A study of the impact of long-term tobacco smoking on postoperative intensive care admission

Smoking is a risk factor for intra-operative pulmonary complications and a wide range of postoperative pulmonary, cardiovascular, infection and wound-related complications. These may all lead to unplanned postoperative intensive care admission. We tested the hypothesis that smokers have an increased incidence of postoperative intensive care admission and more postoperative complications than nonsmokers in a general and orthopaedic surgical population. The following information was assessed in 6026 surgical patients: age, sex and smoking status (pack-years), history of heart and lung disease, American Society of Anesthesiologists (ASA) physical classification, intensive care admission and postoperative complications. Two thousand five hundred and twenty-six (46%) were smokers but for 620 patients (10.3%) smoking status was not confirmed. Postoperative intensive care admission was required by 319 patients (5.3%). Patients with > 50 pack-years were admitted to the intensive care more frequently than were smokers with < or = 50 pack-years history and nonsmokers (p < 0.001). Ex-smokers with > 50 pack-years history had the same risk of postoperative admission to intensive care as smokers with > 50 pack-years history. Smokers admitted to intensive care with > 50 pack-years history had a higher incidence of chronic lung disease (p < 0.005) and heavy alcohol consumption (p < 0.001). These smokers also had a higher incidence of postoperative pulmonary complications (odds ratio = 3.91, p < 0.01). The mortality rate was 37% in smokers with > 50 pack-years history and 24% in nonsmokers (odds ratio = 2.02, p = 0.08). We conclude long-term tobacco smoking (> 50 pack-years) carries a higher risk of postoperative admission to intensive care, and there seems to be a dose relationship between the amount of tobacco consumed and the risk of postoperative intensive care admission.

Dynamic structural disorder of the FeO2 moiety in oxymyoglobin studied by nuclear resonant forward scattering of synchrotron radiation

Oxy- as well as deoxymyoglobin exhibit a pronounced temperature dependence of the quadrupole splitting of the heme iron as detected by conventional Mössbauer spectroscopy. With nuclear resonant forward scattering (NFS) of synchrotron radiation, which can be viewed as Mössbauer spectroscopy in the time domain, it is shown that this spectroscopic behavior, although it is phenomenologically similar in the two cases, is based on completely different physical mechanisms. It is demonstrated that stochastic fluctuations of the iron electric field gradient in MbO(2), which are due to the dynamic structural disorder of the FeO(2) moiety, are the reason for the temperature-dependent alterations of the coherent quantum beat pattern in the NFS spectra of MbO(2), in contrast to deoxyMb where transitions between orbital states of iron take place. This subtle spectroscopic difference cannot be inferred from conventional Mössbauer spectroscopy.

The LDH ratio as a marker for response to plasma exchange in HUS/TTP of the adult

BACKGROUND

Plasma exchange improved the outcome of thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS) of the adult markedly, but a high number of non-responders remain. Identifying these patients at an early stage would help to optimize therapy.

AIM

determine the value of serologic measures in predicting the response to plasma exchange.

MATERIAL AND METHODS

We performed a retrospective chart review of 30 patients with HUS/TTP of the adult treated with plasma exchange. According to the treatment protocol, a mean of 42 +/- 8.2 ml plasma per kilogram of body weight was exchanged daily for 3 days and continued every second day thereafter. Prior to each session, clinical status and serologic markers for hemolysis and kidney function were obtained. To assess the early individual response to plasma exchange, the decline of LDH from the first to the third cycle was calculated as: LDH concentration before the third session/LDH concentration before the first session (LDH ratio).

RESULTS

During the observation period (median 195, range 6-1500 days), 80% of the patients responded to therapy with plasmapheresis. None of the serologic measures or clinical signs obtained before initiation of plasma exchange showed a significant correlation with the outcome. After 2 sessions of plasma exchange, only LDH and platelet level had improved markedly in responding patients. The LDH ratio was the best predictive marker for the individual response. An LDH ratio < 0.6 predicted a favorable outcome with a sensitivity of 0.96 and a specificity of 0.83.

CONCLUSION

The LDH ratio might be a useful marker for separating patients responding to plasma exchange from those not responding at an early stage.

A descriptive study of medical and chiropractic patients with chronic low back pain and sciatica: management by physicians (practice activities) and patients (self-management)

BACKGROUND

A practice-based study of ambulatory patients with low back pain noted a long-term outcome advantage for self-referred chiropractic (DC) patients over medical (MD) patients within a subgroup of patients with chronic low back pain and radiating pain below the knee. The frequency of self-care education by physicians in both provider cohorts coupled with current thinking on management of chronic low back pain led to an exploration and description of physicians' noncore practice activities and patients' self-management attitudes and behaviors.

METHODS

A longitudinal, practice-based, observational study was undertaken in 14 general practice and 51 chiropractic community-based clinics. We enrolled 2945 consecutive patients with ambulatory low back pain of mechanical origin; of these, 268 comprised the subgroup of patients with chronic low back pain and radiating pain below the knee. The patients' low back status was followed for 1 year. Data on physicians' practice activities were obtained from doctor questionnaires completed at each patient visit and from chart abstraction. Patient data obtained from self-administered questionnaires at enrollment included sociodemographics, complaint characteristics, health status, and health encounter preferences. Questionnaires mailed at 2 weeks, 1 month, 3 months, 6 months, and 12 months collected data on low back complaint status and satisfaction with treatment. At 1 to 3 years follow-up, mailed questionnaires collected data on patients' self-management attitudes and behaviors.

RESULTS

Physicians' core practice activities were as expected. Exercise plans and self-care education (>55%) were conspicuous in the frequency of their use in the DC cohort. MD patients appeared to rely more on family and friends for support during periods of back trouble. DC patients were characterized by greater self-efficacy motivation (P = .000). Both groups showed evidence of self-care activities during and between bouts of back pain, although MD patients were far more likely to choose bed rest (P = .007).

CONCLUSIONS

The chiropractic encounter may have enhanced patients' self-efficacy motivation, leading to better coping abilities and better pain and disability outcomes. Understanding, respecting, and capitalizing on the role and influence of psychosocial factors can help all physicians become more effective healers and counselors for their patients with back pain.

To HITH or not to HITH: making a decision about establishing hospital in the home

Hospital in the home is increasingly being considered as an alternative for the provision of acute care. This article provides an overview of Hospital in the Home in Australia, discussing some of the issues that should be considered when determining whether to establish or fund hospital in the home programs such as whether efficiency is increased, care is improved and whether patients perceive more choice. These issues are discussed in the context of a transparent funding strategy that is aimed at achieving predefined goals and objectives.

Efficacy of spinal manipulation for chronic headache: a systematic review

BACKGROUND

Chronic headache is a prevalent condition with substantial socioeconomic impact. Complementary or alternative therapies are increasingly being used by patients to treat headache pain, and spinal manipulative therapy (SMT) is among the most common of these.

OBJECTIVE

To assess the efficacy/effectiveness of SMT for chronic headache through a systematic review of randomized clinical trials.

STUDY SELECTION

Randomized clinical trials on chronic headache (tension, migraine and cervicogenic) were included in the review if they compared SMT with other interventions or placebo. The trials had to have at least 1 patient-rated outcome measure such as pain severity, frequency, duration, improvement, use of analgesics, disability, or quality of life. Studies were identified through a comprehensive search of MEDLINE (1966-1998) and EMBASE (1974-1998). Additionally, all available data from the Cumulative Index of Nursing and Allied Health Literature, the Chiropractic Research Archives Collection, and the Manual, Alternative, and Natural Therapies Information System were used, as well as material gathered through the citation tracking, and hand searching of non-indexed chiropractic, osteopathic, and manual medicine journals.

DATA EXTRACTION

Information about outcome measures, interventions and effect sizes was used to evaluate treatment efficacy. Levels of evidence were determined by a classification system incorporating study validity and statistical significance of study results. Two authors independently extracted data and performed methodological scoring of selected trials.

DATA SYNTHESIS

Nine trials involving 683 patients with chronic headache were included. The methodological quality (validity) scores ranged from 21 to 87 (100-point scale). The trials were too heterogeneous in terms of patient clinical characteristic, control groups, and outcome measures to warrant statistical pooling. Based on predefined criteria, there is moderate evidence that SMT has short-term efficacy similar to amitriptyline in the prophylactic treatment of chronic tension-type headache and migraine. SMT does not appear to improve outcomes when added to soft-tissue massage for episodic tension-type headache. There is moderate evidence that SMT is more efficacious than massage for cervicogenic headache. Sensitivity analyses showed that the results and the overall study conclusions remained the same even when substantial changes in the prespecified assumptions/rules regarding the evidence determination were applied.

CONCLUSIONS

SMT appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine headache. This conclusion rests upon a few trials of adequate methodological quality. Before any firm conclusions can be drawn, further testing should be done in rigorously designed, executed, and analyzed trials with follow-up periods of sufficient length.

Pain, disability, and satisfaction outcomes and predictors of outcomes: a practice-based study of chronic low back pain patients attending primary care and chiropractic physicians

BACKGROUND

Few studies exist on the prognostic value of demographic, clinical, or psychosocial factors on long-term outcomes for patients with chronic low back pain.

OBJECTIVE

This study reports on long-term pain and disability outcomes for patients with chronic low back pain, evaluates predictors of long-term outcomes, and assesses the influence of doctor type on clinical outcome.

METHODS

Sixty chiropractic (DC) and 111 general practice (MD) physicians participated in data collection for a prospective, longitudinal, practice-based, observational study of ambulatory low back pain of mechanical origin. The primary outcomes, measured at 6 months and 12 months, were pain (by using the Visual Analog Scale), and functional disability (by using the Revised Oswestry Disability Questionnaire). Satisfaction was a secondary outcome.

RESULTS

Overall, long-term pain and disability outcomes were generally equivalent for patients seeking care from medical or chiropractic physicians. Medical and chiropractic care were comparable for patients without leg pain and for patients with leg pain above the knee. However, an advantage was noted for chronic chiropractic patients with radiating pain below the knee after adjusting for baseline differences in patient and complaint characteristics between MD and DC cohorts (adjusted differences = 8.0 to 15.2; P <.002). A greater proportion of chiropractic patients were satisfied with all aspects of their care (P =.0000). The strongest predictors of primary outcomes included an interaction of radiating pain below the knee with provider type and baseline values of the outcomes. Income, smoking, comorbidity, and chronic depression were also identified as predictors of outcomes in this study.

CONCLUSION

Chiropractic care compared favorably to medical care with respect to long-term pain and disability outcomes. Further study is required to explore the advantage seen for chiropractic care in patients with leg pain below the knee and in the area of patient satisfaction. Identification of patient and treatment characteristics associated with better or worse outcomes may foster changes in physicians' practice activities that better serve these patients' needs.

Developing better casemix education for rural New South Wales

Casemix is now an important mechanism for the planning, evaluation and funding of health services in Australia. In New South Wales (NSW) it was believed that while staff from most hospitals in metropolitan Sydney had become both literate and vocal about casemix, staff from rural areas were less familiar and much less likely to participate in casemix initiatives. In conjunction with the NSW Casemix Clinical Committee (NCCC), NSW Health considered a special program of casemix education for rural NSW. Before an education program was attempted, NSW Health inquired into the specific needs for casemix education in rural NSW. Qualitative and quantitative methods of analysis were used. Results of the quantitative analysis indicate that the understanding of casemix classifications is highest among managers. Of concern were the relatively low proportion of Allied Health staff who had more than a vague understanding of the Sub- and Non-Acute Patient (SNAP) classification; the lack of any knowledge of the Mental Health Costing And Service Classification (MH-CASC) by nursing staff; and the lack of any knowledge of the emergency department classification: Urgency, Disposition and Age-related Groups (UDAG), either by clinical or nursing staff. The results of the qualitative analysis show that casemix education for rural areas needs to differ from metropolitan education programs. The analysis also highlights the perception of casemix in rural areas and the special circumstances in rural hospitals that place limits on the ability to use casemix more fully.

Assessing the value of hospital-in-the-home: lessons from Australia

OBJECTIVES

To identify factors that influence the cost-effectiveness of hospital-in-the-home (HITH) and to discuss the impact of funding arrangements in creating incentives or disincentives for the establishment of HITH services.

METHODS

A review of HITH services in Australia was undertaken. Based on the review, factors affecting the relative costs of HITH and conventional care were identified, in particular, the effect of funding and organisational arrangements on the incentives for managers and providers to choose between HITH and conventional care.

RESULTS

The review of HITH services identified a wide range of models of HITH in Australia. Factors identified as important to the success of HITH included demographic and location issues, referral mechanisms, the choice of staffing and the management of the programme. However, it was clear that the structure of the programme often related to funding arrangements. Issues such as 'incentive funding', establishment costs and opportunity for cost-shifting were identified as being relevant to incentives for the efficient provision of HITH.

CONCLUSIONS

Evaluations are essential to inform decisions about whether HITH is likely to be a viable and cost-effective alternative to inpatient care. However, the relative costs of HITH and conventional care will depend on local factors. From the point of view of the decision-maker, these will be affected by funding and organisational arrangements. Funders must be aware that complex financial incentives may mask the true costs of HITH services relative to hospital services. They need to ensure that the incentives created by funding arrangements are transparent.

The news on health care funding: a study of reporting in the Australian print media for 1996

OBJECTIVES

To review the coverage of health care funding and resourcing issues in the quality printed media in Australia.

METHODS

Content analysis of all articles in six major print publications with detailed commentary on four major issues.

RESULTS

One thousand one hundred and fifty articles were published over 12 months, most in the front three pages. Coverage of many issues was prompted by an event, such as an election, government budget or policy announcement. Although issues were rarely personalized, the use of an individual authoritative spokesperson was, with some individuals becoming well recognised as experts. In general, these experts represented vested interest or lobby groups. The media discussion rarely dealt with the system as a whole, and generally approached a topic or issue in isolation from its inter-relationships with other issues.

CONCLUSION

Health care funding stories are newsworthy but more for their political interest than as reflection of a social debate about values. Media reports rarely deal with the complexity of health policy issues, or challenge the assumptions and positions put forward.

A distinctive pediatric renal neoplasm characterized by epithelioid morphology, basement membrane production, focal HMB45 immunoreactivity, and t(6;11)(p21.1;q12) chromosome translocation

We report two cases of a hitherto undescribed pediatric renal neoplasm that is distinctive at the morphological, immunohistochemical, ultrastructural, and cytogenetic levels. On light microscopy, the tumors are composed of nests of polygonal, clear to eosinophilic cells associated with a subpopulation of smaller cells that surround hyaline material. Despite their epithelioid morphology, these tumors do not label immunohistochemically for epithelial markers but instead label focally for melanocytic markers HMB45 and Melan A. The hyaline material is positive with periodic acid-Schiff and methenamine-silver histochemical stains, and labels immunohistochemically for type 4 collagen. Ultrastructural examination confirms that it represents basement membrane material. Cytogenetic analysis reveals the identical t(6;11)(p21.1;q12) chromosome translocation as the sole abnormality in these two tumors, confirming their identity and distinctive nature.

Potentials and limitations of the low-molecular-weight protein lysozyme as a carrier for renal drug targeting

Selective targeting of drugs to the kidney may enable an increased renal effectiveness combined with a reduction of extrarenal toxicity. Intrarenal delivery to the proximal tubular cell can be achieved using low-molecular-weight proteins, such as lysozyme. Administration of high dosages of lysozyme, required to study the effects of such conjugates in vivo, however, is restricted since a partial escape of the renal reabsorption and the occurrence of unwanted effects on systemic blood pressure and renal function may occur. The purpose of this study was to investigate the optimal parenteral administration schedule and the maximum dose of lysozyme, providing the most optimal tubular reabsorption and at the same time a minimal effect on blood pressure and renal hemodynamics, comparing continuous infusion of lysozyme with single dose injections. Urinary lysozyme excretion increased dose-dependently, both during continuous infusion and intravenous bolus injections. However, this loss of intact lysozyme into the urine was much higher after 3 injections of in total 250 mg x kg(-1) x 6 h(-1) (51.8+/-3.7% of the dose) compared to the same dose administered by continuous infusion (11.7+/-2.4%, P < 0.001). Continuous infusion of lysozyme up to 1000 mg x kg(-1) in 6 hours had no effect on systemic blood pressure, whereas a bolus injection of lysozyme (167 mg x kg(-1)) resulted in reversible blood pressure lowering of 52.2+/-2.2% (P<0.001). A dose-dependent decline of the glomerular filtration rate was observed at dosages of lysozyme higher than 100 mg x kg(-1) x 6 h(-1), with a maximal reduction of 53.0+/-3.7% after infusion of 1000 mg x kg(-1) x 6 h(-1). Effective renal plasma flow was less affected and only lowered statistically significant at dosages of 500 (-12.6+/-3.3%, P<0.05) to 1000 mg x kg(-1) x 6 h(-1) (-17.2+/-3.9%, P<0.01). We conclude that bolus injections of lysozyme should not be used for renal targeting purposes since it results in considerable tubular loss of lysozyme in the urine as well as cardiovascular side effects. In contrast, continuous infusion of lysozyme using dosages sufficient for renal drug targeting (maximally 15 mg x kg(-1) x h(-1)) only has minimal effects on blood pressure and renal hemodynamics, with a minimal urinary lysozyme loss as well.

Strongly linked current flow in polycrystalline forms of the superconductor MgB2

The discovery of superconductivity at 39 K in magnesium diboride, MgB2, raises many issues, a critical one being whether this material resembles a high-temperature copper oxide superconductor or a low-temperature metallic superconductor in terms of its behaviour in strong magnetic fields. Although the copper oxides exhibit very high transition temperatures, their in-field performance is compromized by their large anisotropy, the result of which is to restrict high bulk current densities to a region much less than the full magnetic-field-temperature (H-T) space over which superconductivity is found. Moreover, the weak coupling across grain boundaries makes transport current densities in untextured polycrystalline samples low and strongly sensitive to magnetic field. Here we report that, despite the multiphase, untextured, microscale, subdivided nature of our MgB2 samples, supercurrents flow throughout the material without exhibiting strong sensitivity to weak magnetic fields. Our combined magnetization, magneto-optical, microscopy and X-ray investigations show that the supercurrent density is mostly determined by flux pinning, rather than by the grain boundary connectivity. Our results therefore suggest that this new superconductor class is not compromized by weak-link problems, a conclusion of significance for practical applications if higher temperature analogues of this compound can be discovered.

Characterization of direct readout contacts of the Myb DNA-binding domain

The Myb protein contacts its recognition sequence by means of direct protein-DNA interactions. We used site-directed mutagenesis in order to substitute amino acids crucial for these contacts and probed the mutant proteins for their DNA-binding and transactiving activities. We could show that amino acids involved in direct readout contacts do not contribute equivalently in the recognition process.

Using programme budgeting and marginal analysis to assist population based strategic planning for coronary heart disease

OBJECTIVES

the objective of this project was to use programme budgeting and marginal analysis (PBMA), to inform the planning process of the South Western Sydney Area Health Service (SWSAHS) in respect of coronary heart disease (CHD).

METHODS

a working party was established to carry out the project. The group set the parameters of the project and identified the programme, and associated the activity and resource use. Three sub-groups were established to undertake the marginal analysis.

RESULTS

each sub-group (representing prevention, treatment, and rehabilitation for CHD) developed a list of potential strategies and provided estimates of resource use and consequences. These were prioritised and presented as recommendations to the SWSAHS. Some recommendations required enhancement funding for the SWSAHS. CONCLUSIOSN: while the use of PBMA presented some challenges, there were also some important outcomes. A comprehensive and detailed picture of resource use enabled the participants to form a view on how additional or reduced resources for CHD should be dealt with at the area level. The ultimate recommendations represent involvement by key stakeholders in the SWSAHS planning process, not just in identifying the 'vision' of CHD services, but also, how service delivery would be organised to achieve the overall objectives of reducing CHD morbidity and mortality.

Reduction in mean glomerular pore size coincides with the development of large shunt pores in patients with diabetic nephropathy

The glomerular size selectivity was determined by neutral dextran clearance sieving technique and plasma cystatin C levels in two groups of patients with long-standing type I diabetes mellitus and different stages of albuminuria but normal glomerular filtration rate and in a group of healthy controls. The sieving characteristics of the glomerular filter were determined using a mathematical model of log normal pore size distribution. Patients with albuminuria above 200 microg/min exhibited a significant increase of cystatin c plasma concentrations and a significant reduction in mean glomerular filtration slit size. Only these patients exhibited large, unrestrictive pores in the glomerular filter (shunt). The plasma cystatin c levels correlated significantly with 26-angstrom neutral dextran plasma levels in microalbuminuric patients and in patients with albuminuria above 200 microg/min. We conclude that a reduction in average pore size of the glomerular filter does not occur earlier than the development of large shunt pores. The renal clearance of cystatin c in patients with proteinuric diabetic nephropathy but a normal glomerular filtration rate is reduced due to its molecular size.

A practical approach to planning health services: using PBMA

Planning health services is a difficult and often complex task. There are many approaches to planning, including the use of tools such as needs assessment, goals and targets, as well as economics-based tools such as cost of illness or economic evaluation. It is not always clear which planning tool is the most appropriate. In this paper we compare an economics approach to planning using program budgeting and marginal analysis (PBMA) with other approaches. We provide an overview of the methods of PBMA, report on experience with its use, and draw conclusions about its likely usefulness to health services planners.

The clinical and pathologic implications of plasmacytic infiltrates in percutaneous renal allograft biopsies

Plasmacytic infiltrates in renal allograft biopsies are uncommon and morphologically distinctive lesions that may represent variants of acute rejection. This study sought significant clinical and pathologic determinants that might have influenced development of these lesions and assessed their prognostic significance. Renal allograft biopsies (n = 19), from 19 patients, with tubulointerstitial inflammatory infiltrates containing abundant plasma cells, composing 32 +/- 8% of the infiltrating mononuclear cells, were classified using Banff '97 criteria. Clonality of the infiltrates was determined by immunoperoxidase staining for kappa and lambda light chains and polymerase chain reaction for immunoglobulin heavy-chain gene rearrangements, using V(H) gene framework 3 and JH consensus primers. In situ hybridization for Epstein-Barr virus encoded RNA (EBER) was performed in 17 cases. The clinical features, histology, and outcome of these cases were compared with kidney allograft biopsies (n = 17) matched for time posttransplantation and type of rejection by Banff '97 criteria, with few plasma cells (7 +/- 5%). Sixteen of 19 biopsies (84%) with plasmacytic infiltrates had EBER-negative (in 14 cases tested) polyclonal plasma cell infiltrates that were classifiable as acute rejection (types 1A [4], 1B [10], and 2A [2]). These biopsies were obtained between 10 and 112 months posttransplantation. Graft loss from acute and/or chronic rejection was 50% at 1 year and 63% at 3 years, and the median time to graft failure was 4.5 months after biopsy. There was no significant difference in overall survival or time to graft failure compared with the controls. Three of 19 biopsies (16%) had EBER-negative polyclonal plasmacytic hyperplasia, mixed monoclonal and polyclonal polymorphous B cell hyperplasia, and monoclonal plasmacytoma-like posttransplantation lymphoproliferative disease (PTLD) and were obtained at 17 months, 12 weeks, and 7 years after transplantation, respectively. Graft nephrectomies were performed at 1, 19, and 5 months after biopsy, respectively. Plasmacytic infiltrates in renal allografts comprise a spectrum of lesions from acute rejection to PTLD, with a generally poor prognosis for long-term graft survival.

Patient characteristics and physicians' practice activities for patients with chronic low back pain: a practice-based study of primary care and chiropractic physicians

BACKGROUND

Chronic low back pain sufferers are among those who account for the greatest usage of health care resources. Primary care medical (MD) physicians and chiropractic (DC) physicians treat most of these patients.

OBJECTIVES

To study patient characteristics and physician practice activities for patients with chronic low back pain treated by DC physicians and MD physicians.

METHODS

A longitudinal, practice-based observational study was undertaken in 14 general practice and 51 DC community-based clinics. A total of 2945 consecutive patients with ambulatory low back pain of mechanical origin were enrolled; 835 patients were in the chronic subgroup. Patients were followed for 12 months. Data were obtained on all of the following: patient demographics, health status, and psychosocial characteristics; history, duration, and severity of low back pain and disability; physicians' practice activities; and low back complaint status at 1 year.

RESULTS

Patients treated by MD physicians were younger and had lower incomes; their care was more often paid for by a third party; their baseline pain and disability were slightly greater. In addition, patients treated by MD physicians had one fourth as many visits as patients treated by DC physicians. Utilization of imaging procedures by enrolling physicians was equivalent for the two provider groups. Medications were prescribed for 80% of the patients enrolled by MD physicians; spinal manipulation was administered to 84% of patients enrolled by DC physicians. Physical modalities, self-care education, exercise, and postural advice characterized low back pain management in both provider groups. Patients' care-seeking was not exclusive to one provider type. Most patients experienced recurrences (patients treated by MD physicians, 59.3%; patients treated by DC physicians, 76.4%); 34.1% of patients treated by MD physicians and 12.7% of patients treated by DC physicians reported 12 months of continuous pain. Only 6.7% of patients treated by MD physicians and 10.9% of patients treated by DC physicians reported 1 resolved episode during the year.

CONCLUSIONS

Differences in sociodemographics, present pain intensity, and functional disability may distinguish patients with chronic low back pain seeking care from primary care medical physicians from those seeking care from DC physicians. Although the primary treatment modality differs, the practice activities of MD physicians and DC physicians have much in common. Long-term evaluation suggests that chronic back pain is persistent and difficult to treat for both provider types.

Practice-based research: the Oregon experience

BACKGROUND

Practice-based research links community-based physicians and their patients with investigators at academic institutions. In 1992, Western States Chiropractic College developed an infrastructure, the Center for Outcomes Studies, to support practice-based research. The Low Back Pain Study, undertaken in collaboration with Oregon Health Sciences University, 111 medical physicians, and 60 chiropractors, relied on the Center for Outcomes Studies infrastructure for support in project implementation and maintenance.

RESULTS

Challenges, many of them critical, were a regular occurrence: dealing with unforeseen obstacles, establishing and maintaining physician buy-in, establishing and maintaining staff buy-in, implementing the protocol as directed and with minimal intrusiveness, maintaining enthusiasm for the project over time, and knowing where (and where not) to allocate the Study's time, energy, and money. Strategies were developed to overcome or minimize the impact of problems on a case-by-case basis.

CONCLUSIONS

Successful practice-based research requires an awareness of study design issues and an appreciation of clinical practice logistics and priorities. Every effort must be made to include doctors and office staff in the implementation of the study in a manner that minimizes the study's intrusiveness and its economic impact on office organization, routine, and personnel. Investigators must understand and accept that there will be areas of the research environment over which they have no direct control. The challenges will be many, but they will be diminished by the rewards.

Interaction between the open reading frame III product and the coat protein is required for transmission of cauliflower mosaic virus by aphids

Transmission of cauliflower mosaic virus (CaMV) by aphids requires two viral nonstructural proteins, the open reading frame (ORF) II and ORF III products (P2 and P3). An interaction between a C-terminal domain of P2 and an N-terminal domain of P3 is essential for transmission. Purified particles of CaMV are efficiently transmitted only if aphids, previously fed a P2-containing solution, are allowed to acquire a preincubated mixture of P3 and virions in a second feed, thus suggesting a direct interaction between P3 and coat protein. Herein we demonstrate that P3 directly interacts with purified viral particles and unassembled coat protein without the need for any other factor and that P3 mediates the association of P2 with purified virus particles. The interaction domain of P3 is located in its C-terminal half, downstream of the P3-P2 interaction domain but overlapping a region which binds nucleic acids. Mutagenesis of P3 which interferes with the interaction between P3 and virions is correlated with the loss of transmission by aphids. Taken together, our results demonstrate that P3 plays a crucial role in the formation of the CaMV transmissible complex by serving as a bridge between P2 and virus particles.

Hypothyroidism as a cause of tacrolimus intoxication and acute renal failure: a case report

The nephrotoxic side effects of cyclophilin-binding agents like cyclosporine A and tacrolimus are well characterized. In severe cases nephrotoxicity may profoundly deteriorate kidney function and even induce acute renal failure. In this report we describe the first case of excessive tacrolimus intoxication caused by hypothyroidism. The patient had undergone single-lung transplantation 6 months earlier, developed hypothyroidism, and was admitted with acute anuric renal failure. Thyroxin is a potent activator of the cytochrome P-450- CYP 3A enzyme system, which is crucial for tacrolimus metabolism. Hence, hypothyroidism reduces cytochrome P-450 activity and may result in drug accumulation. Rapid reversal of toxic drug levels could be achieved by reducing drug intake and increasing thyroxin levels by substitution therapy. In conclusion, it is important to consider thyroid function when prescribing medications with a narrow therapeutic range, which are metabolized by the cytochrome P-450 system such as tacrolimus, and the possible devastating effect of impaired drug metabolism during hypothyroidism.

Angiotensin-converting enzyme gene polymorphism determines the antiproteinuric and systemic hemodynamic effect of enalapril in patients with proteinuric renal disease. Austrian Study Group of the Effects of Enalapril Treatment in Proteinuric Renal Disease

Angiotensin-converting enzyme (ACE) inhibitors are known to reduce blood pressure and proteinuria in a variety of different glomerular diseases. Nonetheless, a marked interindividual difference in the efficacy of these agents exists. The activity of the ACE and therefore of the renin-angiotensin-aldosterone system (RAAS) has been shown to be under genetic influence. Patients with a deletion genotype at the intron 16 of the ACE gene have been shown to exhibit higher activity of plasmatic ACE when compared to patients with the insertion genotype. We therefore studied prospectively the hemodynamic and antiproteinuric effect of a 6-month therapy with enalapril in patients with biopsy-proven proteinuric glomerular diseases and the DD (n = 10) and ID/II (n = 26) genotype. Although patients with the DD genotype received a slightly higher dose of enalapril, blood pressure and proteinuria did not change significantly. However, both were significantly reduced in the II/ID group after 10 weeks and 6 months of therapy. Creatinine clearance decreased steadily in DD patients. In II/ID patients, creatinine clearance was reduced significantly after 10 weeks of therapy but increased again thereafter and the value at 6 months was again comparable to the one obtained in the DD patients. We conclude from our study that the ACE genotype influences the blood pressure-lowering and antiproteinuric effect of enalapril in patients with proteinuric glomerular disease.

ANCA-associated crescentic glomerulonephritis with mesangial IgA deposits

Antineutrophil cytoplasmic autoantibodies (ANCA) are commonly associated with a necrotizing and crescentic glomerulonephritis (GN) that is pauci-immune, with few or no glomerular immune complex deposits detectable by immunofluorescence (IF) or electron microscopy (EM). Immunoglobulin A (IgA) nephropathy may also be manifest as a crescentic GN, but it is characterized by mesangial immune complex deposits containing IgA and is rarely associated with myeloperoxidase (MPO)- or proteinase 3 (PR3)-specific ANCA when an enzyme immunoassay is used to detect these antibodies. This report describes six patients with severe crescentic GN with mesangial IgA deposits by IF and mesangial electron-dense deposits by EM in patients with positive ANCA serological test results (four patients, anti-PR3; one patient, anti-MPO; one patient, anti-PR3 and anti-MPO). Patients presented with acute or progressive renal insufficiency, hematuria, proteinuria (nephrotic range in two patients), and hypertension. Three patients had evidence of systemic vasculitis: two patients at initial presentation and one patient later in the clinical course. Renal biopsy specimens showed crescents in greater than 50% of glomeruli in all cases, but only mild, focal and segmental mesangial and endocapillary hypercellularity, more typical of ANCA-associated crescentic GN than of crescentic IgA nephropathy without associated ANCA. Semiquantitative analysis of mesangial and endocapillary cellularity performed on renal biopsy slides from these six patients and from eight ANCA-negative patients with IgA nephropathy and crescents in greater than 50% of glomeruli showed significantly greater hypercellularity in the ANCA-negative cases. Three of five ANCA-positive patients for whom follow-up clinical data were available showed improved renal function after treatment with cyclophosphamide and corticosteroids and have not developed end-stage renal disease 17, 20, and 25 months postbiopsy. The remaining two patients were dialysis dependent at the time of biopsy and have remained so despite treatment with cyclophosphamide and corticosteroids. The findings suggest an overlap syndrome of ANCA-associated crescentic GN and IgA nephropathy that resembles the former both histologically and in its potential to respond to aggressive therapy if detected relatively early in its course.

Granulomatous tubulointerstitial nephritis in the renal allograft

Granulomatous tubulointerstitial nephritis has rarely been described in renal allografts. Of 1,574 renal allograft tissue specimens obtained from 514 patients in the period 1993 to 1998, we report three cases (0.6%) with interstitial nephritis containing multiple noncaseating granulomas. Biopsy specimen 1 was obtained from a 44-year-old woman with a 6-day history of systemic Candida albicans infection and showed multiple granulomas containing budding yeasts. Biopsy specimen 2 was from a 33-year-old man who presented with miliary spread of Mycobacterium tuberculosis 12 days before the allograft biopsy. Biopsy specimen 3 was from a 23-year-old woman who presented with Escherichia coli urinary infection and bacteremia that was treated with antibiotics for 10 days before the biopsy. Granulomatous inflammation in reponse to infectious agents or drugs in immunosuppressed kidney transplant recipients can rarely give rise to allograft interstitial nephritis that is distinct from acute rejection. To our knowledge, there are no prior reports of granulomatous tubulointerstitial nephritis associated with C albicans and E coli infection or antibiotic therapy in human renal allografts.

Residual dentin thickness after 1.2-mm shoulder preparation for Cerec crowns

Since the introduction of crown software for Cerec, it has been possible to produce full-ceramic crown restorations. Despite the excellent material quality of industrially made ceramic blocks and the good clinical long-term success of these ceramics in inlay- and onlay preparations, extended preparation with high loss of dental tissue is incident to crown restorations, which may endanger the vitality of the respective tooth. The aim of this experimental study was to determine the residual dentin thickness after preparation of an extended circular shoulder in the molar and premolar region. On extracted human molars and premolars, 1.2-mm-wide circular shoulders with rounded inner edges were prepared, and the thickness of the residual dentin wall was measured under a microscope. Using this preparation method, it was found that only the group of maxillary molars showed an average residual dentin thickness of more than 0.7 mm.

The Na-K-Cl cotransporter of secretory epithelia

The Na-K-Cl cotransporters are a class of ion transport proteins that transport Na, K, and Cl ions into and out of cells in an electrically neutral manner, in most cases with a stoichiometry of 1Na:1K:2Cl. To date, two Na-K-Cl cotransporter isoforms have been identified: NKCC1, which is present in a wide variety of secretory epithelia and non-epithelial cells; and NKCC2, which is present exclusively in the kidney, in the epithelial cells of the thick ascending limb of Henle's loop and of the macula densa. Both NKCC isoforms represent part of a diverse family of cation-chloride cotransport proteins that share a common predicted membrane topology; this family also includes Na-Cl cotransporters and multiple K-Cl cotransporter isoforms. In secretory epithelia, the regulation of NKCC1, which is typically present on the basolateral membrane, is tightly coordinated with that of other transporters, including apical Cl channels, to maintain cell volume and integrity during active salt and fluid secretion. Changes in intracellular [Cl] ([Cl]i) appear to be involved in this regulation of NKCC1, which is directly phosphorylated by an unknown protein kinase in response to various secretagogues as well as reductions in [Cl]i and cell volume. This review focuses on structure-function relationships within NKCC1 and on recent developments pertaining to NKCC1 regulation at cellular and molecular levels.

The Na-K-Cl cotransporter of secretory epithelia

The Na-K-Cl cotransporters are a class of ion transport proteins that transport Na, K, and Cl ions into and out of cells in an electrically neutral manner, in most cases with a stoichiometry of 1Na:1K:2Cl. To date, two Na-K-Cl cotransporter isoforms have been identified: NKCC1, which is present in a wide variety of secretory epithelia and non-epithelial cells; and NKCC2, which is present exclusively in the kidney, in the epithelial cells of the thick ascending limb of Henle's loop and of the macula densa. Both NKCC isoforms represent part of a diverse family of cation-chloride cotransport proteins that share a common predicted membrane topology; this family also includes Na-Cl cotransporters and multiple K-Cl cotransporter isoforms. In secretory epithelia, the regulation of NKCC1, which is typically present on the basolateral membrane, is tightly coordinated with that of other transporters, including apical Cl channels, to maintain cell volume and integrity during active salt and fluid secretion. Changes in intracellular [Cl] ([Cl]i) appear to be involved in this regulation of NKCC1, which is directly phosphorylated by an unknown protein kinase in response to various secretagogues as well as reductions in [Cl]i and cell volume. This review focuses on structure-function relationships within NKCC1 and on recent developments pertaining to NKCC1 regulation at cellular and molecular levels.

Involvement of Src and epidermal growth factor receptor in the signal-transducing function of Na+/K+-ATPase

Nontoxic concentrations of ouabain, causing partial inhibition of the cardiac myocyte Na(+)/K(+)-ATPase, induce hypertrophy and several growth-related genes through signal pathways that include the activation of Ras and p42/44 mitogen-activated protein kinase (MAPK). The aim of this work was to examine the ouabain-induced events upstream of the Ras/MAPK cascade. Treatment of myocytes with genistein antagonized ouabain-induced activation of the MAPK, suggesting that protein tyrosine phosphorylation has a role. Tyrosine phosphorylation of several myocyte proteins was increased rapidly upon cell exposure to ouabain. Lowering of extracellular K(+) had a similar ouabain-like effect. Ouabain also increased protein tyrosine phosphorylation in A7r5, HeLa, and L929 cells. In cardiac myocytes and A7r5 cells, herbimycin A antagonized the ouabain-induced increase in protein tyrosine phosphorylation and MAPK activation. In both cell types, ouabain stimulated Src kinase activity, Src translocation to the Triton-insoluble fraction, Src association with the epidermal growth factor receptor, and the tyrosine phosphorylation of this receptor on site(s) other than its major autophosphorylation site, Tyr(1173). The findings suggest that (a) the ouabain-induced activation of Src and the Src-induced phosphorylation of the growth factor receptor provide the scaffolding for the recruitment of adaptor proteins and Ras and the activation of Ras/MAPK cascade; and (b) the activation of such pathways may be a common feature of the signal-transducing function of Na(+)/K(+)-ATPase in most cells.

Ouabain interaction with cardiac Na+/K+-ATPase initiates signal cascades independent of changes in intracellular Na+ and Ca2+ concentrations

We have shown previously that partial inhibition of the cardiac myocyte Na(+)/K(+)-ATPase activates signal pathways that regulate myocyte growth and growth-related genes and that increases in intracellular Ca(2+) concentration ([Ca(2+)](i)) and reactive oxygen species (ROS) are two essential second messengers within these pathways. The aim of this work was to explore the relation between [Ca(2+)](i) and ROS. When myocytes were in a Ca(2+)-free medium, ouabain caused no change in [Ca(2+)](i), but it increased ROS as it did when the cells were in a Ca(2+)-containing medium. Ouabain-induced increase in ROS also occurred under conditions where there was little or no change in [Na(+)](i). Exposure of myocytes in Ca(2+)-free medium to monensin did not increase ROS. Increase in protein tyrosine phosphorylation, an early event induced by ouabain, was also independent of changes in [Ca(2+)](i) and [Na(+)](i). Ouabain-induced generation of ROS in myocytes was antagonized by genistein, a dominant negative Ras, and myxothiazol/diphenyleneiodonium, indicating a mitochondrial origin for the Ras-dependent ROS generation. These findings, along with our previous data, indicate that increases in [Ca(2+)](i) and ROS in cardiac myocytes are induced by two parallel pathways initiated at the plasma membrane: One being the ouabain-altered transient interactions of a fraction of the Na(+)/K(+)-ATPase with neighboring proteins (Src, growth factor receptors, adaptor proteins, and Ras) leading to ROS generation, and the other, inhibition of the transport function of another fraction of the Na(+)/K(+)-ATPase leading to rise in [Ca(2+)](i). Evidently, the gene regulatory effects of ouabain in cardiac myocytes require the downstream collaborations of ROS and [Ca(2+)](i).

Simultaneous enzyme overlay membrane (EOM)-based in situ zymography and immunofluorescence technique reveals cathepsin B-like activity in a subset of tumour vessels

The analysis of the invasion front of oral squamous cell carcinoma (OSCC) has revealed a fundamental invasion-associated remodelling of the extracellular matrix as the result of a complex regulated interplay of matrix synthesis and matrix degradation. Cysteine proteinases, in particular cathepsin B, are implicated in tumour invasion in vivo and in vitro and are thought to be important mediators of metastasis. An in situ zymographic assay based on enzyme overlay membranes (EOMs) was established to define the tissue localisation of cathepsin B activity in OSCC. Using confocal laser scanning microscopy we present a double-labelling method for the rapid and reproducible simultaneous detection of cathepsin B-like activity and cellular or extracellular antigens based on an EOM and immunofluorescence technique on frozen sections. Applying this method, cathepsin B-like activity was mainly found in vascular structures within the invasive front of OSCC. Therefore, the results suggest a particular pathogenic role of cathepsin B in tumour angioneogenesis. The method can simply be transferred to other enzymes and can be recommended for more extensive studies of proteolytic activity in human malignancies.

Patient characteristics, practice activities, and one-month outcomes for chronic, recurrent low-back pain treated by chiropractors and family medicine physicians: a practice-based feasibility study

BACKGROUND

Chronic low-back pain is a significant public health problem for which few therapies are supported by predictable outcomes. In this report, practice activities and 1-month outcomes data are presented for 93 chiropractic patients and 45 medical patients with chronic, recurrent low-back pain.

DESIGN

A prospective, observational, community-based feasibility study involving chiropractors and family medicine physicians.

SETTING

Forty private chiropractic clinics, the outpatient clinic of the Department of Family Medicine at Oregon Health Sciences University, and 5 other Portland area family medicine clinics.

OUTCOMES MEASURES

The main outcome measures were pain severity, functional disability, sensory and affective pain quality at 1 month, and patient satisfaction assessed at 7 to 10 days and at 1 month.

RESULTS

Although differences were noted in age, sex, education, and employment, the patients were closely matched at baseline with respect to frequency, severity, and type of low-back pain and the psychosocial dimensions of general health. The treatment of choice for chiropractors was spinal manipulation and physical therapy modalities; for medical physicians antiinflammatory agents were most frequently used. Chiropractic patients averaged 4 visits, and medical patients averaged 1 visit. On average, chiropractic patients showed improvement across all outcomes: 31% change in pain severity, 29% in functional disability, 36% in sensory pain quality, and 57% in affective pain quality. Medical patients showed minimal improvement in pain severity (6%) and functional disability (1%) and showed deterioration in the sensory (29%) and affective (26%) dimensions of pain quality. Satisfaction scores were higher for chiropractic patients. Outcomes for medical patients were heavily dependent on psychosocial status at baseline.

CONCLUSION

Patients with chronic low-back pain treated by chiropractors show greater improvement and satisfaction at 1 month than patients treated by family physicians. Nonclinical factors may play an important role in patient progress. Findings from the Health Resources and Services Administration-funded project will include a report on the influence of practice activities, including more frequent visits by chiropractic patients, on the clinical course of low-back pain and patient outcomes. (J Manipulative Physiol Ther 2000;23:239-45).

Review article: the stages of gastrointestinal carcinogenesis--application of rodent models to human disease

The development of gastrointestinal cancer in humans and animals occurs through a consecutive series of stages termed initiation, promotion and progression. The characterization of each of these stages has been elucidated in several model systems as well as in human neoplasms. Both single, putatively initiated cells and preneoplastic foci have been identified by marker protein differences as well as by mutational changes. The promotion stage involves the clonal expansion of single initiated cells. Such expansion can be rapidly reversed by a variety of means, of which acute fasting (as exemplified in rat hepatocarcinogenesis) is among the most rapid and efficient. This reversal involves a selective apoptosis of preneoplastic cells and preneoplastic lesions, associated with a marked increase in expression of the proto-oncogene c-myc. Transition of cells from the stage of promotion to that of progression initially involves specific karyotypic alterations, as noted in both the rat liver model and human colon carcinogenesis. In the former, the transition appears to be associated with enhanced expression of the H119 imprinted putative tumour suppressor gene. Thus, the use of model systems may be applied directly to the human circumstance, increasing the potential both for rational prevention of gastrointestinal neoplasia and for new approaches to the therapy of neoplastic disease in the progression stage.

Etiologies and outcome of acute renal insufficiency in older adults: a renal biopsy study of 259 cases

Acute renal insufficiency is a common problem, yet one that is frequently reversible with proper diagnosis and treatment. Although it has been argued that a renal biopsy is not needed for diagnosis in most cases of acute renal failure in the elderly, other studies have shown frequent disagreements between clinical and renal biopsy diagnoses in such cases. To investigate the causes of acute renal insufficiency in patients aged at least 60 years who underwent a renal biopsy and possible correlations between biopsy findings and renal survival, we first identified all native renal biopsy specimens from patients aged 60 years or older processed at The University of Chicago Medical Center (Chicago, IL) from 1991 through 1998 and reviewed the clinical records to determine the indication for the biopsy. We then reviewed again the records of those patients who underwent biopsy because of acute renal insufficiency, recorded the primary renal biopsy diagnosis in each of these cases, and obtained follow-up information for patients who underwent biopsy before July 1996. During the study period, 1,065 of 4,264 biopsy specimens (25.0%) received were obtained from patients aged 60 years or older, and acute renal insufficiency was the indication for biopsy in 259 of these patients (24.3%). The most frequent primary diagnoses on these latter biopsy specimens were pauci-immune crescentic glomerulonephritis (GN) with or without arteritis, 31.2% of biopsy specimens; acute interstitial nephritis, 18.6%; acute tubular necrosis (ATN) with nephrotic syndrome, 7.5%; atheroemboli, 7.1%; ATN alone, 6.7%; light chain cast nephropathy (LCCN), 5.9%; postinfectious GN, 5.5%; anti-glomerular basement membrane antibody nephritis, 4.0%; and immunoglobulin A (IgA) nephropathy and/or Henoch-Schönlein nephritis, 3.6%. Eight biopsy specimens (3.2%) showed only benign nephrosclerosis without an apparent cause of acute renal insufficiency, and another six specimens were inadequate. The renal biopsy diagnosis was in agreement with the prebiopsy clinical diagnosis (or differential diagnosis) in 107 of the 161 cases (67%) in which such information was provided. The distribution of diagnoses was similar in patients in the age groups of 60 to 69, 70 to 79, and 80 years or older, although younger age correlated significantly with improved renal and patient survival. The relative risk for progression to end-stage renal disease (ESRD) also increased according to diagnostic categories: LCCN (greatest risk) > GN other than pauci-immune > atheroemboli congruent with pauci-immune crescentic GN > tubulointerstitial diseases other than LCCN (the latter category including ATN with nephrotic syndrome). Development of ESRD correlated significantly with decreased patient survival. In summary, renal biopsy in patients aged 60 years or older with acute renal insufficiency uncovered the cause in greater than 90% of the cases and provided clinically useful information with respect to expectation for renal survival and potential treatment options.

[Laminin-5 in diseases of the oral cavity]

The basement membrane molecule laminin forms a family of proteins. Laminin-5 was identified as key protein in the anchoring filaments of the basement membrane. The anchoring filaments connect the basement membrane to the epithelial cells and together form the epithelial adhesion complex. Disturbances in the epithelial adhesion complex result in subepithelial blistering dermatosis. Autoantibodies against laminin-5 are found in cicatricial pemphigoid. Mutations in genes of laminin-5 with loss of the protein cause epidermolysis bullosa Herlitz. It can be determined during prenatal genetic diagnostic testing. Laminin-5 supports migration of keratinocytes and forms the basis for migrating keratinocytes in oral wound healing. Positive re-epithelialization via laminin-5 has been the subject of experimental studies. Oral squamous cell carcinomas are found to have a focal loss of laminin-5 in conjunction with a loss of the cellular receptor, and increased synthesis of laminin-5 by budding tumor cells has been observed along with deposition of the protein in the stroma. As a result of these observations laminin-5 has been suggested as a route of invasion. Quantitative assessment of this phenomenon and the modulation of laminin-5-tumor cell interaction offer new and hopeful means of describing and affecting the invasive behaviour of oral squamous carcinoma.

Drug-induced acute interstitial nephritis in renal allografts: histopathologic features and clinical course in six patients

Drug-induced acute interstitial nephritis is a common cause of dysfunction in native kidneys, but is rarely reported in renal allografts. This report describes six renal transplant recipients with acute renal allograft dysfunction or delayed allograft function in whom a renal transplant biopsy showed histopathologic features of drug-induced interstitial nephritis with no diagnostic evidence of acute rejection, cyclosporine or tacrolimus nephrotoxicity, or other lesion that could account for the graft dysfunction. In five of the six patients, interstitial nephritis occurred within 4 weeks of transplantation. All the patients were receiving trimethaprim-sulfamethoxazole and/or other drugs associated with interstitial nephritis. After discontinuation of these drugs and short-term corticosteroid treatment, all patients showed improvement in renal function, although the time course of this improvement varied considerably, with three patients showing a return to baseline serum creatinine level within 2 weeks and two patients showing a gradual improvement over 8 weeks. Four of the five patients followed up for more than 1 year (range, 14 to 33 months) after the episode of interstitial nephritis had good allograft function (serum creatinine level </= 1.6 mg/dL) at most recent follow-up, with one patient who had graft loss because of severe rejection 7.5 months after the development of interstitial nephritis. These findings suggest drug-induced interstitial nephritis may be an infrequent cause of graft dysfunction in kidney transplant recipients. Drug-induced interstitial nephritis is a reversible lesion that should be considered in the differential diagnosis of acute renal allograft dysfunction.

The relationship of untreated borderline infiltrates by the Banff criteria to acute rejection in renal allograft biopsies

The relationship of borderline infiltrates to acute rejection by Banff criteria in renal allografts of patients receiving only maintenance immunosuppression is not clear. Renal allograft biopsies with borderline lesions that were not treated with additional anti-rejection therapy were retrospectively studied. Sixty-five such biopsies were identified from 50 patients, and their outcome was determined by serum creatinine and/or histologic findings in subsequent biopsies, up to 40 d after the initial biopsy. In addition to the borderline infiltrates, there was evidence of acute cyclosporine or tacrolimus toxicity (58%), acute tubular necrosis (12%), and urinary obstruction (12%). Forty-day follow-up after 30 (46%) biopsies revealed serum creatinine < 110% of baseline, and repeat biopsies were not indicated. In 17 (26%), the serum creatinine initially decreased, then increased, and follow-up biopsies showed acute rejection in nine. In 18 (28%), the creatinine remained elevated and follow-up biopsies revealed acute rejection in nine. The untreated borderline infiltrates were thus nonprogressive after 47 biopsies (72%) and progressed to histologic acute rejection after 18 (28%). When there was increasing or persistently elevated creatinine after the initial biopsy, 51% of cases (18 of 35) progressed to acute rejection. Infiltrates that progressed to rejection had more frequent glomerulitis (7 of 18 versus 3 of 47, P = 0.003) and Banff acute score indices (i+t+v+g) >2 (16 of 18 versus 29 of 47, P = 0.03). A majority (72%) of borderline infiltrates not given additional anti-rejection therapy did not progress to acute rejection over 40 d of follow-up, suggesting that conservative management of these lesions, at least in the short term, may be more appropriate than routine treatment as acute rejection.

Building a dialysis facility within the confines of a skilled nursing facility

Creating a dialysis facility within an existing SNF will cost more money then building an independent dialysis facility. If a new building is created and is physically attached to the existing SNF, it will have to meet the regulations that apply to the SNF. It is possible to build a new building adjacent to but not connected with the SNF without having to meet SNF requirements. If this is an option, then it is imperative to determine with the local authorities how much space must be between the structures. If the decision is made to build within the physical confines of the existing SNF, the SNF may no longer meet current regulations. In some cases I have seen, the SNF facility was older and had been grandfathered under current regulations. When the building inspector and fire marshall inspected the new dialysis unit, they made the determination that the SNF had to be upgraded to meet some of the current regulations. This was a very costly situation for the SNF. If the organization is considering creating a dialysis unit in conjunction with a SNF, I would recommend the dialysis unit be constructed as a new, separate building on the campus rather then within the existing building. The combination of these two types of care can be very positive both for the patients and the organizations.

Smooth muscle-specific actin levels in the urine of renal transplant recipients: correlation with cyclosporine or tacrolimus nephrotoxicity

Cyclosporine A (CSA) and tacrolimus (FK506) are powerful immunosuppressive agents that have proven useful for antirejection therapy in patients with solid organ transplants, including kidney. However, both drugs are nephrotoxic, each producing similar histological patterns of injury to renal tubules and preglomerular arterioles, and this toxicity is a major cause of renal allograft dysfunction. A renal transplant biopsy presently represents the most reliable means of diagnosing nephrotoxicity caused by CSA or tacrolimus and distinguishing it from acute rejection. Because CSA and tacrolimus nephrotoxicity often involve arteriolar smooth muscle, whereas vascular smooth muscle is rarely involved in acute rejection, we investigated if the appearance of a smooth muscle-specific isoform of alpha-actin (SMA) in the urine of renal transplant recipients about to undergo a biopsy for graft dysfunction correlated with biopsy evidence of CSA or tacrolimus toxicity. Eighty-nine urine samples from 61 patients, plus 6 samples from healthy control subjects, were analyzed in a blinded manner by enzyme-linked immunosorbent assay using a specific anti-SMA monoclonal antibody. For the patient samples, the results of these assays were then correlated with the biopsy findings. Those 40 cases in which the biopsy showed evidence of CSA or tacrolimus nephrotoxicity had a significantly (P < 0.01) greater SMA level in the corresponding urine samples (0.089 +/- 0.126 microgram/mL; mean +/- SD) than the 49 cases without toxicity (0.018 +/- 0.027 microgram/mL) or 6 control subjects (0.003 +/- 0.007 microgram/mL), although there was considerable overlap of SMA values among these groups. The greatest SMA levels were seen in patients with CSA or tacrolimus nephrotoxicity that was likely to be relatively acute, namely those with thrombotic microangiopathy and those without previous biopsy evidence of toxicity. SMA levels correlated significantly with the estimated severity of arteriolopathy on biopsy. In patients with tubular but not arteriolar lesions of CSA or tacrolimus toxicity, the mean SMA level was not significantly greater than that in patients without toxicity. Urine SMA levels in patients with a biopsy specimen showing acute rejection were not significantly different from those in patients without rejection, and there was no correlation between urine SMA level and severity of rejection. Whereas the degree of overlap of SMA levels in patients with and without nephrotoxicity was far too great to consider this assay as a potential alternative to renal transplant biopsy for the diagnosis of nephrotoxicity, the assay may have potential as a marker for active arteriolar injury in renal transplant recipients and other patients receiving CSA or tacrolimus therapy.

Lipid-lowering therapy in membranous nephropathy

Membranous nephropathy (MN) is a very common cause of nephrotic syndrome in adults, and lipid abnormalities are, therefore, frequently found in these subjects. Although efficient lipid-lowering therapy is available, almost nothing is known about the contribution of hyperlipidemia in the pathogenesis of progressive renal failure in MN. Studies in an experimental animal model of human MN, Heymann nephritis, have shown that lipids play an essential role in the pathogenesis of proteinuria. Local production of reactive oxygen species after subepithelial immune complex deposition leads to the formation of lipid peroxidation (LPO) adducts, which ultimately alter the composition of the glomerular basement membrane. As the magnitude of urinary protein excretion is associated with the long-term prognosis, a normalization of glomerular permselective properties has been used as a surrogate parameter for the beneficial effects of treatment. Probucol, a drug with LPO inhibitor potential, is able to reduce urinary protein excretion in rats with passive Heymann nephritis. In humans with MN, preliminary data also support this observation. It remains to be determined, however, if this intervention, which does not interfere with immune complex formation, will reduce the number of the patients reaching end-stage renal failure because of MN. In conclusion, lipids may contribute to glomerular injury in MN, as LPO might be an especially important factor, opening the possibility for new therapeutic interventions, thereby avoiding the side-effects of the currently used treatment regimen.

Involvement of nuclear factor-kappaB in a murine model for the acute form of autoimmune-like toxic oil syndrome

The toxic oil syndrome (TOS) represents an exogenously induced autoimmune disease with acute or chronic symptoms similar to systemic lupus erythematosus or scleroderma. When genetically different mouse strains were exposed to oleic acid anilide (OAA), it was possible to mimic the different syndrome manifestations. The aim of the present study was to examine the role of NF-kappaB/Rel transcription factors in the development of the severe acute wasting disease observed in A/J mice. Within a week of OAA exposure, the A/J, but not B10.S strain, displayed weight loss, cachexia, apathy, reduced activity, and breathing difficulties. In affected A/J mice we observed a marked increase in NF-kappaB activation (p50/p65 dimers) both in splenic T cells and peritoneal macrophages as well as in tissue from aorta and gut. Incubation of splenocytes with OAA in vitro induced a dose-dependent removal of IkappaB-alpha, accompanied by NF-kappaB activation, whereas Sp-1 binding was not affected. Furthermore, we demonstrated the increased expression of the two NF-kappaB target genes IL-6 and IL-1beta in OAA-exposed mice and a transient OAA-induced accumulation of TNFalpha in vitro. This is the first report which implicates NF-kappaB/Rel in acute forms of chemically induced autoimmune-like disease and may serve as a paradigm for the involvement of this transcriptional system in acute processes associated with autoimmunity, suggesting possible avenues of therapeutic intervention.