Reducing the Effects of Ageing on Cognition with Therapeutic Intervention of an Oral Multi-Nutrient: The REACTION Pilot Trial Study Design

BACKGROUND

Clinical benefits have been reported with a specific multinutrient intervention (Souvenaid) in Alzheimer's disease and mild cognitive impairment due to Alzheimer's disease. The effects of Souvenaid in age-related cognitive decline are not established.

OBJECTIVE

To assess the feasibility of using virtual assessments to study the effects of a multinutrient on cognitive ageing.

DESIGN

This is a randomized, double-blind, placebo-controlled, parallel group virtual pilot trial performed over 6 months in a single-centre. Participants are randomly allocated (1:1) to receive the specific multinutrient (Souvenaid) or an isocaloric, same tasting, placebo.

SETTING

Trial visits are done virtually using secure online video communication.

PARTICIPANTS

English or Spanish speaking people aged 55-89 years from all ethnic groups and considered to have age-related cognitive decline are eligible.

MEASUREMENTS

Neuropyschological tests are done at baseline and after 6 months of intervention. Participants are contacted monthly by telephone to monitor safety, assess motivation and promote compliance. The primary outcome is feasibility determined by assessing recruitment rate, recruitment time, adherence rate and retention rate. A comprehensive set of neuropyschological measures will provide a broad assessment of cognitive function, including verbal memory, processing speed, and attention and executive function. Self-reported questionnaires are used to assess quality of life.

CONCLUSIONS

This pilot trial will provide data to guide inform selection of participants and outcome measures in future studies in age-related cognitive decline.

A Retrospective Observational Study: Is Absolute Lymphocyte Count a Prognostic Marker in COVID-19?

Aim

Our study aimed to find a correlation between low absolute lymphocyte count and COVID-19-related mortality.

Methods

This study followed a retrospective observational cohort design to analyze the data of patients who presented with symptoms and signs of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), at the Conquest Hospital and Eastbourne District General Hospital in East Sussex, United Kingdom, between February 10, 2020 and May 1, 2020, retrospectively. Survival and mortality for the first 30 days and comorbidities were analyzed for all patients who were tested for COVID-19 irrespective of swab results and had blood lymphocyte levels taken at the time of their visit to the ED and their data were analyzed for statistical significance.

Results

A total of 1226 patients had SARS-CoV-2 RNA identification swabs taken between February 10, 2020 and May 1, 2020. A cohort of 742 patients of these patients tested for COVID-19 also had blood lymphocyte levels measured.

Overall, the lymphocyte count did not differ significantly between patients suspected to have COVID-19 infection with either positive or negative COVID-19 swab results.

The lymphocyte count, however, was significantly lower in those who died from COVID-19 (p < 0.001) but when comorbidities were analyzed, we found an association between an increased number of comorbidities and a significantly decreased lymphocyte count.

Conclusion

Once adjusted for comorbidities, the lymphocyte count had no association with COVID-19 infection and mortality.

Sexual Risk Behaviors Associated with Sexually Transmitted Infections in a US Military Population Living with HIV After the Repeal of "Don't Ask, Don't Tell"

Risk behaviors associated with sexually transmitted infections (STIs) among people living with HIV (PLWH) have not been well characterized in the US military. We identified risk behaviors associated with a new STI in this population after the repeal of "Don't Ask, Don't Tell." US Military HIV Natural History Study participants who completed the risk behavior questionnaire (RBQ) between 2014 and 2017 and had at least 1 year of follow-up were included (n = 1589). Logistic regression identified behaviors associated with incident STI in the year following RBQ completion. Overall, 18.9% acquired an STI and 52.7% reported condom use at last sexual encounter. Compared with those with no new sex partners, participants with between one and four or five or more new partners were 1.71 [1.25-2.35] and 6.12 [3.47-10.79] times more likely to get an STI, respectively. Individuals reporting low or medium/high perceived risk of STI were 1.83 [1.23-2.72] and 2.65 [1.70-4.15] times more likely to acquire a new STI than those reporting no perceived risk, respectively. Participants who preferred not to answer about sexual preference, number of new partners, or perceived STI risk were also more likely to acquire a new STI. Our study illustrates that despite regular access to health care and accurate perceptions of risk, rates of STI among PLWH remain high in the US military setting, as in others. Given the potential individual and public health consequences of STI coinfection after HIV, more work is needed to assess interventions aimed at sexual behavior change for PLWH.

Abstract P6-12-19: Healing art: Breast cancer survivor experiences with nipple-areola tattoo procedures during breast reconstruction

Background: Nipple-areola tattoos can provide restoration of a natural looking breast that more closely resembles its pre-surgical appearance while avoiding additional surgeries. To date, the majority of nipple-areola tattoo procedures are performed by healthcare providers with minimal training in tattoo procedures. Substandard results explain the high rates of dissatisfaction among women who receive nipple-areola tattoos. In response, professional tattoo artists have emerged as an alternative provider for women seeking reconstruction. However, few studies have examined expectations and experiences of women undergoing nipple-areola tattoo procedures provided by a professional tattoo artist outside of the traditional healthcare setting. Methods: In-depth interviews were conducted with a racially/ethnically diverse group of 30 women who had undergone nipple-areola tattooing in the past 0-2 years. Interviews were conducted in English, Spanish, Chinese, and Arabic, recorded, and translated and transcribed into English for analysis. A team of three researchers conducted iterative reviews of the data which included closely reading each transcript, coding, running queries of codes, and developing summary documents to highlight recurrent concepts and patterns which were shared and discussed in group meetings. Results: Interview narratives addressed the often unexpected impact nipple-areola tattooing had on body image, self-esteem, emotional well-being, and interpersonal relationships. Women described their decision-making processes as weighing concern about the needle, the pain, and uncertainty about the tattoo artist, setting for the procedure, and outcome with the opportunity to return to a more “normal” appearance without further surgeries. Women discussed how their initial preconceptions of tattoos and tattoo parlors were ameliorated by the spa-like setting and the tattoo artist's anticipation of such concerns which enhanced her ability to put them at ease and provide professional and compassionate care. Participants noted the integral role the tattoo artist played in their positive experiences, describing her as both an “artist” and “caregiver.” The manner in which she guided them through the decision-making process regarding the color, size, shape, and placement of their nipple-areola tattoo was noted as particularly significant and empowering. Conclusions: Nipple-areola tattooing is an acceptable and meaningful reconstruction process for medically underserved public hospital patients. Our results indicate that women should be informed of nipple-areola tattooing as an alternative to more invasive, surgical reconstruction options. Results also illustrate how the healthcare system can extend beyond the traditional healthcare setting to include and leverage non-clinical and non-traditional specialists to provide appropriate care and positive breast health outcomes for women. In order to increase access and legitimacy to these services, additional research is needed to understand how to bring tattoo artists “in-house” (i.e., into the medical setting) and how to incorporate tattoo artists into breast health teams.

Citation Format: Napoles TM, Guerra C, Orenstein F, Luce JA, Merritt S, Burke NJ. Healing art: Breast cancer survivor experiences with nipple-areola tattoo procedures during breast reconstruction [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-19.

Chemical injury caused by acute alendronic acid aspiration

A 79-year-old woman was prescribed bisphosphonates 3 years ago for osteoporosis. At the time of first prescription, she received counselling directions on how to take her medication, which she stringently adhered to. However, she accidentally aspirated an alendronic acid tablet and subsequently developed respiratory tract symptoms. An emergency bronchoscopy was performed. We describe the marked bronchoscopic changes following aspiration of alendronic acid.

Epidemiology of thrombocytopenia in HIV inlection

Thrombocytopenia is a known complication of human immunodeficiency virus Type-1 (HIV-1) infection, and more data need to be collected on its frequency, severity, and clinical sequelae. We determined the frequency of thrombocytopenia and its relationship to other HIV infection characteristics from a review of records of 1004 HIV-infected patients attending two outpatient clinics in Washington, D.C. The self-reported sources of HIV-1 exposure were male homosexual activity (68%), bisexual activity (10%), heterosexual activity (6%), and intravenous drug use (15%). Fifty-nine percent of the individuals were white, 37% were black and 94% were male. Fifteen percent had AIDS. Thrombocytopenia occurred more frequently in subjects with AIDS (21.2%) than in HIV-infected individuals who did not fit clinical criteria for AIDS (9.2%) (p less than 0.001). Patients with few CD4-positive cells and an advanced stage of disease were more likely to have low platelet counts: 30% with an absolute CD4 cell count lower than 200/mm3 vs 8% with CD4 counts between 200 and 500 (p less than 0.00001), and 18.5% with Stage IV disease compared to 7.6% in Stage II (p less than 0.001) had platelet counts less than 150,000/mm3. Thrombocytopenia was more frequent in white males and older subjects. Although subjects infected by heterosexual exposure had a lower frequency of thrombocytopenia, intravenous drug users and homosexual men exhibited similar frequencies of thrombocytopenia. Of all subjects with platelet counts less than 50,000/mm3, 40% reported bleeding and 1 died of an intracranial hemorrhage. Thrombocytopenia occurs frequently in HIV-infected people, primarily in those with AIDS, low CD4 cell numbers, and advanced stages of diseases.

REM sleep behaviour disorder (RBD) and its associations in young patients

STUDY OBJECTIVES

To retrospectively examine the characteristics of a population of patients <50 years of age with clinical and polysomnographic features diagnostic for RBD.

METHODS

Review of our sleep centre's database for patients with RBD diagnosed over the last 7 years. Ninety-one patients were separated into two groups according to their age at the time of diagnosis (<50 y and 50 y). Clinical and polysomnographic data were reviewed.

RESULTS

Sixty-two were male; mean age was 52+/-19 y. Thirty-nine were <50 y. In the group <50 y there was a male predominance but in a smaller proportion (M:F=1.4:1) compared with the group 50 (M:F=3:1). Seventy-six patients complained of abnormal behaviour (AB) during sleep, 12 with narcolepsy complained of excessive daytime sleepiness (EDS) with the AB being elicited only during consultation, and three complained of both EDS and AB. All patients, except one in the group 50, described AB related to vivid dreams with violent content. The majority of the patients had the idiopathic form of RBD in both groups (51.2% group <50, 63.4% group 50). The secondary form was associated with narcolepsy in 38.4% of patients in the group <50 y and with a synucleinopathy in 28.8% of patients in the group 50. A strong association was noted between RBD and non-REM parasomnias.

CONCLUSIONS

In a population of patients with RBD presenting to a regional sleep laboratory, more than one-third of patients were <50 y at time of diagnosis. The commonest associated disorder was narcolepsy in patients <50 y, and synucleinopathy in those 50 y. The coexistence of RBD with a NREM parasomnia was not uncommon in cases of idiopathic RBD affecting patients <50 y.

Brain natriuretic peptide testing for angina in a rapid-access chest pain clinic

BACKGROUND

Patients complaining of chest pain are frequently referred to secondary care, although the majority have pain of non-cardiac origin.

AIM

To investigate whether B-type natriuretic peptide (BNP) levels are predictive of a diagnosis of non-cardiac pain.

DESIGN

Cross-sectional study.

METHODS

Consecutive patients (n = 296) presenting to a rapid-access chest pain clinic (RACPC) received the usual clinical assessment plus near-patient BNP testing, with the assessor blinded to the result. After clinical assessment (including exercise stress testing if clinically indicated), pain was diagnosed likely/definitely cardiac or non-cardiac.

RESULTS

Median BNP was higher in those diagnosed with likely/definite cardiac chest pain (26.5 vs. 8 pg/ml) (p < 0.0001, Wilcoxon rank sum test). The odds ratio for cardiac pain in those with BNP <20 pg/ml was 0.25 (95%CI 0.14-0.47) (p < 0.0005); adjusting for age and sex reduced this to 0.41 (95%CI 0.20-0.83) (p = 0.01). The area under the curve (AUC) for the model including BNP, age and sex was 0.70. With BNP as a continuous variable, the AUC for the same model was 0.72.

DISCUSSION

In typical patients presenting to a RACPC, those with a BNP < or =20 pg/ml were significantly less likely to be diagnosed with cardiac pain. Near-patient BNP testing may have a role as a 'rule out test' for angina in patients presenting to a RACPC.

Comparison of water and lipid content measurements using diffuse optical spectroscopy and MRI in emulsion phantoms

We present a quantitative comparison of lipid and water signals obtained from broadband Diffuse Optical Spectroscopy (DOS) and Magnetic Resonance Imaging (MRI). DOS and MRI measurements were performed on an identical set of emulsion phantoms that were composed of different water/soybean oil fractions. Absolute concentrations of water and lipid ranging from 35-94% and 63-6%, respectively were calculated from quantitative broadband near-infrared (NIR) absorption spectra (650-1000 nm). MR images of fat and water were separated using the three-point Dixon technique. DOS and MRI measured water and lipid were highly correlated (R(2) = 0.98 and R(2) = 0.99, respectively) suggesting that these techniques are complementary over a broad range of physiologically relevant water and lipid values. In addition, comparison of DOS derived concentrations to the MRI "gold standard" technique validates our quantitation approach and permits estimation of DOS accuracy and sensitivity in vivo.

Identification of structural and functional domains in mixed lineage kinase dual leucine zipper-bearing kinase required for complex formation and stress-activated protein kinase activation

Accumulating evidence suggests that mitogen-activated protein kinase signaling pathways form modular signaling complexes. Because the mixed lineage kinase dual leucine zipper-bearing kinase (DLK) is a large modular protein, structure-function analysis was undertaken to examine the role of DLK domains in macromolecular complex formation. DLK mutants were used to demonstrate that a DLK leucine zipper-leucine zipper interaction is necessary for DLK dimerization and to show that DLK dimerization mediated by the leucine zipper domain is prerequisite for DLK activity and subsequent activation of stress-activated protein kinase (SAPK). Heterologous mixed lineage kinase family members can be co-immunoprecipitated. However, the DLK leucine zipper domain interacted specifically only with the DLK leucine zipper domain; in contrast, DLK NH(2)-terminal region was sufficient to co-immunoprecipitate leucine zipper kinase and DLK. DLK has been shown to associate with the putative scaffold protein JIP1. This association occurred through the DLK NH(2)-terminal region and occurred independently of DLK catalytic activity. Although the DLK NH(2)-terminal region associated directly with JIP-1, this region did not interact directly with either DLK or leucine zipper kinase. Therefore, DLK may interact with heterologous mixed lineage kinase proteins via intermediary proteins. The NH(2)-terminal region of overexpressed DLK was required for activation of SAPK. These results provide evidence that protein complex formation is required for signal transduction from DLK to SAPK.

The androgen receptor exon 1 trinucleotide repeat does not act as a modifier of the age of presentation in breast cancer

The CAG repeat in exon 1 of the androgen receptor (AR) genes has been postulated as both a susceptibility allele and phenotypic modifier in BRCA1-associated breast cancers. We have analysed this repeat in a set of 178 breast cancer cases who have been selected only for age of presentation at 65 years or less. No effect of repeat length on age of presentation was found and there was no association between repeat length and family history. In combination with the data from other workers, our findings suggest that the androgen receptor repeat does not act as a modifier gene or susceptibility locus outside the context of the hereditary breast/ovarian cancer syndrome.

cDNA cloning, in vitro expression, and biochemical characterization of cholinesterase 1 and cholinesterase 2 from amphioxus--comparison with cholinesterase 1 and cholinesterase 2 produced in vivo

We have isolated cDNAs coding for the complete amino acid sequences of cholinesterase 1 (ChE1) and cholinesterase 2 (ChE2) from amphioxus. Both ChE transcripts have the characteristics of H-type catalytic subunits, which are inserted in the membrane via an ethanolamine-glycan-phosphatidylinositol anchor. The members of the catalytic triad of ChEs, the three pairs of cysteine residues involved in intrachain disulfide bonding, a cysteine near the carboxy terminal of both sequences, which could mediate interchain disulfide bonding, and 11 of the 14 aromatic amino acids that line the catalytic gorge of AChE are conserved. A remarkable difference between the two enzymes is in the region of the acyl-binding pocket, which plays an important role in determining substrate specificity in cholinesterases. ChE2 contains a sequence that resembles the acyl pocket of invertebrate ChE, while the acyl-binding site of ChE1 is novel. There are also differences between the two enzymes in the peripheral anionic site, which mediates inhibition by certain ligands. In vitro expression in COS-7 cells demonstrates that ChE2 hydrolyzes acetylthiocholine almost exclusively, while ChE1 hydrolyzes both acetylthiocholine and butyrylthiocholine. Both enzymes are inhibited comparably by BW284c51, but ChE1 is considerably more resistant to inhibition by propidium, ethopropazine, and eserine than is ChE2. Velocity sedimentation indicates that ChE1 and ChE2 are present as amphiphilic and nonamphiphilic G2 forms in vivo and in vitro. Another molecular form, which sediments at 17 S, is also present in vivo. Nondenaturing gel electrophoresis in conjunction with digestion by phosphatidylinositol-specific phospholipase C demonstrates that the vast majority of ChE1 and ChE2 is present as ethanolamine-glycan-phosphatidylinositol-anchored G2 forms in vivo. ChE1 also possesses an ethanolamine-glycan-phosphatidylinositol-anchor in vitro; however, ChE2 produced in vitro could not be detected on nondenaturing gels.

Auto theft-related trauma

OBJECTIVE

To determine the medical consequences and economic impact of caring for patients injured after motor vehicle crashes (MVC) involving stolen cars.

METHODS

Presented is a case series of inpatients injured secondary to a MVC involving a stolen car from January of 1993 to December of 1994 and treated at a university Level I trauma center in Newark, New Jersey. During the time period of the study, 1,232 patients (either as the driver or passenger) were admitted after a MVC, 115 patients (8%) were identified as sustaining injuries secondary to a MVC involving a stolen car. Injuries after car theft represent 8% of all MVC-related admissions. Data collected included demographics, types of injuries, surgical intensive care unit and hospital lengths of stay, insurance status, hospital and physician charges, and ultimate outcome.

RESULTS

Of the 84 men and 31 women, 66 were perpetrators, either as the driver (34) or passenger (32) of a stolen vehicle. Perpetrators were significantly younger and more likely to be male than victims. The overall mortality was 11%. An additional nine fatalities occurred at the scene of a MVC linked to a patient in this study. A high rate of speed and the presence of police pursuit seemed to be related to the severity of the crashes. The mean charges (hospital and physician) were over $34,000 per patient, and the aggregate charges for this cohort were greater than $3.6 million. Fifty-four percent of patients were uninsured.

CONCLUSION

Injuries involving stolen cars are common in areas in which the activity has a high prevalence and can compose a significant percentage of a trauma center's MVC population. These data run contrary to the popular belief that auto theft is merely a crime against property, because the injuries sustained as a result of this criminal activity tended to be severe and were associated with a high fatality rate. Restricting police pursuit to only those instances in which other felonious activity is suspected may decrease the number of stolen car MVC. Additionally, the total amount of uncompensated care that these patients receive places another financial burden on limited health care and trauma center resources, which ultimately effects all other citizens.

Low-energy impedance-compensating biphasic waveforms terminate ventricular fibrillation at high rates in victims of out-of-hospital cardiac arrest. LIFE Investigators

INTRODUCTION

New automatic external defibrillators (AEDs), which are smaller, lighter, easier to use, and less costly make the goal of widespread AED deployment and early defibrillation for out-of-hospital cardiac arrest feasible. The objective of this study was to observe the performance of a low-energy impedance-compensating biphasic waveform in the out-of-hospital setting on 100 consecutive victims of sudden cardiac arrest.

METHODS AND RESULTS

AEDs incorporating a 150-J impedance-compensating biphasic waveform were used by 12 EMS systems. Data were obtained from the AED PC card reporting system. Defibrillation was defined as conversion to an organized rhythm or to asystole. Endpoints included: defibrillation efficacy for ventricular fibrillation (VF); restoration of an organized rhythm at the time of patient transfer to an advanced life support (ALS) team or to the emergency department (ED); and time from AED power-on to first defibrillation. The AED correctly identified 44 of 100 patients presenting in VF as requiring a shock (100% sensitivity) and 56 of 100 patients not in VF as not requiring a shock (100% specificity). The time from 911 call to first shock delivery averaged 8.1 +/- 3.0 minutes. A single 150-J biphasic shock defibrillated the initial VF episode in 39 of 44 (89%) patients. The average time from power-on to first defibrillation was 25 +/- 17 seconds. At patient transfer to ALS or ED care, an organized rhythm was present in 34 of 44 (77%) patients presenting with VF. Asystole was present in 7 (16%) and VF in 3 (7%).

CONCLUSIONS

Low-energy impedance-compensating biphasic waveforms terminate long-duration VF at high rates in out-of-hospital cardiac arrest. Use of this waveform allows AED device characteristics consistent with widespread AED deployment and early defibrillation.

Tuberculin screening of trauma admissions at a university hospital. A preventive strategy

OBJECTIVE

To determine the prevalence of tuberculosis (TB) infection in our trauma service population, namely, those patients who had positive Mantoux (purified protein derivative [PPD] [tuberculin]) tests.

DESIGN

Prospective study.

SETTING

Trauma service at a university hospital in Newark, NJ.

PATIENTS AND METHODS

During a 9-month period, 110 admitted trauma patients underwent screening for TB. Of these patients, 20 had undergone recent PPD tests in the last 6 months, of which nine were positive. The remaining 90 patients underwent PPD and delayed-type hypersensitivity skin tests (anergy panel); five patients were unavailable for follow-up. The patients also answered questions regarding human immunodeficiency virus status, risk factors for TB infection, and clinical symptoms.

RESULTS

The mean age of the study group was 34 years (age range, 13 to 69 years). Eighty-four percent of these patients were males who belonged to the high-risk socioeconomic, racial, and ethnic groups (poor, non-white). The tests for 15 patients (17%) were newly discovered to be positive for PPD. Eleven percent of the patients with negative PPD tests were anergic, thus raising the percentage of patients with positive PPD tests to 20%. The human immunodeficiency virus status was known in only 41% of the total patients. All patients with positive PPD tests had a chest x-ray film performed; of these patients, positive findings for TB were determined for one patient. Another patient had evidence of abdominal TB at laparotomy. All patients with positive PPD tests were given appointments in the pulmonary clinic for follow-up, and only three of 15 patients kept their appointments.

CONCLUSIONS

Patients who were admitted to the trauma service were predominantly young males from high-risk groups with a high incidence of TB infection. Their admission to the trauma service was a unique opportunity for screening and implementing existing preventive programs.

Falls: epidemiology and strategies for prevention

Injury secondary to falls is a largely preventable public health problem. The records of 356 patients admitted following a fall to a level I trauma center over a 32-month period were reviewed to determine the epidemiology and to define possible prevention strategies. Falls constituted 9% of total trauma admissions during this time period and had a mortality of 11% (38 of 356). Two hundred ninety-seven falls were accidental, 36 were due to violent criminal behavior, 16 were from suicide attempts, and 7 were from house fires. Sixty-one children under the age of 13 fell; only one died. Falls out of windows accounted for 36% of these falls with over three-quarters of children falling from three stories or less. Elderly patients (age more than 64 years) accounted for only 44 (14%) of falls but over 50% of the deaths. This mortality rate occurred despite the fact that the majority of these falls were from relatively low heights. There were 224 adult falls (ages 18 to 64 years); 36% were occupation-related, and most were by construction workers, roofers, or painters. The remaining adult fall victims had a high rate of unemployment and alcohol and drug use. This study identified several groups where risk factors for falling permit targeted prevention strategies. A large percentage of children who fell were preschool males who fell from windows and this may be related to the lack of window guard legislation in our area.(ABSTRACT TRUNCATED AT 250 WORDS)

ThinPrep Processor. Clinical trials demonstrate an increased detection rate of abnormal cervical cytologic specimens

The authors compared the accuracy of conventionally prepared smears and smears prepared by an automated, fluid-based, thin-layer processing device in the detection of cytologic abnormalities. A total of 3218 patients from five centers took part in this study, in which a single cervical sample was split into a matched pair. The conventional smear was made in the routine fashion; the remainder of the cells on the sampling device were rinsed into a transport-fixation fluid. A slide was then prepared from the solution using the thin-layer processor. Diagnostic findings identified on the two preparations were compared in a blinded fashion, and a discrepancy resolution procedure was used to eliminate screening differences. Overall, there was a high correlation in the diagnoses of the two methods. For low-grade or more severe disease, the thin-layer method resulted in a 13% increase in the rate of detection, as compared with the conventional Papanicolaou smear technique.

Transfusion of blood components to persons infected with human immunodeficiency virus type 1: relationship to opportunistic infection

BACKGROUND

Although a recent study reported shorter survivals in human immunodeficiency virus type 1 (HIV-1)-infected patients who received transfusions, no study has analyzed the relationship in such patients between the frequency of opportunistic infection and transfusion.

STUDY DESIGN AND METHODS

Records of 196 HIV-1-infected subjects with CD4 lymphocyte counts below 250 cells per mm3 were reviewed to determine if there were more opportunistic infections in patients who previously received transfusions than in those who received no transfusions. The decline in CD4 cells was also compared, and the frequency of transfusion reactions and red cell alloantibodies was assessed.

RESULTS

The frequency of cytomegalovirus (CMV), wasting, and bacterial infections (p < 0.01), but not the frequency of Pneumocystis carinii pneumonia (PCP) (p > 0.2), was significantly increased in the patients who had previously received transfusions, and this effect was independent of CD4 count, race, or risk factor. The frequency of CMV infection, but not of PCP, was also related to the number of units of blood received (p < 0.01). Significant bacterial infections occurred primarily in persons with CMV infection, of whom there were more in the transfusion cohort. When analyzed separately in the group of patients without CMV infection, the frequency of bacterial infection was unrelated to transfusion. The death rate in those who received transfusions was also greater than that in patients who had never received a transfusion. None of the 130 patients who received red cell transfusions developed red cell alloantibodies.

CONCLUSION

The higher incidence of certain infectious complications in HIV-1-infected patients who received transfusions indicates that the relationship of transfusion to virus activation in patients with acquired immunodeficiency syndrome and the potential benefits of modifying the preparation of blood components should be investigated further.

Vascular adventitial cell expression of collagen I messenger ribonucleic acid in anti-glomerular basement membrane antibody-induced crescentic nephritis in the rabbit. A cellular source for interstitial collagen synthesis in inflammatory renal disease

BACKGROUND

Scarring in the interstitial compartment of the renal cortex heralds a poor prognosis in many forms of renal injury, however, the mechanism through which glomerular inflammation leads to interstitial scarring is not understood. In a model of anti-GBM disease in the rabbit, development of crescentic glomerulonephritis is associated with marked interstitial fibrosis and decreased renal function. We previously demonstrated that collagen accumulation in the model was preceded by increases in collagen I and IV mRNA and that these changes were primarily extraglomerular at early time points when inflammation was predominantly intraglomerular. In order to identify the cellular origins of extraglomerular collagen synthesis in this model, in situ hybridization using an alpha 2(I) procollagen probe was performed.

EXPERIMENTAL DESIGN

A 602 bp rabbit alpha 2(I) procollagen cDNA was cloned using a PCR strategy and sequenced. The nucleotide sequence of the coding region was 94% identical with the human alpha 2(I) procollagen sequence. Northern blots were performed to define conditions of specific hybridization of the anti-sense riboprobe. Tissue sections from normal rabbit kidneys and from kidneys 4, 5, 7, 10 and 14 days after injection of anti-GBM antibody were hybridized with 35S-labeled sense and anti-sense riboprobes. Cells containing alpha 2(I) mRNA were identified by autoradiography and mRNA abundance was quantitated by grain density.

RESULTS

No specific hybridization was detected with the sense probe at any time. alpha 2(I) mRNA was undetectable with the anti-sense probe in normal kidney sections. In contrast, the anti-sense probe hybridized specifically at all time points after induction of anti-GBM disease. In agreement with previous filter hybridization studies, on day 4, when inflammation was predominantly intraglomerular, cells in the periarterial adventitial compartment of renal cortex hybridized strongly. At later time points, labeling was also present in the interstitial spaces, the periglomerular region, in Bowman's space and in the glomerular tuft itself.

CONCLUSIONS

We conclude that perivascular adventitial cells are among the first to respond to glomerular inflammation and represent a pool of cells that subsequently contribute to interstitial and glomerular scarring.

Analysis of T cells and major histocompatibility complex class I and class II mRNA and protein content and distribution in antiglomerular basement membrane disease in the rabbit

The major interacting components of the immune system, major histocompatibility complex (MHC) class I and class II proteins and T cells were analyzed in a model of anti-GBM (glomerular basement membrane) disease in the rabbit that progresses to develop cellular crescents and glomerular and interstitial fibrosis. Class I and II mRNA and protein were measured in isolated glomeruli and whole renal cortex using cDNA probes and monoclonal antibodies. The distribution of T cells and class I and II proteins was assessed by immunofluorescence. Normal glomeruli contained no T cells and were class II negative. By day 4, glomeruli contained MHC class I and II mRNA and protein and class II positive T cells. Although some animals had T cells in the periglomerular area, these cells were class II negative. By day 7 periglomerular T cells were largely class II positive (activated) and there was increased MHC class I and II mRNA and protein in whole renal cortex. Later T cells accumulated in the tubulo-interstitial compartment, which became diffusely positive for MHC classes I and II, but to a variable extent in different animals. Those with high class II mRNA expression also had detectable T cell antigen receptor mRNA by Northern analysis. The authors conclude 1) in this model there was a close association between mRNA abundance and protein expression for both MHC classes I and II in glomeruli and renal cortex as a whole; 2) in this model of glomerular injury there are three phases of activation. The first phase takes place in the glomerulus and is associated with accumulation of activated T cells and MHC class I and II protein in the glomerulus. Phase 2 is associated with the accumulation of periglomerular T cells and their becoming class II positive. There is subsequent dissemination (phase 3) of activated T cells and accumulation of class I and II mRNA and protein throughout the interstitial compartment. This spacial progression of glomerulocentric inflammation is likely associated with degree of injury and permanent loss of renal function.

Transforming growth factor-beta production in anti-glomerular basement membrane disease in the rabbit

The purpose of this study was to assay for the presence of collagen synthesis stimulatory activity in the kidney during immune-induced renal injury that results in severe fibrosis in both glomerular and interstitial compartments. A model of antiglomerular basement (anti-GBM) disease in the rabbit was induced on day 0 by the injection of anti-GBM antibody and renal cortex tissues were then sampled at various time points. Only conditioned media prepared from diseased renal cortical samples showed collagen synthesis stimulatory activity when tested on rabbit mesangial cells. The activity had an estimated molecular weight range of 16 to 25 kd and was neutralized by antibody to transforming growth factor-beta (TGF-beta). A standard assay for TGF-beta using a mink lung epithelial cell line confirmed the increase in TGF-beta activity in conditioned media of diseased cortex from day 7 and day 14 animals, which was not significantly activated by previous acidification. This suggests that most of the TGF-beta present in renal conditioned media was in the active form. The increase in renal cortical secretion of active TGF-beta was accompanied by increases in renal cortical TGF-beta mRNA content on days 4 and 7 after induction, with subsequent return to control levels. A similar increase in TGF-beta activity was present in nonacidified conditioned media of purified glomeruli from diseased days 7 and 14 animals, which was also accompanied by significant increases in TGF-beta mRNA. However with acidification no significant differences were noted between control and diseased samples, suggesting the presence of substantial latent TGF-beta activity in control glomerular conditioned media. These same control-conditioned media contained inhibitor activity for added exogenous TGF-beta. These results support the conclusion that the association between increased TGF-beta secretion and increased renal cortical collagen synthesis in this model is consistent with a role for this cytokine in directing fibrogenesis in the kidney.

Experiencing primary nursing: three perspectives

While primary nursing holds great promise for both nurses and clients in health care, the reality is that it is not often achieved in practice. The experiences of those involved in primary nursing offer insight into the benefits of this method of care delivery. This paper reports on primary nursing from the perspectives of three practitioners: an administrator, a clinical practitioner and a clinical teacher. If the potential of primary nursing is to be realized, those commited to this modality of care have a responsibility to describe and advance it.

Antibody-induced receptor loss. Different fates for asialoglycoproteins and the asialoglycoprotein receptor in HepG2 cells

The human asialoglycoprotein receptor (ASGP-R) is a membrane glycoprotein which participates in receptor-mediated endocytosis and delivery of its ligands to lysosomes for degradation. In order to examine the pathways and mechanisms responsible for the turnover and degradation of the ASGP-R we have followed the fate of the ASGP-R in HepG2 cells during exposure to anti-receptor antibody as well as inhibitors of lysosomal processing and receptor recycling. Incubation of cells at 37 degrees C with anti-ASGP-R antibody results in the rapid (t 1/2 30 min) loss of mature 46,000-Da ASGP-R (control, t 1/2 20 h). This process requires whole IgG, since Fab fragments do not induce loss of receptor. Furthermore, this antibody-induced loss is specific, since incubation with antibody to the transferrin receptor does not alter cellular ASGP-R content. Of note, weak bases (e.g. primaquine) abrogate this antibody-induced loss of ASGP-R. Inhibitors of lysosomal proteases (EC64 and leupeptin) do not alter this antibody-mediated loss. Furthermore, this effect occurs at 18 degrees C, a temperature at which delivery of ligand to the lysosome is blocked. Thus, the present observations suggest a unique pathway for antibody-induced ASGP-R loss which is distinct from the pathway of lysosomal delivery of ligand.