Emphysema predicts hospitalisation and incident airflow obstruction among older smokers: a prospective cohort study.

BACKGROUND: Emphysema on CT is common in older smokers. We hypothesised that emphysema on CT predicts acute episodes of care for chronic lower respiratory disease among older smokers. MATERIALS AND METHODS: Participants in a lung cancer screening study age ≥ 60 years were recruited into a prospective cohort study in 2001-02. Two radiologists independently visually assessed the severity of emphysema as absent, mild, moderate or severe. Percent emphysema was defined as the proportion of voxels ≤ -910 Hounsfield Units. Participants completed a median of 5 visits over a median of 6 years of follow-up. The primary outcome was hospitalization, emergency room or urgent office visit for chronic lower respiratory disease. Spirometry was performed following ATS/ERS guidelines. Airflow obstruction was defined as FEV1/FVC ratio <0.70 and FEV1<80% predicted. RESULTS: Of 521 participants, 4% had moderate or severe emphysema, which was associated with acute episodes of care (rate ratio 1.89; 95% CI: 1.01-3.52) adjusting for age, sex and race/ethnicity, as was percent emphysema, with similar associations for hospitalisation. Emphysema on visual assessment also predicted incident airflow obstruction (HR 5.14; 95% CI 2.19-21.1). CONCLUSION: Visually assessed emphysema and percent emphysema on CT predicted acute episodes of care for chronic lower respiratory disease, with the former predicting incident airflow obstruction among older smokers.

The Pediatric Heart Network: a primer for the conduct of multicenter studies in children with congenital and acquired heart disease.

Most contemporary diagnostic and treatment strategies for pediatric patients with cardiovascular disease are not supported by evidence from clinical trials but instead are based on expert opinion, single-institution observational studies, or extrapolated from adult cardiovascular medicine. In response to this concern, the National Heart, Lung, and Blood Institute established the Pediatric Heart Disease Clinical Research Network (PHN) in 2001. The purposes of this article are to describe the initiation, structure, and function of the PHN; to review the ongoing studies; and to address current and future challenges. To date, four randomized clinical trials and two observational studies have been launched. Design and conduct of complex, multicenter studies in children with congenital and acquired heart disease must address numerous challenges, including identification of an appropriate clinically relevant primary endpoint, lack of preliminary data on which to base sample size calculations, and recruitment of an adequate number of subjects. The infrastructure is now well developed and capable of implementing complex, multicenter protocols efficiently and recruiting subjects effectively. The PHN is uniquely positioned to contribute to providing evidence-based medicine for and improving the outcomes of pediatric patients with cardiovascular disease.

Reporter gene transactivation by human p53 is inhibited in thioredoxin reductase null yeast by a mechanism associated with thioredoxin oxidation and independent of changes in the redox state of glutathione.

Reporter gene transactivation by human p53 is compromised in S. cerevisiae lacking the TRR1 gene encoding thioredoxin reductase. The basis for p53 inhibition was investigated by measuring the redox state of thioredoxin and glutathione in wild-type and Deltatrr1 yeast. The Deltatrr1 mutation affected the redox state of both molecules. About 34% of thioredoxin was in the disulfide form in wild-type yeast and increased to 70% in Deltatrr1 yeast. About 18% of glutathione was in the GSSG form in wild-type yeast and increased to 32% in Deltatrr1 yeast. The Deltatrr1 mutation also resulted in a 2.9-fold increase in total glutathione per mg extract protein. Highcopy expression of the GLR1 gene encoding glutathione reductase in Deltatrr1 yeast restored the GSSG:GSH ratio to wild-type levels, but did not restore p53 activity. Also, p53 activity was shown to be unaffected by a Deltaglr1 mutation, even though the mutation was known to result in glutathione oxidation. In summary, the results show that, although glutathione becomes more oxidized in Deltatrr1 cells, glutathione oxidation is neither sufficient nor necessary for p53 inhibition. The results indicate that p53 activity has a specific requirement for an intact thioredoxin system, rather than a general dependence on the intracellular reducing environment.

Peripartum cardiomyopathy: National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) workshop recommendations and review.

OBJECTIVE: Peripartum cardiomyopathy (PPCM) is a rare life-threatening cardiomyopathy of unknown cause that occurs in the peripartum period in previously healthy women. In April 1997, the National Heart, Lung, and Blood Institute (NHLBI) and the Office of Rare Diseases of the National Institutes of Health (NIH) convened a Workshop on Peripartum Cardiomyopathy to foster a systematic review of information and to develop recommendations for research and education. PARTICIPANTS: Fourteen workshop participants were selected by NHLBI staff and represented cardiovascular medicine, obstetrics, immunology, and pathology. A representative subgroup of 8 participants and NHLBI staff formed the writing group for this article and updated the literature on which the conclusions were based. The workshop was an open meeting, consistent with NIH policy. EVIDENCE: Data presented at the workshop were augmented by a MEDLINE search for English-language articles published from 1966 to July 1999, using the terms peripartum cardiomyopathy, cardiomyopathy, and pregnancy. Articles on the epidemiology, pathogenesis, pathophysiology, diagnosis, treatment, and prognosis of PPCM were included. RECOMMENDATION PROCESS: After discussion of data presented, workshop participants agreed on a standardized definition of PPCM, a general clinical approach, and the need for a registry to provide an infrastructure for future research. CONCLUSIONS: Peripartum cardiomyopathy is a rare lethal disease about which little is known. Diagnosis is confined to a narrow period and requires echocardiographic evidence of left ventricular systolic dysfunction. Symptomatic patients should receive standard therapy for heart failure, managed by a multidisciplinary team. If subsequent pregnancies occur, they should be managed in collaboration with a high-risk perinatal center. Systematic data collection is required to answer important questions about incidence, treatment, and prognosis.

The human p53 negative regulatory domain mediates inhibition of reporter gene transactivation in yeast lacking thioredoxin reductase.

Stimulation of target gene transcription by human p53 is inhibited in budding yeast lacking the TRR1 gene encoding thioredoxin reductase. LexA/p53 fusion proteins were used to study the basis for thioredoxin reductase dependence. A fusion protein containing all 393 of the residues of p53 efficiently and specifically stimulated transcription of a LexOP-LacZ reporter gene in wild-type yeast but was several-fold less effective in delta trr1 yeast lacking the thioredoxin reductase gene. Thus, even when p53 was tethered to a reporter gene by a heterologous DNA-binding domain, reporter gene transactivation remained dependent on thioredoxin reductase. A fusion protein containing only the activation domain of p53 stimulated reporter gene transcription equally in wild-type and delta trr1 cells, suggesting that p53 residues downstream from the activation domain created the requirement for thioredoxin reductase. Experiments using additional LexA/p53 truncation mutations indicated that the p53 negative regulatory domain, rather than the DNA-binding or oligomerization domains, created the requirement for thioredoxin reductase. The fusion protein results suggested that, under oxidative conditions, the negative regulatory domain inhibited the ability of DNA-bound p53 to stimulate transcription. However, deletion of the negative regulatory domain did not alleviate the requirement of non-LexA-containing p53 for thioredoxin reductase. The results, thus, suggest that oxidative conditions inhibit both DNA binding and transactivation by p53, and that inhibition of the latter requires the negative regulatory domain.

Deletion of the Saccharomyces cerevisiae TRR1 gene encoding thioredoxin reductase inhibits p53-dependent reporter gene expression.

The prevalence of p53 gene mutations in many human tumors implies that p53 protein plays an important role in preventing cancers. Central among the activities ascribed to p53 is its ability to stimulate transcription of other genes that inhibit cells from entering S phase with damaged DNA. Human p53 can be studied in yeast where genetic tools can be used to identify proteins that affect its ability to stimulate transcription. Although p53 strongly stimulated reporter gene expression in wild type yeast, it only weakly stimulated reporter gene expression in Deltatrr1 yeast that lacked the gene encoding thioredoxin reductase. Furthermore, ectoptic expression of TRR1 in Deltatrr1 yeast restored p53-dependent reporter gene activity to high levels. Immunoblot assays established that the Deltatrr1 mutation affected the activity and not the level of p53 protein. The results suggest that p53 can form disulfides and that these disulfides must be reduced in order for the protein to function as a transcription factor.

Regulation, replication, and integration functions of the Vibrio cholerae CTXphi are encoded by region RS2.

CTXphi is a filamentous phage that encodes cholera toxin, one of the principal virulence factors of Vibrio cholerae. CTXphi is unusual among filamentous phages because it can either replicate as a plasmid or integrate into the V. cholerae chromosome at a specific site. The CTXphi genome has two regions, the 'core' and RS2. Integrated CTXphi is frequently flanked by an element known as RS1 which is related to RS2. The nucleotide sequences of RS2 and RS1 were determined. These related elements contain three nearly identical open reading frames (ORFs), which in RS2 were designated rstR, rstA2 and rstB2. RS1 contains an additional ORF designated rstC. Functional analyses indicate that rstA2 is required for CTXphi replication and rstB2 is required for CTXphi integration. The amino terminus of RstR is similar to the amino termini of other phage-encoded repressors, and RstR represses the expression of rstA2. Although genes with related functions are clustered in the genome of CTXphi in a way similar to those for other filamentous phages, the CTXphi RS2-encoded gene products mediating replication, integration and repression appear to be novel.

Cervical aortic arch with aneurysm formation.

Two pediatric cases of cervical aortic arch with aneurysm formation are reported. Only female patients with cervical aortic arch have developed aneurysms, which may influence risk counseling of such patients.

A retrospective review of the role of transesophageal echocardiography in aortic and cardiac trauma in a level I Pediatric Trauma Center.

This study examined the role of transesophageal echocardiography in blunt aortic and cardiac trauma in a Pediatric Level I Trauma Center. In a > 5-year retrospective review, we identified 10 children with blunt cardiac (n = 4; tricuspid valve in two; mitral valve in one; aortic valve in one) and aortic (n = 6; aortic rupture in five, subintimal flap in one) trauma. Diagnosis of the cardiac injuries was made with transthoracic echocardiography, with transesophageal echocardiography providing additional anatomic detail and postoperative assessment in three of four children who required surgical intervention. Diagnosis of the aortic injuries was made with transesophageal echocardiography in five of six patients; one patient underwent aortography before transfer. Transesophageal echocardiography also identified depressed myocardial function in one child and aided in surgical management of the five aortic ruptures. In blunt chest trauma, transesophageal echocardiography provides accurate evaluation of cardiovascular structure and function and guides operative repair.

Small (< or = 3 cm) hyperechoic renal masses: comparison of helical and convention CT for diagnosing angiomyolipoma.

OBJECTIVE: Because hyperechoic renal masses may represent angiomyolipomas or small renal cancers, CT is often used to reveal the fatty component, which allows diagnosis of angiomyolipoma in most cases. Because conventional CT can fail to reveal fat in angiomyolipomas 3 cm or smaller, we conducted a study to determine whether helical CT would improve our detection of fat and allow more of these masses to be diagnosed as angiomyolipomas. SUBJECTS AND METHODS: We used helical and conventional CT to examine 20 masses (5-29 mm in diameter) in 17 patients who had a small hyperechoic mass detected sonographically. Densitometry was performed by three readers and the mean attenuation values were compared. RESULTS: Of the 20 masses, we diagnosed angiomyolipoma in 16 masses using helical CT and in 14 masses using conventional CT. In 11 masses, we found the measured attenuation values to be more negative on helical CT scans than on conventional CT scans. In five masses, we found the opposite to be true. In the remaining four masses, we were unable to diagnose angiomyolipoma. Of the masses that we diagnosed as angiomyolipoma, the mean attenuation value when examined with helical CT (-44 H) was more negative than with conventional CT (-35 H) but not significantly so (p = .058). However, in the subset of patients with masses that were 2 cm or less in diameter (n = 14), the mean attenuation values on helical CT were significantly lower than on conventional CT (-40 H versus -30 H, p < .05). Likewise, for masses with attenuation values that differed by more than 6 H (n = 8), when imaged by the two techniques we again found that mean attenuation values on helical CT were significantly lower (-43 H versus -24 H, p < .05). CONCLUSION: Helical CT revealed angiomyolipoma across all cases as well as conventional CT did. Also, helical CT was more sensitive in revealing fat in masses less than 2 cm in diameter and in masses in which the attenuations of the two CT techniques differed by a significant amount. We preferred helical CT over conventional CT when examining hyperechoic masses for the purpose of diagnosing angiomyolipoma.

Traumatic thoracic aortic rupture in the pediatric patient.

BACKGROUND: Traumatic thoracic aortic rupture is a rare injury in the pediatric patient. Experiences with thoracic aortic rupture in patients less than 17 years of age are needed to help identify factors that can influence injury occurrence, diagnosis, management, and outcome. METHODS: Between July 1989 and December 1995, 6 children were treated operatively for thoracic aortic rupture from blunt trauma at a level I pediatric trauma center. The average age was 13.2 years (range, 8 to 16 years). There were 4 females and 2 males. There were 5 motor vehicle accidents and 1 bicycle accident. Aortic injury was suspected based on the mechanism of injury and abnormal chest roentgenogram results, and was confirmed by aortography (3 cases) or chest computed tomography (2) and transesophageal echocardiography (3). Life-threatening central nervous system or gastrointestinal injuries were evaluated or treated first. Operative repair of the thoracic aorta was performed by cardiopulmonary bypass (2 patients) and clamp and sew technique (4). RESULTS: Aortic ruptures were complete transections at the ligamentum arteriosum in 5 of 6 (83%); the other case was a cervical arch pseudoaneurysm. Associated injuries included pulmonary contusion (100%), pelvic/long bone fractures (50%), visceral laceration/perforation (50%), central nervous system (33%), paraplegia (17%), and myocardial contusion (17%). There were no rib fractures. Four of 5 patients (80%) were not wearing seat belts, and 2 of these were ejected. The average time from injury to the operating room was 17.6 hours (range, 5 to 48 hours); the time from diagnosis to the operating room exceeded 5 hours with aortography and was less than 3 hours with chest computed tomography and transesophageal echocardiography. Each diagnostic modality accurately identified an aortic injury. The average time for cardiopulmonary bypass and for clamp and sew was 52 minutes (range, 49 to 55 minutes) and 34 minutes (range, 16 to 45 minutes), respectively. One patient with preoperative paraplegia regained partial function; there were no other patients with paraplegia. There were no deaths. All patients are alive 2 months to 7 years after repair. CONCLUSIONS: The multiply injured child with severe blunt trauma and an abnormal chest roentgenogram requires a search for aortic injury. We believe the most effective algorithm to follow for the diagnosis of traumatic thoracic aortic rupture in the child involves selective performance of chest computed tomography and transesophageal echocardiography. Our experience suggests that the mechanism of injury, the duration to diagnosis of an aortic injury, and failure to use seat belts may contribute to morbidity. A high index of suspicion and a systematic approach to the diagnosis and to the management strategy for injuries to the thoracic aorta can contribute to a good outcome in those few children who survive the injury.

CTX genetic element encodes a site-specific recombination system and an intestinal colonization factor.

In Vibrio cholerae, the genes encoding cholera toxin (ctxAB) are located on a segment of DNA (termed the "core" region) that is flanked by two or more copies of a repeated sequence called RS1. Together these DNA units comprise the CTX genetic element. Evidence presented here suggests that RS1 sequences encode a site-specific recombination system, which allows integration of a suicide plasmid carrying RS1 into an 18-base-pair sequence (attRS1) located on the chromosome of nontoxigenic V. cholerae strains. Strains of V. cholerae with large deletions removing attRS1 and the entire CTX genetic element no longer undergo site-specific recombination with the RS1 sequence. Additionally, these deletion strains show a defect in intestinal colonization. Recombination experiments localize the gene responsible for enhancing colonization to a portion of the core region of the CTX element. The identified gene encodes a peptide that is highly similar in amino acid sequence to the flexible pilin of Aeromonas hydrophila. These results have important implications in the construction of stable, live attenuated cholera vaccines.

Sequence conversion during postreplicative adenovirus overlap recombination.

Sequence conversion efficiently transfers genetic information in high yield during postreplicative adenovirus overlap recombination. This process is intrinsically nonreciprocal, depends on adenovirus-specific strand-displacement replication by both partner molecules, and requires that complementary sequences on displaced strands must exceed a minimal length to form a heteroduplex intermediate.

Symmetrical adenovirus minichromosomes have hairpin replication intermediates.

A special class of panhandles (hairpin or foldback structures) arising from the replication of symmetrical adenovirus (Ad) minichromosome dimers and oligomers have been identified by two-dimensional gel electrophoresis. Hairpins provide evidence for replicative intermediates in the pathway for Ad complementary-strand synthesis. Furthermore, larger inverted sequences give Ad minichromosomes a replicative advantage.

Cardiac care for infants. Determinants of hospital charges for acute care.

We analyzed hospital use and inpatient charges retrospectively for infants hospitalized at a tertiary referral center in the first year of life for cardiac disease. For 93 infants hospitalized between August 1987 and June 1989, there were 1.8 admissions per patient, with a median stay of 14 days; 24.7% required more than 28 days of acute inpatient care. Total hospital charges (excluding professional fees) in the first year of life were $3,417,612, which represents $36,749 per infant and $35,386 per survivor. Reimbursement totaled 93.2% of charges. Multivariate analysis revealed that complex disease, surgery, and length of stay in the intensive care unit were significantly associated with increased charges, while extracardiac anomalies, birth weight, outcome, and type of insurance were not. The economic benefits of averting infant death outweigh the associated costs by as much as 5.4 to 1. We conclude that current treatment of most infants with cardiac disease is both effective and economically beneficial.

Determinants of outcome in hospitalized infants with congenital heart disease.

To identify determinants of adverse outcome in this era of early, definitive treatment, retrospective data were analyzed for 1988 on infants aged less than 1 year with congenital cardiac disease hospitalized at The Johns Hopkins Hospital. In this cohort of 108 infants, 34% (37 of 108) had complex cardiac disease, 33% (36 of 108) had major extracardiac anomalies, 88 patients (81%) underwent 116 surgical procedures, 37% (40 of 108) were hospitalized for greater than 28 days and 29% (31 of 108) died during the first year. Univariate analysis showed that complex disease (i.e., severe ventricular hypoplasia, ventricular septal malalignment or outflow atresia), extracardiac anomalies, early initial presentation, and prolonged stay in the intensive care unit were significantly associated with infant death, whereas surgery was associated with a significantly increased rate of survival. The findings for complex disease and surgery persisted in multiple logistic regression analysis. It is concluded that outcome in most infants with congenital cardiac defects is now extremely favorable, and that major research and preventive efforts should focus on complex congenital cardiac defects.

Inverted repeats direct repair of adenovirus minichromosome ends.

Adenovirus DNA initiates strand-displacement replication from origins located in identical inverted terminal repetitions (ITRs). Panhandle structures, formed by base pairing between ITRs on the displaced strands, have been proposed as replication intermediates for complementary strand synthesis. We have used a model system, which separates adenovirus replication origin sequences from those involved in panhandle formation, to study the length and sequence integrity of panhandles. By making a series of unidirectional deletion in the panhandle sequence, we show that 31 bp are necessary for panhandle formation. Removal of long stretches of 3'-unpaired nucleotides distal to the panhandle is extremely efficient. Our results argue for the formation of panhandles during adenovirus DNA replication and provide a mechanism for maintaining sequence identity between distantly located inverted repetitions. The size constraint may explain why the adenovirus ITRs are larger than the viral DNA replication origins.

Strands hybridize in postreplicative adenovirus overlap recombination.

We describe a postreplicative mechanism for adenovirus overlap recombination. An adenovirus minichromosome system was used to study overlap recombination driven by adenovirus DNA replication. Crossing-over appeared to occur equally at, but not within, the borders of the overlap between partner molecules. We propose that recombination in the minichromosome system proceeds through an intermediate formed by direct hybridization of complementary sequences on displaced strands generated by adenovirus-specific DNA replication. Some, but not all, heterologous regions in the intermediate are susceptible to mismatch correction. This pathway is intrinsically nonreciprocal and differs significantly from other adenovirus recombinational mechanisms that have been described previously.