Markers of coagulation activation and acute kidney injury in patients after hematopoietic cell transplantation.

Acute kidney injury (AKI) is common after hematopoietic cell transplant (HCT). The etiology of AKI is unknown because biopsies are rarely performed. The pathophysiology of injury is inferred from clinical data. Thrombotic microangiopathy (TMA) is often invoked as the cause of renal injury. Patients >2 years old undergoing their first HCT at Fred Hutchinson Cancer Research Center participated in this study. We prospectively measured plasma markers of coagulation activation, (PAI-1 and tPA) and fibrinolyis (D-dimer) weekly in 149 patients during the first 100 days post transplant. Cox proportional hazards modeling was used to determine associations between these markers and AKI (doubling of baseline serum creatinine). Kruskal-Wallis test was used to determine the associations between day 100 urinary albumin to creatinine ratios and these markers. Thirty one percent of patients developed AKI. Though elevations in these markers occurred frequently, neither PAI-1 nor tPA were associated with the development of AKI. D-dimer was associated with a slightly increased risk of AKI (relative risk=1.76; P-value 0.04). None of these markers were associated with micro- or macroalbuminuria at day 100. The lack of an association with AKI suggests that endothelial injury in the form of TMA is not a common cause of AKI early after transplant.

Smoking abstinence-related expectancies among American Indians, African Americans, and women: potential mechanisms of tobacco-related disparities.

Research has documented tobacco-related health disparities by race and gender. Prior research, however, has not examined expectancies about the smoking cessation process (i.e., abstinence-related expectancies) as potential contributors to tobacco-related disparities in special populations. This cross-sectional study compared abstinence-related expectancies between American Indian (n = 87), African American (n = 151), and White (n = 185) smokers, and between women (n = 231) and men (n = 270) smokers. Abstinence-related expectancies also were examined as mediators of race and gender relationships with motivation to quit and abstinence self efficacy. Results indicated that American Indians and African Americans were less likely than Whites to expect withdrawal effects, and more likely to expect that quitting would be unproblematic. African Americans also were less likely than Whites to expect smoking cessation interventions to be effective. Compared with men, women were more likely to expect withdrawal effects and weight gain. These expectancy differences mediated race and gender relationships with motivation to quit and abstinence self-efficacy. Findings emphasize potential mechanisms underlying tobacco-related health disparities among American Indians, African Americans, and women and suggest a number of specific approaches for targeting tobacco dependence interventions to these populations.

Prolonged anorexia and elevated plasma cytokine levels following myeloablative allogeneic hematopoietic cell transplant.

Myeloablative conditioning regimens commonly lead to prolonged anorexia and poor oral intake. In a prospective study of 147 patients receiving CY, total body irradiation and allogeneic hematopoietic cells, we determined the extent of decline in oral intake and assessed plasma cytokine levels and development of acute GVHD as explanations for protracted anorexia. For each patient, daily oral caloric intake was expressed as a percent of estimated basal requirements, calculated as basal energy expenditure, through day 20. Oral caloric intake was significantly reduced in 92% of patients and remained low. The nadir in oral intake occurred at days 10-12, when median oral caloric intake was 3% of basal energy requirements. Plasma cytokines known to affect appetite (IL2, IL6, tumor necrosis factor-alpha) were significantly elevated above normal following conditioning therapy (P<0.001 for each cytokine). Acute GVHD did not appear to affect oral intake to transplant day 20 in this cohort of patients; however, plasma levels of IL6 rose steeply before the clinical onset of GVHD. Persistent fever occurred with the greatest frequency in patients with most profound reduction in oral intake. We conclude that prolonged alterations in oral intake following this myeloablative regimen may be related to circulating cytokines known to alter eating behavior.

Increased tumor necrosis factor-alpha production after lipopolysaccharide stimulation of whole blood in patients with previous preterm delivery complicated by intra-amniotic infection or inflammation.

OBJECTIVE: To compare cytokine production after lipopolysaccharide stimulation of whole blood from women who were delivered of infants at term compared with women who were delivered of preterm infants with intra-amniotic evidence of infection or inflammation. STUDY DESIGN: Whole blood samples from 12 women who were not pregnant and who had previously had preterm deliveries before 32 weeks complicated by intra-amniotic infection or inflammation and samples from 12 age- and race-matched control subjects were stimulated with Escherichia coli lipopolysaccharide. Tumor necrosis factor-alpha and interleukin-6 levels were quantified at 6 hours and interleukin-10 at 24 hours by enzyme immunoassay. Results were compared with use of the Wilcoxon rank sum test. RESULTS: Tumor necrosis factor-alpha production was significantly higher in whole blood from women with histories of a preterm birth and intra-amniotic infection or inflammation (11,243 +/- 1030 pg/mL [mean +/- SEM]) compared with control subjects (3649 +/- 349 pg/mL) at a lipopolysaccharide concentration of 1 microg/mL (P =.002). There were no significant differences in interleukin-6 or interleukin-10 production. CONCLUSION: Women with previous early preterm deliveries who had evidence of intra-amniotic infection or inflammation had significantly higher tumor necrosis factor-alpha production after lipopolysaccharide stimulation of whole blood compared with women with previous term deliveries.

Different effects of simple anoxic lactic acidosis and simulated in vivo anoxic acidosis on turtle heart.

We compared responses of turtle heart at 20 degrees C to an anoxic lactic acidosis solution (LA) containing 35 mM lactic acid in an otherwise normal turtle Ringers equilibrated with 3% CO2/97% N2 at pH 7.0) to a solution simulating in vivo anoxic acidosis (VA), with elevated concentrations of lactate, Ca2+, Mg2+, and K+, and decreased Cl-, equilibrated with 10.8% CO2/89.2% N2 at pH 7.0. We examined mechanical properties on cardiac muscle strips and determined intracellular pH (pHi) and high energy phosphates on perfused hearts using 31P-NMR. Maximum active force (Fmax) and the maximum rate of force development (dF/dtmax) of muscle strips were significantly higher during VA than during LA superfusion. An elevation of Ca2+ alone (to 6 mM) in LA significantly increased both Fmax and dF/dtmax but the effects diminished toward the end of the exposure; however, hypercapnic anoxic lactic acidosis (addition of 20 mM HCO3- to LA, equilibrated with 10.8% CO2/89.2% N2, pH 7.0) did not significantly affect Fmax or dF/dtmax. During VA perfusion, pHi (6.73 +/- 0.01) was significantly higher than that during LA perfusion (pHi 6.69 +/- 0.013), but the difference is probably too small to have physiological significance. ATP, creatine phosphate, and inorganic phosphate were not significantly different in the two anoxic solutions. We conclude that the reduction of cardiac mechanical function in vivo is minimized by the integrated effects of changes of ionic concentrations, but the observed changes in Ca2+ and pHi cannot fully explain the effect.

Monocyte/macrophage regulation of coagulant events.

Monocytes/macrophages actively regulate both the assembly and function, as well as the substrate specificity, of various coagulation enzymes at their membrane surface. Regulation is effected through a variety of mechanisms, not limited to, but including the expression of receptors (or 'binding sites') for the various protein constituents of the complexes, the expression of different receptors which may alter the function of the protease, and the expression of membrane proteases which may affect protein cofactor function. Monocyte stimulation with various agonists modulates many of these responses as does their adherence to and differentiation on various substrates.

Effects of input pressure on in vitro turtle heart during anoxia and acidosis: a 31P-NMR study.

In vitro working hearts of the turtle, Chrysemys picta bellii, paced at 30 beats/min, were studied over a range of input pressures in the following sequence of perfusion conditions: control normoxia, control anoxia, lactacidotic normoxia, and lactacidotic anoxia. Two such series of experiments were performed. In series 1 (n = 12), ventricular pressure (PV) and cardiac output were measured, and power output and dPV/dt were calculated. In series 2 (n = 5), intracellular phosphorus metabolites and intracellular pH (pHi) were also measured using 31P-nuclear magnetic resonance (31P-NMR) spectroscopy. In series 1 all mechanical variables increased with input pressure in generally similar fashion, except during anoxic acidosis, during which mechanical performance was depressed and was increased less or not at all by input pressure. Creatine phosphate (CP) and pHi fell significantly in anoxia and anoxic acidosis, but neither these variables, ATP, CP/ATP, nor, presumably, ADP changed as a function of input pressure with any perfusate despite often large increments in mechanical output. We conclude that anoxia and acidosis act synergistically to depress cardiac function in turtle hearts. Also, the insensitivity of NMR variables to changes in input pressure and cardiodynamics suggests that changes in these variables are unimportant for controlling energy turnover in this preparation.

The effect of prolonged anoxia at 3 degrees C on tissue high energy phosphates and phosphodiesters in turtles: a 31P-NMR study.

Selected tissues (skeletal muscle, heart ventrical, and liver), sampled from turtles (Chrysemys picta bellii) at 3 degrees C either under normoxic conditions or after 12 weeks of anoxic submergence were quantitatively analysed for intracellular pH and phosphorus metabolites using 31P-NMR. Plasma was tested for osmolality and for the concentrations of lactate, calcium, and magnesium to confirm anoxic stress. We hypothesized that, in the anoxic animals, tissue ATP levels would be maintained and that the increased osmolality of the body fluids of anoxic turtles would be accounted for by a corresponding increase in the concentrations of phosphodiesters. The responses observed differed among the three tissues. In muscle, ATP was unchanged by anoxia but phosphocreatine was reduced by 80%; in heart, both ATP and phosphocreatine fell by 35-40%. The reduction in phosphocreatine in heart tissue at 3 degrees C was similar to that observed in isolated, perfused working hearts from turtles maintained at 20 degrees C but no decrease in ATP occurred in the latter tissues. In liver, although analyses of several specimens were confounded by line-broadening, neither ATP nor phosphocreatine was detectable in anoxic samples. Phosphosdiesters were detected in amounts sufficient to account for 30% of normoxic cell osmotic concentration in heart and 11% and 12% in liver and muscle, respectively. The phosphodiester levels did not change in anoxia. Heart ventricular phosphodiester levels in turtles at 3 degrees C were significantly higher than those determined for whole hearts from turtles at 20 degrees C.(ABSTRACT TRUNCATED AT 250 WORDS)

31P-NMR study of normoxic and anoxic perfused turtle heart during graded CO2 and lactic acidosis.

We studied the effects of graded acidosis (both CO2 and lactic acid) and anoxia on intracellular pH (pHi) regulation, high-energy phosphates, and mechanical function of isolated perfused hearts of the turtle (Chrysemys picta bellii) at 20 degrees C using 31P-nuclear magnetic resonance (NMR) spectroscopy. During CO2 acidosis, anoxia had no effect on apparent nonbicarbonate buffer value (d[HCO3-]/dpHi = 71 and 89 mM/pH in normoxia and anoxia, respectively) or on pHi regulation (dpHi/dpHe = 0.52 and 0.43 in normoxia and anoxia, respectively, where pHe is extracellular pH). During normoxic lactic acidosis, dpHi/dpHe was similar to the values observed in CO2 acidosis and averaged 0.55 overall. During anoxic lactic acidosis, however, similar regulation occurred over only a narrow range of pHe, and then dpHi/dpHe increased to greater than 1.0 at pHe less than 7.1. Creatine phosphate (CP), calculated as the area of the NMR peak, fell more in response to normoxic CO2 acidosis than to normoxic lactic acidosis; in anoxia, the fall in CP was further increased but to similar extreme levels (10-20% of control) in both acid perfusions. Cardiac output and maximum rate of pressure development each fell during acidosis in similar fashion in all protocols, and the responses were similar in normoxic and anoxic hearts. Heart rate, in contrast, decreased during acidosis, but this effect was more pronounced when hearts were anoxic. We conclude that the effect of acidosis on cardiac function can depend on the type of acidosis imposed. Based on the heart's insensitivity to anoxia alone, we suggest that anoxia may normally depress function indirectly via its effect on intracellular acid-base state.

31P-NMR measurements of pHi and high-energy phosphates in isolated turtle hearts during anoxia and acidosis.

We used 31P-nuclear magnetic resonance (NMR) spectroscopy to measure intracellular pH (pHi) and high-energy phosphate levels in hearts of turtles (Chrysemys picta bellii) during either 4 h of anoxia [extracellular pH (pHo) 7.8, 97% N2-3% CO2], 4 h of lactic acidosis (pHo 7.0, 97% O2-3% CO2), or 1.5 h of combined anoxia + lactic acidosis (pHo 7.0, 97% N2-3% CO2) followed by 2 h of oxygenated recovery (pHo 7.8) at 20 degrees C. We also measured heart rate, maximum ventricular-developed pressure, and rate of pressure development (dP/dtmax). 31P-NMR spectra were characterized by the seven peaks typical of mammalian hearts, although turtle spectra were dominated by a large phosphodiester peak. Anoxia caused an increase in Pi to 165% and a decrease in creatine phosphate (CP) to 42% of control, whereas ATP levels remained unchanged. pHi declined from 7.37 +/- 0.01 to 7.22 +/- 0.03 at 1 h of anoxia and remained unchanged through hour 4. Lactic acidosis caused a 59% decrease in Pi, whereas CP and ATP levels remained unchanged. pHi fell to 6.88 +/- 0.04 by hour 1 and then climbed steadily to 7.14 +/- 0.05 at hour 4. During recovery from acidosis, pHi exceeded control values and returned to control by 2 h. Combined anoxia + acidosis caused profound decreases in CP to 14% and pHi to 6.56 +/- 0.03. In anoxic hearts, cardiodynamic variables remained at control levels through hour 3, after which cardiac output, heart rate, and dP/dtmax declined. Cardiodynamic variables were essentially unchanged from control throughout 4 h of acidosis except for dP/dtmax, which declined rapidly. In the combined protocol, all measures of cardiac function decreased. Recovery in all three cases was complete by approximately 2 h. We conclude that turtle hearts were relatively resistant to the stresses imposed in all three protocols compared with mammalian hearts, although anoxia + acidosis depressed the measured cardiac variables more profoundly than predicted from responses to the conditions imposed separately. Our results from the anoxia protocol suggest no direct causal relationship between myocardial CP (or ATP) levels and cardiac function.

Glucose uptake and flux through phosphofructokinase in wounded rat skeletal muscle.

Skeletal muscle injured with lambda-carrageenan has increased aerobic glycolysis. To assess the regulation of this process, the tissue concentrations of glycolytic intermediates, the flux through phosphofructokinase (PFK), and the intracellular concentrations of PFK effectors were examined in wounded rat skeletal muscle and in macrophages, the predominant inflammatory cell in the early stages of this wound model. Autoradiography demonstrated increased 2-deoxy-D-glucose uptake in wounded tissue compared with nonwounded muscle. 2-Deoxy-D-glucose was localized to the cellular infiltrate. The glycolytic intermediate concentrations demonstrated a facilitation of PFK in macrophages and wounded tissue as compared with nonwounded muscle. Wounded tissue had twice the flux through PFK compared with nonwounded muscle (10.0 +/- 0.6 wounded vs. 4.9 +/- 0.4 mumol.h-1.g-1 nonwounded). Macrophages had the highest flux through PFK (63.7 +/- 5.7 mumol.h-1.g-1) and when coincubated with muscle, the combined flux through PFK was equal to that of wounded muscle. The increase in glycolysis associated with wounded tissue may be explained by increased glucose uptake and increased flux through PFK by the inflammatory cells present in wounded tissue.

Nonflammable endotracheal device for CO2 laser ablation of benign laryngeal and proximal tracheal tumors.

A Holinger aspirating tube may be utilized as a nonflammable endotracheal device during CO2 laser ablation of benign laryngeal and proximal tracheal tumors. Adequate jet ventilation may be performed through this small diameter (3.0 mm), metallic device while providing an unobstructed view of the surgical lesion. This technique was well-accepted by surgeons during the clinical trials. Because the 3.0 mm outside diameter was significantly smaller than the smallest flexible, uncuffed metal endotracheal tube currently available (6.9 mm), the rigid structure facilitated atraumatic insertion past the surgical lesion. Both the use of this device and the required anesthetic technique are described in three CO2 laser ablative procedures. The authors consider that this device increases safety during this potentially hazardous procedure by eliminating the flammable polyvinyl chloride endotracheal tube and cottonoid packings most frequently used during this procedure.

Fluctuations in intracellular pH associated with vasopressin stimulation.

Intracellular pH (pHi) was estimated in paired hemibladders isolated from Dominican toads (Bufo marinus) by the tissue distribution of [14C]5,5'-dimethyl-2,4-oxazolidinedione and [3H]inulin. Tissues were incubated with isotopes for 30 min to correlate changes in pHi with the approximate time of peak vasopressin (VP)-induced water flow. At serosal pH 7.1 in the presence of an osmotic gradient, the intracellular hydrogen ion concentration [( H+]i) after 30 min of VP (20 mU/ml) stimulation was 8.29 +/- 0.23 X 10(-8) M (pHi 7.08) compared with 5.19 +/- 0.46 X 10(-8) M (pHi 7.28) in unstimulated paired controls (n = 5, P less than 0.001). The cyclic AMP (cAMP) analogue 8-(p-chlorophenylthio)-cAMP (10(-5) M) mimicked the VP effects. A similar change was observed at serosal bath pH 8.2, where [H+]i was 1.67 +/- 0.06 X 10(-8) M (pHi 7.78) with VP vs. 1.11 +/- 0.04 X 10(-8) M (pHi 7.95) in matched controls (n = 8, P less than 0.001). In all cases, the hydroosmotic response was associated with a significant decrease in inulin space. When the osmotic gradient was eliminated with Ringer solution or isotonic sorbitol in the mucosal bath, VP produced a smaller decrease in pHi (approximately 0.08 pH units) at both serosal pH. 31P-nuclear magnetic resonance spectra showed a similar downward trend in pHi with cell swelling. When vasopressin was removed from the bath, pHi and inulin space in stimulated hemibladders returned to pretreatment values within 30 min, and the tissues were again capable of a maximum hydroosmotic response if rechallenged with the hormone.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of bilirubin on transepithelial transport of sodium, water, and urea.

Urinary concentrating defects and renal salt wasting have been described in the hyperbilirubinemic Gunn strain strain of rat. Homozygous animals demonstrate significant reductions in renal medullary urea and sodium ion concentrations. These observations are consistent with possible bilirubin associated disorders in the transepithelial transport of water and solute. To test this hypothesis, measurements of active sodium transport and passive water and urea fluxes were made in hemibladders isolated from the Dominican toad, Bufo marinus. Tissues were exposed to amphibian bicarbonate Ringer's solution containing 0.1 mM bilirubin with 0.05% bovine serum albumin (BSA) or BSA alone. Vasopressin-stimulated sodium transport, as reflected by short circuit current (SCC), was inhibited by 18 +/- 6% in the presence of bilirubin (N = 10; P less than 0.02). Cyclic AMP (p-Cl-phenylthio cAMP 10(-5) M) stimulated SCC was inhibited to a similar degree in the presence of bilirubin. The inhibition was noted only when bilirubin was in the serosal bath, and it could be abolished with BSA 0.5%. Bilirubin had no effect on the increase in SCC induced by higher concentrations of cyclic AMP (10(-4) M), aldosterone, or amphotericin B. Furthermore, bilirubin had no effect on the hydro-osmotic response to vasopressin and vasopressin-induced changes in urea permeability. These findings show that short-term exposure to bilirubin exerts a tissue-specific effect on the vasopressin-stimulated active transport of sodium but has no effect on the vasopressin-induced fluxes of water and urea.

Lymph node imprint cytology for the rapid assessment of axillary node metastases in breast cancer.

Lymph node imprint cytology was performed on 86 nodes from 13 consecutive patients with breast cancer undergoing simple mastectomy with axillary node sampling, and a prospective comparison with paraffin section was made. The results showed a diagnostic sensitivity and specificity of 0.93 and 0.98 respectively. The predictive value of a positive result was 0.98. This technique can be used to identify patients with Stage I disease rapidly, thereby allowing their exclusion from treatment with peri-operative chemotherapy.

Psychological implications of cystic fibrosis.

A psychological and psychiatric study of 11 children with cystic fibrosis revealed major psychological problems in all of them. Among the parents of the majority of these children, marked psychopathology and gross marital discord were noted. Popular literature concerning cystic fibrosis had a negative effect on the child's attitude toward the disease. Virtually all of these patients showed a preoccupation with death. In this study, the necessity of psychiatric consultation as an integral part of current intensive treatment programs in cystic fibrosis clinics was demonstrated.