Is the process of withdrawal of life-sustaining measures in the intensive care unit different for deceased organ donors compared with other dying patients? A secondary analysis of prospectively collected data.

OBJECTIVE: To investigate whether observable differences exist between patterns of withdrawal of life-sustaining measures (WLSM) for patients eligible for donation after circulatory death (DCD) in whom donation was attempted compared with those patients in whom no donation attempts were made. SETTING: Adult intensive care units from 20 centres in Canada, the Czech Republic and the Netherlands. DESIGN: Secondary analysis of quantitative data collected as part of a large, prospective, cohort study (the Death Prediction and Physiology after Removal of Therapy study). PARTICIPANTS: Patients ≥18 years of age who died after a controlled WLSM in an intensive care unit. Patients were classified as not DCD eligible, DCD eligible with DCD attempted or DCD eligible but DCD was not attempted. PRIMARY AND SECONDARY OUTCOME MEASURES: The process of WLSM (timing and type and, if applicable, dosages of measures withdrawn, dosages of analgesics/sedatives) was compared between groups. RESULTS: Of the 635 patients analysed, 85% had either cardiovascular support stopped or were extubated immediately on WLSM. Of the DCD eligible patients, more were immediately extubated at the initiation of WLSM when DCD was attempted compared with when DCD was not attempted (95% vs 61%, p<0.0001). Initiation of WLSM with the immediate cessation of cardiovascular measures or early extubation was associated with earlier time to death, even after adjusting for confounders (OR 2.94, 95% CI 1.39 to 6.23, at 30 min). Other than in a few patients who received propofol, analgesic and sedative dosing after WLSM between DCD attempted and DCD eligible but not attempted patients was not significantly different. All patients died. CONCLUSIONS: Patients in whom DCD is attempted may receive a different process of WLSM. This highlights the need for a standardised and transparent process for end-of-life care across the spectrum of critically ill patients and potential organ donors.

Neutron Rem Detector Response Changes due to Activation of Components.

The relative response of neutron rem detectors has previously been shown to increase after prolonged exposure to a neutron flux. This increase has been referred to as the "soak factor." The cause of the increased response has been previously unexplained. This note reports on a search for the underlying cause of the increased response. Testing involved gamma-ray spectroscopy of activated neutron rem detector components and testing of instrument response at various rates of neutron flux and accumulated fluence. The proposed primary cause of the increased response is activation of copper in the brass collar at the fill end of the gas-filled detector tube. This component allows for attachment of the extension housing on the tube containing BF3 or He gas. Under a neutron flux, some of this copper activates to Cu. In addition, Mn was detected in activated components but does not seem to be a significant contributor to the detector response. Cadmium isotopes did not appear to be significant. The activated component causes an increase in indicated neutron dose rate due to decay photons from activated components. Photons normally have little impact on neutron rem detector readings because the electrical pulses produced in the probes are below the lower-level discriminator. However, the photon pulses do impact the overall count rate when they occur simultaneously with normally uncounted, lower amplitude, wall-effect neutron pulses.

Alpha Air Sample Counting Efficiency Versus Dust Loading: Evaluation of a Large Data Set.

Dust loading on air sample filters is known to cause a loss of efficiency for direct counting of alpha activity on the filters, but the amount of dust loading and the correction factor needed to account for attenuated alpha particles is difficult to assess. In this paper, correction factors are developed by statistical analysis of a large database of air sample results for a uranium and plutonium processing facility at the Savannah River Site. As is typically the case, dust-loading data is not directly available, but sample volume is found to be a reasonable proxy measure; the amount of dust loading is inferred by a combination of the derived correction factors and a Monte Carlo model. The technique compares the distribution of activity ratios [beta/(beta + alpha)] by volume and applies a range of correction factors on the raw alpha count rate. The best-fit results with this method are compared with MCNP modeling of activity uniformly deposited in the dust and analytical laboratory results of digested filters. A linear fit is proposed to evenly-deposited alpha activity collected on filters with dust loading over a range of about 2 mg cm to 1,000 mg cm.

Distribution and concentration of cholesteryl ester transfer protein in plasma of normolipemic subjects.

A MAb (TP-2) directed against human cholesteryl ester transfer protein (CETP) has been applied to the development of a competitive solid-phase RIA. Experiments with immobilized CETP have shown that upon incubation with plasma or HDL in the presence of Tween (0.05%) apo A-I (but not apo A-II) binds to CETP while TP-2 binding to CETP is concomitantly decreased. With high detergent concentration (0.5% Triton), the interference is eliminated and a specific RIA in which all plasma CETP fractions have the same affinity can be obtained. Plasma levels of CETP, apo A-I, lipids, and lipoproteins were measured in 50 normolipemic, healthy subjects of both sexes. CETP levels varied nearly fourfold with a mean value of 1.7 micrograms/ml. CETP was positively correlated only with apo A-I (r = 0.38) and HDL-triglyceride (r = 0.39). In 29 other normolipemic subjects, where several apolipoproteins were also measured, significant correlations of CETP with apo A-I (0.41), apo E (0.43), and HDL-cholesterol (0.41) were observed, but there was no significant relationship between CETP and either apo A-II, B, or D. In other experiments CETP was shown to be present mostly in HDL3 and VHDL, to display exclusively an alpha 2-electrophoretic migration, and to occur within discrete particles ranging in size from 129 to 154 kD. In conclusion, the association of CETP with apo A-I-containing lipoproteins probably explains the correlation between CETP and apo A-I levels. The relationship between CETP and apo E suggests either a common metabolism or a specific cooperative role in cholesterol ester transport for these proteins.

Coherent use of information by hens observing their former dominant defeating or being defeated by a stranger.

This study examines the role of observation during the formation of triads in female domestic hens. Results indicate that during hierarchy formation, a hen observing agonistic interactions and conflict settlement between its former dominant and a stranger uses this information when in turn confronted by the latter. Under a first condition (E, n = 15 triads), bystanders witnessed their prior dominant being defeated by a stranger before being introduced to them. In a second condition (C1, n = 16 triads), bystanders witnessed the victory of their prior dominant over a stranger. In a third condition (C2, n = 15 triads), bystanders witnessed two strangers establishing a dominance relationship before being introduced to their prior dominant and to a stranger the former had just defeated. The behavioural strategies of bystanders depended on the issue of the conflict they had witnessed. Bystanders of the E condition behaved as having no chance of defeating the stranger. They never initiated an attack against it, and upon being attacked, readily submitted in turn to the stranger. On the contrary, bystanders of the C1 condition behaved as having some chances against the stranger. They initiated attacks in 50% of cases, and won 50% of conflicts against the stranger. Under condition C2, bystanders first initiated contact with the strangers in only 27% of cases, which approximates the average of their chances for defeating the stranger. However, bystanders finally defeated the strangers in 40% of cases. These results suggest that bystanders of conditions E and C1 gained some information on the relationship existing between their prior dominant and the stranger and that they used it coherently, perhaps through transitive inference, thus contributing to the existence of transitive relationships within the triads. Alternate explanations are examined.

An algorithm for source checking continuous air monitors using radon progeny.

Department of Energy requirements contained within 10CFR835 require that continuous air monitors be periodically checked for operability. The DOE air monitoring implementation guide for 10CFR835 allows the use of radon progeny to perform the recommended weekly source check. The Defense Waste Processing Facility located at the Savannah River Site has demonstrated that, through the use of the Hypotheses Concerning Two Means, diurnal change in the radon progeny detected by the monitors meets the requirements for weekly source checks. The use of the diurnal change in radon progeny has replaced the person-hours expended performing direct weekly source checking with an automated system requiring minimal person-hour expenditure.

Visceral adipose tissue accumulation, secretory phospholipase A2-IIA and atherogenecity of LDL.

OBJECTIVE: The aim of the present study was to investigate the combined impact of visceral adipose tissue (VAT) and secretory group IIA phospholipase A(2) (sPLA(2)-IIA) concentrations on the atherogenicity of low-density lipoprotein (LDL) particles among men. SUBJECTS: Analyses were conducted in 74 mid-obese healthy men (age: (mean+/-s.d.) 37.9+/-11.7 years). METHODS: Plasma levels of sPLA(2)-IIA were measured with a commercial ELISA and VAT levels were assessed by computed tomography. Distinct subpopulations of LDL particles were characterized from whole plasma using nondenaturating 2-16% gradient gel electrophoresis. RESULTS: Data indicated that plasma sPLA(2)-IIA levels were approximately 29% (P=0.007) higher among men characterized by a higher accumulation of VAT (>142 vs < or =142 cm(2)). Men having high plasma sPLA(2)-IIA levels (> or =127.2 ng/dl, the median value), were characterized by higher levels of plasma cholesterol (C) and apolipoprotein (apo) B, LDL-C, LDL-apoB, oxidized LDL (OxLDL) and by smaller LDL particles compared to men with sPLA(2)-IIA<127.2 ng/dl. Multiple regression analyses showed that plasma triglycerides and sPLA(2)-IIA levels explained 22.7 and 11.8% of the variance in LDL peak particle size, respectively. Levels of VAT and of sPLA(2)-IIA were the strongest correlates of OxLDL levels explaining, respectively, 15.0 and 5.5% of their variability. CONCLUSION: Both VAT and sPLA(2)-IIA levels modulate the atherogenecity of LDL by accounting for the reduction in their size and their susceptibility to oxidation.

How to develop a creative and self-motivated work team.

In summary, food service managers must use every available tool and resource to do their jobs. The development of self-motivated food service workers will help a great deal. Managers and dietitians must do a better job of dealing with employees as individuals and understanding the dynamics of the kitchen/service team. Good workers are those whose lives are generally healthy and crisis free. Take advantage of programs that will benefit your employees. Develop good delegation skills. It works for managers, it's good for employees. Finally, use the influence of the informal leader to the advantage of the department. They aren't going to go away--turn that man or woman into your ally. As individuals, we managers can't do it all. But, as a motivated team we can.

Newly synthesized human delta opioid receptors retained in the endoplasmic reticulum are retrotranslocated to the cytosol, deglycosylated, ubiquitinated, and degraded by the proteasome.

We have previously shown that only a fraction of the newly synthesized human delta opioid receptors is able to leave the endoplasmic reticulum (ER) and reach the cell surface (Petäjä-Repo, U. E, Hogue, M., Laperrière, A., Walker, P., and Bouvier, M. (2000) J. Biol. Chem. 275, 13727-13736). In the present study, we investigated the fate of those receptors that are retained intracellularly. Pulse-chase experiments revealed that the disappearance of the receptor precursor form (M(r) 45,000) and of two smaller species (M(r) 42,000 and 39,000) is inhibited by the proteasome blocker, lactacystin. The treatment also promoted accumulation of the mature receptor form (M(r) 55,000), indicating that the ER quality control actively routes a significant proportion of rescuable receptors for proteasome degradation. In addition, degradation intermediates that included full-length deglycosylated (M(r) 39,000) and ubiquitinated forms of the receptor were found to accumulate in the cytosol upon inhibition of proteasome function. Finally, coimmunoprecipitation experiments with the beta-subunit of the Sec61 translocon complex revealed that the receptor precursor and its deglycosylated degradation intermediates interact with the translocon. Taken together, these results support a model in which misfolded or incompletely folded receptors are transported to the cytoplasmic side of the ER membrane via the Sec61 translocon, deglycosylated and conjugated with ubiquitin prior to degradation by the cytoplasmic 26 S proteasomes.

Increase in plasma cholesteryl ester transfer protein during probucol treatment. Relation to changes in high density lipoprotein composition.

Probucol is a hypolipidemic agent that causes a marked decrease in high density lipoprotein (HDL) cholesterol. To investigate the mechanism of this effect, two studies were performed in hypercholesterolemic patients who had been stabilized previously on diet and were not receiving other lipid-lowering medication. Plasma cholesteryl ester transfer protein (CETP) concentrations were measured in fasting plasma samples before and after 10 weeks of probucol therapy using a sensitive and specific radioimmunoassay. Plasma total and low density lipoprotein cholesterol concentrations decreased, whereas apolipoprotein (apo) B was unchanged. Plasma apo E concentrations increased markedly. HDL cholesterol and apo A-I decreased in all subjects. These effects of probucol were accompanied by even more striking changes in plasma CETP concentrations, which increased by a mean of 64%. In a second study of six hypercholesterolemic subjects, the time-course effects of probucol on CETP and HDL subspecies were studied. Significant increases in plasma apo E and in CETP occurred after 4 weeks, and CETP, but not apo E, increased further after 16 weeks of treatment. Concomitant and opposite changes occurred in HDL composition, with decreases in HDL cholesterol and lipoprotein containing apo A-I. The increase in plasma CETP concentrations, the decrease in HDL cholesterol, and the increase in plasma apo E concentrations observed during probucol treatment are changes consistent with a postulated increase in reverse cholesterol transport via the remnant pathway.

Expression of apolipoprotein B epitopes in lipoproteins. Relationship to conformation and function.

The immunochemical properties of apolipoprotein (apo) B have been studied in very low density lipoprotein (VLDL)1 (Sf 100 to 400), VLDL2 (Sf 60 to 100), VLDL3 (Sf 20 to 60), different intermediate density lipoprotein (IDL), and low density lipoprotein (LDL) subfractions isolated from patients with type IV hypertriglyceridemia. In these lipoproteins, we characterized the association of apo B with other apolipoproteins and the expression and immunoreactivity of several apo B epitopes close to the apo B receptor binding sites (3F5, 4G3, 3A8, and 5E11) and of other epitopes located on the apo B100-B48 common region (1D1 and 2D8). Immunoprecipitation showed that the proportion of lipoprotein particles expressing each apo B epitope increased from VLDL1 to LDL2; this was more apparent with 3A8 and 5E11 than with 3F5. The VLDL that were negative for apo E epitopes (60% or more of the total) were enriched in apo C. The lipoprotein particles containing apo E and/or apo C-III decreased progressively from VLDL1 (30% and 85%, respectively) to LDL2 (10% and 25%, respectively). Similar observations were made for apo C-I and apo D, demonstrating that apolipoprotein heterogeneity is greatest in the lightest lipoproteins. By competitive radioimmunoassay, the epitope for 4G3 was equally immunoreactive in each lipoprotein subclass, and the affinity constant (Ka) of 4G3 for different lipoproteins showed little variation. In contrast, both immunoreactivity and Ka of 3A8 and 5E11 increased progressively and significantly with the increasing density of the lipoprotein subclasses. This phenomenon is correlated with the increasing binding affinity of apo B in these lipoprotein subclasses to the LDL receptor of fibroblasts. We conclude that, as the apo B-containing lipoproteins become smaller, the conformation of specific regions of apo B is modified: in the receptor binding domain, the conformation of epitope 4G3, which is mapped between residues 2980 and 3080, remains constant, while that of 3A8 and 5E11 (residues 3441 to 3568) changes progressively. We propose the theory that the change in conformation in the domain spanning residues 3441 and 3568 allows the maximum expression of epitopes 3A8 and 5E11 and of the receptor binding site.

Export from the endoplasmic reticulum represents the limiting step in the maturation and cell surface expression of the human delta opioid receptor.

Synthesis and maturation of G protein-coupled receptors are complex events that require an intricate combination of processes that include protein folding, post-translational modifications, and transport through distinct cellular compartments. Relatively little is known about the nature and kinetics of specific steps involved in these processes. Here, the human delta opioid receptor expressed in human embryonic kidney 293S cells is used as a model to delineate these steps and to establish the kinetics of receptor synthesis, glycosylation, and transport. We found that the receptor is synthesized as a core-glycosylated M(r) 45,000 precursor that is converted to the fully mature M(r) 55,000 receptor with a half-time of about 120 min. In addition to trimming and processing of two N-linked oligosaccharides, maturation involves addition of O-glycans containing N-acetylgalactosamine, galactose, and sialic acid. In contrast to N-glycosylation, which is initiated co-translationally and is completed when the protein reaches the trans-Golgi network, O-glycosylation was found to occur only after the receptor exits from the endoplasmic reticulum (ER) and was terminated as early as the trans-Golgi cisternae. Once the carbohydrates are fully processed and the receptor reaches the trans-Golgi network, it is transported to the cell surface in about 10 min. The exit from the ER was found to be the limiting step in overall processing of the receptor. This indicates that early events in the folding of the receptor are probably rate-limiting and that receptor folding intermediates are retained in the ER until they can adopt the correct conformation. The overall low efficiency of receptor maturation, less than 50% of the precursor being processed to the fully glycosylated protein, further suggests that only a fraction of the synthesized receptors attain properly folded conformation that allows exit from the ER. This indicates that folding and ER export are key events in control of receptor cell surface expression. Whether or not the low efficiency of the ER export is a general feature among G protein-coupled receptors remains to be investigated.

Characterization of antigenic determinants on human solubilized apolipoprotein B. Conformational requirements for lipids.

The expression of low density lipoprotein (LDL) antigenic determinants in the delipidated and solubilized apolipoprotein B (apo-B) free of sodium dodecyl sulfate (SDS) has been studied. Of the six distinct determinants which react with previously characterized monoclonal antibodies against LDL (Milne, R.W., Theolis , R., Jr., Verdery , R.B., and Marcel , Y.L. (1983) Arteriosclerosis 3, 23-30), only one, that recognized by antibody 1D1 , was expressed on the soluble apo-B, indicating that soluble apo-B may be partly denatured. The average immunoreactivity of apo-B with antibody 1D1 was similar to or lower than that of intact LDL (mean 36%, range 93-20%). Therefore, delipidation and solubilization did not expose on apo-B any additional site reactive with 1D1 . When apo-B was equilibrated with either SDS micelles or with cholesterol-lecithin liposomes, the immunoreactivity of the determinant recognized by antibody 2D8 was partially regenerated, but not that of the others. In contrast, incubation of apo-B with microemulsions containing a hydrophobic core of cholesteryl esters also restored the antigenicity of the determinants reacting with antibodies 3F5 , 4G3 , and 5E11 . However, the regeneration of these antigenic determinants could only be achieved when solubilized apo-B was treated with SDS prior to equilibration with microemulsion preparations. In conclusion, three types of antigenic determinants have been identified on apo-B. The first type, such as that recognized by antibody 1D1 , is expressed both on LDL and on apo-B and is constituted by the primary and secondary structure of apo-B. The second type, an example being that recognized by 2D8 , is a conformational determinant which requires the presence of amphipathic lipids such as lecithin and cholesterol or SDS micelles. The third type, which reacts with antibodies 3F5 , 4G3 , and 5E11 , represents different conformational determinants which require the association of apo-B with lipid structures having a cholesteryl ester hydrophobic core. It may be significant that the latter determinants are those close to the LDL receptor-binding site on apo-B and that this domain of apo-B has a complex tertiary and quaternary structure as evidenced by the conformational requirements of the antigenic determinants.

Mapping of antigenic determinants of human apolipoprotein B using monoclonal antibodies against low density lipoproteins.

The reactivity of a series of monoclonal antibodies directed against human low density lipoproteins (LDL) has been tested with hepatic and intestinal apolipoprotein B (apo-B) termed B-100 and B-48, respectively (Kane, J. P., Hardman, D. A., and Paulus, H. E. (1980) Proc. Natl. Acad. Sci. U. S. A. 77, 2465-2469). Whereas those antibodies that have been previously shown to recognize determinants close to the LDL receptor recognition site reacted only with B-100, two antibodies specific for other regions of apo-B reacted with both B-100 and B-48. Therefore, it is probable that sequence homologies exist between the two proteins and it must be considered that all or parts of the B-48 sequence may be contained within that of B-100. The specificity of the reaction of these antibodies with proteins designated B-74 and B-26 supports the concept that they represent complementary fragments of B-100. The present results have been incorporated in a theoretical map of the antigenic determinants recognized by these antibodies on the LDL apo-B.

Increased production of active human beta(2)-adrenergic/G(alphas) fusion receptor in Sf-9 cells using nutrient limiting conditions.

Using the baculovirus/insect-cell expression vector system, we succeeded in obtaining a high yield of active human beta(2)-adrenergic receptor/G(alphas) fusion protein. This was achieved following high cell density production under nutrient-limiting conditions using a very low multiplicity of infection (MOI). This approach was found to significantly reduce inactive protein accumulation that occurred when production was done using conventional high MOI procedures. The maximum specific and volumetric yields of active receptor using this strategy increased by factors of two- and sixfold, respectively. Our results suggest that the increase in the ratio of active/total protein produced results from production under nutrient limitation. Since low multiplicity of infection offers many advantages for large-scale applications, we suggest that this simple production method should be considered when optimizing expression of G-protein-coupled receptors and other complex proteins.

Plasma concentrations of cholesteryl ester transfer protein in hyperlipoproteinemia. Relation to cholesteryl ester transfer protein activity and other lipoprotein variables.

Cholesteryl ester transfer protein (CETP) mediates an important pathway for reverse cholesterol transport. Concentrations of CETP in fasting plasma were measured by radioimmunoassay in two different groups of hyperlipoproteinemic subjects. Plasma CETP concentrations measured by radioimmunoassay correlated closely with cholesterol ester transfer activity in normal plasma (r = 0.86). In the first group of 58 patients, plasma CETP concentrations were significantly increased, as compared with those in 79 normal subjects and in hypercholesterolemic (+26%) and combined hyperlipoproteinemic (+25%) subjects but were not altered in moderately hypertriglyceridemic subjects. Marked elevations in plasma CETP levels were documented in patients with dysbetalipoproteinemia (+68%) and severe chylomicronemia (+85%). Similar results were obtained in a second population of 50 hyperlipoproteinemic subjects. Significant correlations were found between plasma CETP levels and total cholesterol (r = 0.52), very low density lipoprotein (VLDL) cholesterol (r = 0.63), and apolipoprotein E concentration (r = 0.40). Correction of the lipoprotein phenotype by dietary means resulted in significant reductions in plasma CETP concentrations in patients with chylomicronemia and dysbetalipoproteinemia. In these subjects, plasma high density lipoprotein cholesterol concentrations increased as CETP decreased. These studies indicate that CETP levels increase in association with enhanced peripheral cholesterol transport via low density lipoprotein, beta-VLDL, or chylomicron remnants.

Tamoxifen and estrogen lower circulating lipoprotein(a) concentrations in healthy postmenopausal women.

Data in the literature suggest that circulating levels of lipoprotein(a) [Lp(a)] and insulinlike growth factor I (IGF-I) respond similarly to therapy with growth hormone, estrogen, or tamoxifen. To more clearly document these relations, we designed a randomized, double-blind, placebo-controlled study of the effects of tamoxifen and continuous estrogen on circulating levels of Lp(a), IGF-I, and IGF binding protein 3 (IGFBP-3) in healthy postmenopausal women. Both estrogen and tamoxifen decreased serum levels of IGF-I to 30% below baseline during the 3 months of treatment, while IGFBP-3 levels were unchanged. Plasma Lp(a) levels decreased to 24% below baseline after 1 month of treatment with either estrogen or tamoxifen (P < .05 for estrogen only); after 3 months Lp(a) decreased to 34% below baseline with tamoxifen therapy (P < .05) but returned to only 16% below baseline with estrogen. The correlation between Lp(a) and IGF-I was highly significant (P < .0001). We conclude that (1) tamoxifen lowers plasma Lp(a) levels in healthy postmenopausal women, (2) the suppressive effects of tamoxifen and estrogen on circulating Lp(a) concentration diverge after the first month of therapy, and (3) circulating levels of Lp(a) and IGF-I are strongly correlated with each other, an indication that they may share regulatory influences.