Mechanisms of hemorrhage in dengue without circulatory collapse.

To characterize the molecular basis for the hemostatic defects of dengue infections, a study was conducted in Bangkok, Thailand. Febrile children (n = 68) hospitalized with suspected dengue were enrolled before their clinical syndromes were classified as either dengue fever (DF) or dengue hemorrhagic fever (DHF). Hospital course and outcome were recorded; blood was obtained during the febrile illness (S1), after defervescence (S2), and 1 month after onset of disease (S4). Patients were classified as DF (n = 21) and DHF grades 1, 2, and 3; (DHF1, n = 8; DHF2, n = 30; and DHF3, n = 9). All had marked thrombocytopenia. Bleeding scores were assigned on the basis of bleeding site. Although there was no correlation between bleeding scores and pleural effusion index (a measure of vascular leakage) or bleeding scores and platelet counts, there was a correlation between pleural effusion index and platelet counts. Bleeding scores did not correlate with hemostatic data. Activated partial thromboplastin time was prolonged, with trends toward decreased fibrinogen and increased levels of prothrombin fragment F1.2 in the acute-phase samples. However, no factor level was dramatically decreased. We conclude that most patients with DF or DHF, even without overt hemorrhage, have consumptive coagulopathy. Nevertheless, hemorrhage in dengue without circulatory collapse is most likely due to activation of platelets rather than coagulopathy, which is well compensated. Our data suggest that vascular alteration may be the principal factor involved in the association of thrombocytopenia and hemorrhage with disease severity.

Physiologic responses of cross-linked hemoglobin in endotoxin-treated rats.

Purified human cross-linked hemoglobin (alpha alpha Hb) as well as recombinant human hemoglobin is undergoing clinical trials in the setting of acute blood loss and perioperative hemodilution. We have previously demonstrated that in rabbits with circulating plasma Hb, such as alpha alpha Hb, infusion of endotoxin (LPS) impairs myocardial contractility which results in hypotension, tissue hypoperfusion and increased mortality. The untoward cardiovascular effects occurring after the combined infusion of LPS and alpha alpha Hb in this model are similar to those reported for other agents that inhibit nitric oxide (NO) availability. To determine if the deleterious effects of alpha alpha Hb and LPS were species specific, we performed similar studies in rats. Anesthetized Sprague-Dawley rats received LPS (4 mg/kg or 40 mg/kg) alone or in combination with alpha alpha Hb (0.7 g/kg). Mean arterial blood pressures (MAP) increased in the group that received alpha alpha Hb alone (105 +/- 8 to 120 +/- 7 mm Hg, p = 0.2) and a decrease was noted in the groups that received low dose LPS (4 mg/kg, p = 0.5) and high dose LPS (40 mg/kg, p = 0.016). MAP in rats treated with the LPS at either dose combined with alpha alpha Hb remained unchanged. Levels of urine nitrite, which was measured as a surrogate marker for plasma NO, were significantly decreased at 2 hr in groups that received the combination of alpha alpha Hb and LPS at 4 mg/kg (p = 0.022) and 40 mg/kg (p = 0.003). No significant decrease was observed in animals treated only with alpha alpha Hb (p = 0.21) or LPS (4 mg/kg; p = 0.78 and 40 mg/kg; p = 0.65). Survival was evaluated during 72 hr in animals that were infused with high dose LPS (40 mg/kg) alone or in combination with alpha alpha Hb and then allowed to recover. The survival of rats treated with LPS alone or the combination was 29% at the end of 24 hr and was 100% for rats receiving only alpha alpha Hb. The data suggest that the toxicity of alpha alpha Hb appears to be a species specific phenomenon.

Cardiovascular toxicity of human cross-linked hemoglobin in a rabbit endotoxemia model.

OBJECTIVE: To determine the possible adverse effects of human cross-linked hemoglobin in endotoxemia. DESIGN: Prospective, controlled, laboratory trial. SETTING: Animal research laboratory. SUBJECTS: New Zealand white rabbits. INTERVENTIONS: Conscious rabbits received intravenous infusions of either lipopolysaccharide (LPS) alone (10 micrograms/kg, Escherichia coli 0111:B4), human hemoglobin cross-linked between the alpha chains (alpha alpha Hb, 0.7 g/kg), or both LPS and alpha alpha Hb. The cardiovascular effects of alpha alpha Hb and LPS as single agents or administered together were then studied in anesthetized rabbits. MEASUREMENTS AND MAIN RESULTS: Mortality in conscious animals that received alpha alpha Hb followed by LPS 4 hrs later (n = 5), or LPS and alpha alpha Hb at the same time (n = 6) was 60% and 67%, respectively. In anesthetized animals, infusion of both LPS and alpha alpha Hb (n = 6) resulted in hypoxia, lactic acidosis, ventricular arrhythmias, and decreased myocardial contractility and left ventricular pressure. In contrast, anesthetized rabbits that received alpha alpha Hb (n = 5) or LPS (n = 5) alone did not develop hypoxia, acidosis, alteration in myocardial contractility, or arrhythmias. Furthermore, death did not occur in any of the conscious animals that received either LPS (n = 7) or alpha alpha Hb (n = 4) as single agents. CONCLUSIONS: In an animal model of nonlethal endotoxemia, infusion of alpha alpha Hb significantly increases mortality. Our data suggest that mortality may be due to the acute increased cardiopulmonary toxicity of alpha alpha Hb in animals with underlying endotoxemia.

Efficiency of human HLA-mismatched CD34+ cells from unrelated donors in establishing in vitro hematopoiesis in allogeneic long-term marrow cultures.

We have examined the capacity of highly purified human CD34+ marrow cell isolates from unrelated, HLA-mismatched donors to establish in vitro hematopoiesis on recipient marrow stromal cells in 2-stage hematopoietic long-term marrow cultures (H-LTMC). HLA-typing of both peripheral blood mononuclear cells and CD34+ marrow cells was performed for both HLA class I and HLA class II antigens for eight healthy individuals. Significant antigenic mismatches for these molecules ranged from three to six antigens for each recipient-donor pair. Comparison of MHC antigen expression by peripheral blood cells and CD34+ marrow cell isolates confirmed the presence of identical HLA-A, -B, and -C, and -DR specificities on the surface of these cells. Typing of -DQ specificities, however, was not consistently reactive on CD34+ cells. The > or = 20% plating efficiency of purified CD34+ cells for BFU-E, CFU-GM, and CFU-MIX allowed us to use inoculum doses of 10(3), 10(4), and 10(5) cells to determine the efficiency of allogeneic CD34+ cells in achieving in vitro engraftment and the establishment of hematopoiesis in H-LTMC. Engraftment of adherent BFU-E, CFU-GM, and CFU-MIX was equally efficient for autologous and allogeneic CD34+ cells. In vitro hematopoiesis reflected by the cumulative recoveries of progenitor cells over time was also equivalent for allogeneic and autologous CD34+ cells. These results demonstrate that highly purified, HLA-mismatched CD34+ marrow cells proliferate and establish in vitro hematopoiesis as efficiently as autologous cells in marrow derived stromal cell cultures and confirm that interactions between stromal cells and highly purified CD34+, DR-, and CD34+, DR+ marrow cell isolates are not MHC-restricted.

Factors affecting growth and development in the Pittwater homebirth community--my experiences.

This is a discussion of the homebirth community in the Pittwater Shire located on Sydney's northern peninsula. Most people choosing a homebirth in this region display the following characteristics: a. They are well-educated or well-skilled in their field. b. They are Caucasian in origin. c. They have strong personal philosophies. d. They are motivated to follow a healthy lifestyle. e. Their approach to living and child rearing is a wholistic one. Within this community, there are many factors which result in a high potential for optimum growth and development of babies and children. However, there are some areas of concern for the Child and Family Health Nurse.

Effects of anti-CD33 blocked ricin immunotoxin on the capacity of CD34+ human marrow cells to establish in vitro hematopoiesis in long-term marrow cultures.

Human marrow cells that express the CD34 antigen but lack CD33 are able to initiate sustained, multilineage in vitro hematopoiesis in long-term Dexter cultures and are believed to include the primitive stem cells responsible for effecting long-term hematopoietic reconstitution in vivo following marrow transplantation. In studies described in this report we investigated the effects of a novel anti-CD33 immunotoxin on the clonogenic potential of normal human CD34+ marrow cells and on the ability of these cells to initiate hematopoiesis in two-stage Dexter cultures (long-term marrow cultures, LTMC). This immunotoxin (anti-CD33-bR), shown previously to kill both clonogenic myelogenous leukemia cells and normal mature myeloid progenitor cells (granulocyte-macrophage colony-forming units, CFU-GM), consists of an anti-CD33 monoclonal antibody conjugated to purified ricin that has been modified by blocking the carbohydrate binding domains of the ricin B-chain to eliminate nonspecific binding. For our studies, normal CD34+ human marrow cells were isolated from the light-density (less than 1.070 g/ml) cells of aspirated marrow by positive selection with immunomagnetic beads linked to the monoclonal antibody K6.1. These cell isolates were highly enriched with both multipotential and lineage-restricted clonogenic, hematopoietic progenitors (mixed lineage colony-forming units, CFU-Mix; CFU-GM; and erythroid burst-forming units, BFU-E) which constituted greater than or equal to 20% of the cells. Recovery of clonogenic progenitors from these CD34+ cell preparations, following treatment with anti-CD33-bR (10 nM), was reduced by greater than or equal to 85% for CFU-GM and 20%-40% for CFU-Mix and BFU-E. However, the capacity of these cells to initiate hematopoietic LTMC was preserved. Indeed, the production of high proliferative potential (HPP) CFU-GM, BFU-E, and CFU-Mix in cultures seeded with 10(5) anti-CD33-bR-treated CD34+ marrow cells was substantially greater than that observed in LTMC seeded with equivalent numbers of untreated CD34+ cells. Moreover, concentrations of long-term culture initiating cells in CD34+ cell isolates, quantified by a limiting dilution technique, were found to be increased following anti-CD33-bR treatment. These findings support the potential usefulness of anti-CD33-bR for in vitro marrow purging or in vivo treatment to eliminate CD33+ leukemic clones, while sparing normal CD34+/CD33- stem cells that support normal hematopoiesis and hematopoietic reconstitution in vivo.

Blocking of iron absorption by a preliminary oral dose of iron.

Using a small-dose iron tolerance test (ITT) in mildly iron-deficient healthy adults, we have examined the phenomenon of mucosal block. First proposed and demonstrated by Hahn et al with radioiron, "mucosal block" describes diminished avidity for iron of the intestinal mucosa following an orally administered blocking dose. In the ITT, the index of absorption is an increase in plasma iron concentration, rather than retained radioactivity. The absorption of a blocked 10-mg test dose of iron was compared with that of a 10-mg control dose given to the same subject. Both 60- and 30-mg blocking doses of iron resulted in diminished absorption of the test dose. The refractory state of the intestine lasted as long as 24 hours.

The effect of antacids on the absorption of simultaneously ingested iron.

Most discussions of iron therapy include a statement about the ineffectiveness of iron ingested simultaneously with antacids. This study was designed to determine whether or not antacids inhibit iron absorption. A small-dose iron tolerance test was used to compare absorption of iron with and without various antacids. Liquid antacid containing aluminum hydroxide and magnesium hydroxide did not significantly decrease iron absorption. Sodium bicarbonate and calcium carbonate caused the plasma iron increase to be 50% and 67% less than the control values, respectively. However, when calcium carbonate was present in a multivitamin-plus-minerals tablet, the plasma iron change was not significantly different from control trials. Presumably the competitive binding of iron by ascorbic acid in the vitamin pill allowed uninhibited absorption of the iron. Our results suggest that certain antacids may be combined with iron therapy without reducing the efficacy of the iron.

Prophylactic antibiotics in patients undergoing total vaginal or abdominal hysterectomy.

A prospective study to evaluate the effect of antibiotic prophylaxis in 57 patients undergoing total abdominal or vaginal hysterectomy was conducted at Arlington Hospital. Patients were assigned randomly to one of two regimens. Group I received a single 1 gram preoperative dose of Cefotaxime (Claforan). Group II received a 2 gram dose of Cefoxitin (Mefoxin) preoperatively and also four 2 gram doses postoperatively. There was no significant group difference in the incidence of postoperative infection or in the mean duration in hospital stay. One dose of Cefotaxime was as effective as five doses of Cefoxitin in preventing infection.

A small-dose iron tolerance test as an indicator of mild iron deficiency.

Small doses of iron (5 to 20 mg) were used to study absorption in normal and mildly iron-deficient men. Plasma iron concentration was measured before and at frequent intervals after ingestion of iron. Men with normal iron stores showed little change in plasma iron levels, while mildly iron-deficient men showed large increases. This consistent observation of increases in plasma iron levels indicates that the iron tolerance test using small doses of iron is a sensitive indicator of iron deficiency. It provides a means of studying iron absorption without the use of radioactive tracers.

Effect of excess dietary zinc on tissue storage of iron in rats.

Earlier investigators observed that addition of large amounts of zinc to the diet or rats can retard growth, lower their hemoglobin levels and reduce storage of iron. In the present studies, addition of 0.75% zinc to a synthetic diet confirmed the reduced storage of iron in the livers and spleens of growing rats, but failed to show an effect on growth rate or hemoglobin levels. The adverse effects of zinc excess on growth and hemoglobin level could, however be reproduced by replacing the Rogers-Harper salt mixture used in the present studies with the Wesson salt mixture use in the earlier studies. Rats fed excess zinc along with the Wesson salt mixture grew less well, had anemia and also had low level in copper in their livers. It is suggested that addition of zinc to the low copper Wesson salt mixture reduced copper absorption sufficiently it deplete liver copper to a level at which mobilization of liver iron stores by a copper-dependent mechanism became impaired, thus depriving red cell production and tissue enzymes of stored iron. The mechanism by which iron stores are depleted by addition of zinc to the better balanced Rogers-Harper salt mixture remains unexplained It is not due to interference by zinc with iron adsorption from the diet nor with cellular uptake of iron from circulating transferrin, and the capacity of tissues to store iron as ferritin is not impaired.

Depressant effect of marihuana smoke on antibactericidal activity of pulmonary alveolar macrophages.

Other than the potentially therapeutic bronchodilatory influences of marihuana, very little is known of its biologic effects on the lung. To evaluate this problem, alveolar macrophages were harvested from rats by bronchopulmonary lavage and incubated in vitro with Staphylococcus albus and marihuana smoke of standardized 2.2-percent tetrahydrocannabinol content in graded amounts. After three hours, control alveolar macrophages inactivated 78.0 +/- 5.0 percent of the staphylococcal challenge. There was a dose-dependent depression of alveolar macrophage bactericidal activity, with 66.7 +/- 7.1 percent, 23.7 +/- 7.0 percent, 20.5 +/- 7.0 percent, and 11.4 +/- 7.6 percent of the bacteria killed following exposures to 2 ml, 4 ml, 6 ml, or 8 ml of marihuana smoke, respectively. Differential filtration of marihuana smoke revealed that the alveolar macrophage cytotoxin was present in the gas phase of the smoke and was water-soluble. Studies on purified tetrahydrocannabinol and on tetrahydrocannoabinol-extracted marihuana revealed that the impairment in alveolar macrophage function was not related to the psychomimetic or bronchodilatory components of marihuana.