Optimizing antibiotic management for patients with acute appendicitis: A quality improvement study

BACKGROUND

To decrease surgical site infections after appendectomy for acute appendicitis, preoperative broad-spectrum antibiotics are often used in clinical practice. However, this treatment strategy has come under scrutiny because of increasing rates of antibiotic-resistant infections.

METHODS

The aim of this multisite quality improvement project was to decrease the treatment of uncomplicated acute appendicitis with piperacillin-tazobactam without increasing the rate of surgical site infections. Our quality improvement intervention had 2 distinct components: (1) updating electronic health record orders to encourage preoperative administration of narrow-spectrum antibiotics and (2) educating surgeons and emergency department clinicians about selecting appropriate antibiotic therapy for acute appendicitis. Patient demographics, clinical characteristics, and outcomes were compared 6 months before and after implementation of the quality improvement intervention.

RESULTS

A total of 352 laparoscopic appendectomies were performed during the 6-month preintervention period, and 369 were performed during the 6-month postintervention period. The preintervention period and postintervention period groups had similar baseline demographics, vital signs, and laboratory test values. The rate of preoperative piperacillin-tazobactam administration significantly decreased after the intervention (51.4% preintervention period vs 20.1% postintervention period, P < .001). The rate of surgical site infections was similar in both groups (superficial surgical site infections = 1.4% preintervention period vs 0.8% postintervention period, P = .50; deep surgical site infections = 1.1% preintervention period vs 0.0% postintervention period, P = .06; and organ space surgical site infections = 3.1% preintervention period vs 3.0% postintervention period, P > .99). Rates of 30-day readmission, reoperation, and Clostridioides difficile infection also did not differ between groups.

CONCLUSION

Our quality improvement intervention successfully decreased piperacillin-tazobactam administration without increasing the rate of surgical site infections in patients with acute appendicitis.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Heterozygous frameshift mutation in keratin 5 in a family with Galli-Galli disease

BACKGROUND

Reticulate pigmentary disorders include the rare autosomal dominant Galli-Galli disease (GGD) and Dowling-Degos disease (DDD). Clinical diagnosis between some of the subtypes can be difficult due to a degree of overlap between clinical features, therefore analysis at the molecular level may be necessary to confirm the diagnosis.

OBJECTIVES

To identify the underlying genetic defect in a 48-year-old Asian-American woman with a clinical diagnosis of GGD.

METHODS

Histological analysis was performed on a skin biopsy using haematoxylin-eosin staining. KRT5 (the gene encoding keratin 5) was amplified from genomic DNA and directly sequenced.

RESULTS

The patient had a history of pruritus and hyperpigmented erythematous macules and thin papules along the flexor surfaces of her arms, her upper back and neck, axillae and inframammary areas. Hypopigmented macules were seen among the hyperpigmentation. A heterozygous 1-bp insertion mutation in KRT5 (c.38dupG; p.Ser14GlnfsTer3) was identified in the proband. This mutation occurs within the head domain of the keratin 5 protein leading to a frameshift and premature stop codon.

CONCLUSIONS

From the histological findings and mutation analysis the individual was identified as having GGD due to haploinsufficiency of keratin 5.

WITHDRAWN: Microsecond resolution of enzymatic conformational changes using dark-field microscopy

We report a novel method to detect angular conformational changes of a molecular motor in a manner sensitive enough to achieve acquisition rates with a time resolution of 2.5mus (equivalent to 400,000fps). We show that this method has sufficient sensitivity to resolve the velocity of the F(1)-ATPase gamma-subunit as it travels from one conformational state to another (transition time). Rotation is detected via a gold nanorod attached to the rotating gamma-subunit of an immobilized F(1)-ATPase. Variations in scattered light intensity allow precise measurement of changes in angular position of the rod below the diffraction limit of light.

Single-molecule detection of DNA via sequence-specific links between F1-ATPase motors and gold nanorod sensors

We report the construction of a novel biosensing nanodevice to detect single, sequence-specific target DNA molecules. Nanodevice assembly occurs through the association of an immobilized F1-ATPase molecular motor and a functionalized gold nanorod via a single 3',5'-dibiotinylated DNA molecule. Target-dependent 3',5'-dibiotinylated DNA bridges form by combining ligation and exonucleation reactions (LXR), with a specificity capable of selecting against a single nucleotide polymorphism (SNP). Using dark field microscopy to detect gold nanorods, quantitation of assembled nanodevices is sufficient to distinguish the presence of as few as 1800 DNA bridges from nonspecifically bound nanorods. The rotary mechanism of F1-ATPase can drive gold nanorod rotation when the nanorod is attached via the DNA bridge. Therefore, rotation discriminates fully assembled devices from nonspecifically bound nanorods, resulting in a sensitivity limit of one zeptomole (600 molecules).

Recent developments of bio-molecular motors as on-chip devices using single molecule techniques

The integration of microfluidic devices with single molecule motor detection techniques allows chip based devices to reach sensitivity levels previously unattainable.

Microsecond time scale rotation measurements of single F1-ATPase molecules

A novel method for detecting F(1)-ATPase rotation in a manner sufficiently sensitive to achieve acquisition rates with a time resolution of 2.5 micros (equivalent to 400,000 fps) is reported. This is sufficient for resolving the rate at which the gamma-subunit travels from one dwell state to another (transition time). Rotation is detected via a gold nanorod attached to the rotating gamma-subunit of an immobilized F(1)-ATPase. Variations in scattered light intensity allow precise measurement of changes in the angular position of the rod below the diffraction limit of light. Using this approach, the transition time of Escherichia coli F(1)-ATPase gamma-subunit rotation was determined to be 7.62 +/- 0.15 (standard deviation) rad/ms. The average rate-limiting dwell time between rotation events observed at the saturating substrate concentration was 8.03 ms, comparable to the observed Mg(2+)-ATPase k(cat) of 130 s(-)(1) (7.7 ms). Histograms of scattered light intensity from ATP-dependent nanorod rotation as a function of polarization angle allowed the determination of the nanorod orientation with respect to the axis of rotation and plane of polarization. This information allowed the drag coefficient to be determined, which implied that the instantaneous torque generated by F(1) was 63.3 +/- 2.9 pN nm. The high temporal resolution of rotation allowed the measurement of the instantaneous torque of F(1), resulting in direct implications for its rotational mechanism.

Infected joint replacements in HIV-positive patients with haemophilia

Joint replacement in HIV-positive patients remains uncommon, with most experience gained in patients with haemophilia. We analysed retrospectively the outcome of 102 replacement arthroplasties in 73 HIV-positive patients from eight specialist haemophilia centres. Of these, 91 were primary procedures. The mean age of the patients at surgery was 39 years, and the median follow-up was for five years. The overall rate of deep sepsis was 18.7% for primary procedures and 36.3% for revisions. This is a much higher rate of infection than that seen in normal populations. A total of 44% of infections resolved fully after medical and/or surgical treatment.

The benefits of arthroplasty in haemophilic patients are well established but the rates of complications are high. As this large study has demonstrated, high rates of infection occur, but survivorship analysis strongly suggests that most patients already diagnosed with HIV infection at the time of surgery should derive many years of symptomatic relief after a successful joint replacement. Careful counselling and education of both patients and healthcare workers before operation are therefore essential.

Infected joint replacements in HIV-positive patients with haemophilia

Joint replacement in HIV-positive patients remains uncommon, with most experience gained in patients with haemophilia. We analysed retrospectively the outcome of 102 replacement arthroplasties in 73 HIV-positive patients from eight specialist haemophilia centres. Of these, 91 were primary procedures. The mean age of the patients at surgery was 39 years, and the median follow-up was for five years. The overall rate of deep sepsis was 18.7% for primary procedures and 36.3% for revisions. This is a much higher rate of infection than that seen in normal populations. A total of 44% of infections resolved fully after medical and/or surgical treatment. The benefits of arthroplasty in haemophilic patients are well established but the rates of complications are high. As this large study has demonstrated, high rates of infection occur, but survivorship analysis strongly suggests that most patients already diagnosed with HIV infection at the time of surgery should derive many years of symptomatic relief after a successful joint replacement. Careful counselling and education of both patients and healthcare workers before operation are therefore essential.

Population coverage by HLA class-I restricted cytotoxic T-lymphocyte epitopes

Vaccination using cytotoxic T-lymphocyte (CTL) epitopes has become a widely used immunization strategy, especially because their structure makes them an attractive alternative to the delivery of whole proteins as immunogens. Nonetheless, their use is limited, in particular because of their specificity, being recognized only by cognate HLA alleles. The potential for immunizing a substantial portion of an ethnically diverse population using a modest number of peptides has been aided by the identification of HLA supertypes. However, the derivation of epitopes is often guided by methods that do not guarantee cross-reactivity, so we consider the feasibility of providing vaccine coverage to a multi-ethnic population under different assumptions. In particular, two large datasets are used to estimate the number of peptides needed to provide > or =90% group-specific coverage of a multiethnic population, when specificity is assumed to be either to a single serologic or molecular type. These assumptions are evaluated utilizing a clinically important epitope repertoire derived from two human cytomegalovirus proteins, and data on the in vitro memory response elicited by these peptides is presented. In summary, our combined theoretical and empiric studies suggest that 90% coverage of some ethnic groups is attainable with 11 uniquely defined HLA-restricted CTL epitopes. The derivation of four or more additional CTL epitopes is needed to attain 90% coverage of Blacks or Asians, the minimally covered groups. Ninety percent coverage of all major ethnic groups in a multi-ethnic population appears feasible without relying on cross-reactivity, but may require two to three times more CTL epitopes than estimated for serologic data, homogenous populations, or HLA alleles grouped as supertypes.

Antibody binding and neutralization of primary and T-cell line-adapted isolates of human immunodeficiency virus type 1

The relative resistance of human immunodeficiency virus type 1 (HIV-1) primary isolates (PIs) to neutralization by a wide range of antibodies remains a theoretical and practical barrier to the development of an effective HIV vaccine. One model to account for the differential neutralization sensitivity between Pls and laboratory (or T-cell line-adapted [TCLA]) strains of HIV suggests that the envelope protein (Env) complex is made more accessible to antibody binding as a consequence of adaptation to growth in established cell lines. Here, we revisit this question using genetically related PI and TCLA viruses and molecularly cloned env genes. By using complementary techniques of flow cytometry and virion binding assays, we show that monoclonal antibodies targeting the V3 loop, CD4-binding site, CD4-induced determinant of gp120, or the ectodomain of gp41 bind equally well to PI and TCLA Env complexes, despite large differences in neutralization outcome. The data suggest that the differential neutralization sensitivity of PI and TCLA viruses may derive not from differences in the initial antibody binding event but rather from differences in the subsequent functioning of the PI and TCLA Envs during virus entry. An understanding of these as yet undefined differences may enhance our ability to generate broadly neutralizing HIV vaccine immunogens.

New surgical treatments for macular degeneration

The new surgical techniques described in this article expand the list of new treatments becoming available for people with macular degeneration.

Mycobacterium chelonae sepsis associated with long-term use of an intravenous catheter for treatment of hyperemesis gravidarum. A case report

BACKGROUND

Of the 1-2% of pregnant women who develop hyperemesis, the great majority are managed successfully with antiemetics and, when needed, short courses of parenteral medications. Only rarely will chronic parenteral therapy be necessary. Such therapy may be associated with significant complications.

CASE

A 38-year-old woman, gravida 3, para 1, induced abortion 1, with a history of hyperemesis in her first pregnancy, developed recurrent hyperemesis at 9 weeks' gestation. After four admissions and a 5.45-kg weight loss at 12 weeks' gestation, a Groshong catheter was placed in the left subclavian vein. The patient was then managed with home droperidol infusions and intravenous hydration as needed. At 30 weeks' gestation she developed tender, erythematous nodules over her legs and right arm. Culture from a biopsy of the nodules grew Mycobacterium chelonae, as did the catheter tip. M chelonae is a ubiquitous, opportunistic, nontuberculous (atypical) mycobacterium. The patient responded slowly to clarithromycin. At 37 weeks she delivered a healthy, 4,080-g, male infant. Three months postpartum the nodules continued to resolve slowly on clarithromycin.

CONCLUSION

When chronic parenteral therapy is required for hyperemesis gravidarum, attention must be given to potential complications. Indwelling catheters should be removed as soon as possible.

Inhibitors of neovascularization

The use of neovascular inhibitors in the treatment of CNV will no doubt have a profound impact in the future. However, complex issues surround the use of these agents. Careful clinical trials will be necessary to determine the optimal parameters for their use. Furthermore, it must be determined whether these inhibitors will be most efficacious as primary agents or as agents used to augment the efficacy of photoreactive laser treatment or feeder vessel treatment.

Fluid resuscitation of patients with multiple injuries and severe closed head injury: experience with an aggressive fluid resuscitation strategy

BACKGROUND

Despite increasing experimental and clinical evidence to the contrary, a dichotomy of management strategies of the patient with multiple injuries still exists, based on the presence or absence of traumatic brain injury. Many still advocate fluid restriction or small volume resuscitation if traumatic brain injury is present.

PURPOSE

To demonstrate results of aggressive fluid resuscitation in a prospective case series of patients with multiple injuries and with severe head injury.

METHODS

Thirty-four patients with Glasgow Coma Scale score < or = 8 and Injury Severity Score > or = 16 were enrolled into the study over a period of 18 months. Fluid resuscitation was guided in part by cerebral perfusion pressures (mean cerebral perfusion pressures > 80) as well as by hemodynamic monitoring and evidence of end organ perfusion. Overall fluid intake, intensive care unit fluid balance, presence or absence of hypoxia, hypotension, or both, were analyzed. Ninety- and 180-day Glasgow Outcome Scale and Disability Rating Scale scores were also obtained.

RESULTS

By using an aggressive fluid resuscitation strategy, secondary insults were avoided in 74% of the patients. A good functional outcome was achieved in 74% and mortality was impressively low at 6%.

CONCLUSION

Fluid restriction is not necessary to achieve good results in the severely injured patient who also has a severe head injury.

Facial attractiveness and the aged

This study examined the relationship between dentofacial appearance and judgments of facial attractiveness in a sample of 60 subjects between ages 65 and 75. Subjects completed questionnaires regarding their current dental appearance and level of satisfaction with their facial attractiveness. Subjects then viewed and ranked four sets of five photographs that had been digitally manipulated to simulate common dental defects. Regardless of background facial attractiveness or gender of stimulus photographs, a specific ranking order for dental defects emerged with rank-order correlations in the 90% range. Findings suggest that dental appearance affects judgments of facial attractiveness regardless of gender or background facial attractiveness.

Stressful life events and loss of hair among adult women, a case-control study

A case-control design was used to compare stress (as measured with the Social Readjustment Rating Scale) in the lives of 25 women who had experienced recent, unexplained hair loss with that of 25 women with no hair loss. High stress was reported by 22 of the women experiencing hair loss and 10 not experiencing hair loss. An odds ratio of 11 suggests that women who experience high stress are 11 times more likely to experience hair loss. Replication is encouraged.

Systemic sclerosis in DRw52-positive silica-exposed males: a case report

The aims of this paper were to describe clinical and laboratory details of 4 siblings, of whom 2 have systemic sclerosis and to describe this family in the context of reported cases of familial systemic sclerosis. The proband and his affected male sibling share the tissue typing antigens: HLA11, B57, DR13, DRw52,- and DQ2,6. Both were concordant for gender, silica exposure, marital status, migration history and antinuclear factor status but discordant for systemic sclerosis subtype, age at disease onset and ENA status. One non-affected sibling had no disease despite concordance for gender, HLA status, silica exposure, marital status, and migration history.

Development of a candidate HLA A*0201 restricted peptide-based vaccine against human cytomegalovirus infection

The development of a protective cellular immune response against human cytomegalovirus (HCMV) is the most important determinant of recovery from HCMV infection after allogeneic bone marrow transplantation (BMT). The ultimate aim of our study is to develop an antigen-specific and peptide-based vaccine strategy against HCMV in the setting of BMT. Toward this end we have studied the cellular immune response against the immunodominant matrix protein pp65 of HCMV. Using an HLA A*0201-restricted T-cell clone reactive against pp65 from peripheral blood from a seropositive individual, we have mapped the position of the cytolytic T lymphocyte (CTL) epitope from HCMV pp65 to an 84-amino acid segment. Of the four peptides which best fit the HLA A*0201 motif in that region, one nonamer sensitized an autologous Epstein-Barr virus immortalized lymphocyte cell line for lysis. In vitro immunization of PBMC from HLA A*0201 and HCMV seropositive volunteers using the defined nonamer peptide stimulated significant recognition of HCMV infected or peptide-sensitized fibroblasts. Similarly, HLA A*0201 transgenic mice immunized with the nonamer peptide developed CTL that recognize both the immunizing peptide and endogenously processed pp65 in an HLA A*0201 restricted manner. Lipid modification of the amino terminus of the nonamer peptide resulted in its ability to stimulate immune responses without the use of adjuvant. This demonstration of a vaccine function of the nonamer peptide without adjuvant suggests its potential for use in an immunization trial of BMT donors to induce protective CTLs in patients undergoing allogeneic BMT.

Increased MCP-1, RANTES, and MIP-1alpha in bronchoalveolar lavage fluid of allergic asthmatic patients

Chemokines are cytokines that induce chemotaxis of inflammatory cells. We studied the presence of chemokines in bronchoalveolar lavage fluid (BALF) obtained from nine allergic asthmatic patients and six nonsmoking normal individuals. The cells were pelleted, and ribonucleic acid (RNA) was extracted by using RNAzol B. BALF was assayed for monocyte chemoattractant protein-1 (MCP-1), regulated upon activation in normal T cells, expressed, probably secreted (RANTES), macrophage inflammatory protein-1alpha (MIP-1alpha) and interleukin-8 (IL-8) by enzyme-linked immunosorbent assay (ELISA). The levels of MCP-1, RANTES, and MIP-1alpha were significantly higher in the asthma patients than in the control subjects (p<0.04). The concentrations of RANTES and MCP-1 correlated with the lymphocyte count in the BAL specimens (r = 0.61 and 0.68, respectively). BALF showed eosinophil chemotactic activity in vitro that was blocked by anti-RANTES and anti-MCP-3 antibodies. The total cellular RNA was reverse-transcribed and the complementary deoxyribonucleic acid (cDNA) was amplified with the polymerase chain reaction (PCR) for MCP-1, MCP-3, RANTES, MIP-1alpha, IL-8, and beta-actin. We found that messenger ribonucleic acids (mRNAs) for MCP-1, MCP-3, RANTES, MIP-1alpha, and IL-8 were produced by BAL cells from most asthmatic and normal subjects. We conclude that chemokines are produced in the airways, and that an increased recovery of MCP-1, RANTES, and MIP-1alpha is observed in allergic asthmatic patients.

Spontaneous proliferation of memory (CD45RO+) and naive (CD45RO-) subsets of CD4 cells and CD8 cells in human T lymphotropic virus (HTLV) infection: distinctive patterns for HTLV-I versus HTLV-II

Spontaneous lymphocyte proliferation (SLP) in vitro is a characteristic feature of about 50% of individuals infected with HTLV-I or HTLV-II. Both CD4 cells and CD8 cells contribute to SLP in HTLV-I infection, whereas SLP in HTLV-II infection is usually restricted to CD8 cells. In this study, we asked if SLP was restricted to the memory (CD45RO+) cell subset of CD4 and CD8 cells in HTLV infection. Purified CD4 and CD8 cells were separated into CD45RO+ and CD45RO- populations by a modified panning technique, and spontaneous proliferation (SP) of the cell subsets was assessed. For all five HTLV-I-infected persons whose mononuclear cell cultures were SLP+, only CD45RO+ cells, but not CD45RO- cells, within CD4 and CD8 subsets showed SP. In contrast, five of six SLP+ HTLV-II+ individuals showed SP in both the CD45RO+ and the CD45RO- subsets of CD4 cells, and 10 of 12 SLP+ HTLV-II+ individuals showed SP of both the CD45RO+ and CD45RO- subsets of CD8 cells. Polymerase chain reaction studies showed that proviral genome was generally present in both CD45RO+ and CD45RO- subsets of CD4 and CD8 cells, regardless of HTLV type and SP activity. These findings show that SP of both CD4 and CD8 cells in HTLV-I infection is usually restricted to CD45RO+ memory cells, whereas in HTLV-II infection, both CD45RO+ memory and CD45RO- naive subsets of CD4 and CD8 cells may exhibit SP. It thus appears that HTLV-I infection and HTLV-II infection exhibit distinctive dysregulatory effects on memory and naive T cell subpopulations.

Reduction of escapee formation in flow cytometric analysis of lymphocyte subsets

Most experienced flow cytometrists performing immunophenotyping of lymphocyte subsets are aware of the escape phenomenon, in which some positive cells are found outside a lymphocyte gate based on forward and right angle scatter. However, little information is available on the levels of escapees formed with different antibodies, the roles of fluorochromes and lysing agents, the mechanism explaining the phenomenon, or methods to reduce it. We thus performed a systematic analysis of the escapee phenomenon to clarify these issues. A panel of monoclonal antibodies, including a phycoerythrin (PE) conjugate and a fluorescein isothiocyanate (FITC) conjugate of the same antibody from one manufacturer, was used to treat whole blood specimens, after which red cells were lysed using 0.15 M ammonium chloride (AmChl). The percentages of gated lymphocytes expressing CD3, CD8, CD19, and HLA-DR, but not CD2, CD4, CD16, and CD25, were significantly lower in FITC-stained versus PE-stained preparations. Correlated analysis of green fluorescence and forward scatter showed that, on average, 18% of CD3+ events, 24% of CD8+ events, and 25% of CD19+ events were escapees when using the FITC conjugate. In dual color analysis, CD3+ escapees were positive for CD62-P, CD13, and CD14, indicating that the escapee events consisted of FITC-anti-CD3-coated lymphocytes complexed with platelet-coated myeloid cells. In studies of the role of lysing agent, essentially no escapees were found in specimens treated with FACS lysing solution, which contains formaldehyde. We therefore included a similar denaturing agent, paraformaldehyde (0.1%), in the AmChl lysing agent, and found that the occurrence of escapees was markedly reduced. These findings show that the escapee phenomenon occurs when using some FITC-conjugated monoclonal antibodies in conjunction with AmChl lysing agent, and can be reduced by inclusion of paraformaldehyde in the lysing agent.

Characterization of circulating CD4+ CD8+ lymphocytes in healthy individuals prompted by identification of a blood donor with a markedly elevated level of CD4+ CD8+ lymphocytes

During flow cytometric analysis of lymphocytes from healthy donors, we identified a donor (donor A) with 22% CD4+ CD8+ cells (versus values of < 4% for 65 other controls). To determine if CD4+ CD8+ cells from donor A and other controls were similar, we first defined the phenotypic profile of control CD4+ CD8+ cells. Enriched CD4+ CD8+ cell populations for 10 controls were prepared by a two-step positive selection scheme with anti-CD4-coated magnetic beads and anti-CD8-coated culture flasks; the selected population averaged 69% CD4+ CD8+ cells and 31% CD4+ CD8- cells. For all 10 controls, two subsets of CD4+ CD8+ cells, CD4dim CD8bright and CD4bright CD8dim, were observed. Phenotypic profiles of these two CD4+ CD8+ subsets were defined by pairing anti-CD8 with other monoclonal antibodies, and the profiles were compared with each other and with those of CD4+ CD8-, CD4- CD8bright, and CD4- CD8dim cells. CD8bright and CD4bright CD8dim cells differed in their proportions of CD62-L+ cells and in their levels of CD11a and CD2 expression. Both CD4+ CD8+ subsets resembled CD4+ CD8- cells in CD45RA, CD45RO, and CD25 expression; the comparable CD- CD8+ cells in CD62-L expression; and CD4- CD8bright cells in CD11b, CD11b, CD16/56, and CD28 expression. CD38 expression in both CD4+ CD8+ subsets was decreased compared with those of other cell subsets. Whereas control CD4+ CD8+ cells averaged 33% CD4dim CD8bright, CD4+ CD8+ cells from donor A were > 90% CD4dim CD8bright. Donor A CD4dim CD8bright cells exhibited proportional decreases in CD25 and CD62-L expression and increases in CD11b and CD54 expression compared with those of control CD4dim CD8bright cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Routine prolactin measurement is not necessary in the initial evaluation of male impotence

The authors determined the prevalence of hyperprolactinemia in impotent men in a community setting and assessed the cost of case detection with routine estimation of serum prolactin. They recruited 299 consecutive patients with impotence and determined the hormonal levels (prolactin, luteinizing hormone, follicle-stimulating hormone, and testosterone). Pituitary gland imaging was done when the prolactin level was elevated. Simultaneous prolactin and testosterone levels were available for 212 patients. Three patients (1.4%) had elevated prolactin levels but none had pituitary tumor. Two of these had low testosterone levels. Overall, 51 patients (24.1%) had low testosterone levels. Cost of selective prolactin estimation in patients with low testosterone levels resulted in a net saving of $2,574 per case detected. The authors conclude that the prevalence of hyperprolactinemia in impotence is low. Routine measurement of prolactin levels in impotence is not indicated. Selective determination in patients with low testosterone reduces the cost of diagnostic evaluation.

Spontaneous lymphocyte proliferation in human T-cell lymphotropic virus type I (HTLV-I) and HTLV-II infection: T-cell subset responses and their relationships to the presence of provirus and viral antigen production

Spontaneous lymphocyte proliferation (SLP) during in vitro culture of mononuclear cells (MCs) characterizes over half of asymptomatic individuals infected with human T-cell lymphotropic virus type I (HTLV-I) or HTLV-II. Both CD4 and CD8 T-cell subsets within MC cultures are activated during SLP, as judged by high-density CD25 (CD25bright) expression; it is unclear, however, whether both cell subsets can directly undergo SLP. In the present investigation, the SLP capacities of purified CD8 and CD4 cells were examined in subjects infected with HTLV-I (n = 19) or HTLV-II (n = 54) in relation to the SLP status of MCs from each subject. No increase in SLP was observed for CD8 or CD4 cells from SLP-negative (SLP-) HTLV-infected subjects, whereas robust SLP characterized CD8 cells from all SLP-positive (SLP+) individuals, regardless of HTLV type. In contrast, SLP+ CD4 cells characterized only 23% (7 of 31) of HTLV-II+ SLP+ individuals, whereas SLP+ CD4 cells characterized 100% of HTLV-I+ SLP+ individuals. In cocultures of HTLV-II+ SLP+ CD8 cells and autologous SLP- CD4 cells, sizable proportions of both CD8 cells and CD4 cells coexpressed CD25bright, suggesting that SLP- CD4 cells were activated in the presence of SLP+ CD8 cells. PCR analysis for tax sequences detected provirus in most CD4- and CD8-cell preparations from HTLV-seropositive individuals, regardless of type and the SLP status of cell subsets. To determine whether SLP was associated with activation of viral genes, levels of HTLV-I and HTLV-II core antigen (Ag) in supernatants were measured. Viral Ag production and SLP responses were significantly correlated for both CD4 and CD8 cells in both HTLV-I and HTLV-II infections. However, inhibition of CD8- or CD4-cell SLP by cyclosporin A or anti-Tac (anti-CD25) did not reduce Ag production, indicating that Ag production is not coupled to SLP. These findings show that CD4 cells from SLP+ HTLV-I+ and SLP+ HTLV-II+ individuals differ in SLP capacity, that the absence of SLP does not indicate a lack of infection, and that production of viral Ag is associated with, but not dependent on, SLP.

Lymphocyte subsets in HTLV-II-infected former blood donors: relationship to spontaneous lymphocyte proliferation

Previous studies showed that over 70% of HTLV-seropositive blood donors from the Los Angeles area are infected with HTLV-II; further, mononuclear cells from about half of these HTLV-II+ donors exhibit spontaneous lymphocyte proliferation (SLP) during in vitro culture. To determine if HTLV-II+SLP+ donors exhibit more marked immune system changes than HTLV-II+SLP- donors, lymphocyte subsets for these two HTLV-II+ groups were compared to an uninfected control group. The percentage of lymphocytes expressing CD3 was significantly increased and the percentage expressing a CD16/56+CD3- phenotype (natural killer cells) was significantly decreased in the HTLV-II+SLP+ group (N = 34) versus the control group (N = 49). On the basis of absolute numbers, the lymphocyte number was significantly higher in the HTLV-II+SLP+ group than in the control group and reflected significant increases in the numbers of both CD4 and CD8 subsets of T cells. Analysis of proportional changes in CD4 and CD8 cell subsets revealed significant increases in the proportions of CD4 cells expressing HLA-DR, CD8 cells expressing HLA-DR, and CD8 cells expressing CD45RO for the HTLV-II+SLP+ group versus the control group. For all phenotypic parameters measured, no significant differences were noted when comparing the HTLV-II+SLP- group (N = 21) and the control group. Cell culture experiments utilizing purified CD4 cells and CD8 cells from a subset of each study group revealed that in vitro spontaneous proliferative capacity resides within both the CD4 cell and CD8 cell populations from SLP+ individuals. These findings show that changes in circulating lymphocyte subsets in HTLV-II infection are found only in association with SLP, and that the capacity to exhibit SLP characterizes both CD4 and CD8 lymphocyte subsets.

Phenotypic comparison of the three populations of human lymphocytes defined by CD45RO and CD45RA expression

Published reports indicate that CD45RO-CD45RAbright T cells are native T cells, CD45RObrightCD45RA- T cells are memory T cells, and that concomitant loss of CD45RA expression and gain of CD45RO expression occurs during transition from naive to memory status. Thus, following in vitro activation of CD45RO- CD45RAbright T cells, a subset of transitional CD45ROdimCD45RAdim T cells is observed before conversion to a CD45RObrightCD45RA- phenotype is completed. Interestingly, all three of these phenotypic subsets are represented in the circulating human lymphocyte pool. We thus used dual-color flow cytometry to phenotypically characterize CD45RObrightCD45RA-, CD45ROdimCD45RAdim, and CD45RO- CD45RAbright lymphocytes. Both the CD45RObrightCD45RA- and CD45ROdimCD45RAdim subsets consisted almost entirely of T cells, whereas the CD45RO-CD45RAbright subset contained T cells plus essentially all of the B and natural killer cells. Additional studies used three-color flow cytometry to assess activation markers on T cells within the three subsets defined by CD45RO/CD45RA expression. CD25 expression increased with conversion from naive to memory status (5% of CD45RO-CD45RAbright, 24% of CD45ROdimCD45RAdim, and 42% of CD45RObrightCD45RA- T cells), whereas CD38 expression decreased during conversion (76, 53, and 27%, respectively). We also assessed the fluorescent intensities of CD11a, CD2, and CD44, shown by others to be increased on memory, compared to naive T cells. Visual inspection of fluorescence cytograms confirmed these findings, and further showed that transitional T cells express these markers at levels indistinguishable from those for naive T cells. These findings suggest that acquisition of CD25 and loss of CD38 occur relatively early in the naive-to-memory transition process, being evident in the transitional cell subset. In contrast, increased expression of CD11a, CD2, and CD44 appear to represent late events, occurring after loss of CD45RA and gain of CD45RO has been completed.

Mobility methods selected for use in home and community environments

Efficient mobility methods are a necessity for maximum participation in home and community environments. Individuals who require the use of assistive devices for mobility are at risk for limited environmental access. Few investigations have compared the effectiveness of various mobility methods as a function of the environments in which mobility is required. Sixty-eight adults with physical disabilities who used assistive devices for independent mobility were surveyed to determine mobility methods selected for use in specific home and community environments and to determine how far they would travel outdoors before resorting to use of a motor vehicle. Results indicated that frequently individuals used more than one mobility method at home but only one method in outdoor and community environments. Individuals who used wheeled mobility methods traveled greater distances outdoors than those who walked. Implications for practice and research are discussed.

Bleomycin induces the hsp 70 heat shock promoter in cultured cells

Bleomycin-induced lung disease is characterized by cell injury followed by fibroblast proliferation. Cells respond to injury by synthesizing a family of heat shock proteins. These proteins are critical to cell survival, and those of the 70,000 MW group (hsp 70) are essential for cell division and proliferation. To evaluate the effect of bleomycin on heat shock gene expression, we transfected a gene construct containing the hsp 70 heat shock gene promoter into fibroblasts. Doses of bleomycin, which have previously been shown to augment lung fibroblast proliferation, induce the hsp 70 heat shock promoter in the transfected cells. Bleomycin did not induce the expression of a non-hsp promoter placed in cells as a control of nonspecific gene activation. These observations suggest that bleomycin exposure may cause significant alterations in important DNA promoter regions such as the hsp 70 promoter and point to new ways to assess bleomycin-induced changes in cells.

Strategies for evaluating clinical change: implications for practice and research

The methods and procedures of evaluation research using single-system or small-N designs are defined and described. Various components of single-system evaluation research, including specifying the problem, measuring and recording the data, selecting an appropriate design, and analyzing the data, are presented and discussed. The argument is made that single-system evaluation research methods are ideally suited to document clinical change on an individual basis and can provide a mechanism for establishing therapeutic accountability. The relationship between single-system evaluation research and the more traditional experimental procedures is briefly explored, and the implications for establishing an empirically derived basis for clinical practice are discussed.

Aplastic anemia in association with gold therapy for rheumatoid arthritis

Over a ten year period five patients developed aplastic anemia in association with gold therapy for rheumatoid arthritis. None of these patients was suitable for bone marrow transplantation due to the lack of a compatible sibling. Four patients with severe aplastic anemia died, despite intensive haemopoietic support and trials of gold chelating agents. Survival ranged from 22 to 103 days (mean 55 days) with death in each case being due to a combination of bleeding and infection. The remaining patient with moderate aplasia survived, recovering over a period of two to three years.

The development of an adolescent life change event scale

A questionnaire listing 31 personal, social and family changes believed stressful to adolescents was administered to 207 subjects aged eleven to eighteen. They were asked to rate the items on a scale of one to five to indicate how "upsetting" they believed the event was. They were also asked to indicate how many of the events they had actually experienced. The Adolescent Life Change Event Scale developed from this data is shown. It is recommended that the questionnaire be given to a much larger sample of adolescents from other socioeconomic, racial and cultural backgrounds before the final weightings are assigned to the scale. Once this has been done, the scale can be used to study relationships between life stress events and illness or other manifestations of stress in adolescents.

Resistance and susceptibility of mice to bacterial infection: course of listeriosis in resistant or susceptible mice

Resistance and susceptibility to Listeria monocytogenes in mice was found to be related to (i) the innate ability of the nonimmune macrophages to kill or inhibit the growth of the organism during the first 24 to 48 h after infection, and (ii) the time of onset of acquired cell-mediated resistance. Resistant C57Bl/6 mice were 10 times more efficient than susceptible BALB/c mice at suppressing the early growth of Listeria in the liver. Furthermore, the onset of acquired immunity occurred 24 to 48 h earlier in C57Bl/6 than in BALB/c mice. Acquired immunity was measured by (i) fall in bacterial numbers in spleen and livers of infected mice (ii) adoptive transfer of immunity to normal mice by using spleen cells from infected mice, (iii) delayed-type hypersensitivity skin testing, and (iv) uptake of tritiated thymidine by lymphocytes in the spleen.