Acute pulmonary oedema with normal left ventricular function in a patient with resistant hypertension--what is the likely diagnosis?

We report the case of a 75-year old woman who presented with shortness of breath and haemoptysis. She had been treated for presumed essential hypertension for many years. On admission she was found to be severely hypertensive. Chest X-ray showed pulmonary oedema. However, an echocardiogram reported good systolic ventricular function. Her hypertension and pulmonary oedema did not respond to medical treatment necessitating intubation. A CT angiogram identified the cause--undiagnosed bilateral severe. We discuss this increasingly common condition that is difficult to manage and easily missed.

Age-dependent poliomyelitis in mice is associated with respiratory failure and viral replication in the central nervous system and lung.

Age-dependent poliomyelitis (ADPM) is a virally induced neuroparalytic disease of mice and a model for amyotrophic lateral sclerosis (ALS). ADPM is triggered in genetically susceptible mice by immunosuppression and infection with lactate dehydrogenase-elevating virus (LDV). Both ADPM and ALS are characterized by progressive degeneration of anterior horn motor neurons, and death in ALS is usually associated with respiratory failure. To assess respiratory function in ADPM, we investigated ventilation in conscious control and LDV-infected C58/J mice breathing air and then 6.5% CO(2) in O(2). Three days after LDV infection, ventilation in response to CO(2) was half of that compared to the uninfected state, but become normalized by 10 days. Administration of cyclophosphamide alone (200 mg/kg, ip), an immunosuppressant, had no effect on ventilation. Induction of ADPM by concomitant administration of LDV to cyclophosphamide-treated mice resulted in altered gait, hindlimb paralysis, wasting, decreased metabolism, and decreased body temperature by 4 degrees C relative to controls. Compared to baseline values, mice with ADPM had decreased tidal volume and ventilation while breathing air, and while exposed to the CO(2) challenge they were unable to increase tidal volume, frequency of breathing, or ventilation. Using in situ hybridization, LDV replication was noted within the spinal cord, brain, and lung, but not in the diaphragm. Thus, respiratory failure is a contributory mechanism leading to death in ADPM and is associated with LDV replication in the CNS and lung. This animal model may be useful to investigate physiological and molecular mechanisms associated with the development of respiratory failure in neurodegenerative diseases.

Prostaglandin E2 suppressed IL-15-mediated human NK cell function through down-regulation of common gamma-chain.

NK cell function is regulated by cytokines and certain biochemical mediators in a positive or negative manner. This study was performed to investigate the suppressive effects of PGE(2) on IL-15-activated human NK cell function. Purified NK cells were cultured with 200 ng/ml IL-15 for 2 days in the presence or absence of 10-200 ng/ml PGE(2). PGE(2) significantly suppressed NK cell-mediated cytotoxicity and IFN-gamma production at the secretional and the transcriptional levels. We also evaluated the effect of PGE(2) on the IL-15R complex that consists of IL-2Rbeta, common gamma-chain (gamma(c)-chain), and a specific chain IL-15Ralpha. Percentage of positive cells and number of binding sites for gamma(c)-chain were significantly increased after IL-15 treatment; however, a substantial decrease was observed with PGE(2) cotreatment. In contrast, constitutive expression of IL-2Rbeta was significantly decreased after IL-15 treatment, with no change detected in the presence of PGE(2.) At the transcriptional level, neither IL-15 nor PGE(2) had significant effects on the expression of beta- or gamma(c)-chains. There was a 3-fold increase in the expression of IL-15Ralpha at the transcriptional level that peaked at 8 h after IL-15 treatment; however, PGE(2) had no significant effect. Suppression of NK function by PGE(2) was not due to the endogenous production of IL-4, IL-10, or TGF-beta(1) by NK cells. These results suggest that down-regulation of surface expression of gamma(c)-chain on NK cells may be one mechanism through which PGE(2) mediates suppression of IL-15-activated NK cell function.

Trauma patients with positive cultures have higher levels of circulating macrophage migration inhibitory factor (MIF).

Macrophage migration inhibitory factor (MIF) is a pituitary "stress" hormone that plays a critical role in the host immune response. The aims of the study were to determine whether MIF was detectable in the circulation of trauma patients, to assess whether MIF levels were associated with injury severity, days post injury, infection, and to examine concentrations of other pro-inflammatory cytokines in circulation. We collected plasma samples from 35 trauma (multiple injury) patients and 18 healthy controls. Concentrations of MIF, TNF-alpha, IL-1beta, and IL-6 were measured by ELISA. Average MIF concentration in plasma of trauma patients was 14 fold higher than that of healthy controls (19,439+/-2,615 pg/ml in trauma vs 1,337+/-286 pg/ml in control; p=0.0002). There was no correlation between MIF values and injury severity score or days post injury. Average level of IL-6 in trauma patients was 587+/-85 pg/ml but was not correlated with MIF concentration. TNF-alpha and IL-1beta were not detectable in trauma patients or healthy controls. Higher MIF levels were associated with positive cultures (blood, urine, sputum, wound). These data suggest that MIF may be a possible indicator of infection in trauma patients.

Mechanism of suppression of natural killer cell activity in trauma patients.

Trauma patients develop a severe immunosuppression that includes suppression of natural killer (NK) cell activity although numbers of NK cells are not reduced. The mechanism of suppression of NK cell activity after major trauma is not known. The aim of the present study was to investigate the in vitro effect of plasma samples from trauma patients (TP) on the cytotoxic activity of normal NK cells. Buffycoat mononuclear cells (5x10(5)/well) were preincubated with either TP or plasma samples from age and sex matched healthy controls (CP) for 0, 16 or 40 h. These effector cells were then cultured with 51Cr labeled K-562 cells (2x10(4)/well) for 4 h at 37 degrees C and % lysis was calculated. No significant differences in % lysis between CP and TP were found with 0 or 16 h preincubation, however 40 h preincubation with TP severely suppressed NK cell function (p=0.003) as compared to preincubation with CP for the same period. Addition of neutralizing anti-IL-4, anti-TGF-beta1, or anti-IL-10 antibodies did not reverse the NK cell suppression. There was a partial reversal of NK cell suppression by catalase but not by SOD or L-NMMA. Removal of monocytes from buffycoat mononuclear cells also significantly reversed the NK cell suppression. These data suggest that suppression of NK cell activity in trauma patients may be an accessory cell dependent phenomenon and may partially depend on production of reactive oxygen metabolites (ROM).

Suppression of natural killer cell activity in patients with fracture/soft tissue injury.

BACKGROUND: Natural killer cells (NKCs) participate in "innate" cell-mediated immunity. Fracture/soft tissue injuries are cytokine rich and may influence cell-mediated immunity. OBJECTIVE: To study the effects of fracture cytokines on NKC function. DESIGN: A case-control study. SETTING: A level I trauma center and laboratory in a university medical center. PARTICIPANTS: Patients requiring open fracture fixation and healthy volunteers. INTERVENTIONS: Fracture supernatants and peripheral plasma were collected during open fracture fixation. Volunteer mononuclear cells were used as effector (NKC) sources. Mononuclear cells were preincubated with fracture supernatants, paired peripheral plasma, or normal plasma under various conditions. MAIN OUTCOME MEASURES: Natural killer cell lysis of K562 target cells was assessed by chromium 51 release. RESULTS: Fracture supernatants suppressed NKC function more rapidly than peripheral plasma. Fracture supernatants from 1 to 4 days after injury were most suppressive. Inactivation of complement and reactive oxygen species failed to restore lysis. Neutralizing antibodies to interleukin 4 and interleukin 10 further suppressed lysis. Antibodies to transforming growth factor beta1 failed to restore lysis. The addition of interferon gamma did not restore lysis but the addition of interleukin 12 did. CONCLUSIONS: Fracture supernatants and peripheral plasma from patients with fractures suppress NKCs. The responsible mediators may be concentrated in fracture/soft tissue injuries. Responses to manipulation of the cytokine environment suggest that fracture cytokines may impair cooperation between NKCs and accessory cells.

A controlled study of anxiety and morbid cognitions at initial screening for human immunodeficiency virus (HIV) in a cohort of people with haemophilia.

AIM: This study examines the relationship between anxiety, psychological state and Human Immunodeficiency Virus (HIV) stages as defined by the Centers for Disease Control at the time of initial screening for HIV in a cohort of people with haemophilia who were at risk of prior exposure to HIV transmission from blood products. METHOD: Psychological scores, immunological measures, and clinical data from case notes for 116 potentially HIV exposed people with haemophilia attending initial screening for HIV infection in 1984-1985, were used to examine the relationship between psychological variables, clinical state and their clinical classification under the Centres for Disease Control categorization. Psychometric test results were obtained for 63 HIV seronegative patients and 53 HIV seropositive patients. Planned comparisons, multiple and logistic regressions, were used to explain observed differences between seronegative and seropositive subjects. The potential confounders of sex, age, severity of haemophilia, haemophilia type and blood product usage were controlled. RESULTS: The major finding of this study was that higher levels of State Anxiety at the time of initial screening for HIV, were observed in those patients who lacked recognized symptoms of HIV infection and were seropositive, compared with seronegative subjects. The State Anxiety scores were predicted by HIV infection or alternatively CD4+ T-cell levels. CONCLUSION: The findings of this study suggest that HIV infection can produce psychological effects prior to any physical symptoms of infection being apparent.

Incidental depiction of cigarettes and smoking in Australian magazines, 1990-1993.

The study aimed to assess evidence of any increase in apparently incidental photographic depictions of cigarettes or smoking in Australian magazines following the ban on tobacco advertising in the print media introduced in January 1991. We examined 27,704 pages in 20 Australian magazines popular among young people or aimed at low socioeconomic groups during three sample periods in 1990 (before the ban), 1991 and 1993 (after the ban). All photographs showing cigarettes or smoking were counted and a smoking rate per page was calculated. When all 20 magazines were combined, there was a 75 per cent increase in the rate of photographs of smoking per page from 1990 (six months before the ban) to 1991 (six months after the ban). However, there was a reduction of 36 per cent in the rate of smoking photographs per page between 1991 and 1993 (18 months after the ban) and a nonsignificant increase of 12 per cent across the three sample periods. Photographs of smoking are infrequent in Australian magazines (mean: 1:147 pages, range: 1:17 pages to zero). There appears to be a commendable constraint by many Australian magazine editors in limiting the publication of photographs that show smoking or cigarettes. Some magazines never show smoking, indicating that a goal of total absence of photographs of smoking is achievable. Some magazines have room for improvement.

Computer-based interaction analysis of the cancer consultation.

There are few data available on which to base recommendations for effective communication in the cancer consultation. This paper describes a computerised interaction analysis system designed specifically for the cancer consultation and its application in a study investigating the relationship between doctor-patient behaviour and patient outcomes. One hundred and forty-two cancer patients attending their first consultation with a cancer specialist were audio taped and a copy of the tape was retained for interaction analysis. Before the consultation patient anxiety and information and involvement preferences were measured. Outcomes included recall of information, patient satisfaction with the consultation and psychological adjustment to cancer. Doctor behaviour was shown to vary significantly according to the age, sex, involvement preferences and in/out-patient status of the patient. The ratio of doctor to patient talk was related to satisfaction with communication, while patients whose questions were answered showed better psychological adjustment at follow-up. The results suggest that patient-centred consultations lead to improved satisfaction and psychological adjustment. These data provide precise information about consultation behaviour which can be used in the documentation of current practice and the evaluation of new interventions to improve communication.

A model to study the transport function of the intestinal viscera during peritoneal dialysis.

A preparation was developed to selectively study the transport properties of the intestinal viscera. A rat was positioned prone on a 100-mL beaker (reservoir) and the viscera were completely immersed and suspended without tension in dialysate solution maintained at 37 degrees C. A volume of 11.6 +/- 0.9 mL was ultrafiltered over a period of 180 minutes with a 5.6% glucose dialysate solution (n = 5) versus 0.5 +/- 0.5 mL for a 1.5% hydrous glucose dialysate solution (n = 4). The suspended viscera were able to absorb glucose from the beaker. The viscera absorbed more glucose when they were suspended in a higher glucose concentration: 922 +/- 46 mg for the 5.6% solution (54% of the initial glucose present) and 151 +/- 13 mg for the 1.5% solution (39% of the initial glucose present). Protein was found to leak from the viscera, and the amount found in dialysate was not related to the concentration of glucose used as dialysate (75 +/- 25 mg for the 5.6% solution and 41 +/- 3 mg for the 1.5% solution; P = NS). Studies also demonstrated transport from blood into the dialysate and that transport into dialysate could be altered by altering visceral blood supply (intravenous infusion of antidiuretic hormone, 800 micrograms/hr). Urea and glucose clearances were greater in the absence of antidiuretic hormone, whereas creatinine and inulin clearances were not different in both groups. This model offers the potential to selectively study the responses of the visceral peritoneum.

Patient participation in the cancer consultation: evaluation of a question prompt sheet.

BACKGROUND: Active participation and asking questions are important ways in which patients can ensure they understand what the doctor has said. This study evaluated a question prompt sheet designed to encourage patients to ask questions in the cancer consultation. PATIENTS AND METHODS: Patients (n = 142) were randomised to receive (i) a question prompt sheet or (ii) a general sheet informing patients of services available through the regional Cancer Council. Recall of information was assessed in a structured interview 4-20 days after the consultation. Questionnaires to assess patient satisfaction and adjustment to cancer were sent by mail. RESULTS: The question prompt sheet had a significant effect in one content area: prognosis. Thirty-five percent of patients who received the question handout asked questions about prognosis compared to 16% of those receiving the information handout. The prompt sheet did not increase the mean number of questions asked overall. Age, in/out-patient status, gender and involvement preference were predictive of both number and duration of patient questions. CONCLUSIONS: A question prompt sheet has a limited but important effect on patient question asking behaviour in the cancer consultation.

General information tapes inhibit recall of the cancer consultation.

PURPOSE: Studies of tape recordings of cancer consultations have produced conflicting results. At the same time, audiotapes containing general information about cancer are poorly evaluated and are distributed to patients in an ad hoc manner. We compared the effects of both interventions on patient satisfaction, psychologic adjustment, and recall of information following their first consultation with a medical oncologist. PATIENTS AND METHODS: Patients (n = 142) were randomized to receive (1) an audiotape of their consultation, (2) an audiotape describing cancer in general terms, or (3) no tape. Recall of information was assessed in a structured interview 4 to 20 days after the consultation. RESULTS: Satisfaction with the consultation increased linearly from no tape to general tape to consultation tape. Satisfaction with the tape itself was higher in patients who received the consultation tape (satisfaction score, 61%) compared with those who received the general tape (43%). Average recall for all groups was 6.4 of the 25 items of information presented, and 2.4 of the six points identified as particularly important by the oncologist. The consultation tape did not improve recall over the no tape control, but the general tape caused a decrease of almost two items in total recall. Spontaneous (ie, unprompted) recall was significantly poorer with the general information tape. Psychologic adjustment to cancer was unaffected. CONCLUSION: We conclude that individual audiotapes have a limited potential to increase recall of information from the oncology consultation. General information tapes about cancer appear to inhibit recall actively.

An analysis of ultrafiltration during acute peritoneal dialysis in rats.

Transport into and from the peritoneal cavity is effected through separate membranes. Peritoneal function is the sum of the contributions of these membranes. The peritoneal dialysis membranes are defined as intestinal viscera and mesentery, parietal lining membrane, and liver and diaphragm. The present study was undertaken to determine which of these membranes participate in ultrafiltration during peritoneal dialysis. Studies were performed in rats using a hypertonic (1200 mOsm/L) dialysate solution containing 5.6% glucose, 2.8% amino acid, and electrolytes. Both intact and eviscerated rats were studied. The experiments were repeated in animals whose diaphragms were fibrotic and densely adherent to liver. Preparation of the diaphragm did not impact upon ultrafiltration. Ultrafiltration in controls (54 vs. 56 ml with and without a fibrotic diaphragm respectively) and in eviscerated groups (44 vs. 45 ml with and without a fibrotic diaphragm respectively) were not significantly different. However, controls had significantly more ultrafiltration than did eviscerated animals (p less than 0.01). The parietal viscera accounted for 56-59% of the ultrafiltration. This study demonstrates that both the intestinal viscera and parietal walls participate in ultrafiltration.

Intraperitoneal insulin--a dose response curve.

To determine a dose response curve for intraperitoneal (i.p.) insulin using Sprague-Dawley rats, human insulin was administered i.p. in 1.5% glucose dialysate at the following doses: 10 U (2.19 U/100 g body wt); 5U (1.23 U/100 g body wt); 2 U (0.49 U/100 g body wt); 1 U (0.27 U/100 g body wt). A bolus injection of glucose was given to elevate blood sugar, followed by infusion of D20%. Blood sugar was maintained at 250 mg/dl by checking at 10 minute intervals and adjusting the IV infusion. Dialysate with regular insulin was instilled after blood sugar was constant for 20 minutes. The end-point was the amount of glucose to maintain a blood sugar of 250 mg/dl after instillation of dialysate and regular insulin. Mean blood sugars were similar within and between each dose group. The effect of regular insulin was noted within 10 minutes. The amount of glucose used with the IV dose differed from all other (p less than 0.05). The amount used by the 5 and 10 U doses of i.p. insulin were similar. Increasing amounts of glucose are required to maintain the blood sugar at increasing doses of intraperitoneal regular insulin up to 5 U. Thus, there appears to be a dose response curve for i.p. insulin.

The minimal importance of the hollow viscera to peritoneal transport during peritoneal dialysis in the rat.

The authors investigated whether the abdominal viscera are important surfaces for peritoneal transport by performing peritoneal dialysis in rats without their abdominal viscera and again when the parietal walls were shielded from contact with dialysate. Urea, creatinine, glucose, and inulin were added to the peritoneal cavity and the percentage of the administered dose absorbed was calculated. Controls with and without parietal shields only absorbed 11% more urea and creatinine, 5-15% more glucose, and 7-12% more inulin, respectively, than eviscerated rats. The findings raise the possibility that the abdominal contents do not account for most of peritoneal transport.

Measurements of peritoneal surface area in man and rat.

The peritoneal dialysis system is composed of unique membranes. To better understand the contribution of these membranes to peritoneal transport, the peritoneal surface areas were measured in human subjects and rats.

Intraperitoneal feeding.

This study evaluated the peritoneal cavity as the sole route for alimentation in 300 g growing rats. Initial studies demonstrated that a solution of high osmolality was required to provide sufficient calories. A nutrient solution was formulated by mixing 20% glucose with electrolytes (10 ml) and 8.5% amino acids with electrolytes (20 ml). Instilling 30 ml of nutrient solution induced an IP volume of 60 ml, which was absorbed in 24 hours. Rats were studied in four groups for 7 days. One group received nutrient solution IP (n = 10); a second group received the same amount PO (n = 10); the third group received electrolytes IP (n = 10); and a fourth group was fed rat chow PO (n = 10). Rats fed this nutrient solution (IP and PO) were acclimatized by administering one third of their required nutrient the first 4 days. On the next 3 days they received two thirds of their required nutrient. Both groups fed nutrient solution (IP and PO) lost 23% body weight. Electrolyte and rat chow fed groups lost 26% and gained 8% of body weight, respectively. Due to the high osmolality (1200 mOsm/L) of this nutrient solution, sufficient food could not be delivered via the peritoneal cavity to adequately feed growing rats. Studies were then initiated to formulate another nutrient solution that contained lipids. This solution (678 mOms/L) contained 20% glucose with electrolytes (10 mls), 8.5% amino acids with electrolytes (20 ml), and 10% lipids without electrolytes (30 ml). Glucose and amino acids contained the same electrolyte concentration.(ABSTRACT TRUNCATED AT 250 WORDS)