Application of TruGraf v1: A Novel Molecular Biomarker for Managing Kidney Transplant Recipients With Stable Renal Function

TruGraf v1 is a laboratory-developed DNA microarray-based gene expression blood test to enable proactive noninvasive serial assessment of kidney transplant recipients with stable renal function. It has been previously validated in patients identified as Transplant eXcellence (TX: stable serum creatinine, normal biopsy results, indicative of immune quiescence), and not-TX (renal dysfunction and/or rejection on biopsy results). TruGraf v1 is intended for use in subjects with stable renal function to measure the immune status as an alternative to invasive, expensive, and risky surveillance biopsies.

MATERIALS AND METHODS

In this study, simultaneous blood tests and clinical assessments were performed in 192 patients from 7 transplant centers to evaluate TruGraf v1. The molecular testing laboratory was blinded to renal function and biopsy results.

RESULTS

Overall, TruGraf v1 accuracy (concordance between TruGraf v1 result and clinical and/or histologic assessment) was 74% (142/192), and a result of TX was accurate in 116 of 125 (93%). The negative predictive value for TruGraf v1 was 90%, with a sensitivity 74% and specificity of 73%. Results did not significantly differ in patients with a biopsy-confirmed diagnosis vs those without a biopsy.

CONCLUSIONS

TruGraf v1 can potentially support a clinical decision enabling unnecessary surveillance biopsies with high confidence, making it an invaluable addition to the transplant physician's tool kit for managing patients. TruGraf v1 testing can potentially avoid painful and risky invasive biopsies, reduce health care costs, and enable frequent assessment of patients with stable renal function to confirm the presence of immune quiescence in the peripheral blood.

Investigator Assessment of the Utility of the TruGraf Molecular Diagnostic Test in Clinical Practice

BACKGROUND

TruGraf v1 is a well-validated DNA microarray-based test that analyzes blood gene expression profiles as an indicator of immune status in kidney transplant recipients with stable renal function.

METHODS

In this study, investigators assessed clinical utility of the TruGraf test in patient management. In a retrospective study, simultaneous blood tests and clinical assessments were performed in 192 patients at 7 transplant centers, and in a prospective observational study they were performed in 45 subjects at 5 transplant centers.

RESULTS

When queried regarding whether or not the TruGraf test result impacted their decision regarding patient management, in 168 of 192 (87.5%) cases the investigator responded affirmatively. The prospective study indicated that TruGraf results supported physicians' decisions on patient management 87% (39/45) of the time, and in 93% of cases physicians indicated that they would use serial TruGraf testing in future patient management. A total of 21 of 39 (54%) reported results confirmed their decision that no intervention was needed, and 17 of 39 (44%) reported that results specifically informed them that a decision not to perform a surveillance biopsy was correct.

CONCLUSIONS

TruGraf is the first and only noninvasive test to be evaluated for clinical utility in determining rejection status of patients with stable renal function and shows promise of providing support for clinical decisions to avoid unnecessary surveillance biopsies with a high degree of confidence. TruGraf is an invaluable addition to the transplant physician's tool kit for managing patient health by avoiding painful and invasive biopsies, reducing health care costs, and enabling frequent assessment of patients with stable renal function to confirm immune quiescence.

Does using lower limit of normal values enhance the ability of a single bone mineral density measure to predict fractures?

Using a single bone mineral density (BMD) measure, we demonstrated that the lower limit of normal (LLN) method is more consistent in predicting osteoporosis fractures than the T-score in white menopausal women from the Study of Osteoporosis Fracture (SOF).

INTRODUCTION

In order to circumvent the inconsistencies and limitations with using the T-score when defining osteoporosis, we propose using 95% LLN values derived from centered polynomial models using the NHANES III BMD measures. The main aim of this study was to compare the two methods in prediction of fracture and agreement in osteoporosis classification using cohort data.

METHODS

We compared the fracture prediction ability of the two methods using a single BMD measurement in 4,948 white women aged 67-74 years in the SOF employing kappa statistics, sensitivity, and specificity.

RESULTS

The T-score provided inconsistent osteoporosis classification (46.6%) across the five hip regions of interest (ROIs) and this was significantly (p<0.0001) reduced when using the LLN method (36.5%). Kappa statistics of incident fracture during 12 years of follow-up related to the prevalence of osteoporosis at baseline was significantly improved using the LLN method compared to using T-score. Sensitivity and specificity for fracture based on a single BMD measurement of different hip ROIs were more consistent using the LLN method.

CONCLUSION

The LLN method provides a more consistent and efficient method for osteoporosis fracture prediction than the T-score in 67- to 74-year-old white women.

Oestradiol and SERM treatments influence oestrogen receptor coregulator gene expression in human skeletal muscle cells

AIM

Oestrogen receptors (ER) are present in human skeletal muscle (hSkM) cells; however, the function of the receptor is currently unknown. We investigated the influence of oestradiol and selective ER modulators [tamoxifen (TAM), raloxifene (RAL)] on ER coregulator mRNA expression in hSkM.

METHODS

Human skeletal muscle cells were treated with 10 nm oestradiol, 5 microm TAM and 10 microm RAL over a 24-h period. Following the treatment period, mRNA expression was quantified using real-time PCR to detect changes in ER-alpha, ER-beta, steroid receptor coactivator (SRC), silencing mediator for retinoid and thyroid hormone receptors (SMRT), MyoD, GLUT4 and c-fos.

RESULTS

ER-alpha mRNA expression increased with all three drug treatments (P < 0.05) while there was no change in mRNA expression of ER-beta in hSkM cells. mRNA expression of SRC increased and SMRT decreased with oestradiol, TAM and RAL in hSkM cells (P < 0.05). Importantly, mRNA expression of MyoD increased with oestradiol and decreased with TAM and RAL in hSkM cells (P < 0.05). mRNA expression of GLUT4 increased with oestradiol and RAL and decreased with TAM in hSkM cells (P < 0.05).

CONCLUSIONS

These findings are novel in that they provide the first evidence that oestradiol and selective ER modulators influence ER-alpha function in hSkM cells. This demonstrates the importance of the ER and alterations in its coregulators, to potentially prevent sarcopenia and promote muscle growth in postmenopausal women using these forms of hormone replacement therapy.

Energy density of foods, but not beverages, is positively associated with body mass index in adult women

Background/Objectives

Energy density (kJ/g) may have a strong influence on energy balance. Although beverages are a considerable source of energy in the US diet, rarely have studies among free-living populations investigated the energy density of foods (EDF) and the energy density of beverages (EDB) simultaneously. We examined the independent simultaneous associations of EDF and EDB on energy intake and Body Mass Index (BMI) in adult women.

Subjects/Methods

This cross-sectional design focused on 348 elementary school employees randomly selected at baseline of a worksite wellness trial in southeastern Louisiana. Two 24-hour recalls were collected, and measured heights and weights were converted into BMI (kg/m²).

Results

Those in the highest EDF tertile consumed more energy and had higher BMIs than those in the lowest tertile (P<0.05). Employees in the highest EDB tertile consumed more energy than those in the lowest, yet there was no difference in BMIs between the two groups. Multivariate regression, with controls for demographic and health variables, confirmed the positive association between EDF and BMI; a 1 kJ/g increase in EDF was associated with a 0.39 kg/m² increase in BMI (P=0.038). Models that did not control for EDB gave estimates of EDF that were 8% to 10% lower.

Conclusions

These findings suggest that EDF and EDB play important, yet distinct, roles in energy intake and BMI. Future studies should evaluate both types of energy density as independent predictors since our results suggest that EDB can confound the association of EDF with BMI.

Interaction of G-protein beta3 subunit and nitric oxide synthase gene polymorphisms on carotid artery intima-media thickness in young adults: the Bogalusa Heart Study

BACKGROUND

G-protein beta3 subunit (GNB3) gene C825T and endothelial nitric oxide (eNOS) gene G894T polymorphisms both influence arterial structure and function. However, information is scant regarding the interaction of these genes on arterial wall thickness.

METHODS

This aspect was examined in 654 white and black subjects, aged 25-43 years (72.9% white, 39.3% male). Arterial wall thickness was assessed in terms of the average intima-media thickness (IMT) of common carotid, internal carotid, and carotid bulb segments by B-mode ultrasonography.

RESULTS

Frequencies of T allele of the GNB3 C825T polymorphism (0.718 vs. 0.304, P < 0.0001) and G allele of the eNOS G894T polymorphism (0.868 vs. 0.661, P < 0.0001) were higher in blacks compared to whites. In a multivariate model including gender, age, mean arterial pressure, body mass index, triglycerides/HDL cholesterol ratio, insulin resistance index, smoking, and/or race, there was no significant genotypic effect on carotid IMT with respect to GNB3 C825T or eNOS G894T polymorphisms among whites, blacks, and total sample. However, the carriers of TT genotype of the GNB3 C825T and T allele of the eNOS G894T had a significantly lower carotid IMT among blacks (P = 0.003) and the total sample (P = 0.006).

CONCLUSION

These results indicate that the genetic variations of the eNOS gene in combination with the GNB3 gene jointly influence carotid artery wall thickening process in young adults, especially in blacks.

Pancreatic panniculitis associated with allograft pancreatitis and rejection in a simultaneous pancreas-kidney transplant recipient

Pancreatic panniculitis is an uncommon condition that can occur in association with pancreatic disease. We present a case of pancreatic panniculitis in a female pancreas-kidney transplant recipient 5 months post-transplant. The patient was on standard immunosuppressive medications and had acute rejection of her renal allograft. The diagnosis of allograft pancreatitis and rejection presenting with pancreatic panniculitis was supported clinically, histopathologically and by laboratory and imaging data. This is the fourth case of pancreatic panniculitis occurring in a transplant recipient and the first in a simultaneous pancreas-kidney transplant recipient. It is also the first case associated with allograft rejection. Clinicians should be aware that pancreatic panniculitis may be a manifestation of underlying allograft pancreatic disease.

Renal allograft injury is associated with urinary tract infection caused by Escherichia coli bearing adherence factors

Urinary tract infections are the most common infection in renal transplant patients and Escherichia coli (E. coli) is the most common clinical isolate. Although acute allograft injury (AAI) secondary to urinary tract infection (UTI) has been reported, the incidence of AAI associated with UTI, the virulence factors express by uropathic E. coli and whether virulence factors are associated with renal allograft outcome have not been described. We collected E. coli from our renal transplant patients with UTI, determined O:H serotypes, P and Dr fimbriae expression and the clinical presentation and allograft function during the UTI and post-UTI period. Pyelonephritis occurred in 40% of our patients, 82% of which had AAI (>20% increase in SCr). Sixty-two percent of E. coli isolates that expressed P fimbriae were associated with AAI, whereas only 29% that did not express P fimbriae had AAI (p = 0.03). The pattern of P fimbriae and O serotypes differed from reported isolates, as the P fimbriae PapG class II and the O25 serotype were the most common. Dr adhesin was expressed on 7 isolates, including 2 of 3 with urosepsis. We propose a unique pattern of uropathogenic serotypes and adherence factors contribute to acute allograft injury in renal transplant patients with UTI.

Efficacy of incisional vs punch biopsy in the histological diagnosis of periocular skin tumours

AIMS

The aim of this study was to compare the accuracy of incisional and punch biopsy techniques in obtaining correct histological diagnosis of periorbital eyelid tumours. The technique of punch biopsy is presented and described in detail.

METHODS

A retrospective analysis was made of 20 consecutive incisional biopsies and 20 consecutive punch biopsies. In each case, the histology obtained at biopsy was compared with that identified at the time of tumour excision.

RESULTS

A total of 40 consecutive biopsies on 38 patients were analysed. The first 20 were incisional; the second 20 were punch biopsies. Of the 20 incisional biopsy specimens, 19 were confirmed accurate at the time of excision of the lesion. Of the 20 punch biopsies, 17 were confirmed accurate at the time of excision. These correspond to accuracy rates of 95 and 85%, respectively.

CONCLUSIONS

Both incisional and punch biopsy techniques have relatively high accuracy rates and there is a high concordance between tissue diagnoses made by each of these techniques. Incisional techniques should preferably be performed on any atypical lesion. Punch biopsy is a quick and simple procedure. It is easy to perform in an outpatient environment and requires a minimum of surgical equipment and no specific surgical skills. If the site of biopsy is carefully chosen, this simple technique provides tissue specimens of adequate size and quality for accurate histology and is a most useful adjunct in the management of periocular tumours.

Relative adrenal insufficiency in post-transplant lymphoproliferative disorder

Post-transplant lymphoproliferative disorder is treated with rapid decrement of immunosuppressive therapy. This cannot be achieved with ease in patients on long-term glucocorticoid therapy, as chronically suppressed adrenal glands may not be capable of mounting adequate response to stress. A 52-year-old Caucasian male presented with fever, orthostatic hypotension, lymphadenopathy and hyponatraemia. Serum cortisol levels were within normal levels with a sub optimal response to stimulation by ACTH. Hyponatraemia and orthostasis responded poorly to fluid restriction, saline and salt repletion but corrected after increasing the steroid dose. The normal baseline cortisol levels represented a stimulated adrenal gland, however, the ACTH stimulation had inadequate response. This sub optimal stimulation and a good response to increased steroids suggest the presence of relative or occult adrenal insufficiency. Relative adrenal insufficiency must be considered in patients who have received prolonged glucocorticoid therapy and have symptoms such as hypotension and/or hyponatraemia.

Histone methylation versus histone acetylation: new insights into epigenetic regulation

Post-translational addition of methyl groups to the amino-terminal tails of histone proteins was discovered more than three decades ago. Only now, however, is the biological significance of lysine and arginine methylation of histone tails being elucidated. Recent findings indicate that methylation of certain core histones is catalyzed by a family of conserved proteins known as the histone methyltransferases (HMTs). New evidence suggests that site-specific methylation, catalyzed by HMTs, is associated with various biological processes ranging from transcriptional regulation to epigenetic silencing via heterochromatin assembly. Taken together, these new findings suggest that histone methylation may provide a stable genomic imprint that may serve to regulate gene expression as well as other epigenetic phenomena.

Role of histone H3 lysine 9 methylation in epigenetic control of heterochromatin assembly

The assembly of higher order chromatin structures has been linked to the covalent modifications of histone tails. We provide in vivo evidence that lysine 9 of histone H3 (H3 Lys9) is preferentially methylated by the Clr4 protein at heterochromatin-associated regions in fission yeast. Both the conserved chromo- and SET domains of Clr4 are required for H3 Lys9 methylation in vivo. Localization of Swi6, a homolog of Drosophila HP1, to heterochomatic regions is dependent on H3 Lys9 methylation. Moreover, an H3-specific deacetylase Clr3 and a beta-propeller domain protein Rik1 are required for H3 Lys9 methylation by Clr4 and Swi6 localization. These data define a conserved pathway wherein sequential histone modifications establish a "histone code" essential for the epigenetic inheritance of heterochromatin assembly.

Role of catalase in pre- and postjunctional responses of mammalian irides to hydrogen peroxide

In the present study, we examined the effect of inhibition of catalase with 3-aminotriazole (3-AT) on hydrogen peroxide (H2O2)-induced enhancement of sympathetic neurotransmission in bovine irides and on the inhibitory effect of this oxidant on norepinephrine (NE) release from human irides, in vitro. Furthermore, we investigated the effect of 3-AT on H2O2-induced attenuation of contractile responses to carbachol in the bovine isolated irides. Isolated mammalian irides were prepared for studies of [3H]NE release using the superfusion method and for contractile studies using isolated organ baths. At concentrations less than 100 microM, H2O2 had no significant effect on field-stimulated [3H]NE release from bovine or human irides. In bovine irides, 3-AT caused significant (P < 0.001) leftward shifts of concentration-response curves to H2O2 (10-300 microM). 3-AT also increased H2O2-induced attenuation of evoked [3H]NE release from human isolated irides. Low concentrations of H2O2 (< 100 microM) had no effect on carbachol contractions. However, 3-AT unmasked an inhibitory effect of low concentrations of H2O2 (3-100 microM) on carbachol-induced contractions. We conclude that inhibition of catalase causes both pre- and postjunctional responses of isolated mammalian irides to be more susceptible to oxidative stress induced by H2O2.

Transcriptional repression of BRCA1 by aberrant cytosine methylation, histone hypoacetylation and chromatin condensation of the BRCA1 promoter

BRCA1 expression is repressed by aberrant cytosine methylation in sporadic breast cancer. We hypothesized that aberrant cytosine methylation of the BRCA1 promoter was associated with the transcriptionally repressive effects of histone hypoacetylation and chromatin condensation. To address this question, we developed an in vitro model of study using normal cells and sporadic breast cancer cells with known levels of BRCA1 transcript to produce a 1.4 kb 5-methylcytosine map of the BRCA1 5' CpG island. While all cell types were densely methylated upstream of -728 relative to BRCA1 transcription start, all normal and BRCA1 expressing cells were non-methylated downstream of -728 suggesting that this region contains the functional BRCA1 5' regulatory region. In contrast, the non-BRCA1 expressing UACC3199 cells were completely methylated at all 75 CpGs. Chromatin immunoprecipitations showed that the UACC3199 cells were hypoacetylated at both histones H3 and H4 in the BRCA1 promoter compared to non-methylated BRCA1 expressing cells. The chromatin of the methylated UACC3199 BRCA1 promoter was inaccessible to DNA-protein interactions. These data indicate that the epigenetic effects of aberrant cytosine methylation, histone hypoacetylation and chromatin condensation act together in a discrete region of the BRCA1 5' CpG island to repress BRCA1 transcription in sporadic breast cancer.

Methylation of the BRCA1 promoter is associated with decreased BRCA1 mRNA levels in clinical breast cancer specimens

Functional inactivation of BRCA1 is an important mechanism involved in breast cancer pathogenesis. Mutation is often responsible for BRCA1 inactivation in familial breast cancer, but is not responsible for the decreased levels of BRCA1 seen in a subset of sporadic breast cancer patients. To determine if aberrant cytosine methylation of the BRCA1 promoter is associated with decreased BRCA1 gene expression in human breast cancer, high resolution bisulfite sequence analysis was used to analyze the cytosine methylation status of the BRCA1 promoter in 21 axillary node negative breast cancer patients with known levels of BRCA1 expression. Aberrant cytosine methylation of the BRCA1 promoter was detected in three of 21 patient specimens. These three specimens also expressed the lowest levels of BRCA1. Results from this analysis show that aberrant cytosine methylation of the BRCA1 promoter is directly correlated with decreased levels of BRCA1 expression in human breast cancer, and suggest that epigenetic silencing may be one mechanism of transcriptional inactivation of BRCA1 in sporadic mammary carcinogenesis.

Effect of inhibition of cyclooxygenase on pre- and postjunctional actions of peroxides in the iris-ciliary body

In the present study, we investigated the effect of inhibition of cyclooxygenase (COX) with flurbiprofen (FBF) on peroxide-induced enhancement of field-stimulated [3H]norepinephrine ([3H]NE) release from bovine isolated irides. Furthermore, the effect of FBF was examined on peroxide-induced attenuation of contractions evoked by carbachol on this tissue. Irides were prepared for studies of neurotransmitter release and for measurement of contractile tension in vitro. Pretreatment of tissues with FBF (10 microM) caused significant (P < 0.001) rightward shifts of concentration-response curves to H2O2 and also decreased cumene hydroperoxide (cuOOH)-induced enhancement of evoked [3H]NE release. FBF (10 microM) partially prevented the attenuation of carbachol-induced contractions induced by H2O2 (300 microM) and cuOOH (300 microM). We conclude that inhibition of the biosynthesis of prostanoids reduced both the prejunctional stimulatory effects of H2O2 and cuOOH on sympathetic neurotransmission and inhibitory effects of peroxides on carbachol-induced contractions the in the bovine isolated iris.

Epigenetic silencing of maspin gene expression in human breast cancers

Maspin is a tumor suppressor whose expression is lost in many advanced breast cancers. Maspin has been shown to inhibit cell motility, invasion and metastasis; however, its precise role in normal mammary epithelium remains to be elucidated. Although expression of maspin mRNA is low or absent in most human breast cancer cells, the maspin gene is rarely re-arranged or deleted. We hypothesized that aberrant cytosine methylation and chromatin condensation of the maspin promoter participates in the silencing of maspin expression during neoplastic progression. To test this hypothesis, we compared cultured normal human mammary epithelial cells (HMECs) to 9 cultured human breast cancer cell lines. HMECs expressed maspin mRNA and displayed a completely non-methylated maspin gene promoter with an open chromatin structure. In contrast, 7 of 9 breast cancer cell lines had no detectable maspin expression and 6 of these 7 maspin-negative breast cancer cell lines also displayed an aberrant pattern of cytosine methylation of the maspin promoter. Interestingly, the maspin promoter was completely methylated in maspin-negative normal peripheral blood lymphocytes. This indicates that the maspin promoter is not a functional CpG island and that cytosine methylation of this region may contribute to normal tissue-restricted gene expression. Chromatin accessibility studies with MCF-7 cells, which lack maspin expression and have a methylated maspin promoter, showed a closed chromatin structure compared with HMECs. Moreover, maspin gene expression could be re-activated in MCF-7 cells by treatment with 5-aza-2;-deoxycytidine, a DNA demethylating agent. Thus, aberrant cytosine methylation and heterochromatinization of the maspin promoter may silence maspin gene expression, thereby contributing to the progression of human mammary cancer.

Epigenetic silencing of maspin gene expression in human breast cancers

Maspin is a tumor suppressor whose expression is lost in many advanced breast cancers. Maspin has been shown to inhibit cell motility, invasion and metastasis; however, its precise role in normal mammary epithelium remains to be elucidated. Although expression of maspin mRNA is low or absent in most human breast cancer cells, the maspin gene is rarely re-arranged or deleted. We hypothesized that aberrant cytosine methylation and chromatin condensation of the maspin promoter participates in the silencing of maspin expression during neoplastic progression. To test this hypothesis, we compared cultured normal human mammary epithelial cells (HMECs) to 9 cultured human breast cancer cell lines. HMECs expressed maspin mRNA and displayed a completely non-methylated maspin gene promoter with an open chromatin structure. In contrast, 7 of 9 breast cancer cell lines had no detectable maspin expression and 6 of these 7 maspin-negative breast cancer cell lines also displayed an aberrant pattern of cytosine methylation of the maspin promoter. Interestingly, the maspin promoter was completely methylated in maspin-negative normal peripheral blood lymphocytes. This indicates that the maspin promoter is not a functional CpG island and that cytosine methylation of this region may contribute to normal tissue-restricted gene expression. Chromatin accessibility studies with MCF-7 cells, which lack maspin expression and have a methylated maspin promoter, showed a closed chromatin structure compared with HMECs. Moreover, maspin gene expression could be re-activated in MCF-7 cells by treatment with 5-aza-2;-deoxycytidine, a DNA demethylating agent. Thus, aberrant cytosine methylation and heterochromatinization of the maspin promoter may silence maspin gene expression, thereby contributing to the progression of human mammary cancer.

Racial identity and its assessment in a sample of African-American men in treatment for cocaine dependence

Substance abuse treatment studies frequently include subjects from different ethnic and racial groups, but many investigations limit the examination of race and ethnicity to the use of nominal labels. This approach reveals little about the social or psychological significance of racial and ethnic group membership to the subjects of study or about the potential effects of these factors on substance-involved behaviors. In this study, a principal components analysis (PCA) with varimax rotation was conducted on the 50-item long form of the Racial Identity Attitude Scale (RIAS) (1) in a sample of 294 African-American men in treatment for cocaine dependence. The RIAS was developed to measure attitudes about race and racial status among blacks, but it has not been utilized widely in substance abuse research. Our findings provide evidence for the structural validity of this instrument in this sample of substance abusers. We discuss how recent advances in racial identity theory and its measurement may provide an important avenue for understanding the psychological consequences of racial group membership and for examining the potential effects of these factors on treatment response in studies of substance misuse.

A two-rate hypothesis for patterns of retention in psychosocial treatments of cocaine dependence: findings from a study of African-American men and a review of the published data

In this article, we examine patterns of retention in psychosocial treatment programs for cocaine dependence. We present new data from a comparison trial of Drug Counseling and Supportive-Expressive Psychotherapy and review published data from all studies utilizing psychosocial interventions alone. We compared Drug Counseling and Psychotherapy on rates of pretreatment and during-treatment attrition in a sample of 294 African-American men seeking treatment for cocaine dependence (mean age, 37.6). Survival analyses were utilized to identify significant differences in during-treatment attrition between the two treatments and to identify significant changes in the rate of attrition during the course of each treatment. We then compared the patterns of retention in this study with those from other available published reports of psychosocial treatments for cocaine abuse. The weekly during-treatment attrition rate was not constant in either treatment condition, and the change in rate of attrition occurred at week six for both Drug Counseling and Psychotherapy. Comparison with other studies suggested that the during-treatment pattern of attrition among most psychosocial treatments for cocaine abuse is typified by two rates, with the rate of subject attrition early in treatment being greater than the rate of later attrition and also exhibiting greater variance. Future studies of treatment retention should identify significant shifts in the rate of during-treatment attrition, examine if the pattern of attrition is typified by two rates, and, if so, determine where the shift occurs. Future studies should also assess if changes in the rate of during-treatment attrition signal the timeframes within which strategies that enhance retention can be implemented in the treatment program.

Endothelial cell regrowth and morphology after balloon catheter injury of alloxan-induced diabetic rabbits

Neointimal thickening after catheter injury has been reported to be influenced by the integrity of the vascular endothelium. We have previously shown that neointimal thickening is significantly reduced in alloxan-induced diabetic New Zealand White rabbits after catheter injury compared with euglycemic rabbits. In the present study, it was hypothesized that endothelial cell regrowth, morphology, and endothelium-dependent vasoreactivity after catheter injury are improved in the diabetic rabbit (glucose >/=400 mg/dl) compared with the euglycemic rabbit. Two weeks after catheter injury, the percent endothelial regrowth was significantly increased in diabetic animals compared with euglycemic animals (32.1 +/- 2 and 15.6 +/- 1, respectively; P < 0.05). The endothelial cell morphology analyzed by scanning electron microscopy was also restored 2 wk after catheter injury in thoracic aortas from the diabetic animals compared with vessels from euglycemic animals. Endothelium-dependent relaxation to ACh in vessels from diabetic and euglycemic rabbits was attenuated 2 wk after injury, and, although improved by 4 and 8 wk, relaxation remained significantly depressed. These results suggest that endothelial cell regrowth and morphology in diabetic animals was improved compared with euglycemic animals; however, endothelium-dependent vasoreactivity remained impaired. Thus the attenuated neointimal thickening seen in the diabetic rabbit may be a function of the rate and degree of regrowth rather than the normalization of ACh-induced relaxation.

Gonorrhea incidence and HIV testing and counseling among adolescents and young adults seen at a clinic for sexually transmitted diseases

OBJECTIVE

To determine whether HIV testing and posttest counseling may be associated with an increase in gonorrhea incidence among adolescents and young adults seen at a clinic for sexually transmitted diseases (STD).

DESIGN

A historical cohort study with the collection of longitudinal data on the patients' HIV testing and counseling experience.

SETTING

Delgado STD clinic of New Orleans, Louisiana, a public ambulatory primary care center that serves mainly the economically disadvantaged Black population.

PATIENTS

A record-based inception cohort of 4031 patients aged 15-25 years diagnosed at the clinic between June 1989 and May 1991 with a first lifetime gonorrhea infection.

INTERVENTION

Routine confidential HIV tests and posttest counseling sessions experienced at the clinic during follow-up.

OUTCOME MEASURE

Incidence rate of reported gonorrhea reinfection.

RESULTS

Of the patients, 51.5% were tested once for HIV antibodies and 25.9% twice or more. Formal posttest counseling occurred after 8.5% of the 4665 HIV-negative and 44.0% of the 49 HIV-positive tests. In the most pessimistic of several models controlling for history of gonorrhea, HIV testing and counseling history, and other potential confounding factors, a significantly lower rate of gonorrhea reinfection was observed after a first HIV-negative test than before [adjusted relative risk (RR), 0.66; 95% confidence interval (CI), 0.59-0.74; P < 0.00011. As compared with the pretest period, significantly higher rates of gonorrhea were observed after respectively a second (RR, 1.18; 95% CI, 1.01-1.37; P = 0.03) and a third (RR, 1.52; 95% CI, 1.22-1.88; P = 0.0001) HIV-negative test. No significant association was found between HIV-positive testing and any variation in gonorrhea rate (RR, 0.95; 95% CI, 0.56-1.62; P = 0.85). Posttest counseling for HIV-negative and HIV-positive results were followed respectively by a significantly higher rate of gonorrhea (RR; 1.27; 95% CI, 1.09-1.48; P = 0.002) and a non-significantly lower rate of gonorrhea (RR, 0.53; 95% CI, 0.17-1.60; P = 0.85).

CONCLUSION

Our results do not exclude the possibility of a modest increase in gonorrhea incidence after routine HIV testing and counseling in an STD clinic. Nevertheless, this conclusion holds only under the least favorable assumptions and applies solely to a minority of patients.

Expression of the polymeric immunoglobulin receptor and excretion of secretory IgA in the postischemic kidney

The humoral mucosal immune response of the kidney involves the transport of secretory IgA (S-IgA) through renal epithelial cells by the polymeric immunoglobulin receptor (pIgR). The pIgR is cleaved and released as free secretory component (FSC) or attached to IgA (S-IgA). We examined the effects of an ischemic model of acute renal failure (ARF) on the expression of pIgR and the secretion of FSC and S-IgA in the urine. Kidney pIgR mRNA levels decreased in ischemic animals by 55% at 4 h and by 85% at 72 h compared with controls. pIgR protein expression in the medullary thick ascending limb (TAL) decreased within 24 h and was nearly undetectable by 72 h. Urinary S-IgA and FSC concentrations decreased by 60% between days 3 and 6. pIgR mRNA and pIgR protein in the kidney returned to approximately 90% of control levels and urinary FSC and S-IgA concentrations returned to approximately 55% of control levels by day 7. We demonstrate that ischemic ARF decreases renal mucosal S-IgA transport in vivo and may contribute to the increased incidence of urinary tract infections.

Antipolymer antibody reactivity in a subset of patients with fibromyalgia correlates with severity

OBJECTIVE

To determine the prevalence of antipolymer antibodies (APA) in patients with fibromyalgia (FM) and autoimmune disease control groups and to determine if the presence of these antibodies correlates with severity in patients with FM.

METHODS

Sera from patients with FM (n = 47), osteoarthritis (OA) (n = 16), and rheumatoid arthritis (RA) (n = 13) were analyzed. Patients with implants of any kind and patients with concurrent autoimmune conditions were excluded from study. Banked sera from autoimmune disease controls including poly/dermatomyosis (n = 15), RA (n = 30), systemic lupus erythmatosus (SLE) (n = 30), and systemic sclerosis (SSc) (n = 30) were also analyzed. To determine if seroreactivity correlates with severity, banked sera from patients with FM assessed as severe (n = 28) or mild (n = 37) and from controls (n = 21) were assayed.

RESULTS

Following analysis, the prevalence of seroreactivity was found to be higher in patients with FM (22/47, 47%) compared to patients with OA (3/16, 19%; p<0.1) or RA (1/13, 8%; p<0.05) and the autoimmune disease control sera from poly/dermatomyosis (2/15, 13%; p<0.05), and patients with RA (3/30, 10%; p<0.01), SLE (1/30, 3%; p<0.01), and SSc (1/30, 3%; p<0.01). The prevalence of APA seroreactivity was also significantly higher in patients with severe FM (17/28, 61%) compared to patients with mild FM (11/37, 30%; p<0.05) and controls (4/21, 19%; p<0.01). In addition, both mean threshold and mean tolerance dolorimetry scores were significantly lower in the seropositive patients with mild FM (1.33+/-0.21, 1.95+/-0.25, respectively) compared to the seronegative patients (1.83+/-0.08, 2.53+/-0.11; p<0.05 for both comparisons, respectively).

CONCLUSION

These results reveal that an immunological response, production of anti-polymer antibodies, is associated with a subset of patients with FM. The results also suggest that the APA assay may be an objective marker in the diagnosis and assessment of FM and may provide additional avenues of investigation into the pathophysiological processes involved in FM.

Aberrant methylation of the BRCA1 CpG island promoter is associated with decreased BRCA1 mRNA in sporadic breast cancer cells

BRCA1 mRNA is reduced in sporadic breast cancer cells despite the lack of mutations. Because a CpG island is found at the 5' end of the BRCA1 gene, we hypothesized that the decreased BRCA1 mRNA in sporadic breast cancer was associated with aberrant cytosine methylation of the CpG island. We examined BRCA1 mRNA expression in normal human mammary epithelial cells (HMECs), peripheral blood lymphocytes (PBLs) and six sporadic breast cancer cell lines using RT-PCR. The normal breast cells expressed high levels of BRCA1 mRNA. The sporadic breast cancer cell lines and PBLs expressed lower levels of BRCA1 mRNA ranging from a 3-16-fold decrease compared to the normal breast cells. We identified a 600 bp region of the BRCA1 CpG island that possessed strong promoter activity (approximately 40-fold above control), and determined the cytosine methylation patterns of the 30 CpG sites within this region by sodium bisulfite genomic sequencing. The HMECs, PBLs and five of the sporadic breast cancer cell lines were largely unmethylated. However, one sporadic breast cancer cell line, UACC3199, was > or = 60% methylated at all 30 CpG sites (18 sites were 100% methylated) and was associated with an eightfold decrease in BRCA1 mRNA compared to normal breast cells. These findings suggest that aberrant cytosine methylation of the BRCA1 CpG island promoter may be one mechanism of BRCA1 repression in sporadic breast cancer.

An analysis of program and family costs of case managed care for technology-dependent infants with bronchopulmonary dysplasia

Caring for technology-dependent infants with bronchopulmonary dysplasia requires a wide range and intense level of services. Case management programs can offer comprehensive services to patients with complex needs. The Neonatal Pulmonary Program at Tulane University Medical Center is a case management program for infants with chronic pulmonary problems. The purpose of this study was to describe the costs of providing care for technology-dependent infants with bronchopulmonary dysplasia and to include the direct and indirect costs to families as well as the Program costs. The study population included 89 infants enrolled in the program from September 1987 through February 1992. Outpatient, inpatient, and professional staff costs were derived from hospital and clinic billing information; all other costs were determined through family interviews. Total costs for outpatient services were $59,627 (89), professional team members time $185,539 (89); inpatient services $1,144,930 (89), professional costs for inpatient services $88,946; direct health costs $32,543 (37) for home health care, equipment, medications, special diets; direct non-health costs $30,670 (37) for transportation, meals, child care, lodging during clinic visits and rehospitalizations and household expenses to accommodate equipment needs; and indirect costs $26,173 (37) for missed work days and employment changes.

Regulation of the polymeric immunoglobulin receptor by water intake and vasopressin in the rat kidney

The polymeric immunoglobulin receptor (pIgR) transports polymeric immunoglobulins (IgA) from the basolateral to the apical surface of epithelial cells. At the apical surface, its amino-terminal domain, termed secretory component (SC), is proteolytically cleaved and released either unbound (free SC) or bound to IgA. We examined the effects of changes in water balance and vasopressin on the production and secretion of the pIgR in the rat kidney in vivo. Water deprivation induced a 2.7-fold increase in the pIgR mRNA and a 2.2-fold increase in intracellular pIgR protein compared with water-loaded animals. Physiological doses of desmopressin reproduced the effects of water deprivation on mRNA and intracellular protein levels, suggesting that pIgR expression may be regulated by a vasopressin-coupled mechanism. Secretion of free SC and secretory IgA in the urine, however, correlated directly with water intake and urine flow. These results suggest that hydration status and vasopressin may affect the mucosal immunity of the kidney by regulating at different steps the epithelial cell production and secretion of the polymeric immunoglobulin transporter/ secretory component.

Nested case-control study of tumors of the hemopoietic and lymphatic systems among workers in the meat industry

Workers in the meat industry are exposed to viruses that cause leukemia and lymphoma in cattle and chickens, and also to carcinogenic chemical agents. This case-control study, nested in a cohort of members of a meatcutters' union in Baltimore, Maryland, investigated whether occupational exposures are associated with death from tumors of the hemopoietic and lymphatic systems. Cases of these tumors represent all deaths which occurred in the cohort between 1949 and 1980. Excess risks of tumors of the hemopoietic and lymphatic systems were observed throughout the meat industry, except in meatpacking plants. Slaughtering activities involving heavy exposure to oncogenic viruses were strongly associated with these tumors, especially with lymphomas. Thus, elevated risks were observed for butchers who killed animals (odds ratio (OR) = 5.3, 95% confidence interval (CI) 1.0-27.0); workers in chicken-slaughtering plants (OR = 3.3, 95% CI 0.8-13.1); and workers in cattle/sheep/pig abattoirs (OR = 2.8, 95% CI 0.8-9.5). Among supermarket workers, wrapping meat (mainly a female activity) was associated with increased risk of tumors of the hemopoietic and lymphatic systems (OR = 3.8, 95% CI 1.0-14.3), with the odds of both lymphomas and tumors of the myeloid stem cell being elevated. On the other hand, meatcutting in supermarkets (almost exclusively a male activity) was associated with multiple myeloma; the odds ratio for men was 18.0 (95% CI 1.6-207.5), with no myeloma cases being recorded in women. These associations persisted after limited control for exposures outside the industry that have also been observed to be associated with excess risk, such as exposure to pesticides, working/living on pig farms, and exposure to X-rays. The findings provide evidence that workers in the meat industry may be at elevated risk of tumors of the hemopoietic and lymphatic systems. Further studies with larger sample sizes are needed to identify more conclusively which exposures play an etiologic role in the occurrence of the different histologic types of these tumors.

Analysis of methylation in the 5' region of the human alpha-galactosidase A gene containing a binding site for methylated DNA-binding protein/RFX1-4

We examined methylation in the 5' untranslated region and surrounding sequences of the X-linked human alpha-galactosidase A gene. This region includes a methylation-dependent binding site for the MDBP/RFX1-4 transcription factor family. By bisulfite-based genomic sequencing, we determined the distribution of 5-methylcytosine residues from position +28 to +143 relative to the major transcription start site of the gene in almost 500 molecular clones from different tissues and individuals. The CpG methylation patterns in DNA from females differed from molecule to molecule with no indication of tissue-specificity or age-dependence. In contrast, the CG dinucleotides within this region were completely unmethylated in almost all of the DNA molecules cloned from male tissues. In female eutherian mammals, 50% of the molecules are expected to be methylated in an X-linked gene region in which methylation is coupled to gene silencing. Of the cloned DNA molecules from female tissues, 40% had 4 or more of the 9 CpG's methylated and the MDBP site was methylated in about one-fifth of the female tissue-derived DNA molecules.

Reminding technology for prospective memory disability: a case study

Congenital or acquired brain damage resulting in prospective memory loss can make a child unable to become independent of care givers. This note describes a memory aid developed for a 17 year old with spina bifida and hydrocephalus who requires continual reminding to perform health maintenance tasks such as medication and feeding. Off-the-shelf computer hardware and software were used to make a reminding system that logged task completion information. Logging is a unique feature of this system, permitting review of the user's response to reminders for health or rehabilitative purposes. The system reduced the need to remind rate from > 75% to less than 10% of the time. Reminding rates returned to > 75% upon removal of the system. With the system this adolescent achieved more independent health maintenance. Weight and power requirements make this system embodiment impractical for general wheelchair use, but the technology in currently available pocket units may support the necessary functions.

The reliability of reporting of contraceptive behavior in DHS calendar data: evidence from Morocco

This report addresses the consistency of reporting in the contraceptive calendar in the 1992 and 1995 Morocco Demographic and Health Surveys. Because a panel design was used in these surveys, the same women were interviewed in both years, providing a unique opportunity to examine the reliability of responses. Measures of reliability for various aspects of contraceptive-use dynamics are computed, and the impact of reporting errors on contraceptive failure, discontinuation, and switching rates is estimated. Results suggest that reporting of contraceptive behavior in Moroccan DHS calendar data appears to be relatively reliable at the aggregate level. Individual respondents, particularly those whose contraceptive patterns have been complex, have a lower level of reliability. The observed inconsistencies do not appear to affect aggregate-level estimates of contraceptive prevalence; however, measures of contraceptive-use dynamics are less stable.

Use of antipolymer antibody assay in recipients of silicone breast implants

BACKGROUND

Local complications (encapsulation, rashes, rupture, and leakage) can occur after placement of silicone gel-containing breast implants (SBI). Whether SBI exposure results in systemic manifestations in some recipients is controversial. We have carried out a blinded study to assess whether there is any difference between SBI recipients and non-exposed controls in the proportions positive for serum antibodies directed against polymeric substances.

METHODS

We recruited female SBI recipients (including those without symptoms) who presented to a single rheumatology clinic. A physician global assessment was used to classify SBI recipients who did not meet criteria for specific autoimmune diseases according to the severity of local and systemic signs and symptoms. Controls were recruited from among clinic staff and their acquaintances. Results of the antipolymer antibody (APA) assay were compared with those of an assay for antinuclear antibodies (ANA) and with the severity of the signs and symptoms.

FINDINGS

Positive APA results were found in one (3%) of 34 SBI recipients with limited symptoms, two (8%) of 26 with mild symptoms, seven (44%) of 16 with moderate symptoms, and 13 (68%) of 19 with advanced symptoms. Four (17%) of 23 healthy non-SBI-exposed controls and two (10%) of 20 non-exposed women with classic autoimmune diseases were positive for APA. Thus, women with moderate or advanced symptoms were significantly more likely than those with limited or mild symptoms, or non-exposed controls to have APA (p < 0.001). The proportion with positive ANA results was higher for women with classic autoimmune diseases 14 (70%) of 20 than for any SBI-exposed subgroup (0-33%).

INTERPRETATION

The APA assay can objectively contribute to distinguishing between SBI recipients with limited or mild signs and symptoms. SBI recipients with more severe manifestations, and patients with specific autoimmune diseases. Further studies will be needed to define the signs and symptoms associated with exposure to SBI.

Obesity and idiopathic dilated cardiomyopathy

To learn more about the dilated form of cardiomyopathy associated with obesity, we conducted a pooled analysis of data from two case-control studies of idiopathic dilated cardiomyopathy. Up to two controls of the same sex and approximate age (+/- 5 years) had been selected for each case using random digit dialing. The subjects had been interviewed by telephone. We compared the cases (N = 224) and controls (N = 353) using conditional logistic regression. We defined severe obesity using national criteria for severely elevated body mass index. We found little association with severe obesity in multivariate analysis (relative odds = 1.1; 95% confidence interval = 0.7-1.9).

Nasal septal squamous cell carcinoma: a chart review and meta-analysis

Squamous cell carcinoma of the nasal septum occurs infrequently and is often misdiagnosed because its symptoms are similar to everyday rhinologic complaints. The published series have been too small to determine the best form of treatment for this cancer. The authors of this study retrospectively reviewed nasal septal squamous cell carcinomas treated at three university-affiliated hospitals over a 30-year period. Sixteen primary tumors were identified and reviewed for presentation, staging, treatment, recurrence patterns, and risk factors. The authors then combined their findings with those of suitable literature series and performed a meta-analysis to evaluate predictors of survival. There were too few patients in each stage and treatment group to significantly determine the optimal treatment for nasal septal squamous cell carcinoma. However, based on the present study and the literature series, the authors suggest that small lesions may be confidently treated with either radiation or surgery and that combined therapy may be reserved for more advanced tumors.

Sensation-seeking, criminality, and spinal cord injury: a case-control study

A retrospective case-control study was performed in New Orleans, Louisiana, in 1985-1986 to test the hypotheses that 1) criminality is a risk factor for severe injury, and 2) the association between criminality and injury can be explained in terms of a common underlying factor--increased sensation-seeking tendencies. A total of 140 males with spinal cord injury were individually matched with 140 driver's license holders on age, race, sex, educational attainment, and zip code of residence and were interviewed by telephone. Criminality prior to spinal cord injury was measured by self-report and police records, and sensation seeking was measured by the Disinhibition and Boredom Susceptibility subscales of Zuckerman's Sensation-Seeking Scale (Form V). Those with spinal cord injuries were significantly more likely than controls to report a history of juvenile delinquency, adult criminality, and incarceration prior to the time of spinal cord injury. Statistically significant but modest difference were also found between cases and controls with respect to Disinhibition, Boredom Susceptibility, and the combined Sensation-Seeking Scale score. Matched-pairs logistic regression analysis indicated that the association between sensation seeking and spinal cord injury remained significant after controlling for criminality, with an estimated relative risk of 2.05 (95% confidence interval 1.67-2.53). However, the association between criminality and spinal cord injury also remained significant after controlling for sensation seeking (estimated relative risk = 2.04, 95% confidence interval 1.09-3.82). On the basis of these results, criminality and sensation seeking may be statistically significant but independent predictors of spinal cord injury.

Renal allograft failure after simultaneous pancreas-kidney transplantation: univariate and multivariate analyses of donor and recipient risk factors

Although donor and recipient risk factors for renal allograft failure are well known after kidney transplantation, they are less well defined after simultaneous pancreas-kidney transplantation. The purpose of this study is to evaluate the impact of donor and recipient risk factors on the outcome of the renal allograft in simultaneous pancreas-kidney recipients. Simultaneous pancreas-kidney transplant performed between 4/88 and 6/94 were reviewed (n = 61) and univariate (Kaplan-Meier) and multivariate (Cox regression) analyses of factors which affect kidney graft survival were performed. Twelve donor and eleven pre- and post-transplant recipient risk factors were evaluated. Overall kidney allograft survival rates at 1, 2 and 5 yr were 81%, 76% and 66%. Donor age > and = 40 yr (RR = 2.3), donor female gender (RR = 3.5), donor admission to pronouncement of brain death > and = 48 h (RR = 3), the occurrence of surgical complications (RR = 2.1), and serum > and = 2 mg/dl on post-transplant day (RR = 1.9) were independently associated with an increased hazard of graft failure. With the exception of length of donor admission, all of these factors were also shown to predict the risk of renal graft failure by univariate analysis. In conclusion, we have identified donor and recipient risk factors which independently predict the risk of renal graft failure after simultaneous pancreas-kidney transplantation. Whether the differences between our center-specific risk factors and those obtained from renal transplant registry data are true differences or simply reflect sampling error is unclear.

The impact of primary health care services on under-five mortality in rural Niger

BACKGROUND

Despite large investments in basic primary health care in sub-Saharan Africa over the past two decades, quantifying the contribution of national programme efforts to the reduction of infant/child mortality in the region has proven difficult. This study takes advantage of the phased implementation of the national Rural Health Improvement Program in Niger and conveniently timed survey data to reassess programme impact on under-five mortality during the 1980-1985 period.

METHODS

Health service use and under-five mortality rates for children born in the 5 years prior to the 1985 survey are compared for three groups of villages: villages served by a dispensary, villages served by village health teams (VHT), and villages without access to modern primary care services. Multi-level regression analyses using both household- and community-level variables are undertaken in estimating the magnitude of effects.

RESULTS

Children residing in villages proximate to health dispensaries were approximately 32% less likely to have died during the study period than children without access to modern health services. Village health teams were not, however, associated with significantly lower mortality probabilities. Formal test for endogeneity indicated that these effects were not the result of non-uniform/non-random allocation of resources.

CONCLUSIONS

The findings are largely supportive of the key premise underlying selective primary health care interventions - that packages of basic services can be effectively mounted nationally in poor countries and have a significant impact over a short time period. In Niger, less than optimal implementation of VHT appears to have reduced the magnitude of the impact achieved.

Treatment of renal allograft acute rejection with methylprednisolone: effect of fixed dose versus dose per body mass index

Considerable interpatient variability in steroid pharmacokinetics has been observed in renal transplant recipients. The purpose of this retrospective study is to evaluate the relationship between the dose of methylprednisolone (MP) used to treat acute rejection (AR) after renal transplantation and the response to treatment. 117 first AR episodes from 408 renal transplants were reviewed. The dose of MP used to treat AR was < 45 mg/kg/m2 in 60 patients and > and = 45 mg/kg/m2 in 57 patients. The correlation between fixed dose ( < 1.25 vs. > and = 1.25 g) and dose based on BMI was evaluated by simple linear regression analysis (r2 = 0.78, p < 0.0005). Response to treatment was as follows: MP successful (Group 1, n = 80); MP failed, OKT3 successful (Group 2, n = 17); MP and OKT3 failed (Group 3, n = 3) and MP failed, no further treatment (n = 17). No relationship was observed between the dose of MP, whether fixed or based on BMI, and (1) response to treatment of the first AR, (2) incidence of a second AR and (3) response to subsequent treatment with OKT3. Actuarial graft survival was higher in Group 1 compared to Group 2 (p < 0.0005), lower in Black recipients (p = 0.02) and higher when > and = 45 mg/kg/m2 of MP was used to treat AR (p = 0.06). In conclusion, no relationship between the dose of MP, whether fixed or based on BMI, and the response to treatment of AR was observed. MP dosage based on BMI may be a reasonable alternative to a fixed-dose regimen with the advantage of limiting steroid exposure and the consequent side-effects.

Epidemiology of idiopathic dilated cardiomyopathy in the elderly: pooled results from two case-control studies

Although idiopathic dilated cardiomyopathy is often viewed as an affliction of young of middle-aged adults, morbidity and mortality rates from idiopathic dilated cardiomyopathy rise sharply with age and are the highest in the elderly. To learn more about the determinants of this increasingly important cause of heart failure in the elderly, the authors conducted a pooled analysis of data from two case-control studies of idiopathic dilated cardiomyopathy carried out in Baltimore, Maryland (1984-1986), and in Washington, DC (1990-1992). Identical diagnostic criteria and interviewing procedures had been used in both studies. All of the cases of idiopathic dilated cardiomyopathy had evidence of ventricular dilation and hypokinesis, with a left ventricular ejection fraction of < 40%. Cases with a history of coronary artery disease were excluded along with those with known secondary forms of cardiomyopathy, Up to two neighborhood controls of the same sex and appropriate age (+/- 5 years) were selected for each case using a random digit dialing technique. The subjects or a suitable surrogate was interviewed by telephone to obtain medical history information. The present analysis was limited to 94 cases and 152 matched controls who were at least 60 years of age. Conditional logistic regression methods were used in the analysis. Significant associations were observed with lower educational attainment and a history of hypertension (P < 0.05). The association with hypertension (relative odds = 2.2, 95% confidence interval 1.1-4.6) persisted after adjustment for race, education, and diabetes and was not accounted for by coronary angiography utilization patterns. The association with diabetes was of borderline significance (p < 0.10). The pattern of risk factors identified in this analysis may allow for the early identification of elderly persons who are at increased risk of idiopathic dilated cardiomyopathy.

Renal retransplants: effect of primary allograft nephrectomy on early function, acute rejection and outcome

Although risk factors for failure of renal retransplants have been well studied, the impact of allograft nephrectomy on subsequent renal transplantation in the cyclosporin era is not well defined. The purpose of this study is to define the effect of nephrectomy of the primary allograft on subsequent allograft survival, early allograft function, incidence of acute rejection and patient sensitization. The records of 127 renal retransplant recipients were reviewed. Of these 127 patients who underwent retransplantation, 40 (31%) underwent nephrectomy of the primary allograft prior to retransplantation whereas 40 (31%) did not. Nephrectomy of cadaveric primary allografts was performed more commonly (48% vs 30%, p = 0.003) and earlier (78% vs 54% < 1 month post-transplant, p = 0.0006) in the pre-CSA period compared to the CSA period. Biopsy-proven acute rejection episodes occurred more frequently in the nephrectomy group (73% vs 42%, p = 0.03). Although primary allograft nephrectomy was associated with higher preformed antibody levels, it had no effect on early graft function, frequency of acute rejection or allograft outcome after retransplantation, in the CSA group. In conclusion, in the cyclosporin era, nephrectomy of the primary allograft has no significant influence on retransplantation.

Renal allograft and patient outcome after transplantation: pancreas-kidney versus kidney-alone transplants in type 1 diabetic patients versus kidney-alone transplants in nondiabetic patients

Despite recent advances and improved outcome, pancreas transplantation remains controversial. The purpose of this review was to study renal allograft outcome after simultaneous pancreas-kidney transplants (SPK, n = 61), kidney-alone transplants in type I diabetic patients (KA-D, n = 63), and kidney-alone transplants in nondiabetic patients (KA-ND, n = 80). Patients were matched for donor age, donor gender, donor race, interval from donor admission to procurement, DR mismatch, and recipient gender. The mean renal allograft cold ischemic time and recipient age were lower in the SPK group. Patient survival was highest in the KA-ND group (99% and 86% at 1 and 5 years, respectively), intermediate in the SPK group (90% and 78% at 1 and 5 years, respectively), and lowest in the KA-D group (89% and 66% at 1 and 5 years, respectively) (P = 0.004). similarly, renal allograft survival was higher in the KA-ND (89% and 63% at 1 and 5 years, respectively) and SPK (82% and 69% at 1 and 5 years, respectively) groups compared with the KA-D group (76% and 49% at 1 and 5 years, respectively) (P = 0.07). This difference disappeared when renal graft survival was censored for death, which probably reflects the selection bias. Actuarial pancreas graft survival was 76% and 62% at 1 and 5 years, respectively. Acute rejection (AR) was more frequent in the SPK group than in the KA-D and KA-ND groups (41% v 16% v 29%; P = 0.007). Delayed graft function (DGF), on the other hand, occurred more frequently in the KA-D group than in the KA-ND and SPK groups (66% v 55% v 38%; P = 0.08). Death as a result of a cardiovascular event occurred more frequently in the KA-D group. Cardiovascular death and renal graft failure occurred earlier in the SPK group. Cox regression analysis revealed a 1.6 and 1.8 times higher risk of renal graft failure in the SPK group when the donor was > or = 40 years old or female and a five times higher risk of graft failure in the KA-ND group in the presence of AR. Graft survival in patients with AR/DGF was lower than that in patients with no AR/no DGF in both the KA-D (71% and 63% v 100% and 100% at 1 and 5 years, respectively; P = 0.03) and KA-ND (90% and 56% v 100% and 100% at 1 and 5 years, respectively; P = 0.001) groups. Acute rejection did not affect graft survival in the SPK group. In the absence of AR, DGF had no effect on graft survival in any of the groups. Although the selection bias in favor of pancreas transplantation does not allow for definitive conclusions, our results show that outcome after SPK transplantation is acceptable and factors that influence the outcome after this procedure may be different from the ones affecting KA-D recipients.

Prognostic factors for all-cause mortality among hemophiliacs infected with human immunodeficiency virus

To identify the prognostic significance of hemophilia- and virus-related factors, the authors undertook a survival analysis among 644 human immunodeficiency virus (HIV)-infected subjects enrolled in the Multicenter Hemophilia Cohort Study between 1985 and 1993. Acquired immunodeficiency syndrome (AIDS) was the leading cause of death, followed by hemorrhage and hepatic disease. Adverse prognostic factors included older age and CD4-positive lymphocyte values below 14 percent either at entry (age-adjusted mortality rate ratio (RR) = 6.4, 95% confidence interval (CI) 3.4-12.1) or after entry (time-dependent RR = 4.2, 95% CI 2.6-6.7); indeterminate antibody responses to hepatitis C virus (RR = 3.0, 95% CI 1.8-5.0); and inhibitory antibodies to factor VIII concentrates (RR = 1.8, 95% CI 1.1-3.1). Indeterminate hepatitis C virus status was associated with mortality from hepatic disease but not with AIDS mortality. Factors that were not prognostic included duration of HIV infection, hepatitis B virus infection, and other hemophilia variables. These findings suggest that fatal liver disease among coinfected subjects with an indeterminate hepatitis C virus status is probably related to an insufficient humoral response secondary to HIV immune dysfunction and that the risk of death among HIV-infected subjects is best evaluated with age and duration of low CD4 percentage.

Differences in the degree of depletion, rate of recovery, and the preferential elimination of naive CD4+ T cells by anti-CD4 monoclonal antibody (GK1.5) in young and aged mice

We compared the degrees of depletion and the rates of recovery of CD4+ T cells in young and old mice given a single injection of an anti-CD4 (GK1.5) mAb. We found that in young mice the CD4+ population of T cells was completely depleted from the peripheral blood and, subsequently, the lymph nodes and spleen. Young mice recovered 80% of CD4+ T cells within 100 days after the injection. Although aged mice have less CD4+ T cells, CD4+ T cells were depleted by only 60% after mAb injection. This finding was associated with prolonged circulation of Ab-coated T cells. The rate of repopulation of peripheral CD4+ T cells was also affected by aging, because 5 times less CD4+ T cells appear in aged than in young mice between days 14 and 100 post injection. Further, we found that the CD4+ T cells that are depleted in both young and old mice by injection of anti-CD4 mAb are CD45RBhigh, suggesting a preferential depletion of immature cells. Finally, the thymus appears to be required to repopulate the T cell population post injection, because thymectomized young mice failed to recover CD3+CD4+ cells.