Erythromycin breath test as an assay of glucocorticoid-inducible liver cytochromes P-450. Studies in rats and patients

The major P-450IIIA gene family member present in human liver is HLp which, like its rat liver orthologue P-450p, is inducible by glucocorticoids and catalyzes erythromycin N-demethylation. To develop a practical method to estimate the amounts of HLp in patients [14C]N-methyl erythromycin was injected into rats that had been pretreated with dexamethasone or with inducers of other forms of cytochrome P-450. The rate of demethylation of this substrate, measured simply as 14CO2 in the breath, correlated well with the concentrations of immunoreactive P-450p protein (r = 0.70), holocytochrome P-450p (r = 0.70), or with erythromycin N-demethylase activity (r = 0.90) determined in the liver microsomes prepared from each rat. Next, [14C]N-methyl erythromycin was administered to 30 patients and there was a sixfold interindividual variation in breath 14CO2 production seemingly unrelated to medications, smoking status or age. However, the average breath test values were twofold greater in female as compared to male patients (P less than 0.01). Breath 14CO2 production rose in patients retested after treatment with the P-450IIIA inducers dexamethasone (P less than 0.05) or rifampicin (P less than 0.05) and was decreased after treatment with the HLp inhibitor triacetyloleandomycin (P less than 0.05). We conclude that the erythromycin breath test provides a convenient assay of P-450IIIA cytochromes in rats and in some patients.

Predictive value of surveillance skin cultures in total-parenteral-nutrition-related infection

To assess the importance of skin flora in the pathogenesis of infection complicating total parenteral nutrition and the predictive value of positive skin cultures for the development of infection 54 patients, who received 59 courses of total parenteral nutrition, were followed up. Three times per week, at the time of dressing and line changes, the skin at the site of insertion of the cannula was swabbed for culture. Results of skin cultures were compared with results of semiquantitative culture of the proximal intravascular portion of the cannula. Infected patients were defined as those having cannula cultures with greater than or equal to 15 colonies or those with primary septicaemia. 21 of 59 courses (36%) were associated with positive skin cultures; 14 of these 21 courses were associated with cannula infection, 2 with bacteraemia or fungaemia, and 12 with local infection. 38 of 59 (64%) courses had sterile skin cultures; in none of these 38 patients did infection develop (p less than 0.001). Skin colonisation was associated with otherwise unexplained fever (11 of 21 with positive skin culture versus 5 of 38 with negative skin culture, p less than 0.001), inflammation at the insertion site (13 of 21 versus 10 of 38, p less than 0.05), and violations of line protocol (11 of 21 versus 10 of 38, p less than 0.05). The absence of any organism on the skin had a negative predictive value of 98%, whereas the presence of an organism on the skin had a positive predictive value of 61%. Skin culture thus seems able to identify which patients receiving parenteral nutrition are at high risk of infection.

Evidence for the participation of actin microfilaments and bristle coats in the internalization of gap junction membrane

Thin sections of rabbit granulosa, human SW-13 adrenal cortical adenocarcinoma, and mouse B-16 melanoma cells revealed an apparent single-layered basket of 4- to 7-nm filaments surrounding cytoplasmic gap junction vesicles. This interpretation was based upon apparent longitudinal, cross, and en face sections of structures surrounding the vesicle profiles in tissue treated with tannic acid-glutaraldehyde. In granulosa cells incubated with the S-1 fragment of heavy meromyosin, arrowhead-decorated filaments were observed at the periphery of the gap junction vesicles, suggesting that these filaments contained actin. In addition, we found that small gap junctional blebs and vesicles at the cell surface were coated with short electron-dense bristles similar in appearance to the cloathrin-containing coat of coated vesicles of nonjunctional membrane. The role of these and other cytoskeletal elements in the possible endocytosis of gap junction membrane is discussed.

Total parenteral nutrition-related infections. Prospective epidemiologic study using semiquantitative methods

Studies of total parenteral nutrition-related infection have incorrectly relied on positive results on culture of the cannula tip to confirm the source. We undertook a prospective study of total parenteral nutrition-related infections in adult patients by obtaining blood from all total parenteral nutrition lines for pour-plate culture twice weekly and culturing intravascular line segments by the technique of Maki. Twelve of 100 courses of total parenteral nutrition (12 percent) in 69 patients resulted in infections--five (5.0 percent) had sepsis, and seven (7.0 percent) had local infection. In five of these 12, pour-plate culture gave positive results (five of 38 pour plates) with counts of 8 colony-forming units per ml (cfu/ml) for Candida tropicalis, and 25 to more than 1,000 for bacterial isolates. In nine of 12, culture of the intravascular line segment gave positive results with more than 50 cfu/ml. Pathogens isolated from intravascular line segments included Staphylococcus epidermidis (three cases), Candida species (three cases), Staphylococcus aureus (two cases), Serratia marcescens (one case) and mixed bacterial pathogens (one case). In contrast, pour-plate culture gave positive results in only seven of 88 uninfected (control) courses (318 pour plates), and culture of intravascular line segments gave positive results in two of 65 uninfected courses (p less than 0.001). No differences existed among patients with and without infection with regard to age, underlying disease, surgery, systemic antibiotic usage, or the presence of other infections. The duration of total parenteral nutrition was longer in courses without infection than in courses with infection (14.7 +/- 9.4 days versus 11.0 +/- 4.0 days; p less than 0.02). In six of 12 courses with infection, the line had been violated compared with 22 of 88 courses without infection (p less than 0.001). T-connectors for the centra administration of intralipid were associatd with infection (p less than 0.02). The value of routine pour-plate culture was illustrated in three courses in which the positive pour-plate culture results antedated positive blood culture results or line removal.

Inducible cytosolic enzyme activity for the production of nitrogen oxides from L-arginine in hepatocytes

The in vivo conditions needed for the induction of nitrogen oxide synthesis by hepatocytes were determined. Hepatocytes obtained from rats injected with killed Corynebacterium parvum spontaneously produced NO2(-)+NO3- in culture and were found to contain cytosolic enzyme activity for nitrogen oxide synthesis. The enzyme activity required both L-arginine and NADPH, and was not found in hepatocytes obtained from normal rats or rats injected with lipopolysaccharide (LPS) alone. In contrast, nonparenchymal cells were stimulated to synthesize NO2(-)+NO3- by LPS. These results show the presence of inducible cytosolic enzyme activity for nitrogen oxide synthesis in hepatocytes, which is distinct from nonparenchymal cell NO. synthesis.

Association between synthesis and release of cGMP and nitric oxide biosynthesis by hepatocytes

Hepatocytes are known to synthesize nitric oxide (NO) from L-arginine via an inducible NO synthase. Studies were performed to determine the relationship between hepatocyte NO production and the stimulation of hepatocyte soluble guanylate cyclase. A combination of lipopolysaccharide (LPS), interferon-gamma, tumor necrosis factor, and interleukin-1 stimulates the biosynthesis of large quantities of nitrite and nitrate (NO2- + NO3-). Hepatocyte NO2- + NO3- production was associated with only small increases in intracellular guanosine 3',5'-cyclic monophosphate (cGMP) levels but much greater increases in extracellular cGMP release over an 18-h time period. This cGMP synthesis was dependent on the L-arginine concentration and was inhibited in a reversible manner by NG-monomethyl-L-arginine. The cytokines or LPS added alone induced small increases in nitrogen oxide production and concomitant minor elevations in cGMP release. Atrial natriuretic peptide also stimulated the release of cGMP by hepatocytes which appeared to be independent of the cytokine+LPS-induced cGMP release. The addition of probenecid reduced the cGMP release by 66%, while cell damage was excluded as a cause for the extracellular release. Addition of 3-isobutyl-1-methylxanthine, but not M&B 22948, increased hepatocyte intra- and extracellular cGMP levels after cytokine+LPS stimulation. Induction of nitrogen oxide synthesis by hepatocytes in vivo by injecting rats with killed Corynebacterium parvum resulted in increased cGMP levels in freshly isolated hepatocytes and increased cGMP release by the hepatocytes when placed in culture.(ABSTRACT TRUNCATED AT 250 WORDS)

The integrated implementation of two end-of-life care tools in nursing care homes in the UK: an in-depth evaluation

In economically developed countries there is a rapidly increasing number of older people living and dying in care homes. The relative isolation of nursing care homes from the development of palliative care, the poor retention and recruitment of staff, and the lack of medical cover, hinder the provision of quality end-of-life care. End-of-life care strategies internationally highlight the benefit of using tools to help improve end-of-life care in care homes. All seven private nursing care homes within one district in Scotland undertook to implement, as a package, two end-of-life care tools, namely, the Gold Standards Framework for Care Homes (GSFCH) and an adapted Liverpool Care Pathway for Care Homes (LCP). A model of high facilitation, visiting the homes every 10-14 days with significant in-house staff training, was used to implement the 18-month programme. The notes of 228 residents who had died prior to and during the project were examined, alongside a staff audit looking at the effect that the project had on practice. A nurse researcher undertook qualitative interviews of bereaved relatives, pre-/post-implementation. This paper reports the results of an in-depth evaluation of professional practices and residents outcomes. There was a highly statistically significant increase in use of Do Not Attempt Resuscitation (DNAR) documentation, advance care planning and use of the LCP. An apparent reduction in unnecessary hospital admissions and a reduction in hospital deaths from 15% deaths pre-study to 8% deaths post-study were also found. Further work is needed to assess the optimum input required for successful implementation.

Listening to local voices: adapting rapid appraisal to assess health and social needs in general practice

OBJECTIVES

To explore the use of rapid appraisal in defining the health and social needs of a community and to formulate joint action plans between the residents and service providers.

DESIGN

Collection of data by an extended primary care team from three sources: existing documents about the neighbourhood, interviews with a range of informants, and direct observations to build a profile of the community.

SETTING

Council estate of 670 homes in Edinburgh.

MAIN OUTCOME MEASURES

Perceived problems of the community and suggestions for change.

RESULTS

The interviews and focus groups identified six priorities for change, many of which were not health related. These changes have been or are being implemented.

CONCLUSIONS

An expanded primary care team can use rapid appraisal as a first step in identifying and meeting local health needs. It facilitates a multidisciplinary approach and complements quantitative methods of assessing need.

Broadband ultrasound attenuation in the os calcis: relationship to bone mineral at other skeletal sites

1. We have examined the relationship between broadband ultrasound attenuation in the os calcis and measurements of bone mineral in the distal forearm and lumbar spine of normal and postmenopausal osteoporotic women. 2. Values of broadband ultrasound attenuation in postmenopausal women with vertebral osteoporotic fractures were significantly lower (35%) than in normal pre- and peri-menopausal women (55.4 +/- 3.8 and 79.6 +/- 0.8 dB/MHz, respectively). 3. Broadband ultrasound attenuation correlated significantly with bone mineral content measured in the distal forearm by single-photon absorptiometry (r = 0.77, P less than 0.0001) and with bone mineral content (r = 0.66, P less than 0.0001) and bone mineral density (r = 0.72, P less than 0.0001) measured in the lumbar spine by dual-photon absorptiometry. 4. Although significant, these correlations are not sufficiently close to be predictive. However, the accuracy of broadband ultrasound attenuation in discriminating between normal subjects and patients with vertebral fracture compared very favourably with direct measurements in the spine by dual-photon absorptiometry. 5. Broadband ultrasound attenuation, but not the other measurements, correlated significantly with age in the osteoporotic patients (r = 0.50, P less than 0.05). 6. These findings may reflect the partial dependence of broadband ultrasound attenuation on the intrinsic trabecular architecture of cancellous bone, the disruption of which contributes to an increase in fracture risk.

A simultaneous outbreak of respiratory syncytial virus and parainfluenza virus type 3 in a newborn nursery

Over a 3-week period, 20 of 34 (59%) infants in a newborn nursery developed nosocomial viral respiratory tract disease. Either respiratory syncytial virus (seven infants) or parainfluenza virus type 3 (five) or both (two) were demonstrated in respiratory secretions from 14 of the 20 symptomatic patients. Symptoms in the 20 infants included rhinitis (15 infants), cough (14), apnea (eight), pulmonary infiltrates (seven), and fever (six). There were no differences in symptoms between children infected with respiratory syncytial virus alone, with parainfluenza virus alone, or with both viruses concurrently. Patients were clustered in the nursery by agent: infants with the same virus tended to share contiguous bed spaces, supporting the concept that parainfluenza virus as well as respiratory syncytial virus can be transmitted from patient to patient. In addition to this risk for contiguous bed spaces, the presence of a nasogastric tube was associated with risk of illness (P less than 0.05). In the presence of a nursery outbreak of respiratory tract disease, more than one virus may circulate concurrently, and an individual patient may be infected simultaneously by more than one virus.

Assessment of broadband ultrasound attenuation in the os calcis in vitro

1. We have examined the relationship between the attenuation of broadband ultrasound in the os calcis in vitro and its bone mineral density measured by quantitative computed tomography and by physical density. 2. Broadband ultrasound attenuation was found to correlate closely with physical density (r = 0.85, P less than 0.0001), but the correlation was less than that observed between quantitative computed tomography and physical density (r = 0.92, P less than 0.0001). Measurements of broadband ultrasound attenuation and quantitative computed tomography were significantly correlated (r = 0.80, P less than 0.0001). 3. Partial correlation analysis showed a significant relationship between broadband ultrasound attenuation and bone density, but when the effect of physical density was taken into account no significant correlation was found between broadband ultrasound attenuation and quantitative computed tomography (r = 0.08, not significant). 4. Broadband ultrasound attenuation in three prospective amputees showed a high degree of concordance between measurements in vivo and in vitro, with no interference by surrounding soft tissues. 5. The correlation between physical density and broadband ultrasound attenuation was independent of quantitative computed tomography, suggesting that the technique measures aspects of density which differ from its mineral density. Broadband ultrasound attenuation holds promise as a reproducible, rapid, radiation-free assessment of skeletal status.

Hormone-induced intercellular signal transfer dissociates cyclic AMP-dependent protein kinase

We used co-cultures of porcine ovarian granulosa cells and mouse adrenocortical tumor cells (Y-1) to examine the kinetics of contact-dependent intercellular signal transfer and to assess the molecular mechanisms employed by this process. Exposure to follicle-stimulating hormone (FSH) caused cAMP-dependent protein kinase dissociation in granulosa cells and, with time, in Y-1 cells if, and only if, they contacted a responding granulosa cell. Y-1 cells close to a granulosa cell but not touching it failed to respond similarly. In reciprocal experiments, co-cultures were stimulated with adrenocorticotropic hormone (ACTH). Y-1 cells dissociated protein kinase as did granulosa cells in contact with Y-1 cells; however, granulosa cells that were not in contact with Y-1 cells failed to respond to the hormone. Fluorogenic steroids were secreted by Y-1 cells cultured alone and stimulated with ACTH, but were not secreted by cultures exposed to FSH. Neither hormone caused fluorogenic steroid production by granulosa cells. On the other hand these steroids were secreted in co-cultures stimulated with ACTH and to a lesser degree in co-cultures exposed to FSH. Autoradiography revealed that I125-FSH bound only to granulosa cells, never to Y-1 cells, even if they were in contact with an ovarian cell. The possibility of cell fusion was tested by experiments in which Y-1 cell membranes were labeled with cationized ferritin. These cells were then placed in co-culture with ovarian granulosa cells that had previously been allowed to ingest latex spheres. At regions of gap junctions between Y-1 and granulosa cells ferritin remained attached to the adrenal cell membrane and was never observed to migrate to the granulosa cell membrane. From these data, we conclude that hormone specific stimulation of one cell type leads to protein kinase dissociation in heterotypic partners only if they contact a hormone responsive cell. This signal transfer is bidirectional, exhibits temporal kinetics and occurs in the absence of apparent cell fusion. The only structural feature connecting Y-1 and granulosa cells were gap junctions implying they provided the communication channels; however, alternative mechanisms cannot be excluded. We have not established the identity of the signal being transferred although cAMP is a logical candidate.

Flavocytochrome P450 BM3: an update on structure and mechanism of a biotechnologically important enzyme

Since its discovery in the 1980s, the fatty acid hydroxylase flavocytochrome P450 (cytochrome P450) BM3 (CYP102A1) from Bacillus megaterium has been adopted as a paradigm for the understanding of structure and mechanism in the P450 superfamily of enzymes. P450 BM3 was the first P450 discovered as a fusion to its redox partner – a eukaryotic-like diflavin reductase. This fact fuelled the interest in soluble P450 BM3 as a model for the mammalian hepatic P450 enzymes, which operate a similar electron transport chain using separate, membrane-embedded P450 and reductase enzymes. Structures of each of the component domains of P450 BM3 have now been resolved and detailed protein engineering and molecular enzymology studies have established roles for several amino acids in, e.g. substrate binding, coenzyme selectivity and catalysis. The potential of P450 BM3 for biotechnological applications has also been recognized, with variants capable of industrially important transformations generated using rational mutagenesis and forced evolution techniques. This paper focuses on recent developments in our understanding of structure and mechanism of this important enzyme and highlights important problems still to be resolved.

Identifying patients with advanced chronic conditions for a progressive palliative care approach: a cross-sectional study of prognostic indicators related to end-of-life trajectories

OBJECTIVES

2 innovative concepts have lately been developed to radically improve the care of patients with advanced chronic conditions (PACC): early identification of palliative care (PC) needs and the 3 end-of-life trajectories in chronic illnesses (acute, intermittent and gradual dwindling). It is not clear (1) what indicators work best for this early identification and (2) if specific clinical indicators exist for each of these trajectories. The objectives of this study are to explore these 2 issues.

SETTING

3 primary care services, an acute care hospital, an intermediate care centre and 4 nursing homes in a mixed urban-rural district in Barcelona, Spain.

PARTICIPANTS

782 patients (61.5% women) with a positive NECPAL CCOMS-ICO test, indicating they might benefit from a PC approach.

OUTCOME MEASURES

The characteristics and distribution of the indicators of the NECPAL CCOMS-ICO tool are analysed with respect to the 3 trajectories and have been arranged by domain (functional, nutritional and cognitive status, emotional problems, geriatric syndromes, social vulnerability and others) and according to their static (severity) and dynamic (progression) properties.

RESULTS

The common indicators associated with early end-of-life identification are functional (44.3%) and nutritional (30.7%) progression, emotional distress (21.9%) and geriatric syndromes (15.7% delirium, 11.2% falls). The rest of the indicators showed differences in the associations per illness trajectories (p<0.05). 48.2% of the total cohort was identified as advanced frailty patients with no advanced disease criteria.

CONCLUSIONS

Dynamic indicators are present in the 3 trajectories and are especially useful to identify PACC for a progressive PC approach purpose. Most of the other indicators are typically associated with a specific trajectory. These findings can help clinicians improve the identification of patients for a palliative approach.

Transcriptional and post-transcriptional control of lysyl oxidase expression in vascular smooth muscle cells: effects of TGF-beta 1 and serum deprivation

Transforming growth factor-beta 1 (TGF-beta 1) markedly reduced cell proliferation and elevated steady state lysyl oxidase (LO) mRNA 3-fold in neonatal rat aorta smooth muscle cells cultured in medium containing 10% fetal bovine serum. The increase in LO mRNA was prevented by the presence of cycloheximide, indicative of controlling events at the level of protein synthesis. The basal level of mRNA in cells proliferating in 10% fetal bovine serum in the absence of TGF-beta 1 was enhanced 7-fold upon decreasing growth by shifting to medium containing 0.5% serum. Changes in LO activity paralleled those in LO mRNA. Nuclear run-on assays revealed that the stimulation of expression in 0.5% serum involved increased gene transcription whereas that caused by TGF-beta 1 was mostly post-transcriptional in origin. LO mRNA was quite labile (t1/2 approximately 3 h) in 10% serum but was markedly stabilized (t1/2 > 12 h) by the presence of TGF-beta 1 in the 10% serum medium. LO mRNA was also considerably more stable under retarded growth conditions (0.5% serum) in the absence of TGF-beta 1. LO promoter activity in luciferase reporter constructs transfected into these cells was low and not significantly affected by the addition of TGF-beta 1 to the 10% serum medium but was markedly elevated by shifting from 10 to 0.5% serum in the absence of TGF-beta 1. Thus, LO expression is inversely correlated with cell proliferation, and is subject to control at transcriptional and post-transcriptional levels. TGF-beta 1 enhances LO expression in these cells by dramatically stabilizing LO mRNA.

Effects of intravenous etidronate disodium on skeletal and calcium metabolism

The induction of hypercalcemia in malignant disease is almost invariably associated with increased bone resorption. However, tumor-induced changes in bone formation and renal tubular resorption of calcium are also important factors that induce hypercalcemia in some patients. In addition, alterations in calcium fluxes to and from the extracellular fluid secondary to hypercalcemia are important in maintaining or aggravating the hypercalcemic effects of increased bone resorption. These factors significantly affect the responses to treatment of hypercalcemia with inhibitors of bone resorption. This study examined the relative importance of these factors and the effects of intravenous etidronate disodium (etidronate) in neoplastic bone disease with and without hypercalcemia and in Paget's disease of bone. It is concluded that intravenous etidronate is an effective inhibitor of bone resorption, which accounts in large measure for its effects on serum calcium concentrations. These studies of etidronate in hypercalcemia suggest the response is sustained for several weeks.

Giant ancient schwannoma of the pelvis

A 43-year-old man with a large ancient schwannoma of the pelvis, presenting with varicose veins, is reported. Ancient schwannoma (neurilemmoma) is a benign tumour of nerve sheath origin characterised histologically by features of severe degeneration and which rarely can grow to a large size. Malignant transformation, though reported, is extremely rare.

Physical functioning, pain and quality of life after amputation for musculoskeletal tumours

Patients who have limb amputation for musculoskeletal tumours are a rare group of cancer survivors. This was a prospective cross-sectional survey of patients from five specialist centres for sarcoma surgery in England. Physical function, pain and quality of life (QOL) outcomes were collected after lower extremity amputation for bone or soft-tissue tumours to evaluate the survivorship experience and inform service provision.

Of 250 patients, 105 (42%) responded between September 2012 and June 2013. From these, completed questionnaires were received from 100 patients with a mean age of 53.6 years (19 to 91). In total 60 (62%) were male and 37 (38%) were female (three not specified). The diagnosis was primary bone sarcoma in 63 and soft-tissue tumour in 37. A total of 20 tumours were located in the hip or pelvis, 31 above the knee, 32 between the knee and ankle and 17 in the ankle or foot. In total 22 had hemipelvectomy, nine hip disarticulation, 35 transfemoral amputation, one knee disarticulation, 30 transtibial amputation, two toe amputations and one rotationplasty. The Toronto Extremity Salvage Score (TESS) differed by amputation level, with poorer scores at higher levels (p < 0.001). Many reported significant pain. In addition, TESS was negatively associated with increasing age, and pain interference scores. QOL for Cancer Survivors was significantly correlated with TESS (p < 0.001). This relationship appeared driven by pain interference scores.

This unprecedented national survey confirms amputation level is linked to physical function, but not QOL or pain measures. Pain and physical function significantly impact on QOL. These results are helpful in managing the expectations of patients about treatment and addressing their complex needs.

Cite this article: Bone Joint J 2015;97-B:1284–90.

A comparative study of imipenem versus piperacillin plus gentamicin in the initial management of febrile neutropenic patients with haematological malignancies

Three-hundred and twelve episodes of fever in 234 neutropenic patients with haematological malignancies were treated empirically with either imipenem or a combination of piperacillin and gentamicin. There were no significant differences in the percentages of patients responding to therapy at either 72 h (59% and 56% of assessable episodes in the imipenem and combination groups respectively) or at the end of treatment (55% and 53% of assessable episodes in the imipenem and combination groups respectively). Patients in the piperacillin plus gentamicin group experienced significantly more renal tubular damage whereas those who received imipenem suffered more nausea or vomiting. We conclude that imipenem monotherapy represents an acceptable alternative to piperacillin plus gentamicin as empirical therapy of the febrile neutropenic patient.

Practice based health needs assessment: use of four methods in a small neighbourhood

OBJECTIVE

To explore the use of four methods to define health needs in a community, with a view to formulating guidelines for practice based assessment of health needs.

DESIGN

Collection of data on health needs for a specific neighbourhood with four complementary methods: rapid participatory appraisal, postal survey, analysis of routinely available small area statistics, and collation of practice held information.

SETTING

Council estate of 670 homes in Edinburgh.

MAIN OUTCOME MEASURES

Description and comparison of health needs found by the different methods.

RESULTS

Each method yielded particular insights into both health and health care needs.

CONCLUSIONS

An extended primary care team with public health support can assess health and health care needs in a neighbourhood by means of a mixture of quantitative and qualitative methods. Different methods may be more suitable to assess different health needs or to explore potential service provision in the community or in primary or secondary care. A composite method may be most informative.