound debridement, virtually eliminated the need for operating room debridement (used in only 22 patients), and eliminated patient discomfort and fear often associated with subsequent debridements. Burn wound-related complications occurred in 54 patients and included wound infection (n = 18), graft loss (n = 9), and pneumonia (n = 4). The incidence of PS complications was 7% with the most common problems including decreased arterial saturation (n = 41), emesis (n = 11), and agitation (n = 8). No patient required intubation or transfer to an intensive care unit bed. The average length of stay (LOS) for all patients was 8.7+/-6.2 days, and 6.2+/-3.8 days in the 200 patients not admitted to the intensive care unit. This compares favorably with the 9.5-day LOS of patients treated in 1990.

CONCLUSIONS

PS in burn patients allows for early aggressive debridement, decreases the use of the operating room for debridement, and a decrease in length of stay when compared with our previous burn patients. PS has a modest risk of complications, enhances the family's cooperation and satisfaction with health care provided, and should be an integral part of burn care in children.

A molecular basis for the different local anesthetic affinities of resting versus open and inactivated states of the sodium channel

Voltage-gated sodium channels are inhibited by local anesthetic drugs. This inhibition has complex voltage- and frequency-dependent properties, consistent with a model in which the sodium channel has low affinity for local anesthetics when it is in resting states and higher affinity when it is in open or inactivated states. Two residues, a phenylalanine (F1710) and a tyrosine (Y1717), in transmembrane segment IVS6 of the channel alpha subunit are critical for state-dependent block. We examined how these residues determine channel sensitivity to local anesthetics by introducing mutations that varied their size, hydrophobicity, and aromaticity. Block of resting channels by tetracaine was correlated with hydrophobicity at position 1710, as if hydrophobic drug-receptor interactions stabilize binding to resting states. In contrast, drug action on open or inactivated channels required an aromatic residue at this position. We propose that the native phenylalanine at position 1710 stabilizes drug binding to open or inactivated states by either cation-pi or aromatic-aromatic interactions between the aromatic side chain of the amino acid and charged or aromatic moieties on the drug molecule. We also consider the alternative possibility that mutations at this position affect drug action by either altering access to the receptor or by allosteric changes in receptor conformation. Mutations at position 1717 also altered drug action; however, these effects were not well-correlated with the size, hydrophobicity, or aromaticity of the substituted amino acid. These results suggest that the residue at this position does not contribute directly to the drug receptor.

Partner abuse and posttraumatic stress disorder as risk factors for suicide attempts in a sample of low-income, inner-city women

This study examined partner abuse and posttraumatic stress disorder (PTSD) as risk factors for suicidal behavior among women, and whether or not PTSD mediated the partner abuse-suicidal behavior association. Attempters (n = 119) were approximately three times more likely to be above clinical cut-points for physical partner abuse, nonphysical abuse, and PTSD than nonattempters (n = 85). Physical partner abuse, but not nonphysical partner abuse, was associated with an increased risk for PTSD. Further, PTSD mediated the link between physical partner abuse and suicidality, such that when PTSD was statistically controlled, the association between physical partner abuse and suicide attempt status was reduced to nonsignificance. Implications of findings for interventions for female victims of partner abuse, and women who make nonfatal suicide attempts are discussed.

The class I antigen-processing pathway for the membrane protein tyrosinase involves translation in the endoplasmic reticulum and processing in the cytosol

Formation of major histocompatibility complex class I-associated peptides from membrane proteins has not been thoroughly investigated. We examined the processing of an HLA-A*0201-associated epitope, YMDGTMSQV, that is derived from the membrane protein tyrosinase by posttranslational conversion of the sequence YMNGTMSQV. Only YMDGTMSQV and not YMNGTMSQV was presented by HLA-A*0201 on cells expressing full-length tyrosinase, although both peptides have similar affinities for HLA-A*0201 and are transported by TAP. In contrast, translation of YMNGTMSQV in the cytosol, as a minigene or a larger fragment of tyrosinase, led to the presentation of the unconverted YMNGTMSQV. This was not due to overexpression leading to saturation of the processing/conversion machinery, since presentation of the converted peptide, YMDGTMSQV, was low or undetectable. Thus, presentation of unconverted peptide was associated with translation in the cytosol, suggesting that processing of the full-length tyrosinase occurs after translation in the endoplasmic reticulum. Nevertheless, presentation of YMDGTMSQV in cells expressing full-length tyrosinase was TAP (transporter associated with antigen processing) and proteasome dependent. After inhibition of proteasome activity, tyrosinase species could be detected in the cytosol. We propose that processing of tyrosinase involves translation in the endoplasmic reticulum, export of full-length tyrosinase to the cytosol, and retransport of converted peptides by TAP for association with HLA-A*0201.

Diagnosis of perinatal human immunodeficiency virus infection by polymerase chain reaction and p24 antigen detection after immune complex dissociation in an urban community hospital

Results of polymerase chain reaction (PCR) and p24 antigen detection after immune complex dissociation (p24-ICD) were compared with antibody results after 18 months of age for human immunodeficiency virus (HIV) diagnosis in 345 prospectively followed, perinatally exposed infants. Of 59 infected and 286 uninfected infants tested at 1-6 months of age, sensitivity and specificity were, respectively, 100% and > 97% for PCR and 90% and > 97% for p24-ICD. Testing was done on > or = 2 occasions in the first 6 months of life in 43 infected infants; 77% had > or = 2 positive results with the same test. Of these infants, 68% had 2 positive p24-ICD tests. In uninfected infants, 96% had only negative tests; none had > 1 positive. By 6 months, all uninfected infants with > or = 2 PCR results could have been diagnosed. HIV status can be determined by PCR by age 6 months in most HIV-exposed infants. p24-ICD should not be used alone, because of its lower sensitivity, but may be useful in areas without advanced laboratory support.

The HLA-A*0201-restricted H-Y antigen contains a posttranslationally modified cysteine that significantly affects T cell recognition

A peptide recognized by two cytotoxic T cell clones specific for the human minor histocompatibility antigen H-Y and restricted by HLA-A*0201 was identified. This peptide originates from SMCY, as do two other H-Y epitopes, supporting the importance of this protein as a major source of H-Y determinants in mice and humans. In naturally processed peptides, T cells only recognize posttranslationally altered forms of this peptide that have undergone modification of a cysteine residue in the seventh position. One of these modifications involves attachment of a second cysteine residue via a disulfide bond. This modification has profound effects on T cell recognition and also occurs in other class I MHC-associated peptides, supporting its general importance as an immunological determinant.

Susceptibility to ankylosing spondylitis correlates with the C-terminal residue of peptides presented by various HLA-B27 subtypes

Susceptibility to spondyloarthropaties is strongly associated with some HLA-B27 alleles. Evidence suggests a direct pathogenic role for the B27 molecules which possibly present an arthritogenic peptide to the T cells. If this hypothesis is true, B27 subtypes that differ structurally but are disease-associated ought to be capable of presenting such peptide(s), while non-disease-associated ones would not. We have recently described a B27 subtype, B*2709, and shown its absence in ankylosing spondylitis (AS) patients. Here, we show the elution and sequence of peptides from HLA-B*2709 molecules. Similar to other B27 subtypes, these peptides are mainly nonamers with an Arg at position P2. Comparison of the C-terminal anchors of peptides eluted from B*2702 and B*2705 with those eluted from B*2709 reveals that, while B*2702 and B*2705 have a broader specificity, B*2709 molecules appear to only accept C-terminal hydrophobic residues. A common feature shared by the two caucasoid AS-associated subtypes (B*2702 and B*2705) but different from B*2709, is the presence of a Tyr as peptide C-terminal anchor. The substitution of Val for Tyr at the C terminus in one of the eluted peptides greatly reduces the binding to B*2709 molecules. This finding suggests Tyr as a discriminative amino acid allowed at the C terminus of peptides bound to the AS-associated B27 subtypes, but not to those which are not associated with AS.

The measure and mismeasure of the tibia: implications for stature estimation

Trotter and Gleser's stature estimation formulae, based on skeletons of the Terry collection and on WWII casualties, have been widely used in forensic work. Our work with the Terry and WWII data yielded tibia lengths too short compared to other data sets. Using Trotter's original measurements, we discovered that she consistently mismeasured the tibia. Contrary to standard practice and her own definitions, she omitted the malleolus from the measurement. Trotter's measurements of the tibia are 10 to 12 mm shorter than they should have been, resulting in stature estimations averaging 2.5 to 3.0 cm too great when the formulae are used with properly measured tibia. We also examined tibia lengths of Korean War casualties, which were measured by technicians rather than by Trotter. Korean tibia measurements are also too short, but by a smaller amount than Terry and WWII. Since the Korean tibia are unavailable for restudy, it is unclear how they were measured. Estimation of stature from Trotter and Gleser's tibia formulae is to be avoided if possible. If necessary, the 1952 formulae could be used with tibia measured in the same manner that Trotter measured, excluding the malleolus.

Allometric secular change in the long bones from the 1800s to the present

Allometric secular changes in the six long limb bones for White and Black males from the mid 1800s to the present are examined. Long bone lengths are available from the Terry collection and WWII casualties. We conducted two types of analysis to reveal secular changes. First, allometry scaling coefficients were derived by regressing log bone length onto log stature. These showed that the femur, tibia and fibula were positively allometric with stature, while the humerus, radius and ulna were isometric. The lower limb bones were more positively allometric in the WWII sample than in the Terry sample. Second, secular changes in length of femur and tibia and in the tibia/femur ratio were evaluated, using modern forensic cases in addition to the Terry and WWII samples. This analysis shows that secular increase in lower limb bone length is accompanied by relatively longer tibiae. Secular changes in proportion may render stature formulae based on nineteenth century samples, such as the Terry collection, inappropriate for modern forensic cases. The positive allometry of the lower limb bones argues against using simple femur/stature ratio, which assumes constant proportionality, as an alternative to regression equations.

Population structure of Algonquian speakers

Speakers of Algonquian languages are widely dispersed geographically but are homogeneous linguistically. We examine anthropometric differentiation among Algonquian-speaking populations distributed from New Brunswick to Montana. Head and face measurements and body measurements were analyzed separately in an attempt to address the effect of phenotypic plasticity on relationships. The head and face and body dimensions yield somewhat different pictures of relationships. From the head and face data an east to west geographic pattern can be discerned. The principal feature of the body measurements is the distinctiveness of the Ojibwa located northwest of Lake Superior. The formal correlation between the two sets of measurements is low and not significant. Only the head and face dimensions correlate significantly with geographic distances. Language distances do not correlate with anthropometric distances. The set of populations is also more strongly differentiated with respect to body measurements than to head and face measurements. We interpret this as reflecting phenotypic plasticity and possibly greater interobserver variation.

Characterization of Centers for Disease Control group NO-1, a fastidious, nonoxidative, gram-negative organism associated with dog and cat bites

Seventeen strains of fastidious, nonoxidative, gram-negative rods, isolated from human wounds resulting primarily from dog or cat bites, formed a distinct group, which was designated Centers for Disease Control (CDC) group nonoxidizer 1 (NO-1). The phenotypic characteristics of CDC group NO-1 were most similar to non-acid-producing Acinetobacter species, with the major difference being a negative reaction in the transformation assay test for Acinetobacter spp. The cellular fatty acid composition of CDC group NO-1 was different from those of Acinetobacter species and all other bacteria tested to date. The isolates were susceptible to a variety of antimicrobial agents including the aminoglycosides, beta-lactam antibiotics, tetracyclines, quinolones, and sulfonamides. Fifty percent of the isolates were resistant to trimethoprim. Ubiquinone-8 was present as the major isoprenoid quinone in CDC group NO-1.

Estimation of stature from metacarpal lengths

Formulae for the estimation of stature from metacarpal lengths are presented. Two samples of metacarpal specimens were employed in the analysis: one of 212 individuals from the Terry Collection, and one of 55 modern males, all of whom had measured statures. One measurement, the midline length, was taken on each metacarpal. Stature was regressed on the basis of the metacarpal length to derive equations for the Terry Collection individuals. Comparisons between the Terry Collection males and the modern sample showed the latter to have longer metacarpals and greater statures. The Terry equations were tested using the modern male sample. In spite of the differences noted, the Terry equations perform acceptably on modern individuals. The performance was slightly better for whites than for blacks. Since the female equations were not tested, they should be employed with greater caution.

Time since death and decomposition of the human body: variables and observations in case and experimental field studies

Much of the difficulty in determining the time since death stems from the lack of systematic observation and research on the decomposition rate of the human body. Continuing studies conducted at the University of Tennessee, Knoxville, provide useful information on the impact of carrion insect activity, ambient temperature, rainfall, clothing, burial and depth, carnivores, bodily trauma, body weight, and the surface with which the body is in contact. This paper reports findings and observations accumulated during eight years of research and case studies that may clarify some of the questions concerning bodily decay.

Deficiency of the fifth component of complement in human subjects. Clinical, genetic and immunologic studies in a large kindred

The discovery of a large kindred with a heritable deficiency of the fifth component of complement (C5) has permitted the accumulation of new clinical, genetic and immunologic data concerning the role of C5 in human subjects. The proband, who has had nine episodes of disseminated gonococcal infection, has a hemolytic C5 level of approximately 0.5 per cent of normal. No C5 protein was detectable, but low levels of functional C5 activity could be found using a sensitive bactericidal assay. The proband's twin as well as another sister also had extremely low levels of hemolytic C5(approximately 0.5 per cent normal), but both these subjects have been healthy. Hemolytic complement and bacteriolytic activity could be restored by the addition of purified C5. No chemotactic activity for polymorphonuclear leukocytes could be generated in the C5-deficient serums upon activation of either the classic or alternative pathways, again demonstrating the importance of C5 in human subjects for the production of chemotactic factors. The chemotactic responsiveness of the patients' polymorphonuclear leukocytes and monocytes to preformed chemotactic factors was not depressed. Twenty-two of 32 other family members from three generations had depressed whole hemolytic complement levels. In 19 of 30 family members, levels of hemolytic C5 ranged from 13 to 64 per cent of normal. No linkage for C5 deficiency and the A or B loci of the major histocompatibility complex could be found. These data suggest an autosomal codominant mode of inheritance of C5 deficiency. Deficiency of C5 is compatible with good health, but it can be associated with repeated disseminated gonococcal infection.

Hereditary C2 deficiency associated with cutaneous lupus erythematosus: clinical, laboratory, and genetic studies

Selective congenital deficiency in the second component of complement has been described in association with lupus erythematosus (LE) and other connective tissue disorders. We identified a 59-year-old woman with a 13-year history of cutaneous LE and no detectable serum C2. The patient's photosensitivity, large polycyclic erosive cutaneous lesions, lack of renal disease, paucity of serological findings, and high incidence of bacterial infection is consistent with previously described patients with this association. Uniquely, the patient demonstrated secondary infection with Staphylococcus aureus and Trichophyton rubrum in the skin lesions themselves. Immunologic studies disclosed depression in both humoral and cellular immunity. Moderation in her clinical disease and immunologic measurements has been observed after treatment with levamisole hydrochloride. Immunogenetic studies of the patient's four-generation kindred was consistent with an autosomal recessive inheritance of C2 deficiency genetically linked to HLA, segregating with the B18 allele. Mixed lymphocyte culture determinations reinforce evidence for linkage between the HLA-D locus and the trait for C2 deficiency.

Epiphysiolysis as a method of limb lengthening

Epiphysiolysis followed by distraction was performed at the proximal tibial growth plates in 18 young rabbits. Union across the distracted plate occurred in all animals. In 12 rabbits skeletally immature at operation, premature fusion of the separated plate resulted in growth arrest of the operated limb. The contralateral control limb was longer at maturity by an average 1.10 cm. In 6 rabbits near skeletal maturity at epiphysiolysis, the operated limb was the longer at maturity by the amount distracted, an average of 0.62 cm. In all animals a permanent loss of joint motion resulted. Epiphyseal distraction in the very young rabbit does not appear to be practical due to consistent premature fusion of the distracted growth plate. It is possible to lengthen the limbs of rabbits near skeletal maturity with this procedure. An added advantage is that union between the epiphysis and the metaphysis always occurred, eliminated the problem of delayed ana non union found in diaphyseal lengthening. However, at this time, until the effects of distraction and compression on the adjacent joint can be minimized, epiphysiolysis as a method of limb lengthening is not recommended in children.

Abnormal monocyte chemotaxis in patients with breast cancer: evidence for a tumor-mediated effect

The chemotactic responsiveness of peripheral blood monocytes was measured in 194 individuals: 37 patients with breast cancer, 17 patients with a history of breast cancer but clinically free of disease after surgery, 42 patients with benign breast masses, and 98 normal controls. Monocyte chemotactic responsiveness (MCR) in vitro was not significantly different from normal [mean = 72.8 migrating monocytes/oil immersion field, +/- 9.3 (1 SD)] in 2 groups of patients: a) those with benign breast masses (mean = 72.6 +/- 15.1; P greater than 0.3) and b) those previously having breast cancer resected and remaining clinically free of disease (mean = 69.0 +/- 12.5; P greater than 0.4). However, MCR was significantly depressed in the group of patients with active breast cancer (mean = 57.2 +/- 20.7; P less than 0.0025). Resection of malignant breast masses resulted in a significant change in MCR (P less than 0.0025), whereas resection of benign lesions did not (P greater than 0.4). MCR was abnormal in all clinical stages of breast cancer, including breast cancer without evidence of metastasis to regional lymph nodes. These data supported the hypothesis that neoplasms adversely affect monocyte function and may thereby hinder immunologically mediated destruction of malignant cells.

Generalized microsporum audoninii infection and depressed cellular immunity associated with a missing plasma factor required for lymphocyte blastogenesis

Described herein is a 15 year old girl with a generalized, possibly systemic Microsporum audouinni infectin associated with anergy and defective lymphocyte transformation as a consequence of a deficiency of an uncharacterized plasma factor. Intravenous administration of plasma, obtained from normal donors, has produced consistent although incomplete clinical improvement. Defective lymphocyte transformation to M. audiouinii antigen cultured in autologous plasma became normal after infusions of normal plasma were instituted. Systemic administrations of griseofulvin, clotrimazole and miconazole produced transient and incomplete clinical improvement. Clearing of the cutaneous infection and stabillization of the neurologic status was finally achieved with plasma infusions combined with parenterally administered amphotericin B.

Abnormalitieis of monocyte chemotaxis in patients with melanoma: effects of immunotherapy and tumor removal

The chemotactic responsiveness of peripheral blood monocytes was studied before and after immunotherapy was administered to 56 patients with melanoma. Abnormal chemotaxis was found in 36 patients (64%) prior to treatment; this abnormality correlated with severity of disease and prognosis. Immunotherapy with BCG and sensitized autologous lymphocytes and X-irradiated melanoma cells or surgical removal of the neoplasm both reduced the percentage of patients with abnormal chemotactic responses. The best prognosis was found for those patients who had normal chemotaxis prior to therapy. The data support the hypothesis that abnormalities of monocyte function might render the host less likely to destroy developing neoplasms and that malignant tumors themselves might affect monocyte function.