Discharge Disposition and Loss of Independence Among Survivors of COVID-19 Admitted to Intensive Care: Results From the SCCM Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS)

OBJECTIVES

To describe incidence and risk factors of loss of previous independent living through nonhome discharge or discharge home with health assistance in survivors of intensive care unit (ICU) admission for coronavirus disease 2019 (COVID-19).

DESIGN

Multicenter observational study including patients admitted to the ICU from January 2020 till June 30, 2021.

HYPOTHESIS

We hypothesized that there is a high risk of nonhome discharge in patients surviving ICU admission due to COVID-19.

SETTING

Data were included from 306 hospitals in 28 countries participating in the SCCM Discovery Viral Infection and Respiratory Illness Universal Study COVID-19 registry.

PATIENTS

Previously independently living adult ICU survivors of COVID-19.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was nonhome discharge. Secondary outcome was the requirement of health assistance among patients who were discharged home. Out of 10 820 patients, 7101 (66%) were discharged alive; 3791 (53%) of these survivors lost their previous independent living status, out of those 2071 (29%) through nonhome discharge, and 1720 (24%) through discharge home requiring health assistance. In adjusted analyses, loss of independence on discharge among survivors was predicted by patient age ≥ 65 years (adjusted odds ratio [aOR] 2.78, 95% confidence interval [CI] 2.47-3.14, P < .0001), former and current smoking status (aOR 1.25, 95% CI 1.08-1.46, P  =  .003 and 1.60 (95% CI 1.18-2.16), P  =  .003, respectively), substance use disorder (aOR 1.52, 95% CI 1.12-2.06, P  =  .007), requirement for mechanical ventilation (aOR 4.17, 95% CI 3.69-4.71, P < .0001), prone positioning (aOR 1.19, 95% CI 1.03-1.38, P  =  .02), and requirement for extracorporeal membrane oxygenation (aOR 2.28, 95% CI 1.55-3.34, P < .0001).

CONCLUSIONS

More than half of ICU survivors hospitalized for COVID-19 are unable to return to independent living status, thereby imposing a significant secondary strain on health care systems worldwide.

Stereotactic Ablative Radiotherapy for the Treatment of Glandular Metastases from Renal Cell Carcinoma

PURPOSE/OBJECTIVE(S)

Glandular metastases including pancreatic and adrenal sites of disease are associated with renal cell carcinoma (RCC) of indolent biology. Adrenal and pancreatic metastases may develop in isolation or involve other organs and are associated with prolonged survival. Glandular metastases can be treated with systemic therapy, stereotactic ablative radiotherapy (SAbR) or surgical resection and the optimal management of these patients is unknown. There is paucity of data on SAbR for RCC glandular metastases. We hypothesize that ablative doses of radiation therapy utilizing SAbR are associated with high rates of local control greater than 90%, with minimal or no acute grade 3 toxicities or higher with this approach. Here, we report local control (LC), progression-free survival (PFS), overall survival (OS) rates as well as toxicities related to SAbR for RCC metastases to the pancreatic and adrenal glands.

MATERIALS/METHODS

This IRB-approved, single-institution, retrospective study included patients with RCC metastases to the adrenal glands and pancreas treated with SAbR. Data on patient demographics, functional status, tumor characteristics, International Metastatic RCC Database Consortium (IMDC) risk category, local and systemic treatments, toxicities, and outcomes were collected and analyzed. RECIST 1.1 principals were utilized to determine LC rates and PFS. PFS was determined from the initiation of SAbR to progression (at SAbR-treated or other sites), or death. OS was defined from the start of SAbR to death. Two independent reviewers assessed these measures and analyzed patient electronic health records for toxicities using CTCAE v5 and relatedness scores.

RESULTS

A total of 50 RCC patients were included in this study with 36 adrenal and 20 pancreatic metastases treated with SAbR. Median dose fractionation used was 40 Gray delivered in 5 fractions. Sixteen patients (32%) were treatment naïve with oligometastatic disease, and thirty-four (68%) were oligo-progressive on systemic therapy with 1-3 prior lines of systemic therapy. For treated adrenal metastatic lesions at 1 year, patients demonstrated a 75.3% OS, 46.7% PFS, and LC of 93.3%. For treated pancreatic metastatic lesions at 1 year, patients demonstrated a 100% OS, 48.6% PFS, and LC of 100%. At 1 year, there was an OS of 82.2%, PFS of 48.2%, and LC of 95.9 % in the combined cohort. The percentage of patients experiencing an acute grade 2 or 3 toxicity attributed to adrenal or pancreatic gland SAbR was 7.4%. There were no acute grade >3 toxicities. The percentage of patients experiencing a late grade 2 or 3 toxicity was 9.3%. Median time to late adverse events was 37.4 months.

CONCLUSION

SAbR of RCC metastases to the pancreas and adrenal glands is feasible, safe and appears to be effective. Median PFS and OS in this cohort compared favorably to those reported in historical cohorts and is consistent with indolent disease.

A realist approach to understanding alliancing within Local Government public health and social care service provision

BACKGROUND

Within the current context of continued austerity and post-pandemic recovery, it remains important that Local Government services address the increasing needs of residents as cost-effectively as possible. Alliancing, whereby services work collaboratively focusing on the 'whole-system', has gained popularity as a tool with the potential to support collaborative whole systems approaches. This synthesis aims to identify how alliancing can be successfully operationalised in the commissioning of public health, wider National Health Service (NHS) and social care-related services.

METHODS

A realist literature synthesis was undertaken in order to identify underlying generative mechanisms associated with alliancing, the contextual conditions surrounding the implementation and operationalisation of the alliancing approach mechanisms, and the outcomes produced as a result. An iterative approach was taken, using a recent systematic review of the effectiveness of Alliancing, online database searches, and grey literature searches.

RESULTS

Three mechanistic components were identified within the data as being core to the successful implementation of alliances in public health and social care-related services within Local Government: (i) Achieving a system-level approach; (ii) placing local populations at the heart of the system; and (iii) creating a cultural shift. Programme theories were postulated within these components.

CONCLUSIONS

The alliancing approach offers an opportunity to achieve system-level change with the potential to benefit local populations. The realist synthesis approach taken within this study has provided insights into the necessary contextual and mechanistic factors of the Alliancing approach, above and beyond effectiveness outcomes typically collected through more conventional evaluation methodologies.

Gateways not gatekeepers – reaching seldom-heard groups to gather public health community insights

Background

Each local authority in England must develop a Health and Wellbeing Strategy (HWS) in collaboration with NHS partners to plan and support delivery of local improvements in health and wellbeing. HWSs often draw on diverse sources but few are informed by consultative exercises involving citizens. South Tyneside Council in Northern England sought to ensure their new HWS was community-informed, specifically including seldom-heard groups and individuals. Specific objectives of this community insights research were to:

1.Target sampling and recruitment activities at typically marginalized, vulnerable or otherwise underrepresented groups

2.Explore the health and wellbeing-related views and priorities of these groups to address health inequalities

Methods

A mapping exercise was undertaken to identify organisations who might act as gatekeepers to accessing participants from underrepresented groups. Focus groups were held in settings-based venues where members would be comfortable and known to one another. Representatives of voluntary and community sector (VCS) organisations often helped to co-facilitate the discussions.

Results

119 participants took part in 16 group discussions. Three were held online, two were outdoors, while 11 involved community venues where the groups regularly met. We reached older and younger people, minority ethnic groups, and vulnerable men and women, including residents who had experienced homelessness, mental health issues, substance misuse, offending, domestic violence and learning disabilities. Participants were largely concerned with the wider determinants of health (such as poverty, employment, and leisure spaces), shifting the narrative away from individual lifestyle factors that tend to be the focus of much public health discourse.

Conclusions

Gatekeepers from the VCS were essentially gateways, enabling us to include underrepresented voices in local consultation processes and generate new insights to inform the South Tyneside HWS.

Key messages

Early surveillance of anthracycline induced cardiotoxicity in children using echocardiography and biomarkers: A prospective study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): CIHR

Background

Anthracyclines, which are commonly used in cancer treatment can induce myocardial damage, result in heart failure during treatment and have cardiac effects even decades after treatment. Monitoring of cardiotoxicity during treatment is largely based on the use of echocardiographic functional markers like ejection fraction and more recently myocardial strain imaging. Some studies have also looked at the utility of biomarkers like troponin and BNP. The utility of this surveillance strategy remains controversial as larger prospective studies are lacking.

Purpose

The aim of this study was to prospectively describe the impact of anthracycline treatment on echocardiographic functional parameters and cardiac biomarkers (high sensitivity troponin T and NT-Pro BNP) during the treatment period and twelve months after completion of treatment. In the current study we wanted to look at whether monitoring parameters during treatment were predictive of left ventricular function 12 months after treatment.

Methods

This was a prospective multi-centre nested case-control study of 256 children diagnosed with cancer requiring anthracycline therapy. Baseline functional echocardiographic parameters  and cardiac biomarkers were obtained prior to starting anthracycline therapy, during the treatment protocol, and 12 months after treatment completion. Patients were assigned to one of two comparison groups based on the fractional shortening at the12-month echocardiogram: patients in group 1 had normal fractional shortening, (FS ³ 28%) while patients in group 2 had reduced fractional shortening (FS &lt; 28%).

Results

A total of 917 echoes were performed, 376 of these occurred during the treatment period. FS was reduced in 27 (7%) of echoes obtained during the treatment period with 22 patients developing new onset dysfunction. Twelve months after treatment completion 232 patients had normal FS (Group 1), while 24 patients showed reduced FS (Group 2). Both groups had normal systolic function and cardiac biomarkers at baseline, however patients in group 2 were older at diagnosis (13.2 years (11.8-16) vs 6.5 years (3.4-13.2), p = 0.003) and received a higher cumulative anthracycline dose (200 mg/m2 (143-318) vs 125 mg/m2 (75-200), p= 0.005). One third (8/24) of patients in group 2 had at least 1 abnormal echo during the treatment period compared to 7% (16/232) in the normal group P &lt; 0.001. The proportion of patients with at least one abnormal biomarker during this period however, was similar between groups.

 Conclusion(s)

Patients receiving higher accumulative anthracycline doses and those with abnormal FS during the treatment period are at higher risk of having reduced cardiac function 12 months after treatment. High sensitivity troponin and NT-Pro BNP levels during the treatment period fail to discriminate patients at risk of developing early reduced systolic function. The relationship of these early results to long term cardiac function remains to be demonstrated.

Molecular cloning of crustacean hyperglycemic hormone (CHH) family members (CHH, molt-inhibiting hormone and mandibular organ-inhibiting hormone) and their expression levels in the Jonah crab, Cancer borealis

The crustacean hyperglycemic hormone (CHH) neuropeptide family has multiple functions in the regulation of hemolymph glucose levels, molting, ion, and water balance and reproduction. In crab species, three neuroendocrine tissues: the eyestalk ganglia (medulla terminalis X-organ and -sinus gland = ES), the pericardial organ (PO), and guts synthesize a tissue-specific isoforms of CHH neuropeptides. Recently the presence of the mandibular organ-inhibiting hormone (MOIH) was reported in the stomatogastric nervous system (STNS) that regulates the rhythmic muscle movements in esophagus, cardiac sac, gastric and pyloric ports of the foregut. In this study, we aimed to determine the presence of a tissue-specific CHH isoform in the Jonah crab, Cancer borealis using PCR with degenerate primers and 5', 3' rapid amplification of cDNA ends (RACE) in the ES. PO, and STNS. The analysis of CHH sequences shows that C. borealis has one type of CHH isoform, unlike other crab species. We also isolated the cDNA sequence of molt-inhibiting hormone (MIH) in the ES and MOIH in the ES and STNS. The presence of CHH, MOIH and MIH in the sinus gland of adult females and males is confirmed by using a dot-blot assay with the putative peaks collected from RP-HPLC and anti-Cancer sera for CHH, MIH, and MOIH. The present of crustacean female sex hormone (CFSH) in the sinus gland of adult females was examined with a dot-blot assay with anti-Callinectes CFSH serum. Levels of CHH, MOIH, and MIH in the sinus gland and their expressions in the eyestalk ganglia are estimated in the adult males, where CHH is the predominant form among these neuropeptides.

The Impact of Hemodynamic Transesophageal Echocardiography on Acute Kidney Injury Management and Use of Continuous Renal Replacement Therapy in Trauma

Resuscitation of critically ill trauma patients can be precarious, and errors can cause acute kidney injuries. If renal failure develops, continuous renal replacement therapy (CRRT) may be necessary, but adds expense. Hemodynamic transesophageal echocardiography (hTEE) provides objective data to guide resuscitation. We hypothesized that hTEE use improved acute kidney injury (AKI) management, reserved CRRT use for more severe AKIs, and decreased cost and resource utilization. We retrospectively reviewed 2413 trauma patients admitted to a Level I trauma center's ICU between 2009 and 2015. Twenty-three patients required CRRT before standard hTEE use and 11 required CRRT after; these are the "CRRT" and "CRRT/hTEE" groups, respectively. The hTEE group comprised 83 patients evaluated with hTEE, with AKI managed without CRRT. We compared the average creatinine, change in creatinine, and Acute Kidney Injury Network (AKIN) of "CRRT" with "CRRT/hTEE" and "hTEE." We also analyzed several quality measures including ICU length of stay and cost. "CRRT" had a lower AKIN score (1.6) than "CRRT/hTEE" (2.9) (P = 0.0003). "hTEE" had an AKIN score of 2.1 (P = 0.0387). "CRRT" also had increased ICU days (25.1) compared with "CRRT/hTEE" (20.2) (P = 0.014) and "hTEE" (16.8) (P = 0.003). "CRRT" accrued on average $198,695.81 per patient compared with "CRRT/hTEE" ($167,534.19) and "hTEE" ($53,929.01). hTEE provides valuable information to tailor resuscitation. At our institution, hTEE utilization reserved CRRT for worse AKIs and decreased hospital costs.

The Impact of Hemodynamic Transesophageal Echocardiography on Acute Kidney Injury Management and Use of Continuous Renal Replacement Therapy in Trauma

Resuscitation of critically ill trauma patients can be precarious, and errors can cause acute kidney injuries. If renal failure develops, continuous renal replacement therapy (CRRT) may be necessary, but adds expense. Hemodynamic transesophageal echocardiography (hTEE) provides objective data to guide resuscitation. We hypothesized that hTEE use improved acute kidney injury (AKI) management, reserved CRRT use for more severe AKIs, and decreased cost and resource utilization. We retrospectively reviewed 2413 trauma patients admitted to a Level I trauma center's ICU between 2009 and 2015. Twenty-three patients required CRRT before standard hTEE use and 11 required CRRTafter; these are the “CRRT” and “CRRT/hTEE” groups, respectively. The hTEE group comprised 83 patients evaluated with hTEE, with AKI managed without CRRT. We compared the average creatinine, change in creatinine, and Acute Kidney Injury Network (AKIN) of “CRRT” with “CRRT/hTEE” and “hTEE.” We also analyzed several quality measures including ICU length of stay and cost. “CRRT” had a lower AKIN score (1.6) than “CRRT/hTEE” (2.9) ( P = 0.0003). “hTEE” had an AKIN score of 2.1 ( P = 0.0387). “CRRT” also had increased ICU days (25.1) compared with “CRRT/hTEE” (20.2) ( P = 0.014) and “hTEE” (16.8) ( P = 0.003). “CRRT” accrued on average $198,695.81 per patient compared with “CRRT/ hTEE” ($167,534.19) and “hTEE” ($53,929.01). hTEE provides valuable information to tailor resuscitation. At our institution, hTEE utilization reserved CRRT for worse AKIs and decreased hospital costs.

Lower-limb magnetic resonance angiography: performance of extracellular contrast agents versus blood pool contrast agent for both dynamic and high spatial resolution imaging in extended phase

AIM

To prospectively compare the performance of extracellular space contrast agents (ECSCAs) versus a blood-pool contrast agent (BPCA) for a comprehensive lower-limb magnetic resonance angiography (MRA) protocol in patients with either claudication or critical ischaemia.

MATERIALS AND METHODS

Thirty patients with claudication underwent lower-limb magnetic resonance angiography (MRA) (dynamic crural, three-station bolus chase, and infra-inguinal high resolution) using a triphasic injection method with both a ECSCA and BPCA to allow intra-individual comparison, and 30 patients with critical ischaemia were scanned with either a ECSCA or BPCA. The dynamic, bolus chase, and high-resolution images were scored for quality on a Likert scale (from 1-5). Signal- and contrast-to-noise ratios were analysed and statistical analysis performed.

RESULTS

Overall, there was no statistically significant difference between the ECSCAs and BPCA for arteriographic dynamic imaging, bolus chase MRA, or the high spatial resolution imaging. Venous image quality was rated higher quality for BPCA scans than for ECSCA images for calf veins (not significantly for thigh veins). Venous imaging signal intensity measures were higher for BPCA imaging.

CONCLUSION

Extended-phase imaging using an ECSCA with this protocol provides arteriographic image quality equal to imaging with a BPCA. Venous depiction is good using ECSCAs with this approach, although better with BPCA.

A survey of nurse staffing levels in interventional radiology units throughout the UK

AIM

To supplement previous surveys analysing provision of interventional radiology (IR), in-hours (IH) and out-of-hours (OOH), by specifically surveying the level of nursing support provided.

MATERIALS AND METHODS

A web-based questionnaire was distributed to all British Society of Interventional Radiology (BSIR) members. This addressed several aspects of radiology nursing support for IR procedures, both IH and OOH.

RESULTS

Sixty percent of respondents indicated that they have a formal OOH service. Of these, all have a dedicated nursing rota, with the vast majority operating with one nurse. IH, 77% of respondents always have a scrubbed nurse assistant, but this reduces to 40% OOH. IH, 4% never have a scrubbed radiology nurse assistant, which rises to 25% OOH. IH, 75% of respondents always have a radiology nurse dedicated to patient monitoring, but this reduces to 20% OOH. IH, 3% never have a radiology nurse dedicated to patient monitoring, which rises to 42% OOH.

CONCLUSION

A significant disparity exists in the level of IR nursing support between IH and OOH. The majority of sites provide a single nurse with ad hoc additional support. This is potentially putting patients at increased risk. Radiology nurses are integral to the safe and sustainable provision of IR OOH services and a greater focus is required to ensure adequate and safe staffing levels for 24/7 IR services.

Abstract P1-07-04: Comparison of HER2 expression by immunohistochemistry (IHC) using automated imaging system and fluorescence in situ hybridization (FISH). A retrospective analysis of 2853 cases

Background: Accurate assessment of HER2 status is critical for selecting patients who will benefit from trastuzumab therapy. There is still no consensus regarding the optimal method to assess HER2 status. Computerized image analysis has been shown to provide a more accurate and objective way for quantification of HER2 expression by IHC than manual evaluation. It has been suggested that the use of image analysis may help to resolve some of the discrepancies between IHC and FISH assay.

We compared the results of HER2 expression by IHC using automated image analysis with fluorescent in situ hybridization (FISH) assay.

Design: Testing for HER2 expression by IHC and FISH was performed on 2853 specimens at UT Southwestern Medical Center between the years 2002 to 2011. Quantification of IHC HER2 expression was done by image analysis and scored as positive (&gt;2.0), borderline (1.5 to 2.0) and negative. (&lt;1.5). The PathVysion kit was used for FISH assay to evaluate HER2 amplification. Ratios &gt;2.0, 1.8 to 2.0 and &lt;1.8 were defined positive, borderline and negative amplification respectively.

Results: IHC compared to FISH

Interventional radiology emergency service provision for a large UK urban population: initial 3.5 years of experience

AIM

To review the activity and impact of an out-of-hours (OOH) interventional radiology service introduced in Glasgow in 2007.

MATERIAL AND METHODS

A retrospective review of the first 42 months formal OOH activity across 11 hospital sites covering a population of 1.2 million was undertaken. The 30 day mortality and cause of death was logged for each procedural subtype [nephrostomy, biliary and abscess drainage, enteric stenting, transjugular intrahepatic porto-systemic shunt (TIPS), thoracic endovascular aortic aneurysm repair (TEVAR), endovascular, and embolization].

RESULTS

From October 2007 to March 2011, 502 cases were identified. The mean number of procedures performed per month was 12 (range 5-21). This represents an event rate of 12/100,000 population/year. A minority (11%) of cases were undertaken after midnight. The activity levels were stable over the 42 month study period. The most frequent procedures were percutaneous nephrostomy (32%) and embolization for haemorrhage (30%). Thirty-day mortality was 17% for the entire group but varied from 53% (biliary intervention) to 0% (TEVAR). There was no death following embolization for obstetric haemorrhage. Approximately half of the deaths were due to a failure of the procedure to control the underlying clinical problem.

CONCLUSION

The demand for OOH services is important but not unduly onerous. There is no evidence of expansion of demand after launching such a service. Mortality rates probably reflect the underlying clinical status of this emergency patient group. Certain procedures carry a high mortality rate, raising issues of clinical judgement, appropriateness of intervention, and/or timing.

Submitting to the Follower Label

Although the importance of followership has been discussed in organizational literature, negative connotations attached to the follower label persist, including followers’ lack of ability and power. In two studies, we found evidence for negative effects of the follower label. Participants who were labeled a follower (Study 1), or self-labeled as followers in their jobs (Study 2), reported lower positive affect, and in turn, fewer extra-role behaviors. These findings suggest that followers might be at risk for reinforcing their negative stereotypes by avoiding opportunities to show their abilities and demonstrate their independence. Recommendations for leaders and opportunities for future research are discussed.

A comparative review of multidetector CT angiography and MRI in the diagnosis of jugular foramen lesions

AIM

To compare the efficiency of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) in the diagnosis of jugular foramen lesions.

MATERIALS AND METHODS

The imaging of 15 patients with tumours predominantly occurring at the jugular foramen was retrospectively reviewed, with postoperative pathology data available for 11 patients. MDCT was performed at arterial phase and MRI with standard sequences and contrast enhancement. All imaging was blindly re-reported by an experienced neuroradiologist.

RESULTS

Pathology reported six glomus jugulare tumours and five neuromas, which were all correctly diagnosed using MDCT. A confident diagnosis was also made in the remaining four cases based on the pattern of enhancement. Only glomus tumours enhanced in the arterial phase. Overall, MRI was used to make a confident diagnosis in eight patients. One showed no enhancement and was correctly diagnosed as a neuroma, and seven demonstrated the tumour flow voids characteristic of a glomus tumour. The remaining seven cases all showed a similar enhancement pattern and could not be confidently differentiated between a neuroma or a glomus tumour. MDCT angiography enabled a confident assessment of the jugular vein in all cases, but MRI was inconclusive in a third of cases. Also, in the nine cases of glomus tumour diagnosed using MDCT, an enlarged feeding artery was identified in eight patients.

CONCLUSION

MDCT is more accurate than MRI in diagnosing glomus tumours, and in particular, neuromas. It also offers valuable preoperative vascular information to the surgeon.

Reliability of a new measure of H-reflex excitability

OBJECTIVE

This study examined the intraclass reliability of different measures extracted from Hoffmann reflex (H-reflex) stimulus-response curve that are used to assess neuromuscular excitability. The following measures were compared: (1) the peak-to-peak amplitude of the H-reflex at a stimulus intensity associated with 5% of the maximum M-wave; (2) the slope of the regression line of the H-reflex stimulus-response curve; and (3) the peak of the first derivative of the H-reflex stimulus-response curve, a new measure introduced in this paper.

METHODS

The H-reflex was elicited in the soleus for 24 subjects (12 males and 12 females) on 5 separate days. Vibration was applied to the Achilles tendon prior to stimulation to test the sensitivity of the measures on test day 4. The stimulus intensity was gradually increased from below the threshold for an H-reflex response to above the maximum M-wave (Mmax) response. The means of 5 evoked potentials at each intensity level were used to create both the H-reflex and M-wave stimulus-response curves for each subject across test days. Determination of reliability involves the consideration of both the stability and consistency of the measures. A repeated measures analysis of variance evaluated the stability of the group means across test sessions. The consistency of scores within individuals was determined by calculating the intraclass correlation coefficient (ICC). Calculation of the 95% confidence interval of estimation was used to assess significant differences between ICCs.

RESULTS

The H-reflex measures were both stable and consistent across the first 3 test days. Achilles tendon vibration resulted in a profound reduction (59-70%) on test day 4, and then there was a return to baseline levels on test day 5. The ICC for H-reflex at a stimulus intensity associated with 5% of the maximum M-wave was 0.85. The ICC for the slope of the regression line of the H-reflex stimulus-response curve was 0.79, while it was 0.89 for the peak of the first derivative of the H-reflex stimulus-response curve. However, there was no statistical significance (P>0.05) between the 3 EMG measures of the H-reflex arc. Maximum M-wave amplitude had an ICC of 0.96 attesting to careful methodological controls.

CONCLUSIONS

The peak of the first derivative of the H-reflex stimulus-response curve was shown to have comparable sensitivity and reliability as other more established measures.

SIGNIFICANCE

The first derivative of the H-reflex stimulus-response curve provides the rate of change, rather than amplitude, making it a robust measure of reflex arc excitability. The higher ICC for the first derivative offers greater statistical power, which is of practical significance.

Facilitated loading of horizontal gels using a capillary comb loader

Manual loading of samples into horizontal gels, such as the agarose gels commonly used for DNA fragment sizing and quantification, is laborious and prone to errors. Manual-loading times for highthroughput gels can reach 10 min/gel, and human error can result in incorrect identification of samples because of reverse loading or other errors in the loading process. To reduce gel-loading times and to improve reliability, a novel comb has been developed that uses glass capillaries and hydrostatic pressure to simplify sample loading from microplates. Accurate sample metering is ensured by the uniform length and volume of the capillaries. The loaded comb is placed in the gel boat over a pre-cast agarose gel, and buffer is added to a reservoir at the top of the comb. Once the buffer rises over the ends of the capillaries, the samples are pushed into the wells by hydrostatic pressure. This technique was successfully demonstrated for a 24-lane comb. This capillary comb loader reduces loading time, maintains well-to-well uniformity, and retains the same geometry and appearance of manually loaded bands, making this loading method compatible with existing downstream processes and software for subsequent analysis of the gel image.

Phospholipid scramblase activation pathways in lymphocytes

In erythrocytes and platelets, activation of a nonspecific lipid flipsite termed the scramblase allows rapid, bidirectional transbilayer movement of all types of phospholipids. When applied to lymphoid cells, scramblase assays reveal a similar activity, with scrambling rates intermediate between those seen in platelets and erythrocytes. Scrambling activity initiated in lymphoid cells by elevation of intracellular Ca(2+) proceeds after a lag not noted in platelets or erythrocytes. The rates of transbilayer movement of phosphatidylserine and phosphatidylcholine analogues are similar whether the scramblase is activated by elevated internal Ca(2+) or by apoptosis. Elevation of internal Ca(2+) levels in apoptotic cells does not result in an additive increase in the rate of lipid movement. In lymphoid cells from a patient with Scott syndrome, scramblase cannot be activated by Ca(2+), but is induced normally during apoptosis. These findings suggest that Ca(2+) and apoptosis operate through different pathways to activate the same scramblase.

The adaptation of BHK cells to a non-ammoniagenic glutamate-based culture medium

Although glutamine is a major carbon source for mammalian cells in culture, its chemical decomposition or cellular metabolism leads to an undesirable excess of ammonia. This limits the shelf-life of glutamine-supplemented media and may reduce the cell yield under certain conditions. We have attempted to develop a less ammoniagenic medium for the growth of BHK-21 cells by a mole-to-mole substitution of glutamine by glutamate. This results in a medium that is thermally stable but unable to support an equivalent growth yield. However, supplementation of the glutamate-based medium with asparagine (3 mM) and a minimal level of glutamine (0.5 mM) restored the original growth capacity of the cultures. Substitution of the low level of glutamine with the glutamine dipeptides, ala-gln (1 mM), or gly-gln (3 mM) resulted in an equivalent cell yield and in a thermally stable medium. The ammonia accumulation in cultures with glutamate-based medium was reduced significantly (>60%). Factors mediating growth and adaptation in medium substituted with glutamate were also investigated. The maximum growth capacity of the BHK-21 cells in glutamate-based medium (without glutamine) was achieved after a period of adaptation of 5 culture passages from growth in glutamine-based cultures. Adaptation was not influenced by increases in glutamate uptake which was constitutively high in BHK cells. Adaptation was associated with changes in the activities of enzymes involved in glutamate or glutamine metabolism. The activities of glutamine synthetase (GS) and alanine aminotransferase (ALT) increased significantly and the activity of phosphate-activated glutaminase (PAG) decreased significantly. The activity of glutamate dehydrogenase (GDH) showed no significant change after adaptation to glutamate. These changes resulted in an altered metabolic profile which included a reduced ammonia production but an increased alanine production. Alanine production is suspected of being an alternative route for removal of excess nitrogen.

Glutamine-based dipeptides are utilized in mammalian cell culture by extracellular hydrolysis catalyzed by a specific peptidase

A murine hybridoma (CC9C10) was grown in media containing alanyl-glutamine (ala-gln) or glycyl-glutamine (gly-gln) as a substitute for glutamine. High cell yields were obtained in the presence of 6 mM ala-gln or 20 mM gly-gln. The final cell yield in gly-gln was 14% higher than in gln. Monoclonal antibody productivity was comparable in gln, ala-gln or gly-gln. Substrate utilisation and metabolism was affected by the presence of the dipeptides, particularly with gly-gln. The specific consumption rates of glucose and six amino acids were reduced. Also the accumulation of ammonia and lactate was significantly lower. The higher concentration of gly-gln was necessary for cell growth because of the presence of a peptidase with a lower affinity for gly-gln. The peptidase activity of the basal medium and serum was low. However, a substantial peptidase activity was found in the cytosolic fraction of the cells with an apparent Km of 1.2 mM with respect to ala-gln and 14 mM with respect to gly-gln. It is proposed that the mechanism of dipeptide utilisation involves extracellular hydrolysis by this peptidase following its release into the culture medium.

Adaptation of mammalian cells to non-ammoniagenic media

Although glutamine is used as a major substrate for the growth of mammalian cells in culture, it suffers from some disadvantages. Glutamine is deaminated through storage or by cellular metabolism, leading to the formation of ammonia which can result in growth inhibition. Non-ammoniagenic alternatives to glutamine have been investigated in an attempt to develop strategies for obtaining improved cell yields for ammonia sensitive cell lines. Glutamate is a suitable substitute for glutamine in some culture systems. A period of adaptation to glutamate is required during which the activity of glutamine synthetase and the rate of transport of glutamate both increase. The cell yield increases when the ammonia accumulation is decreased following culture supplementation with glutamate rather than glutamine. However some cell lines fail to adapt to growth in glutamate and this may be due to a low efficiency transport system. The glutamine-based dipeptides, ala-gln and gly-gln can substitute for glutamine in cultures of antibody-secreting hybridomas. The accumulation of ammonia in these cultures is less and cell yields in dipeptide-based media may be improved compared to glutamine-based controls. In murine hybridomas, a higher concentration of gly-gln is required to obtain comparable cell growth to ala-gln or gln-based cultures. This is attributed to a requirement for dipeptide hydrolysis catalyzed by an enzyme with higher affinity for ala-gln than gly-gln.

Catalase HPII of Escherichia coli catalyzes the conversion of protoheme to cis-heme d

Catalase HPII from aerobically grown Escherichia coli normally contains heme d but cultures grown with poor or no aeration produce HPII containing a mixture of heme d and protoheme IX. The protoheme component of HPII from anaerobically grown cells is converted into heme d during treatment of the purified enzyme with hydrogen peroxide. It is concluded that heme d found in catalase HPII is formed by the cis-hydroxylation of protoheme in a reaction catalyzed by catalase HPII using hydrogen peroxide as a substrate. The distal His128 residue of HPII is absolutely required for the protoheme to heme d conversion. Two mutant enzymes, Ala128 and Asn128, are catalytically inactive and contain only protoheme, which is unaffected by hydrogen peroxide treatment. The Asn201 residue is not an absolute requirement for heme conversion. The mutant enzyme Ala201 contains predominantly heme d and is partially active. However, insertion of a histidyl residue to give the His201 enzyme interferes with the heme conversion reaction. This mutant form is isolated as a protoheme enzyme with limited activity, and a reversible conversion to a heme d-like species occurs in vitro in the presence of continuously generated hydrogen peroxide.

Modulation by extracellular ATP of two distinct currents in rat myocytes

The whole cell voltage-clamp technique was used to study the electrophysiological effects induced by ATP in isolated ventricular myocytes. ATP or 2-methylthio-ATP evoked a transient inward current (IATP) when the transmembrane potential (Vm) was held at -70 mV and increased the Ca2+ current (ICa) when Vm was depolarized to 0 mV. The time course of IATP was fitted by a single exponential equation with a brief time constant (165 ms), whereas the time course of enhancement of ICa by ATP was also fitted by a single exponential equation with a much longer time constant (14 s). IATP was much less pronounced when extracellular Mg2+ was absent, and it was insensitive to dihydropyridines. In contrast, the enhancement of ICa by ATP was not affected by removing extracellular Mg2+, but it was suppressed by Ca2+ channel blockers. Both IATP and ICa were decreased by extracellular Cd2+. Internally applied guanosine 5'-O-(2-thiodiphosphate), which prevents the activation of G proteins, abolished the ATP-enhanced rise in ICa but did not inhibit IATP. These data suggest that ATP elicits IATP and increases ICa through two different mechanisms. IATP appears to be generated via receptor-operated channels that are activated by ATP. The ATP-induced increase of ICa appears to be mediated by G proteins via pathways that are independent of adenosine 3',5'-cyclic monophosphate and phosphoinositide turnover.

Ca2+ mobilization by extracellular ATP in rat cardiac myocytes: regulation by protein kinase C and A

Activation of protein kinase C (PKC) modulates the mobilization of intracellular Ca2+ induced by extracellular ATP in rat ventricular myocytes. Pretreatment of myocytes with PKC activators attenuated both the ATP-induced Ca2+ transient and the noradrenergic potentiation of the Ca2+ response. Various PKC activators decreased both the basal cAMP level and the cAMP levels that had been elevated by norepinephrine, forskolin, or 3-isobutyl-1-methylxanthine. The inhibitory effects of PKC activators were reversed by the PKC inhibitor staurosporine. The ATP-induced Ca2+ response is an integrated response resulting from ATP eliciting an inward cation current (IATP), cellular depolarization, Ca2+ influx through Ca2+ channels, and Ca2+ release from the sarcoplasmic reticulum. We used the whole cell voltage-clamp technique to investigate which steps of this integrated response are affected by PKC. PKC activators did not significantly affect the IATP. In contrast, PKC activators decreased the basal Ca2+ current (ICa) or Ba2+ current and the beta-adrenergic-stimulated ICa. These results suggest that PKC-induced suppression of the ATP-induced Ca2+ response and the beta-adrenergic-potentiated Ca2+ response is achieved at least partially by decreasing the intracellular cAMP level and ICa.

Mechanism of extracellular ATP-induced increase of cytosolic Ca2+ concentration in isolated rat ventricular myocytes

1. Changes in the cytosolic Ca2+ concentration ([Ca2+]i) of isolated rat ventricular myocytes in suspension were measured in response to extracellular ATP using the fluorescent Ca2+ indicators Quin-2 and Fura-2. 2. ATP produced a concentration-, time- and Mg(2+)-dependent, biphasic increase of [Ca2+]i whereas slowly hydrolysable ATP analogues produced a slow, monophasic increase of [Ca2+]i and the non-hydrolysable ATP analogues were without effect. 3. Extracellular Ca2+ was required for the ATP-induced increase of [Ca2+]i and pre-treatment of the cells with caffeine, ryanodine, verapamil or nimodipine partially inhibited the [Ca2+]i increase. 4. Whole-cell patch-clamp experiments revealed that ATP activated an ionic current that had a linear current-voltage relationship with a reversal potential near O mV. Quinidine, a putative P2 purinergic receptor blocker, abolished the ATP-activated current. The ATP-activated current was Mg2+ dependent. 5. Associated with the ATP-activated current was cellular depolarization. In a physiological solution, ATP depolarized cells to the threshold for the firing of action potentials. In the presence of the voltage-activated ion channel blockers tetrodotoxin, 4-aminopyridine, caesium and nitrendipine, ATP depolarized cells to -44 +/- 6 mV from a resting potential of -66 +/- 4 mV (n = 11). 6. Sodium dodecyl sulphate (SDS) polyacrylamide gel electrophoresis and autoradiography demonstrated that extracellular ATP stimulated the phosphorylation of several extracellular membrane-bound proteins. The phosphorylation of these proteins was concentration, time and Mg2+ dependent. Pre-treatment of cells with the slowly hydrolysable ATP analogues inhibited the ATP-induced phosphorylation. Adenosine 5'-O-3-thiotriphosphate (ATP gamma S) thiophosphorylated proteins with the same apparent molecular weight as the proteins phosphorylated by ATP. 7. These results suggest that the ATP-induced increase of [Ca2+]i is a result of the activation, possibly by protein phosphorylation, of a novel ion channel carrying inward current. The ATP-activated channel may be permeable to Na+ and Ca2+ and causes [Ca2+]i to rise. More importantly, this inward current depolarizes the cell to the threshold of inducing spontaneous firing of action potentials. The firing of action potentials results in the influx of Ca2+ through L-type Ca2+ channels which would trigger Ca2+ release from the sarcoplasmic reticulum and lead to the increase in [Ca2+]i.

Synergism between cAMP and ATP in signal transduction in cardiac myocytes

ATP transiently increases the intracellular Ca2+ concentration in cardiac myocyte suspensions. Pretreatment with norepinephrine (NE) greatly potentiates the ATP response. We performed experiments on adult rat myocyte suspensions loaded with fura-2 to investigate the mechanism of NE potentiation. We found that forskolin (an activator of adenylate cyclase), 3-isobutyl-1-methylxanthine (an inhibitor of phosphodiesterase), and permeative adenosine 3',5'-cyclic monophosphate (cAMP) analogues potentiate the increase in cytosolic Ca2+ concentration induced by ATP. NE, forskolin, and 8-(4-chlorophenylthio)-cAMP all increase Vmax of the Ca2+ response curve of ATP. Measurement of cAMP by radioimmunoassay confirmed that the changes in the ATP response were accompanied by an increase in cAMP. These results suggest that the noradrenergic potentiation of the ATP-induced Ca2+ mobilization involves cAMP as a second messenger. Patch-clamp studies of isolated myocytes showed that neither NE nor forskolin alters the inward current elicited by ATP, but rather they increase the duration of secondary slow action potentials elicited by ATP. NE also increases the Ca2+ current through L-type Ca2+ channels in the myocytes. We conclude that NE potentiates the ATP-induced Ca2+ transient by increasing cAMP levels and that one of the early events is the increase of the inward Ca2+ current during the action potential.

Noninvasive differentiation of carotid artery occlusion from high-grade stenosis

The differentiation of high-grade carotid artery stenosis from occlusion can be a difficult but important diagnostic dilemma. The authors used a combination of duplex scanning, pulsed spectrum analysis, audible analysis of continuous wave doppler signal, and peri-orbital doppler compressions to accurately differentiate high-grade stenosis from occlusion in a series of 24 patients.