Addressing narcissistic personality features in the context of medical care: integrating diverse perspectives to inform clinical practice

Narcissistic personality disorder (NPD) is characterized by an unrealistic need for admiration, lack of empathy toward others, and feelings of superiority. NPD presents a unique and significant challenge in clinical practice, particularly in medical settings with limited provider contact time, as health professionals treat individuals who often require excessive admiration and have competing treatment needs. This practice review highlights real case examples across three distinct medically oriented clinical settings (inpatient and outpatient behavioral medicine and a Level I trauma center) to demonstrate the difficult and compromising situations that providers face when treating patients with general medical conditions and comorbid narcissistic personality features. The main goal of this article is to discuss the various challenges and obstacles associated with these cases in medical settings and discuss some strategies that may prove successful. A second goal is to bridge diverse conceptualizations of narcissism/NPD through the discussion of theoretical and empirical perspectives that can inform understanding of the clinical examples. Despite differing perspectives regarding the underlying motivation of narcissistic behavior, this practice review highlights that these paradigms can be integrated when sharing the same ultimate goal: to improve delivery of care across medically oriented clinical settings for patients with narcissistic features.

Resistance to recombinant stem rust race TPPKC in hard red spring wheat

The wheat (Triticum aestivum L.) stem rust (Puccinia graminis Pers.:Pers. f.sp. tritici Eriks. and Henn.) resistance gene SrWld1 conditions resistance to all North American stem rust races and is an important gene in hard red spring (HRS) wheat cultivars. A sexually recombined race having virulence to SrWld1 was isolated in the 1980s. Our objective was to determine the genetics of resistance to the race. The recombinant race was tested with the set of stem rust differentials and with a set of 36 HRS and 6 durum cultivars. Chromosomal location studies in cultivars Len, Coteau, and Stoa were completed using aneuploid analysis, molecular markers, and allelism tests. Stem rust differential tests coded the race as TPPKC, indicating it differed from TPMKC by having added virulence on Sr30 as well as SrWld1. Genes effective against TPPKC were Sr6, Sr9a, Sr9b, Sr13, Sr24, Sr31, and Sr38. Genetic studies of resistance to TPPKC indicated that Len, Coteau, and Stoa likely carried Sr9b, that Coteau and Stoa carried Sr6, and Stoa carried Sr24. Tests of HRS and durum cultivars indicated that five HRS and one durum cultivar were susceptible to TPPKC. Susceptible HRS cultivars were postulated to have SrWld1 as their major stem rust resistance gene. Divide, the susceptible durum cultivar, was postulated to lack Sr13. We concluded that although TPPKC does not constitute a threat similar to TTKSK and its variants, some cultivars would be lost from production if TPPKC became established in the field.

Unplanned excision of soft tissue sarcoma results in increased rates of local recurrence despite full further oncological treatment

BACKGROUND

Unplanned excision of soft tissue sarcoma (STS) accounts for up to 40% of all initial operations for STS and is undertaken when the mass is presumed to be benign. The effect this has on outcome has never been fully established.

METHODS

Patients with extremity or trunk STS between 2001 and 2005 who were treated by an initial inadvertent operation and then referred immediately to our unit were identified. Outcomes were compared with a control group of patients with STS who were stage-matched and had been treated conventionally by core biopsy and definitive surgery. Endpoints were local recurrence, distant metastases and sarcoma-specific survival.

RESULTS

134 patients who had undergone unplanned excision of STS were identified. One hundred twenty-one underwent further re-excision, and 51 (48%) of these patients had residual tumour identified after surgical re-excision. Two hundred nine stage-matched controls were identified who were treated conventionally. Median follow-up was 51.6 months. Local recurrence rates were considerably higher in the study group (23.8 vs. 11%, p = 0.0016), despite the control group having more stage 3 tumours. When the tumours were matched by stage, an increase in local recurrence was seen across all stages but was most pronounced for stage 3 tumours (37.5 vs. 14.2%, p = 0.005). Metastasis-free and sarcoma-specific survival were also significantly increased for stage 3 tumours.

CONCLUSION

Unplanned initial excision of extremity soft tissue sarcoma may compromise long-term local control of extremity STS despite full further oncological management.

Detecting 2009 pandemic influenza A (H1N1) virus infection: availability of diagnostic testing led to rapid pandemic response

Diagnostic tests for detecting emerging influenza virus strains with pandemic potential are critical for directing global influenza prevention and control activities. In 2008, the Centers for Disease Control and Prevention received US Food and Drug Administration approval for a highly sensitive influenza polymerase chain reaction (PCR) assay. Devices were deployed to public health laboratories in the United States and globally. Within 2 weeks of the first recognition of 2009 pandemic influenza H1N1, the Centers for Disease Control and Prevention developed and began distributing a new approved pandemic influenza H1N1 PCR assay, which used the previously deployed device platform to meet a >8-fold increase in specimen submissions. Rapid antigen tests were widely used by clinicians at the point of care; however, test sensitivity was low (40%-69%). Many clinical laboratories developed their own pandemic influenza H1N1 PCR assays to meet clinician demand. Future planning efforts should identify ways to improve availability of reliable testing to manage patient care and approaches for optimal use of molecular testing for detecting and controlling emerging influenza virus strains.

Effects of low molecular weight fungal compounds on inflammatory gene transcription and expression in mouse alveolar macrophages

The inflammatory potential and molecular mechanisms underscoring inflammatory responses of lung cells to compounds from fungi that grow on damp building materials is poorly understood in vitro. In this study we evaluated the effect of pure fungal compounds on potentiating acute inflammatory response in primary mouse alveolar macrophages (AMs) and tested the hypothesis that AM responses to low molecular weight fungal compounds exhibit temporal and compound specificity that mimic that observed in the whole lung. Transcriptional responses of 13 inflammation/respiratory burst-associated genes (KC=Cxcl1, Cxcl2, Cxcl5, Cxcl10, Ccl3, Ccl112, Ccl20, IL-1β, Il-6, ifi27 Tnfα, iNOS and Blvrb) were evaluated in mouse AMs exposed to a 1ml (10(-8)mol) dose of either pure atranone C, brevianimide, cladosporin, curdlan, LPS, neoechinulin A & B, sterigmatocystin or TMC-120A for 2h, 4h and 12h PE using customized reverse transcription (RT)-PCR based arrays. Multianalyte ELISA was used to measure expression of 6 pro-inflammatory cytokines common to the transcriptional assays (Cxcl1, Cxcl10, Ccl3, IL1β, Ifn-λ and Tnf-α) to determine whether gene expression corresponded to the transcription data. Compared to controls, all of these compounds induced significant (≥2.5-fold or ≤-2.5-fold change at p≤0.05) time- and compound-specific transcriptional gene alterations in treatment AMs. The highest number of transcribed genes were in LPS treatment AMs at 12h PE (12/13) followed by neoechinulin B at 4h PE (11/13). Highest fold change values (>30) were associated with KC, Cxcl2, Cxcl5 and IL1β genes in cells exposed to LPS. Compound exposures also induced significant (p≤0.05) time- and compound-specific pro-inflammatory responses manifest as differentially elevated Cxcl1, Cxcl10, Ccl3, Ifn-λ and Tnf-α concentrations in culture supernatant of treatment AMs. Dissimilarity in transcriptional responses in AMs and our in vivo model of lung disease is likely attributable to whole lung vs. isolated cell responsive and dose differences between the two studies. The results not only indicate that low molecular weight compounds from fungi that grow in damp built environments are potently pro-inflammatory in vitro, it further highlights the important role AMs play in innate lung defence, and against exposure to low molecular weight fungal compounds. These observations further support our position that exposure to low molecular weight compounds from indoor-associated fungi may provoke some of the inflammatory health effects reported from humans in damp building environments. They also open up a hypothesis building process that could explain the rise of non-atopic asthma associated with fungi.

Rapid and pervasive occupation of fallen mangrove leaves by a marine zoosporic fungus

Samples of leaves of red mangrove (Rhizophora mangle) were incubated on an agar medium selective for pythiaceous oomycetes. Leaves on trees above the water did not contain oomycetes. Marine oomycetes, principally Phytophthora vesicula, had colonized leaves within 2 h of leaf submergence, probably finding them by chemotaxis. The frequency of occurrence of P. vesicula in submerged leaves reached 100% within 30 h of submergence. By 43 h most, if not all, parts of leaves were occupied, and surface treatment with a biocide indicated that leaves were occupied internally. Frequencies of P. vesicula remained near 100% through about 2 weeks of submergence and then declined to about 60% in older (>/=4 weeks) leaves. Leaves of white mangrove (Laguncularia racemosa) were also extensively occupied by P. vesicula after falling into the water column, but decaying leaves of turtlegrass (Thalassia testudinum) were not colonized by oomycetes. Ergosterol analysis indicated that the standing crop of living, non-oomycete (ergosterol-containing) fungal mass in submerged red-mangrove leaves did not rise above that which had been present in senescent leaves on the tree; decaying turtlegrass leaves had an ergosterol content that was only about 2% of the maximum concentration detected for red-mangrove leaves. These results suggest that oomycetes are the predominant mycelial eucaryotic saprotrophs of mangrove leaves that fall into the water column and that for turtlegrass leaves which live, die, and decompose under submerged conditions, mycelial eucaryotes make no substantial contribution to decomposition.

States of adsorbed dodecyl amine and water at a silica surface as revealed by vibrational spectroscopy

States of adsorbed dodecylamine (DDA) at a silica surface have been studied as a function of pH by vibrational spectroscopy (SFVS, FTIR), contact angle measurements, and molecular dynamics (MD) simulations. The results show that the state of adsorbed DDA at a silica surface varies significantly at different pH values. At pH 6.30, there is no pronounced adsorption of DDA cations and the surface is hydrophilic. At pH 10.0, the vibrational spectroscopy results together with contact angle measurements and MD simulations suggest that amine is adsorbed as a well organized monolayer, the hemimicelle structure. Under these conditions, dehydration occurs based on SFVS analysis and the silica surface becomes hydrophobic. In the case of pH 12.3, it has been confirmed that continued adsorption of DDA neutral molecules occurs with the amine surface state changing from a monolayer to a bilayer or a micellar surface state as revealed both from SFVS analysis and MD simulations. At this high pH, extensive surface hydration is evident from SFVS results and the silica surface becomes hydrophilic.

Inflammation-associated gene transcription and expression in mouse lungs induced by low molecular weight compounds from fungi from the built environment

Few metabolites from fungi found indoors have been tested for inflammatory mediators endpoints in primary cultures of alveolar macrophages or in vivo. In this study, mice were intratracheally instilled with a single dose comprising 4x10(-5)moletoxin/kg lung wt dose of either atranone C, brevianamide, cladosporin, mycophenolic acid, neoechinulin A & B, sterigmatocystin or TMC-120A. These toxins are from fungi common on damp building materials. The dose used was comparable to the estimated doses of possible human exposure. Hematoxylin and eosin (H&E) histology and Alcian Blue/Periodic Acid Schiff (AB/PAS) histochemistry were used to evaluate lungs for time course (4h and 12h post-exposure (PE)) inflammatory and toxic changes. Reverse-transcription (RT)-PCR based arrays were also employed to evaluate time course inflammation-associated gene transcription in lung tissues of the different toxins. Immunohistochemistry (IHC) was used to probe MIP-2 and Tnf-alpha protein expression in treatment lungs to determine whether responses correspond with gene transcription data. Both histology and histochemistry revealed that toxin exposed lungs at 12h PE showed evidence of inflammation. H&E revealed that bronchioli were lined with irregularly thickened and sometimes sloughing epithelium and bronchiolar spaces supported infiltration of leukocytes, cellular and mucus-like debris while alveolar spaces supported swollen macrophages and modest amorphous debris accumulations. All toxin-instilled lungs exhibited copious mucus production and alveolar macrophages with red stained cytoplasm on bronchiolar surfaces, especially at 12h PE. Array analysis of 83 inflammation-associated genes extracted from lung tissue demonstrated a number of patterns, compared to controls. 82 genes assayed at 4h PE and 75 genes at 12h PE were significantly altered (p< or =0.05; >or =1.5-fold or < or =-1.5-fold change) in the different treatment animal groups. Expression of transcriptionally regulated genes was confirmed using immunohistochemistry that demonstrated MIP-2 and Tnf-alpha staining in respiratory bronchiolar epithelia, alveolar macrophages and alveolar type II cells. The transcriptional regulation in these genes in the treatment groups suggests that they may serve central roles in the immunomodulation of toxin-induced pro-inflammatory lung responses. Hierarchical cluster analysis revealed significant patterns of gene transcription linking the response of the toxins at equimolar doses in three groups: (1) brevianamide, mycophenolic acid and neoechinulin B, (2) neoechinulin A and sterigmatocystin, and (3) cladosporin, atranone C and TMC-120. The results further confirm the inflammatory nature of metabolites/toxins from such fungi can contribute to the development of non-allergenic respiratory health effects.

Heat recovery ventilators prevent respiratory disorders in Inuit children

Inuit infants have high rates of reported hospitalization for respiratory infection, associated with overcrowding and reduced ventilation. We performed a randomized, double-blind, placebo controlled trial to determine whether home heat recovery ventilators (HRV) would improve ventilation and reduce the risk of respiratory illnesses in young Inuit children. Inuit children under 6 years of age living in several communities in Nunavut, Canada were randomized to receive an active or placebo HRV. We monitored respiratory symptoms, health center encounters, and indoor air quality for 6 months. HRVs were placed in 68 homes, and 51 houses could be analyzed. Subjects had a mean age of 26.8 months. Active HRVs brought indoor carbon dioxide concentrations to within recommended concentrations. Relative humidity was also reduced. Use of HRV, compared with placebo, was associated with a progressive fall in the odds ratio for reported wheeze of 12.3% per week (95%CI 1.9-21.6%, P = 0.022). Rates of reported rhinitis were significantly lower in the HRV group than the placebo group in month 1 (odds ratio 0.20, 95%CI 0.058-0.69, P = 0.011) and in month 4 (odds ratio 0.24, 95%CI 0.054-0.90, P = 0.035). There were no significant reductions in the number of health center encounters, and there were no hospitalizations. Use of HRVs was associated with in improvement in air quality and reductions in reported respiratory symptoms in Inuit children.

PRACTICAL IMPLICATIONS

Reduced ventilation is common in the houses of Inuit children in arctic Canada, and is associated with an increased risk of respiratory infection. Installation of HRV brings indoor carbon dioxide concentration, as a marker of adequate ventilation, to within recommended concentrations, although relative humidity is also reduced. Installation of HRV is associated with improvements in indoor air quality, and a reduced risk of wheezing and rhinitis not associated with cold air exposure in young Inuit children. Further research is required to explore traditional Inuit cultural attitudes about air movement in dwellings.

Chlamydia trachomatis YtgA is an iron-binding periplasmic protein induced by iron restriction

Chlamydia trachomatis is a Gram-negative obligate intracellular bacterium that is the causative agent of common sexually transmitted diseases and the leading cause of preventable blindness worldwide. It has been observed that YtgA (CT067) is very immunogenic in patients with chlamydial genital infections. Homology analyses suggested that YtgA is a soluble periplasmic protein and a component of an ATP-binding cassette (ABC) transport system for metals such as iron. Since little is known about iron transport in C. trachomatis, biochemical assays were used to determine the potential role of YtgA in iron acquisition. (59)Fe binding and competition studies revealed that YtgA preferentially binds iron over nickel, zinc or manganese. Western blot and densitometry techniques showed that YtgA concentrations specifically increased 3-5-fold in C. trachomatis, when cultured under iron-starvation conditions rather than under general stress conditions, such as exposure to penicillin. Finally, immuno-transmission electron microscopy provided evidence that YtgA is more concentrated in C. trachomatis during iron restriction, supporting a possible role for YtgA as a component of an ABC transporter.

Adsorption states of amphipatic solutes at the surface of naturally hydrophobic minerals: a molecular dynamics simulation study

An initial molecular dynamics simulation study regarding interfacial phenomena at selected naturally hydrophobic surfaces is reported. Simulation results show that, due to the natural hydrophobicity of graphite and talc basal planes, the cationic surfactant dodecyltrimethylammonium bromide preferentially adsorbs at these surfaces through hydrophobic interactions. When a model dextrin molecule is considered, the simulation results suggest that the hydrophobic interaction between the naturally hydrophobic surfaces of graphite, talc basal plane, and sulfur and the hydrophobic moieties (C-H and methylene groups) in the dextrin molecule plays a significant role in dextrin adsorption at these surfaces. The hydroxyl group in the dextrin molecule also contributes to its adsorption at the talc basal plane surface. In contrast, dextrin was not found to adsorb at talc edge surfaces.

Water structure and its influence on the flotation of carbonate and bicarbonate salts

Interfacial water structure is a most important parameter that influences the collector adsorption by salt minerals such as borax, potash and trona. According to previous studies, salts can be classified as water structure makers and water structure breakers. Water structure making and breaking properties of salt minerals in their saturated brine solutions are essential to explain their flotation behavior. In this work, water structure making-breaking studies in solutions of carbonate and bicarbonate salts (Na(2)CO(3), K(2)CO(3), NaHCO(3) and NH(4)HCO(3)) in 4 wt% D(2)O in H(2)O mixtures have been performed by FTIR analysis of the OD stretching band. This method reveals a microscopic picture of the water structure making/breaking character of the salts in terms of the hydrogen bonding between the water molecules in solution. The results from the vibrational spectroscopic studies demonstrate that carbonate salts (Na(2)CO(3) and K(2)CO(3)) act as strong structure makers, whereas bicarbonate salts (NaHCO(3) and NH(4)HCO(3)) act as weak structure makers. In addition, the changes in the OD band parameters of carbonate and bicarbonate salt solutions are in agreement with the viscosity characteristics of their solutions.

A GTPase cycle in initiation of protein translocation across the endoplasmic reticulum membrane

In higher eukaryotes proteins bearing a signal sequence are translocated across the membrane of the endoplasmic reticulum (ER). The initial events of protein translocation are the binding of the signal sequence by the 54 kDa subunit (SRP54) of the signal recognition particle (SRP) and the targeting of the ribosome nascent chain complex to the ER. Targeting is mediated by the binding of SRP to the SRP receptor, a membrane protein comprising two different subunits, SR alpha and SR beta. Interaction of SRP and SR alpha/SR beta causes release of the signal and the engagement of the nascent chain with the membrane-bound translocation apparatus. Both SRP54 and SR alpha contain homologous domains which include a predicted GTPase fold. The transmembrane protein SR beta also contains a GTPase domain, but it is not closely related to those of SRP54 and SR alpha. All three proteins bind GTP specifically, and the SR alpha/SR beta complex stimulates both GTP binding to and GTP hydrolysis by SRP54. We suggest a model for the initiation of protein translocation across the ER in which SR alpha beta catalyses a cycle of GTP binding, hydrolysis and release by SRP54 that regulates its dissociation from the signal sequence.

Indoor air quality risk factors for severe lower respiratory tract infections in Inuit infants in Baffin Region, Nunavut: a pilot study

Inuit infants have extremely high rates of lower respiratory tract infection (LRTI), but the causes for this are unclear. The aims of this study were to assess, in young Inuit children in Baffin Region, Nunavut, the feasibility of an epidemiologic study of the association between indoor air quality (IAQ) and respiratory health; to obtain data on IAQ in their housing; and to identify and classify risk factors for LRTI. Twenty houses in Cape Dorset, Nunavut with children below 2 years of age, were evaluated using a structured housing inspection and measurement of IAQ parameters, and a respiratory health questionnaire was administered. Twenty-five percent of the children had, at some time, been hospitalized for chest illness. Houses were very small, and had a median of six occupants per house. Forty-one percent of the houses had a calculated natural air change rate <0.35 air changes per hour. NO(2) concentrations were within the acceptable range. Smokers were present in at least 90% of the households, and nicotine concentrations exceeded 1.5 microg/m(3) in 25% of the dwellings. Particulates were found to be correlated closely with nicotine but not with NO(2) concentrations, suggesting that their main source was cigarette smoking rather than leakage from furnaces. Mattress fungal levels were markedly increased, although building fungal concentrations were low. Dust-mites were virtually non-existent. Potential risk factors related to IAQ for viral LRTI in Inuit infants were observed in this study, including reduced air exchange and environmental tobacco smoke exposure. Severe lower respiratory tract infection is common in Inuit infants. We found reduced air change rates and high occupancy levels in houses in Cape Dorset, which may increase the risk of respiratory infections. This suggests the measures to promote better ventilation or more housing may be beneficial. Further health benefits may be obtained by reducing bed sharing by infants and greater turnover of mattresses, which were found to have high levels of fungi.

Insomnia following hypocretin2-saporin lesions of the substantia nigra

The neuropeptide hypocretin, also known as orexin, has been implicated in waking since its deletion leads to the sleep disorder narcolepsy. Hypocretin neurons project to major arousal areas, and in an effort to determine which region is responsible for the changes in sleep-wake architecture we have developed the neurotoxin hypocretin2-saporin, which lesions hypocretin receptor bearing neurons. Here, in rats, we investigate the effects of hypocretin2-saporin lesions of the substantia nigra and ventral tegmental area in the regulation of sleep and wakefulness. Bilateral injection of hypocretin2-sap into both the ventral tegmental area and substantia nigra (92 and 184 ng/microl, 0.25 microl in the ventral tegmental area and 0.5 microl in the substantia nigra) or into the substantia nigra alone (184 ng/microl, 0.5 microl) produced insomnia. The insomnia seemed to be associated with a large increase in locomotion on days 4 and 6 postinjection, as hyperactivity and stereotypic movements were consistently observed on the video recordings in all lesioned rats. In these rats, a nearly complete loss of both tyrosine hydroxylase and neuron-specific nuclear protein (neuronal nuclei) immunoreactive cells in the substantia nigra as well as diminution of tyrosine hydroxylase-immunoreactive fibers in the caudate putamen was found. Following bilateral injection of hypocretin2-sap at a lower concentration (46 ng/microl, 0.25 microl in the ventral tegmental area and 0.5 microl in the substantia nigra), very little reduction in the number of tyrosine hydroxylase- and neuronal nuclei-immunoreactive neurons and only a temporary increase in wakefulness (17.4% increase during light-off period on day 6 postinjection) were observed. Ventral tegmental area lesions (184 ng/mul of hypocretin2-sap, 0.25 microl, bilateral injections) did not produce significant changes in sleep, although most of the tyrosine hydroxylase- and neuronal nuclei-immunoreactive neurons in the ventral tegmental area were destroyed. Insomnia following hypocretin2-sap lesions of the substantia nigra could be secondary to increased motor activity resulting from reduction of tonic inhibitory control by the substantia nigra.

Concurrent HLA-related response factors mediate recombinant hepatitis B vaccine major adverse events

Recombinant hepatitis B (HB) vaccines have successfully reduced infection, cirrhosis and carcinoma, but questions have endured about causality of serious adverse events following vaccination. After an event in a pediatric patient an investigation reviewed HLA vaccine response effects and analyzed genetics in reported cases. There are apparent common causal immune mechanisms among reported adverse events. HLA class II alleles/haplotypes linked to HB vaccine cellular/non-response and Crohn's disease can create conditions that actively/passively amplify, respectively, all or other components of the immune response to the HB vaccine. Presence of the HLA class I allele A2 can result in heavy cytotoxic T-cell activation and vaccine/self-peptide presentation to immune cells. If HLA autoimmune susceptibility alleles/haplotypes are present that control other immune response components, the probability is elevated that these will activate cross-reactive immune cells; the cells, their inflammatory secretions and/or auto-antibodies may initiate adverse events reflecting those susceptibilities. Probable DRB1 amplifying alleles are noted. High-resolution DNA typing and results analysis are described to test the hypothesis in known HB vaccine adverse event patients. Possible practical applications stemming from hypothesis validation are described.

A comparison of airborne ergosterol, glucan and Air-O-Cell data in relation to physical assessments of mold damage and some other parameters

We report here a comparison of long duration air samples in 110 homes where the material collected on open faced filter cassettes was analyzed for beta 1,3-d glucan, ergosterol, cholesterol and endotoxin. These data were then compared to careful estimates of visible mold and Air-O-Cell data. All the values found except cholesterol were of a similar magnitude to values reported in the limited number of studies available. Glucan was measured with a factor G based assay of the Limulus Amebocyte Lysate followed by size exclusion chromatography. This showed that the majority of airborne glucan found in these houses was fungal in origin arising from both yeasts and intact spores, as well as hyphal and spore fragments. Hyphal and spore fragments together represented 16% of the intact spore counts but over a broad range. Correlations between airborne glucan were strong for ergosterol and visible mold. However, airborne ergosterol was more highly correlated to visible mold than glucan. Endotoxin and Air-O-Cell measurements were poorly or not related to the other measures in the study. This study provides confidence that long duration air samples of the toxin glucan and ergosterol are related to building damage.

PRACTICAL IMPLICATIONS

Some studies of damp buildings have shown a relationship between extent of water/mold damage and symptoms. This study compared long duration air samples for glucan and ergosterol to extent of visible mold in houses measuring also the nature of the glucans present. Both measures were highly correlated to extent of visible mold damage in the houses; ergosterol was somewhat superior. Spore counts or prevalence of Asp/Pen in Air-O-Cell samples was not related to extent of visible mold damage but the observation of hyphal fragments was more likely when mold damage was present. This indicates that rigorous assessment of mold damage is a useful measure.

Repeat exercise normalizes the gas-exchange impairment induced by a previous exercise bout in asthmatic subjects

Twenty-one subjects with asthma underwent treadmill exercise to exhaustion at a workload that elicited approximately 90% of each subject's maximal O2 uptake (EX1). After EX1, 12 subjects experienced significant exercise-induced bronchospasm [(EIB+), %decrease in forced expiratory volume in 1.0 s = -24.0 +/- 11.5%; pulmonary resistance at rest vs. postexercise = 3.2 +/- 1.5 vs. 8.1 +/- 4.5 cmH2O.l(-1).s(-1)] and nine did not (EIB-). The alveolar-to-arterial Po2 difference (A-aDo2) was widened from rest (9.1 +/- 6.7 Torr) to 23.1 +/- 10.4 and 18.1 +/- 9.1 Torr at 35 min after EX1 in subjects with and without EIB, respectively (P < 0.05). Arterial Po2 (PaO2) was reduced in both groups during recovery (EIB+, -16.0 +/- -13.0 Torr vs. baseline; EIB-, -11.0 +/- 9.4 Torr vs. baseline, P < or = 0.05). Forty minutes after EX1, a second exercise bout was completed at maximal O2 uptake. During the second exercise bout, pulmonary resistance decreased to baseline levels in the EIB+ group and the A-aDo2 and PaO2 returned to match the values seen during EX1 in both groups. Sputum histamine (34.6 +/- 25.9 vs. 61.2 +/- 42.0 ng/ml, pre- vs. postexercise) and urinary 9alpha,11beta-prostaglandin F2 (74.5 +/- 38.6 vs. 164.6 +/- 84.2 ng/mmol creatinine, pre- vs. postexercise) were increased after exercise only in the EIB+ group (P < 0.05), and postexercise sputum histamine was significantly correlated with the exercise PaO2 and A-aDo2 in the EIB+ subjects. Thus exercise causes gas-exchange impairment during the postexercise period in asthmatic subjects independent of decreases in forced expiratory flow rates after the exercise; however, a subsequent exercise bout normalizes this impairment secondary in part to a fast acting, robust exercise-induced bronchodilatory response.

Gas exchange during exercise in habitually active asthmatic subjects

We determined the relations among gas exchange, breathing mechanics, and airway inflammation during moderate- to maximum-intensity exercise in asthmatic subjects. Twenty-one habitually active (48.2 +/- 7.0 ml.kg(-1).min(-1) maximal O2 uptake) mildly to moderately asthmatic subjects (94 +/- 13% predicted forced expiratory volume in 1.0 s) performed treadmill exercise to exhaustion (11.2 +/- 0.15 min) at approximately 90% of maximal O2 uptake. Arterial O2 saturation decreased to < or =94% during the exercise in 8 of 21 subjects, in large part as a result of a decrease in arterial Po2 (PaO2): from 93.0 +/- 7.7 to 79.7 +/- 4.0 Torr. A widened alveolar-to-arterial Po2 difference and the magnitude of the ventilatory response contributed approximately equally to the decrease in PaO2 during exercise. Airflow limitation and airway inflammation at baseline did not correlate with exercise gas exchange, but an exercise-induced increase in sputum histamine levels correlated with exercise Pa(O2) (negatively) and alveolar-to-arterial Po2 difference (positively). Mean pulmonary resistance was high during exercise (3.4 +/- 1.2 cmH2O.l(-1).s) and did not increase throughout exercise. Expiratory flow limitation occurred in 19 of 21 subjects, averaging 43 +/- 35% of tidal volume near end exercise, and end-expiratory lung volume rose progressively to 0.25 +/- 0.47 liter greater than resting end-expiratory lung volume at exhaustion. These mechanical constraints to ventilation contributed to a heterogeneous and frequently insufficient ventilatory response; arterial Pco2 was 30-47 Torr at end exercise. Thus pulmonary gas exchange is impaired during high-intensity exercise in a significant number of habitually active asthmatic subjects because of high airway resistance and, possibly, a deleterious effect of exercise-induced airway inflammation on gas exchange efficiency.

Water structure in aqueous solutions of alkali halide salts: FTIR spectroscopy of the OD stretching band

Water structure making/breaking studies in solutions of five alkali halide salts (KF, KI, NaI, CsF and CsCl) in 4 wt% D(2)O in H(2)O mixtures have been performed by FTIR analysis of the OD stretching band in the full solubility range. The proposed method gives a microscopic picture of the water structure making/breaking character of the salts in terms of the hydrogen bonding between the water molecules in the solution. With the exception of CsCl, there is a very good correlation of the structure making/breaking character of the salts determined by FTIR analysis, and the viscosity coefficients of the solutions. The results fully support and explain previous studies of bubble attachment to microscopic salt particles of the above salts. The investigations support the primary importance of interfacial water structure in the explanation of the flotation of alkali halide salts in their brines.

Differentiation of CD8 T Cells in Response to Acute and Chronic Viral Infections: Implications for HIV Vaccine Development

Successful HIV vaccine strategies will likely require the induction of robust cellular immune responses, in addition to strong humoral responses. Unfortunately, there is no clear molecular definition of an effective HIV-specific CD8 T cell response. In this review, we discuss the differentiation of CD8 T cells in response to acute and chronic viral infections. We then apply concepts derived from these studies to predict the desirable characteristics of HIV-specific CD8 T cell memory.

Laser therapy for an obstructing primary tracheal lymphoma in a patient with AIDS

A patient with AIDS presented with progressive dyspnea leading to respiratory failure with near complete airway obstruction due to primary tracheal lymphoma. Laser therapy was used locally to debulk the tumour, which facilitated extubation and led to definitive treatment with chemotherapy. Alternatives for local airway control are discussed.

Prevalence and Distribution of Common Barberry, the Alternate Host of Puccinia graminis, in Minnesota

A federal and state program operated from 1918 until the 1980s to eradicate common barberry (Berberis vulgaris), the alternate host of Puccinia graminis, from the major areas of cereal production in the United States. Over 500 million bushes were destroyed nationally during the program, approximately 1 million in Minnesota. Some sites in Minnesota where barberry bushes were destroyed remained in the "active" class when eradication was phased out in the 1980s. Active sites were defined as those on which there was still a possibility of emergence of barberry seedlings or sprouts arising from the parent bush. In the present study, from 1998 to 2002, 72 of the approximately 1,200 active sites in Minnesota were surveyed. Areas within 90 m of mapped locations of previously destroyed bushes were searched carefully at each site. Reemerged barberry plants were found on 32 sites. The reproductive status and GPS coordinates were recorded for each reemerged bush. More than 90% of the barberry bushes were found in counties with less than 400 ha of wheat per county, mostly in southeastern Minnesota, but one bush was found in a major wheat-producing county in northwestern Minnesota. Reemergence of barberry may serve as a source of new wheat stem rust races in future epidemics.

A growth study of Coxiella burnetii Nine Mile Phase I and Phase II in fibroblasts

Coxiella burnetii, a slow-growing, gram-negative, obligate intracellular bacterium, is the causative agent of Q fever in humans. The avirulent Phase II C. burnetii Nine Mile strain can invade and establish persistent infections in a wide variety of laboratory cell lines, and is generally considered to be easier to grow in culture than the wild-type Phase I organism. Efforts to improve Phase I organism yield in the BHK-21 cell line demonstrated that high CO2 conditions and the use of Dulbecco's modified Eagle's medium (DMEM) with 4.5 g/l glucose supplementation resulted in higher organism yields. Phase II organisms grown in the same cell line and conditions showed lower growth rates. Analysis revealed that increased average numbers of C. burnetii Phase I organisms within fibroblasts was due to higher growth rates within the hosts rather than to increased uptake or to increased cell-to-cell spreading. Addition of the nucleoside cytidine to the growth medium stimulated growth of Phase II but not Phase I organisms.

Liquid/air interfacial structure of alcohol-octyl hydroxamic acid mixtures: a study by sum-frequency spectroscopy

The molecular structure of the liquid/air interfaces of 1-octanol, 1-decanol, n-decane and the branched decyl alcohol EXXAL 10 has been studied by sum-frequency spectroscopy (SFS) in the C-H stretching vibrational region. The data suggest that the interfaces consist of ordered molecules with closely packed alkyl tails, in close to all-trans conformation with some gauche defects. The degree of surface ordering for the branched alcohol is much higher than for octanol and decanol. When octyl hydroxamic acid (OHA) is dissolved in 1-octanol it increases the gauche conformational defects in the interfacial chains, possibly due to mixing with the surface alcohol molecules and disrupting their ordering. In contrast, we suggest that when octyl hydroxamic acid is dissolved in EXXAL 10, the surface ordering of the alcohol chains does not change. We put forward the hypothesis that the appearance of new bands, belonging to the asymmetric methylene group vibrations and to the asymmetric methyl modes in the SF spectra of the mixture suggests that the surface OHA molecules are arranged with their hydrocarbon tails tilted very close to the interface.

Sodium dodecyl sulfate–poly(amidoamine) interactions studied by AFM imaging, conductivity, and Krafft temperature measurements

The conductivity, kappa, and Krafft temperature, TK, of sodium dodecyl sulfate (SDS) with poly(amidoamine) dendrimers (PAMAM) of 0.0, 0.5, and 1.0 generations (G) have been determined at different surfactant as well as PAMAM concentrations. The critical micelle concentration of SDS increases with the increase in the amount of each generation and the additive effect of 0.5G is maximum. TK of SDS shows a systematic decrease with maximum reduction in the presence of 0.5G. Atomic force microscopy (AFM) captures a layered pattern of 1.0G in the form of nanorods and no AFM images are detected for 1.0G in the presence of SDS. All results demonstrate that SDS has favorable interactions with ester-terminated 0.5G PAMAM rather than amine-terminated 0.0G and 1.0G.

Effect of fibrin glue on air leak and length of hospital stay after pulmonary lobectomy

AIM

Air leaks are a common cause of morbidity and prolonged hospital stay after pulmonary lobectomy. We reviewed our experience with intraoperative fibrin glue to determine if it reduced air leak and improved patient outcomes.

METHODS

Records of patients undergoing pulmonary lobectomy for benign or malignant disease over a 4-year period (1998-2001) were reviewed. Data was collected on age, sex, pulmonary function, pulmonary pathology, use of fibrin glue, duration of chest tube drainage, length of hospital stay, and postoperative complications.

RESULTS

Three hundred and sixty patients underwent lobectomy. Fibrin glue was used intraoperatively to seal air leaks in 102 of the 360 patients (study group: 102;control group: 258). Fibrin glue was used at the discretion of the surgeon, with some surgeons using it routinely. The groups did not differ in age (p=0.29), sex (p=0.42), FEV1 (p=0.57), or pathology (p=0.08). There were no differences in outcomes such as operative mortality (study: 2 of 102, control 6 of 258, p=0.85), empyema (study: 0 of 102, control: 3 of 258, p=0.55), prolonged (>7 days) air leaks (study: 10 of 20; control: 20 of 258, p=0.71), or length of hospital stay (study: 6.3+/-2.5 days, control:7.7+/-7.2 days, p=0.83). The use of fibrin glue was associated with a reduction in the duration of chest tube intubation (study: 4.1+/-3.2 days, control: 5.5+/-3.8 days, p=0.001).

CONCLUSION

Patients treated intraoperatively with fibrin glue had a significantly shorter duration of chest tube intubation after pulmonary lobectomy than those treated conventionally. However, the use of fibrin glue did not significantly influence more clinically relevant outcomes such as length of hospital stay and incidence of prolonged (>7 days) air leaks.

Development of a urinary biomarker of human exposure to deoxynivalenol

Deoxynivalenol (DON) is a mycotoxin frequently found as a contaminant of cereal crops and may be etiologically associated with adverse health effects in developing countries where considerable quantities of contaminated crops are consumed. We investigated the metabolism of DON in rats as a basis to establish methodology for a candidate biomarker of human exposure to this toxin and tested this methodology on urine samples from a potentially highly exposed population. Sprague-Dawley rats received a single dose of [14C]DON (5.0+/-0.1 mg/kg body weight, 5.5+/-0.1 microCi/kg) and the distribution of DON in body fluids was investigated over 72 h. DON and its metabolites were detectable in the plasma of rats with the highest levels at 8 h, at which time approximately 9% was bound to plasma protein. A total of 37% of the administered DON was excreted in the urine and DON-glucuronide was implicated as the major urinary metabolite based on reverse-phase HPLC analysis of beta-glucuronidase- and sulphatase-treated samples. An immunoaffinity column (IAC)-HPLC method was subsequently developed to measure urinary metabolites, with a view to establishing a urine-based human biomarker. Urine samples were collected from female inhabitants of Linxian County, China, a high risk region for oesophageal cancer (OC) and an area of potentially high DON exposure, and Gejiu, a low risk region in China. DON was detected in all 15 samples following beta-glucuronidase treatment and IAC enrichment with the identity of DON being confirmed by mass spectrometry. The mean levels of DON from the suspected high and low exposure regions of China were 37 ng/ml (range 14-94 ng/ml) and 12 ng/ml (range 4-18 ng/ml), respectively. This is estimated to correspond to daily exposures of 1.1-7.4 microg/kg/day and 0.3-1.4 microg/kg/day, respectively. This is the first reported measurement of a urinary biomarker for DON in both animals and humans and should facilitate epidemiological studies of disease associations with this mycotoxin.

Persistence and reversibility of the elevation in free sphingoid bases induced by fumonisin inhibition of ceramide synthase

These studies determined (1) the time course for sphingoid base elevation in the small intestines, liver, and kidney of mice following a single 25 mg/kg body weight (bw) oral dose (high dose) of fumonisin B(1) (FB(1)), (2) the minimum threshold dose of FB(1) that would prolong the elevated sphingoid base concentration in kidney following the single high dose, and (3) the importance of the balance between the rate of sphingoid base biosynthesis and degradation in the persistence of sphingoid base accumulation. Following the high dose of FB(1), there was an increase in sphinganine in intestinal cells and liver that peaked at 4 to 12 h and declined to near the control level by 48 h. In kidney, sphinganine peaked at 6-12 h but remained elevated until 72 h, approaching control levels at 96-120 h. Oral administration of 0.03 mg FB(1)/kg bw (low dose) for 5 days had no effect on the sphingoid bases in kidney. However, following an initial high dose, daily administration of the low dose prolonged the elevation in kidney sphinganine compared to mice receiving a single high dose. Thus, a single exposure to a high dose of FB(1) followed by daily exposure at low levels will prolong the elevation of sphinganine in kidney. In cultured renal cells FB(1) was rapidly eliminated, but elevated sphinganine was persistent. This persistence in renal cells was rapidly reversed in the presence of the serine palmitoyltransferase inhibitor (ISP-1), indicating that the persistence was due to differences in the rates of sphinganine biosynthesis and degradation. The in vivo persistence in kidney may be due to similar differences.

The fungal metabolite culmorin and related compounds

This paper reviews the toxicology of culmorins, a family of compounds found in grains contaminated by Fusarium graminearum and related fungi. We include the results of an Ames test and studies based on Quantitative Structure-Activity Relationships. Culmorin has low toxicity in several in vitro assays and in one study in swine and is Ames test negative. Culmorin is moderately antifungal. QSAR analysis suggested that the plant compound longifolene was similar. Longifolene is a GRAS compound used in cosmetics and is also moderately antifungal.

Handsewn or stapled esophagogastric anastomoses after esophagectomy for cancer: meta-analysis of randomized controlled trials

Gastric transposition with esophagogastric anastomosis is a common method of reconstruction after esophagectomy for cancer. The anastomosis can be fashioned using a handsewn or stapled technique. The choice of anastomotic technique is often debated but there is little evidence to support the use of one method over the other. We performed a meta-analysis of randomized controlled trials (RCTs) to determine the effect of esophagogastric anastomotic method (handsewn or circular stapled) on patient outcomes. Medline and manual searches were done (completed independently and in duplicate) to identify all published RCTs that addressed the issue of handsewn or stapled esophagogastric anastomosis after esophagectomy for cancer. The selection process was inclusive; no trials were excluded. Trial validity assessment was done and a trial quality score was assigned. Major outcomes for quantitative data synthesis included operative mortality, anastomotic leaks, anastomotic strictures, cardiac morbidity, and pulmonary morbidity. A random-effects model was used and relative risk was the principal measure of effect. Systematic qualitative review was used for other outcomes such as duration of operation and time to complete the anastomosis. Data on cancer survival were not available in the RCTs. Five RCTs were selected with quality scores ranging from 2 to 3 (5-point Jadad scale). Selection and validity agreement was strong. Relative risk (95% confidence interval, CI; P-value), expressed as handsewn vs. stapled (treatment vs. control), was 0.45 (0.20, 1.00; P=0.05) for operative mortality, 0.79 (0.44, 1.42; P=0.43) for anastomotic leaks, 0.60 (0.27, 1.33; P=0.21) for anastomotic strictures, 0.99 (0.55, 1.77; P=0.97) for cardiac morbidity, and 0.93 (0.63, 1.37; P=0.72) for pulmonary morbidity. Data synthesized from existing RCTs show that handsewn and circular stapled esophagogastric anastomotic techniques give similar results for anastomotic outcomes, such as leaks and strictures. The stapled anastomotic method appears to increase operative mortality (P=0.05). Although it is difficult to explain this finding, it should not be dismissed. Several hypotheses are discussed.

Dalteparin vs. enoxaparin as prophylaxis for deep-vein thrombosis after total hip or knee arthroplasty: a retrospective analysis

OBJECTIVE

To assess the clinical and economic consequences of a formulary switch from enoxaparin to dalteparin as first-line prophylaxis for deep-vein thrombosis in patients undergoing inpatient rehabilitation after total hip arthroplasty or total knee arthroplasty.

DESIGN

Retrospective cohort study.

RESULTS

There were 461 patients eligible for the study. The age-adjusted risk of a deep-vein thrombosis event confirmed by duplex ultrasonography among patients treated with dalteparin was substantially lower than among patients treated with enoxaparin, whereas the age-adjusted risk of a bleeding event in the dalteparin group was also lower than that in the enoxaparin group. Adjusted per capita costs of deep-vein thrombosis prophylaxis during the rehabilitation stay were $129 lower among subjects treated with dalteparin.

CONCLUSION

The switch to dalteparin as a first-line therapy for deep-vein thrombosis prophylaxis in the rehabilitation period after total hip arthroplasty or total knee arthroplasty has led to substantial cost savings for Kessler Institute without compromising patient care.

Reduced submaximal leg blood flow after high-intensity aerobic training

This study evaluated the hypothesis that active muscle blood flow is lower during exercise at a given submaximal power output after aerobic conditioning as a result of unchanged cardiac output and blunted splanchnic vasoconstriction. Eight untrained subjects (4 men, 4 women, 23-31 yr) performed high-intensity aerobic training for 9-12 wk. Leg blood flow (femoral vein thermodilution), splanchnic blood flow (indocyanine green clearance), cardiac output (acetylene rebreathing), whole body O(2) uptake (VO(2)), and arterial-venous blood gases were measured before and after training at identical submaximal power outputs (70 and 140 W; upright 2-leg cycling). Training increased (P < 0.05) peak VO(2) (12-36%) but did not significantly change submaximal VO(2) or cardiac output. Leg blood flow during both submaximal power outputs averaged 18% lower after training (P = 0.001; n = 7), but these reductions were not correlated with changes in splanchnic vasoconstriction. Submaximal leg VO(2) was also lower after training. These findings support the hypothesis that aerobic training reduces active muscle blood flow at a given submaximal power output. However, changes in leg and splanchnic blood flow resulting from high-intensity training may not be causally linked.

CD8 binding to MHC class I molecules is influenced by T cell maturation and glycosylation

CD8 serves both as an adhesion molecule for class I MHC molecules and as a coreceptor with the TCR for T cell activation. Here we study the developmental regulation of CD8-mediated binding to noncognate peptide/MHC ligands (i.e., those not bound by the TCR). We show that CD8's ability to bind soluble class I MHC tetramers and to mediate T cell adhesion under shear flow conditions diminishes as double-positive thymocytes mature into CD8(+) T cells. Furthermore, we provide evidence that this decreased CD8 binding results from increased T cell sialylation upon T cell maturation. These data suggest that CD8's ability to interact with class I MHC is not fixed and is developmentally regulated through the T cell's glycosylation state.

Survival after conservative (palliative) management of pleural malignant mesothelioma

BACKGROUND AND OBJECTIVES

Malignant mesothelioma is a lethal disease. Aggressive multimodality treatment protocols are reportedly associated with improved survival, but the apparent survival benefits may simply reflect patient selection and the variable natural history of this malignancy. Before embarking on our own protocol of experimental treatment for mesothelioma, we sought to identify important prognostic factors and document the survival of patients treated conservatively (with palliative intent only) in our region.

METHODS

We performed a retrospective review of all patients with a diagnosis of malignant mesothelioma seen at our center between 1987 and 1999. Since curative intent treatment had not been given, we assumed that measured survival would largely reflect the natural history of the malignancy.

RESULTS

There were 101 patients (80 males and 21 females). Mean age was 65 +/- 9.2 years. Symptoms of disease were present for a median time of 5 months before the diagnosis was established. The most common presenting symptoms were dyspnea (46 patients), chest pain (30 patients), and weight loss (22 patients). Sixty-eight patients (68%) had a history of asbestos exposure. Mesothelioma subtypes included epithelial (43 patients), sarcomatous (26 patients), mixed (19 patients), desmoplastic (4 patients), and unspecified (9 patients). All 101 patients were treated with palliative intent. Talc pleurodesis was performed in 70 patients. At the time of analysis, 90 patients had died and 11 remained alive. Median survival was 213 (95% CI 137-289) days. Survival for the three major histological subtypes was significantly different (log rank, P = 0.0016). Histological subtype (epithelial favorable) was the only significant independent prognostic factor (Cox proportional hazard regression, P = 0.0009).

CONCLUSIONS

Patients with epithelial mesothelioma survive longer than those with other histological subtypes. Conservatively managed patients with pleural malignant mesothelioma have a median survival of approximately 7 months. These data from conservatively treated patients can serve as baseline information for future studies of experimental treatments.

A meta-analysis of randomized controlled trials of route of reconstruction after esophagectomy for cancer

BACKGROUND

A gastric conduit is usually used to reconstruct the foregut after esophagectomy for cancer. It can be transposed through a posterior or anterior mediastinal route. The choice of route is often debated but there is little evidence to support the use of one route over the other. We performed a meta-analysis of randomized controlled trials (RCTs) to determine the effect of route of reconstruction on patient outcomes.

METHODS

Medline and manual searches were done (completed independently and in duplicate) to identify all published RCTs that addressed the issue of route of gastric conduit reconstruction after esophagectomy for cancer. The selection process was inclusive; no trials were excluded. Trial validity assessment was done and a trial quality score was assigned. Major outcomes for quantitative data synthesis included operative mortality, anastomotic leaks, cardiac morbidity, and pulmonary morbidity. A random-effects model was used and relative risk was the principal measure of effect. Systematic qualitative review was used for other outcomes such as duration of ventilation, length of hospital stay, operative blood loss, duration of surgery, anastomotic strictures, dysphagia, gastric emptying, and quality of life. Data on cancer survival were not available in the RCTs.

RESULTS

Six RCTs were selected with quality scores ranging from 1 to 4 (5-point Jadad scale). Selection and validity agreement was strong. Relative risk (95% confidence interval; P value), expressed as posterior versus anterior mediastinal route (treatment versus control), was 0.56 (0.17, 1.82; P = 0.34) for mortality, 1.01 (0.35, 2.94; P = 0.98) for leaks, 0.43 (0.17, 1.12; P = 0.08) for cardiac complications, and 0.67 (0.34, 1.33; P = 0.26) for pulmonary complications. Systematic qualitative review did not suggest any difference in other perioperative outcomes or conduit function for the two routes of reconstruction.

CONCLUSIONS

Data synthesized from existing RCTs show that posterior and anterior mediastinal routes of reconstruction are associated with similar outcomes after esophagectomy for cancer. However, a difference in outcomes for the two reconstructive routes remains possible. Further trials with larger numbers of patients are needed.

High-affinity interactions of ligands at recombinant guinea pig 5HT7 receptors

The serotonin 5HT7 receptor has been implicated in numerous physiological and pathological processes from circadian rhythms to depression and schizophrenia. Clonal cell lines heterologously expressing recombinant receptors offer good models for understanding drug-receptor interactions and development of quantitative structure-activity relationships (QSAR). Comparative Molecular Field Analysis (CoMFA) is an important modern QSAR procedure that relates the steric and electrostatic fields of a set of aligned compounds to affinity. Here, we utilized CoMFA to predict affinity for a number of high-affinity ligands at the recombinant guinea pig 5HT7 receptor. Using R-lisuride as the template, a final CoMFA model was derived using procedures similar to those of our recent papers. The final cross-validated model accounted for >85% of the variance in the compound affinity data, while the final non-cross validated model accounted for >99% of the variance. Model evaluation was done using cross-validation methods with groups of 5 ligands. Twenty cross-validation runs yielded an average predictive r2(q2) of 0.779 +/- 0.015 (range: 0.669-0.867). Furthermore, 3D-chemical database search queries derived from the model yielded hit lists of promising agents with high structural similarity to the template. Together, these results suggest a possible basis for high-affinity drug action at 5HT7 receptors.

Mouse model for thoracic congenital scoliosis

SUMMARY

This study sought to produce a dose-response curve for acute and chronic maternal carbon monoxide (CO) exposure versus vertebral anomalies in mouse offspring and to determine the critical day of exposure. In Part I, pregnant CD-1 mice were exposed to an acute dose of CO at 9 days of gestation. A positive dose-response relationship of acute maternal CO exposure and vertebral anomalies in the offspring was produced. In Part II, pregnant females were exposed to chronic CO for the first 11 days of gestation. Chronic exposure to CO did not produce significant vertebral anomalies. In Part III, pregnant females were exposed to an acute dose of 600 ppm of CO at gestation day 8, 9, or 10. Day 9 in this mouse breed is the critical day for maternal exposure to CO. The detected anomalies were predominately in the thoracic spine.

Self-inflicted pneumothoraces

Self-inflicted pneumothoraces are rare manifestations of psychiatric illness. Two patients with self-inflicted pneumothoraces are reported, and the typical clinical features of factitious disorders are described. If thoracic surgeons are aware of these conditions, inappropriate surgery- and poor outcomes-can be avoided.

Factors that affect the occurrence of fumonisin

The two important Fusarium ear rots of corn, Gibberella ear rot (Fusarium graminearum, formally F. moniliforme and allied species) and Fusarium ear rot (F. verticillioides and allied species) grow under different environmental conditions. F. graminearum grows well only between 26 and 28 degrees C and requires rain both at silking and during disease progression. F. verticillioides grows well at higher temperatures, and ear rot and fumonisin accumulation are associated with drought and insect stress and growing hybrids outside their areas of adaptation. In southern Transkei, where esophageal cancer has been associated with the consumption of F. verticillioides and fumonisin-contaminated corn, environmental conditions favor this fungus in most years. In the nearby areas where the soils, crops, food consumption, and populations are the same and where esophageal cancer is low, temperatures are cooler and F. graminearum is favored. Although F. verticillioides is associated with a disease of corn, it may be that this fungus is a mutualistic endophyte of the plant. Perhaps because of this, breeding for resistance to Fusarium ear rot has produced inconclusive results to date. The best available strategies for reducing the risk of fumonisin contents of maize are to ensure that hybrids are adapted to the environment and to limit drought stress and insect herbivory. It may also be necessary to make use of alternative strategies such as producing hybrids that contain enzymes to degrade fumonisin as it is produced.

Core-binding factor beta (CBFbeta), but not CBFbeta-smooth muscle myosin heavy chain, rescues definitive hematopoiesis in CBFbeta-deficient embryonic stem cells

Core-binding factor beta (CBFbeta) is the non-DNA-binding subunit of the heterodimeric CBFs. Genes encoding CBFbeta (CBFB), and one of the DNA-binding CBFalpha subunits, Runx1 (also known as CBFalpha2, AML1, and PEBP2alphaB), are required for normal hematopoiesis and are also frequent targets of chromosomal translocations in acute leukemias in humans. Homozygous disruption of either the Runx1 or Cbfb gene in mice results in embryonic lethality at midgestation due to hemorrhaging in the central nervous system, and severely impairs fetal liver hematopoiesis. Results of this study show that Cbfb-deficient mouse embryonic stem (ES) cells can differentiate into primitive erythroid colonies in vitro, but are impaired in their ability to produce definitive erythroid and myeloid colonies, mimicking the in vivo defect. Definitive hematopoiesis is restored by ectopic expression of full-length Cbfb transgenes, as well as by a transgene encoding only the heterodimerization domain of CBFbeta. In contrast, the CBFbeta-smooth muscle myosin heavy chain (SMMHC) fusion protein generated by the inv(16) associated with acute myeloid leukemias (M4Eo) cannot rescue definitive hematopoiesis by Cbfb-deficient ES cells. Sequences responsible for the inability of CBFbeta-SMMHC to rescue definitive hematopoiesis reside in the SMMHC portion of the fusion protein. Results also show that the CBFbeta-SMMHC fusion protein transdominantly inhibits definitive hematopoiesis, but not to the same extent as homozygous loss of Runx1 or Cbfb. CBFbeta-SMMHC preferentially inhibits the differentiation of myeloid lineage cells, while increasing the number of blastlike cells in culture.

Personality disorders as extreme variants of common personality dimensions: can the Five-Factor Model adequately represent psychopathy?

The present study examined Widiger and Lynam's (1998) hypothesis that psychopathy can be represented using the Five-Factor Model (FFM) of personality. Participants in the study consisted of 481 21-22-year-old men and women who are part of an ongoing longitudinal study. Psychopathy was assessed by the degree of similarity between an individual's NEO-PI-R and an expert-generated FFM psychopathy prototype. The expert-based prototype supported the account of Widiger and Lynam (1998), as did the correlations between the NEO-PI-R Psychopathy Resemblance Index (PRI) and the individual personality dimensions. The PRI was also related in predicted ways to measures of antisocial behavior, drug use, and psychopathology. The results support the contention that psychopathy can be understood as an extreme variant of common dimensions of personality, and underscore the utility of a dimensional model of personality disorders.

Anastomotic leaks after esophagectomy for esophageal cancer: a comparison of thoracic and cervical anastomoses

BACKGROUND AND OBJECTIVES

Esophagogastric anastomotic leaks remain a significant problem after esophagectomy for esophageal cancer. Many investigators have reported that leaks are more frequent after cervical, as opposed to thoracic, esophagogastric anastomoses. We conducted a retrospective review to assess the effect of anastomotic location (thoracic or cervical) on anastomotic leak incidence and severity.

METHODS

Seventy-four consecutive patients with esophageal cancer underwent esophagectomy and esophagogastric anastomoses at our institution over a four-year period. Their charts were reviewed retrospectively and data was collected on age, gender, histology, stage, resection margin status, adjuvant therapy, cancer survival, anastomotic location, anastomotic leaks, and operative mortality.

RESULTS

Cervical anastomoses were done in 19 patients and thoracic anastomoses were done in the other 55 patients. The two groups were similar with respect to age, gender, histology, stage, adjuvant therapy, and overall survival. Operative mortality for the entire group of 74 patients was 4% (3 patients). Resection margins were positive for residual tumor in 2 of 19 (11%) patients with cervical anastomoses and 9 of 55 (16%) patients with thoracic anastomoses (p=0.42). Leaks complicated 1 of 19 (5%) cervical and 9 of 55 (16%) thoracic esophagogastric anastomoses (p=0.21). Positive resection margins and anastomotic leaks were not significantly related (p=0.54). One of 9 (11%) leaks in the thoracic group proved fatal.

CONCLUSIONS

In our experience cervical esophagogastric anastomoses do not have a higher incidence of leaks than thoracic anastomoses.

Open lung biopsy as an outpatient procedure

BACKGROUND

Lung biopsies are frequently needed to diagnose diffuse interstitial lung diseases. Both limited thoracotomy (open lung biopsy) and thoracoscopy can be used for lung biopsies, but both procedures have traditionally required hospital admission. We report a series of patients that underwent outpatient open lung biopsy to show the safety and effectiveness of this practice.

METHODS

We reviewed records of ambulatory, nonoxygen dependent patients with a clinical diagnosis of diffuse interstitial lung disease that underwent outpatient open lung biopsy between January 1997 and December 1999. All procedures were done by a senior surgeon using single lumen endotracheal anesthesia, a small anterolateral thoracotomy without rib spreading, stapled wedge resection, and no chest tube. Patients were discharged the same day.

RESULTS

Thirty-two patients with a clinical diagnosis of diffuse interstitial lung disease underwent outpatient open lung biopsy. Mean age was 58 years (range, 21 to 74 years). Preoperative forced expiratory volume in 1 second was 74.3%+/-7.0% of predicted. A pathologic diagnosis was established in all patients: usual interstitial pneumonia, 26 patients; sarcoidosis, 2; metastatic carcinoma, 2; desquamative interstitial pneumonia, 1; and mixed dust pneumoconiosis, 1 patient. No patient required a chest tube, overnight observation, or hospital admission. No complications occurred.

CONCLUSIONS

Selected patients with a clinical diagnosis of diffuse interstitial lung disease can safely and effectively undergo diagnostic outpatient open lung biopsy. However, careful patient selection and attention to operative detail are essential.

Local recurrence after total or subtotal esophagectomy for esophageal cancer

Cancer recurrence is a common problem after esophagectomy for esophageal cancer. Local recurrence is especially problematic because it often negates the palliative benefit of esophagectomy. We conducted a retrospective review to assess the effect of extent of esophageal resection (subtotal or total esophagectomy) on local cancer recurrence. Seventy-four consecutive patients with esophageal cancer underwent esophagectomy at our institution over a four-year period. Their charts were reviewed retrospectively and data was collected on age, gender, histology, stage, tumor location, operation, resection margin status, anastomotic leaks, operative mortality, adjuvant therapy, cancer survival, and local recurrence. Total esophagectomy was done in 19 patients (transhiatal - 3; McKeown - 16) and subtotal esophagectomy was done in the other 55 patients (Lewis - 25; left thoracoabdominal - 30). The two groups were similar with respect to age, gender, histology, stage, anastomotic leaks, operative mortality, adjuvant therapy, and overall survival. Resection margins were positive for residual tumor in 2 out of 19 (11%) total esophagectomies and 9 out of 55 (16%) subtotal esophagectomies (p=0.42). Local recurrence occurred in 3 of 19 (16%) patients treated with total esophagectomy and 23 out of 55 (42%) patients treated with subtotal esophagectomy (p=0.04). We conclude that total esophagectomy is associated with fewer local cancer recurrences than subtotal esophagectomy. We, therefore, recommend total esophagectomy for the surgical treatment of esophageal cancer.

Prophylactic intracavitary (pneumonectomy space) antibiotic instillation: a comparative study

BACKGROUND AND OBJECTIVES

Postpneumonectomy empyema is a dreaded complication of pneumonectomy. The effectiveness of prophylactic intracavitary antibiotic instillation is not known. We conducted a retrospective review to assess the effect of pneumonectomy space antibiotic instillation on septic complications (empyema and bronchial fistula) of pneumonectomy.

METHODS

Ninety-three consecutive patients underwent pneumonectomy at our institution over a three-year period. Their charts were reviewed retrospectively and data was collected on age, gender, diagnosis, intravenous antibiotics, intracavitary (pneumonectomy space) antibiotics, empyemas, bronchial fistulas, length of hospital stay, and operative mortality.

RESULTS

All 93 patients received 3 perioperative doses of prophylactic intravenous antibiotics. One group (n=47) of patients also received intraoperative intracavitary instillation of an antibiotic solution (penicillin G: 5 million units, bacitracin: 50,000 units, gentamicin: 60 mg, in 1 litre of saline) while the other group (n=46) did not. Age, gender, diagnosis, and length of stay were not significantly different in the two groups. There were no empyemas or bronchial fistulas in the intracavitary antibiotic group. Postpneumonectomy empyemas occurred in 6 (13%) patients (empyema with bronchial fistula: 5, empyema alone: 1) that had not received intracavitary antibiotics (p=0.012). There were 4 deaths (9%) in each group (p=0.63).

CONCLUSIONS

Prophylactic intraoperative intracavitary antibiotic instillation may reduce the incidence of empyemas after pneumonectomy. However, a randomized trial would be needed to prove the effectiveness of this form of prophylactic antibiotic strategy.