Priority allocation of pandemic influenza vaccines in Australia - Recommendations of 3 community juries

BACKGROUND

Pandemic planning has historically been oriented to respond to an influenza virus, with vaccination strategy being a key focus. As the current COVID-19 pandemic plays out, the Australian government is closely monitoring progress towards development of SARS-CoV2 vaccines as a definitive intervention. However, as in any pandemic, initial supply will likely be exceeded by demand due to limited manufacturing output.

METHODS

We convened community juries in three Australian locations in 2019 to assess public acceptability and perceived legitimacy of influenza pandemic vaccination distribution strategies. Preparatory work included literature reviews on pandemic vaccine allocation strategies and on vaccine allocation ethics, and simulation modelling studies. We assumed vaccine would be provided to predefined priority groups. Jurors were then asked to recommend one of two strategies for distributing remaining early doses of vaccine: directly vaccinate people at higher risk of adverse outcomes from influenza; or indirectly protect the general population by vaccinating primary school students, who are most likely to spread infection.

RESULTS

Thirty-four participants of diverse backgrounds and ages were recruited through random digit dialling and topic-blinded social media advertising. Juries heard evidence and arguments supporting different vaccine distribution strategies, and questioned expert presenters. All three community juries supported prioritising school children for influenza vaccination (aiming for indirect protection), one by 10-2 majority and two by consensus. Justifications included that indirect protection benefits more people and is likely to be more publicly acceptable.

CONCLUSIONS

In the context of an influenza pandemic, informed citizens were not opposed to prioritising groups at higher risks of adverse outcomes, but if resources and epidemiological conditions allow, achieving population benefits should be a strategic priority. These insights may inform future SARS-CoV-2 vaccination strategies.

Evidence valued and used by health promotion practitioners

The use of evidence has become a foundational part of health promotion practice. Although there is a general consensus that adopting an evidence-based approach is necessary for practice, disagreement remains about what types of evidence practitioners should use to guide their work. An empirical understanding of how practitioners conceptualize and use evidence has been lacking in the literature. In this article, we explore (i) practitioners' purposes for using evidence, (ii) types of evidence they valued, and (iii) qualities that made evidence useful for practice. 58 semi-structured interviews and 250 h of participant and non-participant observation were conducted with 54 health promotion practitioners working across New South Wales, Australia. Interviews were recorded and transcribed, and field notes were written during the observations; these were analysed using Grounded Theory methods. Practitioners used evidence for practical and strategic purposes, and valued four different types of evidence according to their relevance and usefulness for these purposes. Practitioners' ideal evidence was generated within their practice settings, and met both substantive and procedural evaluation criteria. We argue that due to the complex nature of their work, practitioners rely on a diverse range of evidence and require organizational structures that will support them in doing so.

Smoking mull: a grounded theory model on the dynamics of combined tobacco and cannabis use among adult men

ISSUE ADDRESSED

Australians' use of cannabis has been increasing. Over a third of Australians (35.4%) have used cannabis at some time in their lives and 10.3% are recent users. Almost two-thirds of cannabis users combine cannabis with tobacco. The aim of this study was to understand the process of mulling - smoking tobacco and cannabis together - using a grounded theory approach.

METHODS

Twenty-one in-depth semistructured interviews were conducted with men aged 25-34 and living on the North Coast of New South Wales. Interviews explored participants' smoking practices, histories and cessation attempts.

RESULTS

A model describing mulling behaviour and the dynamics of smoking cannabis and tobacco was developed. It provides an explanatory framework that demonstrates the flexibility in smoking practices, including substance substitution - participants changed the type of cannabis they smoked, the amount of tobacco they mixed with it and the devices they used to smoke according to the situations they were in and the effects sought.

CONCLUSION

Understanding these dynamic smoking practices and the importance of situations and effects, as well as the specific role of tobacco in mulling, may allow health workers to design more relevant and appropriate interventions. SO WHAT? Combining tobacco with cannabis is the most common way of smoking cannabis in Australia. However, tobacco cessation programmes rarely address cannabis use. Further research to develop evidence-based approaches for mull use would improve cessation outcomes.

A comparative case study of bowel cancer screening in the UK and Australia: evidence lost in translation?

OBJECTIVES

(i) To document the current state of the English, Scottish, Welsh, Northern Irish and Australian bowel cancer screening programmes, according to seven key characteristics, and (ii) to explore the policy trade-offs resulting from inadequate funding.

SETTING

United Kingdom and Australia.

METHODS

A comparative case study design using document and key informant interview analysis. Data were collated for each national jurisdiction on seven key programme characteristics: screening frequency, population coverage, quality of test, programme model, quality of follow-up, quality of colonoscopy and quality of data collection. A list of optimal features for each of the seven characteristics was compiled, based on the FOBT screening literature and our detailed examination of each programme.

RESULTS

Each country made different implementation choices or trade-offs intended to conserve costs and/or manage limited and expensive resources. The overall outcome of these trade-offs was probable lower programme effectiveness as a result of compromises such as reduced screening frequency, restricted target age range, the use of less accurate tests, the deliberate setting of low programme positivity rates or increased inconvenience to participants from re-testing.

CONCLUSIONS

Insufficient funding has forced programme administrators to make trade-offs that may undermine the potential net population benefits achieved in randomized controlled trials. Such policy compromise contravenes the principle of evidence-based practice which is dependent on adequate funding being made available.

Diadenosine pentaphosphate is a potent activator of cardiac ryanodine receptors revealing a novel high-affinity binding site for adenine nucleotides

BACKGROUND AND PURPOSE

Diadenosine polyphosphates are normally present in cells at low levels, but significant increases in concentrations can occur during cellular stress. The aim of this study was to investigate the effects of diadenosine pentaphosphate (Ap5A) and an oxidized analogue, oAp5A on the gating of sheep cardiac ryanodine receptors (RyR2).

EXPERIMENTAL APPROACH

RyR2 channel function was monitored after incorporation into planar bilayers under voltage-clamp conditions.

KEY RESULTS

With10 micromol.L(-1) cytosolic Ca2+, a significant 'hump' or plateau at the base of the dose-response relationship to Ap5A was revealed. Open probability (Po) was significantly increased to a plateau of approximately 0.2 in the concentration range 100 pmol x L(-1)-10 micromol x L(-1). High Po values were observed at >10 micromol x L(-1) Ap5A, and Po values close to 1 could be achieved. Nanomolar levels of ATP and adenosine also revealed a hump at the base of the dose-response relationships, although GTP did not activate at any concentration, indicating a common, high-affinity binding site on RyR2 for adenine-based compounds. The oxidized analogue, oAp5A, did not significantly activate RyR2 via the high-affinity binding site; however, it could fully open the channel with an EC(50) of 16 micromol.L(-1) (Ap5A EC(50) = 140 micromol x L(-1)). Perfusion experiments suggest that oAp5A and Ap5A dissociate slowly from their binding sites on RyR2.

CONCLUSIONS AND IMPLICATIONS

The ability of Ap5A compounds to increase Po even in the presence of ATP and their slow dissociation from the channel may enable these compounds to act as physiological regulators of RyR2, particularly under conditions of cellular stress.

Tobacco document research reporting

OBJECTIVE

To understand the use of internal tobacco industry documents in the peer reviewed health literature.

DESIGN

Interpretive analysis of published research.

SAMPLE

173 papers indexed in Medline between 1995 and 2004 that cited tobacco industry documents.

ANALYSIS

Information about year published, journal and author, and a set of codes relating to methods reporting, were managed in N*Vivo. This coding formed the basis of an interpretation of tobacco document research reporting.

RESULTS

Two types of papers were identified. The first used tobacco documents as the primary data source (A-papers). The second was dedicated to another purpose but cited a small number of documents (B-papers). In B-papers documents were used either to provide a specific example or to support an expansive contention. A-papers contained information about purpose, sources, searching, analysis, and limitations that differed by author and journal and over time. A-papers had no clear methodological context, but used words from three major traditions--interpretive research, positivist research, and history--to describe analysis.

INTERPRETATION

A descriptive mainstream form of tobacco document reporting is proposed, initially typical but decreasing, and a continuum of positioning of the researcher, from conduit to constructor. Reporting practices, particularly from experienced researchers, appeared to evolve towards researcher as constructor, with later papers showing more complex purposes, diverse sources, and detail of searching and analysis. Tobacco document research could learn from existing research traditions: a model for planning and evaluating tobacco document research is presented.

"A deep fragrance of academia": the Australian Tobacco Research Foundation

OBJECTIVES

(1) To review the history of the tobacco industry supported Australian Tobacco Research Foundation (ATRF)(1970-1994) for evidence of the industry's use of the Foundation to further its objectives that "more research was needed" on smoking and health and to promulgate the view that nicotine was not addictive. (2) To review efforts by public health advocates to discredit the ATRF as a public relations tool used by the Australian industry.

METHODS

Systematic search of previously internal industry documents released through the US Master Settlement Agreement.

RESULTS

The ATRF was headed by prestigious Australian medical scientists, with at least one considered by the industry to be "industry positive". An international ATRF symposium on nicotine was vetted by the industry and heavily attended by industry approved scientists. Following sustained criticism from the health and medical community about the industry's creation of the ATRF to further its objectives, the ATRF's scientific committee was provoked to publicly declare in 1988 that smoking was a causative agent in disease. This criticism led to growing ATRF boycotts by scientists and substandard applications, causing the industry to see the ATRF as being poor value-for-money and eventually abandoning it.

CONCLUSIONS

The raison d'etre for the ATRF's establishment was to allow the Australian industry to point to its continuing commitment to independent medical research, with the implied corollary that tobacco control measures were premature in the face of insufficient evidence about tobacco's harms. Sustained criticism of tobacco industry funded research schemes can undermine their credibility among the scientific community.

New frontier, new power: the retail environment in Australia's dark market

OBJECTIVE

To investigate the role of the retail environment in cigarette marketing in Australia, one of the "darkest" markets in the world.

DESIGN

Analysis of 172 tobacco industry documents; and articles and advertisements found by hand searching Australia's three leading retail trade journals.

RESULTS

As Australian cigarette marketing was increasingly restricted, the retail environment became the primary communication vehicle for building cigarette brands. When retail marketing was restricted, the industry conceded only incrementally and under duress, and at times continues to break the law. The tobacco industry targets retailers via trade promotional expenditure, financial and practical assistance with point of sale marketing, alliance building, brand advertising, and distribution. Cigarette brand advertising in retail magazines are designed to build brand identities. Philip Morris and British American Tobacco are now competing to control distribution of all products to retailers, placing themselves at the heart of retail business.

CONCLUSIONS

Cigarette companies prize retail marketing in Australia's dark market. Stringent point of sale marketing restrictions should be included in any comprehensive tobacco control measures. Relationships between retailers and the industry will be more difficult to regulate. Retail press advertising and trade promotional expenditure could be banned. In-store marketing assistance, retail-tobacco industry alliance building, and new electronic retail distribution systems may be less amenable to regulation. Alliances between the health and retail sectors and financial support for a move away from retail dependence on tobacco may be necessary to effect cultural change.

"Avoid health warnings on all tobacco products for just as long as we can": a history of Australian tobacco industry efforts to avoid, delay and dilute health warnings on cigarettes

OBJECTIVE

To review critically the history of Australian tobacco industry efforts to avoid, delay, and dilute pack warnings on cigarettes.

DESIGN

Systematic keyword and opportunistic website searches of tobacco industry internal documents made available through the Master Settlement Agreement.

RESULTS

Four industry strategies and six recurrent arguments used by the industry are described, which were used to thwart the passage of three generations of health warnings (implemented in 1973, 1987, and 1995). These strategies are shown to have been associated with major delays in the implementation of the warnings and in keeping them inconspicuous, unattributed to the industry and non-specific, and particularly in delaying the use of warnings about addiction. The industry today continues to oppose warnings, which might "repel" smokers from tobacco use.

CONCLUSIONS

Efforts by governments to introduce potent health warnings will be resisted by the tobacco industry. Tobacco control advocates should anticipate and counter the strategies and arguments used by the industry, which are described in this paper if they wish to maximise the use of the pack as a vehicle for raising awareness about the harms of smoking.

"Australia is one of the darkest markets in the world": the global importance of Australian tobacco control

"Australia is one of the darkest markets in the world... it probably is the darkest, I mean ourselves and Canada fight every month for who's got the darkest conditions to do tobacco manufacturing and marketing. And one of the things we can offer the world is what we do best, which is how to work, maximize, proactively drive our market position in a market that's completely dark. Now that takes a different skillset... a different type of learning. We need to export that... we know we have a lot of expatriates who come down to Australia for learning. they can come here and learn these techniques and take them back to Europe or Latin America or to the United States or to Africa... But the other thing that is really good for us is that we are also a huge net exporter of Australian talent. about 30 or 40 people currently off-shore... We do things really differently here than most other BAT organizations." David Crowe, Marketing Director, British American Tobacco (BAT) Australia(1).

Going below the line: creating transportable brands for Australia's dark market

OBJECTIVE

To investigate non-point-of-sale cigarette marketing in Australia, one of the "darkest" markets in the world.

DESIGN

Analysis of 172 tobacco industry documents.

RESULTS

The tobacco industry has continued to market their products despite severe restrictions on legal marketing activity. They made careful plans to circumvent regulation well in advance. In preparation for bans, they chose and strengthened existing brands to enable their continued success in a dark market and prepared the consumer for bans by increasing their spending on below the line activities. Bans reduced the industry's effectiveness and efficiency. After bans new brand launches stopped: instead key existing brands were strengthened via alterations to the product, line extensions, and stretching loopholes in the legislation as far as possible. In line with the general trend towards integrated marketing, a range of activities have been used in combination, including guerrilla marketing, advertising in imported international magazines, altering the pack, sponsorships, brand stretching, event promotions, lifestyle premiums, and the development of corporate websites.

CONCLUSIONS

The tobacco industry acknowledges that marketing restrictions have an impact, validating their continued use in tobacco control. The industry is extremely creative in circumventing these marketing restrictions, requiring tobacco marketing regulations to be informed by marketing expertise, regularly updated, and to adopt the broadest possible scope. Tobacco control advocates, particularly those communicating with young people, could learn from the creativity of the tobacco industry.

Cooperation and control: the Tobacco Institute of Australia

OBJECTIVE

To describe the history of the Tobacco Institute of Australia (TIA), particularly regarding connections between local and international cigarette manufacturers and tobacco organisations.

DESIGN

Analysis of 4541 industry documents from the world wide web.

RESULTS

From 1978 to 1983 the TIA built strong international networks via ICOSI/INFOTAB and the US Tobacco Institute, and defended existing industry freedoms. 1983 to 1989 was the TIA's aggressive heyday, led primarily by John Dollisson. From 1989 to 1994, following the decision in Australian Federation of Consumer Organisations vs TIA, local and international industry lawyers assumed control. Between 1994 and 1997 a brief revival led into decline and then dissolution, as previously common ground became commercially competitive issues for the manufacturers. The TIA facilitated interconnectedness: between local manufacturers; via individuals who played multiple roles; to international tobacco organisations; through the industry's local and international counsel; and by acting as a conduit for information.

CONCLUSION

The local tobacco industry was comprehensively informed on issues including smoking and health, and connected to the international industry, via the TIA. The manufacturers were closely involved in the TIA's activities, and cooperated through the TIA in a manner detrimental to Australian consumers. The TIA's conduct was the responsibility of local and international manufacturers and their counsel.

Smoking, disease, and obdurate denial: the Australian tobacco industry in the 1980s

OBJECTIVE

To contrast the Australian tobacco industry's awareness of the diseases caused by smoking with their aggressive public denial on the relation between smoking and disease in the 1980s.

DESIGN

Analysis of 325 industry documents from the world wide web.

RESULTS

In the 1980s Australian cigarette manufacturers were informed constantly by the international industry of the medical consensus that smoking caused disease. In addition Philip Morris (Australia) Limited received reports of Philip Morris' international biological research programme and visited its Richmond research facility; and WD&HO Wills part funded, co-managed, and contributed research to the British American Tobacco groups' biological research programme. Despite this knowledge, the Australian manufacturers had a policy of arguing to their employees, decision makers, and the general public that questions of smoking and disease were unresolved. The industry catalogued the literature, developed arguments against the main claims made by health groups, and attacked public health advocates who made statements linking smoking to death and disease. Industry studies suggested that a 20-30% minority of the Australian public agreed with the industry on smoking and disease, diminishing across the decade.

CONCLUSION

Australian manufacturers were clearly negligent in the 1980s, deliberately working to undermine Australians' understandings of the diseases caused by smoking despite their own private knowledge. Continuing scepticism about smoking and disease, corresponding with the industry's deceptions, exists in Australian smokers today, suggesting that their actions may have slowed the rate of decline in smoking prevalence. These revelations provide important evidence for Australian litigation and advocacy.

From legitimate consumers to public relations pawns: the tobacco industry and young Australians

OBJECTIVE

To document the Australian tobacco industry's activities regarding youth smoking to support tobacco control.

METHOD

492 industry documents from primary and secondary websites were abstracted and analysed.

RESULTS

Australian legislation and rhetoric on youth and tobacco has changed dramatically over the last 50 years, from an unproblematic association of teenagers and smoking in the 1960s, through the industry's aggressive attacks and denials in the 1980s, to the 1990s, when industry became newly compliant with "societal expectations" and youth became a dominant bargaining issue in the industry's public relations strategy. The industry's current policy is to simultaneously blame others for underage smoking, frame the industry as socially responsible via voluntary marketing codes, youth access programmes, and school education, and market actively to young adults.

CONCLUSIONS

The arbitrary distinction between 17 and 18 year olds is, particularly in Australia's dark market, a liability for tobacco control and an opportunity for the industry, which is attempting to claim the high moral ground traditionally occupied by tobacco control on the youth issue. The current review of Australia's Tobacco Advertising Prohibition Act of 1992 should prohibit all forms of industry communication targeting young people, including retail access and schools programmes and below-the-line marketing. Tobacco control advocacy should highlight the industry's attempts to use the youth issue in its own favour while laying the blame elsewhere.

The Australian cigarette brand as product, person, and symbol

OBJECTIVE

To examine, for dominant Australian cigarette brands, brand identity (overriding brand vision), brand positioning (brand identity elements communicated to the consumer), brand image (consumers' brand perceptions) and brand equity (financial value).

DESIGN

Tobacco industry documents, articles from retail trade publications since 1990, and current brand advertising from retail trade publications were searched for information about Australian brands.

RESULTS

Cigarette manufacturers benefit from their competitors' brand equity as well as their own. The industry sees Australian smokers as far less brand loyal and strongly oriented to "low tar". A few predominantly local brands dominate the market, with variation by state. Successful Australian brands exist in one of three categories: premium, mainstream, and supervalue. Their brand identity essence is as follows. Premium: quality. Mainstream: a good humoured "fair go" for ordinary Australians. Supervalue: value for money. All supervalue brand identities also include freedom, escape, mildness, an aspirational attitude, blue tones, and waterside scenes. Brand image and brand identity is frequently congruent, even when marketing is restricted, and brand image is generally more positive for a smoker's own brand.

CONCLUSIONS

Tobacco control activities have undermined cigarette brand equity. Further research is needed regarding brand loyalty, low tar, and brand categories. Smokers may respond more positively to tobacco control messages consistent with the identities of their chosen brand, and brand-as-organisation elements may assist. Further marketing restrictions should consider all elements of brand identity, and aim to undermine brand categories.

The Australian tar derby: the origins and fate of a low tar harm reduction programme

OBJECTIVE

To document the development of the low tar harm reduction programme in Australia, including tobacco industry responses.

DATA SOURCES

Tobacco industry documents, retail tobacco journals, newspapers, medical journals, and Anti-Cancer Council of Victoria (ACCV) newsletters and archival records.

STUDY SELECTION

Documents on the strategies and knowledge bases of the ACCV, other Australian health authorities, and the tobacco industry.

RESULTS

The ACCV built a durable system for measuring and publicising the tar and nicotine yields of Australian cigarettes and influencing their development. The tobacco industry initially sought to block the development of this system but later appeared to cooperate with it, as is evidenced by the current market dominance of low tar brands. However, behind the scenes, the industry used its substantial knowledge advantage regarding compensatory smoking and its ability to re-engineer cigarettes to gain effective control of the system and subvert the ACCV's objectives.

CONCLUSIONS

Replacement of the low tar programme with new means of minimising the harms from cigarette smoking should be a policy priority for the Australian government. This will require regulation, rather than further voluntary agreements, and stringent monitoring of successor programmes will be necessary.

Prenatal diagnosis of Bardet-Biedl syndrome by targeted second-trimester sonography

Bardet-Biedl syndrome (BBS) is an autosomal recessive disorder characterized by mental retardation, obesity, retinal degeneration, polydactyly and syndactyly, diabetes mellitus, hypogenitalism, renal dysplasia and short stature. Definitive molecular diagnosis for BBS is not currently available and counseling of affected families is based on the 25% recurrence risk consistent with autosomal recessive inheritance. Our case presents the first successful use of second trimester targeted sonographic anatomy scanning to prospectively identify a fetus affected with BBS, and indicates that ultrasound can be of critical importance in providing precise as well as timely prenatal diagnosis for families at risk for this serious disorder.

Gamma-Aminobutyric acid (GABA) transport across human intestinal epithelial (Caco-2) cell monolayers

1. Transintestinal absorption of gamma-aminobutyric acid (GABA) via a pH-dependent mechanism is demonstrated in the model human intestinal epithelial cell line Caco-2. 2. Experiments with BCECF [2',7',-bis(2-carboxyethyl)-5(6)- carboxyfluorescein]-loaded Caco-2 cells demonstrate that GABA transport across the apical membrane is coupled to proton flow into the cell. 3. Short-circuit current (ISC) measurements using Caco-2 cell monolayers under voltage-clamped conditions demonstrate that pH-dependent GABA transport is a rheogenic process even in the absence of extracellular Na+, consistent with H+/GABA symport. 4. A range of GABA analogues were tested for their abilities to: (a) inhibit pH-dependent [3H]GABA uptake across the apical membrane; (b) stimulate H+ flow across the apical surface of BCECF-loaded Caco-2 cell monolayers; (c) increase inward ISC across voltage-clamped Caco-2 cell monolayers. 5. Nipecotic acid, isonipecotic acid, D,L-beta-aminobutyric acid, and 3-amino-1-propanesulphonic acid each caused a marked acidification of intracellular pH and an increase in ISC when superfused at the apical surface of Caco-2 cell monolayers. In contrast L-alpha-amino-n-butyric acid failed to induce proton flow or ISC. The ability of these compounds to induce proton or current flow across the apical surface of this intestinal epithelium was closely related to the relative inhibitory effects on [3H]GABA uptake. 6. These observations demonstrate H+/GABA symport and suggest that this transport mechanism may be accessible as a route for oral absorption of therapeutically-useful GABA analogues.

Second-trimester molecular prenatal diagnosis of sporadic Apert syndrome following suspicious ultrasound findings

Apert syndrome, an autosomal dominant disorder characterized by craniosynostosis, mid-facial malformations, symmetric bony syndactyly of hands and feet, and varying degrees of mental retardation, is most frequently caused by a de novo mutation. Two missense mutations in the fibroblast growth factor receptor 2 (FGFR2) gene have been found to account for the disorder in approximately 98% of affected patients. Seven cases of prenatal ultrasound diagnosis have been reported. Although one earlier diagnosis has been made in a familial case, sporadic cases have not been definitively diagnosed until the third trimester when craniosynostosis is usually detected. We report a second-trimester molecular diagnosis of a sporadic case, based on the ultrasound observation of fetal 'mitten hands' and craniosynostosis. We discuss the approach to such ultrasound features, given the current availability of molecular diagnosis for Apert syndrome.

Increased production of antigen-specific immunoglobulins G and M following in vivo treatment with the medicinal plants Echinacea angustifolia and Hydrastis canadensis

A number of immunomodulatory effects have been attributed to the medicinal plants Echinacea angustifolia and Goldenseal (Hydrastis canadensis); however, little is known about whether treatment with these plants can enhance antigen-specific immunity. We investigated the antigen-specific in vivo immunomodulatory potential of continuous treatment with Echinacea and Goldenseal root extract over a period of 6 weeks using rats that were injected with the novel antigen keyhole limpet hemocyanin (KLH) and re-exposed to KLH after the initial exposure. Immunoglobulin production was monitored via ELISA continuously over a period of 6 weeks. The Echinacea-treated group showed a significant augmentation of their primary and secondary IgG response to the antigen, whereas the Goldenseal-treated group showed an increase in the primary IgM response during the first 2 weeks of treatment. Our results suggest that medicinal plants like Echinacea or Goldenseal may enhance immune function by increasing antigen-specific immunoglobulin production.

Nonselective beta blockade attenuates the recruitment of CD62L(-)T lymphocytes following exercise

Exercise induces a selective redistribution of CD62L(-) T lymphocytes. This study examined the effects of beta adrenergic receptor blockade on this phenomenon. Twelve healthy men were exercised to exhaustion on a treadmill prior to and following 1 week of treatment with the nonselective beta antagonist propranolol or the beta1 selective antagonist metoprolol. Dynamic exercise resulted in a significant lymphocytosis (p < 0.001). CD8(+)CD62L(-) T cells showed a greater than 3-fold increase in response to exercise (p < 0.001) as compared to CD8(+)CD62L(+) T cells, which showed a more modest increase. Treatment with the nonselective beta antagonist propranolol significantly attenuated the preferential increase of circulating CD8(+)CD62L(-) lymphocytes (p = 0.01) but had no effect on CD8(+)CD62L(+) T cells. Treatment with the beta1 selective antagonist metoprolol did not affect the response of either subset. Our findings replicate a prior study indicating that CD62L expression influences T lymphocyte trafficking in response to exercise and extends those findings by showing that this phenomenon is mediated, in part, via the beta2-adrenergic receptor.

Dynamic exercise leads to an increase in circulating ICAM-1: further evidence for adrenergic modulation of cell adhesion

Acute mental and physical stress lead to a marked lymphocytosis, with circulating natural killer cell numbers showing the most prominent increase. Many studies have linked these acute stress effects on lymphocytes with an increase in catecholamine levels. However, the molecular mechanisms which mediate this redistribution of lymphocytes from lymphocyte reservoirs into the circulation remain unknown. We hypothesized that this form of lymphocytosis was in part due to shedding of cell adhesion molecules from the cell surface and a subsequent detachment of lymphocytes adhering to the vascular endothelium in lymphocyte reservoirs. In this study, healthy human volunteers (n = 12) were exercised on a treadmill until exhaustion. The circulating levels of the soluble cell adhesion molecules ICAM-1 and E-Selectin were determined by ELISA. The subjects were then randomly assigned to treatment with either propranolol or metoprolol and repeated the exercise protocol after 1 week of treatment. Prior to drug treatment, soluble ICAM-1 levels rose from 258 +/- 19 to 321 +/- 28 ng/ml following exercise and returned to approximate baseline levels of 263 +/- 22 ng/ml after 1 h of rest. This highly significant effect of exercise on circulating ICAM-1 levels (p < .005) was mitigated after treatment with the beta-adrenergic antagonists. Soluble E-Selectin levels were not significantly affected by exercise. These results suggest that dynamic exercise leads to shedding of the cell adhesion molecule ICAM-1 via adrenergic mechanisms. We believe that these findings will contribute to the understanding of how physical and mental stress modulate lymphocyte migration and adhesion.

The effects of die-spacing on post-cementation crown elevation and retention

This paper reviews the relevant dental literature concerning the effect of die-spacing on crown elevation and pre- and post-cementation crown retention. Techniques of providing die-spacing and measurement of the thickness of die-spacer are discussed. A review of the role of the provision of a cement space in reducing post-cementation crown elevation is presented. Factors which may affect crown retention prior to and following cementation are also reviewed. The influence of variables in techniques and experimental design on the results of the studies reviewed is discussed.

Placental echolucencies: does their presence influence outcome following genetic amniocentesis?

Women undergoing genetic amniocentesis procedures were evaluated for the presence of ultrasonographic echolucencies within the placenta. Non-calcified sonolucencies < 4 to 5 cm were classified as subchorionic hematomas (SH). Of the 1,000 pregnancies evaluated, 153 (15%) pregnancies manifested SH prior to amniocentesis (study group). The indications for referral were similar in the study and control groups. There were 13 (1.3%) losses: 3 and 10 in the study and control groups, respectively, with no statistical difference in fetal losses between the groups: RR 1.52 (95% confidence interval 0.56-4.14; p = 0.32). Placental sonolucencies < 4 to 5 cm in diameter appear to be incidental ultrasound findings not associated with increased fetal loss following genetic amniocentesis. Complications following invasive prenatal diagnosis cannot be attributed to the presence of these common ultrasound findings.

The effect of die-spacing on crown retention

Ten extracted molar teeth were prepared to a standardised complete crown preparation. Five stone dies were constructed for each tooth and coated with zero, two, four, six, and eight layers of a paint-on die-spacer. Crowns were fabricated on each die and the force required for removal from each tooth was measured prior to cementation. The crown elevation and force required for removal were measured after luting with zinc phosphate cement. The force required to remove the crowns before cementation decreased with increasing layers of die-spacer. Following cementation, the mean crown elevation decreased from 547 micrometers (zero layers) to 38 micrometers (eight layers); while the mean removal force increased from 250 N (zero layers) to 375 N (eight layers).

Effect of prolonged catecholamine infusion on immunoregulatory function: implications in congestive heart failure

OBJECTIVES

This study sought to characterize the effects of prolonged catecholamine infusion on immunoregulatory cell traffic and activation.

BACKGROUND

Immunoregulation has been shown to be partially controlled by the sympathetic nervous system. Although short-term elevation of catecholamine levels is known to alter immunoregulatory cell traffic and activation, the effects of prolonged heightened sympathetic nervous system activity have not adequately been studied. We believe that the alterations in immune function seen in patients with congestive heart failure are linked to a prolonged elevation of circulating catecholamine levels.

METHODS

To characterize the effects of prolonged elevation of catecholamine levels, rats received 4 weeks of constant infusion of epinephrine or norepinephrine through implanted osmotic minipumps. Peripheral and splenic leukocyte subsets, T cell proliferation and interleukin-2 receptor expression were quantified. Antibody production to the novel antigen keyhole limpet hemocyanin was assessed over the 4-week treatment period.

RESULTS

Both epinephrine and norepinephrine caused significant splenic atrophy and cardiac hypertrophy; both were blocked by propranolol. Epinephrine induced lymphocytosis; both catecholamines caused an increase in natural killer cells. In the spleen, both epinephrine and norepinephrine led to a dose-dependent decrease in total T cells, suppressor/cytotoxic T cells and natural killer cells and a significant increase in B cells. Epinephrine at the low dose enhanced mitogen-induced proliferation and interleukin-2 receptor expression. Norepinephrine at the low dose appeared to diminish proliferation. Epinephrine tended to inhibit IgG antibody production, whereas norepinephrine had no effect.

CONCLUSIONS

The results of our study indicate that prolonged elevation of catecholamine levels alters immune cell proliferation and differentiation. These alterations differ greatly from those induced by short-term stimulation but, for the most part, parallel those found in patients with congestive heart failure. We postulate that the shifts in immunoregulatory cell type and function seen in patients with congestive heart failure are due, in part, to longstanding increases in circulating catecholamine levels and may play an important role in the pathogenesis and progression of disease.

Gender differentiated receptivity to sexuality education curricula by adolescents

Teenagers comprise a substantial proportion of the 'at risk' population for sexually transmissible diseases (STDs) and AIDS. They are, also, potentially amenable to the curriculum influences of the high school, suggesting that a high profile needs to be accorded to sexuality education curricula. The variable of receptivity along gender lines to sexuality education programs is explored and reported in this study. An instrument was constructed to measure key constitutive variables in the dimensions of meaning and attitude, and administered to a sample of Western Australian high school students (N = 533). Data were subjected to a two-way ANOVA with sex and school as the dependent variables. It was found that there are differences in receptivity to sexuality education curricula between male and female high school students; that receptivity, irrespective of gender, rises with increasing curriculum provision and with males showing higher gains when compared with females. The findings have implications for policy makers and administrators in providing access to extensive school-based sexuality education curricula.

Measurement of urinary medium chain acyl glycines by gas chromatography--negative ion chemical ionization mass spectrometry

Medium chain acyl-CoA dehydrogenase (MCAD) deficiency is an inborn error of fatty acid metabolism, which is difficult to diagnose, partly because of its unpredictable clinical presentation. A specific diagnostic marker is an increased excretion of certain medium chain acyl glycines. A sensitive and specific method has been developed for the extraction, derivatization, identification and quantitation of urinary medium chain acyl glycines by gas chromatography-negative ion chemical ionization mass spectrometry (GC-NICIMS). The following series of standard acyl glycines has been synthesized and characterized: hexanoyl, octanoyl, 3-phenylpropionyl and suberyl and their respective isotopomers (using 13C2-glycine; for use as internal standards). The range of excretion of these compounds in normal subjects has been established using this method and increased excretion of acyl glycines, particularly hexanoyl, 3-phenylpropionyl and suberyl was successfully demonstrated in three MCAD deficient subjects from one family.

Regulation of cardiac beta-adrenergic receptors by captopril. Implications for congestive heart failure

The interaction of the renin-angiotensin system and the sympathetic nervous system in patients with congestive heart failure is not well understood. We tested the hypothesis that angiotensin-converting enzyme inhibitors can resensitize the beta-adrenergic receptor system. Guinea pigs were given captopril, isoproterenol, or both for 2 weeks. At death, cardiac sarcolemmal and light vesicle fractions and intact mononuclear leukocytes were prepared. Captopril treatment led to an up-regulation of cardiac beta 1- but not mononuclear leukocyte beta 2-adrenergic receptors and an increase in isoproterenol-stimulated adenylate cyclase activity in the heart. Animals treated with isoproterenol developed cardiac hypertrophy, had increased plasma norepinephrine levels, and had a decreased number and responsiveness of both cardiac and mononuclear leukocyte beta-adrenergic receptors. Concomitant treatment with captopril attenuated alterations of heart weight, plasma norepinephrine levels, and cardiac beta-receptor density and function. In contrast to its cardiac effects, captopril treatment did not diminish the down-regulation of mononuclear leukocyte beta 2-adrenergic receptors by isoproterenol. Our data suggest that captopril may resensitize the cardiac but not the mononuclear leukocyte beta-adrenergic receptor-adenylate cyclase system after long-term catecholamine exposure.

Tachyphylaxis with amrinone therapy: association with sequestration and down-regulation of lymphocyte beta-adrenergic receptors

STUDY OBJECTIVE

To determine whether intravenous therapy with amrinone changes number, location or function of the beta-adrenergic receptors on lymphocytes.

DESIGN

Case series.

SETTING

Veterans hospital coronary care unit.

PATIENTS

Eleven patients with decompensated class III or IV heart failure.

INTERVENTIONS

A bolus of intravenous amrinone followed by a continuous infusion at 10 micrograms/kg.min for 72 hours.

MEASUREMENTS AND MAIN RESULTS

At 24 to 36 hours there was a reduction in pulmonary capillary wedge pressure (35%), right atrial pressure (20%), and systemic vascular resistance (25%) with an increase in cardiac output (30%). By 72 hours all these parameters had returned nearly to baseline levels. This partial cardiovascular tolerance to amrinone was accompanied by a 126% increase in the plasma epinephrine, a 182% increase in norepinephrine, a 31% decrease in the number of beta-adrenergic receptors on lymphocytes, and a 36% decrease in isoproterenol-stimulated cyclicadenosine monophosphate on lymphocytes. The number of sequestered receptors doubled during the treatment, and the extent of sequestration correlated well with the extent of receptor down-regulation.

CONCLUSIONS

The hemodynamic responses to amrinone had virtually returned to baseline by 72 hours. This tolerance was accompanied by increased plasma catecholamines, and a down-regulation, desensitization, and sequestration of beta-adrenergic receptors on lymphocytes. We suggest that these receptor changes also occur in cardiovascular tissues and may in part account for the tolerance to amrinone.

Human platelet phenolsulphotransferase: separate control of the two forms and activity range in depressive illness

Human phenolsulphotransferase exists in two forms, one specific for dopamine and tyramine, termed "M" and one for phenol, termed "P". In this study we have shown that these two forms are under separate control by correlating their activities in different individuals using different substrates. There was a highly significant correlation between the activities with dopamine, p-tyramine and 4-hydroxy-3-methoxyphenylglycol, but no significant correlation between the activities with any of these three substrates and that with phenol. Neither age nor sex had any effect on platelet phenolsulphotransferase "M" or "P" activities. Nor was there any significant correlation between platelet monoamine oxidase activity and phenolsulphotransferase "M" or "P" activities. Human platelet phenolsulphotransferase "M" was found to be unstable at temperatures above 35 degree C and it lost substantial activity when stored deep frozen in isotonic saline. However it was stable for up to four months when stored in isotonic sucrose or 10 mmol/l phosphate buffer (pH 7.4). Phenolsulphotransferase "M" amd "P" activities were measured in platelets from depressed patients of a diagnostic type characterized by low output of tyramine-O-sulphate after oral tyramine loading but their enzyme activities were not different from those in two control groups.

Decreased urinary output of conjugated tyramine is associated with lifetime vulnerability to depressive illness

In a group of normal pregnant women whose psychiatric histories were unknown, those with the lowest output of urinary tyramine (free plus conjugated) after an oral tyramine load had a significantly higher lifetime incidence of depressive illness compared with those with the highest output. as none of the women were suffering from depression at the time of tyramine loading, it seems likely that this decreased excretion of tyramine is associated in some way with vulnerability to depressive illness, whether puerperal or nonpuerperal.

Chemotherapy of human tumors in T-lymphocyte-deficient mice

Human lung, ovarian, colonic, and renal carcinomas have been grown in mice artificially deprived of T-lymphocytes. All grew slowly and were shown to have a human karyotype even after several transplant generations. Their responses to chemotherapy were similar to the expected clinical response with the important exception of hexamethylmelamine which caused complete regression of two lung carcinomas (even when weighing up to 2.5 g at the start of treatment) and a renal carcinoma, while completely inhibiting the growth of an ovarian carcinoma and another lung carcinoma. Measurement of plasma carcinoembryonic antigen levels proved to be of value in assessing drug efficacy.