Data scarce modelling the impact of present and future groundwater development on Jordan multiaquifer groundwater resources

Rapidly growing demands and climate change stresses water resources worldwide and leads to highly competitive situations between the environment and socio-economic development of a region, calling for a smart and modelling driven water resources management. However, data scarcity often prevents the realisation of a comprehensive, nation-wide resources model, which provides reliable and spatially discretized results of water resources development. We present a workflow approach to set up a large-scale multi-aquifer model, overcoming data shortage by stepwise calibration and integrating hydrological and numerical groundwater flow modelling into a coupled system. The study aims to develop such a system to assess how groundwater resources react on anthropogenic impacts on the example of the Kingdom of Jordan, one of the water poorest countries on globe. Simulated heads reliably resembled the monitored ones in >70 % of the observation wells. That makes us confident, the model represents all the states well from 1970, prior to the intense development of the country until 2015. The water balance shows an annual deficit of 1.16 million cubic meter (MCM) due to an overdraft. The discharge to the Dead Sea increased from 564 MCM/yr to 696 MCM/yr over the time period. Regional drawdowns of >250 m and groundwater depression with an extension of approx.100 km are observable in both large aquifer complexes. Most severe areas in the upper calcareous aquifer are located in the north of Amman and practically in all urban and agricultural agglomerations across the country. Groundwater tables in the deeper sandstone aquifer are particularly affected in the south as well as in the wider vicinity of the Dead Sea as consequence of its continuous dropping. Simulations of the future development of the groundwater tables indicate a severe deterioration of the situation with further declines in groundwater levels of up to 70 m.

Effects of vitamin D administration on nociception and spinal cord pro-oxidant and antioxidant markers in a rat model of neuropathic pain

Reactive oxygen species (ROS) are involved in neuropathic pain, a complicated condition after nerve tissue lesion. Vitamin D appears to improve symptoms of pain and exhibits antioxidant properties. We investigated the effects of oral administration of vitamin D3, the active form of vitamin D, on nociception, the sciatic functional index (SFI), and spinal cord pro-oxidant and antioxidant markers in rats with chronic constriction injury (CCI) of the sciatic nerve, a model of neuropathic pain. Vitamin D3 (500 IU/kg per day) attenuated the CCI-induced decrease in mechanical withdrawal threshold and thermal withdrawal latency (indicators of antinociception) and SFI. The vitamin prevented increased lipid hydroperoxide levels in injured sciatic nerve without change to total antioxidant capacity (TAC). Vitamin D3 prevented increased lipid hydroperoxide, superoxide anion generation (SAG), and hydrogen peroxide (H2O2) levels in the spinal cord, which were found in rats without treatment at 7 and 28 days post-CCI. A significant negative correlation was found between mechanical threshold and SAG and between mechanical threshold and H2O2 at day 7. Vitamin D3 also prevented decreased spinal cord total thiols content. There was an increase in TAC in the spinal cord of vitamin-treated CCI rats, compared to CCI rats without treatment only at 28 days. No significant changes were found in body weight and blood parameters of hepatic and renal function. These findings demonstrated, for first time, that vitamin D modulated pro-oxidant and antioxidant markers in the spinal cord. Since antinociception occurred in parallel with oxidative changes in the spinal cord, the oxidative changes may have contributed to vitamin D-induced antinociception.

Chronic mild hyperhomocysteinemia induces anxiety-like symptoms, aversive memory deficits and hippocampus atrophy in adult rats: New insights into physiopathological mechanisms

In the last decade, increased homocysteine levels have been implicated as a risk factor for neurodegenerative and psychiatric disorders. We have developed an experimental model of chronic mild hyperhomocysteinemia (HHcy) in order to observe metabolic impairments in the brain of adult rodents. Besides its known effects on brain metabolism, the present study sought to investigate whether chronic mild HHcy could induce learning/memory impairments associated with biochemical and histological damage to the hippocampus. Adult male Wistar rats received daily subcutaneous injections of homocysteine (0.03 μmol/g of body weight) twice a day, from the 30th to the 60th day of life or saline solution (Controls). After injections, anxiety-like and memory tests were performed. Following behavioral analyses, brains were sliced and hippocampal volumes assessed and homogenized for redox state assessment, antioxidant activity, mitochondrial functioning (chain respiratory enzymes and ATP levels) and DNA damage analyses. Behavioral analyses showed that chronic mild HHcy may induce anxiety-like behavior and impair long-term aversive memory (24 h) that was evaluated by inhibitory avoidance task. Mild HHcy decreased locomotor and/or exploratory activities in elevated plus maze test and caused hippocampal atrophy. Decrease in cytochrome c oxidase, DNA damage and redox state changes were also observed in hippocampus of adult rats subjected to mild HHcy. Our findings show that chronic mild HHcy alters biochemical and histological parameters in the hippocampus, leading to behavioral impairments. These findings might be considered in future studies aiming to search for alternative strategies for treating the behavioral impairments in patients with mild elevations in homocysteine levels.

Structural and functional studies of the metalloregulator Fur identify a promoter-binding mechanism and its role in Francisella tularensis virulence

Francisella tularensis is a Gram-negative bacterium causing tularaemia. Classified as possible bioterrorism agent, it may be transmitted to humans via animal infection or inhalation leading to severe pneumonia. Its virulence is related to iron homeostasis involving siderophore biosynthesis directly controlled at the transcription level by the ferric uptake regulator Fur, as presented here together with the first crystal structure of the tetrameric F. tularensis Fur in the presence of its physiological cofactor, Fe²⁺. Through structural, biophysical, biochemical and modelling studies, we show that promoter sequences of F. tularensis containing Fur boxes enable this tetrameric protein to bind them by splitting it into two dimers. Furthermore, the critical role of F. tularensis Fur in virulence and pathogenesis is demonstrated with a fur-deleted mutant showing an attenuated virulence in macrophage-like cells and mice. Together, our study suggests that Fur is an attractive target of new antibiotics that attenuate the virulence of F. tularensis.

Pérard et al. report the structure of Francisella tularensis Fur (FtFur) with its physiological cofactor Fe²⁺, and show that FtFur is important for virulence. This study identifies a promoter-driven tetramer splitting mechanism that may provide insight into future antibiotics development.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

[Ophthalmic Plastic Surgery of Exposure Keratopathy in the Intensive Care Unit]

Critically ill patients in the intensive care unit (ICU) may develop eye problems, due to impaired ocular protective mechanisms or direct involvement of the eye in severe systemic diseases. If eye infections or ocular surface disorders are not identified in time, endophthalmitis or corneal ulcer may develop and can cause permanent functional injuries of the eye. A retrospective analysis was performed and a total of 283 complete intensive care courses of treatment were evaluated, taking into account ophthalmic medical consultations for frequent cardinal symptoms. The most common cardinal symptoms were lagophthalmus (exposure keratopathy), chemosis, redness and periorbital haematoma. The following predisposing risk factors for the onset of ocular complications during intensive care treatment were detected: chemosis (p < 0.001), redness (p = 0.007), lagophthalmus (p = 0.001), ventilation (p < 0.001), use of muscle relaxants (p < 0.001), cardiovascular (p < 0.001), and neurological diseases (p < 0.001). In 71.7 % of ICU patients, additional treatment was prescribed during the eye consultation. This includes special eye care treatment (6.0 %) and/or drug therapy (64.0 %), as well as oculoplastic surgery in 4,3 % of critically ill patients. The most common oculoplastic-surgical procedure in the ICU was lid adhesion to achieve adequate protection of the corneal surface in patients with severe exposure keratopathy. Oculoplastic surgery is the method of choice for protecting the cornea in critically ill patients, when conservative options such as hypoallergenic adhesive tape or a moisture chamber are not sufficient to protect the ocular surface. The main challenges are to pay attention to the indication and performance in due time, and to avoid permanent loss of function through transparency reduction or irregular astigmatism in post-recovery patients.

Novel portable platform for molecular detection of toxigenic Clostridium difficile in faeces: a diagnostic accuracy study

BACKGROUND

A novel portable platform for nucleic acid amplification enables rapid detection of diarrhoea causing toxigenic Clostridium difficile directly from faeces, even in resource-limited settings. We evaluated the accuracy and precision of the new commercial molecular test system.

METHODS

One thousand one hundred and sixty faecal samples from patients suspected of having Clostridium difficile infection (CDI) were analysed using the Orion GenRead C. difficile test system (Orion Diagnostica Oy, Espoo, Finland) and comparative methods in three teaching hospital laboratories in Finland and France. The precision of the Orion GenRead C. difficile test system was evaluated in a reproducibility study with a set of blind-coded samples. The test system is based on a new isothermal amplification technology (Strand Invasion Based Amplification, SIBA®) and detection of the tcdB gene of C. difficile. We calculated the sensitivity, specificity, and the overall agreement according to Clinical and Laboratory Standards Institute recommendations.

FINDINGS

The overall agreement of the Orion GenRead C. difficile test when compared to the comparative methods in routine use in the participating laboratories was between 96.7% and 98.8%. In the reproducibility study; the total percent agreement between three laboratories was 99.8%.

INTERPRETATION

The identification of toxigenic C. difficile from faeces with the light-weight portable Orion GenRead test system was highly sensitive and specific, and the results were reproducible in the participating laboratories. This platform could enable fast and accurate molecular pathogen detection even in resource-limited or point-of-care settings.

[Dihydrotestosterone improves the osseointegration of cobalt-chromium implants]

BACKGROUND

The osseointegration of actually rarely implanted cobalt-chromium implants can be critical in an elderly population. The aim of our study was to evaluate the effect of preoperative testosterone treatment on the osseointegration of cobalt-chromium implants.

MATERIALS AND METHODS

Press-fit implantation of 1.6 mm-diameter cobalt-chromium-molybdenum (CoCrMo) implants was performed in rats without pre-treatment in one group (n = 10) and after pre-treatment with 1 mg dihydrotestosterone (DHT) 2 days before surgery in the other group (n = 10). After 14 days, the specimens were examined by a pull-out test, histology and histomorphometry.

RESULTS

The biomechanical testing delivered inconsistent data leading to no significant difference (6.45 ± 6.94 N vs. 4.66 ± 3.77 N). Histology showed closed contact between surrounding tissue and the implants in both groups. The bone/implant contact area was significantly enhanced after treatment with DHT (42.23 % ± 9.25 vs. 57.57 % ± 16.71, p < 0.05), while the ratio of osteoid was reduced (38.68 % ± 16.7 vs. 27.38 % ± 13.02, not significant).

CONCLUSIONS

Pre-treatment with DHT enhances osseointegration of cobalt-chromium implants through enhanced mineralisation of peri-implant tissue. The treatment might additionally shorten postoperative rehabilitation due to its positive effects on musculature.

[Muscular trunk stability in professional and amateur volleyball players]

AIM

The aim of this study was to analyse the efficiency of muscular activity in the trunk stabilisation of professional volleyball players compared to a group of amateur hobby players. The results were compared amongst the groups as well as with a reference group consisting of asymptomatic individuals. The question to be answered was whether or not professional volleyball players possess a characteristic strength profile in their trunk musculature and if differences exist with regard to the individuals' competitive playing level.

METHOD

In this comparative study 12 professional volleyball players (German Bundesliga) and 18 non-professional volleyball players were analysed with regard to their isometric strength profile in all three planes. The reference group was provided by the Proxomed company, which had previously analysed healthy untrained individuals (n = 1045) of various age groups.

RESULTS

A sports-specific profile for the musculature of volleyball players revealed a significant reduction in the flexion and rotation strength as well as a well-developed lateral flexion strength (highly significant when compared to the reference group). With reference to the level played, better strength values in flexion and lateral flexion were found among the professional athletes.

CONCLUSIONS

Professional volleyball players present with a characteristic trunk musculature strength profile. A detailed analysis of the muscle strength of the spine as part of a sports medicine work-up could prove helpful in preventing injuries and overuse problems in professional and hobby volleyball players.

[Leiomyosarcoma of the inferior vena cava. Diagnosis using endoscopic ultrasound-guided fine-needle aspiration biopsy]

HISTORY AND ADMISSION FINDINGS

A 75-year-old woman was admitted because of upper abdominal pain, nausea and vomiting.

INVESTIGATIONS

These symptoms were caused by a large tumor of the right retroperitoneal space. Computed tomography and transabdominal ultrasound did not unequivocally determine the site of the mass. Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration biopsy (EUS-FNA) ensured safe immunohistochemical diagnosis of a leiomyosarcoma of the inferior vena cava (IVC).

TREATMENT AND COURSE

The patient underwent successful en-bloc resection of the tumor and the IVC followed by prosthetic reconstruction.

CONCLUSIONS

This case emphasizes the role of EUS and EUS-FNA in the diagnosis of retroperitoneal lesions. Leiomyosarcoma of the IVC, although rare, should be considered in the differential diagnosis of a retroperitoneal mass.

[Kyphoplasty - a new minimally invasive treatment for repositioning and stabilising vertebral bodies]

AIM OF THE STUDY

Osteoporotic vertebral fractures are an ailment of the aging population of increasing incidence and high socioeconomic impact. Intractable pain causing significant morbidity leads to long-term hospitalisation. Kyphoplasty offers a new minimal invasive operative stabilisation procedure for these vertebral compression fractures. This study is conducted to investigate whether this procedure significantly reduces both pain and the duration of hospital stay in comparison to conservative treatment modalities.

METHOD

From January until July 2002 a total of 22 patients had undergone kyphoplasty in 37 vertebral bodies. Osteoporotic vertebral fractures were treated in 18 cases, while in another 4 cases prophylactic stabilisation for osteolytic lesions was performed. Both the duration of hospital stay and the reduction of pain symptoms were determined and compared to a conservatively treated control group of 20 patients suffering from 35 fractured vertebral bodies. Pre- and postoperative endplate angles were measured to assess the restoration of the sagittal alignment. The effects on pain symptoms were measured on a self-reported Visual Analogue Score Scale.

RESULTS

The mean pain relief for the patients undergoing kyphoplasty was 82 %, which was significantly higher (p < 0.0001) compared to the group of the conservatively treated patients (42 %). Reduction of the kyphotic deformity was achieved in 4 cases (average 8.5 degrees ). The average in-patient treatment duration for the surgical treated patients was 10 days as opposed to a significantly longer mean hospitalisation of 20 days (p = 0.003). Cement extravasation was observed in 5 out of 37 treated vertebral bodies without clinical sequelae.

CONCLUSION

Kyphoplasty is a safe minimal invasive procedure for the stabilisation of osteoporotic vertebral fractures leading to a statistically significant reduction both of pain status and duration of hospitalisation.

A modular femoral implant for uncemented stem revision in THR

We present the early results of 142 uncemented femoral stem revisions using the modular MRP-Titan system. There were 70 cases with marked preoperative femoral bone defects (Paprosky type 2C and type 3); and bone grafts were used in 31 cases. At a mean follow-up of 2.3 years five cases were re-revised due to dislocation and two due to aseptic loosening. The mean Harris hip score improved from 37.4 preoperatively to 92.4. In 122 cases progressive bone regeneration on X-ray was seen; and no further osteolysis was observed.

[Injury and exertion patterns in football on artificial turf]

This controlled non-selected cross-sectional study supplies a basic survey on the topic analysing 1783 injuries in 433 of 736 athletes out of a closed collective. Aged 11 to 40 years and having played an average of 3.7 years an artificial turf the players had sustained 38% skin injuries (58% in the legs), 28% sprains (64% in the ankle joints, 21% in the knee joints) and 17% muscle injuries. 76% of all injuries were minor, i.e. leading to an interruption of under one week, only 8% were severe with a break of over 3 weeks. The average risk of injury was 6 per 1000 hours of participation, similar to that in football on natural grass. More than half of the players protocol pain in the joints, muscles or column persisting even one day after the game, which only led to medical assistance in 3% of all cases. Playing football on artificial grass displays a specific pattern of injuries and exertion syndromes without a higher rate or grade of injuries and therefore shows no medical need for restriction.

Surfactant abnormalities in idiopathic pulmonary fibrosis, hypersensitivity pneumonitis and sarcoidosis

Bronchoalveolar lavage fluids (BALF) from patients with idiopathic pulmonary fibrosis (IPF; n=36), hypersensitivity pneumonitis (HP; n=32) and sarcoidosis (n=44) were investigated for their surfactant properties and compared to healthy control subjects (n=29). The phospholipid (PL) and protein concentration, the PL:protein ratio, PL subclasses, and the surfactant apoproteins (SP)A and SP-B were quantified in BALF. Large surfactant aggregates (LSA) were measured by means of ultracentrifugation and assayed for surface activity using the pulsating bubble surfactometer. As compared to controls, SP-A concentrations, LSA content and PL:protein ratios were significantly decreased in all groups, whereas PL and SP-B concentrations remained unchanged. Changes in the phospholipid profile, with reduced percentages of phosphatidylcholine (not significant) and phosphatidylglycerol and increased fractions of phosphatidylinositol and sphingomyelin (p<0.05), occurred more in IPF than in HP, and not in sarcoidosis. Surface activity was found to be severely impaired in IPF (minimum surface tension (gamma min) approximately 15-20 mN x m(-1)), but only modestly affected in HP and sarcoidosis (gamma min approximately 5 mN x m(-1)) compared to controls (gamma min approximately 0 mN x m(-1)). Reconstitution of pelleted surfactant material with soluble BALF proteins further increased gamma min values. In conclusion, moderate changes in biochemical and physical surfactant properties are encountered in hypersensitivity pneumonitis and sarcoidosis, but pronounced disturbances occur in idiopathic pulmonary fibrosis.

Measuring the perceptual magnet effect in the perception of /i/ by German listeners

In a study of the internal category structure of the vowel /i/, Kuhl found a "perceptual magnet effect": Discrimination sensitivity was poorer for category instances that were acoustically similar to the category prototype than it was for category instances that were not. The typicality of category exemplars was determined by goodness judgments and was found to correlate with the acoustics of average production. Analysis and interpretation of discrimination performance relied on two important assumptions: that listeners perceived all stimuli presented as exemplars of the same vowel category and that, apart from the influence of phonetic coding, discrimination sensitivity was the same across the investigated part of the vowel space. In the present study, it is shown that production and perception estimates of the category prototype may diverge, possibly because listeners seem to prefer hyperarticulated variants of vowel categories. An approach towards measurement of intra-category discrimination minima is put forward and tested that protects against intercategory confounds and avoids the isosensitivity assumption.

Biochemical separations by continuous-bed chromatography

Innovations in column-packing media for biomolecule purification have progressed from large spherical, porous polysaccharide beads to advanced polymeric supports. Continuous-bed technology is a radical new technology for chromatography based on the polymerization of advanced monomers and ionomers directly in the chromatographic column. The polymer chains form aggregates which coalesce into a dense, homogeneous network of interconnected nodules consisting of microparticles with an average diameter of 3000 A. The voids or channels between the nodules are large enough to permit a high hydrodynamic flow. Due to the high cross-linking of the polymer matrix, the surface of each nodule is nonporous yet the polymeric microparticles provide a very large surface area for high binding capacity. This paper will demonstrate the properties and advantages of using a continuous bed support for high resolution biomolecule separations at high flow-rates without sacrificing capacity.

The relationship between parameters of serotonin metabolism and emetogenic potential of platinum-based chemotherapy regimens

Evaluation of the relationship between parameters of serotonin (5-HT) metabolism and emesis in platinum-based chemotherapy. Female patients receiving chemotherapies containing either cisplatin (35 patients; 80 courses) or carboplatin (65 patients; 102 courses) were recruited. Recording of emesis and measurements of urinary 5-hydroxyindoleacetic acid (5-HIAA), the main metabolite of 5-HT, was performed over 3 days. Comparisons were performed for single-agent cisplatin (DDP) versus single-agent carboplatin (CBDCA), single-agent high-dose DDP (> or = 75 mg/m2) versus high-dose DDP combined with cyclophosphamide, high-dose versus low-dose DDP (< or = 50 mg/m2), and single-agent CBDCA versus a combination with alkylating agents. Cisplatin induced both a significantly higher frequency of emesis and a significantly higher increase of 5-HIAA excretion than carboplatin. The velocity of 5-HIAA increase may correlate better with emetogenic potential than peak 5-HIAA excretion levels. The increase of 5-HIAA excretion induced by cisplatin was limited to day 1. Higher cisplatin doses showed both a higher emetogenic potential and a more pronounced increase in urinary 5-HIAA on day 1. No significant difference was found when single-agent cisplatin was compared with cisplatin combined with cyclophosphamide. In contrast, a combination of carboplatin with alkylating agents induced a larger increase in urinary 5-HIAA and showed a higher emetogenic potential than single-agent carboplatin. Low-dose cisplatin induced less emesis than carboplatin combination therapy, but induced a larger increase in urinary 5-HIAA. Our findings provide evidence for a relationship between emetogenic potential and patterns of 5-HIAA excretion following platinum-based chemotherapy.

Oligonucleotide analysis by capillary polymer sieving electrophoresis using acryloylaminoethoxyethanol-coated capillaries

Capillary polymer sieving electrophoresis using dynamic sieving polymer solutions provides size-based separations of oligonucleotides. The polymer sieving system described here resolves single-stranded oligonucleotides with single-base resolution up to lengths of 30 bases within 10 min. The effect of temperature on the separation of synthetic oligonucleotide standards was examined between 20 degrees C and 40 degrees C, with optimal performance at 35-40 degrees C. By adding urea to the sieving buffer single-base resolution could be extended to 60 bases in about 40 min. Best performance was achieved with capillaries coated with a new monomer, acryloylaminoethoxyethanol. This coating provides the necessary stability to ensure long lifetimes.

Bronchoalveolar and systemic cytokine profiles in patients with ARDS, severe pneumonia and cardiogenic pulmonary oedema

The aim of this study was to investigate whether bronchoalveolar lavage (BAL) and serum levels of proinflammatory cytokines discriminate between different entities of patients with acute respiratory failure. BAL and circulating concentrations of interleukin-6 (IL-6), interleukin-8 (IL-8) and tumour necrosis factor-alpha (TNF-alpha) were measured in 74 mechanically-ventilated patients and 17 healthy controls. Patients were classified as cardiogenic pulmonary oedema (CPO), acute respiratory distress syndrome (ARDS), primary severe pneumonia (PN) and a combined group (PN+ARDS). In all patients with ARDS and/or PN, markedly elevated BAL levels of IL-6 and IL-8 were detected, which were significantly greater than levels in CPO and healthy controls. Absolute quantities and time-course of these cytokines did not differentiate between the absence and presence of lung infection, or different categories of PN. Similarly, circulating IL-6 levels were comparably elevated in patients with ARDS and/or PN, whereas circulating IL-8 concentrations were inconsistently increased. TNF-alpha was rarely detected in BAL samples, but increased serum concentrations were measured in ARDS and/or PN patients. Bronchoalveolar lavage levels of interleukin-6 and interleukin-8, but not tumour necrosis factor-alpha, and serum concentrations of interleukin-6 are consistently elevated in acute respiratory distress syndrome and/or severe pneumonia, discriminating these entities from cardiogenic pulmonary oedema. Alveolar and systemic cytokine profiles do not differentiate between acute respiratory distress syndrome in the absence of lung infection and states of severe primary or secondary pneumonia, which evidently present with comparable local and systemic inflammatory sequelae.

Surfactant alterations in severe pneumonia, acute respiratory distress syndrome, and cardiogenic lung edema

Bronchoalveolar lavage fluids (BALF) were analyzed for surfactant abnormalities in 153 patients with acute respiratory failure necessitating mechanical ventilation. Diagnoses were acute respiratory distress syndrome (ARDS) in the absence of lung infection (n = 16), severe pneumonia (PNEU; n = 88), ARDS and PNEU (n = 36), and cardiogenic lung edema (CLE; n = 13). The PNEU group was subdivided into groups with alveolar PNEU (n = 35), bronchial PNEU (n = 16), interstitial PNEU (n = 18) and nonclassified PNEU (n = 19). Comparison with healthy controls (n = 20) was undertaken. Total phospholipids (PL), proteins, PL classes (HPTLC) and surfactant apoproteins SP-A and SP-B (ELISA) were quantified in the original BALF. The 48,000 x g pellet from centrifugation of the BAL was used to assess the percentage of large surfactant aggregates (LSA) and the biophysical properties of the surfactant (pulsating bubble surfactometer). All groups with inflammatory lung injury (PNEU and/or ARDS) showed some decrease in the lavageable PL pool, a reduced LSA content in BALF, and a manifold increase in alveolar protein load. Marked changes in the PL profile were noted throughout the groups (a decrease in phosphatidylcholine (PC) and phosphatidylglycerol (PG) and an increase in phosphatidylinositol [PI] and sphingomyelin [SPH]). Concentrations of SP-A but not of SP-B in BALF were reduced. Minimum surface-tension values approached 0 mN/m in controls, and ranged from 10 to 25 mN/m in the absence of supernatant protein and from 20 to 35 mN/m in recombination with leaked protein in the groups with ARDS and/or PNEU. Abnormalities in alveolar PNEU surpassed those in bronchial PNEU, and interstitial PNEU presented a distinct pattern with extensive metabolic changes. All surfactant changes were absent in CLE except for a slight inhibition of surface activity by proteins. We conclude that pronounced surfactant abnormalities, comparable to those in ARDS in the absence of lung infection, occur in different entities of severe PNEU, but not in CLE.

The DCCT and medical care for diabetes in the U.S

The Diabetes Control and Complications Trial (DCCT) has convincingly established that intensive treatment of insulin-dependent diabetes mellitus (IDDM) can substantially reduce the incidence and progression of retinopathy, nephropathy, and neuropathy (1). Development of retinopathy in those without retinopathy at baseline was reduced by 76%, and progression of retinopathy in those with early retinal disease at baseline was reduced by 54%. Intensive therapy was associated with a 39% reduction in the occurrence of microalbuminuria (≥40 mg of urine albumin per 24 h) and a 54% reduction in the incidence of albuminuria (≥300 mg of urine albumin per 24 h). Development of clinical neuropathy was reduced by 60%. A reduction also occurred in macrovascular disease events (41%), although this did not reach statistical significance.

Occupational therapy. Making stroke patients feel at home

Stroke may be one of the results of heart disease. Stroke victims returning from the hospital face obstacles they did not imagine even during rehabilitation therapy in the hospital.

Glomerular filtration rate measurements in clinical trials. Modification of Diet in Renal Disease Study Group and the Diabetes Control and Complications Trial Research Group

To assess the utility and precision of GFR measurements in multicenter trials, the test performance and variability of GFR were analyzed in 2,250 patients enrolled in 44 clinical centers participating in either the Modification of Diet in Renal Disease (MDRD) Study or the Diabetes Control and Complications Trial (DCCT). GRF was measured as the renal clearance of [125I]iothalamate after an sc injection without epinephrine. The studies used similar protocols for obtaining blood and urine, training clinical center staff, and processing specimens in central laboratories. The performance of GFR measurements, assessed from adherence to protocol and quality control analyses, was excellent. The variability among the four clearance periods (intratest coefficient of variation [CV]) was acceptable; the median intratest CV for GFR was 9.4% in the MDRD Study and 11.7% in the DCCT. The pattern of decline in serum counts was better approximated by an exponential rather than a linear relationship. The cause of the intratest variability in GFR measurements was explored by univariate and multivariate analysis. The intratest CV was highest at the extremes of GFR. Among patients with a high GFR (> 90 mL/min per 1.73 m2), most of whom were participants in the DCCT, the higher intratest GFR was due, in part, to a systematic decline in GFR during the test. Among patients with a very low GFR (< 13 mL/min per 1.73 m2), technical difficulties in urine collections contributed substantially to the higher intratest CV. Other patient characteristics, including age, gender, weight, serum glucose, renal diagnosis, and use of diuretics, were not strongly correlated with the intratest CV. The precision of GFR measurements was assessed from the variability from measurement to measurement (interest CV). Among MDRD Study subjects, in whom two measurements of GFR were performed over a 3-month interval, the median interest CV was relatively low (6.3%) and was only weakly related to the intratest CV. Thus, GFR measurements are reasonably precise, even if the intratest CV is high. Given the relatively high intratest CV that is characteristic of GFR measurements, the estimate of GFR in an individual is more precise if multiple clearance periods, rather than a single period, are included. Similarly, the estimate of mean GFR for a population is also more precise if multiple clearance periods are included. In conclusion, by the use of standardized methods, an acceptable precision of GFR results can be obtained in multicenter trials. The same methods can be applied in clinical practice.(ABSTRACT TRUNCATED AT 400 WORDS)

The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus

BACKGROUND

Long-term microvascular and neurologic complications cause major morbidity and mortality in patients with insulin-dependent diabetes mellitus (IDDM). We examined whether intensive treatment with the goal of maintaining blood glucose concentrations close to the normal range could decrease the frequency and severity of these complications.

METHODS

A total of 1441 patients with IDDM--726 with no retinopathy at base line (the primary-prevention cohort) and 715 with mild retinopathy (the secondary-intervention cohort) were randomly assigned to intensive therapy administered either with an external insulin pump or by three or more daily insulin injections and guided by frequent blood glucose monitoring or to conventional therapy with one or two daily insulin injections. The patients were followed for a mean of 6.5 years, and the appearance and progression of retinopathy and other complications were assessed regularly.

RESULTS

In the primary-prevention cohort, intensive therapy reduced the adjusted mean risk for the development of retinopathy by 76 percent (95 percent confidence interval, 62 to 85 percent), as compared with conventional therapy. In the secondary-intervention cohort, intensive therapy slowed the progression of retinopathy by 54 percent (95 percent confidence interval, 39 to 66 percent) and reduced the development of proliferative or severe nonproliferative retinopathy by 47 percent (95 percent confidence interval, 14 to 67 percent). In the two cohorts combined, intensive therapy reduced the occurrence of microalbuminuria (urinary albumin excretion of > or = 40 mg per 24 hours) by 39 percent (95 percent confidence interval, 21 to 52 percent), that of albuminuria (urinary albumin excretion of > or = 300 mg per 24 hours) by 54 percent (95 percent confidence interval 19 to 74 percent), and that of clinical neuropathy by 60 percent (95 percent confidence interval, 38 to 74 percent). The chief adverse event associated with intensive therapy was a two-to-threefold increase in severe hypoglycemia.

CONCLUSIONS

Intensive therapy effectively delays the onset and slows the progression of diabetic retinopathy, nephropathy, and neuropathy in patients with IDDM.

Survey of physician practice behaviors related to diabetes mellitus in the U.S. I. Design and methods

OBJECTIVE

To conduct a survey among a representative sample of primary care physicians in the U.S. to assess practice behaviors, treatment goals, and beliefs related to management of diabetes mellitus and prevention of its complications.

RESEARCH DESIGN AND METHODS

A mail survey with telephone follow-up was conducted among 3481 primary care physicians in active practice in the continental U.S. A stratified probability sample was selected using the files of the American Medical Association and American Osteopathic Association. Four specialties were selected to be included in the study: family physician, general practitioner, internist, and pediatrician. Two versions of a questionnaire were constructed: one for pediatricians containing questions about IDDM only and one for the other three specialties containing questions about both IDDM and NIDDM. Physicians who were not actively engaged in practice or did not see patients with diabetes were excluded.

RESULTS

Completed questionnaires were received from 1502 of 3481 sampled physicians. Based on various assumptions of eligibility among nonresponders, an overall response rate to the survey was estimated to be between 65.7 and 86.5%. Discrepancies between specialty identifications as noted on the American Medical Association/American Osteopathic Association files and as self-designated were noted.

CONCLUSIONS

This report describes the methodology used in the design and conduct of the survey, and data are provided to document the technical success of survey execution. This report provides the methodological basis for a series of separate reports on demographic characteristics of the physicians, their practices and their patients, and on specific attitudes, beliefs, and practice behaviors of primary care physicians in the U.S. with regard to diabetes mellitus.

Operational and policy considerations of data monitoring in clinical trials: the Diabetes Control and Complications Trial experience

Many clinical trials incorporate a system for monitoring emerging data that utilizes a committee composed of individuals who are independent of the investigators conducting the study. Although this is a common practice, there is a paucity of publications examining the operating methods of these groups. This paper describes the composition, functions, and procedures of the Data, Safety and Quality Review Group (DSQ) of the Diabetes Control and Complications Trial (DCCT). The DSQ is not masked to emerging data and the voting membership is made up of individuals with a wide diversity of expertise that reflects the needs of the trial. There are also nonvoting exofficio members who represent other components of the study organization. In addition to data monitoring, the DSQ provides external review of coordinating center operations. A distinctive aspect of the DCCT's DSQ is the creation of a free-standing operations manual for the DSQ's use during the trial and the involvement of the study investigators in developing certain sections of this document. Utilizing a process that allowed participation of the investigators was considered critical to achieving a mutual understanding regarding the planned uses and interpretations of the study data prior to the study's completion so as to minimize the chances of major disagreements regarding the conclusions drawn. Equally important, the existence of such a manual provides documentable reassurance to all interested parties that both scientific integrity and patient safety are being closely watched and gives the study investigators confidence that the results of the study will be scientifically credible and clinically important.

Capillary electrophoresis of hemoglobins and globin chains

Capillary isoelectric focusing (cIEF) and free zone capillary electrophoresis were evaluated for separation of native hemoglobins and globin chains. High-resolution separations of adult human hemoglobin A, fetal human hemoglobin F, and hemoglobin variants S and C were obtained using cIEF with cathodic mobilization. Absorbance detection in the UV and visible regions were compared, and on-line fast UV or visible-wavelength scanning detection was used to obtain spectral information on separated components. Globin chain analysis was performed on the same hemoglobin species by free zone capillary electrophoresis following precipitation of the protein with acidic acetone. Free zone separations were carried out at low pH in the presence of 7 M urea.

Effects of submergence on development and gravitropism in the coleoptile of Oryza sativa L

Caryopses of rice (Oryza sativa L. cv. Sasanishiki) were germinated in air or under water. In submerged seedlings a twofold increase in coleoptile growth rate and an inhibition of root growth was observed. The amount of starch in the amyloplasts of submerged coleoptiles was substantially reduced compared to the air-grown control plants and plastids had a proplastidic character. During the rapid elongation of coleoptiles under water, the osmotic concentration of the press sap remained constant, whereas in air-grown coleoptiles a decrease was measured. Determination of curvature of gravistimulated air-grown and submerged shoots was carried out by placing the coleoptiles horizontally in air of 98% relative humidity. Air-grown coleoptiles reached a vertical orientation within 5 h after onset of gravistimulation. In coleoptiles germinated under water the first signs of consistent negative gravitropic bending occurred after 4-5 h and curvature was complete after 24 h. During the first 5 h of gravistimulation the water-grown coleoptiles grew at an average rate of 0.39 mm h-1, whereas in air-grown coleoptiles a rate of 0.27 mm h-1 was measured. Concomitant with the delayed onset of gravitropic bending of the water-grown coleoptiles, a change in plastid ultrastructure and an increase in starch content was observed. We conclude that the gravitropic responsiveness of the rice coleoptile depends on the presence of starch-filled amyloplasts.

[Undesirable side effects of contrast media during i.v. DSA--a comparison of 2 nonionic contrast media]

For the first time a controlled double-blind study was performed to compare side effects and complications of i.v. DSA with central venous application of iopamidol and iopromide. 200 consecutive patients 15-85 years of age were studied. The randomisation brought up two homogeneously structured groups of 100 patients each. Using a given protocol, 66% of the patients were classified as high-risk patients. Side-effects and complications were registered by an extensive, standardised protocol. In 71 (35.5%) of 200 patients contrast-media related side effects and complications were noted. 37 reactions in 24 patients (9 iopamidol, 15 iopromide group) were classified as clinically relevant. In four patients (4%) of each group a drug therapy was initiated. Contrast-media related reactions occurred with delay in 5.5% of initially symptom-free patients. In no case intensive care or hospital admission became necessary. There were no significant differences between the two non-ionic contrast media in the incidence of side effects and complications. Both substances were well tolerated in i.v. DSA. In the total population patients with diseases known as auto-immune diseases and prior drug reactions demonstrated clinically relevant reactions significantly more often.

Rapid cation-exchange chromatography of hemoglobins and other proteins

A new, weak cation exchanger (MA7C) is useful for the very rapid resolution of protein mixtures. MA7C columns (30 X 4.6 mm I.D.) are packed with non-porous spherical particles (7-micron in diameter) having carboxylic acid ion-exchange groups. These columns can readily separate human hemoglobin A1c from other hemoglobin species in 7 min. Quantitative results agree well with those of accepted techniques. Other separations are possible with flow-rates up to 5 ml/min. Chromatography on MA7C columns is characterized by very narrow bandwidths, even at high flow-rates.

Extreme insulin resistance in ataxia telangiectasia: defect in affinity of insulin receptors

The syndrome of ataxia telangiectasia is associated with glucose intolerance and insulin resistance. We examined the status of insulin receptors on circulating monocytes and on cultured fibroblasts from two siblings with ataxia telangiectasia and severe insulin resistance. 125I-insulin binding to monocytes of the two patients consistently demonstrated an 80 to 85 per cent decrease in receptor affinity. In contrast, the defect in receptor affinity was not expressed on the patients' cultured fibroblasts or on monocytes or fibroblasts obtained from unaffected family members. Whole plasma and immunoglobulin-enriched fractions of plasma from the patients inhibited the normal binding of insulin to its receptors on cultured human lymphocytes (IM -9 line) and on human placental membranes. We conclude that the insulin resistance in the two siblings with ataxia telangiectasia was associated with defects in the affinity of the receptors for insulin, probably caused by circulating inhibitors of insulin binding.