The clinical features of immunoglobulin light-chain (AL) amyloidosis with heart involvement

We reviewed clinical presentation, investigations, therapy, prognosis and outcome of 232 patients with primary (AL) cardiac amyloidosis. There were 142 men and 90 women. Median age at presentation was 59 years (range 29-85). AL heart disease was unusual both in patients under the age of 40 (3.0%) and in non-Caucasians (6.5%). Fatigue and weakness were the commonest presenting symptoms. Hallmark features of periorbital ecchymoses and macroglossia were present in 12.5% and 27.2%, respectively. AL cardiac amyloidosis was unusual in isolation (3.9%), and most frequently patients had features of multiorgan dysfunction; heavy proteinuria and features of malabsorption predominating in this respect. Heart involvement represents the worst prognostic indicator, with a median survival from diagnosis of 1.08 years, falling to 0.75 years with the onset of heart failure. Current therapeutic procedures appear to prolong survival, with left ventricular wall thickness, mass and ejection fraction on echocardiography and late potentials on signal averaged electrocardiography of use in prognostic stratification. Cardiac involvement from AL amyloidosis is rapidly fatal. It should be suspected in all patients with heart failure who have wall thickening on echo, normal chamber sizes, low EKG voltages and evidence suggesting a multisystem disease.

Use of the WWW for distributed knowledge engineering for an EMR: the KnowledgeBank concept

Developing automated tools for clinical information management requires an appreciation of user needs and capabilities. To address the reality of practice style variation, and the varying degree of comfort with computers in clinical users, we developed the KnowledgeBank concept. The KnowledgeBank concept includes an end-user authoring tool for clinical content in the EMR, and a web-based repository of content for sharing clinical content. We describe the early experiences of end-users using the KnowledgeBank.

A randomized trial of three iron dextran infusion methods for anemia in EPO-treated dialysis patients

Forty-three hemodialysis patients receiving recombinant erythropoietin (rHuEPO, epoietin alpha) were randomized to receive intravenous iron dextran as a total-dose infusion, 500-mg infusion to total dose, or 100-mg bolus to total dose, in each case during the dialysis procedure. The dose of iron dextran was calculated from the patient's existing hemoglobin to achieve a desired hemoglobin. Patients were eligible to receive intravenous iron dextran if they had a serum ferritin of < or = 100 ng/mL or a serum ferritin of 100 to 200 ng/mL, along with a transferrin saturation of < or = 19%. Patients were excluded if they had prior therapy with iron dextran, aluminum intoxication, or transfusion during the study. The time to the maximum hemoglobin, acute adverse reactions, and delayed adverse reactions were analyzed statistically, and no differences were seen in any of the three groups. Total-dose intravenous iron dextran infusion is safe, convenient, less expensive, and as efficacious as divided-dose infusions.

Introduction of Aedes albopictus into a La Crosse virus--enzootic site in Illinois

In late summer and fall 1997, Aedes albopictus mosquitoes were found in Peoria, Illinois, a long recognized focus of La Crosse virus transmission. Larvae were found in tires and other artificial containers, biting adults were recovered, and eggs were collected in oviposition traps within a 25-ha area. One chipmunk trapped < 0.25 km from the infested area tested positive for neutralizing antibodies against La Crosse virus.

Immune versus natural selection: antibody aldolases with enzymic rates but broader scope

Structural and mechanistic studies show that when the selection criteria of the immune system are changed, catalytic antibodies that have the efficiency of natural enzymes evolve, but the catalytic antibodies are much more accepting of a wide range of substrates. The catalytic antibodies were prepared by reactive immunization, a process whereby the selection criteria of the immune system are changed from simple binding to chemical reactivity. This process yielded aldolase catalytic antibodies that approximated the rate acceleration of the natural enzyme used in glycolysis. Unlike the natural enzyme, however, the antibody aldolases catalyzed a variety of aldol reactions and decarboxylations. The crystal structure of one of these antibodies identified the reactive lysine residue that was selected in the immunization process. This lysine is deeply buried in a hydrophobic pocket at the base of the binding site, thereby accounting for its perturbed pKa.

Regulation of leukotriene and platelet-activating factor synthesis in human alveolar macrophages

It has been suggested that phospholipase A2 (PLA2) contributes to the regulation of leukotriene (LT) and platelet-activating factor (PAF) synthesis by controlling the release of their precursors, arachidonic acid (AA) and lysophosphatidylcholine (lysoPC), from membrane phospholipids. In rat alveolar macrophages (AMs), PLA2 appears to have a major role in LT synthesis but a more limited role in PAF synthesis. The present study was designed to define the role of PLA2 in LT and PAF synthesis in human AMs and determine whether differences exist between AMs obtained from normal subjects and those from patients with asthma. In the normal subjects, the calcium ionophore A23187 (Cal) increased AM PAF synthesis (percent incorporation of tritiated acetate) by 135% (p < 0.01) and LTB4 synthesis 88-fold (p < 0.001). Phorbol myristate acetate (PMA) had little effect alone, but it had a synergistic effect with Cal, increasing PAF synthesis by 466% and LTB4 synthesis to 229-fold above the control values (p < 0.001 for both). Ro 25-4331, a combined cytosolic (c) and secretory (s) PLA2 inhibitor, had little effect on the Cal-stimulated PAF synthesis, but it completely blocked the effect of PMA. It also blocked the Cal- and Cal+PMA-stimulated LTB4 synthesis. AACOCF3, a cPLA2 inhibitor, had no effect on either Cal or Cal+PMA-stimulated PAF synthesis. It reduced LTB4 synthesis, but it did so less effectively than Ro 25-4331. CoA-independent transacylase (CoAI-TA) activity in the AMs increased after stimulation and exposure to Ro 25-4331. SK&F 45905, a CoAI-TA inhibitor, reduced stimulated PAF synthesis by 30% to 40%. Patients with asthma had similar results except that cPLA2 had a greater role in stimulated LTB4 synthesis. These data indicate that PLA2 plays a direct role in human AM LT synthesis; both the cytosolic and secretory forms contribute to LT synthesis; PLA2 appears to have a more limited role in PAF synthesis, although it mediates the synergistic effect of PMA, probably via sPLA2; and CoAI-TA contributes to PAF synthesis during PLA2 inhibition. With the exception of the greater role for cPLA2 in stimulated LTB4 synthesis in the patients with asthma, the contributions of PLA2 and CoAI-TA to AM LT and PAF synthesis appear to be similar in normal subjects and patients with asthma.

Production of rabbit polyclonal antibody against apobec-1 by genetic immunization

Circulating apolipoprotein B (apoB) exists in two forms; apoB-100 and apoB-48. ApoB-48 is a truncated form of apoB resulting from RNA editing. The editing enzyme, called apobec-1, converts a cytidine (C) at nucleotide 6666 in apoB 100 mRNA to a uridine (U) and changes a CAA codon to an in-frame stop codon, UAA. We have produced a specific rabbit polyclonal antiserum against apobec-1 by genetic immunization. The cDNA of mouse apobec-1 was inserted downstream and in-frame at the BamH I site in the last exon of human growth hormone cDNA driven by a cytomegalovirus promoter. This plasmid was injected together with another plasmid expressing granulocyte macrophage colony-stimulating factor into the thigh muscles of a rabbit. The resulting antiserum demonstrated high specificity on Western blots, and inhibited the apoB mRNA editing activity of mouse liver extract in a dose-dependent manner. This report demonstrates that DNA immunization is a powerful technique that can be readily applied to other sparse or difficult-to-purify proteins in lipid metabolism.

Single trial variability within the P300 (250-500 ms) processing window in adolescents with attention deficit hyperactivity disorder

The traditional averaging process used to derive event related potential components (ERPs) is a soundly based method of determining the underlying ERP. Averaging, however, ignores the variability due to the single-trial ERPs that constitute the traditional average ERP. This variability may reflect complementary functional information to the average measure. Our group applied a simple procedure, the response variance curve (RVC), which measures single-trial ERP variability relative to their average. In this study, the average ERP and RVC measures (generated from the same single-trial task-relevant target ERPs) were assessed in an auditory oddball paradigm, in 17 unmedicated male adolescents with attention deficit hyperactivity disorder (ADHD) and in 17 age- and sex-matched normal controls. P300 amplitude, latency and point of maximum variability of the RVC were measured within the P300 processing window (250-500 ms post-stimulus). There were no significant differences in P300 amplitude or latency between the groups. Unmedicated ADHD patients, however, showed significantly increased single-trial variability within the P300 window compared with controls. This variability was significantly reduced with stimulant medication.

Impact of prolonged saline solution prime exposure on integrity of extracorporeal membrane oxygenation circuits

OBJECTIVE

Our purpose was to evaluate the safety of the common practice of preparing extracorporeal membrane oxygenation (ECMO) circuits in advance with saline solution priming by analysis of the surfaces of circuit components and analysis of the prime solution for toxic contaminations.

STUDY DESIGN

In vitro analysis of eight ECMO circuits exposed to saline prime solution for 0, 2, or 4 weeks was performed with scanning electron microscopy. Prime solution analyzed for contamination with aluminum, silicone, and diethylhexylphthalate.

RESULTS

The silicone membrane and heat exchanger demonstrated surface degradation in contact with saline solution. The prime solution showed increasing concentrations of both aluminum and silicone but not diethylhexylphthalate over time.

CONCLUSIONS

Advance preparation of ECMO circuits by prepriming with normal saline solution leads to significant circuit degradation. Prepriming should be avoided.

Cognitive impairment in geriatric chronic schizophrenic patients: a cross-national study in New York and London

Severe cognitive impairment has been reported in large numbers of geriatric chronic schizophrenic patients in the US, with this impairment also being related to severe negative symptoms and adaptive deficits. It is not clear if this impairment is related to the particular environment of the American state hospitals and would not generalize to other countries. In this study, a sample composed of geriatric (age > 70) chronic schizophrenic patients in London, who were assessed by the Team for Assessment of Psychiatric Services (TAPS) (N = 137), and a group of geriatric chronic schizophrenic patients in a New York psychiatric center (N = 86) were compared for the severity of cognitive impairment and on measures of adaptive functioning. Patients received essentially identical Mini-Mental State Examination (MMSE) scores, but differed on 3/4 measures of adaptive functioning. The correlations among all four aspects of adaptive deficit and MMSE scores were very similar in the two samples, suggesting that cognitive deficits and their relationship with adaptive impairments are relatively invariant across different psychiatric systems of care, while adaptive functioning deficits are more variable and possibly more influenced by environmental factors. These data add to previous results suggesting that cognitive impairment is a common feature in poor outcome geriatric patients with schizophrenia.

Determining the effectiveness of a clinical-practice intervention in improving the control of pain in outpatients with cancer

PURPOSE

To determine the effectiveness of a clinical-practice intervention in improving the control of pain in outpatients with cancer.

METHOD

Between July 5 and September 30, 1995, a randomized, controlled trial of 510 cancer outpatients and 13 oncologists was conducted at 23 clinics in Indiana. All the patients completed assessments of their pain, their pain regimens, and the degrees of relief received; they were surveyed again by mail four weeks after their clinic visits. The intervention group's clinical charts contained a summary of the completed pain scales; the oncologists who treated these patients were instructed to review the summary sheet prior to an evaluation. This summary was not available for the oncologists treating the patients in the control group. Each patient's pain management index (PMI) was calculated: the patient's pain medication level was rated on a scale of 0 to 3; the patients's pain level was rated on a scale of 0 to 3 and then subtracted from the first rating. A negative PMI was interpreted as representing insufficient treatment. Data were analyzed with several statistical tests.

RESULTS

In all, only 320 patients who reported cancer-related pain were used in the analysis: 160 to 260 in the control group and 160 of 250 in the intervention group. The groups were similar with respect to demographics, cancer sites, and performance status. A significant difference (p = .0162) in the physicians' prescription patterns was found. In the control group, prescriptions for 86% of the patients did not change, with no decrease in analgesic prescriptions; for 14% of the patients analgesic prescriptions increased. In the intervention group, analgesic prescriptions changed for 25% of the patients, decreasing for 5% and increasing for 20%. A decrease in the incidence of pain described as more than life's usual aches and pains was found for the intervention group (p = .05). No significant difference was found between the groups for the patients undertreated for pain, as measured by PMIs.

CONCLUSION

Although analgesic regimens were altered significantly when the physicians understood more about the patient's pain, cancer pain management remains a complex problem. Future studies should focus on the long-term systematic incorporation of simple pain-assessment tools into daily outpatient oncology practices as well as on innovative ways to address other aspects of managing cancer pain.

A prospective, longitudinal, multicenter study of service utilization and costs in fibromyalgia

OBJECTIVE

To study, for the first time, service utilization and costs in fibromyalgia, a prevalent syndrome associated with high levels of pain, functional disability, and emotional distress.

METHODS

Five hundred thirty-eight fibromyalgia patients from 6 rheumatology centers were enrolled in a 7-year prospective study of fibromyalgia outcome. Patients were assessed every 6 months with validated, mailed questionnaires which included questions regarding fibromyalgia symptoms and severity, utilization of services, and work disability.

RESULTS

Fibromyalgia patients averaged almost 10 outpatient medical visits per year, and when nontraditional treatments were considered, this number increased to approximately 1 visit per month. Patients were hospitalized at a rate of 1 hospitalization every 3 years. In each 6-month study period, patients used a mean of 2.7 fibromyalgia-related drugs. Costs increased over the course of the study. The mean yearly per-patient cost in 1996 dollars was $2,274. However, results were skewed by high utilizers, and many patients used few services and had limited costs. Total costs and utilization were independently associated with the number of self-reported comorbid or associated conditions, functional disability, and global disease severity. Compared with patients with other rheumatic disorders, those with fibromyalgia were more likely to have lifetime surgical interventions, including back or neck surgery, appendectomy, carpal tunnel surgery, gynecologic surgery, abdominal surgery, and tonsillectomy, and were more likely than other rheumatic disease patients to report comorbid or associated conditions. Almost 50% of hospitalizations occurring during the study were related to fibromyalgia-associated symptoms.

CONCLUSION

The average yearly cost for service utilization among fibromyalgia patients is $2,274. Fibromyalgia patients have high lifetime and current rates of utilization of all types of medical services. They report more symptoms and comorbid or associated conditions than patients with other rheumatic conditions, and symptom reporting is linked to service utilization and, to a lesser extent, functional disability and global disease severity.

Health status and disease severity in fibromyalgia: results of a six-center longitudinal study

OBJECTIVE

To determine the intermediate and long-term outcomes of fibromyalgia in patients seen in rheumatology centers in which there is special interest in the syndrome.

METHODS

We conducted a longitudinal outcome study by mailed comprehensive Health Assessment Questionnaire administered every 6 months to 538 patients, from 6 rheumatology centers, whose median duration of disease at first assessment was 7.8 years. The final assessment took place after 7 years. In addition, there was study followup on 85 patients who had attended the Wichita center for > 10 years.

RESULTS

Although functional disability worsened slightly and health satisfaction improved slightly, measures of pain, global severity, fatigue, sleep disturbance, anxiety, depression, and health status were markedly abnormal at study initiation and were essentially unchanged over the study period. Correlations between first and last assessment values were as high as r = 0.82. For some variables, abnormalities were 3 times greater at one center compared with another.

CONCLUSION

Patients with established fibromyalgia, seen in rheumatology centers in which there a special interest in the disease and followed up for as long as 7 years, have markedly abnormal scores for pain, functional disability, fatigue, sleep disturbance, and psychological status, and these values do not change substantially over time. Half the patients are dissatisfied with their health, and 59% rate their health as fair or poor. There are marked differences in disease severity among the various centers, but < 14% of the variance in outcomes can be explained by demographic or center factors. Values at the first assessment are predictive of final values.