Urinary trypsinogen activation peptide (TAP) predicts severity in patients with acute pancreatitis

CONCLUSIONS

Urinary TAP obtained within the first 48 h of the onset of symptoms can distinguish patients with severe acute pancreatitis.

BACKGROUND

Urinary trypsinogen activation peptide (TAP) has recently been described as an early marker of severity in acute pancreatitis.

METHODS

In a multicenter study, urine samples were collected for TAP concentration at 6-12, 24, and 48 h after admission from 139 patients with acute pancreatitis (99 with mild disease, 40 with severe disease) and from 50 control patients. Severity of acute pancreatitis was defined by the presence of organ failure and/ or pancreatic necrosis on dynamic contrast-enhanced computed tomography.

RESULTS

Median urinary TAP in the 139 patients with acute pancreatitis compared to the 50 control patients was significantly higher at admission, 4.6 vs 0.8 ng/mL (p < 0.001), and 6-12 h, 1.9 vs 0.55 ng/mL (p = 0.04). Among patients who presented within 48 h of the onset of symptoms, the median urinary TAP for severe pancreatitis (9 patients) compared to mild pancreatitis (40 patients) was significantly higher at admission, 29.6 vs. 3.6 ng/mL (p = 0.001). Also, when obtained within 48 h of the onset of symptoms, all patients with severe pancreatitis had an admission urinary TAP level > 10 ng/mL. The sensitivity and specificity of an admission urinary TAP > or = 10 for severe pancreatitis was 100 and 85%, respectively. Given a cutoff of 10 ng/mL for an admission urinary TAP obtained within 48 h of the onset of symptoms, the negative predictive value was 100% for mild pancreatitis.

Microbial colonization of closed-system suction catheters used in liver transplant patients

The microbial colonization and the associated risk of respiratory infection during the application of a multiple-use closed-system suction catheter (CSSC) and a single-use open-system suction catheter (OSSC) on liver transplant patients was evaluated in this preliminary study. The cost differential for the two systems was also compared. Twenty post-orthotopic liver transplant (OLTx) patients who were mechanically ventilated via an endotracheal (ET) tube were studied. Ten subjects were randomly allocated ET suction by the CSSC and 10 with OSSC. Both groups were similar according to age, sex, clinical severity, presence of a naso-gastric tube, use of H2 antagonists and antibiotics used. Standard protocols were followed to intubate and suction the patients and to change ventilatory equipment. Suctioning performed with the CSSC did not significantly increase the risk of microbial colonization of the respiratory tract. Similarly there was no apparent difference in the incidence of nosocomial pneumonia between the two suction systems, based on the microbiological and clinical data. The mean daily cost of using the CSSC compared to the OSSC was 11.6 times higher. This may be balanced by a reduction in nursing time and reduced risk of spread of infection associated with the CSSC.

Mediators on human airway smooth muscle

1. Bronchial hyperresponsiveness in asthma may be due to several abnormalities, but must include alterations in the airway smooth muscle responsiveness and/or volume. 2. Increased responsiveness of airway smooth muscle in vitro can be induced by certain inflammatory cell products and by induction of sensitization (atopy). 3. Increased airway smooth muscle growth can also be induced by inflammatory cell products and atopic serum. 4. Mast cell numbers are increased in the airways of asthmatics and, in our studies, in airway smooth muscle that is sensitized and hyperresponsive. 5. We propose that there is a relationship between mast cells and airway smooth muscle cells which, once an allergic process has been initiated, results in the development of critical features in the lungs in asthma.

SHIP, a new player in cytokine-induced signalling

We recently purified and cloned the cDNAs for the murine and human forms of a novel 145 kDa inositol polyphosphate 5-phosphatase (5-ptase) that becomes tyrosine phosphorylated and associated with Shc following stimulation of hemopoietic cells with multiple cytokines. Unlike most 5-ptases which hydrolyze phosphatidylinositol-4,5-P2-bisphosphate (PI-4,5-P2) and/or inositol-1,4,5-trisphosphate (I-1,4,5-P3), this enzyme selectively hydrolyzes the 5'-phosphate from inositol-1,3,4,5-tetraphosphate (I-1,3,4,5-P4) and phosphatidylinositol-3,4,5-trisphosphate (PI-3,4,5-P3), two inositol polyphosphates recently implicated in growth factor-mediated signalling. This 5-ptase is also unique among 5-ptases in that it is the only one to date to possess an SH2 domain. In this review we discuss the cloning, the Shc binding and the potential role of this protein, which we call SHIP, for SH2-containing inositol 5-phosphatase, in cell proliferation, differentiation and apoptosis.

Randomized trial comparing epirubicin, cisplatin, and fluorouracil versus fluorouracil, doxorubicin, and methotrexate in advanced esophagogastric cancer

PURPOSE

We report the results of a prospectively randomized study that compared the combination of epirubicin, cisplatin, and protracted venous infusion fluorouracil (5-FU) (ECF regimen) with the standard combination of 5-FU, doxorubicin, and methotrexate (FAMTX) in previously untreated patients with advanced esophagogastric cancer.

PATIENTS AND METHODS

Two hundred seventy-four patients with adenocarcinoma or undifferentiated carcinoma were randomized and analyzed for survival, tumor response, toxicity, and quality of life (QL).

RESULTS

The overall response rate was 45% (95% confidence interval [CI], 36% to 54%) with ECF and 21% (95% CI, 13% to 29%) with FAMTX (P = .0002). Toxicity was tolerable and there were only three toxic deaths. The FAMTX regimen caused more hematologic toxicity and serious infections, but ECF caused more emesis and alopecia. The median survival duration was 8.9 months with ECF and 5.7 months with FAMTX (P = .0009); at 1 year, 36% (95% CI, 27% to 45%) of ECF and 21% (95% CI, 14% to 29%) of FAMTX patients were alive. The median failure-free survival duration was 7.4 months with ECF and 3.4 months with FAMTX (P = .00006). The global QL scores were better for ECF at 24 weeks, but the remaining QL data showed no differences between either arm of the study. Hospital-based cost analysis on a subset of patients was similar for each arm and translated into an increment cost of $975 per life-year gained.

CONCLUSION

The ECF regimen results in a survival and response advantage, tolerable toxicity, better QL and cost-effectiveness compared with FAMTX chemotherapy. This regimen should now be considered the standard treatment for advanced esophagogastric cancer.

Randomized trial comparing epirubicin, cisplatin, and fluorouracil versus fluorouracil, doxorubicin, and methotrexate in advanced esophagogastric cancer

PURPOSE

We report the results of a prospectively randomized study that compared the combination of epirubicin, cisplatin, and protracted venous infusion fluorouracil (5-FU) (ECF regimen) with the standard combination of 5-FU, doxorubicin, and methotrexate (FAMTX) in previously untreated patients with advanced esophagogastric cancer.

PATIENTS AND METHODS

Two hundred seventy-four patients with adenocarcinoma or undifferentiated carcinoma were randomized and analyzed for survival, tumor response, toxicity, and quality of life (QL).

RESULTS

The overall response rate was 45% (95% confidence interval [CI], 36% to 54%) with ECF and 21% (95% CI, 13% to 29%) with FAMTX (P = .0002). Toxicity was tolerable and there were only three toxic deaths. The FAMTX regimen caused more hematologic toxicity and serious infections, but ECF caused more emesis and alopecia. The median survival duration was 8.9 months with ECF and 5.7 months with FAMTX (P = .0009); at 1 year, 36% (95% CI, 27% to 45%) of ECF and 21% (95% CI, 14% to 29%) of FAMTX patients were alive. The median failure-free survival duration was 7.4 months with ECF and 3.4 months with FAMTX (P = .00006). The global QL scores were better for ECF at 24 weeks, but the remaining QL data showed no differences between either arm of the study. Hospital-based cost analysis on a subset of patients was similar for each arm and translated into an increment cost of $975 per life-year gained.

CONCLUSION

The ECF regimen results in a survival and response advantage, tolerable toxicity, better QL and cost-effectiveness compared with FAMTX chemotherapy. This regimen should now be considered the standard treatment for advanced esophagogastric cancer.

A comparison of maximal bioenergetic enzyme activities obtained with commonly used homogenization techniques

Homogenization of tissue for analysis of bioenergetic enzyme activities is a common practice in studies examining metabolic properties of skeletal muscle adaptation to disease, aging, inactivity or exercise. While numerous homogenization techniques are in use today, limited information exists concerning the efficacy of specific homogenization protocols. Therefore, the purpose of this study was to compare the efficacy of four commonly used approaches to homogenizing skeletal muscle for analysis of bioenergetic enzyme activity. The maximal enzyme activity (Vmax) of citrate synthase (CS) and lactate dehydrogenase (LDH) were measured from homogenous muscle samples (N = 48 per homogenization technique) and used as indicators to determine which protocol had the highest efficacy. The homogenization techniques were: (1) glass-on-glass pestle; (2) a combination of a mechanical blender and a teflon pestle (Potter-Elvehjem); (3) a combination of the mechanical blender and a biological detergent; and (4) the combined use of a mechanical blender and a sonicator. The glass-on-glass pestle homogenization protocol produced significantly higher (P < 0.05) enzyme activities compared to all other protocols for both enzymes. Of the four protocols examined, the data demonstrate that the glass-on-glass pestle homogenization protocol is the technique of choice for studying bioenergetic enzyme activity in skeletal muscle.

Immunogenicity and efficacy against lethal aerosol staphylococcal enterotoxin B challenge in monkeys by intramuscular and respiratory delivery of proteosome-toxoid vaccines

Staphylococcal enterotoxin B (SEB), a primary cause of food poisoning, is also a superantigen that can cause toxic shock after traumatic or surgical staphylococcal wound [correction of would] infections or viral influenza-associated staphylococcal superinfections or when aerosolized for use as a potential biologic warfare threat agent. Intranasal or intramuscular (i.m.) immunization with formalinized SEB toxoid formulated with meningococcal outer membrane protein proteosomes has previously been shown to be immunogenic and protective against lethal respiratory or parenteral SEB challenge in murine models of SEB intoxication. Here, it is demonstrated that immunization of nonhuman primates with the proteosome-SEB toxoid vaccine is safe, immunogenic, and protective against lethal aerosol challenge with 15 50% lethal doses of SEB. Monkeys (10 per group) were primed i.m. and given booster injections by either the i.m. or intratracheal route without adverse side effects. Anamnestic anti-SEB serum immunoglobulin G (IgG) responses were elicited in all monkeys, but strong IgA responses in sera and bronchial secretions were elicited both pre- and post-SEB challenge only in monkeys given booster injections intratracheally. The proteosome-SEB toxoid vaccine was efficacious by both routes in protecting 100% of monkeys against severe symptomatology and death from aerosolized-SEB intoxication. These data confirm the safety, immunogenicity, and efficacy in monkeys of parenteral and respiratory vaccination with the proteosome-SEB toxoid, thereby supporting clinical trials of this vaccine in humans. The safety and enhancement of both bronchial and systemic IgA and IgG responses by the proteosome vaccine delivered by a respiratory route are also encouraging for the development of mucosally delivered proteosome vaccines to protect against SEB and other toxic or infectious respiratory pathogens.

A temperature-sensitive splicing mutation in the bimG gene of Aspergillus produces an N-terminal fragment which interferes with type 1 protein phosphatase function

Progression through anaphase requires high levels of type 1 protein phosphatase (PP1) activity in a variety of eukaryotes, including Aspergillus nidulans. A conditional lethal, temperature-sensitive mutant in one of the Aspergillus PP1 genes, bimG, prevents the normal completion of anaphase when cells are grown at restrictive temperature and this has been shown to be due to a reduction in type 1 phosphatase activity. We show that the bimG11 allele is recessive to the wild-type allele in heterozygous diploids, implying that the mutation is due to loss of function at restrictive temperature, but molecular disruption of the wild-type bimG gene shows that the gene is not essential and has no discernable phenotype under laboratory conditions. Sequence comparison of wild-type and mutant alleles reveals a single base pair difference between the two genes, within the 5' splicing site of the second intron. We demonstrate that the conditional lethal phenotype of bimG11 strains is due to impaired splicing of the mutant mRNA and that this leads to the production of a truncated protein comprising an intact N-subdomain and a modified C-terminus. Over-expression of this truncated form of PP1 in a wild-type haploid produces a lethal phenotype and reduced PP1 activity, supporting the idea that a toxic interfering protein is produced. PP1, therefore, may have at least two spatially separated sites, both of which are required for function. Temperature-sensitive splicing mutations may provide a novel means of engineering conditional versions of other proteins, particularly other phosphatases.

New pharmacologic strategies for acute neuronal injury

The number of new drugs for treating neurotrauma is rapidly expanding. Emerging theories regarding the mechanisms of secondary neuronal injury provide the scientific basis for evaluating these new agents. Some of the most promising mechanisms for intervention are ionotropic channel antagonism, inhibition of lipid peroxidation, and neurotrophic factor augmentation. Many of these new agents are undergoing clinical trials to establish their roles in therapy.

Cutaneous lesions in a case of acute megakaryoblastic leukaemia

We describe the case of a 68-year-old woman who presented with asymptomatic skin nodules and symptoms of anaemia, and was found to have acute megakaryoblastic leukaemia with fibrosis, a condition now believed to correspond to the former diagnosis of acute myelofibrosis. There is only one previous report of skin lesions developing in this condition.

New pharmacologic approaches to acute spinal cord injury

The incidence of spinal cord injury (SCI) in the United States is approximately 10,000 new cases per year. Strategies to prevent injury or salvage a few dermatomal levels may have significant effects on outcome. Several pharmacologic agents have been evaluated for their efficacy in patients with acute SCI. Methylprednisolone, when administered early, was the first drug to show significant improvement in outcome and is a standard of comparison for future agents. Several new drugs show promising results in animal models of SCI, with more extensive human trials currently under way. Results of more well-controlled clinical trials are necessary to determine which agents have significant neurologic benefits.

Urinary trypsinogen activation peptides (TAP) are not increased in mild ERCP-induced pancreatitis

Acute pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) occurs in 3-18% of patients undergoing either diagnostic or therapeutic ERCP. We prospectively measured urinary trypsinogen activation peptides (TAP) by an automated anti-TAP enzyme-linked immunoassay among 107 patients 4 h after ERCP to determine whether this measurement helps in the early diagnosis of ERCP-induced pancreatitis. Pancreatitis was documented in 10 of 107 patients (9.3%). All episodes were graded as mild. Urinary TAP was not significantly increased. We conclude that measurement of urinary TAP 4 h after ERCP is not helpful in documenting mild ERCP-induced acute pancreatitis.

Mammographically negative breast cancer at the Strathfield Breast Centre

BACKGROUND

The current diagnostic modalities used to detect breast cancer are mammography, together with clinical examination, ultrasound and fine needle aspiration biopsy (FNAB). The accuracy rates for each modality varies and a combination of the modalities is recommended to detect cancer early. Some authors have suggested that mammography should be used primarily as a screening tool because of the false negative mammography results that have been reported in the past 10 years. The records of patients at the Strathfield Breast Centre were reviewed to determine the accuracy of other modalities.

METHODS

The records of 371 breast cancer patients treated at the Strathfield Breast Centre in the 6 years form 1989 to 1994 were reviewed to determine the accuracy of mammography, ultrasound, clinical examination and fine needle aspiration biopsy. Of the 371 women with histopathologically diagnosed breast cancer, 349 had mammography.

RESULTS

The accuracy rate of mammography in the present study was 91% with a false negative rate of 9%. It was found that there was no significant delay in treatment of breast cancer in mammogram-negative patients.

CONCLUSIONS

Mammographically negative breast cancer was found to be more common in younger women, to be similar in size to mammogram-positive cancer, to occur in all histological types and grades and was usually invasive rather than noninvasive. The rate of lymph node involvement was similar to the mammogram-positive group.

Key issues in the introduction of nurse endoscopy

The inspection technique of gastrointestinal endoscopy is becoming increasingly popular and services in this area are expanding. Conditions which could only be treated by surgery can now be done endoscopically and this requires suitably trained medical staff. Consequently, there are demands from the medical and nursing professions to develop the role of the nurse endoscopist. This paper raises issues of concern to nurses who wish to undertake diagnostic endoscopy and suggests how the necessary skills and knowledge to gain competence can be obtained.

Clinical experience with preimplantation genetic diagnosis of cystic fibrosis (delta F508)

Preimplantation genetic diagnosis (PGD) was attempted in 12 couples in whom both parents carry the common delta F508 deletion causing cystic fibrosis (CF). In vitro fertilization (IVF) was followed by cleavage stage biopsy on days 2 and 3 and removal of one or two cells for genetic analysis by nested polymerase chain reaction (PCR) and heteroduplex formation. A total of 18 cycles resulted in 137 normally fertilized embryos, of which 115 developed to cleavage stages and 114 were successfully biopsied. Genetic analysis was successful in 83 embryos (73 per cent). With the remaining embryos, either results from two or more cells were discordant or amplification failed. In 15 cycles, one or two either normal or carrier embryos were transferred and five (33 per cent) clinical pregnancies were established. Five singletons have been born and at birth all five babies have been confirmed as homozygous for the normal allele. Our experience demonstrates that IVF and cleavage stage biopsy consistently provides sufficient embryos, diagnosed as unaffected, for transfer in this autosomal recessive disease and that pregnancy rates are comparable to those following IVF.

Zidovudine side effects as reported by black, Hispanic, and white/non-Hispanic patients with early HIV disease: combined analysis of two multicenter placebo-controlled trials

The objective of this study was to determine whether HIV patients' subjective tolerance of zidovudine differs by racial or ethnic grouping by conducting a post hoc analysis of reported symptoms in two multicenter, placebo-controlled trials of zidovudine monotherapy for early HIV disease. Ratios of rates of developing new or worsening symptoms as reported by patients assigned to active drug or placebo were compared in groups of white/non-Hispanic, black, or Hispanic origin. Patients were included in the study if they had asymptomatic HIV disease and entry absolute CD4 lymphocyte counts below 500 cells/microL and were enrolled in National Institute of Allergy and Infectious Diseases AIDS Clinical Trials Group (ACTG) protocol 019 or had mild symptoms of HIV disease, were enrolled in ACTG protocol 016, met protocol eligibility criteria for the respective trial, and were categorized at entry as white/non-Hispanic (N = 1801), black (N = 195), or Hispanic (n = 214). The primary outcome measure was development of a new or worsening symptom of any severity. Among patients treated with zidovudine compared with placebo, the estimated risk for developing a new or worsening symptom was not significantly greater for blacks or Hispanics than for white/non-Hispanics for any of the most frequently reported symptoms (p > 0.05 after adjustment for the multiple comparisons performed). Our analysis of 195 black and 214 Hispanic patients did not reveal a significantly increased risk of subjective zidovudine intolerance compared with white/non-Hispanic subjects. If there is an increased risk of such intolerance in minority groups compared with white/non-Hispanics, it is not likely to be clinically important.