Living and dying with chronic obstructive pulmonary disease

OBJECTIVE

To characterize chronic obstructive pulmonary disease (COPD) over patients' last 6 months of life.

STUDY DESIGN

A retrospective analysis of a prospective cohort from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

SETTING

Hospitalization for exacerbation of COPD at five US teaching hospitals.

PARTICIPANTS

COPD patients who died within 1 year (n = 416) among 1016 enrolled.

METHODS

Interview and medical record data were organized into time windows beginning with death and ending 6 months earlier.

OUTCOME MEASURES

Days in hospital, prognosis, illness severity, function, symptoms, patients' preferences, and impacts on families.

RESULTS

One-year survival was 59%, 39% had > or = 3 comorbidities, and 15 to 25% of the patients' last 6 months were in hospitals. Exacerbation etiologies included respiratory infection (47%) and cardiac problems (30%). Better quality of life predicted longer survival (ARR: 0.36; 95% CI, 0.19-0.87) as did heart failure etiology of exacerbation (ARR: 0.57; CI, 0.40, 0.82). Estimates of survival by physicians and by prognostic model were well calibrated, although patients with the worst prognoses survived longer than predicted. Patients' estimates of prognosis were poorly calibrated. One-quarter of patients had serious pain throughout, and two-thirds had serious dyspnea. Patients' illnesses had a major impact on more than 25% of families. Patients' preferences for Do-Not-Resuscitate orders increased from 40% at 3 to 6 months before death to 77% within 1 month of death; their decisions not to use mechanical ventilation increased from 12 to 31%, and their preferences for resuscitation decreased from 52 to 23%.

CONCLUSIONS

Patients with advanced COPD often die within 1 year and have substantial comorbidities and symptoms. Adequate description anchors improved care.

Dying with acute respiratory failure or multiple organ system failure with sepsis

BACKGROUND

The dying experience of patients with acute respiratory failure (ARF) or multiple organ system failure with sepsis (MOSF) has not been described.

OBJECTIVES

To describe patients dying from ARF or MOSF, including demographic characteristics, baseline function and quality of life, symptoms, preferences, use of life-sustaining treatments, satisfaction with care, and family burden.

DESIGN

A multicenter prospective study.

SETTING

Five US teaching hospitals, in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

PARTICIPANTS

A total of 1295 adults who died during hospitalization for ARF or MOSF.

MEASUREMENTS

Chart reviews and interviews with patients and surrogates.

RESULTS

SUPPORT enrolled 2956 patients with ARF or MOSF, and 44% died during enrollment hospitalization. Quality of life before hospitalization was reported as fair by 87% of patients. The mean number of impairments in their baseline activities of daily living was 1.6. At the time of death, 79% had a DNR order and 31% had an order to withhold ventilator support. The average time from the DNR order to death was 2 days. Dying patients spent an average of 9 days on a ventilator. Surrogates indicated that one out of four patients died with severe pain and one out of three with severe confusion. Families of 42% of the patients who died reported one or more substantial burden.

CONCLUSIONS

Patients in this study reported substantial functional impairments and reduced quality of life. Limitations to aggressive treatments were usually implemented only when death was imminent. Family impact and physical and emotional suffering were substantial.

Dying with lung cancer or chronic obstructive pulmonary disease: insights from SUPPORT. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

CONTEXT

Many are calling for patients with advanced chronic obstructive pulmonary disease (COPD) to receive hospice care, but the traditional hospice model may be insufficient.

OBJECTIVE

To compare the course of illness and patterns of care for patients with non-small cell lung cancer and severe COPD.

DESIGN

Prospective cohort study of seriously ill, hospitalized adults.

SETTING

Five teaching hospitals in the United States.

PATIENTS

Patients with Stage III or IV non-small cell lung cancer (n = 939) or acute exacerbation of severe COPD (n = 1008).

MAIN OUTCOME MEASURES

Patients' preferences for pattern of care and for ventilator use; symptoms; life-sustaining interventions; and survival prognoses.

RESULTS

Sixty percent in each group wanted comfort-focused care; 81% with lung cancer and 78% with COPD were extremely unwilling to have mechanical ventilation indefinitely. Severe dyspnea occurred in 32% of patients with lung cancer and 56% of patients with COPD and severe pain in 28 % of patients with lung cancer and 21% of patients with COPD. Patients with COPD who died during index hospitalization were more likely than patients with lung cancer to receive mechanical ventilation (70.4% vs 19.8%), tube feeding (38.7% vs 18.5%), and cardiopulmonary resuscitation (25.2% vs 7.8%). Mechanical ventilation had greater short term effectiveness in patients with COPD, based on survival to hospital discharge (76% vs 38%). Patients with COPD maintained higher median 2-month and 6-month survival prognoses, even days before death.

CONCLUSIONS

Hospitalized patients with lung cancer or COPD preferred comfort-focused care, yet dyspnea and pain were problematic in both groups. Patients with COPD were more often treated with life-sustaining interventions, and short-term effectiveness was comparatively better than in patients with lung cancer. In caring for patients with severe COPD, consideration should be given to implementing palliative treatments more aggressively, even while remaining open to provision of life-sustaining interventions.

Elderly persons' last six months of life: findings from the Hospitalized Elderly Longitudinal Project

BACKGROUND

Few studies describe the end of life in very old people.

OBJECTIVES

To characterize the last 6 months of life and dying in patients 80 years and older by describing demographic characteristics, functional state and quality of life, symptoms, preferences, use of life-sustaining treatments, satisfaction with care, and family burden.

DESIGN

A retrospective analysis for patients enrolled in a prospective cohort study.

SETTING

Four teaching hospitals who participated in the Hospitalized Elderly Longitudinal Project (HELP).

SUBJECTS

417 patients who died within 1 year of their enrollment hospitalization.

MEASUREMENTS

Chart reviews and interview data with patients and surrogates at several points in time. We constructed four observational time windows backward in time beginning with the patients' death.

RESULTS

Before hospitalization, two out of three patients reported fair quality of life, and patients averaged 2.4 impairments in activities of daily living. Seventy percent preferred comfort care on the third day of hospitalization. During the last month of life, three of five patients interviewed in the hospital and four of five interviewed out of the hospital preferred not to be resuscitated. At the time of death, four of five patients had a do not resuscitate (DNR) order and two of five had an order to withhold a ventilator. During the last month of life, one out of four patients reported severe pain.

CONCLUSIONS

Patients reported increasing functional impairments and limited quality of life. The majority preferred comfort care. The number of patients in severe pain was substantial. Before death, the majority had measures in place to limit aggressive care.

The effect of nutritional supplementation on survival in seriously ill hospitalized adults: an evaluation of the SUPPORT data. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

BACKGROUND

Enteral tube and parenteral hyperalimentation are widely used nutritional support systems. Few studies examine the relation between nutritional support and patient outcomes in seriously ill hospitalized adults.

OBJECTIVE

To explore the association between nutritional support and survival in seriously ill patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

DESIGN

A prospective study of preferences, decision-making, and outcomes.

SETTING

Five teaching hospitals

PARTICIPANTS

6298 patients aged 18 or older meeting diagnostic and illness severity criteria.

MEASUREMENT

Demographic characteristics, diagnoses, comorbid conditions, acute physiology score, nutritional support, and functional status before hospitalization.

RESULTS

A total of 2149 patients received nutritional support. In patients who received artificial nutrition on hospital days 1 or 3 (Cohort 1), enteral feeding was associated with improved survival in coma (hazard: 0.53; 95%CI, 0.42-0.66), and reduced survival in COPD (hazard: 1.57; 95%CI, 1.18-2.08). In patients who were hospitalized on Day 7 and received artificial nutrition on days 1, 3, or 7 (Cohort 2), enteral tube feeding (hazard: 0.35; 95%CI, 0.27-0.46) or hyperalimentation (hazard: 0.58; 95%CI, 0.38-0.90) was associated with improved survival in coma. Tube feeding was associated with decreased survival in acute respiratory failure (ARF) or multiorgan system failure (MOSF) with sepsis (hazard: 1.21; 95%CI, 10.4-1.41), cirrhosis (hazard: 2.15; 95%CI, 1.35-3.42), and COPD (hazard: 1.37; 95%CI, 1.04-1.80). Hyperalimentation was associated with decreased survival in ARF or MOSF with sepsis (hazard: 1.34; 95%CI, 1.12-1.59).

CONCLUSIONS

Nutritional support was associated with improved survival in coma. Enteral feeding and hyperalimentation was associated with decreased survival in ARF or MOSF with sepsis. Tube feeding was associated with decreased survival in cirrhosis and COPD. Except for patients in coma, artificial nutrition was not associated with a survival advantage.

Computed tomography of x-ray index of refraction using the diffraction enhanced imaging method

Diffraction enhanced imaging (DEI) is a new, synchrotron-based, x-ray radiography method that uses monochromatic, fan-shaped beams, with an analyser crystal positioned between the subject and the detector. The analyser allows the detection of only those x-rays transmitted by the subject that fall into the acceptance angle (central part of the rocking curve) of the monochromator/analyser system. As shown by Chapman et al, in addition to the x-ray attenuation, the method provides information on the out-of-plane angular deviation of x-rays. New images result in which the image contrast depends on the x-ray index of refraction and on the yield of small-angle scattering, respectively. We implemented DEI in the tomography mode at the National Synchrotron Light Source using 22 keV x-rays, and imaged a cylindrical acrylic phantom that included oil-filled, slanted channels. The resulting 'refraction CT image' shows the pure image of the out-of-plane gradient of the x-ray index of refraction. No image artefacts were present, indicating that the CT projection data were a consistent set. The 'refraction CT image' signal is linear with the gradient of the refractive index, and its value is equal to that expected. The method, at the energy used or higher, has the potential for use in clinical radiography and in industry.

Human breast cancer specimens: diffraction-enhanced imaging with histologic correlation--improved conspicuity of lesion detail compared with digital radiography

Seven breast cancer specimens were examined with diffraction-enhanced imaging at 18 keV with a silicon crystal with use of the silicon 333 reflection in Bragg mode. Images were compared with digital radiographs of the specimen, and regions of increased detail were identified. Six of the seven cases (86%) showed enhanced visibility of surface spiculation that correlated with histopathologic information, including extension of tumor into surrounding tissue.

[Dynamic features of some biochemical constituents in Gynostemma pentaphyllum under different environments]

With biochemical techniques, the authors preliminarilty examined the dynamics of polyphenols, free amino acids and water-soluble sugars in Gynostemma pentaphyllum collected from different regions and the relationships between them and climate factors. The dynamic patterns of these three types of constituents in stems, blades and shoots under the same environment were different. At different growth phases, stems and blades had different contributions to the constituents. The dynamics of them differed with their environments. Polyphenols, free amino acids and water-soluble sugars might regulate the growth and development of plants. Moreover, they were characterized by plasticity, and the dominant climate factors affecting the dynamics of the constituents varied greatly.

[Response of Capsicum frutescens metapopulation to simulated insect herbivorous behaviors]

Based on the theory of metapopulation, this paper studied the response of different leaf-cutting Capsicum frutescens metapopulation to simulated short-term insect pestes during high temperature period in July. Variance analysis (ANOVA), principal component analysis(PCA) and plant growth analysis were applied. The result shows that C. frutescens had a strong compensatory ability. The number, dry weight and leaf area of old leaves decreased with increasing leaf-cutting, but contrarily for new leaves. The total leaf number did not show any significant difference, but the total area and weight of leaves were significantly different, because of the influence of old leaves. The number, weight and lenght of branches were not significantly different with different treatments, and the number of fruits, flowers and flower buds also showed no significant difference. However, the difference of their dry weights was significant. It is practical to use number indexes, but not dry weight, leaf area and length for plant growth analysis in metapopulation, when the difference of dry weight between modulars is small. It is suggested that a certain degree of herbivory might be beneficial to the growth and fruit yield of C. frutescens during the high temperature period.

Factors associated with use of cardiopulmonary resuscitation in seriously ill hospitalized adults

CONTEXT

The epidemiology of do-not-resuscitate (DNR) orders for hospitalized patients has been reported, but little is known about factors associated with the use of cardiopulmonary resuscitation (CPR).

OBJECTIVE

To identify factors associated with an attempt at CPR for patients who experienced cardiopulmonary arrest.

DESIGN

Secondary analysis of data collected in 2 prospective cohort studies: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT, 1989-1994) and the Hospitalized Elderly Longitudinal Project (HELP, 1994). Setting Five teaching hospitals across the United States.

PARTICIPANTS

A total of 2505 seriously ill hospitalized patients and nonelectively admitted persons aged 80 years or older who experienced cardiopulmonary arrest.

MAIN OUTCOME MEASURES

Medical records data on CPR efforts, DNR orders, disease severity, age, race, sex, length of stay, and survival; functional status and preferences concerning CPR obtained by interviews with patients or surrogates; and 2-month survival estimates provided by physicians.

RESULTS

Five hundred fourteen study subjects (21 %) received CPR during their index hospitalization. Among them, 327 (63.6%) had CPR within 2 days of death and 93 (18.1 %) had resuscitation and survived their index hospitalization. Use of CPR was more likely in men (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.12-1.73), younger patients (OR per 10-year increase, 0.90; 95% CI, 0.84-0.96), African Americans (OR, 1.76; 95% CI, 1.33-2.34), patients whose reported preferences were for CPR (OR, 2.60; 95% CI, 1.91-3.55), who reported better quality of life (OR, 1.49; 95% CI, 1.10-2.03), or who had higher physician estimates for 2-month survival (OR per 10% increase, 1.14; 95% CI, 1.09-1.19). Rates varied significantly with geographic location and diagnosis; the adjusted OR for patients with congestive heart failure was 3.31 (95% CI, 2.12-5.15) compared with patients with acute respiratory failure or multiple organ system failure.

CONCLUSIONS

Our data suggest that a resuscitation attempt is more likely when preferred by patients and when death is least expected. Further study is required to understand variation in use of CPR among sites and for patients with different diagnoses, race, sex, or age.

Glycine: a new anti-inflammatory immunonutrient

The mechanism of the immunosuppressive effects of glycine and its pathophysiological applications are discussed in this review. Glycine has been well characterized in spinal cord as an inhibitory neurotransmitter which activates a glycine-gated chloride channel (GlyR) expressed in postsynaptic membranes. Activation of the channel allows the influx of chloride, preventing depolarization of the plasma membrane and the potentiation of excitatory signals along the axon. Glycine has recently been shown to have similar inhibitory effects on several white blood cells, including hepatic and alveolar macrophages, neutrophils, and lymphocytes. Pharmacological analysis using a GlyR antagonist strychnine, chloride-free buffer, and radiolabeled chloride has provided convincing evidence to support the hypothesis that many white blood cells contain a glycine-gated chloride channel with properties similar to the spinal cord GlyR. Molecular analysis using reverse transcription-polymerase chain reaction and Western blotting has identified the mRNA and protein for the beta subunit of the GlyR in total RNA and purified membrane protein from rat Kupffer cells. Dietary glycine is protective in rat models against endotoxemia, liver ischemia-reperfusion, and liver transplantation, most likely by inactivating the Kupffer cell via this newly identified glycine-gated chloride channel. Glycine also prevents the growth of B 16 melanomas cell in vivo. Moreover, dietary glycine is protective in the kidney against cyclosporin A toxicity and ischemia-reperfusion injury. Glycine may be useful clinically for the treatment of sepsis, adult respiratory distress syndrome, arthritis, and other diseases with an inflammatory component.

Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

CONTEXT

Many individuals involved with care of the dying advocate expanding access to hospice care for persons with advanced lung, heart, or liver disease. However, to be eligible, these patients generally must have a prognosis for survival of less than 6 months.

OBJECTIVE

To test the ability of currently available criteria to identify a population with a survival prognosis of 6 months or less among seriously ill hospitalized patients with 1 of 3 commonly fatal chronic diseases.

DESIGN

Validation study using data from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) phase 1 (June 1989-June 1991) and phase 2 (January 1992-January 1994), with a 6-month follow-up.

SETTING AND PATIENTS

Consecutive sample of 2607 seriously ill patients from 5 US medical centers who were hospitalized with chronic obstructive pulmonary disease, congestive heart failure, or end-stage liver disease, and who survived to hospital discharge.

MAIN OUTCOME MEASURES

Descriptive and operating characteristics of 5 general and 2 disease-specific clinical criteria for identifying patients with a survival prognosis of 6 months or less, and 3 sets of combination criteria (broad, intermediate, and narrow inclusion) aimed at providing low, medium, and high thresholds for hospice eligibility based on National Hospice Organization guidelines.

RESULTS

Seventy-five percent of the sample survived more than 6 months after hospital discharge; 44% expressed a preference for palliative care. Broad inclusion criteria identified 923 patients eligible for hospice care, of whom 70% survived longer than 6 months. Intermediate inclusion criteria identified 300 patients, of whom 65% survived longer than 6 months. Narrow inclusion criteria identified 19 patients, of whom 53% survived longer than 6 months. Sensitivities and specificities of the combination criteria were 41.7% and 66.7% (broad inclusion), 16.2% and 90.1 % (intermediate inclusion), and 1.4% and 99.5% (narrow inclusion), respectively.

CONCLUSIONS

These data indicate that for seriously ill hospitalized patients with advanced chronic obstructive pulmonary disease, congestive heart failure, or end-stage liver disease, recommended clinical prediction criteria are not effective in identifying a population with a survival prognosis of 6 months or less.

[Determination of impurities in osmium powder by ICP-AES using matrix separation]

An inductively coupled plasma-atomic emission spectrometry method has been developed for the determination of impurities in osmium powder. The sample was dissolved in nitric acid at 150-200 degrees C. Osmium was oxided and its oxide vapour was absorbed by NaOH. The residual solution was then analyzed by ICP-AES. The determination limit of the method is 0.005-0.134 microg x mL(-1). The recovery range of the method is 91%-112%. The precision of the method is less than 3%. This method can be used to determine 18 elements simultaneously. It is simple, rapid and precise.

Dietary glycine and renal denervation prevents cyclosporin A-induced hydroxyl radical production in rat kidney

Cyclosporin A (CsA) nephrotoxicity is associated with renal hypoxia and increases in free radicals in the urine. This study was designed to elucidate the mechanism of radical production caused by CsA. Pretreatment of rats with CsA (25 mg/kg, i.g.) for 5 days decreased glomerular filtration rates by 65%, an effect largely prevented by both dietary glycine (5%) or renal denervation. CsA dissolved in olive oil produced a 6-line alpha-(4-pyridyl 1-oxide)-N-tert-butylnitrone (4-POBN)/free radical signal in the urine, which partitioned predominantly into the aqueous phase after chloroform extraction (i.e., it is water soluble). Dimethyl sulfoxide (DMSO) is attacked by the hydroxyl radical to produce a methyl radical; administration of CsA with [(12)C]DMSO produced two radical species in urine, one with hyperfine coupling constants similar to the 4-POBN/methyl radical adduct found in aqueous solution. CsA given with [(13)C]DMSO produced a 12-line spectrum, confirming the formation of hydroxyl radicals. The methyl radical produced by the hydroxyl radical represented 62% of radicals detected in urine but only 15% in bile. Therefore, hydroxyl radicals are produced largely in the kidney. Free radicals in urine were increased about 5-fold by CsA, an effect completely blocked by the inhibitory neurotransmitter, glycine, or by renal denervation. CsA infusion for 30 min increased efferent renal nerve activity 2-fold, and dietary glycine (5%) totally blocked this phenomenon. Taken together, these data are consistent with the hypothesis that CsA increases hydroxyl radical formation by increasing renal nerve activity resulting in vasoconstriction and hypoxia-reoxygenation. Glycine blunts the effect of CsA on the renal nerve, which explains, in part, prevention of nephrotoxicity.

Binge drinking disturbs hepatic microcirculation after transplantation: prevention with free radical scavengers

Disturbances in hepatic microcirculation increase graft injury and failure; therefore, this study evaluates the effects of ethanol on microcirculation after liver transplantation. Donor rats were given one dose of ethanol (5 g/kg) by gavage 20 h before explantation, and grafts were stored in University of Wisconsin solution for 24 h before implantation. Acute ethanol treatment decreased 7-day survival of grafts from about 90 to 30%, increased transaminase release nearly 4-fold, and decreased bile production by 60%. Moreover, portal pressure increased significantly and liver surface oxygen tension decreased about 50%, indicating that ethanol disturbs hepatic microcirculation. Pimonidazole, a 2-nitroimidazole hypoxia marker, was given i.v. to recipients 30 min after implantation, and grafts were harvested 1 h later. Ethanol increased hepatic pimonidazole binding about 3-fold, indicating that ethanol led to hypoxia in fatty grafts. Ethanol also significantly increased free radicals in bile. Catechin (30 mg/kg i.v. upon reperfusion), a free radical scavenger, and Carolina Rinse solution, which contains several agents that inhibit free radical formation, minimized disturbances in microcirculation and prevented pimonidazole adduct formation significantly. These treatments also blunted increases in transaminase release and improved survival of fatty grafts. Destruction of Kupffer cells with GdCl(3) (20 mg/kg i.v. 24 h before explantation) or inhibition of formation of leukotrienes with MK-886 (50 microM in University of Wisconsin or rinse solution) also minimized hypoxia and improved survival after transplantation. Taken together, these results demonstrate that ethanol disturbs hepatic microcirculation, leading to graft hypoxia after transplantation, most likely by activating Kupffer cells and increasing free radical production.

Molecular and functional characteristics of a protective human monoclonal antibody to serotype 8 Streptococcus pneumoniae capsular polysaccharide

The structural characteristics and biological activity of human antibodies that are reactive with the capsular polysaccharides of most serotypes of Streptococcus pneumoniae, including serotype 8, are unknown. This paper describes the generation, molecular structure, and protective efficacy of a human monoclonal antibody (MAb) reactive with the capsular polysaccharide of serotype 8 Streptococcus pneumoniae. We generated the immunoglobulin M(kappa) [IgM(kappa)] MAb D11 by Epstein-Barr virus transformation of peripheral lymphocytes from a Pneumovax recipient. Nucleic acid sequence analysis revealed that MAb D11 uses V3-15/V(H)3 and A20/V(kappa) gene segments with evidence of somatic mutation. In vitro studies revealed MAb D11-dependent complement deposition on the capsule of serotype 8 organisms via either the classical or the alternative complement pathway. In vivo, MAb D11 prolonged the survival of both normal and C4-deficient mice with lethal serotype 8 S. pneumoniae infection. Our findings demonstrate that a serotype-specific human IgM with certain structural and functional characteristics was protective in mice lacking a functional classical complement pathway and show that alternative complement pathway activation is an important determinant of pneumococcal protection.

Glycine improves survival after hemorrhagic shock in the rat

This study investigated the effect of glycine on hemorrhagic shock in the rat. Rats were bled to maintain mean arterial pressure at 30-35 mm Hg for 1 h and subsequently resuscitated with 60% shed blood and lactated Ringer's solution. Only 20% of rats receiving saline just prior to resuscitation survived 72 h after shock. Survival was increased by glycine (11.2-90.0 mg/kg, i.v.) in a dose-dependent manner (half-maximal effect = 25 mg/kg) and reached maximal values of 78% at 45 mg/kg. Eighteen hours after resuscitation, creatinine phosphokinase increased 23-fold, transaminases increased 33-fold, and creatinine was elevated 2.4-fold, indicating injury to the heart, liver, and kidney, respectively. Pulmonary edema, leukocyte infiltration, and hemorrhage were also observed. In the kidney, proximal tubular necrosis, leukocyte infiltration, and severe hemorrhage in the outer medullary area occurred in rats receiving saline. Glycine reduced these pathological alterations significantly. It has been reported that oxidative stress and tumor necrosis factor(TNF)-alpha-production are involved in the pathophysiology of multiple-organ injury after shock. In this study, free radical production was increased 4-fold during shock, an effect blocked largely by glycine. Increases in intracellular calcium and production of TNF-alpha by isolated Kupffer cells stimulated by endotoxin were elevated significantly by hemorrhagic shock, alterations which were totally prevented by glycine. Taken together, it is concluded that glycine reduces organ injury and mortality caused by hemorrhagic shock by preventing free radical production and TNF-alpha formation.

[The epidemiological study on limb deformities among children in Guangdong Province]

OBJECTIVE

To study the incidence of limb deformities of children in Guangdong province.

METHODS

Physical examination on lined-up students and looked over one by one. Detailed examinations of orthopaedics or related subjects were performed on those with susceptive deformity.

RESULTS

Results showed that there were 655 cases of limb deformities (0.64%) in 102,313 pupils of 7 to 14 years old, in which 550 cases (83.97%) needed surgical intervention. The incidence of deformity in economically poor areas was 2.88 times higher than those in advanced areas.

CONCLUSION

Prevention and cure of limb deformities of children, especially those in rural area, should be addressed and emphasized.

Kupffer cell-dependent reperfusion injury in liver transplantation: new clinically relevant use of glycine

Kupffer cell-dependent reperfusion injury occurs to the liver following transplantation, most often in fatty livers which fail most frequently due to primary nonfunction. Failure was largely blocked with Carolina rinse solution, which contains glycine, and prevents the activation of Kupffer cells. Furthermore, gentle in situ organ manipulation, which cannot be prevented using standard harvesting techniques, has a detrimental effect on survival. These effects were also prevented by glycine. Since proteolytic activity is increased in both fatty and manipulated livers, amino acids were measured in rinse effluents collected at harvest. A combination of four amino acids correlated with graft function. It is concluded that glycine could be beneficial in clinical liver transplantation to prevent reperfusion injury, and that amino acids measured at harvest may predict graft function.

Ethanol, not fat accumulation per se, increases free radical production in a low-flow, reflow liver perfusion model

BACKGROUND

Ethanol increases primary graft failure after liver transplantation, yet whether it acts via mechanisms involving fat accumulation remains unclear.

METHODS

Rats were pair-fed a modified Lieber-DeCarli liquid diet containing 35% (high-fat) or 12% (low-fat) of calories as fat combined with 36% of calories as ethanol or isocaloric maltose-dextrin for 4-5 weeks. Reperfusion injury to the liver was studied using a low-flow, reflow perfusion model and a liver transplantation model, and free radicals were detected using electron spin resonance and the spin trapping technique.

RESULTS

As expected, basal hepatic triglycerides were similar in livers from rats fed low- and high-fat control diets. Ethanol did not alter triglyceride levels significantly in rats fed a low-fat diet, but increased values about 2.4-fold in rats fed a high-fat diet. Ethanol increased lactate dehydrogenase release during reperfusion from 10 to 26 IU/g/h in rats fed a low-fat diet and from 17 to 34 IU/g/h in rats fed a high-fat diet, respectively. Portal pressure increased from about 3 to 10.5 cm H2O upon reperfusion in livers from high-fat, ethanol-fed rats, but only reached values of 9.1 in the low-fat, ethanol-fed group. A free radical adduct signal was detected in the bile of livers from ethanol-treated rats, and the magnitude of this signal was similar in livers of ethanol-treated rats fed high- or low-fat diets. However, radical adducts could not be detected in either group in the absence of dietary ethanol. Moreover, 67-77% rats given low-fat or high-fat control diets survived after liver transplantation, but only 11% survived if treated with ethanol.

CONCLUSIONS

It is concluded that ethanol plays a major role in hepatic reperfusion injury, most likely via mechanisms involving free radicals. Increased hepatic fat content alone plays only a minor role, probably by causing slight disturbances in the hepatic microcirculation.

Physician Experience Caring for Dying Patients and Its Relationship to Patient Outcomes

BACKGROUND

The quality of end-of-life care has become important to care systems and the public. No research has assessed how physician factors affect patient and family experience.

OBJECTIVE

The objective of this study was to examine whether physicians' experience with dying is associated with differences in their patients' experiences while dying.

METHODS

This was a prospective cohort study. Data were obtained from five geographically diverse teaching hospitals. The survey population was composed of 765 attending physicians who had at least one patient enrolled in a study of those with a high risk of dying. The patients were 8203 hospitalized adults who were at least 80 years of age or had one of nine serious illnesses. The physician survey provided information about physician characteristics. Physician experience with death was stratified into five groups according to self-reported rate of dying patients in the physician's practice. Patient outcomes included pain, anxiety, depression, satisfaction with pain relief, presence and timing of do-not-resuscitate orders, concordance with their physicians about cardiopulmonary resuscitation, and hospital resource use.

RESULTS

Oncologists and pulmonologists or critical care physicians had more frequent contact with death. Physician characteristics other than specialty were not associated with death experience. Compared with the physician group having no experience with death, the adjusted odds ratios for accord on resuscitation preferences were 1.38 (95% confidence interval [CI], 0.96 to 1.98), 1.47 (95% CI, 1.03 to 2.11), 1.58 (95% CI, 1.10 to 2.26), and 1.64 (95% CI, 1.09 to 2.46) for the other four physician groups with progressively increasing experience. Other outcomes for patients were not associated with increasing physician experience.

CONCLUSION

Most physicians have little experience with dying, and physicians' experience with death has little effect on patient outcomes. The concentration of experience in a small segment of physicians offers opportunities for targeting improvements in the care of dying patients, including physician education.

Generation of lipid free radicals by adherent leukocytes from transplanted rat liver

The production of free radicals in blood correlates with primary nonfunction of transplanted livers, but the source of the free radicals is unknown. The purpose of this study was to determine if adherent leukocytes in the transplanted liver are responsible for the radicals detected in blood. First, a new method to harvest adherent leukocytes from the liver without enzymatic digestion was developed and characterized by transplanting livers from ethanol-treated rats, which increases primary nonfunction, and from saline-treated controls. Free radicals were then detected in isolated leukocytes using the spin-trapping technique and electron spin resonance (ESR) spin spectroscopy. Livers were perfused with a balanced salt solution (200 ml), followed by a Ca(2+)-free solution containing EGTA and heparin (400 ml). Perfusion with Ca(2+)-free buffer removed greater than 90% of all adherent leukocytes from saline-treated livers and nearly 80% of all leukocytes from fatty livers without removing Kupffer cells. Transplanted fatty livers from rats given ethanol contained significantly more adherent leukocytes (5.0 x 10(7) cells/liver) than grafts from control donors (3.2 x 10(7) cells/liver) and almost double the number of adherent neutrophils and monocytes. Moreover, adherent white blood cells from transplanted livers produced the same three free radical species that have been detected previously in blood; however, cells from ethanol-treated livers produced about five times more radical adducts. These data show that adherent white blood cells produce free radicals that are important in the mechanism of primary graft nonfunction.

A human IgM monoclonal antibody prolongs survival of mice with lethal cryptococcosis

Antifungal therapy cannot eradicate Cryptococcus neoformans infections in immunosuppressed patient groups. Therefore, adjunctive antibody-based therapy is being considered to enhance host immune responses to C. neoformans. To characterize potentially protective reagents, the idiotypic repertoire of human antibodies to cryptococcal glucuronoxylomannan (GXM) elicited by the investigational conjugate vaccine GXM-tetanus toxoid was examined. The variable genes used by human antibodies to GXM were analyzed with an antigen-based ELISA and mouse monoclonal antibodies (MAbs) that recognize determinants of human VH1, VH3, and VH4 gene segments. Antibodies to GXM were shown to use VH3 gene segments, and antibodies with the greatest binding to GXM also bound to protein A. A VH3-positive human monoclonal IgM prolonged survival of C. neoformans-infected mice. This is the first report that a human antibody is protective against C. neoformans. These results suggest that human MAbs may have promise as therapeutic reagents against cryptococcosis.

Dietary juniper berry oil minimizes hepatic reperfusion injury in the rat

Juniper berry oil is rich in 5,11,14-eicosatrienoic acid, a polyunsaturated fatty acid similar to one found in fish oil, yet less prone to peroxidation. Dietary fish oil treatment has been shown to effectively reduce reperfusion injury; therefore, the effects of a diet containing juniper berry oil on hepatic reperfusion injury in a low-flow, reflow reperfusion model were investigated in the rat. Rats were fed semisynthetic diets containing either juniper berry oil, fish oil, or corn oil for 14 to 16 days. Daily food consumption averaged around 20 g/d in both the control and treatment groups; average daily weight gain was around 4 g per 100 g rat weight in all three groups studied, and there were no significant differences in these parameters. Livers were initially perfused at low-flow rates to induce pericentral hypoxia followed by a 40-minute reperfusion period. Peak lactate dehydrogenase (LDH) release during reflow averaged 44 U/g/h in the corn oil group and 32 U/g/h in the fish oil group, but was only 21 U/g/h as a result of juniper berry oil treatment. Malondialdehyde (MDA), an end-product of lipid peroxidation, reached a maximum value of 62 nmol/g/h in the corn oil group, but only reached 43 nmol/g/h and 34 nmol/g/h in the fish oil and juniper berry oil groups, respectively. Both juniper berry oil and fish oil treatment improved rates of bile flow from 25 microL/g/h (corn oil) to 36 and 38 microL/g/h, respectively. Importantly, juniper berry oil reduced cell death in pericentral regions of the liver lobule by 75%. Trypan blue distribution time, an indicator of the hepatic microcirculation, was reduced by approximately 25% with fish oil and over 50% by juniper berry oil diets compared with corn oil controls. The rates of entry of fluorescein-dextran, a dye confined to the vascular space, were increased 1.8- and 2.6-fold, and rates of outflow were increased 4.4- and 4.3-fold by fish oil and juniper berry oil, respectively, also reflecting improved microcirculation. Juniper berry oil also blunted increases in intracellular calcium and release of prostaglandin E2 (PGE2) by cultured Kupffer cells stimulated by endotoxin. These results are consistent with the hypothesis that feeding a diet containing juniper berry oil reduces reperfusion injury by inhibiting activation of Kupffer cells, thus reducing vasoactive eicosanoid release and improving the hepatic microcirculation in livers undergoing oxidant stress.

Cyclosporin A increases hypoxia and free radical production in rat kidneys: prevention by dietary glycine

The major side effect of cyclosporin A is severe nephrotoxicity. It is likely that cyclosporin A causes vasoconstriction leading to hypoxia-reperfusion injury; therefore, these experiments were designed to attempt to obtain physical evidence for hypoxia and free radical production in kidney following cyclosporin A. Rats were treated daily with cyclosporin A (25 mg/kg ig) for 5 days, and pimonidazole, a hypoxia marker, was injected 2 h after the last dose of cyclosporin A. A dose of alpha-(4-pyridyl-1-oxide)-N-tert-butylnitrone (4-POBN) was injected 3 h after cyclosporin A to trap free radicals. Cyclosporin A doubled serum creatinine and decreased glomerular filtration rates by 65% as expected. Pimonidazole adduct binding in the kidney was increased nearly threefold by cyclosporin A, providing physical evidence for tissue hypoxia. Moreover, cyclosporin A increased 4-POBN/radical adducts nearly sixfold in the urine but did not alter levels in the serum. Glycine, which causes vasodilatation and prevents cyclosporin A toxicity, minimized hypoxia and blocked free radical production; however, it did not alter cyclosporin A blood levels. These results demonstrate for the first time that cyclosporin A causes hypoxia and increases production of a new free radical species exclusively in the kidney. Therefore, it is concluded that cyclosporin A causes renal injury by mechanisms involving hypoxia-reoxygenation, effects which can be prevented effectively by dietary glycine.

Stimulation of oxygen uptake by prostaglandin E2 is oxygen dependent in perfused rat liver

The aim of this study was to determine if the effect of prostaglandin E2 (PGE2) on hepatic oxygen uptake was affected by oxygen tension. Livers from fed female Sprague-Dawley rats were perfused at normal or high flow rates (4 or 8 ml . g-1 . min-1) to vary local oxygen tension within the liver lobule. During perfusion at normal flow rates, PGE2 (5 microM) infusion increased oxygen uptake by about 50 micromol . g-1 . h-1; however, when livers were perfused at high flow rates, the increase was nearly twice as large. Simultaneously, glucose output was increased rapidly by about 50%, whereas glycolysis was decreased about 60%. When flow rate was held constant, increases in oxygen uptake due to PGE2 were proportional to oxygen delivery. Infusion of PGE2 into livers perfused at normal flow rates increased state 3 rates of oxygen uptake of subsequently isolated mitochondria by about 25%; however, rates were increased 50-75% in mitochondria isolated from livers perfused at high flow rates. Thus it is concluded that PGE2 stimulates oxygen uptake via mechanisms regulated by oxygen tension in perfused rat liver. High flow rates also increased basal rates of oxygen uptake: this increase was prevented by inactivation of Kupffer cells with GdCl3. In addition, conditioned medium from Kupffer cells incubated at high oxygen tension (75% oxygen) stimulated oxygen uptake of isolated parenchymal cells by >30% and elevated PGE2 production about twofold compared with Kupffer cells exposed to normal air-saturated buffer (21% oxygen). These effects were blocked completely by both indomethacin and nisoldipine. These data support the hypothesis that oxygen stimulates Kupffer cells to release mediators such as PGE2 which elevate oxygen consumption in parenchymal cells, possibly by mechanisms involving cyclooxygenase and calcium channels.

Medical applications of diffraction enhanced imaging

We have developed a new X-ray imaging technique, diffraction enhanced imaging (DEI), which can be used to independently visualize the refraction and absorption of an object. The images are almost completely scatter-free, allowing enhanced contrast of objects that develop small angle scattering. The combination of these properties has resulted in images of mammography phantoms and tissues that have dramatically improved contrast over standard imaging techniques. This technique potentially is applicable to mammography and other fields of medical X-ray imaging and to radiology in general, as well as possible use in nondestructive testing and X-ray computed tomography. Images of various tissues and materials are presented to demonstrate the wide applicability of this technique to medical and biological imaging.

Characterization of a murine monoclonal antibody to Cryptococcus neoformans polysaccharide that is a candidate for human therapeutic studies

The murine monoclonal antibody (MAb) 18B7 [immunoglobulin G1(kappa)] is in preclinical development for treatment of Cryptococcus neoformans infections. In anticipation of its use in humans, we defined the serological and biological properties of MAb 18B7 in detail. Structural comparison to the related protective MAb 2H1 revealed conservation of the antigen binding site despite several amino acid differences. MAb 18B7 was shown by immunofluorescence and agglutination studies to bind to all four serotypes of C. neoformans, opsonize C. neoformans serotypes A and D, enhance human and mouse effector cell antifungal activity, and activate the complement pathway leading to deposition of complement component 3 (C3) on the cryptococcal capsule. Administration of MAb 18B7 to mice led to rapid clearance of serum cryptococcal antigen and deposition in the liver and spleen. Immunohistochemical studies revealed that MAb 18B7 bound to capsular glucuronoxylomannan in infected mouse tissues. No reactivity of MAb 18B7 with normal human, rat, or mouse tissues was detected. The results show that both the variable and constant regions of MAb 18B7 are biologically functional and support the use of this MAb in human therapeutic trials.

Antifungal activity of a human antiglucuronoxylomannan antibody

The human immunoglobulin M (IgM) monoclonal antibody (MAb) 2E9 binds the glucuronoxylomannan (GXM) of Cryptococcus neoformans serotypes A, B, and D. This study was undertaken to determine the opsonic efficacy of 2E9 and its ability to promote the antifungal activity of human polymorphonuclear neutrophils (PMNs) against C. neoformans. We incubated purified PMNs with fluorescein isothiocyanate-labeled C. neoformans cells that were treated with the GXM IgM 2E9, IgM antibodies that do not bind GXM, and rabbit and human factor-B-deficient serum as complement sources. PMN-associated C. neoformans cells fluoresced and were detected with a fluorescence-activated cell sorter. The amount of phagocytosis was defined as the percent fluorescing PMNs, which was 37% for yeast cells opsonized with 2E9 plus rabbit serum and 57% for yeast cells opsonized with 2E9 plus factor-B-deficient serum. Phagocytosis was significantly greater for yeast cells that were treated with 2E9 plus a complement source than for yeast cells treated with the complement sources alone or treated with the control IgMs alone or with the complement sources. Fluorescence quenching and light and electron microscopy of the phagocytosis mixtures revealed that 2E9-opsonized yeast cells were internalized by PMNs. Maximal inhibition of C. neoformans growth occurred when PMNs were cocultured with yeast cells that were opsonized with 2E9 plus a complement source. Our data demonstrate that the human GXM IgM 2E9 can mediate PMN phagocytosis and C. neoformans growth inhibition in vitro. These findings strongly suggest that antibody-mediated deposition of complement components on the cryptococcal capsule can augment PMN complement receptor-mediated antifungal activity. Antibody activation of complement-mediated effector cell antifungal mechanisms may play a role in host defense against cryptococcosis and represents a goal for the use of MAbs to treat or prevent human C. neoformans infections.

Role of free radicals in primary nonfunction of marginal fatty grafts from rats treated acutely with ethanol

Acute treatment with one large dose of ethanol, which mimics binge drinking, causes marginal fatty liver and decreases survival significantly after liver transplantation in rats, yet mechanisms remain unclear. Therefore, we evaluated the possible role of free radicals in primary nonfunction caused by acute ethanol. Female donor rats were administered ethanol (5 g/kg orally) 20 hr before explantation, and grafts were stored in UW cold storage solution for 24-42 hr before implantation. Free radicals were trapped with alpha-(4-pyridyl 1-oxide)-N-tert-butylnitrone after transplantation, and adducts were detected using electron spin resonance spectrometry. Ethanol increased a carbon-centered radical adduct in bile approximately 2-fold and elevated serum lipid hydroperoxides approximately 4-fold. Ethanol also increased transaminase release 3.7-fold and decreased bile production by 55%. Catechin, a free radical scavenger, minimized the increase in free radicals, blunted transaminase release, and elevated bile production significantly, indicating that free radical production plays an important role in ethanol-induced fatty graft injury. GdCl3 (20 mg/kg intravenously), a selective Kupffer cell toxicant, largely blocked the increases in free radical and lipid hydroperoxide production caused by ethanol. In addition, ethanol nearly doubled white blood cell adhesion after transplantation, leading to increased superoxide production in fatty grafts. GdCl3 largely blocked leukocyte adhesion as well as superoxide production. Allopurinol, an inhibitor of xanthine oxidase, also diminished free radical production, blunted transaminase release, and improved bile production in fatty grafts significantly. Taken together, we conclude that free radical formation increases in ethanol-induced fatty grafts due mainly to activation of Kupffer cells and increased adhesion of white blood cells. Antioxidants can effectively block free radical formation and minimize injury to marginal fatty grafts caused by binge drinking.

Diffraction enhanced x-ray imaging

Diffraction enhanced imaging is a new x-ray radiographic imaging modality using monochromatic x-rays from a synchrotron which produces images of thick absorbing objects that are almost completely free of scatter. They show dramatically improved contrast over standard imaging applied to the same phantom. The contrast is based not only on attenuation but also the refraction and diffraction properties of the sample. This imaging method may improve image quality for medical applications, industrial radiography for non-destructive testing and x-ray computed tomography.

Monochromatic energy-subtraction radiography using a rotating anode source and a bent Laue monochromator

A system for area-beam energy-subtraction monochromatic radiography was developed and tested. It utilizes a bent Laue crystal monochromator developed at the National Synchrotron Light Source (NSLS), and a compact rotating anode X-ray source developed at the Science Research Laboratory (SRL). The K(alpha) characteristic lines (both K(alpha 1) and K(alpha 2) of the cerium and barium targets were diffracted by the monochromator and used for the above- and below-K-edge imaging, respectively, of phantoms with iodine contrast agents. Digital subtraction of the images produced an iodine image.

Fc gammaRIIa polymorphism in human immunodeficiency virus-infected children with invasive pneumococcal disease

Invasive pneumococcal disease (IPD) occurs frequently in HIV-infected children and adults. Defects in complement function, opsonic capsular antibodies, and Fc receptor antibody-mediated phagocytosis could contribute to impaired host defense against Streptococcus pneumoniae. The objective of this study was to define the distribution of the three Fc gammaRIIa genotypes in HIV+ children, including those with IPD. Forty-eight HIV+ Hispanic children, including eight with IPD, followed at Bronx-Lebanon Hospital Center, Bronx, New York, nine HIV+ adults with IPD, and 56 HIV- Hispanic control subjects were studied. The children and adults were identified retrospectively except for one child who developed IPD during the study. Fc gammaRIIa genotypes were determined by PCR amplification of the Fc gammaRIIa locus from genomic DNA samples and hybridization of the PCR products with allele-specific oligonucleotides. Naturally occurring serum antibodies reactive with four pneumococcal polysaccharide serotypes were determined by ELISA in seven of eight children with IPD. There were no statistical differences in Fc gammaRIIa genotypes between HIV+ children with and without IPD, HIV+ adults with IPD, or HIV- Hispanics. The predominant IgG subclass of pneumococcal polysaccharide binding antibodies in the seven HIV+ children with IPD studied was IgG1. The distribution of Fc gammaRIIa genotypes in HIV+ children with and without IPD is similar to that of the normal Hispanic population. The prospect of passive immunotherapy with specific anticapsular antibodies might be a promising alternative for the treatment and/or prevention of IPD in HIV+ children and other immunodeficient groups.

Prevention of cyclosporine-induced nephrotoxicity with dietary glycine

BACKGROUND

The nonessential amino acid glycine has been used previously to prevent hypoxic and ischemic injury to kidney tissue in vitro. Furthermore, it was recently shown that glycine prevents activation of macrophages and neutrophils in vitro. Because there is some evidence that the immunosuppressant cyclosporine causes nephrotoxicity through a hypoxia-reoxygenation mechanism that could involve infiltration and activation of macrophages and neutrophils, we hypothesized that dietary glycine could prevent this injury.

METHODS

Rats were fed a diet containing glycine (5%) or a control diet for 3 days before cyclosporine treatment. To produce nephrotoxicity, cyclosporine (25 mg/kg daily by gavage) was administered for 28 days while animals were maintained on glycine or control diets. Serum creatinine, urea, glomerular filtration rates, and kidney histology were evaluated in different treatment groups.

RESULTS

All rats gained weight; however, overall weight gain in the cyclosporine, glycine, and cyclosporine+glycine groups was significantly less by about 40% compared with the control group. Diet consumption was not statistically different between the groups. As expected, cyclosporine caused kidney damage in the rats fed control diet, reflected in significantly elevated serum urea and creatinine. In addition, cyclosporine treatment decreased glomerular filtration rate by nearly 70%, caused proximal tubular dilation and necrosis as well as increased macrophage and neutrophil infiltration into the kidney. Dietary glycine prevented or minimized kidney damage due to cyclosporine in all parameters studied nearly completely. Furthermore, feeding glycine for up to 1 month had no detrimental effect on kidney function.

CONCLUSIONS

Dietary glycine is a safe and effective treatment to reduce the nephrotoxicity of cyclosporine.

Peptide epitopes recognized by a human anti-cryptococcal glucuronoxylomannan antibody

Cryptococcus neoformans causes meningitis in 6 to 8% of individuals with AIDS. Recently, immunotherapeutic modalities including antibody therapy have been proposed for the treatment of cryptococcal meningitis in AIDS patients. This is a rational approach because existing antifungal agents fail to eradicate the infection in the setting of profound immunosuppression. Both murine and human antibodies elicited by the investigational cryptococcal capsular polysaccharide vaccine glucuronoxylomannan-tetanus toxoid (GXM-TT) have been shown to be biologically functional in different model systems. The human immunoglobulin M (lambda) GXM monoclonal antibody (MAb) 2E9 expresses idiotypes that are also found in naturally occurring anti-GXM antibodies and opsonic GXM-TT sera. However, the specificity of human anti-GXM antibodies and their possible role in protection against cryptococcosis are not known. In an effort to discover epitopes that are recognized by human anti-GXM antibodies, we screened a random decapeptide phage display library with the human anti-GXM MAb 2E9. An enzyme-linked immunosorbent assay (ELISA)-based screening method led to the selection of phages with peptide inserts that bound 2E9 and inhibited 2E9-GXM binding. Analysis of the amino acid sequences of these phages revealed an increased frequency of combinations of QTGLD residues. Inhibition ELISAs demonstrated that phages with QTG/TL/D motifs inhibited 2E9-GXM binding better than phages with different motifs. A peptide synthesized from one of the inhibitory phages, peptide 13 (GMDGT QLDRW), inhibited GXM binding to solid-phase 2E9 and 2E9 binding to solid-phase GXM. Peptide 13 also inhibited the GXM binding of GXM-TT immune sera and naturally occurring serum antibodies from human immunodeficiency virus (HIV)-negative, but not HIV-positive, individuals. Taken together, our data indicate that the peptide epitopes selected by 2E9 mimic GXM epitopes and that peptide 13 may be a mimotope of a GXM epitope that is recognized by human anti-GXM antibodies.

STAT signaling is active during early mammalian development

Cytokine activation of gene expression can be mediated through signal transducer and activator of transcription (STAT) signaling pathways resulting in expression of target genes. Because many cytokines have important regulatory roles during early development, we wanted to ascertain whether STAT signaling was also active at this time and could therefore have important roles in mediating developmental processes. We have found that Stat1 and Stat3 mRNAs are present in both maternal and extraembryonic tissues during early postimplantation stages of murine development. Furthermore, analyses of STAT activity in E4.5-E9.5 decidual swellings by electrophoretic mobility shift assay demonstrated that Stat3 protein was active during this early developmental period. The identification of activated Stat3 demonstrates that STAT signaling functions during early postimplantation development in the mouse are likely to be important during early embryogenesis.

Single-and dual-energy CT with monochromatic synchrotron x-rays

We explored the potential for clinical research of computed tomography (CT) with monochromatic x-rays using the preclinical multiple energy computed tomography (MECT) system at the National Synchrotron Light Source. MECT has a fixed, horizontal fan beam with a subject apparatus rotating about a vertical axis; it will be used for imaging the human head and neck. Two CdWO4-photodiode array detectors with different spatial resolutions were used. A 10.5 cm diameter acrylic phantom was imaged with MECT at 43 keV and with a conventional CT (CCT) at 80 kVp: spatial resolution approximately equal to 6.5 line pairs (lp)/cm for both; slice height, 2.6 mm for MECT against 3.0 mm for CCT; surface dose, 3.1 cGy for MECT against 2.0 cGy for CCT. The resultant image noise was 1.5 HU for MECT against 3 HU for CCT. Computer simulations of the same images with more precisely matched spatial resolution, slice height and dose indicated an image-noise ratio of 1.4:1.0 for CCT against MECT. A 13.5 cm diameter acrylic phantom imaged with MECT at approximately 0.1 keV above the iodine K edge and with CCT showed, for a 240 micrograms I ml-1 solution, an image contrast of 26 HU for MECT and 13 and 9 HU for the 80 and 100 kVp CCT, respectively. The corresponding numbers from computer simulation of the same images were 26, 12, and 9 HU, respectively. MECT's potential for use in clinical research is discussed.

Study of a calculation method for healthy life expectancy

"To develop a calculation method for healthy life expectancy which would be suitable for China we analyzed the healthy life expectancy of urban residents in China, employing data on residents' deaths and data available from the 1993 national survey for health services and family health conditions.... Results of the study show that the ratio of healthy life expectancy to life expectancy decreases with the increase of the residents' age; healthy life expectancy for females is higher than that for males; [and] healthy life expectancy for residents of large cities is lower than that for residents of medium and small cities."

Opsonization of Cryptococcus neoformans by human anticryptococcal glucuronoxylomannan antibodies

Cryptococcal meningitis occurs in 6 to 8% of human immunodeficiency virus-infected individuals. Despite the availability of powerful antifungal agents that are active against Cryptococcus neoformans, these drugs generally fail to cure cryptococcal infections in immunocompromised hosts. Alternative approaches to prevention and therapy of cryptococcosis are urgently needed. Complement promotes phagocytosis of C. neoformans, but human antibodies to cryptococcal capsular polysaccharide have not been shown to function as complement-independent opsonins. The goal of our studies was to characterize the in vitro biological function of human antibodies to glucuronoxylomannan (GXM) from individuals immunized with a GXM-tetanus toxoid (GXM-TT) vaccine. We studied sera from nine vaccinees that manifested good serologic responses to GXM-TT. The results indicate that GXM-TT-elicited antibodies promote phagocytosis of C. neoformans by both murine J774 cells and human peripheral blood mononuclear cells (PBMCs). The two sera with the highest titers of anti-GXM immunoglobulin G2 antibodies were the most opsonic. When PBMC Fc gamma RIIa receptors were blocked, a 75% decrease in phagocytosis occurred following incubation of the PBMCs with C. neoformans opsonized with these sera. Our data indicate that, in the absence of complement, human anti-GXM-TT antibodies are opsonic and that antibodies of the immunoglobulin G2 isotype are effective opsonins.

Mammographic phantom studies with synchrotron radiation

PURPOSE

To explore the potential improvement in image contrast for breast imaging with use of monoenergetic photons.

MATERIALS AND METHODS

The x-ray energy available from the National Synchrotron Light Source is from 5 to over 50 keV. A specific energy is selected with a tunable crystal monochromator. The object is scanned with a narrow beam of 80.0 x 0.5 mm. Mammography phantoms were imaged with plate and film as the imaging detectors. Phantom images were obtained at 16-24 keV and compared with images obtained with a conventional mammographic unit.

RESULTS

Preliminary findings indicate improved image contrast of the monoenergetic images compared with that obtained from the conventional x-ray source, particularly at 18 keV and below.

CONCLUSION

Pilot results are encouraging, and the authors presently continue to explore monoenergetic photon imaging with improved instrumentation, scatter rejection, and use of tissue samples.

Destruction of Kupffer cells increases survival and reduces graft injury after transplantation of fatty livers from ethanol-treated rats

This study investigated the role of Kupffer cells on survival and graft injury in transplanted fatty livers from rats treated acutely with ethanol. Donor rats were given ethanol (5 g/kg, by mouth) 20 hours before explantation, and liver grafts were preserved in University of Wisconsin cold storage solution for 24 to 42 hours prior to implantation. Blood samples were taken from the inferior vena cava for 3 hours after implantation. During this time, serum aspartate transaminase levels increased gradually from 122 U/L to 597 U/L in control rats, while ethanol treatment elevated values to 2,278 U/L. Gadolinium chloride (20 mg/kg, given intravenously to recipients 24 hours before explantation), a selective inactivator of Kupffer cells, minimized the increase in aspartate transaminase levels significantly. After implantation of grafts cold-stored for 42 hours, survival rates were 88% in control rats but only 33% in ethanol-treated rats. Gadolinium chloride improved survival nearly to control values. Ethanol nearly doubled white blood cell adhesion, an effect also largely blocked by gadolinium chloride. Further, alpha-(4-pyridyl 1-oxid)-N-tert-butylnitrone radical adducts detected in the bile were increased twofold by ethanol treatment. This effect was also reversed by gadolinium chloride. Taken together, these data indicate that survival is poorer and graft injury is greater in fatty livers from ethanol-treated rats. Inactivation of Kupffer cells minimized graft damage, most likely by improving hepatic microcirculation and diminishing lipid peroxidation.

[A comparison of the modified gamma nail and the ender nail for treatment of intertrochanteric fractures]

We made a comparison between the modified Gamma nailing and the Ender nailing in the treatment of 102 patients with intertrochanteric fracture. Sixty patients were treated with the modified Gamma nailing and forty-two patients with the Ender method. The preoperative conditions of the patients in the two groups were similar as showed by statistical analysis. More intraoperative bleeding was recorded in the modified Gamma nail group. However, there were a earlier full weight -bearing, a better hip function and a lower rate of operative complication in the patients treated with the modified Gamma nailing. We conclude that with the modified technique and the modified femoral component the Gamma nail is advanced in the treatment of intertrochanteric fracture. However, it is danger to apply in elderly patients accompanied with certain vital problems. For these patients the Ender nail may be considered.

Differential activation of acute phase response factor/Stat3 and Stat1 via the cytoplasmic domain of the interleukin 6 signal transducer gp130. II. Src homology SH2 domains define the specificity of stat factor activation

Distinct yet overlapping sets of STAT transcription factors are activated by different cytokines. One example is the differential activation of acute phase response factor (APRF, also called Stat3) and Stat1 by interleukin 6 and interferon-gamma. Interleukin 6 activates both factors while, at least in human cells, interferon-gamma recruits only Stat1. Stat1 activation by interferon-gamma is mediated through a cytosolic tyrosine motif, Y440, of the interferon-gamma receptor. In an accompanying paper (Gerhartz, C., Heesel, B., Sasse, J., Hemmann, U., Landgraf, C., Schneider-Mergener, J., Horn, F., Heinrich, P. C., and Graeve, L. (1996) J. Biol. Chem. 271, 12991-12998), we demonstrated that two tyrosine motifs within the cytoplasmic part of the interleukin 6 signal transducer gp130 specifically mediate APRF activation while two others can recruit both APRF and Stat1. By expressing a series of Stat1/APRF domain swap mutants in COS-7 cells, we now determined which domains of Stat1 and APRF are involved in the specific recognition of phosphotyrosine motifs. Our data demonstrate that the SH2 domain is the sole determinant of specific STAT factor recruitment. Furthermore, the SH2 domain of Stat1 is able to recognize two unrelated types of phosphotyrosine motifs, one represented by the interferon-gamma receptor Y440DKPH peptide, and the other by two gp130 YXPQ motifs. By molecular modeling, we propose three-dimensional model structures of the Stat1 and APRF SH2 domains which allow us to explain the different binding preferences of these factors and to predict amino acids crucial for specific peptide recognition.

Kupffer cell prostaglandin E2 stimulates parenchymal cell O2 consumption: alcohol and cell-cell communication

Several studies have demonstrated that ethanol can increase hepatic O2 uptake (e.g., produce a hypermetabolic state); however, a complete explanation of this important phenomenon remains unclear. Here, the effect of conditioned media from Kupffer cells isolated from rats chronically exposed to ethanol on O2 consumption of normal parenchymal cells was studied to evaluate the possibility that cell-cell communication participates in the mechanism of the hepatic hypermetabolic state. Kupffer cells were isolated from rats fed either a liquid control diet or a diet containing ethanol. Kupffer cells were cultured for 4 h, and conditioned media were incubated with parenchymal cells isolated from untreated rats in a closed chamber with an O2 electrode. O2 consumption of parenchymal cells incubated in fresh media or conditioned media from Kupffer cells from untreated rats was approximately 30 microliters.h-1. 10(6) cells-1; however, values were increased by > 30% by conditioned media from Kupffer cells isolated from rats treated with ethanol. Indomethacin, nisoldipine, and boiling the conditioned media blocked this stimulation, suggesting the involvement of eicosanoids. Indeed, prostaglandin E2 (PGE2) added directly to parenchymal cells increased O2 consumption in a dose-dependent manner by nearly 60%. Furthermore, PGE2 levels in conditioned media from Kupffer cells isolated from ethanol-treated rats were elevated about twofold. The addition of endotoxin to cultured cells caused a similar phenomenon. Taken together, these data support the hypothesis that Kupffer cells are activated by ethanol treatment to release mediators such a PGE2, which stimulate O2 consumption in parenchymal cells, possibly by mechanisms involving bacterial endotoxin.