Signal transduction by DR3, a death domain-containing receptor related to TNFR-1 and CD95

Tumor necrosis factor receptor-1 (TNFR-1) and CD95 (also called Fas or APO-1) are cytokine receptors that engage the apoptosis pathway through a region of intracellular homology, designated the "death domain." Another death domain-containing member of the TNFR family, death receptor 3 (DR3), was identified and was shown to induce both apoptosis and activation of nuclear factor kappaB. Expression of DR3 appears to be restricted to tissues enriched in lymphocytes. DR3 signal transduction is mediated by a complex of intracellular signaling molecules including TRADD, TRAF2, FADD, and FLICE. Thus, DR3 likely plays a role in regulating lymphocyte homeostasis.

Reduction of respiratory system resistance of rabbits with surfactant deficiency using a novel ultra thin walled endotracheal tube

The ultra thin walled, two-stage endotracheal tube (UTW-TS-ETT) is very flexible, nonkinking, and has a widened extralaryngeal portion. The UTW-TS-ETT has a greater ID/OD (internal diameter/outer diameter) ratio than a comparable standard endotracheal tube (ST-ETT) because of its thinner wall: 0.2-0.25 mm in UTW-TS-ETT, compared to 0.55-0.8 mm in ST-ETT. The authors hypothesized that in an animal model of lung disease, significant reductions in respiratory system resistance (Rrs) of 30-40% would be achieved using the UTW-TS-ETT, compared to Rrs achieved with the comparable ST-ETT. This study compared the pulmonary mechanics of rabbits (N = 17, body weight 3.4-4.7 kg) before and after induction of surfactant deficiency, using either ST-ETT (OD 4.9 mm, ID 3.5 mm) or UTW-TS-ETT (OD 5.0 mm, ID 4.6 mm). Animals were sedated, paralyzed, and ventilated by an ETT placed through a tracheotomy incision. Surfactant deficiency was induced by lavaging the lungs with normal saline (10 ml/kg). Pulmonary mechanics were measured on identical ventilator settings for each ETT used at baseline and at 45 min after lavage. Compared to ST-ETT, UTW-TS-ETT reduced Rrs by 50.6 +/- 8.7% in normal lungs (significantly more than 40%; p < 0.01), and by 41.47 +/- 16.2% in surfactant deficient lungs (significantly more than 30%; p < 0.05). Tidal volume increased with UTW-TS-ETT in all animals but did not achieve statistical significance. The UTW-TS-ETT did not induce significant changes in respiratory system compliance, PaO2, PaCO2, or pH. It is concluded that UTW-TS-ETT significantly reduces Rrs in rabbits with either normal lungs or with surfactant deficient lungs. This novel ETT may be beneficial for ventilated patients with increased Rrs, by effecting a decrease in Rrs and thus reducing the work of breathing and improving ventilation efficiency.

Cellular basis of decreased immune responses to pneumococcal vaccines in aged mice

Previously, model systems were developed in our laboratory to study murine immune responses to the 23-valent pneumococcal polysaccharide vaccine Pnu-Imune, both in vivo and in vitro (M. Garg and B. Subbarao, Infect. Immun. 60:2329-2336, 1992; M. Garg, A. M. Kaplan, and S. Bondada, J. Immunol. 152: 1589-1596, 1994). Using these systems, we found that aged mice did not respond to the vaccine in vivo or in vitro. Cell separation studies showed that the unresponsiveness of the aged spleen cells to the vaccine was not due to an intrinsic B-cell defect or to T-cell-mediated immunosuppression but resulted from an accessory cell deficiency. Irradiated spleen cells from young mice enabled the old mouse spleen cells to respond to the vaccine. Interestingly, irradiated spleen cells from old mice also restored the vaccine responsiveness in old mice but were required in greater numbers than the young mouse spleen cells to induce similar levels of response. The accessory cell was an adherent cell that could be removed by passage through Sephadex G-10 and thus may be a macrophage. Accessory function could also be provided by the cytokine interleukin-1 (IL-1), IL-4, or IL-5 but not IL-2 or IL-6. Thus, one reason for the deficient immune response to pneumococcal vaccine in aged mice is a quantitative defect in adherent accessory cells.

The CED-3/ICE-like protease Mch2 is activated during apoptosis and cleaves the death substrate lamin A

Phylogenetic analysis of the CED-3/ICE family of cysteine proteases suggests the existence of a subfamily most related to the Caenorhabditis elegans death gene ced-3 and includes Yama (CPP32, apopain), LAP3 (Mch3, CMH1), and Mch2. Here, we show that Mch2 is processed from its zymogen form to a proteolytically active dimeric species during execution of the apoptotic program and by the cytotoxic T cell death protease granzyme B. Additionally, like Yama and LAP3, Mch2 functions downstream of the death inhibitors Bcl-2, Bcl-xL, and CrmA. Importantly, Mch2, but not Yama or LAP3, is capable of cleaving lamin A to its signature apoptotic fragment, indicating that Mch2 is an apoptotic laminase.

Congenital sulfhemoglobin and transient methemoglobinemia secondary to diarrhoea

Sulfhemoglobinemia and Methemoglobinemia are common causes of cyanosis arising due to accumulation of abnormal heme pigment. We present an unusual case of congenital sulfhemoglobinemia along with diarrhoea induced methemo-globinemia in a neonate. A high index of suspicion and a proper diagnostic approach is needed to determine the true frequency of their occurrence together.

A scale for curriculum evaluation and development in the health professions

Schools responsible for the education of health professionals throughout the world are seeking ways to respond to the changing realities of the health professions and society. In an effort to be responsive to as many people as possible, there is a need to develop evaluative instruments that are effective and easily understood by multiple stakeholders. The authors describe the effective utilization of a simple scale for curricular evaluation, innovation, and reform. The scale, which incorporates two previously described instruments, can be used as an aid in several phases of curricular design: (a) during the development of a statement of educational philosophies that aid in goal and objective development, (b) during the selection and organization of learning experiences, and (c) during the evaluation of a curriculum.

Intratracheal pulmonary ventilation versus conventional mechanical ventilation in a rabbit model of surfactant deficiency

Intratracheal pulmonary ventilation (ITPV) enhances the clearance of CO2 from dead space and lungs by a bias flow of gas administered in the distal trachea. ITPV flow is continuously administered through a separate catheter placed within an endotracheal tube (ETT). After exiting from catheter's tip in the distal trachea, the flow of gas is redirected outward away from the lungs. We hypothesized that, compared with conventional mechanical ventilation (CMV), ITPV may increase minute CO2 clearance (VCO2), reduce the partial pressure of CO2 dioxide in arterial gas (PaCO2), and reduce distal tracheal peak inspiratory pressure (dPIP). We induced surfactant deficiency in 15 adult rabbits by lung lavage with 10 mL/kg normal saline. Animals were ventilated through a double-lumen 4.0 ETT, inserted through a tracheotomy incision. dPIP, distal positive end expiratory pressure, and distal mean airway pressure were monitored, and the mean exhaled CO2 concentration was measured. For ventilator rates (respiratory rate) of 30, 45, and 70 breaths/min, the study included two phases: phase I compared CO2 clearance and PaCO2 between ITPV and CMV using similar ventilatory pressures; phase II evaluated the effectiveness of ITPV in reducing dPIP and tidal volume (Vt), compared with CMV, while maintaining eucapnea. When comparing ITPV and CMV, the following results (mean +/- SD) were achieved at respiratory rate of 30, 45, and 70 breaths/min, respectively. Phase I ITPV resulted in mean percent reduction of PaCO2 by 31.4 +/- 10%, 37.1 +/- 9.7% and 38.3 +/- 9%; mean percent increase in VCO2 by 61.3 +/- 29%, 56 +/- 23, and 98 +/- 40%, compared with CMV. Phase II ITPV resulted in mean percent reduction of dPIP by 35.5 +/- 14%, 38 +/- 10.8%, and 37.2 +/- 13.7%, and mean percent reduction in Vt by 34.7 +/- 12.9%, 36.4 +/- 15%, and 52.7 +/- 10.7%, compared with CMV. The changes in PaCO2, VCO2 (phase I), and dPIP and Vt (phase II) were all significantly more than 25% (p < 0.05). Oxygenation and pH were not significantly different between ITPV and CMV. We conclude that, in a surfactant deficiency rabbit model, ITPV is an efficient mode of assisted ventilation that increases CO2 clearance and reduces ventilator pressures required for adequate ventilation. We speculate that ITPV can minimize lung barotrauma associated with mechanical ventilation.

Measurement of lung volumes and pulmonary mechanics during weaning of newborn infants with intractable respiratory failure from extracorporeal membrane oxygenation

Newborn infants with intractable respiratory failure who require extracorporeal membrane oxygenation (ECMO) experience diffuse pulmonary atelectasis shortly after initiation of ECMO. Atelectasis is likely due to the primary lung injury and the reduction of applied inspiratory ventilator pressure when the respirator settings are changed to the "rest settings." These pathophysiologic changes result in a decrease in lung compliance and lung volumes. We hypothesized that improving lung functions observed during ECMO and indicated by an increase in lung volumes will predict successful weaning from ECMO. Sixteen infants (mean +/- SEM: gestational age, 40.3 +/- 0.3 weeks; birth weight, 3.5 +/- 0.1 kg) with meconium aspiration syndrome (n = 13), sepsis (n = 2), and persistent pulmonary hypertension (n = 1) were studied. We measured passive respiratory system mechanics and lung volumes initially during full ECMO support (115 +/- 18 h on ECMO, Study I), and then within 24 h prior to weaning from ECMO (Study II). Respiratory system compliance (Crs), respiratory system resistance (Rrs), functional residual capacity (FRC), and tidal volume (VT) were measured. Prior to Study I lung volumes were too small to be detected. Crs increased between Study I and Study II (0.41 +/- 0.05 to 0.63 +/- 0.05 mL/cmH2O/kg, P < 0.05), and VT increased between Study I and Study II (5.6 +/- 0.6 to 10.4 +/- 0.8 mL/kg, P = 0.0005). FRC increased from 3.6 +/- 1.0 to 7.9 +/- 0.9 mL/kg (P = 0.0001). There was no change in Rrs (88 +/- 8 to 89 +/- 6 cm H2O/L/s, P = 0.9). The combination of Crs > 0.5 mL/cmH2O/kg and FRC > 5 mL/kg was a better predictor (P = 0.0002) of readiness to wean from ECMO than either Crs (> 0.5 mL/cmH2O/kg, P = 0.057) or FRC (> 5 mL/kg, P = 0.007) alone. The combination of FRC and Crs had a sensitivity of 73.3% and specificity of 100% for successful decannulation. We conclude that repeated measurements of FRC and Crs can assess lung recovery and may assist in establishing criteria for successful weaning from ECMO.

Retinoic Acid potently stimulates the production of granulocyte-colony-stimulating factor in the human monocytic thp-1 cell-line

Lipopolysaccharide (LPS) potently induces the production of several cytokines in THP-1 cells pretreated with phorbol 12-myristate 13-acetate (PMA). We report that all-trans retinoic acid (tRA) synergizes with LPS to enhance the production of granulocyte colony-stimulating factor (G-CSF) in PMA-treated cells, whereas the production of granulocyte-macrophage CSF, interleukin 1-beta (IL-1-beta), and tumor necrosis factor-alpha (TNF-alpha) is minimally affected by tRA. The interaction between LPS and tRA on G-CSF production is not due to IL-1-beta or TNF-alpha present in the culture medium during LPS and tRA treatment because neutralization of n-1-beta and TNF-alpha activity does not inhibit the synergy between LPS and tRA. However, exogenous IL-1-beta, but not TNF-alpha, also synergizes with tRA on G-CSF production, suggesting that LPS and IL-l-beta can independently interact with tRA to stimulate G-CSF production.

Screening for HIV seropositive blood - a critical evaluation

HIV screening of all donated blood is mandatory in India. The program instituted has many inherent lacunac like arbitrary identification of centres, absence of a guardian quality control program, criterion for test kit selection and absence of standard guidelines. This study was undertaken to evaluate the effects of frequent change of testing laboratory, change of testing staff, change of reagent kits and time of blood donation. All the donations at blood bank Safdarjang Hospital, during the year 1993, were taken for study. HBsAg and VDRL positivity were used as control/check value for similarity of donor population. Tests done during this period in three different laboratories show that the change of laboratory, change of reagent kit and the experience and training of the testing laboratory staff affect the test results, causing an increase in the number of false positive tests. This leads to destruction of donated blood which would have been otherwise fit for transfusion. It is suggested that a proper policy plan may be made and implemented in order to make the blood screening more effective.

Hydatid cyst of ovary--a case report

A rare case of ovarian hydatid cyst has been reported here in a 30 years old lady. This lady had a pet dog for last 6 years.

Cellular basis of differential responsiveness of lymph nodes and spleen to 23-valent Pnu-Imune vaccine

Subcutaneous administration with 23-valent pneumococcal polysaccharide vaccine (Pnu-Imune) elicited a good antipneumococcal capsular polysaccharide response from the spleen but not from peripheral lymph nodes (LN) (cervical, brachial, axillary, popliteal, inguinal) of BALB/c mice. To evaluate the cellular basis of the unresponsiveness of LN to this vaccine and to identify the cell types in spleen that are necessary for induction of polysaccharide Ab responses, a reliable in vitro culture system was developed to obtain plaque-forming cell responses to the Pnu-Imune vaccine. The in vitro antipneumococcal polysaccharide response of mouse spleen cells was found to be relatively T cell independent. Unlike spleen cells, LN cells did not respond to the Pnu-Imune vaccine in vitro. However, LN cells responded to Pnu-Imune vaccine when co-cultured with irradiated spleen cells or splenic dendritic cells but not with accessory cell-depleted spleen cells. LN cells were found to contain the necessary accessory cells that can support the polysaccharide response but in reduced numbers. The LN response to the vaccine was also reconstituted by IL-1 or Th2-associated cytokine IL-5. In contrast, IFN-gamma, a Th1 cell-derived lymphokine was able to suppress the in vitro splenic response to the vaccine suggesting that differential activation of Th1 and Th2 types of Th cells might be one mechanism by which T cells regulate Ab responses to pneumococcal polysaccharides.

Cellular basis of differential responsiveness of lymph nodes and spleen to 23-valent Pnu-Imune vaccine

Subcutaneous administration with 23-valent pneumococcal polysaccharide vaccine (Pnu-Imune) elicited a good antipneumococcal capsular polysaccharide response from the spleen but not from peripheral lymph nodes (LN) (cervical, brachial, axillary, popliteal, inguinal) of BALB/c mice. To evaluate the cellular basis of the unresponsiveness of LN to this vaccine and to identify the cell types in spleen that are necessary for induction of polysaccharide Ab responses, a reliable in vitro culture system was developed to obtain plaque-forming cell responses to the Pnu-Imune vaccine. The in vitro antipneumococcal polysaccharide response of mouse spleen cells was found to be relatively T cell independent. Unlike spleen cells, LN cells did not respond to the Pnu-Imune vaccine in vitro. However, LN cells responded to Pnu-Imune vaccine when co-cultured with irradiated spleen cells or splenic dendritic cells but not with accessory cell-depleted spleen cells. LN cells were found to contain the necessary accessory cells that can support the polysaccharide response but in reduced numbers. The LN response to the vaccine was also reconstituted by IL-1 or Th2-associated cytokine IL-5. In contrast, IFN-gamma, a Th1 cell-derived lymphokine was able to suppress the in vitro splenic response to the vaccine suggesting that differential activation of Th1 and Th2 types of Th cells might be one mechanism by which T cells regulate Ab responses to pneumococcal polysaccharides.

Feeding trans fatty acids to rats has no effect on the intestinal uptake of glucose, fatty acids or cholesterol

Trans fatty acids are produced in the manufacture of margarine, and these hydrogenated fatty acids may have a deleterious effect on the reduction in fasting levels of serum cholesterol anticipated from the feeding of cis polyunsaturated fatty acids. We undertook this study in rats to test the effect of feeding trans fatty acids on the intestinal uptake of glucose, fatty acids and cholesterol. Adult female Wistar rats were fed for 2 weeks semisynthetic, isocaloric diets containing no oleic acid (18:1), cis 18:1 or trans 18:1. There was no difference between the three dietary groups in the animals' food consumption or body weight gain. Rats fed trans 18:1 had an approximately 20% decline in the total weight of the ileum as compared with controls fed no 18:1, and therefore there was also a decline in the percentage of the ileal tissue comprised of mucosa. When comparing rats fed trans 18:1 with those fed cis 18:1 or no 18:1, there was no difference in the uptake of varying concentrations of D-glucose when expressed as nmol.100 mg tissue-1.min-1 or nmol.100 mg mucosal-1.min-1 for jejunum or for ileum. Also, there was no difference in the value of the maximal transport rate (Vmax), Michaelis constant (Km), or the contribution of passive uptake of glucose assessed with L-glucose. There was no diet-associated change in the jejunal or ileal uptake of a medium-chain length fatty acid (lauric acid), a long-chain length saturated fatty acid (palmitic acid), a monounsaturated fatty acid (oleic acid), two polyunsaturated fatty acids (linoleic and linolenic acids), or cholesterol. Thus, we conclude that 2 weeks' feeding of trans fatty acid to rats has no influence on the jejunal or ileal uptake of glucose, fatty acids or cholesterol.

Patient mix in the primary ambulatory care clinics of an academic medical center

BACKGROUND

The authors wished to learn whether the primary ambulatory care clinics of a university hospital had a sufficiently diverse patient mix for training in common medical problems.

METHOD

Claims data for all the ambulatory care clinics at the University of Illinois Hospital from June 1989 through June 1990 were examined for principal diagnoses. The diagnoses were grouped into common ambulatory care diagnosis clusters. The frequencies of the clusters were compared with the national frequencies from the National Ambulatory Medical Care Survey of 1989.

RESULTS

Only eight of 25 leading clusters nationally were seen with frequencies greater than 1% in the hospital's primary care clinics (i.e., family practice, general internal medicine, general pediatrics). This number increased to 22 when the clinics of other specialties were included.

CONCLUSION

To create an appropriate patient mix for training medical students and residents in ambulatory care, the university hospital examined in this study could supplement the use of its primary care clinics with the use of clinics in other specialties. This may be a less expensive and administratively less complex alternative to using off-campus private practices for such training.

Reversal of age-associated decline in immune response to Pnu-imune vaccine by supplementation with the steroid hormone dehydroepiandrosterone

Recently, we reported that murine antibody responses to the 23-valent pneumococcal polysaccharide (Pnu-Imune) vaccine declined with age. Here we present data to support the concept that age-associated immune defects are not only due to intrinsic defects in immune cells but are also due to extrinsic factors emanating from the neuroendocrine system. We found that supplementation with dehydroepiandrosterone, a steroid hormone known to be reduced in the aged, corrects the immune deficiency of aged mice and significantly enhanced their splenic immune responses to the Pnu-Imune vaccine.

Postoperative wound infections following myocutaneous flap surgery in spinal injury patients

Severe pressure ulcers in patients with spinal cord injury are frequently treated by using musculocutaneous (m-c) flap surgery. There have been few studies of the use of perioperative antibiotics to prevent postoperative infection in this setting. We reviewed 74 m-c flap surgeries in 53 patients (41 male and 12 female) from October 1989 for one year. The sites involved were ischial (31), sacral (24), trochanteric (18), deltoid (2), olecranon (1) and posterior thigh (1). An antibiotic was usually administered perioperatively for 5 days. Patients were followed for a median of 30 (8-96) weeks. Postoperative infections occurred at a median of 12 (4-25) days in 6 of 74 (8%) surgeries. The organisms cultured from the 6 infected wounds were: Bacteroides sp. (4), Proteus mirabilis (2), E. coli (2), MRSA (2), and others (6--each isolated once). These results indicate that antibiotics did not prevent postoperative infection in approximately 8% of patients undergoing m-c surgery. The frequency of isolation of Bacteroides sp. from these infections suggests that anaerobic bacteria may persist in healing pressure ulcers and perioperative antibiotics might include coverage for anaerobic bacteria.

Phospholipid and surfactant protein A concentrations in tracheal aspirates from infants requiring extracorporeal membrane oxygenation

To test the hypothesis that infants with severe respiratory failure and the need for extracorporeal membrane oxygenation (ECMO) are surfactant deficient, we measured the amount of surfactant phospholipids, disaturated phosphatidylcholine, surfactant protein A, and protein in tracheal aspirates from 22 infants, who received ECMO therapy for respiratory failure with meconium aspiration syndrome (n = 18) or pneumonia (n = 4). Tracheal suction material was obtained in a standardized way every 4 hours during the period of ECMO treatment and pooled for 24-hour periods. During ECMO, mean total phospholipid, disaturated phosphatidylcholine, and surfactant protein A values in tracheal aspirates increased and protein values decreased significantly, predominantly during the 72-hour period before infants were weaned from ECMO. Of the 22 infants, 14 had an increase in tracheal aspirate phospholipid values of more than 200% and were found to need a shorter period of ECMO support (p less than 0.005) and post-ECMO ventilatory support (p less than 0.025) than did the eight infants with stationary or only moderate increases in tracheal aspirate phospholipid values, three of whom had pneumonia. We conclude that infants with respiratory failure who require ECMO treatment often have surfactant deficiency. We speculate that surfactant treatment might decrease the need for or the duration of ECMO support.

Immune responses of systemic and mucosal lymphoid organs to Pnu-Imune vaccine as a function of age and the efficacy of monophosphoryl lipid A as an adjuvant

A murine model system was established to study immune responses to the Pnu-Imune vaccine, which is made up of 23 different pneumococcal capsular polysaccharides. In this animal model, antibody-forming cell responses to 21 of 23 individual polysaccharides in the vaccine were detected. The Pnu-Imune vaccine elicited good antibody responses from the spleens and mesenteric lymph nodes (MLN) of young mice, whereas a variety of other peripheral lymph nodes were unresponsive. The immunoglobulin M plaque-forming cell (PFC) response in the spleen to the Pnu-Imune vaccine (given intraperitoneally or subcutaneously) decreased dramatically with increasing age. However, the spleen and MLN differed in their susceptibility to an age-associated decline in immune function. While the PFC responses in the spleen declined with age, the PFC response in the mucosa-associated MLN did not decline with age but instead remained constant over the entire age span of 4 to 28 months studied. These studies showed that the spleen, peripheral lymph nodes, and MLN did not demonstrate parallel age-associated defects in antibody responses to pneumococcal polysaccharides when the antigen was administered systematically. Also, the deficient splenic antibody response to Pnu-Imune vaccine in aged mice could be enhanced by injecting a combination of Pnu-Imune vaccine and the nontoxic adjuvant monophosphoryl lipid A. Moreover, an immunoglobulin G response was induced when the immunogen was a mixture of vaccine and adjuvant.

Pulmonary sequelae at six months following extracorporeal membrane oxygenation

Mechanical assisted ventilation for neonatal respiratory failure is associated with residual lung disease. Because ECMO rests the lungs, it has been suggested that ECMO will prevent chronic lung disease in survivors. To determine whether or not ECMO survivors have evidence of pulmonary sequelae, we studied 19 infants who were treated with ECMO for neonatal respiratory failure. Ten infants still required supplemental oxygen or pulmonary medications or both to treat clinical lung disease during the first six months of life. Thoracic gas volume was normal. Pulmonary mechanics in ECMO survivors were compared with those of 13 preterm infants with BPD at similar age. We conclude that a significant proportion of ECMO survivors have residual abnormalities in pulmonary mechanics at 6 months of age. We speculate that neonatal lung injury due to meconium aspiration and other causes is a more important determinant of abnormal pulmonary sequelae than the method of treatment.

Serial measurement of pulmonary mechanics assists in weaning from extracorporeal membrane oxygenation in neonates with respiratory failure

Extracorporeal membrane oxygenation (ECMO) is a highly invasive therapy for intractable neonatal respiratory failure, and serious complications may occur with increasing duration of bypass. Weaning from bypass is empirical at present. Thus, there is a need to accurately predict when infants can be successfully decannulated. We hypothesized that pulmonary mechanics would reflect lung recovery and, therefore, predict successful weaning from ECMO. We measured pulmonary mechanics daily in 22 neonates, at gestational age of 37.8 +/- 0.6 weeks (SE) requiring ECMO for severe respiratory failure (oxygen index 66 +/- 6). Pulmonary resistance (Rpul), dynamic compliance (Cdyn), and tidal volume (VT) were measured. Rpul did not predict lung recovery. Cdyn within 24 hours of starting ECMO was 0.3 +/- 0.04 ml/cm H2O. Cdyn within 24 hours of weaning from ECMO was 1.2 +/- 0.09 ml/cm H2O (p less than 0.001). All 22 infants had Cdyn greater than 0.6 ml/cm H2O at the time of decannulation, but four infants (20 percent) with Cdyn less than 0.6 ml/cm H2O could not be weaned from ECMO within 20 hours (p less than 0.01). Thus, a minimum Cdyn of 0.6 ml/cm H2O is associated with successful weaning from ECMO. Cdyn of 0.8 ml/cm H2O provided better overall discrimination between those who could be successfully weaned from ECMO. We conclude that serial measurement of dynamic pulmonary compliance predicts successful weaning from ECMO.

The impact of extracorporeal membrane support in the treatment of congenital diaphragmatic hernia

Neonates with congenital diaphragmatic hernia (CDH) treated by immediate surgical intervention and conventional ventilatory support have an overall poor survival. The potential of extracorporeal membrane oxygenation (ECMO) therapy to improve survival of infants with CDH remains controversial. Comparison was made in a single institution's pre-ECMO and post-ECMO survival statistics to establish efficacy of extracorporeal support for persistent pulmonary hypertension (PPH). This study was accomplished by stratifying patients by an oxygen index (OI). Sixty-eight patients were treated for CDH from 1977 to 1986 without ECMO. Fifty-eight patients underwent repair of CDH within the first 24 hours of life. Data could be retrieved for calculation of the OI in 46 patients. Nineteen patients developed an OI of 40 or greater; one survived (5%). Three of 27 patients with an OI less than 40 died (OIs = 34, 38, and 38). Thirty-one patients were treated from 1987 to 1989 and none were excluded from ECMO based on a minimum PO2. Fifteen had an OI less than 40 (range, 1 to 38), were treated conventionally, and 13 survived (87%). Sixteen patients had an OI greater than 40 and 13 qualified for ECMO. Nine of 13 survived (69%). Comparing pre-ECMO and post-ECMO survival for infants with an OI of 40 or greater (5% v 69%), there is a significant improvement in survival when ECMO is used (P less than .001). ECMO support offers a strong adjunct in management of neonates with CDH who develop PPH.

Endocrine regulation of calcium and phosphate in rat eye lens and its significance in cataract formation

Parathyroid hormone (PTH), calcitonin (CT)and calciferol (Vit. D3) operate synchronously to maintain a balance between calcium and phosphate levels in serum. An aberration of specific steps in the homeostatic process results in hypo/hyper phosphatemia. These aberrations may eventually lead to several diseased states. PTH and Vit. D3 induced hypercalcemia can, however, be significantly inhibited by calcitonin (CT). These findings have been correlated with the levels of calcium and phosphate obtained from human senile cataractous lenses of cortical and nuclear types. The comparison of the results indicate that amongst these three hormones PTH is most vulnerable in leading towards conditions for possible cataract formation in rat lens.

An unusual case presentation: pericardial tamponade complicating central venous catheter

The use of central venous catheters in very low birthweight infants to provide adequate calories for growth is an integral part of the care of the high-risk neonate. The use of surgically placed Broviac catheters has been associated with infectious and mechanical complications. Recently, there has been increasing use of silastic central venous catheters inserted through a peripheral vein and advanced to the right atrium. These catheters have a reported low rate of complications. However, we report a case of a very low birthweight infant in whom a peripherally inserted silastic catheter perforated the wall of the right atrial appendage and led to fatal pericardial tamponade. This is a very rare but nearly always fatal complication. It is potentially avoidable by careful placement of the tip of the central venous catheter, so that it is not impinging on a wall of the heart. Serial venograms may be useful to reconfirm the position of the catheter.

Specific antibodies in colostrum of north Indian mothers with special reference to their nutritional status

The anti-S. typhi antibody is predominantly IgA class, and the anti-polio-antibody, antimeasles antibody, anti-E. Coli enterotoxin antibody and anti-S. typhi agglutinins were found adequate in the colostrum samples of well- and under-nourished mothers. No antibody against tetanus toxin was detectable in colostrum samples from mothers of both the groups, although they have been immunized against tetanus toxoid during pregnancy, suggesting thereby that the presence of specific antibody in the mother's breast secretions is associated with the enteromammary axis, leading to the homing of B-lymphocytes which have been specifically sensitized in the gut.

Evidence for critical-period programming of intestinal transport function: variations in the dietary ratio of polyunsaturated to saturated fatty acids alters ontogeny of the rat intestine

2-week isocaloric modifications in the dietary ratio of polyunsaturated/saturated fatty acids (P/S) alters intestinal transport in rats. This study was undertaken to test the hypotheses that (1) the fatty acid composition of a nutritionally adequate diet in early life has lasting consequences for active and passive intestinal transport processes; and (2) early life feeding experiences with diets of varying fatty acid composition influence the intestines' ability to adaptively up- or down-regulate intestinal transport in later life. Female Sprague-Dawley rats were weaned onto S or P and were maintained on these diets for 2, 10 or 12 weeks. An in vitro uptake technique was used in which the bulk phase was vigorously stirred to reduce the effective resistance of the intestinal unstirred water layer. P decreased and S increased the uptake of glucose, and this effect was progressive from 2 to 12 weeks. Switching from a P to an S diet decreased jejunal but increased ileal uptake of glucose, whereas switching from an S to a P diet was associated with a decline in both the jejunal and the ileal uptake of glucose. The ileal uptake of galactose increased as the animals grew on either P or S. Switching from P to S resulted in a decline in ileal uptake of galactose, whereas the opposite effect was observed when switching from S to P. The effect of feeding P or S on hexose uptake was influenced by the animals' dietary history: ileal glucose and galactose uptake was lower in animals fed P at an early age (PSP) than in animals fed P for the first time in later life (SSP). Jejunal glucose and galactose uptake was also lower in animals fed S at an early age (SPS) than in those fed S for the first time in later life (PPS). The alterations in the uptake of long-chain saturated and unsaturated fatty acids and cholesterol did not progress with longer periods of feeding, and in the jejunum, lipid uptake did not change when switching from P to S or S to P. Early feeding with P (PSP vs. SSP) was associated with lower jejunal uptake of 18:3 and lower ileal uptake of 12:0, whereas previous feeding with S (SPS vs. PPS) was associated with lower ileal uptake of cholesterol. The changes in uptake of hexoses and lipids was not explained by differences in the animals' food consumption, body or intestinal weight or mucosal surface area.(ABSTRACT TRUNCATED AT 400 WORDS)

Improved intestinal form and function in diabetic rats fed long-term with a polyunsaturated fatty acid diet

Short-term (two weeks) feeding of isocaloric diets supplemented with polyunsaturated fatty acids (PUFA) is useful for the prevention or treatment of the enhanced uptake of glucose which occurs in rats with streptozotocin-induced diabetes, as compared with animals fed a diet supplemented with saturated fatty acids (SFA). The study was undertaken to compare the effects of long-term (seven weeks) feeding PUFA or SFA to diabetic rats. We have previously reported that diabetic animals fed PUFA had superior body weight gain, lower hemoglobin AlC values, lower plasma cholesterol and triglyceride levels, lower percentage decline in glucose (K value) following intravenous glucose tolerance testing, near-normal values of hepatic microsomal glucose-6-phosphatase activity and near-normal concentrations of 18:2(6) and 20:4(6) in liver microsomal phosphatidylcholine and phosphatidylserine. However, jejunal and ileal uptake of varying concentrations of glucose were similar in the three diet groups. Thus, the potential long-term beneficial effects of feeding diets with a high PUFA/SFA ratio probably have their explanation in metabolic effects distant to their uptake by the intestine.

Dietary effects of omega 3-fatty acids on intestinal transport function

Animals were fed for 2 weeks on one of four isocaloric and isocholesterolic semisynthetic diets: high 18:3 omega 3, low 18:3 omega 3, high 20:5 omega 3, or low 20:5 omega 3. The weight of the intestine and the percentage of the wall consisting of mucosa was greater in high 20:5 omega 3 than in high 18:3 omega 3, and greater in low 20:5 omega 3 than in low 18:3 omega 3, although the mucosal surface area was 26% lower in high 20:5 omega 3 than high 18:3 omega 3. The jejunal uptake of 40 mM glucose and ileal uptake of 40 mM galactose was greater in high 18:3 omega 3 than in high 20:5 omega 3, jejunal uptake of fatty acid 12:0 was higher, but 18:0 was lower in high 18:3 omega 3 than in high 20:5 omega 3. The jejunal or ileal uptake of cholesterol was not affected by 20:5 omega 3. However, 20:5 omega 3 had a variable effect on the uptake of medium- and long-chain fatty acids. Alterations in the uptake of fatty acids and glucose were not explained by any difference in the animals' food consumption, body weight gain, or intestinal weight, but the reduced jejunal uptake of 40 mM glucose in rats fed the high 20:5 omega 3 diet was associated with reduced mucosal surface area. Thus, (i) varying the source of omega 3-fatty acids (vegetable, 18:3 omega 3 versus fish oil, 20:5 omega 3) altered the mucosal mass of the intestine, and (ii) the source of the dietary omega 3-fatty acid (18:3 omega 3 versus 20:5 omega 3) influenced intestinal hexose uptake, with fish oil having an anti-absorptive effect on the jejunal uptake of D-glucose.

Hypoxic arousal responses in infants with bronchopulmonary dysplasia

Infants with bronchopulmonary dysplasia have a high incidence of sudden, unexplained death in the postneonatal period, yet the cause of these deaths is unknown. Frequent episodes of clinically unsuspected arterial oxygen desaturation have recently been described in infants with bronchopulmonary dysplasia. We hypothesized that infants with bronchopulmonary dysplasia who experience frequent episodes of hypoxia may have abnormal arousal responses to these hypoxic episodes. We studied 12 infants with bronchopulmonary dysplasia at 41.4 +/- 1.3 weeks postconceptional age. Hypoxic arousal responses were performed during quiet sleep at an inspired oxygen tension of 80 mm Hg for a maximum of three minutes or until arousal occurred. Of 12 infants, 11 (92%) aroused normally to the hypoxic challenge. However, all infants required vigorous stimulation and supplemental oxygen after the initial arousal response. Of 12 infants with bronchopulmonary dysplasia, eight (67%) experienced prolonged apnea with bradycardia, and four of 12 (33%) required brief ventilatory assistance (bag and mask) to restore normal breathing. Abnormal pneumographic findings did not predict the occurrence of these prolonged periods of apnea and bradycardia following hypoxia. We conclude that an abnormal response to hypoxia following arousal may lead to prolonged apnea and bradycardia in infants with bronchopulmonary dysplasia. We speculate that the inability to recover from this hypoxia may result in sudden death in these infants.

Clinically unsuspected hypoxia during sleep and feeding in infants with bronchopulmonary dysplasia

Infants with bronchopulmonary dysplasia have a high incidence of sudden, unexplained death in the postneonatal period; yet the cause of these deaths is unknown. It was hypothesized that infants with bronchopulmonary dysplasia, thought to be well oxygenated based on awake PaO2 values, would have clinically unsuspected arterial oxygen desaturation during sleep and that these would correlate with the severity of pulmonary function abnormalities. The infants studied were 14 with bronchopulmonary dysplasia, 15 who were preterm, had no bronchopulmonary dysplasia, but did have neonatal respiratory distress syndrome, and eight who were full term and used for control at 37 to 45 weeks postconception. Continuous noninvasive monitoring of oxygenation (arterial oxygen saturation [SaO2, pulse oximetry] and transcutaneous oxygen tension was performed during sleep, wakefulness, and feeding. Greater than 80% of each recording was free of artifact for SaO2. Preterm infants with bronchopulmonary dysplasia and respiratory distress syndrome spent greater time at SaO2 less than 90% than control infants. Most desaturations occurred during feeding and to a lesser extent during wakefulness, active sleep, and quiet sleep. Episodes of desaturation (SaO2 less than 90%) lasted 15 to 20 seconds and were not associated with apnea, bradycardia, cyanosis, or changes in transcutaneous PO2. Only infants with bronchopulmonary dysplasia showed severe desaturations (SaO2 less than 80%). Total desaturation in those infants correlated with airway resistance (body pressure plethysmography). Abnormal pneumographic findings did not predict abnormal desaturations. It was concluded that clinically unsuspected oxygen desaturation occurs frequently in preterm infants with and without bronchopulmonary dysplasia, and profound hypoxemia may be responsible for sudden unexplained deaths in these infants.

Growth failure in infants with bronchopulmonary dysplasia: nutrition and elevated resting metabolic expenditure

The mechanisms underlying growth failure in infants with bronchopulmonary dysplasia are poorly understood. Thirteen infants with bronchopulmonary dysplasia at 6 months of corrected age and 12 full-term healthy control infants matched for age or size were studied. Resting oxygen consumption was measured during natural sleep, and an estimation of the resting metabolic expenditure by indirect calorimetry was performed. Growth parameters were measured, and a nutritional profile including dietary intake, stool analysis, and serum albumin, cholesterol, glucose, and prealbumin was obtained. Seven of the 13 infants with bronchopulmonary dysplasia had growth failure (defined as length and weight less than the tenth percentile of the Babson growth curves). These infants had lower birth weight, lower gestational age, and a greater number of days spent in supplemental oxygen or on mechanical ventilation. There was no statistical difference between the bronchopulmonary dysplasia-growth failure and bronchopulmonary dysplasia-normal growth infants for dietary intake or stool or serum analyses. However, serum prealbumin showed a significant linear correlation with body weight in infants with bronchopulmonary dysplasia. Resting metabolic expenditure was elevated in infants with bronchopulmonary dysplasia with growth failure and was inversely correlated with body weight in all infants with bronchopulmonary dysplasia. Thus, infants with bronchopulmonary dysplasia and growth failure have increased metabolic demands and decreased prealbumin values suggesting a relative state of protein-calorie malnutrition.

Growth failure in bronchopulmonary dysplasia: elevated metabolic rates and pulmonary mechanics

Growth failure is a major problem in infants with bronchopulmonary dysplasia (BPD), but the cause is unknown. We studied 13 infants with BPD but without other medical problems that could contribute to growth failure at 6 months' corrected age. We measured resting oxygen consumption (Vo2), Pao2, airway resistance, specific airway conductance, and dynamic pulmonary compliance (Cdyn) by body plethysmography and growth. Growth failure was defined as height and weight less than the tenth percentile of the Babson growth curves. Vo2 in infants with growth failure and BPD was markedly elevated compared with that in control infants and infants with BPD and normal growth. Vo2 showed an inverse correlation with body weight in infants with BPD but not in control infants. Although Vo2 was inversely related to Cdyn, the total work of breathing only partially explained the increased metabolic demands of the growth failure group. We speculate that growth failure in infants with BPD is partially the result of increased metabolic demands from increased work of breathing but that other mechanisms may act to elevate the metabolic expenditure of these infants.

Spectrum of effects of dietary long-chain fatty acids on rat intestinal glucose and lipid uptake

Isocaloric modification in the ratio of dietary polyunsaturated-to-saturated fatty acids influences intestinal uptake of actively and passively transported nutrients. This study was undertaken to determine which dietary fatty acid was responsible for these alterations in absorption. Adult female rats were fed isocaloric semisynthetic diets high in palmitic and stearic acids (SFA), oleic acid (OA), linoleic acid (LA), or linolenic acid (LNA). An in vitro technique was used to measure the uptake of varying concentrations of glucose as well as a series of fatty acids and cholesterol. Jejunal uptake of 40 mM glucose was highest in rats fed SFA and lowest in those fed LA; ileal glucose uptake was similar in OA, LA, and LNA, but was lowest in SFA. Jejunal uptake of medium-chain fatty acids (8:0-12:0) was higher in OA than in other diet groups; ileal uptake of medium-chain fatty acids was unaffected by diet. Jejunal and ileal uptake of 18:2 was higher in LNA than in SFA or OA; the uptake of the other long-chain saturated or unsaturated fatty acids was unchanged by diet. The ileal but not the jejunal uptake of cholesterol was increased in LA as compared with SFA or OA, and reduced in LNA as compared with LA. These transport changes were not explained by differences in the animals' food consumption, body weight gain, intestinal mass, or mucosal surface area. We postulate that these diet-induced transport alterations may be mediated via changes in brush border membrane phospholipid fatty acyl composition. Thus, intestinal transport of nutrients may be varied by isocaloric changes in the dietary content of individual fatty acids.

Physiology of a temperature-sensitive mutant of Saccharomyces cerevisiae defective in phosphofructokinase activity

In this paper, we describe a temperature-sensitive mutant of the yeast Saccharomyces cerevisiae (P5-9) which at a restrictive temperature (36 degrees C) shows a pleiotropic defect for transport of many different metabolites. The temperature sensitivity of the mutant is closely related to a reduction in phosphofructokinase activity. This conclusion is based on the following criteria. (i) Both the primary isolate, designated P5-9 (ts [rho-] Ino-), which is an inositol auxotroph and respiration deficient, and a purified derivative, SB4 (ts [rho+] Ino+ ), which is respiration competent and capable of growing in the absence of inositol, are temperature sensitive for growth and ethanol production in media containing glucose or fructose as the sole carbon source. (ii) The respiration-competent derivative SB4 is not temperature sensitive in media containing glycerol or glycerol-pyruvate; glucose inhibits its growth at 36 degrees C in these media. (iii) Assays of glycolytic enzymes in P5-9 and SB4 extracts, prepared from cells incubated for 1 to 2 h at 36 degrees C before harvesting, show selective reduction in phosphofructokinase activity. Analysis of tetrads derived from the cross of mutant and nonmutant haploids indicates that temperature sensitivity for growth is due to a single gene or to two closely linked genes. The biochemical analysis of spores from seven such tetrads revealed a uniform cosegregation of temperature sensitivity for growth and phosphofructokinase activity. Transport and ATP levels were drastically reduced in SB4 cells incubated at 36 degrees C for 1 to 2 h with glucose as the carbon source, but not when glycerol-pyruvate or lactate was the energy source. Therefore, depletion of energy as a result of phosphofructokinase inactivation appears to be the cause of the pleiotropic transport defect observed in the mutant.

An evaluation of behavioral techniques reinforced with an anorectic drug in a double-blind weight loss study

Sixty obese outpatients participated in a double-blind comparison of diethylpropion hydrochloride and placebo in conjunction with a behavior modification program for weight reduction. Assessments of efficacy and program acceptance included total weight loss, percent of initial (baseline) weight loss, percent excess weight lost, effectiveness of overall program, and helpfulness of medication. Diethylpropion was significantly better than placebo in all five assessments. An added behavioral technique, a substantial refundable deposit of money, reduced the attrition rate of all study entrants from 50% to 10%; thus patient compliance was greatly enhanced.

Living dangerously--the effect of chronic pulmonary and renal failure on self-image

Patients with severe chronic obstructive lung disease (COLD) are difficult to interview because of their inability to verbalize freely. The draw-a-person (DAP) and the draw-a-house (DAH) tests were given to COLD patients (n = 14), and to patients on chronic renal dialysis (n = 14). The COLD patients showed significantly more disorganization in the drawings (p less than 0.05 for DAP and p less than 0.001 for DAH) than the renal patients. There were certain other findings specific to the circumstances of each disorder. The DAP and DAH may be clinically useful in rapidly identifying the patients in need of greater psychosocial support.

Utilization Pattern Of Nonsteroidal Anti-Inflammatory Drugs(NSAIDS) in Orthopedic Practise at a tertuary Care Hospital In Eastern Nepal

abstract