Bacterial growth dynamics in a rhythmic symbiosis

The symbiotic relationship between the bioluminescent bacterium Vibrio fischeri and the bobtail squid Euprymna scolopes serves as a valuable system to investigate bacterial growth and peptidoglycan (PG) synthesis within animal tissues. To better understand the growth dynamics of V. fischeri in the crypts of the light-emitting organ of its juvenile host, we showed that, after the daily dawn-triggered expulsion of most of the population, the remaining symbionts rapidly proliferate for ∼6 h. At that point the population enters a period of extremely slow growth that continues throughout the night until the next dawn. Further, we found that PG synthesis by the symbionts decreases as they enter the slow-growing stage. Surprisingly, in contrast to the most mature crypts (i.e., Crypt 1) of juvenile animals, most of the symbiont cells in the least mature crypts (i.e., Crypt 3) were not expelled and, instead, remained in the slow-growing state throughout the day, with almost no cell division. Consistent with this observation, the expression of the gene encoding the PG-remodeling enzyme, L,D-transpeptidase (LdtA), was greatest during the slowly growing stage of Crypt 1 but, in contrast, remained continuously high in Crypt 3. Finally, deletion of the ldtA gene resulted in a symbiont that grew and survived normally in culture, but was increasingly defective in competing against its parent strain in the crypts. This result suggests that remodeling of the PG to generate additional 3-3 linkages contributes to the bacterium's fitness in the symbiosis, possibly in response to stresses encountered during the very slow-growing stage.

A new lexicon in the age of microbiome research

At a rapid pace, biologists are learning the many ways in which resident microbes influence, and sometimes even control, their hosts to shape both health and disease. Understanding the biochemistry behind these interactions promises to reveal completely novel and targeted ways of counteracting disease processes. However, in our protocols and publications, we continue to describe these new results using a language that originated in a completely different context. This language developed when microbial interactions with hosts were perceived to be primarily pathogenic, as threats that had to be vanquished. Biomedicine had one dominating thought: winning this war against microorganisms. Today, we know that beyond their defensive roles, host tissues, especially epithelia, are vital to ensuring association with the normal microbiota, the communities of microbes that persistently live with the host. Thus, we need to adopt a language that better encompasses the newly appreciated importance of host-microbiota associations. We also need a language that frames the onset and progression of pathogenic conditions within the context of the normal microbiota. Such a reimagined lexicon should make it clear, from the very nature of its words, that microorganisms are primarily vital to our health, and only more rarely the cause of disease. This article is part of the theme issue 'Sculpting the microbiome: how host factors determine and respond to microbial colonization'.

RF23 | PSAT306 Thyrotoxic Periodic Paralysis: An Uncommon Complication Presenting From an Unsuspected Demographic

Background

Thyrotoxic Periodic Paralysis (TPP) is a rare complication of thyrotoxicosis mostly reported in Eastern Asian countries with relatively few known cases among non-Asian diaspora in the West.

Case

A 28-year-old African American male with no documented medical history reported to the ED with concern for mechanical fall secondary to progressively worsening muscle weakness. Symptoms began the prior evening with proximal lower extremity and bilateral shoulder weakness which then became severe generalized weakness in all four extremities by morning prompting a fall due to unstable gait and inability to maintain stable seated position. A 60 lb weight loss over the prior year was also noted. Vital signs were notable for blood pressure 154/67 mmHg, tachycardia 109 beats per minute, and tachypnea 20 breaths per minute. Initial labs were significant for hypokalemia 2.2 mEq/L (3.5–5.5 mEq/L), hs-troponin 59 ng/L (n < 20 ng/L), CK 444 U/L (38–174 U/L), ALP 186 U/L (35–110 U/L), TSH < 0.01 uIU/mL (0.35–5.5 uIu/mL), free T4 4.13 ng/dL (0.61–1.12 ng/dL), free T3 15.10 pg/mL (2.5–3.9 pg/mL) and total T3 404 ng/dL (87–178 ng/dL). EKG revealed sinus tachycardia with prolonged PR-interval to 236 ms and prominent precordial U-waves. The patient was given potassium chloride 40 meq IV and PO supplementation, started on propranolol 10mg PO QID and methimazole 30mg PO daily, and admitted to telemetry. Endocrinology recommended increasing the methimazole dose to 20mg PO TID. Thyroid ultrasound revealed a heterogeneous hyper-vascular gland. Follow up labs included: thyroid stimulating immunoglobulin 4.97 IU/L (n < 0.10 IU/L), thyroid peroxidase antibody 19 IU/L (n < 9 IU/mL), gamma glutamyl transpeptidase 22 (9–65 U/L). Findings were consistent with Graves’ disease. Repeat metabolic panel showed appropriate potassium response to supplementation trending between 3.9 meq/L to 4.2 meq/L at six-hour intervals. Hs-troponin peaked at 108 ng/L likely due to demand ischemia in the setting of persistent tachycardia. Follow-up 2D echocardiogram was remarkable for borderline LVH with 60% EF. Patient displayed rapid improvement in muscle strength as potassium normalized; creatine kinase trended down to 49 U/L with resolving myopathy. Patient was discharged on methimazole 20mg PO TID and propranolol 10mg PO QID and told to increase PO intake of potassium rich foods. He was advised to avoid strenuous activity for at least 2 weeks.His potassium was 4.5 meq/L on follow-up endocrinology appointment one week after discharge. He did not endorse residual symptoms and remained compliant with medications.

Conclusion

This is a case of TPP amidst undiagnosed Graves’ disease that resolved with timely potassium repletion. Documented TPP cases in non-Asians, especially African Americans, are rare and should be investigated further.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Sunday, June 12, 2022 1:12 p.m. - 1:17 p.m.

ODP106 Mystery of the Calcium: A Case of Exclusive Cutaneous Sarcoidosis presenting with Symptomatic Hypercalcemia

The skin is the second most involved organ after the lung in sarcoidosis. It could be an early manifestation that may progress to systemic disease later. Exclusive cutaneous disease is more frequently seen in females. Specific lesions include erythema nodosum, skin plaques, subcutaneous nodules, maculopapular rashes, lupus pernio, scar lesions, and psoriasiform lesions. Most with cutaneous sarcoidosis need no treatment unless there is associated cosmetic disfigurement. We present a unique case of cutaneous sarcoidosis presenting with symptomatic hypercalcemia without systemic disease. A 75-year-old African American female was admitted with generalized weakness. She had no other symptoms. On arrival, she was bradycardic with other normal vitals. Physical examination was normal. EKG showed sinus bradycardia with RBBB. She was found to have AKI with creatinine of 4.3 mg/dL (0.6-1.3 mg/dL) and a corrected calcium of 12.2 mg/dL (8.6-10.2 mg/dL). TSH was 4.64 uIU/mL (0.35-5.50 uIU/mL). Chest X-ray showed no abnormalities. Renal ultrasound revealed bilateral medical renal disease, with several non-obstructing calculi in the right kidney. The patient was managed with intravenous fluids. Her creatinine improved to 3.1 mg/dL; however, the calcium remained elevated at 11.8 mg/dL. PTH was 31 pg/mL (12-88 pg/mL) and urine 24-hr calcium was elevated at 470 mg (35-250 mg). 25-OH vitamin D level was 40 ng/mL (30-100 ng/mL). With no response to intravenous hydration, IV bisphosphonates were initiated. Despite that, her calcium remained at 11.9 mg/dL. On obtaining a more detailed history, it was revealed that a skin punch biopsy performed six years prior showed sarcoid granulomatous dermatitis. The 1, 25 dihydroxy vitamin D was 93 pg/mL (20-79 pg/mL). The ACE level was high at 64 U/L (8-52 U/L). CT chest showed no evidence of granulomatous disease, including the absence of hilar adenopathy. The patient was started on prednisone 20 mg/day. Her calcium trended down to 10.7 mg/dL over the next three days. Although cutaneous sarcoidosis may not be life-threatening, it may have substantial psychological and social impacts. Hypercalcemia is a high prevailing complication of systemic sarcoidosis. It occurs due to the uncontrolled synthesis of 1,25-OH D3 by macrophages in the sarcoid granulomata. As a result, there is increased calcium absorption in the intestine and calcium resorption in the bone. Glucocorticosteroids act by inhibiting the 1alpha-hydroxylase activity of macrophages. Prednisone 20 to 40 mg/day followed by a taper is the recommended dose. Other medications that may be used include antimalarials, thalidomide, methotrexate, and other immunomodulatory agents. Hypercalcemia in a patient with cutaneous sarcoidosis and no pulmonary involvement is a rare presentation. It is essential to recognize that long-term follow-up is advised for those with cutaneous sarcoidosis, as some may develop systemic involvement subsequently.

Presentation: No date and time listed

Paraganglioma

Introduction: Paragangliomas are rare neuroendocrine tumors arising from extra-adrenal medullary neural crest derivatives. The terms pheochromocytoma and paraganglioma are often used interchangeably because morphologically and functionally these entities are almost the same. However, paragangliomas that arise in the adrenal medulla are called pheochromocytomas and those outside the adrenal gland are called paragangliomas. Paragangliomas are often discovered incidentally during imaging studies performed for other reasons. We report a case of a patient who had incidental finding of retroperitoneal paraganglioma on imaging done for evaluation of thigh and gluteal cellulitis.

Clinical Case: A 24-year-old female presented with chief complaints of episodic headaches, multiple skin abscesses, fever and malaise. She has a history of Type 1DM and had been non-compliant on insulin. Vitals on presentation was significant for tachycardia with heart rate of 124, blood pressure of 119/81, respiratory rate of 16. Initial labs were consistent with DKA. CT abdomen and pelvis done for further evaluation of gluteal and thigh abscess showed incidental finding of a 3.4 cm retroperitoneal/para-aortic well-circumscribed rim-enhancing mass with central hypoenhancing component, suspicious for neoplasm such as paraganglioma. Biochemical testing was performed. 24-hour urine catecholamine levels obtained showed elevated urine norepinephrine level of 1008μg/day (reference range 15-100μg/day), urine dopamine 410μg/day (reference range 65- 400μg/day), urine epinephrine less than 2μg/day (reference range 0-20μg/day). Total urine catecholamines was elevated 1008μg/day (reference range 15-100μg/day). These results confirmed diagnosis of paraganglioma. Treatment options were discussed with the patient including surgery for removal of paraganglioma which she has currently declined.

Conclusion: Diagnosis of a paraganglioma can usually be made using biochemical and radiographic testing. All patients with paraganglioma should be tested for hypersecretion of catecholamines in a 24-hour urine or serum collection, even if they do not present with a clinical picture of catecholamine hypersecretion. Importantly these extra-adrenal tumors do not have the enzymatic capacity to form epinephrine from norepinephrine as was exemplified by our case. For catecholamine-secreting tumors, biochemical diagnosis should be followed by radiological evaluation (typically either CT or MRI of the abdomen and pelvis) to locate the tumor. Treatment options are dependent on location of tumor, size, presence of symptoms and if there is metastatic disease present.

SUN-LB094 Massive Pericardial Effusion as an Initial Presentation of Hashimoto's Thyroiditis

Background: Pericardial effusion is a known complication of hypothyroidism and usually correlates with the severity and duration of the disease. However, massive pericardial effusion as the primary presenting manifestation of Hashimoto’s thyroiditis is extremely rare. Case: We present a 44-year-old female with a past history of diabetes mellitus who presented to the hospital with complaints of chest pain described as intermittent, sharp, non-radiating, 10/10 intensity ongoing for six days. On physical examination, she appeared lethargic with slow speech, cool dry puffy skin and muffled heart sounds on auscultation. EKG showed sinus rhythm and no significant ST-T wave changes and troponins trended negative. Initial lab-work was significant for a very high TSH of 86.4 (0.35-5.5 uIU/ml) and a low free T4 of 0.54 (0.61-1.12 ng/dl) with a normal free T3 and total T4. CBC, ESR and CRP were within normal limits. The patient did not endorse noticing any of the classical symptoms of hypothyroidism prior to this admission. Chest X-ray and Chest CT were concerning for a large pericardial effusion. Bedside echocardiogram revealed an ejection fraction of 30% and a massive pericardial effusion. No pericardial calcification or thickening was noted. Due to concern for tamponade physiology on echocardiogram, emergent pericardiocentesis was performed and 720 ml of straw-colored fluid was removed. Cardiac catheterization did not show any evidence of coronary artery disease and repeat echo showed trivial pericardial effusion with improvement in ejection fraction to 40-45%. The fluid analysis did not show evidence of mesothelial cells and cultures were negative. Serological markers for viral diseases (Coxsackie virus, EBV, Adenovirus), as well as immunological markers for rheumatoid arthritis (rheumatoid factor) and lupus (double-stranded DNA) were negative. Serum thyroid peroxidase (TPO) antibody was strongly positive: 877 IU/ml (<9IU/ml). Ruling out other common etiologies, pericardial effusion was attributed to severe hypothyroidism. The patient was treated with IV levothyroxine and IV hydrocortisone and her mental status improved over the course of her stay. Conclusion: Hypothyroidism should certainly be considered as a differential diagnosis in patients presenting with unexplained pericardial effusion. The mainstay of treatment for cases with mild to moderate effusions is thyroxine supplementation. Pericardiocentesis is only indicated in patients with massive effusion who are at risk of developing tamponade. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

SUN-506 An Interesting Case Of Low-Grade Parathyroid Carcinoma

Background: Parathyroid Carcinoma (PC) is a rare form of malignancy and accounts for < 1% of cases of primary Hyperparathyroidism (PHT). It is challenging to diagnose PC due to lack of specific clinical features and biochemical markers. Pathological diagnosis can be troublesome as well, causing a delay in the ideal surgical treatment. Clinical Case: A 39 year old male with history of HTN, recurrent kidney stones, asthma and drug abuse was involuntarily admitted to the hospital by his fiancé after a domestic fight. Initial labs were significant for Calcium 13.2 mg/dl (N 8.8-10.5 mg/dl), Phosphorus 2.8mg/dl (N 2.5-4.5 mg/dl), Magnesium 1.2 mg/dl (N 1.8-2.4 mg/dl), BUN 24 mg/dl (N 6-22mg/dl), Creatinine 2 mg/dl (N 0.8-1.4 mg/dl), CPK 2550 u/l (32-230 u/l). Due to the physical assault, CT Brain and cervical spine were obtained which showed multiple calcified discs and ligaments along with hyperdense vertebral bodies and salt and pepper appearance of the cranial bones. A 2.7 x 2.3 x 4.5 cm mass adjacent to the posterior aspect of the left thyroid lobe concerning for possible parathyroid adenoma or thyroid neoplasm was also reported. Patient was treated with IV fluids and further investigation revealed iPTH 194 pg/ml (N 15-65 pg/ml), ca 12.7 mg/dl, Vit D(OH)25 - 21 ng/ml. Thyroid US and NM Parathyroid imaging confirmed a large 6 x 2.5 x 2.3 cm left superior parathyroid.The patient underwent parathyroidectomy, intraoperatively PTH dropped from 233 to 64 pg/ml. Kidney function and calcium normalized after the surgery. The patient was screened for MEN due to hyperparathyroidism and resistant hypertension. Gastrin, calcitonin, catecholamines were all within the normal range. During the surgery, a very large gland was noted without any local invasion. Gross pathologic examination of the specimen showed a markedly enlarged, fragmented and hemorrhagic parathyroid (12.6 gm). Histologically, tumor demonstrated uniform oxyphil cells with focal cellular atypia and low mitotic rate, divided by thick fibrous bands. No definitive vascular invasion was seen, however, peripheral nerve entrapment was noted. Fragmentation of the specimen with limited representation of the tumor stroma interface precluded accurate evaluation of capsular invasion and made this a difficult case to diagnose. The specimen was sent to Johns Hopkins for further evaluation. An immunostain for parafibromin demonstrated abnormal loss of nuclear expression, a finding that is 95% specific for parathyroid carcinoma. Based on the combination of these atypical features, the loss of parafibromin staining, entrapment of peripheral nerve, and the markedly enlarged parathyroid, the lesion were best regarded as a low-grade parathyroid carcinoma. Conclusion: PC is often a difficult pre-operative diagnosis and the patients are subjected to recurrent surgeries. Our patient underwent left thyroid lobectomy after the pathological confirmation of PC.

SUN-184 Sertraline-Induced Hypoglycemia in Nondiabetic Patients

Background SSRI’s are effective for treatment of depressive disorders by reducing serotonergic function and hence altering neuroendocrine function. The effects of sertraline on blood glucose in non-diabetic patients was demonstrated in this case. Case 39 year-old African-American female with a medical history of GERD, hypertension, marijuana abuse, and panic attacks on trazadone presented with tremors, insomnia, and diaphoresis. Her symptoms began two days after she started sertraline. Physical examination and EKG were unremarkable. Initial blood glucose was 56. Laboratory results indicated HbA1C 4.5%(4.8 – 6.0%), beta-hydroxybutyrate 0.6mmol/L(0.02 – 0.27mmol/L), TSH 0.81uIU/ml(0.27 – 4.62uIU/mL), and insulin 20.8uU/mL(2.6 – 24.9uU/mL). Her sulfonylurea screen and urine toxicology were negative. UA was positive for glucose and ketones. She discontinued sertraline and was given glucose supplements which improved glucose to 226 and she had a full recovery. Discussion We believe this was SSRI-induced hypoglycemia because of her recent introduction of sertraline. WHO reports more than 440 cases annually of SSRI-induced hypoglycemia and over 100 with sertraline.² One way SSRI’s increase risk of hypoglycemia is by impairing hormonal counter-regulatory response (CRR) of epinephrine and glucagon.³ Sertraline induces linear pharmacokinetics with changes in drug concentration in proportion to change in dose through inhibition of neuronal reuptake of serotonin (5-HT). Study by Sanders et al. found sertraline treatment lasting longer than 6-20 days resulted in increased epinephrine and restored the blunted adreno-medullary response seen in acute administration.³ Another way sertraline can induce hypoglycemia is by regulation of liver receptors through 5-hydroxytryptamine activation and inhibition of potassium channels, resulting in increased insulin sensitivity and production and reduced gluconeogenesis. Study by Gomez et al. showed rats pre-medicated with sertraline neutralized hyperglycemia post-glucose load¹ indicating that symptoms can resolve with discontinuation of sertraline and glucose supplementation. Conclusion and Follow-Up Results Sertraline-induced hypoglycemia is becoming more prevalent in non-diabetic patients. Correction of sertraline-induced hypoglycemia by discontinuing the medication and adding glucose can resolve hypoglycemia and the associated side-effects. References¹Gomez R. Acute effect of different antidepressants on glycemia in diabetic and non-diabetic rats. Braz J Med Biol Res. 2001;34:57–64. ²Khoza S. Glucose dysregulation associated with antidepressant agents: an analysis of 17 published case reports. IJCP. 2011;33:484–492. ³Sanders N. The selective serotonin reuptake inhibitor sertraline enhances counterregulatory responses to hypoglycemia. AJP: Endocrinology and metabolism. 2008;294(5):E853-60.

The model squid-vibrio symbiosis provides a window into the impact of strain- and species-level differences during the initial stages of symbiont engagement

Among horizontally acquired symbioses, the mechanisms underlying microbial strain- and species-level specificity remain poorly understood. Here, confocal-microscopy analyses and genetic manipulation of the squid-vibrio association revealed quantitative differences in a symbiont's capacity to interact with the host during initial engagement. Specifically, dominant strains of Vibrio fischeri, 'D-type', previously named for their dominant, single-strain colonization of the squid's bioluminescent organ, were compared with 'S-type', or 'sharing', strains, which can co-colonize the organ. These D-type strains typically: (i) formed aggregations of 100s-1000s of cells on the light-organ surface, up to 3 orders of magnitude larger than those of S-type strains; (ii) showed dominance in co-aggregation experiments, independent of inoculum size or strain proportion; (iii) perturbed larger areas of the organ's ciliated surface; and, (iv) appeared at the pore of the organ approximately 4×s more quickly than S-type strains. At least in part, genes responsible for biofilm synthesis control the hyperaggregation phenotype of a D-type strain. Other marine vibrios produced relatively small aggregations, while an array of marine Gram-positive and -negative species outside of the Vibrionaceae did not attach to the organ's surface. These studies provide insight into the impact of strain variation on early events leading to establishment of an environmentally acquired symbiosis.

Vibrio fischeri-derived outer membrane vesicles trigger host development

Outer membrane vesicles (OMV) are critical elements in many host-cell/microbe interactions. Previous studies of the symbiotic association between Euprymna scolopes and Vibrio fischeri had shown that within 12 h of colonizing crypts deep within the squid's light organ, the symbionts trigger an irreversible programme of tissue development in the host. Here, we report that OMV produced by V. fischeri are powerful contributors to this process. The first detectable host response to the OMV is an increased trafficking of macrophage-like cells called haemocytes into surface epithelial tissues. We showed that exposing the squid to other Vibrio species fails to induce this trafficking; however, addition of a high concentration of their OMV, which can diffuse into the crypts, does. We also provide evidence that tracheal cytotoxin released by the symbionts, which can induce haemocyte trafficking, is not part of the OMV cargo, suggesting two distinct mechanisms to induce the same morphogenesis event. By manipulating the timing and localization of OMV signal delivery, we showed that haemocyte trafficking is fully induced only when V. fischeri, the sole species able to reach and grow in the crypts, succeeds in establishing a sustained colonization. Further, our data suggest that the host's detection of OMV serves as a symbiotic checkpoint prior to inducing irreversible morphogenesis.

Ezetimibe-induced Acute Pancreatitis

Ezetimibe is a lipid-lowering agent that inhibits the intestinal absorption of cholesterol and other related phytosterols. It is used alone or in combination with other lipid-lowering agents in the treatment of various forms of hypercholesterolemia. Since its FDA approval in 2002, there are no known citations of ezetimibe-induced pancreatitis.

[Combined chemotherapy after prolonged oral etoposide maintenance therapy in patients with small-cell lung cancer]

The authors have reported the results of induction, and maintenance therapy of 36 patients suffering from small-cell lung cancer. The induction chemotherapy with cisplatin and etoposide proved to be successful in 34 cases out of the 36 patients. The patients were divided in two groups following the induction treatment: with 17 patients no further chemotherapy happened. The other 17 patients received maintenance cytotoxic treatment with prolonged oral etoposide. There was a significant increase in the average survival time in cases of patients who received maintenance therapy (p < 0.001). The average survival of these patients was 908.4 days, while that of the patients of the control group proved to be 404.5 days.

Increased platelet transfusion requirement is associated with multiple organ dysfunctions in patients undergoing hematopoietic stem cell transplantation

Organ dysfunction following hematopoietic stem cell transplantation (HSCT) may be a manifestation of a systemic inflammatory response. We speculate that part of the platelet transfusion requirement in HSCT patients results from this systemic inflammatory response, and increased transfusion requirement would be associated with, or precede, organ dysfunction. We studied 199 adults undergoing autologous (n=173) or allogeneic (n=26) HSCT. Patients with CNS (P=0.008) or pulmonary (P=0.002) dysfunction, or with VOD (P=0.05) received a higher mean number of platelet transfusions per week than patients who did not have these dysfunctions. Furthermore, a higher number of platelet transfusions during any 1 week period was significantly associated with development of pulmonary (P=0.0002) or renal (P < 0.0001) dysfunction in the following week. This predictive value was strongest early in the HSCT course, but remained significant over all 4 weeks. In multivariate analysis the number of platelet transfusions during the previous week was independently predictive for development of pulmonary dysfunction in week 2 (P=0.01) and week 3 (P=0.055). We believe that occurrence of increased platelet transfusion requirement prior to onset of dysfunction is consistent with the concept that an antecedent inflammatory response results in both platelet consumption and various organ dysfunctions. Increased platelet transfusion requirement may act as an early marker of subsequent organ dysfunction. Additionally, there may be a direct role of platelets in the development and progression of organ dysfunction in HSCT patients.

Predicting pressure ulcer risk: a multisite study of the predictive validity of the Braden Scale

BACKGROUND

There have been no studies that have tested the Braden Scale for predictive validity and established cutoff points for assessing risk specific to different settings.

OBJECTIVES

To evaluate the predictive validity of the Braden Scale in a variety of settings (tertiary care hospitals, Veterans Administration Medical Centers [VAMCs], and skilled nursing facilities [SNFs]). To determine the critical cutoff point for classifying risk in these settings and whether this cutoff point differs between settings. To determine the optimal timing for assessing risk across settings.

METHOD

Randomly selected subjects (N= 843) older than 19 years of age from a variety of care settings who did not have pressure ulcers on admission were included. Subjects were 63% men, 79% Caucasian, and had a mean age of 63 (+/-16) years. Subjects were assessed for pressure ulcers using the Braden Scale every 48 to 72 hours for 1 to 4 weeks. The Braden Scale score and skin assessment were independently rated, and the data collectors were blind to the findings of the other measures.

RESULTS

One hundred eight of 843 (12.8%) subjects developed pressure ulcers. The incidence was 8.5%, 7.4%, and 23.9% in tertiary care hospitals, VAMCs, and SNFs, respectively. Subjects who developed pressure ulcers were older and more likely to be female than those who did not develop ulcers. Braden Scale scores were significantly (p = .0001) lower in those who developed ulcers than in those who did not develop ulcers. Overall, the critical cutoff score for predicting risk was 18. Risk assessment on admission is highly predictive of pressure ulcer development in all settings but not as predictive as the assessment completed 48 to 72 hours after admission.

CONCLUSIONS

Risk assessment on admission is important for timely planning of preventive strategies. Ongoing assessment in SNFs and VAMCs improves prediction and permits fine-tuning of the risk-based prevention protocols. In tertiary care the most accurate prediction occurs at 48 to 72 hours after admission and at this time the care plan can be refined.

The presence of a C1-inhibitor-like molecule (C1-INH-L) on human sperm: its involvement in sperm motility

PROBLEM

An 88-92-kDa C1-inhibitor-like molecule (C1-INH-L) was previously identified to elicit cytotoxic sperm antibody response in infertile men and women. Here, we document that it is present on the human sperm surface and could be detected by an enzyme-labeled immunoglobulin G (IgG) fraction of anti-human C1-INH antibody.

METHOD OF STUDY

Western blot analysis, enzyme-lined immunoadsorbent assay (ELISA) and computerized sperm motion analysis.

RESULTS

The existence of C1-INH-L on the sperm surface is calcium independent. Phosphatidylinositol-specific phospholipase C (PIPLC), EDTA, and acid (pH 3.0) could not remove the C1-INH-L from sperm, but trypsin did. Activated C1s was able to bind to the sperm surface. Immunofluorescence studies localized the protein to the head and midpiece of the sperm membrane. The C1-INH-L exists on both uncapacitated and capacitated sperm surfaces, which suggests that this protein is a sperm-surface protein. The heat-treated (56 degrees C, 30 min) IgG fraction of anti-C1-INH greatly reduced the percentage of motile spermatozoa and the progressive and path velocities in the absence of complement.

CONCLUSION

Our data suggest that C1-INH is a sperm membrane-anchored protein that may have complement and sperm motility regulatory function.

[Prolonged oral etoposide therapy in advanced stage lung cancer]

Authors discuss results of the prolonged oral etoposide treatment of 79 patients with advanced stage lung cancer. Thirty patients with small-cell lung cancer were treated with Cisplatin in combination with prolonged oral etoposide. Response rate was nearly 100%. Most of the patients (24) were in partial remission, and the mean survival time was 15 months. Forty-nine patients with non-small cell lung cancer were divided at random into two groups: patients in the first group (n = 25) were treated with Cisplatin in combination with prolonged oral etoposide. In the second group (n = 24) was used only prolonged oral etoposide therapy for 14-, or 21 days. Encouraging response rate have been observed with long-term daily administration of oral etoposide to treat non-small cell lung cancer. In both groups there was a response rate nearly 80%. Most of the patients in these two subgroups got into partial remission, and a rest were in stable clinical stage (median duration was 5 months). Besides alopecia, which occurred in all patients, myelosuppression (agranulocytosis) was the predominate toxicity (agranulocytosis in 5 cases), which was affectively treated with combined supportive care. Etoposide given by this dose and schedule (100 mg/d for 14 days) has activity as first-line systemic therapy in combination with Cisplatin for advanced small-cell lung cancer and, has a moderate activity for treatment of non-small cell lung cancer.

[Hematologic abnormalities in pulmonary tuberculosiss]

This study surveys the extent and severity of haematological abnormalities which occurred in 380 patients with pulmonary tuberculosis. Full blood count, bone marrow aspiration smears, and bone marrow trephine biopsy was analyzed by authors. Anaemia was present in 32 percent of patients. Leucocytosis with neutrophilia occurred in 18 percent. Leucopenia with neutropenia, and lymphopenia was observed in 16 percent in patients with very severe clinical tuberculosis. Elevated platelet count occurred in 8 percent with deep vein thrombosis in legs in 50 percent. Dysmyelopoietic syndrome was diagnosed in one case by bone marrow trephine biopsy. There was a close correlation between the haematological abnormalities and the severity of clinical findings of pulmonary tuberculosis. This survey has revealed that haematological abnormalities are relatively common in severe pulmonary tuberculosis. It seems that body weight loss, white blood cell count, haemoglobin level and erythrocyte sedimentation rate are useful indices of severity of the tuberculosis. The return of these indices to a normal level is a good indication of disease control in that they correlate with sputum conversion to acid-fast bacilli negative.

Factors predicting morbidity following hematopoietic stem cell transplantation

Circulating anticoagulants protein C (PC) and antithrombin III (AT) are markers of, and possibly involved in the pathogenesis of, significant organ dysfunction, in patients undergoing autologous peripheral blood stem cell (PSBC) or autologous bone marrow (BM) transplantation. The effect of the stem cell source, the use of hematopoietic growth factors (GFs), and the specific preparative regimen on the incidence of organ system dysfunction or on post-transplant levels of circulating anticoagulants has not been well studied. We analyzed 205 patients in an attempt to correlate organ dysfunction and AT and PC deficiencies with these transplant-specific factors (78 BMT with GM-CSF after transplant, 95 PBSCT without GM-CSF after transplant, and 32 PBSCT with GM-CSF after transplant). Patients transplanted with PBSC had a lower incidence of pulmonary dysfunction (20 vs 40%, P = 0.006) and liver dysfunction (4 vs 13%, P = 0.05) than patients receiving BM. The use of GF after transplant did not influence the development of subsequent organ dysfunction. In multivariate analysis, the stem cell source was again predictive of pulmonary dysfunction. In contrast, although patients transplanted with PBSC also had a lower incidence of PC deficiency (50 vs 81%, P < 0.01) and AT deficiency (20 vs 54%, P < 0.01) as compared with patients receiving BM, use of GM-CSF after transplant was a more significant risk factor for the development of anticoagulant deficiency (PBSC with GF vs PBSC without GF: PC deficiency 50 vs 78%, P = 0.007; AT deficiency 20 vs 47%, P = 0.005). In the multivariate analysis GM-CSF use was the only significant risk factor for development of anticoagulant deficiency. Since the clinical significance of anticoagulant deficiency has been well shown, further studies examining these effects of hematopoietic GFs appear warranted.

Use of continuous infusion granulocyte-macrophage colony-stimulating factor alone or followed by granulocyte colony-stimulating factor to enhance engraftment following high-dose chemotherapy and autologous bone marrow transplantation for lymphoid malignancies

We evaluated the differences in engraftment and toxicities post-autologous transplant using granulocyte-macrophage colony stimulating factor (GM-CSF) as a continuous infusion either alone or in a sequential manner with granulocyte colony-stimulating factor (G-CSF). Patients receiving high-dose chemotherapy and autologous bone marrow transplantation (ABMT) for lymphoid malignancies participated in two phase II trials evaluating either continuous infusion GM-CSF (GM-CSF (CI)) or continuous infusion GM-CSF followed by sequential G-CSF (GM-CSF/G-CSF) administered post-ABMT. These patients were compared to similar historical control patients receiving GM-CSF administered as a 2-h intravenous (i.v.) infusion (GM-CSF (2-h)). Patients receiving GM-CSF (CI) and GM-CSF/G-CSF had a median day to reach an absolute neutrophil count of 500/microliter post-ABMT of 12 and 11 days, respectively. This compared to a median day of 22 in the GM-CSF (2-h) historical control patients. The median day to platelet independence was 18, 18 and 30 days, respectively. The incidence of toxicities such as incidence of infection, pleural effusions, and rash did not differ greatly between the groups. We conclude that the use of continuous infusion GM-CSF either alone or sequentially with G-CSF produced improved engraftment times compared to historical control patients treated with GM-CSF as a 2-h i.v. infusion. The toxicities at a reduced dose of 125 micrograms/m2 given as a continuous infusion appear to be similar to those seen in patients receiving GM-CSF as a 2-h infusion.

Prolonged deficiency of protein C following hematopoietic stem cell transplantation

Deficiencies in circulating anticoagulant protein C (PC) occur in patients undergoing hematopoietic stem cell transplantation. These deficiencies may predispose to thrombotic and other complications, and may contribute to the morbidity of transplantation. In most patients, PC reaches a nadir 14 days after the preparative regimen and then begins to increase toward normal. However, low PC has been seen months after transplantation. Neither the frequency of, nor risk factors for, this prolonged deficiency are known. We examined 71 adults undergoing stem cell transplantation and found low PC antigen and activity in 21% and 20% of patients, respectively. Low PC at day 100 correlated strongly with low PC pre-chemotherapy (PC antigen, r = 0.69, P < 0.001; PC activity, r = 0.59, P < 0.001). The incidence of deficiency of PC at day 100 was lower in patients undergoing peripheral stem cell transplantation compared with patients undergoing autologous BMT (12.5% vs 35%; P = 0.05), although several significant confounding variables exist. We conclude that deficiencies in protein C persist at least 100 days after stem cell transplantation in nearly one quarter of patients undergoing this procedure. Therefore, patients undergoing stem cell transplantation may be at prolonged risk of thrombotic and other complications. Further studies to determine the risk of prolonged deficiency based on stem cell source need to be performed.

T-cell infiltration of primary CNS lymphoma

We stained 13 primary CNS lymphomas (PCNSLs) (six from patients with AIDS, seven from immunocompetent patients) with a panel of antibodies to T cells (pan T cell [CD3], T helper cell [CD4], T suppressor cell [CD8], delta/delta cell [CD4-8-]), B cells (CD20), hematopoietic cells (T200), and NK cell (CD56). We estimated the percentage of tumor cells staining with each antibody. All tumors were B-cell lymphomas. The non-AIDS tumors showed a significant infiltration with CD3+ cells (mean of 10.82% of total cells). The AIDS patients' tumors showed a smaller percentage of CD3+ infiltrating cells (mean, 4.88% of total cells) (p<0.01). CD4+ cells were 9.11% of the total hematopoietic cells in the non-AIDS patients and 3.13% in AIDS patients (p<0.01). AIDS patients showed some CD8+ cells (0.3%), which was significantly higher than in immunocompetent patients (0%) (p<0.05). Very few tumor cells stained with the NK cell and delta/delta cell markers. Both immunocompetent and AIDS patients with PCNSL exhibit significant CD3+ and CD4+ cell infiltration of their tumors; this infiltration is significantly lower in AIDS patients. AIDS patients show a minor CD8+ cell infiltration of their tumors. These results on PCNSL are different from systemic lymphomas, which show a higher CD4 and CD8 cell infiltration, and may offer insights into the more aggressive nature of AIDS-related PCNSL.

Multi-site study of incidence of pressure ulcers and the relationship between risk level, demographic characteristics, diagnoses, and prescription of preventive interventions

OBJECTIVE

To determine the incidence of pressure ulcers in varied populations, and whether demographic characteristics (age, gender, race) and primary diagnosis are factors in pressure ulcer development when the level of risk for developing ulcers is considered. To determine if there is a difference in the type of preventive services prescribed for persons who do or do not develop pressure ulcers when risk is controlled and whether differences can be related to demographic characteristics.

DESIGN

Cohort study.

SETTING

Two skilled nursing homes, two university operated tertiary care hospitals, and two Veteran's Administration Medical Centers (VAMCs) in Omaha, NE, Durham, NC, and Chicago, IL.

PATIENTS

A total of 843 randomly selected patients more than 19 years of age who did not have pressure ulcers on admission to their place of care. Subjects were 63% male, 79% white, and had a mean age of 63 (+/- 16) years.

MEASURES

A head-to-toe skin assessment for pressure ulcers recording site and stage of ulcers, scores for the Braden Scale for Predicting Pressure Sore Risk, demographic characteristics (age, sex, race), and primary diagnosis and preventive interventions (turning or repositioning orders and pressure reduction surface) were documented on the patient record. Observations were made every 48 to 72 hours for a minimum of 1 to a maximum of 4 weeks.

MAIN OUTCOME MEASURES

Presence/absence and stage of pressure ulcers.

MAIN RESULTS

One hundred eight of 843 (12.8%) subjects developed pressure ulcers. The incidence was 8.5%, 7.4%, and 23.9% in tertiary care, VAMCs, and nursing homes, respectively. Logistic regression demonstrated that lower Braden Scale scores, older age and white race predicted pressure ulcers; gender was not predictive. Primary diagnoses were not significant predictors of pressure ulcer risk when the Braden Scale score was entered into the regression. Prescription of turning was predicted by Braden Scale scores and by white race, whereas prescription of pressure reduction was predicted by Braden Scale scores, white race, and female sex.

CONCLUSIONS

Risk assessment, rather than diagnoses or demographic characteristics, is recommended as the basis for prescriptive decisions. Risk assessment should cue health care providers to make more judicious use of turning and support surfaces to prevent pressure ulcers. Persons who are at risk for pressure ulcers should have turning and pressure reduction surfaces consistently prescribed and implemented. The costs and goals of preventive prescription for those not at risk for pressure ulcers should be considered.

Effect of granulocyte-macrophage colony-stimulating factor on oral mucositis after hematopoietic stem-cell transplantation

PURPOSE

Oral mucositis following high-dose chemotherapy may result in systemic infection and airway compromise, and the severity of oral mucositis may be dose-limiting. Here we investigate the effect of granulocyte-macrophage colony-stimulating factor (GM-CSF), which significantly shortens duration of neutropenia after hematopoietic stem-cell transplantation (HSCT) on oral mucositis.

PATIENTS AND METHODS

Thirteen children undergoing HSCT were prepared with etoposide (VP-16), thiotepa (TT), and total-body irradiation (TBI), and 13 with VP-16, TT, and cyclophosphamide (CPM). Following transplantation, 14 patients received GM-CSF at a dose of 125 micrograms/m2/d by continuous intravenous infusion (six prepared with VP-16, TT, and TBI, and eight prepared with VP-16, TT, and CPM), and 12 patients received no growth factor.

RESULTS

Mucositis was more severe and persisted longer in patients prepared with the TBI-containing regimen. For this regimen, the duration of severe oral mucositis was shortened by the administration of GM-CSF, although the severity of mucositis was unaffected. No statistically significant effect of GM-CSF could be shown in patients who received VP-16, TT, and CPM. The incidence of positive fungal oral or blood cultures did not appear different whether patients received GM-CSF or not.

CONCLUSION

For patients undergoing stomatotoxic HSCT regimens, GM-CSF may reduce the duration of oral mucositis, but is unlikely to effect the severity of oral mucositis or risk of airway compromise, and the severity of mucositis is likely to remain dose-limiting.

Recent time trends in uterine cancer

Recent trends in corpus uterine cancer incidence rates were explored using 1979-86 data from the Surveillance and End Results Program (SEER); recent trends in hospitalizations for corpus uterine cancer were explored using 1979-86 data from National Hospital Discharge Surveys (NHDS); and recent trends in exogenous hormone use were delineated using data from the 1980, 1981, and 1985 National Ambulatory Medical Care Surveys (NAMCS). Uterine cancer incidence rates using SEER data have continued to decline since 1979. An acceleration in the decline since 1983-84 is suggested in all women and in women with intact uteri ages 45-64. Hospitalizations for uterine cancer have also declined since 1979, with a marked acceleration in the decline since 1983-84 for all women and for women ages 40-79 has increased 22 percent and use of unopposed exogenous estrogens in women of similar age has increased 7 percent, while use of exogenous progesterones have shown much more substantial increases of approximately 700 percent. Possible relationships between trends in exogenous hormone use and incidence rates of corpus uterine cancer are discussed.

Hypertension and sodium transport in 390 healthy adults in Chicago

A total of 390 people undergoing routine examinations at the Portes Center, a screening center in Chicago, and at the Northwestern Memorial Hospital employee health service, underwent an in-depth battery of tests designed to explore the relationships of both intracellular erythrocyte sodium and sodium-lithium countertransport with age, race, gender, body mass index, pattern of alcohol intake, exogenous hormone use and the presence of hypertension. Erythrocyte sodium was significantly higher in blacks than in whites and in men than in women aged 20-39 years. Relationships of erythrocyte sodium with race and gender, as well as inverse associations with alcohol intake in men, and positive associations with age and the presence of hypertension in women were significant on multivariate analysis after control for other variables. Sodium-lithium countertransport was significantly higher in whites than in blacks and in men than in women aged 20-59 years. Associations of sodium-lithium countertransport with race and gender as well as positive associations of sodium-lithium countertransport with body mass index in men and women were significant on multivariate analysis after control for other variables. Age-related gender differences in both sodium-lithium countertransport and erythrocyte sodium, as well as the association of erythrocyte sodium with the presence of hypertension in women but not in men, suggest a hormonal interaction with sodium transport in the development of hypertension.