Health information resources: tradition and innovation in a medical school curriculum

Changes in LCME accreditation for medical colleges fostered the development of Health Information Resources, a required, for-credit course created by the Saint Louis University Health Sciences Center Library Reference Department for the first-year medical school curriculum. Six content areas were developed for inclusion in the syllabus: "Electronic Resources Survival Kit"; "Introduction to Problem Based Resources"; "Introduction to Literature Searching"; "MEDLINE Searching Hands-On/Publishing Pearls & Pitfalls"; "The World Wide Web and Patient Information"; and "Introduction to Electronic Mail." A combination of lectures, hands-on instruction, and active learning techniques were employed in the teaching of this class. Submission of a Health Information Resource Guide and a two-part final exam were required.

Donor-specific tolerance induction in composite tissue allografts

BACKGROUND

Although prolonged composite tissue allograft (CTA) survival is achievable in animals using immunosuppressive drugs, long-term immunosuppression of CTAs in the clinical setting would be unacceptable for most patients. The purpose of this study was to develop a model for reliable CTA tolerance induction in the adult rat across a strongly antigenic MHC mismatch without the need for long-term immunosuppression.

METHODS

Chimeras were prepared using rat strains with strong MHC incompatibility [WF (RT1Au) + ACI (RT1Aa) --> WF, n = 13]. Syngeneic (WF) and allogeneic (ACI) bone marrow (BM) was harvested and T-cell depleted. Following confirmation of T-cell depletion by flow cytometry, a mixture of T-cell depleted syngeneic and allogeneic BM was injected into the recipient animals (all recipients pretreated with low-dose irradiation, 500 to 700 cGy). In addition, the recipient animals received a single dose of ALS (10 mg) 5 days prior to bone marrow transplantation (BMT) and tacrolimus (1 mg/kg/day) from the day prior to BMT to 10 days postoperatively. Rat chimeras were characterized by flow cytometry at 3 and 12 months after BM reconstitution and following hindlimb transplantation.

RESULTS

Peripheral blood lymphocyte chimerism (WF/ACI) remained stable >12 months after BM reconstitution in 10 of 13 animals. Multilineage chimerism of both lymphoid and myeloid lineages was present, suggesting that engraftment of the pluripotent rat stem cell had occurred. In animals with donor chimerism >60%, there was no sign of limb rejection for the duration of the study. All animals with chimerism <20% developed moderate signs of rejection clinically and histologically. Gross motor and sensory reinnervation (weight bearing, toe spread) occurred at >60 days in 6 of 9 rats. Postoperative flow cytometry studies demonstrated stable chimerism in all animals studied (n = 7).

CONCLUSIONS

Stable mixed allogeneic chimerism can be achieved in a rat hindlimb model of composite tissue allotransplantation. Hindlimb allografts to mixed allogeneic chimeras exhibit prolonged, rejection-free survival. This represents the first reliable model demonstrating rejection-free CTA survival in an adult animal without the long-term use of immunosuppressive agents across a strongly antigenic MHC mismatch.

Aortic valve involvement in calciphylaxis: uremic small artery disease with medial calcification and intimal hyperplasia

Calciphylaxis is a rare manifestation of abnormal calcium metabolism seen in some patients with renal disease. We describe the transesophageal echocardiographic (TEE) findings in a patient with calciphylaxis. These findings included calcification of ascending aorta and aortic valve. TEE was normal before the development of calciphylaxis.

Hydrocarbon exposure and chronic renal disease

The study objective was to investigate further the potential role of long-term exposure to hydrocarbons (HCs) in the development of idiopathic chronic glomerulopathy (ICG) using a more refined measurement of HC exposure. A total of 321 pairs of cases and controls, matched by age, gender, and geographical area, were assembled. A detailed questionnaire was blindly administered to cases and controls to collect information on occupational and medical history and sociodemographic data. By integrating quantified measurements of HC exposure from a variety of sources with each subject's occupational history, a lifetime HC exposure score could be estimated and expressed in parts per million (ppm). Cases had an hydrocarbon exposure mean score of 165 ppm (median 48 ppm) as compared to 162 ppm (median 43 ppm) for controls (P = 0.757). When using hydrocarbon exposure as a dichotomous variable with a cutoff point at 100 ppm, cases had a higher proportion of exposed than controls, but the difference was not statistically significant at the 0.05 level, even after controlling for possible confounders through logistic regression. Subgroup analyses showed mixed results. In most subgroups differences between cases and controls tended to become significant when hydrocarbon was used as a dichotomous variable. Results from this study do not sufficiently support the hypothesized association of HC exposure and ICG in general. Subgroup analyses need further investigations. Efforts to generate accurate estimates of lifetime HC exposure should be emphasized for future investigations.

A longitudinal psychopathological schedule

A schedule is described for rating the symptoms of mental illness over a period of time which includes several episodes. The reliability was measured in a study involving six raters. The sources of information required were studied, in 20 patients, by comparing an interview with the patient, a similar interview with an informant and an analysis of the case records. A synopsis of interview and record data are necessary to obtain adequate information about longitudinal psychopathology and 'lifetime' diagnosis.

Presence of CD4, CD8 double-negative and T-cell receptor-gamma-delta-positive T cells in lymphocyte cultures propagated from coronary arteries from heart transplant patients with graft coronary disease

Previous studies have shown that the interleukin-2-induced propagation of lymphocytes from endomyocardial biopsy specimens, an indicator of cellular rejection, is associated with the development of graft coronary disease in heart transplant patients. To further investigate the concept of cell-mediated immune responses in graft coronary disease, we have applied the methodologies of interleukin-2-induced propagation of lymphocytes from arterial tissues. In a group of 23 patients, which included 6 heart, 6 kidney, and 11 liver transplant recipients, we observed that arterial lymphocyte growth was significantly associated with obliterative vasculopathy (p less than 0.03). T-cell phenotyping analysis of coronary artery-derived lymphocyte cultures from three heart transplant patients with graft coronary disease showed significant numbers of CD4, CD8 double-negative T cells and T-cell receptor-gamma delta cells, especially when the cultures were established with relatively high doses of 400 U/ml of interleukin-2. These data suggest that the subset of CD4-CD8-, T cell receptor-gamma delta+ T cells may play a role in the pathogenesis and progression of graft coronary disease.

Schizophrenia, bipolar disorder and depression. A discriminant analysis, using 'lifetime' psychopathology ratings

Discriminant and canonical variate analyses were performed using 302 patients, on whom ratings of lifetime psychopathology and course of illness has been made. DSM-III diagnoses were used to form the criterion groups. Bipolar disorder emerged as a distinct grouping, but there are reasons for dissatisfaction with its definition. The remaining patients formed a 'schizodepressive continuum', but this also had a tendency to bimodality. It is possible that the distinction between schizophrenia and depression was obscured by inadequacies in the data and the inclusion of excessive numbers of patients with schizoaffective depression in this study.

Monoclonal versus polyclonal antibody therapy for prophylaxis against rejection after heart transplantation

Between August 1986 and December 1987, 88 patients received either RATG or OKT3 for immunoprophylaxis before heart transplantation. By the end of the first month after transplantation, 25% of the patients who received RATG had experienced a rejection episode compared with 43% of those receiving OKT3. This difference was persistent as many as 4 months after transplantation. While 50% of the OKT3 patients had a second episode of rejection, only 35% of the RATG patients did so. Randomization of these agents was complicated by severe cardiopulmonary side effects attributed to the first dose of OKT3. Five hours after the first dose of OKT3, a 25% drop in mean arterial pressure, accompanied by significant hypoxia, was seen in a majority of patients. There was no difference in the incidence of infection between the two groups.

In vitro studies of endomyocardial biopsies from heart transplant recipients on RATG and OKT3 immunoprophylaxis protocols

Endomyocardial biopsy histology and the in vitro propagation of biopsy-infiltrating alloreactive T lymphocytes were analyzed in cardiac transplant patients on RATG (n = 24) and OKT3 (n = 9) immunoprophylaxis protocols. During the first three months posttransplant, 27% of the 167 biopsies in the RATG group showed histological grades of 2 or higher, significantly less than the 44% frequency of positive histology for biopsies in the OKT3 group (P = 0.035). For the histologically positive biopsies the frequency of lymphocyte growth, and the primed lymphocyte testing (PLT)* and CML activity of biopsy grown cells were similar in the RATG and OKT3 groups. However, for histologically negative biopsies, there was significantly more lymphocyte growth in the OKT3 than in the RATG groups (68% vs. 30%; P = 0.005). There was also significantly greater donor-specific CML activity of the biopsy-grown cultures in the OKT3 group. These data that suggest less cellular rejection is associated with RATG than with OKT3 immunoprophylaxis. They extend our previously reported clinical experience of a higher rejection-free survival in patients on the RATG protocol.

Propagation of alloreactive lymphocytes from histologically negative endomyocardial biopsies from heart transplant patients. Association with subsequent histological evidence of allograft rejection

Endomyocardial biopsies from heart transplant patients were cultured in vitro in the presence of Interleukin-2 and irradiated feeder cells to propagate graft-infiltrating lymphocytes. A correlation was seen between the frequency of lymphocyte growth and the degree of cellular infiltration of the biopsies. In this study, 43 of 113 (38%) histologically negative biopsies obtained from 55 patients during the first month post-transplant yielded lymphocyte cultures. The cumulative incidence of subsequent histological rejection was considerably higher in patients with such "grower" biopsies than in patients with "nongrower" biopsies. In the grower group, we were able to obtain data on alloreactivity of 32 lymphocyte cultures assayed by primed lymphocyte testing (PLT). The presence of donor-specific PLT reactivity in the cultured lymphocytes was associated with an additional risk for subsequent histological rejection. These findings suggest that the in vitro culturing of histologically negative endomyocardial biopsies will identify patients at increased risk for developing heart transplant rejection.

A ten-laboratory study of lomefloxacin (NY-198 or SC 47111) antimicrobial activity in Argentina

The antimicrobial activity of a new fluoro-quinolone, lomefloxacin (NY-198, SC47111), was evaluated by standardized susceptibility testing methods at ten laboratories in Argentina. Lomefloxacin was found to be the most active drug against 1,316 recent clinical isolates compared directly to norfloxacin, co-trimoxazole, and gentamicin. Only 1.4% of Enterobacteriaceae were lomefloxacin-resistant (MIC greater than 4 micrograms/ml), and the lomefloxacin MIC90 for all staphylococci was 2 micrograms/ml, including methicillin-resistant isolates. Streptococci, enterococci, and some Pseudomonads (9% resistance) were less susceptible to lomefloxacin. Lomefloxacin was the most active against Neisseria gonorrhoeae strains compared to penicillin, cefuroxime, and spectinomycin. Among the tested Mycobacteria, only the nontuberculosis, slow growers had lomefloxacin MICs of greater than 4 micrograms/ml.

Lymphocyte growth from cardiac allograft biopsy specimens with no or minimal cellular infiltrates: association with subsequent rejection episode

Histologic features of endomyocardial biopsy specimens are essential in the monitoring of heart transplant patients. Significant cellular infiltrates accompanied by myocyte damage are diagnostic of transplant rejection, whereas no or minimal infiltrates (grades 0 and 1) suggest absence of rejection. Biopsy specimens were cultured on the basis of the principle that the allograft is infiltrated by activated lymphocytes, which can be expanded in the presence of interleukin-2, a lymphokine that induces proliferation of activated T cells. Although frequency of cell cultures was proportional to histologic rejection grade, 39% of biopsy specimens with grades 0 and 1 cultured during the first month posttransplantation yielded lymphocyte growth. Cell growth was observed in 28% of biopsy specimens with grades 0 and 1 obtained during the first 10 days posttransplantation. In this group (growers) 73% showed clinical rejection after 9.8 +/- 5.0 days. In contrast, 55% of nongrowers were treated for rejection after 19.1 +/- 13.8 days. For biopsy specimens obtained 11 to 20 days posttransplantation, subsequent rejection episodes were observed in 61% of growers, but in only 33% of nongrowers. For biopsy specimens obtained 21 to 30 days posttransplantation the incidence of clinical rejection was 60% versus 14%, respectively. A sequential analysis of biopsy specimens obtained during the first month posttransplantation enabled us to identify 16 persistent nongrowers; only 6 (37%) experienced clinical rejection during the first 3 months posttransplantation. Most of the persistent nongrowers were found among patients on the immunoprophylactic rabbit antithymocyte globulin protocol. These data suggest that in vitro cultures of biopsy specimens with no detectable or minimal cellular infiltration may be useful in identifying patients at risk of developing rejection.

Assessment of c-myc expression in individual leukemic cells

The expression of the proto-oncogene c-myc was studied at the protein level in cells obtained from patients with AML and CML. In florid AML and during the blastic phase of CML the majority of cells contain c-myc protein with the amount of protein differing widely among the cells of individual patients. In contrast, during complete remission in AML and during the chronic phase of CML cells containing c-myc protein are rare. Several studies demonstrated a discordance in the amount of c-myc transcript and the amount of c-myc protein present in cell populations thereby suggesting the presence of translational or post-translational regulation of c-myc expression. Further, the data suggest that high levels of c-myc protein in the leukemic cells of AML patients are associated with a poor response to therapy and that high levels in AML patients in CR or in the peripheral blood of chronic phase CML patients may be indicative of impending acute leukemia.