Surfactant dysfunction makes lungs vulnerable to repetitive collapse and reexpansion

Reexpansion of collapsed lung creates intrapulmonary shear forces. In an earlier study we showed that application of a negative end-expiratory airway pressure (NEEP) to normal rabbit lungs in vivo produced tidal collapse and reexpansion with transient changes in compliance and gas exchange but no histologic damage. In the present study we examined NEEP in a model of surfactant perturbation produced by an inhaled aerosol of 2% and 5% dioctyl sodium sulfosuccinate (DOSS). DOSS increased alveolocapillary permeability without affecting compliance or oxygenation. Repeated collapse and reexpansion (RECOREX), caused by NEEP for 3 h was compared with ventilation with positive-end expiratory pressure (PEEP). Groups ventilated with PEEP maintained normal lung mechanics and morphology even if pretreated with DOSS. NEEP disturbed lung mechanics and gas exchange with persistent dose-related histologic damage in animals pretreated with DOSS. Lungs subjected to NEEP without DOSS had normal morphology. We conclude that perturbation of the surfactant system makes lungs vulnerable to injury by RECOREX. The combination of DOSS and NEEP might lead to leakage of plasma proteins into alveoli, causing inactivation of surfactants and increased shear forces with resulting lung damage. Similar mechanisms may accelerate lung damage in the respiratory distress syndrome.

[Income, health, and health services utilization in Germany 1992]

Data from the 1992 wave of the Socioeconomic Panel were used to analyse the relation between incomes, need for and utilisation of health care in East- and West Germany employing methods coming from the economic measurement of income distributions. "Self assessed health" and "restricted activities of daily living" were employed as need indicators. Utilisation was measured by the number of "visits to physicians" and "days in hospital". Data was available for 6435 individuals (west) and 3928 individuals (east). Income was defined as equivalent net household income with an equivalence scale derived from the german social assistance program. Compared to the concentration of income all variables in the scope of this study were only marginally concentrated (i.e. equally distributed). A slight concentration of need amongst the lower income was overcompensated by utilisation. Thus a very small impact of the German health care system favouring lower income individuals was measured. The study shows methodological problems when combining data from regions with strongly different income levels instead of analysing them separately. A combined analysis tends to underestimate concentration.

Additive nature of distension and surfactant perturbation on alveolocapillary permeability

The aim of this study was to determine whether the effects of alveolar distention and surfactant dysfunction on alveolocapillary barrier function are different and additive. Pulmonary clearance of aerosolized technetium-99m-labelled human serum albumin (99mTc-HSA) was used to characterize barrier function after perturbing the surfactant system with the detergent dioctyl sodium sulphosuccinate either singly or in combination with large tidal volume ventilation (LTVV). Clearance was measured for 3 h (Experimental ventilation) in four groups (n = 6 each) of rabbits: 1) Controls; 2) Detergent; 3) LTVV; and 4) Detergent + LTVV. Restoration of clearance (Recovery) was studied for 3 h under conventional ventilation. The half-life of clearance (t 1/2) decreased during LTVV (305 min) compared to 1,055 min in Controls. Detergent induced a biexponential clearance with slow (t 1/2S) and fast (t 1/2F) half-lives of 670 and 15.4 min, respectively. The fast fraction (fF) was 0.20. Clearance in the Detergent + LTVV group was also biexponential. The t 1/2F and fF were similar to the Detergent group. The t 1/2S was similar to the LTVV group. The fF in this group increased to 0.36 during Recovery (p < 0.01 versus Detergent group and p < 0.05 versus Experimental ventilation). The diverse kinetics of clearance during large tidal volume ventilation and surfactant dysfunction suggest the presence of different mechanisms affecting the barrier. The mechanisms have additive characteristics, which superimpose to produce lung injury.

Respiratory mechanics in rabbits ventilated with different tidal volumes

Respiratory mechanics was studied in 11 rabbits at tidal volumes (VT) of 6.7, 10, and 20 ml/kg. Flow interruptions were performed during the full respiratory cycle. The viscoelastic pressure (Pve) was measured as the dynamic elastic pressure (Pel(dyn)) after flow cessation minus the static elastic pressure (Pel(st)). Static elastic and viscoelastic parameters were determined with numerical technique. Static hysteresis was minimal even at large VT. The Pel(st)-V curve was linear at small VT and in 6 animals at moderate VT. In 5 animals at moderate VT and in all animals at large VT, a linear segment with constant compliance was followed by a segment with decreasing compliance. The Pve-V curve could be described with a linear model only at small VT. A non-linear model was needed at increased VT. Compliance increased with VT. Both static and viscoelastic behaviours were linear up to larger volume ranges at large VT compared to moderate VT.

A glass fiber/diethylaminoethyl double filter binding assay that measures apoptotic internucleosomal DNA fragmentation

A filter binding assay that measures internucleosomal DNA fragmentation associated with apoptosis is described. The assay is based on a novel principle that consists of using simultaneously two kinds of glass fiber filters to harvest [3H]thymidine-prelabeled cells following their incubation with inducers of apoptosis. One filter, which is neutral, traps intact chromatin and high-molecular-weight DNA. The other filter, which is positively charged with DEAE active groups, traps low-molecular-weight DNA fragments. DNA fragmentation is quantified by measuring the radioactivity retained by each of the filters. The assay was evaluated with the histiocytic lymphoma cell line U937 and the topoisomerase inhibitors camptothecin, etoposide, and doxorubicin. These agents caused a dose-dependent decrease of radioactivity in the neutral filter and a parallel increase of radioactivity in the DEAE filter. Irradiation-induced single strand breaks and topoisomerase-mediated primary DNA damage were not detected by this method. Consistent with the detection of internucleosomal DNA fragmentation, the effects measured by this assay were prevented by the endonuclease inhibitor zinc acetate and by the metabolic inhibitor sodium azide. Results obtained using this assay were validated by observation of DNA ladders on agarose gels and by morphologic examination of apoptotic features. Evaluation of the assay in a mock screen demonstrated that the introduction of the DEAE filter increases the assay sensitivity and eliminates false positives. Thus, this assay may be used in high-throughput screening approaches to discover novel modulators of apoptosis.

Risk factors associated with vancomycin-resistant Enterococcus faecium infection or colonization in 145 matched case patients and control patients

Risk factors and mortality associated with vancomycin-resistant Enterococcus faecium (VREF) infection or colonization were examined at a tertiary care hospital by comparing 145 patients who had VREF isolates (cases) to 145 patients with vancomycin-susceptible Enterococcus faecium (VSEF) isolates (controls). The number of deaths per 100 person-days of hospitalization after diagnosis did not differ significantly between VREF patients (1.2) and VSEF patients (0.8). Multivariate analyses found that the duration of hospitalization ( > or = 7 days), intrahospital transfer between floors, use of antimicrobials (i.e., vancomycin and third-generation cephalosporins), and duration of vancomycin use ( > or = 7 days) was independently associated with VREF infection or colonization. This study, which has a large sample size, confirms some earlier observations regarding risks for VREF infection or colonization and identifies factors that may be potentially exploited to develop interventional strategies for the control of this emerging nosocomial problem.

Improved retroviral vectors for hematopoietic stem cell protection and in vivo selection

Therapeutic gene transfer into hematopoietic cells is critically dependent on the evolution of methods that allow ex vivo expansion, high-frequency transduction, and selection of gene-modified long-term repopulating cells. Progress in this area needs elaboration of defined culture and transduction conditions for long-term repopulating cells and improvement of gene transfer systems. We have optimized retroviral vector constructions based on murine leukemia viruses (MuLV) to overcome the transcriptional repression encountered with the use of conventional Moloney MuLV (MoMuLV) vectors in early hematopoietic progenitor cells (HPC). Novel retroviral vectors, termed FMEV (for Friend-MCF/MESV hybrid vectors), were cloned that mediate greatly improved gene expression in the myeloerythroid compartment. Transfer of the selectable marker multidrug resistance 1 (mdr1), FMEV, in contrast to conventional MoMuLV-related vectors currently in use for clinical protocols, mediated background-free selectability of transduced human HPC in the presence of myeloablative doses of the cytostatic agent paclitaxel in vitro. Furthermore, FMEV also greatly improved chemo-protection of hematopoietic progenitor cells in a murine model system in vivo. Finally, when a second gene was transferred along with mdr1 in an FMEV-backbone, close to 100% coexpression was observed in multidrug-resistant colonies. These observations have significant consequences for a number of ongoing and planned gene therapy trials, for example, stem cell protection to reduce the myelotoxic side effects of anticancer chemotherapy, correction of inherited disorders involving hematopoietic cells, and antagonism of HIV infection.

Male sexual behaviour not abolished after medial preoptic lesion in adult rats

N-methyl-D-aspartic acid (NMDA) was injected into the medial preoptic area (mPOA) of 10 rats to destroy the neurones in this region. Male sexual behaviour was scored before, and on days 2, 6, 10, 17, 24 and 31 after the administration of NMDA. The neurones in the injection site were destroyed in all the rats, but male sexual behaviour was only transiently reduced in the animals with lesions largely restricted to the mPOA. These findings are in contrast to the earlier reports of permanent suppression of sexual behaviour after electrolytic lesion, with damage to the neurones and fibres of passage. The present study shows that the mating behaviour could be expressed even after the destruction of the neurones in the mPOA.

Effect of detergent combined with large tidal volume ventilation on alveolocapillary permeability

The combined effect of large tidal volume ventilation (LTVV) and detergent-induced surfactant dysfunction on the clearance kinetics of technetium-99m-labelled diethylene triamine pentaacetate was investigated. Four groups of rabbits (n = 6 in each) were studied: (1) controls, (2) detergent, (3) LTVV, and (4) detergent + LTVV. Clearance was measured for 3 h and the kinetics was analysed by fitting mono- and biexponential equations to the clearance curve and was expressed as a half-life (T 1/2). Pulmonary clearance of 99mTc-DTPA was monoexponential in control animals (T 1/2 = 194 min) and in animals ventilated with LTVV (T 1/2 = 43 min, P < 0.01 compared with controls). In contrast, clearance was biexponential after detergent administration with or without LTVV. T 1/2 values of the fast and slow compartments were 5.4 and 80 min, respectively, with the fast fraction comprising 81% of the radioactivity after detergent alone. When detergent was combined with LTVV, clearance was bicompartmental as with detergent alone, with the same size of the fast fraction. However, clearance from each of the slow (P < 0.01) and fast compartments (P < 0.05) increased significantly. Clearance from the slow compartment was thus similar to T 1/2 during LTVV alone. Large tidal volume ventilation induced a faster than normal clearance of a single compartment, whereas detergent induced kinetics that was distinctly bicompartmental. The mechanisms increasing permeability of the alveolocapillary barrier after detergent and during LTVV seem different and may be additive.

Magnetic resonance imaging of NMDA-induced lesion of the medial preoptic area and changes in sleep, temperature and sex behaviour

Destruction of the medial preoptic area (mPOA) neurons of rat brain, induced by intracerebral injection of N-methyl D-aspartic acid (NMDA), has been studied by employing the non-invasive Magnetic Resonance Imaging (MRI) technique. Changes in the MRI images are compared and correlated with the functional changes after the mPOA lesion. The progress of the lesion at the injected site has been monitored (using MRI) from 15 min to 1 month after the stereotaxic microinfusion of NMDA (5 micrograms in 0.2 microliter). This study shows that the localised hyperintense (bright) area starts appearing at the mPOA from 3 h after NMDA injection, and the brightness increases progressively for about 2 days. The size and brightness of hyperintense area decrease thereafter. It has not been possible to locate the lesion site after 3 days, using MRI, except in one rat where a vacuole-like area was seen at the NMDA injected site on postmortem histological examination. The reduction in sleep after the mPOA lesion does not show any correlation with the changes in MRI, as it persists throughout the 3 weeks of recording. On the other hand, the initial drastic reduction in male sex behaviour and the increase in body temperature correlated to some extent with the increased brightness in MRI at the site of lesion. The size and location of the hyperintense area, observed during the first 2 days, match with the lesioned area which was histologically identified after 1 month of NMDA administration. Control administration of normal saline into the mPOA did not produce any alteration in the brightness of the MRI image and practically no loss of neurons at the injected site. Though some functional changes have correlation with the alteration in MRI, this cannot be used to interpret the changes in all the physiological parameters. This study also demonstrates that the disappearance of the brightness in MRI should not be taken to indicate a positive prognosis. Though the lesion could not be seen in MRI within 2 hours, its detection after 3-4 h (but within 3 days) after NMDA lesion would give very valuable information for long term studies.

[Cost control in public health by rationing--what are the advantages and disadvantages?]

In Germany, the discussion on the pros and cons of rationing health care services in the statutory health insurance funds has just begun, but it will probably be of great importance in the years to come. Until now, it is mainly a political discussion with only very few researches participating. In order to enhance the matter-of-factness in this controversial debate, the experiences in the USA with rationing health care services are summarised, and in the second part a more general discussion is added on different forms and consequences of rationing. The present discussion in Germany is outlined in the third part of the paper. In our own evaluation two arguments are stressed: Firstly, the central argument that rationing of health care services is inevitable because health care costs are "exploding", has as yeb no firm empirical and theoretical basis. Secondly rationing by taking medically useful benefits from the schedule of benefits in the statutory health insurance funds is not compatible with the ethical principles governing these funds.

Magnetic resonance imaging of temporal changes of neurotoxic lesion in the rat

Destruction of striatal neurons in the rat brain, induced by intracerebral injection of N-methyl D-aspartic acid (NMDA), has been visualized noninvasively by magnetic resonance imaging (MRI). The changes in images were monitored from 12 h to one month after the stereotaxic microinfusion of NMDA (10 micrograms in 0.4 microliter) into the striatum, using a T2-weighted rapid acquisition by relaxation enhancement (RARE) sequence. A localised hyperintense (bright) area was visible after 12 h at the site of the injection, and it persisted for the next three days. The size of the hyperintense area decreased thereafter and, after one week, the increased brightness was restricted to the lateral ventricle. Post-mortem histological examination, done after one month, showed a dilated lateral ventricle. The size and location of the lesioned area, identified in histological sections, corresponded to the hyperintense area observed during these initial days after NMDA lesion. The present study demonstrates that noninvasive MRI techniques, using a typical RARE sequence, offer a powerful tool for the early detection of neurotoxic lesion of the brain area, although some caution is required in its use for estimating the size of the lesioned area three days after its formation. The present findings indicate that, in long-term studies, alterations of the neighbouring structures, such as enlargement of the ventricular system, may confound the MRI evaluation of neurotoxic lesions in vivo.

Dynamics of carbon dioxide elimination following ventilator resetting

BACKGROUND

Carbon dioxide elimination (VCO2) at steady state corresponds to the metabolic rate. A change in tidal ventilation will lead to a transient response in VCO2 if other determinants of VCO2 are constant. This principle may be applied in the critical care unit to reset ventilators.

OBJECTIVE

To define and characterize the transient response of VCO2 to a well-defined change in ventilation.

METHODS

Forty-four patients in stable condition receiving volume-controlled mechanical ventilation had trend recordings of ventilator pressures, flow, volumes, VCO2, and end-tidal CO2 (ETCO2) for 20 min. At time t0, the minute ventilation was either increased (n = 22) or decreased (n = 22) by 10% after which these parameters were monitored over 30 min. Blood gas values were measured 5 and 20 min after the change in ventilation and the dead space fractions were computed using the single breath-CO2 test.

DATA ANALYSIS

The first ten breaths (till t1) after a change in ventilation were excluded. The time constant (tau) of the relative change in VCO2 (delta VCO2) was calculated by fitting exponential regressions to delta VCO2 for periods up to 20 min after t1.

RESULTS

The delta VCO2 at t1 was proportional to the relative change in tidal volume (delta VT). The proportionality decreased gradually during 20 min. The proportionality of the relative change in ETCO2 (delta ETCO2) or PaCO2 (delta PaCO2) with delta VT was minimal at t1 and increased during the 20 min. tau increased progressively when calculated over longer periods (p < 0.001). tau was similar in the groups with increased and decreased ventilation up to 5 min, after which it was longer in the group with decreased ventilation (p < 0.05). The delta PaCO2 after 20 min correlated best with delta VCO2 at t1 (r = -0.8) and with delta ETCO2 at the end of 20 min (r = 0.8).

CONCLUSIONS

Noninvasively monitored VCO2 provides an instantaneous indication of the change in alveolar ventilation in well-sedated, mechanically ventilated patients in stable condition without significant cardiopulmonary disease.

Effect of application of gamma amino butyric acid at the medial preoptic area on sleep-wakefulness

Intracerebral microinjections of gamma amino butyric acid were given bilaterally at the medial preoptic area (mPOA) to determine the possible role of this neurotransmitter in the genesis and regulation of sleep-wakefulness. GABA (50 micrograms/0.2 microliters) when administered through chronically implanted cannulae in free moving rats, did not produce any significant alterations in sleep-wakefulness. This may be attributed either to the non-involvement of GABA at the level of mPOA in the regulation of sleep, or to other factors like the low dose and rapid breakdown of the injected drug.

Advertising in dentistry--a position paper

The limitations on advertising set by current regulations are examined and the possible consequences of relaxing these regulation discussed. The opinions of the dental profession on this issue, as determined through a questionnaire survey of members of the Singapore Dental Association (SDA), are included. Finally, some recommendations are made with respect to modifying current advertising laws.

Differentiation of pathogenic Escherichia coli strains in Brazilian children by PCR

A PCR technique to differentiate pathogenic enteric Escherichia coli strains in a field setting was evaluated. Among 76 children with acute diarrhea, this technique identified 12 children (16%) with enterotoxigenic E. coli, 6 (8%) with enteropathogenic E. coli, and 1 (1%) with enteroinvasive E. coli infection. Compared with the conventional assays, the PCR method proved to be simpler, more rapid, and inexpensive and therefore suitable for application in a developing-country field setting.

Healthy lungs tolerate repetitive collapse and reopening during short periods of mechanical ventilation

The possible occurrence of lung damage if alveolar units are allowed to collapse and reopen breath by breath during mechanical ventilation with normal tidal volumes was investigated. Anaesthetised, paralysed, open chest rabbits were subjected to either intrathoracic negative (NEEP; n = 6) or positive (PEEP; n = 6) end-expiratory pressure during volume controlled mechanical ventilation. Both experimental settings were preceded by a 30 min control period and followed by a 30 min recovery period during which a PEEP of 0.2 kPa was maintained. Pao2 and pulmonary compliance deteriorated significantly in the NEEP group during the experimental period and compared to ventilation with PEEP. Partial restoration of lung mechanics and blood gases was achieved during the recovery period. After an alveolar recruitment manoeuvre, this recovery was complete. Lung clearance studied by depositing an aerosol of technetium-99m-labelled diethylenetriamine pentaacetate (99mTc-DTPA) in the alveoli, was significantly faster during ventilation with NEEP compared to the PEEP group (P = 0.0002) as well as the control period (P = 0.0029). It did not recover completely during the recovery period but remained significantly faster. Light microscopic histology was normal in both groups with no evidence of inflammation or epithelial disruption. We conclude that previously healthy rabbit lungs show only a transient disturbance of lung mechanics and blood gases with repetitive collapse and re-expansion. The integrity of the alveolar microstructure is preserved. The disturbance in the alveolo-capillary permeability persists and may indicate surfactant related alveolo-capillary barrier dysfunction.

Referent opinion and health care satisfaction

The author examines the influence that referent opinion--one's own opinion and the recommendations of relevant others--has on patient perceptions of the quality of care they receive at hospitals. A study of discharged hospital patients reveals that the demographic profile of a patient also has a mediating influence on this effect. Hospital administrators are urged to pay close attention to the relationship between types of referents patients use and how they form their evaluations.

Substrate and product structural requirements for binding of nucleotides to H-ras p21: the mechanism of discrimination between guanosine and adenosine nucleotides

The interaction of the protein product of the H-ras oncogene with a series of nucleoside di- and triphosphates has been examined to investigate the tolerance of the active site to departures from the GTP or GDP structures. Nucleotides which bind relatively strongly could be used as competitors of GDP in a simple filter binding assay to give semiquantitave estimates of their affinities. For more weakly binding nucleotides or to obtain quantitative data, a transient kinetic method was used which was based on determination of the association and dissociation rate constants. The results obtained indicate that substantial modification of the sugar or phosphate structure is tolerated with little or moderate loss of affinity, but that large losses in affinity occur on modification of the base structure. In particular, replacing the guanine by an adenine residue leads to a dramatic loss of affinity. Thus, discrimination against ATP and ADP is very high (relative affinities of ATP and GTP 1:10(7)). This is due not only to loss of positive (stabilizing) interactions, but especially to the introduction of negative ones.

Medial preoptic alpha-2 adrenoceptors in the regulation of sleep-wakefulness

Adrenergic alpha 2 agonist (clonidine) and its antagonist (yohimbine) were locally applied to the medial preoptic area (mPOA), to find out the role of alpha 2 receptors at this brain region in the regulation of sleep-wakefulness. Clonidine produced arousal, whereas yohimbine induced sleep in freely moving animals. Behavioural arousal produced by clonidine administration was accompanied by EEG synchronization. The alpha 2 receptor as the probable site of action of externally applied norepinephrine (NE), is discussed.

[Toward a European health reporting system--starting points and developmental perspectives]

This article first offers a brief introduction to the development of the EC health policy mandate from a competence restricted to health protection at the working place to a wider competence embracing health promotion and disease prevention, albeit still based on the principle of self-responsibility of the Member states. Possible focal points of health reporting within the EC framework are worked out on the basis of suggestions made by the EC commission in respect of priority areas of EC activities in the public health sphere and the commission's own priority criteria. It is then examined whether and to what extent the presently available health databases (especially of WHO and OECD) would cover these requirements. As a result, it is argued, that there is no getting around setting up an own health reporting system that would promote and support the development of an EC public health policy. An important task of such health reporting will be to supply users not only with data but also with adequate knowledge on how to interpret them, in view of the multitude of problems involved in bringing the various national health data under one roof; this cannot be achieved either at short notice or on a medium-term basis. Finally, a few alternatives are given in respect of possible organisational structures of EC health reporting, pointing out decision criteria and practical conditions which would be essential of assessing the usefulness of such organisational setups.

Airway and body surface sensors for triggering in neonatal ventilation

Failure of neonatal patient triggered ventilation may reflect a delay in delivery of flow relative to the inspiratory effort of the infant. Transmission of diaphragmatic contraction to the sensor site (patient delay) and further transmission to and within the sensing device (device delay) both contribute to the delay in triggering. Patient and device delays were studied for different sensing systems in 36 infants, 24 of whom were intubated. Device delay was long (> 40 ms) with a conventional apnoea monitor compared with sensors placed at the airway opening (2 ms), the inspiratory (12 ms) and expiratory (3 ms) pressure transducers of the ventilator, the Graseby capsule (8 ms), strain gauges (3 ms) and oesophageal pressure (6 ms). In near normal infants, the sum of patient and device delays for the latter sensors was less than 20 ms and a minor component of the total delay. However, in severe lung disease the total delay may be more than 100 ms even for airway sensors.

Dynamic properties of body plethysmographs and effects on physiological parameters

A model incorporating compliance, resistance, inertia, and the thermal time constant of plethysmographs is used to describe the effect of its dynamic properties on measured respiratory parameters. Using numerical simulation we studied the effect of distortion of flow signals from 13 infants in whom flow and esophageal pressure had been recorded. The distortion in amplitude, shape, and timing of the recorded flow patterns was dependent on the dynamic properties of the plethysmograph. For constant-volume "pressure" plethysmographs, errors of derived parameters such as compliance and resistance are very important if the thermal time constant is short. These errors are not corrected by calibrating the plethysmograph at the breathing frequency. Time correction of the flow signals in volume-displacement plethysmographs gives accurate results when the plethysmograph resistance and compliance are low. Overall, a volume-displacement plethysmograph with moderately high resistance of the flowmeter, corrected for internal pressure and inertia, gives the best possible results.

Biexponential pulmonary clearance of 99mTc-DTPA induced by detergent aerosol

We measured the pulmonary clearance of technetium-99m-labeled diethylenetriamine pentaacetatic acid (99mTc-DTPA) for 3 h after perturbation of the surfactant system by administration of the detergent dioctyl sodium sulfosuccinate in aerosol. Forty-two rabbits were anesthetized with pentobarbital sodium. Tracheostomies were performed, and the rabbits were mechanically ventilated. Increasing concentrations of detergent (0.125-2%) or vehicle were given for 5 min, and clearance measurements were performed immediately or 60 min after detergent administration. No animals developed respiratory distress. After vehicle, the clearance was monoexponential with a half-life of 153 min. Detergent induced a biexponential clearance with a rapidly clearing additional pool of radioactivity with a half-life of 5-15 min. The relative amount of radioactivity clearing rapidly increased with detergent concentration. The detergent effect was partly reversible. We conclude that detergent induces a biexponential clearance of 99mTc-DTPA by accelerating the transfer of tracer across the alveolocapillary barrier in a proportion of lung units in a dose-related manner.

The crystal structure of glucose dehydrogenase from Thermoplasma acidophilum

BACKGROUND

The archaea are a group of organisms distinct from bacteria and eukaryotes. Structures of proteins from archaea are of interest because they function in extreme environments and because structural studies may reveal evolutionary relationships between proteins. The enzyme glucose dehydrogenase from the thermophilic archaeon Thermoplasma acidophilum is of additional interest because it is involved in an unusual pathway of sugar metabolism.

RESULTS

We have determined the crystal structure of this glucose dehydrogenase to 2.9 A resolution. The monomer comprises a central nucleotide-binding domain, common to other nucleotide-binding dehydrogenases, flanked by the catalytic domain. Unexpectedly, we observed significant structural homology between the catalytic domain of horse liver alcohol dehydrogenase and T. acidophilum glucose dehydrogenase.

CONCLUSIONS

The structural homology between glucose dehydrogenase and alcohol dehydrogenase suggests an evolutionary relationship between these enzymes. The quaternary structure of glucose dehydrogenase may provide a model for other tetrameric alcohol/polyol dehydrogenases. The predicted mode of nucleotide binding provides a plausible explanation for the observed dual-cofactor specificity, the molecular basis of which can be tested by site-directed mutagenesis.

Effect of detergent on alveolar particle clearance due to large tidal ventilation

BACKGROUND

It has recently been shown that large tidal volume ventilation accelerates the alveolar clearance of insoluble particles and this may be related to accelerated surfactant evacuation from the alveolus into the airway. The aim of this study was to investigate if the effect of large tidal volume ventilation is modified in an experimental model of surfactant dysfunction.

METHODS

Fluorescent latex particles of 0.63 microns diameter were administered in aerosol form to 30 rabbits during anaesthesia with thiopentone and mechanical ventilation. Six animals were killed immediately after aerosol administration in order to show the initial deposition of particles. Twenty four animals were divided into two groups and ventilated for three hours with either large tidal volume (mean tidal volume 30 ml/kg) or conventional ventilation (mean tidal volume 12.5 ml/kg). Six rabbits in each of the two groups were administered either the synthetic detergent dioctyl sodium sulphosuccinate in aerosol form or aerosolised vehicle. After the period of experimental ventilation the lungs were removed and dried in the expanded state. Particles in the alveolar region were counted with fluorescent microscopy in sections of the lung.

RESULTS

Compared with the baseline group (mean (SD) 24.8 (9.9)) the count of residual alveolar particles was lower after large tidal volume ventilation in the absence of detergent aerosol (13.2 (6.5)). Particle count after large tidal volume ventilation and detergent treatment (23.3 (6.4)) was similar to that in the baseline group and to that in the groups exposed to conventional ventilation.

CONCLUSIONS

The increase in alveolar clearance of insoluble particles caused by large tidal volume ventilation is inhibited by detergent aerosol. This might be due to reduced stability of the surfactant film after detergent aerosol.

Tidal volume and alveolar clearance of insoluble particles

We studied the effect of 3 h of large tidal volume ventilation on alveolar clearance of 0.63-micron fluorescent latex particles in rabbits during pentobarbital anesthesia. After particle deposition, six animals were killed as controls, six were subjected to large tidal volume ventilation with a peak pressure of 27 cmH2O, and six were subjected to conventional ventilation with a peak pressure of 11 cmH2O. Mean tidal volumes were 30.2 +/- 6.1 and 8.4 +/- 1.6 ml/kg in the large tidal volume and conventional groups, respectively. End-expiratory pressure was 2 cmH2O in all groups. Compliance decreased only after large tidal ventilation (P = 0.0036). Compared with controls the conventional ventilation group showed no alveolar clearance, but more particles were clustered within macrophages (P = 0.01). Compared with other groups the large tidal volume group had fewer alveolar particles (P = 0.0005), most of which were single particles. Accordingly, large tidal volumes enhance alveolar particle clearance, which is possibly related to distension-related evacuation of surfactant to proximal airways. Clearance may be due to accelerated motion of the particle-loaded macrophage in response to the fast film motion. Alternatively, single particles embedded in the surfactant film may be dragged by the fast-moving film toward the airways.

Contrasting effects of identical nutrients given parenterally or enterally after 70% hepatectomy

Based on clinical observations, we hypothesized that prolonged parenteral nutrition (in contrast to enteral nutrition) is detrimental after major hepatic resection. Male Sprague-Dawley rats (300 to 380 g) anesthetized with intraperitoneal sodium pentobarbital had 70% hepatic resection and jugular vein and gastrostomy catheterizations using aseptic techniques and were divided randomly into three groups: (1) total parenteral nutrition (TPN) (nutrients via central vein), (2) total enteral nutrition (TEN) (identical nutrients via gastrostomy), and (3) standard oral feeding (SOF) (chow and water ad libitum). Unused catheters were plugged. In the first set of experiments (n = 42), nutrient intake was formulated to approximate the nutritional intake of normal rats, 216 kcal/kg/d. Infusate was 15% glucose, 4.5% amino acids, electrolytes, trace minerals, vitamins, and 20% fat emulsion given half-strength the first day, three-fourths strength the second day, and full strength thereafter. On postoperative day 7, surviving rats were killed. Mortality prior to day 7 was very high (68%) in the TPN group and low in the TEN (9%) and SOF (9%) groups (p < 0.005). Among survivors, the serum albumin level was lowest (p < 0.002) and serum bilirubin level (p < 0.025) and wet weight of regenerated liver (p < 0.002) highest in the TPN group. However, the livers in TPN rats appeared pale and were found to be abnormal histologically with markedly diminished glycogen and amphophylic hepatocyte cytoplasm, and their spleens were enlarged (by a factor of two). The high mortality of TPN rats was seen whether the fat emulsion was given as a bolus daily, continuously as part of the infusate, or not included as part of the TPN regimen. In the next series (n = 70), nutrient concentrations, volumes, and rates of infusion were varied. There was a high correlation between caloric (r2 = 0.831, p < 0.0006), glucose (r2 = 0.598, p < 0.02), and amino acid (r2 = 0.619, p < 0.03) intakes and mortality in the TPN group: at 140 kcal/kg/d, none died; at 178 kcal/kg/d, 50% to 62% died; and at 230 kcal/kg/d, 80% died. No TEN rat died. In conclusion, 70% hepatectomized rats fed enterally with nutrients approximating the intake of normal rats do well and survive. In sharp contrast, mortality is very high when identical nutrients are infused parenterally. By reducing the levels of nutrients given parenterally, survival improves significantly.

Changes in sleep-wakefulness after kainic acid lesion of the preoptic area in rats

The role of the preoptic area (POA) neurons in the regulation of sleep-wakefulness (S-W) has been investigated in this study. The cell-specific neurotoxin, kainic acid (KA), was injected (0.8 microgram in 0.2 microliter) intracerebrally for lesioning of the POA. S-W was assessed (on the basis of EEG, EMG, and EOG recordings) for a day before bilateral lesion of the POA, and for 3 weeks after the lesion. There was an increase in wakefulness, and a decrease in all the stages of sleep after KA lesion of the POA. The reduction in deep slow wave sleep (S2) and REM sleep (PS) were more marked than light slow wave sleep (S1), and these had not shown any recovery even after 3 weeks of lesion. Two days after the lesion, the reduction in sleep was much more marked during the daytime than at night. There was an increase in locomotor activity, especially during the daytime, though it was only statistically significant on the 6th and the 10th day after the lesion. This study shows that the POA neurons are involved in the induction and maintenance of sleep. The lesion did not have a long lasting effect on the circadian distribution of sleep but the changes in locomotor activity seem to persist for a longer period.

In vitro phosphorylation studies of a conserved region of the transcription factor ATF1

A large family of mammalian transcription factors including multiple variants of CREB, CREM and ATF1 have been implicated in signal transduction by cAMP and other cellular pathways. Although the roles of some members of the family have been characterised the function of ATF1 is poorly understood. We have identified one or more key serine residues that are required for a phosphorylation-induced conformational change in ATF1. The critical serines map to a putative transcriptional activation domain of ATF1 and affect the stability of ATF1 DNA-binding. Intriguingly phosphorylation is modulated by ATF1 homodimerization and by ATF1 binding to DNA. One of the key serine residues required for ATF1 phosphorylation is not conserved in CREB and CREM suggesting that it is likely to determine some specialised function of ATF1.

Short course ciprofloxacin therapy for enteric fever

A short course of ciprofloxacin, 750 mgm b.i.d. for 7 days was found to be effective in the treatment of enteric fever in 21 hospitalized patients with S.typhi (18) and S.paratyphi A(3). Median time for fever response was 3 days. All isolates were susceptible to ciprofloxacin (MIC 0.0078-0.062 mcgm/ml). The mean serum peak and trough levels were 5.4 and 1.6 mcgm/ml respectively. Stool cultures were free of Salmonellae on follow up (11-24 weeks). Two developed recurrence of paratyphoid fever, 17 days and 4 months after therapy.

Kinetic and structural analysis of the Mg(2+)-binding site of the guanine nucleotide-binding protein p21H-ras

The coordination and binding of the Mg2+ ion in the nucleotide-binding site of p21 have been investigated using site-directed mutagenesis, kinetic methods, and phosphorous NMR. Mg2+ in the p21.nucleotide.Mg2+ complex appears to be in fast equilibrium with the solvent. The dissociation constant between Mg2+ and the p21.GDP complex was determined to be 2.8 microM. It decreases 30- or 16-fold on substituting Ser-17 or Asp-57 with alanine, respectively, whereas the T35A mutation has no effect. All three mutations influence the dissociation constants and the association and dissociation rate constants of the interaction between guanine nucleotides and p21, but to a different degree. We conclude that Thr-35 is only complexed to Mg2+ in the GTP conformation and both Asp-57 and Ser-17 appear to be critical for both GDP and GTP binding. 31P NMR spectra of the GDP and Gpp(NH)p (guanosine-5'-(beta,gamma-imido)triphosphate) complexes of mutated p21 show a remarkable perturbation of the guanine nucleotide-binding site compared to wild-type protein. The mutant proteins show reduced GTPase rates, which are not stimulated by the GTPase-activating protein GAP. p21(S17A) has been reported to function just as p21(S17N) as a dominant negative inhibitor of normal p21. We find that it inhibits oncogenic p21-induced survival of primary neurons.

Patient satisfaction: the impact of past experience

The effects of previous hospital experiences on satisfaction with subsequent hospital experiences are significant and cannot be ignored. The study findings suggest that prior satisfaction with the health care system in general and with the same hospital when applicable has a significant influence on patient evaluations of current hospital experience. Suggestions are offered to manage the effects of prior satisfaction on patient evaluations of current hospital experience.

Getting patients to answer: what affects response rates?

Even scientifically validated and reliable surveys are an exercise in futility if response rates are low. The author's study raises the issue of whether the hospital experience itself, among other factors, influences the likelihood of patients' willingness to respond to surveys about their hospital experience. The research questions are framed as testable hypotheses with guidelines for future research. Examining these hypotheses contributes valuable insights for improving the response rates in patient satisfaction surveys.

Mutational and kinetic analyses of the GTPase-activating protein (GAP)-p21 interaction: the C-terminal domain of GAP is not sufficient for full activity

The GTPase-activating protein (GAP) stimulates the GTPase reaction of p21 by 5 orders of magnitude such that the kcat of the reaction is increased to 19 s-1. Mutations of residues in loop L1 (Gly-12 and Gly-13), in loop L2 (Thr-35 and Asp-38), and in loop L4 (Gln-61 and Glu-63) influence the reaction in different ways, but all of these mutant p21 proteins still form complexes with GAP. The C-terminal domain of the human GAP gene product, GAP334, which comprises residues 714 to 1047, is 20 times less active than full-length GAP on a molar basis and has a fourfold lower affinity. This finding indicates that the N terminus of GAP containing the SH2 domains modifies the interaction between the catalytic domain and p21.

A model for understanding benefit segmentation in preventive health care

The marketing of traditional health care services, such as hospital and physician services, has matured with the integration of research from the medical sociology discipline and the marketing literature. In this article, we present a model to illustrate how an understanding of predispositions to health care behavior, integrated with benefit segmentation analysis, can contribute to more focused and effective marketing strategies for health-related products and services.

High-frequency mutagenesis of human cells and characterization of a mutant unresponsive to both alpha and gamma interferons

2fTGH is a human cell line containing the selectable marker guanine phosphoribosyltransferase regulated by alpha interferon (IFN-alpha). Two IFN-alpha-unresponsive mutants were isolated previously at a low frequency (ca. 10(-8)) by selecting mutagenized 2fTGH cells in selective medium containing 6-thioguanine and IFN-alpha. By using five rounds of mutagenesis, mutants can be isolated at an appreciably higher frequency, greater than 3 x 10(-7). Five new mutants have been isolated, and all are recessive, as are the two mutants we described previously. The seven mutants are in four complementation groups (U1-U4). Since several different types of mutants unresponsive to IFN-alpha have been isolated with high frequency, related approaches may succeed with other cytokines or growth factors. Mutants in the two new complementation groups U3 and U4 are unresponsive to IFN-alpha and, surprisingly, also unresponsive to IFN-gamma. They are also partially defective in response to double-stranded RNA. These results indicate that the signaling pathways for the two types of IFN and double-stranded RNA share common components or that their function depends on common enzymes or transcription factors. IFN receptors are unaffected in mutants U3A and U4A. A major defect appears to be in the synthesis or activation of E, the transcription factor mediating the primary response to type I (alpha/beta) IFNs. Band-shift complementation assays show that U3A contains the E gamma subunit but does not contain an active E alpha subunit after treatment with IFN-alpha.

Improving quality through patient-provider communication

Though three hospitals and their patient populations were similar, one hospital was rated significantly higher on quality by its patients than were the other hospitals. Patients at that hospital felt significantly more confident that their hospital performed reliably and that they would have successful medical outcomes than did patients at the other hospitals. Analysis of patient responses shows that communicativeness (information giving and taking) and understanding (interest shown in patient's personal concerns) of medical personnel were significantly different across the three hospitals. Results underscore the importance of educating medical consumers about their medical needs and of understanding and responding to their psychosocial needs.

Isolation and characterization of a new mutant human cell line unresponsive to alpha and beta interferons

Previously we described human cell line 2fTGH, in which expression of guanine phosphoribosyltransferase is tightly controlled by the upstream region of interferon (IFN)-stimulated human gene 6-16. After mutagenesis of 2fTGH and selection with 6-thioguanine and IFN-alpha, we isolated 11.1, a recessive mutant that does not respond to IFN-alpha. We now describe U2, a second recessive mutant, selected similarly, that complements 11.1. U2 had no response to IFN-alpha or IFN-beta, and its response to IFN-gamma was partially defective. Although many genes did respond to IFN-gamma in U2, the 9-27 gene did not and the antiviral response of U2 cells to IFN-gamma was greatly reduced. Band shift assays showed that none of the transcription factors normally induced in 2fTGH cells by IFN-alpha (E and M) or IFN-gamma (G) were induced in U2. However, extracts of untreated U2 cells gave rise to a novel band that was increased by treatment with IFN-gamma but not IFN-alpha. Band shift complementation assays revealed that untreated and IFN-gamma-treated U2 cells lack the functional E gamma subunit of transcription factor E and that IFN-alpha-treated U2 cells do contain the functional E alpha subunit.

Three-dimensional structure of p21 in the active conformation and analysis of an oncogenic mutant

The three-dimensional structure of the active guanosine triphosphate (GTP)-analogue-containing complex of the H-ras-encoded p21 has been determined. It was necessary to correct the topology of p21 as published earlier. The structure analysis shows all of the interactions between protein and GTP and how the important cofactor Mg2+ is bound. From the oncogenic mutants of p21 crystallized, a Gly12 to Arg mutation has been analyzed in detail. It shows that the overall structure of the mutant is not perturbed and that the side chain of Arg12 is coming close to the gamma-phosphate for an interaction.

[Drug interactions in the prescriptions of patients before and after a heart infarct: results of the MONICA Augsburg heart infarct registry]

The prescriptions of 603 patients who had survived acute myocardial infarction (AMI) for at least one year and were registered from 1 Oct 84 to 31 Dec 86 in the Coronary Event Register of the MONICA project Augsburg were analyzed for the presence of drug-drug interactions with the aid of a computerized drug information system (SMA). Prior to AMI, 59% of patients were treated (average of 2 active substance per patient), 100% were treated on release from hospital (4.5 active substances), and 96% one year after AMI (5.8 active substances). Potential drug-drug interactions were found in 18% of patients before AMI, 65% on discharge from hospital, and 66% one year after AMI. While the potential frequency and severity of interactions are minor on average, prescriptions frequently contain several interactions. Calculations show that at least 5-6% of all prescriptions after AMI will produce interactions, so that drug safety for this high-risk patient group can be enhanced by a drug information system. Beta-blockers are the substance group most frequently involved in potential interactions in AMI patients.