Evidence for multidimensional resilience in adult patients with transfusion-dependent thalassemias: Is it more common than we think?

BACKGROUND: Life expectancy of patients with transfusion-dependent thalassemias has increased with the development of improved treatment over the last few decades. However, ß-thalassemia disorder still has considerable lifetime treatment demands and heightened risk of frequent complications due to transfusion-transmitted infections and iron overload, which may affect thalassemic patients' functioning in different domains. OBJECTIVES: The vast majority of published studies on thalassemic patients have focused on children and adolescent functioning, and little research has examined adults. Hence, the current study was planned to examine the functioning and resilience of adult thalassemic patients in a comprehensive way. METHODS: We examined multidimensional resilience and functioning across different domains (psychological adjustment, treatment adherence, social functioning and occupational functioning). We also examined demographic and medical variables that may relate to resilience and functioning. Participants were adult patients [n = 38; age M = 31·63, standard deviation (SD) = 7·72; 72% female] with transfusion-dependent thalassemia in treatment in a hospital in the northeastern United States. RESULTS: The results suggest that most adult thalassemic patients tend to be resilient, demonstrating good functioning in four main domains: psychological adjustment, treatment adherence, social functioning and occupational functioning. CONCLUSION: Despite the considerable demands of their illness, adult thalassemic patients appeared to be adapting well, demonstrating evidence of multidimensional resilience.

Determination of the relative expression levels of rubisco small subunit genes in Arabidopsis by rapid amplification of cDNA ends.

Multigene families are common in higher organisms. However, due to the close similarities between members, it is often difficult to assess the individual contribution of each gene to the overall expression of the family. In Arabidopsis thaliana, there are four genes encoding the small subunits (SSU) of ribulose-1.5-bisphosphate carboxylase oxygenase (rubisco) whose nucleotide sequences are up to 98.4% identical. In order to overcome the technical limitations associated with gene-specific probes (or primers) commonly used in existing methods, we developed a new gene expression assay based on the RACE (rapid amplification of cDNA ends) technique with a single pair of primers. With this RACE gene expression assay, we were able to determine the relative transcript levels between four Arabidopsis SSU genes. We found that the relative SSU gene expression differed significantly between plants grown at different temperatures. Our observation raises the possibility that an adaptation of rubisco to the environment may be achieved through the specific synthesis of the SSU proteins, which is determined by the relative expression levels between the SSU genes.

Polygalacturonase gene expression in kiwifruit: relationship to fruit softening and ethylene production.

In kiwifruit, much of the softening process occurs prior to the respiratory climacteric and production of ethylene. This fruit therefore represents an excellent model system for dissecting the process of softening in the absence of endogenous ethylene production. We have characterized the expression of three polygalacturonase (PG) cDNA clones (CkPGA, B and C) isolated from fruit of Actinidia chinensis. Expression of CkPGA and B was detected by northern analysis only in fruit producing endogenous ethylene, and by RT-PCR in other tissues including flower buds, petals at anthesis, and senescent petals. CkPGA promoter fragments of 1296, 860 and 467 bp fused to the beta-glucuronidase (uidA) reporter gene directed fruit-specific gene expression during the climacteric in transgenic tomato. CkPGC gene expression was observed in softening fruit, and reached maximum levels (50-fold higher than for CkPGA and B) as fruit passed through the climacteric. However, expression of this gene was also readily detected during fruit development and in fruit harvested prior to the onset of softening. Using RT-PCR, expression of CkPGC was also detected at low levels in root tips and in senescent petals. These results suggest that PG expression is required not only during periods of cell wall degeneration, but also during periods of cell wall turnover and expansion.

Neurogenic calcitonin gene-related peptide: a neurotrophic factor in the maintenance of acetylcholinesterase molecular forms in adult skeletal muscles.

This work addresses the role of calcitonin gene-related peptide (CGRP) in the physiological maintenance of acetylcholinesterase (AChE) molecular forms in motor endplate regions of adult Sprague-Dawley rat fast-twitch anterior gracilis muscles. Results show that: (a) CGRP is present in obturator nerve motor neurons which supply the gracilis muscle, as well as in the corresponding motor endplate regions where high levels of both AChE activity and acetylcholine receptors (AChRs) are detected; (b) endplate-associated CGRP declines with muscle denervation several hours before any changes in AChE forms are detected; (c) a single subcutaneous injection of CGRP reversibly reduces the activities of all AChE forms in endplate regions of normally innervated and otherwise untreated gracilis muscles; and (d) similar treatment with hCGRP(8-37), a potent and selective CGRP antagonist, produces the opposite effects, i.e., it reversibly elevates the activities of all AChE forms. These and other findings indicate that CGRP and hCGRP(8-37) influence the mechanism(s) by which AChE forms are maintained in intact adult gracilis muscles. Indeed, the findings lend strong support to the hypothesis that nerve-derived CGRP plays a key role in the trophic regulation of AChE forms at the neuromuscular junction.

Gene encoding polygalacturonase inhibitor in apple fruit is developmentally regulated and activated by wounding and fungal infection.

A cDNA encoding polygalacturonase-inhibiting protein (PGIP) from mature apple fruit has been cloned and characterized. The open reading frame encodes a polypeptide of 330 amino acids, in which 24 amino acids at the N-terminus comprise the signal peptide. Apple PGIP contains 10 imperfect leucine-rich repeat sequence motifs averaging 24 amino acids in length. In addition to the 1.3 kb PGIP transcript, the cloned cDNA also hybridized to RNA molecules with sizes of 3.2 and 5.0 kb. Genomic DNA analysis revealed that the apple PGIP probably belongs to a small family of genes. PGIP transcript levels varied in fruit collected at different maturities, suggesting the gene is developmentally regulated. Very high PGIP transcript levels were detected in decayed areas and the tissue adjacent to the inoculation sites of Penicillium expansum and Botrytis cinerea. However, no increase in the amount of PGIP transcript in tissue distant from the decayed region was observed. Wounding on fruit also induced PGIP gene expression but to a much lessser extent when compared with decayed areas. After storage at 0 degrees C for 1 month, the abundance of PGIP transcript in ripe fruit was substantially increased. The PGIP gene in immature and ripe fruit was rapidly up-regulated by fungal infections, while in stored fruit the induction was very limited and concurred with an increase of fruit susceptibility to fungal colonization. Since PGIP gene expression is regulated by fruit development and responds to wounding, fungal infection and cold storage, these observations suggest that apple PGIP may have multiple roles during fruit development and stress response.

Apple ACC-oxidase and polygalacturonase: ripening-specific gene expression and promoter analysis in transgenic tomato.

Levels of 1-aminocyclopropane-1-carboxylate (ACC) oxidase and polygalacturonase (PG) mRNAs were characterized during ripening of Royal Gala, Braeburn and Granny Smith apples. Both ACC-oxidase and PG mRNAs were up-regulated in ripening fruit of all three cultivars. Expression in Royal Gala was detected earlier than in Braeburn and Granny Smith, relative to internal ethylene concentration. Genomic clones corresponding to the ACC-oxidase and PG mRNAs expressed in ripe apple fruit were isolated and ca. 2 kb of each promoter was sequenced. The start point of transcription in each gene was mapped by primer extension, and sequences homologous to elements in other ethylene-responsive or PG promoters were identified. The fruit specificity of the apple ACC-oxidase and PG promoters was investigated in transgenic tomato plants using a nested set of promoter fragments fused to the beta-glucuronidase (gusA) reporter gene. For the ACC-oxidase gene, 450 bp of 5' promoter sequence was sufficient to drive GUS expression, although this expression was not specific to ripening fruit. Larger fragments of 1966 and 1159 bp showed both fruit and ripening specificity. For the PG gene, promoter fragments of 1460 and 532 bp conferred ripening-specific expression in transgenic tomato fruit. However GUS expression was down-regulated by 2356 bp of promoter, suggesting the presence of a negative regulatory element between positions -1460 and -2356.

Interaction between terbinafine and warfarin.

A 71-year-old woman presented with gastrointestinal bleeding. She had been stabilized on warfarin for the previous few months. Terbinafine had been started 32 days prior to this episode for the treatment of onychomycosis. The patient had been on cimetidine for the previous 2 years and on other medications for the last 10 years. At the time of admission for the gastrointestinal bleeding, the coagulation indices were all above the therapeutic range. Endoscopy of the gastrointestinal tract exhibited diffuse intestinal 'oozing' consistent with coagulopathy as the cause of bleeding. Terbinafine may have had an effect on the metabolism of warfarin since both are metabolized through the liver and cimetidine can reduce terbinafine clearance by 33% resulting in higher concentrations of the antifungal agent. Our experience suggests that caution should be exercised when prescribing terbinafine to a patient receiving warfarin.

Responsibility for clinical innovation. A case study in neonatal medicine.

Proper evaluation of clinical innovations and of the process of their diffusion is essential for the development of sound health care policy. This case study examines transcutaneous oxygen monitoring in neonatal intensive care, a procedure that was rapidly adopted in the late 1970s as a scientific breakthrough of great promise, then all but abandoned within a decade in favor of pulse oximetry, a still more recent technology. The study incorporates the results of interviews with representatives of industry as well as biomedical researchers and clinicians involved with these devices. Factors in technology diffusion are analyzed, with special attention to those susceptible to change by policy makers. Participants in the diffusion process also include nurses, hospital administrators, the legal profession, the news media, and the public, but the pivotal role--and hence ultimate responsibility--is seen to be that of the physician. The discussion is presented in the context of a proposed "ethics of evidence" pertinent to medical decision making.

Doctors and the health industry: a case study of transcutaneous oxygen monitoring in neonatal intensive care.

This case study presents an industry perspective on medical innovation. Introduced as a scientific breakthrough in the late 1970s, transcutaneous oxygen monitoring was rapidly adopted for routine use in neonatal intensive care. But plagued by technical problems, it was within a decade being replaced by pulse oximetry, a still more recent technology. Its use in efforts to prevent retinopathy of prematurity, an eye disease of preterm newborns often leading to blindness, proved disappointing. The project included interviews with executives and design engineers of companies marketing the device, with investigators who had pioneered the technology, and with senior practicing neonatologists. The findings, reflecting complexity and uncertainty, are relevant to issues concerning health care in the United States and other developed nations. They centre on the key role and ultimate responsibility of the medical profession, with a need for greater attention to the scientific training of health care workers, as perceived by members of the medical device industry. The views of senior investigators are integrated into the picture, with discussion of major challenges faced by the medical community.

Effects of various risk factors on plasma protein and serum immunoglobulin concentrations of calves at postpartum hours 10 and 24.

In an attempt to identify important predictors of failure of passive immunoglobulin transfer (< 800 mg of IgG/dl), identify calves with failure of passive immunoglobulin transfer, and determine the effects of a colostrum supplement, blood samples were collected from 263 calves at postpartum hours 10 and 24. Calves of dams diagnosed with mastitis had lower mean plasma protein and IgG concentrations at 10 (P < 0.05) and 24 (P < 0.01) hours. Plasma protein and IgG concentrations were similar for single and twin calves at 10 hours, but IgG concentration at 24 hours was higher (P < 0.01) in twin calves. Calves born to dams that had dystocia had numerically lower mean plasma protein and IgG concentrations than did calves born to dams that had normal delivery. However, observed differences were small and, after adjustment for other important factors, these differences were not significant. Age of dam was associated with plasma protein (P < 0.05) and IgG (P < 0.10) concentrations at 10 hours, but had no effect at 24 hours. Plasma protein and IgG concentrations decreased as calves were born later in the calving season, although the association of birth date with IgG concentration at 24 hours was marginal (P = 0.07). Calf sex, dam body condition score, and birth weight were not related to plasma protein or IgG values. The sensitivity and specificity of a cutoff value of 4.8 g of protein/dl of plasma, measured at 10 hours, for diagnosing failure of passive immunoglobulin transfer at 10 hours were 78 and 94%, and for diagnosing failure of passive immunoglobulin transfer at 24 hours were 88 and 73%, respectively. A colostrum supplement administered to calves with low plasma protein concentration at 10 hours had no effect on plasma protein or IgG values at 24 hours or on preweaning morbidity and mortality.

Platelets are the primary source of amyloid beta-peptide in human blood.

The main component of Alzheimer's disease (AD) amyloid deposits is amyloid beta-peptide (A beta), a fragment of the larger amyloid precursor protein (APP). The cellular source of A beta is not known, but a circulatory origin has been postulated. We studied human blood from healthy individuals and found that platelets account for almost 90% of the total anti-A beta immunoreactivity detected in whole blood. Using reverse-phase HPLC, we identified a platelet peptide which corresponds to A beta by three criteria: (a) it shares a retention time with the synthetic A beta 1-40 peptide in two consecutive HPLC tests; (b) it interacts with two anti-A beta antibodies in separate ELISAs; and, (c) its partial N-terminal amino acid sequence closely matches that of A beta. The detection of this peptide in platelets indicates that, aside from the well-known non-amyloidogenic (secretory) pathway, the processing of APP in platelets from healthy individuals also involves an amyloidogenic pathway. These findings are consistent with the view that platelets are one of the major sources of A beta in the circulation.

An apple polyphenol oxidase cDNA is up-regulated in wounded tissues.

A full-length cDNA clone encoding apple (Malus domesticus) polyphenol oxidase (PPO) was isolated from a fruit peel cDNA library. Southern analysis indicated that apple PPO is encoded by a divergent multigene family. By northern analysis, PPO mRNA was only detected in a fruit sample taken one week after full bloom. PPO mRNA accumulated in wounded tissues, and also in peel tissue showing the symptoms of superficial scald, a post-harvest disorder. The induction of PPO mRNA provides the first evidence for transcriptional control of PPO expression after wounding or the manifestation of a physiological disorder.

Apple beta-galactosidase. Activity against cell wall polysaccharides and characterization of a related cDNA clone.

A beta-galactosidase was purified from cortical tissue of ripe apples (Malus domestica Borkh. cv Granny Smith) using a procedure involving affinity chromatography on lactosyl-Sepharose. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis indicated that two polypeptides of 44 and 32 kD were present in the fraction that showed activity against the synthetic substrate p-nitrophenol-beta-D-galactopyranoside. The enzyme preparation was incubated with polysaccharide extracts from apple cell walls containing beta-(1-->4)-linked galactans, and products of digestion were analyzed by gas chromatography. Small amounts of monomeric galactose were released during incubation, showing that the enzyme was active against native substrates. Amino acid sequence information was obtained from the purified protein, and this showed high homology with the anticipated polypeptide coded by the ethylene-regulated SR12 gene in carnation (K.G. Raghothama, K.A. Lawton, P.B. Goldborough, W.R. Woodson [1991] Plant Mol Biol 17: 61-71) and a harvest-related pTIP31 cDNA from asparagus (G. King, personal communication). Using the asparagus cDNA clone as a probe, an apple homolog (pABG1) was isolated. This clone contains a 2637-bp insert, including an open reading frame that codes for a polypeptide of 731 amino acids. Cleavage of an N-terminal signal sequence would leave a predicted polypeptide of 78.5 kD. Genomic DNA analysis and the isolation of other homologous apple clones suggest that pABG1 represents one member of an apple beta-galactosidase gene family. Northern analysis during fruit development and ripening showed accumulation of pABG1-homologous RNA during fruit ripening. Enzyme activity as measured in crude extracts increased during fruit development to a level that was maintained during ripening.

Positive response to oral divalproex sodium (Depakote) in patients with spasticity and pain.

Divalproex sodium (DVS; Depakote) is a commonly used antiepileptic agent that increases the levels of gamma aminobutyric acid. Spasticity from different causes may be due to a deficiency of inhibitory transmitters like gamma aminobutyric acid or an excess of excitatory neurotransmitters. Spasticity also may be accompanied by pain. The authors administered DVS orally for pain and spasticity in three patients with a history of spinal cord injury and one patient with a history of head injury. Three patients had marked improvement in spasticity and pain. One patient, who had some symptomatic improvement in spasticity, could not tolerate DVS because of gastric irritation. In contrast to the side effects of sedation and increased motor weakness associated with antispasticity drugs commonly used, no such side effects were detected with DVS. It is suggested that a possible enhancement by DVS of gamma aminobutyric acid-ergic postsynaptic inhibition of motor reflex arc in the spinal cord may represent a new nonsedating, management approach for spasticity as a result of traumatic spinal cord and head injuries.

Measurement of volatile fatty acid disappearance and fluid flux across the abomasum of cattle, using an improved omasal cannulation technique.

Six steer calves, surgically fitted with a permanent cannula in the rumen, omasoabomasal orifice, abomasum, and duodenum were used to determine total digesta flow and volatile fatty acid (VFA) concentration at various points in the digestive tract. The omasoabomasal cannula had a flexible nylon sleeve that could be exteriorized through the abomasal cannula to collect omasal effluent. Three experiments were conducted: 95% concentrate fed at maintenance (2,670 g of organic matter intake/d); 95% concentrate fed ad libitum (3,484 g of organic matter intake/d); and brome hay fed ad libitum (2,927 g of organic matter intake/d). Calves were offered the diet in 12 portions daily. Each experiment included a 14-day adaptation period and a 2-day sample collection period during which chromic oxide was used as a digesta flow marker. In all 3 experiments, VFA concentration was greatest in the rumen sample (84 to 109 mM), intermediate in the omasal sample (32 to 40 mM), and lowest in the duodenal sample (7 to 14 mM, P < 0.01). Total fluid flow at the duodenum was 13 to 18 L/d greater than flow at the omasum (P < 0.10). Omasal VFA flow was twofold greater than duodenal VFA flow (P < 0.05). There was a net fluid increase and net disappearance of VFA across the abomasum. The cannulation technique was useful for repeated collection of omasal effluent for at least 3 months.

Neonatal extracorporeal membrane oxygenation (ECMO): clinical trials and the ethics of evidence.

Neonatal extracorporeal membrane oxygenation (ECMO), a technology for the treatment of respiratory failure in newborns, is used as a case study to examine statistical and ethical aspects of clinical trials and to illustrate a proposed 'ethics of evidence', an approach to medical uncertainty within the context of contemporary biomedical ethics. Discussion includes the twofold aim of the ethics of evidence: to clarify the role of uncertainty and scientific evidence in medical decision-making, and to call attention to the need to confront the irreducible nature of uncertainty.

An ethylene-related cDNA from ripening apples.

We report the isolation of a ripening-related apple cDNA which is complementary to a mRNA which may be involved in ethylene production. Poly(A)+ RNA was extracted from cortical tissue of ripe apple fruit (Malus domestica Borkh cv. Golden Delicious) and a cDNA library constructed in the plasmid vector pSPORT. The library was screened with pTOM13, a tomato cDNA clone thought to code for ACC oxidase in that fruit. An apple cDNA clone (pAP4) was isolated and sequenced. The 1182 bp cDNA insert includes an open reading frame of 942 bp, and shows strong homology with reported tomato and avocado sequences, both at the nucleic acid and amino acid levels. The polypeptide has a calculated molecular mass of 35.4 kDa and a calculated pI of 5.15. In apple cortical tissue, expression of pAP4-complementary RNA increased with ethylene production by the fruit during ripening. Expression was also enhanced in both ethylene-treated and wounded fruit.

Myocardial infarction associated with inappropriate use of topical cocaine as treatment for epistaxis.

A case of a 57-year-old man with hypertension and stable angina, on aspirin therapy, who was treated for epistaxis with intranasal cocaine, and who subsequently suffered a non-Q wave myocardial infarction is reported. Of note, the cocaine was administered in a manner which differs from that advocated in standard references. Specifically, intranasal packing soaked with 4% cocaine was left in place with continuous nasal mucous membrane contact over 5 to 6 hours. The authors speculate that myocardial infarction occurred on the basis of coronary artery spasm. This case should alert practitioners to myocardial ischemia occurring as a complication of the therapeutic use of intranasal cocaine for the treatment of epistaxis.