Effects of an in-house coordinator and practitioner referral rather than proxy referral on tissue donation rates.

INTRODUCTION: Timely referral of patients following asystolic death to an organ procurement organization (OPO) may increase tissue donation rates. Lack of education of health care providers and nonphysicians (admitting department) about timely referral to the OPO following asystolic death may adversely affect tissue donation rates. We hypothesized that using an in-house donation coordinator for provider education and changing the responsibility for calling the OPO from the admitting department to the licensed independent practitioner (LIP) declaring death would increase timely referral and tissue donation rates. METHODS: An education program was developed in 2005 by a newly hired in-house coordinator to highlight the importance of tissue donation. In addition, to improve timely referrals to the OPO after death, the instructions accompanying the working copy of the death certificate were altered to require the patient's LIP to call the OPO within 1 hour of death (early 2007). Rates for both timely referrals and tissue donors were modeled by a Poisson regression model with a log link function. RESULTS: Timely referral rates rose from 48% before the interventions to 72% after the intervention (P < .0001). The number of tissue donors per number of referrals also increased significantly (P = .025) over that period. CONCLUSIONS: An in-house donation coordinator initiated education program and LIP referral rather than referral by other parties following asystolic death results in higher tissue donation rates.

A rare case of extra-adrenal pheochromocytoma masquerading as an ovarian mass treated by laparoscopic surgery.

BACKGROUND: Extra-adrenal pheochromocytoma, or paraganglioma, is a rare tumour arising from paraganglion chromaffin cells of the sympathetic nervous system. In adults, pheochromocytomas are often called the "10% tumor" because approximately 10% occur above the diaphragm, 10% of intraabdominal pheochromocytomas are extra-adrenal, 10% are bilateral, 10% are multiple, 10% are familial, 10% are malignant, and 10% recur postoperatively. In children, instead, this tumor occurs in ectopic sites in 30-40% of the cases. This paper reports the successful laparoscopic resection of an extra-adrenal pheochromocytoma, simulating an ovarian tumor, combined with a laparoscopic cholecystectomy for gallstones. CASE REPORT: The case of a 48-year-old woman affected by an extra-adrenal pheochromocytoma that had been unsuspected for a long time is presented. The patient had some clinical symptoms that had been taken for a climacteric syndrome given her premenopausal age. The atypical and rare location of the pheochromocytoma (parauterine) had contributed to misdiagnosing it as an ovarian tumor. Laparoscopic surgery was chosen for the removal of the tumor because it is a safe technique requiring a shorter hospital stay; a concomitant cholecystectomy was performed due to the presence of gallstones. CONCLUSION: Surgical resection is the only treatment option for extra-adrenal pheochromocytomas. With adequate preoperative adrenergic receptor blockers and vascular filling, the laparoscopic approach appears to be a valid alternative to open surgery for paragangliomas. Gynecologists should consider the possibility, although rare, of an extra-adrenal pheocromocytoma when preparing to surgically remove a pelvic mass.

Inferior mesocaval shunt for bleeding anorectal varices and portal vein thrombosis.

Intractable bleeding from anorectal varices is a serious and often misdiagnosed complication of portal hypertension and no agreement has been reached on which could be the optimal diagnostic and therapeutic strategy. Indeed, fatal outcome has been often reported resulting from delayed diagnosis and improper treatment. The case of a 67-year-old gentleman with life-threatening bleeding from anorectal varices who successfully underwent inferior mesocaval shunt is reported, and surgical technique for establishing a shunt between the inferior mesenteric vein and inferior vena cava is described. A review of other therapeutic options is presented and results are discussed and compared to those obtained with this novel form of treatment. In our experience, immediate control of recurrent bleeding from anorectal varices was obtained with inferior mesocaval shunt. Technical ease, promptness of action and effectiveness, low procedure-related morbidity are the main features of the shunt. With the introduction of new promising second-line treatment modalities to primary and metastatic liver tumors, like percutaneous radiofrequency thermal ablation, and improvement in outcome of portal vein thrombosis, the inferior mesocaval shunt may represent a sound alternative for patients who are ineligible for transjugular intrahepatic portosystemic shunt or presenting with clotted shunt.

Single-organism model of host defense against infection: a novel immunotoxicologic approach to evaluate immunomodulatory drugs.

The immunotoxicologic effects of drugs on host defense have been studied widely using various animal models of infection. Here we describe a new approach to testing host defense by using a single organism (Candida albicans) in CBA/J mice. The model is configured to test 3 effector systems via different routes of inoculation to stimulate different effector arms of the immune response. Nonspecific immunity was evaluated by C. albicans colony-forming unit (CFU) count from the spleen at 2 hr (uptake) and > or = 22 hr (clearance) following intravenous inoculation. Cell-mediated immunity was assessed by CFU count from an intramuscular injection site 6 days postinoculation. Humoral immunity was assessed by anti-Candida antibody titer, following multiple subcutaneous immunizations with C. albicans. Finally, overall immunity was evaluated following intravenous injection using survival as the endpoint. Histopathological, immunohistochemical, and electron microscopic evaluation of selected tissues revealed the involvement of the expected cell types in the different effector systems. Several immunomodulatory drugs--dexamethasone, cyclosporine, liposomal muramyltripeptide phosphatidylethanolamine, and SK&F 105685--were evaluated in the C. albicans model. Dexamethasone impaired host defense against C. albicans by suppressing all endpoints measured. Similarly, cyclosporine showed broad immunosuppressive activity, with the exception of yeast uptake from the spleen. In contrast, muramyl tripeptide-phosphatidylethanolamine enhanced all but cell-mediated immunity to C. albicans. SK&F 105685 displayed both stimulatory and inhibitory effects on immune responses to the infection. Our studies demonstrate that a single organism-based approach can be a useful method for evaluating the immunological hazards of drugs on host resistance to infection.

Relationships between antibodies against human soluble complement receptor 1 (hsCR1) from various species.

The relationships between antibodies against human soluble complement receptor 1 (hsCR1) were studied in rodents, dogs, nonhuman primates, and humans. An antibody response occurred in all species except humans. The anti-hsCR1 antibodies from the various species were characterized to determine if they recognize similar epitopes on the hsCR1 molecule. Dog and monkey sera, positve for hsCR1 binding, were used as blocking antibodies against mouse anti-hsCR1 monoclonal antibodies as well as mouse and rat anti-hsCR1-positive sera. Human sera (blood group antisera: anti-Knops, anti-McCoy, anti-Knops/McCoy, anti-Swain-Langley) and serum from one burn patient (who became seropositive despite ever receiving treatment with hsCR1) were also used to test blocking of mouse, rat, dog, and monkey anti-hsCR1. Characterization of anti-hsCR1 antibodies from different species demonstrated that hsCR1 causes divergent antibody responses among animals. While mouse, rat, and dog antibodies cross inhibit binding by approximately 50%, monkey antibodies recognize primarily different epitopes of the hsCR1 molecule. Moreover, human antibodies binding hsCR1 are completely different from the animal antibodies, including monkey. This study indicates that although hsCR1 is immunogenic in animals, there is a difference in response between species, particularly between nonprimates and primates, and finally, that this antibody response is not predictive for humans.

Effect of TNF alpha production inhibitors BRL 61063 and pentoxifylline on the response of rats to poly I:C.

BRL 61063 is a novel xanthine phosphodiesterase (PDE) type IV inhibitor with selective inhibitory activity for tumor necrosis factor (TNF) alpha production. This compound inhibits TNF alpha production by activated human blood monocytes in vitro and in animal models of endotoxemia and influenza infection. Inhibition of TNF alpha may be beneficial in many diseases; however, little is known about potential adverse effects of such inhibition on host defense. In an ex vivo study, we examined the effect of BRL 61,063 on the microbicidal and tumoricidal activity of pulmonary lavage cells during a local inflammatory response in rats challenged with Poly I:C. Pentoxifylline, a PDE inhibitor which also blocks TNF alpha production, was used for comparison. Treatment with BRL 61063 or pentoxifylline did not block the inflammatory response to Poly I:C or the activation of bronchoalveolar lavage (BAL) cells but reduced the level of tumoricidal activity attained. At the dosages used, pentoxifylline was more inhibitory than BRL 61063. Drug treatment did not prevent further stimulation of tumoricidal activity by LPS in vitro. LPS-stimulated cells from BRL 61063-treated rats reached a level of activation similar to the control group while the LPS-stimulated activity of BAL cells from pentoxifylline treated rats remained lower than control. Although pentoxifylline was more inhibitory for tumoricidal activity than BRL 61063, the latter was a more potent inhibitor of TNF alpha release as measured in vivo in LPS-challenged rats. This finding indicates that TNF alpha is not the main mediator involved in the activation of pulmonary macrophage tumoricidal function. Treatment with either BRL 61063 or pentoxifylline had little or no effect on the Poly I:C-induced candidacidal activity of BAL cells indicating that these compounds are unlikely to compromise non-specific host defense against infection.

Divergent effects of rapamycin on mouse and rat cells following mitogenic stimulation.

The immunosuppressive effects of cyclosporin A, FK506, and rapamycin were compared in mouse and rat systems of in vitro cellular stimulation. The inhibitory profile of rapamycin was distinctly different in the two species. In mouse systems, rapamycin caused a dose-dependent inhibition of both Ca(2+)-dependent (concanavalin A (Con A), phytohemagglutinin (PHA), and phorbol 12-myristate 13-acetate + ionomycin) and Ca(2+)-independent (lipopolysaccharide and PMA + interleukin-2) activation, whereas in the rat only Ca(2+)-independent responses were inhibited. Rapamycin's lack of activity in Ca(2+)-dependent responses in the rat does not appear to reside in a general insensitivity of this pathway to inhibition as cyclosporin A and FK506 demonstrated potent inhibitory activity. Additionally, rapamycin was able to block the inhibitory effect of FK506 on rat cells stimulated with the Ca(2+)-dependent stimulus, Con A. These results indicate a further dissociation in the biological activity of rapamycin compared to cyclosporin A and FK506 and may point to intriguing species differences in the immunosuppressive effects of these compounds in vitro.

Effects of SK&F 105685, a novel anti-arthritic agent, on immune function in the dog.

SK&F 105685 (N,N-dimethyl-8,8-dipropyl-2-azaspiro[4,5]decane-2-propanamine+ ++ dihydrochloride) is a novel azaspirane with beneficial activity in animal models of autoimmune disease such as adjuvant-induced arthritis and experimental encephalomyelitis in the Lewis rat and lupus-like disease in the MRL mouse. The activity of SK&F 105685 in these models is associated with the induction of non-specific suppressor cell (SC) activity as defined by the ability of cells from drug-treated animals to inhibit the proliferative response of lymphocytes from control animals to concanavalin A. To evaluate the immunotoxicologic potential of SK&F 105685, the effect on immune function of one month of dosing with 1 mg/kg/day of SK&F 105685 was examined in the dog. Differential blood cell counts and ex vivo immune function assays were performed using blood collected before dosing on days 1 (baseline), 15 and 29, of the study. Immune function assays were performed on spleen cells on day 30. Under the conditions of the study, SK&F 105685 displayed pharmacological activity as demonstrated by the induction of splenic SC activity. The drug did not affect the total number or relative percentages of the various white blood cell types present in peripheral blood and did not cause generalized immunosuppression. The ability of peripheral blood lymphocytes or spleen cells to produce IL-2 or proliferate in response to mitogenic stimulation was not affected by drug treatment. SK&F 105685 also failed to affect the candidacidal activity of polymorphonuclear leucocytes and spleen cells indicating that it is unlikely to compromise nonspecific resistance to infection. SK&F 105685 however, was able to inhibit the generation of a specific in vitro antibody response to sheep red blood cells (SRBC) by splenocytes from treated animals. Inhibition of the anti-SRBC antibody response was also observed upon addition of the drug to normal spleen cells. Addition of the drug at different time points during the culture period indicated that SK&F 105685 was interfering with an event(s) occurring during the first 72 h of culture. Taken together, these results suggest that, in a therapeutic setting, SK&F 105685 is unlikely to compromise the immune status of the host as it can down-regulate a specific immune response without causing generalized immunosuppression.

Induction of suppressor cell activity in vivo and suppression of lymphoproliferative responses in vitro by SK&F 105.685 in the dog.

SK&F 105.685 (N,N-dimethyl-8,8-dipropyl-2-azaspiro[4.5]decane-2-propanamine+ ++ dihydrochloride) is a novel azaspirane with beneficial activity in rat models of adjuvant-induced arthritis and experimental autoimmune encephalomyelitis as well as in the murine lupus model. The mechanism of action in these models appears to be the induction of non-specific suppressor cell activity which is measured by the ability of cells from treated animals to partially inhibit the proliferative response of lymphocytes from control animals to concanavalin A (ConA) in a co-culture assay. In this study we have shown that oral administration of 0.1-3 mg/kg/day of SK&F 105.685 to purebred beagle dogs induced suppressor cell activity in the spleen and bone marrow but not in the peripheral blood. In vitro, SK&F 105.685 partially suppressed the proliferative response of dog splenocytes to the mitogens phytohemagglutinin (PHA), ConA and, to a lesser extent, pokeweed mitogen (PWM). Peripheral blood lymphocytes (PBLs) differed from spleen cells in their susceptibility to suppression by SK&F 105.685. While the PWM and ConA responses of PBLs and spleen cells showed similar levels of inhibition, the PHA response of PBLs, in marked contrast to spleen cells, was resistant to suppression by the compound. Our results show that the immunoregulatory effects of SK&F 105,685 are not limited to rodents and that suppressor cell activity in dogs is induced quickly and by relatively low doses of the compound.

Inhibition of lymphoproliferative responses by SK&F 105685, a novel anti-arthritic agent.

SK&F 105685 (N,N-Dimethyl-8,8-dipropyl-2-azaspiro[4.5]decane-2-propanamine+ ++ dihydrochloride) is a novel azaspirane with beneficial activity in animal models of autoimmune diseases such as adjuvant-induced arthritis and experimental autoimmune encephalomyelitis in the Lewis rat and lupus-like disease in the MRL mouse. The effect of SK&F 105685 on the proliferation of rat lymphoid cells was examined in vitro. The compound inhibited the proliferative response of spleen, thymus and lymph node cells to the mitogen concanavalin A (Con A) in a dose-dependent manner but had little or no effect on the mitogenic response of peripheral blood lymphocytes. Although less potent than cyclosporin A, SK&F 105685 was able to inhibit the proliferation of spleen cells stimulated with PMA and ionomycin or the mitogens phytohemagglutinin (PHA), Con A and pokeweed mitogen (PWM). Relatively early event(s) in cell proliferation were affected by SK&F 105685 since delaying addition of the drug by 24 to 48 hours after Con A stimulation of rat spleen cells resulted in reduced levels of suppression. The mode of action of SK&F 105685 appeared to differ from that of cyclosporin A or rapamycin. Unlike cyclosporin A, SK&F 105685 did not affect IL-2 production by Con A-stimulated spleen cells or the IL-2-producing Jurkat cell line, but, like rapamycin, the compound significantly reduced the IL-2-induced proliferation of rat ConA blasts. These results suggest that inhibition of lymphocyte proliferation by SK&F 105685 may require the activity of an intermediate effector cell(s) present in susceptible populations such as cells from the spleen, thymus, lymph nodes and Con A blast preparations but absent or present in low numbers in resistant populations such as peripheral blood cells. Indomethacin and NG-monomethyl-L-arginine (NGMMA), a competitive inhibitor of nitric oxide synthase, were both unable to relieve SK&F 105685-induced suppression of splenic Con A responses thereby ruling out a role for the production of prostaglandins or nitric oxide by macrophages as an intermediate in drug-mediated suppression. In summary, SK&F 105685 was unable to inhibit lymphoproliferative responses by a mechanism distinct from that of cyclosporin A or rapamycin and which appears to involve regulation of cellular interactions rather than a direct effect on responding lymphocytes.