Reward Learning as a Potential Mechanism for Improvement in Schizophrenia Spectrum Disorders Following Cognitive Remediation: Protocol for a Clinical, Nonrandomized, Pre-Post Pilot Study

BACKGROUND

Cognitive impairment is common with schizophrenia spectrum disorders. Cognitive remediation (CR) is effective in improving global cognition, but not all individuals benefit from this type of intervention. A better understanding of the potential mechanism of action of CR is needed. One proposed mechanism is reward learning (RL), the cognitive processes responsible for adapting behavior following positive or negative feedback. It is proposed that the structure of CR enhances RL and motivation to engage in increasingly challenging tasks, and this is a potential mechanism by which CR improves cognitive functioning in schizophrenia.

OBJECTIVE

Our primary objective is to examine reward processing in individuals with schizophrenia before and after completing CR and to compare this with a group of matched clinical controls. We will assess whether RL mediates the relationship between CR and improved cognitive function and reduced negative symptoms. Potential differences in social RL and nonsocial RL in individuals with schizophrenia will also be investigated and compared with a healthy matched control group.

METHODS

We propose a clinical, nonrandomized, pre-post pilot study comparing the impact of CR on RL and neurocognitive outcomes. The study will use a combination of objective and subjective measures to assess neurocognitive, psychiatric symptoms, and neurophysiological domains. A total of 40 individuals with schizophrenia spectrum disorders (aged 18-35 years) will receive 12 weeks of CR therapy (n=20) or treatment as usual (n=20). Reward processing will be evaluated using a reinforcement learning task with 2 conditions (social reward vs nonsocial reward) at baseline and the 12-week follow-up. Functional magnetic resonance imaging responses will be measured during this task. To validate the reinforcement learning task, RL will also be assessed in 20 healthy controls, matched for age, sex, and premorbid functioning. Mixed-factorial ANOVAs will be conducted to evaluate treatment group differences. For the functional magnetic resonance imaging analysis, computational modeling will allow the estimation of learning parameters at each point in time, during each task condition, for each participant. We will use a variational Bayesian framework to measure how learning occurred during the experimental task and the subprocesses that underlie this learning. Second-level group analyses will examine how learning in patients differs from that observed in control participants and how CR alters learning efficiency and the underlying neural activity.

RESULTS

As of September 2023, this study has enrolled 15 participants in the CR group, 1 participant in the treatment-as-usual group, and 11 participants in the healthy control group. Recruitment is expected to be completed by September 2024. Data analysis is expected to be completed and published in early 2025.

CONCLUSIONS

The results of this study will contribute to the knowledge of CR and RL processes in severe mental illness and the understanding of the systems that impact negative symptoms and cognitive impairments within this population.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52505.

Multidrug-Resistant Shigella sonnei Bacteremia among Persons Experiencing Homelessness, Vancouver, British Columbia, Canada

Increased invasive bloodstream infections caused by multidrug resistant Shigella sonnei were noted in Vancouver, British Columbia, Canada, during 2021-2023. Whole-genome sequencing revealed clonal transmission of genotype 3.6.1.1.2 (CipR.MSM5) among persons experiencing homelessness. Improvements in identifying Shigella species, expanding treatment options for multidrug resistant infections, and developing public health partnerships are needed.

An exploratory study of the gut microbiota in major depression with anxious distress

OBJECTIVES

To explore differences in the diversity and composition of the gut microbiome between major depressive disorder (MDD) with and without anxious distress.

METHODS

The study comprised 117 participants (79 female, 36 male, 2 other, mean age 38.2 ± 13.4 years) with a current major depressive episode (MDE) with (n = 63) and without (n = 54) the anxious distress specifier. A clinical psychologist administered the structured clinical interview for the DSM-5-RV to confirm a diagnosis of depression. Participants provided stool samples which were immediately frozen and stored at -80 °C. These samples were analysed using the Illumina 16S Metagenomics sequencing protocol in which the sequencing primers target the V3 and V4 regions of the 16S rRNA gene. Participants also completed mental health questionnaires to assess severity of depression (BDI-II), generalized anxiety (GAD-7), and stress (PSS).

RESULTS

There were no significant group differences in α-diversity (Shannon's diversity Index; Simpson Index), richness (ACE; Chao1), (Pielou's) evenness, or beta diversity (Bray-Curtis dissimilarity index and weighted UniFrac distance) of gut bacteria. Significant group differences in the relative abundance of gut microbiota however were observed at each taxonomical level, including across 15 genera and 18 species.

LIMITATIONS

This was an exploratory study that needs to be replicated across larger samples and compared with a healthy control group.

CONCLUSIONS

The research contributes to knowledge of the depressive gut microbial profile unique to the anxious distress subtype of MDD.

Attitudes Toward e-Mental Health Services in a Community Sample of Adults: Online Survey

BACKGROUND

Despite evidence that e-mental health services are effective, consumer preferences still appear to be in favor of face-to-face services. However, the theory of planned behavior (TPB) suggests that cognitive intentions are more proximal to behavior and thus may have a more direct influence on service use. Investigating individual characteristics that influence both preferences and intentions to use e-mental health services is important for better understanding factors that might impede or facilitate the use of these services.

OBJECTIVE

This study explores predictors of preferences and intentions to access e-mental health services relative to face-to-face services. Five domains were investigated (demographics, technology factors, personality, psychopathology, and beliefs), identified from previous studies and informed by the Internet interventions model. We expected that more participants would report intentions to use e-mental health services relative to reported preferences for this type of support and that these 5 domains would be significantly associated with both intentions and preferences toward online services.

METHODS

A mixed sample of 308 community members and university students was recruited through social media and the host institution in Australia. Ages ranged between 17 and 68 years, and 82.5% (254/308) were female. Respondents completed an online survey. Chi-square analysis and t tests were used to explore group differences, and logistic regression models were employed to explore factors predicting preferences and intentions.

RESULTS

Most respondents (85.7%, 264/308) preferred face-to-face services over e-mental health services. Relative to preferences, a larger proportion of respondents (39.6%, 122/308) endorsed intentions to use e-mental health services if experiencing mental health difficulties in the future. In terms of the 5 predictor domains, 95% CIs of odds ratios (OR) derived from bootstrapped standard errors suggested that prior experience with online services significantly predicted intentions to use self-help (95% CI 2.08-16.24) and therapist-assisted (95% CI 1.71-11.90) online services in future. Being older predicted increased intentions to use therapist-assisted online services in future (95% CI 1.01-1.06), as did more confidence using computers and the Internet (95% CI 1.06-2.69). Technology confidence was also found to predict greater preference for online services versus face-to-face options (95% CI 1.24-4.82), whereas higher doctor-related locus of control, or LOC (95% CI 0.76-0.95), and extraversion (95% CI 0.88-1.00) were predictive of lower likelihood of preferring online services relative to face-to-face services.

CONCLUSIONS

Despite generally low reported preferences toward e-mental health services, intentions to access these services are higher, raising the question of how to best encourage translation of intentions into behavior (ie, actual use of programs). Strategies designed to ease people into new Internet-based mental health programs (to enhance confidence and familiarity) may be important for increasing the likelihood that they will return to such programs later.

Redintegration, task difficulty, and immediate serial recall tasks

While current theoretical models remain somewhat inconclusive in their explanation of short-term memory (STM), many theories suggest at least a contribution of long-term memory (LTM) to the short-term system. A number of researchers refer to this process as redintegration (e.g., Schweickert, 1993). Under short-term recall conditions, the current study investigated the effects of redintegration and task difficulty in order to extend research conducted by Neale and Tehan (2007). Thirty participants in Experiment 1 and 26 participants in Experiment 2 completed a serial recall task in which retention interval, presentation rate, and articulatory suppression were used to modify task difficulty. Redintegration was examined by manipulating the characteristics of the to-be-remembered items; lexicality in Experiment 1 and wordlikeness in Experiment 2. Responses were scored based on correct-in-position recall, item scoring, and order accuracy scoring. In line with the Neale and Tehan results, as the difficulty of the task increased so did the effects of redintegration. This was evident in that the advantage for words in Experiment 1 and wordlikeness in Experiment 2 decreased as task difficulty increased. This relationship was observed for item but not order memory, and findings were discussed in relation to the theory of redintegration.

Phonological effects in forward and backward serial recall: qualitative and quantitative differences

Forward serial recall is affected by a diverse range of phonological factors that are readily replicated and relatively well understood. In contrast with backward recall, these phonological effects are not consistently replicable in that some studies show that the effects are present and some show the effects are absent or severely attenuated. Moreover at the theoretical level there is no consensus about how participants perform backward recall. The current research was aimed at understanding the differences between forward and backward recall by using meta-analytic techniques on 16 previously published experiments that examined the effects of benchmark phonological factors on both forward and backward recall. In each of the studies, recall was decomposed into 2 components, the first 2 items output and the remaining later responses. A consistent pattern emerged in the data. Each effect was present in both the early and late output positions in forward recall. The effects were present in the late output positions in backward recall, but the effects were weaker than in forward recall. The phonological variables had little impact on early output in backward recall (with the exceptions of articulatory suppression). The presence of qualitative differences between forward and backward recall and quantitative differences between studies have implications for the theoretical understanding of direction of recall in immediate memory tasks.

Oral fluid testing as an alternative to urine testing for drugs of abuse in inpatient forensic settings: giving patients choice

Background and aims

The abuse of illicit substances is very common amongst forensic psychiatry populations and is known to be one of the most potent risk factors for interpersonal violence. Forensic psychiatry units hence strive to keep themselves as free as possible from illicit substances and in Scotland drugs of abuse have traditionally been screened for by means of urine testing. The aim of this study is to examine patients’ preferences for drug testing methods and to compare the acceptability of urine testing versus oral fluid testing (OFT) within a secure hospital setting.

Methods

Patients in three continuing care wards at the State Hospital, Carstairs were offered the choice of either urine or oral fluid testing. We developed protocols and recording forms and trained staff in the administration of the OFT. We recorded the sampling time for OFT and urine, and the views of patients and staff on the testing procedures over a six month period.

Results

Sixty-two samples were taken, with 53 (85%) opting for OFT and nine (15%) opting for urine sampling. The average time taken for OFT was 13 minutes, while the average time taken for urine sampling was 33 minutes. The majority of patients and staff rated oral fluid and urine testing as comfortable and easy. Patients recorded comments on 46 (87%) of OFT samples, only two of which were negative. In general they preferred the OFT because it was quicker and easier and they commented on it being more dignified and private. Patients recorded comments on five (55%) of urine samples, with one of the primary reasons for opting for urine sampling appearing to be a reluctance to try new things, though a few said they did not want to have anything in their mouths. Staff returned comments on 24 (45%) of OFT samples and one (11%) of urine samples. Comments on the OFT were overwhelmingly positive and pointed out the relative speed and ease of this sampling method.

Conclusions

We concluded that the pilot study was successful. OFT was found to be generally preferred by patients and staff. Although there was an additional financial cost, this was considered to be outweighed by the significant benefits arising from offering patients choice, the preservation of patient dignity and staff time savings. The option of OFT has now been extended to all patients within the State Hospital. Practitioners will wish to consider the value of OFT in forensic psychiatry inpatient settings given the benefits identified within this study.

Unsuspected pulmonary embolism identified using multidetector computed tomography in hospital outpatients

AIM

To evaluate the incidence of unsuspected pulmonary embolism (PE) in an unselected population of outpatients undergoing contrast-enhanced multidetector computed tomography (MDCT) for indications other than the investigation of PE.

MATERIALS AND METHODS

Outpatients undergoing CT of the chest over a 6-month period were retrospectively identified and images reviewed. Inpatients and patients undergoing unenhanced CT of the chest were excluded. Data, including referring specialty, patient age and sex, reasons for examination, level of embolism, image quality, and section thickness were recorded. Radiology reports were reviewed with respect to whether or not the embolism was noted at the time of initial reporting.

RESULTS

Following exclusions 440 patients were reviewed (195 women and 245 men). PE was identified in 10 of the 440 patients, an incidence of 2.23%. One pulmonary embolus was in the main pulmonary artery, three were in lobar arteries, three in segmental arteries, and three in subsegmental arteries. Patients over the age of 60 years were more likely to have an embolism (9/300, 2.9%) compared with those under 60 years (1/140, 0.7%). Seven of the 10 positive examinations were carried out in patients who were known or later shown to have malignancy. Seven of the 10 emboli were reported at the time of initial reporting.

CONCLUSION

The outpatient population has a significant incidence of unsuspected PE. PE should be actively sought when reporting examinations performed for alternative indications, particularly where cancer is a known or suspected diagnosis.

Comparison between conventional interrupted high-resolution CT and volume multidetector CT acquisition in the assessment of bronchiectasis

The aim of this study was to determine whether there is superior diagnostic accuracy for the detection and exclusion of bronchiectasis using 16-slice CT of the chest (1 mm) compared with conventional high-resolution CT (HRCT) of the chest (10 mm). A prospective study was carried out in patients who were referred for chest CT by a chest physician for the investigation of bronchiectasis over a 1-year period. All scans were performed using a 16-slice CT scanner. In addition to contiguous 1 mm slices, conventional HRCT images (1 mm slice every 10 mm) were prepared. Both datasets were dual read. There were 53 patients with a median age of 62 years (range, 51.5-71.5 years), comprising 14 males and 39 females. 10 of 53 scans had no bronchiectasis in either dataset. 36 patients had bronchiectasis diagnosed on both HRCT and 1 mm scans. Two patients had tubular bronchiectasis on the HRCT scans, which was not confirmed on the 1 mm scans. Five patients had confirmed tubular bronchiectasis on the 1 mm scans, which was not identified on HRCT scans. 40 extra lobes demonstrated bronchiectasis on the 1 mm vs the HRCT scans; of these, half were labelled as definite bronchiectasis on the 1 mm scan. There was a 32% increased confidence with the 1 mm scans compared with conventional HRCT of the chest in the diagnosis of bronchiectasis (p < 0.001). In conclusion, there is improved diagnostic accuracy and confidence for diagnosis and exclusion of bronchiectasis using 16-slice chest CT (1 mm cuts) compared with conventional HRCT of the chest.

Effectiveness of intermediate care in nursing-led in-patient units

BACKGROUND

The Nursing led inpatient Unit (NLU) is one of a range of services that have been considered in order to manage more successfully the transition between hospital and home for patients with extended recovery times. This is an update of an earlier review published in The Cochrane Library in Issue 3, 2004.

OBJECTIVES

To determine whether nursing-led inpatient units are effective in preparing patients for discharge from hospital compared to usual inpatient care.

SEARCH STRATEGY

We searched The Cochrane Library, the Specialized Register of the Cochrane Effective Practice and Organisation of Care (EPOC) group, MEDLINE, CINAHL, EMBASE, BNI and HMIC databases. Citation searches were undertaken on the science and social science citation indices. Authors were contacted to identify additional data. The initial search was done in January 2001. The register search was updated in October 2006, the other database searches were updated in November 2006 and the citation search was run in January 2007.

SELECTION CRITERIA

Controlled trials and interrupted time series designs that compared the NLU to usual inpatient care managed by doctors. Patients over 18 years of age following an acute hospital admission for a physical health condition.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Ten random or quasi-random controlled trials reported on a total of 1896 patients. There was no statistically significant effect on inpatient mortality (OR 1.10, 95% CI 0.56 to 2.16) or mortality to longest follow up (OR 0.92, 95% CI 0.65 to 1.29) but higher quality studies showed a larger non-significant increase in inpatient mortality (OR 1.52, 95% CI 0.86 to 2.68). Discharge to institutional care was reduced for the NLU (OR 0.44 95% CI 0.22 to 0.89) and functional status at discharge increased (SMD 0.37, 95% CI 0.20 to 0.54) but there was a near significant increase in inpatient stay (WMD 5.13 days 95% CI -0.5 days to 10.76 days). Early readmissions were reduced (OR 0.52 95% CI 0.34 to 0.80). One study compared a NLU for the chronically critically ill with ICU care. Mortality (OR 0.62 95% CI 0.35 to 1.10) and length of inpatient stay differ did not differ (WMD 2 days, 95% CI 10.96 to -6.96 days). Early readmissions were reduced (OR 0.33 95% CI 0.12 to 0.94). Costs of care on the NLU were higher for UK studies but lower for US based studies.

AUTHORS' CONCLUSIONS

There is some evidence that patients discharged from a NLU are better prepared for discharge but it is unclear if this is simply a product of an increased length of inpatient stay. No statistically significant adverse effects were noted but the possibility of increased early mortality cannot be discounted. More research is needed.

Diagnostic tests and algorithms used in the investigation of haematuria: systematic reviews and economic evaluation

OBJECTIVES

To determine the most effective diagnostic strategy for the investigation of microscopic and macroscopic haematuria in adults.

DATA SOURCES

Electronic databases from inception to October 2003, updated in August 2004.

REVIEW METHODS

A systematic review was undertaken according to published guidelines. Decision analytic modelling was undertaken, based on the findings of the review, expert opinion and additional information from the literature, to assess the relative cost-effectiveness of plausible alternative tests that are part of diagnostic algorithms for haematuria.

RESULTS

A total of 118 studies met the inclusion criteria. No studies that evaluated the effectiveness of diagnostic algorithms for haematuria or the effectiveness of screening for haematuria or investigating its underlying cause were identified. Eighteen out of 19 identified studies evaluated dipstick tests and data from these suggested that these are moderately useful in establishing the presence of, but cannot be used to rule out, haematuria. Six studies using haematuria as a test for the presence of a disease indicated that the detection of microhaematuria cannot alone be considered a useful test either to rule in or rule out the presence of a significant underlying pathology (urinary calculi or bladder cancer). Forty-eight of 80 studies addressed methods to localise the source of bleeding (renal or lower urinary tract). The methods and thresholds described in these studies varied greatly, precluding any estimate of a 'best performance' threshold that could be applied across patient groups. However, studies of red blood cell morphology that used a cut-off value of 80% dysmorphic cells for glomerular disease reported consistently high specificities (potentially useful in ruling in a renal cause for haematuria). The reported sensitivities were generally low. Twenty-eight studies included data on the accuracy of laboratory tests (tumour markers, cytology) for the diagnosis of bladder cancer. The majority of tumour marker studies evaluated nuclear matrix protein 22 or bladder tumour antigen. The sensitivity and specificity ranges suggested that neither of these would be useful either for diagnosing bladder cancer or for ruling out patients for further investigation (cystoscopy). However, the evidence remains sparse and the diagnostic accuracy estimates varied widely between studies. Fifteen studies evaluating urine cytology as a test for urinary tract malignancies were heterogeneous and poorly reported. The calculated specificity values were generally high, suggesting some possible utility in confirming malignancy. However, the evidence suggests that urine cytology has no application in ruling out malignancy or excluding patients from further investigation. Fifteen studies evaluated imaging techniques [computed tomography (CT), intravenous urography (IVU) or ultrasound scanning (US)] to detect the underlying cause of haematuria. The target condition and the reference standard varied greatly between these studies. The diagnostic accuracy data for several individual studies appeared promising but meaningful comparison of the available imaging technologies was impossible. Eight studies met the inclusion criteria but addressed different parts of the diagnostic chain (e.g. screening programmes, laboratory investigations, full urological work-up). No single study addressed the complete diagnostic process. The review also highlighted a number of methodological limitations of these studies, including their lack of generalisability to the UK context. Separate decision analytic models were therefore developed to progress estimation of the optimal strategy for the diagnostic management of haematuria. The economic model for the detection of microhaematuria found that immediate microscopy following a positive dipstick test would improve diagnostic efficiency as it eliminates the high number of false positives produced by dipstick testing. Strategies that use routine microscopy may be associated with high numbers of false results, but evidence was lacking regarding the accuracy of routine microscopy and estimates were adopted for the model. The model for imaging the upper urinary tract showed that US detects more tumours than IVU at one-third of the cost, and is also associated with fewer false results. For any cause of haematuria, CT was shown to have a mean incremental cost-effectiveness ratio of pounds sterling 9939 in comparison with the next best option, US. When US is followed up with CT for negative results with persistent haematuria, it dominates the initial use of CT alone, with a saving of pounds sterling 235,000 for the evaluation of 1000 patients. The model for investigation of the lower urinary tract showed that for low-risk patients the use of immediate cystoscopy could be avoided if cystoscopy were used for follow-up patients with a negative initial test using tumour markers and/or cytology, resulting in a saving of pounds sterling 483,000 for the evaluation of 1000 patients. The clinical and economic impact on delayed detection of both upper and lower urinary tract tumours through the use of follow-up testing should be evaluated in future studies.

CONCLUSIONS

There are insufficient data currently available to derive an evidence-based algorithm of the diagnostic pathway for haematuria. A hypothetical algorithm based on the opinion and practice of clinical experts in the review team, other published algorithms and the results of economic modelling is presented in this report. This algorithm is presented, for comparative purposes, alongside current US and UK guidelines. The ideas contained in these algorithms and the specific questions outlined should form the basis of future research. Quality assessment of the diagnostic accuracy studies included in this review highlighted several areas of deficiency.

Randomized clinical trial to investigate the effectiveness of teflubenzuron for treating sea lice on Atlantic salmon

A double-blind, randomized control clinical trial was performed to investigate the effectiveness of teflubenzuron in controlling sea lice Lepeophtheirus salmonis on farmed Atlantic salmon Salmo salar. A total of 40 sea cages from 3 commercial cage sites in Atlantic Canada were used in this Good Clinical Practice (GCP) trial. The teflubenzuron was administered in the feed at a dosage of 10 mg kg(-1) biomass d(-1) for 7 d. Medicated and control cages were matched by site, cage size, and pre-treatment mean lice counts using cages as the unit of concern. Post-treatment lice counts and staging of developmental stages were performed at 1 and 2 wk after the end of treatment. Chalimus stages in medicated cages were significantly lower than in control cages at 1 wk (79% reduction in mean lice counts, p < 0.001), and at 2 wk (53% reduction, p < 0.001). Mobile (pre-adult and adult) stages were also significantly reduced in medicated cages at 1 wk (69% reduction, p < 0.01), and at 2 wk (40% reduction, p < 0.01) post-treatment, respectively. Teflubenzuron was proven effective for reducing lice burdens on salmon despite the low parasite levels experienced during the trial and the recruitment of lice from the untreated cages. The use of cage as the unit of concern was an important design component of this trial.

Historical control clinical trial to assess the effectiveness of teflubenzuron for treating sea lice on Atlantic salmon

A historical control clinical trial was performed to assess the effectiveness of teflubenzuron in controlling sea lice Lepeoptheirus salmonis burdens on farmed Atlantic salmon Salmo salar over time. The study site comprised 9 sea cages, all of which were treated. The teflubenzuron was administered in the feed, at a dosage of 10 mg kg(-1) biomass d(-1), over a treatment period of 7 d. At 1 wk post-treatment, sea lice chalimus and mobile stages were reduced by 92 and 74% (both p < 0.001), respectively. At 2 wk post-treatment, chalimus stages were reduced by 41% and mobile stages 61% (both p < 0.001) compared to pre-treatment levels. At 3 wk post-treatment, chalimus stages were still 36% (p < 0.001) lower than pre-treatment levels, but mobile stages had increased to above pre-treatment levels. Our results show that the effects of teflubenzuron are limited to a 3 wk duration, but that with appropriate management, farms could benefit from these reduced lice burdens for longer periods.

Systematic review of effectiveness of different treatments for childhood retinoblastoma

OBJECTIVES

To assess the clinical effectiveness of treatments for childhood retinoblastoma.

DATA SOURCES

Electronic databases were searched from inception to April 2004.

REVIEW METHODS

Studies of participants diagnosed with childhood retinoblastoma, any interventions and all clinical outcomes were eligible for inclusion. Randomised and non-randomised controlled trials and cohort studies with clear comparisons between treatment groups were included. Methodological quality was assessed. A narrative synthesis was conducted. Where possible, studies assessing common interventions were grouped together, with prospective and retrospective studies grouped separately. Emphasis was placed on prospective studies.

RESULTS

Thirty-one individual studies, from 42 publications, were included in the review. Apart from one non-randomised controlled trial, only comparative studies of observational design were available for any of the treatments. Four of the included studies were prospective and the remaining 27 were retrospective. Most of the studies were of radiotherapy or chemotherapy, with few studies available on enucleation or focal treatments such as brachytherapy, photocoagulation, cryotherapy and thermotherapy. The methodological quality was generally poor, with a high risk of bias in all included studies. The main problems were in relation to how treatment was allocated and lack of consideration of potentially confounding factors, such as initial disease severity, in the study design and data analysis. The evidence base for effectiveness of treatments for childhood retinoblastoma is extremely limited. Owing to the considerable limitations of the evidence identified, it was not possible to make meaningful and robust conclusions about the relative effectiveness of different treatment approaches for childhood retinoblastoma.

CONCLUSIONS

In the authors' opinion, the evidence base for the effectiveness of treatments for childhood retinoblastoma is not sufficiently robust to provide clear guidance for clinical practice. Ideally, good-quality randomised controlled trials (RCTs) assessing the effectiveness of different treatment options for childhood retinoblastoma are required. Research is required on all the treatments currently used for this condition. Where RCTs are not feasible, for ethical or practical reasons, only high-quality, prospective, non-randomised studies should be given consideration, owing to the generally higher risk of bias in retrospective studies. To reduce the risk of confounding due to allocation by clinical indication, studies should compare patients with similar disease severity rather than compare patients of mixed disease severities. Standardised outcomes should be agreed for use in studies assessing the effectiveness of treatment. These outcomes should encompass potential important adverse effects of treatment such as loss of visual acuity and cosmetic outcome, as well as beneficial effects.

Dietary accumulation efficiencies and biotransformation of polybrominated diphenyl ethers in farmed Atlantic salmon (Salmo salar)

The consumer safety of farm-raised salmon could be improved by determining the transfer efficiency of hazardous pollutants from fish feed to the salmon. A controlled feeding trial for 30 weeks was carried out to investigate the transfer of polybrominated diphenyl ethers (PBDEs) in Atlantic salmon (Salmo salar). Using three feed concentrations, an average of 95% of the total PBDE content of feed accumulated in whole salmon. Skinned fillet accumulated 42-59% of the PBDE intake. Equal partitioning according to the lipid content of the tissue was demonstrated. The formation of less brominated PBDEs via preferential debromination from the meta-position was thought to explain the exceptional accumulation efficiencies of BDE 47, BDE 66, BDE 75, BDE 119 and BDE 183 that were either >100% or else increasing with the exposure dose. Monitoring of a larger number of PBDE congeners is recommended to verify the biotransformation routes. The PBDE concentration in salmon of different ages, fed on a known concentration of PBDEs in fish feed, could be predicted by using the accumulation efficiencies determined in this study.

Effectiveness of intermediate care in nursing-led in-patient units

BACKGROUND

The Nursing led inpatient Unit (NLU) is one of a range of services that have been considered in order to manage more successfully the transition between hospital and home for patients with extended recovery times.

OBJECTIVES

To determine whether nursing-led inpatient units are effective in preparing patients for discharge from hospital compared to usual inpatient care.

SEARCH STRATEGY

We searched The Cochrane Library, the Specialized Register of the Cochrane Effective Practice and Organisation of Care (EPOC) group, MEDLINE, CINAHL, EMBASE, BNI and HMIC databases. Citation searches were undertaken on the science and social science citation indices. Authors were contacted to identify additional data.

SELECTION CRITERIA

Controlled trials and interrupted time series designs that compared the NLU to usual inpatient care managed by doctors. Patients over 18 years of age following an acute hospital admission for a physical health condition.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Ten random or quasi-random controlled trials reported on a total of 1896 patients. There was no statistically significant effect on inpatient mortality ( OR 1.10, 95% CI 0.56 to 2.16) or mortality to longest follow up (OR 0.92, 95% CI 0.65 to 1.29) but higher qaulity studies showed a larger non-significant increase in inpatient mortality (OR 1.52, 95% CI 0.86 to 2.68). Discharge to institutional care was reduced for the NLU (OR 0.44 95% CI 0.22 to 0.89) and functional status at discharge increased (SMD 0.37, 95% CI 0.20 to 0.54) but there was a near significant increase in inpatient stay (WMD 5.13 days 95% CI -0.5 days to 10.76 days). Early readmissions were reduced (OR 0.52 95% CI 0.34 to 0.80). One study compared a NLU for the chronically critically ill with ICU care. Mortality (OR 0.62 95% CI 0.35 to 1.10) and length of inpatient stay differ did not differ (WMD 2 days, 95% CI 10.96 to -6.96 days). Early readmissions were reduced (OR 0.33 95% CI 0.12 to 0.94). Costs of care on the NLU were higher for UK studies but lower for US based studies.

REVIEWERS' CONCLUSIONS

There is some evidence that patients discharged from a NLU are better prepared for discharge but it is unclear if this is simply a product of an increased length of inpatient stay. No statistically significant adverse effects were noted but the possibility of increased early mortality cannot be discounted. More research is needed.

Constipation and its implications in the critically ill patient

BACKGROUND

Motility of the lower gut has been little studied in intensive care patients.

METHOD

We prospectively studied constipation in an intensive care unit of a university hospital, and conducted a national survey to assess the generalizability of our findings.

RESULTS

Constipation occurred in 83% of the patients. More constipated patients (42.5%) failed to wean from mechanical ventilation than non-constipated patients (0%), P<0.05. The median length of stay in intensive care and the proportion of patients who failed to feed enterally were greater in constipated than non-constipated patients (10 vs 6.5 days and 27.5 vs 12.5%, respectively (NS)). The survey found similar observations in other units. Delays in weaning from mechanical ventilation and enteral feeding were reported by 28 and 48% of the units surveyed, respectively.

CONCLUSIONS

Constipation has implications for the critically ill.

Clinical efficacy of teflubenzuron (Calicide) for the treatment of Lepeophtheirus salmonis infestations of farmed Atlantic salmon Salmo salar at low water temperatures

The efficacy of teflubenzuron (Calicide) for the treatment of farmed Atlantic salmon Salmo salar L. infested with sea lice Lepeophtheirus salmonis (Krøyer, 1838), was investigated at low water temperatures in 2 commercial salmon farms. Calicide, coated on commercial feed pellets, was administered orally at 10 mg kg(-1) d(-1) for 7 consecutive days. Fish were randomly sampled and lice numbers recorded from both treated and control groups on 3 or 4 sampling occasions post-medication. Statistically significant reductions in the number of L. salmonis per fish were recorded. Maximum efficacy was observed toward chalimus and preadult stages of L. salmonis, and was achieved approximately 26 d post-medication. No adverse drug reactions or palatability problems were associated with the treatments.

Adenosine modulates Mg(2+) uptake in distal convoluted tubule cells via A(1) and A(2) purinoceptors

tk;1Adenosine plays a role in the control of water and electrolyte reabsorption in the distal tubule. As the distal convoluted tubule is important in the regulation of renal Mg(2+) balance, we determined the effects of adenosine on cellular Mg(2+) uptake in this segment. The effect of adenosine was studied on immortalized mouse distal convoluted tubule (MDCT) cells, a model of the intact distal convoluted tubule. The rate of Mg(2+) uptake was measured with fluorescence techniques using mag-fura 2. To assess Mg(2+) uptake, MDCT cells were first Mg(2+) depleted to 0.22 +/- 0.01 mM by being cultured in Mg(2+)-free media for 16 h and then placed in 1.5 mM MgCl(2); next, changes in intracellular Mg(2+) concentration ([Mg(2+)](i)) were determined. [Mg(2+)](i) returned to basal levels, 0.53 +/- 0.02 mM, with a mean refill rate, d([Mg(2+)](i))/dt, of 137 +/- 16 nM/s. Adenosine stimulates basal Mg(2+) uptake by 41 +/- 10%. The selective A(1) purinoceptor agonist N(6)-cyclopentyladenosine (CPA) increased intracellular Ca(2+) and decreased parathyroid hormone (PTH)-stimulated cAMP formation and PTH-mediated Mg(2+) uptake. On the other hand, the selective A(2) receptor agonist 2-[p-(2-carbonyl-ethyl)-phenylethylamino]-5'-N-ethylcarboxamidoadenosine (CGS) stimulated Mg(2+) entry in a concentration-dependent fashion. CGS increased cAMP formation and the protein kinase A inhibitor RpcAMPS inhibited CGS-stimulated Mg(2+) uptake. Selective inhibition of phospholipase C, protein kinase C, or mitogen-activated protein kinase enzyme cascades with U-73122, Ro-31-8220, and PD-98059, respectively, diminished A(2) agonist-mediated Mg(2+) entry. Aldosterone potentiated CGS-mediated Mg(2+) entry, and elevation of extracellular Ca(2+) diminished CGS-responsive cAMP formation and Mg(2+) uptake. Accordingly, MDCT cells possess both A(1) and A(2) purinoceptor subtypes with intracellular signaling typical of these respective receptors. We conclude that adenosine has dual effects on Mg(2+) uptake in MDCT cells through separate A(1) and A(2) purinoceptor pathways.

ATP inhibits Mg(2+) uptake in MDCT cells via P2X purinoceptors

Nucleotides have diverse effects on water and electrolyte reabsorption within the distal tubule of the nephron. As the distal tubule is important in control of renal Mg(2+) balance, we determined the effects of ATP on cellular Mg(2+) uptake in this segment. The effects of ATP on immortalized mouse distal convoluted tubule (MDCT) cells were studied by measuring Mg(2+) uptake with fluorescence techniques. The mean basal Mg(2+) uptake rate was 165 +/- 6 nM/s. ATP inhibited basal Mg(2+) uptake and hormone-stimulated Mg(2+) entry by 40%. Both P2X (P2X1-P2X5 subtypes) and P2Y2 receptor subtypes were identified in MDCT cells using differential RT-PCR. Activation of both receptor subtypes with selective agonists increased intracellular Ca(2+) concentration, P2X purinoceptors by ionotropic-gated channels, and P2Y receptors via G protein-mediated intracellular Ca(2+) release. The more relatively selective P2X agonists [beta,gamma-methylene ATP (beta,gamma-Me-ATP) and 2'- and -3'-O-(4-benzoyl-benzoyl)-ATP] inhibited arginine vasopressin (AVP)- and parathyroid hormone (PTH)-mediated Mg(2+) uptake whereas agonists more selective for P2Y purinoceptors (UTP, ADP, and 2-methylthio-ATP) were without effect. Removal of extracellular Ca(2+) diminished beta,gamma-Me-ATP-mediated increase in intracellular Ca(2+) and inhibition of AVP-stimulated Mg(2+) entry. We conclude from this information that ATP inhibited Mg(2+) uptake in MDCT cells through P2X purinoceptors expressed in this distal convoluted tubule cell line.

1,25(OH)(2)D(3) stimulates Mg2+ uptake into MDCT cells: modulation by extracellular Ca2+ and Mg2+

The distal convoluted tubule plays a significant role in renal magnesium conservation. Although the cells of the distal convoluted tubule possess the vitamin D receptor, little is known about the effects of 1alpha,25-dihydroxyvitamin D [1,25(OH)(2)D(3)] on magnesium transport. In this study, we examined the effect of 1,25(OH)(2)D(3) on distal cellular magnesium uptake and the modulation of this response by extracellular Ca2+ and Mg2+ in an immortalized mouse distal convoluted tubule (MDCT) cell line. MDCT cells possess the divalent cation-sensing receptor (CaSR) that responds to elevation of extracellular Ca2+ and Mg2+ concentrations to diminish peptide hormone-stimulated Mg2+ uptake. Mg2+ uptake rates were determined by microfluorescence in Mg2+ -depleted MDCT cells. Treatment of MDCT cells with 1,25(OH)(2)D(3) for 16-24 h stimulated basal Mg2+ uptake in a concentration-dependent manner from basal levels of 164 +/- 5 to 210 +/- 11 nM/s, representing a 28 +/- 3% change. Pretreatment with actinomycin D or cycloheximide abolished 1,25(OH)(2)D(3)-stimulated(.)Mg2+ uptake (154 +/- 18 nM/s), suggesting that 1,25(OH)(2)D(3) stimulates Mg2+ uptake through gene activation and protein synthesis. Elevation of extracellular Ca2+ inhibited 1,25(OH)(2)D(3)-stimulated Mg2+ uptake (143 +/- 5 nM/s). Preincubation of the cells with an antibody to the CaSR prevented the inhibition by elevated extracellular Ca2+ of 1,25(OH)(2)D(3)-stimulated Mg2+ uptake (202 +/- 8 nM/s). Treatment with an antisense CaSR mRNA oligodeoxynucleotide also abolished the effects of extracellular Ca2+ on 1,25(OH)(2)D(3)-responsive Mg2+ entry. This showed that elevated extracellular calcium modulates 1,25(OH)(2)D-mediated responses through the CaSR. In summary, 1,25(OH)(2)D(3) stimulated Mg2+ uptake in MDCT cells, and this is dependent on de novo protein synthesis. Elevation of extracellular Ca2+, acting via the CaSR, inhibited 1,25(OH)(2)D(3)-stimulated Mg2+ entry. These data indicate that 1,25(OH)(2)D(3) has important effects on the control of magnesium entry in MDCT cells and these responses can be modulated by extracellular divalent cations.

Magnesium transport in the renal distal convoluted tubule

The distal tubule reabsorbs approximately 10% of the filtered Mg(2+), but this is 70-80% of that delivered from the loop of Henle. Because there is little Mg(2+) reabsorption beyond the distal tubule, this segment plays an important role in determining the final urinary excretion. The distal convoluted segment (DCT) is characterized by a negative luminal voltage and high intercellular resistance so that Mg(2+) reabsorption is transcellular and active. This review discusses recent evidence for selective and sensitive control of Mg(2+) transport in the DCT and emphasizes the importance of this control in normal and abnormal renal Mg(2+) conservation. Normally, Mg(2+) absorption is load dependent in the distal tubule, whether delivery is altered by increasing luminal Mg(2+) concentration or increasing the flow rate into the DCT. With the use of microfluorescent studies with an established mouse distal convoluted tubule (MDCT) cell line, it was shown that Mg(2+) uptake was concentration and voltage dependent. Peptide hormones such as parathyroid hormone, calcitonin, glucagon, and arginine vasopressin enhance Mg(2+) absorption in the distal tubule and stimulate Mg(2+) uptake into MDCT cells. Prostaglandin E(2) and isoproterenol increase Mg(2+) entry into MDCT cells. The current evidence indicates that cAMP-dependent protein kinase A, phospholipase C, and protein kinase C signaling pathways are involved in these responses. Steroid hormones have significant effects on distal Mg(2+) transport. Aldosterone does not alter basal Mg(2+) uptake but potentiates hormone-stimulated Mg(2+) entry in MDCT cells by increasing hormone-mediated cAMP formation. 1,25-Dihydroxyvitamin D(3), on the other hand, stimulates basal Mg(2+) uptake. Elevation of plasma Mg(2+) or Ca(2+) inhibits hormone-stimulated cAMP accumulation and Mg(2+) uptake in MDCT cells through activation of extracellular Ca(2+)/Mg(2+)-sensing mechanisms. Mg(2+) restriction selectively increases Mg(2+) uptake with no effect on Ca(2+) absorption. This intrinsic cellular adaptation provides the sensitive and selective control of distal Mg(2+) transport. The distally acting diuretics amiloride and chlorothiazide stimulate Mg(2+) uptake in MDCT cells acting through changes in membrane voltage. A number of familial and acquired disorders have been described that emphasize the diversity of cellular controls affecting renal Mg(2+) balance. Although it is clear that many influences affect Mg(2+) transport within the DCT, the transport processes have not been identified.

beta-Adrenergic agonists stimulate Mg(2+) uptake in mouse distal convoluted tubule cells

beta-Adrenergic agonists influence electrolyte reabsorption in the proximal tubule, loop of Henle, and distal tubule. Although isoproterenol enhances magnesium absorption in the thick ascending limb, it is unclear what effect, if any, beta-adrenergic agonists have on tubular magnesium handling. The effects of isoproterenol were studied in immortalized mouse distal convoluted tubule (MDCT) cells by measuring cellular cAMP formation with radioimmunoassays and Mg(2+) uptake with fluorescence techniques. Intracellular free Mg(2+) concentration ([Mg(2+)](i)) was measured in single MDCT cells by using microfluorescence with mag-fura-2. To assess Mg(2+) uptake, MDCT cells were first Mg(2+) depleted to 0.22 +/- 0.01 mM by culturing in Mg(2+)-free media for 16 h and then placed in 1.5 mM MgCl(2), and the changes in [Mg(2+)](i) were determined. [Mg(2+)](i) returned to basal levels, 0.53 +/- 0.02 mM, with a mean refill rate, d([Mg(2+)](i))/dt, of 168 +/- 11 nM/s. Isoproterenol stimulated Mg(2+) entry in a concentration-dependent manner, with a maximal response of 252 +/- 11 nM/s, at a concentration of 10(-7) M, that represented a 50 +/- 7% increase in uptake rate above control values. This was associated with a sixfold increase in intracellular cAMP generation. Isoproterenol-stimulated Mg(2+) uptake was completely inhibited with RpcAMPS, a protein kinase A inhibitor, and U-73122, a phospholipase C inhibitor, and partially blocked by RO 31-822, a protein kinase C inhibitor. Accordingly, isoproterenol-mediated Mg(2+) entry rates involve multiple intracellular signaling pathways. Aldosterone potentiated isoproterenol-stimulated Mg(2+) uptake (326 +/- 31 nM/s), whereas elevation of extracellular Ca(2+) inhibited isoproterenol-mediated cAMP accumulation and Mg(2+) uptake, 117 +/- 37 nM/s. These studies demonstrate that isoproterenol stimulates Mg(2+) uptake in a cell line of mouse distal convoluted tubules that is modulated by hormonal and extracellular influences.

Aminoglycosides inhibit hormone-stimulated Mg2+ uptake in mouse distal convoluted tubule cells

The clinical use of aminoglycosides often leads to renal magnesium wasting and hypomagnesemia. Of the nephron segments, both the thick ascending limb of Henle's loop and the distal tubule play significant roles in renal magnesium conservation but the distal convoluted tubule exerts the final control of urinary excretion. An immortalized mouse distal convoluted tubule (MDCT) cell line has been extensively used to study the cellular mechanisms of magnesium transport in this nephron segment. Peptide hormones, such as parathyroid hormone (PTH), glucagon, calcitonin, and arginine vasopressin (AVP) stimulate Mg2+ uptake in MDCT cells that is modulated by extracellular polyvalent cations, Ca2+ and Mg2+. The present studies determined the effect of aminoglycosides on parathyroid hormone (PTH)-mediated cAMP formation and Mg2+ uptake in MDCT cells. Gentamicin, a prototypic aminoglycoside, elicited transient increases in intracellular Ca2+ from basal levels of 102 +/- 13 nM to 713 +/- 125 nM, suggesting a receptor-mediated response. In order to determine Mg2+ transport, MDCT cells were Mg(2+)-depleted by culturing in Mg(2+)-free media for 16 h and Mg2+ uptake was measured by microfluorescence after placing the depleted cells in 1.0 mM MgCl2. The mean rate of Mg2+ uptake, d([Mg2+]i)/dt, was 138 +/- 24 nM/s in control MDCT cells. Gentamicin (50 microM) did not affect basal Mg2+ uptake (105 +/- 29 nM/s), but inhibited PTH stimulated Mg2+ entry, decreasing it from 257 +/- 36 nM/s to 108 +/- 42 nM/s. This was associated with diminished PTH-stimulated cAMP formation, from 80 +/- 2.5 to 23 +/- 1 pmol/mg protein x 5 min. Other aminoglycosides such as tobramycin, streptomycin, and neomycin also inhibited PTH-stimulated Mg2+ entry and cAMP formation. As these antibiotics are positively charged, the data suggest that aminoglycosides act through an extracellular polyvalent cation-sensing receptor present in distal convoluted tubule cells. We infer from these studies that aminoglycosides inhibit hormone-stimulated Mg2+ absorption in the distal convoluted tubule that may contribute to the renal magnesium wasting frequently observed with the clinical use of these antibiotics.

Insulin stimulates Mg2+ uptake in mouse distal convoluted tubule cells

Insulin has been shown to be a magnesium-conserving hormone acting, in part, through stimulation of magnesium absorption within the thick ascending limb. Although the distal convoluted tubule possesses the most insulin receptors, it is unclear what, if any, actions insulin has in the distal tubule. The effects of insulin were studied on immortalized mouse distal convoluted tubule (MDCT) cells by measuring cellular cAMP formation with radioimmunoassays and Mg2+ uptake with fluorescence techniques using mag-fura 2. To assess Mg2+ uptake, MDCT cells were first Mg(2+) depleted to 0.22 +/- 0.01 mM by culturing in Mg2+-free media for 16 h and then placed in 1.5 mM MgCl2, and the changes in intracellular Mg2+ concentration ([Mg2+]i) were measured with microfluorescence. [Mg2+]i returned to basal levels, 0.53 +/- 0.02 mM, with a mean refill rate, d([Mg2+]i)/dt, of 164 +/- 5 nM/s. Insulin stimulated Mg2+ entry in a concentration-dependent manner with maximal response of 214 +/- 12 nM/s, which represented a 30 +/- 5% increase in the mean uptake rate above control values. This was associated with a 2.5-fold increase in insulin-mediated cAMP generation (52 +/- 3 pmol. mg protein(-1). 5 min(-1)). Genistein, a tyrosine kinase inhibitor, diminished insulin-stimulated Mg2+ uptake (169 +/- 11 nM/s), but did not change insulin-mediated cAMP formation (47 +/- 5 pmol. mg protein(-1). 5 min(-1)). PTH stimulates Mg2+ entry, in part, through increases in cAMP formation. Insulin and PTH increase Mg2+ uptake in an additive fashion. In conclusion, insulin mediates Mg2+ entry, in part, by a genistein-sensitive mechanism and by modifying hormone-responsive transport. These studies demonstrate that insulin stimulates Mg2+ uptake in MDCT cells and suggest that insulin acts in concert with other peptide and steroid hormones to control magnesium conservation in the distal convoluted tubule.

PGE2 stimulates Mg2+ uptake in mouse distal convoluted tubule cells

Prostaglandins have diverse effects on renal electrolyte reabsorption, inhibiting NaCl absorption in the thick ascending limb and modulating sodium and calcium transport in cortical collecting cells. It is unclear what effect, if any, prostaglandins have on tubular magnesium handling. The effects of prostaglandin E2 (PGE2) were studied on immortalized mouse distal convoluted tubule (MDCT) cells by measuring cellular cAMP formation with radioimmunoassays and Mg2+ uptake with fluorescence techniques. Intracellular free Mg2+ concentration ([Mg2+]i) was measured on single MDCT cells using microfluorescence with mag-fura 2. To assess Mg2+ uptake, MDCT cells were first Mg2+ depleted to 0.22 +/- 0.01 mM by culturing in Mg2+-free media for 16 h and then placed in 1.5 mM MgCl2, and the changes in [Mg2+]i were determined. [Mg2+]i returned to basal levels, 0.53 +/- 0.02 mM, with a mean refill rate, d([Mg2+]i)/dt, of 173 +/- 8 nM/s. Indomethacin, 5 microM, diminished basal Mg2+ uptake, suggesting that endogenous prostaglandins may stimulate Mg2+ entry in control cells. PGE2 stimulated Mg2+ entry in a concentration-dependent manner with maximal response of 311 +/- 12 nM/s, at a concentration of 10(-7) M, which represented an 80 +/- 3% increase in uptake rate above control values. This was associated with a sixfold increase in intracellular cAMP generation. PGE2-stimulated Mg2+ uptake was completely inhibited with the Rp diastereoisomer of adenosine 3',5'-cyclic monophosphothionate (Rp-cAMPS), a protein kinase A inhibitor, and U-73122, a phospholipase C inhibitor, and partially by chelerythrine, a protein kinase C inhibitor. Accordingly, PGE2-mediated Mg2+ entry rates involve multiple intracellular signaling pathways. These studies demonstrate that PGE2 stimulates Mg2+ uptake in a cell line of MDCT.

Mg2+/Ca2+ sensing inhibits hormone-stimulated Mg2+ uptake in mouse distal convoluted tubule cells

The distal convoluted tubule plays a significant role in renal magnesium conservation. An immortalized mouse distal convoluted tubule (MDCT) cell line has been extensively used to study the cellular mechanisms of magnesium transport in this nephron segment. MDCT cells possess an extracellular polyvalent cation-sensing mechanism responsive to Mg2+, Ca2+, and neomycin. The present studies determined the effect of Mg2+/Ca2+ sensing on hormone-mediated cAMP formation and Mg2+ uptake in MDCT cells. MDCT cells were Mg2+ depleted by culturing in Mg2+-free media for 16 h, and Mg2+ uptake was measured by microfluorescence after placing the depleted cells in 1.5 mM MgCl2. The mean rate of Mg2+ uptake was 164 +/- 5 nM/s in control MDCT cells. Activation of Mg2+/Ca2+ sensing with neomycin did not affect basal Mg2+ uptake (155 +/- 5 nM/s). We have previously reported that treatment of MDCT cells with either glucagon or arginine vasopressin (AVP) stimulated Mg2+ entry. In the present studies, the addition of extracellular Mg2+ or Ca2+ inhibited glucagon- and AVP-stimulated cAMP formation and Mg2+ uptake in concentration-dependent manner with half-maximal concentrations of approximately 1.5 and 3.0 mM, respectively. Exogenous cAMP or forskolin stimulated Mg2+ uptake in the presence of Mg2+/Ca2+ sensing activation. We infer from these studies that Mg2+/Ca2+-sensing mechanisms located in the distal convoluted tubule may play a role in control of distal magnesium absorption.

Extracellular Mg2(+)- and Ca2(+)-sensing in mouse distal convoluted tubule cells

An immortalized cell line (designated MDCT) has been extensively used to investigate the cellular mechanisms of electrolyte transport within the mouse distal convoluted tubule. Mouse distal convoluted tubule cells possess many of the functional characteristics of the in vivo distal convoluted tubule. In the present study, we show that MDCT cells also possess a polyvalent cation-sensing mechanism that is responsive to extracellular magnesium and calcium. Southern hybridization of reverse transcribed-polymerase chain reaction (RT-PCR) products, sequence determination and Western analysis indicated that the calcium-sensing receptor (Casr) is expressed in MDCT cells. Using microfluorescence of single MDCT cells to determine cytosolic Ca2+ signaling, it was shown that the polyvalent cation-sensing mechanism is sensitive to extracellular magnesium concentration ([Mg2+]o) and extracellular calcium concentration ([Ca2+]o) in concentration ranges normally observed in the plasma. Moreover, both [Mg2+]o and [Ca2+]o were effective in generating intracellular Ca2+ transients in the presence of large concentrations of [Ca2+]o and [Mg2+]o, respectively. These responses are unlike those observed for the Casr in the parathyroid gland. Finally, activation of the polycation-sensitive mechanism with either [Mg2+]o or [Ca2+]o inhibited parathyroid hormone-, calcitonin-, glucagon- and arginine vasopressin-stimulated cAMP release in MDCT cells. These studies indicate that immortalized MDCT cells possess a polyvalent cation-sensing mechanism and emphasize the important role this mechanism plays in modulating intracellular signals in response to changes in [Mg2+]o as well as in [Ca2+]o.

Glucagon and arginine vasopressin stimulate Mg2+ uptake in mouse distal convoluted tubule cells

Glucagon and arginine vasopressin (AVP) enhance renal magnesium conservation through actions within the loop of Henle and the distal tubule. Studies were performed on an immortalized mouse distal convoluted tubule (MDCT) cell line to characterize the cellular actions of these hormones on Mg2+ transport in this segment of the distal tubule. Glucagon and AVP increased cellular cAMP concentrations by about fivefold above basal levels in normal and Mg(2+)-depleted cells. Intracellular free Mg2+ concentration ([Mg2+]i) was determined on single MDCT cells using microfluorescence with mag-fura 2. To assess Mg2+ uptake, MDCT cells were first Mg2+ depleted (0.22 +/- 0.01 mM) by culturing in Mg(2+)-free media for 16 h and then placed in 1.5 mM MgCl2, and the [Mg2+]i was determined. [Mg2+]i returned to basal levels, 0.53 +/- 0.02 mM, with a mean refill rate, d([Mg2+]i/dt, of 164 +/- 5 nM/s. Both glucagon and AVP stimulated Mg2+ uptake into MDCT cells, 196 +/- 11 and 189 +/- 6 nM/s, respectively, at concentrations of 3 x 10(-7) M and 10(-7) M, respectively. Enhanced Mg2+ uptake for each of the hormones was concentration dependent and inhibited by the channel blocker, nifedipine. Hormone stimulation of Mg2+ entry was not dependent on protein synthesis. 8-Bromo-cAMP, 10(-4) M, enhanced Mg2+ uptake (225 +/- 13 nM/s), whereas phorbol esters were without effect. Finally, protein kinase A inhibition prevented glucagon and AVP stimulation of Mg2+ uptake, supporting the notion that the cAMP pathway is important as expected in the hormone action. These studies demonstrate that glucagon and AVP stimulate Mg2+ uptake in MDCT cells and suggest that these hormones act to control magnesium conservation in the convoluted segment of the distal tubule.

Aldosterone potentiates hormone-stimulated Mg2+ uptake in distal convoluted tubule cells

The distal convoluted tubule reabsorbs significant amounts of filtered magnesium that is under hormonal control. In this study, we describe the effects of aldosterone on Mg2+ uptake in an immortalized mouse distal convoluted tubule (MDCT) cell line. Intracellular free Mg2+ concentration ([Mg2+]i) was determined on single MDCT cells using microfluorescence with mag-fura 2. To determine Mg2+ entry rate into MDCT cells, they were first Mg2+ depleted ([Mg2+]i, 0.22 +/- 0.01 mM) by culturing in Mg(2+)-free media for 16 h and then placed in 1.5 mM MgCl2. The rate of change in [Mg2+]i as measured as a function of time, d([Mg2+]i)/dt, was 164 +/- 5 nM/s in control cells. We have shown that glucagon or arginine vasopressin (AVP) stimulates Mg2+ entry by 63% and 15%, respectively. Incubation of MDCT cells with aldosterone for 16 h did not change the rate of Mg2+ uptake (172 +/- 8 nM/s). However, aldosterone potentiated glucagon- and AVP-stimulated Mg2+ uptake rate up to 330 +/- 39 and 224 +/- 6 nM/s, respectively. Aldosterone also potentiated glucagon- and AVP-induced intracellular cAMP accumulation in a concentration-independent manner. As cAMP stimulates Mg2+ entry in MDCT cells, it is inferred that aldosterone may stimulate Mg2+ uptake through intracellular signaling pathways involving cAMP. The actions of aldosterone were dependent on de novo protein synthesis, as pretreatment of the cells with cycloheximide inhibited aldosterone potentiation of hormone stimulation of Mg2+ uptake and cAMP accumulation. These studies with MDCT cells suggest that aldosterone may modulate the effects of hormones acting within the distal convoluted tubule to control magnesium absorption.

Modulation of Na+/Ca2+ exchange in epithelial cells of porcine thick ascending limb

We have provided functional and molecular evidence for the presence of Na+/Ca2+ exchange in isolated porcine cortical thick ascending limb (CTAL) cells. The present studies were designed to show that this exchange activity may be modulated by phosphorylative processes. Control of intracellular Ca2+ concentration ([Ca2+]i) was determined in isolated CTAL cells with microfluorescence. CTAL cells were pretreated with ouabain to elevate intracellular Na+ concentration ([Na+]i) from 10 to 20 mM. These cells had normal basal [Ca2+]i (79 +/- 3 nM). Substitution of extracellular NaCl (50 mM) with KCl resulted in the rapid elevation of [Ca2+]i to maximal levels of 795 +/- 60 nM (n = 17). The increments of [Ca2+]i were associated with [Na+]i. We next determined the modulation of Na+/Ca2+ exchange activity with phosphorylative inhibitors. Pretreatment of cells with calmidazolium, a Ca(2+)-calmodulin inhibitor, resulted in a shift of the [Na+]i dependence curve to the right. Pretreatment with okadaic acid, a phosphatase 1 and 2A inhibitor, increased the Na+/Ca2+ exchanger activity resulting in half-maximal [Ca2+]i increase near normal [Na+]i of 12 mM. Furthermore, in the presence of okadaic acid in normal CTAL cells, pretreatment with ouabain and the elevation of [Na+]i was not required to elicit increments in [Ca2+]i. These data indicate that Na+/Ca2+ exchange is present in CTAL cells and the exchange activity appears to be modulated, directly or indirectly, by phosphorylation events.

Na+/Ca2+ exchanger in epithelial cells of the porcine cortical thick ascending limb

Intracellular Ca2+ concentration ([Ca2+]i) plays an important role in the signal transduction processes within cortical thick ascending limb (CTAL) cells. Control of [Ca2+]i was investigated in isolated CTAL cells with microfluorescent techniques. CTAL cells pretreated with ouabain to elevate intracellular Na+ concentration ([Na+]i) had basal [Ca2+]i of 86 +/- 2 nM. Removal of extracellular Na (Nao+) or voltage depolarization with KCl (in the presence of Nao+) resulted in a rapid and reversible maximal elevation of [Ca2+]i (1,023 +/- 72 nM, n = 28), which was dependent on the presence of external Ca2+ (Cao2+). The rise in [Ca2+]i was inhibited with La3+, Mg2+, amiloride, and bepridil. The increments of [Ca2+]i with either removal of Nao+ or voltage depolarization were dependent on pretreatment with ouabain and increases in [Na+]i. The presence of a Na+/Ca2+ exchanger was, confirmed with hybridization techniques, and the isoform was identified by sequencing the alternative splicing site within the intracellular loop. A gene transcript that encodes a portion of the intracellular loop of the renal Na+/Ca2+ exchanger was amplified from cortical tissue and single CTAL cells by reverse transcription-polymerase chain reaction, using primers flanking the alternative splicing site. Southern hybridization and DNA sequencing demonstrated the isoform contained exons B and D, which is characteristic of one isoform (NACA3) of the renal Na+/Ca2+ exchanger. The results provide both functional and molecular evidence for a Na+/Ca2+ exchanger in thick ascending limb cells of the porcine kidney.

Inhibition of sodium-phosphate cotransport in renal brush-border membranes with the stilbenedisulfonate, H2-DIDS

Membrane proteins involved with sodium/phosphate cotransport across the renal brush border provide the sensitive control for phosphate homeostasis. The present study describes the inhibition of sodium/phosphate cotransport with the stilbenedisulfonate derivatives, DIDS and H2-DIDS. Preincubation of the rat brush-border membrane vesicles with H2-DIDS led to the inhibition of sodium-dependent phosphate uptake with a half maximal concentration, IC50, of about 10 microM. The inhibition was irreversible supporting the notion that H2-DIDS forms covalent bonds with the cotransporter. The cotransporter could be protected by excess sodium phosphate but not sodium chloride, sodium sulfate, sodium succinate, sodium bicarbonate, nor sodium phosphonoformate. These observations suggest that the stilbenedisulfonates may be useful in labeling the sodium/phosphate cotransporter within renal brush-border membranes.

Some characteristics of sodium-independent phosphate transport across renal basolateral membranes

Sodium-independent phosphate transport was evaluated in porcine renal basolateral membrane vesicles. Phosphate uptake was saturable with an apparent Km 10.1 +/- 1.2 mM and Vmax 13.6 +/- 2.0 nmol (mg protein)-1 min-1, n = 5. Phosphate uptake was trans-stimulated with intravesicle phosphate and was enhanced with a positive transmembrane electrical potential. Arsenate and bicarbonate inhibited phosphate transport but other anions including sulfate and phosphonoformate were without effect. These studies indicate that phosphate uptake across basolateral membranes is present in the absence of sodium, is facilitated, and is specific for phosphate. The apparent affinity and rate of phosphate transport across the basolateral membrane is significantly higher than the respective parameters observed for the brush-border membrane.

Digital image display station performance requirements based on physician experience with a prototype system

The authors report on observations of and interviews with physicians using a prototype digital image display and reporting station. While the users generally agree that image quality is clinically satisfactory, they are unanimous in their opinion that improvements in the man-machine interface are required before case review by this mechanism is clinically acceptable in a production environment. A model image and information user interface is presented. It was developed in answer to the needs of radiologists and referring physicians operating in the imaging department of a community acute-care facility. In such an environment images and related information must be communicated quickly and often simultaneously to different parts of the department and hospital. The user interface with the management system and the management system itself must address the varied functions and the needs of both the medical and clerical staff. Image enhancement processes, for example, must be restricted to those that quickly provide significantly more perceivable diagnostic information. Little-used processes that may occupy significant portions of the display and the console's computing power must be trimmed or eliminated.

A serendipitous isolate of Histoplasma capsulatum

This is a report of an unexpected laboratory diagnosis of Histoplasma capsulatum. The fungus was isolated from an acute cellulitic lesion on the forearm of an elderly male patient with a functioning renal transplant. The patient resides within the environs of Brisbane and has not travelled outside Australia. We consider the isolation of H. capsulatum from a rare site in a patient resident in a non-endemic area indicative of a latent opportunistic infection in an immunocompromised patient.

Prenatal renal ultrasound of Laurence-Moon-Biedl syndrome

Large echogenic kidneys mimicking infantile polycystic kidneys were seen on prenatal ultrasound examination in a patient subsequently found to be affected by Laurence-Moon-Biedl syndrome.

A microcomputer based controller for neuromuscular block during surgery

A microcomputer based control system has been developed to automatically induce and maintain neuromuscular block during surgery. The system repeatedly adjusts the infusion rate of a muscle relaxant, succinylcholine, based on the evoked, rectified, and integrated electromyogram (EMG). The system was tested in 12 patients for a 30-min infusion period with a setpoint of 80% depression of the evoked, rectified, and integrated thenar EMG. The mean time to reach the setpoint for 10 of the patients was 5.5 (+/- 1.87 SD) min and the mean time for 95% recovery after infusion was stopped was 5.4 (+/- 0.83 SD) min. Average overshoot was 9.9% of the baseline (+/- 3.1% SD), and the average time within +/- 10% of the setpoint was 22.1 min (+/- 7.26 SD). The total dose of succinylcholine for these 10 patients ranged from 1.21 to 3.77 mg/kg with a mean of 1.92 mg/kg. The other two patients were relatively insensitive to the drug and the controller was unable to bring the response to the setpoint due to a ceiling placed on infusion rate by the control algorithm.