Abstract 744: Treatment inequities among patients diagnosed with Hodgkin's lymphoma with and without HIV (2018-2019): an analysis of the US National Cancer Database

Background: People living with HIV (PLWH) with Hodgkin’s lymphoma(HL) have similar response and survival rates to people without HIV when standard of care therapies are given. However, PLWH with HL are less likely to receive cancer treatment for unclear reasons. Our objective was to examine the role of social determinants of health(SDOH) with non-receipt of cancer treatment among PLWH with HL.

Methods: Using the U.S. National Cancer Database, we identified 11,517 persons aged 18-90 years, diagnosed with HL (ICD-O-3 codes; C770-779) between 2018-2019. Most patients were diagnosed with classical HL(9650; n=4534, 39%) or nodular sclerosis classical Hodgkin’s lymphoma (9663; n=4725, 41%). As per NCCN guidelines, receipt of first-line treatment was defined as receiving any chemotherapy, radiotherapy or a combination of both. We compared treatment receipt by HIV status and associations of SDOH (e.g., zip-code median household income) with non-receipt of treatment among those with and without HIV. Using multivariable logistic regression, we evaluated the association of treatment receipt with HIV status after adjustment for age, sex, and stage at diagnosis. We stratified this model by zip-code level income, education and race/ethnicity to evaluate the role of SDOH in this exposure-outcome relationship. For each model, we calculated cluster-robust standard errors to account for non-independence within clusters at the facility level to adjust for correlated patient characteristics within hospitals.

Results: Our sample (n=11,517) included 60% adults aged 50 years or below, 55% men, 71% NH-White and 14% NH-Black. About one-third were treated at an academic/research program and 57% were privately insured. PLWH included 6% of the population. Overall, 12% did not receive first-line recommended treatment and were less likely to receive treatment compared to those without HIV (13% vs. 9%, p=0.012). We identified the following characteristics amongst PLWH to be more likely not to receive treatment compared to those without HIV, persons who were: aged 40 years or younger(13% vs. 6%, p=0.001), male(15% vs. 9%, p<0.001), NH-White(13% vs. 8%) and NH-Black(14% vs. 11%) persons(p<0.001), persons residing in areas with lower levels of educational attainment (20% vs. 10%, p<0.001) and low income areas (14% vs 9%, p<0.001), and were Medicaid insured (17% vs. 8%, p<.001). Stratifying by area-level education, this association persisted among those residing in areas with lower levels of education and income.

Conclusion: PLWH with HL were less likely to receive cancer treatment and continue to experience inequities in cancer treatment receipt, with SDOH playing a potential role in inequitable cancer care delivery.

Citation Format: Jessica Yasmine Islam, Jennifer McGee, Yi Guo, Marlene Camacho-Rivera, Lubomir Sokol, Susan T. Vadaparampil, Gita Suneja. Treatment inequities among patients diagnosed with Hodgkin's lymphoma with and without HIV (2018-2019): an analysis of the US National Cancer Database [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 744.

Safety and efficacy of tenecteplase in patients with wake-up stroke assessed by non-contrast CT (TWIST): a multicentre, open-label, randomised controlled trial

BACKGROUND

Current evidence supports the use of intravenous thrombolysis with alteplase in patients with wake-up stroke selected with MRI or perfusion imaging and is recommended in clinical guidelines. However, access to advanced imaging techniques is often scarce. We aimed to determine whether thrombolytic treatment with intravenous tenecteplase given within 4·5 h of awakening improves functional outcome in patients with ischaemic wake-up stroke selected using non-contrast CT.

METHODS

TWIST was an investigator-initiated, multicentre, open-label, randomised controlled trial with blinded endpoint assessment, conducted at 77 hospitals in ten countries. We included patients aged 18 years or older with acute ischaemic stroke symptoms upon awakening, limb weakness, a National Institutes of Health Stroke Scale (NIHSS) score of 3 or higher or aphasia, a non-contrast CT examination of the head, and the ability to receive tenecteplase within 4·5 h of awakening. Patients were randomly assigned (1:1) to either a single intravenous bolus of tenecteplase 0·25 mg per kg of bodyweight (maximum 25 mg) or control (no thrombolysis) using a central, web-based, computer-generated randomisation schedule. Trained research personnel, who conducted telephone interviews at 90 days (follow-up), were masked to treatment allocation. Clinical assessments were performed on day 1 (at baseline) and day 7 of hospital admission (or at discharge, whichever occurred first). The primary outcome was functional outcome assessed by the modified Rankin Scale (mRS) at 90 days and analysed using ordinal logistic regression in the intention-to-treat population. This trial is registered with EudraCT (2014-000096-80), ClinicalTrials.gov (NCT03181360), and ISRCTN (10601890).

FINDINGS

From June 12, 2017, to Sept 30, 2021, 578 of the required 600 patients were enrolled (288 randomly assigned to the tenecteplase group and 290 to the control group [intention-to-treat population]). The median age of participants was 73·7 years (IQR 65·9-81·1). 332 (57%) of 578 participants were male and 246 (43%) were female. Treatment with tenecteplase was not associated with better functional outcome, according to mRS score at 90 days (adjusted OR 1·18, 95% CI 0·88-1·58; p=0·27). Mortality at 90 days did not significantly differ between treatment groups (28 [10%] patients in the tenecteplase group and 23 [8%] in the control group; adjusted HR 1·29, 95% CI 0·74-2·26; p=0·37). Symptomatic intracranial haemorrhage occurred in six (2%) patients in the tenecteplase group versus three (1%) in the control group (adjusted OR 2·17, 95% CI 0·53-8·87; p=0·28), whereas any intracranial haemorrhage occurred in 33 (11%) versus 30 (10%) patients (adjusted OR 1·14, 0·67-1·94; p=0·64).

INTERPRETATION

In patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days. The number of symptomatic haemorrhages and any intracranial haemorrhages in both treatment groups was similar to findings from previous trials of wake-up stroke patients selected using advanced imaging. Current evidence does not support treatment with tenecteplase in patients selected with non-contrast CT.

FUNDING

Norwegian Clinical Research Therapy in the Specialist Health Services Programme, the Swiss Heart Foundation, the British Heart Foundation, and the Norwegian National Association for Public Health.

Adolescent Health Risk and Behavior Survey: A School Based Survey in Central Nepal

Background A comprehensive study of adolescent health risk specific to the Dhulikhel catchment area has not been performed. Objective This survey assesses trends in demographics, nutrition, hygiene and related infrastructure, causes of injury, violence, mental health, substance abuse, and menstrual hygiene. Method A 40 question survey was adapted from the Center for Disease Control (CDC) Youth Risk Behavior Surveillance System, translated into the Nepali language, and administered to 1200 students in eight different schools in central Nepal. Descriptive statistics were used to summarize the data. Result The data has identified nutrition, infrastructure, mental health, and menstrual hygiene as areas for improvement. The number of adolescents who reported going hungry some, most, or all of the time (30.5%, 25.8%, 13.9%) reveals a need for better food access. Approximately 44.5 % of students had no access to soap and water at school. Students who endorse dissatisfaction with themselves was 6.5% and those with suicidal ideation or attempt was 11.8% of the surveyed population. A significantly greater percentage of students who reported suicidal ideation also reported engaging in behaviors related to physical violence, substance abuse, being dissatisfaction with themselves, insomnia due to anxiety, and loneliness. Of the female students, 40.1% reported missing school at least once in the last three months due to their period. Conclusion This data shows a need for better food access, improved infrastructure in schools in central Nepal, and the need to address the prevalence of mental health issues through program interventions.

Weird Science: Frankenstein Foods and States as Laboratories of Democracy

The National Bioengineered Food Disclosure Standard (the 'National Standard') was signed into law July 29, 2016. This Article analyzes the National Standard and posits that Vermont's Act 120 was a more effective labeling law because it safeguarded consumer sovereignty. The State regulatory scheme in place prior to the passage of the National Standard satisfied consumer demand for disclosure while allowing for necessary experimentation with GMO labeling. Part I provides an overview of the current federal scheme regulating GMOs. Part II analyzes of the conflict surrounding GMOs and labeling. Given that analysis, Part III compares the disclosure requirement of the National Standard with the requirements of Vermont's Act 120 and concludes that Vermont's labeling law offered a better safeguard for consumer sovereignty because it included a larger range of products and required a label that immediately relayed disclosures to consumers.

Blood circulating microparticle species in relapsing-remitting and secondary progressive multiple sclerosis. A case-control, cross sectional study with conventional MRI and advanced iron content imaging outcomes

BACKGROUND

Although multiple sclerosis (MS) is thought to represent an excessive and inappropriate immune response to several central nervous system (CNS) autoantigens, increasing evidence also suggests that MS may also be a neurovascular inflammatory disease, characterized by endothelial activation and shedding of cell membrane microdomains known as 'microparticles' into the circulation.

OBJECTIVE

To investigate the relationships between these endothelial biomarkers and MS.

METHODS

We examined the relative abundance of CD31(+)/PECAM-1, CD51(+)CD61(+) (αV-β3) and CD54(+) (ICAM-1) bearing microparticles in sera of healthy individuals, patients with relapsing-remitting MS, and secondary-progressive MS. We also investigated the correlation among circulating levels of different microparticle species in MS with conventional MRI (T2- and T1-lesion volumes and brain atrophy), as well as novel MR modalities [assessment of iron content on susceptibility-weighted imaging (SWI)-filtered phase].

RESULTS

Differences in circulating microparticle levels were found among MS groups, and several microparticle species (CD31(+)/CD51(+)/CD61(+)/CD54(+)) were found to correlate with conventional MRI and SWI features of MS.

CONCLUSION

These results indicate that circulating microparticles' profiles in MS may support mechanistic roles for microvascular stress and injury which is an underlying contributor not only to MS initiation and progression, but also to pro-inflammatory responses.

Cytomegalovirus disease in African-American kidney transplant patients

BACKGROUND

Cytomegalovirus (CMV) disease is a serious infection after kidney transplantation. The risk factors and the impact of CMV disease in African-American (AA) kidney transplant patients have not been well characterized.

METHODS

We performed a retrospective analysis on 448 AA patients transplanted between 1996 and 2005. A 3-month universal chemoprophylaxis with ganciclovir or valganciclovir was administered to CMV donor-positive/recipient-negative (D+/R-) patients and to those treated with anti-thymocyte globulin for rejection, but not routinely to those with other D/R serostatus.

RESULTS

A total of 31 AA patients (7%) developed clinical CMV disease. Compared with other D/R serostatus groups, the D+/R- group had the highest 3-year cumulative incidence of CMV disease (16.9% vs. 6.3% in D+/R+, 4.9% in D-/R+, and 2.4% in D-/R-). The D+/R- group also had the worst 3-year death-censored allograft survival (75% vs. 92% in D+/R+, 94% in D-/R+, and 96% in D-/R-, log-rank P = 0.01). Multivariate analysis found that D+/R- serostatus (odds ratio [OR] 5.4, 95% confidence interval [CI] 0.6-48.2, P = 0.003) and donor age > 60 years (OR 9.1, 95% CI 1.3-65, P = 0.03) were independent risk factors for CMV disease.

CONCLUSION

The D+/R- group has the highest incidence of CMV disease and the worst 3-year renal allograft survival despite 3-month universal prophylaxis. Prolonged chemoprophylaxis may be needed to prevent the late development of CMV disease and to improve allograft survival in the high-risk group of AA kidney transplant recipients.

Early inhibition of the renin-angiotensin system improves the long-term graft survival of single pediatric donor kidneys transplanted in adult recipients

Transplanting single pediatric donor kidneys into adult recipients has an increased risk of hyperfiltration injury and graft loss. It is unknown if renin-angiotensin system (RAS) blockers are beneficial in this setting. We retrospectively analyzed 94 adults who received single kidneys from donors <10 years old during 1996-2009. The recipients were divided into group 1 with RAS blockers (n = 40) and group 2 without RAS blockers (n = 54) in the first year of transplant. There was no significant difference in any donor/recipient demographic between the two groups. Graft function, incidence of delayed graft function, acute rejection, and persistent proteinuria were not statistically different either. Kaplan-Meier estimated death-censored graft survivals were significantly better in group 1 than in group 2: 95 vs. 81.2%, 82.4 vs. 61.2%, 72.6 vs. 58.5%, and 68.5 vs. 47.2% at 1, 3, 5, and 7 years, respectively (log rank P = 0.043). Multivariable analysis found persistent proteinuria was a risk factor for graft loss (OR 2.70, 95% CI 1.33-5.49, P = 0.006), while RAS blockers reduced the risk of graft loss (OR 0.38, 95% CI 0.18-0.79, P = 0.009). Early RAS blockade therapy in the first year of transplant is associated with superior long-term graft survival among adults transplanted with single pediatric donor kidneys.

Measured and modelled leaf and stand-scale productivity across a soil moisture gradient and a severe drought

Environmental controls on carbon dynamics operate at a range of interacting scales from the leaf to landscape. The key questions of this study addressed the influence of water and nitrogen (N) availability on Pinus palustris (Mill.) physiology and primary productivity across leaf and canopy scales, linking the soil-plant-atmosphere (SPA) model to leaf and stand-scale flux and leaf trait/canopy data. We present previously unreported ecophysiological parameters (e.g. V(cmax) and J(max)) for P. palustris and the first modelled estimates of its annual gross primary productivity (GPP) across xeric and mesic sites and under extreme drought. Annual mesic site P. palustris GPP was ∼23% greater than at the xeric site. However, at the leaf level, xeric trees had higher net photosynthetic rates, and water and light use efficiency. At the canopy scale, GPP was limited by light interception (canopy level), but co-limited by nitrogen and water at the leaf level. Contrary to expectations, the impacts of an intense growing season drought were greater at the mesic site. Modelling indicated a 10% greater decrease in mesic GPP compared with the xeric site. Xeric P. palustris trees exhibited drought-tolerant behaviour that contrasted with mesic trees' drought-avoidance behaviour.

Disability and kidney transplantation in the United States

Transplantation is the treatment of choice for patients with end-stage renal disease. Despite complete or partial restoration of renal function, many recipients after transplant continue to self-identify as disabled. It is a designation required for federal healthcare assistance pre-transplant, but in some cases, post-transplantation, the designation is misapplied. When kidney recipients bear the label of disabled, regardless if the disability is real or perceived, they are less likely to participate in work and social activities. Although transplantation improves quality of life, for many recipients the designation of disability can extend an unintended, negative impact. It is well recognized that kidney recipients return to employment, education, and social activities after transplantation. However, there is a portion of the recipient population that can work but chooses not to engage. A large part of the phenomenon is related to disability status and the federal financing of kidney disease. This paper summarizes the history of the relationship between disability and kidney transplantation, the potential pitfalls associated with the relationship, and evidence-based strategies designed to mitigate or lead to mitigation of the unfavorable effects associated with misappropriated, perceived disability after kidney transplantation.

Effects of salsalate therapy on recovery from vascular injury in female Zucker fatty rats

OBJECTIVE

Salsalate is a dimeric form of salicylic acid that has been shown to have anti-inflammatory activity and to reduce glucose levels, insulin resistance, and cytokine expression. However, the effect of salsalate on vascular injury has not been determined. The objective of this study is to investigate the effect of salsalate on vascular injury and repair in a rat model of carotid artery balloon catheter injury.

RESEARCH DESIGN AND METHODS

Salsalate treatment was started in female Zucker fatty rats (insulin resistant) 1 week before carotid artery balloon catheter injury and continued for 21 days, at which time the animals were killed and studied.

RESULTS

Treatment with salsalate significantly decreased the intima-to-media ratio and upregulated the expression of aortic endothelial nitric oxide synthase (eNOS), phosphorylated eNOS (p-eNOS) (ser 1177), and manganese superoxide dismutase (MnSOD) and reduced serum interleukin (IL)-6 with concomitant downregulation of nuclear factor (NF) κB subunit p65 and vascular endothelial growth factor (VEGF) expression in the balloon-injured carotid artery of female Zucker fatty rats.

CONCLUSIONS

The present study shows that salsalate treatment decreases vascular damage caused by balloon catheter injury in female Zucker fatty rats. The beneficial effect of salsalate on vascular injury was associated with upregulation of eNOS, p-eNOS, and MnSOD, which reduce oxidative stress and have anti-inflammatory properties, as evidenced by reduction in serum IL-6 and the downregulation of VEGF and NFκB, which promote inflammation without changing glucose levels. These results suggest that salsalate may be useful in reducing vascular injury and restenosis following interventional revascularization procedures.

Alterations in serum MMP-8, MMP-9, IL-12p40 and IL-23 in multiple sclerosis patients treated with interferon-β1b

Background: Interferon-β1b (IFN-β1b), an effective treatment for multiple sclerosis (MS), lessens disease severity in MS patients. However, the mechanisms of its immunoregulatory and anti-inflammatory effects in MS remain only partially understood. Matrix metalloproteinases (MMP) and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) are involved in blood brain barrier disruption and formation of MS lesions. Th1/Th17 cytokines e.g. interleukins IL-12p40, IL-17, and IL-23, are associated with MS disease activity and are significant players in pathogenesis of MS.

Objective: During a 1-year prospective study, we serially measured serum MMP-8, MMP-9, TIMP-1, IL-12p40, IL-17, and IL-23 in 24 patients with relapsing—remitting MS. We compared the results to clinical course and to brain magnetic resonance imaging. IFN-β1b decreased serum MMP-8 and MMP-9 (not TIMP-1).

Results: The sustained treatment with IFN-β1b attenuated the pro-inflammatory environment by significantly reducing the serum IL-12p40, IL-23, and showed a trend for decreasing IL-17. Decreased serum MMP-8, MMP-9, IL-12 and IL-23 levels were correlated with a decrease in the number of contrast-enhanced T2-weighted lesions.

Conclusion: Early treatment of MS with IFN-β1b may stabilize clinical disease by attenuating levels of inflammatory cytokines and MMPs. Serial measurement of inflammatory mediators may serve as sensitive markers to gauge therapeutic responses to IFN-β1b during the first year of treatment.

Donor-recipient gender and size mismatch affects graft success after kidney transplantation

BACKGROUND

Female recipients of male kidneys have an inferior graft survival, and patients receiving larger kidneys relative to their body size may have a graft survival advantage. Thus, graft survival may be affected by both gender and kidney size mismatches. The objective of this study was to analyze the possible confounding effect of body mass mismatch (body mass as proxy for kidney size) between female recipients of male donor kidneys.

STUDY DESIGN

A total of 668 kidney transplantations between 1996 and 2005 at our center were studied retrospectively. Graft and patient survival were determined by Kaplan-Meier estimation. Multivariate Cox proportional analyses were performed to determine the hazards of graft loss.

RESULTS

There were 146 female recipients of male kidneys. Compared with all other gender combinations, this group had the lowest unadjusted graft survival (86%, 79%, and 78% vs 92%, 88%, and 86% at 1, 2, and 3 years, respectively; log-rank p = 0.01). Donor body mass index (BMI) correlated with donor kidney size (p < 0.001). Male kidneys were a risk factor of graft loss for female recipients (hazard ratio [HR] 3.45, 95% CI 1.40 to 8.51, p = 0.01), but male donors with a larger BMI relative to female recipients' significantly reduced the risk (HR 0.19, 95% CI 0.05 to 0.67, p = 0.01).

CONCLUSIONS

The inferior graft survival for female recipients of male donor kidneys is mitigated by male donors with a larger BMI.

The synthetic GLP-I receptor agonist, exenatide, reduces intimal hyperplasia in insulin resistant rats

We studied the effect of a synthetic GLP-1 receptor agonist, exenatide, a drug approved for the treatment of type 2 diabetes, on the recovery from vascular injury in Zucker (non-diabetic) fatty rats. Exenatide 5.0 microg/kg per day or saline was administered for seven days before, and 21 days after balloon catheter mediated carotid injury. A pair feeding experiment helped differentiate between the drug itself and the known effects of the drug on decreased food intake. Body weight and glucose (weekly), carotid artery I/M ratio, aortic protein eNOS and NFkappaB-p65 were measured. Body weight gain in exenatide rats was significantly lower (53+/-5 vs. 89+/-8 g) than controls. Blood glucose did not change significantly. The I/M ratio in the exenatide group was 0.2+/-0.1 vs. 0.9+/-0.1 in controls (p<0.05). The expression of aortic eNOS was unchanged in exenatide treated rats and a small decrease seen in NFkappaB-p65 expression was not statistically significant. We conclude that exenatide attenuates intimal hyperplasia following balloon catheter induced vascular injury independently of glucose regulation and food intake. Our findings provide additional support for cardiovascular benefits of exenatide, especially in obese and pre-diabetic patients. Further research is needed to elucidate the mechanism underlying these effects.

P-selectin expression in cold preserved kidneys in University of Wisconsin and histidine-tryptophan-ketoglutarate solutions

The differences and efficacy of standard preservation solutions in kidney transplantation, University of Wisconsin (UW) and histidine-tryptophan-ketoglutarate (HTK), remain a topic of debate in recent clinical studies. P-selectins represent glycoproteins expressed on endothelial cells and platelets responsible for the earliest events in ischemia/reperfusion injury in kidney transplantation. This study aimed to compare the levels of P-selectin expression between cold preserved kidney tissues in UW and HTK solutions. Thirty kidneys were procured from male Lewis rats and stored in cold (4°C) solutions for periods of 4, 12, 16, 20, and 24h. Group 1 (n=15) kidneys were stored in UW solutions, and group 2 (n=15) kidneys were submerged in HTK solutions. At the end of each time point, the kidneys underwent preparation and levels of P-selectin expression in the tissues were measured using Immunoblot analyses and adjusted volumetric quantification of Western blot signals. For all periods of cold preservation, P-selectin expression was significantly down-regulated in kidney tissues stored in UW compared with HTK solutions (P<0.001). In summary, UW demonstrated a significant benefit over HTK solution in down-regulating P-selectin expression in cold preserved kidney grafts.

Virilizing luteinized thecoma of the ovary in a 15-year-old female: a case report

BACKGROUND

Only 30% of luteinized thecomas are found in women under the age of 30, and they are typically benign. Only 11% of luteinized thecomas show clinical signs of androgen production. We present an unusual case of a 15-year-old female who presented with secondary amenorrhea and virilization and was subsequently diagnosed with a benign luteinized thecoma of the ovary. This is the youngest nonmalignant luteinized thecoma reported to date.

CASE

A 15-year-old Sri Lankan female presented with increasing hair growth, a hoarse voice, and secondary amenorrhea. On physical examination, there was marked hirsutism and clitoromegaly. Investigations found an elevated free testosterone level and an enlarged, homogenous left ovary with absent normal ovarian architecture. A laparotomy and unilateral salpingo-oophorectomy was performed. The final diagnosis was a luteinized ovarian thecoma, with no evidence of malignancy. Postoperatively, testosterone levels normalized and menstrual cycles resumed. Although laser treatment helped with her hirsutism, her other virilizing symptoms (deepening of voice, clitoromegaly) did not improve postoperatively.

CONCLUSION

This case of a virilizing ovarian luteinized thecoma emphasizes the need for timely evaluation, diagnosis, and treatment of patients presenting with symptoms of excess androgen secretion in order to avoid irreversible unwanted effects. Possible ovarian causes of excess androgen secretion should not be overlooked when considering possible causes of hyperandrogenism and secondary amenorrhea.

Insulin glargine reduces carotid intimal hyperplasia after balloon catheter injury in Zucker fatty rats possibly by reduction in oxidative stress

Diabetes and impaired glucose tolerance are associated with increased cardiovascular disease morbidity and mortality particularly after vascular injury. Since insulin is frequently used in such patients, the effect of glulisine (short acting) and glargine (long acting) were tested in Zucker fatty rat carotid artery subjected to balloon catheter injury. Insulin-resistant Zucker fatty rats were sc injected 0.45 mg/kg/d of glargine (once) or glulisine (twice) for 1 week before, and 3 weeks after balloon injury. Fasting and postprandial glucose was measured twice weekly. Injured and uninjured carotid arteries, liver, and aorta were harvested after 3 weeks of injury. Carotid sections were H&E stained for measuring intima/media ratio or immunostained for nitrotyrosine. Serum and aortic protein were analyzed for IGF-1 and 8-isoprostane, respectively. Carotid intima/media ratio was significantly reduced in the glargine group [0.9 +/- 0.1-control; 0.6 +/- 0.1-glulisine; 0.4 +/- 0.1-glargine, P < 0.05]. Serum IGF-1 levels were higher in both insulins, but significant only in glargine group [567 +/- 121 (ng/ml)-control; 1059 +/- 150 (ng/ml)-glargine; P < 0.05]. The aortic 8-isoprostane levels decreased significantly in the glargine group [(921 vs. 2566 pg/mg protein; P < 0.05]. Compared to control nitrotyrosine staining intensity was significantly lower in both groups of insulin-treated rats; the lowest level was in the glargine group. Insulin glargine attenuates carotid intimal hyperplasia in nondiabetic Zucker fatty rat independent of glucose levels and support a valuable function for insulin in vascular disease that merits additional investigations.

Cadaveric kidney transplant complicated by rupture of native kidney angiomyolipoma: a case report and review of the literature

Kidneys with angiomyolipomas have been used for transplantation, but we are unaware of postoperative hemorrhage from a native kidney angiomyolipoma. A 49-year-old male who underwent a cadaveric renal transplant complicated by postoperative hemorrhage from a native kidney angiomyolipoma is presented. Evaluation and current management strategies are discussed.

Binding to Elongin C inhibits degradation of interacting proteins in yeast

Elongin C is a highly conserved, low molecular weight protein found in a variety of multiprotein complexes in human, rat, fly, worm, and yeast cells. Among the best characterized of these complexes is a mammalian E3 ligase that targets proteins for ubiquitination and subsequent degradation by the 26 S proteasome. Despite its crucial role as a component of such E3 ligases and other complexes, the specific function of Elongin C is unknown. In yeast, Elongin C is a non-essential gene and there is no obvious phenotype as associated with its absence. We previously reported that in Saccharomyces cerevisiae Elongin C (Elc1) interacts specifically and strongly with a class of proteins loosely defined as stress response proteins. In the present study, we examined the role of yeast Elc1 in the turnover of two of these binding partners, Snf4 and Pcl6. Deletion of Elc1 resulted in decreased steady-state levels of Snf4 and Pcl6 as indicated by Western blot analysis. Northern blot analysis of mRNA prepared from elc1 null and wild type strains revealed no difference in mRNA levels for Snf4 and Pcl6 establishing that the effects of Elc1 are not transcriptionally mediated. Reintroduction of either yeast or human Elongin C into Elc1 null strains abrogated this effect. Taken together, these data document that the levels of Snf4 and Pcl6 are dependent on the presence of Elc1 and that binding to Elc1 inhibits the degradation of these proteins. The results suggest a new function for yeast Elongin C that is distinct from a direct role in targeting proteins for ubiquitination and subsequent proteolysis.

Prevention of auditory dysfunction in hypothyroid Tshr mutant mice by thyroxin treatment during development

Based on previous work, it is clear that genetically hypothyroid Tshr(hyt) mutant mice are congenitally deaf [O'Malley et al. (1995) Hear. Res. 88: 181-189, Sprinkle et al. 2001b, J. Assoc. Res. Otolaryngol. DOI: 10.1007/s101620010077]. However, the extent to which auditory development is dependent on the availability of thyroxin (T4) during specific developmental stages is unknown. The aim of this study was to determine the relative importance of prenatal and postnatal thyroxin on the ontogeny of hearing in the hyt mouse. Experimental hypothyroid subjects were offspring of hyt/hyt breeders implanted with T4 or placebo controlled-release pellets 14 days prior to mating. Pups received T4 or saline placebo injections from birth through postnatal day 14 (P14) or the time of testing on P28. In the absence of exogenous T4 replacement, very high stimulus levels (>80 dB SPL) were required to elicit responses. Remarkably, T4 treatment confined to the postnatal period failed to significantly improve auditory function relative to untreated animals, while response thresholds, latencies, and amplitudes of mice born to dams that received T4 during pregnancy were significantly improved relative to both of the untreated groups. Response thresholds were improved somewhat when maternal T4 replacement was followed by treatment during the first 14 days of life, and animals treated throughout prenatal and postnatal life were comparable to those of age-matched euthyroid individuals. Findings from this study show that treatment of hyt/hyt mice with exogenous T4 significantly attenuates hypothyroid-induced otopathology in a develop-mental-stage-dependent manner. In addition, we demonstrate that postnatal development is critically dependent on prenatal exposure to thyroxin and that the critical window of T4 dependence extends throughout development.

Consequences of hypothyroidism on auditory system function in Tshr mutant (hyt) mice

The otological consequences of hypothyroidism and the outcome of thyroxin (T4) administration during the developmental period preceding the onset of hearing were examined in mice that express a point mutation in the gene encoding the thyrotropin receptor (Tshr), the so-called hyt mouse. Progeny of sires homozygous for the trait and heterozygous dams were injected with T4 or saline placebo from birth through the tenth postnatal day and auditory-evoked brainstem responses (ABRs) to acoustic clicks and tone bursts were recorded from young adults. Mutant (hyt/hyt) mice exhibited a distinctive pattern of sensory pathology that was characterized by their insensitivity to sound, prolonged response latencies, reduced peak amplitudes, and steep latency-intensity curves relative to the phenotypically normal, euthyroid, +/hyt littermates. Following thyroxin treatment, hyt/hyt mice responded to acoustic stimuli more frequently, were more sensitive to tone bursts throughout their audiometric range, and exhibited decreased latencies and increased amplitudes when compared with placebo-treated homozygous mutants. Although thresholds to acoustic stimuli were improved relative to the untreated group, T4-treated homozygotes were less sensitive than normal, euthyroid individuals. In addition, energy consumption by auditory brainstem nuclei, measured by 2-deoxyglucose (2-DG) uptake, was significantly lower in hyt/hyt mice compared with heterozygotes, and T4 treatment increased the level of 2-DG utilization. Moreover, mean ages for eye-opening and pinna-raising were delayed in animals that were homozygous for the hyt allele. When T4 was administered to hyt/hyt animals, pinna-raising occurred earlier than in untreated animals. A subset of homozygotes exhibited circling behavior, indicative of vestibular and/or motor dysfunction, even though all individuals assumed a normal righting reflex. These findings, including recruitment-like behavior and the restoration of response magnitude at high levels but not low, suggest that the cochlear amplifier is the primary locus of an enduring otological defect associated with hypothyroidism in the Tshr mouse.

Development of auditory brainstem responses (ABRs) in Tshr mutant mice derived from euthyroid and hypothyroid dams

Developmental changes in auditory brainstem responses (ABRs) to clicks and tone bursts were studied in genetically hypothyroid Tshr mutant mice that were homozygous for the hypothyroid trait (hyt/hyt), as well as in euthyroid individuals that were heterozygous for the trait (+/hyt). The developmental role of maternal thyroid hormones was determined by comparing homozygotes that were offspring of euthyroid (hyt/hyt(c)) or hypothyroid (hyt/hyt(h)) dams; all heterozygotes were born to euthyroid dams (+/hyt(e)). Clear responses to high-level stimuli were recorded from heterozygotes on postnatal day 12 (P12) for most stimulus conditions, and thresholds, response amplitudes, interpeak intervals, and latencies developed normally, achieving nearly adult properties by P21. Most hyt/hyt(h) animals were unresponsive to acoustic stimulation throughout the period of study. Grossly immature responses to high-level stimuli were observed in many hyt/hyt(e) pups on P15; however, clear, low-amplitude responses were not routinely observed until P21. Thresholds improved with age in +/hyt(e) and hyt/hyt(e) individuals, and latency-level curves were relatively steep in young animals and developed normally in +/hyt(e) mice with the most significant changes occurring between P15 and P21. In general, hyt/hyt(e) mice exhibited prolonged latencies, interpeak intervals, and central conduction times throughout the age range studied, and slopes of latency-level curves remained abnormally steep through P28. Response amplitudes were generally larger in heterozygotes than in hyt/hyt(e) mice, regardless of level. Replacement of thyroxin during the first 10 postnatal days in hyt/hyt(h) pups had little to no effect on the development of auditory function, although more animals from this group were responsive at very high stimulation levels. We conclude that auditory function is impaired in hypothyroid Tshr animals throughout development and that impairment is profound when individuals are not exposed to maternal thyroid hormone, i.e., a clear thyroxin-dependent critical prenatal period exists in the Tshr mutant mouse.

Transperineal and transvaginal sonography of perianal inflammatory disease

OBJECTIVE

Perianal infection arises in small intersphincteric anal glands predominantly located at the dentate line. Documentation of fluid collections and the relationship of inflammatory tracts to the sphincter mechanism is important for surgical treatment. Transanal sonography for assessment of perianal inflammatory disease is limited because placement of the rigid probe into the anal canal does not allow assessment of disease in the perineal region. The purpose of this study was to validate the use of transperineal sonography in men and both transvaginal and transperineal sonography in women for evaluation of perianal inflammatory disease.

SUBJECTS AND METHODS

Fifty-four patients, 28 men and 26 women, were imaged with transperineal and a combination of transperineal and transvaginal sonography, respectively. All patients were examined in the supine lithotomy and left lateral position with a transvaginal 8-to 4-MHz probe or a linear 12- to 7-MHz transducer. All fluid collections, sinus tracts, and fistulas were described by their location in relation to the sphincter mechanism and perineum.

RESULTS

Forty-six of 54 patients had perianal fistulas or sinus tracts: 33 transphincteric, seven intersphincteric, and six extrasphincteric. Fifteen patients had an associated abscess. In the eight remaining patients, there were two anovaginal fistulas, one rectovaginal fistula, one prolapsed internal hemorrhoid, two perianal complex masses, and two vascular perianal or perirectal inflammatory masses. Twenty-six patients underwent surgical procedures involving the anorectal canal or perirectal region, and of these, preoperative sonographic findings were confirmed in 22 (85%) of 26 patients. Three patients refused surgery, and six are awaiting surgery at this writing. Fifteen patients were treated conservatively.

CONCLUSION

Transperineal and transvaginal sonography are accurate, painless, and cost-effective methods for documenting perianal fluid collections and fistulas or sinus tracts or both.

Physical management of spasticity

Physical management of people with spasticity is a complex task requiring the collaborative work of a multidisciplinary team. This article reviews some of the most commonly used treatment techniques and theories that lay the framework for the physical management of spasticity. Most crucial to the management of the person with spasticity is the skillful application of the techniques and theories discussed. Given the complexity in the standardized evaluation of children with spasticity, it is recommended that existing outcome measures or standardized scales be applied wherever possible as an adjunct tool to the clinician's assessment and interventions. One must recognize the benefits of such scales and their limitations. Therefore, it is recommended that further development of standardized assessments be supported by funding agencies to develop both quantitative and qualitative measurement tools that will address the particular needs of the person with spasticity. Review of the literature supports the many interventions that are listed; however, further research is recommended by the consensus group.

Wound botulism in California, 1951-1998: recent epidemic in heroin injectors

California has reported most of the world's wound botulism (WB) cases and nearly three-fourths of the cases reported in the United States. We reviewed the clinical, epidemiologic, and laboratory features of WB. From the first case in 1951, through 1998, a total of 127 cases were identified-93 in the last 5 years. The dramatic increase has been due to an epidemic (of WB) in people who inject black tar heroin. Whereas early cases of WB occurred after gross trauma, all but 1 of the last 102 cases occurred in drug users, primarily those who inject drugs subcutaneously ("skin poppers"). Cases are occurring disproportionately in Hispanics and women. Misdiagnosis and diagnostic delays of up to 64 days have occurred. This unprecedented, ongoing epidemic is now being reported in other states. We discuss the clinical and laboratory features that distinguish botulism from conditions that can mimic it, the relative yield of various diagnostic laboratory tests for botulism, and its treatment.

Afferent innervation of outer and inner hair cells is normal in neonatally de-efferented cats

It has been hypothesized that normal pruning of exuberant branching of afferent neurons in the developing cochlea is caused by the arrival of the olivocochlear efferent neurons and the resulting competition for synaptic sites on hair cells. This hypothesis was supported by a report that afferent innervation density on mature outer hair cells (OHCs) is elevated in animals deefferented at birth, before the olivocochlear system reaches the outer hair cell area (Pujol and Carlier [1982] Dev. Brain Res. 3:151-154). In the current study, this claim was evaluated quantitatively at the electron microscopic level in four cats that were de-efferented at birth and allowed to survive for 6-11 months. A semiserial section analysis of 156 OHCs from de-efferented and normal ears showed that, although de-efferentation essentially was complete in all four cases, the number and distribution of afferent terminals on OHCs was indistinguishable from normal, and the morphology of afferent synapses was normal in both the inner hair cell area and the OHC area. Thus, the postnatal presence of an efferent system is not required for the normal development of cochlear afferent innervation, and the synaptic competition hypothesis is not supported.

Variable pulmonary responses from exposure to concentrated ambient air particles in a rat model of bronchitis

Chronic bronchitis may be considered a risk factor in particulate matter (PM)-induced morbidity. We hypothesized that a rat model of human bronchitis would be more susceptible to the pulmonary effects of concentrated ambient particles (CAPs) from Research Triangle Park, NC. Bronchitis was induced in male Sprague-Dawley rats (90-100 days of age) by exposure to 200 ppm sulfur dioxide (SO2), 6 h/day x 5 days/week x 6 weeks. One day following the last SO2 exposure, both healthy (air-exposed) and bronchitic (SO2-exposed) rats were exposed to filtered air (three healthy; four bronchitic) or CAPs (five healthy; four bronchitic) by whole-body inhalation, 6 h/day x 2 or 3 days. Pulmonary injury was determined either immediately (0h) or 18 h following final CAPs exposure. The study protocol involving 0 h time point was repeated four times (study #A, November, 1997; #B, February, 1998; #C and #D, May, 1998), whereas the study protocol involving 18 h time point was done only once (#F). In an additional study (#E), rats were exposed to residual oil fly ash (ROFA), approximately 1 mg/ m(3)x6 h/day x 3 days to mimic the CAPs protocol (February, 1998). The rats allowed 18 h recovery following CAPs exposure (#F) did not depict any CAPs-related differences in bronchoalveolar lavage fluid (BALF) injury markers. Of the four CAPs studies conducted (0 h time point), the first (#A) study (approximately 650 microg/m3 CAPs) revealed significant changes in the lungs of CAPs-exposed bronchitic rats compared to the clean air controls. These rats had increased BALF protein, albumin, N-acetyl glutaminidase (NAG) activity and neutrophils. The second (#B) study (approximately 475 microg/m3 CAPs) did not reveal any significant effects of CAPs on BALF parameters. Study protocols #C (approximately 869 microg/m3 CAPs) and #D (approximately 907 microg/m3 CAPs) revealed only moderate increases in the above mentioned BALF parameters in bronchitic rats exposed to CAPs. Pulmonary histologic evaluation of studies #A, #C, #D, and #F revealed marginally higher congestion and perivascular cellularity in CAPs-exposed bronchitic rats. Healthy and bronchitic rats exposed to ROFA (approximately 1 mg/m3) did not show significant pulmonary injury (#E). Analysis of leachable elemental components of CAPs revealed the presence of sulfur, zinc, manganese, and iron. There was an apparent lack of association between pulmonary injury and CAPs concentration, or its leachable sulfate or elemental content. In summary, real-time atmospheric PM may result in pulmonary injury, particularly in susceptible models. However, the variability observed in pulmonary responses to CAPs emphasizes the need to conduct repeated studies, perhaps in relation to the season, as composition of CAPs may vary. Additionally, potential variability in pathology of induced bronchitis or other lung disease may decrease the ability to distinguish toxic injury due to PM.

The manifestation and nursing management of agitation in institutionalised residents with dementia

This participatory action research study is the first formal research study undertaken by nurses in a nursing development unit. The study emerged as the result of nurses brainstorming issues that they perceived to be problematic in their nursing practice and their unit environment. The nurses of the psycho-geriatric nursing development unit, Wallsend Aged Care Facility, New South Wales, Australia identified that the management of agitated behaviour manifested by their severely demented clients was a major challenge in their practice. As a result, a pilot participatory action research study was designed to measure how agitation manifested, to measure the severity of agitation and to identify current nursing practices used to manage it and their outcome. Results of the study demonstrated that nurse actions triggered the majority of most highly rated episodes of agitated behaviour in this group of elderly residents, and that the majority of these nurse actions related to those involved in carrying out activities of daily living for the residents.

SHP-2 can suppress transformation induced by platelet-derived growth factor

Signaling by either the type alpha or type beta receptors of platelet-derived growth factor occurs by phosphorylation of at least 10 intra-cytoplasmic tyrosine residues and their subsequent association of secondary signaling molecules with Src homology 2 (SH2) domains. Although the role of several of these secondary signaling molecules in mitogenesis has become increasingly clear, their roles in morphological transformation are not as well defined. Here we present evidence that the SHP-2 phosphatase which associates with Tyr 1009 of the type beta receptor and Tyr 720 of the type alpha receptor may suppress transformation induced by the PDGF B chain. Cotransfection of a dominant negative mutant of the SHP-2 gene and the PDGF B chain gene into mouse fibroblasts that only poorly formed foci with the PDGF B chain alone resulted in larger and more prominent foci. Furthermore, introduction of a wild-type copy of the SHP-2 gene into a tumor cell line, U-87MG, which relies on PDGF expression to form foci in vitro, caused a reversion of phenotype.

Contributions of ion conductances to the onset responses of octopus cells in the ventral cochlear nucleus: simulation results

The onset response pattern displayed by octopus cells has been attributed to intrinsic membrane properties, low membrane impedance, and/or synaptic inputs. Although the importance of a low membrane impedance generally is acknowledged as an essential component, views differ on the role that ion channels play in producing the onset response. In this study, we use a computer model to investigate the contributions of ion channels to the responses of octopus cells. Simulations using current ramps indicate that, during the "ramp-up" stage, the membrane depolarizes, activating a low-threshold K(+) channel, K(LT), which increases membrane conductance and dynamically increases the current required to evoke an action potential. As a result, the model is sensitive to the rate that membrane potential changes when initiating an action potential. Results obtained when experimentally recorded spike trains of auditory-nerve fibers served as model inputs (simulating acoustic stimulation) demonstrate that a model with K(LT) conductance as the dominant conductance produces realistic onset response patterns. Systematically replacing the K(LT) conductance by a h-type conductance (which corresponds to a hyperpolarization-activated inward rectifier current, I(h)) or by a leakage conductance reduces the model's sensitivity to rate of change in membrane potential, and the model's response to "acoustic stimulation" becomes more chopper-like. Increasing the h-type conductance while maintaining a large K(LT) conductance causes an increase in threshold to both current steps and acoustic stimulation but does not significantly affect the model's sensitivity to rate of change in membrane potential and the onset response pattern under acoustic stimulation. These findings support the idea that K(LT), which is activated during depolarization, is the primary membrane conductance determining the response properties of octopus cells, and its dynamic role cannot be provided by a static membrane conductance. On the other hand, I(h), which is activated during hyperpolarization, does not play a large role in the basic onset response pattern but may regulate response threshold through its contribution to the membrane conductance.

Clostridium difficile colitis associated with infant botulism: near-fatal case analogous to Hirschsprung's enterocolitis

We present the first five reported cases of Clostridium difficile-associated diarrhea (CDAD) in children with infant botulism caused by Clostridium botulinum. We compare two fulminant cases of colitis in children with colonic stasis, the first caused by infant botulism and the second caused by Hirschsprung's disease. In both children, colitis was accompanied by hypovolemia, hypotension, profuse ascites, pulmonary effusion, restrictive pulmonary disease, and femoral-caval thrombosis. Laboratory findings included pronounced leukocytosis, hypoalbuminemia, hyponatremia, coagulopathy, and, when examined in the child with infant botulism, detection of C. difficile toxin in ascites. CDAD recurred in both children, even though difficile cytotoxin was undetectable in stool after prolonged initial therapy. Four children who had both infant botulism and milder CDAD also are described. Colonic stasis, whether acquired, as in infant botulism, or congenital, as in Hirschsprung's disease, may contribute to the susceptibility to and the severity of CDAD.

Making survey results easy to report to consumers: how reporting needs guided survey design in CAHPS. Consumer Assessment of Health Plans Study

OBJECTIVES

CAHPS is designed to report information about health care quality from the consumer perspective. Enrollees are surveyed about their experiences with their health plan and medical care, and results are reported to other consumers choosing among health plans. Based on survey instruments designed to elicit reliable and valid information about health plan experiences from plan enrollees, the aim of the CAHPS team was to design a series of reporting products that present survey results so that consumers find the information understandable, meaningful, and useful in choosing among health plans.

METHODS

Design of the survey instruments and reporting products were closely linked. The approach to reporting was based on previous research on consumers' information interests and needs in evaluating and choosing among plans. Cognitive tests were conducted with consumers to get their reactions to mock-ups of various approaches to reporting CAHPS survey results.

RESULTS

Findings from previous research and cognitive testing, together with feedback from various experts and the public, were used to modify the survey questions, response options, and reporting formats to make it easier for consumers to understand and use reports. Changes included dropping topics of less interest to consumers, changing question wordings that were hard to understand, minimizing the number of different response categories, and revising questions to make them easier to group together for purposes of reporting.

CONCLUSIONS

The CAHPS focus on reporting results to consumers presented an unusual challenge for survey design, requiring close coordination between instrument design and report development to produce a survey and reporting kit that serves consumers' information needs.

Metabotropic glutamate receptor activation modulates sound level processing in the cochlear nucleus

The principal role of ionotropic glutamate receptors in the transmission and processing of information in the auditory pathway has been investigated extensively. In contrast, little is known about the functional contribution of the G-protein-coupled metabotropic glutamate receptors (mGluRs), although their anatomic location suggests that they exercise a significant influence on auditory processing. To investigate this issue, sound-evoked responses were obtained from single auditory neurons in the cochlear nuclear complex of anesthetized cats and gerbils, and metabotropic ligands were administered locally through microionophoretic pipettes. In general, microionophoresis of the mGluR agonists, (1S, 3R)-1-aminocyclopentane-1,3-dicarboxylic acid or (2S,1'S, 2'S)-2-(carboxycyclopropyl)glycine, initially produced a gradual increase in spontaneous and sound-evoked discharge rates. However, activation and recovery times were significantly longer than those observed for ionotropic agonists, such as N-methyl--aspartate or alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid, consistent with the recruitment of a second-messenger system. The efficacy of mGluR agonists was diminished after administration of the mGluR antagonist, (+)-alpha-methyl-4-carboxyphenylglycine, consistent with a selective action at metabotropic recognition sites. In contrast, two distinct changes were observed after the mGluR agonist had been discontinued for several minutes. Approximately 50% of neurons exhibited a chronic depression of sound-evoked discharge rate reminiscent of long-term depression, a cellular property observed in other systems. Approximately 30% of neurons exhibited a long-lasting enhancement of the sound-evoked response similar to the cellular phenomenon of long-term potentiation. These findings suggest that mGluR activation has a profound influence on the gain of primary afferent driven activity in the caudal cochlear nucleus.