Anti-insulin B cell receptors display skewed immunoglobulin gene usage and limited mutation in pre-symptomatic type 1 diabetes donors

Antibodies targeting insulin and other islet antigens predict type 1 diabetes (T1D) onset. Insulin autoantibody (IAA)-positive individuals progress to diabetes more rapidly, yet little is known about how IAA-precursor anti-insulin B cells (AIBCs) recognize insulin. Complementarity-determining regions (CDRs) of the B cell receptor (BCR) are structurally diverse loops that constitute the antigen-binding site, and amino acid variability in BCRs increases the breadth of repertoire antigen-specificities. To investigate anti-insulin BCRs during the earliest detectable stages of T1D, we enrolled eight insulin therapy-naïve Type 1 Diabetes TrialNet Pathway to Prevention participants who were positive for ≥2 islet autoantibodies and thus at high risk for diabetes. We stimulated donor peripheral blood mononuclear cells to drive BCR secretion as antibody, screened for AIBC-containing wells by ELISA, and immortalized these cells as hybridomas. We validated 25 monoclonal anti-insulin hybridoma lines and sequenced 16 heavy chain (IgH) and 14 light chain (IgL) immunoglobulin genes. 25% of VH and 50% of VL sequences contained at least one mutation within a CDR compared to germline, with 13% of VH and 29% of VL sequences having ≥6 mutations within the V-region. We surveyed previously and currently reported AIBC VH (n=25 BCRs), which revealed skewed VH and JH gene use compared to the total polyclonal IgH repertoire (n= 8790 BCRs, p < 0.001 and p < 0.05, respectively, chi-squared test). These data expose unique features of insulin recognition among AIBCs isolated from pre-symptomatic T1D donors, including V and J gene usage bias and potential for germline IgH insulin recognition, providing genetic and molecular insight into AIBC origins.

Role of spirituality in adjustment of patients with advanced heart failure

Heart failure is a chronic and progressive disease often characterized by severe symptoms, frequent hospitalization, and poor prognosis. It may threaten the individual's sense of self and lead to questions related to spirituality. The purpose of this qualitative, phenomenologic study was to describe the role of spirituality in the adjustment of patients to advanced heart failure. Purposive sampling of all patients who presented to two university-affiliated, outpatient heart failure clinics was used. Eighty-seven patients were interviewed using a semistructured questionnaire. Data were subjected to content analysis and thematic coding. Patients described a three-step process where spirituality contributed to their adjustment to advanced heart failure: development of regret regarding past behaviors and lifestyles; the search for meaning within the present experience of heart failure; and the search for hope for the future and reclaiming of optimism. Assessment and interventions that include a spiritual dimension can facilitate the adjustment of patients to advanced heart failure.

Mutation of Trp1254 in the multispecific organic anion transporter, multidrug resistance protein 2 (MRP2) (ABCC2), alters substrate specificity and results in loss of methotrexate transport activity

The ATP-binding cassette (ABC) proteins comprise a large superfamily of transmembrane transporters that utilize the energy of ATP hydrolysis to translocate their substrates across biological membranes. Multidrug resistance protein (MRP) 2 (ABCC2) belongs to subfamily C of the ABC superfamily and, when overexpressed in tumor cells, confers resistance to a wide variety of anticancer chemotherapeutic agents. MRP2 is also an active transporter of organic anions such as methotrexate (MTX), estradiol glucuronide (E217betaG), and leukotriene C4 and is located on the apical membrane of polarized cells including hepatocytes where it acts as a biliary transporter. We recently identified a highly conserved tryptophan residue in the related MRP1 that is critical for the substrate specificity of this protein. In the present study, we have examined the effect of replacing the analogous tryptophan residue at position 1254 of MRP2. We found that only nonconservative substitutions (Ala and Cys) of Trp1254 eliminated [3H]E217betaG transport by MRP2, whereas more conservative substitutions (Phe and Tyr) had no effect. In addition, only the most conservatively substituted mutant (W1254Y) transported [3H]leukotriene C4, whereas all other substitutions eliminated transport of this substrate. On the other hand, all substitutions of Trp1254 eliminated transport of [3H]MTX. Finally, we found that sulfinpyrazone stimulated [3H]E217betaG transport by wild-type MRP2 4-fold, whereas transport by the Trp1254 substituted mutants was enhanced 6-10-fold. In contrast, sulfinpyrazone failed to stimulate [3H]MTX transport by either wild-type MRP2 or the MRP2-Trp1254 mutants. Taken together, our results demonstrate that Trp1254 plays an important role in the ability of MRP2 to transport conjugated organic anions and identify this amino acid in the putative last transmembrane segment (TM17) of this ABC protein as being critical for transport of MTX.

Educational needs of patients with advanced heart failure and their caregivers

At the time of initial transplant evaluation, we evaluated the information and counseling needs of 82 outpatients with advanced heart failure and compared them with the needs of 74 of their caregivers. Both groups answered a 23-item questionnaire, which used a 5-point Likert scale to assess needs across 6 sub-scales specific to heart failure and the process of determining transplant eligibility. The 5 most important learning needs of patients and caregivers were similar, and we found significant differences only in the groups' responses to 3 individual questions. We conclude that nurses can meet the needs of patients and their caregivers by providing honest explanations, focusing on enhanced quality of life issues, and giving information for dealing with an emergency.

Sexuality of patients with advanced heart failure and their spouses or partners

BACKGROUND

Sexuality is an important aspect of quality of life for patients with advanced heart failure and their spouses or partners. Therefore, we conducted a study to determine the types of sexual problems and concerns of patients and their spouses/partners, their level of interest in receiving information on this topic, and the relationship between their need for information and the degree of sexual problems.

METHODS

Sixty-three couples were recruited from a university-affiliated, outpatient, heart failure program during their initial visit.

RESULTS

The most important sexual relationship issue of both patients and spouses/partners was related to decreased frequency in sexual relations. They reported the need to receive specific information about sexual activity as moderate to very high, but it was unrelated to the level of need for education and counseling.

CONCLUSIONS

Nurses and physicians need to assume interest and provide instruction related to the sexual activity needs of patients and their spouses/partners.

Commitment to function: microsurgical flaps

Microsurgical procedures facilitate the optimal function of patients and provide for an enhanced quality of life. The contribution of this procedure to the eventual positive outcome of multiple patient populations is clear. Therefore, competence in the care of this emerging patient population is essential for the plastic surgical nurse. This article has outlined the history of free flaps, flap anatomy and physiology, evaluation of flap vascularity, and postoperative nursing care. Further work needs to be performed in order to definitively describe nursing and medical interventions, delineate effective wound management techniques, and develop monitoring devices that will augment the success of the free flap procedure.

Cardiovascular effects of recreational cocaine abuse

Deaths related to the recreational use of cocaine in the United States have increased to epidemic proportions within the last decade. Frequently, persons with cocaine toxicity present to the emergency room, require critical care nursing, and are admitted to the intensive care unit. This article outlines the cardiovascular effects of recreational cocaine abuse. Initially, the historical perspective of the drug is outlined. The mechanism of action, administration, absorption, and excretion are discussed. Details regarding the cardiovascular effects of cocaine are described. Although no uniform treatment plan has been developed for every complication of cocaine overdose, the current therapeutic modalities are outlined. Finally, the clinical implications for clinical practice are addressed. The recreational abuse of cocaine presents new patient care challenges for the critical care nurse. With increased knowledge, the health care provider may assist in meeting the clinical needs of this emerging patient population.

Randomized study of high dose oral cyclosporine therapy for mild acute cardiac rejection

Mild acute rejection progresses to moderate rejection in approximately one third of the cases. Standard rejection therapy would then be instituted with the attendant risk of infection and other side effects. We randomized 40 episodes of mild acute rejection (20 episodes in each group) to receive no additional therapy or to have the oral cyclosporine dose increased for 7 to 10 days with repeat endomyocardial biopsy performed. In the group with no additional therapy 30% progressed to moderate rejection, whereas in the group with increased doses of oral cyclosporine, 10% progressed to moderate rejection (p = 0.10). As the purpose of our study was to assess the efficacy of increased cyclosporine levels for preventing progression from mild to moderate rejection, the treated group was redefined according to whether the cyclosporine level increased by greater than or equal to 50% during the study. In this treated group average cyclosporine levels increased from 169 +/- 78 to 413 +/- 267 ng/ml. Progression to moderate rejection occurred in one of 21 cases (5%) compared with seven of 19 cases (37%) in the group without an increase in cyclosporine level (p less than 0.05). The transient increase in cyclosporine levels was well tolerated. This study demonstrates that the use of high dose oral cyclosporine to treat mild acute rejection is well tolerated and may reduce progression to moderate rejection when a significant increase in cyclosporine level is achieved.