Stillbirths: Contribution of preterm birth and size-for-gestational age for 125.4 million total births from nationwide records in 13 countries, 2000-2020

OBJECTIVE

To examine the contribution of preterm birth and size-for-gestational age in stillbirths using six 'newborn types'.

DESIGN

Population-based multi-country analyses.

SETTING

Births collected through routine data systems in 13 countries.

SAMPLE

125 419 255 total births from 22+0 to 44+6 weeks' gestation identified from 2000 to 2020.

METHODS

We included 635 107 stillbirths from 22+0  weeks' gestation from 13 countries. We classified all births, including stillbirths, into six 'newborn types' based on gestational age information (preterm, PT, <37+0  weeks versus term, T, ≥37+0  weeks) and size-for-gestational age defined as small (SGA, <10th centile), appropriate (AGA, 10th-90th centiles) or large (LGA, >90th centile) for gestational age, according to the international newborn size for gestational age and sex INTERGROWTH-21st standards.

MAIN OUTCOME MEASURES

Distribution of stillbirths, stillbirth rates and rate ratios according to six newborn types.

RESULTS

635 107 (0.5%) of the 125 419 255 total births resulted in stillbirth after 22+0  weeks. Most stillbirths (74.3%) were preterm. Around 21.2% were SGA types (PT + SGA [16.2%], PT + AGA [48.3%], T + SGA [5.0%]) and 14.1% were LGA types (PT + LGA [9.9%], T + LGA [4.2%]). The median rate ratio (RR) for stillbirth was highest in PT + SGA babies (RR 81.1, interquartile range [IQR], 68.8-118.8) followed by PT + AGA (RR 25.0, IQR, 20.0-34.3), PT + LGA (RR 25.9, IQR, 13.8-28.7) and T + SGA (RR 5.6, IQR, 5.1-6.0) compared with T + AGA. Stillbirth rate ratios were similar for T + LGA versus T + AGA (RR 0.7, IQR, 0.7-1.1). At the population level, 25% of stillbirths were attributable to small-for-gestational-age.

CONCLUSIONS

In these high-quality data from high/middle income countries, almost three-quarters of stillbirths were born preterm and a fifth small-for-gestational age, with the highest stillbirth rates associated with the coexistence of preterm and SGA. Further analyses are needed to better understand patterns of gestation-specific risk in these populations, as well as patterns in lower-income contexts, especially those with higher rates of intrapartum stillbirth and SGA.

Neonatal mortality risk of large-for-gestational-age and macrosomic live births in 15 countries, including 115.6 million nationwide linked records, 2000-2020

OBJECTIVE

We aimed to compare the prevalence and neonatal mortality associated with large for gestational age (LGA) and macrosomia among 115.6 million live births in 15 countries, between 2000 and 2020.

DESIGN

Population-based, multi-country study.

SETTING

National healthcare systems.

POPULATION

Liveborn infants.

METHODS

We used individual-level data identified for the Vulnerable Newborn Measurement Collaboration. We calculated the prevalence and relative risk (RR) of neonatal mortality among live births born at term + LGA (>90th centile, and also >95th and >97th centiles when the data were available) versus term + appropriate for gestational age (AGA, 10th-90th centiles) and macrosomic (≥4000, ≥4500 and ≥5000 g, regardless of gestational age) versus 2500-3999 g. INTERGROWTH 21st served as the reference population.

MAIN OUTCOME MEASURES

Prevalence and neonatal mortality risks.

RESULTS

Large for gestational age was common (median prevalence 18.2%; interquartile range, IQR, 13.5%-22.0%), and overall was associated with a lower neonatal mortality risk compared with AGA (RR 0.83, 95% CI 0.77-0.89). Around one in ten babies were ≥4000 g (median prevalence 9.6% (IQR 6.4%-13.3%), with 1.2% (IQR 0.7%-2.0%) ≥4500 g and with 0.2% (IQR 0.1%-0.2%) ≥5000 g). Overall, macrosomia of ≥4000 g was not associated with increased neonatal mortality risk (RR 0.80, 95% CI 0.69-0.94); however, a higher risk was observed for birthweights of ≥4500 g (RR 1.52, 95% CI 1.10-2.11) and ≥5000 g (RR 4.54, 95% CI 2.58-7.99), compared with birthweights of 2500-3999 g, with the highest risk observed in the first 7 days of life.

CONCLUSIONS

In this population, birthweight of ≥4500 g was the most useful marker for early mortality risk in big babies and could be used to guide clinical management decisions.

Understanding ethnic inequalities in stillbirth rates: a UK population-based cohort study

OBJECTIVES

To investigate inequalities in stillbirth rates by ethnicity to facilitate development of initiatives to target those at highest risk.

DESIGN

Population-based perinatal mortality surveillance linked to national birth and death registration (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK).

SETTING

UK.

PARTICIPANTS

4 391 569 singleton births at ≥24⁺⁰ weeks gestation between 2014 and 2019.

MAIN OUTCOME MEASURES

Stillbirth rate difference per 1000 total births by ethnicity.

RESULTS

Adjusted absolute differences in stillbirth rates were higher for babies of black African (3.83, 95% CI 3.35 to 4.32), black Caribbean (3.60, 95% CI 2.65 to 4.55) and Pakistani (2.99, 95% CI 2.58 to 3.40) ethnicities compared with white ethnicities. Higher proportions of babies of Bangladeshi (42%), black African (39%), other black (39%) and black Caribbean (37%) ethnicities were from most deprived areas, which were associated with an additional risk of 1.50 stillbirths per 1000 births (95% CI 1.32 to 1.67). Exploring primary cause of death, higher stillbirth rates due to congenital anomalies were observed in babies of Pakistani, Bangladeshi and black African ethnicities (range 0.63-1.05 per 1000 births) and more placental causes in black ethnicities (range 1.97 to 2.24 per 1000 births). For the whole population, over 40% of stillbirths were of unknown cause; however, this was particularly high for babies of other Asian (60%), Bangladeshi (58%) and Indian (52%) ethnicities.

CONCLUSIONS

Stillbirth rates declined in the UK, but substantial excess risk of stillbirth persists among babies of black and Asian ethnicities. The combined disadvantage for black, Pakistani and Bangladeshi ethnicities who are more likely to live in most deprived areas is associated with considerably higher rates. Key causes of death were congenital anomalies and placental causes. Improved strategies for investigation of stillbirth causes are needed to reduce unexplained deaths so that interventions can be targeted to reduce stillbirths.

Standard of living in the retirement survey: A predictor of six-year functional limitation onset and mortality in women, but not in men from ages 55 – 69 years

PURPOSE

To investigate the predictive validity for health decline of a standard of living, a measure that combines basic necessities and consumer durables.

METHOD

A nationally representative sample of those aged 55-69 years was interviewed at home in the Great Britain Retirement and Retirement Plans Survey, (1988; n=3,541). In 1994, 2,247 were re-interviewed, response rate being 70% of survivors. Relationships between socioeconomic status and health decline were investigated using polytomous logistic regression modelling. The outcomes were onset of functional limitation and mortality.

RESULTS

Standard of living was an independent predictor of 6-year functional limitation onset (Odds Ratio compared to good standard of living 2.2; 95% Confidence Interval 1.3-3.8) and mortality (OR=4.6; 95% CI 2.3-8.9) in women, with age, household type, educational qualifications and social class taken into account. However, in men, weaker associations were largely accounted for by differences in education and social class (adjusted OR for functional limitation onset 1.0; 95% CI 0.5-1.9; adjusted OR for mortality 1.4; 95% CI 0.6-2.9). A combined indicator of housing tenure and property value was also an independent predictor of functional limitation onset in women.

CONCLUSIONS

Poor standard of living identifies women but not men at risk of health decline who are missed by social class and educational level. Measures of current home-based material resources are a useful addition to minimum datasets for monitoring health inequalities.

Cohort differences in disease and disability in the young-old: findings from the MRC Cognitive Function and Ageing Study (MRC-CFAS)

Background

Projections of health and social care need are highly sensitive to assumptions about cohort trends in health and disability. We use a repeated population-based cross-sectional study from the Cambridgeshire centre of the UK Medical Research Council Cognitive Function and Ageing Study to investigate trends in the health of the young-old UK population

Methods

Non-overlapping cohorts of men and women aged 65–69 years in 1991/2 (n = 689) and 1996/7 (n = 687) were compared on: self-reported diseases and conditions; self-rated health; mobility limitation; disability by logistic regression and four-year survival by Cox Proportional Hazards Regression models, with adjustments for differences in socio-economic and lifestyle factors.

Results

Survival was similar between cohorts (HR: 0.91, 95% CI: 0.62 to 1.32). There was a significant increase in the number of conditions reported between cohorts, with more participants reporting 3 or more conditions in the new cohort (14.2% vs. 10.1%). When individual conditions were considered, there was a 10% increase in the reporting of arthritis and a significant increase in the reporting of chronic airways obstruction (OR: 1.36, 95% CI: 1.04 to 1.78).

Conclusion

This study provides evidence of rising levels of ill-health, as measured by the prevalence of self-reported chronic conditions, in the newer cohorts of the young-old. Though changes in diagnosis or reporting of disease cannot, as yet, be excluded, to better understand whether our findings reflect real increases in ill-health, investment should be made into improved population-based databases, linking self-report and objective measures of health and function, and including those in long-term care.

The association of diet and other lifestyle factors with the onset of overactive bladder: a longitudinal study in men

Objective:

To investigate associations between diet and non-dietary lifestyle factors and the onset of overactive bladder (OAB) in men.

Subjects:

Random sample of community-dwelling men aged 40 years plus.

Design and methods: Baseline data on urinary symptoms and diet were collected from 5454 men using a postal questionnaire and a food-frequency questionnaire. Follow-up data on urinary symptoms were collected from 4887 men in a postal survey one year later. Logistic regression analysis was used to investigate diet and lifestyle factors associated with onset of OAB in the men without OAB at baseline.

Results:

There was a highly significant negative association between beer intake at baseline and subsequent OAB onset (P = 0.001), with reduced risk at all levels of intake compared with those who seldom/never drank beer. Adjustment for total alcohol intake (g ethanol day−1) reduced the significance of the association (P = 0.02). None of the food groups studied was associated with OAB onset, with the possible exception of potatoes (P = 0.05), which showed an increased risk of onset at the highest level of consumption. Physical activity, smoking and obesity were not significantly associated.

Conclusions:

While most diet and lifestyle factors were not associated with OAB onset, the evidence from this prospective longitudinal study suggests that beer may have a protective role in the development of OAB. This could be due to a non-alcoholic ingredient as well as the alcohol content.

Protein tyrosine phosphatases as negative regulators of the immune response

In this mini-review, we provide an overview of those PTPs (protein tyrosine phosphatases) that are relevant to the immune response, highlighting the function of a number of intracellular and transmembrane PTPs that have been identified as having important negative regulatory roles on distinct aspects of host immunity.

Does socio-economic advantage lead to a longer, healthier old age?

The effect of socio-economic disadvantage on mortality is well documented and differences exist even at older ages. However, whether this translates into differences in the quality of life lived at older ages is less well studied, and in particular in the proportion of remaining life spent without ill health (healthy life expectancy), a key UK Government target. Although there have been studies exploring socio-economic differences in disability-free life expectancy (DFLE) worldwide, these have tended to focus on a single measure of socio-economic advantage, for example, education, race, social class or income, with the majority based on cross-sectional data from younger populations. In this prospective study we examine differences in DFLE and total life expectancy (TLE) at older ages using a range of measures of socio-economic advantage. We use a longitudinal study of 1480 participants aged 75 years or over in 1988 registered with a UK primary care practice, who were followed up until 2003 with measurements at up to seven time points. Disability was defined as difficulty with any one of five activities of daily living. The largest differences in DFLE for both men and women were found for housing tenure. Women aged 75 years living in owned or mortgaged property could expect to live 1 year extra without disability compared with those living in rented accommodation, while for men the difference was almost 1.5 years. The effect of socio-economic advantage on disability-free and total life expectancies appeared to be larger for men than women. In women, socio-economic advantage had more effect on DFLE than total life expectancy for all indicators considered, thus the socio-economically advantaged experienced a compression of disability.

The natural history of overactive bladder and stress urinary incontinence in older women in the community: A 3-year prospective cohort study

AIMS

This is the first study designed to describe the natural history of stress urinary incontinence (SUI) and overactive bladder (OAB), using validated symptom syndrome severity scores developed for the purpose.

METHODS

Two separate but related studies were involved, (i) a clinic sample (N = 2,052) from a randomised controlled trial (RCT) and (ii) a prospective cohort study (N = 12,750) with 3-year follow-up. Subjects in both studies were women aged 40 or more living in the community, approached using similar postal questionnaires. Severity scores using standardised urinary symptoms were derived for SUI and OAB from weightings obtained from logistic regression models of symptoms in relation to urodynamic diagnosis. Symptom severity scores were plotted for baseline and 3 years of follow-up to demonstrate the natural history of the main categories of SUI and OAB.

RESULTS

Overactive bladder and SUI syndrome severity scores showed good criterion validity in relation to relevant clinical measures and good test-retest reliability. OAB severity increased progressively with age including a period of accelerated increase in the 60s. In contrast, SUI severity showed two age-related peaks around age 60 and again at age 80. SUI severity also showed a more fluctuating pattern from year to year compared to OAB.

CONCLUSIONS

Contrasting patterns of natural history for OAB and SUI syndromes were identified consistent with differences in the patterns of related co-morbidities. Further studies are needed to confirm these findings.

Socioeconomic factors associated with the onset of disability in older age: a longitudinal study of people aged 75 years and over

Although the association between socioeconomic status and mortality is well documented, there is less work focusing on the association with morbidity in older people. This is partly due to the difficulties of measuring socioeconomic status at older ages. The work that does exist tends to use cross-sectional data and objective measures of socioeconomic status such as education, social class or income. However, these standard measures may be less relevant for older people. In this study, we explore the association between socioeconomic status and disability in older people using a range of individual, household and area level indicators of socioeconomic status, including a subjective measure of adequacy of income. We use cross-sectional data of 1470 participants aged 75 years or over on 31/12/1987 and registered with a UK primary care practice. Of these 719 participants with no disability at baseline were followed up until 2003 with measurements at up to seven time points to determine onset of disability. Disability was defined as difficulty with any one of five activities of daily living. In cross-sectional multivariate analysis, age, housing tenure, living status and a subjective measure of income adequacy were associated with prevalence of disability. In longitudinal analyses, self-perceived adequacy of income showed the strongest association with onset of disability; with those reporting difficulties managing having a median age of onset 80.5 years, 7 years younger than those who felt their income was adequate (median age 87.8 years). The prospective association between self-perceived adequacy of income and onset of disability decreased with age. This subjective measure of income adequacy may signify difficulties in budgeting, but could also capture differences in objective indicators of status not recorded in this study, such as wealth. Further work is needed to explore what causes older people to experience difficulty in managing their money and to understand the mechanisms behind its impact on their physical health.

Diseases and Impairments as Risk Factors for Onset of Disability in the Older Population in England and Wales: Findings From the Medical Research Council Cognitive Function and Ageing Study

BACKGROUND

This paper reports the association between self-reported diseases and impairments and 2-year onset of disability in a prospective study of people aged 65 years or older in five urban and rural centers in England and Wales (Medical Research Council Cognitive Function and Ageing Study; MRC-CFAS).

METHODS

We initially reviewed risk factors for onset of disability in 35 prospective studies of functional decline in older people published in 1998-2001. In the present study, disability was defined as requiring help from another person at least several times a week and was assessed by dependency in activities of daily living. Polytomous and bivariate logistic regression models were fitted for onset of disability and mortality among those nondisabled at baseline (n=7913), adjusting for age, sex, and sociodemography.

RESULTS

Among prevalent conditions, arthritis (population-attributable risk 11.4%) and cognitive impairment indicated by a Mini-Mental State Examination score of <or=21 (population-attributable risk 6.8%) were powerful predictors of incident disability. Baseline cognitive impairment, stroke, treated diabetes, chronic airways obstruction, coronary heart disease, and treated hypertension were significantly associated with both incident disability and mortality, whereas Parkinson's disease, eyesight problems, and arthritis were statistically significant disabling conditions not associated with mortality. Stroke, heart attack, cognitive impairment, eyesight problems, and hearing problems were newly occurring conditions significantly associated with onset of disability.

CONCLUSIONS

Cognitive impairment, arthritis, followed by stroke, and problems with vision have major impact on population disability at older ages. Both prevalent and incident conditions must be considered as risk factors to accurately assess potential benefits from prevention.

Relationship between urinary symptoms reported in a postal questionnaire and urodynamic diagnosis

AIMS

To describe the relationship between symptoms reported in a self-completed postal questionnaire and urinary disorders based on urodynamic investigation.

METHODS

The study population was selected from women aged 40 years or over living in the community, who responded to a postal questionnaire. Following assessment and appropriate conservative interventions, those with a pre-defined level of severity of symptoms were offered urodynamic investigation. Logistic regression examined the association between urinary symptoms and the urodynamic diagnoses of detrusor overactivity (DO) and urodynamic stress incontinence (USI).

RESULTS

Four hundred eighty-eight women completed urodynamic investigation; 29.1% (142/488) were found to have DO, 33.6% (164/488) USI, 20.7% (101/488) mixed incontinence, and 16.6% (81/488) no urodynamic abnormality. Stress incontinence (SI) and urge incontinence (UI) were included in the risk model for USI. SI reported monthly or more was associated with increased risk of USI, and UI reported weekly or more with decreased risk (sensitivity 76.9%; specificity 56.3%; positive predictive value (PPV) 67.8%). For DO, strong or overwhelming urgency, UI monthly or more, and nocturia once a night or more were all significantly associated with an increased risk while reporting of SUI monthly or more reduced the risk (sensitivity 63.1%; specificity 65.1%; PPV 63.1%).

CONCLUSIONS

Urinary symptoms reported in a postal questionnaire are able to predict urodynamic diagnoses with moderate accuracy. These models may be useful tools with which to categorize urinary disorders for epidemiological study and, with further development, allocate first line treatment.

Continence nurse treatment of women's urinary symptoms

The aim of this study was to establish how accurately a trained continence nurse could allocate appropriate second-line conservative treatment to women without urodynamic investigations. Depending on the number of patients coming taking up the service, there were between five and 12 nurses operating at any one time. Women aged 40 years and over, of which there were 2421 reporting lover urinary tract symptoms, were randomly allocated to a new nurse-led continence service. Of these women, 450 subsequently underwent urodynamic investigation, before which the nurses documented which second-line conservative treatment would be appropriate. The results showed that of all women with detrusor overactivity, 79.1% were correctly allocated anticholinergic treatment, and 64.8% were allocated pelvic floor exercises (PFE). Of all women with urodynamic stress incontinence, 88.8% were allocated only one treatment. This study showed that a trained continence nurse is able to allocate conservative treatment appropriately to the majority of women without the need for urodynamic investigation. This indicated that the management of urinary dysfunction by a team of trained, dedicated nurses has the potential to reduce waiting lists for urodynamic investigation, avoid unnecessary investigations and achieve greater patient satisfaction.

Storage symptoms of the bladder: prevalence, incidence and need for services in the UK

OBJECTIVE

To establish valid and reliable prevalence and incidence rates for urinary incontinence and storage disorder, and estimate the extent of healthcare need and requirement for the UK.

SUBJECTS AND METHODS

This was a cross-sectional and longitudinal population-based study involving registrants with 108 general practices in Leicestershire and Rutland counties (UK). In all, 162 533 (prevalence study) and 39 602 (incidence study) people aged > or = 40 years were approached by postal questionnaire, with response rates of 60% and 63%, respectively; 1050 non-responders were followed up. The main measures were incontinence (involuntary leakage) storage disorder (including incontinence or urgency or frequency or nocturia above clinically defined thresholds), storage symptoms (as for storage disorder, above epidemiologically defined thresholds), professionally defined healthcare need (storage disorder, or storage symptoms with an impact on quality of life, QoL), and healthcare requirement (using services or wanting help among those with a healthcare need), all within the last year.

RESULTS

The period prevalence was: moderate or greater incontinence, 16.1%; storage disorder, 28.5%; storage symptoms with impact on QoL, 30.4%; healthcare need, 37.1% and requirement 20.4%. Among those with storage disorders 81% reported effects on QoL. Annual incidence rates were: incontinence, 6.3%; storage disorder, 14.1%; healthcare need, 15.6% and requirement 8.4%. The remission rates were substantially greater in men than women. The problem becomes increasingly established and less likely to remit with age.

CONCLUSIONS

In the UK over a 1-year period, over a third of people aged > or = 40 years are estimated to have a healthcare need for urinary storage symptoms (i.e. 9 million) and a fifth (i.e. 5 million) are estimated to require healthcare, with unmet requirement affecting 3 million. This represents a major public health problem. Apparent inconsistencies between prevalence, impact and uptake of services are explained.

Nutrient composition of the diet and the development of overactive bladder: A longitudinal study in women

AIMS

Evidence for an association between diet and the symptom syndrome overactive bladder (OAB) would be valuable in understanding its aetiology. The present study investigates prospectively the association between the nutrient composition of the diet and the onset of OAB.

METHODS

A random sample of community dwelling women aged 40 years or over was studied. Baseline data on urinary symptoms and diet were collected from 6,371 women using a postal questionnaire and food frequency questionnaire. Follow-up data on urinary symptoms were collected from 5,816 of the women in a postal survey 1 year later. Logistic regression was used to investigate the association of diet (daily intakes of energy, macro and micronutrients) with 1 year incidence of OAB.

RESULTS

There was evidence that three nutrients may be associated with OAB onset. Higher intakes of vitamin D (P = 0.008), protein (P = 0.03), and potassium (P = 0.05) were significantly associated with decreased risks of onset. Although overall the associations with vitamin B6 and niacin were not significant (P = 0.08 and P = 0.13), there was some evidence of a decreased risk of onset with higher intakes.

CONCLUSIONS

The results from this prospective study suggest possible aetiological associations between certain nutrients and OAB onset. The findings need confirmation and possible mechanisms to explain these associations need further investigation.

Validity and reliability of a questionnaire to measure the impact of lower urinary tract symptoms on quality of life: The Leicester impact scale

AIMS

To develop a condition specific quality of life measure for males and females with urinary storage symptoms of urgency, frequency, nocturia and incontinence.

MATERIALS AND METHODS

A sample of community dwelling males and females aged 40 years or more who were taking part in an epidemiological study provided data for development and validation of the scale. Questions were developed from literature review and discussions with clinicians and patients. Inclusion of items was dependent on levels of missing data and principal components analysis. Validity was assessed by comparison with the Hospital Anxiety and Depression Scale, the Bradburn Negative Affect Scale and single questions concerning the problematic nature of symptoms. Construct validity was assessed by comparing cases and non-cases, and patients with different symptom patterns. Test-retest and inter-rater reliability statistics were calculated for individual items. Responsiveness to change was measured in subjects taking part in a randomised controlled trial of a nursing intervention.

RESULTS

The scale showed high levels of internal consistency and measures of construct validity were as hypothesised. Test-retest and inter-rater reliability was moderate to excellent. The distribution of scores was skewed with low levels of impact but the questionnaire was responsive to conservative treatments in patients receiving a nursing intervention.

CONCLUSIONS

The questionnaire proved to be a valid and reliable interviewer administered instrument for measuring impact of urinary symptoms.

The association of diet and other lifestyle factors with overactive bladder and stress incontinence: a longitudinal study in women

OBJECTIVES

To investigate the role of diet and other lifestyle factors in the incidence of overactive bladder and stress incontinence in women. Studies have suggested relationships between different aspects of lifestyle and symptoms of urinary incontinence, but there is a lack of firm evidence about their role in its cause.

SUBJECTS AND METHODS

A random sample of women aged >or= 40 years living at home took part in a prospective cohort study. Baseline data on urinary symptoms, diet and lifestyle were collected from 7046 women using a postal survey and food-frequency questionnaire. Follow-up data on urinary symptoms were collected from 6424 of the women in a postal survey 1 year later. Logistic regression was used to investigate the association of food and drink consumption and other lifestyle factors with the incidence of overactive bladder and stress incontinence.

RESULTS

In the multivariate model for the onset of an overactive bladder, there were significantly increased risks associated with obesity, smoking and consumption of carbonated drinks, and reduced risks with higher consumption of vegetables, bread and chicken. Obesity and carbonated drinks were also significant risk factors for the onset of stress incontinence, while consumption of bread was associated with a reduced risk.

CONCLUSIONS

Causal associations with obesity, smoking and carbonated drinks are confirmed for bladder disorders associated with incontinence, and additional associations with diet are suggested. Behavioural modification of lifestyle may be important for preventing and treating these disorders.

An investigation into nonresponse bias in a postal survey on urinary symptoms

OBJECTIVE

To investigate nonresponse bias in a postal survey on urinary symptoms in people aged >or= 40 years.

SUBJECTS AND METHODS

Nonresponders to a postal survey on incontinence and other urinary symptoms were studied. A random sample of 1050 nonresponders (stratified for age and sex) was traced by a team of interviewers. Eligible nonresponders were asked several questions from the postal questionnaire, and their reason for not participating in the postal survey.

RESULTS

Only 1% of those not responding were not traced in person or accounted for, and 12% were identified as not eligible to be in the survey sample (moved from address, deceased, residential home). Half of the eligible nonresponders (51%) did not answer the interviewer's questions, the main reason being general unwillingness or disinterest. The number in whom poor health was the reason increased with age. Comparing nonresponders who answered the interviewer's questions with a random sample of responders from the postal survey showed little difference in the reporting of urinary symptoms, although there were differences in general health and long-term health problems. Separate analyses by age showed greater reporting of some urinary symptoms and of poorer general health in the older nonresponders (>or= 70 years).

CONCLUSION

Overall, for people aged >or= 40 years there was no evidence of a nonresponse bias in the reporting of urinary symptoms, providing confidence in such prevalence rates. However, poorer general health and greater reporting of some urinary symptoms by the older nonresponders (>or= 70 years) suggests prevalence rates in this age group may be underestimated.

Improving uptake of influenza vaccination among older people: a randomised controlled trial

BACKGROUND

The uptake of influenza vaccination among older people is suboptimal. Contact with a doctor or nurse is associated with older people deciding to accept influenza vaccination.

AIM

To compare different forms of approach in improving uptake of influenza vaccination among patients aged 75 years and over in primary care.

DESIGN OF STUDY

Randomised controlled trial.

SETTING

One large rural general practice serving the town and surrounding area of Melton Mowbray, Leicestershire.

METHOD

All 2,052 patients aged 75 years and over, registered with the practice and not living in nursing/residential homes or sheltered accommodation, were included in the study. One-third of patients were randomised to receive an offer of influenza vaccination as part of an over-75 health check administered by a practice nurse in the patient's home, and two-thirds of patients were randomised to receive a personal letter of invitation to attend an influenza vaccination clinic held at the surgery. The main outcome measure was uptake of influenza vaccination.

RESULTS

Six hundred and eighty patients were randomised to the health check arm of the trial and 1,372 were randomised to receive a personal letter. Of those randomised to the health check arm, 468 received the health check from the nurse. Overall, the difference in influenza vaccination uptake was 6.4% (95% confidence interval [CI] = 2.2% to 10.4%) with 67.9% (n = 932) of those who were sent a personal letter actually receiving the vaccine, compared with 74.3% (n = 505) of those offered a combined health check and influenza vaccination (P = 0.003).

CONCLUSION

Combining home-based over- 75 health checks with influenza vaccination can improve uptake among older patients. However this intervention is likely to be costly and its effect on influenza vaccination rates is modest. The difference in uptake is greater among those who do not routinely comeforwardfor vaccination and a more viable option may be to target these patients.

Validity and reliability of an interviewer-administered questionnaire to measure the severity of lower urinary tract symptoms of storage abnormality: the Leicester Urinary Symptom Questionnaire

OBJECTIVE

To develop a valid and reliable interviewer-administered questionnaire to measure the presence and severity of storage abnormality symptoms of incontinence, urgency, frequency and nocturia.

SUBJECTS AND METHODS

Subjects were 930 men and women aged >/=40 years, taking part in a randomized controlled trial of a continence nurse practitioner (CNP) service. Criterion validity was tested by comparing questionnaire responses to 24-h pad test and 3-day urinary diary. Responsiveness was assessed by comparing questionnaire responses before and after treatment. Questions about urgency were investigated for construct validity in patients taking part in the trial who underwent urodynamic investigation (243). Test-retest and inter-rater reliability was measured at approximately 6 days in subjects recruited to an associated epidemiological study (104 and 102, respectively).

RESULTS

The questionnaire responses showed significant associations with pad-test and diary measures. Questions about the severity of daytime incontinence performed better than those measuring night-time incontinence. The response categories of soaked, wet, damp and almost dry had better associations with the pad test than other measures of the severity of incontinence. Test-retest and inter-rater reliability was good for all questions, and all were responsive to change in symptoms, showing significant differences before and after treatment.

CONCLUSION

There is a clear need for standardization of measurement using well-validated instruments. This interviewer-administered questionnaire is valid, reliable and sensitive to change in a wide range of severity of symptoms, and in both men and women aged >/=40 years. The questionnaire provides a useful assessment tool for primary and secondary care in research and clinical settings.

Prevalence of faecal incontinence in adults aged 40 years or more living in the community

BACKGROUND

Prevalence studies of faecal incontinence in the general population are rare and the impact of faecal incontinence on quality of life has not been previously addressed.

AIMS

To establish the prevalence of faecal incontinence in adults in terms of frequency of leakage, degree of soiling, and level of impact on quality of life.

METHODS

In a cross sectional postal survey, 15 904 adults aged 40 years or more (excluding residents of nursing and residential homes) were selected randomly by household from the Leicestershire Health Authority patient register. Participants were asked to complete a confidential health questionnaire. Major faecal incontinence was defined as soiling of underwear or worse with a frequency of several times a month or more. Respondents were also asked if bowel symptoms had an impact on their quality of life.

RESULTS

From a total sample of 10 116 respondents, 1.4% reported major faecal incontinence and 0.7% major faecal incontinence with bowel symptoms that had an impact on quality of life. Major faecal incontinence was significantly associated with a lot of impact on quality of life (odds ratio 12.4, 95% confidence interval 7.5-20.6). Incontinence was more prevalent and more severe in older people but there was no significant difference between men and women.

CONCLUSIONS

This study has confirmed that faecal incontinence is a fairly common symptom, particularly in older people. Faecal incontinence in men has received little attention in the past and the results from this study indicate that it is as much of a problem in men as it is in women while the level of unmet need in this group is high. Estimates of need for health care for this symptom should be multidimensional and assess both the severity of symptoms and the impact it has on quality of life.

Evaluating a mental health assessment for older people with depressive symptoms in general practice: a randomised controlled trial

BACKGROUND

There is a lack of evidence on the most effective primary care management of older people with minor depression.

AIM

To evaluate a follow-up assessment by the community mental health team (CMHT) for older people with depressive symptoms identified by practice nurses at a health check for people over the age of 75 years.

DESIGN OF STUDY

A pragmatic randomised controlled trial.

SETTING

A single large general practice in Leicestershire.

METHOD

Patients receiving a health check administered by a practice nurse and scoring 5 or more on the 15-item Geriatric Depression Scale (GDS15) were randomised to either follow-up by the CMHT or routine general practitioner (GP) care. The GDS15 score was measured at the subsequent health check 18 months later.

RESULTS

Forty-seven patients were randomised to CMHT assessment and 46 to routine GP care. Uptake of the intervention was 72% (n = 34). At the follow-up health check a greater proportion of the control group had improved GDS15 scores (P = 0.08). Following assessment, the CMHT recommended their further involvement in the care of 12 patients and this was authorised by patients' GPs in six cases.

CONCLUSIONS

A follow-up mental health assessment by a member of the local CMHT was not effective in improving outcomes for mildly depressed older people. Other than random error possible reasons for this include the length of follow-up and a failure to meet raised expectations among the intervention group. If complex referral procedures do not improve outcomes for this group, then specialist community services should play a more prominent part in the training of practice staff to care for their depressed older patients.

Requirement for CD28 co-stimulation is lower in SHP-1-deficient T cells

This study provides biochemical and functional evidence pertaining to the role of the intracellular protein tyrosine phosphatase, SHP-1, in influencing thresholds for TCR activation. Although the loss of SHP-1 in thymocytes from motheaten mice had minimal effects on the initial rise of cytosolic Ca(2+) concentration following TCR triggering, the post-stimulation equilibrium levels of Ca(2+) were consistently elevated. In keeping with a SHP-1 effect on PLCgamma function, IP3 generation was increased in SHP-1 deficient thymocytes. Importantly, we demonstrate that loss of SHP-1 results in a relaxation of the normally stringent co-stimulatory requirements for IL-2 production. SHP-1 deficient single-positive CD4(+) thymocytes revealed a significantly enhanced capacity to produce IL-2 in response to anti-CD3 stimulation alone. In contrast, the simultaneous triggering of CD3 and CD28 was required for equivalent IL-2 production in control single-positive CD4(+) thymocytes. Furthermore, SHP-1 deficient thymocytes generated an increased and prolonged proliferative response to anti-CD3 stimulation alone. In addition, the simultaneous triggering of CD28 and CD3 resulted in equivalent proliferative responses in SHP-1-deficient and control thymocytes, suggesting that a strong co-stimulatory signal is able to override the effect of SHP-1 loss on TCR hyperresponsiveness. Collectively, these results suggest that SHP-1, rather than acting directly on TCR signaling, may indirectly raise thresholds for TCR triggering by modulating co-stimulatory signals.

Community surveys of late-life depression: who are the non-responders?

BACKGROUND

community surveys of depression among older people may be particularly prone to non-response. Information on non-responders is difficult to obtain and often limited to demographics. Therefore, the full extent of response bias is not always known.

OBJECTIVE

to determine factors associated with non-response at each stage of a two-stage survey of late-life depression.

SETTING

one large general practice (registered population >30000) serving the market town of Melton Mowbray, Leicestershire, UK.

SUBJECTS

community residents (n=2633) aged 65-74 years registered with the practice.

METHODS

a two-stage community survey of patients aged 65-74 years. The first stage was an interviewer-administered general health survey including a measure of depressive symptoms. We asked those who screened positive for possible depression to undergo a semi-structured psychiatric interview. We compared use of services and medication by non-responders and responders to both stages using primary-care records. We compared Townsend deprivation scores using data obtained from the 1991 census.

RESULTS

responders to stage 1 were more likely to use both primary [odds ratio (OR) 1.65, 95% confidence interval (CI) 1.38-1.96] and secondary (OR 1.59, 95% CI 1.25-2.02) services and tended to live in more affluent areas (P=0.002). At stage 2, the only difference observed was a lower level of use of tranquillisers or hypnotics among responders (OR 0.27, 95% CI 0.11-0.67).

CONCLUSIONS

older people with low levels of contact with health services may be under-represented in community surveys of depression. Investigators should look outside traditional health settings to promote the uptake of response in these studies.

Constitutive association of SHP-1 with leukocyte-associated Ig-like receptor-1 in human T cells

The intracellular Src homology 2 (SH2) domain-containing protein tyrosine phosphatase (SHP-1) is a negative regulator of cell signaling and contributes to the establishment of TCR signaling thresholds in both developing and mature T lymphocytes. Although there is much functional data implicating SHP-1 as a regulator of TCR signaling, the molecular basis for SHP-1 activation in T lymphocytes is poorly defined. A modification of the yeast two-hybrid system was employed to identify in T cells phosphotyrosine-containing proteins capable of binding the SH2 domains of SHP-1. From this yeast tri-hybrid screen, the p85beta subunit of phosphatidylinositol 3-kinase and the immunoreceptor tyrosine-based inhibitory motif-containing receptors, leukocyte-associated Ig-like receptor-1 (LAIR-1) and programmed death-1 (PD-1), were identified. Coimmunoprecipitation studies demonstrated that the exclusive phosphotyrosine-containing protein associated with SHP-1 in Jurkat T cells under physiological conditions is LAIR-1. Significantly, this interaction is constitutive and was detected only in the membrane-enriched fraction of cell lysates. Ligand engagement of the SH2 domains of SHP-1 is a prerequisite to activation of the enzyme, and, consistent with an association with LAIR-1, SHP-1 was found to be constitutively active in unstimulated Jurkat T cells. Importantly, a constitutive interaction between LAIR-1 and SHP-1 was also detected in human primary T cells. These results illustrate the sustained recruitment and activation of SHP-1 at the plasma membrane of resting human T cells by an inhibitory receptor. We propose that this mechanism may exert a constitutive negative regulatory role upon T cell signaling.

TCR signaling thresholds regulating T cell development and activation are dependent upon SHP-1

An examination of thymocytes and peripheral T cells from SHP-1-deficient motheaten mice possessing a transgenic MHC class I-restricted TCR has implicated SHP-1 in regulating TCR signaling thresholds at three checkpoints in T cell development and activation. First, in the population of CD4-CD8- double negative thymocytes, SHP-1 appears capable of regulating signals from TCR complexes that control the maturation and proliferation of double negative thymocytes. Second, the loss of SHP-1 increased the number of CD4+CD8+ double positive thymocytes capable of maturing as TCRhigh single positive thymocytes. Third, the loss of SHP-1 altered the basal level of activation of naive lymph node T cells. Accordingly, SHP-1-deficient lymph node T cells bearing the transgenic TCR demonstrated a hyperresponsiveness to stimulation with cognate peptide. However, the loss of SHP-1 did not alter the cytolytic ability of mature effector cytotoxic T lymphocytes. Together these results suggest that SHP-1 contributes to establishing thresholds for TCR signaling in thymocytes and naive peripheral T cells.

Comparison of CD45 extracellular domain sequences from divergent vertebrate species suggests the conservation of three fibronectin type III domains

Mammalian CD45 is a transmembrane protein tyrosine phosphatase expressed by all nucleated cells of hematopoietic origin. In lymphocytes, CD45 is required for Ag-induced signal transduction due to its ability to positively regulate Src family members. The mechanisms by which CD45 function is regulated are unknown. Indeed, the interactions of CD45 extracellular domains are largely undefined. To gain insight into potentially important regions of the extracellular domain, we sought to identify conserved features from divergent species. cDNAs encoding the putative CD45 homologue from Heterodontus francisci (horned shark) were isolated. The cDNA sequence predicts a protein of 1200 amino acids that contains a 452-amino acid extracellular domain, a 22-amino acid transmembrane region, and a 703-amino acid cytoplasmic domain. Alignment searches revealed that the Heterodontus cytoplasmic domain sequence was most identical to mammalian CD45 and a transmembrane protein tyrosine phosphatase sequence identified from chickens, ChPTP lambda. A dendrogram with other transmembrane protein tyrosine phosphatase sequences suggest that the Heterodontus and chicken sequences represents CD45 orthologues for their respective species. Analysis of vertebrate CD45 extracellular domain sequences indicates the conservation of three structural regions: a region containing potential O-linked carbohydrate sites, a cysteine-containing region, and a region containing three fibronectin type III domains. For each vertebrate species, multiple isoforms are generated by alternative splicing of three exons that encode a portion of the region containing potential O-linked glycosylation sites. These studies provide evidence for a conservation in CD45 extracellular domain structure between divergent species and provide a basis for understanding CD45 extracellular domain interactions.

Comparison of CD45 extracellular domain sequences from divergent vertebrate species suggests the conservation of three fibronectin type III domains

Mammalian CD45 is a transmembrane protein tyrosine phosphatase expressed by all nucleated cells of hematopoietic origin. In lymphocytes, CD45 is required for Ag-induced signal transduction due to its ability to positively regulate Src family members. The mechanisms by which CD45 function is regulated are unknown. Indeed, the interactions of CD45 extracellular domains are largely undefined. To gain insight into potentially important regions of the extracellular domain, we sought to identify conserved features from divergent species. cDNAs encoding the putative CD45 homologue from Heterodontus francisci (horned shark) were isolated. The cDNA sequence predicts a protein of 1200 amino acids that contains a 452-amino acid extracellular domain, a 22-amino acid transmembrane region, and a 703-amino acid cytoplasmic domain. Alignment searches revealed that the Heterodontus cytoplasmic domain sequence was most identical to mammalian CD45 and a transmembrane protein tyrosine phosphatase sequence identified from chickens, ChPTP lambda. A dendrogram with other transmembrane protein tyrosine phosphatase sequences suggest that the Heterodontus and chicken sequences represents CD45 orthologues for their respective species. Analysis of vertebrate CD45 extracellular domain sequences indicates the conservation of three structural regions: a region containing potential O-linked carbohydrate sites, a cysteine-containing region, and a region containing three fibronectin type III domains. For each vertebrate species, multiple isoforms are generated by alternative splicing of three exons that encode a portion of the region containing potential O-linked glycosylation sites. These studies provide evidence for a conservation in CD45 extracellular domain structure between divergent species and provide a basis for understanding CD45 extracellular domain interactions.

Direct regulation of ZAP-70 by SHP-1 in T cell antigen receptor signaling

The threshold at which antigen triggers lymphocyte activation is set by the enzymes that regulate tyrosine phosphorylation. Upon T cell activation, the protein tyrosine phosphatase SHP-1 was found to bind to the protein tyrosine kinase ZAP-70. This interaction resulted in an increase in SHP-1 phosphatase activity and a decrease in ZAP-70 kinase activity. Expression of a dominant negative mutant of SHP-1 in T cells increased the sensitivity of the antigen receptor. Thus, SHP-1 functions as a negative regulator of the T cell antigen receptor and in setting the threshold of activation.

A role in B cell activation for CD22 and the protein tyrosine phosphatase SHP

CD22 is a membrane immunoglobulin (mIg)-associated protein of B cells. CD22 is tyrosine-phosphorylated when mIg is ligated. Tyrosine-phosphorylated CD22 binds and activates SHP, a protein tyrosine phosphatase known to negatively regulate signaling through mIg. Ligation of CD22 to prevent its coaggregation with mIg lowers the threshold at which mIg activates the B cell by a factor of 100. In secondary lymphoid organs, CD22 may be sequestered away from mIg through interactions with counterreceptors on T cells. Thus, CD22 is a molecular switch for SHP that may bias mIg signaling to anatomic sites rich in T cells.

Mutations at the murine motheaten locus are within the hematopoietic cell protein-tyrosine phosphatase (Hcph) gene

Mice homozygous for the recessive allelic mutation motheaten (me) or viable motheaten (mev) on chromosome 6 develop severe defects in hematopoiesis. In this paper we present the findings that the me and mev mutations are within the hematopoietic cell protein-tyrosine phosphatase (Hcph) gene. High resolution mapping localized me to an area tightly linked to Hcph on chromosome 6. Abnormalities of the Hcph protein product were demonstrated by Western blot analysis and by activity assays in both me/me and mev/mev mice. Molecular analysis of the Hcph cDNA identified abnormal transcripts in both mutants. DNA sequence analyses of cDNA and genomic clones revealed that both the me and mev mutations are point mutations that result in aberrant splicing of the Hcph transcript. These findings provide the first available animal models for a specific protein-tyrosine phosphatase deficiency, thus facilitating determination of the precise role of this signaling molecule in hematopoiesis.

Do changes in transcardiac impedance modulation correlate with haemodynamic status?

Implantable cardiac pacemakers and defibrillators have the ability to revert a variety of arrhythmias to normal sinus rhythm. For correct operation, such devices require accurate arrhythmia classification. Arrhythmia classification by these devices could be improved with the addition of a suitable haemodynamic sensor. This study investigated the use of transcardiac impedance for haemodynamic sensing. Ventricular fibrillation, ventricular tachycardia, electro-mechanical dissociation and five rates of ventricular pacing, each having a different associated level of haemodynamic compromise, were induced in each of seven mongrel dogs. The amplitude responses of the modulations of transcardiac impedance were compared with those of arterial pulse pressure (an established measure of haemodynamic status), and changes in cycle length. The correlation coefficient for changes in transcardiac impedance modulation amplitude and arterial pulse pressure was found to be 0.89. For transcardiac impedance modulation amplitude and cycle length, the correlation coefficient was 0.77, and for arterial pulse pressure and cycle length, the correlation coefficient was 0.85. In the acute anaesthetised dog, changes in the amplitude of transcardiac impedance modulations were shown to reflect different levels of haemodynamic status.

Characterization of hematopoietic intracellular protein tyrosine phosphatases: description of a phosphatase containing an SH2 domain and another enriched in proline-, glutamic acid-, serine-, and threonine-rich sequences

Protein tyrosine phosphatases (PTPases) are a family of enzymes important in cellular regulation. Characterization of two cDNAs encoding intracellular PTPases expressed primarily in hematopoietic tissues and cell lines has revealed proteins that are potential regulators of signal transduction. One of these, SHP (Src homology region 2 [SH2]-domain phosphatase), possesses two tandem SH2 domains at the amino terminus of the molecule. SH2 domains have previously been described in proteins implicated in signal transduction, and SHP may be one of a family of nonreceptor PTPases that can act as direct antagonists to the nonreceptor protein tyrosine kinases. The SH2 domains of SHP preferentially bind a 15,000-Mr protein expressed by LSTRA cells. LSTRA cells were shown to express SHP protein by immunoprecipitation, thus demonstrating a potential physiological interaction. The other PTPase, PEP (proline-, glutamic acid-, serine-, and threonine-rich [PEST]-domain phosphatase), is distinguished by virtue of a large carboxy-terminal domain of approximately 500 amino acids that is rich in PEST residues. PEST sequences are found in proteins that are rapidly degraded. Both proteins have been expressed by in vitro transcription and translation and in bacterial expression systems, and both have been demonstrated to have PTPase activity. These two additional members of the PTPase family accentuate the variety of PTPase structures and indicate the potential diversity of function for intracellular tyrosine phosphatases.

Characterization and expression of the human leukocyte-common antigen (CD45) gene contained in yeast artificial chromosomes

The leukocyte-common antigen (CD45) is a transmembrane protein tyrosine phosphatase expressed uniquely by cells of hematopoietic origin. There are multiple isoforms of CD45 that are generated by the variable use of three exons (exons 4-6). The use of the variable exons results in changes near the amino-terminus of the mature glycoprotein. The gene is located on chromosome 1 for both human and mouse in a region that is homologous between these two species. This conserved linkage group contains a number of genes of immunological interest, such as the genes for complement regulatory proteins and the FCG2 receptor. Yeast artificial chromosomes provide a vector system in which large fragments of foreign DNA can be isolated and are suited to long-range physical mapping. To this end, three yeast artificial chromosomes containing the human CD45 gene have been isolated and characterized. They overlap to span 475 kb, establishing the largest physical map for DNA within the conserved linkage group. The CD45 gene is entirely encoded within one yeast artificial chromosome clone as determined by mapping with cDNA probes. A mouse B cell line transfected with this YAC clone expressed the low-molecular-weight isoform of the protein into the cell surface. The size of the human CD45 gene was determined to be approximately 120 +/- 10 kb.

Protein tyrosine phosphatase domains from the protochordate Styela plicata

Protein tyrosine phosphorylation is an important regulatory mechanism in cell physiology. While the protein tyrosine kinase (PTKase) family has been extensively studied, only six protein tyrosine phosphatases (PTPases) have been described. By Southern blot analysis, genomic DNA from several different phyla were found to cross-hybridize with a cDNA probe encoding the human leukocyte-common antigen (LCA; CD45) PTPase domains. To pursue this observation further, total mRNA from the protochordate Styela plicata was used as a template to copy and amplify, using polymerase chain reaction (PCR) technology, PTPase domains. Twenty-seven distinct sequences were identified that contain hallmark residues of PTPases; two of these are similar to described mammalian PTPases. Southern blot analysis indicates that at least one other Styela sequence is highly conserved in a variety of phyla. Seven of the Styela domains have significant similarity to each other, indicating a subfamily of PTPases. However, most of the sequences are disparate. A comparison of the 27 Styela sequences with the ten known PTPase domain sequences reveals that only three residues are absolutely conserved and identifies regions that are highly divergent. The data indicate that the PTPase family will be equally as large and diverse as the PTKases. The extent and diversity of the PTPase family suggests that these enzymes are, in their own right, important regulators of cell behavior.

Constrictive pericarditis causing a positive TI-201 SPECT stress test for myocardial ischemia

A case of constritive pericarditis was demonstrated by a positive thallium SPECT stress test for myocardial ischemia. After pericardiectomy, the repeat thallium stress test was normal. The disappearance of the criteria for a positive test suggests that constrictive pericarditis can cause myocardial ischemia, which can be demonstrated by thallium SPECT stress testing.

Identification of an additional member of the protein-tyrosine-phosphatase family: evidence for alternative splicing in the tyrosine phosphatase domain

Protein-tyrosine-phosphatases (protein-tyrosine-phosphate phosphohydrolase, EC 3.13.48) have been implicated in the regulation of cell growth; however, to date few tyrosine phosphatases have been characterized. To identify additional family members, the cDNA for the human tyrosine phosphatase leukocyte common antigen (LCA; CD45) was used to screen, under low stringency, a mouse pre-B-cell cDNA library. Two cDNA clones were isolated and sequence analysis predicts a protein sequence of 793 amino acids. We have named the molecule LRP (LCA-related phosphatase). RNA transfer analysis indicates that the cDNAs were derived from a 3.2-kilobase mRNA. The LRP mRNA is transcribed in a wide variety of tissues. The predicted protein structure can be divided into the following structural features: a short 19-amino acid leader sequence, an exterior domain of 123 amino acids that is predicted to be highly glycosylated, a 24-amino acid membrane-spanning region, and a 627-amino acid cytoplasmic region. The cytoplasmic region contains two approximately 260-amino acid domains, each with homology to the tyrosine phosphatase family. One of the cDNA clones differed in that it had a 108-base-pair insertion that, while preserving the reading frame, would disrupt the first protein-tyrosine-phosphatase domain. Analysis of genomic DNA indicates that the insertion is due to an alternatively spliced exon. LRP appears to be evolutionarily conserved as a putative homologue has been identified in the invertebrate Styela plicata.

Carrier detection through the use of abnormal deletion junction fragments in a case of haemophilia B involving complete deletion of the factor IX gene

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Synthesis and biological activity of ketomethylene-containing nonapeptide analogues of snake venom angiotensin converting enzyme inhibitors

Two ketomethylene-containing nonapeptide analogues were synthesized to determine if ketomethylene analogues of the nonapeptide venom inhibitors of angiotensin converting enzyme (ACE) would have oral ACE inhibition activity. Both ketomethylene-containing nonapeptides 18 and 19 were potent inhibitors of rabbit lung ACE with I50s of 3.4 and 8.0 nM, respectively, compared to 340 nM for their parent nonapeptide and 450 nM for captopril. Peptide 18 was rapidly cleaved by trypsin, but 19 was reasonably stable to all enzyme degradation systems tested with maximum degradation of 50% by pepsin in 3 h. Both 18 and 19 when given iv to normotensive rats were between 3 and 10 times more potent than captopril in inhibiting an angiotensin I induced blood pressure increase. Peptide 19 showed no ACE inhibition activity in unanesthetized normotensive rats when administered orally at doses of 10 or 100 mg/kg. Experiments were conducted to determine whether 19 is adsorbed from the gastrointestinal track following oral administration. These experiments indicated that 19 is adsorbed. It is concluded that the lack of oral activity of 19 is probably due to its rapid excretion, probably into the bile.

Heterogeneity of the factor IX locus in nine hemophilia B inhibitor patients

DNA from nine hemophilia B patients who produce anti-factor IX inhibitors (antibodies), including two brothers, was analyzed by the Southern blotting method and hybridization with factor IX cDNA, intragenomic, and 3'-flanking probes. Two inhibitor patients were shown to have total deletions of the factor IX gene. Two other inhibitor patients, the brothers, were shown to have a presumably identical complex rearrangement of the factor IX gene involving two separate deletions. The first deletion is of approximately 5.0 kb and removes exon e. The second deletion is between 9 and 29 kb and removes exons g and h but leaves exon f intact. An abnormal Taq I fragment at one end of the deletion junctions acted as a marker for the inheritance of hemophilia B in the patients' family. Five other inhibitor patients have a structurally intact factor IX gene as detected by this method. Our studies indicate that whereas large structural factor IX gene defects predispose hemophilia B patients to developing an anti-factor IX inhibitor, the development of an inhibitor can be associated with other defects of the factor IX gene.

Comparison of phenotypic assessment and the use of two restriction fragment length polymorphisms in the diagnosis of the carrier state in haemophilia B

Carrier detection in haemophilia B has previously involved pedigree analysis and assessment of the coagulation phenotype. At best using these methods, carrier evaluation may be made with about 80% certainty (Orstavik et al, 1981). With isolation and cloning of the factor IX gene, DNA probes are now available to detect intragenic nucleotide changes. This study uses one such probe which detects restriction fragment length polymorphisms with the restriction endonucleases Taq 1 and Xmn 1. Seventy-eight individuals from eight haemophilia B kindred were initially evaluated for factor IXC and factor IXAg levels. DNA from these individuals was then digested with the two restriction enzymes and after Southern blotting, analysed for restriction fragment length polymorphisms (RFLPs) with the radiolabelled genomic probe. Four kindred proved informative with RFLP linkage assessment. In three families evaluation was possible with both Taq 1 and Xmn 1 polymorphic markers but in the fourth pedigree only Xmn 1 was informative. Using these techniques five potential carriers have been definitively assigned as either normal or carriers of the haemophilia B gene defect. Problems of phenotypic assessment are well illustrated in pedigree 4 where polymorphic linkage positively identified a carrier whose coagulation data were normal.

Effect of structural change on acute toxicity and antiinflammatory activity in a series of imidazothiazoles and thiazolobenzimidazoles

The effect of structural change on the biological activity of a series of imidazothiazoles and thiazolobenzimidazoles is described. It was found that compounds with polar substituents at the 2 or 3 position of the ring system are less acutely toxic while maintaining antiinflammatory activity. Other structural changes, such as the incorporation of a gem-dimethyl substituent in the 6 position, increase acute toxicity and eliminate antiinflammatory activity. The compound with the best activity/toxicity ratio contains an alkyl sulfonyl substituent on the thiazole ring. The thiazolobenzimidazole analogues are more potent than the imidazole analogues.

Antihypertensive 5,6-diarylpyridazin-3-ones

The synthesis of a series of 5,6-diarylpyridazinones is described. Some members of this series display an antihypertensive effect in both the spontaneously hypertensive rat (SHR) model and the deoxycorticosteroid (DOCA) model of hypertension. The most potent compounds in the series have halogen substituents on the 5,6-diphenyl rings, a beta-substituted alkyl group at the 2 position of the ring, and acetyl or cyano substituent at the 4 position.

A regional study of sources of apathy toward membership in the American Society of Radiologic Technologists

The problem of this study is to determine the reasons why registered technologists do not join The American Society of Radiologic Technologists (ASRT). This was accomplished with an instrument developed by the authors using a modified Delphi Technique and a five item Likert scale. A stratified random sample of technologists was selected from the Houston area to response to the instrument.

A silver primer for hospital executives

How to estimate and recover the silver from a hospital's film developing solution and nonessential x-ray film, and how to sell it, insure it, and account for the revenue.