Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Connectivity-based risk ranking of infectious salmon anaemia virus (ISAv) outbreaks for targeted surveillance planning in Canada and the USA

Infectious salmon anaemia (ISA) can be a serious viral disease of farmed Atlantic salmon (Salmo salar). A tool to rank susceptible farms based on the risk of ISA virus (ISAv) infection spread from infectious farms after initial incursion or re-occurrence in an endemic area, can help guide monitoring and surveillance activities. Such a tool could also support the response strategy to contain virus spread, given available resources. We developed a tool to rank ISAv infection risks using seaway distance and hydrodynamic information separately and combined. The models were validated using 2002-2004 ISAv outbreak data for 30 farms (24 in New Brunswick, Canada and 6 in Maine, United States). Time sequence of infection spread was determined from the outbreak data that included monthly infection status of the cages on these farms. The first infected farm was considered as the index site for potential spread of ISAv to all other farms. To assess the risk of ISAv spreading to susceptible farms, the second and subsequent infected farms were identified using the farm status in the given time period and all infected farms from the previous time periods. Using the three models (hydrodynamic only, seaway-distance, and combined hydrodynamic-seaway-distance based models), we ranked susceptible farms within each time interval by adding the transmission risks from surrounding infected farms and sorting them from highest to lowest. To explore the potential efficiency of targeted sampling, we converted rankings to percentiles and assessed the model's predictive performance by comparing farms identified as high risk based on the rank with those that were infected during the next time interval as observed in the outbreak data. The overall predictive ability of the models was compared using area under the ROC curve (AUC). Farms that become infected in the next period were always within the top 65% of the rank predicted by our models. The overall predictive ability of the combined (hydrodynamic-seaway-distance based model) model (AUC = 0.833) was similar to the model that only used seaway distance (AUC = 0.827). Such models can aid in effective surveillance planning by balancing coverage (number of farms included in surveillance) against the desired level of confidence of including all farms that become infected in the next time period. Our results suggest that 100% of the farms that become infected in the next time period could be targeted in a surveillance program, although at a significant cost of including many false positives.

The roar of the lionfishes Pterois volitans and Pterois miles

Through the analysis of acoustic recordings of captive Pterois spp., this study has confirmed anecdotal evidence that Pterois spp. are soniferous. This report of sound production in Pterois spp. provides the foundation for future research into their specific acoustic capabilities including sound production mechanisms, the role of social behaviour and applied techniques for controlling and monitoring invasive Pterois spp. in the tropical and temperate western Atlantic Ocean.

Abstract P5-08-27: Treatment patterns and clinical outcomes in patients with hormone receptor (HR)+ HER2+ metastatic breast cancer and low vs high levels of HR positivity from the SystHERs Registry

Introduction In 2010, the cutoff for HR positivity in breast cancer was established as ≥1% of cells staining HR+, previously having varied from 1% to 10%. The impact of this change on treatment patterns and outcomes is poorly understood. SystHERs is a prospective, observational cohort registry of patients (pts) with HER2+ metastatic breast cancer (MBC) that commenced enrollment in 2012. To our knowledge, SystHERs is the largest registry to collect and analyze data for the HER2+ subgroup. We report baseline characteristics, treatment patterns, and early outcomes by %HR+ (1–9% vs 10–100%).

Methods SystHERs enrolled pts aged ≥18 years and within 6 months of HER2+ MBC diagnosis. For pts with locally-determined HR+ disease, defined as HR+ in primary or metastatic tissue, %HR+ is the highest percentage of ER+ or PR+ tissue in early breast cancer or MBC. The percentage of ER+ or PR+ cells was not reported for pts considered HR– by the investigator. Median overall survival (OS; Kaplan–Meier) and hazard ratios (Cox regression) were estimated.

Results As of Feb 1, 2016, data were available for 872 eligible pts with known HR status, of whom 608 (70%) had HR+ disease. Of the 608 pts, 53 (9%) had 1–9%HR+ and 496 (82%) had 10–100%HR+; %HR+ was not reported for 59 pts. Baseline characteristics were similar between %HR+ subgroups (Table 1).

As shown in Table 2, the 1–9%HR+ subgroup was less likely to receive first-line hormonal therapy (26%) than the 10–100%HR+ subgroup (56%). 87% and 79% of pts received chemotherapy, respectively.

Median time from MBC diagnosis was 16.5 months (range, 0.4–49.4 months). Median OS was not reached at the data cutoff. The number of deaths was 13 (25%) in the 1–9%HR+ subgroup, and 68 (14%) in the 10–100%HR+ subgroup (log-rank P=0.025). The OS hazard ratio (0.514, 95% CI 0.283–0.931) favored the 10–100%HR+ subgroup. OS did not differ significantly between pts with 1–9%HR+ vs HR– disease (log-rank P=0.582, hazard ratio 1.185, 95% CI 0.647–2.169).

Table 1. Baseline characteristics 1-9%HR+ (n=53)10-100%HR+ (n=496)HR– (n=264)Age at MBC diagnosis, median yrs (range)54 (30–86)57 (21–86)55 (28–88)Race, %   White838372Black151320Premenopausal, %282522ECOG performance status, %   04654441463942≥2878MBC diagnosis type, %   De novo404958Recurrent605142Visceral, %*686275*Non-hepatic abdominal, ascites, CNS, liver, lung, or pleural effusion sites of metastasis

Table 2. First-line treatment 1-9%HR+ (n=53)10-100%HR+ (n=496)HR– (n=264)HER2-targeted therapy, %969391Chemotherapy, %877989Hormonal therapy, %26564

Conclusions These preliminary observational data suggest potential differences in treatment patterns and survival outcomes in low vs moderate/high HR+ expressers, with the former being less likely to receive hormonal therapy (26% vs 56%). Furthermore, low HR positivity was associated with poorer OS and was similar to OS observed in pts with HR– disease.

Citation Format: Jahanzeb M, Tripathy D, Rugo H, Swain S, Kaufman PA, Mayer M, Hurvitz S, O'Shaughnessy J, Mason G, Yardley DA, Brufsky A, Chu L, Antao V, Beattie M, Yoo B, Cobleigh M. Treatment patterns and clinical outcomes in patients with hormone receptor (HR)+ HER2+ metastatic breast cancer and low vs high levels of HR positivity from the SystHERs Registry [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-08-27.

Abstract P5-08-24: How do real-world treatment patterns compare to guideline recommendations for first-line metastatic breast cancer patients in US community clinics?

Background:

Treatment (txt) guidelines are based on trial data from a small minority of patients (pts). Linked electronic health records (EHRs) are a novel approach to examine txt patterns and outcomes in larger and more generalizable populations. Given the increasing importance of real world data and real world outcomes, we utilized linked EHRs from a network of US community clinics to examine how real world txt patterns compare to metastatic breast cancer (mBC) txt guideline recommendations.

Methods:

The Flatiron database provides real world clinical data collected from EHRs used by US cancer care providers. The Flatiron network comprises ~15% of US cancer pts and is geographically and demographically diverse.

Using EHR from Jan 2016 mBC database, we evaluated first-line (1L) txt patterns in mBC by molecular subtype. Pts were selected if they received mBC txt within 60 days of mBC diagnosis between 01Jan2011-31Dec2015, had ≥2 visits within the Flatiron Network on or after 01Jan2013, and were ≥18 years (yrs). Analyses were conducted to describe pt and clinical characteristics and 1L txt by HER2 and/or hormone receptor (HR) status.

Results:

Among 2509 mBC pts identified, 58.9% were HR+/HER2-, 17.7% HER2+, 11.6% HR-/HER2- (triple negative, TNBC), 7.4% HER2 equivocal, and 4.3% 'not done/unknown HER2 status'. Txt patterns in the latter two groups were not analyzed. Selected pt and disease characteristics by subtype are shown in Table 1. Median follow-up since mBC diagnosis was 1.1 yrs (range 0-5 yrs). The 1L mBC txts by subtype are shown in Table 2. Pts with HR+/HER2- subtype were treated primarily with hormonal therapy (68%) and/or chemotherapy (chemo) (35%). Among HER2+ pts, the 1L mBC txt patterns include trastuzumab+pertuzumab with chemo (31%), trastuzumab with chemo (22%), trastuzumab with hormonal therapy (9%), ado-trastuzumab (4%), lapatinib with chemo (3%), and lapatinib with hormonal therapy (1%). For TNBC, the majority received chemo (95%), such as paclitaxel (21%), nab-paclitaxel (13%) and docetaxel (12%).

Conclusion:

This study advances our current understanding of real world 1L patterns of care by molecular subtype among mBC pts and how these compare to guideline recommendations. While the majority of pts are receiving therapy per guidelines, up to 22% of HER2+ of pts are not receiving targeted therapy in 1L mBC

Table 1. Patient and disease characteristics by subtypeN (%)HR+/HER2- (N=1479)HER2+ (N=445)TNBC (N=291)Age at mBC diagnosis (yrs), median (range)66 (24-85)60 (27-85)60 (33-85)Sex   Female1459 (99)441 (99)289 (99)Race   White995 (67)274 (62)168 (58)Black112 (8)44 (10)42 (14)Asian19 (1)14 (3)5 (2)Other179 (12)50 (11)36 (12)Missing173 (12)63 (14)40 (14)MBC type   De novo418 (28)172 (39)94 (32)Recurrent881 (60)225 (51)178 (61)Unknown180 (12)48 (11)19 (7)HR Status   Positive1479 (100)300 (67)--Negative--145 (33)291 (100)

Table 2. 1L mBC treatments by subtypeN (%)HR+/HER2- (N=1479)HER2+ (N=445)TNBC (N=291)Any Targeted Therapy*77 (5)346 (78)12 (4)Any Chemotherapy521 (35)283 (64)276 (95)Any Hormonal Therapy1010 (68)115 (26)16 (6)*Targeted therapy includes trastuzumab, pertuzumab, ado-trastuzumab emtansine, lapatinib and bevacizumab

Citation Format: Chu L, Yoo B, Carrigan G, Lai C, Beattie M, Reyes C. How do real-world treatment patterns compare to guideline recommendations for first-line metastatic breast cancer patients in US community clinics? [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-08-24.

Measurement of direct CP violation parameters in B± → J/ψK± and B± → J/ψπ± decays with 10.4 fb-1 of Tevatron data

We present a measurement of the direct CP-violating charge asymmetry in B(±) mesons decaying to J/ψK(±) and J/ψπ(±) where J/ψ decays to μ(+) μ(-), using the full run II data set of 10.4 fb(-1) of proton-antiproton collisions collected using the D0 detector at the Fermilab Tevatron Collider. A difference in the yield of B(-) and B(+) mesons in these decays is found by fitting to the difference between their reconstructed invariant mass distributions resulting in asymmetries of A(J/ψK) = [0.59 ± 0.37]%, which is the most precise measurement to date, and A(J/ψπ) = [-4.2 ± 4.5]%. Both measurements are consistent with standard model predictions.

Communicating Risk of Hereditary Breast/Ovarian Cancer among Underserved Women: Interim Findings from the CREdIT Study

Purpose: With the support of the Avon Foundation, genetic counseling is available to underserved populations at the San Francisco General Hospital. One of the major challenges in providing genetic counseling for hereditary breast and ovarian cancer among these women is the lack of culturally appropriate educational tools.The purpose of this study is to evaluate the use of a Cancer Risk Educational Intervention (CREdIT), a novel audio-visual PowerPoint-based tool as an adjunct to genetic counseling. Methods: CREdIT took on average 15 minutes to view and was available in English and Spanish. It employed non-scientific images and language specifically designed for use by our target population. Participant questionnaires evaluating patient satisfaction, risk perception, knowledge of cancer genetics, and anxiety were administered before and after the intervention and at 1 year follow-up. For each of the continuous outcomes, differences from pre- to post-intervention were assessed with analyses of variance, while chi-squared tests were used to examine the differences among categorical variables. Results: A total of 52 women of diverse backgrounds who were on average 47 years old (range 27-69) took part in the study. Of these, 15% reported previous history of cancer, 58% were non-white and 59% had a below college education. Twenty-one percent viewed the presentation in Spanish. Following the presentation of CREdIT, we found an increase in the knowledge of BRCA inheritance and associated risk of malignancy, and options for risk reduction (all p < .05). However, participants' perceived risk perception did not change from baseline to post-CREdIT (p=.73). Virtually all participants (98%) reported that CREdIT helped them learn more about cancer risk. Although patient anxiety decreased post-CREdIT (p=.02), 29% patients reported that CREdIT made them worry more about cancer. Among 32 participants who were interviewed at the long-term follow-up, we found that, compared to post-CREdIT, knowledge changed for only two of the seven questions (p< .05). There were also no changes in anxiety or cancer worry compared to baseline (both p< .05). Conclusions: These interim findings suggest that our intervention was successful at increasing knowledge regarding breast cancer genetics without increasing anxiety or cancer worry. Our long-term goal is to perform a large-scale evaluation among underserved women at risk of hereditary cancer across the Avon Foundation-supported clinics nationwide.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4074.

Development and evaluation of a cancer risk educational tool (CREdIT) for women with a family history of breast and ovarian cancer

Abstract #2101

Introduction: In underserved, lower literacy and multiethnic women at risk of Hereditary Breast and Ovarian Cancer (HBOC), there is a need for culturally appropriate educational tools. The purpose of this Phase I study is to evaluate the use of a Cancer Risk Educational Intervention Tool (CREdIT) as an adjunct to genetic counseling for HBOC for underserved women at San Francisco General Hospital (SFGH).
 Methods: CREdIT is a 15 minute audio-visual powerpoint story presentation (available in English and Spanish) which employs non-scientific images and language specifically designed for use by our target population. Participant questionnaires, administered before and after the intervention, evaluate patient satisfaction, risk perception, knowledge of cancer genetics, and anxiety. Genetic counselor questionnaires address counselor satisfaction and time-flow.
 Results: To date, we have recruited 23 women of diverse backgrounds (mean age of 46, range: 26 to 63). Of these, seven (30%) are first-generation immigrants and four (17%) have less than a high school diploma. Eight (35%) have had cancer, and eighteen (78%) reported that cancer runs in their families. We have found an increase in knowledge following the CREdIT presentation, specifically vis-à-vis BRCA inheritance, BRCA-associated cancer risk, and risk-reducing options (all p < 0.05). These improvements occur without an increase in patient anxiety (p > 0.05). All participants believed that the presentation helped them learn more about cancer risk, and genetic counselors reported increased patient preparedness and counselor satisfaction as a result of CREdIT use (p < 0.05). Mean genetic counselor consultation time decreased by 5.5 minutes after CREdIT use.
 Conclusions: CREdIT appears to increase knowledge and improve understanding of BRCA-associated risks without raising anxiety in underserved women at risk of HBOC. Genetic counselors report increased satisfaction and patient preparedness, and decreased counseling time with CREdIT. Future work will involve examining long-term outcomes of CREdIT use; subgroup analyses to identify patient populations most likely to benefit from CREdIT; further evaluation using clinical trial methodology; and strategies for its dissemination to other settings working with underserved, multiethnic populations.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2101.

Matching alcoholics to treatment. Failure to replicate finding of an earlier study

The purpose of the present study was to investigate whether sociopathic alcoholics respond differentially to different types of treatment. An earlier study found that alcoholics with antisocial personality disorder had somewhat better outcomes if treated in individually focused versus relationship-focused cognitive-behavioral treatment. The present study was designed to attempt to replicate these findings. One hundred and forty-nine alcoholics (42 of whom scored high on a measure of sociopathy) were randomly assigned to receive either individually focused cognitive-behavioral treatment or a relationship-focused community reinforcement approach. Follow-up evaluations were conducted every 4 months for 2 years. Results failed to support the study hypothesis. Drinking outcomes were similar for sociopathic alcoholics in both treatment conditions. Directions for future research are identified.

A role for hepatocyte growth factor/scatter factor in fetal mesenchyme-induced pancreatic beta-cell growth

We have investigated the role of hepatocyte growth factor/scatter factor (HGF/SF) in the growth and/or differentiation of pancreatic islet beta-cells. We found that in the human fetal pancreas immunoreactive HGF/SF receptor (c-met proto-oncogene product) is preferentially associated with the developing beta-cells. In the adult pancreas, c-met messenger RNA is highly enriched in the islets and the immunoreactive protein is also restricted to the islet beta-cells. HGF/SF messenger RNA content of fetal pancreas-derived fibroblasts is more than 10-fold higher than that of adult fibroblasts. Culture of human fetal pancreatic epithelial cells in conditioned medium from the fetal pancreatic fibroblasts caused a 2.4-fold stimulation of the formation of islet-like cell clusters that was due to both mitogenic and morphogenic effects. Beta-cell proliferation in the cell clusters was stimulated 3.5-fold by the conditioned medium, and this was associated with a marked decrease in insulin content. All of the effects of the conditioned medium were blocked by anti-HGF/SF antibody. Specificity was confirmed by overriding the blocking effect of the antibody with excess recombinant HGF/SF. Conditioned medium from adult pancreatic fibroblasts stimulated islet-like cell cluster formation only slightly, and did not affect beta-cell replication. These results suggest that HGF/SF secreted by fetal fibroblasts is mitogenic to beta-cells. Taken together, our findings indicate an important role for HGF/SF in fetal mesenchyme-induced pancreatic beta-cell growth.

Trends in pharmacotherapy of Schizoaffective and bipolar affective disorders: a 5-year naturalistic study

OBJECTIVE

The authors' goal was to determine if the actual treatment of schizoaffective and bipolar affective disorders had changed in light of recent clinical drug trials that have suggested that valproate and carbamazepine may be equivalent in efficacy to lithium.

METHOD

Medication utilization rates for each 6-month period from July 1, 1989, to June 30, 1994, were compiled from the clinical database of the Palo Alto Veterans Affairs Medical Center.

RESULTS

The use of valproate and valproate plus lithium was negligible in 1989. by 1994, these medication regimens accounted for 25% of the standard antimanic treatments used for bipolar affective disorder and 38% of the treatments used for schizoaffective disorder. Regimens of carbamazepine and carbamazepine plus lithium dropped from 24% of antimanic treatments in 1989 to 18% in 1994. From 1989 to 1994, there was a decline in the rate of lithium monotherapy for treatment of bipolar affective disorder (from 84% to 43%) and schizoaffective disorder (from 100% to 53%).

CONCLUSIONS

In the past 5 years, valproate monotherapy has increased as a percentage of total antimanic pharmacotherapies, while lithium monotherapy has declined.

Drinking outcomes of alcohol abusers diagnosed as antisocial personality disorder

Clinical research and wisdom suggest that alcoholics with antisocial personality (ASPs) disorders have poorer drinking outcomes after treatment than alcoholics without this disorder. The present study challenges this wisdom, suggesting that poor prognosis and response to treatment have been confounded by not covarying on pretreatment drinking measures. Thirty-one ASPs are compared with 118 non-ASPs randomly assigned to extended cognitive behavioral and relationship enhancement treatments. Thirteen to 18 months after treatment initiation, ASPs average more abstinent days than do non-ASPs. Drinking intensity is a function of a patient-treatment matching effect: ASPs treated with cognitive behavioral treatment (CB) drink less/drinking day than do either non-ASPs treated in CB or ASPs treated in relationship enhancement. This finding is supportive of a comparable matching effect for CB and ASP found by Kadden et al. (1989). Examination of the process indicates that, irrespective of drinking index, ASPs respond poorly when they experience high posttreatment support for abstinence, whereas non-ASPs respond better with support. We conclude that early pessimism for successful treatment of ASP alcoholic drinking outcome may be unwarranted.

Age group differences in response to treatment for problematic alcohol use

That structural characteristics act as markers of modified treatment outcome is a long standing idea in the alcohol treatment field. In order to test whether patient age is a factor to be considered in making treatment assignments, we examined data collected under a clinical trial. Two hundred and twenty-nine patients were randomly assigned to one of three treatment conditions: extended cognitive behavioral treatment (CB), relationship enhancement (RE), or relationship and vocational enhancement (VE). This paper reports on outcome (alcohol use) 3-6 months after treatment assignment. Our question was, would different age groups assigned to the treatment conditions exhibit different outcomes? There were no significant main effects by either treatment condition or age group. There was a significant treatment condition by age group interaction. With increasing age, the differences in treatment seemed to increase. For the younger aged group (18-29 years old) no statistically significant treatment differences were detected. Middle aged patients (30-49 years old) did best in the RE condition. Older aged patients (50 + years old) did best when assigned to the CB condition. These findings lead us to conclude that patient age is a variable which should be considered when testing patient-treatment matching hypotheses.

The Significant-other Behavior Questionnaire (SBQ): an instrument for measuring the behavior of significant others towards a person's drinking and abstinence

The psychometric properties of the Significant-other Behavior Questionnaire (SBQ), an instrument measuring the specific social support in terms of the patient's drinking. Assessments of the significant other's behavior in the presence of the patient drinking is provided by both the patient and significant other. Data from the two SBQ forms were analyzed with a principal axis factor analytic procedure with varimax rotation. The scales were similar for the two forms with four behavioral reactions, withdraw from the patient, support drinking, support sobriety, and punish drinking. Correlations between the two forms on the same four scales were higher than correlations within groups on three of four scales and differed from measures of general social support. Applications of the SBQ are discussed.

The effect of social investment on treatment outcome

Social support is associated with better response to treatment. Treatments focused on relationships, such as marital and family therapy, are directed in part at promoting this support. However, the strength of the relationship between support and abstinence is modest, as is the demonstrated incremental effectiveness of treatments focused on relationships. Treatment-matching research needs to determine under what set of conditions treatments focused on relationships will enhance abstinence. The primary aim of this study was to determine whether the relationship between alcohol involvement and alcohol-specific social support is moderated by a person's social investment. The second aim was to determine the set of circumstances under which extended individually focused cognitive behavioral (CB) treatment and a relationship enhancement (RE) of brief cognitive behavioral treatments would improve outcomes. Patients were randomly assigned to individual or relationship-enhanced outpatient treatment and followed for 12 months. Results indicated that a patient's social investment did moderate the strength of the relationship between support and posttreatment alcohol involvement: Among high investors, there was a strong positive relationship, while the association was weak for low investors. A hypothesized triple-order interaction between social investment, posttreatment support and treatment did not materialize. However, an interaction between support and treatment showed that those with high support did equally well in either treatment, while those posttreatment support was low benefited from CB, but experienced poor outcomes when treated in relationship enhancement of CB. Further analyses indicated that increasing alcohol-specific support for low investors was probably contraindicated. We suggest that patients with low investment should be treated in an extended cognitive behavioral modality, while relationally enhanced CB treatment should be limited to high investors who are likely to experience support for their abstinence following treatment.

Simultaneous kinetic determinations of lipase, chymotrypsin, trypsin, elastase, and amylase on the same microtiter plate

Micromethods are described to determine in 10 min the activity of the five most common pancreatic zymogens: amylase, lipase, trypsin, chymotrypsin, and elastase. Progress of the reactions is monitored at 405 nm, allowing the kinetic determination of the five enzymes on a single 96-well microtiter plate. Amylase activity is measured by the release of p-nitrophenol from a chemically defined substrate. Linearity of the assay is from 10 to 360 U/L of amylase, and activities as low as 0.4 U/L can be easily measured by extending the period of incubation up to 24 h. Chymotrypsin, trypsin, and elastase activities are monitored by the release of p-nitroanilide from specific substrates, and activities are from 25 to 6,500, 15 to 260, and 20 to 600 U/L, respectively. Finally, lipase is determined by the clearing of a commercially available stabilized emulsion of triolein. The lipase determination can be performed from 90 to 3,600 U/L. When microplate methods were compared with conventional procedures, a perfect correspondence was found between the two types of procedure. Factors necessary to convert microplate results to those of conventional assays are provided. These microassays make possible the rapid and simultaneous determination of the three main types of pancreatic hydrolases (a glycohydrolase, three proteases, and a lipase) with < 5 microliters of pancreatic juice by kinetic analysis. They could be easily adopted as routine assays in most research laboratories.

Determinants of neuropsychological impairment in antisocial substance abusers

Persons displaying Antisocial Personality Disorder (ASP) may be at risk for neuropsychological impairment due to a number of developmental and later life experiences to which they are prone. Thirty substance abusers meeting research criteria for ASP were compared to a demographically matched non-ASP cohort on neuropsychological test performance. The ASP subjects were found to have a higher prevalence of neuropsychological deficit. The groups were then compared on factors which might lead to brain impairment. Presence of ASP was associated with earlier and heavier past drinking patterns, more negative health and behavioral effects of alcohol abuse, and greater abuse of other drugs in addition to alcohol. The ASP alcoholics also reported a high prevalence of serious head injury (58%), although they did not differ from non-ASP alcoholics in this regard. Implications for the neuropsychology of alcoholism and for treatment are discussed.

Nasopharyngeal rhabdomyosarcoma presenting as a breast mass

We describe a 13-year-old girl with a primary nasopharyngeal rhabdomyosarcoma presenting with an isolated breast metastasis and no other evidence of distant metastatic spread. Only seven cases have been previously reported, and in all these cases the primary tumor was located either on an extremity or the buttock, and in six the disease was widely disseminated at diagnosis.

Risk factors for neuropsychological impairment in alcoholics: antisocial personality, age, years of drinking and gender

One hundred eighty-two alcoholics were studied using subtests from the Halstead-Reitan Neuropsychological Battery, Wechsler Adult Intelligence Scale and the Wechsler Memory Scale. Alcoholics who displayed antisocial personality disorder (ASPD) were more impaired on the Brain Age Quotient, a summary measure of neuropsychological impairment. Multivariate analyses indicated that presence of ASPD contributed significantly to this impairment, independent of age, length of drinking history or gender. Discriminant analysis using these variables as predictors allowed for clinically useful levels of prediction of neuropsychological impairment in individual subjects.

The major protein of pancreatic zymogen granule membranes (GP-2) is anchored via covalent bonds to phosphatidylinositol

GP-2, the major integral protein characteristic of the pancreatic zymogen granule membrane can be released from the membrane by the action of a phosphatidylinositol specific phospholipase C (PI-PLC). In a hydrophobic/hydrophilic phase separation system using the non-ionic detergent Triton X-114, the membrane-bound form of the protein went from the detergent phase into the hydrophilic phase upon action of the phospholipase. PI-PLC solubilization of GP-2 unmasked an antigenic determinant similar to the cross-reacting determinant of the trypanosome variant surface glycoproteins. This determinant being a distinctive feature of the glycan moiety of phosphatidyl-inositol anchored membrane proteins, it established the glycosyl-phosphatidyl-inositol nature of the GP-2 membrane anchor. Since soluble GP-2 is also found in the contents of the granule and is secreted intact into the pancreatic juice, it is likely that one of the mechanisms responsible for its release could be a specific phospholipase. GP-2 is the first glycosyl-phosphatidyl-inositol-anchored protein that is integral to the membrane of an organelle and not located at the surface of the cell.

Reducing conditions induce a total degradation of the major zymogen granule membrane protein in both its membranous and its soluble form. Immunochemical quantitation of the two forms

The major protein of the pig pancreatic zymogen granule membrane is an integral glycoprotein of 92 X 10(3) daltons (Da) which amounts to 25% of the total proteins of this membrane. When zymogen granule membranes were prepared in presence of 5 mM dithiothreitol (DTT), this glycoprotein specifically vanished from the membrane preparation. During membrane purification two other fractions were produced out of the purified granules: a soluble fraction of zymogens referred to as granule content and a dense pellet. The possibility that DTT could release the 92-kDa protein from the membrane to these other fractions has been rejected. Altogether, addition of DTT during the lysis of the granules induced a total degradation of the 92-kDa protein. This hydrolysis could be inhibited by phenylmethylsulfonyl fluoride but not by N-alpha-p-tosyl-L-lysine chloromethyl ketone or L-1-tosylamide-2-phenylethylchloromethyl ketone. In the course of these experiments, using gel filtration of the granule content, it was found that the 92-kDa protein was also present in the granule content in the form of an aggregate of 300 kDa. A protease was present in this aggregate and could hydrolyse the 92-kDa protein upon addition of DTT. From immunoblotting studies and rocket immunoelectrophoresis, it was found that the soluble 92-kDa protein was antigenically similar to the membrane protein and that 44% of the immunoreactive glycoprotein of the granule was soluble in the content. A cross-reacting fragment of 65 kDa has been observed in all the fractions, yet at different levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Identification of the catalytic subunit of the ATP diphosphohydrolase by photoaffinity labeling of high-affinity ATP-binding sites of pancreatic zymogen granule membranes with 8-azido-[alpha-32P]ATP

Photoaffinity labeling has been performed on pancreatic zymogen granule membranes using 8-azido-[alpha-32P]ATP (8-N3-ATP). Proteins of 92, 67, 53, and 35 kdaltons (kDa) were specifically labeled. ATP (100 microM) inhibited very strongly the labeling with 8-N3-ATP, while ADP was much less potent, AMP and cAMP being inefficient. The apparent constants for 8-N3-ATP binding were in the micromolar concentration range for the four labeled proteins. Without irradiation, 8-N3-ATP was a competitive inhibitor (Ki = 2.66 microM) for the hydrolysis of ATP by the ATP diphosphohydrolase. The optimal conditions for the photolabeling of the 92- and 53-kDa proteins were pH 6.0 in presence of divalent cations. On the other hand the 67- and 35-kDa proteins required an alkaline pH and the addition of EDTA in the photolabeling medium. No proteins could be labeled on intact zymogen granules, showing that all the high-affinity ATP-binding sites of the membrane were located at the interior of the granule. Both the 92- and 53-kDa glycoproteins could bind to concanavalin A-Sepharose and be extracted in the detergent phase in the Triton X-114 phase separation system. These latter properties are typical of integral membrane proteins. In addition, the 53-kDa labeled protein was sensitive to endo-beta-N-acetylglucosaminidase digestion. Photolabeling with 8-N3-ATP of two different preparations of purified ATP diphosphohydrolase also led to the labeling of a 53-kDa protein. Thus among the four proteins labeled with 8-N3-ATP on the pancreatic zymogen granule membrane, the 53-kDa integral membrane glycoprotein was shown to bear the catalytic site of the ATP diphosphohydrolase.

Effectiveness of alcoholism treatment in partial versus inpatient settings: twenty-four month outcomes

The authors examined the effectiveness of the partial hospital setting, in contrast to the inpatient setting, for the rehabilitation of alcohol abusers and alcoholics. Outcomes after 24 months in five life health areas indicated marked improvement from baseline for the entire follow-up period on almost all measures. There also was a strong relationship between drinking outcomes and outcomes in the other health areas. Although there were few between group differences on the clinical outcome measures, differences which were found favored the partial hospital setting. Furthermore, cost of treatment over two years clearly favored the partial hospital.

Identification of the proteins exposed on the cytoplasmic surface of the pancreatic zymogen granule

Lactoperoxidase-catalyzed 125I-iodination was used to label pancreatic zymogen granules. Membrane proteins facing the cytoplasmic surface were specifically labeled. Two low molecular weight proteins of 17 000 and 15 000 were intensely labeled at 0 degree C. Another small 13 kDa protein was strongly iodinated at 25 degrees C along with some others, including the 29 kDa subunit of the ATP diphosphohydrolase. The major glycoprotein of the granule membrane was not iodinated but the presence of an iodinated 80 kDa protein suggests that proteolytic fragments of the 92 kDa glycoprotein were accessible to iodination on the intact granule. These proteins localized on the cytoplasmic surface of the granule are believed to play a major role in the exocytotic phenomenon of the exocrine pancreas.

The integral and peripheral proteins of the zymogen granule membrane

This study reports the lipid and protein composition of purified pig zymogen granule membranes. Lipids made up more than 70% of the membrane dry weight and phosphatidylserine constituted 17% of the total phospholipids. The membrane was shown to contain nine major proteins. A protein of Mr 92 000 was the major constituent accounting for more than 25% of the Coomassie blue staining on gels. Six glycoproteins, including the latter, were revealed by periodic acid-Schiff staining and concanavalin A binding. A phase separation technique using partition of intrinsic and extrinsic membrane proteins in Triton X-114 solutions has shown that most of the proteins were integral membrane proteins. The ATP diphosphohydrolase, which is distinctive of the zymogen granule membrane, segregated with integral proteins. These data constitute a detailed description of a purified membrane fraction from pig pancreatic zymogen granules.

Effects of apomorphine and pimozide on temperature regulation during exercise in the rat

The purpose of this study was to determine the effects of a specific dopamine receptor agonist (apomorphine) and antagonist (pimozide) on thermoregulation when the heat loss pathway was activated by the stress of exercise. Apomorphine or its control vehicle (0.9% wt/vol saline) was injected systemically (0.5, 1.0, 1.5 mg/kg ip) or within the preoptic-anterior hypothalamus (5, 10, 20 micrograms) immediately before the start of treadmill exercise at 21.5 m/min. Colonic, tailskin, and ambient temperatures were recorded each minute. Oxygen consumption was calculated from on-line measurements of percent O2 and CO2. Pimozide injected systemically (0.5 mg/kg ip) had no effect on resting colonic temperature, but caused a significant (P less than 0.05) hyperthermia during treadmill exercise compared to saline controls. Central and systemic injections of apomorphine caused a dose-dependent hypothermia that was blocked by pretreatment with pimozide. Oxygen uptake values during exercise following the central injection of apomorphine were virtually identical to those following the injection of saline, but colonic temperature was significantly (P less than 0.05) lower than saline controls, indicating that the hypothermia observed was not due to a reduction in metabolic rate. These data indicate that dopamine receptors in the preoptic-anterior hypothalamus of the rat participate in the mediation of heat dissipation when the animal is challenged with a heat stress.