Outcomes of re-referrals of patients with alcohol-associated liver disease, who were previously declined for liver transplantation

Since 2018, our program has utilized specific psychosocial criteria and a multidisciplinary approach to assess patients for liver transplant due to alcohol-associated liver disease (ALD), rather than the 6-month abstinence rule alone. If declined based on these criteria, specific recommendations are provided to patients and their providers regarding goals for re-referral to increase the potential for future transplant candidacy. Recommendations include engagement in treatment for alcohol use disorder, serial negative biomarker testing, and maintenance of abstinence from alcohol. In our current study, we evaluate the outcomes of patients with ALD, who were initially declined upon assessment and re-referred to our program. This is a retrospective cohort study that includes 98 patients with ALD, who were previously declined for liver transplantation and were subsequently re-referred for liver transplant assessment between May 1, 2018, and December 31, 2021. We assess the outcomes of patients who were re-referred including acceptance for transplantation following a second assessment. Of the 98 patients who were re-referred, 46 (46.9%) fulfilled the recommendations made and proceeded to further medical evaluation. Nine were eventually transplanted; others are listed and are waiting for transplant. The presence of a partner was independently associated with a higher rate of acceptance (OR 0.16, 95% CI: 0.03-0.97, p = 0.05). Most of the patients who did not proceed further (n = 52) were declined again due to ALD contraindications (n = 33, 63.4%), including ongoing drinking and lack of engagement in recommended addiction treatment. Others had medical contraindications (11.2%), clinically improved (6.1%), had adherence issues (5.1%), or lack of adequate support (2%). Patients with ALD previously declined for a liver transplant can be re-referred and successfully accepted for transplantation by fulfilling the recommendations made by the multidisciplinary team. Important factors including ongoing abstinence, engagement in addiction treatment, and social support are key for successful acceptance.

Canadian Society of Transplantation White Paper: Ethical and Legal Considerations for Alcohol and Cannabis Use in Solid Organ Listing and Allocation

Alcohol and cannabis use as a contraindication to organ transplantation is a controversial issue. Until recently, patients in Canada with alcohol-associated liver disease were required to demonstrate abstinence for 6 mo to receive a liver transplant. There is no equivalent rule that is applied consistently for cannabis use. There is some evidence that alcohol and cannabis use disorder pretransplant could be associated with worse outcomes posttransplantation. However, early liver transplantation for patients with alcohol-associated liver disease in France and in the United States has led to challenges of the 6-mo abstinence rule in Canada in the media. It has also resulted in several legal challenges arguing that the rule violates human rights laws regarding discrimination in the provision of medical services and that the rule is also unconstitutional (this challenge is still before the court). Recent legalization of cannabis use for adults in Canada has led to questions about the appropriateness of limiting transplant access based on cannabis use. The ethics committee of the Canadian Society of Transplantation was asked to provide an ethical analysis of cannabis and alcohol abstinence policies. Our conclusions were as follows: neither cannabis use nor the 6-mo abstinence rule for alcohol use should be an absolute contraindication to transplantation, and transplant could be offered to selected patients, further research should be conducted to ensure evidence-based policies; and the transplant community has a duty not to perpetuate stigma associated with alcohol and cannabis use disorders.

Low Altitude Solar Magnetic Reconnection, Type III Solar Radio Bursts, and X-ray Emissions

Type III solar radio bursts are the Sun's most intense and frequent nonthermal radio emissions. They involve two critical problems in astrophysics, plasma physics, and space physics: how collective processes produce nonthermal radiation and how magnetic reconnection occurs and changes magnetic energy into kinetic energy. Here magnetic reconnection events are identified definitively in Solar Dynamics Observatory UV-EUV data, with strong upward and downward pairs of jets, current sheets, and cusp-like geometries on top of time-varying magnetic loops, and strong outflows along pairs of open magnetic field lines. Type III bursts imaged by the Murchison Widefield Array and detected by the Learmonth radiospectrograph and STEREO B spacecraft are demonstrated to be in very good temporal and spatial coincidence with specific reconnection events and with bursts of X-rays detected by the RHESSI spacecraft. The reconnection sites are low, near heights of 5-10 Mm. These images and event timings provide the long-desired direct evidence that semi-relativistic electrons energized in magnetic reconnection regions produce type III radio bursts. Not all the observed reconnection events produce X-ray events or coronal or interplanetary type III bursts; thus different special conditions exist for electrons leaving reconnection regions to produce observable radio, EUV, UV, and X-ray bursts.

Decomposition, nitrogen and carbon mineralization from food and cover crop residues in the central plateau of Haiti

Cover crops are a major focus of conservation agriculture efforts because they can provide soil cover and increase nutrient availability after their mineralization in cropping systems. To evaluate the effect of residue type and placement on rate of decomposition and carbon (C) and nitrogen (N) mineralization, residues from two food crops, maize (Zea mays L.) and common bean (Phaseolus vulgaris L.), and two promising cover crops, sunn hemp (Crotalaria juncea L.) and sorghum sudangrass (Sorghum bicolor [L.] Moench x S. bicolor var. Sudanese [Piper] Stapf) were used in a litterbag study in the Central Plateau region of Haiti from May to September, 2013. Residues were placed in litterbags at a rate equivalent to 3.25 Mg residue ha⁻¹ either on the soil surface or buried at 15 cm to represent a tilled and no-tillage system, respectively. Initial C:N ratios were: maize > common bean > sorghum sudangrass > sunn hemp. Highest residue mass loss rates and C and N mineralization generally occurred in the reverse order. Overall, surface-placed residues decomposed more slowly with 40 and 17 % of initial residue mass of surface and buried residues, respectively, remaining at 112 days. Carbon and N mineralization was higher when residues were buried. Net N mineralization of buried residues was 0.12, 0.07, 0.06, and 0.03 g N g residue⁻¹ for sunn hemp, sorghum sudangrass, maize, and common bean, respectively over 112 days. To achieve the goal of increasing nutrient supply while maintaining year-round cover, a combination of grass and legume cover crops may be required with benefits increasing over multiple seasons.

Treatment of tobacco dependence in people with mental health and addictive disorders

People with mental health and addictive disorders (MHADs) have higher rates of cigarette smoking, and less success in quitting smoking compared with the general population. Moreover, tobacco-related medical illness may be the leading cause of death in the MHAD population. We discuss the scope of this comorbidity, and approaches to the treatment of tobacco dependence in people with MHAD, including schizophrenia, mood disorders, anxiety disorders, and alcohol and substance use disorders. Finally, at the level of health systems, we emphasize the importance of integrated treatment of tobacco dependence in MHADs.

Surveillance of verocytotoxigenic Escherichia coli in Irish bovine dairy herds

Verocytotoxigenic Escherichia coli (VTEC) are highly significant zoonotic threats to public health, and have been the causative agent implicated in numerous high-profile outbreaks affecting large numbers of people. Serovar O157 is most frequently linked with human illness; however, other serovars, such as O26, O103, O111 and O145, have also been implicated. This study aimed to characterize the prevalence and virulence determinants of these five serovars in Irish dairy farm herds, and their milk. Using real-time PCR (RTi-PCR), bovine rectal faecal swabs and raw milk samples, along with milk filters, were screened for the presence of vt genes. Positive samples were then screened for the five serovars using sero-specific PCR. Serovar-positive samples were subjected to immunomagnetic separation, to isolate viable VTEC strains. These isolates were subsequently screened for four virulence factors: vt1, vt2, eaeA and hlyA. Three hundred and eighty six of the 600 rectal faecal swabs, 85 of the 117 milk-filters and 43 of the 120 bulk-tank milk samples, were positive for vt genes. From these 514 total vt-positive samples, 58 O26, 162 O103, 1 O111, 324 O145 and 26 O157 positives were detected by sero-specific RTi-PCR. Immunomagnetic separation yielded 12 O26, 26 O103, 0 O111, 19 O145 and 10 O157 isolates. Ten of these isolates contained at least one of the four virulence determinants screened for (i.e. vt1, vt2, eaeA and hlyA). Of these 10 isolates, pulsed-field gel electrophoresis showed that two of the O26 isolates from different farms were indistinguishable. Two O157 isolates were also indistinguishable. This study found serovars O103 and O145 to be the most prevalent in samples tested. Apart from the occurrence of VTEC in dairy herds, this study shows a high occurrence of vt genes in the environment, creating the possibility of horizontal gene transfer and emergence of new VTEC strains.

Observer accuracy in the detection of pulmonary nodules on CT: effect of cine frame rate

AIM

To assess the effect of cine frame rate on the accuracy of the detection of pulmonary nodules at computed tomography (CT).

MATERIALS AND METHODS

CT images of 15 consecutive patients with (n = 13) or without (n = 2) pulmonary metastases were identified. Initial assessment by two thoracic radiologists provided the "actual" or reference reading. Subsequently, 10 radiologists [board certified radiologists (n = 4) or radiology residents (n = 6)] used different fixed cine frame rates for nodule detection. Within-subjects analysis of variance (ANOVA) was used to evaluate the data.

RESULTS

Eighty-nine nodules were identified by the thoracic radiologists (median 8, range 0-29 per patient; median diameter 9 mm, range 4-40 mm). There was a non-statistically significant trend to reduced accuracy at higher frame rates (p=0.113) with no statistically significant difference between experienced observers and residents (p = 0.79).

CONCLUSION

The accuracy of pulmonary nodule detection at higher cine frame rates is reduced, unrelated to observer experience.

The role of the PDE4D cAMP phosphodiesterase in the regulation of glucagon-like peptide-1 release

BACKGROUND AND PURPOSE

Increases in intracellular cyclic AMP (cAMP) augment the release/secretion of glucagon-like peptide-1 (GLP-1). As cAMP is hydrolysed by cAMP phosphodiesterases (PDEs), we determined the role of PDEs and particularly PDE4 in regulating GLP-1 release.

EXPERIMENTAL APPROACH

GLP-1 release, PDE expression and activity were investigated using rats and GLUTag cells, a GLP-1-releasing cell line. The effects of rolipram, a selective PDE4 inhibitor both in vivo and in vitro and stably overexpressed catalytically inactive PDE4D5 (D556A-PDE4D5) mutant in vitro on GLP-1 release were investigated.

KEY RESULTS

Rolipram (1.5 mg x kg(-1) i.v.) increased plasma GLP-1 concentrations approximately twofold above controls in anaesthetized rats and enhanced glucose-induced GLP-1 release in GLUTag cells (EC(50) approximately 1.2 nmol x L(-1)). PDE4D mRNA transcript and protein were detected in GLUTag cells using RT-PCR with gene-specific primers and Western blotting with a specific PDE4D antibody respectively. Moreover, significant PDE activity was inhibited by rolipram in GLUTag cells. A GLUTag cell clone (C1) stably overexpressing the D556A-PDE4D5 mutant, exhibited elevated intracellular cAMP levels and increased basal and glucose-induced GLP-1 release compared with vector-transfected control cells. A role for intracellular cAMP/PKA in enhancing GLP-1 release in response to overexpression of D556A-PDE4D5 mutant was demonstrated by the finding that the PKA inhibitor H89 reduced both basal and glucose-induced GLP-1 release by 37% and 39%, respectively, from C1 GLUTag cells.

CONCLUSIONS AND IMPLICATIONS

PDE4D may play an important role in regulating intracellular cAMP linked to the regulation of GLP-1 release.

Social isolation and delayed discovery of bodies in houses: the value of forensic pathology, anthropology, odontology and entomology in the medico-legal investigation

The bodies of socially isolated people may remain undiscovered in their own houses for prolonged periods. Occasionally the body is in situ for sufficient time to become skeletonised, or partially so. Medico-legal investigation of these cases is complicated by degradation and contamination of evidence. Thus, a multidisciplinary forensic investigation is recommended. The potential contributions of forensic pathology, anthropology, odontology and entomology are outlined here with reference to two cases that occurred in Victoria, Australia, in 2003. Forensic pathologists are often unable to determine the cause of death in skeletonised bodies, however, they may find evidence to support either a natural or unnatural mode of death, and they may describe skeletal pathology or trauma, and identify skeletal features to support radiological identification of the deceased. Anthropologists can provide supplementary evidence of skeletal trauma. Additionally, they can assess age, sex, stature and racial affiliation from skeletal remains. Odontologists can identify individuals through comparison with ante-mortem dental records; however, potential difficulties exist in identifying the treating dentist of a socially isolated person. Odontologists may also examine the teeth and oro-facial skeleton for trauma. Entomologists may estimate minimum death time and/or season of death. Entomological examination of insect remains may also confirm that a body has lain in situ for a considerable period.

Flecainide toxicity: cause and contribution to death

In this report, we describe in detail one fatality in which flecainide toxicity was considered to be the primary cause of death and discuss the possible contribution of flecainide in another case. The concentration of flecainide in postmortem specimens is discussed in relation to other drugs as well as some of the difficulties associated with the interpretation of postmortem drug levels.

Issues in child homicides: 11 cases

For a variety of reasons, child homicides are the most difficult cases for forensic pathologists. For example, the events are usually not witnessed, accidental explanations are offered, often there is more than one carer spanning the period over which the injuries might have occurred and there can be conflicting opinions between the various medical specialities. Eleven cases of fatal child abuse are presented to illustrate and briefly discuss particular difficulties. Reference is also made to interaction with the legal process and parallel difficulties the law has with fatal child abuse.

The relationship between lead exposure and homicide

CONTEXT

Previous studies have suggested that excessive lead exposure is related to aggressive and violent behavior.

OBJECTIVE

To evaluate the association between estimated air lead concentrations and homicide rates.

DESIGN

Cross-sectional ecological study.

SETTING

All counties in the contiguous 48 states of the United States. EXPOSURE MEASURE: Estimated air lead concentrations and blood lead levels.

MAIN OUTCOME MEASURE

The homicide rate in each county.

RESULTS

Negative binomial regression was used to examine the relationship between air lead concentrations and the incidence of homicide across counties in the United States (N = 3111). After adjusting for sociologic confounding factors and 9 measures of air pollution, the only indictor of air pollution found to be associated with homicide rates was air lead concentration. Across all counties, estimated air lead concentrations ranged from 0 to 0.17 microg/m(3). The adjusted results suggest that the difference between the highest and lowest level of estimated air lead is associated with a homicide incidence rate ratio of 4.12 (95% confidence interval, 1.02-16.61).

CONCLUSION

The results of this study support recent findings that there is an association between lead exposure and violent behavior.

Fatal benztropine toxicity

Benztropine is an anticholinergic agent used in the treatment of Parkinson's disease and drug induced extrapyramidal disorders. We report a case of fatal benztropine toxicity. This drug is regarded as relatively safe and reports of isolated toxicity are scarce. In ascribing a particular death to fatal drug toxicity the forensic pathologist must take into account the circumstances surrounding the death, the presence and significance of any co-existent natural disease and the potential contribution of any other detected therapeutic or illicit agents. This interpretation will occur in the knowledge that certain drugs will not be detected and that with respect to quantification of postmortem drug levels, the notion of postmortem redistribution should always be considered.

Delaware's first serial killer

The violent murder of Shirley Ellis on November 29, 1987, marked the beginning of the strange and terrible tale of Steven Bryan Pennell's reign as the state of Delaware's first convicted serial killer. Three more bodies followed the first victim, and all had been brutally beaten and sadistically tortured. The body of a fifth woman has never been found. State and county police collaborated with the FBI to identify and hunt down their suspect, forming a task force of over 100 officers and spending about one million dollars. Through their knowledge and experience with other serial killers, the FBI was able to make an amazingly accurate psychological profile of Delaware's serial killer. After months of around-the-clock surveillance, Steven Pennell was arrested on November 29, 1988, one year to the day after the first victim was found. Pennell was found guilty in the deaths of the first two victims on November 29, 1989, and plead no contest to the murder of two others on October 30, 1991. Still maintaining his innocence, he asked for the death penalty so that he could spare his family further agony. Steven Pennell was executed by lethal injection on March 15, 1992.

Forensic aspects of ocular injury

A case of homicidal stabbing resulting in bilateral penetrating ocular injuries is described. The case is noteworthy in that it highlights an unusual mechanism of death in homicidal stabbing. Disturbances in heart rhythm including asystole can be ascribed to the so-called oculocardiac or trigeminocardiac reflex. Although this phenomenon is well known to ophthalmologists, neurosurgeons, and anesthetists, it is much less familiar to forensic pathologists. This is a potential mechanism of death worthy of consideration in cases of sudden unexpected death occurring in the context of facial injury.

Fibrous osteodystrophy in dromedary camels (Camelus dromedarius)

Fibrous osteodystrophy of the facial and long bones was diagnosed in four dromedary camels (Camelus dromedarius). None of the animals responded to treatment with antiinflammatory medications or calcium supplements. The lesions were probably caused by multiple factors, including inappropriate diet and gastrointestinal parasitism. A critical factor in lesion formation may have been vitamin D deficiency secondary to gastrointestinal malabsorption and inadequate winter exposure to ultraviolet light.

Quorum sensing-dependent regulation and blockade of exoprotease production in Aeromonas hydrophila

In Aeromonas hydrophila, the ahyI gene encodes a protein responsible for the synthesis of the quorum sensing signal N-butanoyl-L-homoserine lactone (C4-HSL). Inactivation of the ahyI gene on the A. hydrophila chromosome abolishes C4-HSL production. The exoprotease activity of A. hydrophila consists of both serine protease and metalloprotease activities; in the ahyI-negative strain, both are substantially reduced but can be restored by the addition of exogenous C4-HSL. In contrast, mutation of the LuxR homolog AhyR results in the loss of both exoprotease activities, which cannot be restored by exogenous C4-HSL. Furthermore, a substantial reduction in the production of exoprotease by the ahyI+ parent strain is obtained by the addition of N-acylhomoserine lactone analogs that have acyl side chains of 10, 12, or 14 carbons. The inclusion of N-(3-oxododecanoyl)-L-homoserine lactone or N-(3-oxotetradecanoyl)-L-homoserine lactone at 10 microM in overnight cultures of A. hydrophila abolishes exoprotease production in azocasein assays and reduces the activity of all the exoprotease species seen in zymograms.

High resolution 1H NMR spectroscopic studies on dynamic biochemical processes in incubated human seminal fluid samples

High resolution 600 MHz 1H NMR spectroscopy was used to investigate the changes in biochemical composition of whole human seminal fluid (SF) and an artificial mixture of prostatic (PF) and seminal vesicle fluid (SVF). A variety of time-related biochemical changes were monitored simultaneously and non-invasively in SF, including enzymatic hydrolysis of phosphorylcholine to choline and polypeptides to amino acids. The fastest NMR-observable reactions in SF were the conversion of phosphorylcholine to choline (t1/2 approximately equal to 9 min) and uridine-5'-monophosphate (UMP) to uridine (t1/2 < 2 min). UMP has not previously been detected in SF because of its rapid hydrolysis. Artificial mixtures of separately obtained prostatic and SVF showed very similar biochemical changes to those observed in whole SF. Addition of EDTA to SF incubated for 2 min post ejaculation strongly inhibited peptide hydrolysis. Zn2+, present in whole SF was shown to be non EDTA-chelatable 2 min after ejaculation, whereas after 7 min, a singlet signal from the ethylenic protons of the Zn-EDTA2- complex was clearly observed which remained constant after 7 min. This indicates that soon after ejaculation (< 5 min) Zn2+ is immobilised in a macromolecular complex which is rapidly broken down by proteolytic enzymes, the released Zn2+ then being free to react with EDTA. Mg- and Ca-EDTA2- complexes were observed at 2 min and remained constant (at 1.4 and 2.1 mM, respectively) throughout the entire time course of the experiment. These studies cast new light on the time-related biochemical changes occurring in the post-ejaculatory SF which may have an important role in reproductive function.

Proton MRS of human prostatic fluid: correlations between citrate, spermine, and myo-inositol levels and changes with disease

BACKGROUND

This is a study of the unusual small molecular components of human prostatic fluid using a non-destructive technique.

METHODS

Single pulse high resolution proton MRS of 38 human prostatic fluid samples (12 control, 10 with benign prostatic enlargement, 4 with prostatic cancer, 11 with vasal aplasia, and one with prostatodynia). Regression models for the metabolites measured were made and compared, and correlations were analyzed.

RESULTS

A very strong correlation between the secretion of citrate and spermine (r = 0.94), two of the major components of prostatic fluid, was found. The molar ratio was 5:1 citrate: spermine. There was no difference seen between samples obtained by expression or ejaculation. The regression models suggest there is a significant difference (P < 0.02) in the citrate to spermine ratio in prostatic fluid from men with prostate cancer, with a relatively higher level of spermine.

CONCLUSIONS

The authors speculate that citrate and spermine secretion is linked and may be forming a novel complex.

Organometallic anticancer agents. 2. Aqueous chemistry and interaction of niobocene dichloride with nucleic acid constituents and amino acids

The solution chemistry and interactions of niobocene dichloride, Cp2NbCl2, with nucleosides, nucleotides, and amino acids has been studied by 1H and 31P NMR spectroscopy. The 1H NMR spectrum of Cp2NbCl2 in 10% DMSO-d6/D2O contains two sharp singlets consistent with hydrolysis of the halide ligands and oxidation of the paramagnetic Nb(IV) complex to a diamagnetic Nb(V) complex. Cp2NbCl2 does not dissolve in the absence of oxygen, and Cp2NbCl2(OH) and Cp2NbCl2 when dissolved in 10% DMSO/D2O have identical 1H NMR spectra, consistent with formation of a Nb(V) complex as the antitumor active species in solution. With all nucleosides and nucleotides, except adenosine-5'-monophosphate (dAMP), no evidence of binding was detected on addition of up to 2.0 equiv of niobocene dichloride. In the case of dAMP, a minor complex (10%) was detected with 0.5 equiv of Cp2NbCl2 (pH 5.2). No evidence for interaction of aqueous solutions of Cp2NbCl2 with glutamic acid, serine, or histidine was found. The lack of interaction of niobocene dichloride with nucleic acid constituents and amino acids is markedly different from the chemistry exhibited by antitumor active metallocenes Cp2MCl2 (M = Ti, Mo, V) and suggests that the mechanism of antitumor action of Cp2NbCl2 is significantly different from other metallocene dihalides.

Out-of-hospital rapid-sequence induction for intubation of the pediatric patient

OBJECTIVE

To determine the effectiveness and morbidity of out-of-hospital rapid-sequence induction (RSI) for endotracheal intubation (ETI) in the pediatric population.

METHODS

The medical records were retrospectively reviewed for a consecutive series of pediatric patients undergoing out-of-hospital RSI by flight paramedics from July 1990 through July 1994. Patient demographics, pharmacologic agents, ED arterial blood gas data, pulmonary complications, and RSI-related complications were abstracted.

RESULTS

Forty patients (31 injured, 9 medical) with a mean age of 8.1 years (range 0.5-17 years) underwent out-of-hospital RSI. Indications for intubation included hyperventilation (n = 20), combativeness (n = 16), apnea (n = 5), and unknown (n = 5). Intubation mishaps occurred in 13 patients (33%); these included multiple attempts (n = 9), aspiration (n = 8), and esophageal intubation (n = 1). The success rate of ETI was 97.5% (one failed attempt). Hemodynamic side effects occurred in three patients (8%); all three had bradycardia, with one developing hypotension. Bradycardia was associated with failure to pretreat with atropine (p < 0.05). Sixteen pulmonary complications, seven pneumonia (18%) and nine atelectasis (22.5%), occurred in 13 patients within the first ten hospital days. Intubation mishaps were not associated with pulmonary complications. There were six deaths, none associated with RSI.

CONCLUSIONS

1) Rapid-sequence induction is an effective method for obtaining airway control in the critically ill pediatric patient. 2) Intubation mishaps did not influence the rate of pulmonary complications. 3) Omission of atropine was associated with bradycardia during RSI in pediatric patients.

Pharmacokinetics and bioequivalence of parenterally administered doramectin in cattle

Plasma concentrations of doramectin in 40 cattle dosed by subcutaneous (sc) or intramuscular (i.m.) injection (200 micrograms/kg) were compared to assess the bioequivalence of the two routes of administration. Peak concentration (Cmax), and areas under the concentration curve (AUC0-infinity) were determined from plasma concentrations. Animals treated by the sc route showed a mean AUC0-infinity of 457 +/- 66 ng.day/mL (+/- SD) and a mean Cmax of 27.8 +/- 7.9 ng/mL. Results from the i.m. treatment group showed a mean AUC0-infinity of 475 +/- 82 ng.day/mL and a mean Cmax of 33.1 +/- 9.0 ng/mL. Absorption constants (ka) determined by modelling were 0.542 +/- 0.336 day-1 after sc administration and 0.710 +/- 0.357 day-1 after i.m. administration. The 90% confidence limits on the difference between mean AUC0-infinity values for the sc and i.m. groups fell within 20% of the mean value for the subcutaneous group. Cmax was somewhat greater for the i.m. route. The 90% confidence limits on the difference in mean In(Tmax +1) also fell within 20% of the mean sc value. Based on this analysis, bioequivalence of the sc and i.m. formulation has been established.

Vesical clear cell adenocarcinoma. V. Nephrogenic adenoma: a diagnostic problem

Following the diagnosis of nephrogenic adenoma in a bladder lesion, which was later interpreted as early clear cell adenocarcinoma, the morphological and immunocytochemical features of these two lesions were reviewed to see if differences could be established for future diagnostic application. The architecture, extent, cell type, nuclear pleomorphism, presence of mitotic figures and glycogen content were recorded in 28 nephrogenic adenomas and the clear cell carcinoma. Similarly, the immunoreactivity for CAM 5.2, LP34, EMA and CEA of 10 nephrogenic adenomas and the clear cell carcinoma were compared. Proliferation rate in five nephrogenic adenomas and the carcinoma was assessed by antibody M1B1. Many of the features showed differences in degree or extent (clear cell change, nuclear pleomorphism, CAM 5.2 and CEA positivity). The only features distinct to clear cell carcinoma were the presence of solid islands, mitoses greater than 1/10 HPF (HPF area = 0.4 mm2) and M1B1 counts in excess of 29/200 in clear cell carcinoma (range 30/200-83/200). Only the high M1B1 count was present in the first biopsy of the clear cell carcinoma.

Farnesyltransferase inhibitors are inhibitors of Ras but not R-Ras2/TC21, transformation

Recent results from several laboratories including ours strongly suggest that farnesyltransferase (FT) inhibitors belonging to distinct chemical classes block growth of oncogenic Ras transformed cells at concentrations that do not affect the growth and viability of normal cells. This is despite blocking the farnesylation and thus the membrane association of Ras in both cell types. This is a paradox given the requirement for Ras function in normal cell growth. Recent evidence that R-Ras2/TC21 utilizes components of Ras signal transduction pathways to trigger cellular transformation (Graham et al., MCB 14, 4108-4115, 1994) prompted us to consider the possibility that R-Ras2/TC21 is involved in some aspects of the growth regulation of normal cells. If so, R-Ras2/TC21 may be compensating for Ras function in untransformed cells treated with FT inhibitors. In this study, we demonstrated that a cell active bisubstrate analog FT inhibitor, BMS-186511, completely blocked the function of oncogenic Ras, but did not affect the function of oncogenic R-Ras2/TC21, as determined by several criteria including inhibition of anchorage dependent and independent growth, reversal of transformed morphology and restoration of actin cytoskeleton. While it is known that TC21 protein becomes prenylated, it is not known whether it is farnesylated or geranylgeranylated. Our in vitro prenylation experiments indicate that R-Ras2/TC21 protein serves as a good substrate for FT as well as geranylgeranyltransferase I (GGTI) and thus provide the apparent molecular basis for these differences. Overall, these results, coupled with the ubiquitous expression of R-Ras2/TC21 in many cells including untransformed NIH3T3 cells, are consistent with the possibility that R-Ras2/TC21 may be one of the factors that render normal cells insensitive to the growth inhibitory action of FT inhibitors.

Pharmacokinetics, oral bioavailability and tissue distribution of azithromycin in cats

Azithromycin is the first of a class of antibiotics classified as azalides. In an initial experiment four cats were given a single dose of azithromycin 5 mg/kg orally (p.o.), followed 2 weeks later by a single intravenous bolus (i.v.) dose of 5 mg/kg. Subsequently, six cats were given [14C]azithromycin p.o. in a single dose of 5.4 mg/kg for the study of tissue distribution and metabolism. In both experiments, serial blood samples were collected and the plasma assayed for unchanged azithromycin to determine various pharmacokinetic parameters. After p.o. administration, bioavailability was 58% and absorption rapid with a tmax of 0.85 +/- 0.72 h and a Cmax of 0.97 +/- 0.65 microgram/mL. The harmonic mean terminal t1/2 after i.v. administration was 35 h. Tissue half-lives varied from 13 h in fat to 72 h in cardiac muscle. Three metabolites were identified in bile. Unchanged azithromycin accounted for 100% of the total radioactivity in lung and skin tissues when assayed. In comparison with other species, the bioavailability in cats is higher than in humans but lower than in dogs. As in the dog, > 50% of the azithromycin-related material in feline bile was unchanged azithromycin.

Long term outcome after surgery for extrahepatic portal vein thrombosis

The long term outcome of 21 children with extrahepatic portal hypertension secondary to portal vein thrombosis managed by surgical intervention was evaluated. Portosystemic shunts, used primarily in nine patients (eight central splenorenal, one mesocaval) after conservative treatment had failed, had no associated mortality and a 56% patency rate. Five of these shunted patients had no further bleeding episodes and did not show encephalopathic impairment. Direct attack procedures-portoazygos operation (four patients) was associated with significant complications, including one fatality. Other direct approaches-oesophageal transection and variceal plication (five patients) had variable outcome. Splenectomy alone (three patients) ameliorated hypersplenism; however, further surgery for recurrent haemorrhage (two patients) was necessary. Endoscopic sclerotherapy controlled recurrent variceal bleeding (three patients) when it became available to the unit. Conservative treatment practised in five children had little success: two patients survived, two died from further haemorrhage, and one was lost to follow up. These results suggest that in centres without endoscopic expertise, and for patients who are sclerotherapy 'failures', surgery can be performed safely and achieve reasonable long term success rates in childhood extrahepatic portal hypertension.

Determination of semduramicin sodium in poultry liver by liquid chromatography with vanillin postcolumn derivatization

A liquid chromatographic (LC) method is described for the quantitative determination of semduramicin sodium in broiler liver when administered under projected use conditions. For this procedure, semduramicin sodium is extracted from liver with methanolic ammonium hydroxide, separated and concentrated by solid-phase extraction steps, and determined by LC with postcolumn derivatization with vanillin. The mean recovery of drug was 95% over the 40-320 ng/g range, the coefficient of variation was +/- 10% or better, and no interference was observed from commercial polyether ionophores. The minimum level of detection for semduramicin sodium in broiler liver is 25 ng/g.

Application of the one-dimensional TOCSY pulse sequence in 750 MHz 1H-NMR spectroscopy for assignment of endogenous metabolite resonances in biofluids

The complex 1H-NMR spectrum arising from an intact biofluid has been simplified using a one-dimensional homonuclear polarization transfer experiment (known as TOCSY or HOHAHA). This approach establishes connectivity between sequentially coupled multiplets, and the method is illustrated by the confirmation of the chemical shifts and hence resonance assignment of a number of endogenous metabolites in the 750 MHz 1H-NMR spectrum of seminal fluid. This has allowed the detection and assignment of pyroglutamate and uracil in this fluid for the first time.

Reducing the loss of implants following penile prosthetic surgery

OBJECTIVE

To assess the factors associated with loss of implant following penile prosthetic surgery and to make alterations in the management of patients to prevent this from occurring.

PATIENTS AND METHODS

A retrospective analysis was carried out of the factors associated with post-operative infection and erosion in 188 patients who underwent implantation of penile prostheses. A prospective study was then established in which 62 patients were managed by a set protocol designed to counteract the factors identified as being contributory to loss of implants in the retrospective review.

RESULTS

In the retrospective study nine (4.8%) patients lost a prosthesis due to erosion. Erosion was noted to be more common with one type of implant which has since been modified. Infection was the cause of prosthesis loss in 12.2% of patients in the retrospective review. The new protocol resulted in a significantly reduced infection rate in penile prostheses to 1.6% (P < 0.05).

CONCLUSION

With attention to simple antiseptic prophylaxis, antibiotic penetration and continuing audit, a significant improvement in the loss of penile prostheses can be achieved along with a reduction in the amount of antibiotics prescribed.

Ultra high field NMR spectroscopic studies on human seminal fluid, seminal vesicle and prostatic secretions

Ultra high field 1H-NMR spectroscopic methods have been used to analyse the composition of seminal fluid and its component secretions, prostatic and seminal vesicle fluids from normal human subjects and those with vasal aplasia and non-obstructive infertility. The 1H-NMR spectrum of whole seminal fluid is extremely complex and many resonances are extensively overlapped in single pulse spectra even when measured at 600 or 750 MHz 1H resonance frequency. A combination of 2-D 1H-NMR methods (including J-Resolved and various 1H homonuclear correlation and 1H-13C heteronuclear correlation techniques) were applied at 600 or 750 MHz in order to extensively assign the signals from the organic components of seminal fluid. Prostatic fluid (PF) gives a much less complex metabolite profile than whole seminal fluid and can be completely analysed using 500 MHz 1H-NMR spectroscopy. The 1H-NMR spectra of prostatic fluid are dominated by signals from citrate, spermine and myo-inositol, whereas the spectra of seminal vesicle fluid (SVF) show extensively overlapped signals from complex peptide mixtures together with strong signals for glycerophosphocholine (GPC) and lactate. Whole seminal fluid is a combination of the PF and SVF constituents together with further substances that appear after mixing due to the operation of PF enzymes on SVF, e.g. peptidase activity causes rapid cleavage of peptides to amino acids and GPC is hydrolysed to choline, glycerol and inorganic phosphate. It is also shown that vasal aplasia leads to highly characteristic abnormal metabolite profiles in seminal fluid that can be readily observed in single-pulse 500 and 600 MHz 1H-NMR spectra. Measurement of the molar citrate to choline, or spermine to choline ratios in seminal fluid both show differences of 2 orders of magnitude between vasal aplasia (greater for both ratios) and non-obstructed infertile patients. This work gives an indication of the potential of high field 1H-NMR spectroscopy in the investigation and assessment of the secretory functions of the male genital tract and the evaluation of the infertile male subject.

Confirmation of danofloxacin residues in chicken and cattle liver by microbore high-performance liquid chromatography electrospray ionization tandem mass spectrometry

A specific assay is described for the confirmatory identification of danofloxacin residues in edible tissues of cattle and chicken. The assay utilizes on-line microbore high-performance liquid chromatography and pneumatically assisted electrospray tandem mass spectrometry (MS/MS). Collision-induced dissociation of the danofloxacin protonated molecule results in two significant daughter ions. Monitoring both ions provides the specificity required for this confirmatory assay. Optimum electrospray and MS/MS operating conditions permitted the specific monitoring of danofloxacin and the confirmation of its residues in chicken and cattle liver extracts down to 50 ppb. The analysis of control liver or the commercially available antibacterial quinolones enrofloxacin and its metabolite ciprofloxacin gave no response under the assay conditions. The ratios of the two daughter ions were similar for danofloxacin standard solutions, fortified tissues and incurred tissues.

Transforming growth factor-beta 1 induces transforming growth factor-alpha promoter activity and transforming growth factor-alpha secretion in the human colon adenocarcinoma cell line FET

FET cells are well differentiated human adenocarcinoma cells whose growth is partially inhibited (50-60%) by transforming growth factor-beta 1 (TGF-beta 1). In exponentially growing cultures, TGF-beta 1 induces the expression of transforming growth factor-alpha (TGF-alpha) by 3-fold. To determine whether this induction is the result of increased TGF-alpha promoter activity, FET cells were transiently transfected with a plasmid containing 2816 base pairs of the 5'-flanking region of the TGF-alpha gene linked to luciferase. Transfected FET cells treated with growth-inhibitory concentrations of TGF-beta 1 (10 ng/ml) showed up to a 10-fold increase in luciferase activity. The increase in luciferase activity was dose dependent through the normal physiological range of TGF-beta 1 (0.5-20 ng/ml), saturating at 10 ng/ml. This effect was also TGF-alpha promoter specific, inasmuch as the Rous sarcoma virus long terminal repeat used as a control remained relatively insensitive to the effects of TGF-beta 1. By using progressively smaller portions of the TGF-alpha promoter region, the TGF-beta 1-responsive element was mapped between base pairs -77 and -201 of the 5'-flanking region. TGF-beta 1 treatment also affected epidermal growth factor receptor levels. FET cells treated with TGF-beta 1 (10 ng/ml) for 48 h showed a 20% decrease in the number of epidermal growth factor receptors and a 2-fold increase in the number of high affinity epidermal growth factor receptors on their surface. These results indicate that TGF-beta 1 acts as a positive regulator of TGF-alpha transcription, and they suggest a possible mechanism by which these cells circumvent the growth-inhibitory effects of TGF-beta 1.

Diiodo Acetals and Unsaturated Lactones From Dihydropyran

Reaction of dihydropyran with propiolic acid and N- iodosuccinimide gave an iodo ester which was cyclized under free-radical conditions to form an (E) iodomethylene lactone. Photolysis of this lactone could be controlled to generate mixtures of (E) and (Z) iodomethylene lactones, or alternatively the iodine-free methylene lactone. The structures of some by-products of the iodo ester formation have been shown to be a succinimide derivative and two stereoisomers of a diiodo acetal. X-Ray determination of the structure of one of the diiodo acetal isomers is described.

Testicular prostheses: the patient's perception

There is a paucity of data to determine if the insertion of a testicular prosthesis is effective in overcoming the psychological effects of an absent testis. A review of 25 patients who had had testicular prostheses showed a high overall level of satisfaction in the 19 patients who were traced. This satisfaction was subject to some qualification.

Acidic fibroblast growth factor-Pseudomonas exotoxin chimeric protein elicits antiangiogenic effects on endothelial cells

It has recently been shown that chimeric toxins composed of acidic fibroblast growth factor fused to mutant forms of Pseudomonas exotoxin (aFGF-PE) are cytotoxic to a variety of tumor cell lines with FGF receptors. Although aFGF-PE might be considered as a possible chemotherapeutic toxin, limited knowledge is available concerning its effect on endothelia. This study investigates whether one of the aFGF-PE fusion proteins, aFGF-PE664GluKDEL, can function as an anti-angiogenic agent. Protein synthesis studies using rat epididymal fat pad microvascular endothelial cells (RFCs) indicated that after 24 h in culture, aFGF-PE had a significant inhibitory effect on protein synthesis at concentrations greater than 100 ng/ml. In cultures incubated with 1000 ng/ml aFGF-PE, RFC protein synthesis was inhibited as much as 83%. RFCs were also cultured in a 3-dimensional type I collagen gel and incubated with either transforming growth factor beta 1, aFGF-PE, or a combination of both. Transforming growth factor beta 1 elicits in vitro angiogenesis in these 3-dimensional cultures which consist of rapid formation of complex tubular structures. Transforming growth factor beta 1-treated RFCs incubated with aFGF-PE were unable to produce this angiogenic response, nor were they able to migrate out of the 3-dimensional culture to form a monolayer as shown by controls. Cell viability analyses showed that aFGF-PE produced a dose-dependent toxic effect which ranged from 10 to 90% cell death. Competition assays in which the chimeric toxin was preincubated with antibodies to aFGF resulted in an 89% reversal of the inhibitory effects of aFGF-PE on endothelial cells. Acidic FGF-PE with a mutation in the ADP ribosylation domain of PE was inactive in both 2-dimensional and 3-dimensional cultures. These data show that aFGF-PE has specific in vitro cytotoxic, antiangiogenic, and antimigratory effects on microvascular endothelia.

Lipofectin enhances cellular uptake of antisense DNA while inhibiting tumor cell growth

A natural DNA oligomer (15-mer) was synthesized with a sequence complementary to the translation initiation codon region of the human TGF-alpha mRNA and mixed with Lipofectin to form unilamellar complexes. It was found that tumor cell growth was inhibited when HCT116 cells were treated with Lipofectin-DNA oligomer complexes or with Lipofectin alone. Uptake of 32P-labeled 15-mers into colon tumor cells was compared in the presence and absence of Lipofectin. The amount of labeled oligomer found in cells that received optimal ratios of Lipofectin to DNA was 4- to 10-fold higher than the amount found in cells that received 32P-labeled DNA alone. Although Lipofectin-antisense DNA oligomer treatment of HCT116 cells caused a dose-dependent inhibition of cell growth, there was a subsequent rise in target mRNA product. Because the mechanism of growth inhibition could not involve an inhibition of TGF-alpha expression, it was concluded that Lipofectin probably exerts a nonspecific, detergent-like effect upon the cell membrane, producing an enhancement of TGF-alpha processing and release.

Delayed dehiscence of repaired bladder rupture

A case of dehiscence of a previously repaired bladder rupture occurring 3 years after the original repair is reported. There was no obvious predisposing cause to this event. As this occurrence is very rare, it brings into question the need for long-term review of patients with conservatively treated bladder rupture.

The Wardill test: does it predict future voiding flow?

A prospective study was undertaken to assess the predictive value of measuring the peak flow rate at completion of a transurethral prostatectomy with suprapubic pressure (the Wardill test). Twenty-six patients had their expressed flow rate measured on applying a standardised suprapubic pressure and compared to their peak flow rate measured at least 6 weeks postoperatively. No significant correlation was found to exist between the two variables.

Clinical pharmacokinetics of parenterally administered danofloxacin in cattle

Danofloxacin is a new fluoroquinolone antibacterial, developed specifically for veterinary use. Its in vitro activity and pharmacokinetic properties have been investigated to assess its potential for use in the therapy of respiratory disease in cattle. The minimum inhibitory concentration of danofloxacin against 90% (MIC90) of contemporary European and North American field isolates of Pasteurella haemolytica, Pasteurella multocida and Haemophilus somnus, the most important bacterial respiratory pathogens of cattle, was 0.125 micrograms/ml. The plasma and lung kinetics of danofloxacin following parenteral administration of 1.25 mg/kg were evaluated in two studies. Danofloxacin was rapidly absorbed following intramuscular and subcutaneous injection and bioavailability was virtually complete (101% and 94% respectively). Plasma concentration profiles of danofloxacin were similar for intramuscular and subcutaneous routes with no significant differences in the area under the plasma concentration-time curves (AUC) following one, three or five consecutive daily doses, although slightly higher peak plasma concentrations were achieved by the intramuscular route. Following intramuscular administration, the mean peak lung concentration of danofloxacin was 4.1 times greater than that of plasma. Similarly, the AUC for lung tissue was 3.7 times greater than that for plasma. These data indicate that danofloxacin should be particularly appropriate for the therapy of bacterial respiratory disease in cattle.

Regulation by estrogen through the 5'-flanking region of the transforming growth factor alpha gene

Expression of transforming growth factor alpha (TGF alpha) mRNA and protein can be stimulated by estrogens such as 17 beta-estradiol (E2) in estrogen-responsive rodent and human breast cancer cells. To ascertain if E2 can directly regulate TGF alpha expression through the 5'-flanking region of the human TGF alpha gene, E2-responsive MCF-7 or ZR-75-1 human breast cancer cells or E2-nonresponsive MDA-MB-231 breast cancer cells were transiently transfected with a plasmid containing an 1140-base pair (bp) Sac-I fragment of the TGF alpha 5'-flanking region ligated to the chloramphenicol acetyltransferase (CAT) gene. Cells that were transfected and subsequently treated with physiological concentrations of E2 (10(-11)-10(-8) M) for 24 h exhibited a 2- to 10-fold increase in CAT activity. The E2 stimulation of CAT activity was dose-dependent with an increase first found at 10(-10) M E2. The increase in CAT activity could be detected within 24-36 h after the addition of E2. There was no significant change in CAT activity in transiently transfected MDA-MB-231 cells as mediated through the TGF alpha 5'-flanking region after E2 treatment. MCF-7 cells were also transiently transfected with different fragments of the TGF alpha 5'-flanking region ligated to the luciferase gene. In the absence of E2 treatment, no detectable luciferase activity was found.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of an Antibacterial Powder Spray to Prevent Post Prostatectomy Urinary Infection

To prevent ascending urinary infection in patients following transurethral prostatectomy, we have studied the use of a topical antibacterial agent applied to the groin and external genitalia. A prospective randomized controlled trial was conducted, with 50 patients being treated by daily application of a 2% polynoxylin powder, and 50 patients acting as untreated controls. Patient age and duration of catheterization were similar in the treated and untreated groups. No significant benefit was seen in the treated cohort (P greater than 0.05) in terms of reduction in postoperative urinary infection.