Ultramassive transfusion and adjunctive therapies in a case of blood bank depletion

Background

We present the case of a patient who presents with a high velocity thoracoabdominal gunshot wound requiring ultramassive transfusion who exhausted the county blood bank requiring adjunctive therapies to balanced blood product transfusion while additional blood products could be obtained.

Summary

Thoracoabdominal gunshot wounds carry a high mortality of 14-37 % because of the risk to produce cardiopulmonary, solid organ as well as major vascular injuries (Mandal and Oparah (1989) [1]). Ultramassive transfusion (>20 units of blood product transfusion) also carries high morbidity and mortality and management has generally centered on balanced transfusion (Matthay et al. (2021) [2]).

Conclusion

Balanced blood product transfusion reduces mortality for patients requiring ultramassive transfusion but when this is not possible utilization of adjuncts to blood products may temporize resuscitation until additional blood products can be obtained.

The use of enhanced intrinsic feedback for motor learning in stroke survivors: Clinical trial protocol

BACKGROUND

Stroke can lead to lasting sensorimotor deficits of the upper limb (UL) persisting into the chronic phase despite intensive rehabilitation. A major impairment of reaching after stroke is a decreased range of active elbow extension, which in turn leads to the use of compensatory movements. Retraining movement patterns relies on cognition and motor learning principles. Implicit learning may lead to better outcomes than explicit learning. Error augmentation (EA) is a feedback modality based on implicit learning resulting in improved precision and speed of UL reaching movements in people with stroke. However, accompanying changes in UL joint movement patterns have not been investigated. The objective of this study is to determine the capacity for implicit motor learning in people with chronic stroke and how this capacity is affected by post-stroke cognitive impairments.

METHODS

Fifty-two subjects who have chronic stroke will practice reaching movements 3×/wk. for 9 wk. in a virtual reality environment. Participants will be randomly allocated to 1 of 2 groups to train with or without EA feedback. Outcome measures (pre-, post- and follow-up) will be: endpoint precision, speed, smoothness, and straightness and joint (UL and trunk) kinematics during a functional reaching task. The degree of cognitive impairment, lesion profile, and integrity of descending white matter tracts will be related to training outcomes.

CONCLUSIONS

The results will inform us which patients can best benefit from training programs that rely on motor learning and utilize enhanced feedback.

TRIAL STATUS

Ethical approval for this study was finalized in May 2022. Recruitment and data collection is actively in progress and is planned to finish in 2026. Data analysis and evaluation will occur subsequently, and the final results will be published.

Chloroform-Methanol Extraction Method for Determination of Fat in Foods: Collaborative Study

Achloroform-methanol extraction method (complete extraction of fat in 3 min) for determining fat in processed and prepared foods has been studied collaboratively. Fourteen collaborators reported single replicate fat results on 7 samples representative of various food types and 2 spiked samples by the proposed method. Each sample was accompanied by a blind duplicate. For statistical purposes, the blind duplicates were treated as paired observations, and there were 2 laboratory outliers. There was a 97.9% agreement among the results from the remaining 12 collaborators and the Associate Referee for the unfortified samples. Recoveries of 93.8 and 98.3% were obtained on fortified samples, based on results obtained from 11 collaborators. The statistical analysis of the results indicate (ranges for standard deviations were Sr = 0.083-0.528, Sb = 0.101-0.379, Sd = 8.130-0.631, for fat values ranging from 1.58 to 26.91%) that this method is adequate for quantitating the fat content in a wide variety of processed foods for nutritional labeling. The method has been adopted official first action.

Modeling conduction delays in the corpus callosum using MRI-measured g-ratio

Conduction of action potentials along myelinated axons is affected by their structural features, such as the axonal g-ratio, the ratio between the inner and outer diameters of the myelin sheath surrounding the axon. The effect of g-ratio variance on conduction properties has been quantitatively evaluated using single-axon models. It has recently become possible to estimate a g-ratio weighted measurement in vivo using quantitative MRI. Nevertheless, it is still unclear whether the variance in the g-ratio in the healthy human brain leads to significant differences in conduction velocity. In this work we tested whether the g-ratio MRI measurement can be used to predict conduction delays in the corpus callosum. We present a comprehensive framework in which the structural properties of fibers (i.e. length and g-ratio, measured using MRI), are incorporated in a biophysical model of axon conduction, to model conduction delays of long-range white matter fibers. We applied this framework to the corpus callosum, and found conduction delay estimates that are compatible with previously estimated values of conduction delays. We account for the variance in the velocity given the axon diameter distribution in the splenium, mid-body and genu, to further compare the fibers within the corpus callosum. Conduction delays have been suggested to increase with age. Therefore, we investigated whether there are differences in the g-ratio and the fiber length between young and old adults, and whether this leads to a difference in conduction speed and delays. We found very small differences between the predicted delays of the two groups in the motor fibers of the corpus callosum. We also found that the motor fibers of the corpus callosum have the fastest conduction estimates. Using the axon diameter distributions, we found that the occipital fibers have the slowest estimations, while the frontal and motor fiber tracts have similar estimates. Our study provides a framework for predicting conduction latencies in vivo. The framework could have major implications for future studies of white matter diseases and large range network computations. Our results highlight the need for improving additional in vivo measurements of white matter microstructure.

Abstract P2-03-01: Mutational landscape of breast cancers from PALB2 germline mutation carriers

Background: The PALB2 gene encodes the partner and localizer of the BRCA2 protein, which participates in homologous recombination during DNA repair via an interaction with BRCA1 and BRCA2. Germline mutations in PALB2 are associated with an increased risk of breast cancer, with a cumulative risk of 35% by age 70 in female PALB2 mutant carriers. The aims of this project were to characterize the genomic landscape of PALB2 breast cancers and define the differences in the repertoire of somatic genetic alterations and mutational signatures between PALB2, BRCA1 and BRCA2 breast cancers.

Methods: Representative samples from fourteen breast cancers from patients with known PALB2 germline mutations (seven frame-shift (2 H1170fs, 3 K346fs, 1 T841fs and 1 L531fs), five truncating (3 W1038* and 2 Q775*) and two missense (W1140G and L35P)) were microdissected to ensure a tumor cell content of >70%. DNA samples from microdissected tumors and their matched normal counterparts were subjected to whole exome sequencing on an Illumina HiSeq2000 to a median depth of 118x (range 33-193x). Somatic single nucleotide variations were detected using MuTect, and small insertions and deletions were identified using Strelka and Varscan2. Using ABSOLUTE and FACETS, we investigated the presence of loss of heterozygosity (LOH) of the PALB2 wild-type allele in these tumors. In addition, the mutational signatures and large scale state transitions (LSTs) were defined. The repertoire of somatic mutations identified in PALB2 breast cancers was compared to that of breast cancers from BRCA1 (n=11) and BRCA2 (n=10) germline mutation carriers from The Cancer Genome Atlas study.

Results: PALB2 breast cancers were found to harbor a median of 80 somatic mutations (range 22-286) and one somatic mutation (range 0-13) affecting known cancer genes. Somatic loss of the PALB2 wild-type allele was found in five cases, and in three additional cases, a second PALB2 somatic mutation likely constituted the second 'hit' (two with truncating mutations, Q479* and Q61*, and one with a Q921fs frameshift mutation). Six PALB2 breast cancers displayed the BRCA mutations signature; of these, five had PALB2 bi-allelic inactivation (three LOH of the wild-type allele and two a second PALB2 somatic mutation). 71% of the samples were found to have LSTs, including all cases with a BRCA mutational signature. A significant association between PALB2 bi-allelic inactivation and concurrent BRCA signature and high LST was observed (p=0.015). Breast cancers from PALB2 mutation carriers had fewer somatic TP53 mutations than BRCA1 breast cancers (3/14, 21% vs 9/11, 82%, p=0.004), but no difference in the repertoire of somatic mutations compared to that of BRCA2 breast cancers.

Conclusions: PALB2 breast cancers were found to harbor pathogenic mutations in driver genes, including TP53, PIK3CA, NF1 and NCOR1, however lacked highly recurrent somatic mutations. Unlike BRCA1/2 breast cancers, the majority of breast cancers from PALB2 germline mutation carriers lacked LOH of the PALB2 wild-type allele. Importantly, however, an association between PALB2 bi-allelic inactivation and the BRCA mutational signature and LSTs was observed, providing additional evidence for a homologous recombination-deficient phenotype at least in a subset of PALB2 cancers.

Citation Format: Burke KA, Berman S, Geyer FC, Piscuoglio S, Ng CK, Wen YH, Mannermaa A, Peterlongo P, Tondini C, Janatova M, Soo Hwang T, Ng P-S, Looi LM, Chenevix-Trench G, Southey MC, Weigelt B, Foulkes W, Tischkowitz M, Reis-Filho JS, PALB2 Interest Group. Mutational landscape of breast cancers from PALB2 germline mutation carriers [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-03-01.

Antibodies in autoimmune thyroiditis affect glucose metabolism of anterior cingulate

BACKGROUND

Hypothyroidism induced by an autoimmune process is associated with neuropsychiatric symptoms and metabolic abnormalities in the brain. The aim of this study was to examine the relationship between autoimmune thyroiditis and regional brain function in hypothyroid patients.

METHODS

Cerebral glucose metabolism, as an index of brain function, was assessed in regional whole-brain analyses using positron emission tomography (PET) and [18F]fluorodeoxyglucose in thirteen hypothyroid patients with autoimmune thyroiditis suffering from neuropsychiatric symptoms. The primary biological measures were radioactivity in pre-selected brain regions, relative to whole-brain radioactivity, as a surrogate index of glucose metabolism, and serum levels of thyroglobulin (TG) and thyroid peroxidase (TPO) antibodies as endocrine markers of autoimmune thyroiditis.

RESULTS

Serum levels of anti-TG antibodies in hypothyroid patients were significantly correlated with glucose metabolism in the perigenual anterior cingulate cortex, a brain region previously shown to regulate affect and emotional homeostasis.

CONCLUSION

Thyroid autoimmune processes may play an important role in the still poorly defined pathogenic correlates of disturbed function in brain regions critically involved in emotional processing in hypothyroid conditions.

Preparation of cholera vaccines by fluorocarbon extraction of cholera Vibrio suspensions

Experimental cholera vaccines were prepared from suspensions of cholera vibrios which were extracted with Genetron-113. These vaccines, when compared with a control preparation which was not treated with Genetron, had a lower nitrogen content and were less toxic for mice but were as effective in protecting mice against infection and in inducing agglutinating and vibriocidal antibody responses in rabbits. This procedure may permit the preparation of cholera vaccines with a higher antigenic content without the corresponding increase in toxic reactions.

Emotional intimacy predicts condom use: findings in a group at high sexually transmitted disease risk

Previous studies have reported an inverse relationship between condom use and emotional intimacy. The aim of this study was to determine the relationship between condom use and emotional intimacy. The study was a gonorrhoea case-comparison study with the samples being drawn from public health clinics (cases) and select bars/nightclubs (places) of Houston, TX ( n = 215). Data were collected by questionnaires administered on a laptop computer. The majority of respondents were African-American (97.7%), women (69.3%) and had either high school or GED education (72.6%). Condom use with the last sexual partner was analysed along with intimacy with that partner assessed on a 3-point scale. Analysis showed that higher intimacy was related to greater condom use which was significant in men but not in women. In conclusion, these data were opposite to those of previous studies, which showed an inverse relationship between condom use and emotional intimacy. We hypothesize that in a high-risk environment, people exert more effort in protecting those they feel closer to. These data suggest a need to further explore the complex relationship between emotional intimacy and condom use.

Magnesium administration may improve heart rate variability in patients with heart failure

BACKGROUND AND AIM

Intracellular magnesium (icMg) depletion may coexist with normomagnesemia. Mg deficiency (serum and/or intracellular) and decreased heart rate variability (HRV) are common in heart failure (HF). Since both are predictors of poor prognosis, it was of interest to evaluate the effect of Mg supplementation on HRV in patients with HF.

METHODS AND RESULTS

We investigated the effect of Mg administration on HRV in normomagnesemic patients with systolic HF. HRV, serum Mg and icMg were determined before and after 5-week 300 mg/day Mg citrate treatment in 16 patients (group 1). The control group included 16 Mg-non-treated HF patients (group 2). HRV was determined by a non-linear dynamics analysis, derived from the chaos theory, which calculates HRV-correlation dimension (HRV-CD). After 5 weeks, serum Mg (mmol/l) increased more significantly in group 1 (from 0.78+/-0.04 to 0.89+/-0.06, p<0.001), than in group 2 (from 0.79+/-0.07 to 0.84+/-0.06, p=0.042). IcMg and HRV-CD increased significantly only in group 1 (from 59+/-7 to 66+/-9 mmol/g cell protein, p=0.025, and from 3.47+/-0.42 to 3.94+/-0.36, p<0.001, respectively). In group 2, the differences in the respective parameters were 63+/-12 to 66+/-9 mmol/g cell protein (p=0.7) and 3.59+/-0.42 to 3.55+/-0.4 (p=0.8).

CONCLUSION

Mg administration to normomagnesemic patients with systolic HF increases serum Mg, icMg and HRV-CD. Increasing of HRV by Mg supplementation may prove beneficial to HF patients.

The effect of gestational age on trial of labor after Cesarean section

OBJECTIVES

To evaluate the effect of gestational age on the rate of successful vaginal delivery and the rate of uterine rupture in patients undergoing a trial of labor (TOL) after a prior Cesarean delivery.

STUDY DESIGN

This was a cohort study including patients with a live singleton fetus undergoing a TOL after a previous low transverse Cesarean delivery between 1988 and 2002. Patients were divided into three groups according to gestational age: 24-36 weeks 6 days, 37-40 weeks 6 days and > or = 41 weeks. Obstetric outcomes, including the rates of successful vaginal delivery and symptomatic uterine rupture, were compared between the groups. Multivariate logistic regression analysis was performed to adjust for potential confounding factors.

RESULTS

There were 253, 1911 and 329 patients in each group, respectively. In patients with advanced gestational age (> or = 41 weeks) the rate of uterine rupture was significantly higher (0% vs. 1.0% vs. 2.7%, p = 0.006) and the rate of successful vaginal deliveries was significantly lower (83% vs. 76.9% vs. 62.6%, p < 0.001). After adjusting for confounding variables, advanced gestational age was associated with a lower rate of successful vaginal delivery (odds ratio 0.68, 95% CI 0.51-0.89), and a higher rate of uterine rupture (odds ratio 2.85, 95% CI 1.27-6.42) when compared to 37-40 weeks 6 days.

CONCLUSION

Advanced gestational age is associated with higher rates of failed TOL and uterine rupture.

Unexplained fetal death is associated with changes in the adaptive limb of the maternal immune response consistent with prior antigenic exposure

OBJECTIVE

The causes of fetal death are largely unknown. CD4 T cells have been classified according to the expression of the CD45 isoforms into 'naive-like' T cells (CD45RA) and 'memory-like' T cells (CD45RO). An increase in the percentage of the CD45RO has been interpreted as indicating prior antigenic exposure of the host and, in newborns, evidence of infection. The purpose of this study was to determine whether unexplained fetal death was associated with a change in the proportion of 'naive-like' and 'memory-like T cells' in the maternal blood, as determined by the CD45 isoforms on the surface of CD4+ lymphocytes.

STUDY DESIGN

A prospective study was conducted to compare the CD45 sub-population of lymphocytes in patients with intrauterine fetal death (n = 26) and normal pregnancy (n = 89). The percentages of CD45RA+, CD45RO+ and CD45RA+/CD45RO+ on CD4+ T lymphocytes were determined in maternal blood using flow cytometry and monoclonal antibodies. Results were reported as a percentage of CD4+ lymphocytes. Non-parametric statistics were used for analysis. A p value of < 0.05 was considered significant.

RESULTS

Patients with intrauterine fetal death had a higher percentage of CD45RO+ CD4+ T lymphocytes than normal pregnant women (fetal death: median 57.7%, range 35.4-78.6 vs. normal pregnancy: median 49.9%, range 19.1-86.8; p = 0.004). Fetal death was associated with a lower median percentage of CD45RA+ CD4+ lymphocytes than in normal pregnant women (fetal death: median 32.3%, range 15.3-58.0 vs. normal pregnancy: median 40.2%, range 11.2-67.3; p = 0.01). There was no significant difference in the percentage of cells with dual expression (CD45RA+/CD45RO+) between the study groups.

CONCLUSION

Prior exposure to microbial products (bacterial or viral) or other unidentified antigens may result in a shift of the sub-population of 'naive-like' T cells to 'memory-like' T cells in mothers with unexplained fetal death.

Metabolic and clinical effects of oral magnesium supplementation in furosemide-treated patients with severe congestive heart failure

BACKGROUND

Magnesium depletion and hypomagnesemia are common among furosemide-treated patients with chronic congestive heart failure.

HYPOTHESIS

This investigation evaluated clinical and metabolic effects of oral magnesium supplementation.

METHODS

Ten patients with severe congestive heart failure maintained on high dose furosemide (> or = 80 mg/day) received a supplement of oral magnesium citrate 300 mg/daily for 30 days. Clinical parameters were followed, and peripheral blood mononuclear cell magnesium and zinc content, serum and urine magnesium, potassium, zinc, calcium, phosphorus, and creatinine were assessed.

RESULTS

Peripheral blood mononuclear cell magnesium content and serum potassium rose significantly at the end of the study (2.09 +/- 1.89 to 3.99 +/- 2.26 micrograms/mg cell protein, p < 0.05, and 4.17 +/- 0.38 to 4.39 +/- 0.27 mEq/l, p < 0.05, respectively), while the other parameters remained unchanged.

CONCLUSION

In some of these patients, oral magnesium supplementation is effective in achieving substantial increments in intracellular magnesium and serum potassium which, in turn, may have cardioprotective effects.

Hyperbaric oxygen, oxidative stress, NO bioavailability and ulcer oxygenation in diabetic patients

BACKGROUND

Hyperbaric oxygen therapy (HBO2) increases tissue oxygenation, thus serving as an adjunct therapy for diabetic wounds. However, in some patients there is insufficient increase in tissue O2.

AIMS

To investigate the pathophysiology of insufficient HBO2 and the possible role of N-acetylcysteine (NAC).

METHODS

Prospective, randomized, cross-over trial included 50 diabetic patients with non-healing ulcers. Each patient received two treatments with 100% oxygen/2ATA. NAC was administered i.v. at one of the two treatments. Basal and post-treatment peri-wound transcutaneous O2 (TcPO2) pressure, malondialdehyde (MDA), total anti-oxidant status (TAOS) and nitric oxide (NO) were assessed. An ulcer oxygenation increase above 200 mmHg was accepted as sufficient.

RESULTS

During HBO2, 17 patients (34%) demonstrated insufficient increase in TcPO2. Concomitantly, their TAOS and NO decreased, while MDA increased. NAC administration attenuated these parameters, thus improving the HBO2 outcome. In those affected by NAC, the cure rate was 75%. By contrast, in 66% of patients with sufficient increase in TcPO2 TAOS was increased and MDA decreased irrespective of NAC administration. The cure rate in this subgroup was 82%.

CONCLUSIONS

Insufficient increase of ulcer oxygenation during HBO2 results from exaggerated oxidative stress and decreased NO bioavailability. NAC administration-induced modulation of both parameters and may improve ulcer oxygenation during HBO2.

Dextran 40 (Rheomacrodex) or Polygeline (Haemaccel) as an epidural patch for post dural puncture headache: a neurotoxicity study in a rat model of Dextran 40 and Polygeline injected intrathecally

BACKGROUND AND OBJECTIVE

Although an epidural autologous blood patch is considered the most effective treatment for post dural puncture headache, which sometimes occurs following spinal or inadvertent spinal anaesthesia, there remains a need for alternative materials for epidural patches. We investigated the potential neurotoxicity of Dextran 40 (Rheomacrodex) and Polygeline (Haemaccel) used for this purpose in a rat model.

METHODS

Repeated boluses of 10% Dextran 40, 3.5% Polygeline or 0.9% saline were injected intrathecally over a period of 1 month in three groups of rats.

RESULTS

No behavioural or clinical derangements were observed in any of the three groups during this period. After sacrifice of the animals at the end of the experiment, no significant differences in the histopathological appearances of the spinal cords in the three groups were observed. No toxic effects diminishing viability of spinal cord cells were evident. Similarly, viability of renal, hepatic and peripheral blood mononuclear cells remained unaffected (98% +/- 2%).

CONCLUSIONS

No deleterious effects, clinical or cellular, were evident in this rat model when Dextran 40 or Polygeline were injected intrathecally. Thus, both substances can be considered as possible alternative materials for epidural patches.

Total cellular calcium and magnesium content of cultured human peripheral blood mononuclear cells following exposure to antidiabetic drugs

Drugs modulating the ATP-sensitive potassium (K(ATP)) channel activity are widely used for the treatment of diabetes mellitus, the target being pancreatic beta-cells. However, any cell type possessing K(ATP) channels might be concomitantly affected. We investigated the metabolic effect of glibenclamide, a K(ATP) channel closer, and/or diazoxide, a K(ATP) channel opener, on total intracellular content of calcium (Ca) and magnesium (Mg) of cultured peripheral blood mononuclear cells (PBMC). Metformin and rosiglitazone, acting via cellular mechanisms other than K(ATP) channels, were also tested. Ca and Mg were assessed in PBMC from healthy subjects following 72 h in vitro treatment with the respective drugs. Ca content increased significantly in PBMC treated with glibenclamide or rosiglitazone, however apparently via different intracellular pathways. Mg increased only following treatment with rosiglitazone. Metformin had no effect on intracellular Ca or Mg. Pretreatment with diazoxide resulted in a significant intracellular Ca and Mg loss in each experimental situation. If verified clinically, rosiglitazone-induced increase in Mg content of PBMC might prove beneficial beyond hypoglycaemic control. On the other hand, loss of intracellular Ca/Mg content following K(ATP) channel opening by diazoxide might eventually result in significant intracellular Ca and/or Mg depletion.

Defining intracellular signaling targets in soft tissue sarcoma (STS) using immunohistochemical staining (IHC)

9577

Background: Pathologic events pertaining to the intracellular cell signaling pathway are now being recognized to be directly or indirectly responsible for oncogenic transformation in a variety of malignancies. Many drugs are now available which can block key steps of these signaling pathways. We sought to use IHC stains of previously stored sarcoma specimens to determine if expression of potential molecular targets (mTOR, p 70 S6 Kinase, ERK1/2, NF Kappa B) is present. Methods: Using tumor registry data, our three most common adult STS histopathologic subtypes were identified, and paraffin embedded tissue blocks representing these histologies were retrieved. Each block was reviewed for tissue adequacy. The blocks were cut and then stained with the aforementioned phosphorylated IHC stains (Cell Signal Technologies). Slides were graded on intensity of stain uptake (0–3+) and percentage of cells staining. A particular IHC stain was considered positive if 10% or more cells were stained 1+ or greater in intensity. Results: Seventeen Malignant Fibrous Histiocytomas (MFH), 20 Leiomyosarcomas (LMS) and 7 Liposarcomas were stained for the presence of p-mTOR, p-p70S6 Kinase, p ERK1/2, and p-NF Kappa B. Data for NF Kappa B will be presented at the meeting. The results are summarized in the table below. Conclusions: Pathways involving ERK appear to be active in more frequently diagnosed Sarcomas. Slightly more than half of the MFHs we studied expressed phosphorylated ERK1/2. Further exploration of this pathway, as well as mTOR, as potential targets of therapeutic intervention is indicated in STS.

[Table: see text]

No significant financial relationships to disclose.

Neonates born to pre-eclamptic mothers have a higher percentage of natural killer cells (CD3-/CD56+16+) in umbilical cord blood than those without pre-eclampsia

OBJECTIVE

Maternal endothelial dysfunction and intravascular inflammation have been implicated in the mechanisms of disease responsible for the clinical syndrome of pre-eclampsia. Recently, the activation of the innate limb of the immune response (neutrophils and monocytes) in the fetal circulation has been reported in neonates born to mothers with pre-eclampsia. Natural killer (NK) cells are identified morphologically as a subpopulation of lymphocytes, but functionally as one component of the innate immune system. NK cells participate in the control of viral or bacterial infection, regulation of hematopoiesis, production of cytokines and cytotoxicity of neoplastic cells. Accumulating evidence suggests that the innate system is required for mounting an adequate adaptive response. NK cells, originally defined as effector cells of the innate immune system, may also play a role as regulatory cells for the adaptive immune system. This study was designed to determine the proportion of the NK cell subset of lymphocytes in umbilical cord blood of neonates born to mothers with and without pre-eclampsia.

METHODS

A cross-sectional study including neonates of mothers with (n = 48) and those without pre-eclampsia (control group) (n = 72) was conducted. Pre-eclampsia was diagnosed in the presence of hypertension and proteinuria. The control group consisted of neonates (premature and term) with no evidence of acute inflammation within the extraplacental membranes (chorioamnionitis). Umbilical cord blood was collected at the time of delivery, and assayed using monoclonal antibodies for selective cluster differentiation (CD) antigens in order to determine the proportion of NK cells as a percentage of total lymphocytes. The immunophenotypic characteristic was determined using flow cytometry, and NK cells were identified by positivity of CD16 and CD56 without CD3 (CD3-/CD56+16+). Log transformation of the percentage of NK cells was performed. Parametric statistics were used for analysis. Multiple regression analysis was utilized to examine the contribution of potentially confounding factors on the proportion of NK cells. A p value of < 0.05 was considered statistically significant.

RESULTS

Neonates born to mothers with pre-eclampsia had a significantly higher percentage of NK cells (CD3-/CD56+16+) than those in the control group (pre-eclampsia, mean +/- SD 17 +/- 9% vs. control, mean +/- SD 12 +/- 7.5%; p = 0.001). Multiple regression analysis suggested that umbilical cord blood pH of < 7.2, labor with vaginal delivery and maternal pre-eclampsia were associated with an increased percentage of NK cells in umbilical cord blood.

CONCLUSIONS

Pre-eclampsia is associated with a higher NK cell (CD3-/CD56+16+) subset of lymphocytes in umbilical cord blood than in the control group. This difference cannot be explained by fetal acidosis or the presence of labor.

Intracellular Ca++/Mg++ homeostasis during postnatal growth of experimental rats. Multiple time-point study

In most tissues, various cell membrane ion transporting systems are not fully developed and/or maximally active at the prenatal and early postnatal stage. Their progressive development and expression are a function of growth and maturity. We performed a multiple time-point study, in order to investigate the ability of a variety of tissues to maintain appropriate Ca++ and Mg++ homeostasis at different stages of postnatal development. Total intracellular Ca++ in one-week-old rat liver, brain and spinal cord tissues was significantly elevated, compared to mature animals. It increased further through the first three weeks of gestation. Intracellular Ca++ gradually and significantly declined in adult and mature animal groups. Alterations in total intracellular Mg++ of the same tissue samples, although not so profound, paralleled changes in total intracellular Ca++. We conclude that a developmental switch in intracellular Ca++ and Mg++ homeostasis occurs one to three weeks following birth. It might be related to the incomplete development of Ca++ and Mg++ transmembrane transporting systems, previously reported as being only partially expressed at the early postnatal stage. These developmental alterations in total intracellular Ca++ and Mg++ content might serve as a regulatory mechanism, adjusting cell activities to the physiological requirements of the growing and maturing animal.

Copper and zinc blood levels among children with nonorganic failure to thrive

BACKGROUND AND AIMS

Copper and zinc deficiency are commonly reported among children with organic failure to thrive. In contrast, reports on copper and zinc status in children with non-organic failure to thrive are scarce. The goal of this study was to evaluate copper and zinc blood levels and nutritional intake among children with non-organic failure to thrive.

METHODS

A study group of 32 children with non-organic failure to thrive were investigated and compared with 32 healthy controls. Each child had copper and zinc blood level measurements. In addition, the study group underwent evaluation of thyroid function, immunoglobulins, endomesial antibodies and xylose test. A dietary questionnaire that included a diet history and a 24-h dietary recall was administered to parents by a dietician. Weight for height, height for age and mean daily intake of calories, protein, copper and zinc were calculated.

RESULTS

There were no significant differences between the two groups in either socioeconomic status or caloric, copper or zinc intake. Protein intake was significantly lower in the study group (P<0.0001). Plasma copper levels were within the normal range in both groups (P=0.3). Zinc plasma levels were significantly higher in the study group as compared to controls (P=0.03); however, they remained within the normal range in both groups.

CONCLUSIONS

Children with non-organic failure to thrive can maintain plasma copper and zinc levels within normal range and similar to normal controls.

Antimicrobial peptides in amniotic fluid: defensins, calprotectin and bacterial/permeability-increasing protein in patients with microbial invasion of the amniotic cavity, intra-amniotic inflammation, preterm labor and premature rupture of membranes

OBJECTIVE

Neutrophil defensins (HNP 1-3), bactericidal/permeability-increasing protein (BPI) and calprotectin (MRP8/14) are antimicrobial peptides stored in leukocytes that act as effector molecules of the innate immune response. The purpose of this study was to determine whether parturition, premature rupture of the membranes (PROM) and microbial invasion of the amniotic cavity (MIAC) are associated with changes in amniotic fluid concentrations of these antimicrobial peptides.

STUDY DESIGN

Amniotic fluid was retrieved by amniocentesis from 333 patients in the following groups: group 1, mid-trimester with a subsequent normal pregnancy outcome (n = 84); group 2, preterm labor and intact membranes without MIAC who delivered at term (n = 36), or prematurely (n = 52) and preterm labor with MIAC (n = 26); group 3, preterm PROM with (n = 26) and without (n = 26) MIAC; and group 4, term with intact membranes in the absence of MIAC, in labor (n = 52) and not in labor (n = 31). The concentrations of HNP 1-3, BPI and calprotectin in amniotic fluid were determined by specific and sensitive immunoassays. Placentae of patients in both preterm labor with intact membranes and preterm PROM groups who delivered within 72 h of amniocentesis were examined. Non-parametric statistics, receiver-operating characteristic (ROC) curves and Cox regression models were used for analysis. A p value of < 0.05 was considered statistically significant.

RESULTS

Intra-amniotic infection was associated with a significant increase in amniotic fluid concentrations of immunoreactive HNP 1-3, BPI and calprotectin in both women with preterm labor and intact membranes, and women with preterm PROM. Preterm PROM was associated with a significant increase in amniotic fluid concentrations of immunoreactive HNP 1-3, BPI and calprotectin. Preterm parturition was associated with a significant increase in amniotic fluid concentrations of immunoreactive HNP 1-3, BPI and calprotectin, while parturition at term was associated with a significant increase in amniotic fluid concentrations of immunoreactive HNP 1-3. Among patients with preterm labor and intact membranes, elevation of amniotic fluid HNP 1-3, BPI and calprotectin concentrations was associated with intra-amniotic inflammation, histological chorioamnionitis and a shorter interval to delivery.

CONCLUSION

MIAC, preterm parturition and preterm PROM are associated with increased amniotic fluid concentrations of immunoreactive HNP 1-3, BPI and calprotectin. Moreover, elevated amniotic fluid concentrations of BPI, immunoreactive HNP 1-3 and calprotectin are associated with intra-amniotic inflammation, histological chorioamnionitis and shorter amniocentesis-to-delivery interval in patients presenting with preterm labor with intact membranes.

Zn metabolism affects apoptosis rate and proliferative responsiveness of PBMC from patients on chronic hemodialysis

Patients with end-stage renal failure suffer from severe plasma trace metal deficiency that is not corrected by dialysis. Trace metals, including Zn(2+), are critical for cell differentiation and replication. Zn(2+)also plays important role in cell apoptosis. Both processes are known to be impaired in uremia. The present study was undertaken to evaluate the effect of Zn(2+) supplementation on apoptosis of cultured peripheral blood mononuclear cells (PBMC) from patients on chronic hemodialysis versus those from healthy control subjects, concomitantly with assessment of mitogen-induced cell proliferation. The results showed that (1) basal total cell-associated Zn(2+) was elevated in uremic PBMC, compared to normal controls (23.9 +/- 5.64 v 10.5 +/- 2.64 micromol/L/mg protein). The gap persisted following incubation in Zn(2+)-enriched medium (63.3 +/- 26.12 v 81.6 +/- 13.4 micromol/L/mg protein, P <.005). (2) Basal proliferative response to phytohemagglutinin (PHA) was significantly decreased in uremic PBMC compared to normal controls (12,000 +/- 1,560 cpm v 16,600 +/- 1,460 cpm, P <.01). Incubation of uremic PBMC in Zn(2+)-enriched medium improved their proliferative response to PHA, yielding counts per minute significantly higher compared to their normal counterparts (37,000 +/- 7,500 cpm v 22,000 +/- 3,000 cpm, P <.001). (3) Basal apoptosis rate in uremic PBMC was significantly elevated compared to normal control cells (7.6% v 2.6%, P <.05). Following incubation in Zn(2+)-enriched medium, apoptosis was increased both in normal and uremic PBMC. Percent apoptosis of uremic PBMC remained significantly elevated compared to control cells (11.7% v 5.7%). We conclude that uremic PBMC are more responsive to exogenous Zn(2+) in culture than their normal counterparts. This, among other abnormalities, might reflect an abnormal regulation of Zn(2+) transport by uremic mononuclear cell membranes. The resultant increase in total cell-associated Zn(2+) content improves poor proliferative responsiveness of uremic PBMC. On the other hand, increased total cell-associated Zn(2+) stimulates enhanced apoptosis in uremic PBMC, which, probably by eliminating defective cells, contributes to the functional capability of the population as a whole. The net effect of the 2 processes is still augmentation of cell proliferation.

Is reimbursement for childhood immunizations adequate? evidence from two rural areas in colorado

OBJECTIVE

To assess adequacy of reimbursement for childhood vaccinations in two rural regions in Colorado, the authors measured medical practice costs of providing childhood vaccinations and compared them with reimbursement.

METHODS

A "time-motion" method was used to measure labor costs of providing vaccinations in 13 private and public practices. Practices reported non-labor costs. The authors determined reimbursement by record review.

RESULTS

The average vaccine delivery cost per dose (excluding vaccine cost) ranged from $4.69 for community health centers to $5.60 for private practices. Average reimbursement exceeded average delivery costs for all vaccines and contributed to overhead in private practices. Average reimbursement was less than total cost (vaccine-delivery costs + overhead) in private practices for most vaccines in one region with significant managed care penetration. Reimbursement to public providers was less than the average vaccine delivery costs.

CONCLUSIONS

Current reimbursement may not be adequate to induce private practices to provide childhood vaccinations, particularly in areas with substantial managed care penetration.

The effect of the 5-HT3 receptor antagonist, alosetron, on brain responses to visceral stimulation in irritable bowel syndrome patients

AIM

To conduct a placebo-controlled functional brain imaging study to assess the effect of the 5-hydroxytryptamine-3 receptor antagonist, alosetron, on irritable bowel syndrome symptoms, regional brain activation by rectosigmoid distension and associated perceptual and emotional responses.

METHODS

Fifty-two non-constipated irritable bowel syndrome patients (28 female) were enrolled in a randomized, placebo-controlled trial with alosetron (1-4 mg b.d.). Thirty-seven patients completed both brain scans following randomization. Rectosigmoid stimulation was performed with a computer-controlled barostat. Changes in regional cerebral blood flow were assessed using H215O positron emission tomography. Stimulus ratings and changes in gastrointestinal symptoms were assessed using verbal descriptor scales.

RESULTS

Alosetron, but not placebo, treatment was associated with a decrease in symptom ratings, and reductions in emotional stimulus ratings. Compared to baseline, alosetron treatment was associated with reduced regional cerebral blood flow in bilateral frontotemporal and various limbic structures, including the amygdala. Compared to placebo, decreases in activity of the amygdala, ventral striatum, hypothalamus and infragenual cingulate gyrus were significantly greater after alosetron.

CONCLUSIONS

In non-constipated irritable bowel syndrome patients, 3 weeks of treatment with a 5-hydroxytryptamine-3 receptor antagonist decreases brain activity in response to unanticipated, anticipated and delivered aversive rectal stimuli in structures of the emotional motor system, and this is associated with a decrease in gastrointestinal symptoms.

Evidence of in vivo generation of thrombin in patients with small-for-gestational-age fetuses and pre-eclampsia

OBJECTIVE

Thrombotic lesions in the maternal or fetal compartments are frequently observed in the placentas of patients with small-for-gestational-age (SGA) fetuses and in pre-eclampsia. The objective of this study was to determine whether there was evidence of in vivo generation of thrombin, the rate-limiting enzyme responsible for the formation of fibrin. The plasma concentrations of thrombin-antithrombin (TAT) complexes were used as an index of thrombin generation.

METHODS

TAT complexes were measured in the plasma from 68 women from the following groups: normal pregnancy (n = 29); pre-eclampsia (n = 26); and SGA (defined as estimated fetal weight below the 10th centile for gestational age, which was confirmed by neonatal birth weight) (n = 13). TAT complex plasma concentrations were determined with a specific and sensitive immunoassay. Statistical analysis was performed with non-parametric statistics.

RESULTS

The median plasma TAT complex concentrations were significantly higher in patients who delivered SGA neonates than in normal pregnant women (SGA, median 24.2 microg/l; range 11.9-788.7 vs. normal pregnancy, median: 14.4 microg/l; range 6.8-26.9; p = 0.001). Patients with pre-eclampsia had a higher median plasma TAT complex concentration than normal pregnant women (pre-eclampsia, median 18.1 microg/l; range 10.0-75.2 vs. normal pregnancy, median 14.4 microg/l; range 6.8-26.9; p = 0.02).

CONCLUSION

In vivo generation of thrombin, determined by the plasma concentrations of TAT complexes, is higher in patients with SGA fetuses and patients with pre-eclampsia than in normal pregnancy.

Maternal intravascular inflammation in preterm premature rupture of membranes

OBJECTIVE

Intrauterine inflammation has been implicated in the mechanisms responsible for preterm premature rupture of membranes (PROM). However, it is unclear whether this inflammatory process remains localized to the uterus, at the site of membrane rupture, or extends to the maternal compartment. Flow cytometric analysis is a sensitive method to assess the presence and magnitude of in vivo inflammation. This study was conducted to determine whether preterm PROM is associated with changes in the phenotypic and metabolic characteristics of maternal granulocytes and monocytes consistent with the presence of maternal intravascular inflammation.

STUDY DESIGN

A prospective cross-sectional study was performed including patients with preterm PROM (n = 43) and normal pregnancy (n = 51). Maternal intravascular inflammation was studied using flow cytometry. Maternal blood was assayed to determine granulocyte and monocyte phenotype using monoclonal antibodies, which included cluster differentiation (CD) markers CD11b, CD14, CD15, CD16, CD18, CD49d, CD62L, CD64, CD66b and human leukocyte antigen (HLA)-DR. The quantities of basal intracellular reactive oxygen species (iROS) and oxidative burst was assessed. Statistical analysis was conducted with the use of non-parametric methods. A p value < 0.01 was considered significant.

RESULTS

Preterm PROM was associated with a significant increase in the median mean channel brightness (MCB) of CD11b, CD14, CD64 and CD66b on granulocytes and median MCB of CD11b on monocytes. The oxidative burst and the stimulation index in both cell types were higher in preterm PROM than in normal pregnancy (p < 0.01).

CONCLUSION

Preterm PROM is associated with phenotypic and metabolic changes in circulating granulocytes and monocytes.

Value of amniotic fluid neutrophil collagenase concentrations in preterm premature rupture of membranes

OBJECTIVE

Neutrophils in amniotic fluid are thought to be of fetal origin, and therefore the detection of these cells and/or their products in amniotic fluid may reflect the fetal inflammatory status. We propose that amniotic fluid neutrophil collagenase (matrix metalloproteinase-8) is a useful parameter to predict adverse neonatal outcome, impending preterm labor/delivery, and intrauterine infection in the setting of preterm premature rupture of the membranes.

STUDY DESIGN

Amniotic fluid was obtained by transabdominal amniocentesis from 101 patients with preterm premature rupture of the membranes (gestational age, 24-36 weeks). Fluid was cultured for aerobic and anaerobic bacteria and Mycoplasmas. Amniotic fluid analysis included Gram stain, white blood cell count, and determination of interleukin-6 and matrix metalloproteinase-8 concentrations (enzyme-linked immunosorbent assay).

RESULTS

Neonates with adverse neonatal outcome were born to mothers with a significantly higher median amniotic fluid matrix metalloproteinase-8 concentration than those without adverse neonatal outcome (median, 54.4 ng/mL; range, 0.82-14,500 ng/mL vs median, 28.9 ng/mL; range, 0.78-2451.8 ng/mL; P <.05, respectively). The higher the amniotic fluid matrix metalloproteinase-8 concentrations, the shorter the interval to delivery (Cox proportional hazards model adjusting for gestational age at delivery; hazard ratio, 1.9; 95% CI, 1.1-3.5; P <.03). Amniotic fluid matrix metalloproteinase-8 concentration was more sensitive than an amniotic fluid white blood cell count and interleukin-6 in the detection of microbiologically proven intra-amniotic infection.

CONCLUSION

Increased concentrations of neutrophil collagenase (matrix metalloproteinase-8) in amniotic fluid are associated with intra-amniotic infection, impending preterm delivery, and adverse neonatal outcome in patients with preterm premature rupture of the membranes. Moreover, matrix metalloproteinase-8 in amniotic fluid is a stronger predictor for the duration of pregnancy and intra-amniotic inflammation than interleukin-6 and an amniotic fluid white blood cell count.

Phenotypic and metabolic characteristics of monocytes and granulocytes in normal pregnancy and maternal infection

OBJECTIVE

Normal pregnancy has been proposed to be a state of physiologic activation of the innate limb of the immune response. Recent studies have concluded that normal pregnancy produces inflammatory changes in peripheral blood leukocytes akin to those of sepsis. This unexpected observation has implications that are critical to understanding the susceptibility of pregnant women to sepsis, the pathophysiology of preeclampsia, and the biology of normal pregnancy. This study was designed to examine the phenotypic and metabolic characteristics of monocytes and granulocytes in normal pregnancy and in pregnant patients with acute infection.

STUDY DESIGN

A cross-sectional study was conducted that included nonpregnant women (n = 20), normal pregnant women (n = 57), and pregnant women with a positive blood culture and/or pyelonephritis (n = 16). Phenotypic and metabolic characteristics of monocytes and granulocytes were studied with the use of flow cytometry and monoclonal antibodies against surface markers (CD11b, CD14, CD15, CD16, CD18, CD49d, CD62L, CD64, CD66b, and HLA-DR). Intracellular reactive oxygen species were measured at basal conditions and after stimulation (oxidative burst). The stimulation index (ratio of intracellular reactive oxygen species after oxidative burst over basal state) was calculated. Nonparametric statistics were used. A probability value of <.01 was considered statistically significant.

RESULTS

Granulocytes from normal pregnant women had a higher median mean channel brightness for CD14 and CD64, but lower median mean channel brightness for CD16 and HLA-DR than granulocytes of nonpregnant women. Granulocytes of patients with acute infection had a higher median mean channel brightness for CD64 and CD66b than granulocytes of normal pregnant women. Monocytes from patients with acute infection had a higher mean channel brightness for CD11b, CD16, CD18, CD49d, CD64, and CD66b than monocytes of normal pregnant women. Baseline intracellular reactive oxygen species, oxidative burst, and stimulation index values were significantly higher in the granulocytes and monocytes of normal pregnant women than in the granulocytes and monocytes of nonpregnant women. Similarly, baseline intracellular reactive oxygen species, oxidative burst, and stimulation index values were higher in women with acute infections than in normal pregnant women.

CONCLUSION

Normal pregnancy was associated with phenotypic and metabolic changes of granulocytes and monocytes; pregnant women with acute infection had more marked phenotypic and metabolic changes of leukocytes than normal pregnant women. These qualitative differences indicate that the innate limb of the immune response is not maximally activated during normal pregnancy.

Immunization recall: effectiveness and barriers to success in an urban teaching clinic

OBJECTIVE

To examine effectiveness of immunization recall in an urban pediatric teaching clinic and to identify barriers to recall effectiveness.

DESIGN

Randomized, controlled trial. Children aged 5 to 17 months who were not up to date (UTD) with recommended immunizations were identified and assigned to intervention (n = 294) or control groups (n = 309). The intervention consisted of a mailed postcard and up to 4 telephone calls. Two months after intervention, UTD status, visit, and probable missed opportunity rates were assessed.

RESULTS

Of the intervention group, 30% could not be reached. In 12-month-old children in the intervention group compared with those in the control group, there was a trend toward higher UTD rates (51% vs 39%, P =.07) and a higher proportion of UTD children receiving immunizations as opposed to getting more complete documentation (25% vs 10%, P =.005). Similar differences between intervention and control children were not seen in the 7-month and 19-month age categories. More children in the intervention group had a health maintenance visit (17% vs 11%, P =.03). Of children in the intervention group who were seen when not UTD, 17 of 24 (71%) of those seen for an illness visit and 5 of 24 (21%) of those seen for health maintenance probably had missed opportunities to be immunized.

CONCLUSIONS

Recall efforts were partially successful but were undermined by inability to reach the clinic population, poor documentation of immunizations, and missed opportunities.

Amniotic fluid matrix metalloproteinase-8 in preterm labor with intact membranes

OBJECTIVE

Intra-amniotic inflammation is a major determinant of maternal and neonatal outcome in patients with preterm labor. Matrix metalloproteinase-8 is a sensitive marker of inflammation in body fluids. This study was conducted to examine the value of amniotic fluid matrix metalloproteinase-8 determinations in patients with preterm labor and intact membranes.

STUDY DESIGN

Amniotic fluid was obtained by transabdominal amniocentesis from 371 patients with preterm labor. Fluid was cultured for aerobic and anaerobic bacteria and Mycoplasmas. Amniotic fluid analysis included Gram stain examination, white blood cell count, and matrix metalloproteinase-8 (enzyme-linked immunosorbent assay) determination. Nonparametric statistics were used for analysis.

RESULTS

The rate of preterm delivery was 54% (200/371) and that of intra-amniotic infection was 9.2% (34/371). The median amniotic fluid matrix metalloproteinase-8 concentration was more than 50-fold higher in patients with intra-amniotic infection than in patients with no intra-amniotic infection (median, 605.6 ng/mL; range, 0.65-15,000 ng/mL vs median, 10.6 ng/mL; range, <0.06-16,600 ng/mL, respectively; P <.0001). The matrix metalloproteinase-8 amniotic fluid concentrations were significantly higher in patients who delivered preterm than in patients who delivered at term (median, 19.5 ng/mL; range, <0.06-16,600 ng/mL vs median, 2.1 ng/mL; range, <0.06-500 ng/mL, respectively; P <.001). After exclusion of patients with intra-amniotic infection, patients who delivered preterm had a significantly higher median amniotic fluid matrix metalloproteinase-8 than patients who delivered at term (P <.05). An amniotic fluid matrix metalloproteinase-8 level of >30 ng/mL was an independent predictor for the occurrence of neonatal morbidity (odds ratio, 3.4; 95% CI, 1.9-5.8; P <.01).

CONCLUSION

Increased amniotic fluid matrix metalloproteinase-8 concentrations identify patients at risk for intra-amniotic infection, impending preterm delivery, and adverse neonatal outcome.

The impact of immunization record aggregation on up-to-date rates--implications for immunization registries in rural areas

Problems with poorly documented immunization records may be especially important in rural areas. To evaluate the potential impact of a regional registry in a rural region, this study quantified the change in documented immunization rates for nine primary care sites in rural Colorado resulting from the addition of public health department immunization clinic records. Manual chart reviews of immunization data were conducted at both private primary care and public health department sites in two geographic areas in rural Colorado. Data from private primary care sites were matched to data from the public health department sites. Immunization up-to-date (UTD) rates at each primary care site were then recalculated for 12- and 24-month-olds after including data from public health department sites. Of 1,533 children, 469 (31 percent) were given immunizations at both a private primary care and a public health department site. The UTD rate (3:2:3:2) of 12-month-olds using only data from primary care sites ranged from 32 to 79 percent. Including the public health department data increased the rates by 0 to 26 percent (mean = 11 percent) for 12-month-old children. The UTD rate of 24-month-olds (4:3:1:3 and any Hib on/after 12 months) ranged from 6 to 54 percent at the primary care sites. These rates increased by 6 to 21 percent (mean = 12 percent) when public health department data were added. This "virtual" registry combining primary care and public health department data increased calculated immunization rates at primary care sites substantially, with a range of 0 to 26 percent.

[Acute coronary syndromes without ST segment elevation. Why should we take an interventionist approach?]

The incidence of unstable angina and non-Q-wave myocardial infarction has increased dramatically. Risk of death and infarction is greatest in the first 6-8 weeks after admission. Risk stratification should be performed in patients with acute coronary syndromes at the earliest opportunity. The VANQWISH trial and TIMI-III B suggested that most patients do not benefit from routine, early invasive management. In the FRISC II trial, the rates of death/myocardial infarction at 6 months were 9.4% in patients treated with an early invasive strategy vs 12.1% with a more conservative approach. The previously reported superiority of the invasive strategy was also confirmed by the TACTICS-TIMI 18. The trial's primary composite end point at 6 months was significantly reduced in the invasive group: 15.9% vs 19.4% of the conservative group. The early invasive strategy was more beneficial the higher the patient's risk. We do not know whether we have reached the limits in terms of improving outcome with available strategies. What we do know is that all patients discharged following an acute coronary syndromes need to be treated aggressively in order to neutralize vulnerable atherosclerotic plaques and to manage cardiovascular risk factors.

How much does a regional immunization registry increase documented immunization rates at primary care sites in rural colorado?

OBJECTIVE

To determine increases in immunization up-to-date (UTD) rates at a rural pediatric practice with the sequential addition of records from other sites in a 2-county region.

DESIGN/METHODS

UTD rates for children aged 3 months to 35 months (n = 876) were determined for the index practice and then recalculated after sequential addition of records from 1) the other private practice in the region, 2) 7 public primary care sites, and 3) 2 public health clinics in the region.

RESULTS

Adding records from all sites increased documented UTD rates in the index practice from 49% to 64% at 3 months (N = 33, P = 0.025), 50% to 68% at 5 months (N = 38, P = 0.008), 28% to 45% at 7 months (N = 113, P <.01), 29% to 54% at 12 months (N = 200, P <.001), 11% to 35% at 19 months (N = 124, P <.001), and 10% to 33% at 24 months (N = 368, P <.001).

CONCLUSIONS

Regional registries will be valuable tools for immunization delivery if there is an ongoing commitment to effective collection of current and historical immunization data.

Red eye syndrome: clinical and experimental experience in a new aspect of diffuse eosinophilic infiltration?

Twenty-two of 24 hemodialysis patients dialyzed simultaneously with a new batch of cellulose acetate dialyzers promptly developed a spectrum of symptoms and physical signs including red eyes, hearing loss, tinnitus, and bone pain, previously described as red eye syndrome. We subsequently injected 4 rabbits with an eluate from a dialyzer of the same or a control batch. Six hours following exposure, the animals developed, in addition to red eyes, diffuse eosinophilic infiltration of various organs as well as myopathic changes and moderate brain edema. On the basis of these data, we suggest that it cannot be concluded whether the underlying pathophysiological mechanisms were toxic, allergic or both and that the occurrence of relevant symptomatology in 2 or more simultaneously dialyzed patients is a strong argument against unnecessary diagnostic or therapeutic procedures. Finally, a second exposure in a given patient should be avoided.