A process-based approach to health-related quality of life as a "way of living"

INTRODUCTION

There is an historical initiative to establish common theoretical ground to support a framework for assessing health-related quality of life (HRQL). Our aim was to add to this effort with an analysis of theoretical/philosophical themes embedded in HRQL questionnaires and patient reports.

METHODS AND RESULTS

We reviewed recent developments in HRQL assessment. This included analyzing a representative sample of psychometric measures of HRQL to schematically summarize core theoretical/philosophical themes that are embedded in questionnaire items. This analysis indicated a state-based framework for HRQL that was characterized by themes of hedonic and eudaimonic well-being, and desire-satisfaction. In contrast, a review of patient reports of HRQL indicated a process-based framework where goal-directed activities aimed to secure aspirational life goals while striving to accept the reality of declining health. Given this difference in HRQL themes we used a meta-philosophical approach, based on Hadot's idea of philosophy as a way of living, to identify a process-based theoretical framework for HRQL assessment that addressed patient-reported themes. The Stoic modification of eudaimonic well-being was examined where HRQL and well-being are viewed as a process (vs. state) aimed at transforming the experience of loss or grief in response to adversity through goal-directed activities/exercises (euroia biou, good flow in life). We then introduced a complementary research agenda for HRQL assessment that incorporates self-reported, goal-directed activities that are initiated or maintained to promote HRQL.

CONCLUSION

A process-based approach to HRQL assessment may increase the spectrum of clinically relevant features that currently comprise operational measures of this patient-reported appraisal.

On the arc-sine laws for Lévy processes

Let X be a Lévy process on the real line, and let Fc denote the generalized arcsine law on [0, 1] with parameter c. Then t−1 ⨍0tP0(Xs > 0) ds → c as t → ∞ is a necessary and sufficient condition for t—1 ⨍0t1{Xs>0}ds to converge in P0 law to Fc. Moreover, P0(Xt > 0) = c for all t > 0 is a necessary and sufficient condition for t—1 ⨍0t1{Xs>0}ds under P0 to have law Fc for all t > 0. We give an elementary proof of these results, and show how to derive Spitzer's theorem for random walks in a simple way from the Lévy process version.

Daily Exposure to Sucrose Impairs Subsequent Learning About Food Cues: A Role for Alterations in Ghrelin Signaling and Dopamine D2 Receptors

The prevalence of hedonic foods and associated advertising slogans has contributed to the rise of the obesity epidemic in the modern world. Research has shown that intake of these foods disrupt dopaminergic systems. It may be that a disruption of these circuits produces aberrant learning about food-cue relationships. We found that rodents given 28 days of intermittent access to sucrose exhibited a deficit in the ability to block learning about a stimulus when it is paired in compound with food and another stimulus that has already been established as predictive of the food outcome. This deficit was characterized by an approach to a cue signaling food delivery that is usually blocked by prior learning, an effect dependent on dopaminergic prediction-error signaling in the midbrain. Administering the D2 agonist quinpirole during learning restored blocking in animals with a prior history of sucrose exposure. Further, repeated central infusions of ghrelin produced a deficit in blocking in the same manner as sucrose exposure. We argue that changes in dopaminergic systems resulting from sucrose exposure are mediated by a disruption of ghrelin signaling as rodents come to anticipate delivery of the highly palatable sucrose outside of normal feeding schedules. This suggestion is supported by our finding that both sucrose and ghrelin treatments resulted in increases in amphetamine-induced locomotor responding. Thus, for the first time, we have provided evidence of a potential link between alterations in D2 receptors caused by the intake of hedonic foods and aberrant learning about cue-food relationships capable of promoting inappropriate feeding habits. In addition, we have found preliminary evidence to suggest that this is mediated by changes in ghrelin signaling, a finding that should stimulate further research into modulation of ghrelin activity to treat obesity.

A role for HGF/SF in neural induction and its expression in Hensen's node during gastrulation

It was previously shown (Roberts, C., Platt, N., Streit, A., Schachner, M. and Stern, C. D. (1991) Development 112, 959–970) that grafts of Hensen's node into chick embryos enhanced and maintain expression of the L5 carbohydrate in neighbouring epiblast cells, and that antibodies against L5 inhibit neural induction by such a graft. We now show that L5 is initially widely expressed in the epiblast, but as neural induction proceeds it gradually becomes confined to and up-regulated in the early neural plate. L5 can therefore be considered as a marker for cells that are competent to respond to neural induction. We also show that Hepatocyte Growth Factor/Scatter Factor (HGF/SF) promotes the expression of L5 by extraembryonic epiblast in collagen gels after overnight culture. Explants cultured for several days in the presence of HGF/SF, as well as explants of prospective neural plate, can differentiate into cells with neuronal morphology expressing neuronal markers. To investigate whether HGF/SF is expressed in the chick embryo at appropriate stages of development, we produced specific cDNA probes and used them for in situ hybridization. We find that at the primitive streak stage, HGF/SF is expressed specifically in Hensen's node. We therefore propose that HGF/SF plays a role during the early steps of neural induction, perhaps by inducing or maintaining the competence of the epiblast to respond to neural inducing signals.

Expression of HGF/SF, HGF1/MSP, and c-met suggests new functions during early chick development

We report the cloning of fulllength cDNAs for a plasminogen-related growth factor, hepatocyte growth factor/scatter factor (HGF/SF), its tyrosine kinase receptor, c-met, and a close member of the same family, hepatocyte growth factor-like/macrophage stimulating protein (HGF1/MSP), from the chick. We have used these cDNAs to provide the first report of the expression of this family of growth factors and the c-met receptor at early stages of vertebrate development. RNAase protection and wholemount in situ hybridization were used on chick embryos between formation of the primitive streak and early organogenesis. We find patterns of expression for HGF/SF and its receptor c-met consistent with their known roles in epithelial-mesenchymal transformation and angiogenesis. In addition, these genes and HGF1/MSP are expressed in discrete locations within developing somites, suggesting a role in paraxial mesodermal development. Very strong and early expression of HGF/SF in the elevating limb buds suggests its involvement in limb outgrowth. HGF1/MSP is expressed in the notochord and then in the prospective floor plate region and could play a role in development of the neural tube. Interestingly, c-met is often more closely associated with HGF1/MSP than with its known ligand, HGF/SF, raising the possibility that c-met expression may be induced by HGF1/MSP.

Somatic hypermutation of immunoglobulin kappa may depend on sequences 3′ of C kappa and occurs on passenger transgenes

We have compared the pattern of somatic mutation in different immunoglobulin kappa transgenes and suggest that an element(s) located between 1 kb and 9 kb 3' of C kappa is necessary for somatic hypermutation of the antibody V gene. The sequences of transgenic and endogenous Ig V regions were determined in antigen-specific B cell hybridomas specific for 2-phenyloxazolone from independent lines of hyperimmunized transgenic mice. We analysed somatic mutation of the transgene both in hybridomas in which the transgenic kappa chain contributes to the antigen combining site as well as in hybridomas in which the transgene is a passenger with the expressed antibody being composed of endogenously-encoded heavy and light chains. In both cases, nucleotide changes in the transgene are correctly targeted to the V region and are absent from the C region. They accumulate at a similar rate to that in the endogenous Ig genes within the same cell and we find that, irrespective of whether or not the transgene kappa is directly selected by antigen, somatic mutation occurs at a similar rate and involves only single base substitutions. Furthermore, the pattern of mutations in passenger transgenes gives information about the intrinsic sequence specificities of the somatic hypermutation mechanism.

The importance of the 3'-enhancer region in immunoglobulin kappa gene expression

The first enhancers to be identified in the immunoglobulin gene loci are located in the J-C intron. However, deletion of the immunoglobulin kappa intron-enhancer has little effect on the transcription of kappa transgenes. Here we ask whether the second kappa enhancer which we recently identified at the 3'-end of the locus plays a role in kappa gene expression. We show that its omission leads to 20-40 fold lower expression of kappa transgenes and to poor allelic exclusion. Transfection experiments show that activity of the 3'-enhancer, like that of the kappa-intron enhancer, can be induced in a pre-B cell line by incubation with bacterial lipopolysaccharide. Whereas induction of the kappa-intron enhancer is due to induction of NF-kappa B activity, deletion mapping of the 3'-enhancer localises its activity to a 50 nucleotide region that lacks an NF-kappa B site; indeed the 3'-enhancer allows kappa expression in a cell line which lacks NF-kappa B. Thus, both the 3'- and intron-enhancers can be induced at the same stage of differentiation but by distinct pathways. Furthermore, unlike the intron-enhancer, the 3'-enhancer plays a critical role in the transcription of rearranged immunoglobulin kappa genes.

Lack of somatic mutation in a kappa light chain transgene

Analysis of mice transgenic for immunoglobulin genes should allow definition of the cis-acting DNA sequences required to target somatic mutation to antibody V genes. We have looked for mutations in a chimeric kappa transgene encoding a V region specific for the hapten 2-phenyloxazolone (phOx) linked to a rat C kappa gene. Two independent lines of transgenic mice were hyperimmunized with phOx and splenic hybridomas established. In B cells that had been selected by antigen and which used mouse anti-phOx genes, the endogenous sequences were found to be mutated whereas the transgene remained unchanged. These results suggest either that (a) if the transgene is a "passenger" gene expressed at a low level, transgene mutation is a rare event, or that (b) sequences far from the kappa coding region are necessary to direct somatic mutation.

Cellular selection leads to age-dependent and reversible down-regulation of transgenic immunoglobulin light chain genes

Analysis of immunoglobulin expression in mice transgenic for either a kappa light chain (driven by the kappa enhancer) or lambda light chain (driven by the IgH enhancer) revealed that the transgenic light chains are expressed by the majority of B lymphocytes in the neonatal mice. However, the proportion of B cells that express the transgenes at a detectable level decreases rapidly with age, with a concomitant increase in cells expressing rearrangements of one of the endogenous light chain loci. This appears to be the result of cellular selection. The down-regulation of transgene expression is not due to an irreversible mechanism as incubation of adult splenic lymphocytes with bacterial lipopolysaccharide leads to a rapid increase in the expression of the transgenic light chain on the B cell surface. In mice carrying the lambda transgene (but not in mice carrying the kappa transgene) the change with age in the pattern of transgene expression is accompanied by a shift towards B cells that do not express surface IgD. This shift towards IgM+/IgDlow B cells is also observed in mice transgenic for a chloramphenicol acetyltransferase gene linked to the IgH enhancer. This suggests that the down-regulation of IgD may either be due to the expression of a transgene that impairs B cell development or, alternatively, could be associated with the molecular events responsible for the down-regulation of IgH enhancer activity. The results also draw attention to the contribution of cellular selection in determining the pattern of expression of immunoglobulin transgenes and emphasize the importance of in vivo analysis of neonatal as well as adult transgenic mice.

Double-blind evaluation of nebulized cromolyn, terbutaline, and the combination for childhood asthma

To evaluate whether the potency of a long-acting selective beta 2-agonist negates the need for cromolyn, 27 children, aged 6 to 12 years, with mild to moderate asthma requiring long-term medication, were assessed for the therapeutic effects of cromolyn and/or terbutaline by jet nebulizer. Patients received either cromolyn, 20 mg, terbutaline, 0.1 mg/kg up to 4 mg, or the combination, three times daily. The study design was double-blind, crossover with each patient receiving the three treatment regimens in randomized order for a period of 8 weeks each. Daily diary mean scores generally demonstrated best symptom control with cromolyn or the combination than with terbutaline alone. Cough was significantly less with cromolyn than with terbutaline (p less than 0.05). Morning peak flow measures were higher with combination therapy than with terbutaline (p less than 0.05). Evening peak flow measures were higher with the combination and cromolyn alone than with terbutaline alone (p less than 0.01). Methacholine challenge demonstrated less bronchial hyperreactivity with the combination or cromolyn alone than with terbutaline alone (p less than 0.02). The effectiveness of the nebulizer regimen for children with chronic asthma is better when cromolyn is used alone or in combination with terbutaline than when the beta-agonist is used alone.

Changes in the level of acetylcholinesterase of nematospiroides dubius and Trichostrongylus colubriformis following paralysis by levamisole in vivo

Acetylcholinesterase (acetylcholine acetylhydrolase; EC 3.1.1.7) levels of Nematospiroides dubius from laboratory mice and Trichostrongylus colubriformis from lambs have been measured. The anthelmintic levamisole (leavo isomer of 2,3,5,6-tetrahydro-6-phenylimidazo-(2,1b)-thiazole (Tetramizole)) did not affect the level of acetylcholinesterase in N. dubius in vivo but caused a reduction in the level of the enzyme in T. colubriformis following paralysis in vivo. The effect of levamisole on acetylcholinesterase in the nematodes is explained in terms of the differing roles of the enzyme in these two species.

Changes in the adenylate energy charge of Nematospiroides dubius and Trichostrongylus colubriformis paralysed by levamisole in vivo

The adenine nucleotide content and adenylate energy charge of Nematospiroides dubius from laboratory mice and of Trichostrongylus colubriformis from lambs has been measured. Administration of the anthelmintic, levamisole, to infected hosts resulted in only a slight fall in the adenylate energy charge of N. dubius over a 3-h period but there was a greater fall in the adenylate energy charge of T. colubriformis during this period. In neither case did the energy charge fall quickly, nor did it fall to the low levels which would be expected if the levamisole were inhibiting synthesis of ATP. The changes in energy charge of the nematodes which occurred following administration of levamisole to their hosts was of the order which can be satisfactorily explained by changes in the environment of the nematodes, such as reduced oxygen tension. It is concluded that the maintenance of levamisole-induced paralysis of these two species of trichostrongyle in vivo does not rely on the inhibition of fumarate reductase.

Changes in the adenylate energy charge of Nippostrongylus brasiliensis and Nematodirus battus during the development of immunity to these nematodes in their host

Infection of rats with 2000 infective juveniles of Nippostrongylus brasiliensis and of lambs with 60 000 infective juveniles of Nematodirus battus results in a well-marked immunity to these nematodes in their respective host. There is a fall in the adenylate energy charge value of these nematodes during the course of these infections, reaching values of 0.37 in males and 0.27 in females of N. brasiliensis, and 0.31 in males and 0.23 in females of N. battus towards the end of the infections. In hosts given relatively small numbers of infective juveniles, the values for the nematodes removed from the hosts late in the infection remain at a relatively high level. These results indicate that the immune response of the host may affect the energy status of these nematodes, and this could help to explain their subsequent expulsion from the immune host.