Technical considerations to development of serological tests for SARS-CoV-2

The COVID-19 pandemic has had a devastating impact worldwide and has brought clinical assays both for acute diagnosis and prior exposure determination to the forefront. Serological testing intended for point-of-care or laboratory use can be used to determine more accurate individual and population assessments of prior exposure to SARS-CoV-2; improve our understanding of the degree to which immunity is conveyed to subsequent exposures; and quantify immune response to future vaccines. In response to this pandemic, initially more than 90 companies deployed serology assays to the U.S. market, many of which made overstated claims for their accuracy, regulatory approval status, and utility for intended purpose. The U.S. Food and Drug Administration subsequently instituted an Emergency Use Authorization (EUA) procedure requiring that manufacturers submit validation data, but allowing newly developed serological tests to be marketed without the usual approval process during this crisis. Although this rapid deployment was intended to benefit public health, the incomplete understanding of immune response to the virus and lack of assay vetting resulted in quality issues with some of these tests, and thus many were withdrawn after submission. Common assay platforms include lateral flow assays which can serve an important niche of low cost, rapid turnaround, and increased accessibility whereas established laboratory-based platforms based on ELISAs and chemiluminescence expand existing technologies to SARS-CoV-2 and can provide throughput and quantification capabilities. While most of the currently EUA assays rely on these well-established platforms, despite their apparent technical simplicity, there are numerous practical challenges both for manufacturers in developing and for end-users in running and interpreting such assays. Within are discussed technical challenges to serology development for SARS-CoV-2, with an emphasis on lateral flow assay technology.

Rapid suppression of bone formation marker in response to sleep restriction and circadian disruption in men

We describe the time course of bone formation marker (P1NP) decline in men exposed to ~ 3 weeks of sleep restriction with concurrent circadian disruption. P1NP declined within 10 days and remained lower with ongoing exposure. These data suggest even brief exposure to sleep and circadian disruptions may disrupt bone metabolism.

INTRODUCTION

A serum bone formation marker (procollagen type 1 N-terminal, P1NP) was lower after ~ 3 weeks of sleep restriction combined with circadian disruption. We now describe the time course of decline.

METHODS

The ~ 3-week protocol included two segments: "baseline," ≥ 10-h sleep opportunity/day × 5 days; "forced desynchrony" (FD), recurring 28 h day (circadian disruption) with sleep restriction (~ 5.6-h sleep per 24 h). Fasted plasma P1NP was measured throughout the protocol in nine men (20-59 years old). We tested the hypothesis that PINP would steadily decline across the FD intervention because the magnitude of sleep loss and circadian misalignment accrued as the protocol progressed. A piecewise linear regression model was used to estimate the slope (β) as ΔP1NP per 24 h with a change point mid-protocol to estimate the initial vs. prolonged effects of FD exposure.

RESULTS

Plasma P1NP levels declined significantly within the first 10 days of FD ([Formula: see text] = - 1.33 μg/L per 24 h, p < 0.0001) and remained lower than baseline with prolonged exposure out to 3 weeks ([Formula: see text] = - 0.18 μg/L per 24 h, p = 0.67). As previously reported, levels of a bone resorption marker (C-telopeptide (CTX)) were unchanged.

CONCLUSION

Sleep restriction with concurrent circadian disruption induced a relatively rapid decline in P1NP (despite no change in CTX) and levels remained lower with ongoing exposure. These data suggest (1) even brief sleep restriction and circadian disruption can adversely affect bone metabolism, and (2) there is no P1NP recovery with ongoing exposure that, taken together, could lead to lower bone density over time.

Comparative evaluation of corneal incision enlargement after intraocular lens delivery of new preloaded and manual implantation systems

PURPOSE

To determine whether total corneal incision enlargement after implantation of an intraocular lens with a new preloaded delivery system is comparable to a standard-of-care manual delivery system using an in vitro human cadaver eye model, despite having a smaller initial incision size.

METHODS

Human cadaver phakic whole eye globes were used for these studies (n = 16 per group). Each pair of eyes was randomly assigned to a new preloaded delivery system (UltraSert^TM) or a manual delivery system (MONARCH^® III D). The surgical procedure included creating a 2.2- and 2.4-mm corneal incision for the preloaded and manual delivery systems, respectively, measuring intraocular pressure and pre-implantation corneal incision size, delivering the intraocular lens into the anterior chamber, and measuring the post-implantation incision size.

RESULTS

The final corneal incision enlargement after intraocular lens delivery using the preloaded delivery system was 2.33 ± 0.04 mm, compared to 2.54 ± 0.05 mm after intraocular lens delivery with the manual delivery system. The mean corneal incision enlargement was comparable between the two systems, being 0.13 ± 0.04 mm using the preloaded delivery system and 0.14 ± 0.05 mm using the manual delivery system (p = 0.432).

CONCLUSION

In a human cadaver eye model, the preloaded delivery system demonstrated an intraocular lens delivery performance on cornea incision enlargement was noninferior to the manual, standard-of-care intraocular lens delivery system despite a smaller initial incision size.

TRANSLATIONAL RELEVANCE

Smaller incision sizes for cataract surgery improve patient outcomes via faster visual and wound recovery and decreased risk of complications such as postoperative inflammation and surgically induced astigmatism.

24-hour profile of serum sclerostin and its association with bone biomarkers in men

The osteocyte's role in orchestrating diurnal variations in bone turnover markers (BTMs) is unclear. We identified no rhythm in serum sclerostin (osteocyte protein). These results suggest that serum sclerostin can be measured at any time of day and the osteocyte does not direct the rhythmicity of other BTMs in men.

INTRODUCTION

The osteocyte exerts important effects on bone remodeling, but its rhythmicity and effect on the rhythms of other bone cells are not fully characterized. The purpose of this study was to determine if serum sclerostin displays rhythmicity over a 24-h interval, similar to that of other bone biomarkers.

METHODS

Serum sclerostin, FGF-23, CTX, and P1NP were measured every 2 h over a 24-h interval in ten healthy men aged 20-65 years. Maximum likelihood estimates of the parameters in a repeated measures model were used to determine if these biomarkers displayed a diurnal, sinusoidal rhythm.

RESULTS

No discernible 24-h rhythm was identified for sclerostin (p = 0.99) or P1NP (p = 0.65). CTX rhythmicity was confirmed (p < 0.001), peaking at 05:30 (range 01:30-07:30). FGF-23 levels were also rhythmic (p < 0.001), but time of peak was variable (range 02:30-11:30). The only significant association identified between these four bone biomarkers was for CTX and P1NP mean 24-h metabolite levels (r = 0.65, p = 0.04).

CONCLUSIONS

Sclerostin levels do not appear to be rhythmic in men. This suggests that in contrast to CTX, serum sclerostin could be measured at any time of day. The 24-h profiles of FGF-23 suggest that a component of osteocyte function is rhythmic, but its timing is variable. Our results do not support the hypothesis that osteocytes direct the rhythmicity of other bone turnover markers (CTX), at least not via a sclerostin-mediated mechanism.

Timing of Estradiol Treatment After Menopause May Determine Benefit or Harm to Insulin Action

CONTEXT

Type 2 diabetes (T2D) is reduced in postmenopausal women randomized to estrogen-based hormone therapy (HT) compared with placebo. Insulin sensitivity is a key determinant of T2D risk and overall cardiometabolic health, and studies indicate that estradiol (E2) directly impacts insulin action.

OBJECTIVE

We hypothesized that the timing of E2 administration after menopause is an important determinant of its effect on insulin action.

DESIGN

We performed a randomized, crossover, placebo-controlled study.

PARTICIPANTS

Study participants were early postmenopausal (EPM; ≤ 6 years of final menses; n = 22) and late postmenopausal (LPM; ≥ 10 years since last menses; n = 24) women naive to HT.

INTERVENTION

Study interventions included short-term (1 week) transdermal E2 and placebo.

MAIN OUTCOMES AND MEASURES

The study's main outcome was insulin-mediated glucose disposal (glucose disposal rate [GDR]) via hyperinsulinemic-euglycemic clamp.

RESULTS

Compared to EPM women, LPM women were older (mean ± SD; 63 ± 3 vs 56 ± 4 years, P < .05) and more years past menopause (12 ± 2 vs 3 ± 2 years, P < .05). Body mass index (24 ± 3 vs 25 ± 7 kg/m(2)) and fat mass (25 ± 7 vs 23 ± 6 kg) did not differ between groups, but fat-free mass (FFM) was lower in LPM women compared to EPM women (40 ± 4 vs 43 ± 5 kg, P < .05). Baseline GDR did not differ between groups (11.7 ± 2.8 vs 11.5 ± 2.9 mg/kg FFM/min). In support of our hypothesis, 1 week of E2 decreased GDR in LPM women compared to an increase in EPM women (+0.44 ± 1.7 vs - 0.76 ± 2.1 mg/kg FFM/min, P < .05).

CONCLUSIONS

There was not an apparent decline in GDR with age or time since menopause per se. However, E2 action on GDR was dependent on time since menopause, such that there was an apparent benefit early (≤ 6 years) compared to harm later (≥ 10 years) in menopause. E2-mediated effects on insulin action may be one mechanism by which HT reduces the incidence of T2D in early postmenopausal women.

Type 2 diabetes exaggerates exercise effort and impairs exercise performance in older women

OBJECTIVE

Type 2 diabetes mellitus (T2DM) is associated with high levels of disability and mortality. Regular exercise prevents premature disability and mortality, but people with T2DM are generally sedentary for reasons that are not fully established. We previously observed that premenopausal women with T2DM report greater effort during exercise than their counterparts without diabetes, as measured by the Rating of Perceived Exertion (RPE) scale. We hypothesized that RPE is greater in older women with T2DM versus no T2DM.

RESEARCH DESIGN AND METHODS

We enrolled overweight, sedentary women aged 50-75 years with (n=26) or without T2DM (n=28). Participants performed submaximal cycle ergometer exercise at 30 W and 35% of individually-measured peak oxygen consumption (35% VO2peak). We assessed exercise effort by RPE (self-report) and plasma lactate concentration.

RESULTS

VO2peak was lower in T2DM versus controls (p=0.003). RPE was not significantly greater in T2DM versus controls (30 W: Control, 10.4±3.2, T2DM, 11.7±2.3, p=0.08; 35% VO2peak: Control, 11.1±0.5, T2DM, 12.1±0.5, p=0.21). However, lactate was greater in T2DM versus controls (p=0.004 at 30 W; p<0.05 at 35% VO2peak). Greater RPE was associated with higher lactate, higher heart rate, and a hypertension diagnosis (p<0.05 at 30 W and 35% VO2peak).

CONCLUSIONS

Taken together, physiological measures of exercise effort were greater in older women with T2DM than controls. Exercise effort is a modifiable and thereby targetable end point. In order to facilitate regular exercise, methods to reduce exercise effort in T2DM should be sought.

TRIAL NUMBER

NCT00785005.

Loss of bone strength in response to exercise-induced weight loss in obese postmenopausal women: results from a pilot study

OBJECTIVE

Exercise-induced weight loss (WL) can lead to decreased areal bone mineral density (aBMD). It is unknown whether this translates into decreased volumetric BMD (vBMD) or bone strength. The purpose of this pilot study was to determine whether exercise-induced WL results in decreased vBMD and bone strength in postmenopausal women.

METHODS

Fourteen subjects participated in a 4-month endurance exercise WL intervention. A weight stable (WS) control group (n=10) was followed for 4 months. Proximal femur aBMD was measured by DXA. Femoral neck vBMD and estimates of bone strength (cross-sectional moment of inertia (CSMI) and section modulus (SM)) were measured by quantitative CT.

RESULTS

Women were 54.6±2.4 years, BMI 32.1±5.9 kg/m(2) and 54.4±2.9 years, BMI 27.9±3.6 kg/m(2) in the WL and WS groups, respectively. The WL group lost 3.0±2.6 kg which was predominately fat mass. There was a significant decrease in SMmax. Changes in CSMImax and total hip aBMD were not significant. Total hip vBMD did not decrease significantly in response to WL. There were no significant changes in the WS group.

CONCLUSIONS

WL may lead to decreased bone strength before changes in BMD are detected. Further studies are needed to determine whether bone-targeted exercise can preserve bone strength during WL.

Estrogen or raloxifene during postmenopausal weight loss: adiposity and cardiometabolic outcomes

OBJECTIVE

Estrogen-based hormone therapy (HT) attenuates abdominal fat gain after menopause, but whether HT improves abdominal fat loss during weight loss is unknown. It was hypothesized that HT or a selective estrogen receptor modulator (raloxifene) would augment reductions in abdominal visceral fat during weight loss when compared to placebo, potentially increasing improvements in glucose tolerance and lipid profile.

METHODS

Healthy postmenopausal women (n = 119; age 50-70 yr) underwent a 6-month weight-loss (primarily exercise) intervention with randomization to raloxifene (60 mg/d), HT (conjugated estrogens, 0.625 mg/d), or placebo. Outcomes were change in total and abdominal (visceral and subcutaneous) fat mass, lipid profile, and fasting and post-challenge glucose and insulin.

RESULTS

Neither HT nor raloxifene augmented loss of total or abdominal fat mass during exercise-induced weight loss when compared with placebo. Weight loss-induced improvements in risk factors were similar among the three groups, except for a greater reduction in fasted glucose in the HT group (difference in change [95%CI] from placebo; -0.40 [-0.76, -0.05]) and greater reductions in LDL (-0.36 [-0.63, -0.09]) and increases in HDL (0.15 [0.07, 0.24]) in both treatment groups.

CONCLUSIONS

Postmenopausal HT and raloxifene did not increase abdominal fat loss during weight loss, but did improve some cardiometabolic outcomes.

Defining vitamin D status by secondary hyperparathyroidism in the U.S. population

BACKGROUND

Vitamin D is associated with a variety of health outcomes, but the exact definition of vitamin D sufficiency remains controversial.

AIM

We sought to define skeletal-related vitamin D sufficiency by estimating maximum PTH suppression in the U.S. population.

METHODS

We performed a cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES), 2003-2006. We examined the association between serum 25-hydroxyvitamin D (25OHD) level and serum PTH level in 14,681 participants aged ≥6 yr. We also evaluated the 25OHD-PTH association using 2 thresholds of hyperparathyroidism: PTH≥45 pg/ml and ≥75 pg/ml.

RESULTS

The mean 25OHD level was 24 ng/ml and mean PTH was 42 pg/ml. PTH≥45 pg/ml was present in 35% of the population, while PTH≥75 pg/ml was present in 7%. The prevalence of 25OHD levels <40 ng/ml and <30 ng/ml was 95% and 77%, respectively. In both unadjusted and adjusted models, there was a strong inverse relationship between 25OHD and PTH. Compared to 25OHD≥40 ng/ml, the 25OHD-PTH association was 2.36 [95% confidence interval (CI), 2.08-2.67] times greater for 25OHD<5 ng/ml and 1.12 (95%CI, 1.07-1.17) times greater for 25OHD 30-39.9 ng/ml. Compared to 25OHD≥40 ng/ml, 25OHD levels of 20- 29.9 ng/ml [odds ratio (OR) 2.0 (95%CI, 1.4-2.8)] but not 30- 39.9 ng/ml [OR 1.1 (95%CI, 0.8-1.6)] were independently associated with PTH≥45 pg/ml.

CONCLUSIONS

Optimal vitamin D status, defined by estimated maximum PTH suppression, does not occur until at least 25OHD levels ≥40 ng/ml. Using these thresholds, most of the U.S. population needs more vitamin D. Large, prospective studies are needed to determine optimal vitamin D supplementation.

Methodological issues in weight cycling

Recent studies have suggested that weight changes may be related to disease risk independent of weight status. A critical step in testing this assertion is the measurement of weight change and so-called "weight cycling". However intuitive the concept of weight cycling may appear, research in this area is hampered by complex methodological issues. This article discusses various measures of nominal weight cycling, including the standard deviation, coefficient of variation, regression techniques, and cycles. A cycle is a sequence of a gain followed by a loss or vice versa. The various measures are compared in seven hypothetical cases created to illustrate their strengths and weaknesses. Superior performance of the cycles measure over the coefficient of variation, number of fluctuations, and simple regression methods is argued. The linkage of the cycles measure with the statistical theory of runs also provides a basis for testing the significance of weight fluctuations or other variables that may cycle, such as blood lipids, etc. The cycles measure and runs test provide a viable definition for identifying weight cycling and a tool for evaluating the critical amount of weight gained and/or lost in relationship to risk.

The effect of lopinavir/ritonavir on the renal clearance of tenofovir in HIV-infected patients

We determined the effects of lopinavir/ritonavir on tenofovir renal clearance. Human immunodeficiency virus-infected subjects taking tenofovir disoproxil fumarate (TDF) were matched on age, race, and gender and were enrolled into one of the following two groups: group 1: subjects taking TDF plus lopinavir/ritonavir plus other nucleoside reverse transcriptase inhibitors (NRTIs); group 2: subjects taking TDF plus NRTIs and/or non-NRTIs but no protease inhibitors. Twenty-four-hour blood and urine collections were carried out in subjects for tenofovir quantification. Drug transporter genotype associations with tenofovir pharmacokinetics were examined. In 30 subjects, median (range) tenofovir apparent oral clearance, renal clearance, and fraction excreted in urine were 34.6 l/h (20.6-89.5), 11.3 l/h (6.2-22.6), and 0.33 (0.23-0.5), respectively. After adjusting for renal function, tenofovir renal clearance was 17.5% slower (P=0.04) in subjects taking lopinavir/ritonavir versus those not taking a protease inhibitor, consistent with a renal interaction between these drugs. Future studies should clarify the exact mechanism and whether there is an increased risk of nephrotoxicity.

Lessons learned from the national heart failure project: a center for medicare and medicaid services initiative to improve the care of medicare beneficiaries with heart failure

This column is the seventh in a series reporting on the efforts of the Center for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration, to improve care for Medicare beneficiaries with heart failure. In previous columns we have described the overall structure of Medicare quality improvement efforts, detailed the structure of the national inpatient fee-for-service program known as the National Heart Failure project, and discussed the baseline quality indicator rates for the project, which are focused on rates of ejection fraction documentation and angiotensin-converting enzyme inhibitor prescription. In more recent columns, we reported on quality improvement projects from several participating hospitals, and on a pilot project exploring quality improvement efforts for heart failure based in physicians' offices. This column will focus on ways in which systematic examination of data, such as those from the National Heart Failure project, might shape future quality improvement and research efforts. The National Heart Failure project's quality indicator data are collected primarily to guide and evaluate the efforts of the CMS contractor peer-review organizations to facilitate quality improvement efforts in hospitals throughout the United States. (c)2001 CHF, Inc.

A randomized trial of a brief intervention to increase fruit and vegetable intake: a replication study among callers to the CIS

BACKGROUND

Results are reported from a large randomized trial designed to increase fruit and vegetable consumption among callers to the National Cancer Institute's Cancer Information Service (CIS) (n = 1,717).

METHODS

CIS callers assigned to the intervention group (n = 861) received a brief proactive educational intervention over the telephone at the end of usual service, with two follow-up mailouts. Key educational messages and print material derived from the NCI 5 A Day for Better Health program were provided to intervention participants. Participants were interviewed by telephone at 4 weeks (n = 1,307), 4 months (n = 1,180), and 12 months for follow-up (n = 1,016).

RESULTS

Results obtained from a single-item measure of fruit and vegetable consumption indicate a significant intervention effect of 0.88 servings per day at 4 weeks follow-up (P < 0.001), 0.63 servings per day at 4 months follow-up (P < 0.001), and 0.43 servings per day at 12 months follow-up (P < 0.001). Using a 7-item food frequency measure, an intervention effect of 0.63 servings per day was obtained at 4 weeks follow-up (P < 0.001), compared with 0.39 servings per day at 4 months follow-up (P = 0.002) and 0.44 servings per day at 12 months follow-up (P = 0.002). A 24-h recall assessment included in the 4-month interviews also yielded a significant intervention effect of 0.67 servings per day (P = 0.015). The vast majority of callers (90%) endorsed the strategy of providing 5 A Day information proactively within the CIS.

CONCLUSIONS

This brief educational intervention was associated with higher levels of self-reported fruit and vegetable intake at both short- and long-term follow-up. Additional research is recommended to test this or a similar intervention in diverse populations.

Baseline quality indicator rates from the National Heart Failure Project: a HCFA initiative to improve the care of medicare beneficiaries with heart failure

This column is the third in a series reporting on Health Care Financing Administration (HCFA) initiatives to improve care for Medicare beneficiaries with heart failure. The first paper outlined the history of HCFA quality improvement projects and current initiatives to improve care in six priority areas: heart failure, acute myocardial infarction, stroke, pneumonia, diabetes, and breast cancer. The second reported in more detail the structure of the national inpatient fee-for-service heart failure initiative, known as the National Heart Failure project. It described the development of the quality indicators, the sampling strategy for selecting charts to be reviewed, and the types of local efforts spurred by the project through the activities of each state's HCFA contractor peer review organization. This article discusses baseline quality indicator rates from the National Heart Failure project. (c)2001 by CHF, Inc.

Physician perspectives on increasing minorities in cancer clinical trials: an Eastern Cooperative Oncology Group (ECOG) Initiative

PURPOSE

This paper describes the ECOG-NMA Minority Accrual Initiative to assure minority participation in cancer clinical trials.

METHODS

Focus groups were held to identify physician-reported barriers to the enrollment of minority patients in Cleveland, OH, Indianapolis, IN, Santa Clara County, CA, and Philadelphia, PA. Community physicians affiliated with the National Medical Association (NMA), and Eastern Cooperative Oncology Group (ECOG) investigators participated in the focus groups. A four-step process consisting of focus group workshops were conducted to (i) identify barriers, (ii) develop potential solutions to the barriers, (iii) define solutions to barriers involving specific clinical trials, and (iv) implement the solutions.

RESULTS

Focus group participants identified physician lack of information, patient fears and suspicion, the fear of losing patients, and distrust of the health care system as the major barriers to enrollment of African Americans. We found significant differences between community physicians and cancer program physicians in several areas. Community physicians emphasized personal contacts to address the lack of information and to overcome patient fears and suspicions, while the cancer program physicians emphasized printed materials. There was no difference by region in the barriers identified in the focus group workshops; however, the proposed solutions to overcoming the barriers were specific to each site.

CONCLUSION

The four-step process developed by the ECOG and the NMA used the focus group methodology to identify and overcome barriers to participation of African Americans in cancer clinical trials. Outreach efforts to educate patients, their families, and community physicians about cancer clinical trials should be directed at overcoming patient suspicions and providing practical information to physicians about specific trials and how to enroll patients.

Plasma xanthophyll carotenoids correlate inversely with indices of oxidative DNA damage and lipid peroxidation

Post hoc analysis of data obtained from a study designed to modulate oxidative damage by dietary intervention revealed consistently strong inverse correlations between plasma xanthophyll carotenoids and oxidative damage indices. Thirty-seven women participated in a 14-day dietary intervention that increased mean vegetable and fruit (VF) consumption to approximately 12 servings/day. An additional 10 subjects participated in an intervention that limited VF consumption to less than four servings per day. 8-Hydroxy-2'-deoxyguanosine (8-OHdG) in DNA isolated from peripheral lymphocytes and 8-OHdG excreted in urine were measured as indices of oxidative DNA damage. Lipid peroxidation was assessed by measuring 8-epiprostaglandin F2alpha (8-EPG) in urine. Plasma levels of selected carotenoids were also determined, with the intention of using a-carotene as a biochemical index of VF consumption. Urinary 8-OHdG and 8-EPG were measured by ELISA, and plasma carotenoids were measured by high performance liquid chromatography. Lymphocyte 8-OHdG was measured by reverse phase high performance liquid chromatography with electrochemical detection. We observed that the structurally related xanthophyll carotenoids, lutein and beta-cryptoxanthin, which occur in dissimilar botanical families, were consistently inversely associated with these oxidative indices. Statistically significant inverse correlations were observed between plasma lutein and/or beta-cryptoxanthin levels and lymphocyte 8-OHdG and urinary 8-EPG. Moreover, an inverse correlation was observed between change in plasma xanthophylls and change in lymphocyte 8-OHdG concentration that occurred during the course of the study. These data lead us to hypothesize that lutein and beta-cryptoxanthin serve as markers for the antioxidant milieu provided by plants from which they are derived. Whether these carotenoids are directly responsible for the observed antioxidant phenomena merits further investigation.

Fibronectin fragments induce MMP activity in mouse mammary epithelial cells: evidence for a role in mammary tissue remodeling

Mammary gland form and function are regulated by interactions between epithelium and extracellular matrix. Major glycoprotein components of extracellular matrix have been identified that give survival, proliferation and differentiation signals to mammary epithelial cells. We provide evidence that proteolytic fragments of the extracellular matrix glycoprotein, fibronectin, suppress growth and can promote apoptosis of mouse mammary epithelial cells. During mammary gland involution, total fibronectin and fibronectin fragment levels are increased. The peak levels of fibronectin protein and fragments are observed 4–6 days post-weaning, coincident with the peak in epithelial cell death. Using a model for hormone withdrawal-induced death of mammary epithelium, elevated levels of fibronectin proteolytic fragments were associated with apoptosis in TM-6 cells, a tumorigenic mouse mammary epithelial cell line. Treatment of TM-6 cells with exogenous fibronectin fragments (FN120) reduced cell number, and induced apoptosis and matrix degrading protease activity. Inhibition of matrix protease activity rescued TM-6 cell viability, indicating that FN120-induced cell loss is mediated through matrix protease activity. In a three-dimensional model for mammary gland development, FN120 reduced alveolar-like and promoted ductal-like development by a matrix protease-dependent mechanism. These data suggest that during post-lactational involution, fibronectin fragments may contribute to epithelial cell loss and dissolution of mammary alveoli by inducing matrix degrading proteinases.

Further investigation of traumatic brain injury versus insufficient effort with the California Verbal Learning Test

The present study replicates and attempts to extend previous research using the California Verbal Learning Test (CVLT) to identify malingerers. Documented moderate and severe traumatic brain injury patients (n = 42) were compared with clinical malingerers identified by criteria other than the CVLT (n = 21), malingering simulators instructed in realistic potential injury sequelae (n = 25), and normal controls (n = 21). Results of discriminant function analyses for high and low base rates are reported, showing similar results. Also, the four individual cutoff scores (Recognition Hits, Discriminability, Total Words Recalled, Long Delay Cued Recall) from Millis, Putnam, Adams, and Ricker (1995) were evaluated with these groups. Similar specificity rates were found with all four variables, while sensitivity rates were slightly lower than that of Millis. Adjusted cutoffs derived from the new samples resulted in slightly improved overall classification rates. Overall, present findings support those of Millis et al. (1995) with regard to the use of the CVLT in detection of malingering. Exploratory use of Total Intrusions and Recognition Hits Compared to Long Delay Free Recall was not promising. Simulators were found to be fairly comparable in performance to actual malingerers, affirming their use in malingering research.

Effect of increased vegetable and fruit consumption on markers of oxidative cellular damage

The goal of this study was to test the hypothesis that increased consumption of vegetables and fruit would reduce markers of oxidative cellular damage that can be assessed in blood or urine. Twenty-eight women participated in a 14 day dietary intervention. The primary end-points assessed were: 8-hydroxydeoxyguanosine (8-OHdG) in DNA isolated from peripheral lymphocytes, determined by HPLC with electrochemical detection; 8-OHdG excreted in urine, measured by ELISA; malondialdehyde (MDA) in urine, measured by fluorimetric detection following derivatization with thiobarituric acid and separation via HPLC; urinary 8-isoprostane F-2alpha (8-EPG) detected by ELISA. Pre- and post-intervention plasma levels of selected carotenoids were determined by HPLC. Subjects were free living and consumed a completely defined recipe-based diet that increased their average daily consumption of vegetables and fruit from 5.8 servings at baseline to 12.0 servings throughout the intervention. Overall, the level of 8-OHdG in DNA isolated from lymphocytes and in urine and the level of 8-EPG in urine were reduced by the intervention, whereas urine concentrations of MDA were minimally affected. The reduction in lymphocyte 8-OHdG was greater in magnitude (32 versus 5%) in individuals with lower average pre-intervention levels of plasma alpha-carotene (56 ng/ml) than in individuals with higher average pre-intervention plasma levels of alpha-carotene (148 ng/ml). The results of this study indicate that consumption of a diet that significantly increased vegetable and fruit intake from a diverse number of botanical families resulted in significant reductions in markers of oxidative cellular damage to DNA and lipids.

The effect of diurnal and menstrual cyclicity and menopausal status on estrogen metabolites: implications for disease-risk assessment

It has been proposed that the ratio of two estrogen metabolites, 2-hydroxyestrone (2-OHE1) and 16alpha-hydroxyestrone (16alpha-OHE1), may represent a marker to predict a woman's risk for developing breast cancer and other estrogen-related disease. The present studies evaluated the potential confounders of type of sample, diurnal rhythm, menstrual cycle phase, and menopausal status on the ratio of 2/16alpha-OHE1 using an urine-based monoclonal antibody enzyme immunoassay. Two initial studies to compare a 24-h urine collection with a first-morning void and to evaluate diurnal variation were performed. Subsequently, urine samples were collected every other day for 2 months from five premenopausal subjects to assess the impact of the menstrual cycle. Spot urine samples were then obtained from a total of 67 pre, peri-, early post-, and late post-menopausal women to assess the effect of menopausal status. No significant difference in the ratio of 2/16alpha-OHE1 was found between a 24-h and first-morning void or over a 24-h period. No significant difference in the mean ratio of 2/16alpha-OHE1 was found with the menstrual phase. Intra-individual variability was observed in the ratio of 2/16alpha-OHE1, which was attributable to small fluctuations in the small denominator, 16alpha-OHE1. No difference in the ratio of 2/16alpha-OHE1 was observed in groups of women of different menopausal status. The data suggest that a first-morning void is representative of a 24-h collection and that the 2/16alpha-OHE1 ratio is constant throughout a 24-h period. Moreover, menstrual phase and menopausal status do not appear to significantly influence the ratio of 2/16alpha-OHE1.

Temporal sequence of mammary intraductal proliferations, ductal carcinomas in situ and adenocarcinomas induced by 1-methyl-1-nitrosourea in rats

An experimental model for mammary carcinogenesis has been described in which intraductal proliferations, ductal carcinomas in situ and adenocarcinomas can be readily detected and the frequency of their occurrence quantified. The objective of the experiment reported in this study was to determine the latency period between carcinogen administration and the occurrence of each of these types of lesion. A total of 150 female Sprague-Dawley rats were injected i.p. with 50 mg 1-methyl-1-nitrosourea (MNU)/kg body wt at 21 days of age. Groups of 30 rats each were killed at 7, 14, 21, 28 and 35 days post-carcinogen. Mammary intraductal proliferations were the first detected lesions and were observed in 20% of the animals at 14 days following carcinogen administration. At 21 days post-carcinogen ductal carcinomas in situ and adenocarcinomas were observed. The number of each type of lesion increased with time post-carcinogen, but the temporal pattern of occurrence was different among lesion types. The pattern of lesion occurrence was consistent with intraductal proliferations being a precursor lesion for ductal carcinomas in situ and adenocarcinomas. Furthermore, the data imply that ductal carcinomas in situ represent one pathway of morphological progression by which intraductal proliferations evolve into invasive carcinomas, but that this lesion type, as currently defined histologically, may not be an obligatory intermediate in morphologic progression. These findings are consistent with emerging evidence of multiple but distinct pathogenetic pathways leading to mammary carcinomas that display different morphological patterns and biological activities.

Increasing fruit and vegetable consumption among callers to the CIS: results from a randomized trial

BACKGROUND

Results are reported from a large randomized trial designed to increase fruit and vegetable consumption among callers to the Cancer Information Service (CIS).

METHODS

CIS callers assigned to the intervention group received a brief proactive educational intervention over the telephone at the end of usual service, with two follow-up mailouts. Key educational messages and print material derived from the NCI 5 A Day for Better Health program were provided to intervention subjects. Subjects were interviewed by telephone at both 4-week (n = 1,672) and 4-month (n = 1,286) follow-up.

RESULTS

A single-item measure of fruit and vegetable consumption revealed a significant intervention effect of approximately 0.65 servings per day at 4-week follow-up (P < 0.001) and 0.41 servings per day at 4-month follow-up (P < 0.001). Using a seven-item food frequency measure that was also included in the 4-month interviews, a similar intervention effect of 0.34 servings per day was obtained (P = 0.006). The vast majority of CIS callers (88%) endorsed the strategy of providing 5 A Day information proactively.

CONCLUSIONS

A brief educational intervention delivered to CIS callers at the end of usual service was associated with an increase in self-reported fruit and vegetable intake.

Effectiveness of a telephone outcall intervention to promote screening mammography among low-income women

BACKGROUND

This study evaluated the impact of a telephone outcall intervention (based on the Transtheoretical Model) on screening mammography behavior among lower income, older women.

METHODS

A geodemographic database, INFORUM, was used to identify low-income and minority neighborhoods throughout the state of Colorado. Residences were assigned randomly to three study groups: (1) control, (2) outcall only, and (3) advance "invitation" + outcall. Information Specialists of the Cancer Information Service implemented the protocol. Mammography adherence was assessed in telephone interviews conducted 6 months and 2 years after the initial call.

RESULTS

Neither intervention had a significant effect on the main outcome, receipt of mammography in the 6-month follow-up period. At 6 months, intentions to have a mammogram were significantly stronger in the intervention groups compared with the control group, particularly among those who were precontemplators at baseline. The 2-year follow-up indicated a small increase in mammography adherence attributable to the advance invitation + outcall, but this effect was restricted to those adherent at baseline. Mammography behavior during the 6-month follow-up period was predicted strongly by decisional balance, intentions, receipt of a physical and clinical breast exam, and previous mammography behavior.

CONCLUSIONS

The intervention promoted minimal movement in the stages of change for mammography. Outcall interventions may have promise for encouraging repeat mammography behavior, but more intensive interventions are likely to be necessary to promote behavior change among nonadherent women.

Physician and patient predictors of health maintenance visits

BACKGROUND

Because of a strong association between health maintenance visits (HMVs) and cancer screening, knowledge of the predictors of an HMV have implications for screening.

OBJECTIVE

To examine the association of an HMV with patient, physician, and practice characteristics in the primary care setting.

DESIGN

A statewide study of cancer screening was conducted in Colorado to determine concordance with the National Cancer Institute's guidelines for screening for breast, cervical, prostate, and skin cancer. Medical records form patients were randomly chosen from primary care practices. Predictors of an HMV were determined by fitting a logistic model to baseline data, adjusting for the cluster sampling of patients within practices.

SETTING

Nonacademic primary care practices in Colorado.

PARTICIPANTS

A total of 5746 patients aged 42 to 74 years from 132 primary care practices.

MAIN OUTCOME MEASURE

Whether a patient had an HMV in the previous year.

RESULTS

Of all patients, 31% had an HMV in the previous year. Patient characteristics associated with having HMVs included nonsmoking status, odds ratio (OR) (95% confidence interval [CI]) of 1.27 (1.11-1.46), age, and sex. Women aged 50 to 69 years were significantly more likely to have an HMV than men aged 50 to 69 years (OR, 1.30; 95% CI, 1.10-1.54). Among adults aged 70 years and older, there were no significant sex differences in receiving HMVs. Physician and practice characteristics associated with providing HMVs included practice size (> or = 3 full-time physicians) (OR, 1.34; 95% CI, 1.01-1.77), physician contemplation of changing approaches to cancer screening (OR, 1.33; 95% CI, 1.04-1.70), and physician female sex (OR, 1.33; 95% CI, 1.04-1.70). Physician age and specialty (general internist or family physician) were not associated with the level of health maintenance delivery.

CONCLUSION

Certain subgroups, such as smokers, patients in smaller practices, and physicians not yet considering changing their approach to cancer screening, could be targeted in future intervention studies designed to provide preventive services in primary care settings.

X-radiation induces 8-hydroxy-2'-deoxyguanosine formation in vivo in rat mammary gland DNA

Ionizing radiation is a carcinogen that induces oxidative DNA damage. 8-Hydroxy-2'-deoxyguanosine (8-OHdG) is a relatively abundant, mutagenic lesion that is widely regarded as a reliable index of oxidative DNA damage. The purpose of this study was to examine the effects of X-radiation on levels of 8-OHdG in the context of an experimental model for breast cancer in which chronic radiation exposure has been shown to be carcinogenic in Sprague-Dawley rats. A secondary objective of this study was to determine if the use of phenol during DNA isolation affected the concentration of 8-OHdG subsequently measured. Our results indicate that a profoundly carcinogenic dose of radiation induced a small but significant increase in 8-OHdG concentration in mammary gland DNA, and that the use of a phenol-based versus a salt-based method of DNA isolation had no significant impact on the levels of 8-OHdG detected in either control or irradiated tissue.

A feasibility test of a brief educational intervention to increase fruit and vegetable consumption among callers to the Cancer Information Service

BACKGROUND

In this paper, results are reported from a pilot study designed to test the feasibility of a proactive educational intervention delivered to callers of the Cancer Information Service (CIS).

METHODS

The study used a randomized two-group design (intervention vs control). Callers assigned to the intervention condition received a brief educational intervention at the end of usual service to increase fruit and vegetable consumption. As part of the intervention, key education messages and materials drawn from the 5 A Day for Better Health program of the National Cancer Institute were provided to CIS callers over the telephone and then reinforced with two follow-up mailings.

RESULTS

Results from this pilot study indicated high levels of adherence to protocol by CIS Information Specialists who delivered the intervention to eligible CIS callers. Results obtained from the 4-week telephone follow-up interviews indicated that intervention subjects (n = 142) reported higher consumption of fruits and vegetables, averaging approximately 0.75 servings more per day (P < 0.01) than control subjects (n = 134).

CONCLUSION

Nearly 80% of CIS callers endorsed the strategy of providing 5 A Day information at the end of usual service, even if such information was not specifically requested by the caller (i.e., the information was provided to CIS callers proactively.

Energy availability and mammary carcinogenesis: effects of calorie restriction and exercise

The purpose of this experiment was to compare the carcinogenic response in the mammary gland among groups of rats whose energy metabolism had been modulated by restricting dietary calories and/or by increasing energy expenditure via exercise. Female F344 rats (n = 132) were injected i.p. with 1-methyl-1-nitrosomethylurea (50 mg/kg at 50 and 57 days of age) and were randomized into one of four treatment groups: (i) unrestricted, sedentary; (ii) calorie-restricted, sedentary; (iii) unrestricted, exercised; (iv) calorie-restricted, exercised. The targeted level of calorie-restricted was 20% and exercise was achieved by treadmill-running (20 m/min at a 15% grade for 30 min, 5 days/week). During the 20.5 week study, rats were palpated twice a week for detection of mammary tumors and urine was collected for determination of 24-h cortical steroid excretion. At the end of the study, all mammary lesions were histologically classified. Carcass composition and carcass energy were determined. Mammary carcinogenesis was inhibited among calorie-restricted, sedentary rats compared with unrestricted, sedentary rats (79% inhibition, P < 0.001). No inhibition of carcinogenesis was observed among exercised rats (unrestricted or calorie-restricted) relative to the unrestricted, sedentary rats. Within the present experimental design, exercise had no effect on carcinogenesis despite significant reductions of carcass fat and carcass energy among both groups of rats that exercised. Cortical steroid level was significantly higher only in calorie-restricted, sedentary rats (P < 0.05). These results do not support the hypothesis that reductions of body weight gain, carcass fat or carcass energy are sufficient conditions to inhibit mammary carcinogenesis. The results do suggest that changes in urinary cortical steroid excretion may predict whether an energy-related intervention is likely to alter mammary carcinogenesis.

Immunogenicity of the 23-valent pneumococcal polysaccharide vaccine in Alaska Native chronic alcoholics compared with nonalcoholic Native and non-Native controls

PURPOSE

This study was designed to evaluate the immunogenicity of the 23-valent pneumococcal polysaccharide vaccine in Alaska Native chronic alcoholics and compare these responses with those in age- and sex-matched nonalcoholic, Native and non-Native control subjects.

PATIENTS AND METHODS

Native alcoholic patients were recruited from the inpatient medical service and outpatient clinics. Healthy age- and sex-matched Alaska Native and non-Native nonalcoholics were recruited from hospital employees. At the initial visit, a standardized questionnaire, the Alcohol Dependency Scale, was administered to all participants. Participants were examined for liver diseases; blood was drawn for liver function tests and prevaccination pneumococcal antibody levels. Charts of all Native participants were reviewed for alcohol-related diseases. Participants received one dose of the 23-valent pneumococcal vaccine at the time of the initial visit and returned 20 to 55 days after immunization for liver function tests and pneumococcal antibody level measurement. Serotype-specific pneumococcal antibody levels were measured by radioimmunoassay. Logistic regression analysis was used to examine the proportion of persons whose serotype-specific antibody level doubled following vaccination. A model including adjustments for age, sex, and initial antibody level was used to examine the effect of alcohol status and ethnicity on response to the vaccine. Eighty-five persons completed the study. Of these, 41 were chronic alcoholics and 44 were nonalcoholic. Of these, 21 were Alaska Natives and 23 were non-Natives.

RESULTS

Before vaccination, the geometric mean titers (GMTs) were similar in all 3 groups but were slightly higher in Native alcoholic participants for 11 of 12 serotypes tested. For 11 or more serotypes tested, 46% of alcoholics and 27% of nonalcoholics had total antibody levels at or above 500 nanograms of antibody nitrogen per milliliter (p = 0.11). After vaccination, the GMTs were higher in nonalcoholic than in alcoholic participants for serotypes 3, 7F, and 19F (p < 0.05). When Natives and non-Natives were compared, non-Natives had higher antibody levels than Native participants for 10 of 12 serotypes. After vaccination, 83% of alcoholics and 91% of nonalcoholics had pneumococcal antibody levels of more than 500 nanograms of antibody nitrogen per milliliter for at least 11 serotypes. When responses consisting of a twofold or greater increase in antibody level were compared, a greater proportion of nonalcoholics than alcoholics responded to serotypes 3, 4, 7F, 8, and 19F. This difference was significant for types 3 and 19F only (p < 0.05). In alcoholics there was a direct correlation between pneumococcal antibody level and age both before and after vaccination. This was significant before vaccination for serotypes 4, 6B, 18C, and 23F, and after vaccination for these types and for types 1 and 19F. In nonalcoholics there was a correlation between age and antibody response, following vaccination, for serotype 9N and 18C. Alcoholic males had antibody levels higher than that in females for most serotypes, but significantly so only for serotype 12F before vaccination, and for type 14 after vaccination. There were no sex differences seen among nonalcoholics, and no differences in response to vaccine could be detected in patients with or without liver dysfunction.

CONCLUSION

In this study of Alaska Natives with chronic alcoholism, Native and non-Native participants responded adequately to immunization with the 23-valent pneumococcal vaccine, although significant differences in some serotypes were evident.

Luteinizing hormone and progesterone concentrations in serum of heifers administered a short half-life prostaglandin (PGF2α) or long half-life prostaglandin analogue (fenprostalene) on days six or eleven of the estrous cycle

Two trials were conducted to measure the progesterone (P(4)) decline and luteinizing hormone (LH) surge in serum subsequent to administration of a short half-life (short t (1 2 )) prostaglandin (PGF(2alpha)) or a long half-life (long t (1 2 )) prostaglandin analogue (fenprostalene) on Days 6 or 11 of the estrous cycle. Twenty-five crossbred Shorthorn and five Hereford heifers with a mean weight of 331.4 +/- 29.8 kg were used in both trials. The heifers were randomly allotted to receive either a short t (1 2 ) or long t (1 2 ) prostaglandin treatment on Day 6 or 11 of the estrous cycle. A crossover design for the main effect, treatment (type of prostaglandin), was conducted. Heifers that received PGF(2alpha) in Trial I were given fenprostalene in Trial II and vice versa. Stage of the estrous cycle (day) was the same for each heifer in both trials. Stage of estrous cycle was standardized to either Day 6 or 11 by administering Syncro-Mate B (SMB). Blood was collected every hour for 80 h post injection to quantify LH and P(4) concentrations. There were no significant differences (P > 0.05) between the short t (1 2 ) or long t (1 2 ) for either P(4) or LH profiles. In addition, no differences were detected between stages of the estrous cycle for the timing of the preovulatory surge of LH after prostaglandin administration.

Suramin therapy in AIDS and related disorders. Report of the US Suramin Working Group

Suramin sodium is a reverse transcriptase inhibitor with in vitro activity against the human immunodeficiency virus (HIV), the causative agent of acquired immunodeficiency syndrome (AIDS). Ninety-eight patients with AIDS manifest as opportunistic infections (n = 38), AIDS with Kaposi's sarcoma (n = 38), AIDS-related complex (n = 20), or AIDS-associated non-Hodgkin's lymphoma (NHL) (n = 2) were treated with suramin sodium at 0.5, 1.0, or 1.5 g/wk for six weeks followed by maintenance therapy with 0.5 or 1.0 g/wk. Of 72 patients who were HIV culture positive before therapy and were assessable for subsequent HIV culture 40% became culture negative during treatment, with no apparent correlation between virus recovery and serum suramin concentration. No immunologic improvement was noted. One complete clinical remission was noted in a patient with Kaposi's sarcoma and stage IV NHL. Seven minor clinical responses were also noted. Toxic reactions were generally reversible, and included fever (78%), rash (48%), malaise (43%), nausea (34%), neurologic symptoms (33%), and vomiting (20%). Suramin-induced neutropenia was noted in 26%, thrombocytopenia in 12%, a serum creatinine level of 180 mumol/L or higher (greater than or equal to 2.1 mg/dL) in 12%, liver dysfunction in 14%, and clinical and/or laboratory evidence of adrenal insufficiency in 23%. Sixteen patients died while receiving suramin or within three weeks of discontinuation of drug therapy due to infection (n = 6), hepatic failure (n = 3), pulmonary Kaposi's sarcoma (n = 2), AIDS encephalitis (n = 2), AIDS-associated NHL (n = 1), iatrogenic hemo-pneumothorax (n = 1), or pulmonary disease of uncertain etiology. Suramin as currently administered cannot be recommended as effective therapy for AIDS.

Alterations in cytotoxic and phenotypic subsets of natural killer cells in acquired immune deficiency syndrome (AIDS)

Testing of cytotoxic function using a panel of natural killer (NK)-sensitive target cells, including a unique herpes simplex virus-infected Raji-cell target, was performed in conjunction with phenotypic cell analysis by dual-color flow cytometry to characterize the NK system. Subjects included in the study were at risk for or infected with the etiologic agent of the acquired immune deficiency syndrome (AIDS), human immunodeficiency virus (HIV). A generalized defect in NK function was temporally correlated with disease manifestations, as evidenced by deficient NK lytic function in patients with AIDS and AIDS-related complex (ARC). Healthy at-risk subjects, including those seropositive for HIV, exhibited robust NK-cell function. Phenotypic analysis revealed that normal proportions of the NK-associated CD16+ (Leu11) Leu7- and CD16+(Leu11)Leu7+ lymphocyte subsets were maintained throughout the clinical progression of HIV infection. However, the proportion and numbers of cells of the CD8+(Leu2)Leu7+ subset were increased in AIDS, ARC, and healthy at-risk subjects, including those seronegative for HIV. These results are consistent with a qualitative defect in the NK system in AIDS, perhaps secondary to CD4-cell depletion and a concomitant lack of essential accessory factors. The elevation in CD8+(Leu2)/Leu7+ cells is not solely the result of HIV infection and may be a general response to viruses and/or other antigenic stimulation.

Processing of preproteins by liposomes bearing leader peptidase

Procoat, the precursor form of M13 coat protein, assembles into sealed liposomes bearing only internally oriented leader peptidase and is processed to yield transmembrane coat protein [Ohno-Iwashita, Y., & Wickner, W. (1983) J. Biol. Chem. 258, 1895-1900]. The precursors of maltose-binding protein and of outer membrane protein A (OmpA) are also processed by these liposomes, showing that these preproteins can at least partially insert across a lipid bilayer. The ability to insert into a bilayer may be a general property of preproteins. The cleavage products, mature OmpA and maltose-binding protein, are not sequestered within the liposomes, suggesting that an additional factor(s) is (are) required for complete translocation. Liposomes were also prepared with leader peptidase in a more physiological, membrane-spanning orientation. These liposomes were also active in the cleavage of externally added procoat, pro-OmpA, and pre maltose-binding protein, though the mature OmpA and maltose-binding protein were still not sequestered within the liposomes. Pretreatment of these liposomes with trypsin cleaved near the amino terminus of the leader peptidase, inactivating the enzyme. The function of this amino-terminal domain, on the opposite side of the membrane from the catalytic domain, is unknown.

Unusually large nasopalatine cyst: CT findings

In a patient presenting with nasal obstruction the clinical suspicion of a nasal mass led to computed tomography that demonstrated findings thought to be characteristic of an unusually large nasopalatine cyst. The definitive diagnosis of nasopalatine cyst is more easily made on plain films. The entity is described, emphasizing once again the necessity of including dental and facial abnormalities in the differential diagnosis of lesions of the sinuses and nose.

The facial nerve between the stylomastoid foramen and the parotid: computed tomographic imaging

A small segment of the facial nerve between its exit from the stylomastoid foramen and its entrance into the parotid is surrounded by fat and, therefore, can be imaged well using modern computed tomography. A small dot can be seen surrounded by fat just beneath the stylomastoid foramen on computed tomographic scan. To verify that this indeed represented the facial nerve, tissue sections and an injection into the mastoid segment of the intratemporal facial nerve were performed. The anatomic correlation and clinical material demonstrating involvement of the facial nerve in this region are presented.

Malignant external otitis: CT evaluation

Malignant external otitis is an aggressive infection caused by Pseudomonas aeruginosa that most often occurs in elderly diabetics. Malignant external otitis often spreads inferiorly from the external canal to involve the subtemporal area and progresses medically towards the petrous apex leading to multiple cranial nerve palsies. The computed tomographic (CT) findings in malignant external otitis include obliteration of the normal fat planes in the subtemporal area as well as patchy destruction of the bony cortex of the mastoid. The point of exit of the various cranial nerves can be identified on CT scans, and the extent of the inflammatory mass correlates well with the clinical findings. Four cases of malignant external otitis are presented. In each case CT provided a good demonstration of involvement of the soft tissues at the base of the skull.

Total parathyroidectomy and autotransplantation

Total parathyroidectomy and autotransplantation of tissue to the forearm was practiced in 50 chronic renal failure patients as treatment for secondary hyperparathyroidism. Four hyperplastic glands were removed in all cases. Followup observation ranged from 3 to 42 months. Serum parathyroid hormone, alkaline phosphatase, calcium and phosphorus levels decreased significantly following the procedure (P less than 0.005) and remained stable during the period of observation. Significant bone pain present in 26 patients improved or ceased in 19; pruritus, present in 39 patients, universally improved. Strong radiographic suggestion of secondary hyperparathyroidism, present in 38 patients, improved or disappeared in 17. Three patients remained functionally hyperparathyroid, requiring further tissue removal. Autograft function 3 to 7 days after transplantation was demonstrated in 3 cases by differential parathyroid hormone concentration determinations. Essentially all patients experienced symptomatic improvement after surgery and most showed objective evidence of improved calcium-phosphorus metabolism and bone healing.

Dietary intakes of preschool children in LA Pa, El Salvador, Central America

A dietary survey was conducted in a department of El Salvador as part of an assessment of the nutritional status of preschool children. Intake of calories, protein and retinol equivalents were estimated using a 24-hour recall technique. The average daily energy intake for children 1-4 years old was 866 Kcal representing 60% of the 1973 level recommended by the Institute of Nutrition of Central America and Panama (INCAP), for this age group, and 76% of the recommended level on a body-weight basis. Average protein intake per child per day in the same age group was 31.3 g, which represents 110% of the recommended level for the age group, and 136% of the recommended level on a body weight basis. The estimated retinol equivalent intake was 36% of the recommended allowance. In general, the results of the present study were similar to those obtained in the study carried out in El Salvador by INCAP during the period September-November, 1965.