Patient perspectives on emergency department initiation of medication for alcohol use disorder

OBJECTIVE

Alcohol use disorder (AUD) is a leading cause of preventable death and is a frequent diagnosis in the emergency department (ED). Treatment in the ED, however, typically focuses on managing the sequelae of AUD, such as acute withdrawal, rather than addressing the underlying addiction. For many patients, these ED encounters are a missed opportunity to connect with medication for AUD. In 2020, our ED created a pathway to offer patients with AUD treatment with naltrexone (NTX) during their ED visit. The aim of this study was to identify what barriers and facilitators patients perceive to NTX initiation in the ED.

METHODS

Adopting the theoretical framework of the behavior change wheel (BCW), we conducted qualitative interviews with patients to elicit their perspectives on ED initiation of NTX. Interviews were coded and analyzed using both inductive and deductive approaches. Themes were categorized according to patients' capabilities, opportunities, and motivations. Barriers were then mapped through the BCW to design interventions that will improve our treatment pathway.

RESULTS

Twenty-eight patients with AUD were interviewed. Facilitators of accepting NTX included having recently experienced sequelae of AUD, rapid management of withdrawal symptoms by the ED provider, having a choice between intramuscular and oral formulations of the medication, and experiencing positive interactions in the ED that destigmatized the patient's AUD. Barriers to accepting treatment included lack of provider knowledge about NTX, dependence on alcohol as self-treatment for psychiatric trauma and physical pain, perceived discriminatory treatment and stigma about AUD, aversion to potential side effects, and lack of access to continued treatment.

CONCLUSIONS

Initiation of treatment of AUD with NTX in the ED is acceptable to patients and can be facilitated by knowledgeable ED providers who create a destigmatizing environment, effectively manage withdrawal symptoms, and connect patients to providers who will continue treatment.

Clinical Comparison of Three Indirect Pulp Capping Restorative Protocols: A Randomized Controlled Prospective Study

OBJECTIVES

The objective of this prospective double-blind clinical trial was to compare clinical outcomes of indirect pulp capping restorative protocols on permanent teeth over a 12-month period.

METHODS AND MATERIALS

Deep carious lesions in permanent teeth (90) were randomly assigned to three indirect pulp capping protocols (n=30: TheraCal LC, Dycal, and no liner). All teeth were restored with resin composite. The outcome measures were pain (VAS scale) and success rate (pulp vitality based on percussion, palpation, cold test, and radiographic findings), collected at screening, intervention, and 24-hour, 7-day, 3-month, 6-month, and 12-month follow-up visits.

RESULTS

There was no statistically significant difference in tooth sensitivity among the three indirect pulp capping protocols nor in success rates among the restorative protocols after 1 year of follow-up (p>0.1).The respective success rates, as defined by the tooth remaining vital, after 1 year were: 96.2% for TheraCal LC, 100% for Dycal, and 100% for no liner.

CONCLUSIONS

After 12-month evaluation, the success rate of indirect pulp capping therapy on permanent teeth was not affected by the pulp capping restorative protocol.

Using 3D Printing to Improve Student Education of Complex Anatomy: a Systematic Review and Meta-analysis

Objective

Additive manufacturing has played an increasingly important role in the field of health care. One of the most recent applications has been the development of 3D printed anatomical models specifically to improve student education. The purpose of this review was to assess the potential for 3D printed models to improve understanding of complex anatomy in undergraduate and medical/professional students.

Methods

A systematic review was performed to investigate the different implementations of 3D printed anatomical models in educational curricula. In addition, a meta-analysis was conducted to assess the differences in comprehension between students who received 3D printed models as part of their instruction and those taught with traditional methods.

Results

Of the 10 groups included in the meta-analysis, students whose educational experience included a 3D printed model scored roughly 11% better on objective assessments compared to students who did not use such models (Hedge's g = 0.742, p < 0.001).

Conclusion

Based on these findings, the use of 3D printed anatomical models as a method of education is likely to improve students' understanding of complex anatomical structures.

Evaluation of data quality in the Spanish EURECCA Esophagogastric Cancer Registry

BACKGROUND

Although the number of nationwide clinical registries in upper gastrointestinal cancer is increasing, few of them perform regular clinical audits. The Spanish EURECCA Esophagogastric Cancer Registry (SEEGCR) was launched in 2013. The aim of this study was to assess the reliability of the data in terms of completeness and accuracy.

METHODS

Patients who were registered (2014-2017) in the online SEEGCR and underwent esophagectomy or gastrectomy with curative intent were selected for auditing. Independent teams of surgeons visited each center between July 2018 and December 2019 and checked the reliability of data entered into the registry. Completeness was established by comparing the cases reported in the registry with those provided by the Medical Documentation Service of each center. Twenty percent of randomly selected cases per hospital were checked during on-site visits for testing the accuracy of data (27 items per patient file). Correlation between the quality of the data and the hospital volume was also assessed.

RESULTS

Some 1839 patients from 19 centers were included in the registry. The mean completeness rate in the whole series was 97.8% (range 82.8-100%). For the accuracy, 462 (25.1%) cases were checked. Out of 12,312 items, 10,905 were available for verification, resulting in a perfect agreement of 95% (87.1-98.7%). There were 509 (4.7%) incorrect and 35 (0.3%) missing entries. No correlation between hospital volume and the rate of completeness and accuracy was observed.

CONCLUSIONS

Our results indicate that the SEEGCR contains reliable data.

Textbook outcome and survival after gastric cancer resection with curative intent: A population-based analysis

BACKGROUND

The concept of textbook outcome (TO) has been proposed for analyzing quality of surgical care. This study assessed the incidence of TO among patients undergoing curative gastric cancer resection, predictors for TO achievement, and the association of TO with survival.

METHOD

All patients with gastric and gastroesophageal junction cancers undergoing curative gastrectomy between January 2014-December 2017 were identified from a population-based database (Spanish EURECCA Registry). TO included: macroscopically complete resection at the time of operation, R0 resection, ≥15 lymph nodes removed and examined, no serious postoperative complications (Clavien-Dindo ≥II), no re-intervention, hospital stay ≤14 days, no 30-day readmissions and no 90-day mortality. Logistic regression was used to assess the adjusted achievement of TO. Cox survival regression was used to compare conditional adjusted survival across groups.

RESULTS

In total, 1293 patients were included, and TO was achieved in 541 patients (41.1%). Among the criteria, "macroscopically complete resection" had the highest compliance (96.5%) while "no serious complications" had the lowest compliance (63.7%). Age (OR 0.53 for the 65-74 years and OR 0.34 for the ≥75 years age group), Charlson comorbidity index ≥3 (OR 0.53, 95%CI 0.34-0.82), neoadjuvant chemoradiotherapy (OR 0.24, 95%CI 0.08-0.70), multivisceral resection (OR 0.55, 95%CI 0.33-0.91), and surgery performed in a community hospital (OR 0.65, CI95% 0.46-0.91) were independently associated with not achieving TO. TO was independently associated with conditional survival (HR 0.67, 95%CI 0.55-0.83).

CONCLUSION

TO was achieved in 41.1% of patients who underwent gastric cancer resection with curative intent and was associated with longer survival.

Rheumatic myocarditis: a poorly recognized etiology of left ventricular dysfunction in valvular heart disease patients

Background

Heart failure is present in about 10% of patients with acute rheumatic fever (RF), and several studies showed that cardiac decompensation in RF results primary from valvular disease, and not due to primary myocarditis. However, literature is scarce in this topic and a recent case series showed that recurrent RF could cause ventricular dysfunction even in the absence of valvular heart disease.

Purpose

To evaluate clinical, laboratory and echocardiographic profile of rheumatic fever patients with confirmed myocarditis diagnosis using Fluorine-18-fluorodeoxyglucose positron emission tomography (18F-FDG PET/CT) or Gallium-67 cardiac scintigraphy.

Methods

Clinical, laboratory and imaging characteristics of 25 consecutive patients with diagnosis of myocarditis, using 18F-FDG PET/CT or gallium-67 cardiac scintigraphy (Figure 1A and 1B, respectively), and RF reactivation according to revised Jones Criteria, were evaluated. Patients underwent 3 sequential echocardiograms: (1) baseline, (2) during myocarditis and (3) post- corticosteroid treatment, and were divided according to the presence (Group 1) or absence (Group 2) of reduced left ventricular ejection fraction (LVEF) during myocarditis episode.

Results

Median age was 42 (17–51) years, 64% had more than 40 years and 64% were women. Comparing patients in Group 1 (n=16) with Group 2 (n=9), there was no demographic, echocardiographic or laboratory difference between groups, except for NYHA III/IV heart failure (Group 1: 100.0% versus Group 2: 50.0%; p=0.012) and LVEF (30 [25–37] versus 56 [49–62] %, respectively; p&lt;0.001), as expected. Group 1 patients had significant reduction of LVEF during carditis with further improvement after treatment (Figure 1C). There was no correlation between LVEF and valvular dysfunction during myocarditis. Of all patients, 19 (76%) underwent 18F-FDG PET/CT, with positive scan in 68.4% and 21 (84%) underwent Gallium-67 cardiac scintigraphy, with positive uptake in 95.2%, both with no difference between groups.

Conclusion

Myocarditis due to rheumatic fever reactivation can cause left ventricular dysfunction despite of valvular disease, and is reversible after corticosteroid treatment.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Rheumatic Myocarditis: A Poorly Recognized Etiology of Left Ventricular Dysfunction in Valvular Heart Disease Patients

Background: Heart failure occurs in ~10% of patients with acute rheumatic fever (RF), and several studies have shown that cardiac decompensation in RF results primarily from valvular disease and is not due to primary myocarditis. However, the literature on this topic is scarce, and a recent case series has shown that recurrent RF can cause ventricular dysfunction even in the absence of valvular heart disease. Methods: The present study evaluated the clinical, laboratory and imaging characteristics of 25 consecutive patients with a clinical diagnosis of myocarditis confirmed by 18F-FDG PET/CT or gallium-67 cardiac scintigraphy and RF reactivation according to the revised Jones Criteria. Patients underwent three sequential echocardiograms at (1) baseline, (2) during myocarditis and (3) post corticosteroid treatment. Patients were divided according to the presence (Group 1) or absence (Group 2) of reduced left ventricular ejection fraction (LVEF) during myocarditis episodes. Results: The median age was 42 (17-51) years, 64% of patients were older than 40 years, and 64% were women. Between Group 1 (n = 16) and in Group 2 (n = 9), there were no demographic, echocardiographic or laboratory differences except for NYHA III/IV heart failure (Group 1: 100.0% vs. Group 2: 50.0%; p = 0.012) and LVEF (30 [25-37] vs. 56 [49-62]%, respectively; p < 0.001), as expected. Group 1 patients showed a significant reduction in LVEF during carditis with further improvement after treatment. There was no correlation between LVEF and valvular dysfunction during myocarditis. Among all patients, 19 (76%) underwent 18F-FDG PET/CT, with a positive scan in 68.4%, and 21 (84%) underwent gallium-67 cardiac scintigraphy, with positive uptake in 95.2%, there was no difference between these groups. Conclusion: Myocarditis due to rheumatic fever reactivation can cause left ventricular dysfunction despite valvular disease, and it is reversible after corticosteroid treatment.

Brain lateralization in children with upper-limb reduction deficiency

Background

The purpose of the current study was to determine the influence of upper-limb prostheses on brain activity and gross dexterity in children with congenital unilateral upper-limb reduction deficiencies (ULD) compared to typically developing children (TD).

Methods

Five children with ULD (3 boys, 2 girls, 8.76 ± 3.37 years of age) and five age- and sex-matched TD children (3 boys, 2 girls, 8.96 ± 3.23 years of age) performed a gross manual dexterity task (Box and Block Test) while measuring brain activity (functional near-infrared spectroscopy; fNIRS).

Results

There were no significant differences (p = 0.948) in gross dexterity performance between the ULD group with prosthesis (7.23 ± 3.37 blocks per minute) and TD group with the prosthetic simulator (7.63 ± 5.61 blocks per minute). However, there was a significant (p = 0.001) difference in Laterality Index (LI) between the ULD group with prosthesis (LI = − 0.2888 ± 0.0205) and TD group with simulator (LI = 0.0504 ± 0.0296) showing in a significant ipsilateral control for the ULD group. Thus, the major finding of the present investigation was that children with ULD, unlike the control group, showed significant activation in the ipsilateral motor cortex on the non-preferred side using a prosthesis during a gross manual dexterity task.

Conclusions

This ipsilateral response may be a compensation strategy in which the existing cortical representations of the non-affected (preferred) side are been used by the affected (non-preferred) side to operate the prosthesis. This study is the first to report altered lateralization in children with ULD while using a prosthesis.

Trial registration The clinical trial (ClinicalTrial.gov ID: NCT04110730 and unique protocol ID: IRB # 614-16-FB) was registered on October 1, 2019 (https://clinicaltrials.gov/ct2/show/NCT04110730) and posted on October 1, 2019. The study start date was January 10, 2020. The first participant was enrolled on January 14, 2020, and the trial is scheduled to be completed by August 23, 2023. The trial was updated January 18, 2020 and is currently recruiting

RESULTS OF VERA APPLICATION TO THE AP1000® PWR STARTUP

This paper describes the application of the Virtual Environment for Reactor Applications, VERA, under development by the Consortium for Advanced Simulation of LWRs (CASL) to the core physics analysis of the AP1000 PWR.

The AP1000 PWR features an advanced first core with radial and axial heterogeneities which provides significant enhancements compared to traditional first cores, allowing best fuel usage and short transition to the equilibrium cycle with subsequent fuel reloads. These core advanced features can pose some challenges to the core physics tools making application of VERA to the AP1000 PWR first core especially relevant to qualify VERA performance.

This paper focuses on the qualification efforts at hot zero power conditions, where Monte-Carlo reference solutions have also been established. In particular, the paper focuses on the comparison of the predictions obtained with VERA for the four AP1000 units that recently started up with the measured values. It is shown that there is excellent agreement between VERA and the key reactor physics parameters measured during the AP1000 startup.

Acanthosis nigricans as a composite marker of cardiometabolic risk and its complex association with obesity and insulin resistance in Mexican American children

AIM

Acanthosis nigricans (AN) is a strong correlate of obesity and is considered a marker of insulin resistance (IR). AN is associated with various other cardiometabolic risk factors (CMRFs). However, the direct causal relationship of IR with AN in obesity has been debated. Therefore, we aimed to examine the complex causal relationships among the troika of AN, obesity, and IR in Mexican Americans (MAs).

METHODS

We used data from 670 non-diabetic MA children, aged 6-17 years (49% girls). AN (prevalence 33%) severity scores (range 0-5) were used as a quasi-quantitative trait (AN-q) for analysis. We used the program SOLAR for determining phenotypic, genetic, and environmental correlations between AN-q and CMRFs (e.g., BMI, HOMA-IR, lipids, blood pressure, hs-C-reactive protein (CRP), and Harvard physical fitness score (PFS)). The genetic and environmental correlations were subsequently used in mediation analysis (AMOS program). Model comparisons were made using goodness-of-fit indexes.

RESULTS

Heritability of AN-q was 0.75 (p<0.0001). It was positively/significantly (p<0.05) correlated with traits such as BMI, HOMA-IR, and CRP, and negatively with HDL-C and PFS. Of the models tested, indirect mediation analysis of BMI→HOMA-IR→AN-q yielded lower goodness-of-fit than a partial mediation model where BMI explained the relationship with both HOMA-IR and AN-q simultaneously. Using complex models, BMI was associated with AN-q and IR mediating most of the CMRFs; but no relationship between IR and AN-q.

CONCLUSION

Our study suggests that obesity explains the association of IR with AN, but no causal relationship between IR and AN in Mexican American children.

Use of a three-dimensional printed anatomical model for tumor management in a pediatric patient

The purpose of this study was to investigate the usage of an anatomical model to improve surgical planning of a complex schwannoma resection. As advancements in additive manufacturing continue to prosper, new applications of this valuable technology are being implemented in the medical field. One of the most recent applications has been in the development of patient-specific anatomical models for unique clinical education as well as for preoperative planning. In this case, a multidisciplinary team with expertise in research, three-dimensional printing, and medicine was formed to develop a three-dimensional printed model that could be used to help plan the reduction of a tumor from the cervical spine of a pediatric patient. Image segmentation and stereolithography creation were accomplished using Mimics and 3-matic, respectively. Models were developed on two different printer types to view different aspects of the region of interest. Reports from the operating surgeon indicated that the model was instrumental in the planning procedures of the operation and reducing operation time.

Bridging the Gaps Through Nurse-Led Nutrition Education to Underserved Children

Although children residing in impoverished rural communities located along the Texas-Mexico border are at disproportionately high risk of unhealthy eating, limited resources may prevent devoting sufficient attention to school-based nutrition education. The purpose of this quasi-experimental study was to examine the teaching effectiveness of graduate nursing students on fourth-grade student learning about healthy eating. Purposive sampling was used to select 213 predominately Hispanic fourth-grade students enrolled in one of three low-socioeconomic status underserved elementary schools located in rural South Texas. Ten graduate nursing students implemented the Creating Healthy Eating Choices for Kids Nutrition Curriculum to approximately 40 fourth-graders per group who attended weekly 45- to 50-minute sessions for 6 weeks. The MyPlate standardized tests were administered before and following the intervention. Results showed a significant improvement in learning on all program modules for fourth-graders from each school ( p = .000). Results support the value of creating a strategic partnership between a university school of nursing and key community leaders as a feasible method of providing nutrition education for fourth-graders enrolled in schools with limited resources.

Continuous interscalene brachial plexus blockade is associated with reduced length of stay after shoulder arthroplasty

BACKGROUND

Catheter-delivered continuous interscalene anesthesia has demonstrated improved pain control in randomized clinical trials. The purpose of this study is to determine whether the introduction of continuous catheter anesthesia was associated with a change in length of stay (LOS), readmission, rates of discharge home without home health or nursing services, or opioid administration. We hypothesized that the introduction of continuous catheter anesthesia would be associated with a decrease in LOS, readmission, non-home discharge, and opioid administration.

METHODS

During 2012, our center transitioned from ultrasound-guided single-dose interscalene regional anesthesia to combined single-dose anesthesia and additional continuous catheter anesthesia over 48-72hours. This retrospective chart review compared primary shoulder arthroplasties with single-dose anesthesia to those with continuous catheter anesthesia, after excluding the learning curve, with univariate and multivariate analyses.

RESULTS

In total, 1697 patients met criteria, 41% with single-dose anesthesia and 59% with continuous catheter anesthesia. On univariate analysis, the continuous catheter group LOS was 2.2±0.7 day and single-dose group LOS was 2.5±0.8 days (P≤0.001). One day LOS's comprised 1% of the single-dose group and 27% of the continuous catheter group (P<0.001). Anesthesia type remained a significant predictor on multivariate analysis (P<0.001) Readmission at 30 and 90 days (P=0.091 and 0.576), and home discharge (P=0.456) were not different. Opioid administration was higher in the continuous catheter group on univariate analysis (P<0.001), but not on multivariate analysis (P=0.607).

CONCLUSION

In this retrospective review of 1697 primary shoulder arthroplasties performed at our high-volume, referral center, continuous catheter anesthesia was associated with reduced length of stay when compared to single-dose anesthesia.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Can posterior capsular stretching rehabilitation protocol change scapula kinematics in asymptomatic baseball pitchers?

PURPOSE

Scapular dyskinesis is a recognized cause of shoulder pain in the throwing shoulder of baseball pitchers and athletes who participate in overhead sports. Past studies have assessed scapular kinematics using electromagnetic tracking devices and have shown a correlation between posterior shoulder tightness and forward scapular posture. The purpose of our study is to evaluate the scapular kinematics, before and after a 4-week posterior stretching protocol in asymptomatic pitchers.

METHOD

Eleven asymptomatic collegiate baseball pitchers were involved in the study and divided into group A (6 pitchers) underwent 4 weeks of a regimented therapy protocol and group B (5 pitchers) did not receive any treatment. Each pitcher was tested on two separate days: at the first day of the study (S1) and after 4 weeks (S2).

RESULTS

The results demonstrate that there are statistically significant differences in the kinematics of several athletes from the "treated group" (group A) between S1 and S2. It is also important to notice that variations in group A occurred in both flexextension and ab/adduction movements, strengthening the conclusion that the variation was real.

CONCLUSION

The results of the study can indicate that, in order to prevent the pathologic cascade linked to these sports activities, this physical training protocol might become integral part of the normal daily exercises of baseball pitchers and overhead athletes. Level of evidence II.

High prevalence of bla OXA-23 in Acinetobacter spp. and detection of bla NDM-1 in A. soli in Cuba: report from National Surveillance Program (2010-2012)

As a first national surveillance of Acinetobacter in Cuba, a total of 500 Acinetobacter spp. isolates recovered from 30 hospitals between 2010 and 2012 were studied. Acinetobacter baumannii–calcoaceticus complex accounted for 96.4% of all the Acinetobacter isolates, while other species were detected at low frequency (A. junii 1.6%, A. lwoffii 1%, A. haemolyticus 0.8%, A. soli 0.2%). Resistance rates of isolates were 34–61% to third-generation cephalosporins, 49–50% to β-lactams/inhibitor combinations, 42–47% to aminoglycosides, 42–44% to carbapenems and 55% to ciprofloxacin. However, resistance rates to colistin, doxycycline, tetracycline and rifampin were less than 5%. Among carbapenem-resistant isolates, 75% harboured different bla_OXA genes (OXA-23, 73%; OXA-24, 18%; OXA-58, 3%). The bla_NDM-1 gene was identified in an A. soli strain, of which the species was confirmed by sequence analysis of 16S rRNA gene, rpoB, rpoB–rpoC and rpoL–rpoB intergenic spacer regions and gyrB. The sequences of bla_NDM-1 and its surrounding genes were identical to those reported for plasmids of A. baumannii and A. lwoffi strains. This is the first report of bla_NDM-1 in A. soli, together with a high prevalence of OXA-23 carbapenemase for carbapenem resistance in Acinetobacter spp. in Cuba.

First Report of Alternaria Black Spot of Pomegranate Caused by Alternaria alternata in Spain

Since 2010, a new foliar and fruit disease was observed in pomegranate (Punica granatum L.) orchards in Alicante Province (eastern Spain). Symptoms included black spots on leaves and fruits, as well as chlorosis and premature abscission of leaves. Fungal isolates were obtained by surface-disinfecting small fragments of symptomatic leaf and fruit tissues in 0.5% NaOCl, double-rinsing in sterile water, and plating them onto potato dextrose agar (PDA) amended with 0.5 g/liter of streptomycin sulfate. Gray-to-black colonies were obtained, which were identified as Alternaria sp. based on the dark, brown, obclavate to obpyriform catenulate conidia with longitudinal and transverse septa tapering to a prominent beak attached in chains on a simple and short conidiophore (4). Conidia (n = 100) measured (12.2-) 20.2 (-27.6) × (5.7-) 9.2 (-12.0) μm, and had 3 to 6 transverse and 0 to 5 longitudinal septa. Single spore cultures were obtained and their genomic DNA was extracted. The internal transcribed spacer (ITS) region of rDNA and partial sequences of the beta tubulin gene were amplified and sequenced with primers ITS1-ITS4 and Bt1a-Bt1b, respectively (3). BLAST analysis of the sequences showed that they were 100% identical to a pathogenic A. alternata (Fr.) Keissl. isolate obtained from black spot disease of pomegranate in Israel (Accession No. JN247826.1, ITS and Accession No. JN247836.1, beta tubulin) (2). As all the sequences obtained showed 100% homology, ITS and beta tubulin sequences of a representative isolate (1516B) were submitted to GenBank (KF199871 and KF199872, respectively). In addition, a PCR reaction with specific primers (C_for/C_rev) designed to recognize highly virulent isolates of A. alternata causing black spot of pomegranate was used with all isolates (2). A characteristic fragment of ~950 bp was amplified in two isolates: 1552B and 1707B. Pathogenicity was assessed on plants and detached fruit of pomegranate cv. Mollar (1). Two-year-old pomegranate trees were inoculated with isolates 1552B and 1707B by spraying a conidial suspension (10⁶ conidia/ml) onto the upper and lower leaf surfaces. Five plants per fungal isolate were used and five control plants were sprayed with sterile water. Plants were covered with transparent plastic bags and incubated in a growth chamber for 1 month at 25°C, with a 12-h photoperiod. One-month-old fruits were surface sterilized in 1.5% sodium hypochlorite solution for 1 min and rinsed twice in water. Two filter paper squares (5 × 5 mm) were dipped in the conidial suspensions and placed on the fruit surface. Inoculated fruit were incubated in a humid chamber in the dark at 25°C. Ten fruit per fungal isolate were used and 10 control fruit were inoculated with sterile water. Black spots were visible on inoculated leaves and fruit, 10 and 3 days after inoculation, respectively. Symptoms were not observed on controls. The fungus was re-isolated from leaf and fruit lesions, confirming Koch's postulates. Leaf black spot of pomegranate caused by A. alternata was first described in India in 1988, and later in Israel in 2010 affecting both fruit and leaves (1). To our knowledge, this is the first report of the disease in Spain, where it could represent a threat for pomegranate cultivation due to the increasing amount of area dedicated to this crop. References: (1) D. Ezra et al. Australas. Plant Dis. Notes 5:1, 2010. (2) T. Gat et al. Plant Dis. 96:1513, 2012. (3) N. L. Glass and G. C. Donaldson. Appl. Environ. Microbiol. 61:1323, 1995. (4) E. G. Simmons. Alternaria: An identification manual. CBS Fungal Biodiversity Center, Utrecht, Netherlands, 2007.

Study of heating capacity of focused IR light soldering systems

An experimental study about four optical setups used for developing a Focused IR Light Soldering System (FILSS) for Surface Mount Technology (SMT) lead-free electronic devices specifically for Ball Grid Arrays (BGA) is presented. An analysis of irradiance and infrared thermography at BGA surface is presented, as well as heat transfer by radiation and conduction process from the surface of the BGA to the solder balls. The results of this work show that the heating provided by our proposed optical setups, measured at the BGA under soldering process, meets the high temperature and uniform thermal distribution requirements, which are defined by the reflow solder method for SMT devices.

Development of a Predictive Pharmacokinetic Model for a Novel Cyclooxygenase-2 Inhibitor

A predictive population pharmacokinetic model was developed for a novel cyclooxygenase-2 (COX-2) inhibitor CS-706, using data from 130 subjects in 3 phase 1 trials after single or multiple doses of CS-706 (2- to 800-mg doses daily, up to 14 days) and validated using sparse data from a separate study. A 2-compartment model described the data. Typical apparent clearance (CL/F) was 47.2 L/h and was reduced by 43% at doses greater than 200 mg. Apparent clearance was decreased by 38% in female subjects and by 64% and 15%, respectively, in poor/intermediate CYP 2D6 and poor CYP 2C9 metabolizers. Typical apparent volume of the central compartment was 166 L and increased with body weight. Bioavailability increased by 42% after nighttime doses and decreased saturably with increasing dose (50% reduction at 221 mg). Predicted exposures in Japanese subjects were reduced relative to whites because of a lower frequency of poor metabolizers. The model may aid in optimizing the design of future studies and predicting exposures in other subpopulations.

Predictive Population Pharmacokinetic/Pharmacodynamic Model for a Novel COX-2 Inhibitor

The objectives of these analyses were to (1) develop a population pharmacokinetic/pharmacodynamic model for a novel COX-2 inhibitor (CS-706) using data from primarily Caucasian subjects, (2) predict responses in subpopulations of interest (including Japanese subjects), and (3) correlate pharmacodynamic parameters to safety outcomes. The model was developed using data from 130 healthy adults following single or multiple doses of CS-706. Serial plasma concentrations of CS-706 and ex vivo whole-blood cyclooxygenase-1 (COX-1) and COX-2 activity were determined up to 72 hours postdose. An E(max) model described relationships between CS-706 plasma concentrations and COX-1 and COX-2 inhibition. CS-706 potency (EC(50)) was 397 ng/mL for COX-1 and 20 ng/mL for COX-2. None of the tested covariates influenced the pharmacodynamics of CS-706. Japanese subjects are expected to show a slightly reduced response to CS-706, consistent with lower exposure following the same dose given to Caucasian subjects. Predictive pharmacokinetic/pharmacodynamic modeling for COX-1 and COX-2 inhibition indicates a 20-fold potency ratio that is expected to be similar in Japanese and Caucasians. There was good correlation between COX-1 inhibition and the incidence of 7-day gastroduodenal mucosal injury. A dose of less than 25 mg bid could be adequate to inhibit COX-2 activity with a low risk of gastrointestinal mucosal injury.

Racial disparity in maternal and fetal-cord bisphenol A concentrations

OBJECTIVE

To determine if racial disparities exist in maternal and fetal cord serum concentrations of bisphenol A (BPA).

STUDY DESIGN

A nested cross-sectional study was performed from a cohort of 600 term nulliparas. In 27 patients (8 Caucasian, 8 African-American and 11 Hispanic), term pre-labor maternal serum and corresponding fetal-cord serum were analyzed for BPA. result: African-Americans had the highest maternal serum concentrations, 10-fold higher than Caucasians (30.13 vs 3.14 ng ml(-1); P=0.038). Hispanics had intermediate concentrations with a trend towards higher concentrations compared with Caucasians (24.46 vs 3.14 ng ml(-1); P=0.051). Overall concentrations were 10-fold higher in maternal samples than fetal samples (14.1 vs 1.3 ng ml(-1); P=0.001). Hispanics had higher fetal concentrations than non-Hispanics (2.05 vs 0.35 ng ml(-1); P=0.025).

CONCLUSION

We found significant racial/ethnic differences in maternal/fetal BPA concentrations. Further study is needed to determine if these differences reflect disparities in exposure, metabolism or placental transfer.

Common polymorphisms of CYP2C19 and CYP2C9 affect the pharmacokinetic and pharmacodynamic response to clopidogrel but not prasugrel

BACKGROUND

Thienopyridines are metabolized to active metabolites that irreversibly inhibit the platelet P2Y(12) adenosine diphosphate receptor. The pharmacodynamic response to clopidogrel is more variable than the response to prasugrel, but the reasons for variation in response to clopidogrel are not well characterized.

OBJECTIVE

To determine the relationship between genetic variation in cytochrome P450 (CYP) isoenzymes and the pharmacokinetic/pharmacodynamic response to prasugrel and clopidogrel.

METHODS

Genotyping was performed for CYP1A2, CYP2B6, CYP2C19, CYP2C9, CYP3A4 and CYP3A5 on samples from healthy subjects participating in studies evaluating pharmacokinetic and pharmacodynamic responses to prasugrel (60 mg, n = 71) or clopidogrel (300 mg, n = 74).

RESULTS

In subjects receiving clopidogrel, the presence of the CYP2C19*2 loss of function variant was significantly associated with lower exposure to clopidogrel active metabolite, as measured by the area under the concentration curve (AUC(0-24); P = 0.004) and maximal plasma concentration (C(max); P = 0.020), lower inhibition of platelet aggregation at 4 h (P = 0.003) and poor-responder status (P = 0.030). Similarly, CYP2C9 loss of function variants were significantly associated with lower AUC(0-24) (P = 0.043), lower C(max) (P = 0.006), lower IPA (P = 0.046) and poor-responder status (P = 0.024). For prasugrel, there was no relationship observed between CYP2C19 or CYP2C9 loss of function genotypes and exposure to the active metabolite of prasugrel or pharmacodynamic response.

CONCLUSIONS

The common loss of function polymorphisms of CYP2C19 and CYP2C9 are associated with decreased exposure to the active metabolite of clopidogrel but not prasugrel. Decreased exposure to its active metabolite is associated with a diminished pharmacodynamic response to clopidogrel.

Design principles underlying circadian clocks

A fundamental problem for regulatory networks is to understand the relation between form and function: to uncover the underlying design principles of the network. Circadian clocks present a particularly interesting instance, as recent work has shown that they have complex structures involving multiple interconnected feedback loops with both positive and negative feedback. While several authors have speculated on the reasons for this, a convincing explanation is still lacking. We analyse both the flexibility of clock networks and the relationships between various desirable properties such as robust entrainment, temperature compensation, and stability to environmental variations and parameter fluctuations. We use this to argue that the complexity provides the flexibility necessary to simultaneously attain multiple key properties of circadian clocks. As part of our analysis we show how to quantify the key evolutionary aims using infinitesimal response curves, a tool that we believe will be of general utility in the analysis of regulatory networks. Our results suggest that regulatory and signalling networks might be much less flexible and of lower dimension than their apparent complexity would suggest.

Clinical impact of histidine-ketoglutarate-tryptophan (HTK) cardioplegic solution on the perioperative period in open heart surgery patients

BACKGROUND

Ischemia-reperfusion injury during open heart surgery related to unsuccessful myocardial protection may increase morbidity or mortality. We analyze the clinical outcome after cardiac surgery with a cardioplegic solution based on intracellular components added with histidine-ketoglutarate-tryptophan.

METHODS

Thirty patients programmed for elective open heart surgery were randomized into two groups. In group I (n = 15), myocardial protection was carried out with Bretschenider solution (HTK), and in group II (n = 15) with conventional crystalloid cardioplegia. The incidence of arrhythmias, inotropic support requirement, and length-of-stay in the intensive care unit were evaluated.

RESULTS

During reperfusion, there was no difference in incidence of arrhythmias; however, in the postoperative period group I had a lower incidence of arrhythmias (p = 0.001). Inotropic support (p = 0.003) and length-of-stay in the intensive care unit (p = 0.037) were lower in group I. There were no deaths in either group.

CONCLUSIONS

It was concluded that myocardial protection with Bretschneider solution effectively decreases incidence of arrhythmias, inotropic support, and length-of-stay in the intensive care unit.

Uruguay facio-cardio-musculo-skeletal syndrome: a novel X-linked recessive disorder

We report on three male patients from a single family with a brachyturricephaly, "pugilistic" facial appearance, a muffled voice, cardiomyopathy, muscular hypertrophy, broad hands, wide feet with progressive pes cavus deformities, dislocation of toes, variable congenital hip dislocation, and scoliosis. Three other males in the family, now deceased from cardiac disease, appear to have had the same disorder. The mother of the propositus has milder signs of the syndrome. All affected males are related through the maternal line. These cases represent an apparently previously undescribed X-linked recessive syndrome.

Exclusion of the Ellis-van Creveld region on chromosome 4p16 in some families with asphyxiating thoracic dystrophy and short-rib polydactyly syndromes

Ellis-van Creveld syndrome (EVC) is a relatively rare, usually non-lethal, autosomal recessive skeletal dysplasia characterized by short stature, polydactyly, cardiac and renal anomalies. Linkage analysis has localized the disease gene to chromosome 4p16, with the markers at loci D4S827 and D4S3135 defining the centromeric and telomeric limits of the linked interval, respectively. There has been long-term speculation that asphyxiating thoracic dystrophy (ATD) and the short-rib polydactyly syndromes (SRP) represent the severe end of the EVC disease spectrum. We performed linkage analysis using markers from the EVC region in seven families manifesting either ATD or SRP type III. In two of the families, one segregating ATD and one SRP kindred, linkage of the phenotype to the EVC region was excluded. In the other five families linkage of the phenotype to the EVC region could not be excluded, but the families were too small for linkage to the region to be established. The exclusion of the EVC region in ATD and SRP III families suggests that locus heterogeneity exists within the short-rib dysplasia (with and without polydactyly) group of disorders.

Effects of thrombin on intracellular calcium and pH in human and murine platelets

The aim of this study was to compare the effect of thrombin (Thr) on cytosolic calcium [Ca2]+i and intracellular pH [pH]i in human and murine platelets. Rich-platelet suspensions from both species were loaded with Fura-2 (2 microM) or BCECF (0.75 microM) by incubation with their respective acetoxymethyl esters to measure cytosolic calcium [Ca2+]i or intracellular pH [pH]i, respectively. Suspensions were challenged with increasing concentrations of Thr, from 0.1 to 10 IU/ml. Basal [Ca2+]i in human platelets was 98 +/- 6 and 99.1 +/- 9 nM in rat platelets (n = 20). Thr increased [Ca2+]i, EC50 was 1.1 +/- 0.04 in human and 0.97 +/- 0.06 IU/ml in rat platelets (n = 7). Extracellular Mg2+ (4 or 8 mM) abolished Thr response on [Ca2+]i. [pH]i in human was 7.09 +/- 0.08 and 7.11 +/- 0.04 in rat platelets. Thr induced alkalinization of platelets in both species. Our results indicate that the potency of Thr to change [Ca2+]i and [pH]i was similar in both species, allowing for comparisons between human and murine platelets and to extrapolate results from an animal model to human pathology.

Crystal structure of Paracoccus denitrificans electron transfer flavoprotein: structural and electrostatic analysis of a conserved flavin binding domain

The crystal structure of electron transfer flavoprotein (ETF) from Paracoccus denitrificans was determined and refined to an R-factor of 19.3% at 2.6 A resolution. The overall fold is identical to that of the human enzyme, with the exception of a single loop region. Like the human structure, the structure of the P. denitrificans ETF is comprised of three distinct domains, two contributed by the alpha-subunit and the third from the beta-subunit. Close analysis of the structure reveals that the loop containing betaI63 is in part responsible for conferring the high specificity of AMP binding by the ETF protein. Using the sequence and structures of the human and P. denitrificans enzymes as models, a detailed sequence alignment has been constructed for several members of the ETF family, including sequences derived for the putative FixA and FixB proteins. From this alignment, it is evident that in all members of the ETF family the residues located in the immediate vicinity of the FAD cofactor are identical, with the exception of the substitution of serine and leucine residues in the W3A1 ETF protein for the human residues alphaT266 and betaY16, respectively. Mapping of ionic differences between the human and P. denitrificans ETF onto the structure identifies a surface that is electrostatically very similar between the two proteins, thus supporting a previous docking model between human ETF and pig medium-chain acyl-CoA dehydrogenase (MCAD). Analysis of the ionic strength dependence of the electron transfer reaction between either human or P. denitrificans ETF and MCAD demonstrates that the human ETF functions optimally at low ( approximately 10 mequiv) ionic strength, while P. denitrificans ETF is a better electron acceptor at higher (>75 mequiv) ionic strength. This suggests that the electrostatic surface potential of the two proteins is very different and is consistent with the difference in isoelectric points between the proteins. Analysis of the electrostatic potentials of the human and P. denitrificans ETFs reveals that the P. denitrificans ETF is more negatively charged. This excess negative charge may contribute to the difference in redox potentials between the two ETF flavoproteins and suggests an explanation for the opposing ionic strength dependencies for the reaction of MCAD with the two ETFs. Furthermore, by analysis of a model of the previously described human-P. denitrificans chimeric ETF protein, it is possible to identify one region of ETF that participates in docking with ETF-ubiquinone oxidoreductase, the physiological electron acceptor for ETF.

Effects of pimozide on the psychopathology of delusional disorder

1. The effects of pimozide on the psychopathology of delusional disorder were studied. 2. After six weeks, pimozide (2-12 mg/day) administration had no effect on the Brief Psychiatric Rating Scale, or in the psychological, social and occupational functioning, as measured by the Global Assessment of Functioning Scale. 3. When the different dimensions of the delusional experience were looked upon, no modifications were observed in any of them after six weeks of pimozide treatment. 4. These data failed to support the therapeutic role of pimozide in the treatment of delusional disorder and may suggest, when compared to other disorders with prominent delusions such as schizophrenia, a different neurobiology for the illness.

Optical channel waveguides by copper ion-exchange in glass

Optical channel waveguides have been obtained by electric?field?assisted diffusion of copper films on glass substrates. The mode indices of these channel waveguides were determined with the prism?coupling technique, and the refractive?index profile of the waveguide was reconstructed from measurements of the near?field intensity distribution.

Expression and characterization of two pathogenic mutations in human electron transfer flavoprotein

Defects in electron transfer flavoprotein (ETF) or its electron acceptor, electron transfer flavoprotein-ubiquinone oxidoreductase (ETF-QO), cause the human inherited metabolic disease glutaric acidemia type II. In this disease, electron transfer from nine primary flavoprotein dehydrogenases to the main respiratory chain is impaired. Among these dehydrogenases are the four chain length-specific flavoprotein dehydrogenases of fatty acid beta-oxidation. In this investigation, two mutations in the alpha subunit that have been identified in patients were expressed in Escherichia coli. Of the two mutant alleles, alphaT266M and alphaG116R, the former is the most frequent mutation found in patients with ETF deficiency. The crystal structure of human ETF shows that alphaG116 lies in a hydrophobic pocket, under a contact residue of the alpha/beta subunit interface, and that the hydroxyl hydrogen of alphaT266 is hydrogen-bonded to N(5) of the FAD; the amide backbone hydrogen of alphaT266 is hydrogen-bonded to C(4)-O of the flavin prosthetic group (Roberts, D. L., Frerman, F. E. and Kim, J-J. P. (1996) Proc. Natl. Acad. Sci. U. S. A. 93, 14355-14360). Stable expression of the alphaG116R ETF required coexpression of the chaperonins, GroEL and GroES. alphaG116R ETF folds into a conformation different from the wild type, and is catalytically inactive in crude extracts. It is unstable and could not be extensively purified. The alphaT266M ETF was purified and characterized after stabilization to proteolysis in crude extracts. Although the global structure of this mutant protein is unchanged, its flavin environment is altered as indicated by absorption and circular dichroism spectroscopy and the kinetics of flavin release from the oxidized and reduced protein. The loss of the hydrogen bond at N(5) of the flavin and the altered flavin binding increase the thermodynamic stability of the flavin semiquinone by 10-fold relative to the semiquinone of wild type ETF. The mutation has relatively little effect on the reductive half-reaction of ETF catalyzed by sarcosine and medium chain acyl-CoA dehydrogenases which reduce the flavin to the semiquinone. However, kcat/Km of ETF-QO in a coupled acyl-CoA:ubiquinone reductase assay with oxidized alphaT266M ETF as substrate is reduced 33-fold; this decrease is due in largest part to a decrease in the rate of disproportionation of the alphaT266M ETF semiquinone catalyzed by ETF-QO.

Metals in lung tissue from autopsy cases in Mexico City residents: comparison of cases from the 1950s and the 1980s

In autopsies performed on residents of Mexico City during the 1950s and 1980s (45 males and 24 females and 42 males and 42 females, respectively), concentrations of cadmium, copper, cobalt, nickel, and lead in the lungs were studied by atomic absorption spectrometry. Sharp increases were noted in samples taken in the 1980s compared to those from the 1950s. In samples from both time periods, the concentrations were influenced by gender. Smoking was not associated with higher levels of the metals. Only lead seemed to have a relation with age. The enormous differences by gender in the 1950s could be due to different patterns of exposure. The differences among samples from both periods appear to be associated with the increase of air pollutants in the metropolitan areas of Mexico City during the years under study. These results reinforce the importance of studying lung tissue to monitor air pollution by metals.

Pharmacokinetics and pharmacodynamics of the monoamine oxidase B inhibitor mofegiline assessed during a phase I dose tolerance trial

The safety, pharmacokinetics, and pharmacodynamics of single oral doses of up to 48 mg and daily (for 28 days) doses of up 24 mg mofegiline were investigated in healthy male volunteers. Plasma pharmacokinetics indicated rapid absorption and elimination: time to reach maximum concentration occurred at about 1 hour; half-life ranged from 1 to 3 hours. Maximal plasma concentration and area under the plasma concentration-time curve increased and oral clearance decreased disproportionately with dose. Mofegiline rapidly and markedly inhibited platelet monoamine oxidase B (MAOB) activity, which returned to baseline within 14 days. Urinary excretion of phenylethylamine increased proportionately with doses up to 24 mg. No changes in urinary elimination of catecholamines, blood pressure, heart rate, or ECG were observed. A classic maximum tolerated dose was not achieved in these studies. However, the 48 mg single dose and the 24 mg multiple daily dose far exceeded the dose (1 mg) that was associated with > 90% platelet MAOB inhibition.

Experimental study of Cu(+)-Na(+) exchanged glass waveguides

Optical waveguides have been obtained by field-assisted Cu(+)-Na(+) exchanged on glass. The refractive index profiles of the waveguides are determined by means of the prism-coupling technique and Chiang's method [J. Lightwave Technol. LT-3, 385 (1985)], and they correlate with the index profile calculated as a function of the glass composition. The composition profile is examined with the aid of a scanning electron microscopy with energy-dispersive x-ray analysis, and the diffusion process is explained by the one-dimensional diffusion equation.

Expression and characterization of human and chimeric human-Paracoccus denitrificans electron transfer flavoproteins

Electron transfer flavoprotein (ETF) is a heterodimer that contains a single equivalent of FAD and accepts electrons from nine flavoprotein dehydrogenases in the mitochondrial matrix. Human ETF was expressed in Escherichia coli using the expression vector previously employed to express Paracoccus denitrificans ETF (Bedzyk, L. A., Escudero, K. W., Gill, R. E., Griffin, K. J., and Frerman, F. E. (1993) J. Biol. Chem. 268, 20211-20217). cDNAs encoding the beta and alpha subunits of the human protein were inserted into the vector, mimicking the arrangement of the P. denitrificans genes in which coding sequences are joined by overlapping termination and initiation codons. A human ETF containing 30% P. denitrificans sequence at the amino terminus of the beta subunit was also expressed and purified. This chimeric ETF has 64% sequence identity with the human sequence in the substituted region. Kinetic constants of medium chain and short chain acyl-CoA dehydrogenases for the chimeric ETFs were slightly changed from those of human ETF; but, there are marked differences in the kinetic constants of sarcosine dehydrogenase and electron transfer flavoprotein-ubiquinone oxidoreductase with the two ETFs. Absorption spectra of the three redox states of human, chimeric, and P. denitrificans ETF flavins are identical. However, the flavin circular dichroism spectra of the three ETFs are characteristic for each species. The spectrum of the chimeric ETF has both human and P. denitrificans ETF features. The amplitude of the 436 nm band is identical to that of the of the human ETF flavin, but the amplitude of the 375 nm band is identical to that of the P. denitrificans ETF flavin. Thus, flavin in the chimeric ETF appears to be exposed to dipoles in the protein framework provided by human and bacterial sequences. These spectral data indicate that the flavin is located in the vicinity of the amino-terminal region of the beta subunit. The kinetic data suggest that the amino-terminal region of the beta subunit comprises part of the docking site for some primary dehydrogenases and electron transfer flavoprotein-ubiquinone oxidoreductase.

Hologram interferometry: carrier fringes

The sensitivity of the interferometric techniques to longitudinal variations of the optical path can be increased by introducing carrier fringes. A new method for introducing such fringes is presented.

Natural antitumor defense system of the murine liver

Murine nonparenchymal liver cells from various genetic strains isolated by collagenase digestion and differential sedimentation contain both lymphocytes and macrophages. Nonparenchymal liver cells as well as spleen cells, mononuclear blood cells, and peritoneal exudate cells from C3HeB/FeJ mice were tested for natural cytotoxicity against YAC-1 (sensitive to NK cells) and P815 (resistant to NK cells) tumor cell lines. Resident peritoneal exudate cells exerted no cytotoxicity against either tumor cell, whereas spleen and mononuclear blood cells lysed only YAC-1. In contrast, nonparenchymal liver cells lysed both YAC-1(4 h) and P815 (18 h) tumor cells. Treatment of nonparenchymal liver cells with anti-asialo GM1 and complement abolished the antitumor activity against both tumor cell lines but not the phagocytic activity. Nonadherent nonparenchymal liver cells exerted greater cytotoxicity against YAC-1 tumor cells but little cytotoxicity against P815 tumor cells when compared with unfractionated cells. Adherent nonparenchymal liver cells (macrophages) from untreated mice exerted no antitumor activity against either tumor cell. In contrast, adherent nonparenchymal liver cells from Corynebacerium parvum treated mice were directly cytotoxic to P815 tumor cells. Spleen cells that are normally not cytotoxic to P815 tumor cells (18 h) became cytotoxic when mixed with adherent nonparenchymal liver cells from untreated mice. These results indicate that the tumoricidal effector cell in nonparenchymal liver cells from untreated mice appears to be the NK cell. Apparently, murine liver macrophages from untreated mice do not have tumoricidal activity per se but can "activate" NK cells to kill tumor cells normally resistant to NK cells.

Multiple tumoricidal effector mechanisms induced by adriamycin

The antitumor cytotoxic mechanisms of Adriamycin-elicited peritoneal exudate cells were investigated. Peritoneal exudate cells from mice collected 1 day after an i.p. injection of Adriamycin (10 mg/kg) displayed enhanced cytotoxicity against P815 (natural killer-insensitive, macrophage-sensitive) but not YAC-1 (natural killer-sensitive) tumor cell lines. These cells contained a sufficient concentration of the drug to be cytotoxic for P815 tumor cells in 18-hr chromium release assays. Freeze-thaw lysates of these peritoneal exudate cells were found to be as cytotoxic to P815 as their corresponding whole cells. The lytic activity of these lysates was removed by centrifugation at 100,000 X g, indicating the insolubility of the effector moiety. These cells were also shown to produce significant amounts of superoxide anion and H2O2 in response to phorbol myristate acetate. A catalase-inhibitable augmentation of the cytotoxicity of these cells against P815 was observed when phorbol myristate acetate was added to the assay. Neutrophils and not macrophages were likely responsible for this effect. Peritoneal lymphocytes from mice given injections of Adriamycin 5 to 7 days previously were cytotoxic to YAC-1 tumor cells in 4-hr assays. Finally, peritoneal macrophages harvested 5 to 7 days after Adriamycin administration were cytotoxic to P815 in the absence of detectable Adriamycin. The addition of phorbol myristate acetate inhibited the lysis of P815 by these cells.