Transplantation rate of the blood group B waiting list is increased by using A2 and A2B kidneys

BACKGROUND

We have increased the transplantation rate for blood group B cadaveric waiting list candidates by transplanting them with A2 and A2B kidneys.

METHODS

Since 1991, five of the seven renal transplant programs in our organ procurement organization service area have preferentially transplanted blood group A2 and A2B cadaveric kidneys to B blood group waiting list candidates with histories of low anti-A isoagglutinin titers.

RESULTS

Between 1991 and 1997, these five centers performed transplantations on 71 patients from the B cadaveric waiting list. Of those 71 patients, 29% (21 of 71) underwent transplantation with either A2 (n=18) or A2B (n=3) cadaveric kidneys. In 1997 alone, 48% (11 of 23) of the B patient transplant recipients received A2 or A2B kidneys.

CONCLUSIONS

Transplantation of A2 and A2B kidneys into B waiting list patients has successfully increased access of B patients to kidneys. Such an allocation algorithm implemented nationally may similarly increase the transplantation rate of B waiting list candidates.

Symptomatic venous hypertension because of occult iliofemoral deep vein thrombosis: a report of two cases

Two 25-year-old males with symptomatic venous hypertension (venous claudication, n = 1; swollen leg, n = 1) were evaluated for iliofemoral venous occlusive disease. One patient had a common femoral vein/external iliac vein occlusion with no history of deep vein thrombosis or trauma. The second patient had an acute deep vein thrombosis superimposed on a chronic external iliac vein stenosis. No source of extrinsic venous compression was identified in either patient. Venous reconstruction with vein bypass (patient no. 1) and vein patch angioplasty (patient no. 2) led to resolution of their hypertensive symptoms. Intraoperative examination of the involved vein segments revealed chronic changes consistent with a prior occult deep vein thrombosis in both patients. Occult iliofemoral deep vein thrombosis in young healthy males is rarely seen. The acute deep vein thrombosis may manifest minimal or no symptoms but it can lead to chronic venous occlusive disease and serious post-phlebitic morbidity. In this context, these two cases are discussed with a review of the pertinent literature.

Proteolysis of cell adhesion molecules by serine proteases: a role in long term potentiation?

Tissue plasminogen activator (tPA), a serine protease endogenous to hippocampal neurons, is shown to recognize a highly conserved sequence in the extracellular domain of cell adhesion molecules (CAMs). When added to brain homogenates, tPA generated a CAM fragment similar in size to that produced in hippocampal slices by brief periods of NMDA receptor stimulation. The serine protease inhibitor 4-(2-Aminoethyl)-benzenesulfonyl fluoride blocked the effects of tPA with an approximately 50% suppression at 250 microM. The inhibitor at this concentration had no evident effect on synaptic responses but caused long term potentiation to decay back to baseline over a 1 h period. These results suggest that extracellular breakdown of cell adhesion molecules initiated by NMDA receptors and mediated by serine proteases contributes to the formation of stable potentiation.

Endothelial cell VE-cadherin functions as a receptor for the beta15-42 sequence of fibrin

The contact of fibrin with the apical surface of human umbilical vein endothelial cells (HUVEC) can induce capillary tube formation via the interaction of fibrin beta15-42 with a putative cell receptor (Chalupowicz, D. G., Chowdhury, Z. A., Bach, T. L., Barsigian, C., and Martinez, J. (1995) J. Cell Biol. 130, 207-215). To characterize this interaction, we studied the binding of the thrombin-cleaved N-terminal disulfide knot of fibrin (NDSK II), a dimeric fragment with exposed beta15-42, to HUVEC in three separate assay systems. Time-course binding of 125I-NDSK II to HUVEC monolayers or suspensions revealed that binding was specific at 50-60%, as determined by the addition of unlabeled NDSK II. Specific binding of 125I-NDSK II to HUVEC was 70% reversible by dilution or by competition, and was found to be divalent cation-independent. Binding plateaued after 10 min at a saturation of 15-20 nM. Scatchard analysis using the LIGAND computer program defined a single population of receptors with a KD of 7.7 +/- 1.6 nM and approximately 21,000 +/- 7000 binding sites/cell. N-terminal disulfide knot derivatives in which beta15-42 was absent (NDSK 325) or unexposed (NDSK, NDSK I) did not show specific binding. Specific binding of 125I-NDSK II could not be inhibited by RGDS or by antibodies to the alphavbeta3 or beta1 integrins, PECAM-1, ICAM-1, or N-cadherin. In contrast, a synthetic beta15-42/ovalbumin conjugate inhibited total 125I-NDSK II binding by 47 +/- 19% (corresponding to 95% of specific 125I-NDSK II bound) and a monoclonal antibody to vascular endothelial cadherin (VE-cadherin) inhibited binding by 35 +/- 8% (corresponding to 70% of specific 125I-NDSK II bound). Another assay was based on the capture of cadherins from HUVEC lysates by a polyclonal pan-cadherin antibody immobilized on plastic dishes. Binding of NDSK II to the captured cadherins was 89 +/- 5% specific, while specific binding of NDSK 325 and NDSK was negligible. An immortalized line of human adipose-derived microvascular endothelial cells, which express N-cadherin but not VE-cadherin, demonstrated no specific binding of NDSK II by the capture assay. These data define a novel interaction of fibrin with VE-cadherin, which is mediated by the fibrin N-terminal beta15-42 sequence, and may contribute to the mechanism through which fibrin induces angiogenesis.

Immunohistochemical demonstration of tissue transglutaminase in amyloid plaques

The brain of Alzheimer's disease patients contains deposits of the 39-42-amino acid (approximately 4 kDa) amyloid beta-peptide, which is derived from the beta-amyloid precursor protein. These pathological deposits have been shown to consist in part of insoluble 8- and 16-kDa aggregates of the amyloid beta-peptide. This report confirms that the amyloid beta-peptide is a substrate for tissue transglutaminase (TGase) and demonstrates that human brain preparations from Alzheimer's disease patients and control patients form cross-linked dimers from added iodinated amyloid beta-peptide. Immunohistochemical staining for TGase revealed its presence in tissue sections and isolated amyloid plaque cores obtained from brains of patients diagnosed as having Alzheimer's disease. These results provide evidence that the previously described insoluble amyloid deposits in Alzheimer's disease may involve TGase-mediated cross-linked amyloid beta-peptide polymers, and suggest a potential role for TGase in the pathogenesis of this disease.

A man with vague rheumatic complaints

A 52-year-old man presented with a four-month history of malaise, low-grade fever, decreased appetite, and a 20-pound weight loss. He complained of joint pain and swelling, proximal muscle weakness, exertional dyspnea, and a dry cough. He also noted that his fingers had turned white and then blue when chilled and red when rewarmed. He had not had pleuritic chest pain, dysphagia, dry eyes or mouth, rash, or skin photosensitivity.

Prevalence of micro- and macroalbuminuria in a Canarian population of type 2 diabetic patients. Relationship with blood pressure, lipid profile, obesity and metabolic control

We performed a cross-sectional study on the prevalence of micro- and macroalbuminuria in a population of 288 Type 2 diabetic patients from Northern Gran Canaria Island (age 59 +/- 9.5, years; 48% male): 179 unselected patients referred by their family physicians, and 109 from our diabetes clinic. Sex, age, duration of diabetes and hypertension, blood pressure, body mass index, waist-hip ratio, HbA1c, creatinine, cholesterol (total and HDL), triglycerides, lipoprotein (a), and the presence of retinopathy, polyneuropathy, and coronary and cerebrovascular disease were assessed. The prevalences of micro- and macroalbuminuria were 28.5% and 11.8%. Among the patients referred by their family physicians, 32.4% were micro- and 6.1% macroalbuminuric. In our diabetes clinic, there were respectively 22% and 21% (with a higher prevalence of macroalbuminuria than in primary care, p < 0.05). Seventy-three percent were hypertensive in both settings. Prevalence was 31.5% for diabetic retinopathy, 21.0% for diabetic polyneuropathy, 8.1% for cerebrovascular disease, and 20.2% for coronary heart disease. The albumin excretion rate was significantly correlated with plasma creatinine levels, diastolic blood pressure, total cholesterol and the presence of coronary heart disease and diabetic retinopathy, but not with age, duration of diabetes or hypertension, body mass index, waist/hip ratio, glycated haemoglobin or triglycerides.

Clinical Experience in Hospice and Palliative Medicine for Clinicians in Practice

Many healthcare professionals already in practice have identified their need to pursue further practical training in the provision of hospice and palliative care. We began offering a 1-week clinical experience to physicians, nurses, pharmacists, social workers, and chaplains in the summer of 1995. As of October 1,1997, there have been 190 requests for application materials from individuals in more than 22 states, as well as from Singapore and Uganda. Thirty-five individuals completed visits by October 31,1997; 17 nurses, 16 physicians, 1 psychologist, and 1 chaplain. Although all are working in areas related to palliative care, 57% (20 of 35) were not currently working for a hospice program. A 25-question examination was administered as a needs-assessment test. Overall they scored 75% correct. They did especially poorly on questions related to dosing of opioids, assessment of pain, and prognosis in AIDS. They completed a videotaped interview with a standardized patient focusing on skills in discussing a terminal prognosis, "do not resuscitate" (DNR) status, and hospice referral. They evaluated the entire educational experience with a self-report at the end of their visit using a Likert Scale with values of 1 to 5. To the statement "I achieved the specific goals which I set for myself," the average score was 4.6 (range 1-5). To the statement "The experience was worth the time and effort," the average score was 4.9. To the statement "I would recommend this experience to others," the average score was 4.9. The evaluation was repeated 6 months after the visit with similar scores. In addition, to the statement "My current efforts are helping to change the way dying patients and their families are cared for in the broader environment in which I work," the average score was 4.9 (range 4-5). We conclude that this is a successful program of clinical exposure to hospice and palliative medicine for clinicians in practice.

A Program of Hospice and Palliative Care in a Private, Nonprofit U.S. Teaching Hospital

A hospice and palliative care program was established at Northwestern Memorial Hospital, a 773-bed private nonprofit hospital located in the urban center of Chicago. The program consists of three components: consultation service, acute inpatient unit, and home-hospice program. The consultation service saw an average of 57 new patients per month (range 45-80) in fiscal year 1997. The 12-bed acute care inpatient unit had an average midnight census of 9.8 in fiscal 1996. This decreased to 6.9 in fiscal 1997 due to new treatment approaches for AIDS and has rebounded to nine in the third quarter of fiscal 1998. The unit cares for more than one third of dying patients in the hospital. Patients do not have to access hospice insurance benefits to be admitted to the unit. The home-hospice program has a median length of stay of 31 days and serves patients living within the city limits of Chicago. A total of 800 patients were referred to the program, and 370 patients died in the program in fiscal 1997. A total of 219 different physicians were attending physicians for patients in the program during a 3- year period. Revenue exceeded direct expenses by $1.48 million. Fee-for-service billing for physician services outside of those provided or billed under the Medicare Hospice Benefit are not included in these figures. The group practice that bills for the physicians collected an average of 50.5% of billed charges over 4 years. We conclude that a program of hospice and palliative care can be successful in a private teaching hospital in the United States.

Neurocircuitry of conditioned inhibition of analgesia: effects of amygdala, dorsal raphe, ventral medullary, and spinal cord lesions on antianalgesia in the rat

Pain inhibition (analgesia) is produced by learned danger signals and inhibited by learned safety signals (antianalgesia). Conditioned analgesia is mediated by brain-to-spinal pathways releasing spinal endogenous opiates. Spinal morphine mimics learned danger signals in producing analgesia, which is inhibited by antianalgesia. The circuitry mediating antianalgesia is unknown. These experiments demonstrate that raphe dorsalis, raphe magnus, and spinal dorsolateral funiculus lesions abolish antianalgesia. Other lesions had no effect on antianalgesia. More important, lesions that blocked development of conditioned analgesia did not block development of antianalgesia. Thus, neural circuitries mediating analgesia and antianalgesia were found to be distinct, and conditioned inhibition of analgesia was found to act by inhibiting the most distal part of the conditioned analgesia circuit, namely, the spinal cord.

Oxyntomodulin reduces hydromineral transport through rat small intestine

Glicentin (GLIC) and oxyntomodulin (OXM) are released from the ileum and colon during digestion. Both hormones reduce fluid and proton secretion in the stomach. The luminal concentration of sodium and chloride underlying the nutrient absorption, the effect of OXM on electrolyte transport through the small intestine, was assessed in vivo using ligated loops and in vitro using Ussing chambers. In vivo, a zero transport state, estimated by the net water, chloride, and sodium fluxes, was observed when an 80 mM NaCl normoosmolar solution (274 mosm) was administered intraluminally. Active secretion was observed with hyperosmotic challenge (474 mosm). The amplitude of this active secretion increased 2.5- to 3-fold when an electrogenic challenge (NaCl 40 mM) was substituted to the hyperosmotic one. OXM (800 fmol/ml plasma) did not modify the basal transport in the duodenum or in the jejunum (t = 45 min). When active secretion was induced by the hyperosmotic challenge, OXM (200 fmol/ml plasma) had no effect on duodenal or jejunal transport (t = 50 min). When active secretion was induced by an electrogenic challenge, OXM (300 fmol/ml plasma) preferentially reduced the hydromineral transport in jejunum. In vitro, OXM also induced a reduction in the ion transport towards the jejunal lumen (EC50 = 20 pM), the amplitude of which depended upon the integrity of the tetrodotoxin-sensitive neurons. In conclusion, OXM was able to reduce the large secretion induced in rat jejunum in vivo by an electrogenic gradient. In vitro, the antisecretory effect of OXM was partly mediated by the neurons present in the intrajejunal wall.

Synthesis and pharmacological evaluation of dimer derivatives of the bradykinin receptor antagonist HOE-140

The synthesis and pharmacological evaluation of dimer derivatives of the C-terminal fragments of the potent bradykinin antagonist HOE-140, linked through their N-termini, were performed. The influence of peptide moiety length was studied using the succinyl moiety as a linker. Our attention focused on the dimer of the C-terminal tetrapeptide of HOE-140 (compound JMV 980), which displayed some inhibiting activity (IC50 = 247 nM) for bradykinin B2 receptors. Unexpectedly, it was orally active in inhibiting bradykinin-induced hypotension in the rat. Based on this tetrapeptide dimer model, we synthesized pseudotetrapeptide dimer bradykinin antagonists 29 and 33, which exhibited high affinity (Ki = 76 and 61 nM, respectively) for the human cloned B2 receptor. In addition, compound 29 inhibited bradykinin-induced contraction of the human umbilical vein giving a pKB value of 6.45. Compounds 29 and 33 were selective toward B2 receptors because they did not bind to the cloned human B1 receptor up to 10 microM.

Maturational changes in the thermal nociceptive responses of developing rats

Some find developmental differences in rodent thermal nociceptive responses and others do not. To address these inconsistencies, the escape latencies of immature (5-to 25-day-old) and adult (3-to 4-month-old) albino rats were recorded following tail exposure to different intensities of radiant heat (650-W halogen lamp placed 10-30 mm from the tail) or conductive heat 35-50 degrees C water). Developmental differences in tail flick latencies were not observed in immature rats when the lamp was closest to the tail (although adult latencies were longer than 5-and 15-day-old responses) When radiant heat intensity was reduced, 5-day-old rats had shorter escape latencies than 15-, 25-, and 90-day-old animals. Age differences persisted in the latencies of immature animals even when the test aperture was varied to compensate for maturational changes in tail width (whereas adult responses no longer differed from those of 5-and 15-day-old rats). Developmental differences were eliminated when the tail skin was blackened so as to normalize the absorption of radiant heat across age. Similar age-and intensity-dependent differences were observed in rats exposed to conductive heat: Five-and 10-day-old pups had shorter escape responses than older rats when tails were immersed in intermediate (40 or 45 degrees C) but not lower (35 degree C) or higher (50 degrees C) temperature water. Blackening the tails did not change conductive heat escape latencies. No sex differences were found at any age or stimulus intensity with either type of heat. Higher intensities of thermal stimuli applied to the tail are required to elicit escape responses in older rats compared to younger ones, but the use of relatively intense thermal test stimuli can mask age-dependent differences in nociception. Some of the inconsistent results reported previously about maturational changes in thermal nociception may be due to intensity differences in the noxious test stimuli used. Maturational differences in the radiant absorption properties of the tail seem to account for most of the age-related changes in rodent responses to radiant heat, but the mechanism(s) which subserve developmental differences in conductive heat nociception need to be elucidated.

An inflamed elbow after an insect sting

A 63-year-old man presented with fever and a painfully swollen right elbow and forearm. He had been stung by a yellow jacket two weeks earlier and had since found it increasingly difficult to bend his arm.

Platelet kinetics in autosomal dominant macrothrombocytopenia

A family with autosomal dominant macrothrombocytopenia is described. Despite severe thrombocytopenia, only a moderate hemorrhagic tendency was observed. Kinetic studies revealed a normal platelet survival, normal megakaryocytic numbers, and normal bone marrow responsiveness. The rate of platelet production was set low, despite moderately impaired hemostasis and thrombocytopenia; it apparently was set to maintain another platelet parameter at an optimal level. Measurements of total circulating platelet mass and platelet surface suggested that the platelet production was set to maintain the platelet surface rather than the platelet mass at a normal value.

Youth counseled for HIV testing at school- and hospital-based clinics

The prevalence of human immunodeficiency virus (HIV) in adolescents is difficult to assess as few adolescents consent to testing. This prospective study characterized urban youth requesting HIV testing at two types of health settings, inner-city school-based and hospital-based clinics. Data were obtained on 1652 inner-city youths aged 13 to 19 years who consented to individualized HIV counseling and testing from January 1993 to January 1994. Identified risks for HIV included sexual activity, sexually transmitted disease (STD) history, and substance use by self-report during a confidential structured interview. Data were analyzed using chi-squared analysis. Of the 1652 youth who were counseled, 1602 were from hospital-based clinics. A total of 827 (50%) requested HIV testing. Females accounted for the majority of youth who underwent counseling (79%) and requested HIV testing (75%). However, once counseled, males were more likely to be tested. Risk factors differed by gender; females were more likely to report STDs and marijuana use, and males more likely to report alcohol and cocaine use. These results indicate a need to identify developmentally appropriate methods to educate and counsel youth about HIV that will lead to more youth willing to be tested. School-based clinics may provide easier access than traditional health models for confidential HIV services.

[Strategies for identification of secretases implicated in Alzheimer's disease]

In Alzheimer's disease, cortical areas of affected patients are invaded by extracellular proteinous deposits called senile plaques, the main component of which is called amyloid beta-peptide or A beta. This peptide derives from the proteolytic attack of a precursor, the beta-amyloid precursor protein, by two enzymes called beta- and gamma-secretases. Alternatively, beta APP can be cleaved by an additional activity named alpha-secretase that occurs inside the A beta sequence, thereby precluding its formation, and concomitantly liberating a secreted fragment, namely APP alpha. Therefore, secretases seem to play a key role in the control of physiological and potentially pathogenic beta APP catabolites and could be envisioned as possible therapeutic targets in Alzheimer's disease. Here, we describe possible experimental approaches to identify such proteolytic activities.

Differential expression of systemic cytokine profiles in Chagas' disease is associated with endemicity of Trypanosoma cruzi infections

Chagas' disease is a serious public health problem in Paraguay, however, the immunoepidemiology of the disease has not been well documented. A preliminary cross-sectional survey was carried out in two villages of the Paraguayan Chaco region and in five villages of the Oriental region to assess the endemicity of Trypanosoma cruzi infections. Thereafter, a subset of individuals (ages ranging from 23 to 65 years) participated in a follow-up study to evaluate clinical and parasitological parameters. Physical examinations and electrocardiograms (ECG) were conducted and blood samples collected for parasite detection and serology. The most frequent ECG abnormalities which were observed among chagasic individuals were left anterior hemifascicular block and right bundle branch block. Thirty-two of these subjects, seropositive and non-parasitemic from the high endemic Chaco (n = 16) and low endemic Oriental (n = 16) regions, were randomly selected for an analysis of T. cruzi-induced expression of cytokines IL-2, IFN-gamma, IL-4 and IL-10 by RT-PCR. The individuals were grouped (n = 8) according to the presence or absence of abnormal ECG. In subjects that exhibited abnormal ECG profiles, five of eight (63%) individuals from the high endemic area showed a dominant type 2 (IL-4) response, whereas a comparable number (63%) of subjects from the low endemic area expressed a strong type 1 (IFN-gamma) response; the remainder (37%) presented a Th0-type (IFN-gamma, IL-4) response. Subjects with normal ECG showed a defined cytokine profile according to endemicity. All subjects from the high endemic region showed a Th0 response, whereas 100% of the individuals from the low endemic area demonstrated a type 1 response. In most chagasic patients regardless of ECG profile and endemicity, IL-2 expression was depressed, while IL-10 mRNA transcripts were consistently elevated. Taken together, these data indicate that chronic human chagasic disease is associated with increased systemic production of type 2 cytokines in response to T. cruzi infection and may be involved in the reciprocal down-regulation of IL-2 production.

Neurocircuitry of conditioned inhibition of analgesia: effects of amygdala, dorsal raphe, ventral medullary, and spinal cord lesions on antianalgesia in the rat

Pain inhibition (analgesia) is produced by learned danger signals and inhibited by learned safety signals (antianalgesia). Conditioned analgesia is mediated by brain-to-spinal pathways releasing spinal endogenous opiates. Spinal morphine mimics learned danger signals in producing analgesia, which is inhibited by antianalgesia. The circuitry mediating antianalgesia is unknown. These experiments demonstrate that raphe dorsalis, raphe magnus, and spinal dorsolateral funiculus lesions abolish antianalgesia. Other lesions had no effect on antianalgesia. More important, lesions that blocked development of conditioned analgesia did not block development of antianalgesia. Thus, neural circuitries mediating analgesia and antianalgesia were found to be distinct, and conditioned inhibition of analgesia was found to act by inhibiting the most distal part of the conditioned analgesia circuit, namely, the spinal cord.

Budesonide epimer R or dexamethasone selectively inhibit platelet-activating factor-induced or interleukin 1beta-induced DNA binding activity of cis-acting transcription factors and cyclooxygenase-2 gene expression in human epidermal keratinocytes

To further understand the molecular mechanism of glucocorticoid action on gene expression, DNA-binding activities of the cis-acting transcription factors activator protein 1 (AP1), AP2, Egr1 (zif268), NF-kappaB, the signal transducers and activators of transcription proteins gamma interferon activation site (GAS), Sis-inducible element, and the TATA binding protein transcription factor II D (TFIID) were examined in human epidermal keratinocytes. The cytokine interleukin 1beta (IL-1beta) and platelet-activating factor (PAF), both potent mediators of inflammation, were used as triggers for gene expression. Budesonide epimer R (BUDeR) and dexamethasone (DEX) were studied as potential antagonists. BUDeR or DEX before IL-1beta- or PAF-mediated gene induction elicited strong inhibition of AP1-, GAS-, and in particular NF-kappaB-DNA binding (P < 0.001, ANOVA). Only small effects were noted on AP2, Egr1 (zif268), and Sis-inducible element-DNA binding (P > 0.05). No significant effect was noted on the basal transcription factor TFIID recognition of TATA-containing core promoter sequences (P > 0.68). To test the hypothesis that changing cis-acting transcription factor binding activity may be involved in inflammatory-response related gene transcription, RNA message abundance for human cyclooxygenase (COX)-1 and -2 (E.C.1.14.99.1) was assessed in parallel by using reverse transcription-PCR. Although the COX-1 gene was found to be expressed at constitutively low levels, the TATA-containing COX-2 gene, which contains AP1-like, GAS, and NF-kappaB DNA-binding sites in its immediate promoter, was found to be strongly induced by IL-1beta or PAF (P < 0.001). BUDeR and DEX both suppressed COX-2 RNA message generation; however, no correlation was associated with TFIID-DNA binding. These results suggest that on stimulation by mediators of inflammation, although the basal transcription machinery remains intact, modulation of cis-activating transcription factor AP1, GAS, and NF-kappaB-DNA binding by the glucocorticoids BUDeR and DEX play important regulatory roles in the extent of specific promoter activation and hence the expression of key genes involved in the inflammatory response.

Prospective Evaluation of Referrals to a Hospice/Palliative Medicine Consultation Service

A hospice/palliative medicine consultation team was formed in July 1993 in a U.S. teaching hospital to provide patient care and education. The team consists of an attending physician, nurse, fellow, and any residents or medical students rotating on the service. More than 500 consultations are received each year. Beginning in January 1995,108 consecutive referrals to the service were assessed using a standard form completed by the nurse. The average age was 62 years. The gender of patients was 58% male and 42% female. At the time of consultation 87% were hospitalized on general medical services (including hematology/oncology), 4% were on surgical services, 3% on the neurology service, and 6% were in an intensive care unit. Cancer was the primary diagnosis in 52%, AIDS in 24%, with the rest being distributed among cardiac, renal, pulmonary, neurologic, and other diseases. The most prominent physical symptoms were 48% weakness/malaise, 44% pain, 28% dyspnea, and 23% agitation/confusion. The average length of time patients were followed was 2 days (range 1-10). We conclude that a hospice/palliative medicine consultation service sees a broad range of patients and problems and is a rich resource for teaching hospice and palliative medicine.

Tenidap decreases IL-8 and monocyte chemotactic peptide-1 (MCP-1) mRNA expression in the synovial tissue of rabbits with antigen arthritis and in cultured synovial cells

Since IL-8 and MCP-1 are chemoattractant proteins that participate in the recruitment of inflammatory cells into the arthritic joint, we examined the effects of tenidap, a new anti-inflammatory drug of the oxindole family, on IL-8 and MCP-1 expression in the joints of rabbits with acute antigen arthritis. The model was induced by injecting 5 mg/ml ovalbumin into the knees of 20 preimmunized rabbits. Animals were randomized into two groups: treated with tenidap (15 mg/kg per 12 h), or untreated. The effect of tenidap treatment was evaluated on chemokine production in synovial membranes of rabbits with arthritis and in cultured monocytic and synovial cells (SC). By immunoperoxidase staining, chemokines were localized in the synovial tissue. Chemokine messenger RNA levels in the synovial membranes and in cultured cells were analysed by reverse transcription-polymerase chain reaction (RT-PCR). At the end of the study, tenidap significantly reduced neutrophil infiltration into the joint cavity (27+/-4 x 10(6) cells/ml versus 45+/-6 x 10(6) cells/ml in untreated; P<0.05), and synovial effusion (134+/-15 microl versus 236+/-19 microl in untreated; P<0.005). Untreated rabbits showed synovial membrane up-regulation in mRNA expression of IL-8 and MCP-1 (11- and seven-fold versus healthy rabbits, respectively) that was markedly decreased by tenidap (two- and three-fold versus healthy rabbits, respectively). IL-8 and MCP-1 were localized in the synovial tissue in a perivascular pattern and areas of the interstitium and lining, mostly coinciding with cell infiltration. Tenidap also reduced the accumulation of IL-8 and MCP-1 proteins. In cultured synovial and monocytic cells, tumour necrosis factor-alpha (TNF-alpha) elicited an increase in gene expression of IL-8 (four- and nine-fold, respectively) and MCP-1 (nine- and four-fold, respectively) that was significantly reversed in both cell types by 10 microM tenidap. These results suggest that the beneficial effect of tenidap in acute antigen arthritis could be related to the down-regulation in gene expression and synthesis of IL-8 and MCP-1, two key chemokines involved in the recruitment of inflammatory cells.