Can a severe degree of ketoacidosis develop overnight?

Insulin-dependent diabetes mellitus in poor control, alcohol intake associated with extracellular fluid volume contraction, or hypoglycemia may each lead to an increased rate of production of ketoacids. Generally, several days of illness are required before ketoacidosis becomes severe. Two clinical examples are presented to suggest that a severe degree of ketoacidosis may develop over a short period of time, literally overnight. In both examples, there was the ingestion of a modest amount of ethanol. From a quantitative analysis of factors that may influence the rate of production and removal of ketoacids, the following were deduced. Contributing factors to the very rapid development of maximal ketoacidosis could include the absence of a lag period for the conversion of ethanol to acetyl-coenzyme A in the liver and an impaired ability of the brain and kidneys to oxidize ketoacids, especially if these ketoacids are produced very rapidly and/or if less metabolic work is performed by these organs. In special settings, ketoacidosis may develop more rapidly than is generally appreciated.

Adenocarcinoma at ureterosigmoidostomy junction in a renal transplant recipient 15 years after conversion to ileal conduit

In recent years, adenocarcinoma of the colon mucosa has become a recognized complication of ureterosigmoidostomy and in most cases the tumor arises at the site of ureterocolonic anastomosis. We report a case of a 29-year-old renal transplant recipient who developed two colonic carcinomas at the site of ureterosigmoidostomy 25 years after the urinary diversion and 15 years after conversion to an ileal conduit. This case emphasizes the need for a careful life-long follow-up of all patients who undergo ureterosigmoidostomy.

Chronic myelomonocytic leukemia associated with primary amyloidosis

A case of chronic myelomonocytic leukemia (CMML) associated with primary amyloidosis (AL) is presented. Hepatosplenomegaly, macroglossia, and xanthelasma were the major physical findings. Laboratory tests showed macrocytic anemia, thrombocytopenia, monocytosis and a bi-clonal gammopathy. Early monocytes and monoblasts were noted in the bone marrow aspiration biopsy. Cytogenetic evaluation showed a clonal deletion of chromosome 21 long arm (21q-). Amyloid was present in the liver, tongue and xanthelasma. In addition, the patient was noted to have osteosclerosis of the lower extremities. Treatment with prednisone and colchicine resulted in a subjective response. The unusual association of CMML, and primary amyloidosis is discussed.

Organ transplants from living donors

I. Survey of Transplant Techniques

The kidney is one of the few organs which today can be successfully transplanted from a living donor to an ailing recipient. A healthy donor can function satisfactorily with a single kidney; therefore the removal of one kidney for transplantation does not significantly endanger the donor's life. However, removal, or even partial removal, of other organs, such as the heart, lungs, or pancreas, will present a serious risk to the health and life of the donor.

In addition to organs, skin, bone marrow, blood and other body parts can be transplanted from living donors.

A. Kidney Transplants

The kidneys function to regulate the body's electrolyte and water balance and eliminate various wastes. Severe kidney dysfunction endangers the patient's life, and requires treatment by dialysis or kidney transplant. Up until a decade ago, the life expectancy of patients treated by dialysis exceeded that of patients who underwent kidney transplants. Over the past decade, the life expectancy of patients who have undergone kidney transplants from deceased donors has increased to a point where it is now comparable with the life expectancy of patients on dialysis.

Chronic lactic acidosis in a patient with acquired immunodeficiency syndrome and mitochondrial myopathy: biochemical studies

A 30-yr-old man with acquired immunodeficiency syndrome treated with zidovudine developed biopsy-proven mitochondrial myopathy. Chronic lactic acidosis (lactate, 10 +/- 1 mmol/L) persisted for more than 5 wk. Liver function tests were normal, but the concentration of lactose rose to 16.1 mmol/L when 500 mmol of ethanol was infused. The concentration of lactose rose by only 1.5 mmol/L with maximally tolerated exercise. If this mitochondrial lesion compromised flux through the electron transport system, increased turnover of ATP with exercise should have exacerbated the degree of lactic acidosis because of increased need to regenerate ATP via glycolysis. Two possible explanations will be discussed: first, there was both a rapid rate of production of lactic acid in affected muscles in conjunction and an equally rapid rate of removal by uninvolved organs. Second, there was a low net rate of production of lactic acid in involved muscles despite the exercise.

Can oxygen consumption in blood in vitro be detected by a change in PCO2?

The PO2 measured in a sample of blood can be misleadingly low, owing to consumption of oxygen in vitro in patients with leukemia. The purpose of this study was to determine whether a rise in PCO2 in such blood could be a useful indication of consumption of oxygen in vitro. Because of the non-bocarbonate buffer capacity of blood and the carriage of CO2, mainly as bicarbonate, we reasoned that the rise in PCO2 would be too small to be helpful. Hence the quantitative relationship between the consumption of oxygen and the production of CO2 in blood was determined. Other reactions yielding CO2 (the titration of lactic acid) were monitored. Consumption of oxygen was stimulated in blood of normals in vitro by adding methylene blue (100 mumol/L); in addition, blood from four patients with leukemia was studied without additions. The rate of consumption of oxygen at 22 degrees C was linear over 60 min; the respiratory quotient was close to unity. The rise in PCO2 was small even when the fall in PO2 was 60 mmHg. We conclude that a rise in PCO2 is not a reliable way to diagnose consumption of oxygen in blood in vitro as patients may hyperventilate, making it very difficult to recognize a small rise in PCO2.

Moloney murine leukemia virus IN protein from disrupted virions binds and specifically cleaves its target sequence in vitro

The integration of retroviral DNA plays an essential role in the viral life cycle. Previous studies of the Moloney murine leukemia virus (M-MuLV) have shown that viral integration is mediated by the integrase (IN) protein acting on the 13-bp inverted repeats that flank the linear viral DNA produced during reverse transcription. Prior studies have also shown that when the M-MuLV IN protein is produced in Escherichia coli it retains an ability to specifically associate with the viral inverted repeats (Krogstad and Champoux, 1990). In this study we present evidence that the IN protein present in detergent-disrupted virions is capable of specifically interacting with double-stranded oligonucleotides that correspond to the viral inverted repeats, and that this interaction may change after integration-related processing of the viral att sites. We further present evidence that, in vitro, detergent-disrupted virions are capable of specifically cleaving ds-IR oligonucleotides in an IN-dependent reaction that mimics the trimming step that precedes integration.

Early methodological developments for clinical trials at the National Heart, Lung and Blood Institute

The National Heart Institute, now known as the National Heart, Lung and Blood Institute (NHLBI), initiated its first multicentre randomized clinical trials of rheumatic fever and rheumatic heart disease in 1951. The modern era of multicentre trials began, however, when the Coronary Drug Project was initiated in the 1960s. This trial and subsequent NHLBI trials stimulated a wide variety of research on clinical trial methodology. This paper reviews early methodologic developments in four areas. First, an organizational structure for multicentre clinical trials was developed and codified in the 'Greenberg Report' in 1967. Second, design considerations related to patient risk, non-compliance, a lag in treatment effect, and changing risk were explored. The 'intention-to-treat' principle was implicit in these investigations. Thirdly, the concept of periodic review of accumulating data, recommended in the Greenberg report, stimulated research on methods for sequential analysis. Three statistical approaches were developed and investigation of their statistical properties continues today. These approaches are usually described as group sequential, stochastic curtailment, and Bayesian methods. Finally, comparison of treatments in longitudinal studies has been an increasing part of NHLBI research and methods have been developed for design and analysis of longitudinal studies.

Enzyme-linked immunosorbent assay for distinguishing serological responses of lepromatous and tuberculoid leprosies to the 29/33-kilodalton doublet and 64-kilodalton antigens of Mycobacterium tuberculosis

Immunoblot assays for the antibodies to Mycobacterium tuberculosis sonic extracts showed that all serum specimens of 40 lepromatous and of 28 tuberculoid leprosy patients reacted in a significant manner to 29/33-kilodalton (kDa) doublet and 64-kDa antigens, respectively. By using an enzyme-linked immunosorbent assay, we observed a significantly high immunoglobulin G antibody titer to the purified M. tuberculosis 29/33-kDa doublet and 64-kDa antigens in lepromatous and tuberculoid leprosy patients, respectively, as compared with normal subjects and tuberculosis patients. This enzyme-linked immunosorbent assay serology may be useful for distinguishing two polar types of leprosy and for diagnosing leprosy in general.

Distribution-free confidence intervals for a parameter of Wilcoxon-Mann-Whitney type for ordered categories and progressive censoring

Halperin, Gilbert, and Lachin (1987, Biometrics 43, 71-80) obtain confidence intervals for Pr(X less than Y) based on the two-sample Wilcoxon statistic for continuous data. Their approach is applied here to ordered categorical data and right-censored continuous data, using the generalization zeta = Pr(X less than Y) + 1/2Pr(X = Y) to account for ties. Deviations from nominal coverage probability for various sample sizes and values of zeta are obtained via simulation of either three or six ordered categories based on underlying Poisson or exponential distributions. The simulation results indicate that the proposed method performs quite well, and it is apparently superior to the approach of Hochberg (1981, Communications in Statistics--Theory and Methods A10, 1719-1732) for values of zeta far from 1/2.

Stochastic curtailing for comparison of slopes in longitudinal studies

In some clinical trials, rate of change of a physiological function is used as a surrogate for a more serious outcome. We assume an expected change linear in time for each study participant with variation in slopes and intercepts from individual to individual and repeated measures over time for each individual. We also assume that deviations of response for an individual from expected response have zero mean, constant variance, and are uncorrelated. Under these assumptions we describe ways in which stochastic curtailing as defined by Lan, Simon, and Halperin (Commun Stat Seq Anal 1:207-219, 1982) can be implemented in a two-treatment trial for one-sided comparison of slopes in the two groups. Staggered entry is taken into account, as is the possibility that some of an individual's responses are not available; this is assumed to be random. The analysis assumes the number of participants in each group is large and that most individuals have at least two measurements (including baseline value). The possibility that rate of change is not constant and its consequences are discussed.

Interleukin 1 inhibitory activity secreted by a human myelomonocytic cell line (M20)

Culture supernatants from a myelomonocytic cell line (M20) were found to inhibit interleukin 1 (IL 1) activity in vitro. The factor, isolated from these supernatants, inhibited augmentation of phytohemagglutinin response of mouse thymus cells induced by IL 1 derived from several established cell lines. Various IL 1-dependent activities such as lymphocyte and fibroblast proliferation in vitro were also inhibited by the factor. The factor did not inhibit IL 2-induced or other proliferative responses not related to IL 1. Preliminary biochemical characterization of the factor indicated that the activity resides in a protein with a molecular mass of 52 kDa.

The orthogonal electrocardiogram as risk indicator for the prediction of myocardial infarction and/or cardiac death

In a prospective study on Coronary Heart Disease (CHD) orthogonal electrocardiograms (Frank) were recorded annually for ten years from 1,444 asymptomatic, middle-aged males with a mean age of 57.4 +/- 10.6 years. Cases with overt or suspected CHD were excluded. The purpose of the study was to identify risk indicators in electrocardiograms and to compare them with other known risk factors used for prediction of acute CHD events such as myocardial infarction (MI) and/or cardiac death (CD). Such acute events occurred in 88 cases. Pre-event ECGs of these acute events were compared with all others without events, using logistic regression analysis. Identified ECG risk indicators were then compared with other known risk factors such as smoking, blood pressure, cholesterol, age, weight, etc. The predictive power of the ECG, derived mainly from the ST-T complex, exceeded all others by a wide margin. The amplitude of the first 1/8 of the ST-T complex in lead x (similar to V5-V6) together with relative body weight proved best when one pre-event record was available. Prediction improved when ECG changes between two pre-event recordings were included. Precision of measurements by computer appeared essential for improvements in CHD prediction.

Detection of different interleukin-1 activities in human monocytes and monocytic cell lines

Culture supernatants from normal human monocytes, monocyte hybrid cell lines, and myelomonoblastic cell lines were tested for human interleukin-1 (IL-1) activity. In the present study, we report the detection of IL-1 secreted by several cell lines of monocyte origin and compare their biological and biochemical characteristics. IL-1 activity was tested by the regular assay of phytohemagglutinin (PHA) response of mouse thymus cells. IL-1 was found to be constitutively secreted by U937 and the M20 cell lines, as well as by three of the monocyte hybrid cell lines. The activity was always augmented following dialysis and did not require the presence of serum for its secretion. We compared the IL-1 activity of the myelomonoblastic M20 and hybrid 1C4 cell lines to that of normal monocytes. We found differences in the kinetics of IL-1 secretion, the pattern of activity following dilution of concentrated supernatants, and augmentation of activity by various inducers. The differences described may be explained by concomitant secretion of IL-1 inhibitory factors, as well as the secretion of activities other than IL-1. Preliminary biochemical analysis showed that all three cell sources tested shared some species of molecules characterized by gel filtration and ion-exchange chromatography. However, some species of molecules expressing IL-1 activity were unique to the cell lines and were not found in normal monocytes.

In vitro differentiation and establishment of cell lines derived from human myelomonocytic leukemia cells

Primary cultures of cells derived from 13 patients with acute myelomonocytic leukemia (AMML) were studied with particular emphasis on in vitro proliferation, cell differentiation and the mode for establishment of cell lines. Using irradiated human macrophage monolayers to assist cell growth, we obtained four new cell lines of myelomonocytic origin. All the cell lines were characterized for cytochemical markers and response to phorbol esters (TPA), a differentiation inducing agent. In the absence of any inducing agent, spontaneous differentiation of blast cells into mature macrophages-like cells occurred in 8 out of the 13 primary cultures. Thus, maturation induction by agents such as TPA is not always required in order to obtain leukemic cell differentiation in vitro. The regulation of cell proliferation and differentiation by cellular interactions and by extrinsic soluble products is discussed in detail, in the light of these findings.

Regulation of glutamine metabolism in dog kidney in vivo

In summary, we propose: that renal ammoniagenesis is regulated both by factors dependent and independent of the acid-base status, the net effect of the ammoniagenic process on the proton balance being directly related to the rate of urinary ammonium excretion; that the renal metabolism of glutamine should not be examined independently of the metabolism of other substrate physiologically taken up by the kidney; that different pathways for glutamine metabolism will change during acid-base disorders of organic or nonorganic origin; that, among the main glutamine utilizing pathways, only the GLDH pathway is influenced directly by the acid-base status; the ammoniagenic transamination pathways is regulated by substrate availability in the kidney; that the lowest ammoniagenic flux in the kidney coincides with the rate of alanine production since alanine appears to derive directly from glutamine. When this pathway is stimulated without concomitant acidosis, most of the ammonia produced is not excreted in urine but released in the renal venous blood: thus, no significant effect on the acid-base balance is produced; that glutamine is metabolized by proximal kidney tubules of acidotic dogs probably through net oxidation; that the quantitative analysis of the metabolic consequence of this process indicates that the rate of ATP turnover at this site may effectively place an upper limit to the rate of glutamine oxidation, and ammonia production by the kidney, and that this limit is nearly reached in chronically acidotic animals.

Inhibition of natural killer cell-mediated cytotoxicity by lipids extracted from Mycobacterium bovis BCG

Several studies have demonstrated an augmentation of natural killer (NK) cell-mediated cytotoxicity by various adjuvants including BCG. Inhibitory effects of BCG have also been reported, particularly for relatively high doses. Because the cell wall of Mycobacterium bovis BCG contains a high proportion of lipids, the possibility was considered that these lipids may modulate NK activity. A total lipid fraction was extracted from Mycobacterium bovis BCG and used for the lipid modulation of NK effector and target cells. Treatment of effector or target cells resulted in decreased membrane fluidity and decreased NK cell-mediated cytotoxicity in both cases. Pretreatment of target cells did not affect the binding between target and effector cells, as shown in the single cell assay, whereas pretreatment of effectors resulted in inhibition of conjugation. It was further demonstrated that treatment of target cells which were first programmed for lysis protected these cells from subsequent lysis during the killer cell independent lysis stage. The results of this study suggest that adverse effects of BCG treatment on immune functions may be mediated by BCG derived lipids.

Studies on the "labile-bound" glucose compartment in erythrocytes: studies on Psammomys obesus (sand rat) and preliminary studies on human erythrocytes

Enzymatic (glucose oxidase) measurement of glucose concentration in the fluid compartment of Psammomys erythrocytes (Gfe) and of its concentration in the fluid compartment of blood plasma (Gfp) gives the ratio (mean +/- SD): Gfe/Gfp = 1.50 +/- 0.43 (n = 12, 23 degrees C). However, when we added 3H-labeled glucose (G*) in vitro to the whole blood, the ratio after 2 min was G*fe/G*fp = 0.90 (SD 0.11) and after 5 min G*fe/G*fp = 0.97 (SD 0.12). These calculations were based on previous determination of the fractional volumes of the fluid and non-fluid compartments in Psammomys blood. The results suggest that there is more than one compartment of measurable glucose in Psammomys erythrocytes. Glucose undergoes a fast free transfer between the plasma and the erythrocyte fluids, and a much slower transmission to another measurable compartment in the erythrocyte, where it is loosely bound to other molecules. This loosely bound glucose does not participate in the fast kinetic transmission across the erythrocyte membrane, but it is measurable by the glucose-oxidase-based method. Preliminary studies on human erythrocytes lead to similar conclusions.

Studies on the "labile-bound" glucose compartment in erythrocytes: studies on Psammomys obesus (sand rat) and preliminary studies on human erythrocytes

Enzymatic (glucose oxidase) measurement of glucose concentration in the fluid compartment of Psammomys erythrocytes (Gfe) and of its concentration in the fluid compartment of blood plasma (Gfp) gives the ratio (mean +/- SD): Gfe/Gfp = 1.50 +/- 0.43 (n = 12, 23 degrees C). However, when we added 3H-labeled glucose (G*) in vitro to the whole blood, the ratio after 2 min was G*fe/G*fp = 0.90 (SD 0.11) and after 5 min G*fe/G*fp = 0.97 (SD 0.12). These calculations were based on previous determination of the fractional volumes of the fluid and non-fluid compartments in Psammomys blood. The results suggest that there is more than one compartment of measurable glucose in Psammomys erythrocytes. Glucose undergoes a fast free transfer between the plasma and the erythrocyte fluids, and a much slower transmission to another measurable compartment in the erythrocyte, where it is loosely bound to other molecules. This loosely bound glucose does not participate in the fast kinetic transmission across the erythrocyte membrane, but it is measurable by the glucose-oxidase-based method. Preliminary studies on human erythrocytes lead to similar conclusions.

A new myelomonoblastic cell line (M20): analysis of properties, differentiation, and comparison with other established lines of similar origin

A new myelomonoblastic cell line (M20) was established from the peripheral blood of a ten-year-old child with acute myeloblastic leukemia, using an improved method for supporting the initial stages of cell proliferation. The addition of irradiated macrophage monolayers to the proliferating cells appeared to overcome the deterioration of the primary cultures and enable them to continue proliferating until they became independent of this environment. The cell line that developed consisted of myeloblasts and promyelocytes characterized by light and scanning electron microscopy, cytochemistry, and enzymatic activities. The cells expressed Fc receptors and WT1 antigens but did not exhibit HLA-DR, HMA1, Epstein-Barr virus nuclear antigen, and surface Ig. The M20 cells produced colonies when cultured in semisolid medium and secreted lysozyme, prostaglandin E2, and interleukin 1. An attempt was also made to analyse the position of the M20 cells in the scheme of differentiation of the myelomonocytic lineage using different approaches. Treatment of the cells with 12-O-tetradecanoyl phorbol 13-acetate induced their adherence to plastic surfaces and partial maturation to macrophages as judged by morphological criteria, cytochemistry, and enzyme activities. However, comparison of the M20 cells to other well-established myelomonoblastic cell lines did not reveal any pattern suggesting a possible relationship between surface markers, cell function, and differentiation pathway of the various cell lines tested. Establishment of additional cell lines and identification of new markers may assist in defining the mechanisms involved in normal differentiation and malignant transformation of this cell lineage. In addition, such cell lines may also provide a tool for the quantitative recovery of a variety of monokines.

On the use of the logistic model in prospective studies

We describe the usual statistical concepts and consequent appropriate simulations of a prospective study for the simple case of a single risk variable and an assumed logistic model. We examine the simulations of Lilienfeld and Pyne, and show that they are seriously flawed. Contrary to those authors' claims, the estimates of parameters by the Walker-Duncan technique are both accurate and reliable.