Health Equity Achievement in Radiation Therapy (HEART) Score: A Social Prognosis

PURPOSE/OBJECTIVE(S)

The aim of this study was to develop a Health Equity Achievement in Radiation Therapy (HEART) score that can help identify patients at risk of experiencing suboptimal quality-of-care (QoC) early on in the patient-provider encounter and prior to initiation of treatment. Such a score may improve shared decision making to improve QoC.

MATERIALS/METHODS

A retrospective analysis was conducted using the National Cancer Database (NCDB) for prostate cancer cases between 2004-2017. Sociodemographic factors, clinical characteristics, and treatment information were collected. A composite HEART score was built to predict suboptimal QoC, defined as treatment refusal, incomplete treatment, or treatment delay. 70% of the data was allocated to training and 30% to validating a logistic regression model through which a nomogram was constructed.

RESULTS

A total of 1,599,785 patients were included in the analysis, of whom 126,917 (7.9%) had at least one suboptimal QoC. The strongest predictors were Black race, uninsured status, lower educational status, geographic location, and nodal disease (Table). The nomogram demonstrated a fair ability to predict quality metrics, with an area under the receiver operating characteristic curve (AUC) of 0.57 in the test group. The nomogram facilitated graphic interpretation of systemic factors in contributing to suboptimal QoC.

CONCLUSION

With observed potential for predicting suboptimal QoC outcomes in patients with prostate cancer by considering systemic barriers, this NCDB-based nomogram has potential utility as a tool for identifying patients who may benefit from additional social support, including the financial resources associated with these services, to improve access to care. Further validation in diverse datasets is needed to improve performance and generalizability to broader patient populations and different disease sites.

The human liver microenvironment shapes the homing and function of CD4+ T-cell populations

OBJECTIVE

Tissue-resident memory T cells (TRM) are vital immune sentinels that provide protective immunity. While hepatic CD8+ TRM have been well described, little is known about the location, phenotype and function of CD4+ TRM.

DESIGN

We used multiparametric flow cytometry, histological assessment and novel human tissue coculture systems to interrogate the ex vivo phenotype, function and generation of the intrahepatic CD4+ T-cell compartment. We also used leukocytes isolated from human leukocyte antigen (HLA)-disparate liver allografts to assess long-term retention.

RESULTS

Hepatic CD4+ T cells were delineated into three distinct populations based on CD69 expression: CD69-, CD69INT and CD69HI. CD69HICD4+ cells were identified as tissue-resident CD4+ T cells on the basis of their exclusion from the circulation, phenotypical profile (CXCR6+CD49a+S1PR1-PD-1+) and long-term persistence within the pool of donor-derived leukcoocytes in HLA-disparate liver allografts. CD69HICD4+ T cells produced robust type 1 polyfunctional cytokine responses on stimulation. Conversely, CD69INTCD4+ T cells represented a more heterogenous population containing cells with a more activated phenotype, a distinct chemokine receptor profile (CX3CR1+CXCR3+CXCR1+) and a bias towards interleukin-4 production. While CD69INTCD4+ T cells could be found in the circulation and lymph nodes, these cells also formed part of the long-term resident pool, persisting in HLA-mismatched allografts. Notably, frequencies of CD69INTCD4+ T cells correlated with necroinflammatory scores in chronic hepatitis B infection. Finally, we demonstrated that interaction with hepatic epithelia was sufficient to generate CD69INTCD4+ T cells, while additional signals from the liver microenvironment were required to generate liver-resident CD69HICD4+ T cells.

CONCLUSIONS

High and intermediate CD69 expressions mark human hepatic CD4+ TRM and a novel functionally distinct recirculating population, respectively, both shaped by the liver microenvironment to achieve diverse immunosurveillance.

Resolving the polygenic aetiology of a late onset combined immune deficiency caused by NFKB1 haploinsufficiency and modified by PIK3R1 and TNFRSF13B variants

Genetic variants in PIK3CD, PIK3R1 and NFKB1 cause the primary immune deficiencies, activated PI3Kδ syndrome (APDS) 1, APDS2 and NFκB1 haploinsufficiency, respectively. We have identified a family with known or potentially pathogenic variants NFKB1, TNFRSF13B and PIK3R1. The study's aim was to describe their associated immune and cellular phenotypes and compare with individuals with monogenic disease. NFκB1 pathway function was measured by immunoblotting and PI3Kδ pathway activity by phospho-flow cytometry. p105/p50 expression was absent in two individuals but elevated pS6 only in the index case. Transfection of primary T cells demonstrated increased basal pS6 signalling due to mutant PIK3R1, but not mutant NFKB1 or their wildtype forms. We report on the presence of pathogenic variant NFKB1, with likely modifying variants in TNFRSF13B and PIK3R1 in a family. We describe immune features of both NFκB1 haploinsufficiency and APDS2, and the inhibition of excessive PI3K signalling by rapamycin in vitro.

The Role of B Cells in Adult and Paediatric Liver Injury

B lymphocytes are multitasking cells that direct the immune response by producing pro- or anti-inflammatory cytokines, by presenting processed antigen for T cell activation and co-stimulation, and by turning into antibody-secreting cells. These functions are important to control infection in the liver but can also exacerbate tissue damage and fibrosis as part of persistent inflammation that can lead to end stage disease requiring a transplant. In transplantation, immunosuppression increases the incidence of lymphoma and often this is of B cell origin. In this review we bring together information on liver B cell biology from different liver diseases, including alcohol-related and metabolic fatty liver disease, autoimmune hepatitis, primary biliary and primary sclerosing cholangitis, viral hepatitis and, in infants, biliary atresia. We also discuss the impact of B cell depletion therapy in the liver setting. Taken together, our analysis shows that B cells are important in the pathogenesis of liver diseases and that further research is necessary to fully characterise the human liver B cell compartment.

Decreased ATM Function Causes Delayed DNA Repair and Apoptosis in Common Variable Immunodeficiency Disorders

PURPOSE

Common variable immunodeficiency disorders (CVID) is characterized by low/absent serum immunoglobulins and susceptibility to bacterial infection. Patients can develop an infections-only phenotype or a complex disease course with inflammatory, autoimmune, and/or malignant complications. We hypothesized that deficient DNA repair mechanisms may be responsible for the antibody deficiency and susceptibility to inflammation and cancer in some patients.

METHODS

Germline variants were identified following targeted sequencing of n = 252 genes related to DNA repair in n = 38 patients. NanoString nCounter PlexSet assay measured gene expression in n = 20 CVID patients and n = 7 controls. DNA damage and apoptosis were assessed by flow cytometry in n = 34 CVID patients and n = 11 controls.

RESULTS

Targeted sequencing supported enrichment of rare genetic variants in genes related to DNA repair pathways with novel and rare likely pathogenic variants identified and an altered gene expression signature that distinguished patients from controls and complex patients from those with an infections-only phenotype. Consistent with this, flow cytometric analyses of lymphocytes following DNA damage revealed a subset of CVID patients whose immune cells have downregulated ATM, impairing the recruitment of other repair factors, delaying repair and promoting apoptosis.

CONCLUSION

These data suggest that germline genetics and altered gene expression predispose a subset of CVID patients to increased sensitivity to DNA damage and reduced DNA repair capacity.

Efficacy and Safety of Percutaneous Microwave Ablation and Cementoplasty in the Treatment of Painful Spinal Metastases and Myeloma

BACKGROUND AND PURPOSE

Painful spinal metastases are a common cause of cancer-related morbidity. Percutaneous ablation presents an attractive minimally invasive alternative to conventional therapies. We performed a retrospective review of 69 patients with 102 painful spinal metastases undergoing microwave ablation and cementoplasty to determine the efficacy and safety of this treatment.

MATERIALS AND METHODS

Procedures were performed between January 2015 and October 2016 with the patient under general anesthesia using image guidance for 102 spinal metastases in 69 patients in the following areas: cervical (n = 2), thoracic (n = 50), lumbar (n = 34), and sacral (n = 16) spine. Tumor pathologies included the following: multiple myeloma (n = 10), breast (n = 27), lung (n = 12), thyroid (n = 6), prostate (n = 5), colon (n = 4), renal cell (n = 3), oral squamous cell (n = 1), and adenocarcinoma of unknown origin (n = 1). Procedural efficacy was determined using the visual analog scale measured preprocedurally and at 2-4 weeks and 20-24 weeks postprocedure. Tumor locoregional control was assessed on follow-up cross-sectional imaging. Procedural complications were recorded to establish the safety profile.

RESULTS

The median ablation time was 4 minutes 30 seconds ± 7 seconds, and energy dose, 4.1 ± 1.6 kJ. Median visual analog scale scores were the following: 7.0 ± 1.8 preprocedurally, 2 ± 1.6 at 2-4 weeks, and 2 ± 2.1 at 20-24 weeks. Eight patients died within 6 months following the procedure. Follow-up imaging in the surviving patients at 20-24 weeks demonstrated no locoregional progression in 59/61 patients. Two complications were documented (S1 nerve thermal injury and skin burn).

CONCLUSIONS

Microwave ablation is an effective and safe treatment technique for painful spinal metastases. Further studies may be helpful in determining the role of microwave ablation in locoregional control of metastases.

Characteristics and Evaluation of Geographically Distant vs Geographically Nearby Living Kidney Donors

BACKGROUND

Living donor kidney transplant (LDKT) can be impeded by multiple barriers. One possible barrier to LDKT is a large physical distance between the living donor's home residence and the procuring transplant center.

METHODS

We performed a retrospective, single-center study of living kidney donors in the United States who were geographically distant (residing ≥150 miles) from our transplant center. Each distant donor was matched to 4 geographically nearby donors (<150 miles from our center) as controls.

RESULTS

From 2007 to 2010, of 429 live kidney donors, 55 (12.8%) were geographically distant. Black donors composed a higher proportion of geographically distant vs nearby donors (34.6% vs 15.5%), whereas Hispanic and Asian donors composed a lower proportion (P = .001). Distant vs nearby donors had similar median times from donor referral to actual donation (165 vs 161 days, P = .81). The geographically distant donors lived a median of 703 miles (25% to 75% range, 244 to 1072) from our center and 21.2 miles (25% to 75% range, 9.8 to 49.7) from the nearest kidney transplant center. The proportion of geographically distant donors who had their physician evaluation (21.6%), psychosocial evaluation (21.6%), or computed tomography angiogram (29.4%) performed close to home, rather than at our center, was low.

CONCLUSIONS

Many geographically distant donors live close to transplant centers other than the procuring transplant center, but few of these donors perform parts of their donor evaluation at these closer centers. Black donors comprise a large proportion of geographically distant donors. The evaluation of geographically distant donors, especially among minorities, warrants further study.

Synaptic abnormalities of mice lacking toll-like receptor (TLR)-9

Motor, sensory, and autonomic abnormalities are reported for toll-like receptor 9 (TLR9) knock-out (KO) mice. However, a physiological role of TLR9 in the nervous system is largely unknown. Since altered synaptic transmission can contribute to sensory and motor abnormalities, we evaluated neuromuscular junction (NMJ) function and morphology of TLR9 KO mice. Triangularis sterni nerve-muscle preparations were dissected from TLR9 KO and age-matched control mice. Two-electrode voltage clamp of the motor endplate revealed that the amplitude and frequency of miniature end plate currents (mEPCs) for TLR9 KO NMJs were significantly greater than control. In contrast, mean endplate current (EPC, 1Hz) amplitude was equivalent to control. The ratio of mean EPC to mean mEPC amplitude indicated a decline of quantal content (m) for TLR9 KO NMJs. Furthermore, m declined more rapidly than control in response to 50-Hz stimulus trains. A rightward shift of the mEPC amplitude distribution suggested formation of vesicles containing larger amounts of acetylcholine (ACh). Staining with rhodamine α-bungarotoxin revealed a significant decline of endplate size in TLR9 KO mice. This alteration may result from ACh-induced decline of acetylcholine receptor (AChR) expression resulting from increased frequency and amplitude of mEPCs. At the same time, excessive spontaneous vesicular ACh release may initiate retrograde suppression of excitation-secretion coupling. These data suggest a novel role of TLR9 in the development of the NMJ.

Effect of a novel Omegacoeur®/Doluperine® nutritional combination on human embryonic kidney cell viability

Holistica Laboratories (Eguilles, France) developed the nutritional supplements Omegacoeur® and Doluperine® based on two of the most ancient and unique dietary health traditions. Omegacoeur® is formulated to supply key active components of Mediterranean diet (omega 3,6,9 fatty acids, garlic, and basil) and the formulation of Doluperine® was based on the Ayurvedic tradition (curcuma, pepper, ginger extracts). Interestingly, recent studies suggest that an combination of the ingredients supplied by these two supplements could provide additional and previously unanticipated benefit through synergistic actions of some of their key components. However, the effect of such combination on human cell viability has not been investigated. In this present article, a review of the various effects of the individual compounds of the new combination and the reported active doses, and the result of a study of an combination of Omegacoeur® / Dolupérine® on Human Embryonic Kidney (HEK 293) cells. Incremental doses of 4 Omegacoeur® / Dolupérine® combinations prepared so that the molar ratio DHA (Docosahexaenoic acid) in Omegacoeur® / curcumin in Dolupérine® was kept constant, at 2.5 DHA / 1 curcumin, were added to the culture media. After 24h of incubation, cell viability was assessed by the trypan blue exclusion method. The data suggest that the combination of Omegacoeur® with Dolupérine® does not affect HEK 293 cells viability in the range of doses that have demonstrated beneficial effects in earlier studies.

Fatal graft-versus-host disease presenting as fever of unknown origin in a pancreas-after-kidney transplant recipient

Acute graft-versus-host disease (GVHD) is a rare complication of pancreas transplantation. We describe a 54-year-old male with type 1 diabetes who received a zero-antigen mismatched pancreas-after-kidney transplant from a pancreas donor who was homozygous at the HLA-B, -Cw, -DR, and -DQ alleles. Starting on postoperative day (POD) #22, the patient developed persistent fevers. Workup was notable only for low-grade cytomegalovirus viremia, which was treated. The fevers eventually disappeared. On POD #106, the patient was noted to have a diffuse erythematous rash. A skin biopsy was consistent with GVHD. Short tandem repeat DNA analysis of both peripheral blood lymphocytes and skin demonstrated mixed chimerism, confirming the diagnosis of GHVD. Soon after diagnosis, the patient developed pancytopenia and fevers and died of multiorgan failure on POD #145. Transplant clinicians should consider GVHD as a possible, although admittedly rare, cause of fevers of unknown origin in recipients of pancreas transplants.

Renal transplantation in patients with pre-transplant donor-specific antibodies and negative flow cytometry crossmatches

The clinical significance of pre-transplant donor-specific antibodies (DSA), despite negative cytotoxicity and flow cytometry crossmatches (FCXMs), is unknown. We performed a retrospective cohort study of 60 living donor renal transplant recipients, all with pre-transplant cytotoxicity and T-cell and B-cell FCXMs that were negative. Twenty recipients had pre-transplant DSA detected by enzyme-linked immunosorbent assays (ELISA) and/or microbead methods. Forty contemporaneous DSA-negative controls were selected. In the DSA-positive group, after a median follow-up of 8.2 months (25-75% range, 5.4-22.8 months), patient survival was 100% and allograft survival was 95.0%. Acute humoral rejection (AHR) developed in four patients (20.0%). Three of the AHR episodes occurred within the first month post-transplant. Median serum creatinine at last follow-up was 1.3 mg/dL (25-75% range, 1.0-1.6 mg/dL), versus 1.1 mg/dL (25-75% range, 0.9-1.4 mg/dL) in the DSA-negative controls (p = 0.29). Only one of the 40 controls developed AHR (2.5%). Pre-transplant DSA was associated with a significantly increased incidence of AHR (p = 0.02 by log-rank test). In conclusion, despite negative pre-transplant cytotoxicity and FCXMs, renal transplant recipients with pre-transplant DSA detected by solid-phase methods may have an increased incidence of AHR and require close monitoring post-transplant.

Retrospective analysis of early steroid-induced adverse reactions in kidney and kidney-pancreas transplant recipients

Corticosteroids (steroids) are associated with numerous adverse drug reactions (ADRs). Long-term ADRs are well characterized, but there are limited data on the incidence and likelihood of short-term ADRs. We sought to determine the incidence of ADRs potentially related to early administration of steroids in kidney and kidney-pancreas transplant recipients and to determine the probability that the ADR was due to the steroid. We retrospectively evaluated the records of all eligible kidney or pancreas-kidney transplants during 2003. ADRs were rated by two reviewers according to the Naranjo algorithm, and identified as "definite," "probable," "possible," or "doubtful." ADRs were identified in 100% of patients (n = 103) by 8.2 +/- 4.9 days. The mean ADRs per patient were 3.26 +/- 1.04. Weight gain occurred in 79.6%, hypertension in 71.8%, diabetes mellitus in 52.4%, hyperglycemia in 47.6%, leukocytosis in 31.1%, insomnia in 27.2%, anxiety in 10.7%, and psychosis in 1.9%. Based on mean interinvestigator score, leukocytosis was judged as "probable" and weight gain and psychosis were "possible to probable." Diabetes, hyperglycemia, hypertension, and insomnia were "possible" and anxiety was "possible to doubtful." These results provide evidence of the incidence and likelihood of early steroid-related ADRs.

Appropriate consent and referral for general anaesthesia — a survey in the Paediatric Day Care Unit, Barnsley DGH NHS Trust, South Yorkshire

BACKGROUND

In November 1998 the General Dental Council introduced guidelines for dental practitioners when referring a patient for general anaesthesia (GA). The practitioner is required to explain the risks associated with GA and the alternatives, give a detailed medical history and a clear justification for providing GA in the letter of referral.

METHOD

A survey was administered on 202 parents or guardians, which aimed to investigate whether they felt that their dental practitioners had advised them of any risks of GA prior to referral. A record was also made if any reasons were given for the provision of GA in the letter of referral.

RESULTS

The majority of the parents or guardians (66%) felt that they were not informed of any of the risks of GA and 25% felt that they were. From the letters of referral, 37% contained a reason for GA and 63% did not give any reason or justification for GA.

CONCLUSION

There is evidence that referring practitioners do not adequately explain the risks of the anaesthetic to parents or guardians of children undergoing GA. There is also a lack of clear justification in the letters of referral for providing GA.

PRACTICE IMPLICATION

It is essential that the alternatives and the risks of GA are discussed and if GA is still required, a clear justification should be contained in the letter of referral as part of informed consent. More importantly the referring practitioner should keep a contemporaneous record of this, preferably with a signature from the parent or guardian on agreement of referral.

Tuberculosis-related deaths in Queensland, Australia, 1989-1998: characteristics and risk factors

OBJECTIVE

To review factors associated with TB-related deaths in Queensland, Australia.

DESIGN

Review of data for TB patients dying before treatment completion; demographic and clinico-pathological comparison of TB-related deaths with other notified patients after exclusion of losses to follow-up; matched case-control study of co-morbid conditions in patients under 75 years.

RESULTS

Of 1003 tuberculosis cases notified between 1989 and 1998, 127 died before completing anti-tuberculosis treatment. Tuberculosis was the main cause of death in 53 cases, a significant contributor in 34 and unrelated in 40, giving a TB-related case fatality rate of 8.7%. Decedents were older on average, except among indigenous Australians (IA); age-adjusted case fatality rates did not vary significantly among ethnic groups. Pulmonary and disseminated TB, coexistent malnutrition, renal disease and liver disease increased the risk of death. HIV infection increased the risk of dying, but was uncommon among Queensland cases. Neither sputum smear positivity nor drug resistance was associated with risk of death. Twenty-five TB-related deaths occurred before diagnosis, with significant overrepresentation of IA. Most had serious co-morbidities and symptomatic pulmonary disease. Seven socially or geographically isolated decedents did not access documented health care for tuberculosis.

CONCLUSIONS

Fatality was related to older age, disseminated disease and co-morbidity. Dying undiagnosed from tuberculosis was associated with respiratory co-morbidity and social and geographical isolation, mainly in the aged in low TB risk populations and in IA in remote regions.

Torsional response and stiffening of individual multiwalled carbon nanotubes

We report on the characterization of torsional oscillators which use multiwalled carbon nanotubes as the spring elements. Through atomic-force-microscope force-distance measurements we are able to apply torsional strains to the nanotubes and measure their torsional spring constants, and estimate their effective shear moduli. The data show that the nanotubes are stiffened by repeated flexing. We speculate that changes in the intershell mechanical coupling are responsible for the stiffening.

Hypersensitivity pneumonitis: current concepts and future questions

Hypersensitivity pneumonitis (extrinsic allergic alveolitis) caused by inhaled allergens can progress to disabling or even fatal end-stage lung disease. The only truly effective treatment is early recognition and control of exposure. Although patients produce antibody exuberantly, the immunopathogenesis involves cellular immunity--notably, CD8(+) cytotoxic lymphocytes, multinucleate giant cell granulomas, and ultimately interstitial fibrosis. Many causative agents have been recognized in occupational dusts or mists, but most current new cases arise from residential exposure to pet birds (pigeons and parakeets), contaminated humidifiers, and indoor molds. The symptoms and physical findings are nonspecific. Serum IgG containing high titers of specific antibody to the offending antigen is elevated. Pulmonary function tests show restrictive and diffusion defects with hypoxemia, especially after exercise. Occasionally, small airways disease causes obstruction. Radio-graphic changes vary according to the stage of the disease and are best evaluated by means of high-resolution computed tomography. In typical cases, the history of a known exposure and the presence of a characteristic interstitial lung disease with serologic confirmation of IgG antibody to the offending antigen suffice for diagnosis. In more obscure cases, observation of changes after a natural environmental exposure, bronchoalveolar lavage, and lung biopsy might be indicated. Among the many questions that remain are the following: What is the prevalence of hypersensitivity pneumonitis and how often is it the cause of chronic interstitial fibrosis? What is the long-term prognosis? Why do most individuals exposed to these antigens develop a vigorous antibody response whereas only a few develop the disease? How does exposure to endotoxin and cigarette smoking affect the disease? To answer these questions, standardized and validated clinical laboratory immunochemical tests are needed, in addition to a systematic approach to diagnosis, classification of disease severity, risk assessment, and management. This review is limited to the disease caused by airborne allergens and focuses on its immunopathogenesis, eliciting agents, clinical manifestations, diagnosis, management, and prognosis.

Investigation of some commercially available spacer devices for the delivery of glucocorticoid steroids from a pMDI

Five commercially available spacers were investigated to determine their influence on the percentage of drug retained in the spacer device, percentage fine particle fraction (FPF), percentage deposited in the induction port, mass median aerodynamic diameter (MMAD), and geometric standard deviation (GSD). Betamethasone valerate (BMV) and triamcinolone acetonide (TAA) were used as model drugs in the pressurized metered dose inhaler (pMDI) formulations containing the propellant HFA 134a. The BMV was dissolved in an ethanol/HFA 134a system, and the TAA was suspended in HFA 134a using ethanol as a dispersing agent. The metering chamber volume of the valve was either 50 microl or 150 microl. The spacer devices investigated included the ACE, Aerochamber, Azmacort, Easivent, and Ellipse spacers. Each spacer device was attached to an Andersen Cascade Impactor powered by a vacuum pump. Cascade impaction data were used to derive the percentage drug deposited in the induction port, MMAD, GSD, and FPF. The BMV particles emitted from the spacers were finer than the TAA particles because the dissolved drug precipitated as the cosolvent evaporated. The TAA particles had significantly larger MMADs because many undissolved drug particles were contained within each droplet following actuation. After evaporation of the liquid continuous phase, the suspended drug aggregated to form larger agglomerates than those particles precipitated from the BMV pMDI solution droplets. The addition of a spacer device lowered the MMAD to less than 4.7 microm for particles from both the BMV pMDI solution and the TAA pMDI suspension. The addition of a spacer device also lowered the percentage drug deposited in the induction port. The FPF was significantly increased when a spacer device was used. The MMAD significantly decreased when a spacer device was added for the two model drugs when using the 150-microl metering valves, but the difference was not statistically significant when the 50-microl valves were used (P < .05). The GSD was not influenced by the use of a spacer device. The use of a spacer device will enhance pMDI therapy by reducing the amount of drug deposited in the oropharyngeal region, which will lead to fewer instances of local and systemic side effects. In addition, the spacer devices investigated will allow a higher dose of drug to reach the deep lung, which may permit the use of lower dosage regimens with increased therapeutic efficacy.

Using the Internet in the management of asthma

The ultimate goals of managing asthma are to eliminate death, prevent or promptly treat exacerbations, and maximize the quality of life and health status of patients. Current strategies include appropriate education, trigger control, and timely access to effective pharmacotherapy and follow-up. Internet-based technologies have emerged as potentially powerful tools to enable meaningful communication and proactive partnership in care for various medical conditions. The main types of Internet-based applications for asthma management include remote monitoring and feedback between health professionals and their patients; online education and marketing for either patients or professionals; networking and collaborative research; and administrative oversight through policy making, planning, and decision support. With increased understanding of integrated disease management and the technostructural as well as psychodynamic issues related to Internet use, further refinement and evolution of the Internet and related technologies may drastically improve the way we monitor, educate, treat, and establish policies for this global problem while attending to individual or local community needs. This review presents a conceptual overview of the current challenges and use of the Internet for improving asthma management through timely and tailored education and appropriate access to health care expertise.

Prevalence, pathophysiology, and treatment of patients with asthma and gastroesophageal reflux disease

About one third of the US adult population experiences symptoms of gastroesophageal reflux on a monthly basis. Asthma is present in about 5% of the same population. This article reviews and summarizes the literature in the following areas: (1) prevalence of gastroesophageal reflux disease (GERD) in asthmatic patients based on clinical symptoms, endoscopic esophagitis, and 24-hour ambulatory esophageal pH recordings; (2) proposed pathophysiologic mechanisms linking the 2 diseases; and (3) medical and surgical treatment trial results of antireflux therapy for asthmatic patients. Asthmatic patients appear to have an increased prevalence of GERD symptoms and 24-hour esophageal acid exposure. The clinical management of these patients remains controversial. Common management approaches to GERD in asthmatic patients include medical therapy with a proton pump inhibitor and/or antireflux surgery, which improve asthma symptoms in many patients but minimally affect pulmonary function.

Treatment of underlying atrial fibrillation: paced rhythm obscures recognition

OBJECTIVES

The purpose of this study was to evaluate the rate of recognition of atrial fibrillation (AF), use of warfarin and prevalence of cerebrovascular accident (CVA) in paced versus unpaced patients during admission to a tertiary care teaching hospital.

BACKGROUND

The presence of AF underlying a continuously paced rhythm may be under recognized and result in a lower rate of anticoagulation and higher incidence of CVA.

METHODS

The identification of AF on 12 lead electrocardiogram (ECG) and telemetry, "optimal use" of anticoagulants that is, warfarin or aspirin, when warfarin is contraindicated and history of prior CVA was studied in three groups: 1) group A with continuously paced rhythm on ECG and telemetry (n = 30), 2) group B with intermittently paced rhythm on ECG and telemetry (n = 59), and 3) group C with persistent AF and no permanent pacemaker (n = 50).

RESULTS

The identification and documentation of AF was significantly lower in the continuously paced group A (20%) versus the intermittently paced group B (44%). Both groups A and B were substantially lower than unpaced controls. "Optimal use" of anticoagulants was significantly lower in group A (40%) compared with groups B (78%) and C (72%) but was not different between groups B and C. The prevalence of prior CVA was not significantly different between the three groups.

CONCLUSIONS

All ECGs in patients with paced rhythm should be examined closely for underlying AF to prevent under-recognition and under-treatment with anticoagulants.

Consultation for asthma: results of a generalist survey

BACKGROUND

There are few studies that examine referral patterns for asthma and few studies that examine the referring physicians' reasons for consultation.

OBJECTIVE

The purpose of this study was to survey generalist physicians on their referral patterns for adult patients with asthma.

METHODS

We mailed a questionnaire to all the staff (faculty) in the Department of Family Medicine and the Division of Community Internal Medicine at the Mayo Clinic in Rochester, Minnesota. There were 37 completed questionnaires (18 family medicine and 19 internal medicine) out of a total of 58 for a response rate of 64%. The survey asked what were reasons for consultation, whether allergists or pulmonologists were preferred, and the characteristics of a good consultation.

RESULTS

We asked respondents to indicate "how often you consult a specialist for an adult asthma patient" for a variety of clinical indications. The percentage responding "always" (for the top five indications) were if the patient requests one (46%), for allergen immunotherapy (38%), for single life-threatening attack (27%), for allergy testing (14%), and for steroid-dependent asthma or poorly controlled asthma (11%). Twenty-seven percent of respondents generally consulted allergists only, 22% generally consulted pulmonologists only, 3% indicated both, while 46% had no preference. Respondents did express a preference for a pulmonologist when the reported reason for the consultation was diagnosis of asthma uncertain, chronic cough, asthma in smoker, exercise training, or for an allergist when the reported reason for consultation was allergy evaluation or immunotherapy. The respondents indicated that the top six characteristics of a good consultation were the following: clear recommendations, clinically appropriate recommendations, high patient satisfaction, including recommendations for future management scenarios, including educational content in the consultation, and calling the referring physician before requesting a secondary consultation.

CONCLUSIONS

These results suggest that while consultation occurs often for severe or uncontrolled asthma, some asthma patients who may benefit from consultation may not be seeing the specialist. There were no systematic preferences for consultations with allergists versus pulmonologists for asthma although for some clinical indications pulmonologists or allergists were favored. Referring physicians value clear, clinically appropriate recommendations.

Attachment of periosteal grafts to articular cartilage with fibrin sealant

Favorable results using fibrin sealants in vascular surgery and soft tissue reconstruction have prompted investigation of these biologic adhesives for orthopedic applications. One important recent application was as a sealant for periosteal grafts applied to defects in articular surfaces, a procedure that contained injected chondrocytes cultured in vitro. The low and variable adhesive strength of autologous fibrin substances prompted our investigation of allogeneic fibrin. An in vitro test method was developed to investigate the use of a fibrin sealant for attaching periosteal (bovine) patches to articular cartilage (bovine). Dermis-dermis (porcine) adhesion also was evaluated. In tests of the periosteum-to-cartilage bond performed in a physiological environment, we determined the effects of the following variables on the adhesive shear strength: set time, source of fibrinogen (bovine versus human), and fibrinogen concentration. A specially designed test rig was developed to avoid nonshear force components. Adhesive shear strength increased with fibrin set time for both fibrinogen concentrations and sources (p <.03). The 30-min set time yielded data with less variance than the 5-min set time in all cases except with the higher human fibrinogen concentration (50-80 mg/mL). While there was a trend at each set time towards greater shear strength with increased protein concentration (50-80 mg/mL versus 25-40 mg/mL), only the 5-min trial of the bovine product provided a significant advantage (p <.006). There was no significant difference in adhesive strength between the fibrin products produced with human and bovine fibrinogen. The periosteum-cartilage adhesive strengths obtained in our model were comparable to values recorded for the dermis-dermis bonding. The greater strength at the 30-min set time suggests that a certain time period of joint immobilization might be beneficial in procedures in which grafts are glued to articular cartilage. This study has shown that adhesive strengths achieved with fibrin glues in treating skin wounds also can be achieved in the attachment of periosteal grafts to articular cartilage.

Concerted action of cytosolic Ca2+ and protein kinase C in receptor-mediated phospholipase D activation in Chinese hamster ovary cells expressing the cholecystokinin-A receptor

Receptor-mediated activation of phosphatidylcholine phosphatidohydrolase or phospholipase D (PLD) was studied in Chinese hamster ovary (CHO) cells expressing the cholecystokinin-A (CCK-A) receptor. Cells were labelled with [3H]myristic acid for 24 h and PLD-catalysed [3H]phosphatidylethanol formation was measured in the presence of 1% (v/v) ethanol. Cholecystokinin-(26-33)-peptide amide (CCK8) increased PLD activity both time- and dose-dependently. Maximal activation of protein kinase C (PKC) with 1 microM PMA or sustained elevation of the cytosolic free Ca2+ concentration ([Ca2+]i) with 1 microM thapsigargin increased PLD activity to 50% and 70% of the maximal value obtained with CCK8 respectively. The stimulatory effects of CCK8, PMA and thapsigargin were abolished in cells in which PKC was downregulated or inhibited by chelerythrine. PMA/Ca2+-stimulated PLD activity was absent in a homogenate of PKC-downregulated cells but could be restored upon addition of purified rat brain PKC. CCK8-induced PLD activation was inhibited by 90% in the absence of external Ca2+, demonstrating that receptor-mediated activation of PKC in itself does not significantly add to PLD activation but requires a sustained increase in [Ca2+]i. Taken together, the results presented demonstrate that, in CHO-CCK-A cells, receptor-mediated PLD activation is completely dependent on PKC, but that the extent to which PLD becomes activated depends largely, if not entirely, on the magnitude and duration of the agonist-induced increase in [Ca2+]i.

U73122 and U73343 inhibit receptor-mediated phospholipase D activation downstream of phospholipase C in CHO cells

The aminosteroid 1-(6-¿[17beta-3-methoxyestra- 1,3,5(10)-trien- 17-yl]-amino¿hexyl)- 1H-pyrrole-2,5-dione (U73122) and its inactive analogue 1-(6-¿[17beta-3-methoxyestra-1,3,5(10)-trien- 17-yl]-amino¿hexyl-2,5-pyrrolidine-dione (U73343) are widely used to study the involvement of G protein-coupled 1-phosphatidylinositol-phosphodiesterase, or phospholipase C, in receptor-mediated cell activation. The present work shows that both aminosteroids inhibit cholecystokinin-(26-33)-peptide amide (CCK-8)-induced phospholipase D activation equipotently in Chinese hamster ovary cells expressing the cholecystokinin-A receptor (CHO-CCK(A) cells). In addition, the two aminosteroids virtually completely inhibited thapsigargin- and 12-O-tetradecanoylphorbol 13-acetate (TPA)-induced phospholipase D activation. Since the latter two drugs mimic inositol 1,4,5-trisphosphate-mediated Ca2+ mobilisation and 1,2-diacylglycerol-mediated protein kinase C activation. respectively, this suggests that both U73122 and U73343 act downstream of phospholipase C to inhibit receptor-mediated phospholipase D activation. U73122, but not U73343. effectively inhibited both TPA/Ca2+-stimulated phospholipase D activation and TPA/phosphatidylserine-stimulated protein kinase C activation in a homogenate of CHO-CCK(A) cells. The data presented suggest that U73122 may act at the level of protein kinase C to inhibit activation of phospholipase D. The exact site of action of U73343 is presently unknown.

Practical considerations for managing asthma in adults

Asthma is a common, chronic inflammatory disorder of the airways associated with pronounced health and economic consequences. Consistent and effective education that promotes an active partnership with patients remains the cornerstone for managing asthma. Identification and control of asthma triggers, regular monitoring of lung function, and adequate pharmacologic therapy are three other critical components. In this article, we describe several practical considerations for developing a collaborative, multidisciplinary approach to asthma care that emphasizes patient education and strengthens the partnership between patients and health-care professionals.

Tribological evaluation of oxidized zirconium using an articular cartilage counterface: a novel material for potential use in hemiarthroplasty

Problems with total joint replacement that have surfaced in recent years have made reconsideration of more conservative hip reconstructive procedures compelling. Moreover, procedures such as hemiarthroplasty might benefit from newly developed materials that could provide more favourable tribological performance when employed as a counterface for articulation with articular cartilage. The objective of this study was to evaluate the tribology of a new biomaterial, oxidized zirconium, with articular cartilage in a laboratory test apparatus. Oxidized zirconium components are produced by oxidizing the zirconium alloy to form a relatively thick (7 microns), adherent, abrasion-resistant ceramic surface. We found that the coefficient of friction of bovine articular cartilage rubbed against oxidized zirconium was lower than with cobalt-chromium alloy control surfaces, and that there was a trend toward less wear with oxidized zirconium. A defined layer of degraded tissue was found on the surface of the articular cartilage specimens, providing some indication of the mechanism of wear. Results of this study warrant further investigation of oxidized zirconium as the bearing surface for hemiarthroplasty.

Amplification and expression of EMS-1 (cortactin) in head and neck squamous cell carcinoma cell lines

Amplification of chromosome 11q13 DNA sequences is detected in approximately 30% of primary head and neck squamous cell carcinomas (HNSCC). The amplified region includes genes for cyclin D1, hst-1, int-2, and more recently, ems-1. Ems-1 encodes an 80/85kd cytoskeletal associated protein termed cortactin, which has been shown to bind F-actin and is a pp60src substrate. We investigated 16 HNSCC cell lines for ems-1 DNA amplification and gene expression by western blotting and immunofluorescence using mAb 4F11. Amplification of ems-1 DNA was detected in 8/16 (50%) cell lines and was related directly to over-expression of cortactin by western blotting and immunofluorescence. Western blotting detected both forms of cortactin, p80 and p85, at equal intensity. Immunofluorescent staining revealed low levels of cortactin localized to the cytoplasm and surface membrane in normal bronchial epithelial cells and tumor cell cultures with single copy ems-1 DNA. In contrast, tumor cell cultures with ems-1 DNA amplification demonstrated intense, homogeneous cortactin cytoplasmic staining. These results suggest that overexpression of p80/85 may be a useful marker to identify 11q13 amplification, a molecular alteration correlated with the presence of lymph node metastasis in head and neck cancer.

Degradation of Escherichia coli uncB mRNA by multiple endonucleolytic cleavages

The mechanism of segmental decay of the uncB sequence near the 5' end of the 7-kb Escherichia coli unc operon mRNA was investigated. Northern (RNA) blots of mRNA expressed from a plasmid carrying the uncBE portion of the operon revealed that the uncB message was rapidly degraded by multiple internal cleavages which resulted in the formation of at least five discrete species having a common 3' end. Turnover studies indicated that processing rapidly converted all species to the smallest. Identification of the 5' ends by primer extension analysis revealed that the cleavages were made either in the uncB coding region or in the intercistronic region between uncB and uncE, the latter being the most 3' cleavage. An rne mutant strain contained much higher levels of the uncBE message, implying that RNase E, the product of the rne gene, is essential for the normal degradation of uncB, and a number of the 5' ends were not detected in the rne mutant. The cleavage sites in chromosomally encoded unc mRNA were also identified by primer extension. These studies reveal that the segmental decay of the uncB region of unc mRNA occurs rapidly through a series of endonucleolytic cleavages. The rapid decay of uncB is expected to play a role in limiting expression of this gene relative to that of the other genes of the operon.

Avoidance and management of adverse reactions to antituberculosis drugs

Potent antibiotics are required to cure tuberculosis and reduce the burden of illness in the community. Minor adverse effects are commonly encountered and can be managed by reassurance and explanation. Significant hypersensitivity reactions require cessation of all antituberculosis drugs. Adverse effects should be treated appropriately. An effective antituberculosis regimen should be reestablished as soon as possible. Desensitisation may be necessary if suitable alternative drugs cannot be used. In the event of drug-induced hepatitis, all hepatotoxic drugs should be ceased until symptoms resolve and liver function tests return to normal. Other significant direct toxic effects should be promptly detected and appropriately treated. A thorough knowledge of potential adverse reactions and pharmacokinetics is essential for any physician using antituberculosis drugs.

Gossypibomas mimicking echinococcal cyst disease of the lung

Gossypibomas, masses of retained cotton materials, may produce a variety of postoperative complications. This case report of hemoptysis of 18 months' duration and cavitating chest masses in a 62-year-old man with previous cardiac operations illustrates several salient features about the presentation, differential diagnosis, and management of gossypibomas.

The role of transcarinal needle aspiration in the staging of bronchogenic carcinoma

Metastatic spread to subcarinal lymph nodes in patients with bronchogenic carcinoma generally indicates unresectability. Transcarinal needle aspiration of the main carina (TCNA) has been used to obviate the need for more invasive procedures, particularly thoracic surgery. Of 510 transbronchial needle aspirations performed at our institution from 1983 to 1991, 88 (17 percent) were from the main carina in patients with bronchogenic carcinoma. We reviewed these 88 TCNA procedures to assess our experience with TCNA in the staging of lung cancer. The TCNA results were positive in 32 of 88 (36 percent) patients (20 non-small-cell cancers, 12 small-cell lung cancers). Following bronchoscopy, TCNA was the only evidence of unresectability in all 20 patients with non-small-cell lung cancer and was the only mode of diagnosis in 5 of 12 (42 percent) patients with small-cell lung cancer. Thirteen patients with non-small-cell lung cancer and positive TCNA also had positive bronchial secretion cytologic studies. Five of these patients had further subcarinal sampling and in all cases metastatic involvement was confirmed. TCNA was positive in 29 of 67 (43 percent) patients with radiographic evidence of mediastinal adenopathy. Of the remaining 38 patients with radiographic evidence of mediastinal adenopathy and negative TCNA results, 23 patients had further mediastinal sampling with mediastinoscopy or thoracotomy and in all cases mediastinal spread of cancer was established. Nineteen of 58 (33 percent) patients with an endoscopically normal-appearing main carina had a positive TCNA, while 13 of 30 (43 percent) patients with broadening or widening of the main carina had positive TCNA results. There were no complications. We conclude that TCNA is often a safe and useful staging modality in patients with bronchogenic carcinoma.

Angiosarcoma in the lung

Angiosarcoma involving the lung is a rare disorder and its clinical features are not well known. We conducted a retrospective analysis of 15 patients seen at our institution from 1950 to 1990 in an attempt to better characterize the spectrum of clinical and radiographic findings of angiosarcoma in the lung. No documented case of primary angiosarcoma of the lung was seen. The diagnosis of metastatic angiosarcoma to the lung was made antemortem in 12 of 15 cases, either by lung biopsy specimen (5 patients), biopsy evidence of metastatic disease elsewhere with abnormal chest radiograph (4 patients), or a compatible clinical picture in a patient with previously documented angiosarcoma arising in an extrapulmonary site (3 patients). The median age at the time of diagnosis was 45 years with the most common presenting symptom being hemoptysis (7 of 15 patients). Other presenting complaints included weight loss (6 of 15), cough (4 of 15), and chest pain (4 of 15) occurring 6 weeks to 1 year prior to diagnosis. Chest radiographs frequently disclosed multiple pulmonary nodules (11 of 15). Primary origins of the angiosarcoma most commonly included the heart and breast. Metastatic sites other than the lung included the pericardium, liver, spleen, kidney, adrenal gland, bone, and brain. The prognosis is generally poor, with our study population surviving an average of 9 months after diagnosis.

Staging systems of lung cancer

The staging of lung cancer involves assessment of the anatomic extent of disease based on the best available data. Such a definition of neoplastic burden facilitates the systematic analysis and meaningful communication of diagnostic, therapeutic, and prognostic information. Clinical staging involves the best estimate of extent of disease before performance of surgical resection or biopsy procedures (or both). Surgical-pathologic staging is based on the histopathologic analysis of resected specimens, including determining the extent of local and regional disease. During the past 50 years, two major classification schemes for staging of lung cancer have evolved--one for non-small-cell lung cancers (the TNM system, indicating the status of primary tumor [T], regional lymph node [N], and metastatic [M] involvement) and the other for small-cell carcinoma of the lung (based on limited versus extensive disease). In this report, we review the evolution of the current staging systems used for primary lung cancer and their prognostic implications.

Paraneoplastic syndromes associated with lung cancer

Paraneoplastic phenomena associated with primary lung cancer have diverse initial manifestations and epitomize the systemic nature of human malignant disease. The spectrum of clinical features in patients with paraneoplastic syndromes ranges from mild systemic or cutaneous disease to hypercoagulability and severe neuromyopathic disorders. Although the diagnosis is often one of exclusion, an improved understanding of the pathogenesis involved in some of these syndromes has provided another means of recognizing the disorders and perhaps treating the affected patients. Proposed mechanisms of paraneoplastic processes include the aberrant release of humoral mediators such as hormones and hormone-like peptides, cytokines, and antibodies. In this update, we review the potential mechanisms, diagnosis, and treatment of paraneoplastic syndromes associated with lung cancer.

Clinical manifestations of lung cancer

The initial clinical manifestations of lung cancer are diverse and may occur with or without symptoms. Manifestations of pulmonary malignant lesions are produced by local growth or invasion, metastatic disease, or paraneoplastic processes. Patterns of local invasion such as Pancoast's syndrome or the superior vena cava syndrome are relatively uncommon but well recognized. Metastatic lung cancer can involve almost any anatomic area by hematogenous, lymphatic, or, occasionally, interalveolar dissemination. Complications related to malnutrition, infection, electrolyte disturbances, and coexisting diseases influence the initial manifestations. Although individual tumor cell types are associated with characteristic features, no constellation of findings is pathognomonic for a specific histologic variant. Because successful treatment of pulmonary carcinoma depends on early detection, awareness of the typical clinical manifestations is important.

Analysis of prostatic tumor cultures using fluorescence in-situ hybridization (FISH)

Analysis of ten primary prostatic tumor cultures using fluorescence in-situ hybridization (FISH) with pericentromeric probes for chromosomes 7, 8, 10, 16, 17, and 18 revealed aneusomies in nine of these specimens. Classical cytogenetics by G-banding indicated that only four of those same ten specimens had any (but not consistent) clonal abnormalities. This preliminary study suggests that aneusomy is a common event in early-stage prostatic tumors, and also supports the notion that multiple chromosomes are involved. In combination with routine cytogenetic analysis, FISH is thus likely to be a powerful tool in the evaluation of prostatic cancer.

RNase E-dependent cleavages in the 5' and 3' regions of the Escherichia coli unc mRNA

The endonucleolytic processing of the unc mRNA encoding the eight subunits of the Escherichia coli F1F0-ATPase was studied. Northern (RNA) blots of mRNA expressed from a plasmid which contained the 3'-terminal portion of the operon including the uncDC sequences revealed, in addition to the expected 2-kb mRNA, a 0.5-kb RNA species which hybridized to an uncC antisense RNA probe. An uncD antisense RNA probe hybridized to only the 2-kb mRNA, implying that the upstream 1.5-kb fragment is rapidly degraded. The 5' end of the 0.5-kb fragment was determined by primer extension analysis to be 11 bases into the coding region of the uncC gene. In RNase E-deficient strains, the amount of the 0.5-kb product was strongly reduced while the levels of the precursor uncDC transcript remained high. Similar RNase E-dependent processing was found in the chromosomally encoded unc mRNA. As this RNase E-dependent cleavage directly inactivates uncC and appears to leave uncD susceptible to degradation, it seems unlikely to play a role in differential expression of the gene products but may be an important event in unc mRNA degradation. RNase E mutants also showed altered processing of the chromosomally encoded unc mRNA in the uncB region near the 5' end. The expected full-length (7-kb) transcript was recognized when RNA from the RNase E-deficient strain was subjected to Northern blot analysis with uncB- and uncC-specific probes. RNA from strains with functional RNase E lacked the 7-kb transcript but had a 6.2-kb mRNA detectable with the uncC but not the uncB probe. RNase E is therefore implicated in multiple cleavages of the unc mRNA.

Characterization of 10 marker chromosomes in a prostatic cancer cell line by in situ hybridization

Marker chromosomes contain potentially valuable information about breakpoints in cancer. However, routine banding procedures, by themselves, provide only limited information about the identity of marker chromosomes. In this study, the use of fluorescence in situ hybridization (FISH) with chromosome-specific centromeric probes and whole-chromosome-specific DNA libraries greatly enhanced the identification of 10 marker chromosomes in the primary prostatic cancer cell line PPC-1. Centromeric probes for chromosomes 1, 2, 3, 4, 10, 12, and 17 and whole-chromosome paint libraries for chromosomes 1, 2, 3, 4, 8, and 12, in conjunction with analysis of G-banded metaphases, allowed the major portion(s) of these 10 PPC-1 marker chromosomes to be defined. The results increase the number of identifiable chromosomal breakpoints in this cell line from 9 to 28 sites.