Clostridium difficile infection is a risk factor for bacteremia due to vancomycin-resistant enterococci (VRE) in VRE-colonized patients with acute leukemia

A cohort study was conducted in a cancer center to identify risk factors for bacteremia with vancomycin-resistant enterococci (VRE) in neutropenic cancer patients colonized with VRE. There were 10 patients with VRE bacteremia among 56 colonized with VRE, of whose charts 51 were available for review. One hundred percent of patients with VRE bacteremia (10 of 10) vs. 56% of patients without VRE bacteremia (23 of 41) had acute leukemia (P = .01, Fisher's exact test). Four of the 10 patients with VRE bacteremia had a positive Clostridium difficile toxin assay within 6 days of their first positive VRE blood culture. Both C. difficile infection and antimicrobial (vancomycin and ciprofloxacin) use during VRE colonization were significant risk factors for VRE bacteremia in univariate analysis. When a Cox proportional hazards model was used to account for differences in follow-up time, C. difficile infection was the only statistically significant risk factor (risk ratio, 8.2; P = .007) for VRE bacteremia in VRE-colonized patients with acute leukemia.

Physical activity as a factor in the action of dietary restriction on aging: effects in Fischer 344 rats

Dietary restriction (DR) slows the rate of aging in laboratory rodents but the mechanism of action is unknown. DR is known to induce beneficial effects in a variety of tissues and organ systems. DR also maintains high levels of physical activity over the life span. We tested the hypothesis that lifelong physical activity is an important component of the anti-aging action of DR. Male specific pathogen-free Fischer 344 rats were divided into 4 groups at 6 weeks of age: A: fed old libitum; AE: fed ad libitum and in cages with running wheels; B: fed 60% ad libitum; BE: fed 60% ad libitum and in cages with running wheels. Running activity and spontaneous cage activity were measured over 24 hours and over the life span. Metabolic rate was measured indirectly by analysis of air entering and leaving cages. AE rats exhibited low levels of running activity and ran very little beyond 6 months of age. In contrast, BE rats sustained high running levels even after all A and AE rats had died. High levels of wheel running did not decrease spontaneous cage activity. Median life span (50% survival) was in the order A = AE < B < BE. Ten percent survival was in the order A = AE < B = BE. BE rats had greatest median life span and also highest specific metabolic rate. Exercise and DR altered pathology: At death BE rats had a high incidence of cardiomyopathy, whereas A and AE rats had high incidence of chronic nephropathy and pituitary tumors. The data indicate that increased physical activity is probably not an important factor in the action of DR on aging.

Elevated levels of albumin in soleus and diaphragm muscles of mdx mice

Muscle damage is often associated with an influx of extracellular fluid containing albumin into the muscle. Muscles affected by muscular dystrophy undergo severe muscle damage; therefore, the hypothesis was tested that muscles of dystrophic (mdx) mice contain elevated levels of albumin. Albumin levels in diaphragm (DIA) and soleus (SOL) muscles of control and mdx mice were measured at 3 months and 1 year of age. Albumin in mdx DIA at 1 year of age was twice that of control. In mdx SOL at 1 year of age albumin was increased 25% compared with control. The increase in albumin correlates well with the decline in function in mdx DIA and SOL muscles. Electron microscopy of muscles suggests that albumin is co-localized with transverse tubules of muscle fibers and thus may be mainly located in extracellular fluid. We conclude that albumin is elevated in muscles affected by muscular dystrophy and suggest that this may be of clinical importance in view of substances bound to albumin under physiological conditions.

Influence of age, exercise, and dietary restriction on oxidative stress in rats

This study was undertaken to investigate the effects of exercise, dietary restriction (DR) and aging on the formation of reactive oxidant species (ROS), antioxidant defenses, and membrane fluidity. Test were performed on hepatic microsomes, mitochondria, and cytosol from 9- and 20-month-old male Fischer 344 rats, which were divided into four groups: ad libitum fed, sedentary (AS); restricted, sedentary (RS); ad libitum fed, exercised (AE); and restricted, exercised (RE). Results show that both exercise and DR suppressed microsomal ROS production, but not mitochondrial ROS production, which increased with age in all groups. Exercise and DR increased catalase and glutathione peroxidase (GSH-Px) activities and maintained cytosolic ascorbic acid concentration at high levels. Exercise led to significantly higher levels of cytosolic glutathione (GSH). Activity of cytosolic superoxide dismutase (SOD) remained unchanged, whereas glutathione-s-transferase (GST) activity significantly increased with DR. The fluidity of the mitochondrial membrane from exercised and DR rats deteriorated less with age than the membrane from AS rats. Exercise alone was found to improve fluidity, but was more effective when coupled with DR. These results suggest for the first time that the combination of exercise training and DR is the most effective means of preserving membrane fluidity and suppressing microsomal ROS production.

The relationship of growth rate, plasma growth hormone (GH) concentration, and GH-binding protein

Growth hormone (GH)-binding protein (GHBP) and GH secretion are potential mediators of linear growth in children. To study the relationship between these variables, we measured GHBP activity, peak stimulated GH (PKGH), and 24-hour integrated GH concentration (ICGH) in 76 children referred for evaluation of growth. Linear growth was expressed as an age- and sex-specific growth rate standard deviation score (GRSD), which was calculated from sequential height measurements in the 6-month period immediately before GH testing. Using multiple regression models, we found that the relationship between GHBP and growth (GRSD) depended on height (height standard deviation [HGTSD] expressed as an age- and sex-specific z score) controlling for ICGH or PKGH. In further analysis of this relationship, we divided the subjects by HGTSD in subsequent analyses. In 19 children of normal stature (HGTSD > -2), GRSD increased with GH concentration (measured both as PKGH and ICGH: P <.013,R2 = .56) but decreased with higher levels of GHBP (P < .005,R2 = .62). In contrast, for 57 subjects with severe short stature (HGTSD < or = -2), GRSD could not be predicted from GHBP, GH secretion, HGTSD, or interaction involving these variables. These data suggest the hypothesis that under normal conditions, GHBP and GH level may be important predictors of growth rate in children.

Exercise and diet modulate cardiac lipid peroxidation and antioxidant defenses

Free radical metabolism can be altered by several interventions, including dietary restriction (DR) and exercise. Most of the previous work has focused on the liver and skeletal muscle. The following experiments were performed to determine whether long-term DR and chronic exercise affect free radical metabolism and change the status of the antioxidant defenses of the heart. Rats were subjected to DR and/or endurance exercise for 18.5 months and were sacrificed along with their ad lib fed and sedentary controls. Both DR and exercise decreased the malondialdehyde content of cardiac mitochondria, indicating a decrease in lipid peroxidation damage. The antioxidant enzymes in the cytosol, superoxide dismutase, selenium dependent glutathione peroxidase, and glutathione S-transferase were all increased by DR. Catalase activity was unaffected by DR but was increased by exercise. The following results demonstrate that long-term DR and exercise modulate the extent of free radical damage in the heart and enhance the antioxidant defense system.

Beneficial versus adverse effects of long-term use of clenbuterol in mdx mice

Long-term administration of the beta 2-adrenergic agonist clenbuterol in mdx mice was used to test the hypothesis that increasing contractile protein content in skeletal muscle will decrease the progression of muscular dystrophy. C57BL/10SNJ (control) and dystrophic (mdx) mice were given clenbuterol (1.0-1.5 mg/kg body weight/day) in the drinking water. Ventilatory function and morphological and functional characteristics of soleus (SOL) and diaphragm (DIA) muscles were evaluated. Clenbuterol administration was associated with increased SOL muscle weight, and SOL muscle weight to body weight ratio in control and mdx mice at both ages. There was a 22% increase in myosin concentration of mdx DIA at 1 year of age, correlating well with increased normalized active tension in mdx DIA at this age. Also, absolute tetanic tension increased in control and mdx SOL with clenbuterol at both ages. Ventilatory function was significantly impaired in mdx mice at both ages and clenbuterol administration did not alleviate this. Clenbuterol treatment was associated with a 30-40% increase in fatigability in DIA and SOL muscles of control and mdx mice at both ages. Furthermore, 1-year-old mdx mice receiving clenbuterol exhibited deformities in hindlimbs and spine. These results suggest that long-term clenbuterol treatment has a positive effect on muscle growth and force generation, but has adverse side effects such as increased muscle fatigability and development of deformities.

Role of caloric restriction in the prolongation of life

Restriction of caloric intake increases longevity, slows the rate of functional decline, and reduces incidence of age-related disease in a variety of species. Most laboratory rodent studies have initiated restriction before puberty, whereas ongoing studies in nonhuman primates utilize restriction in adulthood. The mechanism of action of caloric restriction remains unknown; however, data suggest that cellular functions are altered in such a way that destructive by-products of metabolism are reduced, and defense or repair systems are enhanced by this nutritional manipulation.

Enterococci resistant to multiple antimicrobial agents, including vancomycin. Establishment of endemicity in a university medical center

OBJECTIVES

To determine the distribution of and risk factors for colonization and infection with vancomycin-resistant enterococci; to evaluate the molecular epidemiology of these strains; and to assess the effect of interventions, including 1) strict adherence to infection control procedures and 2) restricted use of vancomycin.

DESIGN

Problem identification based on descriptive studies, point-prevalence surveys, and case-control studies and followed by specific interventions and evaluation of the response to these interventions.

SETTING

University medical center.

PARTICIPANTS

All patients hospitalized between May 1992 and June 1994 (59,196 admissions).

MAIN RESULTS

75 active infections attributed to vancomycin-resistant enterococci were identified. Thirty-one patients (41%) had bloodstream infections and 6 (8%) died. The incidence of active infection was highest in the organ transplantation unit (13.2 infections/1000 admissions). In the point-prevalence studies, vancomycin-resistant enterococci were isolated from 20% of a random sample of hospitalized patients in July, August, and September 1993 (adjusted prevalence, 16.9%). Case-control studies showed significant associations between colonization and infection and 1) receipt of antimicrobial agents, particularly vancomycin, and 2) severity of illness. Although several small case clusters had isolates with identical banding patterns on pulsed field gel electrophoresis, at least 45 different banding patterns were noted among medical center isolates. Interventions took place in November and December 1993. Vancomycin restriction policies resulted in a 59% decrease in intravenous vancomycin use and an 85% decrease in oral vancomycin use. Point-prevalence surveys done in April, May, and June 1994 showed a consistent 20% level of colonization with vancomycin-resistant enterococci strains (adjusted prevalence, 18.7%). No significant changes were seen in rates of vancomycin-resistant enterococci infection.

CONCLUSIONS

Vancomycin-resistant enterococci are an important cause of illness and death in the study institution, particularly among organ transplant recipients and other seriously ill persons; they have also become a common intestinal colonizer among hospitalized patients. The diversity of isolates (based on molecular typing studies) suggests that resistant organisms have been introduced from multiple sources. Interventions that effectively lower the overall level of colonization with vancomycin-resistant enterococci must still be identified.

Interrater reliability of an etiologic classification of ischemic stroke

BACKGROUND AND PURPOSE

Precise identification of the cause of stroke is critical to research and clinical practice. Published series of ischemic stroke show considerable variation in the proportion of cases classified as atherosclerotic large-vessel disease, lacunar infarct, cardioembolic stroke, stroke of other known cause, and stroke of undetermined etiology. We describe the development and use of an etiology-specific classification of ischemic stroke. The interrater reliability of the classification is then evaluated.

METHODS

A total of 160 cases of ischemic strokes in young adults were reviewed by paired neurologists who assigned cases to prioritized categories. The results of paired ratings were evaluated for each of the potential causes. Interrater agreement was assessed by means of kappa, which is the chance-adjusted percent agreement.

RESULTS

For standard pairs, kappa was fair to good for all causes except lacunar stroke (kappa = 0.31); however, pair-to-pair variation was greatest for lacunar strokes. Strokes of undetermined cause and hematologic/other cause were of borderline fair reliability.

CONCLUSIONS

The utility of a stroke classification system is dependent on its intended use. An etiologic classification is useful in studies of the epidemiology and pathophysiological basis of stroke. Fair to good reliability for an etiologic classification of stroke can be obtained when criteria are explicit.

Voluntary exercise decreases progression of muscular dystrophy in diaphragm of mdx mice

Effects of voluntary wheel running on contractile properties of diaphragm (DIA) and soleus (SOL) of dystrophic (mdx) and control (C57BL/10SNJ) mice were evaluated. In particular, we tested the hypothesis that daily voluntary running is not deleterious to muscle function in mdx mice. Both groups of mice ran extensively (control mice approximately 7 km/day, mdx mice approximately 5 km/day). Exercise increased maximal specific tetanus tension of mdx DIA from 1.02 +/- 0.04 to 1.33 +/- 0.06 kg/cm2 but did not restore it to the control level (2.55 +/- 0.17 kg/cm2). Maximal tetanus tension of sedentary mdx SOL (2.41 +/- 0.17 kg/cm2) was reduced compared with control (3.10 +/- 0.15 kg/cm2) and was not altered by running activity. Optimal length was significantly lower in DIA of mdx mice, and exercise did not change this. Fatigability and contractile properties of muscles measured in vitro were not altered by running activity with the exception of increased contraction time in mdx DIA. In conclusion, extensive wheel running is not deleterious to muscle function in mdx mice contrary to predictions of the "work overload" theory of muscular dystrophy. Rather, this exercise is beneficial for active tension generation of mdx DIA, the muscle most closely resembling muscles of patients with Duchenne muscular dystrophy.

Does muscular dystrophy affect metabolic rate? A study in mdx mice

In this study metabolic consequences of muscular dystrophy were investigated using the mdx mouse model. Measurements were performed on C57BL/10SNJ (control) and dystrophic (mdx) mice of ages 4-6 weeks (young) and 1 year (adult), i.e. at times when muscle degeneration and regeneration are known to be high (young) and low (adult). Whole body metabolic rate (MR) was measured indirectly under usual living conditions by recording O2 consumption and CO2 production over 24 h. Physical activity of mice was measured simultaneously. Oxygen consumption of soleus (SOL) and extensor digitorum longus (EDL) muscles of control and mdx mice was recorded in vitro, using polarographic O2 electrodes. MR in young mdx was significantly decreased compared to young control, but no differences were found in adults. Also, food consumption and physical activity of mdx were decreased significantly compared to control in young but not in adult mice. There was no difference in resting oxygen consumption of muscles from young mdx and control mice, but oxygen consumption of EDL from adult mdx was less than control. Results suggest that muscular dystrophy results in decreased rate of energy metabolism mainly as a consequence of decreased physical activity. The extensive muscular degeneration and regeneration characteristic of muscular dystrophy therefore do not appear to lead to an increase in whole body metabolism.

Black-white differences in stroke risk among young adults

BACKGROUND AND PURPOSE

Little information is available regarding black-white differences in stroke incidence in young adults.

METHODS

Cerebral infarction and intracerebral hemorrhage rates among adults 15 to 44 years of age were studied in Baltimore City and Baltimore County for 1988. Diagnoses were based on neurologist review of data obtained from medical records at 41 hospitals by neurological nurses.

RESULTS

The cerebral infarction rates per 100,000 were 22.8 for black males, 10.3 for white males, 20.7 for black females, and 10.8 for white females. The intracerebral hemorrhage rates per 100,000 were 14.2 for black males, 4.6 for white males, 4.8 for black females, and 1.5 for white females.

CONCLUSIONS

Blacks had significantly (P < .05) higher rates than whites for both cerebral infarction and intracerebral hemorrhage. Cerebral infarction rates are high in Baltimore compared with Florence, Italy, or Stockholm, Sweden.

Effect of third-party reimbursement on use of services and indexes of management among indigent diabetic patients

OBJECTIVE

To determine the effect of third-party reimbursement on the use of services and indexes of diabetes-related health management among inner-city diabetic patients.

RESEARCH DESIGN AND METHODS

Adult diabetic patients (n = 158; 67% women, 33% men) from an inner-city diabetes clinic were categorized by level of third-party medical coverage: complete reimbursement for all services (full); partial reimbursement (part); and no reimbursement (none). Patients were followed for 13 mo. Use of billable medical services, diabetes clinic visits, emergency room visits, and hospital admissions were recorded. Use of a free, day-time diabetes telephone hot line was also documented. Indexes of diabetes-related health management, HbA1, blood pressure, and weight were compared from the beginning and the end of the study. Diabetes complications were scored and tabulated.

RESULTS

Univariate analysis showed that patients with full reimbursement were more likely to use services than patients without reimbursement. When the combined effects of reimbursement status, age, sex, type of diabetes, and diabetes complications on use of services were analyzed together in a multivariate analysis, complications was the best predictor of admissions to the hospital and whether a patient called the hot line. IDDM patients and patients with full reimbursement were most likely to have an emergency room visit. Age was the best predictor of diabetes clinic attendance. No difference was noted in blood pressure or weight among the reimbursement groups at the beginning and end of study. However, the trend was toward (P < 0.05) an increase in HbA1 in the none group.

CONCLUSIONS

Among inner-city diabetic patients, multiple factors influence use of medical services. Indigent diabetic patients without third-party reimbursement were observed to have a rise in HbA1. These factors should be taken into consideration when planning strategies to prevent diabetes complications and the most effective allocation of health-care resources.

Predictors of frequent middle school health room use

Disproportionately high use of school health room (HR) services by small groups of users has been reported. This study investigated predictors of frequent HR use in two suburban middle schools involving 1089 students who made at least one HR visit during a single academic year. Subsets of high and low users were compared using logistic regression. Predictor variables included gender, grade, academic ability, and existence of a chronic health condition. Although demographic characteristics of the study schools varied significantly, a pattern of increasing HR use associated with progressive lowering of academic ability was demonstrated in both schools. Existence of a chronic health condition was associated with increased HR use, even when controlling for routine medication visits. Gender and grade were not predictive. These findings suggest that HR use reflects more than medical concerns. Patterns of HR use by students with chronic health conditions deserve additional study to determine whether current strategies to meet their needs are adequate.

Respiratory muscle stiffness is age- and muscle-specific

We investigated the possible contribution of respiratory muscles to the well documented increase in chest wall stiffness with age. Diaphragm and internal intercostal muscle strips were dissected from male Fischer 344 rats of 3, 6, 12, and 24 months of age. Muscles were subjected, in vitro, to stress-strain and yield point tests. Passive tension data from these tests were normalized to a reference length (Lr), which was defined in terms of absolute stress, 700 Pascals. In general, Lr of diaphragm was found to be 90% of the length (Lo) required for maximal tetanic tension. Within a range of stretch between Lr and 130% Lr, diaphragm muscles from adult rats (6-12 month) were more compliant than those of either young (3 month) or old (24 month) animals. In contrast, intercostal muscles from old rats were stiffer than those of young or adult rats. Yield strength of both muscles was constant with age, but diaphragm muscles were found to have a higher yield strength than intercostal muscles from any age. Thus, only some passive mechanical properties of respiratory muscles vary with age, and this variation in muscle-specific. A surprising finding of this study was that diaphragm muscles of adult animals were more compliant than those of either young or old rats.

Spatial memory in alcohol-dependent subjects: using a push-button maze to test the principle of equiavailability

The principle of equiavailability states that once the locations in a spatial array are learned, then all locations in the array are simultaneously available in memory (Levine, Jankovic, & Palij, 1982). To test the application of this principle, 21 nonamnesic, alcohol-dependent, male subjects and 20 demographic and ability-matched male control subjects were required to learn a series of push-button maze paths and to perform shortcut or retrace movements on the paths. The results for the control subjects conformed to the principle of equiavailability. In contrast, the alcohol-dependent subjects did not show equiavailability. This pattern of results is interpreted as evidence of a spatial memory deficit in the alcohol-dependent subjects.

Cardiovascular reflex abnormalities in children and adolescents with diabetes mellitus

OBJECTIVE

To assess the usefulness of specific cardiovascular reflex tests in childhood and to estimate the prevalence of cardiovascular reflex abnormalities among children with IDDM. In adults, abnormal cardiovascular reflexes are a frequent complication of diabetes, associated with increased morbidity and mortality.

RESEARCH DESIGN AND METHODS

We measured heart-rate responses to deep breathing and standing in ambulatory children with and without IDDM between 6-19 yr of age. A subgroup of the IDDM patients was retested after 1 yr.

RESULTS

We found the best techniques for detecting cardiovascular reflex abnormality in children were as follows: to record heart-rate responses to deep breathing either as the change in heart rate corrected for inspiratory heart rate or as the ratio of R-R intervals during expiration and inspiration; and to use the Maximum-minimum ratio for heart-rate responses to standing. HR-DBc was lower in diabetic than nondiabetic children (28.6 +/- 9.2% [n = 248] vs. 33.6 +/- 6.8% [n = 60]; P < 0.0005). Similarly, E:I was lower in children with IDDM than control subjects (1.42 +/- 0.19 [n = 248] vs. 1.52 +/- 0.15 [n = 60]; P < 0.0005). In the IDDM group, 21% of the children had abnormal HR-DBc or E:I responses. HR-STND M/m was lower in children with IDDM than control subjects (1.28 +/- 0.20 [n = 167] vs. 1.38 +/- 0.22 [n = 45]; P < 0.014). Among children with IDDM, 11.4% had abnormal HR-STND M/m responses. Overall, 29% of IDDM children tested abnormal in either HR-DBc or HR-STND M/m; 3% were abnormal in both tests. We found no correlation of HbA1c levels (n = 74) or duration of diabetes with either HR-DB, expiration to inspiration (n = 248), or HR-STND M/m (n = 167). In patients who were reevaluated after 1 yr we found a high correlation of the first and repeat HR-DBc tests (r = 0.47, n = 75, P < 0.0001), E:I (r = 0.53, n = 75, P < 0.0001), and HR-STND M/m (r = .49, n = 37, P < 0.002), but no evidence of an increased number of children with cardiovascular reflex abnormality.

CONCLUSIONS

With easily performed HR-DB and HR-STND tests, we detected cardiovascular reflex abnormality in 29% of children with IDDM. We found no correlation of changes in HR-DB and HR-STND with HbA1c or duration of diabetes. These tests provide an objective clinical measurement to monitor autonomic neuropathy in children with diabetes.

Dietary restriction alters characteristics of glucose fuel use

A longitudinal study of plasma glucose and insulin concentrations in ad libitum fed and dietary restricted male F344 rats was carried out. The life span diurnal pattern of plasma glucose concentration was such that through most of the day dietary restricted rats have significantly lower plasma glucose levels than ad libitum fed rats. Throughout the life span, dietary restricted rats maintain mean 24-hour plasma glucose concentrations about 15% below those of ad libitum fed rats. Plasma insulin levels are maintained in dietary restricted rats at about 50% of the levels in ad libitum fed rats. Although plasma glucose and insulin levels are lower, dietary restricted rats use glucose fuel at the same rate per unit of metabolic mass per day as rats fed ad libitum. While these findings are consistent with the glycation hypothesis of aging and with our hypothesis that dietary restriction retards the aging processes by altering the characteristics of fuel use, they do not establish the validity of either. It is possible that this effect of dietary restriction on carbohydrate metabolism plays no role in its antiaging action. Further studies are required to define the role of these altered characteristics of carbohydrate metabolism in the aging processes.

Differential expression of muscular dystrophy in diaphragm versus hindlimb muscles of mdx mice

Contractile properties of diaphragm (DIA) from mdx and control mice were compared with those of hindlimb muscles [soleus (SOL) and extensor digitorum longus (EDL)] in vitro. Mice ranged in age from 2 weeks to 1.5 years. Muscles were directly stimulated and properties measured were: contraction time, half-relaxation time, active tension per unit area, fatigue index, and maximal velocity of shortening (Vmax). Active tension decreased significantly with age in mdx DIA but not in control DIA. SOL and EDL active tensions were less in mdx than control over the whole age range and did not decrease with age. Vmax was decreased in mdx DIA, but not in mdx SOL or EDL. These results demonstrate that DIA is more affected by muscular dystrophy than hindlimb muscles. Since many Duchenne patients exhibit respiratory distress, this differential expression of dystrophy in diaphragm, as compared to limb muscles, may have important clinical implications.

Energy metabolism and aging: a lifelong study of Fischer 344 rats

Metabolic rate is widely regarded as an important component of aging processes, but variation of metabolic rate with age has not been well characterized. The purpose of the present study was to measure daily metabolic rate under usual living conditions over the lifespan of barrier-maintained Fischer 344 rats. In addition, effects of life-prolonging food restriction were assessed. Metabolic rate was measured indirectly by analysis of gas entering and leaving standard rodent cages over a 24-h period. Group A rats were fed ad libitum. Group B rats were fed 60% of ad libitum intake from 6 wk of age. Both group A and group B rats exhibited variation of metabolic rate per unit lean mass over the lifespan, with metabolic rate decreasing from 6 to 18 mo and then increasing from 18 to 24 mo of age. Results show estimates of lifetime energy expenditure in rats should take account of variability of metabolic rate and confirm the life-prolonging action of food restriction is not a consequence of reduced metabolic rate per unit metabolic mass. Rather, restricted rats are able to sustain appropriate fluxes of nutrients and appropriate metabolic rate under conditions of fuel utilization which promote maintenance of cellular homeostasis.