Reproducibility of the intravascular ultrasound assessment of stent implantation in saphenous vein grafts

IVUS measurements of stent and reference lumen dimensions and cross-sectional areas are highly reproducible. Furthermore, paramedical personnel can be trained to perform these measurements accurately. Thus, IVUS measurements may become the gold standard for the acute, chronic, and serial assessment of stent implantation procedures.

Processing of bacterial antigens for presentation to class I and II MHC-restricted T lymphocytes

Phagocytosis leads to the destruction of many bacteria and the proteolytic degradation of bacterial antigens within phagolysosomes to produce immunogenic peptides that bind to Class II major histocompatibility (MHC) molecules within vacuolar compartments. On the other hand, Class I MHC molecules bind cytosol-derived peptides, including peptides from bacteria that escape the vacuolar system and penetrate into the cytosol. A recently described pathway may also allow the presentation of peptides from intravacuolar organisms by Class I MHC molecules in some cases. T cell recognition of peptide-MHC complexes then provides the primary basis for specific immunity to protein antigens of bacteria. This article will review the subcellular compartments and mechanisms involved in generating immunogenic peptides, the subcellular localization of MHC molecules that bind these peptides, and bacterial parameters that affect antigen processing.

Positive sacroiliac screening tests in asymptomatic adults

STUDY DESIGN

In a prospective, single-blinded study, the incidence of false-positive screening tests for sacroiliac joint dysfunction was investigated using the standing flexion, seated flexion, and Gillet tests in 101 asymptomatic subjects.

OBJECTIVES

This study determined if these commonly used sacroiliac screening tests can be abnormal in an asymptomatic population.

SUMMARY OF BACKGROUND DATA

The sacroiliac joint is a potential source of back and leg pain. One condition affecting this joint is termed sacroiliac joint dysfunction. Diagnosis of this is made primarily by physical examination using screening tests as preliminary diagnostic tools. These screening tests evaluate for asymmetry in sacroiliac motion due to a relative, unilateral hypomobility in one the sacroiliac joints. The specificity of these tests, however, has not been thoroughly evaluated in a well-selected asymptomatic population.

METHODS

A single-blinded examiner performed the standing flexion, seated flexion, and Gillet tests on all subjects. An asymptomatic and a symptomatic group were studied.

RESULTS

Overall, 20% of asymptomatic individuals had positive findings in one or more of these tests. The specific percentage of false positives are reported by test, age, sex, and side.

CONCLUSION

This study suggests that asymmetry in sacroiliac motion due to relative hypomobility as determined by these tests can occur in asymptomatic joints. Obviously, one should not rely solely on these tests to diagnose symptomatic sacroiliac dysfunction.

Recombinant human gamma interferon administered by continuous intravenous infusion in acute myelogenous leukemia and myelodysplastic syndromes

Nine patients (median age, 58; range: 37-74) with relapsed de novo acute myeloid leukemia (AML) (3), AML after prior myelodysplastic syndrome (MDS) (4), or MDS (2) were treated with 2-20 x 10(6) U/m2/day (1-10 mg/m2/day) of recombinant human interferon gamma (rIFN gamma; Biogen) on a 14-day continuous intravenous infusion schedule. The two patients who received the initial dose of 20 x 10(6) U/m2/day (1.0 mg/m2/day) could only tolerate 6 days of therapy because of severe hepatotoxicity. Two patients who received the revised starting dose of 10 x 10(6) U/m2/day also could not complete a full course of rIFN gamma due to renal failure in one case and pulmonary deterioration in the other. A reversible dose-related rise in SGOT was seen in six patients. All patients developed a severe flu-like syndrome characterized by myalgias and fevers. These toxicities were not associated with detectable serum levels of tumor necrosis factor (TNF). Although blasts from three of five assessable patients displayed increased expression of the Ia (HLA-DR) antigen, there were no hematological responses. Steady-state rIFN gamma plasma levels in patients who tolerated a complete infusion were < 40 U/ml, a concentration below that required to induce differentiation of myeloid leukemic cell lines in vitro. We conclude that continuous infusions of rIFN gamma at doses as low as 2 x 10(6) U/m2/day are poorly tolerated in patients with AML and MDS; the maximum tolerated dose is approximately 2 x 10(6) U/m2/day.

Munchausen's syndrome: the importance of a comprehensive medical history

Munchausen's syndrome was first described by Asher in 1951. Then Ireland, et al, described eight criteria that characterized these patients. These characteristics include factitious illness of a dramatic nature, factitious evidence of disease, evidence of multiple medical procedures, pathologic lying, aggressive behavior, leaving the hospital against medical advice, multiple hospitalizations with traveling and absence of any obvious secondary gain. Another form of this disease is Munchausen's syndrome by proxy which describes parental behavior that creates the appearance of, or produces, physical illness in a child with harmful consequences to the child. In this report, we present a complex case of Munchausen's syndrome in a patient who has been traveling around the country, going from one hospital to another for several years. We ask physicians to be aware of the features of this patient, bearing in mind that this was her third hospitalization at the University of Wisconsin Hospital in Madison.

Haemoccult does not reduce the need for colonoscopy in surveillance after curative resection for colorectal cancer

Patients who had undergone curative resection for colorectal cancer were studied to compare the efficacy of faecal occult blood detection (Haemoccult test) with colonoscopy in the detection of metachronous tumours. Fifty nine patients were studied and both Haemoccult testing and colonoscopy were successfully completed in 54 patients. In 37 patients, both tests were negative. One patient with a positive Haemoccult test had no colonoscopic abnormality and remains alive and well two years later. There were, however, 16 patients with negative Haemoccult tests in whom an abnormality was found on colonoscopy. In four patients, one Dukes's A cancer and seven tubulovillous adenomas were found--all neoplastic lesions that would have been missed if surveillance had been by Haemoccult alone.

Effect of insurance status on pain medication prescriptions in a hematology/oncology practice

To determine whether insurance status (payer class) affects the amount and type of pain medication prescribed, and whether patients in those groups without prescription drug coverage received lower-cost medications, a case-control study with retrospective chart review was initiated in a university-based hematology/oncology practice in northwest Louisiana. Charts of 710 active patients among all insurance groups (private insurance, Medicare, Medicaid, State Hospital System) were analyzed to determine insurance status, pain medication (amount and type), and diagnosis. The proportion of Medicaid patients receiving pain medications was significantly increased in relation to their representation in the practice when compared with Medicare patients, patients with private insurance, uninsured patients whose health care costs were provided by the State Hospital System, and the overall patient population. Medicaid patients, especially those with solid tumor malignancies, received the most expensive class of pain medications at a significantly higher rate than other patients. In the studied population of hematology and oncology patients, there is a significant difference in the amount and type of pain medications prescribed between patients with prescription drug coverage (Medicaid) and those without (all other groups including those covered by the statewide system). We propose that consideration be given to alternative methods of financing prescription medications for medically indigent patients.

Characterization of a human chorionic gonadotropin-like protein from Candida albicans

Studies from our laboratory have demonstrated that human CG (hCG), human LH, (hLH), and an hCG-like protein extracted from Xanthomonas maltophilia were able to induce Candida albicans transition from the blastospore to the germ tube stage. In the present study, we describe the characterization of an hCG-like material extracted from Candida albicans blastospores (CaCGLP), which is potent in inducing transition and presumably represents the endogenous transition-inducing substance. This material was extracted from Candida albicans blastospores with glacial acetic acid and purified by affinity chromatography using a polyclonal rabbit anti-hCG antibody. The product obtained is a 68-kilodalton single band protein, as analyzed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blot analysis. Under reduced conditions a protein smear is seen. Amino acid analysis showed a predominance of glycine (22%), followed by serine (12%), and glutamate (12%). This protein reacted in the following hCG immunoassays: 1) a polyclonal rabbit anti-hCG equilibrium assay, 2) a carboxyl-tail hCG equilibrium assay, 3) two hCG equilibrium assays using monoclonal antibodies (CG no. 4 and CG no. 9), 4) a free alpha-subunit equilibrium assay using a monoclonal antibody, and 5) an ultrasensitive immunoradiometric assay for hCG which does not cross-react with hLH, nor the free beta-subunit of hCG. The CaCGLP showed no reaction in a specific hLH immunoradiometric assay. When CaCGLP was tested in the transition assay, in the presence of 4% rat serum, it was found that this protein was 100 times more potent than hCG in producing Candida albicans transition. We conclude that Candida albicans produces a protein that has certain tertiary structure similarities to hCG and that this material is able to induce germ tube formation. We postulate that CaCGLP has an autocrine/paracrine effect in Candida albicans as a transition factor to control its own pathogenicity.

Phase II study of liposomal muramyl tripeptide in osteosarcoma: the cytokine cascade and monocyte activation following administration

PURPOSE

A phase II trial that uses liposome-encapsulated muramyl tripeptide phosphatidylethanolamine (L-MTP-PE) in patients with relapsed osteosarcoma is underway. To determine if in vivo cytokine induction plays a role in the mechanism of action of L-MTP-PE, we investigated the circulating cytokine levels of 16 patients who were undergoing therapy.

PATIENTS AND METHODS

Patients had histologically proven osteosarcoma and pulmonary metastases that developed either during adjuvant chemotherapy or that were present at diagnosis and persisted despite chemotherapy. Patients were rendered disease-free by surgery. The major goal of the study was to improve the disease-free interval in this high-risk group. L-MTP-PE 2 mg/m2 was infused during a 1-hour period twice a week for 12 weeks, then once a week for 12 weeks. Serial blood samples were collected after L-MTP-PE administration and were assayed for cytokine levels (tumor necrosis factor-alpha [TNF alpha] interleukin-1 alpha [IL-1 alpha], IL-1 beta, IL-6, interferon-gamma [IFN-gamma], neopterin, C-reactive protein).

RESULTS

After the infusion of L-MTP-PE, there was rapid induction of circulating TNF alpha and IL-6. TNF alpha levels peaked 1 to 2 hours after infusion in 10 of 16 patients, whereas peak IL-6 levels were detected at 2 to 3 hours in all patients. Induction of circulating TNF alpha and IL-6 was evident only after the first dose of L-MTP-PE. Neither IL-1 alpha nor IL-1 beta was detected in the plasma. Neopterin levels increased at 24 hours postinfusion, which indicated macrophage activation, and were not related to the induction of circulating IFN-gamma. C-reactive protein was elevated in all patients at 24 hours and decreased by 72 hours. Unlike circulating TNF alpha and IL-6, elevations in C-reactive protein and neopterin could be detected throughout the treatment course.

CONCLUSION

It is concluded that L-MTP-PE has specific biologic effects in patients with osteosarcoma that may be important to the drug's immunostimulatory capacity and its effectiveness as an antitumor agent.

Comparison of extracellular matrix antigens in subtypes of bronchioloalveolar carcinoma and conventional pulmonary adenocarcinoma. An immunohistochemical study

In contrast to the conventional pulmonary adenocarcinomas (CPAs), bronchioloalveolar carcinoma (BAC) grows predominantly by spreading along the existing alveolar septal framework. Within the BAC category, three subtypes have been identified: mucinous, nonmucinous, and sclerosing BAC. Of these, mucinous and sclerosing BACs have worse prognoses compared with nonmucinous BAC. However, the manifestation of aggressive behavior is different between the mucinous and sclerosing types of BACs. Multifocality is often produced by aerogenous spread, especially in the case of mucinous BACs. To study the differences between the BAC subtypes and the conventional pulmonary adenocarcinomas, we employed a battery of immunohistochemical stains marking the extracellular matrix architecture (laminin, collagen IV, fibronectin, and collagen III), a degradative enzyme against a basement membrane component (anti-type IV collagenase) and cellular receptors for laminin and collagen IV (alpha 2 integrin) on 16 BACs (5 mucinous, 5 nonmucinous, and 6 sclerosing) and 30 CPAs. The mucinous and nonmucinous BACs demonstrated neoplastic epithelial cells growing along a continuous basement membrane. A similar growth pattern with intact basement membrane was noted in the periphery of sclerosing BACs. However, in contrast to mucinous and nonmucinous BACs, all cases of sclerosing BACs showed disruption or complete absence of basement membrane components (laminin and collagen IV) around the embedded glands located centrally in the sclerotic fibrous stroma, as was seen in the basement membrane analysis of conventional adenocarcinomas. Furthermore, increased type IV collagenase activity was seen in the small centrally located embedded glands in comparison to the peripheral glands. These architectural alterations of basement membrane disruption and phenotypic expression of degradative activity may be a reflection of the invasive behavior of the sclerosing BACs and their tendency to produce lymph node metastasis. Although the mucinous BACs did not show evidence of basement membrane disruption, there was a marked increase in their levels of type IV collagenase expression along with consistently low levels of alpha 2 integrin receptor (laminin and collagen IV receptor) expression. These findings may be related to the ability of the mucinous BACs to detach from the underlying basement membrane and spread aerogenously, and is to be contrasted with the stromal infiltration and desmoplasia of sclerosing BACs and CPAs.

Long-term multicenter experience with a second-generation implantable pacemaker-defibrillator in patients with malignant ventricular tachyarrhythmias. The Guardian Multicenter Investigators Group

A second-generation implantable pacemaker-cardioverter-defibrillator was evaluated in 200 patients with sustained ventricular tachycardia, ventricular fibrillation or prior cardiac arrest. The device permits demand ventricular pacing for bradyarrhythmias and for long QT interval or tachycardia suppression, uses programmable (3 to 30 J) energy shocks for conversion of ventricular tachycardia and ventricular fibrillation and is used with conventional pacing and defibrillation leads. Ventricular tachycardia/fibrillation recognition is based on the ventricular electrogram rate and requires reconfirmation before shock delivery. Two hundred patients (mean age 62 years, mean left ventricular ejection fraction 36%) were enrolled and followed up for 0 to 23 months (mean 12). Epicardial lead system implantation was performed with use of an anterolateral thoracotomy (38%), median sternotomy (26%) and subxiphoid (20%) or subcostal (16%) approach. Perioperative mortality rate was 5.5% (all nonarrhythmic deaths). Implant defibrillation threshold ranged from 3 to 30 J (mean 15), with initial programmed shock energy ranging from 3 to 30 J (mean 22). Ventricular tachycardia/fibrillation sensing threshold ranged from 0.7 to 1.8 mV (median 1) and the tachycardia detection interval from 288 to 416 ms (median 320). Reprogramming of implant variables was necessary for reliable electrographic sensing (54 patients), programmed shock therapy (61 patients) and tachycardia detection rate (63 patients). Device activation for potential shock delivery occurred in 111 patients (55.5%) with actual shock delivery after ventricular tachycardia/fibrillation reconfirmation in 66 patients (33%). During follow-up study, there was a 1% arrhythmia mortality rate, 6.5% cardiac mortality rate and 10.5% total mortality rate. This study demonstrates that the programmable implantable pacemaker-cardioverter-defibrillator is effective in preventing arrhythmic death, yet reduces patient exposure to repeated shock therapy. Reprogramming is usually necessary during follow-up for optimal function.

Human immunodeficiency virus type 1 mutants resistant to nonnucleoside inhibitors of reverse transcriptase arise in tissue culture

We have recently described a nonnucleoside compound that specifically inhibits the reverse transcriptase of human immunodeficiency virus type 1 (HIV-1), the causative agent of AIDS. This compound, nevirapine (BI-RG-587), interacts with highly conserved tyrosine residues at positions 181 and 188 in the reverse transcriptase to inhibit the recombinant enzyme and virus replication in cell culture with 50% inhibitory concentrations in the 40 nM range. HIV-1 variants resistant to nevirapine emerged with passage in cell culture in the presence of drug. This resistant phenotype was stable with continued passage in the absence of drug. These mutants had a substitution of cysteine for the tyrosine at position 181. Introduction of this mutation into the recombinant enzyme increased the inhibitory concentration of nevirapine 100-fold. Substitution of cysteine for tyrosine at residue 181 into the wild-type viral genome conferred a similar reduction in susceptibility to nevirapine. Mutants were also resistant to a tetrahydroimidazo[4,5,1-jk][1,4]benzodiazepin-2(1H)-one and -thione derivative and two 6-phenylthiouracil derivatives but retained their sensitivity to the other reverse transcriptase inhibitors, 3'-azido-3'-deoxythymidine and foscarnet.

Ultrasensitive, specific, two-antibody immunoradiometric assay that detects free alpha subunits of glycoprotein hormones in blood of nonpregnant humans

This noncompetitive, sensitive, immunoradiometric assay of the free alpha subunit of human pituitary glycoprotein hormones is based on two monoclonal antibodies and an avidin-biotin separation system. The affinity of the first antibody, mouse anti-alpha subunit covalently conjugated to biotin, is 3.8 x 10(11) L/mol. The second antibody, radiolabeled with 125I, has an affinity of 5.4 x 10(11) L/mol. A polystyrene ball coated with avidin serves as the separation system. Tests of "purified" immunochemical-grade intact human glycoprotein hormones yielded cross-reactions of approximately 2% in the assay. Sephadex G-100 column chromatography showed that this "cross-reaction" was caused by contamination of the various hormone preparations with free alpha subunit. When the intact glycoprotein hormones were further purified with specific anti-alpha monoclonal antibody, their reaction in the alpha subunit assay was undetectable (less than 0.01%). Interassay CV averaged 3.5%, and intra-assay CV averaged 7.5% at low concentrations of subunit. The detection limit of the assay (0.01 micrograms/L) is adequate to detect free alpha subunit in the blood of normal humans. Mean (SD) concentrations of free alpha subunit in normal humans were as follows: eugonadal men = 437 (35) ng/L; postmenopausal women = 1231 (40) ng/L; eugonadal women, follicular phase = 1061 (40) ng/L; eugonadal luteal phase = 780 (45) ng/L.

Effect of dantrolene in Duchenne muscular dystrophy

We have demonstrated that maneuvers capable of reducing Ca influx into cells have beneficial effects in dystrophic hamsters and Duchenne muscular dystrophy. Since dantrolene inhibits Ca release from the sarcoplasmic reticulum, its effects on DMD was studied in 7 patients of 6 to 13 years of age (mean 10.8 years). Patients were studied for 4 years with tri-monthly evaluations of manual muscle testing (MMT), functional activity, and serum CK and aldolase. During the first 2-year period, no medicines were given and served as control. In the second 2-year period, dantrolene 8 mg/kg/d was administered. No side effects were observed. In 1 patient, mild weakness occurred that disappeared when the dose was reduced to 6 mg/kg/d. The 95% confidence limit for the difference in slopes of regression lines from tri-monthly MMT was asymmetric in favor of dantrolene in 5 of 7 patients. Serum CK did not differ between the first and second year of the control and treatment periods, respectively. However, it fell significantly from the second year of control to the first year of treatment (P = 0.003). The fall during the first year of treatment was significantly greater (P less than 0.01) than in age-matched natural history controls during the same length of observation. There was a 3-fold reduction in CK when the pooled values of the first and second year control vs. treatment periods were analyzed. No changes were observed in functional activity and serum aldolase. The data suggest that dantrolene reduces serum CK in DMD associated with a lessening trend in MMT deterioration.

Purified preparations of human luteinizing hormone are contaminated with small amounts of a chorionic gonadotropin-like material

We have identified a CG-like protein contaminating a purified human LH preparation of immunochemical grade. This CG-like material is estimated to comprise 0.17%, by weight, of the LH and reacts in specific, sequential-type, two-monoclonal antibody, immunoradiometric assays for CG as well as in the carboxyl-tail CG RIA. The CG-like material is not separable from LH by size exclusion or ion exchange chromatography. The LH can be freed of this small contamination of CG-like material by immunopurification employing specific monoclonal antibodies. Sephadex G-100 chromatography shows this material to have a mol wt of 40.0K. Western blot analysis of the LH run under nonreducing conditions, using an anti-CG carboxyl-tail primary antibody, reveals two bands of this CG-like material, one at 60.8K and one at 50.7K. When electrophoresed under reducing conditions, the material reacts with the anti-CG carboxyl-tail antibody at several mol wt, ranging from 10.5-64K.

A chorionic gonadotropin-secreting human pituitary cell

Recent data from our laboratory show that hCG is secreted in a pulsatile manner in parallel with human LH (hLH) in nonpregnant normal humans. Furthermore, GnRH stimulates hCG and hLH release. Using a monoclonal antibody specific for the beta-chain of hCG and not reacting with hLH, we have identified a heretofore unknown cell type in human pituitaries which stains only for hCG. The light microscopic, immunocytochemical, and ultrastructural features are described. These data coupled to those from multiple earlier studies indicate that hCG is secreted by these cells in normal nonpregnant humans.

Polyneuropathy syndromes associated with serum antibodies to sulfatide and myelin-associated glycoprotein

We studied a series of 64 patients with sensory +/- motor peripheral neuropathies by comparing clinical and physiologic features to serum antibody reactivity against compounds containing sulfated carbohydrate moieties. We determined antibody reactivity by an enzyme-linked immunosorbent assay (ELISA) using purified glycolipids and glycoproteins as antigens, and we used high-performance thin-layer chromatography and Western blotting to test the specificity of results. Twelve patients with high titers of IgM antibodies directed against the myelin-associated glycoprotein (MAG) had sensory-motor polyneuropathies with physiologic evidence of demyelination. IgM antibody reactivity to MAG was associated with an IgM serum M protein in five patients. Eight other patients, most with sensory greater than motor polyneuropathies, had high titers of antibody reactivity to sulfatide but not of IgM to MAG. Two had an associated IgM paraprotein. None of the patients with selective serum antisulfatide activity had predominantly demyelinating features on physiologic testing. We conclude that (1) high ELISA titers of antibodies to MAG may be more common than previously suspected in patients with chronic demyelinating sensory-motor neuropathies, and (2) the presence of high titers of antisulfatide antibodies in serum may provide clues to the pathogenesis of otherwise idiopathic, axonal, predominantly sensory neuropathies.

A spoonful of competence helps the medicine go down

The Organisation Development Consultancy based in the training department of the North Western RHA has been involved recently in a variety of projects researching into management competencies. This article outlines the findings from a project undertaken at Tameside and Glossop HA. The aim of the research was to provide an information base on which to build an appropriate recruitment and selection strategy and training and development policy for the continued future development of the district.

Chorionic gonadotropin secretion in normal, nonpregnant humans

A chorionic gonadotropinlike material is present in blood and urine of normal, nonpregnant humans, is secreted in pulsatile fashion in parallel with luteinizing hormone, is stimulated by gonadotropin-releasing hormone, and is suppressed by GnRH agonists and estrogen. The source is probably the pituitary gland.

Secretion of chorionic gonadotropin by cultured human pituitary cells

To investigate the possibility that the human pituitary gland secretes CG, we used a highly specific, two-site, double monoclonal immunoradiometric assay to measure CG in the medium in which the dispersed cells of pituitary glands from human fetuses of 20-24 weeks gestation were cultured. The cross-reactivity of immunopurified human LH in the CG assay was less than 0.03%. LH was also measured by a double monoclonal immunoradiometric assay. Secretion of CG by the cultured fetal pituitary cells was readily detectable, although in gradually decreasing amounts, for the 11 days of culture. LH secretion paralleled CG secretion and was much greater in magnitude. Pituitary cells from female fetuses generally secreted more CG as well as more LH than those from male fetuses. Dilutions of the medium showed that the secreted CG exhibited parallelism with the CG standard. Chromatofocusing of the medium across a pH 6-9 gradient yielded several peaks of LH immunoreactivity between pH 6.5 and 8.5, but no peaks of CG. Chromatofocusing of the medium across a pH 3-7 gradient yielded peaks of CG, but not LH, between pH 4.0-5.5. These data indicate that CG immunoreactivity, distinct and separable from LH immunoreactivity, is secreted by the dispersed cells of fetal human pituitary glands.

Identification of amino acids in the gamma-carboxylation recognition site on the propeptide of prothrombin

A gamma-carboxylation recognition site on the propeptide of the vitamin K-dependent blood coagulation proteins directs the carboxylation of glutamic acid residues by binding to the vitamin K-dependent carboxylase. To determine residues that define this site, we evaluated the effect of mutation of certain residues in the prothrombin propeptide on the extent of carboxylation. The prothrombin cDNA modified by site-specific mutagenesis was expressed in Chinese hamster ovary cells using a system that yields functional fully carboxylated prothrombin. The cell supernatants containing recombinant prothrombin were evaluated for the extent of gamma-carboxylation by immunoassay. Conformation-specific anti-prothrombin:Ca(II)-specific antibodies measure native completely carboxylated prothrombin; anti-prothrombin:total antibodies measure all forms of prothrombin, regardless of gamma-carboxyglutamic acid content. Mutation of His-18 to Gly, Val-17 to Ser, Leu-15 to Gly or Asp, or Ala-10 to Asp was associated with a partial (30-65%) inhibition of gamma-carboxylation. Mutation of Ala-14 to Ser or Ser-8 to Val did not inhibit gamma-carboxylation. From this and earlier work, residues whose mutation leads to a significant impairment of carboxylation include His-18, Val-17, Phe-16, Leu-15, and Ala-10. Residues whose mutation does not alter the carboxylation recognition site include Ala-14, Ser-8, Arg-4, and Arg-1. To determine the size of the recognition site, the in vitro carboxylation of propeptide-containing synthetic peptides was compared. A 28-residue peptide, based upon residues -18 to +10 of prothrombin, and a 54-residue peptide, based upon residues -18 to +36 of prothrombin, were carboxylated by partially purified bovine carboxylase with similar Km values of 2-5 microM. These results indicate that the gamma-carboxyglutamic acid-rich region of prothrombin makes a minimal contribution to carboxylase binding. A molecular surface of about five amino acids located within the propeptide appears to define the carboxylation recognition site on the precursor forms of the vitamin K-dependent proteins.

Developing a test of knowledge of surgical options for breast cancer

Because many women now have a choice regarding the type of surgery they prefer for early stage breast cancer, it is important for clinicians to provide comprehensive information about these options and to determine whether patients have understood this information. The purpose of this study was to develop a short, easily administered, valid and reliable test of women's knowledge of surgical treatment options for early stage breast cancer. Instrument development was carried out in two phases: (a) content domains were established and items were generated and examined for content validity and clarity; and (b) the known-groups technique was used to determine construct validity and to generate data for reliability testing. The test was administered to 44 student nurses, 21 women with breast cancer, and 24 practicing nurses. An 18-item test--the BCIT-R (Breast Cancer Information Test-Revised)--with modest internal consistency and very good construct validity resulted from these steps. Nurses scored significantly better than either students or patients. The instrument is discussed in terms of psychometric issues and clinical use.

Structure of the gene encoding the human leukocyte adhesion molecule-1 (TQ1, Leu-8) of lymphocytes and neutrophils

The leukocyte adhesion molecule-1 (LAM-1, TQ1, Leu-8), expressed by human lymphocytes, neutrophils, monocytes, and their precursors, is a member of the selectin family of cellular adhesion/homing receptors which play important roles in leukocyte-endothelial cell interactions. These cell surface molecules contain an amino-terminal lectin-like domain followed by an epidermal growth factor-like domain and a variable number of short consensus repeat sequences similar to those found in C3/C4 binding proteins. In this report, the structure of the lyam-1 gene that encodes the LAM-1 protein was determined by isolating overlapping genomic DNA clones that hybridized with a LAM-1 cDNA probe. The lyam-1 gene spans greater than 30 kilo base pairs of DNA and is composed of at least 10 exons. The 5' end of the LAM-1 mRNA was mapped by primer extension analysis revealing a single initiation region for transcription. Exons II through X contain translated sequences; exon II encodes the translation initiation codon; exon III, the leader peptide; IV, the lectin-like domain; V, the epidermal growth factor-like domain; VI and VII, the short consensus repeat units; exon VIII, the transmembrane region; exon IX encodes seven amino acids containing a potential phosphorylation site; and exon X encodes the five remaining amino acids of the cytoplasmic tail and the long 3' untranslated region. Sequencing of LAM-1 cDNA clones derived from neutrophils revealed that the protein expressed by neutrophils would be identical in sequence with the protein expressed by lymphocytes and cDNAs that would encode different isoforms of LAM-1 protein were not detected. In addition, the level of LAM-1 expression by lymphocytes and neutrophils from two patients with paroxysmal nocturnal hemoglobinuria, a disorder in which linkage of phosphatidylinositol anchors to proteins is defective, was similar to that of normal controls. Therefore, the usage of exons II through X results in the generation of a single major LAM-1 protein product expressed by lymphocytes and neutrophils.

Cardiovascular response to gait training and ambulation in a hemiparetic heart recipient

Little has been reported about the rehabilitation of heart recipients who experience disabling neurologic complications. This is of particular interest to physiatrists because the number of cardiac transplants is increasing and the cardiovascular response of the denervated heart to exercise is altered. The case reported here describes a 42-year-old woman who underwent heart transplantation for ischemic cardiomyopathy. One year after transplantation, the patient was hospitalized for evaluation of headaches and mental status changes. A lymphoma involving the left basal ganglia was diagnosed and the patient underwent a course of radiation therapy. She was transferred for rehabilitation of a left hemiparesis and made functional gains in mobility and self-care skills. Weekly recordings of heart rate and blood pressure were obtained before and after ambulation. Small increases in both heart rate and blood pressure were recorded after ambulation to the point of fatigue. In both parameters, the patient's maximum response was below that reported for nondisabled cardiac recipients, highlighting the need for symptom-oriented exercise guidelines in these patients.

HIV seropositivity of needles from shooting galleries in south Florida

Needle/syringe combinations were collected from three shooting galleries in South Florida and tested for the presence of antibodies to HIV-1. Fifteen of 148 needles (10.1 percent) tested positive for HIV-1 antibody. Seropositivity rates did not vary by the day of the week of collection, nor by shooting gallery from which they were collected. When the needle appeared to contain blood residue, 20.0 percent were positive versus 5.1 percent with no blood residue. These findings suggest that needles/syringes used in shooting galleries are likely to serve as reservoirs and/or vectors of transmission of the HIV-1 virus, and that although visual inspection of the needle/syringe may be useful in lessening the chance for transmission, even the visually "clean" needles may result in transmission of infection.

Nutrient intakes during pregnancy: observations on the influence of smoking and social class

The influence of smoking and social class on dietary intake in pregnancy was investigated in a random sample of smokers (greater than or equal to 15 cigarettes/d) and nonsmokers. A total of 206 subjects (94 smokers and 112 nonsmokers) completed a 7-d weighed dietary intake at 28 wk gestation and 178 completed a second assessment at 36 wk. Nonsmokers had higher intakes of almost all nutrients than did smokers and the nutrient density of their diet was greater. Energy intake was nonsignificantly higher in nonsmokers. Women in higher social classes had the highest nutrient intakes. Smokers were shorter than nonsmokers and tended to be of lower social class. After maternal height and social class were controlled for, smoking had a significant effect on intake of many micronutrients. Dietary intake was reduced in late pregnancy, particularly in smokers. These data suggest that smokers in all social classes have a poorer quality of diet.

Octadeca-9,11-dienoic acid in cervical intraepithelial neoplasia: a colposcopic study

488 women were studied to evaluate the use of the molar ratio (%MR) of octadeca-9,11-dienoic acid (18:2(9, 11] to linoleic acid (18:2(9, 12] as a new screening method for cervical cancer and pre-cancer. A combination of Papanicolaou cytology, colposcopy and %MR 18:2(9, 11)/18:2(9, 12) were employed. 86 women (17.6%) were found to have histologically proven cervical intraepithelial neoplasia (CIN). The %MR was obtained in 452 cases (92%). There was no significant difference in %MR in cervical cell scrapes from women with or without CIN. The %MR of cervical scrapes in some women with anaerobic vaginosis was significantly elevated suggesting bacterial generation of 18:2(9, 11). The %MR of 18:2(9, 11)/18:2(9, 12) is unsuitable for the diagnosis of cervical intraepithelial neoplasia.

Failure of ultrasound to detect extra-pancreatic abscesses in severe acute pancreatitis

The development of intra-abdominal abscesses in patients with severe acute pancreatitis can be associated with a mortality as high as 100%. The clinical findings in these patients may be non specific and therefore imaging is essential. Computed tomography (CT) is the imaging modality of choice. However, a satisfactory ultrasound examination may be regarded as sufficient, particularly when there is limited availability of CT. A case of extra-pancreatic abscess complicating severe acute pancreatitis, in whom sonography was "normal", but CT demonstrated the abscess is presented. The importance of CT in these patients in whom an abscess is suspected and our experience with similar cases is discussed.

The product of the retinoblastoma susceptibility gene has properties of a cell cycle regulatory element

The retinoblastoma susceptibility gene product, Rb, is suspected to suppress cell growth. Rb is a 110-114 kd nuclear phosphoprotein. We have previously demonstrated that SV40 T antigen binds only to unphosphorylated Rb, and not pp112-114Rb, the family of phosphorylated Rb. Here we demonstrate the cell cycle-dependent phosphorylation of Rb. In G0/G1 cells, virtually all the Rb is unphosphorylated. In contrast, during S and G2, it is largely, if not exclusively, phosphorylated. Rb phosphorylation occurs at the G1/S boundary in several cell types tested. A 14 residue peptide, corresponding to the SV40 T domain required for transformation, is able to compete effectively with SV40 T for binding to p110Rb. We propose a model to explain how Rb may suppress cell growth by acting as a cell cycle regulatory element.

Complex wound management: a case study

Mr. G.'s situation was challenging, because it did not readily conform to the management techniques currently available and required consideration of psychosocial and other physical factors. To meet individual patient needs, nurses must be creative in finding solutions to unusual problems. By focusing on the short-term goals for wound management and the goals for family-centered home care as a guide to interventions, adaptations were made to fit this patient's needs.

Pulsatile secretion of chorionic gonadotropin during the normal menstrual cycle

Several groups of investigators have previously reported that small amounts of hCG are present in blood and urine of nonpregnant eugonadal women and men. We have developed highly sensitive and specific, two-monoclonal antibody, sandwich-type assays which can quantify both hCG and LH in sera from postmenopausal women, women at all phases of the menstrual cycle, and men. Using these assays we have also reported that hCG is secreted in a pulsatile fashion in postmenopausal women, is stimulated by GnRH in both men and postmenopausal women, and is suppressed by a GnRH agonist in castrate men. Employing these same sandwich assays, we report herein that hCG is secreted in a pulsatile manner during the follicular and luteal phases of the normal menstrual cycle. During the follicular phase 0.68 +/- 09 (+/- SEM) pulses of hCG occurred each hour, while 0.62 +/- 0.08 pulses of LH occurred. Pulse durations during the follicular phase for hCG and LH, respectively, were 38.3 +/- 4.4 and 62.5 +/- 11.1 min (P less than or equal to 0.05). During the luteal phase there were 0.42 +/- 0.16 pulses/h of hCG and 0.38 +/- 0.08 pulses of LH (P greater than 0.05). Pulse durations were 22.3 +/- 7.5 and 126.4 +/- 19.0 min for hCG and LH, respectively (P less than 0.01). The t1/2 of hCG disappearance was 37.2 +/- 3.8 min during the follicular phase and 22.9 +/- 4.6 min during the luteal phase. The t1/2 values of LH were 82.9 +/- 5.7 and 67.5 +/- 5.12 min during follicular and luteal phases, respectively. The t1/2 of LH was greater than the t1/2 of hCG (P less than 0.01). We conclude that small amounts of hCG are secreted in a pulsatile manner during follicular and luteal phases of the human menstrual cycle.