Improving adherence to medications in pediatric liver transplant recipients.

We describe results from a clinical program, which aimed at improving adherence to medications in children who had a liver transplant. We followed the medical outcomes of 23 children and adolescents who participated in a clinical adherence-improvement protocol during the years 2001-2002. The protocol included identification of non-adherent patients by examining tacrolimus blood levels and intervention by increasing the frequency of clinic visits for non-adherent patients. In the two-yr preintervention (1999-2000), there was no improvement in any of the outcomes. After the intervention, the number of patients with high alanine aminotransferase levels (100 and above) decreased significantly, from eight before the intervention to four afterwards. Other outcomes, including the number of rejection episodes (three before, none after) and the degree of adherence to tacrolimus, also improved, but the improvement did not reach statistical significance. Although non-adherent patients were called to clinic more often under the protocol, the intervention did not lead to increased outpatient costs. This adherence--improvement intervention appears to be promising in improving outcomes in pediatric liver transplant recipients. Larger, controlled studies are needed to establish the efficacy of this or other approaches.

The phagocytosis-associated respiratory burst in human monocytes is associated with increased uptake of glutathione.

During the phagocytic respiratory burst, oxygen is converted to potent cytotoxic oxidants. Monocytes and macrophages are potentially long-lived, and we have hypothesized that protective mechanisms against oxidant stress are varied and fully expressed in these cells. We report here that the respiratory burst in monocytes is accompanied by an increase in the uptake of [35S]glutathione ([35S]GSH) after 20-30 min to levels up to 10-fold greater than those at baseline. By 30 min, 49% of the cell-associated radioactivity was in the cytosol, 41% was in membrane, and 10% was associated with the nuclear fraction. GSH uptake was inhibited by catalase, which removes hydrogen peroxide (H2O2), and micromolar H2O2 stimulated GSH uptake effectively in monocytes and also lymphocytes. Oxidation of GSH to glutathione disulfide with H2O2 and glutathione peroxidase prevented uptake. Acivicin, which inhibits GSH breakdown by gamma-glutamyl transpeptidase (GGT), had no effect on the enhanced uptake seen during the respiratory burst. Uptake of cysteine or cystine, possible products of GGT activity, stayed the same or decreased during the respiratory burst. These results suggest that a GGT-independent mechanism is responsible for the enhanced GSH uptake seen during the respiratory burst. We describe here a sodium-independent, methionine-inhibitable transport system with a Km (8.5 microM) for GSH approximating the plasma GSH concentration. These results suggest that monocytes have a specific GSH transporter that is triggered by the release of H2O2 during the respiratory burst and that induces the uptake of GSH into the cell. Such a mechanism has the potential to protect the phagocyte against oxidant damage.

Fetal lung mRNA levels of Hox genes are differentially altered by maternal diabetes and butyrate in rats.

Diabetes is known to be associated with delayed lung development in humans and in experimental animals. This includes delayed expression of surfactant apoproteins. An important component of the metabolic abnormalities in diabetes is elevated levels of analogs of butyric acid, and the effects of diabetes on surfactant apoproteins can be reproduced by exposure of fetal rat lung explants to butyrate. Dexamethasone has the opposite effects on lung development. In humans, antenatal exposure to dexamethasone results in a lower incidence of RDS, whereas in experimental animals, dexamethasone increases the expression of surfactant apoproteins. A subset of Hox genes are expressed in developing lung, and their level of expression decreases with advancing gestation. We hypothesized that: 1) lungs of fetuses of rats with streptozotocin-induced diabetes would have altered levels of expression of Hox genes, 2) the effect would be mediated in part through elevated levels of butyrate, and 3) dexamethasone would reverse the effect. We tested our hypotheses in vivo using fetuses from streptozotocin-treated rats and in vitro by treating lung explants from normal rats with sodium butyrate. Streptozotocin treatment increased expression of Hoxb-5 at 18 d of gestation, but did not affect Hoxa-5 expression. This was associated with a 20-fold increase in alpha-aminobutyrate levels. Dexamethasone tended to reverse this effect. In contrast, butyrate treatment of explants decreased the expression of Hoxa-5 and Hoxb-5. We conclude that diabetes alters expression of Hox genes, but that the effect of butyrate on lung development, and in particular on surfactant apoprotein expression, is independent of its effects on Hox genes.

Targeted lung expression of interleukin-11 enhances murine tolerance of 100% oxygen and diminishes hyperoxia-induced DNA fragmentation.

Acute lung injury is a frequent and treatment-limiting consequence of therapy with hyperoxic gas mixtures. To determine if IL-11 is protective in oxygen toxicity, we compared the effects of 100% O2 on transgenic mice that overexpress IL-11 in the lung and transgene (-) controls. IL-11 markedly enhanced survival in 100% O2 with 100% of transgene (-) animals dying within 72-96 h and > 90% of transgene (+) animals surviving for more than 10 d. This protection was associated with markedly diminished alveolar-capillary protein leak, endothelial and epithelial membrane injury, lipid peroxidation, and pulmonary neutrophil recruitment. Significant differences in copper zinc superoxide dismutase and catalase activities were not noted and the levels of total, reduced and oxidized glutathione were similar in transgene (+) and (-) animals. Glutathione reductase, glutathione peroxidase, and manganese superoxide dismutase activities were slightly higher in transgene (+) as versus (-) mice after 100% O2 exposure, and IL-11 diminished hyperoxia-induced expression of IL-1 and TNF. Hyperoxia also caused cell death with DNA fragmentation in the lungs of transgene (-) animals and IL-11 markedly diminished this cell death response. These studies demonstrate that IL-11 markedly diminishes hyperoxic lung injury. They also demonstrate this protection is associated with small changes in lung antioxidants, diminished hyperoxia-induced IL-1 and TNF production, and markedly suppressed hyperoxia-induced DNA fragmentation.

Effect of chronic hypoxia on glucose transporters in heart and skeletal muscle of immature and adult rats.

Glucose transporter (GLUT) modulation can be an important mechanism that contributes to adaptation to hypoxic stress, but little is known about GLUT modulation in heart and skeletal muscle with prolonged hypoxia. In this work, the effect of chronic hypoxia on GLUT-4 and GLUT-1 mRNA and protein was studied in these two tissues in the adult and during development. Hypoxia (fractional inspired O2 = 9 +/- 0.5%) was administered to two groups, i.e., an immature group exposed from 3 to 30 days of age and an adult group exposed from 90 to 120 days of age. Rats were then killed and their heart and skeletal muscles were sampled for measurements of GLUT mRNA and protein with Northern and Western blots. In the adult, chronic hypoxia significantly decreased cardiac GLUT mRNA level by > 25% of control (P < 0.05), but had little effect on GLUT protein. A very different hypoxic effect was seen in the immature rat heart with a major increase in protein and no appreciable change in mRNA density. Adult skeletal muscle had no change in GLUT mRNA level but GLUT protein increased (15-20%, P < 0.05) while both GLUT mRNA and protein were significantly increased in the immature skeletal muscles (60-90% over control). We conclude that during chronic O2 deprivation, GLUT-1 and GLUT-4 expressions show a similar pattern but greatly depend on tissue type and age. These differences in GLUT regulation may be due to different strategies for coping with prolonged O2 deprivation in both immature and adult animals.

Characterization of multiple cysteine and cystine transporters in rat alveolar type II cells.

Cysteine availability is rate limiting for the synthesis of glutathione, an important antioxidant in the lung. We used rat alveolar epithelial type II cells to study the mechanism of cysteine and cystine uptake. Consistent with carrier-mediated transport, each uptake process was saturable with Michaelis-Menten kinetics and was inhibited at 4 degrees C and by micromolar levels of amino acids or analogs known to be substrates for a specific transporter. A unique system XAG was found that transports cysteine and cystine (as well as glutamate and aspartate, the only substrates previously described for system XAG). We also identified a second Na(+)-dependent cysteine transporter system, system ASC, and two Na(+)-independent transporter systems, system xc for cystine and system L for cysteine. In the presence of glutathione at levels measured in rat plasma and alveolar lining fluid, cystine was reduced to cysteine and was transported on systems ASC and XAG, doubling the transport rate. Cysteinylglycine, released from glutathione at the cell surface by gamma-glutamyl transpeptidase, also stimulated uptake after reduction of cystine. These findings suggest that, under physiological conditions, cysteine and cystine transport is influenced by the extracellular redox state.

Hyperoxia enhances expression of gamma-glutamyl transpeptidase and increases protein S-glutathiolation in rat lung.

By participating in glutathione (GSH) synthesis, gamma-glutamyl transpeptidase (GGT) influences the GSH redox cycle, which is a major contributor in protecting against reactive oxygen metabolites. This study determined the effect of prolonged exposure of neonatal rats to > 98% oxygen on expression of GGT and on GSH metabolism. Lungs of neonatal rats chronically exposed to hyperoxia had increased expression of GGT mRNA, resulting in significantly higher GGT protein levels and enzyme activity than in lungs of animals raised in room air. Hyperoxia also upregulated glucose-6-phosphate dehydrogenase, but Na-K-ATPase activity was not changed. GGT mRNA, protein level, and enzyme activity returned to control levels after recovery in room air for 3 days. Levels of GSH, glutathione disulfide, and protein-bound GSH (S-glutathiolated protein) rose with hyperoxia and fell during recovery. S-glutathiolation is likely a mechanism for protection and a regulatory modification of protein sulfhydryl groups. Hyperoxia-induced upregulation of GGT and the concomitant increase in protein S-glutathiolation appear to be additional components fundamental in protecting the lung against oxidative injury.

Dexamethasone enhances surfactant protein gene expression in streptozotocin-induced immature rat lungs.

Because surfactant protein (SP) mRNA levels in rat fetuses are increased by maternal dexamethasone (dex) treatment and decreased in streptozotocin-induced diabetic (STZ-DB) pregnancy, we investigated the in vivo effects of dex on SP gene expression in STZ-DB pregnancy. The mRNA levels of SP (SP-A, SP-B, SP-C) were assessed in d 18 and 20 fetuses by Northern blot analysis, and nuclear run-on assays were performed with lung nuclei from d 20 fetuses (term = 22 d). Our findings indicate: 1) dex causes a greater increase in SP-A and SP-B mRNA levels in d 18 (12-16-fold) compared with day 20 (4-6-fold) fetuses (p < 0.05) in normal and STZ-DB pregnancy; 2) a 2-3-fold increase in SP-C mRNA levels was observed in response to dex in d 18 and 20 fetuses; 3) the increase in transcription of SP-A and SP-B in d 20 fetuses after dex is 68 and 60%, respectively, of the increase in their mRNA levels whereas in STZ-DB, the decrease in transcription compared with mRNA levels is 3.67-fold for SP-A and 2.42 fold SP-B; and 4) changes in SP-C transcription in either in vivo model, dex-treated or STZ-DB, correspond well with changes in mRNA levels. Together, these findings indicate that dex can enhance SP expression in STZ-DB immature lungs and support differential regulation of fetal SP genes in the models studied.

Telemedicine: delivering medical expertise across the state and around the world.

Many aspects of medical care can now be delivered at a distance using telemedicine technology. Rapid video and computer-based communication of medical information makes it possible for a physician to "examine" a patient located in another city, to view highly detailed medical images, to consult with distant subspecialists, or to supervise complex medical procedures. This same technology can bring scattered health-care workers together for joint teaching conferences. The Yale Telemedicine Center has initiated a number of such programs ranging from providing consultations in real time to physicians in Saudi Arabia, to interpreting medical images across town or across the state. Telemedicine will become a powerful tool for managed health-care organizations which are responsible for the medical needs of widely distributed patients in a vertically integrated health-care delivery system. This paper reviews the evolution of telemedicine, its technical fundamentals, specific medical applications, and the activities of the Yale Telemedicine Center. Evolving uses for telemedicine in Connecticut are described.

Chronic hypoxia causes opposite effects on glucose transporter 1 mRNA in mature versus immature rat brain.

We have shown previously that chronic hypoxia can regulate the expression of membrane proteins. Since there are virtually no glucose stores in the brain and glucose transport can be rate-limiting during stress, the role of glucose transporters becomes crucial for cell survival under stress. In the present study, we asked whether mRNA levels for glucose transporter 1 (GT1), which is expressed in a variety of cells in the brain, especially in the microvessels for glucose transport from blood vessels to brain, change in response to chronic hypoxia. Because major developmental changes occur in the rat CNS in-utero and in the first few weeks postnatally, we studied brain GT1 mRNA using Northern blot analysis at different ages after exposure of fetuses (from embryonic day 10 to birth), developing rats (from birth to 30 day old) or adult rats (from 90 to 120 day old) to hypoxia (Fractional inspired O2 9%). Our data show that (i) GT1 mRNA level was much lower in the newborn than in the adult and increased with age; (ii) chronic hypoxia caused a decrease of approximately 65% in GT1 mRNA in adult brain but induced an increase in fetal (more than 50%) and developing (approximately 80%) rats and (iii) the response of housekeeping gene (glyceraldehyde 3-phosphate dehydrogenase) was not similar to that of GT1, suggesting that the changes of GT1 mRNA are specific to glucose transporter.(ABSTRACT TRUNCATED AT 250 WORDS)

Heat shock does not induce tolerance to hyperoxia.

Thermal stress is associated with the induction of a specific set of proteins called heat shock proteins and with the induction of thermal tolerance. Heat stress has been shown to be capable of inducing at least partial tolerance to other stresses, including some oxidant stresses. Furthermore, these oxidant stresses are reported to be inducers of heat shock proteins. We hypothesized that hyperoxic stress would induce heat shock proteins and that factors induced by thermal stress, including heat shock proteins, would offer at least partial protection from hyperoxic exposure. We were particularly interested in a level of protection that would be relevant to clinical situations. Lung fibroblasts and live animals were exposed to thermal stress and/or hyperoxic stress and examined for induction of HSP70 (the most conserved of the heat shock proteins) and for induced tolerance as determined by the ability of cells to metabolize 3-(4,5-di-methylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide and by comparison of lung wet to dry weight ratios in live animals. Each stress induced tolerance to itself, but there was no evidence of heat stress inducing tolerance to hyperoxic stress. Furthermore, there was only minimal induction of HSP70 mRNA by hyperoxic exposure. We conclude that some overlap of mechanisms of induced tolerance by hyperoxic and thermal stress exists, but that differences far outweigh similarities.

The history and future of operative laparoscopy.

Laparoscopic sterilization was first performed in the United States in 1941. During the 1950s and 1960s hospitals procured the relatively inexpensive basic laparoscopic instrumentation, and education for physicians learning the techniques was provided mostly by academic centers during residency training. Interest in expansion of laparoscopic procedures was slight until the mid-1980s when operative laparoscopic management of ectopic pregnancies began to spread from academic centers to the private sector. Major technologic developments in instrumentation greatly simplified the endoscopic procedures and provided the first impetus for an explosive growth of operative laparoscopic applications in surgery. The great financial resources of private hospitals enabled them to adapt and retool quickly for operative endoscopy. Lacking these resources, academic institutions lagged behind; thus a growing divergence began between academic and private institutions in their influence on the development, use, and acceptance of the new technology. The development of expensive disposable instruments, with costs passed on to patients by private hospitals, further priced academic institutions out of the market. Two concerns today are paramount regarding operative laparoscopy: (1) The majority of laparoscopic techniques and procedures being performed by surgeons in this country have not been taught in the controlled setting of a residency or fellowship training program; (2) the legitimacy of the procedures themselves is questionable because of lack of sufficient data in the literature to support them. Academic institutions, working in tandem with the private sector, must assume the responsibility for answering these concerns.

Invasive cervical cancer in young women. Clinicopathologic correlation and demonstration of human papillomavirus by in situ hybridization.

It has been suggested that invasive cervical carcinoma is biologically more aggressive in young patients than in older patients. The clinicopathologic characteristics and human papillomavirus (HPV) status of women < or = 35 years of age with invasive cervical carcinoma treated at Emory University Hospital from 1985-1989, were evaluated in a retrospective study. The group consisted of 23 patients, 35% of all patients with invasive cervical carcinoma. Age at diagnosis, clinical stage, histologic classification, lymph node status, treatment and clinical follow-up were obtained from medical records. HPV status was evaluated by colorimetric in situ hybridization for HPV types 6, 11, 16, 18, 31, 33 and 35 in archival formalin-fixed paraffin-embedded tumor material available from 16 of the patients. This study found that the young patients had lower survival and greater extent of disease than predicted by clinical staging. The rate of detection of HPV (69% positive) and HPV typing (type 16 predominated) in these young patients showed no difference from other series of cervical carcinomas from all age groups. Although a higher proportion of patients who died of disease had HPV-negative tumors (3/7, 43%) than those patients who were alive and free of disease (2/9, 22%), this difference was not statistically significant (P = .73, Fisher's Exact T-Test).

Delayed hydrophobic surfactant protein (SP-B, SP-C) expression in fetuses of streptozotocin-treated rats.

Tissues from fetuses and neonates of control and streptozotocin (STZ)-treated Sprague-Dawley rats were used to study the content and distribution of the hydrophobic surfactant protein B (SP-B) and the mRNAs for SP-B and SP-C using immunohistochemistry, RNA blotting, and tissue in situ hybridization. A dose of 50 mg/kg STZ was used to treat female rats before mating. The fetuses were sacrificed at fetal days 18 through 21 and neonates were obtained on neonatal days 1 and 2 (day of birth = end of day 22). At fetal day 18, SP-B was barely detectable by immunohistochemistry in control animals but the levels were progressively increased through gestation and easily detected by fetal day 21. At all fetal ages, SP-B was decreased in the STZ group compared with control animals. Both SP-B and SP-C mRNA were detectable at fetal day 18 in the control group and increased with advancing gestational age. In fetal lungs from the STZ group, SP-B and SP-C mRNA also showed an increase with advancing gestational age, but the levels were decreased compared with controls at fetal days 18, 20, and 21 (P less than 0.05). At fetal day 19, this difference did not achieve statistical significance. Differences between the two groups were no longer detected by neonatal days 1 and 2. The difference between the STZ and control groups, in both protein (SP-B) and mRNA (SP-B and SP-C), diminished with advancing fetal age but remained significant up to fetal day 21.(ABSTRACT TRUNCATED AT 250 WORDS)

Surfactant protein A expression is delayed in fetuses of streptozotocin-treated rats.

The content and distribution of the 26-to 38-kDa surfactant protein (SP-A) and its mRNA were determined in fetuses of control and streptozotocin (STZ)-treated Sprague-Dawley rats using immunohistochemistry, RNA blotting, and in situ hybridization. Female rats were treated with 50 mg/kg STZ before mating, and the fetuses were killed at fetal days 18-21 or on neonatal days 1 and 2 (day of birth = end of day 22). SP-A was barely detectable on fetal day 18 in controls and easily detected by fetal day 21. In the STZ group, SP-A was decreased compared with controls at fetal days 18-21. However, by neonatal days 1-2, there were no significant differences in SP-A levels between groups. SP-A mRNA was detectable at fetal day 18 in controls, but it was decreased in the STZ group at day 18-21 (P less than 0.02) and differences were no longer detected by neonatal days 1-2. SP-A and SP-A mRNA accumulated with advancing gestational age in both groups until neonatal days 1-2. The differences in SP-A and SP-A mRNA levels in the two groups diminished with advancing age but remained significant at fetal day 21. These data suggest that STZ-induced diabetes interferes with normal expression of SP-A in the developing fetal lung.

Nutritional perturbations in infants of diabetic mothers and intrauterine growth retardation.

The fetal nutritional milieu may have important regulatory influences on fetal growth and maturation. Fetuses of diabetics exposed to excessive glucose in late gestation show delayed maturation, whereas, fetuses subjected to nutrient deprivation resulting from decreased uterine blood flow exhibit restricted growth and accelerated maturation. Under conditions of nutrient deficiency, restricted growth and accelerated maturation may be important adaptations mediated through hormonal and growth factor signalling.

Fluorinated sugar analogues of potential anti-HIV-1 nucleosides.

In order to obtain agents with therapeutic indices superior to those of AZT, FLT, or D4T, several analogues of anti-HIV-1 nucleosides were synthesized. These include 2',3'-dideoxy-2',3' -difluoro-5-methyluridine (13), its arabino analogue 19, arabino-5-methylcytosine analogue 21, 3'-deoxy-2',3'-didehydro-2' -fluorothymidine (25), 3'-azido-2',3'-dideoxy-2'-fluoro-5-methyluridine (29), 2'-azido-3'-fluoro-2',3'-dideoxy-5-methyluridine (31), and 2'3'-dideoxy-2' -fluoro-5-methyluridine (37). These new nucleosides were screened for their activity against HIV and feline TLV in vitro. None of the compounds showed significant activity. It is interesting to note that such a small modification in the sugar moiety of active anti-HIV nucleosides (i.e., displacement of hydrogen by fluorine) almost completely inactivate the agents.