Scaling Up Latent Tuberculosis Infection Testing and Treatment for Non-US Born Patients in a Federally Qualified Community Health Center

In the United States (US), tuberculosis elimination strategies include scaling up latent tuberculosis infection (LTBI) diagnosis and treatment for persons at risk of progression to tuberculosis disease. The Massachusetts Department of Public Health partnered with Lynn Community Health Center to provide care to patients with LTBI who were born outside the US. The electronic health record was modified to facilitate collection of data elements for public health assessment of the LTBI care cascade. Among health center patients born outside the US, testing for tuberculosis infection increased by over 190%. From October 1, 2016 to March 21, 2019, 8827 patients were screened and 1368 (15.5%) were diagnosed with LTBI. Using the electronic health record, we documented treatment completion for 645/1368 (47.1%) patients. The greatest drop-offs occurred between testing for TB infection and clinical evaluation after a positive test (24.3%) and between the recommendation for LTBI treatment and completion of a treatment course (22.8%). Tuberculosis care delivery was embedded in the primary care medical home, bringing patient-centered care to those at high risk for loss to follow up. The partnership between public health and the community health center promoted quality improvement.

Evidence of Electron Heating by Alpha Particles in JET Deuterium-Tritium Plasmas

The fusion-born alpha particle heating in magnetically confined fusion machines is a high priority subject for studies. The self-heating of thermonuclear fusion plasma by alpha particles was observed in recent deuterium-tritium (D-T) experiments on the joint European torus. This observation was possible by conducting so-called "afterglow" experiments where transient high fusion yield was achieved with neutral beam injection as the only external heating source, and then termination of the heating at peak performance. This allowed the first direct evidence for electron heating of plasmas by fusion-born alphas to be obtained. Interpretive transport modeling of the relevant D-T and reference deuterium discharges is consistent with the alpha particle heating observation.

Meta-analysis on the comparison of direct oral anticoagulants versus vitamin K antagonists after transcatheter aortic valve implantation in patients with pre-existing atrial fibrillation

Background

Transcatheter aortic valve replacement is a treatment option for symptomatic patients with severe aortic stenosis who are candidates for a bioprosthesis across the entire spectrum of risk. TAVR carries a risk for thrombotic and bleeding events, underscoring the importance of defining the optimal adjuvant antithrombotic regimen. Antithrombotic consideration is complicated by the fact that many patients undergoing TAVR are generally elderly with multiple comorbidities, including conditions that may require long-term oral anticoagulation such as atrial fibrillation. The optimal antithrombotic regimen for patients with AF undergoing TAVR is currently unknown. The objective of this meta-analysis is to add knowledge to existing data involving the use of direct oral anticoagulant in patients with pre-existing atrial fibrillation undergoing TAVI and to explore the safety and efficacy of DOACs compared with VKA in this population

Methods

A systematic search for randomized controlled trials which compare direct oral anticoagulant and vitamin K antagonist was done using PubMed, Cochrane, MEDLINE and Clinicaltrials.gov. Studies which were done in the last five years (January 2016-October 2021) and those that involved human subjects were included in the study. Search terms include “Direct Oral Anticoagulant”, “Vitamin K Antagonist”, “TAVR”, “atrial fibrillation”, “DOAC” AND “TAVI” OR “VKA” AND “TAVI” AND “atrial fibrillation” AND “randomized controlled trial”.

Results

Five retrospective observational studies and two RCTs (3,998) were included in this meta-analysis comparing direct oral anticoagulant vs vitamin K antagonist in patients with known atrial fibrillation post TAVI. Dabigatran, Rivaroxaban, Apixaban, and Edoxaban were used in these different studies. Among patients with concomitant indication of oral anticoagulant like atrial fibrillation, there is no significant difference between direct oral anticoagulant and vitamin K antagonist in terms of outcomes on all-cause mortality, major and/or life threatening bleeding and stroke as shown in these values, (OR 1.05, 95% CI: 0.89–1.25, P=0.57, I2=39%), (OR=1.04, 95% CI: 0.85–1.27, P=0.70, I2=45%) and (OR=1.10, 95% CI: 0.80–1.51, p=0.56, I2=0%), respectively. When only the two RCTs are compared, still there is no significant difference on the outcomes mentioned above between direct oral anticoagulant and vitamin K antagonist based on these values (OR=1.07, 95% CI: 0.85–1.36, P=0.57, I2=0%), (OR=1.15, 95% CI: 0.59–2.24, P=0.68, I2=66%) and (OR=0.99, 95% CI: 0.65–1.49, p=0.95, I2=39%), respectively.

Conclusion

Use of direct oral anticoagulant was non inferior with vitamin K antagonist in terms of outcomes on all-cause mortality, major and/or life threatening bleeding and stroke. Direct oral anticoagulant is easier to use with its known safety profile, hence, it is a plausible alternative to warfarin in this population in patients with known atrial fibrillation post TAVR.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): St. Luke's Medical Center Taguig City

Colchicine in patients with acute myocardial infarction: an updated meta-analysis of randomized controlled trials

Background

Improvement in cardiovascular outcomes and treatment with anti-inflammatory agents have been the subject of many research. Colchicine inhibits tubulin polymerization and is used in treating pericarditis. Recent studies have shown its benefit when used for coronary events. The objective of this meta-analysis is to reexamine the role of colchicine in reducing cardiovascular events in acute coronary syndromes in light of more recent trials.

Methods

A systematic search for randomized controlled trials which involves use of colchicine and acute coronary syndrome was done using PubMed, Google Scholar, MEDLINE and Clinicaltrials.gov. Studies done in the last decade and those involving human subjects were included in the study.

Results

Seven RCT's (n: 11,282) were included in this meta-analysis comparing colchicine vs. placebo. Dose ranged from 0.5mg/day to 1mg/day. Among patients being treated for ACS, colchicine was associated with a significant reduction in composite cardiovascular outcomes (RR 0.69, 95% CI 0.60 – 0.79, P<0.ehab724.12731), unstable angina (RR 0.67, 95% CI 0.55 – 0.82, P<0.0001), and myocardial infarction (RR 0.75, 95% CI 0.62 – 0.92, P<0.005,). Gastrointestinal events were evident in the colchicine group with no statistical difference between the two (RR 1.28, 95% CI 0.98 – 1.67, P 0.07).

Conclusion

Use of colchicine reduces composite cardiovascular outcomes, recurrence of unstable angina and MI among patient who had ACS. There was no statistically significant difference between colchicine and placebo in terms of gastrointestinal events. It is possible that colchicine be part of the standard treatment in patients with acute coronary syndrome.

Funding Acknowledgement

Type of funding sources: None. Myocardial infarction forest plot

JET diagnostic enhancements testing and commissioning in preparation for DT scientific campaigns

In order to optimize the scientific exploitation of JET (Joint European Torus) during the upcoming deuterium-tritium experiments, a set of diagnostic systems is being enhanced. These upgrades focus mainly on the experimental and operational conditions expected during tritium campaigns. It should be stressed that measurements relevant for burning plasmas are specifically targeted. Previously non-available capabilities, such as a current measurement system fully covering all poloidal field circuits, are described in detail. Instrument descriptions, performance prediction, testing, and initial commissioning results of these systems are presented.

MHD marking using the MSE polarimeter optics in ILW JET plasmas

In this communication we propose a novel diagnostic technique, which uses the collection optics of the JET Motional Stark Effect (MSE) diagnostic, to perform polarimetry marking of observed MHD in high temperature plasma regimes. To introduce the technique, first we will present measurements of the coherence between MSE polarimeter, electron cyclotron emission, and Mirnov coil signals aiming to show the feasibility of the method. The next step consists of measuring the amplitude fluctuation of the raw MSE polarimeter signals, for each MSE channel, following carefully the MHD frequency on Mirnov coil data spectrograms. A variety of experimental examples in JET ITER-Like Wall (ILW) plasmas are presented, providing an adequate picture and interpretation for the MSE optics polarimeter technique.

Ion temperature and toroidal rotation in JET's low torque plasmas

This paper reports on the procedure developed as the best method to provide an accurate and reliable estimation of the ion temperature T_i and the toroidal velocity v_ϕ from Charge-eXchange Recombination Spectroscopy (CXRS) data from intrinsic rotation experiments at the Joint European Torus with the carbon wall. The low impurity content observed in such plasmas, resulting in low active CXRS signal, alongside low Doppler shifts makes the determination of T_i and v_ϕ particularly difficult. The beam modulation method will be discussed along with the measures taken to increase photon statistics and minimise errors from the absolute calibration and magneto-hydro-dynamics effects that may impact the CXRS passive emission.

Pennyroyal and gastrointestinal cells: multi-target protection of phenolic compounds against t-BHP-induced toxicity

Pennyroyal infusion maintains gastrointestinal cells antioxidant balance.

Cancer risk with alemtuzumab following kidney transplantation

Alemtuzumab has been employed for induction therapy in kidney transplantation with low rates of acute rejection and excellent graft and patient survival. Antibody induction therapy has been linked to increased vulnerability to cancer. Data regarding malignancy rates with alemtuzumab are limited. We studied 1350 kidney transplant recipients (between 2001 and 2009) at the University of Pittsburgh Starzl Transplant Institute, for post-transplant de novo and recurrent malignancy, excluding non-melanoma skin cancer, among patients receiving alemtuzumab, thymoglobulin, and no induction therapies. Of the 1350 patients, 1002 (74.2%) received alemtuzumab, 205 (15.2%) received thymoglobulin, and 122 (9%) received no induction therapy. After excluding cancers occurring within 60 d post-transplantation, 43 (3.25%) malignancies were observed during a median follow-up time of 4.0 yr. The incidence of malignancy was 5.4% (1.09 per 100 patient-years [PY]) with thymoglobulin, 2.8% (0.74 per 100 PY) with alemtuzumab, and 3.3% (0.66 per 100 PY) with no induction (across all groups; p = 0.2342, thymoglobulin vs. alemtuzumab; p = 0.008). Thus, with the exception of non-melanoma skin cancer which we did not evaluate, alemtuzumab induction was not associated with increased cancer incidence post-kidney transplantation when compared to no induction therapy and was associated with lower cancer incidence when compared to thymoglobulin.

[Sternal fractures - a case report, our hospital experience and a review of the literature]

Thoracic trauma is a common cause of consultation in the emergency department, and may include fractures of the sternum in about 8% of cases. Due to the anatomical relations of this bone, in complicated cases, the fracture is associated with lesions of vital organs, which should be readily identified. In this paper, we present a case recently operated in our Department, make a statistical evaluation of the treatment of these fractures in our hospital in the last ten years and review of the relevant literature.

Deciduoid pleural mesothelioma--a rare entity in a young woman

Deciduoid Mesothelioma is a rare variant of epithelioid mesothelioma; it was initially thought that it only occurred in the peritoneum of young women and had nothing to do with asbestos exposure. However, since these early findings it has also been observed in the pleura and the pericardium, with possible association to asbestos. In general the prognosis is poor compared to epithelioid mesothelioma. 45 cases have been reported in the literature up to now, 22 of these were located in the pleural cavity. The authors describe a case of deciduoid pleural mesothelioma in a 40-year-old-woman who presented with right pleuritic chest pain, with no history of asbestos exposure, treated with chemotherapy followed by surgery and who died postoperatively.

Mycobacterium tuberculosis testing practices in hospital, commercial and state laboratories in the New England states

SETTING

The mycobacterial laboratory is assuming an increasingly important role in tuberculosis (TB) control in the United States today.

OBJECTIVE

To assess mycobacterial laboratory capacity and practices in the New England states, USA.

DESIGN

We surveyed 143 hospital and commercial laboratories and five of the six state public health laboratories in New England that offer testing services for Mycobacterium tuberculosis. The survey captured information on types of services offered and volume of testing, use of state laboratories for testing, and promptness of reporting results to TB control programs.

RESULTS

State laboratories perform the majority of testing services, particularly for more specialized tests. All state laboratories surveyed perform species identification of acid-fast isolates, culture and first-line drug susceptibility testing. Less than 20% of hospital and commercial laboratories offer these services, and 78.6% of hospitals and commercial laboratories refer specimens to state laboratories for culture.

CONCLUSION

Surveys of M. tuberculosis testing capacities in a region can help decision makers ensure maintenance of essential services. Hospital and commercial laboratories with lower testing volume might increase efficiency by referring more specimens to state laboratories. State health departments might consider organizing regional laboratory service networks to monitor the provision of services, improve efficiency and oversee quality improvement initiatives.

[Septic arthritis and gout--a case report]

The authors describe a 54 year-old male patient, admitted after presenting in the emergency room with acute oligoarthritis affecting the shoulders and right tibiotarsal and sternoclavicular joints, with a week's duration. He was non-febrile and related a purulent discharge from the stump of a traumatic amputation of the left thumb, starting a few days prior to the presenting complaints. There was a previous history of gouty arthritis and moderate alcoholism. Lab work revealed an elevation of the acute phase markers, with marked neutrophilia. Upon admittance, the patient underwent arthrocentesis, revealing a purulent discharge with sodium monourate crystals, which cultured positively for meticillin-sensitive Staphylococcus aureus. Besides antibiotherapy, on Day 5 the patient presented with a cervical abscess with extension to mediastinum; the abscess was drained by a cardiothoracic surgeon, and the right sternoclavicular and first costochondral articulations were found to be destroyed. The authors note that, although it is a rare occurrence septic arthritis can coexist with gout, while discussing the possible mecanisms of this association, as well as particular details of the clinical case presented.

242 EFFECT OF SPERMATOZOA HEAD MORPHOMETRIC DIMENSIONS ON FREEZABILITY IN BROWN BEAR (URSUS ARCTOS)

Having recently observed that survival of red deer spermatozoa after cryopreservation seemed to reflect the size of sperm heads, we hypothesized that cryoresistance of brown bear spermatozoa might also be dependent on head size, since in a preliminary study we had also observed significant differences in sperm head sizes among male brown bears (median values for area 22.2 �m2, perimeter 18.2, length 6.1 and width 4.4 �m). In the present report, we analyzed the post-thaw survival of spermatozoa of 6 brown bears that were assigned to 2 groups (3 bears/group) based on sperm size: Group A with large-size sperm heads; Group B with small-size heads. Ejaculates were obtained by electroejaculation of adult brown bears (semi-free ranging in Cabarceno Park, Cantabria, Spain) under general anesthesia (7 mg kg-1 tiletamine + zolazepan and 2 mg kg-1 ketamine). Semen was diluted (Tes-Tris-fructose, 8% glycerol, 20% egg yolk, EDTA, and Equex paste), loaded in 0.25-mL straws, and frozen in a biofreezer at 20�C min-1 to -100�C. After storage in liquid nitrogen, samples were thawed in water at 65�C for 6 s and survival was measured. Sperm motility (TM: total, and PM: progressive; %) was assessed microscopically, and sperm viability, acrosome integrity (PI/PNA-FITC), and mitochondrial status (JC-1) were assayed for fresh and thawed sperm by flow cytometry. Recovery rates (RR: thawed/fresh � 100) were calculated for all parameters. For measurement of head size, fresh sperm samples were fixed in glutaraldehyde and slides were air-dried for 2 h. The samples were then stained with Diff-Quik� staining at 37�C. The area (Ar), perimeter (P), length (L), and width (W) of the heads of >100 spermatozoa per slide were measured (Sperm Class Analyzer�; Microptic S.L., Barcelona, Spain). Data were analyzed with the SAS ver8 system, and the Wilcoxon test was applied. The respective morphometric dimensions of the 2 groups were practically identical (Ar = 22; P = 18; L = 6; W = 4). The post-thaw recovery rates of spermatozoa from Group A were: TM: 60.1 � 29.3; PM: 54.8 � 36.0; viability: 99.4 � 8.0; acrosomes: 96.2 � 3.1; mitochondria: 70.9 � 15.5. The recovery rates for Group B were: TM: 78.7 � 13.8; PM: 69.0 � 18.8; viability: 93.8 � 5.2; acrosomes: 98.2 � 9.8; mitochondria: 72.5 � 22.5. Because of the high variability of recovery rates between males within each group, there were no statistical differences between the 2 groups. The absence of differences can be explained by the small number of males examined and the high variability between them. More studies are necessary to determine whether large sperm cells of brown bears are more susceptible to damage during cryopreservation. This work was supported in part by CANTUR S.A. and CICYT (CGL 2004-0278/BOS).

215 EPIDIDYMAL SPERM CRYOPRESERVATION OF ONE SOMALIA WILD ASS (EQUUS AFRICANUS SOMALIENSIS) USING SIX DIFFERENT EXTENDERS

The Somalia wild ass (Equus africanus somaliensis) is a critically endangered taxon (IUCN 2004 red list) which could benefit from biological resource banking. In this work, we studied the effect of different extenders applied to the cryopreservation of epididymal sperm obtained from one male of this subspecies. This animal (13 years old; housed in Cabarceno Park, Cantabria, Spain) was castrated because of very aggressive behavior with other mature males. Genitalia were dissected and weighed (testicles: right, 166 g, and left, 179 g; cauda epididymis: right, 9.3 g, and left, 11.8 g). Sperm were flushed from the cauda epididymis, yielding 15 mL of sample. Sperm concentration was 15 × 109 spermatozoa/mL, totaling 225 × 109 (allowing 4500 doses at 50 × 106 sperm/dose). Sperm motility (TM = % total motile; PM = % progressive; VAP = average path velocity) was assessed by CASA (Microptic, Barcelona, Spain). Viability (VIAB = % viable sperm) and acrosomal status (ACR = % viable spermatozoa with intact acrosomes) were assessed using propidium iodide (37 μmol/L) and PNA-FITC (1 ng/L) and flow cytometry. Chemicals were purchased from Sigma (Madrid, Spain). Part of the sample was divided into six aliquots and diluted 1:1 with different extenders: UL4: Tes-Tris-Fructose (TTF), 10% egg yolk (EG), and 4% glycerol (G); UL8: TTF, 20% EG, and 8% G; AND4: Andromed® (Minitüb, Tiefenbach, Germany) and 4% G; AND7: Andromed® and 7% G; GENT: Gent 1045; and INRA: INRA96 and 4% G. Andromed, Gent, and INRA are commercial extenders. Samples were cooled to 5°C (−0.2°C/min) and then diluted to 200 × 106 sperm/mL. Samples were packed (0.5-mL straws) and frozen using a biofreezer (from 5°C to −15°C at −15°C/min, and from −15°C to −100°C at −25°C/min). Samples were thawed at 65°C for 6 s, and assessed as for pre-freezing (Table 1). Post-thawing motility recovery using AND7 was excellent. The highest viability recovery was achieved by UL4, although that in AND7 was similar. The poor results of equine commercial extender Gent 1045 in this species are remarkable. Our results highlight the importance of species differences in the field of sperm cryopreservation. It is necessary to carry out continuous research for optimizing cryopreservation protocols in order to create germplasm banks for wild species. Table 1. Quality assessment results

Clonal relationships in a shelter-associated outbreak of drug-resistant tuberculosis: 1983-1997

SETTING

An outbreak of tuberculosis caused by Mycobacterium tuberculosis resistant to isoniazid and streptomycin (HS-resistant) was documented in Boston's homeless population in 1984. Isolate relatedness was confirmed at the time by phage typing. In the late 1990s, cases of HS-resistant tuberculosis in the homeless were also documented, confirmed by RFLP typing using IS6110. None of the phage typed isolates from the 1980s were viable for performing RFLP analysis. We attempted to determine, using mixed-linker PCR (M-L PCR) finger-printing, whether or not these cases were all due to the same strain of M. tuberculosis.

DESIGN

Isolates from 10 HS-resistant patients-four non-viable isolates from the 1980s and six viable isolates from 1996-1997-were sent to the Centers for Disease Control and Prevention for M-L PCR fingerprinting. These results were combined with record reviews of older cases and an ongoing epidemiologic investigation.

RESULTS

Eight of 10 of the isolates were clonal, and the other two were strongly suspected matches. Epidemiologic investigation determined that transmission continued to occur after the initial outbreak in 1984-1985, and that a streptomycin-monoresistant variant of the strain was also circulating.

CONCLUSION

M-L PCR fingerprinting combined with epidemiology was able to document links between cases across 15 years.

Comparison of a whole-blood interferon gamma assay with tuberculin skin testing for detecting latent Mycobacterium tuberculosis infection

CONTEXT

Identifying persons with latent tuberculosis infection (LTBI) is crucial to the goal of TB elimination. A whole-blood interferon gamma (IFN-gamma) assay, the QuantiFERON-TB test, is a promising in vitro diagnostic test for LTBI that has potential advantages over the tuberculin skin test (TST).

OBJECTIVES

To compare the IFN-gamma assay with the TST and to identify factors associated with discordance between the tests.

DESIGN AND SETTING

Prospective comparison study conducted at 5 university-affiliated sites in the United States between March 1, 1998 and June 30, 1999.

PARTICIPANTS

A total of 1226 adults (mean age, 39 years) with varying risks of Mycobacterium tuberculosis infection or documented or suspected active TB, all of whom underwent both the IFN-gamma assay and the TST.

MAIN OUTCOME MEASURE

Level of agreement between the IFN-gamma assay and the TST.

RESULTS

Three hundred ninety participants (31.8%) had a positive TST result and 349 (28.5%) had a positive IFN-gamma assay result. Overall agreement between the IFN-gamma assay and the TST was 83.1% (kappa = 0.60). Multivariate analysis revealed that the odds of having a positive TST result but negative IFN-gamma assay result were 7 times higher for BCG-vaccinated persons compared with unvaccinated persons. The IFN-gamma assay provided evidence that among unvaccinated persons with a positive TST result but negative IFN-gamma assay result, 21.2% were responding to mycobacteria other than M tuberculosis.

CONCLUSIONS

For all study participants, as well as for those being screened for LTBI, the IFN-gamma assay was comparable with the TST in its ability to detect LTBI, was less affected by BCG vaccination, discriminated responses due to nontuberculous mycobacteria, and avoided variability and subjectivity associated with placing and reading the TST.

Surgery for bronchiectasis

OBJECTIVE

The incidence of bronchiectasis has declined markedly in developed countries. However, a reasonable number of patients still need surgery, despite aggressive physiotherapy and antibiotic therapy. We have reviewed our patients to clarify the benefits from surgery and to analyse the complications.

MATERIAL AND METHODS

Between 1988 and 1999, we have operated on 119 patients with bronchiectasis, 71 female and 48 male, with a mean age of 42.2 years (range 11--77 years). Surgery was indicated because of unsuccessful medical therapy in 66 patients (55%), 31 (26%) had haemoptysis, 11 (9.2%) had lung abscess, 10 (8.4%) had lung masses, and three (2.5%) had pneumothorax. The most common manifestations were cough with sputum in 90 patients (76%), haemoptysis in 45 (38%) and recurrent infections in 57 (48%). The mean duration of the symptoms was 4 years (range 1--40 years). The lower lobes were diseased in 61 patients and bilateral disease was found in ten. The mean number of involved pulmonary segments was five (range 1-15). A lobectomy was performed in 75 patients (62%), a segmentectomy in 12 (10%), a pneumonectomy in nine (7.4%) and a bilobectomy in four (3.3%). Complete resection of the disease was achieved in 108 cases (91%).

RESULTS

There was no operative mortality and perioperative morbidity occurred in 15 patients (15%), including temporary broncho-pleural fistulae in 7 (5.8%), and post-operative haemorrhage and atrial arrhythmias in four (3.3%) each. After a mean follow-up was 4.5 years, 73 patients (68%) of this group were asymptomatic, and 31 (29%) had meaningful clinical improvement, while only four (3.7%) maintained or worsened prior symptoms. The best clinical improvement occurred in patients with complete resection of the disease (P=0.008). There were no differences in the respiratory function, comparing pre- and post-operative data, with a 2-year of minimum interval. The VC was 91 and 89% and the FEV1 was 83% and 81% of expected, respectively before and after surgery, (P=NS).

CONCLUSION

Surgery of pulmonary bronchiectasis has few complications and markedly improves symptoms in the great majority of patients, especially when complete resection of the disease is achieved. Pulmonary resection of bronchiectasis does not alter respiratory function.

Excision of pulmonary metastases of osteogenic sarcoma of the limbs

OBJECTIVE

The combination of surgery and chemotherapy improves the prognosis of patients with osteogenic sarcoma of the limbs without detectable metastases at presentation. However, lung metastases are a frequent complication. To evaluate the role of the resection of pulmonary metastases of osteogenic sarcoma of the limbs, we have reviewed our experience with this type of surgery, combined with a multidrug chemotherapy protocol.

PATIENTS AND METHODS

From January 89 to December 97, 198 patients operated on for osteogenic sarcomas of the limbs were followed in our centre. Of these, 31 patients (15.7%), with a mean age of 25 years (range 10-54 years), developed lung metastases and had undergone 45 thoracotomies. All patients received chemotherapy, followed by resection of metastatic lesions and additional chemotherapy. The mean time interval between resection of the primary tumour and the diagnosis of lung metastases was 22 months (4-122 months). Eight patients (25.8%) needed more than one (2-4) thoracotomy. The mean time interval between the first and second thoracic surgeries was 9.2 months (2-14 months).

RESULTS

There was no operative mortality or major morbidity. During the 45 thoracotomies, five lobectomies and 40 wedge resections were necessary. The mean number of metastases resected per thoracotomy was 3.4 (range 1-10). The degree of necrosis was evaluated by seriated sections for a histologic study. In the end the mean necrotic volume was calculated. A strong correlation was found between the degree of necrosis of the metastases and the need for reoperation for new metastatic lesions, because all the patients who needed more than one operation had less than 80% of necrosis of metastases. The patients were followed for a mean period of 28 months (6-72 months). Ten patients (32.2%) died of related causes at a mean of 19.4 months after thoracic surgery, three of whom had more than one operation. The 3-year survival after metastasectomy was 61%. Patients without pulmonary metastases had a 3-year survival of 79%.

CONCLUSIONS

In patients with lung metastases of an osteogenic sarcoma, the combination of chemotherapy and surgery improves the outcome. In our series the mortality was not influenced by the number or thoracotomies required.

Cardiac lymphatic dynamics after ischemia and reperfusion--experimental model

ABSTRACT. The aim of the present study was to investigate the lymphatic cardiac circulation in an experimental model of ischemia plus reperfusion in mongrel dogs (Canis familiaris L). As radiotracer we used 0.2-0.25 ml (111 MBq) of 99mTc-Re2S7 colloid (+/-10 microm), injected subcapsullary below the second diagonal of the descending anterior ligated coronary artery with a special needle. A gamma-camera/Starport + DecStation were used for data acquisition. Four experimental groups with five animals each were established: G I = controls; G II = immediately after acute myocardial infarction (AMI); G III = late infarction (5 days after AMI); G IV = ischemia (90 min) + reperfusion. Four regions of interest (ROIs) were chosen: injection area (ZA), above (ZB), near right (ZD), and far right (ZC) from ZA. Mean disappearance times in ZA and dynamic parameters in the other ROIs were determined from activity/time curves drawn in each area, using homemade software. The results obtained seem to indicate that the methodology is appropriate to a detailed study of lymphatic drainage in pathological situations in animal models.

Differential responses of human mononuclear phagocytes to mycobacterial lipoarabinomannans: role of CD14 and the mannose receptor

CD14 is a signaling receptor for both gram-negative bacterial lipopolysaccharide (LPS) and mycobacterial lipoarabinomannan (LAM) that lacks terminal mannosyl units (AraLAM). In contrast, terminally mannosylated LAM (ManLAM) binds the macrophage mannose receptor (MMRc), although the ability of the MMRc to serve as a signaling receptor has not been previously reported. We compared the abilities of AraLAM and ManLAM to induce distinct responses in two monocytic cell populations, freshly isolated human peripheral blood monocytes (PBM) and monocyte-derived macrophages (MDM). The responses examined were chemotaxis and transient changes in free cytosolic calcium ([Ca2+]in). We found that AraLAM but not ManLAM was chemotactic for both PBM and MDM. Migration of these cells in vitro to AraLAM was specifically blocked by an anti-CD14 monoclonal antibody, suggesting that CD14 mediates the chemotactic response to AraLAM. Subsequently, we found that AraLAM induced a transient rise in [Ca2+]in levels within a subpopulation of PBM but not MDM. This response was blocked by anti-CD14 antibodies. In contrast, ManLAM induced a transient rise in [Ca2+]in levels within a subpopulation of MDM but not PBM. This response was blocked by either anti-CD14 or anti-MMRc antibodies. These data suggest that the MMRc can serve as a signaling receptor and that coligation of both CD14 and the MMRc is required to elicit a specific response. Thus, one response to LAM (chemotaxis) can be elicited solely by engaging CD14, whereas a different response (changes in [Ca2+]in levels) depends on both the differentiation state of the cells and concomitant engagement of CD14 and the MMRc.

Adherence-dependent calcium signaling in monocytes: induction of a CD14-high phenotype, stimulus-responsive subpopulation

Isolation of monocytes by plastic adherence alters cell morphology and function. In order to study the effects of cell isolation procedures and subsequent culture on monocyte function, we examined cytoplasmic calcium concentration changes (delta[Ca2+]in) in human monocytes isolated by either negative (magnetic bead) or positive (plastic adherence) selection then stimulated with formyl-Met-Leu-Phe (fMLP), either immediately after isolation, or after 48 h in culture. We have previously shown that fresh adherence-isolated monocytes respond to fMLP with small delta[Ca2+]in and oxidative burst responses, exhibiting larger responses following 48 h of incubation. We now demonstrate that fresh monocytes, prevented from adhering by negative selection, exhibit an even smaller fMLP-induced delta[Ca2+]in, which does not increase during 48 h in culture if cells are kept nonadherent, in Teflon. Calcium responses of adherent, fresh monocytes do not increase if cells are subsequently placed into suspension and maintained nonadherent, but increase if nonadherent cells are permitted to adhere to plastic. Furthermore, augmented fMLP-[Ca2+]in and oxidative burst responses in plastic-adherent cells are restricted to a CD14-high phenotype subpopulation. The CD14-high phenotype also describes a subpopulation of cells that responds to CD4 crosslinking with a rapid delta[Ca2+]in. Induction of a subpopulation of CD14-high expressing cells by adherence may explain in part maturation-induced response changes observed in macrophage but not in monocyte in vitro systems.

Endotracheal reintubation: a closer look at a preventable condition

We designed a prospective study of endotracheal intubations and reintubations in our inner city Level 1 Trauma Center, to determine the frequency and causes of reintubation and evaluate the impact of an educational intervention aimed at minimizing unplanned extubations (UEs). After an initial 3-month phase, efforts were instituted to educate healthcare providers to the causes of reintubation noted. An identical 3-month period was then studied to evaluate the efficacy of the interventions. There were 862 patients, all adults, in the initial phase of the study, with 40 reintubation events in 22 patients; of the 808 in the second phase, there were 16 reintubations in 13 patients. The reintubation rate decreased from 4.4% to 1.9% (p = 0.005). Reintubations after UEs decreased from 14% to 5.2% (rate ratio, 0.374; 95% confidence interval = 0.141, 0.990). Multiple reintubation events decreased from 45% to 18.8% (p = 0.07). Increased provider education and protocol changes were associated with lower reintubation rates.

[The implantable cardioverter-defibrillator: the Portuguese experience]

OBJECTIVE

The aim of this study was to review the Portuguese experience with implantable cardioverter-defibrillator therapy (ICD), in order to evaluate the increase in the number of ICD implanted, the main indications for this kind of therapy, the technical evolution of the procedure and the results of the follow-up of these patients during the last five years.

PATIENT SELECTION

The study group consists of 58 patients, 53 male and 5 female, mean age 54 +/- 14 years with ICD implanted in our country since 1992. The ICDs were implanted in 4 Hospitals, namely, Santa Cruz Hospital with 36 patients, Santa Maria Hospital with 11, Santa Marta Hospital with 8 and Coimbra University Hospital with 3 patients. Twenty six patients were resuscitated from cardiac arrest and the other 32 had ventricular tachycardia (VT) not tolerated haemodynamically and refractory to therapy. The diagnosis was coronary artery disease in 31 patients, dilated cardiomyopathy in 8, valvular disease in 4, congenital cardiopathy in 3, right ventricular dysplasia in 2, congenital long QT syndrome in 1, hypertrophic cardiomyopathy in one. Seven patients had idiopathic ventricular fibrillation without structural heart disease and one patient had isolated right ventricular dilatation.

METHODS

All patients underwent electrophysiological study before ICD implantation. In 2 patients epicardial leads were used and in the remaining 56 patients a transvenous approach was used. The device was implanted in an abdominal position in 36 patients and in a pectoral position in 22. Defibrillation and pacing thresholds were measured during the implantation procedure and whenever necessary. Patients were followed up on an outpatient basis with evaluation of the number of arrhythmic episodes, therapy efficacy with reprogramming of the device when required.

RESULTS

The number of implantations has increased, from 4 devices implanted in 1992, to 32 in 1996. The implantation was successful and without mortality or complications in all patients. Defibrillation threshold was 16 +/- 3 J, with an electrode impedance of 48 +/- 9 Ohms. During a mean follow-up time of 18 +/- 15 months (1 to 56) 5 patients died, one of sudden death and 4 of non cardiac deaths, 15 patients were re-admitted to hospital and in 8 patients the device was replaced due to exhaustion. In this period, 37 patients (64%) had arrhythmic episodes detected by the device, 32 patients (55%) had shocks and 9 (16%) were treated with anti-tachycardia pacing. Inappropriate shocks were observed in 10 patients (17%). The ICD were reprogrammed in 11 patients.

CONCLUSIONS

Portuguese experience with IC implantation is increasing and has shown to be a safe procedure with no operative mortality or morbidity. The incidence of appropriate shocks was high with a good efficacy in sudden death reduction.

Rifampin preventive therapy for tuberculosis in Boston's homeless

An epidemic of isoniazid (INH)- and streptomycin (SM)-resistant tuberculosis began among Boston's homeless population in 1984. Individuals with skin test conversions who agreed to preventive therapy received either INH, rifampin, or a combination of INH and rifampin. A total of 204 individuals with documented tuberculin skin test conversions who did not have active tuberculosis at the time of the clinical evaluation for their positive skin test were eligible for preventive therapy. Data on type and length of preventive therapy were obtained from the Tuberculosis Clinic and the Boston Tuberculosis Registry records at Boston City Hospital. The individuals were followed for development of active tuberculosis. Six of 71 (8.6%) individuals who received no therapy, 3 of 38 (7.9%) in the INH group, and none in the rifampin or rifampin plus INH groups (49 and 37 persons, respectively) developed active tuberculosis. Patients in the rifampin group were significantly less likely to develop tuberculosis than patients in the no therapy group (p = 0.04; odds ratio [OR] = 0.00, 95% confidence interval [CI] = 0.00-0.91). Treatment with any rifampin-containing preventive therapy (rifampin or rifampin plus INH) was effective (p < 0.01 ) in preventing development of active disease. The three INH failures were with organisms that were resistant to INH.

Neutrophil functional responses depend on immune complex valency

Ligand-induced cross-linking of Fc gamma receptors (Fc gamma R) on neutrophils plays a significant role in their stimulation, shown here by contrasting the responses induced by low valency immune complexes (LICs) and high valency immune complexes (HICs) and by cross-linking LICs in situ (L/Ab) after their addition to the cells. Multiparameter flow cytometry was used to measure immune complex (IC)-elicited changes in cytoplasmic Ca2+ concentration and initiation of the oxidative burst simultaneously in the same cell and to correlate these with Fc gamma R occupancy. We have previously shown that subpopulations of neutrophils respond maximally to subsaturating concentrations of HIC; saturating dosages stimulate the entire population. This discrepancy was not due to differences in receptor occupancy. The magnitude of the transient Ca2+ increase was independent of the dose of HIC but depended on the dose when an LIC was used. As shown here, L/Ab cross-linking elicited Ca2+ responses similar to those observed in HIC-stimulated cells. In contrast, LIC elicited only minimal intracellular delta pH and no oxidative burst or membrane potential changes at all unless Fc gamma R was cross-linked, accomplished by HIC or by L/Ab. However, azurophilic degranulation, as determined by elastase release, was not observed in cells stimulated by the in situ cross-linking method, whereas the HIC preparation triggered azurophilic degranulation. Thus, some Fc gamma R-mediated neutrophil effector functions such as azurophilic degranulation and oxidative burst initiation have an absolute requirement for Fc gamma R cross-linking, whereas signaling functions such as changes in membrane potential, intracellular pH, and intracellular Ca2+ concentration can occur, albeit more slowly and to a lesser extent, if single Fc gamma R are occupied.

Role of the Fc gamma R subclasses Fc gamma RII and Fc gamma RIII in the activation of human neutrophils by low and high valency immune complexes

Two Fc gamma receptor (Fc gamma R) subclasses on human neutrophils, Fc gamma RII and Fc gamma RIII, activate different cellular functions. To examine the involvement of each receptor subtype in polymorphonuclear leukocyte activation, Fab and F(ab')2 fragments of subclass-specific monoclonal antibodies ([mAbs] mAb IV.3 against Fc gamma RII and mAb 3G8 against Fc gamma RIII, respectively) were used to block the binding of low valency immune complexes (LICs) and high valency immune complexes (HICs). Flow cytometry then permitted the simultaneous quantitation of antibody and ligand binding, the elicited intracellular Ca2+ concentration (delta[Ca2+]int), initiation of the oxidative burst, and/or the phospholipase A activation in the same cell. We have previously demonstrated that subsaturating dosages of HIC bind uniformly to all the cells but elicit an "all-or-none" (i.e., dose independent) maximal delta[Ca2+]int in a dose-dependent subpopulation of the cells. In contrast, both the proportion of cells responding and the magnitude of the delta[Ca2+]int transient depend on the subsaturating dose of LIC, even though it too binds uniformly to all the cells, nonresponding as well as responding. These earlier findings have here been extended by single cell flow cytometric analysis to demonstrate that F(ab')2 Fc gamma RIII is the major Fc gamma R involved in HIC binding (and [Ca2+]int mobilization), as well as in oxidative burst and phospholipase A activation. In contrast, both receptor subclasses must be available for LIC-elicited delta[Ca2+]int, as blockage by either of the mAb Fab or F(ab')2 fragments abrogates this response, even though LIC binding to the receptors is not decreased. Furthermore, LIC elicited little oxidative burst activity and failed to activate phospholipase A but cross-linking to achieve multivalency, previously shown to induce [Ca2+]int and oxidative burst responses, elicited phospholipase A activity via Fc gamma RIII. Fc gamma RII's role appears to be modulation of the small, late Ca2+ influx observed at > 1 min, whereas Fc gamma RIII modulates all the earlier larger events. Thus, simultaneous observation of receptor identity, receptor occupancy, and consequent activation parameters in the same cell by flow cytometry permits use to demonstrate that Fc gamma RII is necessary for the small signal transduction elicited by LIC; it plays a relatively small role in polymorphonuclear leukocyte stimulation by HIC. Fc gamma RIII is the main receptor responsible for immune complex-elicited polymorphonuclear leukocyte responses; its efficacy is greatly enhanced when the receptors are cross-linked, either by preequilibrated multivalent complexes or by in situ cross-linking of bound LIC with excess antibody.

Cytokine binding to CD4+ inflammatory cells: implications for asthma

While LCF is present in BAL early after antigen challenge, we know little about its other potential effects beyond CD4+ T cell, monocyte, and eosinophil chemotaxis and monocyte and CD4+ T cell activation. The work described here focuses on the hypothesis that the secreted protein products of T cells participate in the airway inflammatory process that underlies human asthma, and in particular that LCF could play an early role because of the unusual responsiveness of LCF-producing T to histamine. To date, most studies have addressed the measurement of cytokines derived from CD4+ T cells (e.g., IL-2, IL-3, IL-4, IL-5, and GM-CSF) in the airways of asthmatics, and attempted to correlate the presence of protein or mRNA with the complexion of the inflammatory infiltrate. These studies have been based upon the reports that there are increased numbers of CD4+ T cells in the airways of asthmatics, and that the presence of eosinophils might correlate with the secretion of TH2-type cytokines like IL-3, -4, and -5. Using this information as a background, our work has approached the problem in an entirely different way. We have focused our attention on the early events in antigen-induced asthma that are responsible for CD4+ cell accumulation in the lung, including CD4+ T cells, eosinophils, and monocytes. We have attempted to identify mechanisms by which mast cell mediators, in particular histamine, might play a role in the secretion of chemotactic lymphokines that are selective for CD4+ cells by using CD4 itself as a chemotactic factor receptor.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of pulmonary systemic blood flow using ECG gated acquisition

We propose a functional parametric analysis method using ECG-gated 99mTc-labeled red blood cell (RBC) imaging for detection and characterization of periodic variations in local blood activity in the lungs during cardiac cycle. We validated in animal experiments that such count variations correlate with cyclical pulmonary blood flow and may be used for evaluation of systemic-to-pulmonary shunts. Clinical studies were performed in 48 patients. After labeling the RBC pool with 99mTc, ECG-gated gamma camera images of both lung fields were acquired and processed to obtain Fourier transforms of time/activity functions in selected regions. The first harmonic parametric images of amplitude and phase were derived. There was an excellent correlation (r = 0.92) between activity variations and pulsatile flow measured by our method with that obtained by the thermodilution method in dog experiments (n = 10) after implantation of a systemic-to-pulmonary shunt. Patient studies showed the technique to be sensitive in detecting and quantifying abnormal systemic-to-pulmonary blood flow. Lung pulsatile flow can thus be noninvasively measured from functional parametric phase and amplitude images; the technique may be useful for detecting and quantifying abnormal systemic-to-pulmonary blood flow in man.

Chemotactic peptide-induced cytoplasmic pH changes in incubated human monocytes

Stimulation of phagocytic leukocytes with chemotactic factors results in transient acidification, followed by alkalinization of the cytosol. Human monocytes are known to alter their functional responses to the chemotactic peptide N-formylmethionyl-leucyl-phenylalanine (fMLP) in a complex fashion as they mature in vitro to macrophages. To examine the evolution of the cytoplasmic pH (pHi) response of monocytes to fMLP as they mature into macrophages, we incubated cells for 0, 24, 48, and 96 h (Medium-199 + 10% fetal bovine serum; 37 degrees C) and examined pHi using the fluorescent probe 2',7'-bis(carboxyethyl)-5(6)-carboxyfluorescein (BCECF; 1 microM) and a Perkin-Elmer 650/10 spectrofluorimeter (lambda em = 530 nm, lambda ex = 500, 450 nm) as previously described. The resting pHi of fresh (0 h) monocytes was 7.07 +/- 0.16 (SD) and was unchanged after incubation for 24, 48, or 96 h (7.09, 7.11, 7.05, respectively). Cells exhibited an fMLP dose-dependent cytoplasmic acidification, with maximal delta pHi occurring 30-60 s after exposure to 10(-7) M fMLP. The response to fMLP did not change with the duration of incubation and, as with neutrophils, cytoplasmic realkalinization was blocked by dimethylamiloride (20 microM). Incubation with 2-deoxyglucose (10 min, 5 mM), sufficient to inhibit by more than 90% the formyl peptide-stimulated superoxide generation by monocytes, slowed fMLP-induced acidification and abrogated the alkalinization. In addition, monocytes isolated from the blood of a patient with X-linked chronic granulomatous disease (CGD) underwent fMLP-induced acidification that was unmasked further by coincubation with dimethylamiloride, in a manner quantitatively similar to that of normal monocytes, despite the inability of the CGD cells to produce superoxide. The chemotactic factor-induced cytoplasmic pH responses of monocytes/macrophages remained constant as the cells matured in vitro and exhibited a dimethylamiloride-independent acidification and dependent alkalinization, as did the response in neutrophils. The cytoplasmic acidification of these cells thus did not correlate with the cells' production of superoxide and with the concomitant hexose monophosphate shunt activation, as has been suggested for other leukocyte types.

Flow cytometric kinetic measurements of neutrophil phospholipase A activation

The interrelationships between activation of phospholipases and neutrophil stimulus-induced Ca2+ responses remain unclear. We report here that immune complexes activate a phosphatidylcholine-specific phospholipase A in a neutrophil only after the cytoplasmic Ca2+ transient has been initiated in the same cell, while chemotactic peptide activation does not proceed via such a phospholipase A-mediated mechanism. Measurements of [Ca2+] changes and of phosphatidylcholine-specific phospholipase A activity were made by flow cytometry, using Indo-1 for Ca2+ indication, and a new fluorescent probe, bis-BODIPY-phosphatidylcholine, localized in the inner leaflet of the plasma membrane, to measure phospholipase A activation. Both 100 nM formyl-methionyl-leucyl-phenylalanine (with or without cytochalasin B) and 60 micrograms/ml insoluble immune complexes elicited cytoplasmic Ca2+ transients, but only insoluble immune complexes stimulated phospholipase A activation in a subpopulation of cells exhibiting an elevation of [Ca2+]in. Phospholipase A activation followed the Ca2+ transient, starting, in each cell, after [Ca2+]in had begun to decrease as Ca2+ redistributed in the activated cell. The products of this phospholipase activation were confirmed by thin layer chromatography. We conclude that neutrophils respond to immune complexes with an elevated cytoplasmic Ca(2+)-requiring phosphatidylcholine-specific phospholipase A activation and to chemotactic peptides by a different mechanism.

Tuberculosis: a disease of the 1990s

In the United States, the decades preceding the 1980s were characterized by a decline in the incidence of tuberculosis. More recently, the trend has undergone a significant reversal: Case rates have been increasing by 3% to 6% annually. In 1990, more than 25,700 cases were reported to the Centers for Disease Control. In a sense, tuberculosis is adapting to the '90s. The recent increase in its incidence tends to affect populations with identifiable characteristics. Among the most important of these groups are the populations at high risk for infection by the human immunodeficiency virus. The increase is also fueled by cases in populations that are medically underserved, including foreign-born persons from high-prevalence countries, persons with low incomes, and persons living in long-term-care facilities--especially persons with previous tuberculosis infection. Thus, factors such as homelessness, chronic alcohol or drug abuse, malnutrition, and crowded living conditions continue to favor development and transmission of disease. The increase in the incidence of tuberculosis appears to be greatest when subpopulations in such circumstances are also at high risk for HIV infection. Complex issues in the diagnosis and treatment of tuberculosis arise from these epidemiologic patterns. HIV infection is associated with unusual presentations of tuberculosis. Thus, the clinician must maintain a high index of suspicion for the disease in the setting of HIV infection or risk of the infection. The populations at greatest risk are likely to be mistrustful of the medical system, making the long-term administration of potentially toxic chemotherapy more difficult than it already is. Chronic substance abuse may complicate compliance and add further difficulties to the monitoring of chemotherapy. At the same time, the monitoring becomes even more important in the physician's effort to minimize adverse effects of the medications. Outbreaks of drug-resistant disease have recently occurred, complicating the selection of drugs and affecting the duration of treatment. Despite all of these problems, it is essential to establish a diagnosis and initiate treatment rapidly, both to arrest the disease process and to limit its transmission. Since Mycobacterium tuberculosis is spread to uninfected persons in aerosols generated by coughing or sneezing, the infectiousness of a patient with active disease can be related, at least in part, to the number of organisms seen on sputum smears. Initiation of therapy is followed by a rapid decline in infectivity.

Effect of salt supplementation on amphotericin B nephrotoxicity

It has been suggested that salt loading protects against amphotericin B-induced nephrotoxicity. The influence of saline loading on the nephrotoxic response to amphotericin B (50 mg/dose given i.v. over 4 hr 3 X/week for 10 weeks) was assessed in two groups of ten patients each who were diagnosed with mucocutaneous leishmaniasis. Patients were randomized to receive either 1 liter of 0.9% saline or 1 liter of 5% dextrose in water, administered i.v. over one hour in a double-blinded manner, directly prior to amphotericin B administration. Renal function was monitored on a weekly basis two days after the last dose of amphotericin B. Baseline characteristics were similar in both groups except for a slightly higher serum creatinine concentration (Cr) in the saline group (0.8 +/- 0.05 vs. 0.6 +/- 0.04 mg/dl). Baseline sodium (Na) excretion was relatively high (262 +/- 23 mmol/day in the dextrose group and 224 +/- 17 mmol/day in the saline group). None of the patients sustained an increase in Cr to values greater than 1.7 mg/dl. Although mean Cr remained within normal, there was a significant difference between the two groups over the ten week period, with the dextrose group sustaining a significant increase in Cr and the saline group remaining unchanged. Serum potassium (K) levels fell in both groups necessitating oral K supplementation. The saline group required significantly greater amounts of K supplementation to maintain a normal serum K. Amphotericin B caused a rapid reduction in the acidification ability of the kidney in response to an ammonium chloride load. Under these conditions, the saline group had a poorer ability to acidify the urine.(ABSTRACT TRUNCATED AT 250 WORDS)