Loch Raven VA Medical Center

The effect of systemic glucocorticoid treatment on early- and late-phase nasal allergic reactions after allergen challenge was determined in a double-blind, cross-over study in 13 allergic individuals. The subjects were pretreated for 2 d before challenge with 60 mg prednisone per day or a matching placebo. A previously described model using repeated nasal lavages for measuring mediator release in vivo was utilized. Symptom scores obtained repeatedly before, during, and after the challenge and the number and timing of sneezes were recorded. The mediators measured were histamine. N-alpha-p-tosyl-L-arginine methyl ester (TAME)-esterase activity, kinins, PGD2, and LTC4/D4. Albumin was also measured as a marker of plasma transudation. Blood samples were taken for determination of total number of white blood cells, differential count, and total blood histamine content. No effect of steroid therapy was found on the appearance of symptoms or any of the mediators, except a reduction in kinins, in the early phase of the allergic reaction. However, in the late phase, the prednisone reduced the number of sneezes (P less than 0.01), as well as the level of histamine (P less than 0.05), TAME-esterase activity (P less than 0.05), kinins (P less than 0.05), and albumin (P less than 0.05). Only low levels of leukotrienes were found in the late phase, but the quantities of these mediators seemed to be decreased by the glucocorticoid treatment (P = 0.06). PGD2 did not increase during the LPR and thus was not affected by glucocorticosteroids. The immediate response to a second challenge 11 h after the first was also evaluated. Whereas the appearance of mediators was enhanced over the initial response to the same challenge dose in placebo-treated subjects, this enhancement was abrogated after prednisone treatment. As this dose of drug is known to be clinically effective in treating hay fever, the present study confirms the earlier findings of others that short-term systemic glucocorticoid treatment inhibits the late phase but not the immediate phase of antigen challenge. Furthermore, secondary enhancement of immediate responses is inhibited. This study shows that glucocorticoids inhibit the generation or release of inflammatory mediators during the late reaction and the physiologic response.

The injection of DBA/2 (D2) spleen cells into (C57BL/6 x DBA/2)F1 mice (BDF1) induces a chronic, autoimmune graft-vs-host disease (GVHD) that is characterized by: increased production of Th2-associated cytokines; increased levels of serum Ig, including IgE; increased production of IgG anti-DNA Abs; and no detectable antihost CTL activity. Experiments were performed to determine if treatment with the cytokine IL-12, which stimulates the production of Th1-associated cytokines and inhibits Th2-associated cytokine production, would inhibit humoral autoimmunity in this system. Treatment of mice with 100 ng IL-12 per day for 5 days, starting on the day of cell transfer, resulted in: 1) near complete suppression of autoantibody production; 2) decreased serum Ig levels; 3) detectable donor antihost CTL activity; and 4) greatly reduced numbers of host splenic B and T cells. Treatment of mice with a neutralizing anti-IFN-gamma mAb did not reverse these effects of IL-12. Thirty nanograms per day resulted in reduced numbers of host B cells and reduced serum anti-DNA levels, but no detectable antihost CTL activity. IL-12 treatment initiated 7 days after cell transfer had little effect on the development of autoimmune GVHD. These observations suggest the following: 1) IL-12 inhibits humoral autoimmunity in a murine parent-->F1 GVHD model by inducing the activation of host-reactive CTLs that reject the host immune system. 2) This effect is IFN-gamma-independent. 3) IL-12 needs to be present during the initial differentiation of T cells in this system to have this effect.

We evaluated the absolute bioavailability of ciprofloxacin, a new quinoline carboxylic acid, in 12 healthy male volunteers. Doses of 200 mg were given to each of the volunteers in a randomized, crossover manner 1 week apart orally and as a 10-min intravenous infusion. Half-lives (mean +/- standard deviation) for the intravenous and oral administration arms were 4.2 +/- 0.77 and 4.11 +/- 0.74 h, respectively. The serum clearance rate averaged 28.5 +/- 4.7 liters/h per 1.73 m2 for the intravenous administration arm. The renal clearance rate accounted for approximately 60% of the corresponding serum clearance rate and was 16.9 +/- 3.0 liters/h per 1.73 m2 for the intravenous arm and 17.0 +/- 2.86 liters/h per 1.73 m2 for the oral administration arm. Absorption was rapid, with peak concentrations in serum occurring at 0.71 +/- 0.15 h. Bioavailability, defined as the ratio of the area under the curve from 0 h to infinity for the oral to the intravenous dose, was 69 +/- 7%. We conclude that ciprofloxacin is rapidly absorbed and reliably bioavailable in these healthy volunteers. Further studies with ciprofloxacin should be undertaken in target patient populations under actual clinical circumstances.

BACKGROUND: Frailty, a validated measure of physiologic reserve, predicts adverse health outcomes among adults with end-stage renal disease. Frailty typically is not measured clinically; instead, a surrogate-perceived frailty-is used to inform clinical decision-making. Because correlations between perceived and measured frailty remain unknown, the aim of this study was to assess their relationship. METHODS: 146 adults undergoing hemodialysis were recruited from a single dialysis center in Baltimore, Maryland. Patient characteristics associated with perceived (reported by nephrologists, nurse practitioners (NPs), or patients) or measured frailty (using the Fried criteria) were identified using ordered logistic regression. The relationship between perceived and measured frailty was assessed using percent agreement, kappa statistic, Pearson's correlation coefficient, and prevalence of misclassification of frailty. Patient characteristics associated with misclassification were determined using Fisher's exact tests, t-tests, or median tests. RESULTS: Older age (adjusted OR [aOR] = 1.36, 95%CI:1.11-1.68, P = 0.003 per 5-years older) and comorbidity (aOR = 1.49, 95%CI:1.27-1.75, P < 0.001 per additional comorbidity) were associated with greater likelihood of nephrologist-perceived frailty. Being non-African American was associated with greater likelihood of NP- (aOR = 5.51, 95%CI:3.21-9.48, P = 0.003) and patient- (aOR = 4.20, 95%CI:1.61-10.9, P = 0.003) perceived frailty. Percent agreement between perceived and measured frailty was poor (nephrologist, NP, and patient: 64.1%, 67.0%, and 55.5%). Among non-frail participants, 34.4%, 30.0%, and 31.6% were perceived as frail by a nephrologist, NP, or themselves. Older adults (P < 0.001) were more likely to be misclassified as frail by a nephrologist; women (P = 0.04) and non-African Americans (P = 0.02) were more likely to be misclassified by an NP. Neither age, sex, nor race was associated with patient misclassification. CONCLUSIONS: Perceived frailty is an inadequate proxy for measured frailty among patients undergoing hemodialysis.

Prior work using the parent-into-F1 model of graft-versus-host disease (GVHD) has shown that production of IL-2 by donor CD4+T cells is an early, initiating event in either acute or stimulatory forms of GVHD. The aim of the present study was to determine whether acute GVHD could be prevented by blocking the effects of IL-2 in vivo during the first 2 weeks of disease. Acute GVHD was induced in B6D2F1 mice by the injection of C57BL/6 spleen cells i.v. Mice were untreated or received either anti-IL-2 mAb (S4B6) or control mAb at the time of GVHD induction and 1 week later. At 2 weeks, untreated or control mAb treated GVHD mice exhibited findings typical of acute GVHD, I.e. (i) in vitro donor anti-host cytotoxic T lymphocyte (CTL) activity, (ii) significant reductions in both numbers and function of splenic lymphocytes, and (iii) in vitro suppressor cell activity which profoundly blocked IL-2 production by normal syngeneic spleen cells. All of these findings were reversed or significantly inhibited in acute GVHD mice receiving anti-IL-2 treatment. Additionally, anti-IL-2 treated GVHD mice exhibited features previously observed in stimulatory GVHD such as: (i) B cell hyperactivity, (ii) a mild defect in CD4+ T cell production of IL-2 in vitro, and (iii) the ability to induce in co-culture a similar CD4+ cell defect in normal, syngeneic F1 spleen cells. B cell hyperactivity, observed in the form of increased B cell expression of MHC class II, increased serum anti-DNA antibody, and increased serum IgG1 and IgE levels, is consistent with the presence of B cell stimulatory cytokines (possibly IL 14 and/or IL-10) in vivo. Thus, it appears that IL-2 production plays a critical role in the early development of acute GVHD, most likely by facilitating the development of donor-anti-host CTL. In contrast, production of B cell stimulatory cytokines in this model in much less dependent (If at all) on the presence of IL-2.

Three unusual primary neoplasms in the skin that occurred in elderly patients (64, 77, and 69 years of age) are presented. Two histologic components were found in each of the three neoplasms, one being small cell or oat cell-like carcinoma and the other squamous cell carcinoma. Study by electron microscopy revealed neurosecretory granules, though few, in the small cell component. The lack of clinical evidence of oat cell carcinoma elsewhere, the autopsy finding of two histologic components in one patient, and the findings by conventional and electron microscopy lead us to conclude that these three neoplasms are primary in the skin and of Merkel cell origin. We suggest further that small cell carcinoma of the skin represents a poorly differentiated counterpart of trabecular carcinoma. The spectrum of malignant Merkel cell neoplasm is, therefore, expanding. Two of our three patients died of their neoplasms 2 and 2 1/2 years, respectively, after the initial diagnosis.

In our study, we have measured in vitro proliferation and IL-2 production by human PBL to characterize the interactions between Th cells and accessory cells (AC) involved in responses to either conventional Ag or alloantigens. IL-2 production and proliferative responses to conventional Ag, such as influenza or tetanus, are exclusively dependent on the presence of CD4+ T cells and AC. In contrast, IL-2 and proliferative responses to alloantigen can be mediated by either CD4+ or CD8+ T cells. CD4+ T cells respond to alloantigen using either autologous AC (self-restricted), or allogeneic AC (allo-restricted), whereas CD8+ T cells respond to alloantigen using allogeneic AC only. The understanding of Th cell-AC interactions involved in in vitro allogeneic responses will be important for delineating the Th cell-AC interactions involved in transplantation immunity as well as in clinical disorders characterized by T cell dysfunction such as human immunodeficiency virus infection and systemic lupus erythematosus.

The purpose of this study was to determine whether macrophages were directly stimulated by tumor cells to release TNF-alpha. We found that several murine and human tumor cell lines and crude cell membrane vesicles prepared from these tumor cells stimulated pyran copolymer-elicited murine peritoneal macrophages (PEM) to release as much as 362 +/- 69 (mean +/- SE) units of TNF activity per 10(6) PEM in vitro. By contrast, several nontransformed cells, including Con A-stimulated splenic leukocytes and CTLL cloned T lymphocytes, failed to stimulate PEM to release TNF. Antibody and complement-mediated depletion of macrophages abrogated the release of TNF; whereas depletion of NK cells and T lymphocytes did not affect tumor-stimulated TNF release, suggesting that tumor cells directly stimulated PEM to release TNF. Tumor-stimulated TNF release was rapid, peaking in 2 to 3 h with subsequent loss of TNF activity from the medium. In the absence of tumor, PEM contained detectable levels of TNF mRNA, but did not release functionally active TNF. The addition of P815 tumor cell membrane vesicles increased both TNF mRNA levels, peaking at 1 to 2 h, and release of high levels of TNF activity. Confounding effects of endotoxin were excluded by the resistance of tumor-stimulated TNF release to neutralization by polymixin B, and by the equivalent responsiveness of PEM from endotoxin-resistant (C3H/HeJ) and endotoxin-sensitive (C3H/HeN) mice to stimulation by tumor cells. Factors which stimulated PEM to release TNF could be extracted from tumor cell membrane, with 77% of the macrophage-stimulating activity recoverable in aqueous phase. In conclusion, we have demonstrated that some tumor cell lines express specific characteristics which can be recognized by macrophages and which stimulate macrophages to release TNF.

Basaloid squamous carcinoma is believed to be a histologically distinct variant of squamous cell carcinoma of the neck region with 11 cases reported. Two cases arising in the pyriform fossa and vallecula are reported, both of which were associated with second primary malignant tumors: esophageal small cell carcinoma and palatal squamous cell carcinoma, respectively. The authors suggest that basaloid squamous carcinoma may be associated with a high incidence of second primary tumors in the upper gastrointestinal tract or larynx.

Four cases of warfarin-induced skin necrosis are reported, and previous reports of this adverse drug reaction are summarized. A 53-year-old man experienced two episodes of skin necrosis on his left flank and buttock, following the initiation of warfarin therapy for acute thrombophlebitis and after a dose adjustment. The lesion formed multiple hemorrhagic bullae that ruptured, and an eschar formed that did not heal and eventually required skin grafting. Seven days after the initiation of warfarin therapy, an area of erythema surrounded by a halo was noted on the left thigh of a 79-year-old woman. Following the typical pattern, the erythematic area turned to a blue-black color and rapidly formed an eschar deep into the subcutaneous tissue that required debridement. A 70-year-old man was given a warfarin dose of 10 mg daily that was reduced to 2.5 mg daily. It was discontinued when bullous violaceous lesions were discovered on his lower left leg and foot. His prothrombin times never exceeded 20 seconds with a control of 10.6 seconds. A 37-year-old woman was admitted with an erythematous area on her right thigh that turned blue-black and subsequently formed an eschar. Her prothrombin time was 21 seconds with a control of 10.6 seconds. Of the 50 reports of warfarin-induced skin necrosis in the literature (including the four here), 74% of the cases involved women. The mean age of the patients was 54 years, and 60% of the lesions occurred on the thigh, breast, or buttock. Usually the onset of the lesion was noted on days 3--5 of warfarin therapy. Sixty percent of the patients were hypocoagulated. The etiology of warfarin-induced skin necrosis has not been definitively established. In the event of this unusual complication, warfarin therapy should be discontinued, vitamin K should be administered to reverse the effects of warfarin, and heparin should be used to provide anticoagulation.

Induction of graft-vs-host disease (GVHD) in the parent-into-F1 model is dependent on the presence of T cells in the donor inoculum. Although in vivo activation of donor T cells in response to F1 alloantigens is thought to be critical to GVHD induction, direct evidence of activated donor T cells has been lacking in this model. In the present study, spleen cells from acute or chronic GVHD mice were studied for evidence of T cell activation at multiple intervals early after GVHD induction. Spleen cells from both acute and chronic GVHD mice exhibited striking elevations in spontaneous proliferation and IL-2 production, which were maximal 24 to 48 h after GVHD induction. Persistent lower levels of spontaneous in vitro activity were observed for spleen cells from mice tested 7 to 9 days after GVHD induction. In both forms of GVHD, increased spontaneous proliferation and IL-2 production were dependent on the presence of donor CD4+ T cells. These results strongly support the presence of activated donor T cells in vivo. Furthermore, these data imply that despite the significant differences in outcome, acute and chronic GVHD share a common early event.

To investigate the pathogenesis of allergic rhinitis, we developed a nasal challenge model in which we examined the early, late, and rechallenge responses to antigen provocation. In these three aspects of the allergic reaction the physiologic responses are associated with inflammatory mediator release. Whereas the early response appears to be related mainly to mast cell activation and mediator release, the late reaction involves a different pattern of mediator release and an inflammatory cell influx, consisting of basophils, neutrophils, and eosinophils. Rechallenge with antigen 11 hours later results in an augmented immediate response. Pretreatment with aspirin reduces the levels of cyclooxygenase metabolites in nasal secretions without affecting the immediate physiologic response to antigen or the expected increase in the levels of histamine, N-alpha-tosyl-L-arginine methyl ester-esterase activity, and leukotriene C4. Pretreatment with systemic steroids does not affect the early allergic response, but significantly reduces mediator release during the late and rechallenge responses. The influx of eosinophils is inhibited by pretreatment with systemic steroids, but neutrophil influx is not. In contrast, pretreatment with topical steroids blocks the early response and the late and rechallenge responses. Influx of all cell types, including the neutrophil, was prevented. These studies show unequivocally that an inflammatory process follows the initial response to antigen and that this inflammation is affected by drugs important in the treatment of chronic allergic disease. We speculate that understanding allergic inflammation will lead to new therapeutic development.

Yaremchuk, Michael J. M.D.; Sedacca, Tamela B.A.; Schiller, Alan L. M.D.; May, James W. Jr. M.D.; Weiland, Andrew J. M.D.Author Information

The majority of asymptomatic, human immune deficiency virus seropositive (HIV+) individuals exhibit a defect in CD4+ T helper cell (Th) function that is selective for responses to recall antigens, but not to HLA alloantigens. The CD4-dependent Th response to HLA alloantigens (Allo) can be mediated by two distinct Th pathways: self-restricted CD4+ Th that recognize allogeneic determinants processed and presented by autologous or self accessory or antigen-presenting cells (sAC); and allo-restricted, CD4+ Th that recognize allogeneic determinants directly on allogeneic accessory or antigen-presenting cells (aAC). In contrast, the Th response to recall antigens requires CD4+ Th and sAC and is therefore limited to the major histocompatibility complex (MHC) self-restricted pathway. Peripheral blood leukocytes from 56 asymptomatic HIV+ patients that exhibited a selective defect in CD4+ Th function were analyzed to determine whether the Th response to Allo was entirely functional, or whether one of the CD4-mediated components of the Allo Th response was also defective. By depletion of AC and/or CD8+ Th subsets (to analyze CD4+ Th function), we demonstrated that HIV+ patients who were selectively deficient in Th function to recall antigens were also unresponsive to Allo presented by autologous AC (HLA self-restricted Th pathway), but retained Allo Th activity presented by allogeneic AC (allo-restricted CD4+ Th pathway). These findings indicate that the CD4+ Th defect seen in the majority of asymptomatic, HIV+ individuals is not limited to recall antigens, but also extends to the component of the response to HLA alloantigens that involves the self-restricted, CD4+ Th pathway. Thus, the Th defect observed in asymptomatic, HIV+ patients does not involve a CD4+ Th defect per se, but is limited to the HLA self-restricted component of Th function.

Evaluation of a binge drinker who died suddenly after a weekend of heavy beer consumption, and had been resuscitated successfully, revealed no evidence of clinically detectable heart disease. Baseline electrophysiological testing was normal. Following intravenous ethanol infusion, paired ventricular extrastimuli from the right ventricle induced a rapid polymorphic ventricular tachycardia requiring cardioversion. Repeat electrophysiological testing 24 hours later without alcohol infusion was again normal. The patient was discharged on no medications and was instructed to refrain from drinking alcohol. Approximately 3 months later the patient died suddenly after heavy beer consumption. Alcohol should be considered in the evaluation of survivors of cardiac arrest and alcohol challenge may be useful in their evaluation.

We have constructed a model (Fig. 2) to explain the activation and regulation of autoreactive T cells by antigen. Antigen priming appears to be important for both antigen-specific and autoreactive T cells. Once activated, these T cells have the capacity to stimulate B cells to produce antibody in a very similar manner. It is possible that these two types of T cells work in concert to maintain an active immune response. Under circumstances where antigen-specific T-cell help may be limiting, autoreactive T cells may function to enhance B-cell responses. In addition, antigen appears to activate the regulatory mechanisms that are important for down-regulating the B-cell antibody response. Carrier-specific T-suppressor cells are antigen-specific in their activation but can be antigen-nonspecific in their effector function. In this way the regulatory mechanism driven by antigen can function to inactivate the antigen-specific and the autoreactive T-cell activation of B cells.

BACKGROUND: The National Kidney Foundation (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) developed guidelines to care for patients with chronic kidney disease (CKD). While these are disseminated through the NKF's website and publications, the guidelines' usage remains suboptimal. The KDOQI Educational Committee was formed to identify barriers to guideline implementation, determine provider and patient educational needs and develop tools to improve care of patients with CKD. METHODS: An online survey was conducted from May to September 2010 to evaluate renal providers' familiarity, current use of and attitudes toward the guidelines and tools to implement the guidelines. RESULTS: Most responders reported using the guidelines often and felt that they could be easily implemented into clinical practice; however, approximately one-half identified at least one barrier. Physicians and physician extenders most commonly cited the lack of evidence supporting KDOQI guidelines while allied health professionals most commonly listed patient non-adherence, unrealistic guideline goals and provider time-constraints. Providers thought that the guidelines included too much detail and identified the lack of a quick resource as a barrier to clinical implementation. Most were unaware of the Clinical Action Plans. CONCLUSIONS: Perceived barriers differed between renal clinicians and allied health professionals; educational and implementation tools tailored for different providers are needed.

Between the years of 1975 and 1979, the frequency of diagnosis of esophageal cancer has doubled at the Baltimore VA Medical Center due to a rapid increase of esophageal cancer among black males. This increase was not related to increased yearly hospital admission rates, percentage of black patients admitted yearly, or increased use of the hospital for chronic disease processes. Detailed chart review and comparison with consecutive medical admissions as controls revealed heavy alcohol use and urbanization to be risk factors experienced more frequently by black than white male veterans. A serious question needs to be quickly answered: Does the rise of esophageal cancer at the Baltimore VAMC reflect a rise among black males only in Baltimore or does it reflect a rise nationwide among black males with a history of previous employment in the armed forces?

We studied 41 patients with urethral stricture who had failed at least 1 operation, and were being maintained with filiform and follower dilation every 6 to 12 weeks. The patients were instructed in clean intermittent self-catheterization with a 16F red rubber catheter, which was performed every 1 to 30 days. Followup from 9 to 36 months revealed excellent compliance and average peak uroflow rates increased from 5.5 cc per second before dilation to 17.1 cc per second at the last followup visit. Clean intermittent self-catheterization is a simple method to maintain a patent urethra and obviates the need for further operations or painful dilations.

Sampliner, R. E. (VA Medical Center, Baltimore, MD 21218), B. L. Loevinger, E. Tabor and R. J. Gerety. intrafamllial cluster of hepatitis B virus infection: study of a large family in the United States. Am J Epidemiol 1981;113:50–54. Seventy-eight persons in an Italian-American family were tested for hepatitis B serologic markers. Fifty-one (65%) had serologic evidence of active or prior hepatitis B infection. Twenty-eight (36%) had evidence of active infection, including twenty-six with hepatitis B surface antigen (HBsAg), and two with antibody to the hepatitis B core antigen only. Severe chronic liver disease was documented in four family members, three of whom had serologic evidence of active hepatitis B infection and the fourth died before the availability of hepatitis B testing. Thirteen of 18 (72%) offspring of six HBsAg positive mothers were HBsAg positive. No epldemlologic explanation of the high prevalence of hepatitis B infection in this family was found, although mother-to-child transmission in years past is a possible explanation.