The aging cardiovascular system: changes in autonomic function at rest and in response to exercise

Tonic vagal modulation of cardiac period (R-R interval) decreases with advancing age, but is greater in middle-aged and older adults who habitually perform aerobic exercise compared with their sedentary peers. Cardiovagal baroreflex sensitivity also declines markedly with age in sedentary adults but only 50% as much in regularly exercising adults. In previously sedentary middle-aged and older adults, a 3-month program of moderate aerobic exercise increases cardiovagal baroreflex sensitivity by 25%. Tonic (basal) sympathetic nervous system (SNS) activity increases with advancing age in both sedentary and habitually exercising adults. Despite this, SNS beta-adrenergic support of energy metabolism (resting metabolic rate--RMR) declines with age in sedentary individuals. However, SNS beta-adrenergic support of RMR is maintained with age in endurance exercise-trained adults and therefore is much greater in middle-aged and older individuals who exercise regularly compared with their sedentary peers. Thus, regular aerobic (endurance) exercise modulates selective age-associated impairments in autonomic nervous system-physiological function.

Public-private partnerships. Public pain, private gain

Using private hospitals over 11 weeks this winter enabled a health authority to remove more than 1,000 patients from waiting lists. Prices were comparable to, and sometimes cheaper than, the NHS. The average cost was 1,120 Pounds per treatment. Patient satisfaction seemed high. Consultant productivity was higher in the private sector.

Crossover trial of pagoclone and placebo in patients with DSM-IV panic disorder

Pagoclone is a cyclopyrrolone that is believed to act as a partial agonist at the gamma-aminobutyric acid (GABA)-A/benzodiazepine (BDZ) receptor. In theory, such partial agonists should be anxiolytic but lack the adverse side-effects of sedation, tolerance and withdrawal associated with full GABA-A/BDZ agonists. The objective of the randomized double-blind crossover study was to assess whether pagoclone was an effective anti-panic agent and also to assess its side-effect profile. Patients recruited had a diagnosis of Panic Disorder (DSM-IV) with at least one panic attack per week. Following a 2-week screening period, patients entered a 6-week trial consisting of two 2-week treatment periods, each followed by a 1-week washout. Patients were randomly assigned to receive either pagoclone 0.1 mg t.d.s. or placebo on their first treatment period and the converse on their second. The primary measure was daily panic attack dairy. Fourteen patients completed the study, the mean number of panic attacks during screening was 5.8+/-0.8 (SEM), this fell to 3.6+/-0.5 during treatment with pagoclone (p = 0.05) and 4.3+/-0.8 with placebo (p = 0.14). There was no significant difference on direct comparison of pagoclone with placebo or in any of the secondary measures (including Rickels withdrawal scale) or the adverse event profiles. The study provides preliminary evidence that pagoclone has anxiolytic properties in the absence of typical BDZ side-effects. This is consistent with its theoretical mode of action as a partial agonist at the GABA(A)/BDZ receptor.

Tonic sympathetic support of metabolic rate is attenuated with age, sedentary lifestyle, and female sex in healthy adults

We recently demonstrated in young adult humans that the sympathetic nervous system contributes to the control of resting metabolic rate via tonic beta-adrenergic receptor stimulation. In the present follow-up study we determined the respective effects of age, habitual exercise status, and sex on this regulatory mechanism. Resting metabolic rate (ventilated hood, indirect calorimetry) was determined in 55 healthy sedentary or endurance exercise-trained adults, aged 18-35 or 60-75 yr (29 men and 26 women), before (baseline) and during the infusion of either a nonselective beta-adrenergic receptor antagonist (propranolol) or saline (control). Relative to baseline values, during beta-adrenergic receptor antagonism resting metabolic rate adjusted for fat-free mass was reduced to a lesser extent in older (mean +/- SE, -130 +/- 46 kJ/d) compared with young (-297 +/- 46) adults, sedentary (-151 +/- 50) compared with endurance exercise-trained (-268 +/- 46) adults, and women (-105 +/- 33) compared with men (-318 +/- 50; all P < 0.01). Reductions in resting metabolic rate during beta-adrenergic receptor antagonism were positively related to higher baseline resting metabolic rate and plasma catecholamine concentrations and negatively related to adiposity (all P < 0.05). Resting metabolic rate was unchanged in response to saline control in all groups. These results provide experimental support for the hypothesis that aging, sedentary living, and female sex are associated with attenuated sympathetic nervous system support of resting metabolic rate in healthy adult humans.

Determinants of oxygen uptake kinetics in older humans following single-limb endurance exercise training

We hypothesised that the observed acceleration in the kinetics of exercise on-transient oxygen uptake (VO2) of five older humans (77 +/- 7 years (mean +/- S.D.) following 9 weeks of single-leg endurance exercise training was due to adaptations at the level of the muscle cell. Prior to, and following training, subjects performed constant-load single-limb knee extension exercise. Following training VO2 kinetics (phase 2, tau) were accelerated in the trained leg (week 0, 92 +/- 44 s; week 9, 48 +/- 22 s) and unchanged in the untrained leg (week 0, 104 +/- 43 s; week 9, 126 +/- 35 s). The kinetics of mean blood velocity in the femoral artery were faster than the kinetics of VO2, but were unchanged in both the trained (week 0, 19 +/- 10 s; week 9, 26 +/- 11 s) and untrained leg (week 0, 20 +/- 18 s; week 9, 18 +/- 10 s). Maximal citrate synthase activity, measured from biopsies of the vastus lateralis muscle, increased (P < 0.05) in the trained leg (week 0, 6.7 +/- 2.0 micromol x (g wet wt)(-1) x min(-1); week 9, 11.4 +/- 3.6 micromol x (g wet wt)(-1) x min(-1)) but was unchanged in the untrained leg (week 0, 5.9 +/- 0.5 micromol x (g wet wt)(-1) x min(-1); week 9, 7.9 +/- 1.9 micromol x (g wet wt)(-1) x min(-1)). These data suggest that the acceleration of VO2 kinetics was due to an improved rate of O2 utilisation by the muscle, but was not a result of increased O2 delivery.

Evaluation of digital blood pressure measured with the Omron F3 device as an index of brachial arterial pressure, under different thermal and hormonal conditions

BACKGROUND

Devices that record from the finger have potential practical advantages for home monitoring of blood pressure. However, digital arterial pressure may vary substantially from that in the brachial artery, due to the influence of peripheral wave reflection.

AIMS

(1) To compare digital arterial pressure, as measured with the Omron F3 device, with brachial arterial pressure and (2) to determine the effect on digital pressure of changing local vascular resistance.

METHOD

The subjects were normotensive young adult non-smokers (12 males, 14 females). Pressures were recorded simultaneously from arm (using an Omron HEM-705CP) and finger with subjects seated and both recording sites at the level of the xiphisternum. Measurements were made at ambient temperatures of 19 degrees C and 30 degrees C; at rest, during brief contralateral hand cooling and after hand rewarming.

RESULTS

In many cases, resting finger values differed substantially from arm values; sometimes by 20 mm Hg or more. The extent of individual variations was not correlated with gender or temperature. However, group pressure differences between the sites were greater in females at ovulation than at menstruation and greater at 30 degrees C than at 19 degrees C. For all groups, pressure differences between sites were attenuated during hand cooling and restored by rewarming.

CONCLUSIONS

Finger blood pressure, as measured with the Omron F3, misestimates brachial blood pressure in a high proportion of normal subjects. This error is increased under circumstances associated with cutaneous vasodilation. The Omron F3 does not appear to be suitable for unsupervised home monitoring of blood pressure.

A comparison of modelling techniques used to characterise oxygen uptake kinetics during the on-transient of exercise

We compared estimates for the phase 2 time constant (tau) of oxygen uptake (VO2) during moderate- and heavy-intensity exercise, and the slow component of VO2 during heavy-intensity exercise using previously published exponential models. Estimates for tau and the slow component were different (P < 0.05) among models. For moderate-intensity exercise, a two-component exponential model, or a mono-exponential model fitted from 20 s to 3 min were best. For heavy-intensity exercise, a three-component model fitted throughout the entire 6 min bout of exercise, or a two-component model fitted from 20 s were best. When the time delays for the two- and three-component models were equal the best statistical fit was obtained; however, this model produced an inappropriately low DeltaVO2/DeltaWR (WR, work rate) for the projected phase 2 steady state, and the estimate of phase 2 tau was shortened compared with other models. The slow component was quantified as the difference between VO2 at end-exercise (6 min) and at 3 min (DeltaVO2 (6-3 min)); 259 ml x min(-1)), and also using the phase 3 amplitude terms (truncated to end-exercise) from exponential fits (409-833 ml x min(-1)). Onset of the slow component was identified by the phase 3 time delay parameter as being of delayed onset approximately 2 min (vs. arbitrary 3 min). Using this delay DeltaVO2 (6-2 min) was approximately 400 ml x min(-1). Use of valid consistent methods to estimate tau and the slow component in exercise are needed to advance physiological understanding.

Training reduces autonomic cardiovascular responses to both exercise-dependent and -independent stimuli in humans

Training attenuates the sympathetic pressor response to dynamic exercise. However, it is uncertain how training alters other patterns of cardiovascular autonomic activation. Therefore, we have quantified circulatory responses to a series of standard autonomic tests in highly fit and unfit subjects and examined the effects of a short-term training programme on these responses. Subjects were defined as either unfit (n = 8) or fit (n = 8) on the basis of training history and a maximal fitness test (VO2peak 54 +/- 2.3 cf. 68 +/- 2.8 (ml min(-1)) kg(-1), means + S.E.M., P < 0.05). On a separate day, the blood pressure, heart rate and forearm vascular conductance responses to a sustained handgrip to fatigue, 2 min mental arithmetic and 2 min of cold exposure were measured. All stimuli were associated with elevated blood pressures and heart rates, but these responses were significantly attenuated in the trained group. In the untrained subjects, forearm vascular conductance increased during exercise (from 0.032 +/- 0.004 to 0.05 +/- 0.007 (ml min(-1)) 100 ml(-1) mm Hg(-1), P < 0.05) and during mental arithmetic (from 0.028 +/- 0.003 to 0.04 +/- 0.006 (ml min(-1)) 100 ml(-1) mm Hg(-1) , p < 0.05), but trained subjects showed no rise in conductance during either test. All untrained subjects undertook a moderate intensity 5-week training programme, which significantly increased VO2peak (54 +/- 2.3 to 57 +/- 2 (ml min(-1)) kg(-1), p < 0.05). Qualitatively similar blunting of pressor, tachycardic and vasodilator responses were seen in this group post-training. These results demonstrate that the blunting of sympathetic vasomotor activation that follows training is not restricted to reflexes associated with exercise, and does not depend on training being prolonged or intense.

Physical activity in Dublin children aged 7-9 years

OBJECTIVES

To investigate the amount of regular activity and time spent in sedentary occupations in children aged 7--9 years. Sex differences in levels of activity and time and facilities for physical education at school were also examined.

METHODS

A 10% sample of Dublin National Schools were selected. Parents of children in second class were surveyed. The questionnaire used was a modification of the Modifiable Activity Questionnaire for Adolescents. Teachers of second class were questioned about the time and facilities for physical education in schools.

RESULTS

Some 39% of children were participating in hard exercise for at least 20 minutes three or more times a week, with fewer girls (28%) than boys (53%) contributing to this result. A further 57% of children were engaging in at least 20 minutes of light exercise three or more times a week, with no sex differences. Estimated energy expenditure in regular activity was higher in boys than girls. Most (78%) of the children were spending one to three hours a day sedentary in front of a screen.

CONCLUSIONS

This study provides comprehensive data on physical activity levels in Dublin schoolchildren aged 7--9 years. The amount of inactivity is of concern. Even at this young age, boys are reported to participate in more physical activity than girls.

Crevicular fluid elastase levels in relation to periodontitis and metabolic control of diabetes

The purpose of this study was to investigate the associations between gingival crevicular fluid (GCF) elastase levels, clinical measures of periodontal status, and metabolic control of diabetes in insulin dependent (type 1) diabetes (IDDM) and non-insulin dependent (type 2) diabetes (NIDDM) patients. Sixty patients were recruited from the Diabetes Center at the University of California in San Francisco. Thirty subjects were type 1 diabetics and 30 subjects were type 2 diabetics. Metabolic control was evaluated by glycosylatted hemoglobin (HbA1c) levels. Demographic information was obtained using a structured interview with the subjects. Clinical measurements and GCF samples were taken from the mesio-buccal surfaces of 2 premolars and 2 molars from the most diseased sextant. GCF elastase was determined by measurement of p-Nitroanalide resulting from hydrolysis of elastase specific peptide. Crevicular fluid elastase levels were significantly correlated with gingival index, bleeding index, probing depth and attachment level in both type 1 and type 2 diabetes groups (0.01 <p < 0.001). HbA1c levels were not correlated with clinical measurements and GCF elastase. The results suggest that GCF elastase. age and smoking are risk indicators for periodontitis in patients with diabetes mellitus, and periodontal status is not associated with the duration and metabolic control of diabetes.

A genome-wide scan suggests a locus on chromosome 1q21-q23 contributes to normal variation in plasma cholesterol concentration

To identify genes that influence plasma cholesterol, triglyceride, and high-density and low-density lipoproteins concentrations we conducted a genome-wide scan using 354 polymorphic markers spaced at 10-cM intervals in 75 obese but otherwise normal human families. The results of the genome scan using sibling pair analysis of quantitative phenotypes suggested that 1q21-q23 contains a locus that influences plasma cholesterol concentration. Chromosome 12 gave evidence of linkage to plasma triglyceride concentration (D12SPAH) and chromosomes 3, 6, 7, 10, 11, 17, and 20 yielded additional evidence of linkage for lipid phenotypes at lower levels of statistical significance. Allele sharing for markers near prominent candidate genes was either very weakly related or unrelated to sibling similarity for lipid concentrations. Together these results suggest that genes with important roles in regulating normal cholesterol and triglyceride concentrations do not coincide with the location of previously known candidate genes.

Direct evidence for tonic sympathetic support of resting metabolic rate in healthy adult humans

The sympathetic nervous system (SNS) plays an important role in the regulation of energy expenditure. However, whether tonic SNS activity contributes to resting metabolic rate (RMR) in healthy adult humans is controversial, with the majority of studies showing no effect. We hypothesized that an intravenous propranolol infusion designed to achieve complete beta-adrenergic blockade would result in a significant acute decrease in RMR in healthy adults. RMR (ventilated hood, indirect calorimetry) was measured in 29 healthy adults (15 males, 14 females) before and during complete beta-adrenergic blockade documented by plasma propranolol concentrations > or =100 ng/ml, lack of heart rate response to isoproterenol, and a plateau in RMR with increased doses of propranolol. Propranolol infusion evoked an acute decrease in RMR (-71 +/- 11 kcal/day; -5 +/- 0.7%, P < 0.0001), whereas RMR was unchanged from baseline levels during a saline control infusion (P > 0.05). The response to propranolol differed from the response to saline control (P < 0.01). The absolute and percent decreases in RMR with propranolol were modestly related to baseline plasma concentration of norepinephrine (r = 0.38, P = 0.05; r = 0.44, P = 0.02, respectively). These findings provide direct evidence for the concept of tonic sympathetic beta-adrenergic support of RMR in healthy nonobese adults.

Tryptophan depletion and its implications for psychiatry

BACKGROUND

Over the past 10 years the technique of tryptophan depletion has been used increasingly as a tool for studying brain serotonergic systems.

AIMS

To review the technique of tryptophan depletion and its current status as a tool for investigating psychiatric disorders.

METHOD

Systematic review of preclinical and clinical studies.

RESULTS

Tryptophan depletion produces a marked reduction in plasma tryptophan and consequently brain serotonin (5-HT) synthesis and release. In healthy volunteers the effects of tryptophan depletion are influenced by the characteristics of the subjects and include some mood lowering, some memory impairment and an increase in aggression. In patients with depression tryptophan depletion tends to result in no worsening of depression in untreated subjects but a relapse in those who have responded to antidepressants (particularly serotonergic agents). In panic disorder the results are similar.

CONCLUSIONS

The findings that tryptophan depletion produces a relapse of symptoms in patients with depression and panic disorder who have responded to treatment with antidepressants suggests that enhanced 5-HT function is important in maintaining response in these conditions.

Longitudinal evaluation of GCF MMP-3 and TIMP-1 levels as prognostic factors for progression of periodontitis

BACKGROUND

To determine whether matrix metalloproteinase-3 (MMP-3) and tissue inhibitor of metalloproteinases-1 (TIMP-1) in gingival crevicular fluid (GCF) could serve as prognostic factors for the progression of periodontitis, we monitored GCF MMP-3 and TIMP-1 and periodontal status of selected sites in 40 medically healthy subjects over a 6-month period.

METHOD

Clinical measurements including gingival index (GI), plaque index, bleeding on probing, suppuration, probing depth (PD), attachment loss (AL), and GCF samples were taken from 2 healthy sites (including sites with gingival recession, GI=0 PD < or =3 mm; AL < or =2 mm) and 2 periodontitis sites (GI > or =1; PD > or =5 mm; AL > or =3 mm) of each patient at baseline, 3-month and 6-month visits by means of sterile paper strips. GCF levels of MMP-3 and TIMP-1 were determined by sandwich ELISA assays.

RESULTS

The mean amounts of MMP-3 and TIMP-1 in diseased sites were significantly higher than in healthy sites (p<0.0001). Significantly higher GCF levels of MMP-3 and TIMP-1 were found at progressing sites than in nonprogressing periodontitis sites (0.001<p<0.01). A progressing site was defined as a site which had > or =2 mm loss of attachment during 6- month study period. GCF levels of MMP-3 were highly correlated with clinical measurements taken at baseline, 3-month and 6-month visits (p<0.001). TIMP-1 levels were only moderately correlated with probing depth and attachment level (p<0.01). Step-wise multiple regression analysis was performed to construct models for the prediction of probing depth and attachment loss increases. The most parsimonious regression models which had the best R2 values included the following variables and accounted for the indicated % of variability. The regression model for the prediction of probing depth increase included MMP-3, smoking pack-years, TIMP-1 and accounted for 53% of the variability. The best model for the prediction of attachment loss increase included MMP-3, smoking pack-years, age, TIMP-1 and explained 59% of the variability.

CONCLUSION

These data indicate that sites with high GCF levels of MMP-3 and TIMP-1 are at significantly greater risk for progression of periodontitis.

Mutation screening of the TNFRSF11A gene encoding receptor activator of NF kappa B (RANK) in familial and sporadic Paget's disease of bone and osteosarcoma

Paget's disease of bone (PDB) is a common disorder characterized by focal areas of increased and disorganized osteoclastic bone resorption, leading to bone pain, deformity, pathological fracture, and an increased risk of osteosarcoma. Genetic factors play an important role in the pathogenesis of Paget's disease. In some families, the disease has been found to be linked to a susceptibility locus on chromosome 18q21-22, which also contains the gene responsible for familial expansile osteolysis (FEO)--a rare bone dysplasia with many similarities to Paget's disease. Insertion mutations of the TNFRSF11A gene encoding Receptor Activator of NF kappa B (RANK) have recently been found to be responsible for FEO and rare cases of early onset familial Paget's disease. Loss of heterozygosity (LOH) affecting the PDB/FEO critical region has also been described in osteosarcomas suggesting that TNFRSF11A might also be involved in the development of osteosarcoma. In order to investigate the possible role of TNFRSF11A in the pathogenesis of Paget's disease and osteosarcoma, we conducted mutation screening of the TNFRSF11A gene in patients with familial and sporadic Paget's disease as well as DNA extracted from Pagetic bone lesions, an osteosarcoma arising in Pagetic bone and six osteosarcoma cell lines. No specific abnormalities of the TNFRSF11A gene were identified in a Pagetic osteosarcoma, the osteosarcoma cell lines, DNA extracted from Pagetic bone lesions, or DNA extracted from peripheral blood in patients with familial or sporadic Paget's disease including several individuals with early onset Paget's disease. These data indicate that TNFRSF11A mutations contribute neither to the vast majority of cases of sporadic or familial PDB, nor to the development of osteosarcoma.

Amelioration of neurotoxic effects of HIV envelope protein gp120 by fibroblast growth factor: a strategy for neuroprotection

Approximately two thirds of patients with human immunodeficiency virus encephalitis (HIVE) show cognitive impairment and neurodegeneration, while one third are cognitively unimpaired and their neuronal populations are preserved. Thus, it is possible that these individuals might have the capacity to produce neurotrophic factors capable of protecting neurons against the deleterious effects of HIV. In this context, the main objective of this study was to determine whether fibroblast growth factor 1 (FGF1) is protective against HIV. For this purpose levels of FGF1 immunoreactivity were determined in the frontal cortex of 35 AIDS cases subdivided into 4 groups according to the presence or absence of HIVE and neurodegeneration. In cases without both HIVE and neurodegeneration, mild to moderate levels of FGFI immunoreactivity were observed in pyramidal neurons, while in cases with HIVE but without neurodegeneration, levels were significiantly elevated. In contrast, individuals with both HIVE and neurodegeneration showed low levels of neuronal FGF1 immunoreactivity. Furthermore, studies in primary human neuronal cultures treated with the HIV envelope protein-gp120 in the presence or absence of FGF1 showed that FGF1 was protective against gpl20 neurotoxicity in a dose-dependent manner. Taken together, these results support the notion that upregulation of certain neurotrophic factors, such as FGF1, might protect the central nervous system from the neurotoxic effects of HIV.

Polyclonal sandwich ELISAs to detect F18 fimbriated Escherichia coli in pigs in Northern Ireland

F18 fimbriated Escherichia coli are a newly described cause of postweaning diarrhea in pigs. Polyclonal rabbit antisera were raised to the antigenic variants, F18ab and F18ac, of these fimbriae and were used to develop monospecific sandwich enzyme-linked immunosorbent assays (ELISAs). The ELISAs were standardized with type cultures characterized by polymerase chain reaction techniques (PCR) and then used to conduct a study of the prevalence of F18 fimbriated E. coli in pigs in Northern Ireland. A total of 176 isolates were tested by ELISA and PCR. Eight isolates were positive for F18 by ELISA, of which 2 were shown to be false positives by PCR and one was PCR positive but ELISA negative. Of the 6 confirmed ELISA positives, all produced VT2 toxin and 3 produced ST toxin. Four positives were from serogroups O138 and O139, previously associated with porcine diarrhea.

Steroid responsive polyneuropathy in a family with a novel myelin protein zero mutation

OBJECTIVE

To report a novel hereditary motor and sensory neuropathy (HMSN) phenotype, with partial steroid responsiveness, caused by a novel dominant mutation in the myelin protein zero (MPZ) gene. Most MPZ mutations lead to the HMSN type I phenotype, with recent reports of Déjérine-Sottas, congenital hypomyelination, and HMSN II also ascribed to MPZ mutations. Differing phenotypes may reflect the effect of particular mutations on MPZ structure and adhesivity.

METHODS

Clinical, neurophysiological, neuropathological, and molecular genetic analysis of a family presenting with an unusual hereditary neuropathy.

RESULTS

Progressive disabling weakness, with positive sensory phenomena and areflexia, occurred in the proband with raised CSF protein and initial steroid responsiveness. Nerve biopsy in a less severely affected sibling disclosed a demyelinating process with disruption of compacted myelin. The younger generation were so far less severely affected, becoming symptomatic only after 30 years. All affected family members were heterozygous for a novel MPZ mutation (Ile99Thr), in a conserved residue.

CONCLUSIONS

This broadens the range of familial neuropathy associated with MPZ mutations to include steroid responsive neuropathy, initially diagnosed as chronic inflammatory demyelinating polyneuropathy.

The influence of patient geometry on the selection of chest wall irradiation techniques in post-mastectomy breast cancer patients

BACKGROUND AND PURPOSE

To evaluate three chest wall (CW) irradiation techniques: wide tangential photon beams, direct appositional electron field and electron arc therapy with regards to target coverage and normal tissue tolerance.

MATERIALS AND METHODS

Thirty-two post-mastectomy breast cancer patients were planned using three CW irradiation techniques. Computed tomography (CT) simulation was done on all patients and clinical target, heart and lung volumes were contoured. For each technique, dose distributions and dose-volume histograms (DVH) were calculated. Pass/fail criteria were applied based on volumetric target and critical structure dose coverage. Passing criteria for target was 95% of target receiving 95% of dose using a standard dose of 50 Gy/25 fractions, for heart </=10% volume receiving 50% dose (i.e. 25 Gy) and for lung </=25% volume ipsilateral lung receiving 50% dose (i.e. 25 Gy).

RESULTS

The number of patients optimally treated by each technique were as follows: wide tangential photon beams 23/32 (72%), direct appositional electron field 1/32 (3%), electron arc 4/32 (12.5%) and in 4/32 (12.5%) no technique was optimal. Geometric predictors for technique suitability include CW thickness, medial to lateral CW curvature, uniformity of superior to inferior CW curvature and length of mastectomy scar.

CONCLUSIONS

This study confirms the utility of CT planning and DVH analysis for treatment planning of breast cancer. Patient factors that predict for treatment technique suitability and aid in technique selection can be identified. In a small subset of patients, none of the currently studied techniques were optimal and more novel methods of chest wall irradiation are required.

A comprehensive league table of cost-utility ratios and a sub-table of "panel-worthy" studies

OBJECTIVES

The authors compiled a comprehensive league table of cost/QALY ratios, and a standardized table of analyses satisfying selected Reference Case criteria from the USPHS Panel on Cost-Effectiveness in Health and Medicine.

METHODS

They identified 228 cost-utility analyses (CUAs) through literature searches, and abstracted data on methods and cost-utility ratios. The subset of "Panel-worthy" analyses used: a societal or broad health-care perspective, community or patient preference weights, net costs, incremental comparisons, and discounting of costs and QALYs.

RESULTS

The 228 CUAs included ratios for 647 interventions, ranging from cost-saving to $52,000,000/QALY (median = $12,000/QALY). The standardized table presents 112 ratios that met the "Panel-worthy" criteria, with articles published in recent years more likely to meet all of the criteria.

CONCLUSIONS

The comprehensive league table (available on the Web) provides a useful reference, but ratios may not be comparable because of methodologic variations. The standardized table focuses on studies meeting basic methodologic criteria, potentially allowing for better comparison with future Reference Case analyses. Future studies should investigate the quality of analyses' underlying assumptions in addition to whether certain key procedural protocols were met.

Involving families in an urban HIV preventive intervention: how community collaboration addresses barriers to participation

This article addresses the increasing need within urban communities for effective, culturally relevant HIV prevention programs. The recruitment efforts of a family-based prevention program aimed at promoting health and preventing HIV risk exposure in urban, African American fourth and fifth grade children living in a community with high rates of HIV infection is detailed. The program, referred to as the CHAMP (Chicago HIV Prevention and Adolescent Mental Health Project) Family Program, is overseen by a collaborative partnership of community parents, school staff, and university-based researchers (Paikoff & McKay, 1995). The recruitment strategies developed as a result of this community-research collaboration are described. Preliminary results of the project's efforts to reach out to families within the targeted, inner-city community are presented.

Clinical and laboratory findings in cases of toxic mastitis in cows in Northern Ireland

This paper describes the clinical and laboratory findings from 264 cases of toxic mastitis in cows in Northern Ireland between October 1995 and May 1997. Nearly all the cases occurred during the winter housing period, with 84 per cent occurring between November and March inclusive, and 30 per cent in March. Sixty per cent of the cases occurred within one month of calving, and 29 per cent within four days of calving. The most common clinical signs were lethargy (92 per cent), discoloured milk (90 per cent), anorexia (72 per cent), tachypnoea (23 per cent), diarrhoea (23 per cent), recumbency (18 per cent) and staggering (15 per cent). Severe pyrexia (18 per cent) and clinical dehydration (44 per cent) were relatively common findings. Pure growths of Escherichia coli were isolated from 50 per cent of the milk samples, but 11 per cent yielded no bacterial growth. In vitro sensitivity tests indicated that enrofloxacin was effective against 98 per cent of the bacteria isolated, and framycetin and amoxycillin/clavulanic acid against 91 per cent. Abnormally high blood urea levels were observed in 31 per cent of cases, high blood creatinine levels in 42 per cent, and severe leucopenia in 56 per cent. Of the cases which were followed up, 14 per cent died, 21 per cent were culled early and a further 22 per cent lost milk production from the affected quarter.

Reduced inflammation in genetically hypertensive rat airways is associated with reduced tachykinin NK(1) receptor numbers

The airways of the genetically hypertensive rat (GH) are hyperinnervated by substance P-containing sensory nerves and exhibit reduced inflammatory responsiveness to substance P and to capsaicin. The present study measured tracheal inflammation to resiniferatoxin (1.0 microgram/kg i.v.), a capsaicin analogue, which lacks the hypotensive action of capsaicin itself, alone or after the neuronal nitric oxide synthase inhibitor 1-(2-trifluoromethylphenyl)imidazole (TRIM) (50 mg/kg i.p.). The inflammatory response to resiniferatoxin alone was 50% lower in untreated GH than in control rats, a similar strain difference to that seen previously with capsaicin. Pre-treatment with TRIM had no effect on inflammation in either strain. Binding kinetics of the tachykinin NK(1) receptor antagonist [3H](S)-1-(2-[3-(3, 4-dichlorophenyl)-1-(3-isopropoxyphenylacetyl)piperidin-3-yl]ethyl)-4- phenyl-l-azoniabicyclo[2,2,2,]octane chloride ([3H]SR140333)(0.125-16.0 nM) showed 50% reduction of B(max) in GH versus control tracheae (74+/-13 cf.165+/-26 fmol/mg protein). Our results indicate that the reduced neurogenic inflammatory responsiveness in GH rats can be attributed entirely to reduced tachykinin NK(1) receptor numbers.

The effects of exercise and training on human cardiovascular reflex control

During physical activity, there is a graded withdrawal of vagal cardiac tone and a graded increase in sympathetic cardiac and vasomotor tone, initiated through both central command from the somatic motor cortex and muscle chemoreceptive and mechanoreceptive inputs. In parallel, there is an upward resetting of the operating point of the arterial baroreflex, with preserved reflex sensitivity. In contrast to the traditional interpretation that blood flow through exercising muscle is independent of vasomotor neural influences because of the dominance of local dilator metabolites, recent evidence suggests that both constrictor and dilator sympathetic neural influences may be involved in determining absolute levels of perfusion. Post-exercise, there is a period of relative hypotension that is associated with decreased peripheral resistance. Some, but not all, evidence indicates a causal role for reduced sympathetic drive. Chronic exercise training appears to reduce resting sympathetic activity, with parallel changes in the gain of a variety of cardiovascular autonomic reflexes initiated from cardiovascular sites. These changes may be attributable at least partly to masking of arterial baroreflexes by the impact of elevated blood volume on low-pressure baroreceptors. The reductions in sympathetic drive that follow training are more pronounced in patients with essential hypertension than in normotensive individuals and are likely to underlie the anti-hypertensive effect of exercise.

Cost-utility analyses of clinical preventive services: published ratios, 1976-1997

BACKGROUND

Cost-effectiveness analyses of clinical preventive services are a potential means to aid public health resource allocation. Cost-utility analysis (CUA) is a specific form of cost-effectiveness analysis where results are expressed in terms of cost per quality-adjusted life year (QALY) gained. To increase the transparency and comparability of CUAs, standardization of methods has been recommended.

OBJECTIVES

The purposes of this study were as follows: (1) identify published articles with original CUAs of primary and secondary clinical preventive services, (2) summarize the ratios found in these analyses, (3) identify articles employing comparable methods, and (4) explore analytic methods employed over time.

METHODS

As part of a larger study we conducted a comprehensive search of published CUAs in the area of clinical preventive services and systematically collected data on the results of the analyses and analytic methods employed. Cost-effectiveness ratios were standardized and organized into a table.

RESULTS

We found 50 CUAs pertaining to clinical preventive services (primary, n=22, 44%; and secondary, n=28, 56%) and 174 cost-effectiveness ratios. These ratios ranged from cost-savings up to $27,000,000/QALY, with a median of $14,000/QALY. Only three (6%) of the CUAs met minimum reference case requirements. There was no apparent improvement of methods over time.

CONCLUSIONS

Immunizations and chemoprophylaxis have the most favorable cost-effectiveness ratios, and preventive services are more cost-effective when targeted at high-risk populations. However, there is wide variation in the methods used in these analyses. This study allows us to define where improvements in methodologic rigor need to occur, provides a base-line for future audits, and highlights disease areas in clinical preventive services that have been omitted or underevaluated.

Cumulative effect of family environment on psychiatric symptomatology among multiethnic adolescents

PURPOSE

To examine the influence of family adversity and support on levels of psychiatric symptomatology in Hawaiian and non-Hawaiian adolescents.

METHOD

More than 4000 students from five high schools in Hawaii completed a survey during the 1992-1993 school year about their family environment and mental health. The response rate was approximately 60%. Logistic regression analyses were performed and responses for Hawaiians and non-Hawaiians were compared.

RESULTS

Hawaiian adolescents experienced significantly more adversity than their non-Hawaiian counterparts. The cumulative effect of family adversity had a greater effect on psychiatric symptomatology than any single indicator. Family support reduced the risk for internalizing symptoms, particularly for Hawaiian adolescents. The influence of family support was less clear for externalizing symptoms, increasing the risk for some adolescents and decreasing the risk for others.

CONCLUSION

We identified strong associations between family adversity and levels of psychiatric symptomatology. We found that Hawaiian adolescents are at increased risk for psychiatric symptomatology, given the presence of family adversity and the effect of reduced family support. However, risk was also substantial for non-Hawaiians. Clinicians need to assess the family environment routinely and implement family-oriented interventions.

Trauma and dissociation: treatment perspectives

TOPIC

How advanced practice nurses can work with trauma survivors to decrease dissociation as a needed coping mechanism.

PURPOSE

To review the literature on trauma and dissociation as well as current treatment perspectives.

SOURCES

Review of the literature and authors' clinical experience.

CONCLUSIONS

Advanced practice nurses can use knowledge of selected psychopharmacological medications and Erikson's stages of psychosocial development to plan treatment for posttrauma clients.

Genomewide search for type 2 diabetes susceptibility genes in four American populations

Type 2 diabetes is a serious, genetically influenced disease for which no fully effective treatments are available. Identification of biochemical or regulatory pathways involved in the disease syndrome could lead to innovative therapeutic interventions. One way to identify such pathways is the genetic analysis of families with multiple affected members where disease predisposing genes are likely to be segregating. We undertook a genomewide screen (389-395 microsatellite markers) in samples of 835 white, 591 Mexican American, 229 black, and 128 Japanese American individuals collected as part of the American Diabetes Association's GENNID study. Multipoint nonparametric linkage analyses were performed with diabetes, and diabetes or impaired glucose homeostasis (IH). Linkage to diabetes or IH was detected near markers D5S1404 (map position 77 cM, LOD = 2.80), D12S853 (map position 82 cM, LOD = 2.81) and GATA172D05 (X-chromosome map position 130 cM, LOD = 2.99) in whites, near marker D3S2432 (map position 51 cM, LOD = 3.91) in Mexican Americans, and near marker D10S1412 (map position 14 cM, LOD = 2.39) in African Americans mainly collected in phase 1 of the study. Further analyses showed evidence for interactions between the chromosome 5 locus and region on chromosome 12 containing the MODY 3 gene (map position 132 cM) and between the X-chromosome locus and region near D12S853 (map position 82 cM) in whites. Although these results were not replicated in samples collected in phase 2 of the GENNID study, the region on chromosome 12 was replicated in samples from whites described by Bektas et al. (1999).

Sleep changes during long-term treatment of depression with fluvoxamine--a home-based study

RATIONALE

The effects of antidepressants on sleep in depression have been extensively investigated, although to date there have been relatively few studies of newer drug classes such as specific serotonin reuptake inhibitors (SSRIs). All reported studies on SSRIs have been conducted in patients admitted to sleep laboratories and very few longitudinal studies have continued to measure sleep beyond 5 weeks of treatment. The growing trend towards outpatient and community care has highlighted the need for studies of sleep in depression in a more naturalistic setting, and during longer periods of treatment in line with recommended clinical practice.

OBJECTIVES

To establish if the changes in sleep architecture and continuity described during early treatment with SSRIs persist after 3 months, to relate these changes to clinical state, and to establish whether home recordings would yield similar results to previous laboratory studies.

METHODS

We have recorded objective sleep parameters in 12 depressed patients before and during 12-week treatment with an SSRI, fluvoxamine. All the sleep recordings were performed in the patients' own homes, using the Oxford Medilog system.

RESULTS

At 12 weeks, 7/12 patients had responded (HAM-D decreased by > 50%). REM latency showed the expected increase early in treatment; this change was less obvious at weeks 3 and 12. Amount of REM sleep was decreased at day 2 and week 3, but returned to baseline by week 12. Slow wave sleep was slightly increased at day 2 and decreased at week 12. Of the sleep continuity measures, the only significant change was in sleep onset latency, which was increased at week 3; the other measures showed non-significant worsening at night 2 and week 3, but most were better than baseline by 12 weeks. Subjective sleep (the three sleep items on the HAM-D) showed a progressive improvement over time, especially in the responders.

CONCLUSIONS

The effects of the SSRI fluvoxamine on objective sleep measures are in the direction predicted by its pharmacological actions and some persist for at least 12 weeks. In addition subjective appraisal of sleep is strongly affected by mood state. All patients found the home recording procedure acceptable and only minimally disruptive.

Flumazenil challenge in social phobia

The benzodiazepine antagonist, flumazenil, can provoke panic attacks in some panic disorder patients. It has been predicted that panic responses to flumazenil may be associated with situational fear. Patients with social phobia frequently experience situational anxiety and panic attacks. The current study tested whether flumazenil induces panic in patients with social phobia. Fourteen patients with social phobia (DSM-III-R) and 14 age- and sex-matched controls were tested in a single session, double blind crossover challenge design, using intravenous flumazenil 2 mg/20 ml or matched placebo infusions 1 hour apart. Panic attacks occurred during flumazenil challenge in 2/14 subjects with social phobia. The rate of panic attacks and the severity of panic symptoms following flumazenil were not significantly greater in patients than in controls. Situational fears that are provoked by social cues therefore do not predict panic responses to flumazenil.

Use of ambulatory electrocardiography for the detection of paroxysmal atrial fibrillation in patients with stroke. Canadian Task Force on Preventive Health Care

BACKGROUND

Patients with stroke commonly undergo investigations to determine the underlying cause of stroke. These investigations often include ambulatory electrocardiography to detect paroxysmal atrial fibrillation. There is conflicting evidence in the literature regarding whether routine ambulatory electrocardiography should be performed in all or selected stroke patients. This paper reviews the available evidence on (1) the yield of ambulatory electrocardiography in detecting paroxysmal atrial fibrillation in patients with stroke or transient ischemic attack and (2) the effectiveness of anticoagulation in preventing recurrent stroke in patients with paroxysmal atrial fibrillation.

METHODS

A MEDLINE search for primary articles was performed, and the references were reviewed manually. In addition, citations were obtained from experts. The evidence was systematically reviewed using the evidence-based methodology of the Canadian Task Force on Preventive Health Care.

RESULTS

Ambulatory electrocardiography can detect atrial fibrillation not found on initial electrocardiogram in between 1% and 5% of people with stroke. Ambulatory electrocardiography is generally safe. The risk of recurrent stroke in the setting of paroxysmal atrial fibrillation is uncertain, but appears to be similar to that seen with chronic atrial fibrillation (about 12% per year). Therapy with warfarin may reduce this risk by about two-thirds as compared to placebo. The annual risk of major bleeding with warfarin therapy is between 1% and 3% but rates for individual patients depend on various specific risk factors.

INTERPRETATION

There is insufficient evidence to recommend for or against the use of ambulatory electrocardiography for the detection of paroxysmal atrial fibrillation in either selected or unselected patients with stroke (C Recommendation). There is fair evidence to recommend therapy with warfarin for patients with stroke and paroxysmal atrial fibrillation (B Recommendation).

The Timed Get-up-and-Go test revisited: measurement of the component tasks

The "Timed Get-up-and-Go" (TGUG) test measures the overall time to complete a series of functionally important tasks. In the "Expanded Timed Get-up-and-Go" (ETGUG) test, times for the component tasks are measured using a multimemory stopwatch. Results from the ETGUG test were compared to those from the TGUG test on three groups of subjects: nonimpaired young, nonimpaired elderly, and elderly subjects at risk of falling. Significant differences were found between the two control groups and the at-risk group for all components of the test. Walking speed was the only measurement found to be significantly different between the young and elderly controls. The ETGUG test is a sensitive and objective assessment of function that requires minimal equipment, training, or expense. It better isolates functional deficits, thereby aiding the clinician in devising prevention strategies and guiding both treatment and further testing.

Mutations in TNFRSF11A, affecting the signal peptide of RANK, cause familial expansile osteolysis

Familial expansile osteolysis (FEO, MIM 174810) is a rare, autosomal dominant bone disorder characterized by focal areas of increased bone remodelling. The osteolytic lesions, which develop usually in the long bones during early adulthood, show increased osteoblast and osteoclast activity. Our previous linkage studies mapped the gene responsible for FEO to an interval of less than 5 cM between D18S64 and D18S51 on chromosome 18q21.2-21.3 in a large Northern Irish family. The gene encoding receptor activator of nuclear factor-kappa B (RANK; ref. 5), TNFRSF11A, maps to this region. RANK is essential in osteoclast formation. We identified two heterozygous insertion mutations in exon 1 of TNFRSF11A in affected members of four families with FEO or familial Paget disease of bone (PDB). One was a duplication of 18 bases and the other a duplication of 27 bases, both of which affected the signal peptide region of the RANK molecule. Expression of recombinant forms of the mutant RANK proteins revealed perturbations in expression levels and lack of normal cleavage of the signal peptide. Both mutations caused an increase in RANK-mediated nuclear factor-kappaB (NF-kappaB) signalling in vitro, consistent with the presence of an activating mutation.

Monoclonal antibodies that distinguish between two related digitalis glycosides, ouabain and digoxin

The exogenous digitalis glycosides, ouabain and digoxin, have been widely used in humans to treat congestive heart failure and cardiac arrhythmias. Several reports have also pointed to the existence of endogenous ouabain- and digoxin-like compounds, but their precise roles in mammalian physiology and various disorders of the circulation are not clear. In an attempt to produce specific Abs for the purification and identification of endogenous ouabain-like compounds, somatic cell fusion was used to produce mAbs specific for ouabain. Our attempts to produce ouabain-specific mAbs were unsuccessful when ouabain was coupled to exogenous proteins such as bovine gamma-globulins, BSA, and human serum albumin. However, when ouabain was coupled to an Ab of A/J mice origin and the same strain of mouse was used for immunization with ouabain-Ab conjugate, three Abs (1-10, 5A12, and 7-1) specific for ouabain were obtained. In assays of fluorescence quenching and saturation equilibrium with tritiated ouabain, Ab 1-10 exhibited 200 nM affinity for ouabain. These three mAbs are distinguished from existing Abs to ouabain and digoxin by their specificity for ouabain and lack of cross-reactivity with digoxin. Specificity studies showed that the loss of cross-reactivity was correlated with the presence of a hydroxyl group at either position 12beta (digoxin) or 16beta (gitoxin) of the steroid ring. These Abs can be used to develop assays for detection and characterization of ouabain-like molecules in vivo.

Oligonucleotide NX1838 inhibits VEGF165-mediated cellular responses in vitro

VEGF (vascular endothelial growth factor) overproduction has been identified as a major factor underlying pathological angiogenesis in vivo, including such conditions as psoriasis, macular degeneration, and tumor proliferation. Endothelial cell tyrosine kinase receptors, KDR and Flt-1, have been implicated in VEGF responses including cellular migration, proliferation, and modulation of vascular permeability. Therefore, agents that limit VEGF-cellular interaction are likely therapeutic candidates for VEGF-mediated disease states (particularly agents blocking activity of VEGF165, the most frequently occurring VEGF isoform). To that end, a nuclease-resistant, VEGF165-specific aptamer NX1838 (2'-fluoropyrimidine, RNA-based oligonucleotide/40-kDa-PEG) was developed. We have assessed NX1838 inhibition of a variety of cellular events associated with VEGF, including cellular binding, signal transduction, calcium mobilization, and induction of cellular proliferation. Our data indicate that NX1838 inhibits binding of VEGF to HUVECs (human umbilical vein endothelial cells) and dose-dependently prevents VEGF-mediated phosphorylation of KDR and PLCgamma, calcium flux, and ultimately VEGF-induced cell proliferation. NX1838-inhibition of VEGF-mediated cellular events was comparable to that observed with anti-VEGF monoclonal antibody, but was ineffective as an inhibitor of VEGF121-induced HUVEC proliferation. These findings, coupled with nuclease stability of the molecule, suggest that NX1838 may provide therapeutic utility in vivo.

Aptamer affinity chromatography: combinatorial chemistry applied to protein purification

The systematic evolution of ligands by exponential enrichment process is a combinatorial chemistry method that allows the identification of specific oligonucleotide sequences, known as aptamers, that bind to a desired target molecule with high affinity and specificity. Here, a DNA-aptamer specific for human L-selectin was immobilized to a chromatography support to create an affinity column. This column was effectively applied as either the first or second step in the purification of a recombinant human L-selectin-Ig fusion protein from Chinese hamster ovary cell-conditioned medium. The fusion protein was efficiently bound to the column and efficiently eluted by gentle elution schemes. Application of the aptamer column as the initial purification step resulted in a 1500-fold purification with an 83% single step recovery. These results demonstrate that oligonucleotide aptamers can be effective affinity purification reagents.