Outcomes and native renal recovery following simultaneous liver-kidney transplantation.

With the increase in patients having impaired renal function at liver transplant due to MELD, accurate predictors of posttransplant native renal recovery are needed to select candidates for simultaneous liver-kidney transplantation (SLK). Current UNOS guidelines rely on specific clinical criteria for SLK allocation. To examine these guidelines and other variables predicting nonrecovery, we analyzed 155 SLK recipients, focusing on a subset (n = 78) that had post-SLK native GFR (nGFR) determined by radionuclide renal scans. The 77 patients not having renal scans received a higher number of extended criteria donor organs and had worse posttransplant survival. Of the 78 renal scan patients, 31 met and 47 did not meet pre-SLK UNOS criteria. The UNOS criteria were more predictive than our institutional criteria for all nGFR recovery thresholds (20-40 mL/min), although at the most conservative cut-off (nGFR ≤ 20) it had low sensitivity (55.3%), specificity (75%), PPV (67.6%) and NPV (63.8%) for predicting post-SLK nonrecovery. On multivariate analysis, the only predictor of native renal nonrecovery (nGFR ≤ 20) was abnormal pre-SLK renal imaging (OR 3.85, CI 1.22-12.5). Our data support the need to refine SLK selection utilizing more definitive biomarkers and predictors of native renal recovery than current clinical criteria.

Reduced effect of propofol at human {alpha}1{beta}2(N289M){gamma}2 and {alpha}2{beta}3(N290M){gamma}2 mutant GABA(A) receptors.

BACKGROUND: Propofol is an i.v. anaesthetic commonly used during general anaesthesia and intensive care. It is known that the second transmembrane segment of the beta subunit in the GABA(A) receptor is an important target for the effects of propofol; however, this has not been investigated in human receptors. The aim of this study was to investigate the effect of propofol on human beta2 and beta3 GABA(A) subunits with point mutations corresponding to the N265M mutation in the rat beta2 and beta3 subunits. METHODS: Asparagine-to-methionine replacement at amino acid position 289 and 290 (N289M and N290M) in the beta2 and beta3 GABA(A) receptor subunits, respectively, was accomplished by site-directed mutagenesis. Thereafter, subunits for three human wild-type (alpha1beta2gamma2, alpha2beta2gamma2, and alpha2beta3gamma2) and two mutant GABA(A) receptor channels [alpha1beta2(N289M)gamma2 and alpha2beta3(N290M)gamma2] were introduced into Xenopus oocytes and studied with two-electrode voltage clamp. RESULTS: The mutant receptors left-shifted the GABA concentration-response curve. In comparison with the wild-type receptors, both the positive modulatory and the agonistic effects of propofol were strongly reduced in potency and amplitude at both mutated GABA(A) channels. CONCLUSIONS: We demonstrate that N289M or N290M mutation in human GABA(A) beta2 and beta3 subunits increases sensitivity to GABA, which is in contrast to the corresponding rat N265M mutation. Furthermore, the N289M and N289M mutations reduce both the potentiation of GABA-induced currents and the direct effect of propofol on channels incorporating either of the mutated subunits, which confirms earlier findings concerning the corresponding mutation in rat receptors and knock-in mice.

N-terminal domains in the NR2 subunit control desensitization of NMDA receptors.

Recent molecular studies of glutamate channels have provided increasingly detailed models of the agonist-binding site and of the channel pore. However, little information is available on the domains involved in channel gating. We examined the molecular determinants for the NR2-subunit specificity of glycine-independent desensitization of NMDA channels using NR2C/NR2A chimeric subunits expressed in HEK 293 cells. We show that glycine-independent desensitization is controlled by N-terminal domains of the NR2 subunit that flank the putative agonist-binding domain: a four amino acid (aa) segment immediately preceding the first transmembrane domain (M1) and a region containing the leucine/isoleucine/valine-binding protein-like (LIVBP-like) domain. Our results provide evidence for a functional role of the region containing the LIVBP-like domain in glutamate receptor channels. We suggest that the pre-M1 segment, presumably situated near the entrance to the pore, serves as a dynamic link between ligand binding and channel gating.

A use-dependent tyrosine dephosphorylation of NMDA receptors is independent of ion flux.

Tyrosine phosphorylation can upregulate NMDA receptor activity during pathological and physiological alterations of synaptic strength. Here we describe downregulation of recombinant NR1/2A receptors by tyrosine dephosphorylation that requires agonist binding, but is independent of ion flux. The tyrosine residues involved in this new form of NMDA receptor modulation likely form a 'ring' adjacent to the last transmembrane domain. The downregulation was due to a reduction in the number of functional channels, and was blocked by co-expressing a dominant-negative mu2-subunit of the clathrin-adaptor protein AP-2. Our results provide a mechanism by which synaptic NMDA receptors can be modulated in a use-dependent manner even when the postsynaptic membrane is not sufficiently depolarized to relieve channel block by magnesium ions.

Improving Transitions to Postacute Care for Elderly Patients Using a Novel Video-Conferencing Program: ECHO-Care Transitions.

PURPOSE: Within 30 days of hospital discharge to a skilled nursing facility, older adults are at high risk for death, re-hospitalization, and high-cost health care. The purpose of this study was to examine whether a novel videoconference program called Extension for Community Health Outcomes-Care Transitions (ECHO-CT) that connects an interdisciplinary hospital-based team with clinicians at skilled nursing facilities reduces patient mortality, hospital readmission, skilled nursing facility length of stay, and 30-day health care costs. METHODS: We undertook a prospective cohort study comparing cost and health care utilization outcomes between ECHO-CT facilities and matched comparisons from January 2014-December 2014. RESULTS: Thirty-day readmission rates were significantly lower in the intervention group (odds ratio 0.57; 95% CI, 0.34-0.96; P-value .04), as were the 30-day total health care cost ($2602.19 lower; 95% CI, -$4133.90 to -$1070.48; P-value <.001) and the average length of stay at the skilled nursing facility (-5.52 days; 95% CI, -9.61 to -1.43; P = .001). The 30-day mortality rate was not significantly lower in the intervention group (odds ratio 0.38; 95% CI, 0.11-1.24; P = .11). CONCLUSION: Patients discharged to skilled nursing facilities participating in the ECHO-CT program had shorter lengths of stay, lower 30-day rehospitalization rates, and lower 30-day health care costs compared with those in matched skilled nursing facilities delivering usual care. ECHO-CT may improve patient transitions to postacute care at lower overall cost.

Extension for Community Healthcare Outcomes-Care Transitions: Enhancing Geriatric Care Transitions Through a Multidisciplinary Videoconference.

OBJECTIVES: To examine whether a novel videoconference that connects an interdisciplinary hospital-based team with clinicians at postacute care sites improves interprofessional communication and reduces medication errors. DESIGN: Prospective cohort. SETTING: One tertiary care medical center and eight postacute care sites. PARTICIPANTS: Hospital-based providers (hospitalists, geriatricians, pharmacists, social workers, medical trainees, and subspecialists) and postacute care clinicians. INTERVENTION: All patients discharged to eight postacute care sites were discussed in a weekly videoconference. MEASUREMENT: Preliminary data including demographic characteristics of the patients discussed, postacute care provider satisfaction survey results, and data on medication errors are reported. RESULTS: Over 2 years, 907 patients were discussed; 84.6% were discussed with staff at subacute skilled nursing facilities and the remainder with clinicians at one long-term acute care facility. They had an average hospital length of stay of 6.8 days. Postacute care providers felt that the videoconference enhanced communication and provided much-needed access to information and hospital staff. Of the 106 pharmacy discrepancies identified, 16% involved an omission of a medication. CONCLUSION: As increasing numbers of older adults are discharged to postacute care facilities, they face high-risk care transitions. Extension for Community Healthcare Outcomes-Care Transitions (ECHO-CT) facilitates interdisciplinary communication between hospital and postacute care providers, who normally have minimal interaction. Preliminary data suggests that ECHO-CT may improve the transitions of care processes between these sites.

Varicella-zoster virus infection of human mononuclear cells.

Varicella-zoster virus (VZV) DNA was detected in mononuclear cells (MNC) of 7 humans with acute zoster 1-23 days after the onset of skin lesions. To further study the interaction of VZV with human MNC, cells obtained from seropositive normal donors were infected with VZV and analyzed for the presence of viral DNA and proteins. VZV-DNA was detected in T, B, and OKM 1 (monocyte-macrophage) positive cells, and virus-specific proteins were demonstrated by indirect immunofluorescence and immunoprecipitation. Hybridization studies revealed that VZV-DNA did not replicate in human MNC.

Postnatal change of glycinergic IPSC decay in sympathetic preganglionic neurons.

The characteristics of glycinergic inhibitory postsynaptic currents (IPSCs) in sympathetic preganglionic neurons (SPNs) of neonatal rats were studied by whole-cell recordings in transverse spinal cord slices. In relation to postnatal age, the decay time constants of these currents decreased without a comparable effect on their rise time. This may result from alpha-subunit switching of the glycine receptor and/or increased glycine uptake during this period of postnatal life. The kinetics of glycinergic IPSCs were also temperature- and voltage-dependent. Whereas, compared with room temperature, rise and decay of the events were faster at more physiological temperature, only the decay increased upon depolarization. Visual identification of SPNs was confirmed by intracellular staining and comparison with retrogradely labeled SPNs.

Pregnancy, programming and preeclampsia: gap junctions at the nexus of pregnancy-induced adaptation of endothelial function and endothelial adaptive failure in PE.

The challenge of pregnancy to the mother requires that her own metabolic and endocrine needs be met while also taking on the literally growing demands of the unborn child. While all of the mother's organs require continued support, the uterus and now added placenta must also develop substantially. One critical area of adaptation is thus the ability to provide added blood flow over and above that already serving the preexisting maternal organs. Previous reviews have covered in detail how this is achieved from an endocrine or indeed vascular physiology standpoint and we will not repeat that here. Suffice it to say in addition to new vessel growth, there is also the need to achieve reduced vascular resistance through maintenance of endothelial vasodilation, particularly through NO and PGI2 production in response to multiple agonists and their associated cell signaling systems. In this review, we continue our focus on pregnancy adaptive changes at the level of cell signaling, with a particular emphasis now on the developing story of the critical role of gap junctions. Remapping of cell signaling itself beyond changes in individual hormones and respective receptors brings about global changes in cell function, and recent studies have revealed that such post-receptor changes in cell signaling are equally if not more important in the process of pregnancy adaptation of endothelial function than the upregulated expression of vasodilator synthetic pathways themselves. The principle significance, however, of reviewing this aspect of pregnancy adaptation of endothelial cell function is that these same gap junction proteins that mediate pregnancy-adapted changes in vasodilatory signaling function may also be the focal point of failure in diseased pregnancy, and clues as to how and why are given by comparing studies of Cx43 functional suppression at wound sites with studies of preeclamptic pregnancy. If preeclamptic pregnancy is indeed a pregnancy misconstrued by the body in endocrine terms to be a wound, then the kinases so activated that correspondingly suppress Cx43 function in the vascular endothelium may also be valid pharmacologic targets for novel therapies in the near future.

Synaptic- and agonist-induced chloride currents in neonatal rat sympathetic preganglionic neurones in vitro.

1. By using the whole-cell recording configuration of the patch-clamp technique in a spinal cord slice preparation, we have made recordings from visually identified neurones in the lateral horn of the thoracic and lumbar spinal cord of neonatal rats (newborn to 14 days postnatal). 2. Some of the recorded neurones were labelled with the fluorescent dye Lucifer Yellow (n = 27). Their morphology was typical for sympathetic preganglionic neurones (SPNs). Based on the size of the cell soma and the electrophysiological properties, unlabelled neurones were also regarded as SPNs. 3. Spontaneous synaptic activity of different patterns could be observed in 73% of the recorded neurones (n = 106). It reversed at the chloride equilibrium potential (ECl) and could be reversibly blocked by strychnine (1-10 microM), but not by bicuculline (10 microM) or SR95531 (5-10 microM). 4. Synaptic activity could be elicited by focal electrical stimulation in the vicinity of the recorded neurone. These evoked synaptic events exhibited features similar to the spontaneous synaptic activity. 5. Application of glycine (100 microM-1 mM) by a fast microperfusion system induced a chloride current in twenty-seven out of thirty cells tested. The currents were reversibly blocked by strychnine (1-10 microM), but were only weakly sensitive to bicuculline (10 microM). Stability of current responses to glycine was increased by inclusion of ATP (4 mM) in the intracellular medium. 6. Application of gamma-aminobutyric acid (GABA; 100 microM-1 mM) by the fast microperfusion system induced a chloride current in all twenty neurones tested. These currents were reversibly blocked by bicuculline (10 microM). Strychnine (1-10 microM) blocked this current only weakly. Run-down of GABA-induced currents was prevented to a great extent by inclusion of ATP (4 mM) in the pipette. 7. These results suggest that the inhibitory synaptic activity recorded from SPNs in thin, transverse slices of neonatal rat spinal cord is mediated by glycine receptor-gated Cl- channels. GABAA receptor-gated Cl- channels might be activated by inputs from other spinal segments and/or descending pathways from higher brain regions.

Excitatory postsynaptic currents and glutamate receptors in neonatal rat sympathetic preganglionic neurons in vitro.

1. We obtained whole cell patch-clamp recordings from visually identified sympathetic preganglionic neurons (SPNs) in thin (200-300 microns) transverse spinal cord slices of neonatal rats (1-14 days postnatal). Exogenous application of glutamate (100 microM), N-methyl-D-aspartate (NMDA; 100 microM), kainate (100 microM), quisqualate (1 microM), and alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid (AMPA; 50 microM) induced inward currents at a holding potential of -30 mV. 2. Excitatory postsynaptic currents (EPSCs) were evoked by electrical stimulation either in the dorsal horn or the lateral funiculus. They reversed at 1.2 +/- 4.6 (SD) mV and could in most cases (49 of 51) be separated into two components. 3. In the presence of DL-2-amino-5-phosphonovalerate (10-40 microM) the current-voltage (I-V) relationship of the remaining EPSC was linear. When stimulated in the lateral funiculus, its rise time (10-90%) and the time constant of the monoexponential decay were 1.6 +/- 1.0 and 5.5 +/- 2.7 ms, respectively. By contrast, when stimulated in the dorsal horn, this component had a rise time (10-90%) of 3.0 +/- 0.8 ms and a decay time constant of 13.7 +/- 7.6 ms. 4. We studied the NMDA receptor-mediated component of the EPSCs after superfusion of 6-cyano-7-nitroquinoxaline-2,3-dione (5 microM). The I-V relationship of this component had a region of negative slope conductance between -30 and -80 mV, which was abolished in Mg(2+)-free saline. The rise time (10-90%) ranged from 3.3 to 9.5 ms and the decay was biexponential. Both decay time constants increased with depolarization. Mg(2+)-free saline reduced this voltage sensitivity. 5. At a membrane potential of -80 mV and in 1 mM extracellular Mg2+, the NMDA receptor-mediated component represented 74.8 +/- 11.2% of the total charge carried by the EPSCs evoked by stimulation in the dorsal horn. In contrast, when stimulated from the lateral funiculus, 28.9 +/- 18.9% of the total charge carried during the EPSC was mediated by the NMDA receptor-mediated component. The contribution of the NMDA receptor-mediated component increased in both cases with depolarization. In addition, in 2 of 18 SPNs the EPSC evoked in the dorsal horn was exclusively carried by NMDA receptors. 6. We conclude that L-glutamate or a related substance mediates the fast excitatory input onto SPNs. Viscerosomatic and supraspinal inputs form synapses with different topographical locations on the SPN.(ABSTRACT TRUNCATED AT 400 WORDS)

Real-time measurement of RFR energy distribution in the Macaca mulatta head.

Temperature increases due to absorption of 1.2 GHz, CW, 70 mW/cm2, radio frequency (RF) energy, were measured in 3.3-cm-radius homogeneous muscle-equivalent spheres, M. mulatta cadaver heads (both detached from and attached to the body) and living, anesthetized M. mulatta heads. Temperatures were measured with a Vitek, Model 101 Electrothermia Monitor and temperature distributions were compared to theoretical predictions from a thermal-response model of a simulated cranial structure. The results show that the thermal response model accurately predicts the temperature distribution in muscle-equivalent spheres, the distribution of temperature in detached M. mulatta heads when exposed from the back of the head, and the distribution of temperature in attached M. mulatta cadaver heads for animals oriented with body parallel to the H-field. The temperature distribution in the detached M. mulatta heads varies markedly with exposure orientation, ie, facing forward, backward, or to the side. The orientation of the M. mulatta cadaver body significantly affects the temperature distribution in the head - with H-field orientation showing high, nonuniform values, and E-field orientation showing low, uniform values. In live animals blood flow produces a significant short-term effect on the temperature distribution in the midbrain, but not the cortex. Midbrain temperatures are both significantly higher and lower than the comparable cadaver measurements, depending on location.

Electrophysiological evidence for multiple glycinergic inputs to neonatal rat sympathetic preganglionic neurons in vitro.

The time pattern of glycinergic inhibitory postsynaptic currents (IPSCs) in sympathetic preganglionic neurons was studied in thin transverse spinal cord slices of neonatal (1-10 days postnatal) rats by means of the patchclamp technique. Three time patterns could be distinguished: (i) large events [mostly > 400 pA (30-36 degrees C)] occurring at regular intervals, (ii) small events occurring at irregular intervals, and (iii) small events occurring in transient (1.5-10 s), high-frequency (> 15 Hz) bursts of synaptic activity. The large regular events had uniform kinetics which was consistent with the idea of a proximal site of origin for all of these events. They were reversibly inhibited in amplitude and frequency by extracellular application of a high concentration of acetylcholine (200 microM) or the specific nicotinic acetylcholine receptor agonist dimethylphenylpiperazinium iodide (DMPP; 1 mM), but unaffected by glutamate (100 microM). IPSCs occurring in bursts had slower and less uniform kinetics, suggesting a more diverse site of origin. The frequency of events decreased during a burst. Similar bursts could be induced by extracellular application of glutamate receptor agonists. These results indicate that sympathetic pregnanglionic neurons in a thin, transverse spinal cord slice receive at least two different glycinergic inputs.

Morphological and ultrastructural changes in vegetative cells and heterocysts of Anabaena variabilis grown with fructose.

The morphology and ultrastructure of Anabaena variabilis grown in medium with and without 40 mM fructose were compared. Vegetative cells and young heterocysts in fructose-supplemented medium were significantly larger, were filled with glycogen granules, and had fewer thylakoids. Developing heterocysts contained large numbers of glycogen granules well into mature stages, and envelope formation was precocious. As heterocysts enlarged in fructose medium, their shape became more broadly oblong compared with the more rectangular heterocysts in fructose-free medium.

Cytoskeletal interactions with glutamate receptors at central synapses.

The data presented here are clearly just the beginning of any comprehensive understanding of the set of regulatory and cytoskeletal proteins that interact with membrane receptors in the postsynaptic density. They do, however, indicate that both glutamate channels at central excitatory synapses are involved in complex protein-protein interactions. For example, while NR2A is important for Ca-dependent inactivation of NMDA receptors, studies in several systems suggest that the other major NR2 subunit in hippocampal neurons, NR2B, predominates at critical times during synapse formation. In addition, the COOH terminus of NR2B binds to several novel cytoskeletal proteins. These results provide circumstantial evidence that NR2B may play specific roles in function and localization of receptors at excitatory synapses. The possible role of NR2B in early synaptic function gains additional support from functional data suggesting that NMDA receptors have specific roles during development (Komuro and Rakic, 1993; Rabacchi et al., 1992; Yen et al., 1993). The essential role of NR1 and NR2B in development is graphically demonstrated by the neonatal death of transgenic mice lacking either of these two subunits (Forrest et al., 1994; Kutsuwada et al., 1996) whereas NR2A and NR2C-deficient mice are less severely affected (Sakimura et al., 1995; Ebralidze et al., 1996).

Involuntary weight loss: diagnostic and prognostic significance.

We prospectively evaluated 91 patients with involuntary weight loss. Thirty-two (35%) had no identifiable physical cause of weight loss, whereas the remainder had various physical illnesses. During the year after the index visit, 23 (25%) of the patients died and another 14 (15%) deteriorated clinically. Physical causes of weight loss were clinically evident on the initial evaluation in 55 of 59 patients. The four patients in whom the diagnosis was initially missed had cancer, and in only one of these patients was the illness truly occult. Because diagnoses were usually made rapidly in patients with a physical cause of weight loss, we conclude that involuntary weight loss is rarely due to "occult" disease. We developed a decision rule that used six attributes to correctly identify 57 of 59 patients (97%) with a physical cause of weight loss and 23 of 32 patients without. Thus, our rule may help in the early triage of patients with involuntary weight loss.