Do men develop type 2 diabetes at lower body mass indices than women?

AIMS/HYPOTHESIS

To describe the associations between age, sex and BMI at diagnosis of type 2 diabetes, and test the hypothesis that men are diagnosed with diabetes at lower average BMI than women of similar age.

METHODS

Linear regression was used to estimate and compare the relationship between age and BMI at diagnosis among 51,920 men and 43,137 women included in a population-based diabetes register in Scotland for whom an index BMI measurement was taken within 1 year of diabetes diagnosis. We also examined HbA(1c) values by sex within the same timescale.

RESULTS

Mean BMI closest to date of diagnosis of type 2 diabetes mellitus was 31.83 kg/m(2) (SD 5.13) in men and 33.69 kg/m(2) (SD 6.43) in women. The inverse relationship between age and BMI at diagnosis of type 2 diabetes mellitus was significantly steeper in women than in men (slope estimate in men -0.12 kg/m(2) per year [95% CI -0.13, -0.12] women -0.18 kg/m(2) per year [95% CI -0.18, -0.17], p < 0.0001 for formal test of interaction). Mean BMI difference was most marked at younger ages and narrowed with advancing age. However, HbA(1c) levels within 1 year of diagnoses were broadly similar in men and women.

CONCLUSIONS/INTERPRETATION

Men are diagnosed with type 2 diabetes at lower BMI than women across the age range. This observation may help explain why type 2 diabetes is more common among middle-aged men in populations of European extraction. Whether the same pattern is also observed in other ethnic groups requires confirmation.

A national approach to diabetes foot risk stratification and foot care

The Scottish Diabetes Foot Action Group (SDG) has developed and introduced a national strategy plan for diabetic foot care across Scotland. This has involved the implementation of an evidence-based national foot screening and risk stratification programme that has already covered 61% of the population in just the first two years. Nationally agreed patient information foot leaflets and professional education material have been introduced, and a consensus for antibiotic use in the diabetic foot has been published. Information on multidisciplinary specialist foot services has been collected, indicating that 58% of Health Board areas have consultants with dedicated sessions in their job plan to a foot clinic, and 42% had integrated orthotic involvement. The SDG aims to increase these figures. Work has been undertaken to support local podiatry networks and improve communication between the specialist centre and the community. At a national level the SDG is working with Foot in Diabetes UK (FDUK) to recognize key podiatry skills by developing core competencies and a competency framework for the diabetes podiatrist and diabetes orthotist. The annual Scottish Diabetes Survey indicates some improvement in amputation rates with prevalence decreasing from 0.8% to 0.5%, and improved recording of foot ulceration at a national level. This national strategy has helped highlight the importance and difficulties facing diabetes foot care and should help to continue to improve the quality of care of people with diabetes who have foot-related problems.

The effect of spectra on calibration and measurement with mammographic ionization chambers

Mammographic imaging uses x-ray tubes with molybdenum, rhodium, or tungsten anodes with the produced bremsstrahlung filtered by thin sheets of molybdenum, rhodium, or aluminum. The National Institute of Standards and Technology, the Accredited Dosimetry Calibration Laboratories, and several manufacturers offer calibrations of mammography ionization chambers with reference x-ray beams with different radiation qualities in the range 23-40 kVp. The energy response of ten commercially available chambers was determined for these reference radiation qualities using the Attix variable-length free-air chamber. The evaluated chambers are designed with thin entrance windows of varying thickness and composition. The chambers show variation in their air kerma response as a function of beam radiation quality. This response with beam radiation quality may affect the measurement of clinical beam half value layer (HVL) and the determination of the mean glandular dose. The combined effect of the chamber's energy dependence and HVL measurement affects the mean glandular dose calculation resulting in differences ranging from -1.8% to +2.5%.

Measurements and Monte Carlo calculations to determine the absolute detector response of radiochromic film for brachytherapy dosimetry

GafChromic (MD-55-2) radiochromic film has become increasingly popular for medical applications and has proven to be useful for brachytherapy dosimetry. To measure the absolute dose near a brachytherapy source, the response of the proposed detector in the measurement conditions relative to the response of the detector in calibration conditions must be known. MD-55-2 radiochromic film has been exposed in four different photon beams, a 30 and 40 kVp tungsten anode x-ray beam, a 75 kVp orthovoltage therapy beam, and a 60Co teletherapy beam to measure the relative detector response. These measurements were combined with coupled photon/electron Monte Carlo transport calculations to determine the absolute detector response. The Los Alamos National Laboratory Monte Carlo transport code MCNP4B2 was used. The measured relative response of this batch of MD-55-2 film varies from 8.79 mOD/Gy, measured for the 60Co beam, by as much as 42% for the low-energy x-ray beams. However, the absolute detector response varies from 4.32 mOD/Gy for the 60Co beam by, at most, only 6.3%. In this work we demonstrate that the absolute detector response of MD-55-2 radiochromic film is a constant and independent of beam quality. Further, this work shows that MCNP4B2 accurately simulates the energy response and geometry artifacts of the radiochromic film.

Dependence of scatter on atomic number for x rays from tungsten and molybdenum anodes in the mammographic energy range

A study was done to determine the relative amounts of scatter for the following materials with atomic numbers ranging from Z=6 to Z=82: C, Al, Ti, Fe, Cu, Zn, Zr, Y, Mo, Ta, and Pb. Measurements were performed for each material on two constant potential x-ray units--one fitted with a molybdenum (Mo) anode-Mo filter and the other with a tungsten (W) anode-aluminum (Al) filter (medium filtration) at 30 kVp. Theoretical calculations were also performed for each anode to explain the scatter behavior and to aid in predicting the behavior for materials where measurements were not made. There was good agreement between the theoretical calculations and the experimental data.

The management of hypertension in a diabetic pregnancy

Pregnancy in a woman with Type 1 diabetes poses several clinical challenges. In addition to meticulous glycaemic control, careful attention must be paid to the management of developing and pre-existing diabetic complications which may progress in severity during pregnancy. Pregnancy-induced hypertension is more common in women with diabetes and especially in those with diabetes of long duration. Diabetic renal disease is associated with hypertension which often deteriorates during pregnancy. The management of hypertension is difficult because of limited therapeutic options and the need to consider the implications for the developing fetus as well as the mother. This case report details the clinical management of a young woman with Type 1 diabetes whose pregnancy was complicated by the development of hypertension.

Registration using tomographic projection files

An algorithm has been developed and experimentally verified for tomographic registration--a patient positioning method using internal anatomy and standard external fiducial marks. This algorithm improves patient set-up and verification to an accuracy sufficient for tomotherapy. By implementation of this technique, the time-consuming reconstruction process is avoided. Instead, offsets in the x, y and z directions are determined directly from sinogram data by an algorithm that utilizes cross-correlations and Fourier transforms. To verify the efficiency and stability of the algorithm, data were collected on the University of Wisconsin's dedicated tomotherapy research workbench. The experiment indicates offset statistical errors of less than +/-0.8 mm for offsets up to 30 mm. With standard clinical techniques, initial patient offsets are expected to be less than 5 mm, so the 30 mm limitation is of no consequence. The angular resolution for the direction of patient translation is within the +/-2 degrees needed for tomotherapy.

Response of thermoluminescent lithium fluoride (TLD-100) to photon beams of 275, 400, 500, 600, 730, 900, 1200, 1500, and 2550 eV

LiF:Mg,Ti (TLD-100) extruded ribbons and cleaved crystals were exposed to monoenergetic photons of 275-2550 eV energy to determine their potential usefulness as radiation dosimeters for radiobiology experiments at these energies. The radiation source was synchrotron radiation from the 1 GeV electron storage ring, Aladdin. The authors report TLD response and glow curves for He- and air-annealed dosimeters. The undesirable effects of air annealing increase with decreasing photon penetration in the dosimeter. Under certain experimental conditions, UV radiation produced anomalous bleaching of high-temperature traps. The crystals and the chips presented a supralinear response, Supralinearity factors were determined to be of the order of 1.5 for crystals, and 1.7 for the chips. The authors' results indicate that TLDs are a reliable means to monitor the total energy deposited in irradiated cells and are now used routinely for radiobiology cell irradiations.

Synchroton-produced ultrasoft X rays: equivalent cell survival at the isoattenuating energies 273 eV and 860 eV

In this paper we report on survival of Chinese hamster V79 and mouse C3H 10T1/2 cells after irradiation with synchrotron-produced 273 eV and 860 eV ultrasoft X rays. These two energies, which are available by multilayer monochromatization of the synchrotron output spectrum, exhibit equal attenuation within living cells. Such an isoattenuating energy pair allows the direct examination of how biological effectiveness varies with the energy of the ultrasoft X rays. In comparing survival results, we find similar biological effectiveness of these two energies for both the C3H 10T1/2 and the V79 cells. These results are not consistent with previous findings of increasing RBE with decreasing ultrasoft X-ray energies. In addition, after correcting for mean nuclear dose based on measurements of cell thickness obtained with confocal microscopy, we find no significant differences in survival between the two ultrasoft X-ray energies and 250 kVp X rays. These results suggest that RBE does not increase with decreasing energy of ultrasoft X rays between 860 eV and 273 eV. The possible impact of our results on past results for ultrasoft X rays is discussed.

A double mirror W/C multilayer monochromator for radiation biology applications

A double-mirror multilayer monochromator was developed for the purpose of irradiating live cell cultures at the Synchrotron Radiation Center, University of Wisconsin-Madison. The monochromator is designed for the soft x-ray region with photon energies between 270 and 2400 eV. Multilayer mirrors with 55 bilayers of W/C and a bilayer spacing of d = 3.0 nm are sputter deposited on Si substrates. By proper masking of the sputtering sources, variation in the bilayer spacing over the area of the mirror is minimized. The uniformity of the bilayer spacing was measured to be delta d/d < 1%, over the 75 mm x 25 mm area of the mirrors. The reflectivity was measured as a function of energy to determine the integrated reflectivity and evaluate the contribution of the specular reflection and higher orders to the monochromatic beam. The use of suitable filters with a Si(Li) detector allows determination of the spectral output of the monochromator. The output power of the monochromator between 270 and 2400 eV is measured. The resolution of the monochromator is delta lambda/lambda = 0.04. Applications of the monochromator to radiation biology are discussed.

Soluble leucocyte adhesion molecules in diabetic retinopathy stimulate retinal capillary endothelial cell migration

Diabetic retinal neovascularisation is considered to be a consequence of retinal ischaemia caused by capillary occlusion. Capillary occlusion is the result of microvascular thrombi in which erythrocytes, platelets and leucocytes each may play a role. We investigated the role of leucocytes in this process and the subsequent angiogenic response. We studied the serum levels of the soluble leucocyte adhesion molecules soluble E-Selectin, soluble vascular cell adhesion molecule-1 (sVCAM-1) and soluble intercellular adhesion molecule-1 (sICAM-1) in the serum of 93 patients with insulin-dependent diabetes (IDDM) and varying degrees of retinopathy and 47 healthy age and sex matched control subjects. We also measured the ability of serum to stimulate retinal capillary endothelial cell migration using an assay of angiogenesis in vitro. Soluble E-Selectin and sVCAM-1 levels were raised in all patients with IDDM (p < 0.001; p < 0.001) particularly those with retinopathy (p < 0.001; p < 0.001). Soluble E-Selectin levels were highest in the patients with severe non-proliferative diabetic retinopathy (p < 0.001) and sVCAM-1 levels were highest in patients with proliferative diabetic retinopathy (p < 0.01). In contrast soluble ICAM-1 levels were the same in patients and control subjects (p > 0.05). Soluble E-Selectin levels in diabetic patients were correlated with the level of glycated haemoglobin (p < 0.05). Retinal endothelial cell migration-inducing (ECMI) activity was increased in patients with IDDM (p < 0.01) in particular in those with retinopathy (p < 0.01). Furthermore, in vitro ECMI activity could be blocked by antibodies to sVCAM-1 and sE-Selectin. These data point to a functional role for leucocyte adhesion in the microvasculopathy of diabetic retinopathy and may have implications for the induction of retinal angiogenesis.

Comparison of exposure standards in the mammography x-ray region

Direct comparisons of the National Institute of Standards and Technology's (NIST) Ritz 20 kV to 100 kV standard free-air ionization chamber and a portable variable-length free-air ionization chamber designed by the University of Wisconsin-Madison Accredited Dosimetry Calibration Laboratory (UW-ADCL) were made on NISTs low-energy tungsten x-ray range. As a result of this direct comparison, NIST has established a UW-ADCL designed chamber, the Attix chamber, as the national standard chamber for the mammography energy x-ray range. The Ritz standard chamber and the Attix standard chamber have been extensively compared using the new molybdenum and rhodium beam qualities. The results indicate that exposure measurements in the mammography energy x-ray region with the two free-air chambers can be made with a discrepancy of less than 0.35%.

Calreticulin biosynthesis and processing in human myeloid cells: demonstration of signal peptide cleavage and N-glycosylation

Calreticulin is a soluble endoplasmic reticulum protein comprising the major storage reservoir for inositol trisphosphate-releasable calcium. Although its highly conserved primary structure and a wide range of functions have been well described, less attention has been paid to its biosynthesis, particularly in human tissues. We report analyses of synthesis, proteolytic processing and glycosylation of human calreticulin. In both HL-60 and PLB-985 myeloid cell lines calreticulin was immunoprecipitated as a single 60-kD species without evidence of precursor forms. However, in vitro cell-free synthesis produced a 62-kD primary translation product, which in the presence of microsomal membranes, was processed by cotranslational signal peptide cleavage to a 60-kD species that comigrated with mature calreticulin produced in myeloid cells. Neither tunicamycin treatment of the cells nor endoglycosidase digestion of calreticulin resulted in any forms other than the 60-kD protein on sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis, suggesting that the potential site for N-glycosylation at asparagine-327 was unmodified. However, oxidative derivatization of carbohydrate components with digoxigenin showed that human calreticulin produced in either HL-60 cells or Sf9 insect cells is glycosylated, indicating that glycosylated and nonglycosylated human calreticulin have indistinguishable electrophoretic mobilities. Direct measurement by phenol-H2SO4 confirmed the presence of carbohydrate on recombinant human calreticulin. These data show that human myeloid calreticulin undergoes cotranslational signal peptide cleavage and posttranslational N-linked glycosylation. Although glycosylation of calreticulin has been shown in rat liver and bovine liver and brain, it has been reported to be lacking in other tissues including human lymphocytes.

Human inositol 1,4,5-trisphosphate type-1 receptor, InsP3R1: structure, function, regulation of expression and chromosomal localization

We have isolated cDNA clones encoding an inositol 1,4,5-trisphosphate receptor type 1 (InsP3R1) from human uteri and a leukaemic cell line, HL-60. Northern-blot analysis showed that approx. 10 kb of InsP3R1 mRNA is expressed in human uteri, oviducts and HL-60 cells. The predicted amino acid sequence of human InsP3R1 (2695 amino acids) has 99% identity with that of the mouse SI-/SII- splicing counterpart. Western-blot analysis with anti-(mouse InsP3R1) antibodies showed that InsP3R1 protein of human uteri and oviducts of approx 220 kDa is immunostained. Northern-blot analysis of HL-60 cell differentiation along the neutrophilic lineage induced by retinoic acid or dimethylsulphoxide showed an accompanying enhanced expression of InsP3R1 mRNA. Immunohistochemical analysis of the cerebella of spinocerebellar degeneration patients showed a variable loss of Purkinje cells with an altered pattern of immunostaining. The InsP3R1 gene (Insp3r1) was localized to the 3P25-26 region of human chromosome 3. The data presented here clearly show that InsP3R1 exists widely in human tissues and may play critical roles in various kinds of cellular functions.

Evidence for a readily dissociable complex of p47phox and p67phox in cytosol of unstimulated human neutrophils

We explored the association between two cytosolic components of the phagocyte respiratory burst oxidase, p47phox and p67phox. Both of these proteins bound to immobilized GTP or 2',5'-ADP, but not to GDP or ATP. Similarly, triazine dye-ligand chromatography demonstrated coisolation of p47phox and p67phox. Binding of p67phox to GTP was less avid than that of p47phox. Each of the proteins in whole neutrophil cytosol bound separately to GTP in the absence of the other, whereas studies with recombinant proteins showed binding of p47phox but not p67phox. These data suggest that p47phox and p67phox exist as a complex that very likely involves at least one additional cytosolic protein. Sequential precipitation in graded concentrations of ammonium sulfate demonstrated similar profiles for p47phox and p67phox. Charge-based separations using either an anion or cation exchange resin resulted in coelution of the two cytosolic oxidase components, in spite of their widely differing charges as shown by separate analysis of the recombinant proteins. Moreover, preparative isoelectric focusing showed that a portion of the p47phox and p67phox in cytosol coisolated at a pI (7.3-8.3) midway between those of the separate proteins. Despite this, each protein sedimented independently in sucrose density gradients. The data indicate that the complex of p47phox and p67phox was dissociated by increased temperature, high osmolarity, or prolonged incubation. We suggest that under the physiologic conditions in the cytosol of intact phagocytes p47phox, p67phox and probably other proteins exist as a macromolecular complex, the function of which may be to permit en bloc translocation of oxidase components to the plasma membrane.

Maternal glucose response to a standardized test meal throughout pregnancy and postnatally

OBJECTIVE

Our purpose was to determine the maternal blood glucose response to food throughout pregnancy.

STUDY DESIGN

Forty-five normal, healthy primiparous women with singleton pregnancies were studied longitudinally throughout pregnancy. Blood glucose levels were determined at each stage of pregnancy after a standardized test meal.

RESULTS

Fasting plasma glucose decreased throughout gestation and rose again significantly post partum. Glucose values at 30, 60, 90, and 120 minutes after a standardized test meal were similar at all gestational ages studied.

CONCLUSIONS

Plasma glucose levels after a physiologic challenge with food do not alter with advancing gestation. This has implications both for the management of insulin-dependent diabetes during pregnancy and for the diagnosis of gestational diabetes.

The ranges of insulin response and glucose tolerance in lean, normal, and obese women during pregnancy

OBJECTIVE

We characterized insulin secretion and glucose disposal in a large unselected group of women, encompassing the full spectrum of glucose tolerance in pregnancy, and related the findings to maternal obesity.

STUDY DESIGN

Intravenous glucose tolerance and first-phase insulin response were measured at about 32 weeks' gestation in 690 unselected pregnancies. The women were designated as "lean," "normal," or "obese" on weight-for-height criteria.

RESULTS

The distribution of insulin response was bimodal, but there was no corresponding dichotomy in maternal glucose disposal rate. Insulin response was greatest and glucose disposal rate slowest in obese women. In general, "poor" glucose tolerance was associated with relatively low insulin output. It was not possible to identify any cluster of women, obese or otherwise, in whom poor glucose tolerance was specifically associated with an unusually high insulin response.

CONCLUSION

The data indicate that the distribution of glucose tolerance in pregnancy is a continuum. Glucose intolerance represents one end of that spectrum and is attributable to insufficient insulin secretion. This relative insufficiency is most frequent with maternal obesity.

A simple approach to screening for microalbuminuria in a type 1 (insulin-dependent) diabetic population

The reproducibility of albumin concentration in first-morning samples of urine was assessed in 334 insulin-dependent diabetic patients aged 18-60 years. The albumin excretion rate was determined immunoturbidimetrically in three sterile, Albustix-negative, first-morning urine samples submitted over a week. An abnormally high mean value, greater than or equal to 2.5 mg albumin per mmol creatinine (Ua/Uc), was found in 33 patients (9.9%). These patients were older (mean 42 vs 34 years, P less than 0.01), had longer disease duration (18 vs 14 years, P less than 0.01) and higher HbA1c values (6.8 vs 6.3%, P less than 0.05) than those without microalbuminuria. Although triplicate samples were collected within 7 days, Ua/Uc showed considerable intraindividual variation, with a mean coefficient of variation of 49%. Despite this it was found that Ua/Uc values greater than 1 mg/mmol on the first specimen had a sensitivity of 97% and a specificity of 82% for detecting those with a three-sample mean value greater than 2.5 mg/mmol. Thus virtually all those with microalbuminuria (32/33) had a single first-morning result greater than 1 mg/mmol, and in those with a lower ratio microalbuminuria was excluded with more than 99% certainty.

Facial dysmorphism: a marker of autosomal dominant cranial diabetes insipidus

We report a family with autosomal dominant cranial diabetes insipidus in which a characteristic facial appearance of hypertelorism, broad and prominent nasal bridge, short nose, and long philtrum is seen in affected members.

Calibration of 192Ir high-dose-rate afterloading systems

A method is described for calibration of 192Ir high-dose-rate (HDR) brachytherapy afterloading systems. Since NIST does not offer calibration of ionization chambers with the gamma-ray spectrum of iridium-192, an interpolation procedure is employed, using calibrations above (137Cs, 662 keV) and below (250 kVcp, 146-keV x rays) the exposure-weighted average 192Ir energy of 397 keV. The same total wall + cap thickness must be used for both calibrations, and for the 192Ir measurements. A wall + cap thickness of 0.3 g/cm2 is recommended to assure charged particle equilibrium and to exclude secondary electrons emitted from the source encapsulation. Procedures are described for determining the corrections for source-chamber distance and room scatter during the source calibration in inverse-square-law geometry. A new well-type ionization chamber has been designed specifically for convenient routine use with the HDR afterloading system. It can be calibrated by means of a previously calibrated 192Ir source, and offers a simple means for verifying the decay rate and for calibrating 192Ir replacement sources.

Synchrotron-produced ultrasoft X-rays: a tool for testing biophysical models of radiation action

Ultrasoft X-rays are useful for mechanistic studies of ionizing radiation damage in living cells due to the localized nature of their energy depositions. To date radiobiology experiments in this energy region have relied on characteristic X-rays (mainly Alk and Ck) from X-ray tubes. However, limitations in the photon intensity and the available energies from X-ray tube sources prevent a definitive characterization of the relationship between photon energy and biological damage. Synchrotron radiation has the potential to avoid these limitations, since it produces X-rays with high intensity over a continuous spectrum. We have established a synchrotron-based system for radiation biology studies using the ES-0 exposure station of the Center for X-ray Lithography at the University of Wisconsin Synchrotron Radiation Center storage ring, Aladdin. A characterization of the system including spectral and intensity properties of the photon beam is presented. The first mammalian cell survival curve for synchrotron-produced ultrasoft X-rays was generated and is presented. Cell survival curves of C3H/10T 1/2 cells using synchrotron radiation of 1.48 keV agree with previous data using Alk X-rays (1.49 keV). An RBE of 1.47 +/- 0.30 at the 10% survival level was measured with reference to 250 kVp X-rays.

Mortality in diabetes mellitus: experience of a geographically defined population

A population-based cohort study identified 915 deaths in 4186 patients with diabetes mellitus over a 5-year period. Ischaemic heart disease, cerebrovascular disease and malignant neoplasms were the major causes of death and accounted for 40%, 16%, and 14% of deaths, respectively, compared with 27%, 14%, and 25% of deaths in the non-diabetic population. Diabetic patients had a standardized mortality ratio (SMR) of 1.15 (95% Cl 1.08-1.22) (p less than 0.001). This excess risk of death was largely due to the excess death from ischaemic heart disease (SMR 1.55 (1.40-1.71); p less than 0.001) and the impact was greatest in middle-aged female patients. Stroke mortality was not significantly increased (SMR 1.09 (0.92-1.29)) while cancer mortality was reduced (SMR 0.75 (0.63-0.89); p less than 0.01). Death rates in diabetic male patients (SMR 1.04 (0.96-1.13)) did not differ significantly from those in non-diabetic male patients because the increased risk of ischaemic heart disease deaths (SMR 1.41 (1.22-1.62); p less than 0.001) was offset by the reduced risk of deaths from malignant neoplasms (SMR 0.65 (0.51-0.82); p less than 0.001). The reduction in cancer mortality did not reach statistical significance in diabetic women (SMR 0.82 (0.64-1.05)). Diabetic nephropathy and metabolic disasters were uncommon as causes of death.

Neutrophil nicotinamide adenine dinucleotide phosphate oxidase assembly. Translocation of p47-phox and p67-phox requires interaction between p47-phox and cytochrome b558

Two of the cytosolic NADPH oxidase components, p47-phox and p67-phox, translocate to the plasma membrane in normal neutrophils stimulated with phorbol myristate acetate (PMA). We have now studied the translocation process in neutrophils of patients with chronic granulomatous disease (CGD), an inherited syndrome in which the oxidase system fails to produce superoxide due to lesions affecting any one of its four known components: the gp91-phox and p22-phox subunits of cytochrome b558 (the membrane-bound terminal electron transporter of the oxidase), p47-phox, and p67-phox. In contrast to normal cells, neither p47-phox nor p67-phox translocated to the membrane in PMA-stimulated CGD neutrophils which lack cytochrome b558. In one patient with a rare X-linked form of CGD caused by a Pro----His substitution in gp91-phox, but whose neutrophils have normal levels of this mutant cytochrome b558, translocation was normal. In two patients with p47-phox deficiency, p67-phox failed to translocate, whereas p47-phox was detected in the particulate fraction of PMA-stimulated neutrophils from two patients deficient in p67-phox. Our data suggest that cytochrome b558 or a closely linked factor provides an essential membrane docking site for the cytosolic oxidase components and that it is p47-phox that mediates the assembly of these components on the membrane.

A comparison between the diets of pregnant diabetic women and pregnant non-diabetic women

In order to assess the effect of dietary advice for pregnant diabetic women, the habitual dietary intake of 8 pregnant diabetic women was assessed by 7-day weighed food records. These results were compared with records from 8 non-diabetic women, matched for age and gestation. Despite intense personalized dietetic advice to the diabetic women, there were no statistically significant differences in macro-nutrient intake between the two groups. The diabetic women were encouraged to increase their carbohydrate intake slightly, but failed to achieve current British Diabetic Association dietary recommendations with respect to percent energy from carbohydrate (41 +/- 5 (+/- SE)(range 29-47)%, BDA recommendation greater than 50%) and percentage from fat 43 +/- 6 (33-51)%, BDA recommendation less than 30%). Intake of bread and cereals was increased in the diabetic women, but increases in complex carbohydrates were insufficient to compensate for a reduced intake of high-sugar foods. Intakes of energy from simple sugars were significantly lower (p less than 0.05) in the diabetic group (12 +/- 2 (5-20)%) than in the non-diabetic group (21 +/- 2 (12-28)%). There was no detectable difference in sources of fats in the diet between the two groups.

Insulin management during labour and delivery in mothers with diabetes

A standardized intravenous regimen has been assessed, in 25 insulin-treated diabetic women, for insulin and dextrose therapy in labour and delivery. Adjustments to insulin infusion rate are determined by trends in blood glucose as well as by absolute concentration, in order to approach normoglycaemia. Blood glucose was 5.0 (SD 1.7) mmol l-1 on arrival in labour (or at 0800 h before planned delivery) and was maintained at 6.0 (SD 1.8) mmol l-1 with insulin 0-5 U h-1 for up to 29 h before delivery, when it was 6.3 (SD 2.1, range 3.0-9.0) mmol l-1 with insulin infusion rate 0-4 U h-1. Neonatal blood glucose (less than 2.0 mmol l-1 in 11 babies) correlated with both maternal HbA1c (rs = -0.47, p less than 0.02) and maternal blood glucose at delivery (rs = -0.58, p less than 0.01). During 12 months observation on the intravenous regimen, 339 measurements of blood glucose were made; 10 were less than 3.0 mmol l-1, 242 were 3.0-8.0 mmol l-1, and 81 were greater than 8.0 mmol l-1 (mean 6.5, range 2.7-13.5 mmol l-1). Insulin infusion rate ranged from 0 to 5 U h-1, with 139 rate adjustments. Only one mild clinical hypoglycaemic episode, responding to increased dextrose infusion, was recorded. This simple flexible regimen proved clinically reliable for both midwifery and medical staff.

Measurement of dose distributions of linear energy transfer in matter irradiated by fast neutrons

A detector has been developed and used to measure dose distributions versus linear energy transfer to thin gas targets in spherical geometry from fast neutron irradiation of tissue-equivalent plastic and carbon. The detector is a hemispherical proportional counter with a Cs(T1) scintillator at the center of the hemisphere. The coincidence of the proportional counter signals constrain the measurements to charged particles traversing the radius of the hemisphere. The charged particle energy deposition distributions are directly measured for a known pathlength. The A-150 kerma factor was measured at a neutron energy of 14.8 MeV and is in agreement with tabulated values. The carbon kerma factor measurements are less than the tabulated value at 14.8 MeV. The alpha-particle production in carbon was measured for neutron energies from 14.1 to 14.8 MeV and is compared with existing data.

Genetic variants of chronic granulomatous disease: prevalence of deficiencies of two cytosolic components of the NADPH oxidase system

Chronic granulomatous disease, a syndrome of recurrent infections and failure of oxidative microbicidal activity in phagocytes, results from defects in the gene for one of several components of an oxidase system that can undergo activation. To determine the relative prevalence of certain of the genetic variants of this disorder, we used immunoblotting to detect two specific neutrophil cytosolic proteins of 47 and 67 kd recently shown to be required for oxidase activation. Chronic granulomatous disease is usually an X-linked disorder associated with the absence of membrane cytochrome b558. Of our 94 patients with chronic granulomatous disease, however, 36 had a phenotype characterized by autosomal inheritance, normal membrane oxidase components (including cytochrome b558), and functionally defective cytosolic activity in a cell-free oxidase system. We studied 25 of these 36 patients and found that 22 lacked the 47-kd cytosolic protein, and the remaining 3 were missing the 67-kd component. Patients with chronic granulomatous disease whose functional defect was localized to the neutrophil membrane (classic X-linked cytochrome b-negative type and two other rare variants) had normal amounts of both cytosolic components. We estimate that approximately 33 percent of all patients with chronic granulomatous disease are missing the 47-kd cytosolic oxidase component and about 5 percent of patients are missing the 67-kd component. Chronic granulomatous disease caused by a defect in any cytosolic factors other than the 47-kd and 67-kd proteins, if it exists, is apparently rare.

Inactivation of transferrin iron binding capacity by the neutrophil myeloperoxidase system

Human serum apotransferrin was exposed to the isolated myeloperoxidase-H2O2-halide system or to phorbol ester-activated human neutrophils. Such treatment resulted in a marked loss in transferrin iron binding capacity as well as concomitant iodination of transferrin. Each component of the cell-free system (myeloperoxidase, H2O2, iodide) or neutrophil system (neutrophils, phorbol ester, iodide) was required in order to observe these changes. In the cell-free system, the H2O2 requirement was fulfilled by either reagent H2O2 or the peroxide-generating system glucose oxidase plus glucose. Both loss of iron binding capacity and transferrin iodination by either the myeloperoxidase system or activated neutrophils were blocked by azide or catalase. The isolated peroxidase system had an acidic pH optimum, whereas the intact cell system was more efficient at neutral pH. The kinetics of changes in iron binding capacity and iodination closely paralleled one another, exhibiting t1/2 values of less than 1 min for the myeloperoxidase-H2O2 system, 3-4 min for the myeloperoxidase-glucose oxidase system, and 8 min for the neutrophil system. That the occupied binding site is protected from the myeloperoxidase system was suggested by 1) a failure to mobilize iron from iron-loaded transferrin, 2) an inverse correlation between initial iron saturation and myeloperoxidase-mediated loss of iron binding capacity, and 3) decreased myeloperoxidase-mediated iodination of iron-loaded versus apotransferrin. Since as little as 1 atom of iodide bound per molecule of transferrin was associated with substantial losses in iron binding capacity, there appears to be a high specificity of myeloperoxidase-catalyzed iodination for residues at or near the iron binding sites. Amino acid analysis of iodinated transferrin (approximately 2 atoms/molecule) demonstrated that iodotyrosine was the predominant iodinated species. These observations document the ability of neutrophils to inactivate transferrin iron binding capacity via the secretion of myeloperoxidase, formation of H2O2, and subsequent myeloperoxidase-catalyzed iodination. This sequence of events may help to explain the changes in iron metabolism associated with the in vivo inflammatory response.

Management of the pregnant diabetic patient

The prognosis in diabetic pregnancy has greatly improved as a result of patient education and the availability of home blood glucose monitoring techniques enabling the implementation of good metabolic control pre-pregnancy, antenatal and intrapartum. These in turn have made possible the benefits to the offspring of vaginal delivery at term. Screening for gestational diabetes is important and the prognosis is also good where maternal normoglycaemia is achieved. All diabetic pregnancies should be cared for in specialist units under the supervision of an integrated team comprising an obstetrician, diabetologist and paediatrician, and for optimal results care should start prior to conception.

The influence of maternal glucose metabolism on fetal growth, development and morbidity in 917 singleton pregnancies in nondiabetic women

To study the effects on the fetus of variations in maternal glucose tolerance, a 25 g rapid intravenous glucose tolerance test was performed at or about 32 weeks gestation in 917 randomly selected nondiabetic women with singleton pregnancies. The results were withheld from the patients and their obstetricians and paediatricians, and no treatment or advice was offered. Fasting plasma glucose and indices of glucose disposal (including a new index which we have termed "summed glucose") were distributed unimodally, with no evidence of a separate pathological group towards the diabetic end of the distributions. Significant associations were found between maternal glucose metabolism and various measures of neonatal nutrition and morbidity, including the incidence of congenital malformations and morbidity related to asphyxia, suggesting that variations within the normal range in maternal glucose metabolism can influence growth and development in the fetus. These relationships were continuous throughout the range of maternal glucose tolerance and were not of predictive value in individual cases.

An in vivo technique for the measurement of bone blood flow in animals

A new technique to measure the in vivo clearance of 41Ar from the bone mineral matrix is demonstrated following fast neutron production of 41Ar in bone via the 44Ca(n, alpha) reaction at 14.1 MeV. At the end of irradiation, the 41Ar activity is assayed with a Ge(Li) detector where sequential gamma-ray spectra are taken. Following full-energy peak integration, background and dead time correction, the activity of 41Ar as a function of time is determined. Results indicated that the Ar washout from bone in rats using this technique was approximately 16 ml (100 ml min)-1 and in agreement with other measurement techniques. For sheep the bone perfusion in the tibia was approximately 1.9 +/- 0.2 ml (100 ml min)-1.

NADPH oxidase of human neutrophils. Subcellular localization and characterization of an arachidonate-activatable superoxide-generating system

The superoxide-forming NADPH oxidase of human neutrophils was studied in subcellular fractions of unstimulated cells. Purified neutrophils were disrupted by nitrogen cavitation and separated on Percoll density gradients into four fractions: alpha, azurophil granules; beta, mostly specific granules; gamma, plasma membrane, and cytosol. NADPH-dependent O2-. formation by these fractions was quantitated as the rate of superoxide dismutase-inhibitable reduction of ferricytochrome c. In the presence of cytosol, NADPH, and either arachidonic acid (optimum 90 microM) or sodium dodecyl sulfate (optimum 160 microM), 70-75% of the oxidase was in the beta fraction and about 25% was in the gamma fraction. A similar distribution was found for cytochrome b559 and FAD, two putative components of the oxidase. The reaction rates observed with arachidonic acid activation were sufficient to account for 25-75% of the O2-. generated by intact neutrophils. The properties of the beta and gamma enzymes were similar and closely resembled those of the oxidase in intact neutrophils or disrupted prestimulated cells. These included resistance to azide and cyanide, a pH optimum of 7.4, and a preference for NADPH (Km approximately 40-45 microM) rather than NADH (Km approximately 2.5 mM) as the electron donor. The combination of beta and gamma fractions displayed additive activity. The activatable oxidase required Mg2+ but not Ca2+. ATP was required for maximum reaction rates. When beta and gamma membranes were preincubated with cytosol and arachidonic acid in the presence of millimolar Mg2+ and then ultracentrifuged membrane-bound O2-. -forming activity was recovered in the pellet and the enzyme required only NADPH (i.e. no cytosol, arachidonic acid, or Mg2+) for expression of activity. These data suggest that cytosol contains a Mg2+-dependent oxidase-activating factor. Molecular sieve chromatography of cytosol indicated a single peak of activity (i.e. ability to activate O2-. generation by beta and/or gamma fraction) eluting with molecules of about 10,000 daltons.

The ability of the serum thyrotrophin receptor antibody (TRAb) index and HLA status to predict long-term remission of thyrotoxicosis following medical therapy for Graves' disease

In agreement with previous authors we found patients with Graves' disease to have an increased incidence of the DR 3 antigen. We could find no association, however, between the presence of the antigen and relapse after carbimazole treatment. A concordant HLA status and thyrotrophin receptor antibody (TRAb) index, obtained at either 6 or 12 months after the start of treatment could only predict cases of relapse and remission in a minority of patients making this of very limited clinical use. The TRAb index obtained at 12 months after the start of medical therapy could accurately predict cases of relapse and remission for the next 3 years in 24/30 patients studied.

Relapse of Graves' disease after medical therapy: predictive value of thyroidal technetium-99m uptake and serum thyroid stimulating hormone receptor antibody levels

In 49 patients with Graves' disease, the 20-min thyroidal uptake of 99mTc and serum levels of thyroid stimulating hormone (TSH) receptor antibody were estimated at presentation and at intervals during a 1-yr course of carbimazole and triiodothyronine. In the 12 mo after cessation of therapy, 29 patients developed recurrent thyrotoxicosis. Thyroidal 99mTc uptake had a poor predictive value for recurrence of thyrotoxicosis, both at presentation and during therapy. A very high level of TSH receptor antibody was present in seven patients at presentation, all of whom relapsed on withdrawing therapy. An abnormal value of TSH receptor antibody at the end of the course of medical therapy was present in 24/29 (83%) patients who relapsed and in 1/20 (5%) patients who remained euthyroid 1 yr after stopping antithyroid drugs.

Selenium deficiency in cultured adrenocortical cells: restoration of glutathione peroxidase and resistance to hydroperoxides on addition of selenium

Cultured bovine adrenocortical cells were previously shown to be functionally deficient in selenium and vitamin E when grown in medium supplemented with fetal bovine serum. In the present experiments, the lack of significant bioavailable amounts of selenium in the medium was demonstrated by the finding of only low levels of glutathione peroxidase in the cultured cells (0.008 U/mg protein compared with 0.045 U/mg protein in fresh adrenocortical tissue). When 20 nM selenium as selenite was added to the cultured adrenocortical cells, glutathione peroxidase activity increased continuously over 72 h, with a total increase of about eightfold over this period. Over the same time-course, the highest concentration of cumene hydroperoxide tolerated by the cells without cell death increased progressively from 10 microM to 50 microM. Addition of 1 microM alpha-tocopherol also increased the amount of cumene hydroperoxide tolerated to 50 microM. Cell death was measured by cloning efficiency after removal of cumene hydroperoxide. Addition of either selenium or alpha-tocopherol had little effect on the growth rate of the cells over six passages, even when residual vitamin E was removed from the serum by extraction with ether and residual low molecular weight selenium compounds were removed by dialysis. It is concluded that combined deficiency of selenium and vitamin E, at least in the presence of other components of fetal bovine serum, has little effect on the ability of the cells to survive under normal conditions, as evidenced by continued long-term proliferation. However, the low levels of glutathione peroxidase resulting from selenium deficiency cause an increase susceptibility to peroxide-mediated toxicity. The combined deficiency of selenium and vitamin E impairs the ability of cells to survive under adverse conditions, as well as altering mitochondrial functions, as previously demonstrated.

Performance characteristics of A 150 plastic-equivalent gases in A 150 plastic proportional counters for 14.8-MeV neutrons

Two recently developed A 150 plastic-equivalent gas mixtures have been tested for suitability in proportional counter applications. Methane- and propane-based "tissue-equivalent" gases were also included for comparison purposes. Event-size weighted dose distributions were measured in a 14.8-MeV neutron beam. Resolution was found to be independent of gas mixture. Moreover the gains of the two A 150 mixtures were the same, and comparable to that of the methane-based gas mixture. The ionization yield per event size was also independent of the hydrogenous gas mixture employed. Neutron doses determined with the proportional counter were in reasonable agreement with those obtained from an ionization chamber.

Reporting of ventilation perfusion images for pulmonary embolism: accuracy and precision

Thirty-four hospital patients with suspected pulmonary embolism (PE) had ventilation perfusion (VP) imaging after pulmonary angiography to assess the performance of highly specific criteria for diagnosis of PE and to evaluate the precision of image reporting. A diagnostic result was obtained from VP imaging in 21 of 34 patients giving a sensitivity for PE of 80% and a specificity of 100% in this subgroup. Six of 11 patients with PE had an indeterminate study which reduced the overall sensitivity of the technique for PE in the whole group. A critical analysis of image reporting by two readers gave an 85% inter-observer agreement on ranking as diagnostic or indeterminate for PE (k 0.69) and 91%-94% agreement for consensus reproducibility (k 0.82). We conclude that the degree of accuracy and precision of reporting that can be obtained using specific criteria will provide a reliable diagnosis in a significant number of patients suspected of having PE. Consensus reporting by two readers is shown to be more reliable than individual reporting.

V79 survival following simultaneous or sequential irradiation by 15-MeV neutrons and 60Co photons

A unique tandem source irradiation facility, composed of an intense d-T neutron source and a 60Co teletherapy unit, was used to investigate biological responses for different neutron/photon configurations. V79 Chinese hamster cells, attached as monolayers in log-phase growth, were irradiated at 37 degrees C by either 14.8-MeV neutrons, 60Co, or a mixture of 40% neutrons and 60% photons in simultaneous or sequential application. Measurements of cell survival indicate an increased effectiveness in cell killing for simultaneously administered neutrons and photons compared to that measured or predicted for sequentially applied beam modalities. An understanding of the magnitude of these interactive effects is important both for calculating accurate effective doses for neutron radiotherapy of deep-seated tumors, for which the photon component is appreciable, and for determination of environmental hazards to people occupationally exposed to mixtures of photons and neutrons.

The effect of initial phosphate and sucrose levels on nicotine accumulation in batch suspension cultures of Nicotiana tabacum L

A system of liquid batch culture of tobacco (Nicotiana tabacum cv NC2512) is described in which up to 2% nicotine accumulates on a dry weight basis. Nicotine accumulation is first detected in cultures when medium phosphate is completely depleted. By reducing initial medium phosphate to 1/10th levels normally employed, alkaloid accumulation is accelerated while the raising of initial medium sucrose (30-50 g 1(-1)) results in a five-fold increase in peak accumulation of nicotine. The roles of medium phosphate and sucrose levels in culture growth and nicotine production are discussed.

Characteristics of A-150 plastic-equivalent gas in A-150 plastic ionization chambers for p(66)Be(49) neutrons

The evaluation of a gas mixture having an atomic composition similar to that of A-150 tissue-equivalent (TE) plastic has been extended to a high-energy neutron therapy beam. "A-150" gas, air, and methane-based TE gas were each flowed through A-150 plastic-walled ion chambers of different sizes and irradiated with p(66)Be(49) neutrons. A tentative value for W(A-150) of 27.3 +/- 0.5 JC-1 was derived for this beam. The W value of the A-150 gas mixture is compared to those of methane-based TE gas and of air for the p(66)Be(49) neutron beam as well as to corresponding values found in similar experiments using 14.8-MeV monoenergetic neutrons.