Laser trabecular ablation (LTA).

As part of a pilot study for glaucoma surgery, the use of 3 infrared solid state lasers with 4 fiber optic delivery systems to ablate human trabecular meshwork was investigated. Laser trabecular ablation (LTA) was attempted with the Erbium:YAG (2.94 microns), Erbium:YSGG (2.79 microns), and Holmium:YSGG (2.1 microns) lasers. Laser energy was delivered as a single pulse (250 microseconds) by tissue fiber optic contact with low hydroxyl-fused silica (200 and 500 microns), zirconium fluoride (250 microns), or sapphire (250 microns) fiber optics. Total energy required and thermal effects decreased as laser wavelength increased. LTA was best achieved at 2.94 microns (4 mJ total energy; energy densities = 8.2-12.7 J/cm2; pulse length 250 microseconds) with average thermal damage zones of 5.3-10.3 +/- 1.3-2.4 microns (means +/- SDs) to contiguous structures. This finding has potential applications in the surgical treatment of open-angle and congenital glaucoma and may minimize failure rates seen in other types of surgery on the trabecular meshwork where disrupted trabecular meshwork is not removed.     

Pericardial Tamponade Secondary to Central Venous Catheterization and Hyperalimentation in a Very Low Birthweight Infant

A very low birthweight infant developed pericardial tamponade secondary to leakage of fat emulsion through a catheter lodged in the right atrial appendage. At autopsy examination a thrombus was lodged in the appendage, which presumably resulted in immobilization of the catheter and leakage of the fluid through an attenuated and necrotic myocardial wall.     

Linkage of a familial platelet disorder with a propensity to develop myeloid malignancies to human chromosome 21q22.1-22.2

Linkage analysis was performed on a large pedigree with an autosomal dominant platelet disorder and a striking propensity in affected family members to develop hematologic malignancy, predominantly acute myelogenous leukemia. We report the linkage of the autosomal dominant platelet disorder to markers on chromosome 21q22. Four genetic markers completely cosegregate with the trait and yield maximum logarithm of difference scores ranging from 4.9 to 10.5 (theta = .001). Two flanking markers, D21S1265 and D21S167, define a critical region for the disease locus of 15.2 centimorgan. Further analysis of this locus may identify a gene product that affects platelet production and function and contributes to the molecular evolution of hematologic malignancy.     

Gamma-carboxylated isoforms of recombinant human protein S with different biologic properties

Human protein S (HPS), a regulator of hemostasis, is a vitamin K- dependent plasma protein with potential clinical utility. We have obtained high-level expression of the cDNA for HPS in two mammalian cell lines. Both cell lines secreted single chain recombinant HPS (rHPS) in serum-free medium as determined by Western blot analysis. The ability of the rHPS from both cell lines to act as a cofactor for human protein C (HPC) was determined; the rHPS secreted from the human 293 cell line had an activity six times that of the rHPS from the AV12-664 Syrian hamster cell line. Furthermore, the relative specific cofactor activity of rHPS from the 293 cell line was actually 2.5-fold higher than that of single-chain human plasma-derived HPS. Essentially all of the rHPS secreted from the 293 cell line exhibited a calcium-dependent elution profile on anion exchange chromatography, whereas only 25% to 35% of the hamster cell-derived rHPS exhibited this profile. However, the calcium-eluted rHPS from the AV12 cell line had a high specific cofactor activity, equivalent to that of the 293-derived rHPS. A NaCl- elutable rHPS fraction (calcium nondependent) was isolated from the recombinant AV12-664 cell line, further purified, and found to have reduced activity, only 40% that of the calcium-dependent rHPS. The only observable difference in the calcium-dependent and nondependent rHPS molecules was in the content of gamma-carboxyglutamic acid (Gla); the calcium-dependent material contained approximately 10 mol Gla/mol protein whereas the calcium-nondependent material contained only approximately 8 mol Gla/mol of protein. In addition, the calcium- nondependent rHPS had reduced ability to interact with phospholipid vesicles as evidenced by an eightfold increase in the apparent kd. Our data demonstrate the isolation of rHPS with high specific activity, and show that a reduction in as few as two Gla residues dramatically decreases its functional cofactor activity for HPC, due to a reduction in ability to interact with the phospholipid bilayer.     

Non-specific stimulation of cell-free protein synthesis by a dialyzable factor isolated from reticulocyte initiation factors ("iRNA").

The specificity of a dialyzable component, isolated from rabbit reticulocyte initiation factors, in stimulating protein synthesis was examined. It appeard that his factor (hereafter designated as "iRNA") was able to restore the activity of initiation factor preparations that were inactivated by dialysis. The "iRNA" from reticulocytes stimulated polypeptide synthesis directed by the homologous globin mRNA as well as heterologous lens crystallin mRNAs. No selectivity in its stimulating action with regard to the type of mRNA studied could be observed. The source of ribosomes or supernatant enzymes did not influence the effect of "iRNA". However, in an ascites lysate that was dependent on the addition of initiation factors, "iRNA" increased polypeptide formation only marginally, suggesting that in this lysate a similar factor was already present in an active form. It is concluded that "iRNA" may regulate protein synthesis, but without exhibiting specificity towards mRNAs, at least those tested so far.     

Increase of AKR-specific sequences in tumor tissues of leukemic AKR mice.

AKR mice produce, from shortly after birth, high titers of their endogenous Gross type murine leukemia virus, and develop a thymus-derived leukemia at 7-9 months of age. We show that this oncogenesis is accompanied by an increase in the number of AKR-specific DNA sequences in the tumor tissues, whereas the "non-target" organs are not affected. Sequence increase was determined by kinetic analysis of DNA reassociation using an AKR-murine leukemia virus (MuLV)-specific cDNA and also by hybridization with excess AKR cDNA. The AKR cDNA was selected to recognize AKR sequences without significant crossreaction with DNA sequences of other endogenous viruses. The results show that during the development of the leukemia, the number of AKR-MuLV-specific genes increases in tumor tissues by a factor of 1 1/2 to 2.     

Protection of ovarian function by oral contraceptives in women receiving chemotherapy for Hodgkin's disease

It has been reported by us and by others that after chemotherapy for Hodgkin's disease the ovary contains fewer than 5 primordial and primary follicles per 5 x 5 mm biopsy section. In young women this is associated with premature menopause. We report here that before treatment the tissue contains 18--55 such follicles per biopsy section. When women took combination oral contraceptives throughout the course of MVPP therapy, the posttreatment ovarian biopsy tissue had more than 20 follicles per histologic section. Normal menses were established in the five women who discontinued oral contraceptives at the end of MVPP therapy, and one of them is now pregnant.     

History-Adjusted Marginal Structural Analysis of the Association between Hemoglobin Variability and Mortality among Chronic Hemodialysis Patients

Background and objectives: Hemoglobin variability is common among dialysis patients, and has been associated with increased mortality. The causal nature of this association has been difficult to ascertain because of potential time-dependent confounding, for which traditional statistical methods do not control.Design, settings, participants, & measurements: A retrospective cohort of 34,963 Fresenius Medical care dialysis patients from 1996 was assembled. Hemoglobin variability, absolute hemoglobin level, and temporal hemoglobin trend were measured over rolling 6-mo exposure windows. Their association with mortality was estimated using history-adjusted marginal structural analysis that adjusts for time-dependent confounding by applying weights to observations inversely related to the predictability of observed levels of hemoglobin.Results: In the primary analysis, each g/dl increase in hemoglobin variability was associated with an adjusted hazard ratio (HR) [95% confidence interval (CI)] for all-cause mortality of 1.93 (1.20 to 3.10). Neither higher absolute hemoglobin level nor increasing hemoglobin trend were significantly associated with mortality; adjusted HR (95% CI) 0.85 (0.64 to 1.11) and 0.60 (0.25 to 1.45), respectively.Conclusions: Marginal structural analysis demonstrates that hemoglobin variability is associated with increased mortality among chronic hemodialysis patients, and that this effect is more pronounced than appreciated using standard statistical techniques that do not take time-dependent confounding into account.Hemodialysis patients experience substantial changes in hemoglobin concentration over time (1–4). This variability derives both from patterns of care, such as changes in erythropoietin and intravenous iron dosing, as well as from comorbid conditions that either influence sensitivity to these therapies, or that directly affect red cell mass. Recently, we demonstrated an association between increased hemoglobin variability (Hgb-Var) and all-cause mortality among chronic dialysis patients (5).As is the case in all nonrandomized research, the observed association between Hgb-Var and death was subject to potential confounding. Confounding occurs when a variable (or variables) affects the likelihood of exposure (e.g. Hgb-Var) and of outcome (e.g. death), but does not serve as an intermediate between exposure and outcome. Standard methods of statistical adjustment are often sufficient to adjust for these confounders when they do not vary over time compared with their baseline values.Unfortunately, there are instances when application of standard statistical techniques may yield biased associations, such as in the presence of time-dependent confounding. Time-dependent confounders (TDC) are variables that have two different roles that are difficult to distinguish: (1) they influence subsequent exposure and outcome like confounders that are fixed over time, and (2) they also serve as intermediates (or links) between exposure and outcome. Although it is appropriate to adjust for their role as confounders, it is inappropriate to adjust for their role as intermediates on the causal pathway from exposure to outcome. If standard statistical techniques are used to adjust for TDC, they adjust for both roles simultaneously and, therefore, may underestimate true associations owing to the adjustment for the role as a causal pathway factor. For example, if Hgb-Var is both influenced by comorbid conditions and promotes these same conditions as part of the mechanism through which it causes poor clinical outcomes, simple adjustment for these comorbidities would lead to biased estimates of the Hgb-Var outcome relationship. Figure 1 serves to illustrate one potential TDC of the association between Hgb-Var and death, namely intravenous iron administration, which may independently be associated with Hgb-Var and mortality (Figure 1A), and may also serve on the causal pathway (Figure 1B).Open in a separate windowFigure 1.Example of the potential time-dependent confounding influence of intravenous iron on the association between hemoglobin variability (Hgb-Var) and death (A) when intravenous iron affects the degree of Hgb-Var and the likelihood of death and (B) also serves as an intermediate between Hgb-Var and death.The best means to avoid the possibility of time-dependent confounding is through randomization to fixed treatment protocols (9). Extending the prior example, this would mean randomizing subjects to high and low levels of Hgb-Var, and treating each group with equivalent amounts of intravenous iron. Unfortunately, current therapies do not enable randomization of subjects to varying degrees of Hgb-Var. Nonetheless, observational research can take advantage of newer statistical tools, such as history-adjusted marginal structural models (HA-MSM), which enable estimation of less biased measures of association from observational data in the presence of time-dependent confounding (8,10–11).Considering that the prior association may have been biased by the presence of time-dependent confounders, we have reanalyzed our data using HA-MSM to better estimate the causal association between Hgb-Var and mortality.     

Respiratory infection and otitis media visits in relation to pneumococcal conjugate vaccine use in Saskatchewan

BACKGROUND:

In Saskatchewan, pneumococcal conjugate vaccination (PCV) was offered to high-risk children in 2002 and to all infants in 2005.

OBJECTIVE:

To describe trends in the frequency of medical visits for lower respiratory tract infection (LRI) and otitis media (OM) in relation to PCV use during the period 1990 to 2008.

METHODS:

Statistics regarding the number of children covered by the health insurance plan, PCV administration, and medical visits with a diagnostic code associated with LRI and OM were provided by Saskatchewan Health. Monthly rates were analyzed using dynamic state space models.

RESULTS:

In all series, there was a marked seasonal cycle and some higher-than-expected winter peak values, possibly associated with epidemics of specific respiratory viruses. Three abrupt decreases in baseline rate were observed for LRI and the final one, in February 2007, could be related to the increased proportion of children vaccinated with PCV. There was no statistical correlation between PCV use and OM visit frequency.

CONCLUSION:

Many environmental, biological and administrative factors may influence health services use, and an effect of low magnitude of a particular vaccine pertaining to nonspecific outcomes could be obscured in time-series analyses.