Human immunodeficiency virus type 1-related transient neurological deficits

PURPOSE

To characterize human immunodeficiency virus type 1 (HIV-1)-related transient neurological deficit (TND).

DESIGN

A 3-year prospective study based at a tertiary referral center.

METHODS

Patients with TND in the absence of an opportunistic infection, neoplasm, neurosyphilis, or seizure were recruited and further investigated. The frequency of hospital admission for these patients was compared with those who were HIV-1 seronegative and with those who were admitted for HIV-1-related thromboembolic events.

RESULTS

Twenty-seven patients were identified: mean age of 39 +/- 9 years; CD4+ cell count of 130 +/- 80/microL. Seven patients had no history of an AIDS-defining illness. Hemiparesis and hemisensory disturbance occurred in 23 patients (85%); 15 had preexisting ADC, 7 stage 1 and 8 stage 2; 3 developed ADC after 18 months. Thirteen patients had multiple attacks and 5 had more than 20; 2 patients developed a cerebral infarct. No cause for the TND was identified in 8 patients (30%). Anticardiolipin antibodies were found in 70% and low protein S levels in 53% which was significantly more often than in a neurologically normal group with similarly advanced HIV-1 disease. The frequency of admission was 0.8% whereas the frequency for similar TND in HIV-1-seronegative patients was 0.4% and the frequency for HIV-1-related thromboembolic events was 0.9%.

CONCLUSIONS

Transient neurological deficits occur in advanced HIV-1 disease and are often associated with ADC, elevated concentrations of anticardiolipin antibodies, and low protein S levels. Future studies will need to define the precise role of these associations in the pathogenesis of HIV-1-related TND.

Genetic studies of the Lac repressor. XV: 4000 single amino acid substitutions and analysis of the resulting phenotypes on the basis of the protein structure

Each amino acid from position 2 to 329 of Lac repressor was replaced by 12 or 13 of the 20 natural occurring amino acids. The resulting phenotypes are discussed on the basis of (1) the recently published structure of the Lac repressor core complexed with the inducer IPTG and (2) a model of the dimeric Lac repressor built by homology modelling from the X-ray structure of the purine repressor-corepressor-operator complex. This phenotype analysis, based on 4000 well-defined mutants, yields a functional description of each amino acid position of Lac repressor. In most cases, mutant effects can be directly correlated with the structure and function of the protein. This connection between the amino acid position and the structure and function of the protein is in most cases direct and not complicated: amino acids which are directly involved in sugar binding are affected in Lac repressor mutants of the Is type; small amino acids which can only be replaced by other small acids are located in the core of the protein; positions at which nearly all amino acids are tolerated are in most cases located on the surface of the protein. Amino acids which are highly conserved throughout the LacI family of repressors, and not directly involved in specific functions of the protein like DNA recognition or sugar binding, form a network of contacts with other amino acids. Such amino acids are either located inside one subunit, mostly at the interface between secondary structure elements, or are involved in the dimerisation interface.

Organic Electroluminescent Devices

Electroluminescence from organic materials has the potential to enable low-cost, full-color flat-panel displays, as well as other emissive products. Some materials have now demonstrated adequate efficiencies (1 to 15 lumens/watt) and lifetimes (>5000 hours) for practical use; however, the factors that govern lifetime remain poorly understood. This article provides a brief review of device principles and applications requirements and focuses on the understanding of reliability issues.

Differential post-transcriptional control of ornithine decarboxylase and spermidine-spermine N1-acetyltransferase by polyamines

Ornithine decarboxylase (ODC) and spermidine/ spermine N1-acetyltransferase (SSAT) are short-lived polyamine enzymes with rate-limiting roles in controlling polyamine biosynthesis and catabolism, respectively. We have found that treatment of MALME-3M human melanoma cells for 6 h with 10 micrograms/ml cycloheximide (CHX) increases ODC and SSAT mRNA 6-9-fold. When cells containing CHX-induced SSAT mRNA were washed and post-incubated for an additional 6 h in drug free media, enzyme activity increased only 2-fold above that in untreated cells despite the > 6-fold increase in accumulated mRNA. Inclusion of 10 microM spermine or spermidine in the post-incubation medium increased SSAT activity approximately 7-fold without further elevating SSAT mRNA levels. This indicates post-transcriptional regulation which, due to the similarity between polyamine-mediated increases in SSAT activity and available mRNA, probably occurs at the level of mRNA translation. In contrast to the SSAT response, polyamines markedly reduced ODC activity (but not mRNA) to one sixth that in cells not exposed to polyamines. The findings illustrate how via post-transcriptional mechanisms, shifts in intracellular polyamine pools can simultaneously and differentially regulate polyamine biosynthesis and catabolism. It is hypothesized that these post-transcriptional responses enable cells to rapidly and sensitively control intracellular spermidine and spermine pools.

Granulocyte colony-stimulating factor recruitment of CD34+ progenitors to peripheral blood: impaired mobilization in chronic granulomatous disease and adenosine deaminase--deficient severe combined immunodeficiency disease patients

Peripheral blood (PB) CD34+ cells mobilized by granulocyte colony-stimulating factor (G-CSF) administration are potentially useful for transplantation and as a target of gene transfer for therapy of hematopoietic disorders. Efficient harvest and planning for clinical use of PB CD34+ cells ideally requires foreknowledge of the expected mobilization kinetics and yield. We developed a sensitive flow cytometric assay for accurately enumerating CD34+ cells throughout the range seen at baseline to peak mobilization. We used this assay to assess the kinetics of G-CSF-mediated mobilization of CD34+ cells to PB in normal volunteers and in patients with chronic granulomatous disease (CGD) or adenosine deaminase (ADA)-deficient severe combined immunodeficiency disease (SCID). Two dose levels of G-CSF were examined (5 and 10 micrograms/kg/d for 7 days). Both doses were well tolerated. For normal subjects and patients an increase in PB CD34+ cells was first detected only preceding the third dose of G-CSF (day 3), peaked transiently on day 5 or 6, and then decreased thereafter despite additional doses of G-CSF. With 32 normal volunteers mean peak CD34+ cell counts were 57 and 76 cells/mm2 of blood (5 and 10 micrograms doses, respectively), whereas for 18 CGD patients the mean peaks were 31 and 40 cells/mm2 of blood. For 2 ADA-deficient SCID patients studied at a G-CSF dose of 5 micrograms/kg/d, the average peak was 16 cells/mm2 of blood. For both of these patient groups mobilization of CD34+ cells to PB was impaired compared with similarly treated normal subjects (P < .05). By contrast to the kinetics of the CD34+ cell mobilization, the absolute neutrophil count (ANC) increased markedly by 6 hours after the first dose of G-CSF and then increased steadily through day 8. At days 5 and 6 (peak mobilization of CD34+ cells) the mean ANC of CGD and ADA patients was only slightly lower ( < or = 15%) than that seen with normal subjects, whereas the difference in CD34+ cell mobilization was > 48%. Thus, ANC is not a reliable surrogate to predict peak PB CD34+ cell counts and direct enumeration of PB CD34+ counts should be undertaken in decisions regarding timing and duration of apheresis to harvest a specific number of these cells. Finally, unexpected, but significant differences in the PB CD34+ cell mobilization between normal subjects and patients with inherited disorders can occur and underscores the importance of establishing the expected mobilization of PB CD34+ cells in the planning of treatment approaches using these cells.

Relapse after non-T-cell-depleted allogeneic bone marrow transplantation for chronic myelogenous leukemia: early transplantation, use of an unrelated donor, and chronic graft-versus-host disease are protective

We analyzed the incidence of posttransplant chronic myelogenous leukemia (CML) relapse in 283 consecutive related-donor (n = 177) and unrelated-donor (n = 106) allogeneic transplant recipients. Twenty-two of 165 related-donor recipients with stable or advanced disease at the time of transplant had hematologic relapse of CML following transplant (5-year Kaplan-Meier estimate of relapse, 20%; 95% confidence interval [CI], 11 to 30%). One of 12 patients transplanted in second stable phase following blast crisis also relapsed. Fifteen related-donor transplant recipients relapsed within 5 years of transplant; however, seven relapsed between 5 and 9 years after transplant. Factors independently associated with an increased risk of posttransplant relapse for related-donor recipients included prolonged interval between diagnosis and transplant (relative risk, [RR], 3.81; P = .009) and bone marrow basophilia (RR, 5.62; P = .01). Related-donor recipients with posttransplant chronic graft-versus-host disease (CGVHD) had a decreased risk of relapse (RR, 0.24; P = .005). Only two of 106 unrelated-donor transplant recipients relapsed following transplant (5-year Kaplan-Meier estimate of relapse, 3%; 95% CI, 0% to 7%). When both related- and unrelated-donor recipients were considered, the use of an unrelated donor was independently associated with a decreased risk of relapse (RR, 0.24; P = .07). Twelve of 16 relapsing patients who received further therapy (nine of 13 who underwent second transplant and three of three who received donor leukocyte infusions) remain alive. This analysis shows that relapse, sometimes occurring long after transplant, is an important adverse outcome in allogeneic transplantation for CML. Early transplant, posttransplant CGVHD, and use of an unrelated donor are associated with a reduced incidence of relapse, perhaps due to allogeneic disparities enhancing the graft-versus-leukemia effect.

The assessment of discomfort in elderly confused patients: a preliminary study

With the increasing numbers of older adults in our population, nurses are reexamining all aspects of nursing care in order to best meet the needs of these individuals. Normal age changes, the impact of decades of environmental challenges, successful adaptations, acute illnesses, trauma and chronic illnesses combine to create a challenge for accurate and effective assessment of elderly patients. The nurse finds her assessment skills challenged with increasing frequency by the elderly patient who is also acutely confused and experiencing discomfort. The purpose of this study was to explore the clinical utility, validity and reliability of four different approaches to nursing assessment of discomfort with this particularly vulnerable group of elders.

Outreach to homeless mentally ill people: conceptual and clinical considerations

This paper describes a model of outreach predicated on developing a trusting, meaningful relationship between the outreach worker and the homeless person with mental illness. We describe five common tasks inherent in this model of outreach (establishing contact and credibility, identifying people with mental illness, engaging clients, conducting assessments and treatment planning, and providing ongoing service). Other issues discussed include: (a) Responding to dependency needs and promoting autonomy; (b) setting limits while maintaining flexibility; (c) resistance to mental health treatment and follow-up service options.

The fragmentation of 510 MeV/nucleon iron-56 in polyethylene. II. Comparisons between data and a model

The results of a Monte Carlo model for calculating fragment fluences and LET spectra are compared to data taken with 600 MeV/nucleon iron ions incident on an accelerator beamline configured for irradiation of biological samples, with no target and with 2, 5 and 8 cm of polyethylene. The model uses a multi-generation nuclear fragmentation code, coupled with a formulation of ionization energy loss based on the Bethe-Bloch equation. In the region where the data are reliable and the experimental acceptance is well understood, many of the features of the experimental spectra are well replicated by the model. To obtain good agreement with the experimental data, the model must allow for at least two generations of fragment production in the target.

The fragmentation of 510 MeV/nucleon iron-56 in polyethylene. I. Fragment fluence spectra

The fragmentation of 510 MeV/nucleon iron ions in several thicknesses of polyethylene has been measured. Non-interacting primary beam particles and fragments have been identified and their LETs calculated by measuring ionization energy loss in a stack of silicon detectors. Fluences, normalized to the incident beam intensity and corrected for detector effects, are presented for each fragment charge and target. Histograms of fluence as a function of LET are also presented. Some implications of these data for measurements of the biological effects of heavy ions are discussed.

Early graft loss secondary to massive hemorrhagic necrosis following orthotopic liver transplantation. Evidence for cytokine-mediated univisceral Shwartzman reaction

Massive hemorrhagic necrosis (MHN) of the liver following orthotopic liver transplantation (OLT) occurs infrequently during an otherwise uneventful recovery 1 week after OLT. It is characterized by fever and sudden deterioration of allograft function leading to failure in the absence of vascular thrombosis. The etiology is unknown, although it is usually preceded by some degree of allograft rejection. Between 6 and 8 days after OLT, four patients (out of 150) became febrile, hypotensive, and experienced a rapid rise in transaminases within 48 hr. Two patients had evidence of mild rejection; the other two had moderate to severe acute cellular rejection. All patients were ABO identical, crossmatch negative. Bolus steroids were given followed by OKT3 in the two patients with severe rejection. Although sepsis was suspected, antibiotic therapy did not ameliorate the clinical course. Each patient progressed to MHN with severe centrilobular necrosis and variable portal infiltrate. High levels of interferon-gamma and tumor necrosis factor-alpha occurred prior to the rise in transaminases in each MHN patient (155 +/- 39 pg/ml and 414 +/- 201 pg/ml, respectively) compared with levels in OLT patients with severe rejection (14 +/- 4 pg/ml and 26 +/- 5 pg/ml, respectively, P < 0.05). These data support the concept of a cytokine-mediated inflammatory response leading to a univisceral Shwartzman reaction in the transplanted liver. Early recognition of this syndrome and retransplantation are critical for survival.

Internal fixation in pelvic fractures and primary repairs of associated genitourinary disruptions: a team approach

Associated urological and orthopedic injuries of the pelvic ring are complex with numerous potential complications. These patients are treated optimally using a team approach. The combined expertise is not only helpful initially when managing these difficult patients, but also later as problems develop. This study describes a treatment protocol and reports the early results of 23 patients with unstable pelvic fractures and associated bladder or urethral disruptions, or both, treated surgically with open reduction and internal fixation of the anterior pelvic ring injuries at the same anesthetic and using the same surgical exposure as the urethral realignments or bladder repairs or both. Early complications occurred in four patients (17%): one patient sustained a fifth lumbar nerve injury caused by the pelvic reduction procedure, and three patients had anterior pelvic internal fixation failures. Late complications occurred in eight patients (35%). There was one deep wound infection (4.3%) that presented 6 weeks after injury. Late urological complications occurred in seven patients (30%). Four of the nine male patients with urethral disruptions had urethral stricture after their primary urethral realignments (44%). Three of the 18 male patients admitted to impotence (16.7%). One of the three had a residual thoracic paraplegia caused by a burst fracture. One of the five female patients had urinary incontinence and required a bladder suspension operation to restore normal function (20%). A low infection rate can be expected despite the use of internal fixation. Early urethral "indirect" realignments avoid more difficult delayed open repairs; however, late urological complication rates are still high. Early "direct" bladder repairs are easily performed at the time of anterior pelvic open reduction and internal fixation. Suprapubic tubes are not necessary to adequately divert the urine when large diameter urethral catheters are used in these patients.

Efficacy of several modes of continuous-flow insufflation for resuscitation of a canine model of acute respiratory arrest

STUDY OBJECTIVE

To test the efficacy of several modes of continuous-flow insufflation on the maintenance of physiologic parameters in a model of respiratory arrest, and the effect of these modes on neurologic outcome.

METHODS

Anesthetized dogs were slowly infused with tetrodotoxin over 75 minutes to the point of respiratory arrest. We used two different modes of continuous-flow insufflation: endobronchial insufflation (EI) of air 3 cm distal to the carina (.25 or 1.0 L.kg-1.min-1); and tracheal insufflation of oxygen (TRIO) 1 cm proximal to the carina (.08 or .2 L.kg-1.min-1).

RESULTS

EI at either flow rate provided ventilation sufficient to allow the dogs to recover effective spontaneous breathing and be removed from ventilation after 4 hours. By this time, almost all cardiovascular variables and blood gas values were normal. TRIO at .2 L.kg-1.min-1 also resulted in successful recovery, although Pa02, as well as systemic and pulmonary arterial pressures and vascular resistances, remained increased at the end of the 4-hour period. TRIO at the low flow rate, however, resulted in deterioration of blood gas values and systemic arterial pressure; dogs required conventional mechanical ventilation after 45 minutes of low-flow TRIO.

CONCLUSION

EI can be used to maintain oxygenation in acute respiratory arrest when conventional techniques are not feasible; TRIO at .2 L.kg-1.min-1 is also effective.

The influence of depression on physician-patient interaction in primary care

BACKGROUND

Depression is common but not well diagnosed in primary care medicine. This study examines the influence of depression and its recognition on the physician-patient encounter.

METHODS

A total of 508 new adult patients were assigned randomly to 105 primary care providers. Self-reported depression was determined by the Beck Depression Inventory (BDI) on entry to the study. Initial visits were videotaped and analyzed using the Davis Observation Code. Chart notes were reviewed for diagnosis of depression.

RESULTS

Seventy-seven of the 508 study patients (15%) were identified as depressed in chart notes, while 130 patients (26%) had a BDI score > or = 9, indicating moderate to severe depression. Recognition of depression was associated with increased counseling, decreased time conducting physical examination, and an increase in overall visit length. Both elevated BDI scores and physician recognition of depression were associated with decreases in chatting. Failure to recognize depression was associated with increased time taking medical history.

CONCLUSIONS

Results support the potential value of psychological screening instruments in primary care and provide information for training physicians in the recognition and management of depression. The content of office visits is different when patients are depressed or are diagnosed as depressed.

Effectiveness of a urinary control insert in the management of stress urinary incontinence: early results of a multicenter study

OBJECTIVES

The purpose of this study was to test the safety and effectiveness of a urethral insert for managing stress or mixed urinary incontinence.

METHODS

We performed a prospective, multicenter study of 135 female patients who were treated for 4 months with the Reliance Urinary Control Insert. The effectiveness of the insert was measured objectively at the time of first use and after 4 months' use by standardized pad weight studies. Insert effectiveness was also measured by reports of symptom improvement during patient interviews and on patient diaries. Urine microscopy and culture were obtained monthly; cystoscopy and urodynamics were conducted at study entry and at 4 months.

RESULTS

Significant improvement in involuntary urine loss was observed. Objective measurement of urine loss revealed that 80% of the patients were completely dry, and 95% of the patients achieved greater than an 80% decrease in urine loss. In addition, patients' perceptions of acceptability, incontinence symptom improvement, ease of learning, comfort, and time to habituation also showed improvements. Untoward events reported during the study included hematuria, bacteriuria, and bladder irritation. These events did not require significant medical intervention and did not result in any long-term clinical sequelae.

CONCLUSIONS

These preliminary results indicate that the Reliance Urinary Control Insert may be a safe, effective, and well-tolerated alternative to other available methods for the management of stress or mixed incontinence in women. Additional long-term follow-up will be required to substantiate this conclusion.

Variation in the process of pediatric asthma care

In May 1994, the continuous quality improvement team at Hermann Children's Hospital in Houston, TX, began to study the structure, process, and outcome of asthma care for pediatric patients. The team's immediate goals were to identify variation in the treatment of pediatric asthma and to determine the most cost-effective interventions. This article details the team's development of a clinical pathway to reduce variation in patient care; use of the pathway led to a reduction in length of stay and a corresponding reduction in costs.

Destructive allograft fungal arteritis following simultaneous pancreas-kidney transplantation

Fungal arteritis of the Y graft used to revascularize the whole pancreas graft developed in 2 recipients of simultaneous pancreas-kidney transplant that were performed within 36 hr of each other. The vascular infection became manifest 6-7 days following transplantation. In both patients, the vasculitis culminated in an arterial rupture that required immediate operative intervention. This compromise of the Y grafts contributed to loss of both pancreatic grafts and necessitated vascular reconstruction to reperfuse the lower extremity. To date, both patients continue to experience normal kidney transplant function.

Association of interleukin-10 with rejection-sparing effect in septic kidney transplant recipients

Certain cytokines, particularly gamma-interferon (IFN) and interleukin (IL)-2 associated with TH1 cell function, have been shown to play a role in allograft rejection. One paradigm for long-term allograft acceptance involves TH2 cytokine predominance (IL-4 and IL-10). We describe two renal allograft recipients for whom immunosuppression was discontinued due to serious sepsis and who maintained stable renal function over 2-6 months without immunosuppression. During this time, there were higher levels of both IFN-gamma and IL-10 in the peripheral blood than in stable control kidney transplant recipients on immunosuppression. In one of the patients, levels of IL-10 fell, while those of IFN-gamma remained persistently elevated. This was associated with biopsy-proven rejection. Although peripheral blood cytokine levels may not reflect intragraft events, these data are consistent with an allograft protective role for IL-10 offsetting that of IFN-gamma in both patients off immunosuppression.

Audiogenic seizures following global ischemia induced by chest compression in Long-Evans rats

Transient global ischemia was used to produce a rat model of generalized tonic-clonic epilepsy. Controlled chest compression in ketamine-anesthesized Long-Evans rats produced transient global ischemia by mechanically preventing the heart from pumping blood. Circulation was restored by standard cardiopulmonary resuscitation techniques. With a temporal muscle (skull) temperature of 35 +/- 0.4 degrees C, 75% (76/102) of the rats survived 7 min of chest compression. Generalized seizures could be evoked in 78% (59/76) of the surviving rats by a 60 s exposure to a loud sound (bell, 110 dB) beginning 24 h after the ischemic episode. The seizure patterns seen resembled those described by Maresceaux (1987) for genetically seizure-prone Wistar rats. Susceptibility to sound-induced seizures declined with time, with wide variations in recovery rate between individuals; one rat showed a daily sound-induced seizure for over 5 months. Seizures were attenuated or blocked by treatment with carbamazepine or sodium valproate. This model is similar to the great vessel occlusion model used by Kawai et al. (1995), but is less invasive. We believe it will be useful in the evaluation of therapies for acquired generalized (grand mal) seizures.