The effects of systemic immunomodulatory treatments on COVID-19 outcomes in patients with atopic dermatitis: Results from the global SECURE-AD registry

BACKGROUND

Limited data are available on the effects of systemic immunomodulatory treatments on COVID-19 outcomes in patients with atopic dermatitis (AD).

OBJECTIVE

To investigate COVID-19 outcomes in patients with AD treated with or without systemic immunomodulatory treatments, using a global registry platform.

METHODS

Clinicians were encouraged to report cases of COVID-19 in their patients with AD in the Surveillance Epidemiology of Coronavirus Under Research Exclusion for Atopic Dermatitis (SECURE-AD) registry. Data entered from 1 April 2020 to 31 October 2021 were analysed using multivariable logistic regression. The primary outcome was hospitalization from COVID-19, according to AD treatment groups.

RESULTS

442 AD patients (mean age 35.9 years, 51.8% male) from 27 countries with strongly suspected or confirmed COVID-19 were included in analyses. 428 (96.8%) patients were treated with a single systemic therapy (n = 297 [67.2%]) or topical therapy only (n = 131 [29.6%]). Most patients treated with systemic therapies received dupilumab (n = 216). Fourteen patients (3.2%) received a combination of systemic therapies. Twenty-six patients (5.9%) were hospitalized. No deaths were reported. Patients treated with topical treatments had significantly higher odds of hospitalization, compared with those treated with dupilumab monotherapy (odds ratio (OR) 4.65 [95%CI 1.71-14.78]), including after adjustment for confounding variables (adjusted OR (aOR) 4.99 [95%CI 1.4-20.84]). Combination systemic therapy which did not include systemic corticosteroids was associated with increased odds of hospitalization, compared with single agent non-steroidal immunosuppressive systemic treatment (OR 8.09 [95%CI 0.4-59.96], aOR 37.57 [95%CI 1.05-871.11]). Hospitalization was most likely in patients treated with combination systemic therapy which included systemic corticosteroids (OR 40.43 [95%CI 8.16-207.49], aOR 45.75 [95%CI 4.54-616.22]).

CONCLUSIONS

Overall, the risk of COVID-19 complications appears low in patients with AD, even when treated with systemic immunomodulatory agents. Dupilumab monotherapy was associated with lower hospitalization than other therapies. Combination systemic treatment, particularly combinations including systemic corticosteroids, was associated with the highest risk of severe COVID-19.

Recommended core outcome instruments for health-related quality of life, long-term control and itch intensity in atopic eczema trials: results of the HOME VII consensus meeting

Background

The Harmonising Outcome Measures for Eczema (HOME) initiative has established a core outcome set of domains for atopic eczema (AE) clinical trials. Previous consensus meetings have agreed on preferred instruments for clinician‐reported signs (Eczema Area and Severity Index, EASI) and patient‐reported symptoms (Patient‐Oriented Eczema Measure, POEM). This paper reports consensus decisions from the HOME VII meeting.

Objectives

To complete the core outcome set for AE by agreeing on core outcome instruments for the domains of quality of life (QoL), long‐term control and itch intensity.

Methods

A face‐to‐face consensus meeting was held in Tokyo, Japan (8–10 April 2019) including 75 participants (49 healthcare professionals/methodologists, 14 patients, 12 industry representatives) from 16 countries. Consensus decisions were made by presentations of evidence, followed by whole and small group discussions and anonymous voting using predefined consensus rules.

Results

It was agreed by consensus that QoL should be measured using the Dermatology Life Quality Index (DLQI) for adults, the Children’s Dermatology Life Quality Index (CDLQI) for children and the Infant’s Dermatology Quality of Life Index (IDQoL) for infants. For long‐term control, the Recap of Atopic Eczema (RECAP) instrument or the Atopic Dermatitis Control Test (ADCT) should be used. Consensus was not reached over the frequency of data collection for long‐term control. The peak itch numerical rating scale (NRS)‐11 past 24 h was recommended as an additional instrument for the symptom domain in trials of older children and adults. Agreement was reached that all core outcome instruments should be captured at baseline and at the time of primary outcome assessment as a minimum.

Conclusions

For now, the core outcome set for clinical trials in AE is complete. The specified domains and instruments should be used in all new clinical trials and systematic reviews of eczema treatments.

What is already known about this topic?

Core outcomes sets improve the design and reporting of clinical trials, reduce selective outcome reporting bias and facilitate meta‐analysis of results in systematic reviews.

The HOME core outcome set for eczema recommends the inclusion of four core domains in all atopic eczema trials: clinician‐reported signs, patient‐reported symptoms, health‐related quality of life (HrQoL) and long‐term control.

Clinician‐reported signs should be captured using the Eczema Area and Severity Index (EASI) and patient‐reported symptoms using the Patient‐Oriented Eczema Measure (POEM).

What does this study add?

The HOME core outcome set is now complete and recommended core outcome instruments have been agreed on for all four domains.

Core outcome instruments for HrQoL: Dermatology Life Quality Index (DLQI) for adults, Children’s Dermatology Life Quality Index (CDLQI) for children and Infant’s Dermatology Quality of Life Index (IDQoL) for infants.

Core outcome instruments for long‐term control: either the Recap of Atopic Eczema (RECAP) or the Atopic Dermatitis Control Test (ADCT).

In addition, itch intensity should be measured using the peak NRS‐11 past 24 h for trials including older children and adults.

What are the clinical implications of this work?

If all future trials of eczema treatments include the HOME core outcome instruments, then trial results will be more readily incorporated into meta‐analyses in systematic reviews and clinical care will be informed by the best available evidence.

Linked Comment: D.F. Murrell and C.F. Paul. Br J Dermatol 2021; 185:13–14.

Recommended core outcome instruments for health-related quality of life, long-term control and itch intensity in atopic eczema trials: results of the HOME VII consensus meeting

BACKGROUND

The Harmonising Outcome Measures for Eczema (HOME) initiative has established a core outcome set of domains for atopic eczema clinical trials. Previous consensus meetings have agreed upon preferred instruments for clinician-reported signs (Eczema Area and Severity Index - EASI) and patient-reported symptoms (Patient-Oriented Eczema Measure - POEM). This paper reports consensus decisions from the HOME VII meeting.

OBJECTIVE

To complete the core outcome set for atopic eczema by agreeing upon core outcome instruments for the domains of quality of life, long-term control and itch intensity.

METHODS

Face-to-face consensus meeting held in Tokyo, Japan (8th to 10th April, 2019) including 74 participants (47 healthcare professionals/methodologists, 14 patients, 13 industry representatives), from 16 countries. Consensus decisions were made by presentations of evidence, followed by whole and small group discussions and anonymous voting using pre-defined consensus rules.

RESULTS

It was agreed by consensus that quality of life should be measured using the Dermatology Life Quality Index (DLQI) for adults, the Children's Dermatology Life Quality Index (CDLQI) for children, and the Infant's Dermatology Quality of Life Index (IDQoL) for infants. For long-term control, the Recap of Atopic Eczema (RECAP) instrument or the Atopic Dermatitis Control Test (ADCT) should be used. Consensus was not reached over the frequency of data collection for long-term control. The peak itch numerical rating scale(NRS)-11 past 24 hours was recommended as an additional instrument for the symptom domain in trials of older children and adults. Agreement was reached that all core outcome instruments should be captured at baseline and at the time of primary outcome assessment as a minimum.

CONCLUSIONS

For now, the core outcome set for clinical trials in atopic eczema is complete. The specified domains and instruments should be used in all new clinical trials and systematic reviews of eczema treatments.

Development and initial testing of a new instrument to measure the experience of eczema control in adults and children: Recap of atopic eczema (RECAP)

Background

Eczema control has been identified as an important outcome by key stakeholders in eczema research (including patients, carers, healthcare professionals and researchers) but no validated instruments for the domain have been identified.

Objectives

To develop a measurement instrument to capture a patient's perspective of eczema control that is suitable for use in eczema clinical trials.

Methods

Best practice for the development of a patient‐reported outcome was followed. A mixed‐methods approach was used to develop and refine a conceptual framework, generate, refine and select items and to test the distribution and construct validity of the final scale. The mixed‐methods approach involved expert panel meetings (including patient representatives, healthcare professionals and methodologists), and data collection using a focus group, cognitive interviews and an online survey with people with eczema and caregivers. Multivariable linear regression was used in the item selection process.

Results

Fourteen expert panel members co‐produced the instrument, with input from people with eczema and caregivers via a focus group (n = 6), cognitive interviews (n = 13) and an online survey (n = 330). The resulting instrument, Recap of atopic eczema (RECAP), is a seven‐item questionnaire that captures eczema control via self or caregiver report. The development process aimed to ensure good content validity and feasibility. Initial testing suggested no floor or ceiling effects and good construct validity. Hypothesized correlation with the Patient‐Oriented Eczema Measure was confirmed [r(258) = 0·83, P < 0·001].

Conclusions

RECAP has the potential to improve reporting of eczema control in research and clinical practice. Further exploration of measurement properties is required.

Linked Comment: Pattinson and Bundy. Br J Dermatol 2020; 183:418–419.

What's already known about this topic?

Eczema control has been identified as an important outcome by key stakeholders in eczema research (including patients, carers, healthcare professionals and researchers).

Qualitative studies suggest eczema control is a multifaceted and individual experience and no instrument has been identified that captures eczema control in this way.

What does this study add?

We have developed Recap of atopic eczema (RECAP), a seven‐item questionnaire to capture the experience of eczema control in all ages and eczema severities; there are two versions: a self‐reported version for adults and older children with eczema, and a caregiver‐reported version for younger children with eczema.

Designed with input from people with eczema, caregivers and healthcare professionals to ensure good content validity.

Initial testing of score distributions and construct validity suggests good measurement properties.

What are the clinical implications of the work?

The RECAP instrument is appropriate and feasible for measuring eczema control in clinical trials and may also be useful in routine practice.

Linked Comment: Pattinson and Bundy. Br J Dermatol 2020; 183:418–419.

Plain language summary available online

Abstract 110: Clinical Characteristics and Anticoagulant Transition Patterns of Hospitalized Patients with Venous Thromboembolism: A Retrospective Analysis Using Electronic Health Record Data

Objective: Describe the clinical characteristics and anticoagulant use of patients with venous thromboembolism (VTE) transitioning from a hospital setting using an electronic health care (EHR) database.

Methods: This retrospective EHR study analyzed adults (18+ years) with a VTE diagnosis code during a hospital encounter (emergency department [ED], observation [OBS] area, or inpatient [IP] stay) between 1/1/2012-8/31/2017 (ID period). The first VTE hospital encounter (from admission to discharge) during the ID period was defined as the index VTE encounter. Patients with evidence of atrial fibrillation/flutter, pregnancy, or multiple oral anticoagulants during the index VTE encounter were excluded. Clinical characteristics and anticoagulants administered during the index VTE encounter and ordered on the discharge date were reported descriptively.

Results: Among the 282,978 patients identified, the mean age (SD) age was 61 (17) years; 48% (136,155 of 282,978) were male; 78% (221,120 of 282,978) were Caucasian; 59% (167,628 of 282,978) had deep vein thrombosis without a pulmonary embolism; 18% (49,596 of 282,978) had evidence of cancer; and 7% (19,447 of 282,978) had evidence of a provoked etiology (hormonal therapy, lower extremity fracture/trauma, pelvic/orthopedic surgery) during the index VTE encounter. Nearly three-quarters (199,568 of 282,978) were admitted for an IP stay with a median length of stay of 6 days; the remaining 29% (83,410 of 282,978) were treated in an ED or OBS area only. Overall, 73% (207,640 of 282,978) were discharged home, 19% (54,283 of 282,978) were discharged to another IP facility, and 7% (21,055 of 282,978) had other or unknown discharge status. During the index VTE encounter, 67% (188,271 of 282,978) received heparin (low molecular weight or unfractionated), 34% (95,090 of 282,978) received warfarin, 12% (34,540 of 282,978) received a non-vitamin K oral anticoagulant (DOAC), and 27% (76,877 of 282,978) had no record of anticoagulant administration. Of those with heparin, 41% (76,471 of 188,271) received heparin only. More than half of those with an order for a DOAC or warfarin on the discharge date had received the same anticoagulant during the index VTE encounter, namely, 65% (22,344 of 34,540) with a DOAC during the index VTE encounter received a discharge order for a DOAC and 58% (55,369 of 95,090) with warfarin during the index VTE encounter received a discharge order for warfarin. Among those with heparin only during the index VTE encounter, approximately 18% (13,759 of 76,471) received an order for heparin, 6% (4,217 of 76,471) received an order for a DOAC, and 5% (3,810 of 76,471) received an order for warfarin on discharge.

Conclusion: This EHR study observed that a sizable proportion of hospitalized patients with VTE were either prescribed a different anticoagulant on discharge or discharged without an anticoagulant prescription.

Report from the fifth international consensus meeting to harmonize core outcome measures for atopic eczema/dermatitis clinical trials (HOME initiative)

This is the report from the fifth meeting of the Harmonising Outcome Measures for Eczema initiative (HOME V). The meeting was held on 12-14 June 2017 in Nantes, France, with 81 participants. The main aims of the meeting were (i) to achieve consensus over the definition of the core domain of long-term control and how to measure it and (ii) to prioritize future areas of research for the measurement of the core domain of quality of life (QoL) in children. Moderated whole-group and small-group consensus discussions were informed by presentations of qualitative studies, systematic reviews and validation studies. Small-group allocations were performed a priori to ensure that each group included different stakeholders from a variety of geographical regions. Anonymous whole-group voting was carried out using handheld electronic voting pads according to predefined consensus rules. It was agreed by consensus that the long-term control domain should include signs, symptoms, quality of life and a patient global instrument. The group agreed that itch intensity should be measured when assessing long-term control of eczema in addition to the frequency of itch captured by the symptoms domain. There was no recommendation of an instrument for the core outcome domain of quality of life in children, but existing instruments were assessed for face validity and feasibility, and future work that will facilitate the recommendation of an instrument was agreed upon.

Interventions for hidradenitis suppurativa: a Cochrane systematic review incorporating GRADE assessment of evidence quality

More than 50 interventions have been used to treat hidradenitis suppurativa (HS), and so therapy decisions can be challenging. Our objective was to summarize and appraise randomized controlled trial (RCT) evidence for HS interventions in adults. Searches were conducted in Medline, Embase, CENTRAL, LILACS, five trials registers and abstracts from eight dermatology conferences until 13 August 2015. Two review authors independently assessed study eligibility, extracted data and assessed methodological quality. Primary outcomes were quality of life and adverse effects of the interventions. Twelve trials, from 1983 to 2015, investigating 15 different interventions met our inclusion criteria. The median trial duration was 16 weeks and the median number of participants was 27. Adalimumab 40 mg weekly improved the Dermatology Life Quality Index (DLQI) by 4·0 points, which equates to the minimal clinically important difference for the scale, compared with placebo (95% confidence interval -6·5 to -1·5 points). Evidence quality was reduced to 'moderate' because the results are based on only a single study. Adalimumab 40 mg every other week was ineffective in a meta-analysis of two studies comprising 124 participants. Infliximab 5 mg kg(-1) improved the DLQI score by 8·4 points after 8 weeks in a moderate-quality study completed by 33 of 38 participants. Etanercept 50 mg twice weekly was ineffective. Inclusion of a gentamicin sponge prior to primary closure did not improve outcomes. Other interventions, including topical and oral antibiotics, were investigated by relatively small studies, preventing treatment recommendations due to imprecision. More, larger RCTs are required to investigate most HS interventions, particularly oral treatments and surgical therapy. Moderate-quality evidence suggests that adalimumab given weekly and infliximab are effective, whereas adalimumab every other week is ineffective.

Report from the third international consensus meeting to harmonise core outcome measures for atopic eczema/dermatitis clinical trials (HOME)

This report provides a summary of the third meeting of the Harmonising Outcome Measures for Eczema (HOME) initiative held in San Diego, CA, U.S.A., 6-7 April 2013 (HOME III). The meeting addressed the four domains that had previously been agreed should be measured in every eczema clinical trial: clinical signs, patient-reported symptoms, long-term control and quality of life. Formal presentations and nominal group techniques were used at this working meeting, attended by 56 voting participants (31 of whom were dermatologists). Significant progress was made on the domain of clinical signs. Without reference to any named scales, it was agreed that the intensity and extent of erythema, excoriation, oedema/papulation and lichenification should be included in the core outcome measure for the scale to have content validity. The group then discussed a systematic review of all scales measuring the clinical signs of eczema and their measurement properties, followed by a consensus vote on which scale to recommend for inclusion in the core outcome set. Research into the remaining three domains was presented, followed by discussions. The symptoms group and quality of life groups need to systematically identify all available tools and rate the quality of the tools. A definition of long-term control is needed before progress can be made towards recommending a core outcome measure.

The Hidradenitis Suppurativa Priority Setting Partnership

BACKGROUND

Hidradenitis suppurativa (HS) has been neglected by medical researchers and society in general, despite being a relatively common, painful, chronic skin disease.

OBJECTIVES

To generate a top 10 list of HS research priorities, from the perspectives of patients with HS, carers and clinicians, to take to funding bodies.

METHODS

A priority setting partnership was established between patients with HS, carers and clinicians, following the James Lind Alliance process. Survey 1 requested submission of HS uncertainties, which were grouped into 'indicative uncertainties' for prioritization in survey 2. The 30 highest-ranked indicative uncertainties were reduced to a 'top 10' list using nominal group technique at a prioritization workshop attended by all relevant HS stakeholders.

RESULTS

In total 1495 potential uncertainties were submitted in survey 1, including 57% from patients with HS and carers, and grouped into 55 indicative uncertainties. Ranking in survey 2 was completed by 371 participants, 50% of whom were patients and carers. The final workshop was attended by 22 HS stakeholders and four facilitators and produced a top 10 list, the three highest priorities in descending order being (i) What is the most effective and safe group of oral treatments in treating HS? (ii) What is the best management of an acute flare? (iii)What is the impact of HS and its treatment on people with HS?

CONCLUSIONS

The top 10 HS research priorities have been directly disseminated to funders to raise awareness of HS. The next step is to generate research questions that will provide the evidence needed to improve care for patients with HS.

What causes intraspecific variation in resting metabolic rate and what are its ecological consequences?

Individual differences in the energy cost of self-maintenance (resting metabolic rate, RMR) are substantial and the focus of an emerging research area. These differences may influence fitness because self-maintenance is considered as a life-history component along with growth and reproduction. In this review, we ask why do some individuals have two to three times the 'maintenance costs' of conspecifics, and what are the fitness consequences? Using evidence from a range of species, we demonstrate that diverse factors, such as genotypes, maternal effects, early developmental conditions and personality differences contribute to variation in individual RMR. We review evidence that RMR is linked with fitness, showing correlations with traits such as growth and survival. However, these relationships are modulated by environmental conditions (e.g. food supply), suggesting that the fitness consequences of a given RMR may be context-dependent. Then, using empirical examples, we discuss broad-scale reasons why variation in RMR might persist in natural populations, including the role of both spatial and temporal variation in selection pressures and trans-generational effects. To conclude, we discuss experimental approaches that will enable more rigorous examination of the causes and consequences of individual variation in this key physiological trait.

Implantation of cocoa butter reduces egg and hatchling size in Salmo trutta

This study demonstrated that, irrespective of hormone type or dose, administering cocoa butter implants during egg development affected the growth of female brown trout Salmo trutta and reduced the size of their offspring. Cortisol treatment also increased adult mortality. Caution is urged in the use of implants for studies of maternal hormonal influences on adult fishes and their offspring.

The prevalence of ocular disease in chronic lymphocytic leukaemia

AIM

Previous surveys of ocular disease in leukaemia patients have shown the retina, choroid, and orbit as the most commonly involved sites. Depending on the type of leukaemia and the study design, the prevalence of ocular disease in leukaemia varies from 30 to 90%. Although chronic lymphocytic leukaemia (CLL) is the most common leukaemia in Western countries, the prevalence of ocular disease in CLL is not known. The aim of this prospective study was to estimate the prevalence of ocular disease in CLL.

PATIENTS AND METHODS

All CLL patients attending either a teaching or district general hospital haematology clinic were invited to undergo a full eye examination. The clinical stage of the CLL (Binet) at the time of the eye examination and the most recent full blood count (FBC) indices were recorded for each patient.

RESULTS

Over 6 months, 25 patients with an average age of 65 were recruited. A total of 18 patients had Binet stage A disease, three had stage B, and four stage C. The mean FBC indices at the time of examination were haemoglobin 13.5 g/dl, white cell count 37.4 x 10(9)/l, and platelets 172 x 10(9)/l. Only three patients (12%) had ocular disease that was likely to be a secondary complication of CLL. These secondary complications included bilateral posterior subcapsular cataract following radiotherapy, unilateral acute retinal necrosis, and unilateral conjunctival vascular anomalies. The presence of ocular complications was not related to the CLL stage or to the current FBC parameters.

DISCUSSION

This study demonstrates that ocular involvement in CLL is uncommon, a reflection of the indolent course of CLL as compared to other leukaemias. Although sight-threatening ocular complications have been documented in this and other studies, the low prevalence of complications and the lack of association with disease parameters make it impossible to identify a 'high-risk' group. Routine screening of CLL patients for ocular complications is not justified.

Comminuted fracture of the talus not visible on the initial radiograph

Fractures of the talus are rare injuries and fractures of the body of the talus are particularly rare. Diagnosis of these fractures is also difficult as initial radiographs may be normal, particularly with osteochondral talar dome fractures. Long term morbidity is common after fractures of the talus. A case is presented of a patient with a comminuted fracture of the body of the talus with non-diagnostic initial standard ankle radiographs. Accident and emergency doctors should be aware of this injury, and be suspicious that patients with an appropriate mechanism of injury and pronounced pain may require further investigation despite normal standard ankle radiographs, as an occult fracture of the talus may be present.

Patient comfort during cataract surgery with modified topical and peribulbar anesthesia

PURPOSE

To evaluate patient comfort during cataract surgery performed using modified topical and peribulbar anesthesia.

SETTING

Sunderland Eye Infirmary Cataract Treatment Centre, Sunderland, United Kingdom.

METHODS

In this prospective study, 50 consecutive patients scheduled for cataract surgery with local anesthesia were randomly assigned to receive topical bupivacaine hydrochloride plus 0.1 mL subconjunctival lignocaine or standard peribulbar anesthesia. All surgery was performed by one surgeon using a scleral pocket bimanual phacoemulsification technique. Patients were asked to grade the pain experienced during administration of the anesthetic and during cataract surgery using a visual analog scale.

RESULTS

No statistically significant difference in patient comfort was demonstrated between the two groups during cataract surgery (P < .4, Wilcoxon rank-sum test), and all patients were satisfied with the anesthesia. However, administration of topical bupivacaine was significantly less painful than peribulbar injections (P < .001, Wilcoxon rank-sum test). In eight patients in the topical anesthesia group, the cataract in the fellow eye was removed using peribulbar anesthesia; seven of these patients stated a preference for the modified topical method, while one patient thought there was no difference between the two methods. There was no difference between the groups in surgical complications, but 24% of the peribulbar group had a minor subconjunctival hemorrhage at the needle entry site.

CONCLUSION

The modified topical technique provided satisfactory patient comfort during cataract surgery; it was comparable to the comfort achieved using peribulbar injections. The speed and ease of administering topical anesthesia coupled with the rapid visual recovery after surgery makes this method a suitable and safe choice for day-case phacoemulsification cataract surgery.

Baseline for the evaluation of an AIDS programme using prevention indicators: a case study in Ethiopia

Strategies for preventing transmission of human immunodeficiency virus (HIV) include ensuring that individuals have adequate knowledge of how HIV infection can be prevented and encouraging behaviours that decrease risk of HIV infection. In addition, there is evidence that early and appropriate management of other sexually transmitted disease is effective in reducing HIV transmission. Programmes and projects promoting prevention of HIV transmission should be evaluated periodically for their effectiveness. Between March and September 1995, ten prevention indicators developed by the WHO Global Programme on AIDS were used to establish a baseline measure for evaluating the effectiveness of the Ethiopian AIDS control programme. The indicators were measured using a structured population survey, through record review and key informants, structured observation and interview in health care facilities, and through a serosurvey among antenatal clinic attenders. The following results were found: promoting knowledge of preventive practices was successful; a relatively high proportion of young male adults had sexual risk behaviour; poor condom availability outside Addis Ababa, the capital; and very weak STD case management. The prevalence of syphilis and HIV were 8.8% and 13.6%, respectively, among pregnant women aged 15-49 years. These results should serve as a baseline for repeat surveys to assess the effectiveness of HIV prevention programmes in Ethiopia.

Similarities between dynamic elastance of left ventricular chamber and papillary muscle of rabbit heart

The frequency-dependent dynamic elastance of the left ventricle (LV) of isolated rabbit heart was determined and compared with dynamic stiffness of excised rabbit papillary muscle. Comparison was made in three states: 1) relaxed, 2) BaCl2 contracture, and 3) rigor. Dynamic chamber elastance was determined by pressure-to-volume ratio at 12 frequencies of sinusoidal volume variation between 0.1 and 30 Hz. Dynamic elastance during BaCl2 contracture was distinctly different from that during either relaxed or rigor states. Characteristics of BaCl2 contracture were 1) as frequency increased, polar plot of real and imaginary elastance showed a progressively opening clockwise spiral that tended eventually to become tangent to the apogee of a semi-circle by 30 Hz; 2) modulus spectrum exhibited asymptotes at low and high frequencies with an intervening dip to a minimum at 1.25 Hz; and 3) phase showed a sharp transition at dip frequency from small negative values at lower frequencies to large positive values at intermediate frequencies and then declined at highest frequencies. There was little dependence of dynamic elastance on frequency in both relaxed and rigor states. Dynamic muscle stiffness exhibited all features of dynamic chamber elastance in all three states. We concluded that dynamic elements responsible for myofiber stiffness were also responsible for LV chamber elastance. Furthermore, it was possible to describe and interpret dynamic chamber elastance and muscle stiffness with a common model based on muscle cross-bridge theory. This model did a reasonable job of reproducing all important features of experimentally observed LV chamber elastance and muscle stiffness. Thus dynamic homologies between chamber and muscle were established in experimental data and in the fact that a single interpretive model served equally well for both chamber elastance and muscle stiffness.

Expression of vascular endothelial growth factor does not promote transformation but confers a growth advantage in vivo to Chinese hamster ovary cells

Vascular endothelial growth factor (VEGF) is a mitogen with a specificity for endothelial cells in vitro and an angiogenic inducer in vivo. We tested the hypothesis that VEGF may confer on expressing cells a growth advantage in vivo. Dihydrofolatereductase--Chinese hamster ovary cells were transfected with expression vectors which direct the constitutive synthesis of VEGF. Neither the expression nor the exogenous administration of VEGF stimulated anchorage-dependent or anchorage-independent growth of Chinese hamster ovary cells in vitro. However, VEGF-expressing clones, unlike control cells, demonstrated an ability to proliferate in nude mice. Histologic examination revealed that the proliferative lesions were compact, well vascularized, and nonedematous. Ultrastructural analysis revealed that capillaries within the lesions were of the continuous type. These findings indicate that the expression of VEGF may confer on cells the ability to grow in vivo in the absence of transformation by purely paracrine mechanisms. Since VEGF is a widely distributed protein, this property may have relevance for a variety of physiological and pathological proliferative processes.

Effects of cicletanine on haemodynamics, arrhythmias and extent of necrosis during coronary ligation in rabbits

1. The effects of cicletanine on arrhythmias, haemodynamics and extent of necrosis during myocardial ischaemia were investigated in rabbits subjected to coronary ligation. 2. Cicletanine increased cardiac output prior to coronary occlusion (P < 0.01) but had no other significant haemodynamic effects at this time and did not significantly alter heart rate, blood pressure or cardiac output during 30 min of ischaemia or 30 min of reperfusion. 3. Ventricular fibrillation and mortality were greater in control (65% and 60% respectively) than treated animals (15.4% and 15.4%, P < 0.01). 4. The extent of myocardial necrosis expressed as a percentage of the area at risk was also reduced by cicletanine from 61 +/- 8% in controls to 37 +/- 6% (P < 0.05). 5. These findings indicate that cicletanine attenuates arrhythmias and preserves myocardium in the early phase of ischaemia and this effect appears to be independent of an established antihypertensive action.

Discordant segregation of Na+,K(+)-adenosine triphosphatase alleles and essential hypertension

OBJECTIVES

To determine whether the alpha 2 and or beta 1 isoforms of the Na+,K(+)-adenosine triphosphatase (Na+,K(+)-ATPase) are involved in the pathogenesis of essential hypertension.

DESIGN

Segregation analysis of polymorphic DNA markers was used to test the involvement of Na+,K(+)-ATPase in essential hypertension.

PARTICIPANTS

Children with persistent hypertension having one parent with essential hypertension were included in the study. Criteria for persistent hypertension were blood pressure readings with systolic and/or diastolic levels exceeding the 95th percentile based upon age and sex. The diagnosis of hypertension for adults, including parents and older siblings, was confirmed using criteria recommended in the 1988 report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure.

RESULTS

In three essential hypertensive families consisting of 18 members including 11 hypertensives, several obligate recombinants between the Na+,K(+)-ATPase alpha 2 isoform marker and the hypertension phenotype were observed. Similarly, in one hypertension family consisting of four members, obligate recombinants between the beta 1 isoform marker and the disease were observed.

CONCLUSIONS

The discordant segregation of the alpha 2 and beta 1 isoform markers and essential hypertension suggests that neither the Na+,K(+)-ATPase alpha 2 nor beta 1 isoform genes play a primary role in the pathogenesis of hypertension in the families studied.

Aortic smooth muscle cells express and secrete vascular endothelial growth factor

We examined whether cultured bovine aortic smooth muscle (ASM) cells express VEGF. RNA blot analysis of total cellular RNA derived from ASM cells demonstrates the expression of the VEGF gene. ASM cells release in the medium a VEGF-like endothelial cell mitogen which binds to heparin-sepharose and has an apparent molecular weight of 40-45 kDa as assessed by an HPLC gel filtration column. Consistent with VEGF, this mitogen does not stimulate the proliferation of ASM cells. Immunoblot analysis of the bioactive material with an antibody specific for VEGF demonstrates the presence of a major immunoreactive band with an apparent molecular mass of 23 kDa and a minor band with a molecular mass of approximately 18 kDa, in reducing conditions. The major band has very similar apparent molecular weight as the 165 amino-acid species of human recombinant VEGF of folliculo-stellate cells derived VEGF. These data demonstrate the expression and synthesis of VEGF by cultured ASM cells and suggest that the 164 amino-acid species is the predominant molecular form of the growth factor secreted by such cells. VEGF released by ASM cells may play a paracrine role in the maintenance of the integrity of the endothelial lining or in the abnormal proliferation of the vasa vasorum which takes place in atherosclerosis.

Relationships among measures of communication, marital satisfaction and exposure during couples treatment of agoraphobia

The goals of this study were to examine the relationships among measures of couples interactions (satisfaction and communication), and response to treatment within a group of agoraphobic clients and their partners. The treatment included the clients' partners in structured, graduated in vivo exposure practices. Twenty-two clients and their partners completed pre-, mid- and post-treatment assessments. Treatment responders rated themselves and their partners as more communicative regarding the client's fears, at pre- and mid-assessments in comparison to nonresponders; measures of communication related inversely to levels of anxiety reported during exposures, but marital satisfaction did not relate to any measure of exposure. In addition, level of anxiety during exposure differentiated responders from nonresponders; responders experienced a significant reduction in their levels of anxiety. Finally, ratings of frequency of communication at mid-assessment were highly predictive of treatment outcome at post-assessment. The implications from these findings for communication skills training for a subset of couples who enter couples treatment for agoraphobia are discussed.

Effects of whole-tree harvest on epilithic bacterial populations in headwater streams

Bacteria attached to rock and glass surfaces were studied in streams draining a whole-tree harvested watershed (WTH) and a nonharvested (CONTROL) watershed in the Hubbard Brook Experimental Forest, New Hampshire, U.S.A. Seasonal trends in numbers of cells/cm(2), mean cell volume, cell size-frequency distribution, and bacterial biomass were determined using 4'6-diamidino-2-phenylindole (DAPI) epifluorescent microscopy and scanning electron microscopy (SEM); the response of these parameters to decreased pH and increased nitrate concentration in the WTH stream was assessed via controlled manipulation of stream water chemistry in artificial channels placed in the CONTROL stream. Bacterial distribution varied significantly between the two streams and seasonally within each stream in apparent response to differential availability of dissolved organic carbon from algae and autumn-shed leaves. Decreased pH similar to that in the WTH stream had a significant effect on cell numbers, mean cell volume, and biomass in the CONTROL stream. Decreased pH accounted for some aspects of the altered bacterial distributions observed in the WTH stream. Nitrate at concentrations similar to those in the WTH stream had no effect on bacterial distribution in the CONTROL stream suggesting that headwater stream epilithic bacteria were carbon limited.

Retinoschisis associated with optic nerve pits

Stereoscopic transparencies studied with magnification and projection suggest that the retinal elevation that communicates with optic pits is frequently a schisislike separation of the internal layers of retina. Thirteen of 15 eyes with optic pits and maculopathy fit the schisis pattern. Separation of the outer layers of the retina is a secondary phenomenon that starts in the macula.

An atypical endocrine tumor of the lung responsive to radiation therapy and 5-fluorouracil-streptozotocin

A case is reported of a patient who presented with a peripheral left upper-lobe lung mass, a thyroid nodule, and multiple enlarged cervical and supraclavicular lymph nodes. Fine-needle aspiration cytology of the lung lesion, the thyroid nodule, and several of the lymph nodes was interpreted as small cell cancer of the lung (SCCL). The patient was treated with Cytoxan (cyclophosphamide), Adriamycin (doxorubicin), and vincristine (CAV), alternating with VP-16 + cisplatin. When progressive disease was documented after three cycles of chemotherapy, an involved cervical lymph node was biopsied. By light microscopy (LM) the tumor appeared to be a poorly differentiated adenocarcinoma, but by transmission electron microscopy (TEM) it was found to have both neuroendocrine and glandular features. Biochemical analysis of the biopsy specimen revealed immunoreactive bombesin, and on immunoperoxidase staining many tumor cells contained neuron-specific enolase. The tumor was therefore classified as an atypical endocrine tumor of the lung (AETL), a recently described morphologic variant for which no therapy has yet been established. The patient was treated with radiation therapy (RT) followed by chemotherapy including 5-fluorouracil (5-FU) (500 mg/m2 IV, d 1-5) and streptozotocin (STZ) (500 mg/m2 IV, d 1-5) every 5-6 weeks, with objective evidence of tumor regression following each modality. This report illustrates the importance of ultrastructural study in the characterization of lung cancer, and indicates the need for the further evaluation of RT and 5FU + STZ in the treatment of neuroendocrine tumors of the lung.

Epidemiologic characteristics of necrotizing enterocolitis: a population-based study

The authors studied retrospectively the epidemiologic characteristics of necrotizing enterocolitis occurring among Georgia infants born during 1977 and 1978; 148 cases of necrotizing enterocolitis were identified. The highest incidence rate for necrotizing enterocolitis occurred among infants weighing 751-1000 g at birth and declined with increasing birth weight to less than 0.2 cases per 1000 live births among infants weighing more than 2500 g at birth. The overall incidence rate for blacks was significantly greater than that for whites (1.6 vs. 0.5 cases per 1000 live births, p = 0.01). The overall case fatality ratio was 38.5%; there were no differences in these ratios between blacks and whites. Necrotizing enterocolitis accounted for 15% of all deaths after the first week of life for infants weighting 1500 g or less at birth. If Georgia incidence rates and fatality ratios are applied to 1978 US births, it is estimated that 2210 cases of necrotizing enterocolitis with over 900 associated deaths would have occurred.