CollAborative care for Screen-Positive EldeRs with major depression (CASPER plus): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness

BACKGROUND

Depression in older adults is common and is associated with poor quality of life, increased morbidity and early mortality, and increased health and social care use. Collaborative care, a low-intensity intervention for depression that is shown to be effective in working-age adults, has not yet been evaluated in older people with depression who are managed in UK primary care. The CollAborative care for Screen-Positive EldeRs (CASPER) plus trial fills the evidence gap identified by the most recent guidelines on depression management.

OBJECTIVES

To establish the clinical effectiveness and cost-effectiveness of collaborative care for older adults with major depressive disorder in primary care.

DESIGN

A pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with embedded qualitative study. Participants were automatically randomised by computer, by the York Trials Unit Randomisation Service, on a 1 : 1 basis using simple unstratified randomisation after informed consent and baseline measures were collected. Blinding was not possible.

SETTING

Sixty-nine general practices in the north of England.

PARTICIPANTS

A total of 485 participants aged ≥ 65 years with major depressive disorder.

INTERVENTIONS

A low-intensity intervention of collaborative care, including behavioural activation, delivered by a case manager for an average of six sessions over 7-8 weeks, alongside usual general practitioner (GP) care. The control arm received only usual GP care.

MAIN OUTCOME MEASURES

The primary outcome measure was Patient Health Questionnaire-9 items score at 4 months post randomisation. Secondary outcome measures included depression severity and caseness at 12 and 18 months, the EuroQol-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder-7 items, Connor-Davidson Resilience Scale-2 items, a medication questionnaire, objective data and adverse events. Participants were followed up at 12 and 18 months.

RESULTS

In total, 485 participants were randomised (collaborative care, n = 249; usual care, n = 236), with 390 participants (80%: collaborative care, 75%; usual care, 86%) followed up at 4 months, 358 participants (74%: collaborative care, 70%; usual care, 78%) followed up at 12 months and 344 participants (71%: collaborative care, 67%; usual care, 75%) followed up at 18 months. A total of 415 participants were included in primary analysis (collaborative care, n = 198; usual care, n = 217), which revealed a statistically significant effect in favour of collaborative care at the primary end point at 4 months [8.98 vs. 10.90 score points, mean difference 1.92 score points, 95% confidence interval (CI) 0.85 to 2.99 score points; p  < 0.001], equivalent to a standard effect size of 0.34. However, treatment differences were not maintained in the longer term (at 12 months: 0.19 score points, 95% CI -0.92 to 1.29 score points; p = 0.741; at 18 months: < 0.01 score points, 95% CI -1.12 to 1.12 score points; p = 0.997). The study recorded details of all serious adverse events (SAEs), which consisted of 'unscheduled hospitalisation', 'other medically important condition' and 'death'. No SAEs were related to the intervention. Collaborative care showed a small but non-significant increase in quality-adjusted life-years (QALYs) over the 18-month period, with a higher cost. Overall, the mean cost per incremental QALY for collaborative care compared with usual care was £26,016; however, for participants attending six or more sessions, collaborative care appears to represent better value for money (£9876/QALY).

LIMITATIONS

Study limitations are identified at different stages: design (blinding unfeasible, potential contamination), process (relatively low overall consent rate, differential attrition/retention rates) and analysis (no baseline health-care resource cost or secondary/social care data).

CONCLUSION

Collaborative care was effective for older people with case-level depression across a range of outcomes in the short term though the reduction in depression severity was not maintained over the longer term of 12 or 18 months. Participants who received six or more sessions of collaborative care did benefit substantially more than those who received fewer treatment sessions but this difference was not statistically significant.

FUTURE WORK RECOMMENDATIONS

Recommendations for future research include investigating the longer-term effect of the intervention. Depression is a recurrent disorder and it would be useful to assess its impact on relapse and the prevention of future case-level depression.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN45842879.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 67. See the NIHR Journals Library website for further project information.

CollAborative care and active surveillance for Screen-Positive EldeRs with subthreshold depression (CASPER): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness

BACKGROUND

Efforts to reduce the burden of illness and personal suffering associated with depression in older adults have focused on those with more severe depressive syndromes. Less attention has been paid to those with mild disorders/subthreshold depression, but these patients also suffer significant impairments in their quality of life and level of functioning. There is currently no clear evidence-based guidance regarding treatment for this patient group.

OBJECTIVES

To establish the clinical effectiveness and cost-effectiveness of a low-intensity intervention of collaborative care for primary care older adults who screened positive for subthreshold depression.

DESIGN

A pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with a qualitative study embedded within the pilot. Randomisation occurred after informed consent and baseline measures were collected.

SETTING

Thirty-two general practitioner (GP) practices in the north of England.

PARTICIPANTS

A total of 705 participants aged ≥ 75 years during the pilot phase and ≥ 65 years during the main trial with subthreshold depression.

INTERVENTIONS

Participants in the intervention group received a low-intensity intervention of collaborative care, which included behavioural activation delivered by a case manager for an average of six sessions over 7-8 weeks, alongside usual GP care. Control-arm participants received only usual GP care.

MAIN OUTCOME MEASURES

The primary outcome measure was a self-reported measure of depression severity, the Patient Health Questionnaire-9 items PHQ-9 score at 4 months post randomisation. Secondary outcome measures included the European Quality of Life-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder seven-item scale, Connor-Davidson Resilience Scale two-item version, a medication questionnaire and objective data. Participants were followed up for 12 months.

RESULTS

In total, 705 participants were randomised (collaborative care n = 344, usual care n = 361), with 586 participants (83%; collaborative care 76%, usual care 90%) followed up at 4 months and 519 participants (74%; collaborative care 68%, usual care 79%) followed up at 12 months. Attrition was markedly greater in the collaborative care arm. Model estimates at the primary end point of 4 months revealed a statistically significant effect in favour of collaborative care compared with usual care [mean difference 1.31 score points, 95% confidence interval (CI) 0.67 to 1.95 score points; p < 0.001]. The difference equates to a standard effect size of 0.30, for which the trial was powered. Treatment differences measured by the PHQ-9 were maintained at 12 months' follow-up (mean difference 1.33 score points, 95% CI 0.55 to 2.10 score points; p = 0.001). Base-case cost-effectiveness analysis found that the incremental cost-effectiveness ratio was £9633 per quality-adjusted life-year (QALY). On average, participants allocated to collaborative care displayed significantly higher QALYs than those allocated to the control group (annual difference in adjusted QALYs of 0.044, 95% bias-corrected CI 0.015 to 0.072; p = 0.003).

CONCLUSIONS

Collaborative care has been shown to be clinically effective and cost-effective for older adults with subthreshold depression and to reduce the proportion of people who go on to develop case-level depression at 12 months. This intervention could feasibly be delivered in the NHS at an acceptable cost-benefit ratio. Important future work would include investigating the longer-term effect of collaborative care on the CASPER population, which could be conducted by introducing an extension to follow-up, and investigating the impact of collaborative care on managing multimorbidities in people with subthreshold depression.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN02202951.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 8. See the NIHR Journals Library website for further project information.

Effect of Collaborative Care vs Usual Care on Depressive Symptoms in Older Adults With Subthreshold Depression: The CASPER Randomized Clinical Trial

IMPORTANCE

There is little evidence to guide management of depressive symptoms in older people.

OBJECTIVE

To evaluate whether a collaborative care intervention can reduce depressive symptoms and prevent more severe depression in older people.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted from May 24, 2011, to November 14, 2014, in 32 primary care centers in the United Kingdom among 705 participants aged 65 years or older with Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) subthreshold depression; participants were followed up for 12 months.

INTERVENTIONS

Collaborative care (n=344) was coordinated by a case manager who assessed functional impairments relating to mood symptoms. Participants were offered behavioral activation and completed an average of 6 weekly sessions. The control group received usual primary care (n=361).

MAIN OUTCOMES AND MEASURES

The primary outcome was self-reported depression severity at 4-month follow-up on the 9-item Patient Health Questionnaire (PHQ-9; score range, 0-27). Included among 10 prespecified secondary outcomes were the PHQ-9 score at 12-month follow-up and the proportion meeting criteria for depressive disorder (PHQ-9 score ≥10) at 4- and 12-month follow-up.

RESULTS

The 705 participants were 58% female with a mean age of 77 (SD, 7.1) years. Four-month retention was 83%, with higher loss to follow-up in collaborative care (82/344 [24%]) vs usual care (37/361 [10%]). Collaborative care resulted in lower PHQ-9 scores vs usual care at 4-month follow-up (mean score with collaborative care, 5.36 vs with usual care, 6.67; mean difference, -1.31; 95% CI, -1.95 to -0.67; P < .001). Treatment differences remained at 12 months (mean PHQ-9 score with collaborative care, 5.93 vs with usual care, 7.25; mean difference, -1.33; 95% CI, -2.10 to -0.55). The proportions of participants meeting criteria for depression at 4-month follow-up were 17.2% (45/262) vs 23.5% (76/324), respectively (difference, -6.3% [95% CI, -12.8% to 0.2%]; relative risk, 0.83 [95% CI, 0.61-1.27]; P = .25) and at 12-month follow-up were 15.7% (37/235) vs 27.8% (79/284) (difference, -12.1% [95% CI, -19.1% to -5.1%]; relative risk, 0.65 [95% CI, 0.46-0.91]; P = .01).

CONCLUSIONS AND RELEVANCE

Among older adults with subthreshold depression, collaborative care compared with usual care resulted in a statistically significant difference in depressive symptoms at 4-month follow-up, of uncertain clinical importance. Although differences persisted through 12 months, findings are limited by attrition, and further research is needed to assess longer-term efficacy.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN02202951.

‘Baking Gives You Confidence’: Users' Views of Engaging in the Occupation of Baking

The quality of care in acute inpatient areas has been identified as unacceptable and, in some areas, as counter-therapeutic (Sainsbury Centre for Mental Health 1998). Occupational therapy continues to make a significant contribution within this practice area. However, specific research that has addressed the acute service user's perspective of engagement in occupation is limited.

This qualitative study explored 12 mental health service users' perspectives of engagement in the occupation of baking through a semi-structured interview. The findings identified that the opportunity to acquire new skills and, importantly, confidence while producing an end product stimulated the participants to attend the treatment session. The engagement in baking was also influenced by the participants' desire to add structure to their daily routine.

The study concludes that the physical and social environment in which the therapy takes place is a powerful motivating factor in facilitating individuals to participate in an occupation. The findings emphasise the importance of engagement in occupations, in conducive settings that meet the individual's needs. The study highlights that baking has many recognisable benefits for service users, offering a flexible and valued occupation.

Diversity in emergency medicine--a model program

Emergency medicine's (EM's) development as a specialty has spanned the last 25 years, with the first certifying examination administered by the American Board of Emergency Medicine in 1980. National census data project that the new millennium will bring a U.S. population that will be 40% minority. In the year 2000, the U.S. population had a projected minority population of 28%. The diversity of the patients we treat demonstrates the need for EM programs to diversify their faculty and residency staff. Strategies include expanding recruitment and supporting retention of underrepresented students, faculty, and trainees, addressing barriers that may exist for promotion of underrepresented women and minorities, mentoring underrepresented minority (URM) faculty in research and education, providing opportunities for URMs to advance in the field, and mentoring URMs at the junior high and high school levels in the sciences to expand the applicant pool in the field. The authors describe an academic EM program that is a model program for diversity within our specialty.

Comparative structure, proximal promoter elements, and chromosome location of the human eosinophil major basic protein genes

Human eosinophil major basic protein (MBP) is strongly implicated as a mediator of disease, especially bronchial asthma. We recently isolated a highly divergent human homologue of MBP (MBPH). Given human MBP's importance in disease and the restricted expression of it and human MBPH, we isolated the 4.6-kb human MBPH gene (HGMW-approved symbol PRG3). Comparisons among the human MBP (PRG2), human MBPH, and murine MBP-1 (mMBP-1; Prg2) genes suggest that the human MBP and mMBP-1 genes are more closely related than either is to the human MBPH gene. Proximal promoters of these three genes show conservation of potential binding sites for IK2 and STAT and of a known GATA site. However, a known C/EBP site is altered in the human MBPH gene's proximal promoter. The human MBP and MBPH genes localized to chromosome 11 in the centromere to 11q12 region. Thus, the human MBP and MBPH genes have diverged considerably, probably following a gene duplication event. Furthermore, the identified conserved and distinct proximal promoter elements likely contribute to the eosinophil-restricted and relatively reduced transcription of the human MBPH gene.

Root cause analysis of laboratory delays to an emergency department

The Q-Probes study has identified benchmark interinstitutional laboratory median turnaround times (TAT) of 25 min for hemoglobin and 36 min for potassium. Our objectives were to measure the emergency department (ED)/laboratory TAT and other relevant laboratory processing and reporting times, and to identify root causes of laboratory delay. A flow chart was developed for the ordering, collecting, analyzing, and reporting of laboratory results. Time intervals were prospectively recorded for complete blood count (CBC) and K+ in a cross-sectional study, using the flow chart, and defined as follows: TAT was the interval from blood draw (BD) to ED report; BD time was the interval from order processing to BD; and order processing time was the interval from physician ordering to the unit coordinator processing the orders. Median times with interquartile ranges are reported. CBC TAT was 38 min (29-51.5), and K+ TAT 58 min (45-76.5). Order processing time was 7 min (4-15). The laboratory assistant BD time was 17 min (8-30) for CBC and 15 min (7.75-32.25) for K+ as compared to 0 min for a nurse, yet the venipuncture method (laboratory assistant technique) had a recollection rate of 1% (1/93) due to hemolysis vs. 20% (19/95) via the i.v. catheter (nurse technique). Of stat ED blood work, 24% was for admitted patients held in the ED. Laboratory reporting times are delayed with these root causes: laboratory assistant availability; recollection rate; volume of tests for ED admitted patients; and order processing time.

Histopathology of in-stent restenosis in patients with peripheral artery disease

BACKGROUND

Clinical studies have suggested that smooth muscle cell (SMC) hyperplasia is the most likely cause of in-stent restenosis. However, pathological data regarding this issue are limited. Specifically, direct evidence of proliferative activity in tissues excised from stenotic stents has not been previously reported.

METHODS AND RESULTS

Tissue specimens were retrieved by directional atherectomy from 10 patients in whom in-stent restenosis complicated percutaneous revascularization of peripheral artery disease. Analysis of cellular composition was performed quantitatively after cell-specific immunostaining. For specimens preserved in methanol (7 of 10), cellular proliferation was evaluated by use of antibodies to proliferating cell nuclear antigen (PCNA), cyclin E, and cdk2. TUNEL staining for apoptosis was performed on 8 paraformaldehyde-preserved specimens. Each of the 10 specimens contained extensive foci of hypercellularity composed predominantly of SMCs (mean+/-SEM, 59.3+/-3.0%). Evidence of ongoing proliferative activity was documented in all 7 methanol-preserved specimens: 24.6+/-2.3% of SMCs were PCNA-positive, 24.8+/-3.1% were cyclin E-positive, and 22.5+/-2.2% were cdk2-positive. Apoptotic cells were detected in all 8 specimens that had been appropriately preserved to permit DNA nick-end labeling. Macrophages and leukocytes were identified in each of the 10 specimens but accounted for a proportionately smaller number of cells (14.5+/-1.9% and 9.5+/-1.4%, respectively). Organized thrombus was observed in 6 of the 10 specimens.

CONCLUSIONS

These findings support the notion that in-stent restenosis results from SMC hyperplasia and suggest that adjunctive therapies designed to inhibit SMC proliferation may further enhance the utility of endovascular stents.

A possible role for L-selectin in the release of polymorphonuclear leukocytes from bone marrow

Previous studies from our laboratory have shown that the expression of L-selectin on polymorphonuclear leukocytes (PMN) is higher in the bone marrow than in peripheral blood. The present study was designed to determine the location of this L-selectin loss as the PMN pass from the hematopoietic tissue into venous sinusoids of the bone marrow. Bone marrow and peripheral blood samples were collected at the beginning, during, and just after five normothermic cardiopulmonary bypass procedures in which there was active marrow release and compared with five hypothermic procedures in which marrow release was suppressed by lowering body temperature to 27 degrees C. L-selectin expression was measured on PMN in the hematopoietic tissue and venous sinusoids in the bone marrow using quantitative histology and immunocytochemistry. At baseline there was more L-selectin on PMN in the bone marrow hematopoietic tissue than in the sinusoids (24.7 +/- 3.5 vs. 10.3 +/- 2.5%, P < 0.004). Bone marrow release during normothermic cardiopulmonary bypass procedure was associated with a rise in peripheral blood band cells (0.18 +/- 0.7 vs. 2.98 +/- 0.56 x 10(9)/l, P < 0.01) and a further reduction of L-selectin expression on PMN in the sinusoids (P < 0.03). Hypothermia (27 degrees C) prevented both the rise in peripheral blood band cells and the reduction in L-selectin on PMN in the sinusoids. In vitro studies showed that lowering the temperature had a similar effect on shedding of L-selectin from PMN. We conclude that PMN shed L-selectin as they move from the hematopoietic compartment into the venous sinusoids of the bone marrow and postulate that this could control the release of PMN from the marrow.

Restenosis of endovascular stents from stent compression

OBJECTIVES

We sought to determine the basis for restenosis within superficial femoral arteries (SFAs) and hemodialysis conduits treated with balloon-expandable stents.

BACKGROUND

Use of stents within coronary and peripheral vessels continues to increase exponentially. The mechanism of restenosis within stents placed at various vascular sites is not well understood. In particular, the implications of deploying a balloon-expandable stent in a compressible site are not well understood.

METHODS

After the serendipitous detection of stent deformation during intravascular ultrasound (IVUS) examination of a restenosed dialysis fistula, we evaluated a consecutive series of patients with stents placed in compressible vascular sites, including the SFA (six patients) and hemodialysis fistulae (five patients). Clinical, angiographic and IVUS examinations were performed to evaluate mechanisms of restenosis.

RESULTS

Stent compression was identified as the principal cause of restenosis in all dialysis conduits and SFAs. Stent deformity was not reliably identified by angiography; however, IVUS identified compression of two forms: eccentric deformation, implicating two-point compressive force, and complete circumferential encroachment of stent struts around the catheter, suggesting multidirectional compressive force. Despite redilation, secondary restenosis resulting from recurrent compression recurred in most sites.

CONCLUSIONS

Restenosis within balloon-expandable endovascular stents may occur as a result of stent compression, a phenomenon readily detected by IVUS, but often not by angiography. These findings have significant implications for the use of balloon-expandable stents within vascular sites subject to extrinsic compression, such as hemodialysis conduits, the adductor canal segment of the SFA and carotid arteries.

Clinical evidence of angiogenesis after arterial gene transfer of phVEGF165 in patient with ischaemic limb

BACKGROUND

Preclinical findings suggest that intra-arterial gene transfer of a plasmid which encodes for vascular endothelial growth factor (VEGF) can improve blood supply to the ischaemic limb. We have used the method in a patient.

METHODS

Our patient was the eighth in a dose-ranging series. She was aged 71 with an ischaemic right leg. We administered 2,000 micrograms human plasmid phVEGF165 that was applied to the hydrogel polymer coating of an angioplasty balloon. By inflating the balloon, plasmid DNA was transferred to the distal popliteal artery.

FINDINGS

Digital subtraction angiography 4 weeks after gene therapy showed an increase in collateral vessels at the knee, mid-tibial, and ankle levels, which persisted at a 12-week view. Intra-arterial doppler-flow studies showed increased resting and maximum flows (by 82% and 72%, respectively). Three spider angiomas developed on the right foot/ankle about a week after gene transfer; one lesion was excised and revealed proliferative endothelium, the other two regressed. The patient developed oedema in her right leg, which was treated successfully.

INTERPRETATION

Administration of endothelial cell mitogens promotes angiogenesis in patients with limb ischaemia.

Variation in plasma RNA levels, CD4 cell counts, and p24 antigen levels in clinically stable men with human immunodeficiency virus infection

Short-term variability in CD4 cell counts, plasma RNA levels, and p24 antigenemia was measured in clinically stable men with human immunodeficiency virus infection. Blood samples were obtained three times in each of 2 weeks 4 weeks apart. Differences between duplicate assays were considered to be due to technical factors; variation among visits was attributed to physiologic factors. Median enrollment values of CD4 cell counts, plasma RNA levels, and immune complex-dissociated (ICD) p24 antigenemia were 400 cells/mm3, 3.4 log10 copies/mL, and 38 pg/mL, respectively. Median absolute differences between duplicate CD4 cell counts, plasma RNA levels, and ICD p24 antigen were 16 cells/mm3, 0.21 log10 copies/mL, and 9.3 pg/mL. Median intraindividual ranges were 119 cells/mm3, 0.83 log10 copies/mL, and 18 pg/mL. Above 500 copies/mL, plasma RNA levels have a variability of 0.5 log10; the test is unreliable below this level.

Species distribution in human immunodeficiency virus-related mycobacterial infections: implications for selection of initial treatment

Management of mycobacterial infection is species specific; however, treatment is prompted by positive smears or cultures, often several weeks before species identification. The objective of this study was to determine the species distribution of mycobacterial isolates from various body sites in patients infected with human immunodeficiency virus (HIV). All mycobacterial isolates recovered at St. Paul's Hospital (Vancouver, British Columbia, Canada) from April 1989 to March 1993 were reviewed. Among 357 HIV-positive patients with mycobacterial infections, 64% (96) of the sputum isolates were Mycobacterium avium complex (MAC), 18% were Mycobacterium tuberculosis, and 17% were Mycobacterium kansasii. Lymph node involvement (25 patients) was due to either MAC (72%) or M. tuberculosis (24%). Two hundred ninety-eight episodes of mycobacteremia were due to MAC (98%), M. tuberculosis (1%), and M. kansasii (1%). Similarly, cultures of 84 bone marrow biopsy specimens (99%), 19 intestinal biopsy specimens (100%), and 30 stool specimens (97%) yielded predominantly MAC. These results have implications for initial therapy, particularly in areas where rapid methods for species identification are not readily available. Because of considerable geographic variation, development of guidelines for selection of initial therapy depends on regional determination of species distribution in HIV-related mycobacterial infections.

Variability in leukocyte subset measurements among five laboratories in Vancouver

Cell counts and percentages of CD4 are widely used in the prognostic and clinical management of HIV-infected patients, and as surrogate outcomes in clinical trials involving HIV-infected individuals. Considerable variability in CD4 counts has been documented due to physiologic and methodologic factors. While studies of variability of CD4 counts among American and French laboratories have been reported in the literature, no published data are available for Canadian laboratories. This paper describes the results of a study to determine the variability of leukocyte subsets among 5 laboratories in Vancouver, British Columbia. Samples were collected in a prospective fashion from 52 HIV-negative patients from July 1991 to November 1993. Coefficients of variation (CV) were calculated for leukocyte subset percentages and absolute cell counts among laboratories. Our results demonstrate that the variability in leukocyte subsets among 5 Vancouver laboratories was lower than or comparable with published findings. The variability remained stable over the time period of the study, although 4 of the 5 laboratories participated in quality assurance programs. This suggests a plateau in the impact of this program. Since the variability among laboratories is less than the variability attributable to physiologic factors, further research efforts to reduce this variability should focus on physiologic sources.

L-selectin expression increases on peripheral blood polymorphonuclear leukocytes during active marrow release

The cell adhesion molecule L-selectin is highly expressed on mature bone marrow polymorphonuclear leukocytes (PMN), and the release of these cells from the bone marrow could produce a population of circulating PMN expressing high levels of L-selectin. Because L-selectin initiates the interaction of PMN with activated endothelium, these cells could be important in the pathogenesis of multiorgan failure following sepsis and septic shock. The present study was designed to test the hypothesis that the release of PMN from the bone marrow increases the expression of L-selectin on circulating PMN. Peripheral blood and bone marrow samples were obtained immediately after sternotomy (BM1) and during (BM2) and just before closing the sternum (BM3) in five normothermic and five hypothermic cardiopulmonary bypass (CPB) procedures. L-selectin was measured using both immunocytochemistry and flow cytometry. The results showed that L-selectin expression on bone marrow PMN was greater than on peripheral blood PMN (p < 0.01) in all patients at baseline. Bone marrow release of PMN during normothermic CPB was associated with a rise in peripheral blood band cells (0.18 +/- 0.7 versus 0.56 x 10(9)/L) (p < 0.01) and an increase in the percentage of PMN expressing high levels of L-selectin (9 +/- 3.3 to 36 +/- 6.6%, p < 0.03) and the L-selectin mean fluorescence intensity (MFI) on PMN (p < 0.05). The expression of L-selectin on band cells was higher than on segmented PMN in the circulation (p < 0.01). Hypothermia (27 degrees C) prevented the release of band cells into the circulation and the increased expression of L-selectin on the PMN.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantification of the variation due to laboratory and physiologic sources in CD4 lymphocyte counts of clinically stable HIV-infected individuals

We have conducted a study to quantify the amount of variation in the CD4 lymphocyte counts of HIV-infected individuals due to laboratory and physiological factors. Thirty HIV-infected male volunteers had blood drawn on six occasions: three times in each of 2 weeks, 4 weeks apart. Two tubes of blood were drawn at each visit, and duplicate measurements were obtained from one of the tubes of blood. Differences between duplicate measurements from a single tube of blood and between CD4 counts obtained from two tubes of blood drawn on the same day were attributed to laboratory factors. Differences between CD4 counts obtained on different days were attributed to a combination of laboratory factors and physiologic factors, which included the effects of exercise, tobacco, and the consumption of alcohol and caffeine. The mean absolute CD4 count at the first visit was 450 (range 86-1,081). The short-term coefficient of variation of CD4 count was 13.7 (95% CI: 12.9, 14.6). Physiologic and laboratory factors accounted for 85% and 15% of the variation in CD4 counts, respectively. Variation in the absolute white blood cell count, lymphocyte percentage, and CD4 percentage accounted fo 52%, 29%, and 19% of the physiologic variation in CD4 counts, respectively. Our results confirm a high degree of short-term variability of CD4 counts among HIV-infected individuals, which can be largely attributed to physiological factors. This variability can be minimized more effectively by repeating CD4 counts over time than by repeating measurements at a single visit.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of cigarette smoking on lymphocyte subsets and progression to AIDS in a cohort of homosexual men

We investigated the effect of cigarette smoking on the percentage of CD4 and CD8 cells (CD4%, CD8%) within a prospective study of homosexual men in Vancouver, Canada and compared progression rates to AIDS among seroincident smokers and non-smokers. Serial measurements of CD4% and CD8% obtained from four annual visits were available for 299 men and were compared with respect to smoking status and serologic group. CD4% was significantly elevated (p less than 0.025) and CD8% was significantly lower (p less than 0.002) in seronegative smokers compared to non-smokers. However, no effect of smoking was observed in the seropositive group for either of these variables. In a prospective analysis of 122 seroincident subjects, we failed to find a significant association between smoking and progression to AIDS (p = 0.829) or Pneumocystis carinii pneumonia (p = 0.894). At 72 months, cumulative AIDS progression was 29.1% in seroincident smokers compared to 25.2% in seroincident non-smokers. These data suggest that in the absence of HIV, smoking is associated with higher CD4% and lower CD8% but these effects are not present in seropositive subjects with longer durations of infection. Cigarette smoking does not appear to be associated with an altered rate of progression to AIDS.

Red blood cell alloimmunization in transfused patients on AZT

Significant numbers of patients receiving azidothymidine (AZT) develop anaemia requiring an adjustment of AZT dosage. Fear of red blood cell (RBC) alloimmunization may act as a deterrent to exposing a patient to long-term transfusion therapy which is the alternative to AZT dosage reduction or discontinuation. This retrospective study was done to assess the incidence of RBC alloimmunization in transfused patients on AZT. Records of 72 patients receiving long-term AZT were analysed to assess the incidence of alloimmunization. Other study parameters included duration of transfusion therapy, total number of pRBC units transfused/patient, alloantibody specificity, rates of autoantibody detection and their specificity. For comparison, a parallel analysis was carried out on 188 male patients transfused during the same period of time for chronic renal failure (CRF). Only one of 72 AZT patients (1.4%) developed an alloantibody compared with seven of the 118 CRF patients (5.9%) (P = NS). The incidence of autoantibodies and positive direct antiglobulin testing in the AZT and CRF populations was found to be similar (9.7% v. 7.6% respectively; P = NS). The two populations were similar with respect to mean number of pRBC units transfused (AZT: 10.5 v. CRF: 11.5 units; P = NS); however, there was a significant difference in the mean duration of transfusion therapy (AZT: 4.5 months v. CRF 19.4 months; P less than 0.001). We conclude there is an insignificant incidence of alloimmunization in the multiply-transfused AZT population. Furthermore, in this study the incidence of RBC autoantibodies in AZT patients appears to be low and no different from that of patients with chronic renal failure.

Agrobacterium-mediated transformation of Solanum tuberosum L. cv. 'Russet Burbank'

Stem sections from shoot cultures maintained in vitro were used to produce transgenic plants of the potato, Solanum tuberosum L. cv. 'Russet Burbank'. Stem internode pieces inoculated with Agrobacterium tumefaciens containing coat protein genes from potato virus X and potato virus Y, produced shoots with a frequency of 60% in the absence of selection and 10% on medium containing 100 mg/l kanamycin monosulfate. Regenerated shoots were assayed for kanamycin resistance by placing stem segments on callus induction medium containing an increased level of kanamycin. Of a total 255 regenerated shoots, 47 (18%) were kanamycin resistant. Of the kanamycin resistant shoots, 25 (53%) expressed the PVX or PVY coat protein genes as assayed by enzyme-linked immunosorbent assay or Western immunoblot analysis.

The second amino acid of alfalfa mosaic virus coat protein is critical for coat protein-mediated protection

Transgenic plants expressing the coat protein (CP) of alfalfa mosaic virus (AIMV) are resistant to infection by AIMV. A mutation was introduced into the second amino acid of the cDNA for the CP of AIMV. Three different transgenic tobacco lines expressing the mutant CP and two different transgenic tobacco lines expressing the wild-type CP at similar levels were challenged with AIMV virions and viral RNA. Whereas the lines expressing the wild-type CP were highly resistant to infection by AIMV virions and viral RNA, the lines expressing the mutant CP were susceptible to infection by both. The binding affinity of the mutant and the wild-type CPs for the 3' terminal protein binding site on AIMV RNAs was similar, as determined by electrophoretic mobility shift assay. A mixture of AIMV genomic RNAs 1-3 was infectious on the plants expressing the mutant CP but not on vector control plants or plants expressing the wild-type CP, indicating that the mutant CP can activate the AIMV genomic RNAs for infection. These results demonstrate that the second amino acid of the AIMV CP is critical for protection from AIMV but not for the initial interaction between the AIMV RNA and CP, suggesting that this initial interaction does not play a major role in CP-mediated protection.

Catecholamine levels in pregnant physicians and nurses: a pilot study of stress and pregnancy

As a pilot study of occupational stress and pregnancy, we measured urinary catecholamine excretion in ten pregnant physicians and three intensive care nurses between 26-37 weeks' gestation, once during a work day and again during a non-work day. Urinary catecholamines were increased by 58% (P less than .03) during work periods compared with non-work periods. Catecholamine levels were also increased by 64% (P less than .025) over those of a working non-physician control group of similar gestational age. Urinary catecholamine levels are a direct reflection of plasma catecholamine levels. Catecholamine levels are known to increase with physical stress, such as standing, and with mental stress, such as difficult problem-solving. Catecholamines are also known to decrease uterine blood flow. Measurement of catecholamines may be a helpful marker in investigating the relationship between occupation and pregnancy outcome.

Engineering Resistance to Mixed Virus Infection in a Commercial Potato Cultivar: Resistance to Potato Virus X and Potato Virus Y in Transgenic Russet Burbank

Potato virus X (PVX) and potato virus Y (PVY) infection in potato may result in the loss of certification of seed potatoes and affect quality and yield of potatoes in commercial production. We transformed a major commercial cultivar of potato, Russet Burbank, with the coat protein genes of PVX and PVY. Transgenic plants that expressed both CP genes were resistant to infection by PVX and PVY by mechanical inoculation. One line was also resistant when PVY was inoculated with viruliferous green peach aphids. These experiments demonstrate that CP protection is effective against mixed infection by two different viruses and against mechanical and aphid transmission of PVY.

Fine-needle aspiration cytology in lymphomas and related disorders

Fine-needle aspiration (FNA) is a useful technique in the care of patients with lymphomas and related diseases. It is most effective when the aspiration and interpretation are performed by the same individual and when a Romanowsky stain is the primary stain. Special studies that are applicable to lymph nodes biopsies can also be utilized in specimens obtained by FNA. In the previously undiagnosed patient, where a presumptive diagnosis of lymphoma is made by FNA, a subsequent open biopsy will usually be necessary. At that time, all the measures necessary for the precise classification of the lymphoma can be undertaken under ideal conditions. If a lesion appears reactive by FNA, then a period of clinical observation is required. In the patient with a previously diagnosed lymphoma, FNA is chiefly useful to exclude other coincidental disease and to confirm or exclude transformation of low-grade lymphoma to a more aggressive phase.

Gene sequences coding for S-adenosylmethionine decarboxylase are present on human chromosome 6 and the X and are not amplified in colon neoplasia

Sequences for human S-adenosylmethionine decarboxylase, an enzyme involved in polyamine biosynthesis, which is elevated in tumors, have been localized on chromosome 6 and the X.

Interleukin 2 (IL2) is assigned to human chromosome 4

The human gene for interleukin 2 (IL2) was assigned to chromosome 4 using human-mouse somatic cell hybrids and Southern filter hybridization of cell hybrid DNA. To identify IL2, a recombinant DNA probe ( pIL2 - 50A ) was used which contained a human interleukin 2 cDNA insert which hybridized to a 3.5-kb fragment in human DNA when cleaved with the restriction enzyme EcoRI.

Human-mouse cell hybrids: a suggestion of structural mutation for dipeptidase-2 deficiency in mouse cells

The dipeptidase-2 enzyme is inactive in certain cultured cell lines from the mouse. In somatic cell hybrids between such deficient cells and diploid human fibroblasts, the mouse deficiency was complemented when the homologous human peptidase-A was retained. The results suggested that the murine peptidase deficiency was the result of a structural mutation, rather than a regulatory one.