92. Utility of Sinus CT in the Evaluation of Patients with Febrile Neutropenia

Background

The etiology of febrile neutropenia in patients with hematological malignancy is identified in only 20–30% of cases. Sinus computed tomography (CT) is often used, regardless of symptoms, to rule out rhinocerebral source of infection. There are no clear guidelines on when to perform sinus CT in this population. In this study, we evaluated the role of sinus CT in febrile neutropenic patients.

Methods

We retrospectively reviewed medical records of all adults (age ≥18 years) with febrile neutropenia (T≥ 38.3ºC, ANC < 0.5 x 109/L) and hematological malignancies who underwent sinus CT from January 2014 to May 2020. We present the preliminary analysis of the impact of sinus CT findings on the management of febrile neutropenia.

Results

47 patients with a total of 56 episodes of febrile neutropenia met the inclusion criteria. The median age at presentation was 57 years (IQR: 42 - 68 years). The most common underlying malignancy was acute myeloid leukemia (51%), followed by myelodysplastic syndrome (19%). At presentation, 47% had refractory disease, 21% were newly diagnosed, 15% had relapsed, 15% were in complete remission, and 2% were in partial remission. Of the total 56 episodes, 29 (52%) had symptoms of rhinorrhea (20%), facial pain (14%), and sinus congestion (14%). The remaining 27 of 56 episodes (48%) had no sinus symptoms. Sinus CT was abnormal in 48 of 56 episodes (86%); the most common finding was mucosal thickening (47/48; 98%), followed by air-fluid levels (7/48; 14.5%), partial opacification (6/48; 12.5%), complete opacification (2/48; 4%), and bony invasion (2/48; 4%). The source of febrile neutropenia was attributed to the CT sinus findings in 9 cases (9/48; 29%), leading to a change in therapeutic management. All 9 patients were symptomatic, with evidence of necrosis in 22% (2/9) and purulence in 22% (2/9) on nasal endoscopy.

Table 1

Conclusion

Mucosal thickening is a frequent and non-specific imaging finding, particularly in patients without sinus symptoms. Sinus CT findings in patients with febrile neutropenia without sinus symptoms had no impact on clinical management. Consequently, sinus CT may be reserved for patients presenting with sinus symptoms.

Disclosures

M. Rizwan Sohail, MD, Aziyo Biologics (Consultant)Medtronic Inc (Consultant, Research Grant or Support)

Drivers of the Decision to Biopsy and Follow-Up of Small Suspicious Thyroid Nodules

OBJECTIVE

In 2015, the updated American Thyroid Association (ATA) guidelines recommended observation for suspicious subcentimeter thyroid nodules, based on their indolent course. We aimed to evaluate the frequency of biopsy in suspicious thyroid nodules since the introduction of these guidelines, including factors contributing to clinical decision-making in a tertiary care center.

METHODS

We conducted a retrospective study of patients in the Mayo Clinic, Rochester, Minnesota, with new, subcentimeter suspicious thyroid nodules (by report or by sonographic features) between March, 2015, and November, 2017, not previously biopsied.

RESULTS

We identified 141 nodules in 129 patients: mean age 58.1±14.1 years, 74% female, 87% Caucasian. The frequency of biopsy in suspicious thyroid nodules was 39%. Ultrasound features that were the strongest predictors for biopsy on multivariate analysis included: nodule volume (odds ratio [OR] 37.3 [7.5-188.7]), radiology recommendation for biopsy (OR 2.6 [1.8-3.9]) and radiology report of the nodule as "suspicious" (OR 2.1 [1.4-3.2]). Patient's age and degree of comorbidities did not change the likelihood for biopsy, nor did it vary by clinician type or how the nodule was initially found (incidentally or not incidentally). Among 86 nodules that were not biopsied, 41% had no specific follow-up recommendations.

CONCLUSION

One third of suspicious thyroid nodules underwent biopsy since the release of updated ATA guidelines. Factors driving thyroid biopsy seem to be associated with nodule characteristics but not with patient factors including age and comorbidities. Further studies and development of decision aides may be helpful in providing individualized approaches for suspicious thyroid nodules.

ABBREVIATIONS

ATA = American Thyroid Association; OR = odds ratio.

Association of hyperlipidaemia with 5-year survival after hospitalisation for acute myocardial infarction: a propensity score matched analysis

Objectives

The primary objective was to examine the association between hyperlipidaemia (HLP) and 5-year survival after incident acute myocardial infarction (AMI). The secondary objectives were to assess the effect of HLP on survival to discharge across patient subgroups, and the impact of statin prescription, intensity and long-term statin adherence on 5-year survival.

Methods

Retrospective cohort study of 7071 patients hospitalised for AMI at Mayo Clinic from 2001 through 2011. Of these, 2091 patients with HLP (age (mean±SD) 69.7±13.5) were propensity score matched to 2091 patients without HLP (age 70.6±14.2).

Results

In matched patients, HLP was associated with higher rate of survival to discharge than no HLP (95% vs 91%; log-rank <0.0001). At year 5, the adjusted HR for all-cause mortality in patients with HLP versus no HLP was 0.66 (95% CI 0.58–0.74), and patients with prescription statin versus no statin was 0.24 (95% CI 0.21 to 0.28). The mean survival was 0.35 year greater in patients with HLP than in those with no HLP (95% CI 0.25 to 0.46). Patients with HLP gained on an average 0.17 life year and those treated with statin 0.67 life year at 5 years after AMI. The benefit of concurrent HLP was consistent across study subgroups.

Conclusions

In patients with AMI, concomitant HLP was associated with increased survival and a net gain in life years, independent of survival benefit from statin therapy. The results also reaffirm the role of statin prescription, intensity and adherence in reducing the mortality after incident AMI.

Resistance to intercompartmental mass transfer limits β2-microglobulin removal by post-dilution hemodiafiltration

Although clearance of beta(2)-microglobulin is greater with hemodiafiltration than with high-flux hemodialysis, beta(2)-microglobulin concentrations after long-term hemodiafiltration are only slightly less than those obtained with high-flux hemodialysis. Resistance to beta(2)-microglobulin transfer between body compartments could explain this observation. beta(2)-Microglobulin kinetics were determined in patients receiving on-line post-dilution hemodiafiltration for 4 h with 18 l of filtration. Plasma beta(2)-microglobulin concentrations were measured during and for 2 h following hemodiafiltration and immediately before the next treatment. The filter clearance of beta(2)-microglobulin was determined from arterial and venous concentrations. The beta(2)-microglobulin generation rate was calculated from the change in the plasma concentration between treatments. The intercompartmental clearance was obtained by fitting the observed concentrations to a two-compartment, variable volume model. The plasma clearance of beta(2)-microglobulin by the filter was 73 +/- 2 ml/min. Plasma beta(2)-microglobulin concentrations decreased by 68 +/- 2% from pre- to post-treatment (27.1 +/- 2.2-8.5 +/- 0.7 mg/l), but rebounded by 32+/-3% over the next 90 min. The generation rate of beta(2)-microglobulin was 0.136 +/- 0.008 mg/min. The model fit yielded an intercompartmental clearance of 82 +/- 7 ml/min and a volume of distribution of 10.2 +/- 0.6 l, corresponding to 14.3 +/- 0.7% of body weight. Hemodiafiltration provides a beta(2)-microglobulin clearance of similar magnitude to the intercompartmental clearance within the body. As a result, intercompartmental mass transfer limits beta(2)-microglobulin removal by hemodiafiltration. This finding suggests that alternative strategies, such as increased treatment times or frequency of treatment, are needed to further reduce plasma beta(2)-microglobulin concentrations.

Increasing dialysate flow rate increases dialyzer urea mass transfer-area coefficients during clinical use

Dialyzer clearance depends on blood and dialysate flow rates and the product of the membrane surface area and mass transfer coefficient for the solute of interest, K(o)A. K(o)A is usually assumed to be constant for a given dialyzer and solute. Results of two recent studies challenge this assumption. Therefore, we examined the hypothesis that K(o)A depends on blood and dialysate flow rates during clinical dialysis. Urea clearances were measured for two different dialyzers at all four combinations of two blood flow rates (300 and 400 mL/min) and two dialysate flow rates (500 and 800 mL/min). Urea K(o)A was calculated by using standard equations for mass transfer in dialyzers operated with countercurrent flows. The impact of blood and dialysate flow rates on K(o)A was assessed by analysis of variance. Increasing dialysate flow rate from 500 to 800 mL/min significantly increased K(o)A (P = 0.018). Increasing blood flow rate from 300 to 400 mL/min did not significantly increase K(o)A (P = 0.083). Also, K(o)A decreased significantly with increasing hematocrit (P = 0.022). The results of this study extend previous in vitro findings by showing that increasing the dialysate flow rate increases urea K(o)A during clinical dialysis. However, the increase in K(o)A observed during clinical dialysis (5.7%) is less than that previously reported in vitro (14.7%), possibly because of the impact of blood cells and proteins on blood-side mass transfer resistance.

Priming of the neutrophil respiratory burst involves p38 mitogen-activated protein kinase-dependent exocytosis of flavocytochrome b558-containing granules

The respiratory burst of human neutrophils is primed by a number of pro-inflammatory stimuli, including tumor necrosis factor-alpha (TNFalpha) and lipopolysaccharide (LPS); however, the mechanism of priming remains unknown. LPS has been shown previously to increase membrane expression of flavocytochrome b(558), a component of the NADPH oxidase. This study shows that TNFalpha also increases membrane expression of flavocytochrome b(558). Mitogen-activated protein kinase (MAPK) modules have been implicated in the action of priming agents. Pharmacologic inhibitors of MAPKs, SB203580 and PD098059, revealed that priming of the respiratory burst and up-regulation of flavocytochrome b(558) are dependent on p38 MAPK but not on extracellular-signal regulated kinase (ERK). TNFalpha and LPS primed respiratory burst activity and increased membrane expression of CD35 and CD66b, specific markers of secretory vesicles and specific granules that contain flavocytochrome b(558), with similar time courses and concentration dependences. These processes also required p38 MAPK but were independent of ERK. TNFalpha failed to prime respiratory burst activity or to increase membrane CD35 expression in enucleated neutrophil cytoplasts. These data suggest that one mechanism by which TNFalpha and LPS prime neutrophil respiratory burst activity is by increasing membrane expression of flavocytochrome b(558) through exocytosis of intracellular granules in a process regulated by p38 MAPK.

Ultrapure dialysate: a desirable and achievable goal for routine hemodialysis

United States standards for the microbiologic quality of dialysate are not very stringent and have remained unchanged for more than 20 years, despite significant changes in the patient population and in the technology of hemodialysis. Numerous studies have demonstrated that bacterial products can cross dialysis membranes and stimulate an inflammatory response in the patient. Inflammation has been implicated in several complications associated with long-term hemodialysis therapy, and the use of ultrapure dialysate has been shown to reduce the incidence of one of these complications, beta2-microglobulin amyloidosis. Since technological innovations in water treatment and improvements in dialysis machine design allow the routine production of ultrapure dialysate, its use should now become standard.

Deficient homologous desensitization of formyl peptide receptors stably expressed in undifferentiated HL-60 cells

The ability of formyl peptide receptors (FPRs) stably expressed in undifferentiated HL-60 cells to undergo ligand-induced desensitization was compared with their ability in normal and vector-transfected HL-60 cells following granulocyte differentiation with DMSO. fMet-Leu-Phe failed to induce uncoupling of FPRs from G-proteins in FPR-transfected cells, whereas uncoupling was induced in differentiated HL-60 cells and differentiated vector-transfected HL-60 cells, as determined by ligand-stimulated guanosine 5'-(gamma-thio)triphosphate (GTPgammaS) binding and GTPgammaS inhibition of fMet-Leu-Phe binding to isolated membranes. Immunoprecipitation of Galpha(i2) from solubilized, azidoanalide (AA-gammaGTP) photolabeled membranes showed that receptors in desensitized FPR-transfected HL-60 cells remained coupled to Galpha(i2), whereas desensitized receptors in differentiated HL-60 cell membranes were uncoupled from Galpha(i2). As determined by immunoblotting, Galpha(i2) expression was similar in undifferentiated and differentiated HL-60 cells and FPR-transfected cells. Ligand-stimulated receptor internalization and desensitization of calcium redistribution were similar in all three groups of cells. Immunoblotting also indicated that G-protein-coupled receptor kinases (GRKs) 2 and 4 were present in undifferentiated FPR-transfected HL-60 cells at 50% of the level seen in differentiated HL-60 cells. However, differentiation did not increase GRK2 or GRK4 expression, indicating that differences in GRK expression do not explain deficient desensitization. The data indicated that undifferentiated HL-60 cells are unable to induce homologous desensitization of FPRs.

Summary of new distribution records for mosquito species in the United States and Canada for the period 1981-99

In order to elucidate the recent spread of mosquito species in the United States and Canada, a summary of new records for states and provinces has been prepared to include those reported mostly from 1981 to 1998, although some records before 1989 are also given. We are reporting 132 new records for 58 species of mosquitoes.

Improved dialyzer reuse after use of a population pharmacodynamic model to determine heparin doses

Anticoagulation with heparin is performed to prevent clotting during dialysis. However, heparin doses are usually determined empirically, and dialyzer clotting is a common reason for discarding reused dialyzers. We hypothesized that using a population pharmacodynamic model to determine individual heparin doses would improve dialyzer reuse rates. A previously published model was used to determine the loading dose and infusion rate of heparin needed to increase the intradialytic whole-blood clotting time to 150% of the predialysis value. The effectiveness of the model was assessed by comparing dialyzer reuse rates and delivered Kt/V(urea) before and after implementation of the model in 22 chronic hemodialysis patients. As an additional control, a similar group of 22 patients were followed up during the same period without adjustment of their heparin doses. Implementation of the model resulted in no change in the average loading dose (2,382 +/- 628 versus 2,425 +/- 908 IU; P = not significant) or average infusion rate (1,398 +/- 367 versus 1,393 +/- 532 IU/h; P = not significant) of heparin. However, individual patients required changes in loading dose or infusion rate. Dialyzer reuse rates increased significantly over time in the treatment group but remained unchanged in the control group (P < 0.003). Kt/V(urea) remained unchanged throughout the study period in both patient groups. From these data, we conclude that the use of a heparin model can improve dialyzer reuse rates without compromising the delivered dose of dialysis.

Cruciate injury patterns in knee hyperextension: a cadaveric model

We created an experimental model to evaluate the effects of strain rate on the mechanism of combined cruciate ligament injuries in knee hyperextension. Using straight knee hyperextension to rupture the anterior and posterior cruciates, two strain rates (approximately 100% per second and 5400% per second) were applied to reproduce two clinical injury patterns of the knee: low energy (sporting) and high energy (pedestrian-motor vehicle accident). Ten pairs of fresh-frozen cadaveric knees were injured to 45 degrees of hyperextension. Strain rate sensitivity of the posterior cruciate ligament was shown in this model, with midsubstance tears occuring in specimens tested at a low rate and avulsion "stripping" injuries from the femoral side occuring at a high rate. A variable pattern of anterior cruciate ligament tears at both high and low rates suggests that the specific injury mechanism may also involve other factors including notch morphology. We present a simplified mathematic model used to estimate posterior cruciate ligament strain during knee hyperextension.

Transplantation, not dialysis, corrects azotemia-dependent priming of the neutrophil oxidative burst

The oxidative burst of neutrophils from patients with renal failure before the initiation of dialysis is primed for an enhanced response after stimulation by phagocytosis or chemoattractants. This study shows that phagocytosis-stimulated oxidative burst activity remains primed in patients treated with both high-efficiency hemodialysis and continuous ambulatory peritoneal dialysis (CAPD), but it is normal in patients with a functioning renal transplant. Incubation of normal neutrophils or HL-60 granulocytes in azotemic plasma results in increased resting and phagocytosis-stimulated H2O2 production, which is rapidly reversible on removal of the plasma. Priming of the oxidative burst by azotemic plasma is independent of changes in opsonization and phagocytosis and does not require protein synthesis. These results suggest that azotemic plasma contains a substance or substances capable of reversibly priming oxidative burst activity in neutrophils and neutrophil-like cell lines. The Inability of high-efficiency hemodialysis and CAPD to normalize oxidative burst activity suggests that this substance is of higher molecular weight.

Blood flow rate: an important determinant of urea clearance and delivered Kt/V

Implementation of the Dialysis Outcomes Quality Initiative (DOQI) Guidelines for hemodialysis adequacy will necessitate an increase in delivered Kt/V for many patients. Before increasing Kt/V by prolonging the patient's treatment time, it is important to verify that the prescribed dialyzer urea clearance is being achieved. The principal determinant of dialyzer urea clearance is blood flow rate. Actual blood flow rates are frequently less than the nominal blood flow rate displayed by the dialysis machine, particularly at higher flow rates, leading to lower than expected urea clearances. The major reason for the reduction in blood flow rate is a low pressure in the arterial blood line proximal to the blood pump. This effect can be mitigated by the use of large bore access needles. For quality assurance purposes, actual blood flow rates should be determined by correcting nominal blood flow rates for pressure effects using empirical relationships or by using an ultrasonic flow meter. Because a poorly functioning blood access may further reduce the effective blood flow rate, blood access performance should also be monitored regularly.

Bacterial phagocytosis activates extracellular signal-regulated kinase and p38 mitogen-activated protein kinase cascades in human neutrophils

The hypothesis that bacterial phagocytosis by human polymorphonuclear neutrophils (PMNs) stimulates MAPK cascades that regulate respiratory burst activation was tested. Extracellular response kinase (ERK) and p38 kinase, but not c-Jun NH2-terminal kinase, activities were increased within 5 min of phagocytosis of plasma-opsonized Staphylococcus aureus (S-SA), reached maximum at 20-30 min, and remained elevated through 60 min. The role of Fcy receptors was examined using gamma globulin-opsonized SA (IgG-SA), whereas CR3 receptors were activated by particulate beta-glucan. IgG-SA stimulated a maximal ERK activity at 30 min, whereas p38 activity was maximal at 5 min. Beta-glucan stimulated maximal ERK activity at 5 min and maximal p38 activity at 2 min. Non-opsonized bacteria were ingested at 10% of the level of S-SA and stimulated a minimal increase in ERK and p38 activity at 60 min. S-SA stimulation of ERK was inhibited by wortmannin, LY294002, and genistein, but not calphostin C; whereas p38 stimulation was inhibited by calphostin C and genistein, but not wortmannin and LY294002. Simultaneous measurement of phagocytosis and H2O2 production by flow cytometry was used to assess the role of ERKs and p38 kinase in phagocytosis. The MEK inhibitor PD098059 had no significant effect on phagocytosis or H2O2 production. The p38 kinase inhibitor SB203580 significantly attenuated H2O2 production, whereas phagocytosis was unaffected. In conclusion, bacterial phagocytosis stimulates ERK and p38 activation by distinct signal transduction pathways. Phagocytosis-stimulated p38 kinase activity is necessary for optimal H2O2 production.

Activation of mitogen-activated protein kinase cascades during priming of human neutrophils by TNF-alpha and GM-CSF

The signal transduction pathways activated by tumor necrosis factor alpha (TNF-alpha) and granulocyte-macrophage colony-stimulating factor (GM-CSF) that lead to priming of polymorphonuclear leukocytes (PMNs) are unknown. The hypotheses that these cytokines stimulate multiple mitogen-activated protein kinase (MAPK) cascades, including extracellular signal-regulated kinases (ERKs), c-Jun amino-terminal kinases (JNKs), and p38 MAPK, and that these MAPKs participate in priming of human PMNs were examined. TNF-alpha stimulated a dose-dependent increase in ERK and p38 MAPK activities that was maximal at 10 min. JNKs were not stimulated by TNF-alpha or GM-CSF. GM-CSF stimulated ERK activity comparable to that of TNF-alpha, but GM-CSF was a less potent stimulus of p38 MAPK activity. The tyrosine kinase inhibitor, genistein, inhibited ERK and p38 MAPK stimulation by both cytokines. The phosphatidylinositol 3-kinase inhibitor, wortmannin, attenuated stimulation of ERKs and p38 MAPK by GM-CSF, but not TNF-alpha. GM-CSF, but not TNF-alpha, stimulated wortmannin-sensitive activation of Raf-1. TNF-alpha and GM-CSF priming of superoxide release stimulated by N-formyl-methionyl-leucyl-phenylalanine was significantly attenuated by the MEK inhibitor, PD098059, and the p38 MAPK inhibitor, SB203580. Incubation with both MAPK inhibitors produced an additive effect. Our data suggest that TNF-alpha and GM-CSF activate ERKs and p38 MAPK by different signal transduction pathways. Both ERK and p38 MAPK cascades contribute to the ability of TNF-alpha and GM-CSF to prime the respiratory burst response in human PMNs.

Prediction of anticoagulation during hemodialysis by population kinetics and an artificial neural network

All systems currently used for routine hemodialysis require heparin administration to prevent blood clotting in the extracorporeal circuit. We tested the hypothesis that population-based statistical techniques can be used to predict heparin concentrations during routine hemodialysis. Two predictive models were developed, one based on nonlinear mixed effects modeling (NONMEM) and the other on a multilayer perceptron neural network. Serial clotting time data were obtained from forty-nine patients and used to develop the models. The models were used to predict the clotting times of 70 patients in a prospective test. We determined that the neural network provided greater precision, had fewer outliers in its predictions, and did not have the model misspecification in bolus administration that the NONMEM predictions demonstrated. A final NONMEM model was developed using all data from 119 patients to identify important covariates for predicting the heparin pharmacodynamic parameters, volume of distribution, and clearance. Both the volume of distribution and clearance increased following the initiation of dialysis and as the patient's baseline clotting time increased. The volume of distribution also increased as the patient's weight increased but was decreased by smoking and diabetes. Population-based statistical techniques may provide a useful alternative to existing methods for prescribing heparin.

Quality of life during and between hemodialysis treatments: role of L-carnitine supplementation

End-stage renal disease affects every aspect of a patient's life, including perception of health and quality of life. It is likely that a hemodialysis patient's perceptions of health-related quality of life directly influence compliance with medical, nursing, and nutritional prescriptions. Because L-carnitine supplementation is known to enhance muscle strength and energy in hemodialysis patients, we hypothesized that L-carnitine supplementation would enhance a hemodialysis patient's perception of health-related quality of life. To test this hypothesis, 1 g L-carnitine or placebo was administered orally to 101 patients immediately before and after every hemodialysis treatment for 6 months. To assess health-related quality of life from the patient's perspective, the Medical Outcomes Study Short Form 36 instrument was administered before the study and at 1.5-month intervals for the duration of the study. In addition, a 10-item questionnaire designed to assess common intradialytic symptoms was administered at the end of each dialysis treatment. Other parameters analyzed included Kt/V(urea) and level of nutrition. In the 6-month group, oral L-carnitine supplementation had an early positive effect on general health (P < 0.02) and physical function (P < 0.03), but the perceived effect was not sustained throughout the 6 months of the study. In the 3-month group, L-carnitine supplementation improved vitality (P < 0.02) and general health (P < 0.01). There was no association between Kt/V(urea) and perceived health-related quality of life. Serum albumin concentration was directly correlated to how patients perceived the quality of their lives.

Natural habitats of Aedes Aegypti in the Caribbean--a review

Natural breeding habitats of Aedes aegypti in the Caribbean region were reviewed by conducting larval surveys in Trinidad. Puerto Rico, and the U.S. Virgin Islands and referring to records from the Mosquitoes of Middle America project. Twelve types of natural habitats were recorded: rock holes (9.7%), calabashes (2.4%), tree holes (19.5%), leaf axils (4.8%), bamboo joints (14.9%), papaya stumps (7.3%), coconut shells (4.8%), bromeliads (7.3%), ground pools (14.9%), coral rock holes (9.7%), crab holes (2.4%), and conch shells (7.3%), of which the coconut shell and calabash habitats were new to the Caribbean. The countries having the highest prevalence of natural habitats were Trinidad. Puerto Rico, and Jamaica, with 9 types (22.0%), 7 types (17.0%), and 6 types (14.6%), respectively. The distribution of natural habitats of Ae. aegypti in the Caribbean region is discussed in relation to vector control measures.

Maintaining blood compartment volume in dialyzers reprocessed with peracetic acid maintains Kt/V but not beta2-microglobulin removal

A dialyzer is reused if its blood compartment volume is 80% of its initial value, a condition believed to ensure that the urea clearance remains at 90% of its initial value. This criterion was developed for dialyzers containing low permeability cellulose membranes reprocessed with formaldehyde. We tested the hypothesis that the criterion is also valid for more permeable membranes when dialyzers are reprocessed with peracetic acid/hydrogen peroxide. Kt/V for urea and reduction in beta2-microglobulin concentration were measured for up to 15 uses in dialyzers containing polysulfone or cellulose membranes. Kt/V for urea did not change for either dialyzer provided blood compartment volumes remained 80% of their initial value. The reduction in plasma beta2-microglobulin concentration from predialysis to postdialysis was 30% for the first use of the dialyzer containing polysulfone membranes, but decreased significantly (P = 0.042) following reuse to 12% for the tenth use. For the dialyzers containing cellulose membranes, the reduction in plasma beta2-microglobulin concentration was 18% for the first use and decreased to 12% by the twelfth use; however, this change was not significant. We conclude that removal of urea is maintained during reuse with peracetic acid/hydrogen peroxide provided the blood compartment volume remains 80% of its initial value. However, removal of beta2-microglobulin may not be maintained, even though blood compartment volumes remain at 80% of their initial value.

A comparison of dialysers with low-flux membranes: significant differences in spite of many similarities

The solute removal characteristics and haemocompatibility of low-flux dialysers containing Cuprophan, cellulose acetate, polymethylmethacrylate (PMMA), and polycarbonate-polyether (Gambrane) membranes were compared in a multicentre cross-over clinical trial. While all four dialysers provided comparable removal of urea and creatinine, the dialyser containing PMMA membrane showed a reduced ability to remove phosphate compared to that containing Cuprophan membrane. Significant beta 2-microglobulin removal was obtained with the dialyser containing Gambrane membrane, whereas the other three dialysers had no impact on plasma beta 2-microglobulin concentrations. The ability to activate complement, measured as changes in the plasma concentrations of C3a des Arg and the terminal complement complex, and to produce leukopenia was greater for the dialyser containing Cuprophan membrane than for the other three. The ability to activate complement and cause leukopenia was not consistent among the remaining three dialysers and the degree of leukopenia could not be predicted from the level of complement activation. Neutrophil degranulation, as indicated by the release of elastase-alpha 1-proteinase inhibitor, occurred to a greater extent with the dialysers containing Cuprophan and Gambrane membranes. None of the dialysers was overtly thrombogenic as judged by changes in platelet count and plasma concentrations of the thrombin-antithrombin III complex. Our results demonstrate that although there are many similarities between dialysers containing low-flux membranes, there are also significant differences. These differences may enable improvements in therapy, while allowing continued use of low-flux dialysers.

Azotemia, TNF alpha, and LPS prime the human neutrophil oxidative burst by distinct mechanisms

The oxidative burst of neutrophils from azotemic patients (AzoPMNs) is primed for an enhanced response compared to neutrophils from normal subjects (NorPMNs). The mechanism for this priming is unknown, although TNF alpha does not further prime AzoPMNs. The present study examines the hypothesis that azotemia and TNF alpha prime neutrophils by the same mechanism. Formyl peptide receptor expression and degranulation were not primed in AzoPMNs, but were primed by both LPS and TNF alpha. LPS was also able to prime the AzoPMN oxidative burst. Guanine nucleotide exchange by multiple guanine nucleotide binding proteins, including heterotrimeric G-proteins and low molecular weight GTP-binding proteins (LMWGs), was increased in AzoPMNs, as demonstrated by GTP gamma S binding and azidoanilide GTP photoaffinity labeling. The plasma membrane density of G-protein alpha i2, alpha i3, and alpha s subunits and the density in the cytosol of the LMWG, Rap1A, was present in significantly greater amounts on plasma membranes from AzoPMNs. FMet-Leu-Phe-stimulated phospholipase D activity, but not basal activity, was significantly greater in AzoPMNs. Finally, incubation of NorPMNs in plasma from azotemic patients resulted in a significant increase in basal GTP gamma S binding. These results demonstrate that priming of AzoPMNs is restricted to oxidative burst activity and that it occurs by a mechanism distinct from that utilized by TNF alpha and LPS. While the exact mechanism remains unknown, it appears to involve a plasma factor and changes in LMWG expression or activity.

Heparinization for routine hemodialysis

Routine hemodialysis requires anticoagulation with heparin to prevent clotting in the extracorporeal circuit. Activated whole blood clotting times are used to measure the level of anticoagulation during dialysis. The magnitude of the clotting time obtained for a given level of heparin depends on the test used, and each dialysis unit must establish its own target range. The preferred dosage regimen for heparin is an initial loading dose, followed by a constant infusion. Dosage regimens based on intermittent boluses of heparin are associated with periods of under- and over-anticoagulation and require more staff attention during dialysis. Because patient responses to heparin differ markedly, the doses required to achieve suitable anticoagulation must be determined on an individual basis. The doses of heparin for an individual patient are best determined using a simple pharmacodynamic model, although they can be found empirically through trial and error. In spite of careful anticoagulation, an unsatisfactory outcome may still result. Patient-specific factors may be responsible for some of these adverse outcomes; however, in most cases they result from poor technique, including failure to deliver the prescribed dose of heparin, turbulence and foam formation in the extracorporeal circuit, and excessive access recirculation.

Hemodialysis with cellulose membranes primes the neutrophil oxidative burst

Hemodialysis with cellulose membranes causes a complement-mediated neutropenia. Changes in neutrophil function have also been reported; however, it is unclear if these changes indicate a direct effect of the membrane on neutrophils or if they are a consequence of the neutropenia. We tested the hypothesis that neutrophil oxidative burst activity is enhanced during dialysis with cellulose membranes. Resting and Staphylococcus aureus-stimulated H2O2 production were determined predialysis and in blood entering and leaving the dialyzer during the first 30 min of dialysis and in blood leaving the membrane module in a single-pass on-line model of hemodialysis. Resting H2O2 production increased slightly but significantly during the first 30 min of dialysis. Transit of neutrophils through the dialyzer caused a marked increase in stimulated H2O2 production, indicating priming of the oxidative burst. However, priming was limited to the first 5 min of dialysis before the onset of neutropenia. In contrast, stimulation and priming of H2O2 production persisted throughout 30 min of single-pass on-line perfusion. These results indicate that cellulose membranes both stimulate and prime neutrophil oxidative burst activity but that these effects are partially obscured by neutropenia.

Depletion of total salivary gland protein in blood-fed Anopheles mosquitoes

Reduction in total salivary gland protein from four anopheline vectors of human malaria, Anopheles stephensi Liston, An. albimanus Wiedmann, An. gambiae Giles, and An. freeborni Aitken, was quantified after mosquitoes blood-fed to repletion on human volunteers, hamsters or through a Baudruche artificial membrane. Total salivary gland protein from pools of six unfed mosquitoes ranged from 4.33 to 7.91 micrograms/ml. The difference between the total protein of glands from unfed and blood-fed mosquitoes for all species ranged from 1.77 to 3.12 (micrograms/ml for six pooled salivary glands. Total salivary gland protein for mosquitoes blood-fed to repletion was significantly less than that of unfed controls from the same cohort. Reduction in total salivary gland protein for An. freeborni and An stephensi blood fed to repletion on human volunteers, hamsters, and a Baudruche membrane ranged from 24 to 46%, from 43 to 56%, and from 24 to 51%, respectively. An. stephensi mosquitoes were allowed to blood feed on humans for 0 (unfed), 0.5-, 1.0-, 2.0-min time periods or to repletion (> 2-5 min). As feeding time increased, there was a significant decrease in total amount of protein in the salivary glands. This decrease was proportional over time, indicating that salivation occurred continuously from the beginning (probing) of blood feeding to withdrawal of the mosquito mouthparts at repletion. These data indicate that during blood feeding there difference between species in the salivary gland output measured as amount of protein depleted from the salivary glands and that depletion of salivary protein from the glands occurred continuously as mosquitoes fed to repletion.

Chemoattractant receptor-specific differences in G protein activation rates regulate effector enzyme and functional responses

The hypothesis that disparate neutrophil functional responses to various chemoattractants are regulated by receptor-specific rates of G protein activation was examined in HL-60 granulocytes. The initial rates of G protein activation and the affinity of receptor-stimulated G proteins for GTP gamma S in HL-60 membranes stimulated by fMet-Leu-Phe, C5a, and leukotriene B4 (LTB4) differed significantly among the chemoattractants, with a rank order of fMet-Leu-Phe > C5a > LTB4. Equilibrium GTP gamma S binding showed that all three chemoattractants activated a common pool of G proteins. Stimulation of phospholipase D activation, measured as phosphatidylethanol generation, and superoxide release in intact cells also occurred with a rank order of fMet-Leu-Phe > C5a > LTB4. On the other hand, the rank order of receptor affinities for ligand and of the EC50 of chemoattractant stimulation of GTP gamma S binding was C5a > LTB4 > fMet-Leu-Phe. C5a and LTB4 receptor densities were similar but were less than formyl peptide receptor density. Graded pertussis toxin treatment proportionally reduced superoxide release and phospholipase D activation to all three chemoattractants. The results suggest that receptor-specific differences in G protein affinity for guanine nucleotides lead to different rates of guanine nucleotide exchange and, thereby, contribute to disparate effector enzyme and functional responses.

Polymorphonuclear leukocyte oxidative burst is enhanced in patients with chronic renal insufficiency

Previous reports that polymorphonuclear leukocyte (PMN) function is impaired in hemodialysis patients do not differentiate between effects of dialysis and of uremia. The hypothesis that chronic renal insufficiency impairs PMN function was tested. Phagocytosis and oxidative burst were measured in PMN from patients with varying degrees of chronic renal insufficiency impairs PMN function was tested. Phagocytosis and oxidative burst were measured in PMN from patients with varying degrees of chronic renal insufficiency (creatinine clearance, 6 to 35 mL/min per 1.73 m2) and normal subjects. The ability of tumor necrosis factor-alpha (TNF-alpha) to prime the oxidative burst was also assessed. Phagocytosis of Staphylococcus aureus and basal H2O2 and O2- release by PMN did not differ between normal subjects and patients with chronic renal insufficiency. However, the oxidative burst stimulated by S. aureus and formyl-Met-Leu-Phe, but not phorbol myristate acetate, was significantly enhanced in PMN from patients with chronic renal insufficiency. The increase in formyl-Met-Leu-Phe-stimulated oxidative burst correlated significantly with the level of renal function. TNF-alpha significantly increased S. aureus-induced H2O2 production in normal PMN, but not in PMN from patients with chronic renal insufficiency. These data indicate that chronic renal insufficiency does not impair PMN phagocytosis and oxidative burst. To the contrary, it enhances receptor-mediated oxidative burst. The inability of TNF-alpha to further enhance the oxidative burst suggests that PMN exist in a primed state in patients with chronic renal insufficiency.

Technical challenges to successful dialyzer reuse

Limitations of dialyzer reuse technology may contribute to adverse patient outcomes. Assessing changes in dialyzer performance by measuring changes in total cell volume may not be valid for all membranes and reprocessing methods. Systems which determine dialyzer performance on-line are superior. Compliance with standards for microbial contamination of reprocessing fluids is poor and improvements in water treatment system design and monitoring are needed. Technological innovation is required to enable dialyzer performance to be monitored over an expanded molecular weight range and to ensure that dialyzer reprocessing can be routinely performed with sterile, non-pyrogenic solutions.

The effects of RU 33965 and RU 34030, two new 3-cyclopropyl carbonyl imidazobenzodiazepines, on GABAA receptor-mediated synaptic transmission in cerebellar slices in the rat

1. Two 3-cyclopropyl carbonyl imidazobenzodiazepines, RU 33965 and RU 34030, were tested for their ability to modulate GABAA synaptic transmission in rat cerebellar slices. The action of the full benzodiazepine agonist RU 32007 and the inverse agonist Ro19-4603 were tested for comparison. 2. Extracellular recordings were made from the Purkinje cell layer of the cerebellar slices and inhibition induced by just threshold electrical stimulation of the parallel fibres was bicuculline sensitive. 3. The major effect of RU 32007 when examined at 100 nM and 1 microM was to increase the GABAA mediated inhibition in the slice. 4. In contrast the major effect of the inverse agonist Ro19-4603 was to reduce the period of inhibition. 5. RU 33965 and RU 34030 at 10 and 1 microM respectively either had little effect on GABAA mediated inhibition or decreased it slightly. 6. RU 34030, 1 microM, abolished the agonist effect of RU 32007, 1 microM. 7. The effects of RU 32007 and Ro19-4603 were abolished by the benzodiazepine antagonist flumazenil. 8. It is concluded that both RU 33965 and RU 34030 have marginal inverse agonist properties.

Soluble tumor necrosis factor receptors are increased in hemodialysis patients

Tumor necrosis factor-alpha (TNF alpha) interacts with cells through specific membrane receptors. Exposure to agonists, such as C5a, causes cells to shed these receptors, forming soluble TNF alpha binding proteins (sTNFR). Because cellulose membranes activate complement, we tested the hypothesis that dialysis with these membranes contributes to the increased levels of sTNFR observed in hemodialysis patients. sTNFR levels were measured pre- and post-dialysis in patients treated with dialyzers containing new cellulose membranes. Plasma sTNFR concentrations were markedly increased pre-dialysis, compared with normal (38.3 +/- 13.5 ng/ml versus 2.1 +/- 0.7 ng/ml), and increased further during dialysis, even after post-dialysis concentrations were corrected for hemoconcentration. We examined the impact of the increased sTNFR levels on the ability of TNF alpha to prime neutrophil superoxide production in cross-incubation experiments. When normal neutrophils were incubated with TNF alpha in the presence of hemodialysis patient plasma, the resulting increase in fMLP stimulated superoxide production was significantly less than when normal plasma was used. Incubation of hemodialysis patient neutrophils in normal plasma only partly restored their ability to be primed by TNF alpha, suggesting an intrinsic functional defect in these cells, in addition to the effects of sTNFR. Our results suggest that dialysis with cellulose membranes contributes to the increased levels of sTNFR observed in dialysis patients, and that these concentrations are sufficient to impair the normal actions of TNF alpha.

Biocompatibility of a new high-permeability modified cellulose membrane for haemodialysis

The biocompatibility and solute permeability characteristics of a high-permeability modified cellulose membrane (Hemophan-HP) (He-HP) were compared with those of two synthetic membranes (poly(ethylene-co-vinyl alcohol) (EVAL) and poly(acrylonitrile-co-sodium methallyl sulphonate) (AN69)) and Cuprophan in a multicentre, four-way cross-over clinical trial. Cuprophan membranes caused significant complement activation, leukopenia, and granulocyte elastase release. He-HP membranes demonstrated a lesser effect, which was similar to that observed for the EVAL membrane, although less than that seen with the AN69 membrane. A similar order for the four membranes was seen for their effect on platelets. Cuprophan membranes provided superior small-molecule removal to the other three membranes. In contrast, Cuprophan was essentially impermeable to beta 2-microglobulin, whereas He-HP, EVAL, and AN69 allowed the removal of 60-90 mg of beta 2-microglobulin per treatment. However, a decrease in the plasma concentration of beta 2-microglobulin was observed only with the AN69 membrane, most probably as a result of the ability of that membrane to adsorb proteins. Our results demonstrate that high-permeability membranes of comparable biocompatibility to some synthetic membranes can be fabricated from cellulose derivatives.

Effects of RU33368, a low affinity ligand for neuronal benzodiazepine receptors, on rodent behaviours and GABA-mediated synaptic transmission in rat cerebellar slices

1. The effects of the low affinity benzodiazepine receptor ligand RU33368 were studied on rodent behaviours and on GABA-mediated synaptic transmission in rat cerebellar slices. 2. RU33368 inhibited stress induced ultrasounds in rat pups without inducing marked muscle relaxation. RU33368 also enhanced operant responding in rats that had been suppressed by mild footshock. These effects of RU33368 in these two models of anxiety were both blocked by the benzodiazepine antagonist Ro15-1788 (flumazonil). 3. In cerebellar slices RU33368 enhanced stimulus-induced synaptic inhibition of Purkinje layer cells with a minimal effective concentration in the order of 1 microM. The classical benzodiazepine agonist RU32007 was approx. 10 times more potent. This action of RU33368 was blocked by Ro15-1788. 4. The minimal effective concentration of RU33368 fully blocked the effect of RU32007 in 2 of 4 cells tested and partially antagonized it in a third cell. 5. These data suggest that RU33368 is a partial agonist at benzodiazepine receptors and this, at least in part, explains its non-sedative anxiolytic behavioural profile.

Origin and fate of fetuin-containing neurons in the developing neocortex of the fetal sheep

The development of the neocortex has previously been extensively studied in carnivores (cat and ferret), rodents (rat and mouse) and primates (monkey and human). In these species, it has been shown that the initial population of cells migrating from the ventricular zone forms the primordial plexiform layer. This is subsequently split into marginal zone and subplate zone by the insertion of later-migrating cells into the primordial plexiform layer, to form the cortical plate proper. Many of the cells derived from the split primordial plexiform layer are transient. The neurons of the subplate zone are found in the deeper part of layer VI, and white matter deep to layer VI in the more mature cortex; most of these neurons disappear by adulthood. [3H]-thymidine labelling in the present study has shown a similar pattern of neocortical development in Artiodactyla (sheep). In addition it has been shown that the previously described staining of subplate and cortical plate cells for the fetal protein fetuin indicates that fetuin is a useful marker for a proportion of this transient population of neurons and defines its extent in neocortical development more clearly. Dividing cells were labelled by a single intra-amniotic injection of [3H]-thymidine at E26 to E35 (birth is at E150). The brains were subsequently examined at E40 or E80 for [3H]-thymidine labelling and fetuin staining by a combination of autoradiography and immunocytochemistry. The earliest generated neocortical cells detected in this study (E26) were found in two layers by E40, the outer marginal zone and inner subplate zone. Neurons of the marginal zone were generated up to E28; those of the early subplate zone were generated up to E31. The cortical plate proper was generated by cells "born" on E32 and later. This sequence is similar to that described in other species, especially the cat. A proportion of the early-generated neurons in the marginal zone, subplate zone and early cortical plate stained for fetuin. By E80 these earliest-generated, fetuin-positive cells were found in the white matter deep to the forming neocortical layers and in layer VI. In adult brains no fetuin-positive neurons could be identified in the neocortex, and neurons had almost entirely disappeared from the white matter. The fetal glycoprotein fetuin seems to be specifically associated with a population of cells that has the same developmental history as the transient marginal zone and subplate neurons described in other species.(ABSTRACT TRUNCATED AT 400 WORDS)

Evaluation of prostaglandin F2 alpha and prostacyclin interactions in the isolated perfused rat lung

To characterize the interactions between prostaglandin F2 alpha and prostacyclin in controlling tone in the pulmonary circulation, isolated rat lungs were ventilated, perfused with blood, and subjected to challenge by prostaglandin F2 alpha in increasing doses. The pulmonary resistance was evaluated using occlusion techniques that separate the resistance into segments of large and small arteries and veins. The total vascular compliance was evaluated using outflow occlusion. Resistance increased after prostaglandin F2 alpha, and this resistance change was primarily in the small artery segment. The maximum resistance increase by prostaglandin F2 alpha (Rmax,PGF2 alpha), calculated from the Michaelis-Menton equation, was 16.6 +/- 3.6 cmH2O.l-1.min.100 g-1 for total vascular resistance with a concentration required to produce 50% Rmax (K0.5) of 5.26 +/- 3.57 nM. The Rmax,PGF2 alpha for small artery resistance was 13.5 +/- 2.4 cmH2O.l-1.min.100 g-1 with a K0.5 of 2.35 +/- 1.57 nM. The vascular compliance decreased during vasoconstriction by prostaglandin F2 alpha, and the maximum decrease in compliance (Cmin,PGF2 alpha) was -0.43 +/- 0.12 ml/cmH2O with a K0.5 of 2.84 +/- 2.99 nM. At each dose of prostaglandin F2 alpha, prostacyclin was administered in increasing doses to reverse the vasoconstriction caused by prostaglandin F2 alpha. For each concentration of prostaglandin F2 alpha, prostacyclin almost completely reversed the resistance increases and approximately one-half the compliance decrease. The maximum change in vascular resistance or compliance produced by prostacyclin was dependent on the dose of prostaglandin F2 alpha; yet the K0.5 for prostacyclin was within the picomolar range for all doses of prostaglandin F2 alpha.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterization of thromboxane and prostacyclin effects on pulmonary vascular resistance

Although thromboxane and prostacyclin (PGI2) have long been described as major controllers of pulmonary vascular resistance, little has been reported on the characteristics of the interactions between the two arachidonic acid products. The current study uses segmental vascular resistance and compliance measurements to evaluate the actions of thromboxane and PGI2 in isolated blood-perfused rat lung. The thromboxane analogue U-46619 increases pulmonary vascular resistance by increasing only small artery resistance and decreases pulmonary vascular compliance in the middle compartment. Among the vascular effects of U-46619 are a maximum increase in resistance (RmaxU-46619) of 60.3 +/- 15.6 cmH2O.l-1.min.100 g-1 and a concentration required for 50% of maximum increase (K0.5,U-46619) of 1.60 +/- 0.85 nM for small artery resistance, a minimum vascular compliance (CminU-46619) of -0.93 +/- 0.58 cmH2O, and a K0.5,U-46619 of 1.10 +/- 1.60 nM for middle compartment compliance. Similar results were obtained for total resistance and total compliance. The effects of PGI2 on thromboxane-induced resistance and compliance changes were evaluated using K0.5,PGI2, RmaxPGI2, and CmaxPGI2 at each dose of thromboxane. PGI2 was more effective in reversing the thromboxane constriction at higher concentrations of thromboxane. These data show that the absolute concentration of PGI2 and thromboxane and not a simple ratio of thromboxane to PGI2 determines vascular tone.

Effects of hemodialysis on platelet-derived thrombospondin

The effects on platelet-derived thrombospondin (TSP) of hemodialysis with a cellulose membrane were studied in patients during routine hemodialysis and in normal subjects using an ex vivo model. Plasma and platelet-bound TSP were determined pre- and post-dialysis, in blood entering and leaving the dialyzer after 1, 3, 5, 15, and 30 minutes of dialysis, and in blood leaving the ex vivo module after 5, 10, 15, 20, and 25 minutes of perfusion. Plasma concentrations of beta-thromboglobulin (beta TG) and thromboxane B2 (TxB2), and platelet membrane expression of the alpha-granule protein GMP-140, were also measured. Significant increases in plasma concentrations of TSP and beta TG occurred between the inlet and outlet of the dialyzer after 5, 15, and 30 minutes of dialysis, accompanied by a slow, but significant, increase in their arterial plasma concentrations. In contrast, initiation of dialysis was associated with an immediate increase in plasma TxB2 concentration between the inlet and outlet of the dialyzer and an abrupt increase in arterial plasma TxB2 concentration which plateaued at 250% of the pre-dialysis value after five minutes. Transit of platelets through the dialyzer had no effect on platelet-membrane-associated TSP or GMP-140. Plasma TSP and beta TG concentrations at the outlet of the ex vivo module also increased significantly during perfusion, but plasma TSP concentrations were twofold greater than those during hemodialysis. In vitro stimulation of platelets with thrombin and immunoblotting studies of platelet release proteins showed reduced TSP release by platelets of hemodialysis patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of extracorporeal membrane oxygenation on leukocyte function in neonates

The impact of extracorporeal membrane oxygenation (ECMO) on neonatal leukocyte content and function was examined in six patients. Patients were treated with ECMO for a mean of 134 h (range 44-246 h). Absolute neutrophil counts decreased from 14679 +/- 2291/mm3 to 7791 +/- 1672/mm3 after 2 h of ECMO. However, neutrophil phagocytosis and oxidative burst remained unchanged during the first 48 h of bypass. Monocyte counts also decreased during bypass, and at times were undetectable in 50% of patients. Monocyte HLA-DR content was decreased compared to normal cord blood prior to initiation of ECMO, and remained low throughout ECMO. However, the content increased significantly after termination of bypass. Plasma C3a levels increased transiently, paralleled by an increase in neutrophil CR3 expression. While moribund infants had some impairment of host defenses prior to ECMO, there was no further impact of ECMO per se on the parameters measured, other than transient complement activation and decreased monocyte counts.

Understanding the regulatory requirements for dialysate

It is important for providers to remember that dialysate is considered by federal regulatory agencies to be a medical device, but that most of the regulations are aimed at the manufacturers. The manufacturers are subject to FDA inspection and they must comply with Good Manufacturing Practices. Once the product reaches the provider's door, the manufacturer's responsibility ends, as does most close regulation. The best way for facilities to protect themselves is to develop a good quality assurance program that establishes and maintains policies and procedures which will ensure safe and effective use of dialysate.

Modulation of GABA-mediated inhibition in rat cerebellar slices by benzodiazepine receptor ligands

1. Extracellular recordings were made from the Purkinje cell layer of rat cerebellar slices. Compounds were perfused over the slice and bipolar stimulating electrodes placed in the external layer of the slice close to the recording electrode. 2. Stimulus-evoked inhibition of Purkinje layer cell activity was sensitive to bicuculline methiodide and picrotoxin, suggesting it was gamma-aminobutyric acid (GABA) mediated. The benzodiazepine ligands RU 32007 and Ro 19-0528 reversibly increased the period of inhibition, as did pentobarbital. This benzodiazepine effect was antagonised by Ro 15-1788. 3. Five inverse agonists all reduced the period of stimulated inhibition and this effect was reversed by Ro 15-1788, suggesting the involvement of benzodiazepine receptors. 4. It is concluded that this system provides a convenient physiological and possibly quantitative model for studying the action of benzodiazepine receptor ligands.

Low-dose heparinization can be used with DEAE-cellulose hemodialysis membranes

The ability of DEAE-cellulose (Hemophan) membranes to bind heparin may reduce bioavailable heparin and predispose to dialyzer clotting, thus preventing use of Hemophan with low-dose heparin. To examine this possibility, residual blood volumes were determined following 95 treatments with dialyzers containing Hemophan membranes in 11 patients. No heparin was added to the saline used to prime the dialyzers. The anticoagulant effect of heparin was measured using recalcified activated clotting times (RACT). Two heparin doses, calculated by a pharmacokinetic model to increase baseline RACT by 12.5% and 25%, were used for each patient. The mean heparin loading doses were 10.2 +/- 2.8 and 15.3 +/- 2.2 IU/kg, respectively, and the mean infusion rates were 11.1 +/- 3.2 and 14.7 +/- 3.2 IU/kg/h, respectively. Residual blood volumes were determined by red cell lysis and hemoglobinometry. In 88 treatments, residual blood volume averaged 1.6 +/- 1.5 ml. In the other seven treatments, residual blood volume greater than 10 ml was seen. In five of these cases, clotting appeared to propagate from the arterial drip chamber. Residual blood volume did not correlate with the level of heparin. The data show that low-dose heparin can be used with Hemophan membranes, and suggest that blood tubing design may be an important factor in blood circuit clotting during hemodialysis.

Age and patterns of HMO satisfaction

Consumerism and increasing complexity in health care options highlight the importance of health care satisfaction. Patterns and sources of satisfaction are assessed for health maintenance organizations (HMOs), a relatively novel option, using national survey data. Particular attention is paid to age differences, because HMO Medicare coverage is a recent development and older people generally express little HMO familiarity or receptivity. Higher satisfaction is expressed by HMO members than by nonmembers for both younger and older persons. HMO satisfaction is higher for older than for younger members, a pattern at odds with nonmember attitudes about HMOs. Member satisfaction is a function of the nature of patient/provider ties and related attitudes, as it is among nonmembers. Importance of a "regular" provider is particularly evident among older HMO members. Patterns of HMO satisfaction among older members likely reflects both cohort differences and age-associated patterns of health and related attitudes.

Differential activation of monocytes in haemodialysis patients exposed to different types of membranes

Peripheral blood mononuclear cells (PBMC) from haemodialysis patients treated with different types of membranes were isolated, incubated in vitro, and extracellular and cell-associated interleukin I (IL-1) assayed by radioimmunological methods. Extracellular IL-1 was low and not different from controls, regardless of the dialyser used. In contrast, cell-associated IL-1 was increased in patients treated with dialysers containing low-flux Cuprophan (CU, n = 5) and polyacrylonitrile sheet membrane (AN69, n = 5). Patients treated with dialysers containing high-flux polysulphone (PS, n = 7), and polymethylmethacrylate (PMMA, n = 8), exhibited no increase in cell-associated IL-1 under these conditions. To elucidate the mechanism of the activation, aqueous extracts of dialysers containing CU, PS, and AN69 were tested for their ability to induce IL-1 generation in PBMC from healthy donors. Extracts from unrinsed CU-containing dialysers caused significant IL-1 synthesis and release, whereas incubation with extracts from dialysers containing PS and AN69 sheet membranes did not. Hence, although both CU and AN69 sheet-type dialysers result in activation of blood monocytes the mechanism of action appears to be different. We speculate that functional signs of PBMC activation as evidenced by increased spontaneous IL-1 production observed in some patients on long-term haemodialysis may result from extractable dialyser membrane material while in other instances direct cell membrane interactions or endotoxin transfer from the dialysate may be relevant.

Quantitative analysis of gamma-aminobutyric acid (GABA) receptors of Purkinje cell layer from rat cerebellar slices

1. Extracellular recordings were made from Purkinje cell layer of rat cerebellar slices. Cell activity was sensitive to both magnesium and manganese ions. 2. Glutamic and aspartic acids both excited cell activity while gamma-aminobutyric acid (GABA), muscimol, taurine, beta-alanine and delta-aminolaevulinic acid all inhibited activity. 3. The sensitivity to GABA varied with depth while no such effect was observed with muscimol. 4. Bicuculline methiodide, picrotoxin and pitrazepin blocked the action of muscimol with pA2 values of 5.92, 5.97 and 5.71 respectively. 5. The benzodiazepines flurazepam and RU 32007 both potentiated the GABA inhibition and this potentiation was blocked by Ro 15-1788, a benzodiazepine antagonist.