The Impact of Hydroxyethyl Starch Use in Deceased Organ Donors on the Development of Delayed Graft Function in Kidney Transplant Recipients: A Propensity-Adjusted Analysis.

Our objective was to evaluate the impact of hydroxyethyl starch (HES) use in organ donors after neurologic determination of death (DNDD) on recipient renal graft outcomes. The following data elements were prospectively collected for every DNDD managed by a single organ procurement organization from June 2011 to July 2013: demographics; critical care endpoints; treatments, including the use of HES; graft cold ischemia time (CIT); and the occurrence of recipient delayed graft function (DGF, dialysis in the first week after transplantation). Logistic regression was performed to identify independent predictors of DGF with a p-value <0.05. The results were then adjusted for each donor's calculated propensity to receive HES. Nine hundred eighty-six kidneys were transplanted from 529 donors. Forty-two percent received HES (1217 ± 528 mL) and 35% developed DGF. Kidneys from DNDDs who received HES had a higher crude rate of DGF (41% vs. 31%, p < 0.001). After accounting for the propensity to receive HES, independent predictors of DGF were age (OR 1.02 [1.01-1.04] per year), CIT (OR 1.04[1.02-1.06] per hour), creatinine (OR 1.5 [1.32-1.72] per mg/dL) and HES use (OR 1.41 [1.02-1.95]). HES use during donor management was independently associated with a 41% increase in the risk of DGF in kidney transplant recipients.

A biofilm microreactor system for simultaneous electrochemical and nuclear magnetic resonance techniques.

Nuclear magnetic resonance (NMR) techniques are ideally suited for the study of biofilms and for probing their microenvironments because these techniques allow for noninvasive interrogation and in situ monitoring with high resolution. By combining NMR with simultaneous electrochemical techniques, it is possible to sustain and study live biofilms respiring on electrodes. Here, we describe a biofilm microreactor system, including a reusable and a disposable reactor, that allows for simultaneous electrochemical and NMR techniques (EC-NMR) at the microscale. Microreactors were designed with custom radio frequency resonator coils, which allowed for NMR measurements of biofilms growing on polarized gold electrodes. For an example application of this system we grew Geobacter sulfurreducens biofilms on electrodes. EC-NMR was used to investigate growth medium flow velocities and depth-resolved acetate concentration inside the biofilm. As a novel contribution we used Monte Carlo error analysis to estimate the standard deviations of the acetate concentration measurements. Overall, we found that the disposable EC-NMR microreactor provided a 9.7 times better signal-to-noise ratio over the reusable reactor. The EC-NMR biofilm microreactor system can ultimately be used to correlate extracellular electron transfer rates with metabolic reactions and explore extracellular electron transfer mechanisms.

The new SQUID biosusceptometer at Oakland: first year of experience.

Liver iron measurements using biosusceptometers have been validated on two low-TC SQUID (Superconducting Quantum Interference Device) systems (New York and Hamburg) built in the 1980's. Recently, two new instruments have been installed in Torino, Italy (2001), and Oakland, California (2003). The design of the Oakland system is similar to those in Hamburg and Torino. Improvements were made to adjust for significant environmental noise, moreover, an active electronic noise cancellation, a computer controlled water coupling reference system using a pressure feedback and a faster data acquisition system using software lockin amplifiers have been implemented. All 3 systems (Hamburg, Torino, Oakland) are using the same standardized operational protocol. Presented herein are the data collected from 276 patients measured with the SQUID biosusceptometer at Oakland since installation. The results from 149 patients with beta-thalassemia (beta-Thal, age: 2-66 y), 76 patients with sickle-cell disease (SCD, age: 5-55 y), 35 patients with various rare diseases (RD, age: 2-80 y), and 16 patients with hereditary hemochromatosis (HHC, age: 6-74 y) are reported. The liver iron concentration in the different groups are 222 - 7570 (beta-Thal), 518 - 7918 (SCD), 511 - 6234 (RD), 258 - 2041 (HHC) microg/g-liver (in vivo wet weight). The long-term reproducibility (12 months) in a patient on constant treatment regimen demonstrated a mean liver iron of 1141 +/- 133 microg/g-liver. The new SQUID Ferritometer located on the US West coast will give more patients access to this non-invasive liver iron assessment.

Development and implementation of an information management and information technology strategy for improving healthcare services: a case study.

PeaceHealth is a multistate, not-for-profit integrated delivery network that owns and operates five acute care hospitals, one critical access hospital, and twenty-five outpatient clinics. PeaceHealth employs approximately two hundred physicians and seventy allied health professionals; it has relationships with one thousand affiliated physicians. In 1990, PeaceHealth developed a set of strategic priorities for delivering seamless care across the continuum, and creating partnerships between caregivers and patient-consumers. A major component of these strategies was development and implementation of the technology, knowledge, organizational, and community infrastructures that would support delivering and using high-quality, timely information when and where it is needed for effective clinical, operational, and financial decision making. Executing this strategy has resulted in implementation of standard enterprisewide information systems, including a computer-based patient record system in inpatient and outpatient settings, tactical and strategic decision support systems, a well-developed intranet and access to the Internet, and a knowledgeable workforce that have enabled PeaceHealth to support and improve its services and business by bringing interactive information directly to patients, caregivers, managers, directors, and executives. This case study discusses the drivers behind the development of this strategy, specific components of the information management and information technology infrastructure, examples of the impact they have had on patients, caregivers, and the organization, and lessons learned.

DOCK 4.0: search strategies for automated molecular docking of flexible molecule databases.

In this paper we describe the search strategies developed for docking flexible molecules to macomolecular sites that are incorporated into the widely distributed DOCK software, version 4.0. The search strategies include incremental construction and random conformation search and utilize the existing Coulombic and Lennard-Jones grid-based scoring function. The incremental construction strategy is tested with a panel of 15 crystallographic testcases, created from 12 unique complexes whose ligands vary in size and flexibility. For all testcases, at least one docked position is generated within 2 A of the crystallographic position. For 7 of 15 testcases, the top scoring position is also within 2 A of the crystallographic position. The algorithm is fast enough to successfully dock a few testcases within seconds and most within 100 s. The incremental construction and the random search strategy are evaluated as database docking techniques with a database of 51 molecules docked to two of the crystallographic testcases. Incremental construction outperforms random search and is fast enough to reliably rank the database of compounds within 15 s per molecule on an SGI R10000 cpu.

Two paraneoplastic syndromes in a patient with ovarian cancer: nephrotic syndrome and paraneoplastic cerebellar degeneration.

BACKGROUND: A paraneoplastic syndrome-a rare, indirect system disturbance located distant from a neoplasm-has been reported in association with ovarian cancer. CASE: Two paraneoplastic syndromes-nephrotic syndrome and paraneoplastic cerebellar degeneration (PCD)-developed in a patient who had no symptoms from ovarian cancer. She presented with the nephrotic syndrome. Evaluation for metastasis, including computed tomography (CT) scan and ultrasonography, showed a slightly enlarged right ovary and a 2-cm lower paraaortic lymph node on the right side. A 5-cm ovarian mass and multiple paraaortic lymph nodes were excised, and six cycles of carboplatin and paclitaxel were given. Nephrotic syndrome symptoms had greatly subsided at 6 weeks after surgery. At 7 months after surgery, symptoms of PCD developed yet CT, CA-125 levels, and physical examination showed no evidence of ovarian cancer. CONCLUSION: To our knowledge, development of two paraneoplastic syndromes in one patient with ovarian cancer has not been reported. Nephrotic syndrome resolved with treatment of the neoplasm whereas PCD did not.

Safety, feasibility, and efficacy of a resistance training program in preadolescent obese children.

BACKGROUND: Safe and effective exercise programs are needed to prevent and treat chronic diseases in childhood. In particular, preadolescent obese children should participate in activities that are specific to their special needs. Resistance or strength training has been prescribed for adult obese persons. Research is limited concerning the use of resistance training in programs that treat obese preadolescents. METHODS: Nineteen treatment subjects (7-12 years of age) were enrolled in a 10-week weight management program which included diet, behavior modification, and aerobic and flexibility exercises. Forty-eight control subjects (7-12 years of age) participated in the diet, behavior modification program, and a thrice-a-week walking program. The efficacy of the overall weight management program was examined by anthropometry at 10 weeks and 1 year. RESULTS: Fifteen treatment subjects completed the 10-week program (retention rate, 78.9%). Thereafter compliance decreased by approximately 33% for the long-term study. Seventeen control subjects completed the program (retention rate, 35%). Weight, percent of ideal body weight, and body mass index were reduced significantly at 10 weeks (P<0.0001) and did not increase significantly at 1-year follow-up in both treatment and control groups. Height increased significantly at 1 year in both treatment and control subjects. In the treatment subjects, percent fat decreased significantly (P<0.001), whereas fat-free mass did not change significantly (P>0.05). CONCLUSIONS: A resistance-training program may be included safely in a multidisciplinary weight management program for obese preadolescent male and female children. The addition of specific exercise regimes such as resistance training may improve program retention especially in severely obese youth.

Effect of clindamycin hydrochloride on oral malodor, plaque, calculus, and gingivitis in dogs with periodontitis.

Periodontal disease is considered the most common disease of dogs and cats. The clinical sign most frequently reported by clients is oral malodor. Clindamycin hydrochloride has been used for several years for the treatment of periodontal disease in both cats and dogs. This study was designed to assess the effect of clindamycin HCl when used in two different post-prophylaxis treatment regimens on oral malodor and periodontal disease in a controlled clinical trial. This study demonstrated that a 5-day postprophylaxis regimen was significantly effective in reducing oral malodor compared with a dental prophylaxis alone. Clindamycin HCl significantly reduced oral malodor from the animals' baseline levels through 42 days. In addition, although no effect was observed on periodontal pocket depth, this treatment regimen also resulted in significant reductions in dental plaque, dental calculus, and gingival bleeding.

DREAM++: flexible docking program for virtual combinatorial libraries.

We present a set of programs, DREAM+2 (Docking and Reaction programs using Efficient seArch Methods written in C++), for docking computationally generated ligands into macromolecular binding sites. DREAM++ is composed of three programs: ORIENT++, REACT++ and SEARCH++. The program ORIENT++ positions molecules in a binding site with the DOCK algorithm. Its output can be used as input to REACT++ and SEARCH+2. The program REACT++ performs user-specific chemical reactions on a docked molecule, so that reaction products can be evaluated for three dimensional complementarity with the macromolecular site. The program SEARCH++ performs an efficient conformation search on the reaction products using a hybrid backtrack and incremental construction algorithm. We have applied the programs to HIV protease-inhibitor complexes as test systems. We found that we can differentiate high-affinity ligands based on several measures: interaction energies, occupancy of protein subsites and the number of successfully docked conformations for each product. Encouraged by the results in the test case, we applied the programs to propose novel inhibitors of HIV protease. These inhibitors can be generated by organic reactions using commercially available reagents. They are alternatives to the inhibitors synthesized by Glaxo.

High dose rate transperineal interstitial brachytherapy for cervical cancer: high pelvic control and low complication rates.

PURPOSE: To report the clinical outcome for cervical carcinoma treated with external beam pelvic radiotherapy and interstitial high dose rate (IS-HDR) brachytherapy. METHODS AND MATERIALS: Between July 1991 and June 1996, 62 patients with locally advanced stage cervical carcinoma or early stage carcinoma that precluded satisfactory tandem and ovoid insertion were treated. Most patients received 36 Gy (range: 25 Gy-45 Gy) external beam radiotherapy (EBRT) to the pelvis prior to brachytherapy implant. EBRT was continued, with central shielding, to a dose of 50 Gy to the pelvic sidewalls. HDR Iridium-192 brachytherapy was given in 6 fractions of 5.5 to 6.0 Gy. The mean follow-up was 40 months. RESULTS: Stage distribution was: Stage IB (12), Stage IIA (1), Stage IIB (26), Stage IIIA (6), Stage IIIB (13), and Stage IVA (4). The overall local tumor control was 94%. Local control rates by FIGO stage were Stage I (12/12) 100%, Stage II (25/27) 93%, Stage III (18/19) 95%, and Stage IV (3/4) 75%. The regional pelvic control rates were overall 81%, Stage I (12/12) 100%, Stage II (22/27) 81%, Stage III (15/19) 79%, and Stage IV (1/4) 25%. Distant metastasis developed in 20 patients (32%). The actuarial 5-year disease-free survival was for all patients 48%, Stage I 81%, Stage II 47%, Stage III 39%, and Stage IV O%. Grade 3-4 delayed morbidity resulting from treatment, occurred in 6.5% (4/62) of patients. A fistula without local recurrence occurred in 1.6% (1/62) patients. CONCLUSIONS: We report excellent local and regional pelvic control results using a 6 fraction IS-HDR brachytherapy protocol for cervical carcinoma. The incidence of severe complications is low and suggests that a consistent brachytherapy technique and multiple HDR fractions are therapeutically advantageous to patients treated for cervical carcinoma.

Inclusion of resistance exercise in a multidisciplinary outpatient treatment program for preadolescent obese children.

BACKGROUND: Safe and effective exercise programs are needed to prevent and treat chronic diseases in childhood. In particular, preadolescent obese children should participate in activities that are specific to their special needs. METHODS: We included a moderate intensity, progressive resistance training program in a multidisciplinary weight management program for obese preadolescent children. The program included diet, behavior modification, and aerobic and flexibility exercises. RESULTS: The subjects reported no accidents or injuries and 100% compliance with the minimum required exercise prescription. Weight, percent ideal body weight, body mass index, and percent fat were reduced significantly at 10 weeks and did not increase significantly at 1 year follow-up. Height and lean body mass increased significantly at 1 year. CONCLUSION: A resistance training program may be safely included in a multidisciplinary weight management program for obese preadolescent children.

Potent, low-molecular-weight non-peptide inhibitors of malarial aspartyl protease plasmepsin II.

A number of single-digit nanomolar, low-molecular-weight plasmepsin II aspartyl protease inhibitors have been identified using combinatorial chemistry and structure-based design. By identifying multiple, small-molecule inhibitors using the parallel synthesis of several focused libraries, it was possible to select for compounds with desirable characteristics including enzyme specificity and minimal binding to serum proteins. The best inhibitors identified have Ki's of 2-10 nM, molecular weights between 594 and 650 Da, between 3- and 15-fold selectivity toward plasmepsin II over cathepsin D, the most closely related human protease, good calculated log P values (2.86-4.56), and no apparent binding to human serum albumin at 1 mg/mL in an in vitro assay. These compounds represent the most potent non-peptide plasmepsin II inhibitors reported to date.

CombiDOCK: structure-based combinatorial docking and library design.

We have developed a strategy for efficiently docking a large combinatorial library into a target receptor. For each scaffold orientation, all potential fragments are attached to the scaffold, their interactions with the receptor are individually scored and factorial combinations of fragments are constructed. To test its effectiveness, this approach is compared to two simple control algorithms. Our method is more efficient than the controls at selecting best scoring molecules and at selecting fragments for the construction of an exhaustive combinatorial library. We also carried out a retrospective analysis of the experimental results of a 10 x 10 x 10 exhaustive combinatorial library. An enrichment factor of approximately 4 was found for identifying the compounds in the library that are active at 330 nM.

Structure-based design and combinatorial chemistry yield low nanomolar inhibitors of cathepsin D.

BACKGROUND: The identification of potent small molecule ligands to receptors and enzymes is one of the major goals of chemical and biological research. Two powerful new tools that can be used in these efforts are combinatorial chemistry and structure-based design. Here we address how to join these methods in a design protocol that produces libraries of compounds that are directed against specific macromolecular targets. The aspartyl class of proteases, which is involved in numerous biological processes, was chosen to demonstrate this effective procedure. RESULTS: Using cathepsin D, a prototypical aspartyl protease, a number of low nanomolar inhibitors were rapidly identified. Although cathepsin D is implicated in a number of therapeutically relevant processes, potent nonpeptide inhibitors have not been reported previously. The libraries, synthesized on solid support, displayed nonpeptide functionality about the (hydroxyethyl)amine isostere. The (hydroxyethyl)amine isostere, which targets the aspartyl protease class, is a stable mimetic of the tetrahedral intermediate of amide hydrolysis. Structure-based design, using the crystal structure of cathepsin D complexed with the peptide-based natural product pepstatin, was used to select the building blocks for the library synthesis. The library yielded a 'hit rate' of 6-7% at 1 microM inhibitor concentrations, with the most potent compound having a Ki value of 73 nM. More potent, nonpeptide inhibitors (Ki = 9-15 nM) of cathepsin D were rapidly identified by synthesizing and screening a small second generation library. CONCLUSIONS: The success of these studies clearly demonstrates the power of coupling the complementary methods of combinatorial chemistry and structure-based design. We anticipate that the general approaches described here will be successful for other members of the aspartyl protease class and for many other enzyme classes.

New molecular shape descriptors: application in database screening.

Geometric descriptors are becoming popular tools for encoding molecular shape, for use in database screening and clustering calculations. They provide condensed representations of complex objects and, as a consequence, can usually be compared quite rapidly. Here we present a number of new descriptors and methods for the quantification of molecular shape similarity. The techniques are tested using two different biological systems, with particular emphasis on their potential utility as methods for prescreening shape-based database searches. Results are compared with data sets produced using the DOCK program. We find that such similarity evaluations are useful for finding molecules with complementary shape, and that they contain an enriched number of potential DOCK hits when compared to the original databases. Significant limitations in the utility of such DOCK prescreens are discussed, and potential solutions are considered.

Protein synthesis in splanchnic tissues of sheep offered two levels of intake.

Protein synthesis rates were measured in liver and gastrointestinal tract (GIT) sections of fattening sheep offered lucerne (Medicago sativa) pellets at either 1.25 or 2 times energy maintenance. The measurement technique involved a large dose of [1-13C]valine over 60 min. Animals on the higher intake had a larger mass of liver protein (143 v. 100 g, P = 0.02), similar fractional synthesis rates (ks; 22.5 v. 22.1%/d, not significant) and greater absolute amounts of protein synthesis (32 v. 23 g/d; P = 0.016) compared with those on the smaller amount of ration. The ks values and RNA: protein in the GIT sections also tended to increase with food intake. Estimated total GIT protein synthesis was approximately three-fold that in liver and probably constituted 25-35% of whole body synthesis. All splanchnic tissues measured had lower translational efficiencies (g protein synthesized/d per g total RNA) than reported for milk-fed and newly-weaned lambs and this may relate to the decline in the rate of protein deposition as lambs progress to the fattening condition.

Paget's disease of the vulva treated by combined surgery and laser.

Six patients with Paget's disease of the vulva, four after local excision of the gross lesion, one after multiple biopsies, and one after a radical vulvectomy, were successfully treated using the CO2 laser. Biopsy specimens 2 cm peripheral to the excised gross lesion were used in four of the patients in planning subsequent laser treatment. Two patients were admitted to the hospital because they had hysterectomies necessitated by endometrial cancer at the time of the wide local excision. A third patient was admitted twice: initially for a radical vulvectomy and subsequently for laser vaporization and simple hysterectomy for vaginal prolapse. Local excision and the subsequent laser treatment can usually be done on an outpatient basis. Use of skin grafts was avoided in all cases. There have been no recurrences in follow-up periods ranging from 4 months to 4 1/2 years.