An antigen immunologically related to the external domain of gp185 is shed from nude mouse tumors overexpressing the c-erbB-2 (HER-2/neu) oncogene

An antigen, immunologically related to the external domain of the c-erbB-2 (HER-2/neu) protein, was found shed into the serum of nude mice bearing tumors that overexpress the c-erbB-2 protein (gp185). Utilizing paired combinations from a panel of monoclonal antibodies (TAbs 250-265), with specificity for extracellular epitopes of gp185, an immunoradiometric assay was developed to quantitate this shed antigen. The immunoradiometric assay detected membrane-bound and soluble gp185 as well as a soluble derivative corresponding in sequence to the extracellular domain of gp185 (designated gp75). This recombinantly expressed gp75 was immunoaffinity purified and used to generate a standard curve from which serum samples were quantitated. Increases in antigen levels measured in the sera of tumor-bearing nude mice correlated with both overexpression of the c-erbB-2 protein and increased tumor volume. Positive sera were obtained from mice given implants of NIH3T3 cells transfected with c-erbB-2 complementary DNA (NIH3T3t), or ovarian (SK-OV-3) or breast (MDA-MB-361) tumor cell lines overexpressing the c-erbB-2 protein. In mice bearing NIH3T3t tumors, increases in tumor volume from 80 to 9000 mm3 resulted in levels of shed antigen from 8 to greater than 1000 ng/ml gp75 equivalents. Sera from mice with c-erbB-2-negative tumors or tumors overexpressing the epidermal growth factor receptor were negative in the assay. This assay, and the quantitation of shed antigen levels, may have diagnostic or monitoring utility in cancers, such as breast and ovarian, in which the c-erbB-2 protein is overexpressed.

Recommendations for a change in living situation resulting from an outpatient geriatric assessment: type, frequency and risk factors

We analyzed the outcomes of 480 comprehensive outpatient geriatric assessments to determine the frequency of recommendations for home help or a change in residence and to determine whether simple clinical observations could predict such recommendations. Fifty-eight percent (280) of the patients received no recommendation for a change in the living situation. Of the 200 patients receiving a recommendation for a change in living situation, 97 (49%) were felt to be able to stay at home with increased in-home support and/or day care, and 51.5% (103) were advised to seek placement. After adjusting for age and gender, risk factors predicting a recommendation for change were dementia (odds-ratio = 9.98), vision deficits (odds ratio = 2.02), lower education level compared to college (odds-ratio = 1.88 high school, 1.42 for less than high school), an increasing number of medical diagnoses (odds-ratio = 1.49 per diagnosis), and a functional impairment on the Katz index (odds-ratio = 1.09). The presence of these risk factors should lead to consideration of further evaluation of the home environment in this study. We conclude that geriatric patients presenting for a comprehensive outpatient evaluation commonly need a change in home situation, though most can remain in their home, and that simple clinical observations can be helpful in screening patients for further evaluation of their home environment.

Factors affecting bone mineral density in elderly men receiving chronic in-center hemodialysis

Twenty-five elderly men receiving chronic hemodialysis had measurements of their bone mineral density (BMD) by dual-photon absorptiometry (DPA). Loss of BMD was much more pronounced in femoral necks than in lumbar vertebrae. Stepwise multiple liner-regression analysis showed that low BMD was associated with 1) hypoalbuminemia, hypermagnesemia, hyperaluminemia, and high serum alkaline phosphatase for femoral necks and 2) hypercalcemia and hypermagnesemia for lumbar vertebrae. These observations suggest that the femoral neck is the preferred site for measurement of BMD in dialysis patients. Along with factors directly affecting bone metabolism, nutritional factors may affect BMD in such patients.

Coil embolization of pulmonary arteriovenous malformations

Pulmonary arteriovenous malformations (PAVMs) are uncommon lesions that can be treated by surgery or interventional radiology. Forty-four PAVMs in 11 patients were occluded by transcatheter coil embolization with only one symptomatic complication, deep venous thrombosis, attributable to the procedure. There was a significant improvement in symptoms and a reduction in pulmonary AV shunting in the 9 patients in whom embolization of all visible discrete lesions was successfully completed. Coil embolization is an effective alternative to other methods of treating PAVMs.

Quantitative in vitro drug potency and drug susceptibility evaluation of Leishmania ssp. from patients unresponsive to pentavalent antimony therapy

Quantitative in vitro drug sensitivity of 32 Leishmania isolates (16 from patients failing pentavalent antimony [SbV] therapy) was determined using a radiorespirometric microtechnique (RAM). Of 30 isolates with histories, 22 (73%) RAM tests agreed with patient history; the remaining 8 (27%) did not. There was no difference in RAM drug sensitivity: clinical correlation between 15 isolates tested blindly and 15 with known clinical history (4 did not agree with clinical history in both). Test sensitivity appeared to be limited only by the sensitivity of the Leishmania to SbV and could be detected at 2 micrograms/ml Sb (about 10% of serum drug level). An isolate from a patient with untreated self-healing cutaneous disease was drug resistant. Using RAM, parasite drug sensitivity can be quantified apart from patient physiologic and immunologic variables intrinsic to clinical data. Potency differed a maximum of 100% (weight% Sb:weight% Sb) among drug lots and also between Glucantime and Pentostam. Potency changes between drug lots were not explainable based on Sb content or test-to-test variability. This microtest offers a rapid method for evaluating the drug sensitivity of patient isolates and for determining of the activity of pentavalent antimonials and other candidate anti-leishmanials prior to the initiation of therapy.

Cognitive function testing in comprehensive geriatric assessment. A comparison of cognitive test performance in residential and clinic settings

Tests of cognitive function are frequently used in geriatric assessment, but the effect of test setting has rarely been explored. To determine the effect of testing site on the performance of elderly patients undergoing a comprehensive geriatric assessment, we administered the Mini-Mental State Exam to 116 geriatric patients in the clinic and at their residence. Their cognitive abilities varied from normal to severely impaired. The patients' scores were 1.5 +/- 3.6 (mean +/- SD) higher at their residence. The clinical importance of a difference in score of 1.5 is not clear. For this reason a second analysis was performed in which a difference in scores of five points or greater between settings was considered clinically meaningful. Twenty-five percent (29 of 116) differed by five points or more. Of these 29 patients, 22 (76%) tested better in the residential setting. These differences were statistically significant (P = .001). We conclude that the testing site may affect test performance and that in-home assessment may reveal the optimal cognitive function of geriatric patients.

Effect of percutaneous transcatheter embolization on pulmonary function, right-to-left shunt, and arterial oxygenation in patients with pulmonary arteriovenous malformations

The effects of percutaneous transcatheter embolization on pulmonary function and exercise capacity were assessed in 15 patients with pulmonary arteriovenous malformations (PAVM). Vital capacity (VC), FEV1, DLCO, SaO2, exercise performance, and right-to-left shunt (100% oxygen method) were measured before and 2 to 6 months after treatment. Surgical correction had been attempted in 9 patients prior to referral, and 11 had associated hereditary hemorrhagic telangiectasia (HHT). Lung function tests before intervention showed normal VC and FEV1/VC ratios, reduced DLCO (mean 71% predicted, range 36 to 123%), a resting supine SaO2 of 86% (range 67 to 95%) and mean shunt fraction of 33% (range 15 to 47%). Despite further marked falls in SaO2 on exertion, exercise capacity was well preserved. Following steel coil embolization of all PAVM with a feed vessel internal diameter greater than 3 mm (one to four sessions per patient), mean shunt fraction improved from 33 to 19% and resting SaO2 from 86 to 92% with no change in VC. A consistent improvement in diffusing capacity was seen only in patients with coexisting HHT. Exercise capacity increased in the majority (unchanged in 6), and SaO2 during maximal exercise improved in all except one patient. There were no long-term complications following embolization. These findings indicate that embolization of all macroscopic PAVM, undertaken primarily to reduce the risk of paradoxical embolization, is safe and results in substantial improvements in resting and exercise SaO2 without evidence of loss of normal lung. The right-to-left shunts remaining following embolization may reflect the presence of numerous microscopic PAVM in these patients.

Biliary endoprosthesis dysfunction in patients with malignant hilar tumors: successful treatment by percutaneous replacement of the stent

Symptoms caused by malignant hilar bile duct tumors are often palliated by the insertion of a percutaneous biliary endoprosthesis. However, these often occlude early and may be difficult to replace. We have reviewed our experience with percutaneous replacement of endoprostheses in 17 patients with 31 episodes of stent dysfunction. The stent was changed successfully in 30 of the 31 attempts. The average durations of initial and subsequent stent patencies were 28 and 20 weeks, respectively. Significant acute complications occurred in three patients, one of whom had a perihepatic abscess and two of whom had septicemia. Two patients died within 30 days of their last stent change. The one patient in whom attempted insertion of a new stent was unsuccessful had to remain on continuous external catheter drainage. The occluded or migrated endoprosthesis was successfully removed either percutaneously (55%) or endoscopically (26%) in 25 of the 31 cases. Successful removal of the stent and reinsertion after blockage or migration is possible in most patients. Our experience suggests that patients with malignant obstruction of the bile duct should not be refused an indwelling endoprosthesis just because of the frequent occurrence of early occlusion of the stent.

An in vitro micromethod for drug sensitivity testing of Leishmania

We describe an in vitro microtest which is quantitative, rapid, and readily applicable to parasites isolated from all major forms of human leishmaniasis. It is based on drug-mediated inhibition of promastigote catabolism of a battery of simple 14C-substrates to 14CO2. Each test requires less than 1 microCi. The test is conducted in a serum-free, chemically defined medium containing 120 micrograms protein/ml, minimizing the possible interference of drug: serum protein interaction. Prior adaptation is not necessary to cultivate "difficult-to-grow" species. Leishmania sensitivity to pentavalent antimonials is detectable at micrograms levels below concentrations achievable in patients' sera.

Lipiodol retention at the site of liver biopsy; a false positive result in the investigation of hepatocellular carcinoma

A case is described in which Lipiodol, selectively injected into the hepatic artery as part of the investigation of a patient with hepatocellular carcinoma, was retained at the site of a previous liver biopsy leading to the false positive diagnosis of a daughter nodule. This has not been previously described.

Teaching the home care client

Patient education in home health care continues to hold many challenges for the professional nurse. With the changing climate of the health care delivery system, an increasing number of clients are returning to their home "quicker but sicker." The demand on the nurse to provide more in-depth patient education in the client's home will increase. The nurse must be prepared to make a thorough assessment of the client's learning needs, develop and implement an effective teaching plan, evaluate learning, and revise the plan as necessary, as well as document the teaching. All of this must be achieved to ensure continuity of quality patient care and reimbursement by third-party payers.

Increased urinary prostaglandin excretion in galactose-fed rats

Increased renal production of prostaglandins (PG) may contribute to the hyperfiltration that accompanies early diabetes. It was postulated that a putative metabolic abnormality of diabetes, ie, increased flux through the polyol pathway, stimulates renal PG production and that this phenomenon can be prevented by aldose-reductase inhibition. To test this hypothesis, the effects of polyol accumulation on urinary excretion rates (UER) of PGE2 and 6-keto-PGF1 alpha were studied, using the galactose-fed rat model. UER of PGE2 and 6-keto-PGF1 alpha were measured in three groups of weanling Wistar male rats. Group 1 was maintained on normal chow (n = 6), group 2 was fed chow supplemented with 30% galactose (n = 6), and group 3 received chow supplemented with 30% galactose and 0.7% sorbinil (n = 6). Ten 24-hour urine samples were obtained from each group between 151 and 240 days on the respective diets. UER of PGE2 (P less than .001) and 6-keto-PGF1 alpha (P less than .01) were higher in group 2 than in group 1. UER of PGE2 (NS) and 6-keto-PGF1 alpha (NS), respectively, were similar in groups 1 and 3. These data indicate that flux through the polyol pathway modulates the UER of PGE2 and 6-keto-PGF1 alpha. This phenomenon may contribute to the glomerular hyperfiltration of early diabetes.

The yield of a home visit in the assessment of geriatric patients

Elderly patients often have problems not easily detected during an office visit. We investigated the yield of a home visit by a geriatric nurse specialist as part of an interdisciplinary assessment process. Compared with the findings of an office-based assessment by a general internist, the home visit resulted in up to four new problems (median = 2, mean = 1.7, 95% confidence interval = 1.5-1.8) and one to eight new recommendations (median = 4, mean = 3.6, 95% confidence interval = 3.4-3.9). Twenty-three percent of the problems could have resulted in death or significant morbidity. The most frequent problems related to psychobehavioral difficulties (23.1% of problems involving 38.3% of patients), safety (21.6% of problems involving 35.7% of patients), and caregiver related problems (20.4% of problems involving 33.8% of patients). The most common recommendations related to safety (30.7% of recommendations involving 81.8% of patients), caregiver well-being (19.8% of recommendations involving 52.6% of patients), and social issues (12.7% involving 33.8% of patients). Baseline clinical information did not predict the yield of the home visit in this sample. We conclude that an in-home assessment contributes unique and meaningful information to the geriatric assessment process.

Reliability of drug histories in a specialized geriatric outpatient clinic

To examine the reliability of drug histories of elderly outpatients, records of 122 frail elderly patients in a geriatric outpatient evaluation clinic were reviewed. Drug histories were taken by an internist during an initial clinical evaluation and by a nurse practitioner during a home visit. Home and office drug lists disagreed in 39 cases (32%). Roughly equal numbers of "extra" drugs were listed in the two settings. Number of medications (especially two or more), number of active medical problems (especially four or more), and depression were significant, independent predictors of an unreliable drug history. Neither dementia nor living situation was a significant predictor of an unreliable drug history. The only drugs associated with an unreliable history were megavitamins, beta-blockers, and centrally-acting antihypertensive agents. Using the home list as the reference, there were equal numbers of omission errors and commission errors in the office drug histories. Strategies to optimize the reliability of office drug histories need further investigation.

Ethanol elimination in the anesthetized dog: intragastric versus intravenous administration

We computed by linear kinetics predicted equilibrated plasma concentrations, elimination parameters and availability of ethanol for fasting anesthetized dogs who received the same dose (11 mmol/kg) of ethanol twice, once intragastrically and once intravenously. Agreement between predicted (y) and observed (x) equilibrated plasma levels above 3 mmol/l was for intragastric ethanol y = 0.031 + 1.008x (r = 0.973) and for intravenous ethanol y = 0.2 + 0.99x (r = 0.992). Linear elimination (elimination rate, clearance, time of disappearance of half the dose) was significantly slower and Widmark's ratio r was significantly greater for intragastric than for intravenous ethanol. Apparent availability of intragastric ethanol, computed by dividing the intragastric by the intravenous plasma ethanol concentration at zero time (both values extrapolated from the linear portion of the blood alcohol curve), was 0.739 +/- 0.125. Considerable ethanol residuals were present in the stomach four hours after intragastric instillation. We conclude that retention of ethanol in the stomach, probably because of anesthesia, created the apparent differences in elimination of ethanol between intragastric and intravenous administration. Despite gastric retention, decrease of ethanol levels was linear above 3 mmol/l after intragastric instillation.