Implementation of early warning system in the clinical teaching unit to reduce unexpected deaths

BACKGROUND

Early detection of patients with clinical deterioration admitted to the hospital is critical. The early warning system (EWS) is developed to identify early clinical deterioration. Using individual patient's vital sign records, this bedside score can identify early clinical deterioration, triggering a communication algorithm between nurses and physicians, thereby facilitating early patient intervention. Although various models have been developed and implemented in emergency rooms and paediatric units, data remain sparse on the utility of the EWS in patients admitted to general internal medicine wards and the processes and challenges encountered during the implementation.

LOCAL PROBLEM

There is a lack of standardised tools to recognise early deterioration of patient condition.

METHODS

This was a quality improvement project piloted in the clinical teaching unit of a tertiary care hospital. Data were collected 24 weeks pre-EWS and 55 weeks post-EWS implementation. A series of Plan, Do, Study, Act cycles were conducted to identify the root cause, develop a driver diagram to understand the drivers of unexpected deaths, run a sham test trial run of the EWS, educate and obtained feedback of clinical care teams involved, assess adherence to the EWS during the pilot project (6 weeks pre-EWS and 6 weeks post-EWS implementation), evaluate outcomes by extending the duration to 24 weeks pre-EWS and 55 weeks post-EWS implementation, and retrospectively review the uptake of the EWS.

INTERVENTIONS

Implementation of a standardised protocol to detect deterioration in patient condition.

RESULTS

During the pre-EWS implementation phase (24 weeks), there were 4.4 events per week (1.2 septic workups, 1.9 observation unit transfers, 0.7 critical care transfers, 0.13 cardiac arrests and 0.46 per week unexpected deaths). In the post-EWS implementation phase (55 weeks), there were 4.2 events per week (1.0 septic workup, 1.9 observation unit transfers, 0.82 critical care transfers, 0.25 cardiac arrests and 0.25 unexpected deaths).

CONCLUSION

The EWS can improve patient care; however, more engagement of stakeholders and electronic vital sign documentation may improve the uptake of the system.

POS0834 LONG-TERM OUTCOME OF SSC ASSOCIATED ILD: IMPROVED SURVIVAL IN PPI TREATED PATIENTS

Background:

Gastroesophageal reflux disease (GERD) occurs frequently in patients with systemic sclerosis (SSc) and SSc-associated interstitial lung disease (SSc-ILD). PPI use has to been shown to improve survival in patients with idiopathic pulmonary fibrosis, whereas to date there are no data on the use of PPI in SSc-ILD.

Objectives:

This study was aimed to assess whether use of PPI is associated with progression of SSc-ILD and survival.

Methods:

We retrospectively analysed 1931 patients with SSc and SSc-ILD from the German Network for Systemic Sclerosis (DNSS) database (2003 onwards). Kaplan–Meier analysis compared overall survival (OS) and progression-free survival (PFS) in patients with vs. without GERD (SSc and SSc-ILD), and PPI vs. no PPI use (SSc-ILD only). Progression was defined as a decrease in either % predicted forced vital capacity ≥10% or single-breath diffusing capacity for carbon monoxide ≥15%, or death.

Results:

GERD was not associated with decreased OS or PFS in patients with either SSc or SSc-ILD. In patients with SSc-ILD, PPI use was associated with improved OS vs. no PPI use after 1 year (98.4% [95% confidence interval: 97.6–99.3]; n=760 vs. 90.8% [87.9–93.8]; n=290) and after 5 years (91.4% [89.2–93.8]; n=357 vs. 70.9% [65.2–77.1]; n=106; p<0.0001). PPI use was also associated with improved PFS vs. no PPI use after 1 year (95.9% [94.6–97.3]; n=745 vs. 86.4% [82.9–90.1]; n=278) and after 5 years (66.8% [63.0–70.8]; n=286 vs. 45.9% [39.6–53.2]; n=69; p<0.0001).

Conclusion:

GERD had no effect on survival in SSc or SSc-ILD. PPIs improved survival in patients with SSc-ILD; however, controlled, prospective trials are needed to confirm this finding.

Disclosure of Interests:

Michael Kreuter Speakers bureau: Boehringer, Consultant of: Boehringer, Grant/research support from: Boehringer, Francesco Bonella Speakers bureau: Boehringer, Roche, GSK, Consultant of: Boehringer, Roche, GSK, Grant/research support from: Boehringer, Kuhr Kathrin: None declared, Jörg Henes Speakers bureau: Abbvie, Boehringer, Chugai, Roche, Janssen, Novartis, SOBI, Pfizer and UCB, Consultant of: Boehringer, Celgene, Chugai, Roche, Janssen, Novartis, SOBI, Grant/research support from: Chugai, Roche, Janssen, Novartis, SOBI, Pfizer, Elise Siegert: None declared, Gabriela Riemekasten Speakers bureau: Novartis, Janssen, Roche, GSK, Boehringer, Consultant of: Janssen, Actelion, Boehringer, Norbert Blank Consultant of: Sobi, Novartis, Roche, UCB, MSD, Pfizer, Actelion, Abbvie, Boehringer, Grant/research support from: Novartis, Sobi, Christiane Pfeiffer: None declared, Ulf Müller-Ladner: None declared, Alexander Kreuter Speakers bureau: MSD, Boehringer, InfectoPharm, Paid instructor for: MSD, PETER KORSTEN Consultant of: Glaxo, Abbvie, Pfizer, BMS, Chugai, Sanofi, Lilly, Boehringer, Novartis, Grant/research support from: Glaxo, Aaron Juche: None declared, Marc Schmalzing Speakers bureau: Chugai Roche, Boehringer, Celgene, Medac, UCB, Paid instructor for: Novartis, Abbvie, Astra Zeneca, Chugai Roche, Janssen, Consultant of: Chugai Roche, Hexal Sandoz, Gilead, Abbvie, Janssen, Boehringer, Margitta Worm Speakers bureau: Boehringer, Ilona Jandova Speakers bureau: Boehringer, Novartis, Abbvie, Laura Susok Speakers bureau: MSD, Novartis, BMS, Sunpharma, Consultant of: MSD, Tim Schmeiser Consultant of: Abbvie, Boehringer, Novartis, UCB, Claudia Guenther Paid instructor for: Advisory Board Boehringer January 2020, Employee of: Novartis 2002-2005, Gernot Keyszer Consultant of: Boehringer, Jan Ehrchen Speakers bureau: Boehringer, Janssen, Chugai, Sobi, Employee of: Pfizer, Actelion (now Janssen), Andreas Ramming Speakers bureau: Boehringer, Gilead, Janssen, Pfizer, Roche, Consultant of: Boehringer, Pfizer, Grant/research support from: Novartis, Pfizer, Ina Kötter Speakers bureau: several companies, Consultant of: several companies, Grant/research support from: several companies, Hanns-Martin Lorenz Speakers bureau: Abbvie, Astra Zeneca, Actelion, Alexion Amgen, Bayer Vital, Baxter, Biogen, Boehringer, BMS, Celgene, Fresenius, Genzyme, GSK, Gilead, Hexal, Janssen, Lilly, Medac, MSD, Mundipharm, Mylan, Novartis, Octapharm, Pfizer, Roche Chugai, Sandoz, Sanofi, Shire SOBI, Thermo Fischer, UCB, Grant/research support from: basic research studies: Pfizer, Novartis, Abbvie, Gilead, Lilly, MSD, Roche Chugai, Pia Moinzadeh Speakers bureau: Boehringer, Actelion, Grant/research support from: Actelion, Nicolas Hunzelmann Speakers bureau: Boehringer Janssen, Roche, Sanofi, Consultant of: Boehringer

AB0584 DOES ANTI-ACID TREATMENT INFLUENCE DISEASE PROGRESSION IN SYSTEMIC SCLEROSIS INTERSTITIAL LUNG DISEASE (SSC-ILD)? DATA FROM THE GERMAN SSC-NETWORK

Background:

Gastroesophageal reflux (GER) is common in SSc and thus treatment with anti-acid therapy (AAT) is frequent. An association between GER and the development / progression of SSc-ILD has been hypothesized. However, outcomes of AAT on disease progression in SSc-ILD has only sparsely been studied.

Objectives:

Methods:

The German Network for Systemic Scleroderma (DNSS), which includes SSc pts. prospectively, was analyzed for SSc-ILD. Those without progression at ILD 1stdiagnosis were categorized in AAT vs. no-AAT users and disease outcome was assessed.

Results:

SSc-ILD was reported in 1165 (28.2%) out of 4131 pts. 712 of SSc-ILD pts had no disease progression at ILD 1stdiagnosis. 567 used AAT while 145 did not. Baseline characteristics were similar between groups with regards to age (mean 54.7 years), BMI, time since SSc diagnosis and immunosuppressant use. Significant differences in no-AAT vs. AAT were found for gender (male 18% vs. 25%, p=0.05), SSc subtype (p=0.002, diffuse more common in AAT), lung function (DLCO 66% vs. 58%, p=0.001; FVC 86% vs. 77%, p=0.001), mRSS (8 vs. 11.5, p<0.01), esophageal involvement (32% vs. 56%, p<0.01) and steroid use (30% vs. 43%, p=0.005). While mortality did not differ between groups (3.9%, p= 0.59), disease progression was more common in the AAT group than in no-AAT users (24.5% vs. 13%, p=0.03). Furthermore, there was a significant difference in decline of FVC≥10% with 30% in the AAT compared to 14% in no-AAT (p=0.018); a decline in DLCO≥15% was more common in the AAT group by trend (23% vs. 14%, p=0.087).

Conclusion:

While results may have partially been biased by differences in baseline characteristics, this current analysis disfavors the approach of AAT use for SSc-ILD.

Disclosure of Interests:

Michael Kreuter Grant/research support from: Roche, Boehringer, Consultant of: Roche, Boehringer, Speakers bureau: Boehringer, Roche, Francesco Bonella Grant/research support from: Boehringer, Consultant of: Boehringer, Roche, Bristol MS, Galapagos, Speakers bureau: Boehringer, Roche, Gabriela Riemekasten Consultant of: Cell Trend GmbH, Janssen, Actelion, Boehringer Ingelheim, Speakers bureau: Actelion, Novartis, Janssen, Roche, GlaxoSmithKline, Boehringer Ingelheim, Pfizer, Ulf Müller-Ladner Speakers bureau: Biogen, Jörg Henes Grant/research support from: Novartis, Roche-Chugai, Consultant of: Novartis, Roche, Celgene, Pfizer, Abbvie, Sanofi, Boehringer-Ingelheim,, Elise Siegert Grant/research support from: Actelion, Consultant of: AEC, Speakers bureau: NA, Claudia Guenther: None declared, Ina Koetter Grant/research support from: Novartis, Roche, Speakers bureau: Abbvie, Actelion, Celgene, MSD, UCB, Sanofi, Lilly, Pfizer, Novartis, Chugai, Roche, Boehringer, Norbert Blank Speakers bureau: Actelion, Roche, Boehringer, Pfizer, Chugai, Christiane Pfeiffer: None declared, Marc Schmalzing: None declared, Gabriele Zeidler: None declared, PETER KORSTEN Grant/research support from: Novartis, Juarms GmbH, Consultant of: Abbvie, Pfizer, Lilly, BMS, Speakers bureau: Abbvie, Pfizer, chugai, BMS, Lilly, Sanofi aventis, Laura Susok: None declared, Aaron Juche: None declared, Margitta Worm Consultant of: Mylan Gemany, Bencard Allergie, BBV Technologies S.A., Novartis, Biotest, Sanofi, Aimmune Therapies, Regeneron, Speakers bureau: ALK-Abello, Novartis, Sanofi, Biotest, Mylan, Actelion, HAL Allergie, Aimmune Bencard Allergie, Ilona Jandova: None declared, Jan Ehrchen: None declared, Cord Sunderkoetter: None declared, Gernot Keyszer: None declared, Andreas Ramming Grant/research support from: Pfizer, Novartis, Consultant of: Boehringer Ingelheim, Novartis, Gilead, Pfizer, Speakers bureau: Boehringer Ingelheim, Roche, Janssen, Tim Schmeiser Speakers bureau: Actelion, UCB, Pfizer, Alexander Kreuter Speakers bureau: Sanofi, Abbvie, Merck Sharp&Dohme, Boehringer, Kathrin Kuhr: None declared, Hanns-Martin Lorenz Grant/research support from: Consultancy and/or speaker fees and/or travel reimbursements: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly. Scientific support and/or educational seminars and/or clinical studies: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly, Baxter, SOBI, Biogen, Actelion, Bayer Vital, Shire, Octapharm, Sanofi, Hexal, Mundipharm, Thermo Fisher., Consultant of: see above, Pia Moinzadeh: None declared, Nicolas Hunzelmann Speakers bureau: Actelion, Boehringer

The progressive ankylosis protein regulates cementum apposition and extracellular matrix composition

BACKGROUND/AIMS

Tooth root cementum is sensitive to modulation of inorganic pyrophosphate (PP(i)), an inhibitor of hydroxyapatite precipitation. Factors increasing PP(i) include progressive ankylosis protein (ANK) and ectonucleotide pyrophosphatase/phosphodiesterase 1 (NPP1) while tissue nonspecific alkaline phosphatase hydrolyzes PP(i). Studies here aimed to define the role of ANK in root and cementum by analyzing tooth development in Ank knock-out (KO) mice versus wild type.

MATERIALS AND METHODS

Periodontal development in KO versus control mice was analyzed by histology, histomorphometry, immunohistochemistry, in situ hybridization, electron microscopy, and nanoindentation. Cementoblast cultures were used in vitro to provide mechanistic underpinnings for PP(i) modulation of cell function.

RESULTS

Over the course of root development, Ank KO cervical cementum became 8- to 12-fold thicker than control cervical cementum. Periodontal ligament width was maintained and other dentoalveolar tissues, including apical cementum, were unaltered. Cervical cementum uncharacteristically included numerous cells, from rapid cementogenesis. Ank KO increased osteopontin and dentin matrix protein 1 gene and protein expression, and markedly increased NPP1 protein expression in cementoblasts but not in other cell types. Conditional ablation of Ank in joints and periodontia confirmed a local role for ANK in cementogenesis. In vitro studies employing cementoblasts indicated that Ank and Enpp1 mRNA levels increased in step with mineral nodule formation, supporting a role for these factors in regulation of cementum matrix mineralization.

CONCLUSION

ANK, by modulating local PP(i), controls cervical cementum apposition and extracellular matrix. Loss of ANK created a local environment conducive to rapid cementogenesis; therefore, approaches modulating PP(i) in periodontal tissues have potential to promote cementum regeneration.

Shaping skeletal growth by modular regulatory elements in the Bmp5 gene

Cartilage and bone are formed into a remarkable range of shapes and sizes that underlie many anatomical adaptations to different lifestyles in vertebrates. Although the morphological blueprints for individual cartilage and bony structures must somehow be encoded in the genome, we currently know little about the detailed genomic mechanisms that direct precise growth patterns for particular bones. We have carried out large-scale enhancer surveys to identify the regulatory architecture controlling developmental expression of the mouse Bmp5 gene, which encodes a secreted signaling molecule required for normal morphology of specific skeletal features. Although Bmp5 is expressed in many skeletal precursors, different enhancers control expression in individual bones. Remarkably, we show here that different enhancers also exist for highly restricted spatial subdomains along the surface of individual skeletal structures, including ribs and nasal cartilages. Transgenic, null, and regulatory mutations confirm that these anatomy-specific sequences are sufficient to trigger local changes in skeletal morphology and are required for establishing normal growth rates on separate bone surfaces. Our findings suggest that individual bones are composite structures whose detailed growth patterns are built from many smaller lineage and gene expression domains. Individual enhancers in BMP genes provide a genomic mechanism for controlling precise growth domains in particular cartilages and bones, making it possible to separately regulate skeletal anatomy at highly specific locations in the body.

Every bone in the skeleton has a specific shape and size. These characteristic features must be under separate genetic control, because individual bones can undergo striking morphological changes in different species. Researchers have long postulated that the morphology of individual bones arises from the local activity of many separate growth domains around each bone's surface. Differential growth within such domains could modify size, curvature, and formation of specific processes. Here, we show that local growth domains around individual bones are controlled by independent regulatory sequences in bone morphogenetic protein (BMP) genes. We identify multiple regulatory sequences in the Bmp5 gene that control expression in particular bones, rather than all bones. We show that some of these elements are remarkably specific for individual subdomains around the surface of individual bones. Finally, we show that local BMP signaling is necessary and sufficient to trigger highly localized growth patterns in ribs and nasal cartilages. These results suggest that the detailed pattern of growth of individual skeletal structures is encoded in part by multiple regulatory sequences in BMP genes. Gain and loss of anatomy-specific sequences in BMP genes may provide a flexible genomic mechanism for modifying local skeletal anatomy during vertebrate evolution.

Dual hindlimb control elements in the Tbx4 gene and region-specific control of bone size in vertebrate limbs

The Tbx4 transcription factor is crucial for normal hindlimb and vascular development, yet little is known about how its highly conserved expression patterns are generated. We have used comparative genomics and functional scanning in transgenic mice to identify a dispersed group of enhancers controlling Tbx4 expression in different tissues. Two independent enhancers control hindlimb expression, one located upstream and one downstream of the Tbx4 coding exons. These two enhancers, hindlimb enhancer A and hindlimb enhancer B (HLEA and HLEB), differ in their primary sequence, in their precise patterns of activity within the hindlimb, and in their degree of sequence conservation across animals. HLEB is highly conserved from fish to mammals. Although Tbx4 expression and hindlimb development occur at different axial levels in fish and mammals, HLEB cloned from either fish or mouse is capable of driving expression at the appropriate position of hindlimb development in mouse embryos. HLEA is highly conserved only in mammals. Deletion of HLEA from the endogenous mouse locus reduces expression of Tbx4 in the hindlimb during embryogenesis, bypasses the embryonic lethality of Tbx4-null mutations, and produces viable, fertile mice with characteristic changes in the size of bones in the hindlimb but not the forelimb. We speculate that dual hindlimb enhancers provide a flexible genomic mechanism for altering the strength and location of Tbx4 expression during normal development, making it possible to separately modify the size of forelimb and hindlimb bones during vertebrate evolution.

Over-expression of BMP4 and BMP5 in a child with axial skeletal malformations and heterotopic ossification: a new syndrome

Bone morphogenetic proteins (BMPs) are a highly conserved class of signaling molecules that induce ectopic cartilage and bone formation in vivo. Dysregulated expression of bone morphogenetic protein 4 (BMP4) is found in the cells of patients who have fibrodysplasia ossificans progressiva (FOP), a genetic disorder of axial and appendicular skeletal malformation and progressive heterotopic ossification. Loss of function mutations in the bone morphogenetic protein 5 (bmp5) gene leading to under-expression of BMP5 cause the murine short ear syndrome, characterized by small malformed ears and a broad range of axial skeletal malformations. We found features reminiscent of both the short ear mouse and FOP in a child with malformed external ears, multiple malformations of the axial skeleton, and progressive heterotopic ossification in the neck and back. We examined BMP mRNA expression in transformed lymphocytes by semi-quantitative RT-PCR and protein expression by ELISA assays and immunohistochemistry. Elevated levels of BMP4 and BMP5 mRNA and protein were detected in the patient's cells while levels of BMP2 mRNA were unchanged. Our data suggest that dysregulated expression of BMP4 and BMP5 genes is associated with an array of human axial skeletal abnormalities similar to the short ear mouse and FOP.

Mineral formation in joints caused by complete or joint-specific loss of ANK function

To reveal the ANK complete loss of function phenotype in mice, we generated conditional and null alleles. Mice homozygous for the null allele exhibited widespread joint mineralization, similar in severity to animals harboring the original ank allele. A delayed yet similar phenotype was observed in mice with joint-specific loss of ANK function.

INTRODUCTION

The ANK pyrophosphate regulator was originally identified and proposed to play a key role in articular cartilage maintenance based on a single spontaneous mouse mutation (ank) that causes severe generalized arthritis. A number of human mutations have subsequently been reported in the human ortholog (ANKH), some of which produce skull and long bone defects with no apparent defects in joints or articular cartilage. None of the currently known mouse or human mutations clearly eliminate the function of the endogenous gene.

MATERIALS AND METHODS

Two new Ank alleles were generated using homologous recombination in mouse embryonic stem (ES) cells. Joint range of motion assays and muCT studies were used to quantitatively assess phenotypic severity in wildtype, heterozygous, and homozygous mice carrying either the null (Anknull) or original (Ankank) allele. A Gdf5-Cre expressing line was crossed to mice harboring the conditional (Ankfloxp) allele to eliminate ANK function specifically in the joints. Histological stains and beta-galactosidase (LACZ) activity were used to determine the correlation between local loss of ANK function and defective joint phenotypes.

RESULTS

Anknull/Anknull mice develop severe ectopic postnatal crystal deposition in almost every joint of the body, leading to eventual joint fusion and loss of mobility. The severity of phenotype in these mice is indistinguishable from that of Ankank/Ankank mice. In addition, despite the widespread expression of Ank in many tissues, the specific deletion of Ank in joints also produces joint mineralization and ankylosis.

CONCLUSIONS

These studies show that ANK function is required locally in joints to inhibit mineral formation and that the Ank gene plays a key role in postnatal maintenance of joint mobility and function.

C. elegans HAM-1 positions the cleavage plane and regulates apoptosis in asymmetric neuroblast divisions

Asymmetric cell division occurs when a mother cell divides to generate two distinct daughter cells, a process that promotes the generation of cellular diversity in metazoans. During Caenorhabditis elegans development, the asymmetric divisions of neural progenitors generate neurons, neural support cells and apoptotic cells. C. elegans HAM-1 is an asymmetrically distributed cortical protein that regulates several of these asymmetric neuroblast divisions. Here, we show that HAM-1 is a novel protein and define residues important for HAM-1 function and distribution to the cell cortex. Our phenotypic analysis of ham-1 mutant embryos suggests that HAM-1 controls only neuroblast divisions that produce apoptotic cells. Moreover, ham-1 mutant embryos contain many unusually large cell-death corpses. An investigation of this corpse phenotype revealed that it results from a reversal of neuroblast polarity. A misplacement of the neuroblast cleavage plane generates daughter cells of abnormal size, with the apoptotic daughters larger than normal. Thus, HAM-1 regulates the position of the cleavage plane, apoptosis and mitotic potential in C. elegans asymmetric cell divisions.

A general approach for identifying distant regulatory elements applied to the Gdf6 gene

Regulatory sequences in higher genomes can map large distances from gene coding regions, and cannot yet be identified by simple inspection of primary DNA sequence information. Here we describe an efficient method of surveying large genomic regions for gene regulatory information, and subdividing complex sets of distant regulatory elements into smaller intervals for detailed study. The mouse Gdf6 gene is expressed in a number of distinct embryonic locations that are involved in the patterning of skeletal and soft tissues. To identify sequences responsible for Gdf6 regulation, we first isolated a series of overlapping bacterial artificial chromosomes (BACs) that extend varying distances upstream and downstream of the gene. A LacZ reporter cassette was integrated into the Gdf6 transcription unit of each BAC using homologous recombination in bacteria. Each modified BAC was injected into fertilized mouse eggs, and founder transgenic embryos were analyzed for LacZ expression mid-gestation. The overlapping segments defined by the BAC clones revealed five separate regulatory regions that drive LacZ expression in 11 distinct anatomical locations. To further localize sequences that control expression in developing skeletal joints, we created a series of BAC constructs with precise deletions across a putative joint-control region. This approach further narrowed the critical control region to an area containing several stretches of sequence that are highly conserved between mice and humans. A distant 2.9-kilobase fragment containing the highly conserved regions is able to direct very specific expression of a minimal promoter/LacZ reporter in proximal limb joints. These results demonstrate that even distant, complex regulatory sequences can be identified using a combination of BAC scanning, BAC deletion, and comparative sequencing approaches.

Determining epidural catheter location using nerve stimulation with radiological confirmation

BACKGROUND AND OBJECTIVES

The use of epidural stimulation to confirm epidural catheter placement has been shown. This case report describes the benefits and problems of using the epidural stimulation test to confirm epidural catheter placement and provides supporting evidence for these observations using radiological imaging.

CASE REPORT

METHODS

A nerve stimulator was connected to the proximal end of an epidural catheter via an adapter. The cathode lead was connected to the adapter. The anode lead was connected to an electrode placed on the upper extremity as a grounding site. Using 1 to 10 mA current, a segmental motor response indicated that the catheter was in the epidural space. The absence of a motor response indicated that it was not.

CASES

In the first patient, the new test predicted subcutaneous epidural catheter placement, which was subsequently confirmed radiologically. In the second patient, the catheter tip was found to be lying near a nerve root, which was again confirmed radiologically. In the third case, a negative test was initially observed with only local muscle movement over the biceps area (T2). After relocation of the grounding electrode to the lower extremity, segmental intercostal muscle movement (T4-5 level) was observed. The catheter placement was radiologically shown to be in the T4-5 region.

CONCLUSION

This report illustrates some of the potential benefits and problems of using the nerve stimulation test to confirm epidural catheter placement, with radiological verification.

Haemodialysis-membrane biocompatibility and mortality of patients with dialysis-dependent acute renal failure: a prospective randomised multicentre trial. International Multicentre Study Group

BACKGROUND

There is controversy as to whether haemodialysis-membrane biocompatibility (ie, the potential to activate complement and neutrophils) influences mortality of patients with acute renal failure. We did a prospective randomised multicentre trial in patients with dialysis-dependent acute renal failure treated with two different types of low-flux membrane.

METHODS

180 patients with acute renal failure were randomly assigned bioincompatible Cuprophan (n=90) or polymethyl-methacrylate (n=90) membranes. The main outcome was survival 14 days after the end of therapy (treatment success). Odds ratios for survival were calculated and the two groups were compared by Fisher's exact test. Analyses were based on patients treated according to protocol (76 Cuprophan, 84 polymethyl methacrylate).

FINDINGS

At the start of dialysis, the groups did not differ significantly in age, sex, severity of illness (as calculated by APACHE II scores), prevalence of oliguria, or biochemical measures of acute renal failure. 44 patients (58% [95% CI 46-69]) assigned Cuprophan membranes and 50 patients (60% [48-70]) assigned polymethyl-methacrylate membranes survived. The odds ratio for treatment failure on Cuprophan compared with polymethyl-methacrylate membranes was 1.07 (0.54-2.11; p=0.87). No difference between Cuprophan and polymethyl-methacrylate membranes was detected when the analysis was adjusted for age and APACHE II score. 18 patients in the Cuprophan group and 20 in the polymethyl-methacrylate group had clinical complications of therapy (mainly hypotension).

INTERPRETATION

There were no differences in outcome for patients with dialysis-dependent acute renal failure between those treated with Cuprophan membranes and those treated with polymethyl-methacrylate membranes.

The Caenorhabditis elegans gene ham-2 links Hox patterning to migration of the HSN motor neuron

The Caenorhabditis elegans HSN motor neurons permit genetic analysis of neuronal development at single-cell resolution. The egl-5 Hox gene, which patterns the posterior of the embryo, is required for both early (embryonic) and late (larval) development of the HSN. Here we show that ham-2 encodes a zinc finger protein that acts downstream of egl-5 to direct HSN cell migration, an early differentiation event. We also demonstrate that the EGL-43 zinc finger protein, also required for HSN migration, is expressed in the HSN specifically during its migration. In an egl-5 mutant background, the HSN still expresses EGL-43, but expression is no longer down-regulated at the end of the cell's migration. Finally, we find a new role in early HSN differentiation for UNC-86, a POU homeodomain transcription factor shown previously to act downstream of egl-5 in the regulation of late HSN differentiation. In an unc-86; ham-2 double mutant the HSNs are defective in EGL-43 down-regulation, an egl-5-like phenotype that is absent in either single mutant. Thus, in the HSN, a Hox gene, egl-5, regulates cell fate by activating the transcription of genes encoding the transcription factors HAM-2 and UNC-86 that in turn individually control some differentiation events and combinatorially affect others.

Asymmetric distribution of the C. elegans HAM-1 protein in neuroblasts enables daughter cells to adopt distinct fates

One mechanism of generating cellular diversity is to distribute developmental potential asymmetrically to daughter cells at mitosis. Two observations described in this report suggest that the C. elegans HAM-1 protein functions in dividing neuroblasts to produce daughter cells that adopt distinct fates. First, HAM-1 is asymmetrically distributed to the periphery of certain mitotic cells, ensuring that it will be inherited by only one daughter cell. Second, ham-1 mutations disrupt the asymmetric divisions of five neuroblasts. In one of these divisions, loss of ham-1 function causes the daughter cell that does not inherit HAM-1 to adopt the fate of the daughter cell that normally inherits HAM-1. We propose that asymmetric distribution of HAM-1 enables daughter cells to adopt distinct fates.

Effects of various vaccination protocols on passive and active immunity to Pasteurella haemolytica and Haemophilus somnus in beef calves

Two field trials were conducted in a beef cow herd in Saskatchewan to determine the effectiveness of a combined Pasteurella haemolytica and Haemophilus somnus vaccine in increasing passively and actively acquired antibodies in beef calves. Vaccination of dams at 4 and/or 7 weeks prepartum was associated with increased antibody titers to P. haemolytica and H. somnus in their serum (P < 0.05), colostrum(P < 0.05), and serum of their calves at 3 days and 1 month of age (P < 0.05). There was no significant(P > 0.05) difference in antibody titers in the colostrum and serum of calves from single or double vaccinated dams. Calves vaccinated at 1 and 2 months of age in the face of maternal antibodies toP. haemolytica and H. somnus had significantly(P < 0.05) higher antibodies to P. haemolytica and H. somnus at 4 and 6 months of age than did unvaccinated calves. Calves vaccinated at 3 and 4 months of age in the face of low levels of preexisting antibodies had significantly (P < 0.05) higher antibodies toP. haemolytica at 5 months of age and to H. somnus at 5 and 6 months of age than did unvaccinated calves. Calves vaccinated once at 4 months of age had significantly(P < 0.05) higher antibody titers toP. haemolytica and H. somnus at 4.5 months of age than did unvaccinated calves, but this difference was not apparent at 6 months of age. These results suggest that vaccination of beef cows with a combined Pasteurella haemolytica and Haemophilus somnus vaccine once at 4 weeks prepartum will significantly (P < 0.05) increase passive antibody titers toP. haemolytica and H. somnus in their calves. Double vaccination of calves with preexisting maternal antibodies at 1 and 2 months of age will increase antibody titers to P. haemolytica and H. somnus until 6 months of age. Vaccination of beef calves with low levels of preexisting antibody at 3 and 4 months of age will increase antibody titers to H. somnus until 6 months of age and to P. haemolytica until 5 months of age.However, the level of antibodies achieved by vaccination may depend on the calves being studied, the level of preexisting antibodies, and the efficiency of passive transfer.

RFLP analysis of chromosomal segregation in progeny from an interspecific hexaploid somatic hybrid between Solanum brevidens and Solanum tuberosum

Segregation of restriction fragment length polymorphism (RFLP) loci was monitored to determine the degree of homeologous pairing and recombination in a hexaploid somatic hybrid, A206, the result of protoplast fusion between Solanum tuberosum (PI 203900, a tetraploid cultivated potato) and Solanum brevidens (PI 218228), a diploid, sexually incompatible, distant relative harboring several traits for disease resistance. Somatic hybrid A206 was crossed to Katahdin, a tetraploid potato cultivar, to generate a segregating population of pentaploid progeny. Although the clones of the tetraploid S. tuberosum lines PI 203900 and Katahdin were highly polymorphic, the diploid S. brevidens clone was homozygous at all but two of the tested RFLP loci. Thus, homeologous recombination could be detected only when S. tuberosum and S. brevidens chromosomes paired and the S. brevidens homologs then segregated into separate gametes. A bias toward homologous pairing was observed for all 12 chromosomes. At least four and perhaps six chromosomes participated in homologous pairing only; each of 24 progeny contained all S. brevidens-derived RFLP markers for chromosomes 4, 8, 9 and 10. The remaining six chromosomes paired with their homolog(s) about twice as often as expected if hexaploid pairings were completely random. Where detectable with RFLPs, homeologous recombination (both single and double) occurred at a frequency of 1.31 per chromosome. Cytological observations of meiosis I in the somatic hybrid indicated that homeologous pairing had occurred. Enhanced recombinational activity was observed for chromosome 2. A specific small deletion from chromosome 4 was detected in A206 and 11 other somatic hybrids out of 14 screened.(ABSTRACT TRUNCATED AT 250 WORDS)

Migrations of the Caenorhabditis elegans HSNs are regulated by egl-43, a gene encoding two zinc finger proteins

During embryonic development, the two Caenorhabditis elegans HSN motor neurons migrate from their birthplace in the tail to positions near the middle of the embryo. Here, we demonstrate that of all cells that undergo long-range migrations, only the HSNs are affected in animals that lack function of the egl-43 gene. We also show that egl-43 function is required for normal development of phasmid neurons, which are sensory neurons located in the tail. The egl-43 gene encodes two proteins containing zinc finger motifs that are similar to the zinc fingers of the murine Evi-1 proto-oncoprotein. Our genetic and molecular results suggest that egl-43 encodes two transcription factors and acts to control HSN migration and phasmid neuron development, presumably by regulating other genes that function directly in these processes.

Closing in on a breast cancer gene on chromosome 17q

Linkage of early-onset familial breast and ovarian cancer to 11 markers on chromosome 17q12-q21 defines an 8-cM region which is very likely to include the disease gene BRCA 1. The most closely linked marker is D17S579, a highly informative CA repeat polymorphism. D17S579 has no recombinants with inherited breast or ovarian cancer in 79 informative meioses in the seven families with early-onset disease (lod score 9.12 at zero recombination). There is no evidence for linkage heterogeneity in the families with early-onset disease. The proportion of older-onset breast cancer attributable to BRCA 1 is not yet determinable, because both inherited and sporadic cases occur in older-onset families.

Serum proteins of neonatal pigs orally inoculated with Isospora suis oocysts

Serum proteins were evaluated by agarose electrophoresis at periodic intervals between postinoculation days (PID) 2 and 35 in 4 litters of pigs inoculated orally at 36 to 38 hours of age with 70,000 sporulated Isospora suis oocysts and in 4 litters of age-matched noninoculated control pigs. In inoculated pigs, clinical disease characterized by vomiting and diarrhea began at PID 3 to 4 and was resolved by PID 11. Isospora suis oocysts were detected in feces of inoculated pigs from PID 5 to 25, with peak numbers present on PID 5 to 6. Of 43 pigs inoculated with I suis oocysts, 4(9.3%) died of coccidiosis, and samples were not obtained for serum protein evaluation. Of 39 noninoculated control pigs, all remained clinically normal, and I suis oocysts were not detected in their feces. Serum protein fraction values in inoculated and control groups compared at each sample collection time did not differ significantly, except at PID 15, when beta-globulin values were lower in inoculated pigs (P = 0.02). At PID 35, total serum proteins, albumin, and alpha 1-, beta-, and gamma-globulin values of inoculated pigs were lower than those of controls, but there were too few pigs examined for definitive statistical analysis. Differences in trends over time were observed between inoculated and control groups for several serum protein fractions. In inoculated pigs, total proteins (P less than 0.1) and beta-globulins (P less than 0.01) decreased with time, whereas those of control pigs increased. Similar differences in trends were noticed for albumin and alpha 1-globulins, but these were not significant.(ABSTRACT TRUNCATED AT 250 WORDS)