56 Ageism in Myelodysplastic Syndrome

Background

Myelodysplastic Syndromes (MDS) are a group of haematological disorders which are common in older people and can be amenable to treatment. Ageism has previously been identified in studies of treatment for conditions affecting older people.

Objectives

To assess for the presence of ageism in studies of treatment for MDS.

Design

A review of the Cochrane Library of Systematic Reviews.

Setting

Desk-based.

Methods

Systematic reviews were analysed to determine: use of age as an exclusion criteria in randomized-control trials (RCTs); the comparison of ages of patients in RCTs to that of the median age of patients with MDS; exclusion of patients from RCTs on the basis of dementia or other conditions associated with ageing.

Results

17 reviews were identified, 2 of which were suitable for analysis. The two remaining systematic reviews reported data on 13 RCTs—of which 2 did not report age. The median age of all patients was 68. Three RCTs used a maximum age limit for therapy—one of which was lower than the median age of diagnosis of MDS. More recent studies tended to include older patients. No studies excluded patients on the basis of cognitive status.

Conclusion

There was some evidence of ageism identified in studies of treatment for MDS. There was limited data available in the Cochrane database of Systematic Reviews, which may itself be suggestive of ageism in such reviews.

The Added Value of Different Data Types for Calibrating and Testing a Hydrologic Model in a Small Catchment

This study investigated the added value of different data for calibrating a runoff model for small basins. The analysis was performed in the 66 ha Hydrological Open Air Laboratory, in Austria. An Hydrologiska Byråns Vattenbalansavdelning (HBV) type, spatially lumped hydrologic model was parameterized following two approaches. First, the model was calibrated using only runoff data. Second, a step-by-step approach was followed, where the modules of the model (snow, soil moisture, and runoff generation) were calibrated using measurements of runoff and model state variables and output fluxes. These measurements comprised laser-based measurements of precipitation, satellite and camera observations of snow, ultrasonic measurements of snow depth, eddy covariance measurements of evapotranspiration, time domain transmissometry-based soil moisture measurements, time-lapse photography of overland flow, and groundwater level measurements by piezometers. The two model parameterizations were evaluated on annual, seasonal, and daily time scales, in terms of how well they simulated snow, soil moisture, evapotranspiration, overland flow, storage change in the saturated zone, and runoff. Using the proposed step-by-step approach, the relative runoff volume errors in the calibration and validation periods were 0.00 and -0.01, the monthly Pearson correlation coefficients were 0.92 and 0.82, and the daily logarithmic Nash Sutcliffe efficiencies were 0.59 and 0.18, respectively. By using different sources of data besides runoff, the overall process consistency improved, compared to the case when only runoff was used for calibration. Soil moisture and evapotranspiration observations had the largest influence on simulated runoff, while the parameterization of the snow and runoff generation modules had a smaller influence.

Crude Fat, Diethyl Ether Extraction, in Feed, Cereal Grain, and Forage (Randall/Soxtec/Submersion Method): Collaborative Study

A method for determining crude fat in animal feed, cereal grain, and forage (plant tissue) was collaboratively studied. Crude fat was extracted from the animal feed, cereal grain, or forage material with diethyl ether by the Randall method, also called the Soxtec method or the submersion method. The proposed submersion method considerably decreases the extraction time required to complete a batch of samples. The increase in throughput is very desirable in the quest for faster turnaround times and the greater efficiency in the use of labor. In addition, this method provides for reclamation of the solvent as a step of the method. The submersion method for fat extraction was previously studied for meat and meat products and was accepted as AOAC Official Method 991.36. Fourteen blind samples were sent to 12 collaborators in the United States, Sweden, Canada, and Germany. The within-laboratory relative standard deviation (repeatability) ranged from 1.09 to 9.26% for crude fat. Among-laboratory (including within) relative standard deviation (reproducibility) ranged from 1.0 to 21.0%. The method is recommended for Official First Action.

Crude Fat, Hexanes Extraction, in Feed, Cereal Grain, and Forage (Randall/Soxtec/Submersion Method): Collaborative Study

A method for determining crude fat in animal feed, cereal grain, and forage (plant tissue) was collaboratively studied. Crude fat was extracted from the animal feed, cereal grain, or forage material with hexanes by the Randall method, also called the Soxtec method or the submersion method. The use of hexanes provides for an alternative to diethyl ether for fat extractions. The proposed submersion method considerably decreases the extraction time required to complete a batch of samples compared to Soxhlet. The increase in throughput is very desirable in the quest for faster turnaround times and the greater efficiency in the use of labor. In addition, this method provides for reclamation of the solvent as a step of the method. The submersion method for fat extraction was previously studied for meat and meat products and was accepted as AOAC Official Method 991.36. Fourteen blind samples were sent to 14 collaborators in the United States, Sweden, Canada, and Germany. The within-laboratory relative standard deviation (repeatability) ranged from 1.23 to 5.80% for crude fat. Among-laboratory (including within) relative standard deviation (reproducibility) ranged from 1.88 to 14.1%. The method is recommended for Official First Action.

Separation of Scales in Transpiration Effects on Low Flows: A Spatial Analysis in the Hydrological Open Air Laboratory

The objective of this study was to understand whether spatial differences in runoff generation mechanisms affect the magnitudes of diurnal streamflow fluctuations during low flow periods and which part of the catchment induces the diurnal streamflow signal. The spatiotemporal variability of the streamflow fluctuations observed at 12 locations in the 66-ha Hydrological Open Air Laboratory experimental catchment in Austria was explained by differences in the vegetation cover and runoff generation mechanisms. Almost a quarter of the volume associated with diurnal streamflow fluctuations at the catchment outlet was explained by transpiration from vegetation along the tributaries; more than three quarters was due to transpiration by the riparian forest along the main stream. The lag times between radiative forcing and evapotranspiration estimated by a solar radiation-driven model increased from 3 to 11 hr from spring to autumn. The recession time scales increased from 21 days in spring to 54 days in autumn. Observations and model simulations suggest that a separation of scales in transpiration effects on low flows exists both in time and space; that is, the diurnal streamflow fluctuations are induced by transpiration from the riparian vegetation, while most of the catchment evapotranspiration, such as evapotranspiration from the crop fields further away from the stream, do not influence the diurnal signal in streamflow.

Deep vein thrombosis, an unreported first manifestation of polyglandular autoimmune syndrome type III

A 71-year-old woman with severe right lower leg pain, edema and erythema was presented to the Emergency Department and was found to have an extensive deep vein thrombosis (DVT) confirmed by ultrasound. She underwent an extensive evaluation due to her prior history of malignancy and new hypercoagulable state, but no evidence of recurrent disease was detected. Further investigation revealed pernicious anemia (PA), confirmed by the presence of a macrocytic anemia (MCV=115.8fL/red cell, Hgb=9.0g/dL), decreased serum B12 levels (56pg/mL), with resultant increased methylmalonic acid (5303nmol/L) and hyperhomocysteinemia (131μmol/L), the presumed etiology of the DVT. The patient also suffered from autoimmune thyroid disease (AITD), and both antithyroglobulin and anti-intrinsic factor antibodies were detected. She responded briskly to anticoagulation with heparin and coumadin and treatment of PA with intramuscular vitamin B12 injections. Our case suggests that a DVT secondary to hyperhomocystenemia may represent the first sign of polyglandular autoimmune syndrome III-B (PAS III-B), defined as the coexistent autoimmune conditions AITD and PA. It is important to recognize this clinical entity, as patients may not only require acute treatment with vitamin B12 supplementation and prolonged anticoagulation, as in this patient, but may also harbor other autoimmune diseases.

LEARNING POINTS

A DVT can be the first physical manifestation of a polyglandular autoimmune syndrome.Hyperhomocysteinemia secondary to pernicious anemia should be considered as an etiology of an unprovoked DVT in a euthyroid patient with autoimmune thyroid disease.Patients with DVT secondary to hyperhomocysteinemia should undergo screening for the presence of co-existent autoimmune diseases in addition to treatment with B12 supplementation and anticoagulation to prevent recurrent thromboembolism.

A new mixing diagnostic and Gulf oil spill movement

Chaotic advection has served as the paradigm for mixing in fluid flows with simple time dependence. Its skeletal structure is based on analysis of invariant attracting and repelling manifolds in fluid flows. Here we develop a finite-time theory for two-dimensional incompressible fluid flows with arbitrary time dependence and introduce a new mixing diagnostic based on it. Besides stretching events around attracting and repelling manifolds, this allows us to detect hyperbolic mixing zones. We used the new diagnostic to forecast the spatial location and timing of oil washing ashore in Plaquemines Parish and Grand Isle, Louisiana, and Pensacola, Florida, in May 2010 and the flow of oil toward Panama City Beach, Florida, in June 2010.

Clinical and bacteriological outcomes in hospitalised patients with community-acquired pneumonia treated with azithromycin plus ceftriaxone, or ceftriaxone plus clarithromycin or erythromycin: a prospective, randomised, multicentre study

This study compared patients with moderate-to-severe community-acquired pneumonia (CAP) requiring hospitalisation, who received initial therapy with either intravenous ceftriaxone plus intravenous azithromycin, followed by step-down to oral azithromycin (n = 135), with patients who received intravenous ceftriaxone combined with either intravenous clarithromycin or erythromycin, followed by step-down to either oral clarithromycin or erythromycin (n = 143). Clinical and bacteriological outcomes were evaluated at the end of therapy (EOT; day 12-16) or at the end of study (EOS; day 28-35). At baseline, mean APACHE II scores were 13.3 and 12.6, respectively, with >50% of patients classified as Fine Pneumonia Severity Index (PSI) category IV or V. Clinical success rates (cure or improvement) in the modified intent-to-treat (MITT) population at EOT were 84.3% in the ceftriaxone/azithromycin group and 82.7% in the ceftriaxone/clarithromycin or erythromycin group. At EOS, MITT success rates (cure only) were 81.7% and 75.0%, respectively. Equivalent success rates in the clinically evaluable population were 83% and 87%, respectively, at EOT, and 79% and 78%, respectively, at EOS. MITT bacteriological eradication rates were 73.2% and 67.4%, respectively, at EOT, and 68.3% vs. 60.9%, respectively, at EOS. Mean length of hospital stay (LOS) was 10.7 and 12.6 days, and the mean duration of therapy was 9.5 and 10.5 days, respectively. The incidence of infusion-related adverse events was 16.3% and 25.2% (p 0.04), respectively. An intravenous-to-oral regimen of ceftriaxone/azithromycin was at least equivalent in efficacy and safety to the comparator regimen and appeared to be a suitable treatment option for hospitalised patients with CAP.

Polymorphisms within the CTLA4 gene are associated with infant atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is one of the most common childhood disorders. It can have a significant impact on the physical and psychological well-being of affected individuals. Although environmental triggers are important, AD also has a strong genetic component. Identifying genes associated with AD may help to understand better the basis of this disorder and its relationship with other allergic disorders such as asthma.

OBJECTIVES

Polymorphisms in the gene encoding the inhibitory CTLA4 receptor, an important regulator of T cells, are associated with asthma as well as autoimmune disorders. We have now tested whether polymorphisms in the CTLA4 gene are also associated with early childhood AD.

METHODS

A family-based cohort of 112 children and their parents was recruited from Western Sydney, Australia. All children were seen by a paediatric dermatologist and presented with AD within the first 3 years of life. Using the transmission disequilibrium test, individual and haplotypic associations with the +49 and CT60 polymorphisms in exon 1 and the 3' nontranslated DNA of the CTLA4 gene were tested.

RESULTS

Single tests of association revealed significant association of the +49(A) [P = 0.037, odds ratio (OR) 1.59, 95% confidence interval (CI) 1-2.55] and borderline significance of the CT60(A) alleles (P = 0.055, OR 1.51, 95% CI 1-2.38). Significant association of the +49(A)/CT60(A) haplotype was detected (P = 0.002, OR 1.78, 95% CI 1.2-2.65).

CONCLUSIONS

Polymorphisms within the gene encoding CTLA4 were associated with early onset infant AD. This is in agreement with findings from asthmatic cohorts, suggesting that the +49(A)/CT60(A) haplotype is a genetic risk factor common to asthma and AD.

Baseline experience with Modified Mini Mental State Exam: The Women's Health Initiative Memory Study (WHIMS)

The Modified Mini Mental State Exam (3MS) is widely used for screening global cognitive functioning, however little is known about its performance in clinical trials. We report the distribution of 3MS scores among women enrolled in the Women's Health Initiative Memory Study (WHIMS) and describe differences in these scores associated with age, education, and ethnicity. The 3MS exams were administered to 7,480 women aged 65-80 who had volunteered for and were eligible for a clinical trial on postmenopausal hormone therapy. General linear models were used to describe demographic differences among scores. Factor analysis was used to characterize the correlational structure of exam subscales.The distribution of 3MS scores at baseline was compressed in WHIMS compared to population-based data. Mean 3MS scores (overall 95.1) tended to decrease with age and increase with education, however these associations varied among ethnic groups (p< 0.0001) even after adjustment for health, physical disability and occupation attainment. Four factors accounted for 37% of the total variance. Each varied with education and ethnicity; the two most prominent factors also varied with age. Despite relatively narrow distributions in WHIMS, baseline 3MS scores retained associations with age and education. These associations varied among ethnic groups, so that care must be taken in comparing data across populations.

Differences in antimicrobial susceptibility among hospitals in an integrated health system

We evaluated the differences in antimicrobial susceptibility among hospitals in three different integrated healthcare systems. Each system provided antibiogram-susceptibility reports from representative hospitals. Reports were analyzed for statistically significant differences between hospitals in a given system for nine important organisms. We found numerous significant interhospital differences in antimicrobial-susceptibility patterns within health systems. For this reason, the practice of combining antibiotic-susceptibility data into a systemwide antibiogram should be discouraged.

Human resource management strategies for the retention of nurses

Retention of nurses is a critical problem facing health care managers across Australia today. Retention of experienced employees is not only cost effective, but of great importance to the continued high performance of the nursing services in health care organisations. This article will examine innovative human resource management strategies to promote the retention of nurses.

Characteristics of inactive primary care patients: baseline data from the activity counseling trial. For the Activity Counseling Trial Research Group

BACKGROUND

Although many primary care patients are inactive, being able to classify even small amounts and intensities of activity and factors associated with these activity levels could be helpful for physicians who are trying to motivate their patients to become more physically active.

METHODS

Sociodemographics, physical activity, fitness, other cardiovascular risk factors, and psychosocial measures were measured at baseline in the 874 patients in the Activity Counseling Trial. Patients were categorized into three groups: (1) no moderate-to-vigorous physical activity (MVPA), (2) some moderate but no vigorous activity, and (3) some vigorous activity. Multiple logistic regression was used to determine factors cross-sectionally associated with activity intensity.

RESULTS

One or more cardiovascular risk factors in addition to physical inactivity were present in 84% of participants. Maximal oxygen uptake averaged 25.2 ml/kg/min; 85% had poor to fair aerobic fitness. Physical activity averaged 32.7 kcal/kg/day, with 13.5 min of MVPA/day; 26% engaged in some vigorous activity, 11% engaged in no MVPA. In unadjusted analyses, gender, age, race, education, income, employment, smoking, alcohol use, and exercise self-efficacy were associated with activity intensity (P = 0.05-0.001). A greater percentage engaged in moderate than in vigorous activity in all subgroups. In multiple logistic regression analyses, odds ratios (95% confidence intervals) for engaging in vigorous activity were 0. 39 (0.28, 0.56) for women, 0.38 (0.19, 0.75) for 65+ compared with 35- to 44-year-olds, and 1.14 (1.06, 1.22) for 10-unit increases in performance self-efficacy score.

CONCLUSIONS

Most primary care patients who are physically inactive have additional cardiovascular risk factors, particularly overweight and obesity. All subgroups pursue moderate-intensity activity more often than vigorous activity. Women, older persons, and those with lower exercise self-efficacy are less likely to engage in vigorous activity.

Influence of HLA matching and associated factors on aortic valve homograft function

BACKGROUND AND AIM OF THE STUDY

Evidence suggests that the implanted aortic valve homograft suffers eventual loss of function due to early donor-specific antibody and T cell-mediated responses to human leukocyte antigens (HLA). The association between rejection/dysfunction and donor/recipient HLA mismatch for vascularized organ homografts has not been revealed for aortic valve homografts. An aortic valve homograft recipient cohort was studied to determine whether HLA mismatch and associated factors predicted homograft dysfunction.

METHODS

Both donor and recipient HLA type was obtained for 162 recipients of cryopreserved aortic valve homografts between 1986 and 1998. Structural deterioration of the homograft was defined by echocardiography as at least moderate aortic stenosis or regurgitation. Patients' records were searched for postoperative fever, ABO blood type disparity, and other associated factors. HLA class 1 (A and B antigens) were typed serologically, and HLA class 2 (DR antigens) by molecular genotyping. Associations were analyzed using chi-square tests and Kaplan-Meier curves of freedom from structural deterioration in all patients, and in those with > or =5 years of follow up. Cox regression was used to determine independent predictors of structural deterioration.

RESULTS

Class 2 antigen mismatch had a significant association (p = 0.04) with decrease in cryopreserved aortic valve homograft freedom from structural deterioration in patients with long-term follow up (> or =5 years). In addition, there was an important difference in frequency of postoperative fever in recipients with two DR mismatches (31.2%), and in those with no or one DR mismatch (16.9%; p = 0.051). Significant associations were not found between homograft dysfunction and HLA mismatch at the class-1 loci. Young age at operation and short time (<4 h) between homograft procurement and cryopreservation were associated with an increase in structural deterioration.

CONCLUSION

The association between aortic valve homograft dysfunction and HLA DR mismatch suggests that elements of the anti-donor immune response penetrate and damage the homograft. A similar link to postoperative fever indicates that immune stimulation may be an early event. Further investigation will reveal the exact pathways by which this occurs and by which therapy (immunosuppression of the recipient, genetic engineering of the donor graft, or other techniques) this recipient anti-donor response can be modified.

Unilateral pigmented purpuric eruption

Three cases of unilateral pigmented purpuric eruption (UPPE) occurring in children aged between 7 and 12 years are reported. The lesions were asymptomatic and occurred on the lower limb and torso; one case demonstrated a quadrantic configuration with a sharp midline cutoff. The purpuric component resolved spontaneously within 3 months in all cases, while pigmentation showed partial resolution in the two cases followed up for 12 months. Our cases support previous reports of UPPE being a benign self-limiting condition mainly affecting young patients. The cause is unknown.

Paying more and losing ground: how employer cost-shifting is eroding health coverage of working families

This report describes the decline in employer-based health coverage between 1989 and 1996 and the underlying causes of that decline--including rapidly rising worker premiums and other economic variables. The analysis combines data from a variety of sources, including the U.S. Census Bureau's Current Population Survey, the National Medical Expenditures Survey for workers with employer coverage, and annual KPMG Peat Marwick Surveys. The authors employed regression analysis to determine the relative importance of economic factors on an individual's probability of having employer-based coverage--as either a worker or dependent. In addition to providing a basis for measuring the impact of various factors on the level of coverage of workers and dependents during the 1989 to 1996 period, these models also allowed projection of coverage levels in future years under alternative assumptions about premium growth, employee contribution shares, and other economic factors.

Cost of tax-exempt health benefits in 1998

The tax expenditure for health benefits is the amount of revenues that the federal government forgoes by exempting the following from the federal income and Social Security taxes: (1) employer health benefits contribution, (2) health spending under flexible spending plans, and (3) the tax deduction for health expenses. The health tax expenditure was $111.2 billion in 1998. This figure varied from $2,357 per family among those with annual incomes of $100,000 or more to $71 per family among those with annual incomes of less than $15,000. Families with incomes of $100,000 or more (10 percent of the population) accounted for 23.6 percent of all tax expenditures.

Crusted scabies in two immunocompromised children: successful treatment with oral ivermectin

Two immunodeficient children, aged 4 and 12 years, with crusted scabies were successfully treated with a single oral dose of ivermectin (200 micrograms/kg). One child had been diagnosed in infancy with an undefined congenital T cell immunodeficiency and the other with chronic mucocutaneous candidiasis. Both had failed to respond to conventional topical therapy. In view of the excellent therapeutic response and absence of side-effects, ivermectin should be considered in the treatment of recalcitrant crusted scabies in children.

Symptom relief and side effects of postmenopausal hormones: results from the Postmenopausal Estrogen/Progestin Interventions Trial

OBJECTIVE

To assess pair-wise differences between placebo, estrogen, and each of three estrogen-progestin regimens on selected symptoms.

METHODS

This was a 3-year, multicenter, double-blind, placebo-controlled trial in 875 postmenopausal women aged 45-64 years at baseline. Participants were assigned randomly to one of five groups: 1) placebo, 2) daily conjugated equine estrogens, 3) conjugated equine estrogens plus cyclical medroxyprogesterone acetate, 4) conjugated equine estrogens plus daily medroxyprogesterone acetate, and 5) conjugated equine estrogens plus cyclical micronized progesterone. Symptoms were self-reported using a checklist at 1 and 3 years. Factor analysis reduced 52 symptoms to a set of six symptom groups.

RESULTS

In intention-to-treat analyses at 1 year, each active treatment demonstrated a marked, statistically significant, protective effect against vasomotor symptoms compared with placebo (odds ratios [ORs] 0.17-0.28); there was no additional benefit of estrogen-progestin over estrogen alone. Only progestin-containing regimens were significantly associated with higher levels of breast discomfort (OR 1.92-2.27). Compared with placebo, women randomized to conjugated equine estrogens reported no increase in perceived weight. Those randomized to medroxyprogesterone acetate reported less perceived weight gain (OR 0.61-0.69) than placebo. Anxiety, cognitive, and affective symptoms did not differ by treatment assignment. Analyses restricted to adherent women were not materially different than those using intention-to-treat, except that women adherent to medroxyprogesterone acetate and micronized progesterone regimens reported fewer musculoskeletal symptoms (OR 0.62-0.68).

CONCLUSION

These results confirm the usefulness of post-menopausal hormone therapy for hot flashes, show convincingly that estrogen plus progestin causes breast discomfort, and demonstrate little influence of postmenopausal hormones on anxiety, cognition, or affect.

A study of the workforce in emergency medicine

STUDY OBJECTIVE

Emergency medicine has progressed significantly since its initial recognition as a medical specialty. Relatively little factual information is known, however, regarding who or how many physicians practice emergency medicine. The purpose of this study is to determine the total number of physicians practicing clinical emergency medicine during a specified period, to describe certain characteristics of those individuals, and to estimate the total number of full-time equivalents (FTEs), as well as the total number of individuals needed to staff those FTEs.

METHODS

Data were gathered from a survey of a random sample of 2,062 hospitals drawn from a population of 5,220 hospitals reported by the American Hospital Association as having, or potentially having, an emergency department. The survey instrument addressed items such as descriptive data on the institution, enumeration of physicians in the ED, as well as the total number working during the period June 1, 1997, through June 14, 1997. Demographic data on the individuals were also collected.

RESULTS

A total of 942 hospitals responded (a 45.7% return rate). These hospitals reported a total of 5,872 physicians were working during the specified period, or an average of 7.48 persons scheduled per institution. The physicians were scheduled for a total of 297,062 hours. The average standard for FTE was 40 clinical hours per week. This equates to 3,713 FTEs or 4.96 FTEs per institution. The ratio of persons to FTEs was 1.51:1. With regard to demographics, 83% of the physicians were men and 81% were white. Their average age was 42 years. As to professional credentials, 58% were emergency medicine-residency trained and 53% were board certified in emergency medicine; 46% were certified by the American Board of Emergency Medicine.

CONCLUSION

Given that there are 4,945 hospitals with EDs and given that the data indicate there are 4.96 FTEs per ED, the total number of FTEs is projected to be 24,548 (standard error = 437). Given further that the data indicate a physician/FTE ratio of 1.51:1, we conclude that there are 36,990 persons (standard error = 683) needed to staff those FTEs. When adjusted for persons working at more than one ED, that number is reduced to 32,026.

Genetic and physical localization of the root-knot nematode resistance locus mi in tomato

As part of a map-based cloning strategy designed to isolate the root-knot nematode resistance gene Mi, tomato F2 populations were analyzed in order to identify recombination points close to this economically important gene. A total of 21,089 F2 progeny plants were screened using morphological markers. An additional 1887 F2 were screened using PCR-based flanking markers. Fine-structure mapping of recombinants with newly developed AFLP markers, and RFLP markers derived from physically mapped cosmid subclones, localized Mi to a genomic region of about 550 kb. The low frequency of recombinants indicated that recombination was generally suppressed in these crosses and that crossovers were restricted to particular regions. To circumvent this problem, a population of Lycopersicon peruvianum, the species from which Mi was originally introgressed, that was segregating for resistance was developed. Screening of this population with PCR, RFLP and AFLP markers identified several plants with crossovers near Mi. Recombination frequency was approximately eight-fold higher in the Mi region of the L. peruvianum cross. However, even within the wild species cross, recombination sites were not uniformly distributed in the region. By combining data from the L. esculentum and L. peruvianum recombinant analyses, it was possible to localize Mi to a region of the genome spanning less than 65 kb.

Baseline correlates with quality of life among men and women with medication-controlled hypertension. The trial of nonpharmacologic interventions in the elderly (TONE)

OBJECTIVES

To examine Quality of Life (QOL) and its correlates among older adults with medication-controlled hypertension.

DESIGN

Baseline data from the TONE clinical trial.

MEASUREMENTS

Demographic variables (age, race, income), hypertension treatment (medication class, years treated), health status (obesity, physical symptoms), and QOL status (MOS-Short-Form 36, Jenkins Sleep Disturbance, and CES-D Depression).

PARTICIPANTS

A total of 975 men and women, aged 60 to 81 years and free of major diseases and disability, with a screening blood pressure (BP) of < or = 145/85 mm Hg, treated medically for hypertension with antihypertensive medication.

RESULTS

On average, TONE participants reported a QOL level on the SF-36 that was similar to or better than that reported by older adults in the general population. However, there was a strikingly high prevalence of physical complaints or symptoms: 90.3% of men and 93.3% of women experienced one or more physical symptoms or complaints, and nearly 50% reported that such symptoms had disrupted their daily functioning. Among variables-considered, only the physical symptoms index score, number of severe symptoms, and obesity status were correlated consistently with QOL among TONE men and women. Lower QOL scores were associated with higher symptom scores and with obesity. Neither medication class nor age were appreciably associated with QOL status.

CONCLUSIONS

Physical symptoms, rather than medication class and age, were the strongest correlates of QOL in TONE. This underscores the importance of identifying the etiology of symptoms as a means to improve the QOL of order hypertensive persons rather than substituting medication. The association of poorer physical well-being with obesity suggests that weight reduction to manage BP may also improve QOL for some individuals.

Human aortic valve allografts elicit a donor-specific immune response

OBJECTIVE

The nature and magnitude of the immunologic response to implantation of human cryopreserved aortic valve allografts was investigated.

METHODS

Twenty aortic valve allograft recipients were investigated for donor-specific antibody and T-cell-mediated responses with serial flow cytometric and microlymphocytotoxic crossmatch assays and one-way mixed lymphocyte cultures.

RESULTS

Donor-specific immunoglobulin G antibodies to class I and II human leukocyte antigens were first detected in the serum of all aortic valve allograft recipients at 30 days after implantation and persisted in substantial amounts in all but one of the recipients at day 365. Recipient T-cell alloreactivity toward donor lymphocytes was significantly increased at day 30 compared with levels before and 10 days after operation.

CONCLUSIONS

Cryopreserved aortic valve allografts elicit a substantial allogeneic response in recipients. This alloreactivity may contribute to the observed morphologic changes in aortic valve allografts and eventual long-term deterioration of allograft function.

Molecular identification of a major retinoic-acid-synthesizing enzyme, a retinaldehyde-specific dehydrogenase

Retinoic acid, a developmental signal implicated in the formation of the neural axis, is present at high levels in the early embryonic trunk region, where it is synthesized by a novel dehydrogenase. Here we show that the same enzyme is inducible by retinoic acid in P19 teratocarcinoma cells, and we report the cloning from P19 cells of a cDNA encoding a novel dehydrogenase, named retinaldehyde dehydrogenase-2 (RALDH-2). Expression in COS cells shows RALDH-2 to be highly effective in oxidation of retinaldehyde, with no detectable activity on any other aldehyde tested. In situ hybridization histochemistry on the embryonic trunk reveals RALDH-2 mRNA both in mesoderm and neuroectoderm, with highest neuroectodermal expression in the ventral horn of the spinal cord at two restricted locations along the anteroposterior axis, presumably the subpopulation of motoneurons that innervate the limbs.

Plasma lipopolysaccharide binding protein and bactericidal/permeability increasing factor in CRF and HD patients

The recent characterization of lipopolysaccharide binding protein (LBP) and bactericidal/permeability increasing factor (BPI) have provided the opportunity to examine the natural factors that regulate cytokine production in response to endotoxin in patients on hemodialysis (HD). Whole blood was collected in EDTA from 28 undialyzed patients with chronic renal failure (undialyzed CRF), 36 patients on chronic HD (HD) and 15 healthy controls, and plasma levels of LBP and BPI were measured by a sandwich ELISA. Plasma LBP levels in undialyzed patients with CRF (P = 0.04) and patients on HD (P = 0.01) were significantly higher than those in healthy controls, but not significantly different from each other. Plasma BPI levels in undialyzed patients with CRF and patients on HD were not significantly different from those in healthy controls. There was no correlation between serum creatinine and plasma levels of either LBP or BPI. Peripheral blood mononuclear cells (PBMC) were harvested from healthy volunteers by FLcoll-Hypaque separation, and 0.125 mL of 10 x 10(6)/mL suspensions were incubated with 0.125 mL of test plasma (containing different LBP/BPI ratios) and 0.25 mL of RPMI, containing 1 ng/mL of endotoxin, for 24 h at 37 degrees C. Samples were subjected to three freeze-thaw cycles, and total interleukin-1 receptor antagonist (IL-1Ra) or interleukin-1 alpha (IL-1 alpha) production was measured by a specific non-crossreactive RIA. The results of this study showed: (1) IL-1Ra production by endotoxin-stimulated PBMC incubated with pooled plasma from HD patients with LBP/BPI ratios of 11 x 10(2), 167 x 10(2), 379 x 10(2), and 778 x 10(2), respectively was 1466 +/- 195 pg, 3105 +/- 462 pg, 8179 +/- 1020 pg, and 4770 +/- 1185 pg (P < 0.001); (2) Paired plasma collected before dialysis (predialysis) and at 15 min after the start of dialysis (15 minute) with cellulose membranes showed a negligible change in plasma LBP levels (-3 +/- 5%), but a 6681 +/- 1788% increase in plasma BPI levels. Consequently, compared with predialysis plasma, there was a 35 +/- 6% decrease in endotoxin-stimulated IL-1 alpha production by PBMC incubated with plasma drawn at 15 min (P = 0.001); (3) Compared with the PBMC incubated with predialysis plasma from HD patients, there was a 39 +/- 5%, 53 +/- 5%, and 60 +/- 5% decrease in endotoxin-stimulated IL-1 alpha production in the presence of 1 ng/ mL, 10 ng/mL, or 1 microgram/mL of recombinant BPI, respectively (P < 0.003). These results suggest that the plasma LBP:BPI ratio could influence cytokine production in response to bacterial endotoxin; the high LBP:BPI ratios observed in patients with chronic renal failure probably imparts an increased susceptibility to endotoxin-stimulated cytokine production; and natural or pharmacological increases in plasma BPI levels and the consequent decrease in LBP:BPI ratios could attenuate this susceptibility to endotoxin-stimulated cytokine production.

Common skin, hair and nail problems during the first six months of life

When an infant under 6 months of age presents to the family doctor with a skin, hair or nail problem, the evaluation process must determine whether the findings are physiologic and of no concern or due to a pathologic process. In addition to preventing unnecessary investigations and treatment, this distinction will enable the early assessment of those infants with pathologic processes that can involve structures other than the skin. The common causes (physiologic and pathologic) of those skin, hair and nail findings which present during the first 6 months of life will be discussed with the focus on the clinical features and differential diagnosis of each condition. Treatment will not be discussed. This is the first of three such articles.

Circumscribed pigmented lesions

In this second article of common skin, hair, and nail problems during the first six months of life, issues related to pigmentation changes in the skin are addressed. These changes may be circumscribed or linear in appearance and either brown or blue.

Cardiac demands of heavy snow shoveling

OBJECTIVE

To assess the physiologic responses to manual (shoveling) vs automated (electric snow thrower) snow removal in healthy, untrained men.

DESIGN

Observational, controlled trial.

SETTING

A community-based, acute care, teaching-research hospital.

PARTICIPANTS

A volunteer sample of 10 apparently healthy untrained men (mean +/- SD age = 32.4 +/- 2.1 years) met all eligibility criteria and completed the study.

INTERVENTION

Each subject cleared two 10 +/- 2-cm-high, 15-m-long tracts of heavy, wet snow in the cold (2 degrees C), using self-paced manual and automated methods, in random order, with 10- to 15-minute rest periods between each 10-minute bout of work.

MAIN OUTCOME MEASURES

Heart rate, blood pressure, oxygen uptake, and perceived exertion during snow removal were compared with values obtained during maximal arm-ergometer and treadmill tests.

RESULTS

Mean heart rate during shoveling was 154 and 173 beats per minute at 2 and 10 minutes, respectively, corresponding to 86% and 97% of maximal heart rate. Relative heart rate (percentage of maximal heart rate) during shoveling was inversely related to aerobic fitness (r = -0.65; P = .05). The highest heart rate and perceived exertion responses during shoveling, arm-ergometer, and treadmill testing were comparable. Systolic blood pressure during snow shoveling (198 +/- 17 mm Hg) was significantly greater (P < .003) than during arm ergometry or automated snow removal and slightly greater than during maximal treadmill testing (181 +/- 25 mm Hg). Oxygen uptake during shoveling was similar to that for arm ergometry (5.7 vs 6.3 metabolic equivalents), but lower than for treadmill testing (9.3 metabolic equivalents). Cardiorespiratory and perceived exertion responses were reduced during automated snow removal.

CONCLUSION

Heavy snow shoveling elicits myocardial and aerobic demands that rival maximal treadmill and arm-ergometer testing in sedentary men. These responses may contribute to cardiovascular events reported after heavy snowfalls.

Donor-specific immune response after aortic valve allografting in the rat

The allospecific immune response in rats to a major histocompatibility complex-disparate aortic valve allograft was investigated using three in vitro assays. In each assay, DA strain (RT-1a) rats served as allograft recipient and syngeneic donor, Lewis strain (RT-1l) rats were allogeneic donors, and Buffalo (RT-1b) rats provided third-party control cells. Mixed lymphocyte cultures using spleen cells demonstrated donor-specific stimulation indices of 3.04 +/- 0.44, 4.14 +/- 0.62, and 6.32 +/- 0.60 at 7, 14, and 28 days, respectively, after aortic valve allografting; 8.19 +/- 2.91, 8.51 +/- 1.25, and 10.80 +/- 0.53 after skin allografting; and 1.84 +/- 0.56, 1.82 +/- 0.38, and 1.82 +/- 0.53 after aortic valve isografting. Limiting dilution analysis of splenocytes showed a donor-specific cytotoxic T lymphocyte precursor frequency at 7, 14, and 28 days of 1:6,853, 1:4,714, and 1:1,964 after aortic valve allografting; 1:4,181, 1:1,611, and 1:1,018 after skin allografting; and 1:14,517, 1:11,882, and 1:10,995 after aortic valve isografting. Flow cytometry detected an increase in the level of donor-specific anti-T cell antibodies in both valve and skin allograft recipients but not in isografted animals. Aortic valve allografting from Lewis into DA rats elicits allospecific cellular and humoral immune responses similar in magnitude to skin allografting but somewhat slower in onset. Investigation of the immune response to aortic allografts in humans is warranted, as donor-specific T cells, antibodies, or both may damage the allograft.