Abstract 174: Investigating Subclinical Cardiotoxicity in Long-term Breast Cancer Survivors Following Chemotherapy With DENSE-based 3D Strain Analysis

This study investigated if left ventricular (LV) mechanical contractile parameters in addition to LV ejection fraction (LVEF) indicated cardiac remodeling and fibrosis in patients exposed to cardiotoxic chemotherapy agents (CCA). Cardiac deformation data were obtained using single-scan acquisitions with the Displacement Encoding with Stimulated Echoes (DENSE) MRI sequence. Contractile analysis consisted of automated myocardial boundary detection and unwrapping 3D DENSE phase images for intra-myocardial displacements, and followed by analyzing torsion and 3D strains with the meshfree Radial Point Interpolation Method (RPIM). Data were acquired on 13 CCA-exposed patients who were undergoing chemotherapy and/or care for cardiac complications. DENSE LVEF measurements in patients were validated against steady-state free precession (SSFP) MRI data, all contractility computations were compared to healthy subjects and Bland-Altman agreements established between strains computed by independent observers. A significant difference was not found between DENSE and SSFP LVEF computations (52 ± 11% vs 48 ± 15%, p=0.33). Significant differences were seen with enlarged LV diameters in patients versus healthy subjects (6.0 ± 1.1 cm vs 4.9 ± 0.7 cm, p<0.001) and similarly for torsion and longitudinal strain but not in LVEF results (p > 0.05). Bland-Altman agreements were 0.01 ± 0.06 for longitudinal strain and 0.1 ± 1.9 ° for torsion. Statistical analysis confirm changed LV size and function in patients and indicate remodeling that is otherwise not demonstrated by LVEF measurements, which may precede clinically apparent heart failure development and worsened morbidity.

A thermodynamically-based model for predicting microbial growth and community composition coupled to system geochemistry: Application to uranium bioreduction

'Bioimmobilization' of redox-sensitive heavy metals and radionuclides is being investigated as a way to remediate contaminated groundwater and sediments. In one approach, growth-limiting substrates are added to the subsurface to stimulate the activity of targeted groups of indigenous microorganisms and create conditions favorable for the microbially-mediated reductive precipitation ('bioreduction') of targeted contaminants. We present a theoretical framework for modeling this process that modifies conventional geochemical reaction path modeling to include thermodynamic descriptions for microbial growth and may be called biogeochemical reaction path modeling. In this approach, the actual microbial community is represented by a synthetic microbial community consisting of a collection of microbial groups; each with a unique growth equation that couples a specific pair of energy yielding redox reactions. The growth equations and their computed standard-state free energy yields are appended to the thermodynamic database used in conventional geochemical reaction path modeling, providing a direct coupling between chemical species participating in both microbial growth and geochemical reactions. To compute the biogeochemical reaction paths, growth substrates are reacted incrementally with the defined geochemical environment and the coupled equations are solved simultaneously to predict reaction paths that display changing microbial biomass, community composition (i.e. the fraction of total biomass in each microbial group), and the aqueous and mineral composition of the system, including aqueous speciation and oxidation state of the targeted contaminants. The approach, with growth equations derived from the literature using well-known bioenergetics principles, was used to predict the results of a laboratory microcosm experiment and an in situ field experiment that investigated the bioreduction of uranium. Predicted effects of ethanol or acetate addition on uranium concentration and speciation, major ion geochemistry, mineralogy, microbial biomass and community composition were in qualitative agreement with experimental observations although the available data precluded rigorous model testing. While originally developed for use in better understanding of bioimmobilization of heavy metals and radionuclides, the modeling approach is potentially useful for exploring the coupling of microbial growth and geochemical reactions in a variety of other basic and applied biotechnology research settings.

Human AML cells in NOD/SCID mice: engraftment potential and gene expression

Most cases of human acute myeloid leukemia (AML) engraft in irradiated non-obese diabetic/severe combined immunodeficient (NOD/SCID) mice. Intravenous transfer of as few as 10(5) human AML cells resulted in engraftment. Cases with poor prognosis clinical features, including FLT3 mutations, tended to engraft efficiently. Nevertheless, AML cells obtained from patients at relapse did not engraft more efficiently than cells obtained from the same patients at initial diagnosis. One passage of human AML cells in NOD/SCID mice did not appear to select for increased virulence, as measured by serial transplantation efficiency. Finally, cDNA microarray analyses indicated that approximately 95% of genes were expressed at similar levels in human AML cells immunopurified after growth in mice, as compared to cells assessed directly from patients. Thus, the growth of human AML cells in NOD/SCID mice could yield large numbers of human AML cells for direct experimental use and could also function as a renewable, potentially unlimited source of leukemia cells, via serial transplantation.

Correlates of disruptive behavior in severely cognitively impaired nursing home residents

This article provides information about correlates of "disruptive behaviors" among nursing home residents with dementia. We used averages of multiple observations for a wide range of behaviors (n = 45) across 11 months to gather this information. We placed behaviors into four separate categories: physically aggressive, physically non-aggressive, vocally agitated, and vocally aggressive. Then, we tested associations between these categories and demographic, cognitive, and health variables. Cognitive status and selected demographic variables were associated with the behavior categories; adding health variables did not improve prediction. Lower cognitive status was associated with more disruptive behaviors. Our findings suggest that cognitive status, but not health variables, predicts disruptive behavior among nursing home residents with dementia.

Long-term entrainment of circannual reproductive and metabolic cycles by Northern and Southern Hemisphere photoperiods in woodchucks (Marmota monax)

Woodchucks were exposed to simulated Northern Hemisphere (boreal) or Southern Hemisphere (austral) natural photoperiods in groups of 17 males and 17-18 females at 20-23 degrees C for 69 mo and examined monthly. Photoentrainment of endogenous cycles was evaluated based on dates of peak body weight, peak testis volume, increased serum testosterone in males, and increased serum progesterone in females. Boreal photoperiods entrained and synchronized annual cycles in 15 of 17 males and in all 17 females; 2 males never entrained and free-ran at 9- to 11-mo intervals. Austral photoperiods phase-advanced cycles by approximately 6 mo after 2.5 yr in 34 of 35 animals. Four entrained males became refractory after 4 yr, free-running at 6- to 10-mo intervals. Photoentrained boreal animals became phase-advanced by 1 mo during the first 2 yr, and then had 12-mo cycles for 4 yr. In Year 5, on average, boreal cycles included initial testosterone elevations in mid-January (vs. mid-July in australs), parturition in early March (vs. early September in australs), and peak body weight in mid-July (vs. late January in australs). The results confirm that endogenous circannual cycles of woodchucks can be entrained and synchronized for 6 yr by daily changes in photoperiod similar to those of midnorthern latitudes, and can be re-entrained and phase-advanced 6 mo by photoperiods of midsouthern latitudes.

Variation in prostate position quantitation and implications for three-dimensional conformal treatment planning

PURPOSE

This study describes and quantitates the motion, i.e., variation in position, of the prostate within the pelvis and its effect on target and normal organ dose.

METHODS AND MATERIALS

The motion of the planning target volume (PTV) borders and center of mass was studied in 13 patients with carcinoma of the prostate through the use of superimposed serial computerized tomography (CT) scans. Changes in bladder and rectal volumes were measured and their relationship to displacements of the PTV position were noted. The effects of this motion on target and normal organ doses were measured.

RESULTS

A variability in the position of the PTV is seen over time, which is related to changes in bladder and rectal volumes. The one standard deviation displacements of the PTV center of mass with respect to the planning scan center of mass position were 0.12, 0.40, and 0.31 cm in the lateral, anterior-posterior, and superior-inferior directions, respectively. Movement was significantly larger in the superior part of the PTV above the base of the bladder than in the inferior part. Movement of the borders of the PTV outward from the patient axis; hence, toward the edges of the treatment field, was also examined. Outward displacements of the anterior target border below the base of the bladder were less than 0.3 cm in 90% of the cases, and 1.4 cm above the bladder base. For the posterior wall these displacements were less than 0.7 cm and 1.1 cm, respectively, whereas the lateral border displacements were less than 0.3 cm throughout (90% confidence limits). These displacements would cause a median of 6% of the PTV to receive less than 95% of the planned dose for any given treatment day in these patients; the effect on rectal and bladder wall doses was greater and true doses may not be measurable through the use of only one treatment planning CT scan.

CONCLUSIONS

The prostate is not a static organ, but rather has some limited motion in the pelvis secondary to bladder and rectal volume changes. This motion has been quantified for a group of patients, and may provide a guide to further studies on the placement of field borders.

Estrus, fertility, early embryo development, and autologous embryo transfer in laboratory woodchucks (Marmota monax)

Reproductive parameters were studied in female laboratory woodchucks over a 6-year period. The pregnancy rate in adult females after ad libitum exposure to a male (n = 643) was 72%; that after limited (4 to 8 h) exposure with video observations (n = 31) was only 37%. However, limited exposure resulted in a 75% ovulation rate, suggesting a problem with fertilization and not ovulation. The ovulation rate was 0% in the absence of mating (n = 10), suggesting that spontaneous ovulation is not the usual situation in this species. With ad libitum mating, fertility was greater (P < 0.05) for 2- to 4-year-old females (73%) than for 1-year-old (56%) or > or = 5-year-old (58%) females. Mean (+/-SEM) litter size at birth was greater (P < 0.05) for 2- to 5-year-old animals (4.0 +/- 0.1) than for 1-year-old animals (2.9 +/- 0.2). However, in 1-year-old females the neonatal mortality was low, and the litter size at weaning (2.4 +/- 0.3 pups) did not differ from that of older females (2.7 +/- 0.1 pups). The measurement of vulval diameter every 3 to 4 days in 31 adult females suggested that enlargement to > or = 7 mm was indicative of proestrus or estrus and was a good indicator of willingness to accept mounting by males. Vulval swelling > or = 7 mm (n = 31) lasted 5 to 47 days. Fertile mating occurred from 3 to 30 days after vulval diameter reached > or = 7 mm, near the time of peak enlargement (10.1 +/- 0.2 mm), and was followed in several days by a decrease in vulval size. Fifty-three females were allowed only limited (6 to 10 h) video-observed exposure to males, with (n = 26) or without (n = 27) another 12 to 24 h of unobserved exposure, and were examined surgically for ovulation and pregnancy at known times after mating. There were no consistent differences among nonovulating, ovulating nonfertile, and fertile females in the longest duration of mating (7.2 +/- 0.4 min) or in the number of matings lasting > or = 1 min (5.7 +/- 0.8). Compared with nonfertile females, fertile females experienced more matings > or = 3 min in duration (3.3 +/- 0.4 versus 1.8 +/- 0.2) and > or = 5 min in duration (2.9 +/- 0.4 versus 1.1 +/- 0.1). At postmating days 1, 2, 3, 4, 5, 6, and 7 the embryos were observed to be 1-, 4-, 4- to 32-cell morulae, 16- to 60-cell morulae, free-floating blastocysts, anti-measometrial peri-implantation blastocysts, and attached blastocysts respectively. Autologous transfer of day-5 uterine embryos of normal appearance into the noncontiguous contralateral uterine horn was performed in five females that had been subjected to a hemi-ovariectomy. Transfers resulted in pregnancy and litters in four of the five females. The results suggest that this large, circannual sciurid rodent can be successfully and predictably bred as a laboratory animal model, has vulval changes indicative of proestrus, is principally an induced ovulator, has an early embryo development rate similar to that of rats and mice, and may be amenable to reproductive technologies developed for more common laboratory rodents.

Comparing two strategies of cardiopulmonary bypass cooling on jugular venous oxygen saturation in neonates and infants

BACKGROUND

Cerebral protection during deep hypothermic circulatory arrest is predicted on efficient and complete cerebral cooling. Institutions approach cooling quite differently. We compared two different cooling strategies in terms of measured jugular venous bulb saturations in 39 infants undergoing deep hypothermic cardiopulmonary bypass to evaluate the effect of institutional cooling practices on jugular venous bulb saturation, an indirect measure of cerebral cooling efficiency.

METHODS

The patients were grouped based on the method of core cooling. In group A (n = 17), core cooling was achieved rapidly by setting the water bath temperature of the heat exchanger at 4 degrees to 5 degrees C, and the patient was cooled until rectal temperature and nasopharyngeal temperature were 15 degrees C or lower. In group B (n = 22), the heat exchanger was initially set at 18 degrees C and slowly lowered to 12 degrees C. Hypothermic temperatures of 12 degrees C were maintained until the nasopharyngeal temperature was 18 degrees C or less and the rectal temperature was 20 degrees C or lower. Once cooling was complete, blood samples were analyzed by cooximetry for determination of arterial oxygen saturation and jugular venous bulb saturation.

RESULTS

In group A, the measured jugular venous bulb saturation was 98.0% +/- 0.9% and the oxygen saturation to jugular venous bulb saturation difference was 0.3% +/- 0.5%, measured at the time that institutional cooling objectives were achieved (total cooling time, 15.0 +/- 0.45 minutes). In group B, jugular venous bulb saturation was 86.2% +/- 12% and the oxygen saturation to jugular venous bulb saturation difference was 10.8% +/- 12.2%, measured at the time that institutional cooling objectives were achieved (total cooling time, 17.5 +/- 1.1 minutes (p < 0.01).

CONCLUSIONS

Differences in cardiopulmonary bypass cooling techniques may alter the rate at which jugular bulb saturations rise. We believe this represents an indirect measure of the efficiency of brain cooling and therefore of cerebral protection.

Neuropsychiatry and SPECT of an acute obsessive-compulsive syndrome patient

BACKGROUND

A 71-year-old man with no previous psychiatric history presented with an acute onset of obsessive-compulsive disorder (OCD) symptoms associated with a right inferior parietal infarct. There were no abnormal neurological signs. There were no noteworthy abnormalities on neuropsychological testing.

METHOD

Whereas a computerised tomography scan showed only a right inferior parietal infarct, a single photon emission computerised tomography (SPECT) scan revealed that in addition to the infarct there was decreased regional cerebral blood flow in the right basal ganglia and temporal areas. There was higher activity in the right orbitofrontal area than in the left.

RESULTS

The patient improved with standard drug therapy and psychotherapy.

CONCLUSIONS

SPECT is effective in the diagnosis of neuropsychiatric disorders such as OCD, and the pathological changes in brain metabolism detected by SPECT may be reversed by both drug therapy and psychotherapy.

[Pick and focal brain atrophy]

In 1892 Arnold Pick presented the case of an elderly demented patient with severe aphasia and global brain atrophy most accentuated at the left temporal lobe. Picks main interest was the relationship between focally accentuated brain degeneration and focally accentuated neuropsychological deficits, and this was what he wanted to demonstrate. He made no effort to describe a new form of dementia. The term "Pick's disease" which was introduced 30 years later implies the existence of a nosological entity with characteristic clinical features, localisation and histology. The neuropathological causes of focally accentuated brain atrophies are varied. Neocortical pyramidal cell loss with or without spongiform changes, cortical and subcortical gliosis have commonly been described. Achromatic neuronal ballooning ("Pick's cells") and intraneuronal argentophilic inclusion bodies ("Pick's bodies"), Alzheimer type plaques and tangles and other features were found in a smaller number of cases. Several authors confirmed an association between the localisation of brain atrophy and its clinical manifestations, but no convincing relationship has been demonstrated between the clinical symptoms and the underlying histology. In several studies frontal lobe degeneration was found in 10% to 20% of the demented patients, whereas aphasia, apraxia and other pronounced deficits in the context of focally accentuated brain atrophy were described less frequently. An early clinical distinction between atypical early stages of Alzheimer's disease and other forms of slowly progressive dementing disorders is virtually impossible in these cases. Prospective studies documenting the clinical and anatomical findings are needed to examine the reliability of these surmised brain-behaviour relationships in degenerative brain diseases more reliably. A descriptive approach offers a better basis for data collection than the premature diagnosis of a poorly defined disease like "Pick's".

Effect of altering pump flow rate on cerebral blood flow and metabolism in infants and children

The effects of reduced pump flow rate (PFR) on cerebral blood flow, cerebral oxygen consumption (CMRO2), oxygen extraction, cerebral vascular resistance, and total body vascular resistance were examined in 27 pediatric patients during hypothermic cardiopulmonary bypass (hCPB). During steady state hCPB the extracorporeal flows were randomly adjusted to a conventional PFR and a reduced PFR for each patient. The reduced pump flow rates were dictated by surgical needs. Cerebral blood flow measured using Xenon 133 clearance, and CMRO2 and oxygen extraction were calculated. Our results demonstrated that cerebral blood flow and CMRO2 are unchanged if pump flow rates are reduced by 35% to 45% of conventional PFRs at moderate and deep hypothermic temperatures. Reductions in PFR of 45%-70% from conventional PFRs affect the brain differently during either moderate or deep hCPB. At moderate hCPB (26 degrees to 29 degrees C), reductions in PFRs of 45% to 70% resulted in a significant decrease in cerebral blood flow and CMRO2, whereas oxygen extraction increased in a compensatory manner. During deep hCPB (18 degrees to 22 degrees C), PFR reductions of 45% to 70% of conventional PFR significantly reduced cerebral blood flow and CMRO2 but did not increase oxygen extraction, suggesting that at deep hypothermic temperatures, cerebral blood flow and CMRO2 exceed cerebral metabolic needs. Cerebral vascular resistance increased significantly with decreasing temperature but was not affected by pump flow reductions. We have derived indices for minimal acceptable low-flow cardiopulmonary bypass based on the known effects of temperature on cerebral metabolism and have speculated on its utility based on our limited data and a literature review.

Three-dimensional dosimetry for radioimmunotherapy treatment planning

Absorbed-dose calculations for radioimmunotherapy are generally based on tracer imaging studies of the labeled antibody. Such calculations yield estimates of the average dose to normal and target tissues assuming idealized geometries for both the radioactivity source volume and the target volume. This work describes a methodology that integrates functional information obtained from SPECT or PET with anatomical information from CT or MRI. These imaging modalities are used to define the actual shape and position of the radioactivity source volume relative to the patient's anatomy. This information is then used to calculate the spatially varying absorbed dose, depicted in "colorwash" superimposed on the anatomical imaging study. By accounting for individual uptake characteristics of a particular tumor and/or normal tissue volume and superimposing resulting absorbed-dose distribution over patient anatomy, this approach provides a patient-specific assessment of the target-to-surrounding normal tissue absorbed-dose ratio. Such information is particularly important in a treatment planning approach to radioimmunotherapy, wherein a therapeutic administration of antibody is preceded by a tracer imaging study to assess therapeutic benefit.

Detecting depression in elderly medically ill patients: the use of the Geriatric Depression Scale compared with medical and nursing observations

In a study of 59 elderly medically ill in-patients, 35% were found to have significant depressive symptomatology, as detected by the Geriatric Mental Status Schedule (GMSS). Of two screening methods, the Geriatric Depression Scale (GDS) performed satisfactorily but detection by nurses was poor. Acknowledgement of depression in medical casenotes was low. Training of nurses might improve detection; otherwise a mood-rating scale such as the GDS should be incorporated into routine practice.

'Pick's disease'--101 years on still there, but in need of reform

On 23 April 1892, Arnold Pick reported the case of AH, who died aged 71 years following a two-year history of progressive ‘feeble-mindedness', outbursts of rage, fits and, in the later stages, severe aphasia (Pick, 1892). The post-mortem showed cerebral atrophy, particularly affecting the left temporal lobe. Pick went on to describe further cases of circumscribed atrophy affecting the temporal lobe (Pick, 1901, 1904), and parietal and frontal lobes (Pick, 1906). Although he believed the focal pathology represented a local emphasis of ‘senile cortical atrophy’, he wanted to show that a localised form of cerebral atrophy could nevertheless cause specific symptoms:

Alteration of growth, advancement of puberty, and season-appropriate circannual breeding during 28 months of photoperiod reversal in woodchucks (Marmota monax)

In woodchucks (Marmota monax), as in other marmotine rodents, endogenous circannual metabolic and reproductive cycles persist and free-run at intervals of 10-12 mo for up to 4 yr in a neutral photoperiod of 12L:12D. The annual metabolic cycle is not altered by exposure to constant long days or short days for several months. In the wild, changes in food intake cause body weight to peak in late summer and reach nadirs in early spring, and there is a single annual breeding season in late winter. To determine whether normal changes in photoperiod entrain the endogenous circannual cycle, aspects of reproduction, food intake, and body weight were studied for 28 mo in eight groups of woodchucks housed in light-controlled rooms. These included four groups of 7-10 males and four groups of 7-10 females exposed to automated and continuous daily changes in photoperiod. The imposed changes in photoperiod resembled native Northern Hemisphere (boreal) changes or Southern Hemisphere (austral) changes in photoperiod. The treatments started at the summer solstice shortly after capture as 2.5-mo-old juveniles or 14.5-mo-old yearling adults. In austral vs. boreal woodchucks, started as juveniles, annual increases in testosterone and testis descent at 5, 14, and 23 mo of study were advanced by 2, 5, and 6 mo, respectively. Annual increases in progesterone at 7, 16, and 25 mo of study were advanced by 4, 5, and 6 mo, respectively. The older woodchucks were significantly but less dramatically affected by austral photoperiod for the first 6 mo of study, and by 8-12 mo were advanced the same as the younger animals. At 16-17 and 26-27 mo of photoperiod reversal, 16 austral females had normal pregnancy rates (78%) and produced normal-sized litters (4.3 +/- 0.2) that were advanced by 5 and 6 mo, respectively, relative to those of boreal controls. Body weights in austral vs. boreal juveniles were reduced at 3-5 mo of study but not in older woodchucks. At 1 and then 2 yr of austral lighting, peaks in body weight were advanced by 4 and then 5 mo relative to boreal controls in young animals, and by 2 and then 5 mo in older animals. Between 1 and 2 yr of austral lighting in both age groups the nadirs in food intake (45 g per day) were about 16-25% of peak food intake 6-8 mo earlier, as in boreals, but advanced by 5-6 mo relative to boreals.(ABSTRACT TRUNCATED AT 400 WORDS)

EIS (executive information systems): a better way to view hospital trends

Executive information systems (EIS) are changing the way managers and executives view information. EIS is a work-station based information system that integrates information from the important parts of a healthcare organization to give executives a high-level perspective on key performance indicators and trends affecting their institutions. Such systems employ graphics and color to display real-time data in a format that is easily interpreted by executives and that helps them make better decisions. EIS technology is particularly appropriate for disseminating and highlighting financial information. However, for such systems to work effectively and for executives to obtain the greatest benefits from them, financial managers must help establish and promote EIS.

Evaluating the appropriateness of a nurse expert system's patient assessment

The Urological Nursing Information System (UNIS) is an expert-system prototype designed to help nurses perform patient assessments on elderly nursing home residents known to be incontinent of urine. A study was conducted to evaluate the appropriateness of the patient-assessment parameters stored in the knowledge base of UNIS. These parameters were stored as objects--a kind of template for holding related clusters of data, facts, rules, hypotheses, or any knowledge in a single conceptual unit. Each object was rated for its appropriateness by 14 nurse experts. Resulting scores ranged from +14 to -14. The effect of the nurse experts' educational backgrounds and work settings on their ratings were also analyzed. The results indicated that 95.6% of the objects received favorable ratings from the nurse experts. Educational background was not a significant factor chi 2 = 5.2, but work settings did have a significant affect chi 2 = 21.07, p = 0.01.

A comparison of outcomes using three different methods of breast reconstruction

In a review of 325 postmastectomy breast reconstructions, the aesthetic quality of the result and the risk of unsuccessful outcome were compared for three techniques: tissue expansion (105 breasts), latissimus dorsi myocutaneous flap (47 breasts), and TRAM flap (173 breasts). The aesthetic successes achievable with the three methods were similar, and some excellent results were achieved with each of them. The failure rate after tissue expansion (21 percent) was significantly higher than those observed with the TRAM (3 percent) and latissimus (9 percent) flaps. Tissue expansion also was not as aesthetically successful as other techniques in obese patients. For immediate breast reconstruction, the TRAM flap was the most aesthetically successful technique. Although tissue expansion has advantages and may be the best choice for some patients, methods that used autogenous tissue provided more consistent success.

Immunosuppression with cyclosporine during the incubation period of experimental woodchuck hepatitis virus infection increases the frequency of chronic infection in adult woodchucks

The immunosuppressive agent cyclosporine was given to adult woodchucks during acute experimental infection with woodchuck hepatitis virus (WHV). All 17 woodchucks given WHV alone or with a vehicle resolved the infection (i.e., zero chronicity), but when cyclosporine was given throughout the incubation and acute phases of infection (0-12 or 14 weeks; n = 12), the rate of chronic infection increased to 92%. When cyclosporine was given only during the incubation period (0-4 weeks; n = 10) or only during the acute phase of infection (2-12 weeks; n = 9), the rates increased to 50% and 55%, respectively. However, when the drug was given after the acute phase (8-18 weeks; n = 9), the chronic infection rate (11%) did not differ from that in untreated and vehicle controls. Immune responses inhibited by cyclosporine are important in resolution of acute WHV infection and occur mainly during the first 8 weeks. Immunosuppression of these responses for even short intervals during incubation (e.g., 0-4 weeks) increases the risk of chronicity.

The human fibroblast receptor for gp86 of human cytomegalovirus is a phosphorylated glycoprotein

A human embryonic lung (HEL) cell receptor for gp86 of human cytomegalovirus that functions in virus-cell fusion was further characterized. Anti-idiotype antibodies that mimic gp86 were used to immunoprecipitate the 92.5-kDa fibroblast membrane receptor for gp86, which was preincubated with various endoglycosidases. The receptor, which has a pI ranging from 5.3 to 5.6, appears to be a glycoprotein with primarily N-linked sugar residues, some of which have high concentrations of mannose and some of which are complex oligosaccharides. Western blots (immunoblots) of electrophoretically transferred receptor incubated with various biotinylated lectins confirmed the presence of sugar moieties, including N-acetylglucosamine, glucose or mannose, and galactose, but not fucose or N-acetylgalactosamine. This gp86 receptor from uninfected HEL cells also incorporated radiolabeled phosphate from orthophosphoric acid, indicating that it is a constitutively phosphorylated receptor.

Clinically relevant optimization of 3-D conformal treatments

In this paper a method of computer-aided optimization of 3-D conformal treatment plans is presented which incorporates models to predict the clinical consequences of resulting dose distributions. Even though these models are simplistic, it is submitted that their intelligent use leads to treatment plans which indicate lower normal tissue complications and higher tumor control. Dose distribution data, biological models, and observed normal tissue and tumor response data are used to compute tumor control and normal tissue complication probabilities for each of the critical normal structures encountered in a treatment plan. These quantities are combined into a single score using an objective function which incorporates the importance of each end point as assessed by the physician. Using the "simulated annealing" method of optimization, the beam weights are adjusted to maximize the score. Additional constraints are applied to ensure consistency of the results of optimization with the judgment of the physician. These optimization methods have been applied to conformal treatment plans consisting of multiple fixed fields with conformal field shaping. The results indicate that the methods presented have considerable potential.

AHCA (American Health Care Association) leaders look to the year ahead

During the past 15 months, long term care providers have worked diligently to implement the nursing facility reform provisions of the Omnibus Budget Reconciliation Act of 1987 (OBRA). Other significant events, such as the release of final rules clarifying OBRA and state funding shortfalls, promise to keep the industry busy in the coming years. Provider interviewed leaders of the American Health Care Association (AHCA) to assess the present state of the industry and talk about the Association's goals.

Improving documentation of aggressive behavior in nursing home residents

1. Although 66% of the 1.3 million elderly nursing home residents in the US exhibit aggressive tendencies, research indicates that caregivers underdocument aggressive incidents. As a result, the extent of aggression is unknown. 2. This study found that LPNs reported the largest percentage (41%) of the 51 documented aggressive incidents, which reportedly occurred most frequently in the bathroom (49% of the time) between 5 AM and noon (86% of the time). Most aggressive residents (55.1%) never had visitors. 3. This study concludes that nursing practice would benefit from a consistent definition of aggression, an easy-to-use clinical instrument to collect data on aggression, and caregiver education programs on assessing aggression.

Workers Compensation cases with traumatic brain injury: an insurance carrier's analysis of care, costs, and outcomes

The purpose of this survey was to review the medical care, medical costs, and outcomes of 86 Workers Compensation cases involving traumatic brain injury. An analysis of ICD-9 diagnoses, Rancho Los Amigos Cognitive Levels, age, sex, accident description, management techniques, costs, outcomes, and many other factors was conducted. The total indemnity (wage loss) and medical payments amounted to $27.1 million. For example, one case with temporal lobe hematoma, due to a fall in 1972, has had $1.1 million in medical payments since the injury occurred. The current average age is 40 years with 71% still residing at home. Only 10% are currently employed and 40% are known to be receiving other benefits. The increasing frequency and severity of these cases, as well as the extension of survival due to improved care and technology, highlight the need to address the question, "Who will be the caretakers, and what will be the associated costs?" Actuarial projections into the 21st century are given. It is concluded that, while further long-term studies are needed, Workers Compensation carrier representatives and health care providers must continue to work together on the interdisciplinary rehabilitation team.

Correlates of disruptive behavior in cognitively impaired elderly nursing home residents

Disruptive behavior, resulting in negative consequences for both residents and caregivers, occurs in a large proportion of the nursing home population. This review of literature surveys studies that describe disruptive behavior and the correlates of this behavior in the cognitively impaired elderly. In the studies reviewed, the average prevalence of reported disruptive behavior among a total of 5,650 subjects was 42.8%. Correlates most frequently linked with disruptive behavior include cognitive status, functional ability, age, and premorbid personality. Suggestions for future research are discussed.

Anti-idiotype antibodies that mimic gp86 of human cytomegalovirus inhibit viral fusion but not attachment

Human cytomegalovirus (CMV) infects cells by sequential processes involving attachment, fusion with the cell membrane, and penetration of the capsid. We used two monoclonal anti-idiotype that mimic one of the CMV envelope glycoproteins, gp86, to study its role in the early phases of CMV infection. Neither of two such antibodies inhibited virus binding to human embryonic lung (HEL) fibroblasts; however, both antibodies inhibited the fusion of CMV with HEL cells, as measured by an assay in which viral envelope is labeled with a fluorescent amphiphile (octadecyl rhodamine B chloride, or R18), resulting in increased fluorescence during fusion of virus with the cell membrane. Because these anti-idiotype antibodies were shown previously to bind to specific receptors on HEL cell membranes, these findings suggest that both gp86 and its cell membrane receptor may function in the fusion of human CMV with HEL cells.

The trauma of suction-assisted lipectomy cannula on flap circulation in rats

The effect of suction-assisted lipectomy on cutaneous blood vessels of inguinal skin flaps was studied and compared in 191 rats. Different types of cannula tips were used; the number of passes was standardized. In one experiment, following suctioning, 3 X 2 cm groin island flaps based on inferior epigastric pedicles were raised and then reattached. Fluorescein dye study and microangiography were performed to evaluate flap viability. Flap survival was determined clinically and by histologic examination on the fifth postoperative day. Three-sided inguinal random-pattern flaps were raised in a second experiment and reattached following suctioning. On the fifth postoperative day, surviving flap areas were measured using standard photographs and an imaging computer and were compared with controls. Results showed that cannula passes accompanied by vacuum are harmful to vessels, while those unaccompanied by vacuum are not. The greater the number of suctioning passes, the more trauma there is to vessels and the greater is the likelihood of flap necrosis. Conical and spatula tips were more harmful to vessels than spherical, cobra, keel cobra, or Fournier tips. These results support the conclusion that suction-assisted lipectomy enhances the possibility of skin necrosis by traumatizing the vascular pedicle of a flap, especially when it is used as an adjunct to flap elevation.

Elevated formation of nitrate and N-nitrosodimethylamine in woodchucks (Marmota monax) associated with chronic woodchuck hepatitis virus infection

Nitrate balance and N-nitrosodimethylamine (NDMA) excretion were studied in woodchucks chronically infected with woodchuck hepatitis virus (WHV). Twenty-four-h urinary recovery of a bolus dose of [15N]nitrate was 54 +/- 12% in woodchucks. WHV-infected animals formed 3-fold more nitrate endogenously than did control animals (P less than 0.01). Treatment of WHV-infected animals with Escherichia coli lipopolysaccharide increased nitrate excretion 15-fold, while uninfected animals increased nitrate excretion 4-fold. The endogenous formation of NDMA was higher in WHV-infected woodchucks than in uninfected controls. After administration of L-[15N2]arginine, [15N]nitrate, and [15N]NDMA were detected in urine indicating that arginine is a precursor of biosynthesized nitrate and the hepatocarcinogen NDMA. NDMA probably results from the formation of nitrosating agents during the oxidation of arginine to oxides of nitrogen and citrulline. Woodchucks chronically infected with WHV develop hepatocellular carcinomas with high frequency. Our observations suggest an additional mechanism that may be involved in the pathogenesis of hepatocellular carcinoma associated with chronic WHV infection.

The effect of hypothermic cardiopulmonary bypass and total circulatory arrest on cerebral metabolism in neonates, infants, and children

Cardiopulmonary bypass management in neonates, infants, and children often requires the use of deep hypothermia at 18 degrees C with occasional periods of circulatory arrest and represents marked physiologic extremes of temperature and perfusion. The safety of these techniques is largely dependent on the reduction of metabolism, particularly cerebral metabolism. We studied the effect of hypothermia on cerebral metabolism during cardiac surgery and quantified the changes. Cerebral metabolism was measured before, during, and after hypothermic cardiopulmonary bypass in 46 pediatric patients, aged 1 day to 14 years. Patients were grouped on the basis of the different bypass techniques commonly used in children: group A--moderate hypothermic bypass at 28 degrees C; group B--deep hypothermic bypass at 18 degrees to 20 degrees C with maintenance of continuous flow; and group C--deep hypothermic circulatory arrest at 18 degrees C. Cerebral metabolism significantly decreased under hypothermic conditions in all groups compared with control levels at normothermia, the data demonstrating an exponential relationship between temperature and cerebral metabolism and an average temperature coefficient of 3.65. There was no significant difference in the rate of metabolism reduction (temperature coefficient) in patients cooled to 28 degrees and 18 degrees C. From these data we were able to derive an equation that numerically expresses a hypothermic metabolic index, which quantitates duration of brain protection provided by reduction of cerebral metabolism owing to hypothermic bypass over any temperature range. Based on this index, patients cooled to 28 degrees C have a predicted ischemic tolerance of 11 to 19 minutes. The predicted duration that the brain can tolerate ischemia ("safe" period of deep hypothermic circulatory arrest) in patients cooled to 18 degrees C, based on our metabolic index, is 39 to 65 minutes, similar to the safe period of deep hypothermic circulatory arrest known to be tolerated clinically. In groups A and B (no circulatory arrest), cerebral metabolism returned to control in the rewarming phase of bypass and after bypass. In group C (circulatory arrest), cerebral metabolism and oxygen extraction remained significantly reduced during rewarming and after bypass, suggesting disordered cerebral metabolism and oxygen utilization after deep hypothermic circulatory arrest. The results of this study suggest that cerebral metabolism is exponentially related to temperature during hypothermic bypass with a temperature coefficient of 3.65 in neonates infants and children. Deep hypothermic circulatory arrest changes cerebral metabolism and blood flow after the arrest period despite adequate hypothermic suppression of metabolism.

Cyclosporin A modulates the course of woodchuck hepatitis virus infection and induces chronicity

Immunosuppression is known to influence the state of chronic hepatitis B virus infection, and is thought to increase the risk of developing chronic infection in newly exposed individuals. Cyclosporin A (CsA), an immunosuppressive agent that inhibits Th cell function, was administered to woodchucks chronically infected with woodchuck hepatitis virus (WHV), and resulted in a decreased severity of chronic hepatitis and an increased viremia during the treatment. Adult woodchucks inoculated with WHV and given CsA for 14 wk had increased viremias, decreased acute phase liver injury, and developed chronic infections at a higher rate compared with immunocompetent woodchucks given virus alone (chronicity in seven of seven WHV + CsA + vs zero of nine WHV + CsA-; p less than 0.001). These results in a relevant animal model of hepatitis B virus infection indicate: 1) that liver injury in acute hepadnavirus infections is immune-mediated and not a direct cytopathic effect of virus replication; 2) that Th cells function in the inflammatory response and in the immunologic control of hepadnavirus infection; and 3) that suppression of Th cell function in acute hepadnavirus infection decreases liver injury but alters the outcome of infection in favor of chronicity. These results also suggest continued challenges in the application of CsA in liver transplantation for hepatitis B virus-induced diseases.

Cyclosporin A modulates the course of woodchuck hepatitis virus infection and induces chronicity

Immunosuppression is known to influence the state of chronic hepatitis B virus infection, and is thought to increase the risk of developing chronic infection in newly exposed individuals. Cyclosporin A (CsA), an immunosuppressive agent that inhibits Th cell function, was administered to woodchucks chronically infected with woodchuck hepatitis virus (WHV), and resulted in a decreased severity of chronic hepatitis and an increased viremia during the treatment. Adult woodchucks inoculated with WHV and given CsA for 14 wk had increased viremias, decreased acute phase liver injury, and developed chronic infections at a higher rate compared with immunocompetent woodchucks given virus alone (chronicity in seven of seven WHV + CsA + vs zero of nine WHV + CsA-; p less than 0.001). These results in a relevant animal model of hepatitis B virus infection indicate: 1) that liver injury in acute hepadnavirus infections is immune-mediated and not a direct cytopathic effect of virus replication; 2) that Th cells function in the inflammatory response and in the immunologic control of hepadnavirus infection; and 3) that suppression of Th cell function in acute hepadnavirus infection decreases liver injury but alters the outcome of infection in favor of chronicity. These results also suggest continued challenges in the application of CsA in liver transplantation for hepatitis B virus-induced diseases.

Cerebral blood flow response to changes in arterial carbon dioxide tension during hypothermic cardiopulmonary bypass in children

We examined the relationship of changes in partial pressure of carbon dioxide on cerebral blood flow responsiveness in 20 pediatric patients undergoing hypothermic cardiopulmonary bypass. Cerebral blood flow was measured during steady-state hypothermic cardiopulmonary bypass with the use of xenon 133 clearance methodology at two different arterial carbon dioxide tensions. During these measurements there was no significant change in mean arterial pressure, nasopharyngeal temperature, pump flow rate, or hematocrit value. Cerebral blood flow was found to be significantly greater at higher arterial carbon dioxide tensions (p less than 0.01), so that for every millimeter of mercury rise in arterial carbon dioxide tension there was a 1.2 ml.100 gm-1.min-1 increase in cerebral blood flow. Two factors, deep hypothermia (18 degrees to 22 degrees C) and reduced age (less than 1 year), diminished the effect carbon dioxide had on cerebral blood flow responsiveness but did not eliminate it. We conclude that cerebral blood flow remains responsive to changes in arterial carbon dioxide tension during hypothermic cardiopulmonary bypass in infants and children; that is, increasing arterial carbon dioxide tension will independently increase cerebral blood flow.

Stiff-man syndrome: a GABAergic autoimmune disorder with autoantigenic heterogeneity

Autoantibodies that reacted with cell bodies and axon terminals of gamma-aminobutyric acid (GABA)ergic neurons were present in the serum and cerebrospinal fluid in a patient with stiff-man syndrome with type I diabetes. Immunoblot experiments using this patient's serum and cerebrospinal fluid did not corroborate an earlier observation that these autoantibodies are directed against the GABAergic cytosolic enzyme, L-glutamic acid decarboxylase. While L-glutamic acid decarboxylase autoantibodies may be associated with this syndrome, they do not appear to be easily demonstrated.

Natural history of experimental woodchuck hepatitis virus infection: molecular virologic features of the pancreas, kidney, ovary, and testis

The kinetic patterns of woodchuck hepatitis virus (WHV) infection were monitored in the pancreas, kidneys, ovaries, and testes. Groups of woodchucks experimentally infected with a standardized inoculum of WHV were sacrificed at different times over a 65-week period beginning in the preacute phase of viral infection and continuing to the period of serologic recovery or the establishment of chronic infections and subsequent hepatocellular carcinoma (B. E. Korba, P. J. Cote, F. V. Wells, B. Baldwin, H. Popper, R. H. Purcell, B. C. Tennant, and J. L. Gerin, J. Virol. 63:1360-1370, 1989). Tissues from an additional group of long-term (2 to 3 years) chronic WHV carriers which had been infected with the same WHV inocula were also examined. Viral DNA replication intermediates were found in all four tissues during the acute phase of WHV infection. However, WHV DNA replication intermediates were observed only in the kidneys of a small proportion of the chronically infected animals. Following the acute phase of infection, WHV DNA was present only in the pancreas, kidneys, and ovaries of the chronically infected woodchucks. A progressive evolution of different WHV genomic forms related to the replicative state of WHV was observed in these tissues. Histologic evaluation of these four tissues revealed only minimal, localized lesions which were not correlated with the state of WHV activity. The observations compiled in this study further extend the tissue tropism of WHV.

Caregivers' perception of aggressive behavior in cognitively impaired nursing home residents

Aggressive behaviors of nursing home residents represent a significant problem for caregivers and families. A guided interview format was used to collect data from 21 nurses and 20 nursing assistants in order to gather information on the characteristics of aggressive behavior and how it is managed in cognitively impaired nursing home residents. Sixty-eight percent of the caregivers stated the residents were physically aggressive, while 95% cited verbal aggression. Aggression occurred most commonly in the mornings while the caregiver was dressing the resident. Inadequate staffing and new staff were both seen as problems by the caregivers. Talking soothingly and assuring the resident were techniques initially used to comfort the residents. Reasoning with the resident was the most common follow-up procedure used by the caregivers.

Endocrine correlates of hibernation-independent gonadal recrudescence and the limited late-winter breeding season in woodchucks, Marmota monax

Woodchucks (Marmota monax) normally experience gonadal recrudescence towards the end of a 4-5 month hibernation, emerge in late winter, immediately breed in a short 3-week breeding season, and have regressed gonads before the next hibernation. Our studies of wild and captive animals show that fertile females give birth to single litters after a 32-day gestation and their breeding season is terminated by a reactivation of the corpora lutea of pregnancy for 1-3 months immediately postpartum. In nonbred females the breeding season is likewise terminated by spontaneous luteinization of the ovaries for 1-3 months shortly after the vernal equinox. Tests regress and testosterone declines during and after the breeding season. Circannual reproductive cycles persist in the absence of hibernation and are shortened to 9-10 months after 3-5 years of a 12L:12D photoperiod. Unique aspects of this species that merit endocrine investigation include descent/retraction of testes, transient luteolysis at parturition, superactivation of postpartum corpora lutea, regulation of the pituitary-gonadal axis by an annual endogenous metabolic cycle entrained to the annual change in photoperiod, and the hormonal basis of hibernation.

Expression of infectious woodchuck hepatitis virus in murine and avian fibroblasts

The liver is the primary site for replication of the hepadnavirus genome. We asked whether the posttranscriptional phase of the viral replication cycle would depend on hepatocyte-specific functions. For this purpose, we assayed a previously constructed chimera between sequences of the cytomegalovirus immediate-early promoter-enhancer region and woodchuck hepatitis virus (WHV) (C. Seeger and J. Maragos, J. Virol. 63:1907-1915, 1989) for its ability to direct the synthesis of infectious WHV in hepatoma cells and in murine and avian fibroblast cells. Viruslike particles containing WHV DNA were produced transiently in transfected hepatoma cells and in fibroblasts. Inoculation of woodchucks with culture medium from hepatoma cells or fibroblasts transfected with viral DNA led to productive WHV infection, as observed following infection of woodchucks with serum from WHV-infected animals. These results demonstrate that posttranscriptional events of the hepadnavirus replication cycle are not dependent on hepatocyte-specific functions.

Hepatocellular carcinoma in woodchuck hepatitis virus-infected woodchucks: presence of viral DNA in tumor tissue from chronic carriers and animals serologically recovered from acute infections

During long-term studies of the natural history of woodchuck hepatitis virus infection, five cases of histologically confirmed, primary hepatocellular carcinoma were observed in a total of 92 woodchucks which had recovered, by analysis of viral serologic markers (WHsAg-, anti-WHc+, anti-WHs+), from experimental acute woodchuck hepatitis virus infections 20 to 30 months prior to the detection of hepatocellular carcinoma. No hepatocellular carcinoma was observed in 167 uninfected controls at least 3 years of age and held in the same laboratory environment. Southern blot hybridization analysis of liver tissue taken from four of these recovered woodchucks revealed the presence of low levels (0.1 to 0.3 copies per cell) of integrated woodchuck hepatitis virus DNA in hepatocellular carcinoma (four of four animals) and nonneoplastic tissue (three of four animals). Similarly, hepatocellular carcinoma tissue obtained from two wild-caught, naturally infected and serologically recovered woodchucks also contained low levels of integrated woodchuck hepatitis virus DNA. Liver tissues from another 27 of these 92 recovered woodchucks (without hepatocellular carcinoma) were examined for woodchuck hepatitis virus nucleic acids 13 to 31 months following experimental woodchuck hepatitis virus infection. Nonreplicating woodchuck hepatitis virus DNA was present in the liver of eight (30%) and in the peripheral blood lymphocytes from eight (30%) of these 27 animals. These results were in marked contrast to the analysis of woodchuck hepatitis virus DNA in the liver tissue of chronic woodchuck hepatitis virus carriers (20 experimentally infected and nine naturally infected). In these animals, high levels of replicating woodchuck hepatitis virus DNA (up to 2,000 copies per cell) were observed in all hepatocellular carcinoma and nonneoplastic liver tissue. Integrated woodchuck hepatitis virus DNA was found in eight of 60 individual hepatocellular carcinomas detected in 29 chronic carriers, 15 to 40 months postinfection. Integrated woodchuck hepatitis virus DNA was present in the nonneoplastic tissue from four of these 29 chronic woodchuck hepatitis virus carriers.

Natural history of woodchuck hepatitis virus infections during the course of experimental viral infection: molecular virologic features of the liver and lymphoid tissues

In this study, the kinetic patterns of woodchuck hepatitis virus (WHV) infection were monitored in the liver and the five primary components of the lymphoid system (peripheral blood lymphocytes, lymph nodes, bone marrow, spleen, and thymus). Groups of woodchucks experimentally infected with a standardized inoculum of WHV were sacrificed at different times over a 65-week period beginning in the preacute phase of viral infection and continuing to the period of serologic recovery or the establishment of chronic infections and subsequent hepatocellular carcinoma. Infection by WHV was not limited to the liver but involved the major components of the lymphoid system during all stages of virus infection. A complex series of kinetic patterns was observed for the appearance of WHV DNA in the different lymphoid compartments and the liver during the entire course of viral infection. A progressive evolution of different WHV genomic forms related to the replicative state of WHV was also observed. Lymphoid cells of the bone marrow were the first cells in which WHV DNA was detected, followed in order by the liver, the spleen, peripheral blood lymphocytes, lymph nodes, and finally the thymus. Several differences were observed in the cellular WHV DNA patterns between woodchucks that developed chronic WHV infections and those that serologically recovered from acute WHV infections. The observations compiled in this study indicate that the host lymphoid system is intimately involved in the natural history of hepadnavirus infections from the earliest stages of virus entry.