Dermal patch graft correction of severe chordee secondary to penile corporal body disproportion without urethral division in boys without hypospadias.

Historically, significant ventral penile curvature secondary to corporal body disproportion has been corrected either by dorsal plication or division of the urethral plate. In the rare situations where there is severe chordee in the face of an intact urethra with an orthotopic meatus, division of the urethral plate is commonly performed at the time of grafting the ventral defect created by incising the tunica albuginea. Subsequently, a staged procedure is necessary to reconnect the urethra at a later date. Herein the authors present a novel technique that shows it is possible to perform successful dermal patch orthoplasty without division of the urethra in patients with a normal orthotopic meatus and urethra via urethral mobilization. Three patients over the past 3 years with severe ventral chordee, orthotopic meati and normal urethral anatomy presented for correction. Two patients were 18 years old and one was 10 years old. All three boys were circumcised. The two older boys insisted on dorsal plication as a first approach which worked only temporarily for about 6 months while the younger boy had no prior surgery performed. Each boy underwent a circumcising incision, degloving of the shaft skin, extensive urethral mobilization and dermal patch graft orthoplasty to correct chordee. All surgeries were performed in an outpatient setting. No urinary drainage was used in any patient and a simple bio-occlusive dressing was employed in each case. Follow-up ranged from 11 months to 2 years (mean 1.5 years). All three boys have strong straight erections, full well directed urinary streams and no complications noted to date. Our conclusion based on this experience is that extensive urethral mobilization can allow for correction of severe ventral chordee without urethral division in a single operative setting in boys without hypospadias and a normal urethra. The accompanying movie herein describes the surgical technique.

Role of registered nurses in error prevention, discovery and correction.

BACKGROUND: Registered nurses have a vital role in discovering and correcting medical error. OBJECTIVE: To describe the type and frequency of errors detected by American critical care nurses, and to ascertain who made the errors discovered by study participants. METHODS: Daily logbooks were used to collect information about errors discovered by a random sample of 502 critical care nurses during a 28-day period. RESULTS: Although the majority of errors discovered and corrected by critical care nurses involved medications (163/367), procedural errors were common (n = 115). Charting and transcription errors were less frequently discovered. The errors discovered by participants were attributed to a wide variety of staff members including nurses, doctors, pharmacists, technicians and unit secretaries. CONCLUSIONS: Given the importance of nurses in maintaining patient safety, future studies should identify factors that enhance their effectiveness to prevent, intercept and correct healthcare errors.

AnkB, a periplasmic ankyrin-like protein in Pseudomonas aeruginosa, is required for optimal catalase B (KatB) activity and resistance to hydrogen peroxide.

In this study, we have cloned the ankB gene, encoding an ankyrin-like protein in Pseudomonas aeruginosa. The ankB gene is composed of 549 bp encoding a protein of 183 amino acids that possesses four 33-amino-acid ankyrin repeats that are a hallmark of erythrocyte and brain ankyrins. The location of ankB is 57 bp downstream of katB, encoding a hydrogen peroxide-inducible catalase, KatB. Monomeric AnkB is a 19.4-kDa protein with a pI of 5.5 that possesses 22 primarily hydrophobic amino acids at residues 3 to 25, predicting an inner-membrane-spanning motif with the N terminus in the cytoplasm and the C terminus in the periplasm. Such an orientation in the cytoplasmic membrane and, ultimately, periplasmic space was confirmed using AnkB-BlaM and AnkB-PhoA protein fusions. Circular dichroism analysis of recombinant AnkB minus its signal peptide revealed a secondary structure that is approximately 65% alpha-helical. RNase protection and KatB- and AnkB-LacZ translational fusion analyses indicated that katB and ankB are part of a small operon whose transcription is induced dramatically by H(2)O(2), and controlled by the global transactivator OxyR. Interestingly, unlike the spherical nature of ankyrin-deficient erythrocytes, the cellular morphology of an ankB mutant was identical to that of wild-type bacteria, yet the mutant produced more membrane vesicles. The mutant also exhibited a fourfold reduction in KatB activity and increased sensitivity to H(2)O(2), phenotypes that could be complemented in trans by a plasmid constitutively expressing ankB. Our results suggest that AnkB may form an antioxidant scaffolding with KatB in the periplasm at the cytoplasmic membrane, thus providing a protective lattice work for optimal H(2)O(2) detoxification.

La Vega slit procedure for the treatment of phimosis.

OBJECTIVES: The surgical treatment of phimosis is usually circumcision. In countries in which circumcision is not widely practiced, this approach results in a phallus that is cosmetically unacceptable. We applied a ventral slit procedure to boys with severe phimosis and achieved outstanding results. METHODS: All patients were selected during a 1-week medical mission to La Vega in the Dominican Republic during April 1997. Eight patients presented with severe phimosis. The patient age ranged from 3 to 7 years (mean 4.4). All patients were cleared by the team pediatrician before undergoing the procedure. RESULTS: Eight patients underwent the procedure without complications. The operative time was less than 10 minutes in all instances. All had excellent postoperative cosmesis, were able to retract their foreskins, and voided without difficulty. A follow-up mission to La Vega in March 1998 yielded no complications involving this group of patients. CONCLUSIONS: Unlike circumcision and the dorsal slit procedure, this approach yields a phallus that on initial appearance is indistinguishable from an uncircumcised phallus. The procedure is easily performed and should be considered in the treatment of phimosis whenever foreskin preservation is desired.

Chordee repair utilizing a novel technique ensuring neurovascular bundle preservation.

Penile chordee, with and without hypospadias, is amenable to surgical correction. The Nesbit technique of dorsal plication of the ventral tunica albuginea is effective in correcting most cases of corporal disproportion. A hazard with this approach is the potential inclusion of the dorsal neurovascular bundle, with resultant erectile and sensory dysfunction. We developed a simple technique using the Freer elevator to isolate the neurovascular bundle prior to plication. This ensures that no injury occurs to the neurovascular bundle during plication. Since 1994, 37 boys with chordee have been repaired using this approach. Their ages at the time of operation ranged from 5 months to 28 years (mean 9 months). Following standard degloving of the penis, an incision through Buck's fascia is made lateral and parallel to the neurovascular bundle at the maximum level of the chordee. A similar incision is carried out on the contralateral side. A 4-mm-wide Freer elevator is positioned under Buck's fascia while hugging the tunica albuginea. The Freer elevator slides across the midline to the contralateral side, separating Buck's fascia and underlying layers from the tunica albuginea. Following isolation of the bundle, each corporal body is plicated by creating a longitudinal incision through the tunica albuginea, which then is closed transversely with a 5-0 polydioxanone suture. Buck's fascia subsequently is closed with an absorbable suture following confirmation of chordee correction. No complications have been encountered during a mean follow-up of 21 months (range 5-51 months). No patients have required reoperation for persistent chordee. We developed a technique that elevates the neurovascular bundle prior to plication, thereby ensuring no injury to this structure. We have successfully used this modified Nesbit technique since 1994 and have had no complications. Utilization of the Freer elevator adds an estimated 5 minutes to chordee correction compared to a standard plication lateral to the neurovascular bundles. Although long-term follow-up needs to be performed to confirm any erectile or sensory advantage, this approach should be considered whenever plication is to be performed.

Medical management of phimosis in children: our experience with topical steroids.

PURPOSE: Circumcision has traditionally been regarded as primary therapy for persistent phimosis in boys. Recently groups in Europe and Australia have advocated the use of topical steroids as conservative treatment in children. We report our experience with this approach. MATERIALS AND METHODS: Between July 1997 and February 1998, 25 boys with a mean age of 8.3 years who presented to our clinic with phimosis were started on a topical steroid. After counseling the family regarding treatment options we prescribed a 1-month course of 0.05% betamethasone cream applied twice daily. RESULTS: Of the 25 patients 24 completed the treatment and were evaluated. A total of 16 boys (67%) had a normal appearing foreskin that was easily retracted, while in the remaining 8 the outcome was unsuccessful and circumcision was scheduled. CONCLUSIONS: Our study demonstrates that the application of topical steroids is a viable alternative for treating phimosis in children. Appropriate candidates for this therapy include boys older than 3 years who have persistent phimosis and no evidence of infection.

A PC12 variant lacking regulated secretory organelles: aberrant protein targeting and evidence for a factor inhibiting neuroendocrine gene expression.

A variant of the PC12 pheochromocytoma cell line (termed A35C) has been isolated that lacks regulated secretory organelles and several constituent proteins. Northern and Southern blot analyses suggested a block at the transcriptional level. The proprotein-converting enzyme carboxypeptidase H was synthesised in the A35C cell line but was secreted by the constitutive pathway. Transient transfection of A35C cells with cDNAs encoding the regulated secretory proteins dopamine beta-hydroxylase and synaptotagmin I resulted in distinct patterns of mistargeting of these proteins. It is surprising that hybrid cells created by fusing normal PC12 cells with A35C cells exhibited the variant phenotype, suggesting that A35C cells express an inhibitory factor that represses neuroendocrine-specific gene expression.

Regulation of the macrophage vacuolar ATPase and phagosome-lysosome fusion by Histoplasma capsulatum.

Histoplasma capsulatum (Hc) maintains a phagosomal pH of about 6.5. This strategy allows Hc to obtain iron from transferrin, and minimize the activity of macrophage (Mo) lysosomal hydrolases. To determine the mechanism of pH regulation, we evaluated the function of the vacuolar ATPase (V-ATPase) in RAW264.7 Mo infected with Hc yeast or the nonpathogenic yeast Saccharomyces cerevisae (Sc). Incubation of Hc-infected Mo with bafilomycin, an inhibitor of the V-ATPase, did not affect the intracellular growth of Hc, nor did it affect the intraphagosomal pH. In contrast, upon addition of bafilomycin, phagosomes containing Sc rapidly changed their pH from 5 to 7. Hc-containing phagosomes had 5-fold less V-ATPase than Sc-containing phagosomes as quantified by immunoelectron microscopy. Furthermore, Hc-containing phagosomes inhibited phagolysosomal fusion as quantified by the presence of acid phosphatase, accumulation of LAMP2, and fusion with rhodamine B-isothiocyanate-labeled dextran-loaded lysosomes. Finally, in Hc-containing phagosomes, uptake of ferritin was equivalent to phagosomes containing Sc, indicating that Hc-containing phagosomes have full access to the early "bulk flow" endocytic pathway. Thus, Hc yeasts inhibit phagolysosomal fusion, inhibit accumulation of the V-ATPase in the phagosome, and actively acidify the phagosomal pH to 6.5 as part of their strategy to survive in Mo phagosomes.

Quantification of axonal damage in traumatic brain injury: affinity purification and characterization of cerebrospinal fluid tau proteins.

Diffuse axonal injury is a primary feature of head trauma and is one of the most frequent causes of mortality and morbidity. Diffuse axonal injury is microscopic in nature and difficult or impossible to detect with imaging techniques. The objective of the present study was to determine whether axonal injury in head trauma patients could be quantified by measuring levels of CSF tau proteins. Tau proteins are structural microtubule binding proteins primarily localized in the axonal compartment of neurons. Monoclonal antibodies recognizing the form of tau found in the CSF of head trauma patients were developed by differential CSF hybridoma screening using CSF from head trauma and control patients. Clones positive for head trauma CSF tau proteins were used to characterize this form of tau and for ELISA development. Using the developed ELISA, CSF tau levels were elevated >1,000-fold in head trauma patients (mean, 1,519 ng/ml of CSF) when compared with patients with multiple sclerosis (mean, 0.014 ng/ml of CSF; p < 0.001), normal pressure hydrocephalus (nondetectable CSF tau), neurologic controls (mean, 0.031 ng/ml of CSF; p < 0.001), or nonneurologic controls (nondetectable CSF tau; p < 0.001). In head trauma, a relationship between clinical improvement and decreased CSF tau levels was observed. These data suggest that CSF tau levels may prove a clinically useful assay for quantifying the axonal injury associated with head trauma and monitoring efficacy of neuroprotective agents. Affinity purification of CSF tau from head trauma patients indicated a uniform cleavage of approximately 18 kDa from all six tau isoforms, reducing their apparent molecular sizes to 30-50 kDa. These cleaved forms of CSF tau consisted of the interior portion of the tau sequence, including the microtubule binding domain, as judged by cyanogen bromide digestion. Consistent with these data, CSF cleaved tau bound taxol-polymerized microtubules, indicating a functionally intact microtubule binding domain. Furthermore, epitope mapping studies suggested that CSF cleaved tau proteins consist of the interior portion of the tau sequence with cleavage at both N and C terminals.

Disposable bedpads for incontinence: predicting their clinical leakage properties using laboratory tests.

A multi-centre project has been run to identify laboratory tests capable of predicting the leakage performance of disposable incontinence bedpads. Each of 95 subjects tested each of six products for a week in turn and reported whether or not they and/or their carers found the leakage performance of each product acceptable. In addition, carers noted the severity with which individual used bedpads had leaked so that, when they had been weighed, their leakage performance could be determined as a function of urine weight. These clinical data were compared with results from the 16 different laboratory tests used routinely for bedpad evaluation in three hospital laboratories. Each test was evaluated by seeing how well the data it yielded correlated with the clinical test data. No individual test was very successful at predicting the performance of bedpads when used as sole protection but a combination of an absorption capacity test and an absorption time test predicted the percentage of users/carers finding leakage performance acceptable, accurate to within +/- eight percentage points for all six test products. A different absorption capacity test proved most successful for bedpads used as back-up to body-worn products. It predicted the percentage of users/carers finding leakage performance acceptable, accurate to +/- five percentage points for all six products.

Predicting the leakage performance of small bodyworn disposable incontinence pads using laboratory tests.

An international multi-centre project has been run to create an international standard for measuring the leakage performance of small, disposable incontinence pads for lightly incontinent women. One hundred and thirteen women tested batches of nine different incontinence pads of widely differing designs and noted the severity with which each individual used pad had leaked so that leakage performance could be determined as a function of urine weight. In addition, testers rated the overall leakage performance of each of the nine products on a five-point scale. These clinical data were compared with laboratory data from 153 different pad measurements, each of which was evaluated by seeing how well the data it yielded correlated with the clinical test data. A wetback test emerged as the clear winner. It usually predicted the clinical leakage performance of pads to an accuracy of +/- 10%. It involved applying 25 ml of 1% w/v saline to a pad and measuring how much escaped into a filter paper held against the wet pad for 1 min under a pressure of 1.5 kPa. Pads which released the least test fluid into the filter paper leaked least in the user tests. The method will be published as an ISO standard during 1997.

Active and passive compliance of the fetal bovine bladder.

PURPOSE: Others have shown that the fetal bovine bladder is relatively noncompliant. Previous studies on compliance of fetal bovine bladders have demonstrated that the youngest fetal bladders had lowest and the oldest fetal bladders (near full-term) had greatest compliance. Our study was designed to determine the level of participation of active tension in the compliance of fetal bladders during gestation. MATERIALS AND METHODS: Fetal bovine bladders were obtained immediately after maternal harvest and crown-to-rump length was measured to determine gestational age. The fetus was inspected for genitourinary anomalies and the bladder was immediately placed in chilled M199 media. Strips (1 x 0.5 cm.) were excised from the anterior sagittal plane of the bladder and subjected to length-tension analysis in oxygenated Tyrode's buffer at 37C. Tension was measured using a force transducer and length was increased using a micropositioner. Compliance refers to the length-tension studies performed in normal Tyrode's solution and consists of a combination of active (smooth muscle tone) and passive properties. Passive compliance refers to length-tension studies performed after inactivation of bladder smooth muscle tone. Compliance with muscle tone intact was determined by incrementally stretching the strips to twice resting length in physiological buffer and then permitting them to return to resting length. Passive compliance with muscle tone ablated was determined in the same fashion after overnight incubation in calcium-free Tyrode's buffer in the presence of 5 mM. egtazic acid and 10 mM. sodium azide. An exponential function was fit to the normalized length-tension curves, where the exponential coefficient (EC) is numerically inversely proportional to compliance. RESULTS: Passive compliance was greatest in the youngest bladders (EC = 0.5 in the first trimester) and gradually decreased with increasing fetal age (EC = 1.2 in the third trimester). Active compliance demonstrated the opposite pattern, since the younger bladders were more stiff (EC = 2.1 in the first and 1.6 in the third trimesters). CONCLUSIONS: These studies demonstrate that passive compliance is greatest in the youngest bladders and progressively decreases with gestation. However, active smooth muscle tone is greatest in the youngest bladders and decreases with gestation. Thus, high active smooth muscle tone in the youngest fetal bladders results in relatively poor compliance of the early stage fetal bladder.

Active specific immunotherapy of metastatic melanoma with an antiidiotype vaccine: a phase I/II trial of I-Mel-2 plus SAF-m.

PURPOSE: To determine the toxicity and immunologic activity of an antiidiotype melanoma vaccine that consists of monoclonal antibody I-Mel-2 (MELIMMUNE-2, IDEC Pharmaceuticals, La Jolla, CA) and an immunologic adjuvant SAF-m. PATIENTS AND METHODS: Twenty-six patients with metastatic melanoma, 17 of whom had previously received chemotherapy, were given 2 mg of I-Mel-2 and either 100 micrograms (n = 6) or 250 micrograms (n = 20) of SAF-m. Antiidiotype vaccine was given intramuscularly (IM) biweekly for 4 weeks, and then bimonthly until disease progression. Human antimurine antibodies (HAMA), anti-I-Mel-2 antibodies, and specific antibody (Ab)3 against the melanoma epitope mimicked by the vaccine were titrated before treatment, biweekly from weeks 4 to 12, and every 4 to 8 weeks thereafter. Computed tomographic (CT) scans of the chest, abdomen, and pelvis and magnetic resonance imaging (MRI) of the brain were obtained before and bimonthly during treatment to evaluate responses. RESULTS: Elevated titers of human antimouse antibodies and anti-I-Mel-2 antibodies were associated with clinical antitumor effect (P = .02 and P = .05, respectively). Ab3 was absent in most patients, but was found in the best clinical responder. Fever, myalgias/arthralgias, fatigue, nausea, and headaches were the most common toxicities. Grade III myalgias/arthralgias and headaches required dose reduction of SAF-m in eight patients at the 250-microgram dose. No treatment-related death occurred. Six patients had an antitumor effect: one complete response in liver and lung, two minor responses, and three stable disease. The patient with a complete response has survived nearly 5 years. CONCLUSION: I-Mel-2 antiidiotype vaccine was safe, tolerated best at the 100-microgram dose of SAF-m, and had immunologic and clinical activity.

Fumarase C activity is elevated in response to iron deprivation and in mucoid, alginate-producing Pseudomonas aeruginosa: cloning and characterization of fumC and purification of native fumC.

We report the discovery of fumC, encoding a fumarase, upstream of the sodA gene, encoding manganese superoxide dismutase, in Pseudomonas aeruginosa. The fumC open reading frame, which terminates 485 bp upstream of sodA, contains 1,374 bp that encode 458 amino acids. A second 444-bp open reading frame located between fumC and sodA, called orfX, showed no homology with any genes or proteins in database searches. A fumarase activity stain revealed that P. aeruginosa possesses at least two and possibly three fumarases. Total fumarase activity was at least approximately 1.6-fold greater in mucoid, alginate-producing bacteria than in nonmucoid bacteria and decreased 84 to 95% during the first 5 h of aerobic growth, followed by a rapid rise to maximum activity in stationary phase. Bacteria exposed to the iron chelator 2,2'-dipyridyl, but not ferric chloride, demonstrated an increase in fumarase activity. Mucoid bacteria produced approximately twofold-higher levels of the siderophores pyoverdin and pyochelin than nonmucoid bacteria. Northern blot analysis revealed a transcript that included fumC, orfX, and sodA, the amount of which was increased in response to iron deprivation. A P. aeruginosa fumC mutant produced only approximately 40% the alginate of wild-type bacteria. Interestingly, a sodA mutant possessed an alginate-stable phenotype, a trait that is typically unstable in vitro. These data suggest that mucoid bacteria either are in an iron-starved state relative to nonmucoid bacteria or simply require more iron for the process of alginate biosynthesis. In addition, the iron-regulated, tricarboxylic acid cycle enzyme fumarase C is essential for optimal alginate production by P. aeruginosa.

An operon containing fumC and sodA encoding fumarase C and manganese superoxide dismutase is controlled by the ferric uptake regulator in Pseudomonas aeruginosa: fur mutants produce elevated alginate levels.

The activities of fumarase- and manganese-cofactored superoxide dismutase (SOD), encoded by the fumC and sodA genes in Pseudomonas aeruginosa, are elevated in mucoid, alginate-producing bacteria and in response to iron deprivation (D. J. Hassett, M. L. Howell, P. A. Sokol, M. L. Vasil, and G. E. Dean, J. Bacteriol. 179:1442-1451, 1997). In this study, a 393-bp open reading frame, fagA (Fur-associated gene), was identified immediately upstream of fumC, in an operon with orfX and sodA. Two iron boxes or Fur (ferric uptake regulatory protein) binding sites were discovered just upstream of fagA. Purified P. aeruginosa Fur caused a gel mobility shift of a PCR product containing these iron box regions. DNA footprinting analysis revealed a 37-bp region that included the Fur binding sites and was protected by Fur. Primer extension analysis and RNase protection assays revealed that the operon is composed of at least three major iron-regulated transcripts. Four mucoid fur mutants produced 1.7- to 2.6-fold-greater fumarase activity and 1.7- to 2.3-greater amounts of alginate than wild-type organisms. A strain devoid of the alternative sigma factor AlgT(U) produced elevated levels of one major transcript and fumarase C and manganase-cofactored SOD activity, suggesting that AlgT(U) may either play a role in regulating this transcript or function in some facet of iron metabolism. These data suggest that the P. aeruginosa fagA, fumC, orfX, and sodA genes reside together on a small operon that is regulated by Fur and is transcribed in response to iron limitation in mucoid, alginate-producing bacteria.

Identification of microtubule-associated protein tau isoforms in Alzheimer's paired helical filaments.

AD66 proteins derived from sodium dodecylsulfate (SDS) insoluble paired helical filaments (PHF) were isolated from Alzheimer's brain using a purification procedure developed previously in this laboratory, and characterized by immunologic and chemical cleavage methods. AD66 proteins were immunoreactive with antibodies that recognize the amino terminal, tubulin-binding, and carboxy terminal domains of microtubule-associated protein tau indicating the presence of the entire tau sequence in AD66 proteins. These proteins were reactive with antibody 423 that binds to PHF but not human adult tau. Immunologic and chemical cleavage studies indicated that only two of the six tau isoforms were present in these proteins. AD66 proteins were comprised of tau proteins containing only three tubulin binding domains with either a 29 amino acid insert or no amino terminal insert. For comparative purposes, SDS soluble PHF-tau (A68 proteins) was purified from Alzheimer's brains and normal adult tau purified from control brains. Antibody Alz-50 was immunoreactive with PHF-tau or normal tau regardless of alkaline phosphatase treatment while immunoreactivity was only observed with dephosphorylated AD66 proteins. A second phosphorylated epitope on AD66 proteins but not PHF-tau or normal tau proteins was demonstrated with antibody PHF9. These data suggest that AD66 proteins represent a more phosphorylated form of tau than PHF-tau or normal tau proteins. Two-dimensional gel electrophoresis demonstrated that AD66 proteins have higher apparent molecular weights and lower pI values than normal tau, differences possibly due to the greater phosphorylation observed in these proteins.

Monoclonal antibody PHF-9 recognizes phosphorylated serine 404 of tau protein and labels paired helical filaments.

Paired helical filaments (PHFs) purified from alzheimer's brain consist of hyperphosphorylated microtubule-associated protein tau. In PHF, phosphorylation occurs at ser/thr tau residues. Several of these ser/thr phosphorylation sites lie immediately C-terminal to the tau tubulin binding domain. The C-terminal ser396 to thr413 tau region contains two or more phosphorylated residues and eight possible ser/thr phosphorylation sites. Immunologic studies and mass spectroscopy have identified ser396 as one of the phosphorylation sites but identification of more C-terminal phosphorylated residues has been hampered by the lack of monoclonal antibodies (Mabs) that recognize defined epitopes in this region. We have raised Mabs against PHF purified from Alzheimer's brain. One of these Mabs, PHF-9, showed phosphorylation-dependent binding to purified PHF and recognized a phosphorylated epitope in the C-terminal portion of cyanogen bromide-digested PHF. Epitope mapping studies employing synthetic tau phosphopeptides indicated that PHF-9 labeled a 13-mer tau peptide phosphorylated at ser404 but not the corresponding non-phosphorylated peptide. PHF-9 demonstrated no immunoreactivity with a synthetic peptide phosphorylated at ser396 indicating that the PHF-9 epitope is C-terminal to ser396. In conclusion, the present study describes a Mab, PHF-9, which recognizes phosphorylated ser404 of tau independently of phosphorylated ser396 and indicates that tau ser404 is phosphorylated in PHF.

Resorption-cycle-dependent polarization of mRNAs for different subunits of V-ATPase in bone-resorbing osteoclasts.

Protein sorting in eukaryotic cells is mainly done by specific targeting of polypeptides. The present evidence from oocytes, neurons, and some other polarized cells suggests that protein sorting can be further facilitated by concentrating mRNAs to their corresponding subcellular areas. However, very little is known about the mechanism(s) involved in mRNA targeting, or how widespread and dynamic such mRNA sorting might be. In this study, we have used an in vitro cell culture system, where large multinucleated osteoclasts undergo continuous structural and functional changes from polarized (resorbing) to a nonpolarized (resting) stage. We demonstrate here, using a nonradioactive in situ hybridization technique and confocal microscopy, that mRNAs for several vacuolar H(+)-ATPase subunits change their localization and polarity in osteoclasts according to the resorption cycle, whereas mRNA for cytoplasmic carbonic anhydrase II is found diffusely located throughout the osteoclast during the whole resorption cycle. Antisense RNA against the 16-kDa or 60-kDa V-ATPase subunit inhibits polarization of the osteoclasts, as determined by cytoskeleton staining. Antisense RNA against carbonic anhydrase II, however, has no such effect.

An institutional commitment to pain management.

PURPOSE: To share the development, implementation, and evaluation of a program called "An Institutional Commitment to Pain Management," which is based on the philosophy of organizational influence on pain management. METHODS: A tested pain education model was disseminated to 32 physician/nurse teams in settings throughout California, after which the 64 professionals returned to their institutions to serve as role models and catalysts to change the practice of pain management. Each team member completed a 39-item survey about knowledge and attitudes related to pain, which was developed by B.R.F. and colleagues, and also identified three goals for the implementation of course information. Precourse data also included administration of the knowledge and attitudes survey to participating physicians' and nurses' colleagues (10 physicians and 20 nurses per institution). Each team completed five chart audits using the pain audit tool (PAT), which was developed by B.R.F. and colleagues at the City of Hope National Medical Center. The PAT identifies how pain is managed currently at the institutional level. Final course evaluation 8 months after course completion included a summary of activities implemented by the teams as well as the factors that served as barriers and benefits to improve the quality of pain management. RESULTS: Two hundred seventy-two physicians and 629 nurses completed the survey about knowledge and attitudes related to pain, and 154 PATs were submitted. These results, as well as evaluation at the completion of the course, are discussed. CONCLUSION: The Institutional Commitment to Pain Management program is an evolving model that was developed to overcome barriers to pain relief by obtaining the commitment from institutions to improve the management of pain for their patients.