Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial

BACKGROUND

Closed-loop insulin delivery systems have the potential to address suboptimal glucose control in children and adolescents with type 1 diabetes. We compared safety and efficacy of the Cambridge hybrid closed-loop algorithm with usual care over 6 months in this population.

METHODS

In a multicentre, multinational, parallel randomised controlled trial, participants aged 6-18 years using insulin pump therapy were recruited at seven UK and five US paediatric diabetes centres. Key inclusion criteria were diagnosis of type 1 diabetes for at least 12 months, insulin pump therapy for at least 3 months, and screening HbA1c levels between 53 and 86 mmol/mol (7·0-10·0%). Using block randomisation and central randomisation software, we randomly assigned participants to either closed-loop insulin delivery (closed-loop group) or to usual care with insulin pump therapy (control group) for 6 months. Randomisation was stratified at each centre by local baseline HbA1c. The Cambridge closed-loop algorithm running on a smartphone was used with either (1) a modified Medtronic 640G pump, Medtronic Guardian 3 sensor, and Medtronic prototype phone enclosure (FlorenceM configuration), or (2) a Sooil Dana RS pump and Dexcom G6 sensor (CamAPS FX configuration). The primary endpoint was change in HbA1c at 6 months combining data from both configurations. The primary analysis was done in all randomised patients (intention to treat). Trial registration ClinicalTrials.gov, NCT02925299.

FINDINGS

Of 147 people initially screened, 133 participants (mean age 13·0 years [SD 2·8]; 57% female, 43% male) were randomly assigned to either the closed-loop group (n=65) or the control group (n=68). Mean baseline HbA1c was 8·2% (SD 0·7) in the closed-loop group and 8·3% (0·7) in the control group. At 6 months, HbA1c was lower in the closed-loop group than in the control group (between-group difference -3·5 mmol/mol (95% CI -6·5 to -0·5 [-0·32 percentage points, -0·59 to -0·04]; p=0·023). Closed-loop usage was low with FlorenceM due to failing phone enclosures (median 40% [IQR 26-53]), but consistently high with CamAPS FX (93% [88-96]), impacting efficacy. A total of 155 adverse events occurred after randomisation (67 in the closed-loop group, 88 in the control group), including seven severe hypoglycaemia events (four in the closed-loop group, three in the control group), two diabetic ketoacidosis events (both in the closed-loop group), and two non-treatment-related serious adverse events. There were 23 reportable hyperglycaemia events (11 in the closed-loop group, 12 in the control group), which did not meet criteria for diabetic ketoacidosis.

INTERPRETATION

The Cambridge hybrid closed-loop algorithm had an acceptable safety profile, and improved glycaemic control in children and adolescents with type 1 diabetes. To ensure optimal efficacy of the closed-loop system, usage needs to be consistently high, as demonstrated with CamAPS FX.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

Energy penetration into arrays of aligned nanowires irradiated with relativistic intensities: Scaling to terabar pressures

Ultrahigh-energy density (UHED) matter, characterized by energy densities >1 × 10⁸ J cm^-3 and pressures greater than a gigabar, is encountered in the center of stars and inertial confinement fusion capsules driven by the world's largest lasers. Similar conditions can be obtained with compact, ultrahigh contrast, femtosecond lasers focused to relativistic intensities onto targets composed of aligned nanowire arrays. We report the measurement of the key physical process in determining the energy density deposited in high-aspect-ratio nanowire array plasmas: the energy penetration. By monitoring the x-ray emission from buried Co tracer segments in Ni nanowire arrays irradiated at an intensity of 4 × 10¹⁹ W cm^-2, we demonstrate energy penetration depths of several micrometers, leading to UHED plasmas of that size. Relativistic three-dimensional particle-in-cell simulations, validated by these measurements, predict that irradiation of nanostructures at intensities of >1 × 10²² W cm^-2 will lead to a virtually unexplored extreme UHED plasma regime characterized by energy densities in excess of 8 × 10¹⁰ J cm^-3, equivalent to a pressure of 0.35 Tbar.

Optical Management Using Monovision and Yoked Prism for Acquired Strabismus and Nystagmus Secondary to a Neurodegenerative Disease

Acquired involuntary eye movement disorders, including noncomitant strabismus, nystagmus, and saccadic dyskinesia, are common ocular manifestations of many neurodegenerative diseases. These patients may experience visual symptoms, such as blurred vision, diplopia, and oscillopsia, which can significantly impact their use of vision. The goal of the management for these patients is to reduce the visual symptoms using any combination of available management strategies. This case report discusses the effective optical management using the combination of spectacle monovision correction and yoked prism to improve visual symptoms in a patient with olivopontocerebellar atrophy.

Charged-particle spectroscopy for diagnosing shock ρR and strength in NIF implosions

The compact Wedge Range Filter (WRF) proton spectrometer was developed for OMEGA and transferred to the National Ignition Facility (NIF) as a National Ignition Campaign diagnostic. The WRF measures the spectrum of protons from D-(3)He reactions in tuning-campaign implosions containing D and (3)He gas; in this work we report on the first proton spectroscopy measurement on the NIF using WRFs. The energy downshift of the 14.7-MeV proton is directly related to the total ρR through the plasma stopping power. Additionally, the shock proton yield is measured, which is a metric of the final merged shock strength.

Protease inhibitor levels in periodontal health and disease

BACKGROUND AND OBJECTIVE

Our previous study showed that protease inhibitors were attenuated by the periodontal pathogen Porphyromonas gingivalis in cultured gingival epithelial cells. We hypothesize that fewer protease inhibitors would be present in more advanced periodontal disease sites, where the level of P. gingivalis may be high. The goal of this study was to investigate the relationship between the protease inhibitor [secretory leukocyte protease inhibitor (SLPI), elastase-specific inhibitor (ELAFIN) and squamous cell carcinoma antigen (SCCA)] levels in gingival crevicular fluid and the number of P. gingivalis micro-organisms in subgingival plaque.

MATERIAL AND METHODS

Plaque samples from subjects without (n = 18) and with moderate to advanced periodontitis (n = 41) were used to quantify P. gingivalis using real-time PCR. Protease inhibitor levels in the gingival crevicular fluid of all the subjects were determined by ELISA.

RESULTS

P. gingivalis was detected in 68.3% of patients with periodontitis, while 16.7% of subjects without periodontitis had a detectable level of P. gingivalis. Patients with periodontitis and P. gingivalis in their plaque exhibited lower SLPI and ELAFIN levels (p < 0.001) compared with control subjects without periodontitis. Secretory leukocyte protease inhibitor was also reduced (p < 0.05) in gingival crevicular fluid of periodontitis patients without a detectable level of P. gingivalis. Periodontitis patients with high vs. low levels of P. gingivalis exhibited reciprocal mean levels of SLPI and ELAFIN concentrations.

CONCLUSION

The reduced concentrations of SLPI and ELAFIN may contribute to the loss of host protective capacity and increase susceptibility to breakdown from chronic infection. The work of this investigation may aid in finding diagnostic and prognostic markers in periodontal health and disease and may also help in finding pharmacological targets directed against periodontal inflammation.

Damage mechanisms of MoN/SiN multilayer optics for next-generation pulsed XUV light sources

We investigated the damage mechanism of MoN/SiN multilayer XUV optics under two extreme conditions: thermal annealing and irradiation with single shot intense XUV pulses from the free-electron laser facility in Hamburg - FLASH. The damage was studied "post-mortem" by means of X-ray diffraction, interference-polarizing optical microscopy, atomic force microscopy, and scanning transmission electron microscopy. Although the timescale of the damage processes and the damage threshold temperatures were different (in the case of annealing it was the dissociation temperature of Mo2N and in the case of XUV irradiation it was the melting temperature of MoN) the main damage mechanism is very similar: molecular dissociation and the formation of N2, leading to bubbles inside the multilayer structure.

Backscatter measurements for NIF ignition targets (invited)

Backscattered light via laser-plasma instabilities has been measured in early NIF hohlraum experiments on two beam quads using a suite of detectors. A full aperture backscatter system and near backscatter imager (NBI) instrument separately measure the stimulated Brillouin and stimulated Raman scattered light. Both instruments work in conjunction to determine the total backscattered power to an accuracy of ∼15%. In order to achieve the power accuracy we have added time-resolution to the NBI for the first time. This capability provides a temporally resolved spatial image of the backscatter which can be viewed as a movie.

Single shot damage mechanism of Mo/Si multilayer optics under intense pulsed XUV-exposure

We investigated single shot damage of Mo/Si multilayer coatings exposed to the intense fs XUV radiation at the Free-electron LASer facility in Hamburg - FLASH. The interaction process was studied in situ by XUV reflectometry, time resolved optical microscopy, and "post-mortem" by interference-polarizing optical microscopy (with Nomarski contrast), atomic force microscopy, and scanning transmission electron microcopy. An ultrafast molybdenum silicide formation due to enhanced atomic diffusion in melted silicon has been determined to be the key process in the damage mechanism. The influence of the energy diffusion on the damage process was estimated. The results are of significance for the design of multilayer optics for a new generation of pulsed (from atto- to nanosecond) XUV sources.

Fixation disparity analysis: sensory and motor approaches

PURPOSE

Fixation disparity measurement as a tool for analyzing the binocular visual system has taken very different approaches in the United States and Central Europe. In the United States, testing has primarily followed a motor approach, and resulting management has followed parameters established by graphical analysis closely. In German-speaking countries, a strong sensory-based analysis has been popular for decades, utilizing equipment rarely seen in the United States. Management in these countries has been almost exclusively directed toward prismatic prescription.

METHODS

This report examines the instrumentation, underlying strategies, and management used in both the motor and sensory approaches to fixation disparity analysis. Testing protocols and management options are detailed for each approach.

CONCLUSION

Although both approaches agree that fixation disparity has the potential to reveal a more realistic view of binocular system functioning under normal viewing conditions than other systems of analysis, the approaches diverge in some very important ways, particularly in the understanding of the development of fixation disparity and its management. Whereas the philosophy underlying testing and management of the motor-based approach will be familiar to most clinicians in the United States, the sensory approach offers a very different perspective. It views the development of fixation disparity as a shift of correspondence within Panum's area. In effect, this may be thought of as the oxymoron "a normal, anomalous correspondence"; that is, a shift of correspondence occurring in nonstrabismic patients. Management in these cases is based on accurate prism prescription to re-establish bifoveal fusion.

A randomized clinical trial of vision therapy/orthoptics versus pencil pushups for the treatment of convergence insufficiency in young adults

PURPOSE

: The purpose of this article is to compare vision therapy/orthoptics, pencil pushups, and placebo vision therapy/orthoptics as treatments for symptomatic convergence insufficiency in adults 19 to 30 years of age.

METHODS

: In a randomized, multicenter clinical trial, 46 adults 19 to 30 years of age with symptomatic convergence insufficiency were randomly assigned to receive 12 weeks of office-based vision therapy/orthoptics, office-based placebo vision therapy/orthoptics, or home-based pencil pushups. The primary outcome measure was the symptom score on the Convergence Insufficiency Symptom Survey. Secondary outcome measures were the near point of convergence and positive fusional vergence at near.

RESULTS

: Only patients in the vision therapy/orthoptics group demonstrated statistically and clinically significant changes in the near point of convergence (12.8 cm to 5.3 cm, p = 0.002) and positive fusional vergence at near (11.3Delta to 29.7Delta, p = 0.001). Patients in all three treatment arms demonstrated statistically significant improvement in symptoms with 42% in office-based vision therapy/orthoptics, 31% in office-based placebo vision therapy/orthoptics, and 20% in home-based pencil pushups achieving a score <21 (our predetermined criteria for elimination of symptoms) at the 12-week visit.

DISCUSSION

: In this study, vision therapy/orthoptics was the only treatment that produced clinically significant improvements in the near point of convergence and positive fusional vergence. However, over half of the patients in this group (58%) were still symptomatic at the end of treatment, although their symptoms were significantly reduced. All three groups demonstrated statistically significant changes in symptoms with 42% in office-based vision therapy/orthoptics, 31% in office-based placebo vision therapy/orthoptics, and 20% in home-based pencil push-ups meeting our criteria for elimination of symptoms.

A randomized clinical trial of treatments for convergence insufficiency in children

OBJECTIVE

To compare vision therapy/orthoptics, pencil push-ups, and placebo vision therapy/orthoptics as treatments for symptomatic convergence insufficiency in children 9 to 18 years of age.

METHODS

In a randomized, multicenter clinical trial, 47 children 9 to 18 years of age with symptomatic convergence insufficiency were randomly assigned to receive 12 weeks of office-based vision therapy/orthoptics, office-based placebo vision therapy/orthoptics, or home-based pencil push-ups therapy.

MAIN OUTCOME MEASURES

The primary outcome measure was the symptom score on the Convergence Insufficiency Symptom Survey. Secondary outcome measures were the near point of convergence and positive fusional vergence at near.

RESULTS

Symptoms, which were similar in all groups at baseline, were significantly reduced in the vision therapy/orthoptics group (mean symptom score decreased from 32.1 to 9.5) but not in the pencil push-ups (mean symptom score decreased from 29.3 to 25.9) or placebo vision therapy/orthoptics groups (mean symptom score decreased from 30.7 to 24.2). Only patients in the vision therapy/orthoptics group demonstrated both statistically and clinically significant changes in the clinical measures of near point of convergence (from 13.7 cm to 4.5 cm; P < .001) and positive fusional vergence at near (from 12.5 prism diopters to 31.8 prism diopters; P < .001).

CONCLUSIONS

In this pilot study, vision therapy/orthoptics was more effective than pencil push-ups or placebo vision therapy/orthoptics in reducing symptoms and improving signs of convergence insufficiency in children 9 to 18 years of age. Neither pencil push-ups nor placebo vision therapy/orthoptics was effective in improving either symptoms or signs associated with convergence insufficiency.

Validity and reliability of the revised convergence insufficiency symptom survey in adults

PURPOSE

To assess the validity and reliability of the revised Convergence Insufficiency Symptom Survey (CISS) in adults aged 19-30 years. The CISS was developed to be the primary outcome measure for studies evaluating various treatments for convergence insufficiency (CI).

METHODS

CISS mean scores from adults with symptomatic CI and adults with normal binocular vision (NBV) were compared to assess the survey's validity. Adults with symptomatic CI were given the CISS twice to evaluate reliability, which was assessed using intraclass correlation coefficient (ICC) and 95% limits of agreement.

RESULTS

Forty-six adults with CI and 46 adults with NBV participated in the study. The mean CISS score for the CI group was 37.3 (S.D. = 9.3) and 11.0 (S.D. = 8.2) for the NBV group. These mean values were significantly different (p < 0.0001). Good discrimination (sensitivity = 97.8%, specificity = 87%) was obtained using a score of 21 or higher. For the CI group the ICC was 0.885 (95% CI of 0.798, 0.936) and the 95% limits of agreement were -9.0 to 7.6.

CONCLUSIONS

Adults with symptomatic CI had a significantly higher CISS score than adults with NBV. The results of the study demonstrate that the CISS is a valid and reliable instrument that can be used clinically or as an outcome measure for research studies of adults with CI.

Validity and Reliability of the Revised Convergence Insufficiency Symptom Survey in Children Aged 9 to 18 Years

PURPOSE

To assess the validity and reliability of the Convergence Insufficiency Symptom Survey (CISS) in children aged 9 to 18 years. The CISS is the primary outcome measure for a pilot study evaluating two different treatments for convergence insufficiency (CI).

METHODS

Children with CI were given the CISS twice to assess reliability. CISS scores for the first administration were also compared with scores from children with normal binocular vision to assess the validity of the CISS.

RESULTS

Forty-seven children with CI and 56 children with normal binocular vision participated in the study. Reliability was assessed using intraclass correlation and 95% limits of agreement for the children with CI. For children with CI, the intraclass correlation was 0.77 (95% confidence interval, 0.613 to 0.873), and the 95% limits of agreement were -10.2 to +12.1. The mean (+/-SD) CISS score was 30.8 +/- 8.4 for the children with CI and 8.4 +/- 6.4 for the children with normal binocular vision. These means were significantly different (p < 0.0001). Good discrimination (sensitivity, 96%; specificity, 88%) was obtained using a score of >/=16.

CONCLUSIONS

Children with CI showed a significantly higher CISS symptom score than children with normal binocular vision. The results of the study indicate that the CISS is a valid and reliable instrument to use as an outcome measure for children aged 9 to 18 who are enrolled in clinical research concerning CI.

Coherent X-ray diffractive imaging: applications and limitations

The inversion of a diffraction pattern offers aberration-free diffraction-limited 3D images without the resolution and depth-of-field limitations of lens-based tomographic systems, the only limitation being radiation damage. We review our experimental results, discuss the fundamental limits of this technique and future plans.

Post-traumatic pseudomyopia

BACKGROUND

Many clinicians have noted that patients demonstrate a myopic refractive change following Traumatic Brain Injury (TBI). This apparent myopic shift disappears with cycloplegia, yet stubbornly reappears as soon as the pharmaceutical effect wears off. We propose that this shift is secondary to an irritative lesion that affects the parasympathetic innervation, resulting in ciliary body contracture. The dilemma for the clinician is whether to provide the immediate relief of clear distance vision by prescribing additional minus lenses, or to work toward attempting to re-establish the baseline refractive error.

CASE REPORTS

The natural history of post-traumatic pseudomyopia in our experience involves one of the following three courses: (1) a transient condition that will occasionally resolve; (2) the typical case, a recalcitrant condition that will resolve under cycloplegic intervention, but immediately return as the cycloplegic wears off; or (3) a less-common subgroup of patients who continue to show an increase in myopia over time. Our description of these cases demonstrates management strategies (including atropinization) to relax accommodative spasm, traditional vision therapy techniques aimed at loosening the accommodative system, and refractive corrections.

CONCLUSIONS

Pseudomyopia is one of many ocular and behavioral sequelae following TBI. By understanding the natural course and potential management options for post-traumatic pseudomyopia, the clinician will be better prepared to deal with these challenging cases. Flexibility is required, since options that work with one patient may prove ineffective with another. Counseling the patient as to potential outcomes given the natural history of this condition helps establish more-realistic expectations by the patients being treated.

Primary care residents self assessment skills in dementia

The ability to accurately self-assess is a critical component of professionalism and is included in the newly required Accreditation Council of Graduate Medical Education (ACGME) core competencies. To assess residents' ability to accurately self-assess their competencies related to a commonly presenting problem in geriatrics, a Standardized Patient, portraying an individual with early signs of dementia, was inserted into family medicine residents' clinic schedules. Immediately post the encounter, each resident self-assessed his/her performance using a four category (Communication, History of Present Illness, Social History, Functional Assessment), 17-item behavioral checklist. The items in each category highlighted items specific to a dementia-screening interview (e.g., HPI: Used a standardized exam which includes orientation, memory, recall and registration). Resident ratings were compared to ratings from two faculty assessors who independently viewed the videotape of each resident's SP interview. While statistically significant differences between the self-assessment and expert assessors appeared in only one of the four major checklist categories (functional assessment), item specific analysis revealed significant differences on discrete items within the dementia screening interview. Implications for teaching and assessment consistent with the ACGME required competency assessment category of professionalism are discussed.

Laser-tattoo removal--a study of the mechanism and the optimal treatment strategy via computer simulations

BACKGROUND AND OBJECTIVE

The physical mechanisms for laser-tattoo interactions and the tattoo particle breakup process are not well understood. This study investigates whether the mechanism of the breakup process can be identified via computer simulations and proposes a treatment strategy that can potentially minimize the collateral damage to the surrounding tissues. Note that the "removal" of tattoo particles is defined here as breakup of particles into smaller ones with sizes approaching or smaller than the visible wavelength of light so that they become less visible.

STUDY DESIGN/MATERIALS AND METHODS

The radiation-hydrodynamics code LATIS is used for the modeling. We first identify the magnitude of the tensile stress generated inside graphite tattoo particles as functions of laser pulse length and particle size. We then calculate the relationship between the surface laser fluence (defined as the time integrated energy flux) and the tensile strength of the tattoo particle at a given depth.

RESULTS

If the laser pulse length is sufficiently short, strong acoustic waves with tensile strengths exceeding the fracture thresholds for graphite are generated. The strength of the wave decreases with particle size and increases as the laser pulse length decreases. Simulation results are in general agreement with clinical studies. Although temperatures of the tattoo particles never reach the melting point, a cavitation bubble around the particle can be formed. The steam generated can get into the cracked particles and induce steam-carbon reactions. Laser energy density decreases rapidly with the skin depth. Therefore, the minimum surface laser fluence, for a given pulse length, required for breaking up tattoo particles at a given skin depth, increases with particle depth.

CONCLUSIONS

Computer simulations confirm that the breakup of tattoo particles is photoacoustic. For the same amount of laser energy, a shorter pulse is more efficient. The optimal pulse length is approximately 10-100 picosecond to minimize the laser fluence and the collateral damage. It is more difficult to break up the smallest tattoo particles that have diameters smaller than 10 nm; however, smaller particles are less important because they are less visible. Tissue surrounding the tattoo particles can be damaged by cavitation bubbles. These bubbles could be the cause of the empty vacuoles in the ash-white lesions throughout the dermis seen after treatment. Steam-carbon reactions can be induced. Particles then become grossly transparent because of this reaction. Different laser intensity should be used for pigments at different depths in order to minimize the collateral damage to the dermis.

A survey of treatment modalities for convergence insufficiency

BACKGROUND

Convergence insufficiency (CI) is a common and distinct binocular vision disorder. However, there is a lack of consensus regarding the treatment most appropriate for Cl. Possible treatment modalities include base-in prism, pencil pushup therapy (PPT), reading glasses, home-based vision therapy/orthoptics (HBVT), and office-based vision therapy/orthoptics (OBVT). The purpose of this study was to investigate the care process for Cl by surveying eyecare professionals regarding the most common treatment modalities used by both optometrists and ophthalmologists across the United States.

METHODS

Surveys requesting doctors to indicate which treatment(s) they prescribed and believed to be most effective for symptomatic CI patients were mailed to 863 optometrists and 863 ophthalmologists in the United States.

RESULTS

Fifty-eight percent of the optometrists responded to the survey; the most common treatment prescribed was PPT (36%) followed by HBVT (22%) and OBVT (16%). For the ophthalmologists (who had a 23% response rate), the most common treatment prescribed was PPT (50%) followed by HBVT (21 %) and base-in prism (10%).

CONCLUSIONS

This survey suggests that most eyecare practitioners prescribe PPT as the initial treatment for CI.

Spontaneous hydrolysis of 4-trifluoromethylphenol to a quinone methide and subsequent protein alkylation

4-Trifluoromethylphenol (4-TFMP) was cytotoxic to precision-cut rat liver slices as indicated by loss of intracellular potassium. Intracellular glutathione levels decreased and fluoride ion levels increased in a time and concentration-dependent manner. The cytotoxicity of 4-TFMP did not appear to be due to the release of fluoride, however, since equimolar concentrations of sodium fluoride or potassium fluoride were not toxic. The ortho isomer (2-TFMP), which had a threefold slower rate of fluoride release, was much less toxic to liver slices. In incubations without slices, 4-TFMP spontaneously hydrolyzed in aqueous buffer at physiological pH to form 4-hydroxybenzoic acid via a quinone methide intermediate. The quinone methide was trapped by the addition of glutathione. Analysis of the glutathione adduct indicated that all of the fluorine atoms were lost during the hydrolysis, yielding a cresol derivative with the glutathione moiety attached to a benzylic carbonyl group. The glutathione conjugate was the primary product formed at low alkylphenol/glutathione ratios; however, at higher 4-TFMP concentrations additional unidentified products were observed. 4-TFMP also inhibited the in vitro enzyme activity of purlfied glyceraldehyde-3-phosphate dehydrogenase, a sulfhydryl-dependent enzyme, in a time and concentration-dependentmanner. Loss of thiol residues closely paralleled the loss in enzyme activity. The coaddition of glutathione prevented 4-TFMP-induced loss of enzyme activity. The cytotoxicity of 4-TFMP therefore appears to be due to spontaneous quinone methide formation and subsequent alkylation of cellular macromolecules.

Toward a standard of care for treating suicidal outpatients: a survey of social workers' beliefs about appropriate treatment behaviors

This study attempts to establish what reasonable, prudent professionals, named in the standard of care, believe is appropriate treatment for suicidal outpatients. We hope to move toward establishing a standard of care based on actuarial data, rather than after the fact evaluation by experts, judges, and lawyers. Previously, Greaney (1995, doctoral dissertation, Pacific Graduate School, Palo Alto, CA) empirically examined the beliefs of psychologists in appropriately treating suicidal outpatients. Our goal is to broaden the perspective of existing empirical data by examining the beliefs of clinical social workers in treating suicidal outpatients.

Prognostic factors for persons with idiopathic chronic fatigue

BACKGROUND

The simultaneous examination of a large number of patient characteristics in a prospective study of patients with chronic fatigue.

OBJECTIVE

To compare the relative importance of these characteristics as prognostic factors.

METHODS

The data analyzed were from 199 subjects in a registry of persons who were aged 18 years or older and had idiopathic fatigue for at least 6 months. All subjects completed an extensive baseline questionnaire that provided information about fatigue, demographic characteristics, medical conditions, lifestyle, sleeping habits, psychological characteristics, and the presence of criteria for chronic fatigue syndrome. Changes in fatigue severity from baseline to 2-year follow-up were tested for an association with risk factors at baseline and with changes in symptoms other than fatigue during the follow-up period.

RESULTS

The following characteristics at baseline significantly and independently predicted greater fatigue improvement: less unclear thinking, fewer somatoform symptoms not used to define chronic fatigue syndrome, infrequent awakening, fewer hours sleeping, and being married. Of 29 subjects who at baseline reported no somatoform symptoms unrelated to chronic fatigue syndrome and who thought clearly most of the time, 8 substantially improved, compared with 1 of 29 subjects who had more than 2 somatoform symptoms and never thought clearly (P = .01). Improvements in the following symptoms were significantly and independently associated with improvements in fatigue: unclear thinking, depression, muscle aches, and trouble falling asleep.

CONCLUSIONS

This study identified characteristics of subjects that seem to be of prognostic importance for idiopathic chronic fatigue. Symptoms that change concomitantly with changes in fatigue may be intrinsically linked to fatigue.

Characterization of human and murine PMP20 peroxisomal proteins that exhibit antioxidant activity in vitro

We have isolated the cDNAs encoding human and mouse homologues of a yeast protein, termed peroxisomal membrane protein 20 (PMP20). Comparison of the amino acid sequences of human (HsPMP20) and mouse (MmPMP20) PMP20 proteins revealed a high degree of identity (93%), whereas resemblance to the yeast Candida boidinii PMP20A and PMP20B (CbPMP20A and CbPMP20B) was less (30% identity). Both HsPMP20 and MmPMP20 lack transmembrane regions, as do CbPMP20A and CbPMP20B. HsPMP20 mRNA expression was low in human fetal tissues, especially in the brain. In adult tissues, HsPMP20 mRNA was expressed in the majority of tissues tested. HsPMP20 and MmPMP20 contained the C-terminal tripeptide sequence Ser-Gln-Leu (SQL), which is similar to the peroxisomal targeting signal 1 utilized for protein import into peroxisomes. HsPMP20 bound directly to the human peroxisomal targeting signal 1 receptor, HsPEX5. Mutagenesis analysis showed that the C-terminal tripeptide sequence, SQL, of HsPMP20 is necessary for its binding to HsPEX5. Subcellular fractionation of HeLa cells, expressing epitope-tagged PMP20, revealed that HsPMP20 is localized in the cytoplasm and in a particulate fraction containing peroxisomes. Double-staining immunofluorescence studies showed colocalization of HsPMP20 and thiolase, a bona fide peroxisomal protein. The amino acid sequence alignment of HsPMP20, MmPMP20, CbPMP20A, and CbPMP20B displayed high similarity to thiol-specific antioxidant proteins. HsPMP20 exerted an inhibitory effect on the inactivation of glutamine synthetase in the thiol metal-catalyzed oxidation system but not in the nonthiol metal-catalyzed oxidation system, suggesting that HsPMP20 possesses thiol-specific antioxidant activity. In addition, HsPMP20 removed hydrogen peroxide by its thiol-peroxidase activity. These results indicate that HsPMP20 is imported into the peroxisomal matrix via PEX5p and may work to protect peroxisomal proteins against oxidative stress. Because some portion of PMP20 might also be present in the cytosol, HsPMP20 may also have a protective effect in the cytoplasm.

The receptor protein tyrosine phosphatase, PTP-RO, is upregulated during megakaryocyte differentiation and Is associated with the c-Kit receptor

We have recently isolated a cDNA encoding a novel human receptor-type tyrosine phosphatase, termed PTP-RO (for a protein tyrosine phosphatase receptor omicron), from 5-fluorouracil-treated murine bone marrow cells. PTP-RO is a human homologue of murine PTPlambda and is related to the homotypically adhering kappa and mu receptor-type tyrosine phosphatases. PTP-RO is expressed in human megakaryocytic cell lines, primary bone marrow megakaryocytes, and stem cells. PTP-RO mRNA and protein expression are upregulated upon phorbol 12-myristate 13-acetate (PMA) treatment of the megakaryocytic cell lines CMS, CMK, and Dami. To elucidate the function of PTP-RO in megakaryocytic cells and its potential involvement in the stem cell factor (SCF)/c-Kit receptor pathway, COS-7 and 293 cells were cotransfected with the cDNAs of both the c-Kit tyrosine kinase receptor and PTP-RO. PTP-RO was found to be associated with the c-Kit receptor in these transfected cells and the SCF/Kit ligand induced a rapid tyrosine phosphorylation of PTP-RO. Interestingly, these transfected cells demonstrated a decrease in their proliferative response to the SCF/Kit ligand. In addition, we assessed the association of PTP-RO with c-Kit in vivo. The results demonstrated that PTP-RO associates with c-Kit but not with the tyrosine kinase receptor FGF-R and that PTP-RO is tyrosine-phosphorylated after SCF stimulation of Mo7e and CMK cells. Antisense oligonucleotides directed against PTP-RO mRNA sequences significantly inhibited megakaryocyte progenitor proliferation. Therefore, these data show that the novel tyrosine kinase phosphatase PTP-RO is involved in megakaryocytopoiesis and that its function is mediated by the SCF/c-Kit pathway.

Payer cost savings with endometrial ablation therapy

CONTEXT

Dysfunctional uterine bleeding (DUB) is a significant cost burden for payers in the US healthcare system because hysterectomy, the common curative treatment, is associated with high hospitalization costs.

OBJECTIVE

To determine the potential economic benefit to payers of endometrial ablation as an alternate treatment for the benign DUB disorder.

STUDY DESIGN

A retrospective analysis of healthcare claims including the total direct costs to the payer (reimbursement) and patient (copayment). The study was designed to capture all DUB-related claims costs for the entire episode of care from initial diagnosis through follow-up care for 12 months postprocedure.

PATIENTS AND METHODS

Twenty-four months of claims data from premenopausal women aged 25 to 50 years enrolled in a large managed care organization were screened based on relevant diagnostic and procedural codes. Incidence and costs of hysterectomy and ablation were determined, and potential payer savings were calculated based on hypothetical hysterectomy-to-ablation conversion rates of 25% to 50%.

RESULTS

By performing ablation in lieu of hysterectomy for DUB, an average per-case savings of approximately $4,300 is possible. Potential annual payer savings are approximately $515,000 and $1.03 million for a 1-million-member plan, based on the 25% and 50% conversion rates, respectively. The recently approved uterine balloon therapy ablation technique could be instrumental in overcoming current barriers to wider utilization of ablation surgery.

CONCLUSION

If ablation is used in lieu of hysterectomy when medically appropriate, a payer organization could reduce the cost of treating patients with DUB who are not responsive to drug therapy or dilation and curettage alone. Our data suggest that hysterectomy is the most common surgical therapy for this disorder, even though the less invasive endometrial ablation approach is more consistent with accepted DUB treatment guidelines. Payers therefore have an economic incentive to adopt guidelines and reimbursement policies that promote ablation therapy for DUB.

Regulation of the Ca2+ gradient across the sarcoplasmic reticulum in perfused rabbit heart. A 19F nuclear magnetic resonance study

Myocardial contractility depends on Ca2+ release from and uptake into the sarcoplasmic reticulum (SR). The Ca2+ gradient between the SR matrix and the cytosol (SR Ca2+ gradient) is maintained by the SR Ca2+-ATPase using the free energy available from hydrolysis of ATP. The activity of the SR Ca2+-ATPase is not only dependent on the energy state of the cell but is also kinetically regulated by SR proteins such as phospholamban. To evaluate the importance of thermodynamic and kinetic regulation of the SR Ca2+ gradient, we examined the relationship between the energy available from ATP hydrolysis (DeltaGATP) and the energy required for maintenance of the SR Ca2+ gradient (DeltaGCa2+SR) during physiological and pathological manipulations that alter DeltaGATP and the phosphorylation state of phospholamban. We used our previously developed 19F nuclear magnetic resonance method to measure the ionized [Ca2+] in the SR of Langendorff-perfused rabbit hearts. We found that addition of either pyruvate or isoproterenol resulted in an increase in left ventricular developed pressure and an increase in [Ca2+]SR. Pyruvate increased DeltaGATP, and the increase in the SR Ca2+ gradient was matched to the increase in DeltaGATP; DeltaGATP increased from 58.3+/-0.5 to 60.4+/-1.0 kJ/mol (P<0.05), and DeltaGCa2+SR increased from 47.1+/-0.3 to 48.5+/-0.1 kJ/mol (P<0.05). In contrast, the increase in the SR Ca2+ gradient in the presence of isoproterenol occurred despite a decline in DeltaGATP from 58. 3+/-0.5 to 55.8+/-0.6 kJ/mol. Thus, the data indicate that the SR Ca2+ gradient can be increased by an increase in DeltaGATP, and that the positive inotropic effect of pyruvate can be explained by improved energy-linked SR Ca2+ handling, whereas the results with isoproterenol are consistent with removal of the kinetic limitation of phospholamban on the activity of the sarcoplasmic/endoplasmic reticulum Ca2+-ATPase, which allows the SR Ca2+ gradient to move closer to its thermodynamic limit. Ischemia decreases DeltaGATP, and this should also have an effect on SR Ca2+ handling. During 30 minutes of ischemia, DeltaGATP decreased by 12 kJ/mol, but the decrease in DeltaGCa2+SR was 16 kJ/mol, greater than would be predicted by the fall in DeltaGATP and consistent with increased SR Ca2+ release and increased SR Ca2+ cycling. Because ischemic preconditioning is reported to decrease SR Ca2+ cycling during a subsequent sustained period of ischemia, we examined whether ischemic preconditioning affects the relationship between the fall in DeltaGATP and the fall in DeltaGCa2+SR during ischemia. We found that preconditioning attenuated the fall in DeltaGCa2+SR during ischemia; the fall in DeltaGCa2+SR was of comparable magnitude to the fall in DeltaGATP, and this was associated with a significant improvement in functional recovery during reperfusion. The data suggest that there is both thermodynamic regulation of the SR Ca2+ gradient by DeltaGATP and kinetic regulation, which can alter the relationship between DeltaGATP and DeltaGCa2+SR.

Mouse steroid sulfotransferases: substrate specificity and preliminary X-ray crystallographic analysis

Three mouse cytosolic sulfotransferases were expressed in Escherichia coli cells in order to study their substrate specificities toward natural as well as synthetic steroid hormones. The Km and Vmax values confirmed the high substrate specificity of estrogen and hydroxysteroid sulfotransferases toward estradiol and dehydroepiandrosterone, respectively. In sharp contrast, the synthetic estrogen diethylstilbestrol was metabolized efficiently by both enzymes to its disulfate ester. These sulfotransferases display highly stereospecific sulfotransferase activity for sulfating only the trans-isomer of diethylstilbestrol. Crystals suitable for high-resolution structure determination of estrogen sulfotransferase were grown with polyethylene glycol. The crystals belong to the orthorhombic space group P2(1)2(1)2, and diffracted to 2.5 A.

Characterization and chromosomal localization of PTPRO, a novel receptor protein tyrosine phosphatase, expressed in hematopoietic stem cells

Hematopoietic stem cells (HSCs) support blood cells throughout life by utilizing their self-renewing and multilineage differentiating capabilities. Hematopoietic growth factors mediate their effects on stem cells by the tyrosine phosphorylation of proteins. Regulation of tyrosine phosphorylation is partially mediated by protein tyrosine phosphatases (PTPases). A possible mechanism by which hematopoietic stem cells maintain their self-renewing capacity and undifferentiated state is by controlling the balanced and opposing actions of protein tyrosine kinases (PTKs), receptors for growth factors, and PTPases. We have characterized the expression of PTPases in 5-fluorouracil (5-FU)-treated murine bone marrow cells, which represent a very primitive population of progenitors enriched for reconstituting stem cells, by using a consensus polymerase chain reaction (PCR) method. Several PTPases were expressed abundantly in the 5-FU-treated bone marrow stem cells. A novel PTP, termed protein tyrosine phosphatase receptor omicron (PTPRO), which is related to the homotypically adhering kappa, mu and PCP-2 receptor-type tyrosine phosphatases, was identified and characterized. We have cloned the murine and full-length human PTPRO cDNAs which share 89% homology, indicating that PTPRO is highly conserved between these species. The human PTPRO cDNA clone encodes a polypeptide of 1439 amino acids (aa) and has a calculated molecular mass of approximately 162 kDa. PTPRO consists of an extracellular segment containing a MAM domain, an immunoglobulin (Ig) domain, four fibronectin-type III (FN-III) repeats, a transmembrane segment, and two tandem intracellular PTP domains. The human PTPRO gene was assigned to human chromosome 1p35-pter using Southern blot analyses of genomic DNAs from rodent/human somatic hybrid cell lines containing human chromosome 1 or the p35-pter region of the chromosome. The mouse Ptpro gene was mapped to chromosome 4, closely linked to D4Mit16 and Elp1 (elliptocytosis-1), by using genomic DNAs from a (C57BL/6J x Mus spretus)F1 x Mus spretus backcross. In fetal tissues, PTPRO expression was observed in the brain and lung, whereas lower levels were observed in the kidney. In adult tissues, PTPRO was less restricted and was observed in the lung, heart, skeletal muscle, prostate, testis, and in various areas of the brain, indicating that PTPRO expression is developmentally regulated. Expression of PTPRO was also observed in human CD34+ bone marrow cells and 5-FU-treated murine primitive stem cells. These results suggest a potential role for PTPRO in stem cell adhesion and in mediating homophilic cell-cell interactions in other cell types.

Practice guideline for arterial blood gas measurement in the intensive care unit decreases numbers and increases appropriateness of tests

OBJECTIVE

To test the hypothesis that implementation of a practice guideline for blood gas measurement would decrease numbers and increase appropriateness of tests (according to criteria in the guideline) for up to 1 yr after introduction of the guideline.

DESIGN

Numbers of tests and appropriateness of each test were measured retrospectively during each of five periods: two baseline periods 2 yrs and 1 yr before introduction of the guideline and three follow-up periods 2 to 3 months, 6 to 7 months, and 12 to 13 months after introduction of the guideline.

SETTING

A ten-bed multidisciplinary intensive care unit (ICU) within a 500-bed tertiary teaching hospital.

PATIENTS

A random sample of 30 patients admitted to the ICU during each of the periods specified above.

INTERVENTIONS

The nominal group process was used to develop a new guideline and a multipronged educational approach was used to facilitate implementation of the guideline.

MEASUREMENTS AND MAIN RESULTS

At 2 to 3 months, test numbers decreased from 4.9 +/- 1.6 to 3.1 +/- 1.8 (SD) tests/patient/day and to 2.4 +/- 1.2 tests/patient/day at 12 to 13 months. Appropriateness increased from a mean of 44% at baseline to 78% at 2 to 3 months and 79% at 12 to 13 months. There were no differences in Acute Physiology and Chronic Health Evaluation scores or ICU mortality among the patient groups and no differences in number of ventilator days or time to wean from ventilation. Cost-minimization analysis showed that the incremental cost-saving 1 yr after introduction of the guideline was $19.18 per patient per day.

CONCLUSIONS

Implementation of this guideline for arterial blood gas measurement increases efficiency of test utilization without prolonging mechanical ventilation or affecting outcome.

Tyrosine phosphorylation of the related adhesion focal tyrosine kinase in megakaryocytes upon stem cell factor and phorbol myristate acetate stimulation and its association with paxillin

We have characterized signaling pathways involving the related adhesion focal tyrosine kinase (RAFTK, also known as PYK2 or CAK-beta) in CMK human megakaryocytic cells. Stem cell factor, which potentiates the growth of megakaryocytes and their progenitors, and phorbol myristate acetate, which causes differentiation of megakaryocytic cell lines, induced the tyrosine phosphorylation of RAFTK but not of focal adhesion kinase. Stimulation of CMK cells with stem cell factor resulted in an increase in the autophosphorylation and kinase activity of RAFTK. Phosphorylation of RAFTK under these conditions was mediated by a protein kinase C-dependent pathway. Cytochalasin D, which disrupts the cytoskeleton, abolished the phosphorylation of RAFTK upon phorbol myristate acetate and stem cell factor stimulation, indicating that RAFTK association with the actin cytoskeleton appears to be critical for its phosphorylation. In addition, we observed an association of RAFTK with paxillin, a 68-kDa cytoskeleton protein. Using in vitro binding assays, RAFTK and paxillin were shown to bind directly through the C-terminal proline-rich domain. Transient overexpression of a dominant-negative mutant of RAFTK inhibited significantly the tyrosine phosphorylation of paxillin upon phorbol myristate acetate stimulation. These observations indicate that RAFTK might play an important role in the phosphorylation of signaling pathways within the focal adhesions and that RAFTK participates in signaling events that link signals from the cell surface to the cytoskeleton. Furthermore, this study suggests that RAFTK might be involved in megakaryocyte proliferation and differentiation.

Metabolism and toxicity of 4-hydroxyphenylacetone in rat liver slices: comparison with acetaminophen

Acetaminophen is oxidized by cytochrome P450 to a reactive quinone imine, N-acetyl-p-benzoquinone imine, which is thought to be responsible for its hepatotoxic effects. 4-Hydroxyphenylacetone (4-HPA) is a structural analog of acetaminophen in which the amine group is replaced by a methylene group. Following a similar metabolic pathway, 4-HPA would be oxidized to form a reactive quinone methide intermediate. We compared the metabolism and toxicity of 4-HPA and acetaminophen in liver microsomes and precision-cut liver slices from male Sprague-Dawley rats. Both 4-HPA and acetaminophen formed glutathione conjugates in microsomal incubations. 4-HPA formed diastereomeric glutathione conjugates, which is consistent with the formation of an intermediate quinone methide. The rate of conjugate formation with 4-HPA was 8.5-fold greater than that with acetaminophen. In rat liver slices a concentration of 5 mM 4-HPA killed approximately 50% of hepatocytes after 6 hr of incubation, whereas acetaminophen was not toxic at concentrations up to 50 mM. N-Acetylcysteine protected slices from 4-HPA-induced toxicity, whereas phenobarbital enhanced metabolism and toxicity. In summary, 4-HPA is more hepatotoxic than acetaminophen, and this may be the result of differences in the metabolic rate and/or the type of reactive intermediate formed.

Studies on the mechanism of hepatotoxicity of 4-methylphenol (p-cresol): effects of deuterium labeling and ring substitution

We recently observed that 4-methylphenol (p-cresol) is toxic to rat liver tissue slices. A possible mechanism involves biotransformation of 4-methylphenol to a reactive quinone methide intermediate which covalently binds to cellular macromolecules and elicits cytotoxicity. In order to obtain further evidence for this proposed mechanism, we studied the effects of deuterium-labeled 4-methylphenol (4-[alpha, alpha, alpha-d3]-methylphenol), and the presence of various ring substituents, on the metabolism and toxicity of 4-methylphenol in precision cut liver slices prepared from male Sprague-Dawley rats. Deuterium-labeled 4-methylphenol was significantly less toxic than the parent compound in rat liver slices (LC50 = 3.36 vs. 1.31 mM, respectively). In addition, the deuterium-labeled compound was metabolized to a reactive intermediate (measured as glutathione conjugate formation) at a slower rate than that of 4-methylphenol in both liver slices and liver microsomal incubations. The presence of electron withdrawing substituents (2-chloro or 2-bromo) markedly enhanced both metabolism and toxicity, with the exception of 2,6-dibromocresol, which was similar to cresol in terms of rate of metabolism and toxicity. Conversely, the presence of electron donating substituents (2-methoxy, 2-methyl or 2,6-dimethyl) diminished metabolism and toxicity. In addition, methylation of the hydroxyl group to form 4-methylanisole, greatly reduced toxicity. These results support the hypothesis that the toxicity of 4-methylphenol is dependent on the formation of a reactive quinone methide intermediate.

Modulation of megakaryocytopoiesis by human macrophage-stimulating protein, the ligand for the RON receptor

We observed that human megakaryocytes expressed the heterodimeric tyrosine kinase RON, which serves as a receptor for macrophage-stimulating protein (MSP). MSP appears to be structurally related to hepatocyte growth factor (HGF), which is a pleiotropic growth factor for a broad spectrum of tissues and cell types. The effects of human rMSP and rHGF on permanent human megakaryocytic cell lines as well as on human and murine primary marrow megakaryocytes were studied. MSP enhanced the maturation of the primary bone marrow megakaryocytes and human megakaryocytic cell lines, CMK and DAMI, as assessed by an increase in ploidy content. The increase in ploidy was blocked by specific Abs for MSP and by anti-IL-6 Abs. MSP treatment of primary human marrow megakaryocytes, DAMI cells, or CMK cells resulted in enhanced secretion of IL-6. The addition of MSP to cultures of immature murine megakaryoblasts showed a significant growth response, similar to that of exogenous IL-6. This increased growth of immature murine megakaryoblasts in response to MSP was abrogated either by Abs against MSP or by neutralizing mAbs to IL-6. HGF, over a range of concentrations (10 to 100 ng/ml) alone or in combination with IL-3, granulocyte-macrophage-CSF, or IL-6, had no effect on differentiation of human or murine marrow megakaryocytes. These results indicate that megakaryocytes express a novel tyrosine kinase receptor (RON), and that its ligand, MSP, appears capable of regulating megakaryocyte maturation, possibly via an autocrine mechanism mediated by induction of the cytokine IL-6.

Modulation of megakaryocytopoiesis by human macrophage-stimulating protein, the ligand for the RON receptor

We observed that human megakaryocytes expressed the heterodimeric tyrosine kinase RON, which serves as a receptor for macrophage-stimulating protein (MSP). MSP appears to be structurally related to hepatocyte growth factor (HGF), which is a pleiotropic growth factor for a broad spectrum of tissues and cell types. The effects of human rMSP and rHGF on permanent human megakaryocytic cell lines as well as on human and murine primary marrow megakaryocytes were studied. MSP enhanced the maturation of the primary bone marrow megakaryocytes and human megakaryocytic cell lines, CMK and DAMI, as assessed by an increase in ploidy content. The increase in ploidy was blocked by specific Abs for MSP and by anti-IL-6 Abs. MSP treatment of primary human marrow megakaryocytes, DAMI cells, or CMK cells resulted in enhanced secretion of IL-6. The addition of MSP to cultures of immature murine megakaryoblasts showed a significant growth response, similar to that of exogenous IL-6. This increased growth of immature murine megakaryoblasts in response to MSP was abrogated either by Abs against MSP or by neutralizing mAbs to IL-6. HGF, over a range of concentrations (10 to 100 ng/ml) alone or in combination with IL-3, granulocyte-macrophage-CSF, or IL-6, had no effect on differentiation of human or murine marrow megakaryocytes. These results indicate that megakaryocytes express a novel tyrosine kinase receptor (RON), and that its ligand, MSP, appears capable of regulating megakaryocyte maturation, possibly via an autocrine mechanism mediated by induction of the cytokine IL-6.

Identification and characterization of a novel related adhesion focal tyrosine kinase (RAFTK) from megakaryocytes and brain

We have isolated a cDNA encoding a novel human intracytoplasmic tyrosine kinase, termed RAFTK (for a related adhesion focal tyrosine kinase). In addition, we have cloned and characterized the murine homolog of the human RAFTK cDNA. Comparison of the deduced amino acid sequences of human RAFTK and murine Raftk cDNAs revealed 95% homology, indicating that RAFTK is highly conserved between these species. The RAFTK cDNA clone, encoding a polypeptide of 1009 amino acids, has closest homology (48% identity, 65% similarity) to the focal adhesion kinase (pp125FAK). Comparison of the deduced amino acid sequences also indicates that RAFTK, like pp125FAK, lacks a transmembrane region, myristylation sites, and SH2 and SH3 domains. In addition, like pp125FAK, RAFTK contains a kinase domain flanked by large N-terminal (426 residues) and C-terminal (331 residues) domains, and the C-terminal region contains a predicted proline-rich stretch of residues. In fetal tissues, RAFTK expression was abundant in brain, and low levels were observed in lung and liver. In adult tissues, it was less restricted, indicating that RAFTK expression is developmentally up-regulated. Expression of RAFTK was also observed in human CD34+ marrow cells, primary bone marrow megakaryocytes, platelets, and various areas of brain. The human RAFTK gene was assigned to human chromosome 8 using genomic DNAs from human/rodent somatic cell hybrid lines. The mouse Raftk gene was mapped to chromosome 14, closely linked to gonadotropin-releasing hormone. Using specific antibodies for RAFTK, a approximately 123-kDa protein from the human megakaryocytic CMK cell line was immunoprecipitated. Treatment of the megakaryocytic CMK cells with thrombin caused a rapid induction of tyrosine phosphorylation of RAFTK protein. The structural features of RAFTK suggest that it is a member of the focal adhesion kinase gene family and may participate in signal transduction in human megakaryocytes and brain as well as in other cell types.

The importance of periodontal pathogens in guided periodontal tissue regeneration and guided bone regeneration

Although guided tissue regeneration (GTR) procedures in periodontitis lesions and around endosseous dental implants represent exciting new therapeutic modalities in periodontics, these treatments can fail because of shortcomings in surgical techniques, restriction in the size and shape of the defect, anatomic features interfering with surgery, or infectious complications. Our studies show that optimal tissue regeneration cannot be expected for a nonbioabsorbable barrier membrane placed in a site infected by periodontopathic microorganisms. Our data also indicate that treatment failure is most frequent in patients who harbor high levels of periodontal pathogens and show evidence of severe periodontitis in numerous teeth. To decrease the risk of infection and to ensure proper healing, periodontal therapy should precede insertion of the barrier membrane for GTR. Recently, we have studied the effect of the pathogens on periodontal GTR and guided bone regeneration around dental implants and the results are reviewed in this article.

B cell differentiation factor-induced B cell maturation: regulation via reduction in cAMP

We have previously described a novel human B cell differentiation factor (BCDF), 446-BCDF, that is distinct biochemically and functionally from other cytokines. Since signal transduction pathways involved in human B cell differentiation have been incompletely studied and are poorly understood, we assessed the effects of 446-BCDF on various intracellular second messenger systems. After exposure of B cells to 446-BCDF, intracellular cAMP concentration started to decrease at 5 min and was significantly lower at 30 min and reached the lowest level at 4 hr. In most cases, cAMP concentrations returned toward baseline by 24 hr. A cAMP analog (dibutyryl cAMP), a stimulator of adenyl cyclase (forskolin), and phosphodiesterase inhibitors (aminophylline and IBMX) which inhibited the 446-BCDF-induced decrease in intracellular cAMP, inhibited 446-BCDF-induced B cell differentiation, suggesting that the fall in intracellular cAMP was a critical event in this process. To understand the mechanism involved in the reduction of cAMP, B cells were treated with pertussis toxin (PTX), a Gi protein inhibitor. Pertussis toxin blocked 446-BCDF-induced B cell differentiation as well, suggesting that 446-BCDF may function by stimulation of a Gi-linked receptor resulting in the inhibition of adenylate cyclase with a consequent reduction in cAMP. Other cytokines known to promote Ig secretion (IL2 and IL6) also caused a reduction in cAMP, suggesting that this pathway may be generally important in B cell differentiation. Taken together, these data suggest that at least one pathway of terminal maturation in B cells may involve the reduction of intracellular cAMP.

The economic value of contraception: a comparison of 15 methods

OBJECTIVES

The purpose of the study was to determine the clinical and economic impact of alternative contraceptive methods.

METHODS

Direct medical costs (method use, side effects, and unintended pregnancies) associated with 15 contraceptive methods were modeled from the perspectives of a private payer and a publicly funded program. Cost data were drawn from a national claims database and MediCal. The main outcome measures included 1-year and 5-year costs and number of pregnancies avoided compared with use of no contraceptive method.

RESULTS

All 15 contraceptives were more effective and less costly than no method. Over 5 years, the copper-T IUD, vasectomy, the contraceptive implant, and the injectable contraceptive were the most cost-effective, saving $14,122, $13,899, $13,813, and $13,373, respectively, and preventing approximately the same number of pregnancies (4.2) per person. Because of their high failure rates, barrier methods, spermicides, withdrawal, and periodic abstinence were costly but still saved from $8933 to $12,239 over 5 years. Oral contraceptives fell between these groups, costing $1784 over 5 years, saving $12,879, and preventing 4.1 pregnancies.

CONCLUSIONS

Contraceptives save health care resources by preventing unintended pregnancies. Up-front acquisition costs are inaccurate predictors of the total economic costs of competing contraceptive methods.

Quinone methide formation from para isomers of methylphenol (cresol), ethylphenol, and isopropylphenol: relationship to toxicity

The oxidative metabolism and toxicity of the para isomers of methylphenol (cresol), ethylphenol, and isopropylphenol were studied using male Sprague-Dawley rat liver microsomes and precision-cut liver slices. Reactive intermediates from each compound were trapped using radiolabeled glutathione and were detected and quantified by HPLC. Conjugates were collected and their structures determined by fast atom bombardment mass spectrometry and proton nuclear magnetic resonance. During microsomal incubations each test compound formed monoglutathione conjugates with structures which are consistent with the formation of quinone methide intermediates. In each case the glutathione moiety was attached to the benzylic carbon on the alkyl side chain of the phenol. With ethylphenol, which has a prochiral benzylic carbon, two isomeric conjugates were detected. The rate of formation of the glutathione conjugates in liver slice incubations was 4-isopropylphenol > 4-ethylphenol > 4-methylphenol. This correlated with the toxicity of the three compounds in liver slices. At equimolar concentrations 4-isopropylphenol was the most toxic while 4-methylphenol was the least toxic. Depletion of intracellular glutathione was observed in the presence of each test compound which preceded cell death. Enhancement of cellular thiol levels with N-acetylcysteine protected cells from the toxic effects of all three compounds as did inhibition of cytochrome P450 activity with metyrapone. These results suggest the formation of quinone methide intermediates from three alkylphenols during oxidative metabolism and demonstrate a correlation between the amount of reactive intermediate formed and toxicity observed in liver slices.

Cytokine production by primary bone marrow megakaryocytes

Primary human bone marrow megakaryocytes were studied for their ability to express and release cytokines potentially relevant to their proliferation and/or differentiation. The purity of the bone marrow megakaryocytes was assessed by morphologic and immunocytochemical criteria. Unstimulated marrow megakaryocytes constitutively expressed genes for interleukin-1 beta (IL-1 beta), IL-6, granulocyte-macrophage colony-stimulating factor (GM-CSF), and tumor necrosis factor-alpha (TNF-alpha), by the polymerase chain reaction (PCR) and Northern blot analysis. At the protein level, megakaryocytes secreted significant amounts of IL-1 beta (53.6 +/- 3.6 pg/mL), IL-6 (57.6 +/- 15.6 pg/mL), and GM-CSF (24 +/- 4 pg/mL) but not TNF-alpha. Exposure of human marrow megakaryocytes to IL-1 beta increased the levels of IL-6 (87.3 +/- 2.3 pg/mL) detected in the culture supernatants. Transforming growth factor-beta was also able to stimulate IL-6, IL-1 beta, and GM-CSF secretion, but was less potent than stimulation with phorbol-12-myristate-13-acetate (PMA). The secreted cytokines acted additively to maintain and increase the number of colony-forming unit-megakaryocytes colonies (approximately 35%). These studies demonstrate the production of multiple cytokines by isolated human bone marrow megakaryocytes constitutively or stimulated in vitro. The capacity of human megakaryocytes to synthesize several cytokines known to modulate hematopoietic cells supports the concept that there may be an autocrine mechanism operative in the regulation of megakaryocytopoiesis.

Identification and characterization of a novel tyrosine kinase from megakaryocytes

Protein-tyrosine kinases play pivotal roles in cell signal transduction. We have isolated a cDNA clone encoding a novel human intracytoplasmic tyrosine kinase, termed matk (megakaryocyte-associated tyrosine kinase). Expression of matk mRNA was predominantly found in cells of megakaryocytic lineage. The matk cDNA clone encodes a polypeptide of 527 amino acids and has closest sequence similarity to the csk tyrosine kinase. Sequence comparisons also indicate that matk contains src homology region 2 and 3 domains but lacks the NH2-terminal myristylation signal, the negative regulatory tyrosine (Tyr-527), and the autophosphorylation site (Tyr-416) corresponding to those found in src. Antibodies raised against the NH2 terminus of matk immunoprecipitated a 60-kDa protein from the CMK human megakaryocyte cell line. Expression of matk mRNA was up-regulated in megakaryocytic cells induced to differentiate by the phorbol ester. Based on its restriction in expression and its modulation during in vitro differentiation, it is likely that matk participates in signal transduction during megakaryocytopoiesis.

Soft opaque contact lenses in binocular vision problems

Soft opaque contact lenses may be useful in certain recalcitrant vision problems. When the full central area is opaque, contact lenses eliminate the visual image, provide acceptable cosmesis, and may be useful in cases of intractable diplopia as well as in the treatment of amblyopia. Artificial iris contact lenses eliminate para-axial rays in monocular diplopia, aniridia, and albinism.

Differences in pattern visual evoked potential (PVEP) between hemodialysis and peritoneal dialysis patients

The visual evoked potential was recorded in peritoneal and hemodialysis patients as compared to normal controls. By using the appropriate visual stimulus we were able to disclose specific VEP abnormalities for each of the two dialysis groups. The dissociation found between the latency of N70 and P100 in peritoneal dialysis patients suggests a possible postsynaptic visual abnormality not described previously. The correlation between the high serum aluminum and the P100 latency of peritoneal dialysis patients requires further investigation.