The minimal dose of dialysis required for a target KT/V in continuous peritoneal dialysis

This study attempted to define the minimal dose of dialysis needed to produce a target KT/V in continuous peritoneal dialysis (CPD). In a training set of 143 clearance studies performed in 92 CPD patients, logistic regression identified low urine volume (UV) and low dialysate drain volume normalized by body water (DV/V) as predictors of weekly KT/V urea < or = 1.70. Solution of the regression equation with UV fixed at 0.00 1/24 h and at different probabilities of low KT/V provided a series of minimal DV/V values consistent with weekly KT/V > or = 1.70 in anuria. The accuracy of the logistic regression model and of the DV/V cut-offs was tested in a validation set (VS) of 189 urea kinetic studies performed in another 102 CPD patients. In the VS, the area under the Receiver Operating Characteristic curve generated by the regression model was 0.832 (95% Confidence Interval: 0.798-0.866). The DV/V cut-off value of 0.301 per 24 h, calculated by solving the regression model at p = 0.442 and with UV = 0, identified studies with weekly KT/V < 1.70 with a sensitivity of 89.3% and a specificity of 78.1% in anuric VS subjects (n = 60). Use of only the first urea kinetic study from each patient did not modify the predictors of KT/V or the cut-off values derived from solution of the regression model. The DV/V cut-off of 0.324 per 24 h, derived from the logistic regression model predicting KT/V < or = 1.90, identified KT/V < 1.90 in VS anuric subjects with a sensitivity of 94.3% and a specificity of 81.0%. Low UV and DV/V predict low KT/V urea in CPD. Prescribed 24 h exchange volume in anuric CPD subjects should be calculated to produce DV/V values exceeding 0.301 1/24 h per 1 body water for a KT/V of 1.70 and 0.324 1/24 h per 1 body water for a target weekly KT/V of 1.90.

HIV replication in IL-2-stimulated peripheral blood mononuclear cells is driven in an autocrine/paracrine manner by endogenous cytokines

Replication of HIV is regulated by virus-encoded regulatory proteins, as well as by a variety of cellular factors including cytokines. In the present study, we have investigated the autocrine/paracrine effects of endogenous cytokines on HIV replication in primary PBMCs of healthy HIV seronegative individuals. Addition of rIL-2 to cultures between 0 and 72 h after isolation of PBMCs allowed the replication of primary HIV isolates and laboratory-adapted HIV strains to levels comparable with or greater than those obtained in parallel cultures of autologous PHA-blasts. In this regard, both major cellular targets of HIV infection, CD4+ T lymphocytes and mononuclear phagocytes, were maintained for several weeks in IL-2-stimulated PBMC cultures and virion production was observed in both cell lineages. The kinetics of secretion of several cytokines (such as TNF-alpha, IL-1 beta, IL-6, and IFN-gamma), as well as expression of cellular activation markers, paralleled HIV replication in IL-2-stimulated PBMCs. Endogenous pro-inflammatory cytokines and IFN-gamma played a major role in the regulation of HIV replication in IL-2-stimulated PBMCs, as determined by the ability of several anti-cytokine Abs or antagonists to suppress HIV production; this was not the case in parallel cultures of autologous PHA-blasts. Thus, IL-2-stimulated PBMCs may represent a more physiologic in vitro system than PHA-blasts for the study of HIV infection and replication, and should prove useful in investigating the role of cytokines and other host factors in the regulation of HIV production.

HIV replication in IL-2-stimulated peripheral blood mononuclear cells is driven in an autocrine/paracrine manner by endogenous cytokines

Replication of HIV is regulated by virus-encoded regulatory proteins, as well as by a variety of cellular factors including cytokines. In the present study, we have investigated the autocrine/paracrine effects of endogenous cytokines on HIV replication in primary PBMCs of healthy HIV seronegative individuals. Addition of rIL-2 to cultures between 0 and 72 h after isolation of PBMCs allowed the replication of primary HIV isolates and laboratory-adapted HIV strains to levels comparable with or greater than those obtained in parallel cultures of autologous PHA-blasts. In this regard, both major cellular targets of HIV infection, CD4+ T lymphocytes and mononuclear phagocytes, were maintained for several weeks in IL-2-stimulated PBMC cultures and virion production was observed in both cell lineages. The kinetics of secretion of several cytokines (such as TNF-alpha, IL-1 beta, IL-6, and IFN-gamma), as well as expression of cellular activation markers, paralleled HIV replication in IL-2-stimulated PBMCs. Endogenous pro-inflammatory cytokines and IFN-gamma played a major role in the regulation of HIV replication in IL-2-stimulated PBMCs, as determined by the ability of several anti-cytokine Abs or antagonists to suppress HIV production; this was not the case in parallel cultures of autologous PHA-blasts. Thus, IL-2-stimulated PBMCs may represent a more physiologic in vitro system than PHA-blasts for the study of HIV infection and replication, and should prove useful in investigating the role of cytokines and other host factors in the regulation of HIV production.

Cross-sectional analysis of erythropoietin use in CPD: its relation to azotemic index clearances

The association between the use of erythropoietin and urea or creatinine clearance was studied in two populations on continuous peritoneal dialysis (CPD) residing either at an altitude of 1600 m (n = 194) or at sea level (n = 108). Among peritoneal and total KT/V urea and creatinine clearance (CCr) indices, only total CCr was lower in the high altitude group receiving erythropoietin than in the corresponding group not receiving erythropoietin (68.0 +/- 34.9 vs 82.9 +/- 40.9 L/1.73 m2 weekly, p < 0.01). However, 24-hour urine volume and urinary KT/V urea and CCr were consistently lower in the groups receiving erythropoietin than in those not receiving erythropoietin. Total weekly KT/V urea < or = 1.70 and CCr < or = 52 L/1.73 m2 were considered indicators of inadequate CPD. Although the percent of patients receiving erythropoietin did not differ overall between groups with adequate and those with inadequate CPD, a trend towards more frequent use of erythropoietin was found in the sea level group with inadequate CCr versus the group with adequate CCr (28.2% vs 16.9%, p = 0.084). In CPD decreased renal function is associated with more frequent use of erythropoietin. Whether inadequate total urea or creatinine clearance is also associated with more frequent erythropoietin use requires further study.

Predicting the course of peritonitis in patients receiving continuous ambulatory peritoneal dialysis

BACKGROUND

Peritonitis is a common problem for patients receiving continuous ambulatory peritoneal dialysis. Episodes that do not respond to antibiotics within 96 hours are associated with substantial morbidity and mortality. The purpose of this study was to develop a method for identifying these patients at the time of hospital admission.

METHODS

We reviewed all cases of peritonitis associated with continuous ambulatory peritoneal dialysis that occurred at the Albuquerque (NM) Veterans Affairs Medical Center during a 10-year period. Episodes of peritonitis were randomly assigned to a training set or a validation set. Persistent infections were those lasting more than 96 hours. For training cases, stepwise logistic regression was used to develop a predictive model for persistent infection using information available at the time of hospital admission. The model was then used to assign validation cases to "high-" and "low-risk" categories. The group difference in the proportion of persistent cases was tested by chi 2 analysis.

RESULTS

Sixty patients had 120 episodes of peritonitis during the study period. Of 63 episodes assigned to the training set, 26 (41.3%) lasted more than 96 hours (persistent cases) and 37 were cured in 96 hours or less (usual cases). Compared with usual cases, persistent episodes were characterized by a higher age at presentation and a greater decline from preinfection values for hemoglobin and serum potassium, serum urea nitrogen, creatinine, albumin, and calcium. Advanced age and marked declines in serum potassium and albumin levels were identified by logistic regression as independent risk factors for persistent infection. The model identified 28 of 57 validation cases as high risk. Compared with low-risk cases, these episodes were much more likely to be persistent (64.3% vs 24.1%; P = .002) and result in death (32.1% vs 3.4%; P = .005).

CONCLUSIONS

Advanced age and marked declines in serum albumin and potassium levels are poor prognostic signs in peritonitis associated with continuous ambulatory peritoneal dialysis. Patients with these findings should be treated aggressively.

Comparative effects of endothelin (ET-1) and U46619 on human saphenous vein and gastroepiploic artery, sources of human autologous grafts

The effects of endothelin (ET-1) on smooth muscle contractile activity were investigated and compared in human saphenous vein and gastroepiploic artery, vessels frequently used in revascularization procedures. ET-1 contracted saphenous vein and gastroepiploic artery in a concentration-dependent manner. The peptide produced a greater maximal effect in the vein than in the artery and, in both preparations, ET-1 was less efficacious than U46619, an agent which mimics the actions of thromboxane A2 at the thromboxane A2/prostaglandin H2 receptor. The contractile response to ET-1 declined spontaneously at a more rapid rate in the artery than in the vein. The present data indicate that ET-1 has significant contractile activity in both vessels which are used for coronary arterial bypass surgery and suggest that although, a weaker vasoconstrictor than U46619, the peptide could induce vasospasm in both graft vessels.

Lupus nephritis in a pediatric renal transplant recipient

A case of aggressive lupus nephritis in a pediatric renal transplant patient is described. She initially presented with end-stage glomerulonephritis for which an underlying etiology could not be determined. Ten months after cadaveric renal transplantation, systemic lupus erythematosus was diagnosed, when she developed diffuse proliferative glomerulonephritis in association with antinuclear antibody, anti-double-stranded DNA antibody and extrarenal manifestations of lupus. It is plausible that she developed recurrent rather than de novo lupus nephritis following transplantation. Reactivation of lupus nephritis in a renal transplant is unusual in adults, and is previously unreported in children.

Frequency of reisolation of Staphylococcus aureus from multiple sequential milk samples

Bacterial cultures were performed on multiple sequential composite samples of milk from 1,172 cows in 9 dairy herds. If the initial diagnosis of Staphylococcus aureus infection was based on the first positive culture, an average of 37.8% of subsequent cultures on the same cows were negative for S aureus. However, if the initial diagnosis of S aureus infection was confirmed by 2 or 2 of 3 sequential positive cultures and any conversions from S aureus positive to negative were confirmed by 2 or 2 of 3 sequential negative cultures, then only 17.0% converted to a negative diagnosis. Conversion of cows from S aureus culture-positive to -negative varied between herds; 8.1 to 69% for single cultures and 0.0 to greater than 40% for confirmed cultures.

Metabolic differences between persistent and routine peritonitis in CAPD

Changes in 10 metabolic parameters (body weight, blood hemoglobin, and serum albumin, urea, creatinine, cholesterol, triglycerides, potassium, calcium and phosphorus) were compared in 28 episodes of routine peritonitis and 27 episodes of persistent peritonitis. These infections occurred in 20 CAPD patients, all of whom acquired both types of peritonitis on separate occasions. Coagulase-negative staphylococci predominated in the routine infections, while Staphylococcus aureus and Gram-negative bacilli, especially Pseudomonas, were associated with persistent peritonitis. Decreases during infection were significantly larger in persistent as compared with routine peritonitis episodes for all 10 nutritional parameters. Time required for recovery of all nutritional variables except serum potassium and urea was significantly longer in the persistent episodes. Persistent peritonitis led to peritoneal catheter loss in 13 of the 27 episodes and was associated with 4 deaths, while routine peritonitis was associated with neither catheter loss nor death. In contrast to routine peritonitis, persistent CAPD peritonitis is associated with severe malnutrition, considerable morbidity, and mortality.

Mechanism of aluminum-induced inhibition of hepatic glycolysis: inactivation of phosphofructokinase

Aluminum, an abundant element in the earth's crust, has been implicated in various pathological disorders and low concentrations of this element have recently been shown to inhibit brain glycolysis. However, despite the fact that aluminum accumulates in high concentrations in the liver, potential effects of this metal on hepatic intermediary metabolism have not been explored. In perfused livers from untreated rats, maximal rates of production of lactate plus pyruvate (glycolysis) were 93 +/- 15 mumols/g/hr. Glycolysis was severely inhibited in livers from aluminum-treated rats (0.5 mg/kg, 6 hr before experiment) with maximal rates of only 23 +/- 4 mumols/g/hr. In contrast, glucose production (glycogenolysis) and hepatic oxygen uptake were not altered significantly by prior treatment with aluminum. In livers from fasted rats, pretreatment with aluminum did not influence gluconeogenesis or production of lactate and pyruvate from fructose (5 mM). This finding indicates that pyruvate kinase is not inhibited by aluminum and implicates phosphofructokinase, hexokinase and/or glucokinase as sites for the inhibitory effect of aluminum on glycolysis. In liver homogenates from untreated rats, increasing concentrations of aluminum did not show any appreciable effect on hexokinase or glucokinase activity but did cause progressive decreases in phosphofructokinase activity. Therefore, aluminum-induced inhibition of liver phosphofructokinase, an important control site in the glycolytic pathway, is most likely responsible for aluminum-induced inhibition of hepatic glycolysis.

Ten-year experience with extracorporeal membrane oxygenation for severe respiratory failure

In the last ten years, 17 patients with respiratory failure refractory to standard ventilator therapy have been treated with extracorporeal membrane oxygenation (ECMO) at the Toronto General Hospital. One patient was treated with ECMO twice. Four perfusions were veno-arterial, the remainder veno-venous. Perfusions ranged from 1 1/2 to 19 days, with a mean of six days. Ten patients died during treatment or soon after it was discontinued. Eight patients improved enough to allow resumption of standard ventilation, and four patients recovered sufficiently to have normal arterial blood gas levels on room air. Three are long-term survivors. Multiple surgical procedures have been performed successfully during use of ECMO including lung lavage, open lung biopsy and three lung transplants. Major complications include hemorrhagic diatheses and sepsis. The technique involves a substantial commitment of time and personnel but remains a tenable option for presumed reversible life-threatening respiratory failure.

Personalising the service--the Trent initiative

Liz Fox, who has been working with Trent RHA as its external consultant, describes its campaign to introduce the philosophy of personal service throughout the region, providing opportunities for NHS management and staff to personalise the service they provide.

Patterns of language comprehension deficit in abused and neglected children

The similarity between factors associated with child abuse/neglect and those associated with language disability suggests that maltreated children are a population at risk for language problems. This study investigated the performance of three groups of abused/neglected children and a matched group of nonmaltreated subjects on three tests of language comprehension. Results revealed significant differences among groups for all measures. Severely neglected children obtained the lowest scores on all tests; the abused children consistently obtained lower scores than the controls; and generally neglected children showed the smallest difference in performance from the control group. These findings suggest a model for understanding relationships between abuse/neglect and language disability.

Enhancing cancer pain control regimens through patient education

The problem of cancer-related pain afflicts millions of people annually. The study described here was aimed at improving cancer patients' pain control through a planned patient education program. A randomized clinical trial with a Solomon Four-Group design was used to assess the effectiveness of a patient education intervention consisting of nurse counseling and printed materials. The sample included 230 cancer patients. One month later, patients in the experimental group were more likely to have taken their pain medicine on the correct schedule and to have taken the correct dosage. The experimental group also was significantly less likely to report stopping the medicine when they felt better. In addition, they were significantly less worried about tolerance and addiction to pain medicines. Forty-four percent of the experimental group compared to 24% of the control group reported no or mild pain at the posttest.

Synaptic ribbon populations in the pineal gland of the rhesus monkey (Macaca mulatta)

Pinealocytes of rhesus monkeys that had been ovariectomized and given intramuscular injections of 250 micrograms estradiol-benzoate for 3 consecutive days tended to have more synaptic ribbons (SR) and exhibited a significantly greater size of ribbon fields (RF) compared to untreated animals. These data are consistent with hypotheses that pinealocyte function in primates is altered by hormonal imbalances and that the SR participates in this response. RF were positioned in various parts of the cytoplasm and along the plasma membrane. Participation of SR in direct cell-to-cell contacts was suggested by the formation of densities along the plasma membrane. It is postulated that large RF serve as storage organelles and that the formation of RF results from division of pre-existing SR in each field. Reconstructions made from serial thin sections revealed that profiles of RF comprised separate SR that were not folded and sectioned along various planes.

Pineal ultrastructure and indole profiles spanning the summer rise in arginine vasotocin immunoactivity

A correlative radioimmunological-biochemical-ultrastructural study of the rat pineal gland was undertaken during the summer months when pineal arginine vasotocin (AVT) immunoactivity increases up to 200-fold. RIA confirmed a rapid rise in AVT activity during mid-August regardless of the time of day sampled. Pineal indoles were separated by HPLC and measured using electrochemical detection. Serotonin (5-HT) and 5-hydroxyindoleacetic acid levels were consistently elevated in daytime samples, and there was a significant trend for increased day and nighttime levels of 5-HT from July to September. Mid-dark levels of melatonin also exhibited a significant increase over the sample period. Nighttime levels of N-acetylserotonin mirrored fluctuations in 5-HT in the preceding photoperiod. Ultrastructural components implicated in peptide/protein and/or indole biosynthesis were quantified by stereological morphometry. The greatest amounts of rough endoplasmic reticulum stacks, lipid droplets, and annulate lamellae-like bodies coincided with peak AVT activity. Dense-cored vesicles and synaptic ribbons were consistently more frequent during the dark period. The number of dense-cored vesicles and nucleolar size tended to be greatest before and after the peak in AVT immunoactivity. These observations are consistent with the hypotheses that endoplasmic reticulum and lipid are functionally related to the synthesis and/or storage of peptide/protein factors and that numerical changes in synaptic ribbons and dense-cored vesicles are more closely related to day/night differences in indole metabolism.

Antiserum to lens antigens immunostains Müller glia cells in the neural retina

Antiserum to a lens fraction enriched for alpha-crystallin selectively immunostains Müller glia cells in the neural retina of several vertebrate species. Also, in embryonic retina (chicken), this antiserum reacts with Müller cells and, at early stages of development, with their apparent precursors. Thus, antibodies to a lens product(s) detect a Müller glia cell marker that begins to be expressed very early in their ontogeny and can be useful in studies on differentiation, function, and pathologies of this cell type.

Fulminant meningococcemia in children

In all respects, the child with fulminant meningococcemia presents a formidable challenge to those who care for him/her. Only with prompt recognition of the disease and immediate institution of intensive treatment can the likelihood of survival be improved and morbidity minimized.

Prolonged cardiac arrest and resuscitation in dogs: brain mitochondrial function with different artificial perfusion methods

Clinical techniques for artificial perfusion have not previously been examined directly for their effects on brain high-energy metabolism. Our study involved 24 large mongrel dogs that were anesthetized, instrumented for central venous intravenous access, and subjected to craniotomy to expose the dura and underlying parietal cortex. The animals were divided into the following six experimental groups of four animals each: nonischemic controls; 15-minute cardiac arrest without resuscitation; 45-minute cardiac arrest without resuscitation; 15-minute cardiac arrest plus 30 minutes resuscitation with conventional cardiopulmonary resuscitation (CPR); 15-minute cardiac arrest plus 30 minutes resuscitation with interposed abdominal compression (IAC) CPR; and 15-minute cardiac arrest plus 30 minutes resuscitation with internal cardiac massage. Cardiac arrest was induced by central venous injection of KCl 0.6 mEq/kg, and it was confirmed by continuous ECG monitoring. The three active resuscitation models included administration of NaHCO3 and epinephrine, but no attempt was made to restart the heart by defibrillation during resuscitation. At the indicated time in each group, a 4- to 5-g sample of brain was removed through the craniotomy, immediately cooled to 0 C and processed for isolation of mitochondria. The mitochondria were studied for their content of superoxide dismutase and for quantitative oxygen consumption with glutamate/malate substrate during resting and ADP-stimulated respiration. Our results show a significant drop in brain mitochondrial superoxide dismutase activity during the first 15 minutes of cardiac arrest. There is minimal injury to brain mitochondrial oxygen consumption during both 15 and 45 minutes of complete ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)