The Pancreas Can Take the Cold: Lower Waitlist Times Through Importation.

BACKGROUND: Our center has used a strategy of pancreas importation owing to long regional waitlist times. Here we assess the clinical outcomes and financial considerations of this strategy. METHODS: This was a retrospective observational cohort study of patients who received a pancreas transplant at Montefiore Medical Center (MMC) from 2014 to 2017 (n = 28). Clinical parameters, including hemoglobin A1c and complications, were analyzed. The cohort was compared with United Network for Organ Sharing (UNOS) Region 9 with the use of the UNOS/Organ Procurement and Transplantation Network database. Cost analysis of length of stay (LOS), standard acquisition (SAC) fees, and transportation was performed with the use of internal financial data. RESULTS: Pancreas importation resulted in significantly shorter simultaneous pancreas kidney transplant waitlist times compared with Region 9: 518 days vs 1001 days (P = .038). In addition, postoperative complications and 1-year HbA1c did not differ between groups: local 6.30% vs import 6.17% (P = .87). Patients receiving local pancreata stayed an average of 9.2 days compared with 11 days for the import group (P = .36). As such, pancreas importation was associated with higher mean charges ($445,968) compared with local pancreas recipients ($325,470). CONCLUSIONS: Long waitlist times in Region 9 have encouraged our center's adoption of pancreas importation to address the needs of our patient population. This practice has resulted in a reduction of waitlist times by an average of 483 days. Understandably, centers have long been wary of importation owing to perceived risk in clinical outcomes. In our single-center experience, we have demonstrated equivalent postoperative glucose control and graft survival. Importantly, there does appear to be increased costs associated with importation, which are mainly driven by LOS. Curiously, importation from regions with lower SAC fees has the potential to offset costs related to transportation expenses. Notwithstanding these findings, pancreas importation does have the potential to lessen the financial societal burden through reduction in waitlist times.

Pancreas Transplantation Is Feasible in Donors With Shprintzen-Goldberg Syndrome.

Shprintzen-Goldberg syndrome (SGS) is an autosomal dominant connective tissue disorder. To date, this report is the first account of a successful pancreas transplantation from an SGS donor. The similarity of the outcomes from previous year-on-year pancreas transplantations at the same center demonstrates promising results. Increasing awareness of the utilization of donors with SGS may promote expansion of center-specific criteria for organ acceptance. Therefore, every consideration should be given for use of organs from donors with this genetic abnormality because there is no evidence to suggest poorer allograft viability.

Transplantation for hepatocellular carcinoma in younger patients has an equivocal survival advantage as compared with resection.

Whereas some investigators in the surgical field advocate liver resection for the treatment of hepatocellular carcinoma (HCC), orthotopic liver transplantation (OLT) shows a significant survival advantage. Age was used to stratify survival in these groups to analyze beneficence. The Surveillance, Epidemiology, and End Results database (1998-2008) was used to identify 2355 patients who underwent either a segmentectomy, lobectomy, or extended lobectomy (resection) and 1873 patients who underwent an OLT for HCC. These patients were further stratified according to age and their relative survival was calculated. As shown in previous studies, the survival advantage is maintained in patients 40 to 59 and 60 to 79 years of age with HCC treated with OLT. However, within the 20 to 39-year-old age group, this advantage is insignificant. In this younger age group, resection patients (n = 157) have a 5-year survival rate of 50.9% whereas the OLT group (n = 40) has a 5-year survival rate of 58.9% (P = .42). Moreover, when assessing patient with lesions within the Milan criteria ages 20 to 39 years, resection shows a slight, although insignificant 4-year survival advantage: 78.2% for resection (n = 56) and 64.4% for OLT (n = 21; P = .283). This data may temper the enthusiasm for OLT in younger patients given the possibility of equivalent treatment with surgical resection.

Templating an organic array with Si(111)-7×7.

We demonstrate that nearest neighbor molecular adsorption can be sterically hindered on the Si(111)-7×7 surface reconstruction. This breaks the energetic equivalence of corner and edge di-σ attachment geometries and allows a translationally ordered organic layer to be templated directly on the 7×7 reconstruction.

Viral infection induces de novo lesions of coronary allograft vasculopathy through a natural killer cell-dependent pathway.

Viral infections including those due to cytomegalovirus have been associated with accelerated cardiac allograft vasculopathy (CAV) in clinical trials and some animal models. Evidence demonstrating a direct causal relationship between such infections and de novo formation of coronary vascular lesions is lacking. Heterotopic murine cardiac transplants were performed in a parental to F1 combination in animals lacking both T- and B-lymphocytes (RAG(-/-)). Coronary vasculopathy developed almost exclusively in the presence of recipient infection with lymphocytic choriomeningitis virus but not in uninfected controls. This process was also dependent upon the presence of natural killer (NK) cells as depletion of NK cells abrogated the process. These data show that a viral infection in its native host, and not previously implicated in the production of CAV, can contribute to the development of advanced coronary vascular lesions in cardiac allotransplants in mice. These data also suggest that virus-induced CAV can develop via an NK-cell-dependent pathway in the absence of T- and B-lymphocytes.

Episodes of pragmatic behaviors in parent-child interactions.

Pragmatic behavior, or the socially appropriate use of language, is important to parents of preschool children. In 1994 Becker noted several questions that still remain to be answered, including issues such as developmental changes in the pragmatic teaching of preschoolers and whether there are differences in the parents' goals for pragmatic teaching in private versus public interactions. The present study addressed these issues. 29 parent-child dyads were videotaped for 30 min. Transcripts were coded for episodes of pragmatic behavior that occurred in the dyadic interaction. Analysis indicated that pragmatic behaviors across the age groups largely focused on issues of what to say and how to say it. The teaching and use of pragmatic behaviors in public interactions is relatively important to parents of children between 2 1/2 and 4 years. The spontaneous use of pragmatic behaviors was the most common form of input (78% overall). Pragmatic behaviors were more often prompted with direct, as opposed to indirect, comments. Discussion focuses on a content analysis of the direct versus indirect prompts in the different age groups.

The nasal air sampler: a device for sampling inhaled aeroallergens.

OBJECTIVE: The object is to design, develop, and test a personal aerosol sampling device consisting of impaction samplers worn just inside the nostrils, driven by the wearer's respiration. The device provides a novel and unique measure of individual exposure to aeroallergens. It was conceived as an integral part of an allergen diagnostic system, in which collected aerosols are immunostained with monoclonal antibodies or the patient's IgE and associated particles positively identified using techniques of image analysis. METHODS: Each sampler comprises a slot impactor with a detachable impaction plate covered with either a specially developed medical adhesive or a protein-binding membrane. Sampler performance has been validated by rig tests of aerodynamic resistance and collection efficiency of different sized particles at various flow rates. There have also been field trials with human subjects which show that the sampler can be comfortably worn for periods of up to 4 hours. This is sufficient to gather a representative sample of inhaled allergens in most environments. RESULTS: The sampler collects an increasing proportion of particles in the inhalable range at and above 5 microm. This includes most bioaerosols of interest to allergists. Sampler prototypes have been built by CNC mill and stereolithography. Batches of samplers have been molded in biocompatible materials for field and clinical trials. CONCLUSIONS: The device successfully collects aeroallergens from a patient's own respiration. While developed specifically as a vehicle for the allergen diagnostic system, it can be adapted for studies of other aspects of air quality or for prophylactic use.

Human damage-specific DNA-binding protein p48. Characterization of XPE mutations and regulation following UV irradiation.

Damage-specific DNA binding (DDB) activity purifies from HeLa cells as a heterodimer (p127 and p48) and is absent from cells of a subset (Ddb(-)) of xeroderma pigmentosum Group E (XPE) patients. Each subunit was overexpressed in insect cells and purified. Both must be present for the damaged DNA band shift characteristic of the HeLa heterodimer. However, overexpressed p48 peptides containing the mutations found in three Ddb(-) XPE strains are inactive, and wild type p48 restores DDB activity to extracts from a fourth XPE Ddb(-) strain, GM01389, in which compound heterozygous mutations in DDB2 (p48) lead to a L350P change from one allele and a Asn-349 deletion from the other. Although these results indicate that these mutations are each responsible for the loss of DDB activity, they do not affect nuclear localization of p48. In normal fibroblasts, a 4-fold increase in p48 mRNA amount was observed 38 h after UV irradiation, preceding a similar elevation in p48 protein and DDB activity at 48 h, implying that p48 limits DDB activity in vivo. Because DNA repair is virtually complete before 48 h, a role for DDB other than DNA repair is suggested.

Nuclear transport of human DDB protein induced by ultraviolet light.

Human damage-specific DNA-binding (DDB) protein can be purified as a heterodimer (p48 and p127) that binds to DNA damaged by ultraviolet light. We report here the effects of UV irradiation on the cellular localization of each DDB subunit as a function of time using green fluorescent fusion proteins in three diploid fibroblast strains: repair-proficient IMR-90 and two repair-deficient xeroderma pigmentosum group E strains (XP95TO and XP3RO). Although p48 remained in the nucleus after UV irradiation, a dynamic nuclear accumulation of p127 from the cytoplasm was found after 24 h. In IMR-90 cells, the nuclear localization of p127 corresponded to the up-regulation of p48 mRNA and protein levels and of DDB activity. XP3RO cells showed delayed but similar kinetics with less transport, whereas XP95TO cells appeared to have different kinetics, suggesting that these cells exhibit different defects in p127 translocation. We propose that p48 might act as the transporter for nuclear entry of p127 but that a third factor might be necessary for efficient transportation.

The EPA health risk assessment of methylcyclopentadienyl manganese tricarbonyl (MMT).

This paper describes the U.S. Environmental Protection Agency's assessment of potential health risks associated with the possible widespread use of a manganese (Mn)-based fuel additive, methylcyclopentadienyl manganese tricarbonyl (MMT). This assessment was significant in several respects and may be instructive in identifying certain methodological issues of general relevance to risk assessment. A major feature of the inhalation health risk assessment was the derivation of Mn inhalation reference concentration (RfC) estimates using various statistical approaches, including benchmark dose and Bayesian analyses. The exposure assessment component used data from the Particle Total Exposure Assessment Methodology (PTEAM) study and other sources to estimate personal exposure levels of particulate Mn attributable to the permitted use of MMT in leaded gasoline in Riverside, CA, at the time of the PTEAM study; on this basis it was then possible to predict a distribution of possible future exposure levels associated with the use of MMT in all unleaded gasoline. Qualitative as well as quantitative aspects of the risk characterization are summarized, along with inherent uncertainties due to data limitations.

Hypoxic vasoconstriction in pulmonary arterioles and venules.

Pulmonary microvessels (<70 microm) lack a complete muscular media. We tested the hypothesis that these thin-walled vessels do not participate in the hypoxic pressor response. Isolated canine lobes were pump perfused at precisely known microvascular pressures. A videomicroscope, coupled to a computerized image-enhancement system, permitted accurate diameter measurements of subpleural arterioles and venules, with each vessel serving as its own control. While vascular pressure was maintained constant throughout the protocol, hypoxia caused an average reduction of 25% of microvessel diameters. The constriction was reversed when nitric oxide was added to the hypoxic gas mixture. The nitric oxide reversal, combined with a lack of lobar blood flow redistribution as measured by fluorescent microspheres, shows that the constriction was active. This response suggests the unexpected potential for active intra-acinar ventilation-perfusion matching.

Immunologic responses to vaccinia vaccines administered by different parenteral routes.

To develop a less reactogenic but equally immunogenic vaccine, this study of 91 human volunteers compared the safety and immunogenic potency of a new, cell culture-derived vaccinia virus vaccine administered intradermally and intramuscularly with the licensed vaccinia vaccine administered by scarification. Cutaneous pox lesions developed in a higher proportion of scarification vaccinees. Scarification and intradermal vaccine recipients who developed cutaneous pox lesions had more local reactions but also achieved significantly higher cell-mediated and neutralizing antibody responses than those who did not develop pox lesions. Although less reactogenic, intradermal or intramuscular administration of vaccinia vaccine without the concomitant development of a cutaneous pox lesion induced lower immune responses.

The S-oxidative degradation of a novel corticosteroid tipredane (INN) Part III. Detailed investigations into the disulphoxidation of tipredane.

The methyl- and ethylsulphoxide diastereoisomers (V and VI) of the corticosteroid tipredane (INN, I) have been shown to undergo further stereoselective S-oxidation to yield diastereoisomeric disulphoxides (II). Interactive computer optimisation software was employed to develop semi-preparative chromatography conditions for the isolation of the disulphoxide diastereoisomers (II) and to develop a multiselective gradient HPLC analysis of tipredane (I), the four monosulphoxide diastereoisomeric pairs (V, VI, IX and X), the four disulphoxide diastereoisomers (II), the vinyl methyl and ethyl derivatives (XI and XII) and the methylsulphone of tipredane (VII). The four diastereoisomeric disulphoxides (II) have been isolated by semi-preparative HPLC and their structures unambiguously confirmed by high resolution multinuclear NMR and mass spectrometry. The stereochemical assignment of the four disulphoxide diastereoisomers (II), the ethylsulphoxide diastereoisomeric pair (VI), and the vinyl methyl and ethylsulphoxide diastereoisomeric pairs (IX and X) was determined by degradation/synthesis and relation to the S/R-disulphoxide (II) whose stereochemistry was determined by X-ray crystallography. The monosulphoxides (V and VI) showed a high degree of site and stereoselectivity towards further S-oxidation. S-Oxidation on the C-17 beta-substituent of tipredane occurred at a rate approximately 50-fold faster than that on the alpha-substituent. The disulphoxides (II) have been shown to be susceptible to thermolysis yielding the vinyl methylsulphoxide diastereoisomers (IX) preferentially. The loss of the ethylsulphenic acid from the disulphoxide diastereoisomers (II) could be rationalised in terms of the preferred rotamers of the C-17 substituents.

Effect of capillary pressure and lung distension on capillary recruitment.

To investigate the effect of capillary pressure and alveolar distension on capillary recruitment, we used video-microscopy to quantify capillary recruitment in individual subpleural alveolar walls. Canine lobes were perfused with autologous blood either while inflated by positive airway pressure or while inflated by negative intrapleural pressure in the intact thorax with airway pressure remaining atmospheric. Low flow rates minimized the arteriovenous pressure gradient (< 5 mmHg), permitting capillary pressure estimation by averaging these pressures. Capillary pressure was varied stepwise from airway pressure to 30 mmHg above airway pressure. Capillary recruitment always began as capillary pressure exceeded airway pressure. At low positive airway pressures, the capillaries of the excised lobes opened suddenly over a narrow pressure range. AT higher airway pressures and in the intact thorax, recruitment occurred over a wide range of capillary pressures. We conclude that capillary perfusion begins when intracapillary pressure just exceeds alveolar pressure but that further increases in capillary pressure recruit capillaries depending on tension in the alveolar wall, whether imposed by positive airway pressure or by gravity when the lung is suspended in an intact thorax.

Distribution of pulmonary capillary red blood cell transit times.

In theory, red blood cells can pass through the pulmonary capillaries too rapidly to be completely saturated with oxygen during exercise. This idea has not been directly tested because the transit times of the fastest red blood cells are unknown. We report the first measurements of the entire transit time distribution for red blood cells crossing single subpleural capillary networks of canine lung using in vivo fluorescence videomicroscopy and compare those times with the distribution of plasma transit times in the same capillary networks. On average, plasma took 1.4 times longer than red blood cells to pass through the capillary bed. Decreased transit times with increased cardiac output were mitigated by both capillary recruitment and a narrowing of the transit time distribution. This design feature of the pulmonary capillary bed kept the shortest times from falling below the theoretical minimum time for complete oxygenation.

Sites of leukocyte sequestration in the pulmonary microcirculation.

The location and mechanisms of leukocyte sequestration in the pulmonary circulation have been investigated by using high-magnification in vivo videomicroscopy to record the passage of unlabeled native leukocytes through canine pulmonary capillaries. Of 650 leukocytes traversing capillary networks, 46 +/- 6% (SE) of the leukocytes passed through without stopping, 42 +/- 9% stopped in segments between junctions, and 12 +/- 4% stopped in junctions. Leukocytes rolling along arteriolar walls were nearly spherical, as 94% had aspect ratios (major axis divided by minor axis) < or = 1.25. To pass through the capillary bed, the leukocytes deformed into elongated shapes. Many leukocytes remained elongated after entering the venules (53% had aspect ratios > or = 1.25). Venular rolling was blocked by fucoidin (blocking both L- and P-selectin) but not by anti-P-selectin antibodies alone, indicating that rolling leukocytes adhered to the venular endothelium by L-selectin. These observations demonstrate that leukocytes deform to transit the capillary bed, that they stop more frequently in segments than in junctions, and that rolling leukocytes in the venular marginated pool adhere via L-selectin.