Educational level and use of osteoporosis drugs in elderly men and women: a Swedish nationwide register-based study

SUMMARY

We examined educational disparities in use of osteoporosis drugs in a nationwide population of Swedes aged 75-89 years old. Individuals with high education were more likely to receive osteoporosis drug treatment than lower educated individuals, particularly among women.

INTRODUCTION

This study aims to investigate whether educational level is associated with use of osteoporosis drugs in the general population of older men and women in Sweden, also after adjustment for fractures.

METHODS

By record linkage of The Swedish Prescribed Drug Register, The Swedish Patient Register, and The Swedish Education Register, we obtained information on filling of prescriptions for osteoporosis drugs (bisphosphonates, calcium/vitamin D combinations, and selective estrogen receptor modulators) from July to October 2005, osteoporotic fractures from 1998 to 2004, and educational level for 645,429 people aged 75-89 years. Multivariate logistic regression analysis was used to investigate whether education was associated with use of osteoporosis drug therapy.

RESULTS

Higher education was associated with use of osteoporosis drugs for both men [odds ratio (OR)(high education vs low), 1.27; 95% confidence interval (CI), 1.19-1.35] and women (OR(high education vs low), 1.57; 95% CI, 1.52-1.61), after adjustment for age, osteoporotic fractures, and comorbidity (i.e., number of other drugs). Among those who had sustained a fracture (n = 57,613), the educational differences in osteoporosis drug treatment were more pronounced in women than men. Further, women were more likely to receive osteoporosis drug treatment after osteoporotic fracture.

CONCLUSION

Uptake of osteoporosis drug therapy seems to be unequally distributed in the elderly population, even in a country with presumably equal access to health care.

Cognitive impairments in adult mice with constitutive inactivation of RIP140 gene expression

Receptor-interacting protein 140 (RIP140) is a negative transcriptional coregulator of nuclear receptors such as estrogen, retinoic acid or glucocorticoid receptors. Recruitment of RIP140 results in an inhibition of target gene expression through different repressive domains interacting with histone deacetylases or C-terminal binding proteins. In this study, we analyzed the role of RIP140 activity in memory processes using RIP140-deficient transgenic mice. Although the RIP140 protein was clearly expressed in the brain (cortical and hippocampus areas), the morphological examination of RIP140(-/-) mouse brain failed to show grossly observable alterations. Using male 2-month-old RIP140(-/-) , RIP140(+/-) or RIP140(+/+) mice, we did not observe any significant differences in the open-field test, rotarod test and in terms of spontaneous alternation in the Y-maze. By contrast, RIP140(-/-) mice showed long-term memory deficits, with an absence of decrease in escape latencies when animals were tested using a fixed platform position procedure in the water maze and in the passive avoidance test. Noteworthy, RIP140(-/-) mice showed decreased swimming speed, suggesting swimming alterations that may in part account for the marked alterations measured in the water maze. Moreover, RIP140(+/-) and RIP140(-/-) mice showed a significant increase in immobility time in the forced swimming test as compared with wild-type animals. These observations showed that RIP140 gene depletion results in learning and memory deficits as well as stress response, bringing to light a major role for this transcriptional coregulator in the neurophysiological developmental mechanisms underlying cognitive functions.

Human fetal mesenchymal stem cells differentiate into brown and white adipocytes: a role for ERRalpha in human UCP1 expression

We investigated the ability of fetal mesenchymal stem cells (fMSCs) to differentiate into brown and white adipocytes and compared the expression of a number of marker genes and key regulatory factors. We showed that the expression of key adipocyte regulators and markers during differentiation is similar to that in other human and murine adipocyte models, including induction of PPARgamma2 and FABP4. Notably, we found that the preadipocyte marker, Pref-1, is induced early in differentiation and then declines markedly as the process continues, suggesting that fMSCs first acquire preadipocyte characteristics as they commit to the adipogenic lineage, prior to their differentiation into mature adipocytes. After adipogenic induction, some stem cell isolates differentiated into cells resembling brown adipocytes and others into white adipocytes. Detailed investigation of one isolate showed that the novel brown fat-determining factor PRDM16 is expressed both before and after differentiation. Importantly, these cells exhibited elevated basal UCP-1 expression, which was dependent on the activity of the orphan nuclear receptor ERRalpha, highlighting a novel role for ERRalpha in human brown fat. Thus fMSCs represent a useful in vitro model for human adipogenesis, and provide opportunities to study the stages prior to commitment to the adipocyte lineage. They also offer invaluable insights into the characteristics of human brown fat.

Conditionally immortalized white preadipocytes: a novel adipocyte model

This study describes a novel approach to generate conditionally immortalized preadipocyte cell lines from white adipose tissue (IMWAT) that can be induced to differentiate into white adipocytes even after expansion in culture. Such adipocytes express markers of white fat such as peroxisome proliferator-activated receptor gamma and aP2 but not brown fat markers, have an intact insulin signaling pathway, and express proinflammatory cytokines. They can be readily transduced with adenoviral vectors, allowing them to be used to investigate the consequences of the depletion of specific adipocyte factors using short hairpin RNA. This approach has been used to study the effect of reduced expression of the nuclear receptor corepressor receptor interacting protein 140 (RIP140), a regulator of adipocyte function. The depletion of RIP140 results in changes in metabolic gene expression that resemble those in adipose tissue of the RIP140 null mouse. Thus, IMWAT cells provide a novel model for adipocytes that are derived from preadipocytes rather than fibroblasts and provide an alternative system to primary preadipocytes for the investigation of adipocyte function.

Mechanisms of androgen receptor activation in advanced prostate cancer: differential co-activator recruitment and gene expression

Prostate tumour growth depends on androgens; hence treatment includes androgen ablation and anti-androgens. Eventually tumours progress and in approximately 30% of patients this is associated with mutation of the androgen receptor. Several receptor variants associated with advanced disease show promiscuous activation by other hormones and anti-androgens. Such loss of specificity could promote receptor activation, hence tumour growth, in the absence of conventional ligands, explaining therapy failure. We aimed to elucidate mechanisms by which alternative ligands promote receptor activation. The three most commonly identified variants in tumours (with amino-acid substitutions H874Y, T877A and T877S) and wild-type receptor showed differences in co-activator recruitment dependent upon ligand and the interaction motif utilized. Co-expression and knockdown of co-activators that bind via leucine or phenylalanine motifs, combined with chromatin immunoprecipitation and quantitative PCR, revealed these preferences extend to co-activator recruitment in vivo and affect receptor activity at the transcriptional level, with subsequent effects on target gene regulation. The findings suggest that mutant receptors, activated by alternative ligands, drive growth via different mechanisms to androgen-activated wild-type receptor. Tumours may hence behave differently dependent upon any androgen receptor mutation present and what ligand is driving growth, as distinct subsets of genes may be regulated.

The nuclear receptor co-repressor RIP140 controls the expression of metabolic gene networks

NRs (nuclear receptors) regulate the expression of specific gene networks in target cells by recruiting cofactor complexes involved in chromatin remodelling and in the assembly of transcription complexes. The importance of activating gene expression, in metabolic tissues, is well established, but the contribution of transcriptional inhibition is less well defined. In this review, we highlight a crucial role for RIP140 (receptor-interacting protein 140), a transcriptional co-repressor for NR, in the regulation of metabolic gene expression. Many genes involved in lipid and carbohydrate metabolism are repressed by RIP140 in adipose and muscle. The repressive function of RIP140 results from its ability to bridge NRs to repressive enzyme complexes that modify DNA and histones. In the absence of RIP140, expression from many metabolic genes is increased so that mice exhibit a lean phenotype and resistance to high-fat-diet-induced obesity and display increased glucose tolerance and insulin sensitivity. We propose that a functional interplay between transcriptional activators and the co-repressor RIP140 is an essential process in metabolic regulation.

Predictors of mortality for the oldest old. A 4-year follow-up of community-based elderly in Sweden

The aim of this study is to investigate predictors for mortality in two age groups, 75-84 years old and 85 years and older. Interviews were carried out on 161 community-based persons aged 75-84 and 260 persons aged 85 and over. Predictors for mortality 4 years later were analyzed using logistic regression. Different models to predict mortality were found for the two age groups. Gender and IADL (Instrumental Activities of Daily Living) were found to be significant for the older group while ADL (Primary Activities of Daily Living), mobility and life satisfaction were significant for the younger group. Eliminating variables based on the nurse's evaluations did not change the model for the 85+ age group; in the 75-84 age group the nurse's assessment of ADL was replaced by a self-reported IADL index. Results confirm the heterogeneity of the elderly population and the importance of ADL and subjective measures for predicting mortality.

Identification of novel oestrogen receptor target genes in human ZR75-1 breast cancer cells by expression profiling

Oligonucleotide microarrays were used to analyse gene expression profiles in human ZR75-1 breast cancer cells in the presence of 17beta-oestradiol and oestrogen antagonists. Differential gene expression of a number of genes was confirmed by quantitative RNA analysis. In addition to known oestrogen-responsive genes, an appreciable number of novel targets were identified, including growth factors and components of the cell cycle, adhesion molecules, enzymes, signalling molecules and transcription factors. The most pronounced oestrogen-sensitive gene was that for the cytochrome P450-IIB enzyme, involved in metabolising steroids and xenobiotics, which was increased 100-fold over a 24 h period. It is a direct target gene for oestrogens, because its expression was increased in the presence of cyclohexamide. In contrast, expression of cytochrome P450-IIB was not detected in human MCF7 breast cancer cells. Expressions of the cationic amino acid transporter E16, gap junction protein and insulin-like growth factor binding protein 4 were also markedly increased by oestrogens, but the kinetics of induction varied according to the target gene. With the exception of the cationic amino acid transporter E16 and the insulin-like growth factor binding protein 4, the expression of the majority of the genes was unaffected by antioestrogen treatment. Further analysis of this set of markers will provide alternative approaches to the investigation of the mitogenicity of oestrogens in breast cancer cells.

Influence of sociocultural and structural factors on functional ability: the case of elderly people in Bangladesh

OBJECTIVE

To describe and contextualize functional status of elderly people (greater or lesser than 60 years) in Bangladesh by relating it to gender, region, and socioeconomic status.

METHODS

In this community-based study (N = 696), functional status was described through assessment of activities of daily living (ADL) and instrumental activities of daily living (IADL). Information was obtained on type of help used for ADLs and IADLs and reason for nonperformance of IADLs.

RESULTS

Findings indicate differential performance in ADLs and IADLs by gender and region. Socioeconomic status is found to influence IADLs only. Empirical evidence regarding type of help used and reason for not performing a task enables understanding of sociocultural and structural influence on functional ability.

DISCUSSION

The underlying assumption of ADL and IADL instruments that an individual will perform an activity given physical or cognitive ability is questioned. It is suggested that sociocultural and structural factors are strong determinants of task performance.

Cross-talk between Stat5b and estrogen receptor-alpha and -beta in mammary epithelial cells

Both 17beta-estradiol and prolactin play important roles in the mammary gland, raising the possibility of functional cross-talk between the two signaling pathways. Here, we demonstrate that estrogen receptor-alpha (ERalpha) and -beta (ERbeta) are both able to potentiate transcription from a Stat5-responsive promoter when activated by prolactin. Potentiation was observed not only in the presence of 17beta-estradiol, but also in the presence of anti-estrogens such as tamoxifen and ICI 182,780. The magnitude of the response was dependent on cell-type: in the HC11 mouse mammary epithelial cell line ERbeta potentiates transcription efficiently whereas ERalpha showed low activity. Conversely, in COS-7 cells, both estrogen receptors were active. We show that activation domains in the N-terminus (AF-1) and the C-terminus (AF-2) of the ERs are dispensable for potentiation. The effects are dependent on the presence of an intact DNA-binding/hinge domain, which we show is capable of interacting with Stat5b in vitro and in HC11 cell extracts. We conclude that ERalpha and ERbeta act as coactivators for Stat5b through a mechanism which is independent of AF-1 and AF-2.

Use of suppressor mutants to probe the function of estrogen receptor-p160 coactivator interactions

Estrogen-dependent recruitment of coactivators by estrogen receptor alpha (ERalpha) represents a crucial step in the transcriptional activation of target genes. However, studies of the function of individual coactivators has been hindered by the presence of endogenous coactivators, many of which are potentially recruited in the presence of agonist via a common mechanism. To circumvent this problem, we have generated second-site suppressor mutations in the nuclear receptor interaction domain of p160 coactivators which rescue their binding to a transcriptionally defective ERalpha that is refractory to wild-type coactivators. Analysis of these altered-specificity receptor-coactivator combinations, in the absence of interference from endogenous coregulators, indicated that estrogen-dependent transcription from reporter genes is critically dependent on direct recruitment of a p160 coactivator in mammalian cells and that the three p160 family members serve functionally redundant roles. Furthermore, our results suggest that such a change-of-specificity mutation may act as a transposable protein-protein interaction module which provides a novel tool with which to dissect the functional roles of other nuclear receptor coregulators at the cellular level.

Sweden and the United States: is the challenge of an aging society leading to a convergence of policy?

The aging of the population is one of many forces behind a current reconstruction of welfare benefits in both Sweden and the United States. While both countries represent ideological polarities regarding social policy, they are struggling to meet their welfare goals with limited resources, and both are adopting similar strategies, for example, decentralization, targeting, and an increased emphasis on privatization and evaluation. This paper summarizes some of the differences between Sweden and the United States and describes some of the forces at work that are lessening the differences between the two countries in strategies and policy regarding care services for elderly people.

An outcomes analysis and satisfaction survey of 199 consecutive abdominoplasties

Abdominoplasty is a popular body-contouring procedure. In this study the authors review retrospectively 199 abdominoplasty patients during a 15-year period to identify factors that affect overall outcome. Patients included 190 women and 9 men. The complication rate was 32% with few major complications (1.4%). The revision rate was 43%, and was related to fine-tuning the aesthetic appearance. Patients were divided into four groups based on tobacco use and history of diabetes and hypertension. There was no significant difference in revision rates or major complications between the subgroups. Minor complication rates, however, were significantly higher in smokers and patients with diabetes and/or hypertension. Complication and revision rates in patients undergoing intra-abdominal procedures combined with abdominoplasty were not significantly different from those patients undergoing abdominoplasty alone. A patient survey revealed symptom improvement in 95% of patients. Eighty-six percent of patients were satisfied with their result, and 86% would recommend abdominoplasty to a friend. The authors conclude that abdominoplasty is a safe and satisfying procedure, whether performed alone or in conjunction with another procedure. Patients are pleased with the outcome and have improvement in their symptoms, with minimal health risk. There is, however, a significant incidence of minor complications, related primarily to wound healing. These complications are increased significantly in smokers and patients with diabetes and/or hypertension. Revision rates are not different significantly between the subgroups. When complications do occur or revisions are required, they are minor and managed easily in an office setting.

Core LXXLL motif sequences in CREB-binding protein, SRC1, and RIP140 define affinity and selectivity for steroid and retinoid receptors

An alpha-helical motif containing the sequence LXXLL is required for the ligand-dependent binding of transcriptional co-activators to nuclear receptors. By using a peptide inhibition assay, we have defined the minimal "core" LXXLL motif as an 8-amino acid sequence spanning positions -2 to +6 relative to the primary conserved leucine residue. In yeast two-hybrid assays, core LXXLL motif sequences derived from steroid receptor co-activator (SRC1), the 140-kDa receptor interacting protein (RIP140), and CREB-binding protein (CBP) displayed differences in selectivity and affinity for nuclear receptor ligand binding domains. Although core LXXLL motifs from SRC1 and RIP140 mediated strong interactions with steroid and retinoid receptors, three LXXLL motifs present in the global co-activator CBP were found to have very weak affinity for these proteins. Core motifs with high affinity for steroid and retinoid receptors were generally found to contain a hydrophobic residue at position -1 relative to the first conserved leucine and a nonhydrophobic residue at position +2. Our results indicate that variant residues in LXXLL core motifs influence the affinity and selectivity of co-activators for nuclear receptors.

Differential effects of xenoestrogens on coactivator recruitment by estrogen receptor (ER) alpha and ERbeta

It has been proposed that tissue-specific estrogenic and/or antiestrogenic actions of certain xenoestrogens may be associated with alterations in the tertiary structure of estrogen receptor (ER) alpha and/or ERbeta following ligand binding; changes which are sensed by cellular factors (coactivators) required for normal gene expression. However, it is still unclear whether xenoestrogens affect the normal behavior of ERalpha and/or ERbeta subsequent to receptor binding. In view of the wide range of structural forms now recognized to mimic the actions of the natural estrogens, we have assessed the ability of ERalpha and ERbeta to recruit TIF2 and SRC-1a in the presence of 17beta-estradiol, genistein, diethylstilbestrol, 4-tert-octylphenol, 2',3',4', 5'-tetrachlorobiphenyl-ol, and bisphenol A. We show that ligand-dependent differences exist in the ability of ERalpha and ERbeta to bind coactivator proteins in vitro, despite the similarity in binding affinity of the various ligands for both ER subtypes. The enhanced ability of ERbeta (over ERalpha) to recruit coactivators in the presence of xenoestrogens was consistent with a greater ability of ERbeta to potentiate reporter gene activity in transiently transfected HeLa cells expressing SRC-1e and TIF2. We conclude that ligand-dependent differences in the ability of ERalpha and ERbeta to recruit coactivator proteins may contribute to the complex tissue-dependent agonistic/antagonistic responses observed with certain xenoestrogens.

Functional interaction between the p160 coactivator proteins and the transcriptional enhancer factor family of transcription factors

SRC1, initially identified as a nuclear receptor coactivator, was found to interact with a member of the transcriptional enhancer factor (TEF) family of transcription factors, TEF-4. The interaction, which occurs in both intact cells and in a cell-free system, is mediated by the highly conserved basic helix-loop-helix/Per-Arnt-Sim (bHLH-PAS) domain present in the N-terminal region of SRC1. Moreover, all three members of the p160 family of nuclear receptor coactivators, SRC1, TIF2, and RAC3, are able to potentiate transcription from a TEF response element in transient transfection experiments, and this activation requires the presence of the bHLH-PAS domain. These results suggest that the p160 proteins could be bona fide coactivators of the TEF family of transcription factors.

Priorities in care and services for elderly people: a path without guidelines?

The growing gap between demands and resources is putting immense pressure on all government spending in Sweden. The gap is especially apparent in care and services for elderly people in light of the rapid aging of the population. The article considers the decisions and priorities concerning resource allocation in the welfare sector in general and in elderly care in particular. The aim is to describe the political and administrative setting and to provide a conceptual structure that outlines the nature of the problem. Various levels of decision making are identified and discussed in the context of political accountability. Current transitions in elderly care are described with respect to service provision, marketisation, coverage rates, and eligibility standards. Basic principles of distribution are highlighted in order to clarify some central concepts of efficiency and justice, and a number of strategies for actual prioritising are identified. The article concludes with an endorsement of more conscious decisions in resource allocation. Existing knowledge and information concerning the effects of various strategies must be utilised, and the values and assumptions used for setting priorities must be made explicit.

Mutations in the estrogen receptor ligand binding domain discriminate between hormone-dependent transactivation and transrepression

The estrogen receptor (ER) suppresses transcriptional activity of the RelA subunit of nuclear factor-kappaB in a hormone-dependent manner by a mechanism involving both the receptor DNA binding domain and ligand binding domain (LBD). In this study we examine the role of the ER LBD in mediating ligand-dependent RelA transrepression. Both ERalpha and ERbeta inhibit RelA in response to 17beta-estradiol but not in the presence of antihormones. We have identified residues within the ERalpha LBD that are responsible for receptor dimerization and show that dimerization is necessary for transactivation and transrepression. Moreover we have generated mutant receptors that have lost their ability to inhibit RelA but retain their capacity to stimulate transcription and conversely mutants that are transcriptionally defective but capable of antagonizing RelA. Overexpression of p160 and cAMP-response element-binding protein-binding protein/p300 co-activators failed to relieve repression of RelA, which is consistent with the demonstration that RelA inhibition can occur independently of these co-activators. These findings suggest it is unlikely that sequestration of these cofactors required for ER transcriptional activation can account for hormone-dependent antagonism of RelA. The identification of ER mutants that discriminate between transactivation and transrepression implies that distinct surfaces within the LBD are involved in mediating these two receptor functions.

Mobility limitations in the Swedish population from 1968 to 1992: age, gender and social class differences

Mobility limitations are closely related to disability in old age. The study of mobility limitations in the population may improve the understanding of the development of disability, as well as gender and class patterns in disability in old age. Representative samples of the Swedish population between the ages of 18 and 75 years were interviewed in 1968, 1974, 1981, and 1991. A further sample of people aged 76+ years was interviewed in 1992. The questionnaire included the ability to walk 100 meters, to walk up and down stairs, and to run 100 meters. Mobility limitations begin to appear around age 40 years, and increase with age. In 1992 nearly none in the oldest age group (85+) could run 100 meters, and less than half could walk 100 meters, or go up and down stairs without difficulty. Between 1968 and 1991, the proportion of people with mobility limitations was reduced by one third, with the most prominent reduction among the oldest age groups. Women were more likely to report mobility limitations compared to men at all waves; however, the gender difference decreased between 1968 and 1991. Blue-collar workers had more mobility limitations than white-collar workers, and this discrepancy did not decrease over time. Mobility limitations often begin early in life, and differences between cohorts, men and women, and social classes can be seen well before the age of 50. The results suggest that gender differences in functional limitations among elderly people may decrease in the future, while social class inequalities are likely to persist.

Panniculectomy at the time of gynecologic surgery in morbidly obese patients

OBJECTIVE

Our goal was to demonstrate that panniculectomy performed at the time of gynecologic surgery aids in reducing the operative time and exposure and does not increase the wound infection rate in morbidly obese patients.

STUDY DESIGN

A retrospective survey was performed of massively obese patients who underwent panniculectomy at the time of gynecologic surgery at Northeastern Ohio Universities College of Medicine consortium hospitals from 1990-1999. Data collected during surgery included the patient's weight, operative opening and closing times, blood loss, and weight of the removed panniculus adiposus. Postoperative wound infection rates were monitored, and patients were followed up for 6 months.

RESULTS

Seventy-eight patients underwent the following operations: radical hysterectomy (n = 19), extrafascial hysterectomy (n = 18), standard hysterectomy (n = 32), or other gynecologic surgery (n = 9). The average blood loss was 71 mL. Opening and closing times were 27 and 33 minutes, respectively, adding a minimal amount of operative time to the required gynecologic surgery. The average removed panniculus adiposus weighed 4745 g. Efficiency in obtaining exposure to the operative site was noted. A total of 2 wound infections were recorded in the postoperative period. In 1 case debridement was required, and in the other healing occurred by secondary intention. Minimal separation occurred in 4 other cases and required no intervention.

CONCLUSION

Massively obese patients can safely undergo panniculectomy simultaneously with a gynecologic procedure. The difficulty with operative exposure is reduced, and these patients are better served intraoperatively. Postoperatively, the wound infection rates quoted for this population were markedly improved from prior studies and involved a larger group of patients.

Cofactor competition between the ligand-bound oestrogen receptor and an intron 1 enhancer leads to oestrogen repression of ERBB2 expression in breast cancer

Overexpression of the ERBB2 proto-oncogene in breast tumours, which occurs in 25-30% of patients, correlates with poor prognosis. In oestrogen receptor (ER) positive breast epithelial cells oestrogens reduce ERBB2 mRNA and protein levels, an effect that is reversed in the presence of anti-oestrogens such as tamoxifen and ICI 182780. Our previous studies have shown that the major effect of oestrogen on ERBB2 expression is at the level of transcription and that this is mediated through a region within the ERBB2 first intron which can act as an oestrogen-suppressible enhancer in ER positive breast cells. In vitro footprinting of the smallest DNA fragment that retained full activity revealed four transcription factor binding sites. We report here that two of these sites are recognized by AP-2 proteins and the other two are bound by a variety of bZIP factors, including CREB and ATFI, with a major complex containing ATFa/ JunD. However, by using ER mutants it is clear that repression occurs essentially off the DNA. Indeed, the essential domain of the ER responsible for repression of the ERBB2 enhancer is a region termed AF2 which is required for the ligand-dependent association of non-DNA binding cofactors. We further demonstrate that one of these ER cofactors, SRC-1, can relieve oestrogen repression of the ERBB2 enhancer and conclude that these data fit with a model whereby the ER and the ERBB2 enhancer compete for this limiting, non-DNA binding cofactor. Thus, in oestrogenic conditions SRC-1 preferentially binds to the ER which effectively sequesters it thereby reducing enhancer activity, but in antioestrogenic media the cofactor is released from the ER and is therefore available to activate the ERBB2 enhancer.

Socioeconomic status, marital status and hip fracture risk: a population-based case-control study

Socioeconomic status and social support have been identified as important determinants of several diseases and overall mortality, but these factors have not been adequately examined in relation to hip fracture risk. The aim of this study was to determine the relationship of socioeconomic status and marital status to hip fracture risk. We used data from a population-based case-control study in postmenopausal women aged 50-81 years during 1993-1995 who resided in six counties in Sweden. The analysis was based on 1327 incident cases of hip fracture and 3262 randomly selected controls. Socioeconomic and marital status were obtained by record linkage with census data in 1960, 1970, 1980 and 1990. Information on other possible risk factors for hip fracture was collected by a mailed questionnaire. Women who were gainfully employed in 1990 had an odds ratio (OR) of 0.74 [95% confidence interval (CI) 0.56-0.96] compared with those not gainfully employed; those in the highest tertile of household income had an OR of 0.74 (95% CI 0.60-0.90) compared with those in the lowest tertile of income. Women who lived in a one-family house had an OR of 0.85 (95% CI 0.72-0.99) compared with those living in an apartment. Divorced, widowed or unmarried women had a higher risk of hip fracture than married or cohabiting women; the OR was 1.40 (95% CI 1.06-1.85). Married women who were both gainfully employed and were living in a one-family house had a substantially decreased risk of hip fracture compared with unemployed women living without a partner in an apartment (OR 0.39; 95% CI 0.22-0.71). Occupational affiliation among women ever employed, and educational level, were not associated with hip fracture risk. We conclude that employment, household income, type of housing and marital status seem to be risk indicators of hip fracture risk independent of known osteoporotic risk factors.

The AF1 and AF2 domains of the androgen receptor interact with distinct regions of SRC1

The androgen receptor is unusual among nuclear receptors in that most, if not all, of its activity is mediated via the constitutive activation function in the N terminus. Here we demonstrate that p160 coactivators such as SRC1 (steroid receptor coactivator 1) interact directly with the N terminus in a ligand-independent manner via a conserved glutamine-rich region between residues 1053 and 1123. Although SRC1 is capable of interacting with the ligand-binding domain by means of LXXLL motifs, this interaction is not essential since an SRC1 mutant with no functional LXXLL motifs retains its ability to potentiate androgen receptor activity. In contrast, mutants lacking the glutamine-rich region are inactive, indicating that this region is both necessary and sufficient for recruitment of SRC1 to the androgen receptor. This recruitment is in direct contrast to the recruitment of SRC1 to the estrogen receptor, which requires interaction with the ligand-binding domain.

Expression of nuclear receptor interacting proteins TIF-1, SUG-1, receptor interacting protein 140, and corepressor SMRT in tamoxifen-resistant breast cancer

Regulation of gene transcription as a consequence of steroid receptor-DNA interaction is mediated via nuclear receptor interacting proteins (RIPs), including coactivator or corepressor proteins, which interact with both the receptor and components of the basic transcriptional unit and vary between cell types. The aim of this study was to test the hypothesis that resistance of some breast carcinomas to tamoxifen was associated with inappropriate expression of some of these RIPs. Using Northern analysis, we observed no significant difference between the amount of either TIF-1 or SUG-1 mRNA expressed in parental MCF-7 and MCF-7 tamoxifen-resistant cell lines. However, the expression of RIP140 mRNA was lower in the resistant cell line and in the presence of estradiol, the level of RIP140 mRNA was higher in the resistant cells but not in the parental cells. In a cohort of 19 tamoxifen-resistant breast tumor samples, there was no significant difference in the level of the RIP140 and TIF-1 and corepressor SMRT mRNA compared with tamoxifen-treated tumors (n = 6) or untreated tumors (n = 21). However, SUG-1 mRNA was lower in resistant breast tumors. These data provide no support for increased expression of these RIPs or decreased expression of corepressor SMRT for being a mechanism for resistance of breast tumors to tamoxifen.

Molecular determinants of the estrogen receptor-coactivator interface

Transcriptional activation by the estrogen receptor is mediated through its interaction with coactivator proteins upon ligand binding. By systematic mutagenesis, we have identified a group of conserved hydrophobic residues in the ligand binding domain that are required for binding the p160 family of coactivators. Together with helix 12 and lysine 366 at the C-terminal end of helix 3, they form a hydrophobic groove that accommodates an LXXLL motif, which is essential for mediating coactivator binding to the receptor. Furthermore, we demonstrated that the high-affinity binding of motif 2, conserved in the p160 family, is due to the presence of three basic residues N terminal to the core LXXLL motif. The recruitment of p160 coactivators to the estrogen receptor is therefore likely to depend not only on the LXXLL motif making hydrophobic interactions with the docking surface on the receptor, but also on adjacent basic residues, which may be involved in the recognition of charged residues on the receptor to allow the initial docking of the motif.

A comparison of transcriptional activation by ER alpha and ER beta

We have compared the ability of ER alpha and ER beta to stimulate transcription from a number of reporter genes in different cell lines and demonstrate that the activity of AF1 in ER beta is negligible compared with that of ER alpha on ERE based reporters. The activity of AF2 in ER alpha and ER beta is similar and this is likely to reflect their similar ability to bind coactivators. As a consequence, when transcription from a gene depends on both AF1 and AF2 the activity of ER alpha greatly exceeds that of ER beta but when AF1 is not required ER alpha and ER beta have similar transcriptional activities.

Transcriptional activation by oestrogen receptors

The oestrogen receptor belongs to a superfamily of nuclear receptors that function as hormone-dependent transcription factors. Transcriptional activation is mediated by two activation regions: AF-1 in the N-terminal domain and AF-2 in the ligand binding domain. AF-1, whose activity is also regulated by epidermal growth factor and insulin-like growth factor-I, varies considerably between receptors, whereas AF-2 seems to be conserved in nuclear receptors. From recent structural analysis of the ligand binding domains of two retinoid receptors and the thyroid hormone receptor, it appears that this domain contains a common fold that generates a conserved ligand binding pocket. As a consequence of ligand binding, a C-terminal helix is realigned over the ligand binding pocket to form a novel interacting surface to which co-activators are likely to bind. Several candidate proteins have been identified, including receptor-interacting protein (RIP)-140, RIP-160, transcription intermediary factor (TIF)-1, suppressor of gal4D lesions (SUG)-1 and steroid receptor co-activator (SRC)-1. These proteins interact with receptors only in the presence of their respective hormonal ligands; moreover, their interaction with a series of mutant receptors correlates with their transcriptional activity, suggesting that they may play a role in transcriptional activation. However, only SRC-1 stimulates the transcriptional activity of receptors in transfected mammalian cells, implying that the proteins have different functions. The properties of RIP-140 and SRC-1 will be described and their potential role and mechanism of action discussed.

Steroid sulphatase: expression, isolation and inhibition for active-site identification studies

Steroid sulphatase, which can hydrolyse 3-hydroxysteroid sulphates, has important roles in several physiological and pathological processes. A number of steroid sulphatase inhibitors have now been developed, of which the most potent to date is oestrone-3-O-sulphamate (EMATE). This inhibitor inactivates steroid sulphatase in an irreversible, time- and concentration-dependent manner. In order to be able to use a radiolabelled derivative of EMATE to study the active site, it will be essential to prepare the steroid sulphatase in a pure form. For this, attempts have been made to express the protein, using the steroid sulphatase cDNA, in the pGEX2T expression system and also to express a mutant form of the protein, in which the putative membrane-spanning domain was deleted, in CHO cells. In addition, a soluble steroid sulphatase has been identified from the snail Helix pomatia. This steroid sulphatase is inhibited by EMATE in an irreversible manner, similar to the human steroid sulphatase and appears to possess a histidine residue at its active site. The expression and/or isolation of a steroid sulphatase, in conjunction with the use of a radiolabelled derivative of EMATE should allow important new information about the active site of this enzyme and the mechanism of its inactivation to be obtained.

Isoforms of steroid receptor co-activator 1 differ in their ability to potentiate transcription by the oestrogen receptor

Steroid receptor co-activator (SRC1) is one of a number of transcriptional co-activators that are capable of potentiating the activity of nuclear receptors including the oestrogen receptor (ER). Here we report that two isoforms, SRC1a and SRC1e, which diverge at their C-termini, are functionally distinct as they differ in their abilities to enhance the activity of the ER in intact cells. SRC1e enhanced the ability of the ER to stimulate transcription to a greater extent than SRC1a, which had negligible effects on certain promoters. To elucidate the basis of this functional difference, we compared the nuclear receptor-binding properties and mapped the transcriptional activation domains in the two SRC1 isoforms. Both isoforms share a triplet of nuclear receptor-binding motifs (LXXLL motifs) for binding to functional ER dimers, and an activation domain which co-localizes with the CBP-binding domain, while SRC1a contains a unique LXXLL motif in its C-terminus. Although this LXXLL motif increases the affinity for the ER in vitro, it does not appear to be responsible for the functional difference between the two isoforms. This difference is due to a second activation domain that is CBP independent and is suppressed in the SRC1a isoform. Thus, SRC1 exists as functionally distinct isoforms which are likely to play different roles in ER-mediated transcription.

Estrogen receptors alpha and beta form heterodimers on DNA

The estrogen receptor (ER) is expressed in two forms, ERalpha and ERbeta. Here we show that ERalpha and ERbeta, expressed both in vitro and in vivo, form heterodimers which bind to DNA with an affinity (Kd of approximately 2 nM) similar to that of ERalpha and greater than that of ERbeta homodimers. Mutation analysis of the hormone binding domain of ERalpha suggests that the dimerization interface required to form heterodimers with ERbeta is very similar but not identical to that required for homodimer formation. The heterodimer, like the homodimers, are capable of binding the steroid receptor coactivator-1 when bound to DNA and stimulating transcription of a reporter gene in transfected cells. Given the relative expression of ERalpha and ERbeta in tissues and the difference in DNA binding activity between ERalpha/ERbeta heterodimers and ERbeta it seems likely that the heterodimer is functionally active in a subset of target cells.

The estrogenic activity of phthalate esters in vitro

A large number of phthalate esters were screened for estrogenic activity using a recombinant yeast screen. a selection of these was also tested for mitogenic effect on estrogen-responsive human breast cancer cells. A small number of the commercially available phthalates tested showed extremely weak estrogenic activity. The relative potencies of these descended in the order butyl benzyl phthalate (BBP) > dibutyl phthalate (DBP) > diisobutyl phthalate (DIBP) > diethyl phthalate (DEP) > diisiononyl phthalate (DINP). Potencies ranged from approximately 1 x 10(6) to 5 x 10(7) times less than 17beta-estradiol. The phthalates that were estrogenic in the yeast screen were also mitogenic on the human breast cancer cells. Di(2-ethylhexyl) phthalate (DEHP) showed no estrogenic activity in these in vitro assays. A number of metabolites were tested, including mono-butyl phthalate, mono-benzyl phthalate, mono-ethylhexyl phthalate, mon-n-octyl phthalate; all were wound to be inactive. One of the phthalates, ditridecyl phthalate (DTDP), produced inconsistent results; one sample was weakly estrogenic, whereas another, obtained from a different source, was inactive. analysis by gel chromatography-mass spectometry showed that the preparation exhibiting estrogenic activity contained 0.5% of the ortho-isomer of bisphenol A. It is likely that the presence of this antioxidant in the phthalate standard was responsible for the generation of a dose-response curve--which was not observed with an alternative sample that had not been supplemented with o,p'-bisphenol A--in the yeast screen; hence, DTDP is probably not weakly estrogenic. The activities of simple mixtures of BBP, DBP, and 17beta-estradiol were assessed in the yeast screen. No synergism was observed, although the activities of the mixtures were approximately additive. In summary, a small number of phthalates are weakly estrogenic in vitro. No data has yet been published on whether these are also estrogenic in vitro. No data has yet been published on whether these are also estrogenic in vivo; this will require tests using different classes of vertebrates and different routes of exposure.

A signature motif in transcriptional co-activators mediates binding to nuclear receptors

The binding of lipophilic hormones, retinoids and vitamins to members of the nuclear-receptor superfamily modifies the DNA-binding and transcriptional properties of these receptors, resulting in the activation or repression of target genes. Ligand binding induces conformational changes in nuclear receptors and promotes their association with a diverse group of nuclear proteins, including SRC-1/p160, TIF-2/GRIP-1 and CBP/p300 which function as co-activators of transcription, and RIP-140, TIF-1 and TRIP-1/SUG-1 whose functions are unclear. Here we report that a short sequence motif LXXLL (where L is leucine and X is any amino acid) present in RIP-140, SRC-1 and CBP is necessary and sufficient to mediate the binding of these proteins to liganded nuclear receptors. We show that the ability of SRC-1 to bind the oestrogen receptor and enhance its transcriptional activity is dependent upon the integrity of the LXXLL motifs and on key hydrophobic residues in a conserved helix (helix 12) of the oestrogen receptor that are required for its ligand-induced activation function. We propose that the LXXLL motif is a signature sequence that facilitates the interaction of different proteins with nuclear receptors, and is thus a defining feature of a new family of nuclear proteins.

A longitudinal study of pain: reported pain from middle age to old age

OBJECTIVE

Describe patterns of pain reporting over a span of 24 years.

DESIGN

Individuals were interviewed on four occasions (1968, 1974, 1981, 1992).

PARTICIPANTS

Representative sample (n = 321) of the Swedish population aged 53-63 at baseline.

MEASURES

Self-reported pain in the chest, abdomen, and musculoskeletal system (back or hips, shoulders, hands, elbows, legs, or knees).

RESULTS

Less than 1% reported chest or abdominal pain on all four occasions. Whereas 21.8% of the sample reported musculoskeletal pain on all four occasions. More than half of the sample reported some kind of pain on three or four occasions. Women reported more severe and more persistent pain compared with men. There were more people who developed pain during the 24-year period than there were who became pain free. An increase in pain was equally common for chest and musculoskeletal pain, but a decrease in pain was much more common for musculoskeletal pain than chest pain.

CONCLUSIONS

Cross-sectional studies have shown differing age patterns in pain. This longitudinal study demonstrates different patterns for men and women and for different pain localities.

Fatty acids, eicosanoids, and hypolipidemic agents identified as ligands of peroxisome proliferator-activated receptors by coactivator-dependent receptor ligand assay

Peroxisome proliferator-activated receptors (PPARs) are nuclear hormone receptors controlling the expression of genes involved in lipid homeostasis. PPARs activate gene transcription in response to a variety of compounds including hypolipidemic drugs as well as natural fatty acids. From the plethora of PPAR activators, Scatchard analysis of receptor-ligand interactions has thus far identified only four ligands. These are the chemotactic agent leukotriene B4 and the hypolipidemic drug Wy 14,643 for the alpha-subtype and a prostaglandin J2 metabolite and synthetic antidiabetic thiazolidinediones for the gamma-subtype. Based on the hypothesis that ligand binding to PPAR would induce interactions of the receptor with transcriptional coactivators, we have developed a novel ligand sensor assay, termed coactivator-dependent receptor ligand assay (CARLA). With CARLA we have screened several natural and synthetic candidate ligands and have identified naturally occurring fatty acids and metabolites as well as hypolipidemic drugs as bona fide ligands of the three PPAR subtypes from Xenopus laevis. Our results suggest that PPARs, by their ability to interact with a number of structurally diverse compounds, have acquired unique ligand-binding properties among the superfamily of nuclear receptors that are compatible with their biological activity.

Thyroid hormone-mediated enhancement of heterodimer formation between thyroid hormone receptor beta and retinoid X receptor

A subset of nuclear receptors, including those for thyroid hormone (TR), retinoic acid, vitamin D3, and eicosanoids, can form heterodimers with the retinoid X receptor (RXR) on DNA regulatory elements in the absence of their cognate ligands. In a mammalian two-hybrid assay, we have found that recruitment of a VP16-RXR chimera by a Gal4-TRbeta ligand-binding domain fusion is enhanced up to 50-fold by thyroid hormone (T3). This was also observed with a mutant fusion, Gal4-TR(L454A), lacking ligand-inducible activation function (AF-2) and unable to interact with putative coactivators, suggesting that the AF-2 activity of TR or intermediary cofactors is not involved in this effect. The wild-type and mutant Gal4-TR fusions also exhibited hormone-dependent recruitment of RXR in yeast. Hormone-dependent recruitment of RXR was also evident with another Gal4-TR mutant, AHTm, which does not interact with the nuclear receptor corepressor N-CoR, suggesting that ligand-enhanced dimerization is not a result of T3-induced corepressor release. Finally, we have shown that the interaction between RXR and TR is augmented by T3 in vitro, arguing against altered expression of either partner in vivo mediating this effect. We propose that ligand-dependent heterodimerization of TR and RXR in solution may provide a further level of control in nuclear receptor signaling.

AF-2 activity and recruitment of steroid receptor coactivator 1 to the estrogen receptor depend on a lysine residue conserved in nuclear receptors

Hormone-dependent transcriptional activation by nuclear receptors depends on the presence of a conserved C-terminal amphipathic alpha-helix (helix 12) in the ligand-binding domain. Here we show that a lysine residue, which is conserved in most nuclear receptors in the predicted helix 3, is also required for estrogen-dependent transactivation. The replacement of lysine 366 with alanine appreciably reduced activation function 2 (AF-2) activity without affecting steroid- or DNA-binding activity in the mouse estrogen receptor. The mutation dramatically reduced the ability of the receptor to bind steroid receptor coactivator 1 (SRC-1) but had no effect on receptor-interacting protein 140 (RIP-140) binding, indicating that while their sites of interaction overlap, they are not entirely consistent and in keeping with the proposal that the recruitment of coactivators, such as SRC-1, is required for AF-2 activity. Although the function of RIP-140 remains to be established, RIP-140 appears to be capable of recruiting the basal transcription machinery, since overexpression of the protein markedly increased the transcriptional activity of the mutant receptor. Since the lysine residue is conserved, we propose that it is required, together with residues in helix 12, to form the surface by which members of the nuclear receptor family interact with coactivators.

Ligand-independent activation of the oestrogen receptor by mutation of a conserved tyrosine

The oestrogen receptor is a member of the nuclear receptor family of transcription factors which, on binding the steroid hormone 17beta-oestradiol, interacts with co-activator proteins and stimulates gene expression. Replacement of a single tyrosine in the hormone-binding domain generated activated forms of the receptor which stimulated transcription in the absence of hormone. This increased activation is related to a decrease in hydrophobicity and a reduction in size of the side chain of the amino acid with which the tyrosine is replaced. Ligand-independent, in common with ligand-dependent transcriptional activation, requires an amphipathic alpha-helix at the C-terminus of the ligand-binding domain which is essential for the interaction of the receptor with a number of potential co-activator proteins. In contrast to the wild-type protein, constitutively active receptors were able to bind both the receptor-interacting protein RIP-140 and the steroid receptor co-activator SRC-1 in a ligand-independent manner, although in the case of SRC-1 this was only evident when the receptors were prebound to DNA. We propose, therefore, that this tyrosine is required to maintain the receptor in a transcriptionally inactive state in the absence of hormone. Modification of this residue may generate a conformational change in the ligand-binding domain of the receptor to form an interacting surface which allows the recruitment of co-activators independent of hormone binding. This suggests that this tyrosine may be a target for a different signalling pathway which forms an alternative mechanism of activating oestrogen receptor-mediated transcription.

Profound hypophosphatemia and isolated hyperphosphaturia in two cases of multiple myeloma

We describe the development of severe hypophosphatemia and urinary phosphate wasting in two patients with multiple myeloma. In both cases, the serum phosphorus was repeatedly less than 1.0 mg/dL despite vigorous replacement, and the calculated fractional excretion of urinary phosphorus was greater than 100%. Neither patient demonstrated other tubular defects typical of Fanconi's syndrome. With treatment of the myeloma, both patients achieved normalization of the serum phosphorus and no longer required phosphorus supplementation. We believe that multiple myeloma should be considered in the differential diagnosis in patients with profound hypophosphatemia, urinary phosphate wasting, and otherwise intact tubular function.

A natural transactivation mutation in the thyroid hormone beta receptor: impaired interaction with putative transcriptional mediators

The syndrome of resistance to thyroid hormone is characterized by elevated serum free thyroid hormones, failure to suppress pituitary thyrotropin secretion, and variable peripheral refractoriness to hormone action. Here we describe a novel leucine to valine mutation in codon 454 (L454V) of the thyroid hormone beta receptor (TR beta) in this disorder, resulting in a mutant receptor with unusual functional properties. Although the mutant protein binds ligand comparably to wild-type receptor and forms homo- and heterodimers on direct repeat, everted repeat, or palindromic thyroid response elements, its ability to activate transcription via these elements is markedly impaired. The hydrophobic leucine residue lies within an amphipathic alpha-helix at the carboxyl terminus of TR beta and the position of the homologous residue in the crystal structure of TR alpha indicates that its side chain is solvent-exposed and might interact with other proteins. We find that two putative transcriptional mediators (RIP140 and SRC-1) exhibit hormone-dependent association with wild-type TR. In comparison, the interaction of this natural mutant (L454V) and artificial mutants (L454A, E457A) with RIP140 and SRC-1 is markedly reduced. Furthermore, coexpression of SRC-1 is able to restore the transcriptional activity of the L454V mutant receptor, indicating that the interaction of this residue with accessory proteins is critical for transcriptional activation. Finally, the occurrence of the L454V mutation in resistance to thyroid hormone, together with impaired negative regulation of the thyroid-stimulating hormone alpha promoter by this mutant, suggests that the amphipathic alpha-helix also mediates hormone-dependent transcriptional inhibition, perhaps via interaction with these or other accessory factors.

RIP-140 interacts with multiple nuclear receptors by means of two distinct sites

We have characterized two distinct binding sites, called site 1 and site 2, in the nuclear protein RIP-140 which interact with the ligand binding domain of the estrogen receptor both in solution and when the receptor is bound to DNA. Both sites are capable of independently interacting with other nuclear receptors, including the thyroid hormone and retinoic acid receptors, but they are not identical since the interaction with retinoid X receptor is mediated primarily by site 1. The interaction is enhanced by agonists but not by antagonists, and the in vitro binding activities to a number of mutant receptors correlate with their abilities to stimulate transcription in vivo. When RIP-140 is fused to heterologous DNA binding domains, it is able to stimulate the transcription of reporter genes in both yeast and mammalian cells. Thus, RIP-140 is likely to function as a bridging protein between receptors and the basal transcription machinery and thereby stimulate the transcription of target genes.

Aromatase activity and CYP19 gene expression in breast cancers

The aromatase enzyme complex is responsible for the conversion of C19 androgens to oestrogens. Aromatase expression in oestrogen-responsive breast cancers may be an important mechanism of autocrine regulation in tumour growth. To evaluate whether aromatase cytochrome P450 (P450arom) transcript levels within breast tumours were correlated to the enzyme activity, a specific competitive reverse transcription-polymerase chain reaction (RT-PCR) was developed. In this reaction, a 32 base-deleted complementary RNA was used as internal standard. In vitro aromatase activity was measured by either the tritium release assay or characterization of oestrogen fractions. Results indicate that there is a positive correlation between P450arom transcript levels and enzyme activity, but the relationship does not reach statistical significance. Therefore, whereas aromatase mRNA quantification may be an option by which to monitor the potential of tumour to synthesize oestrogens, it will not accurately reflect enzyme activity in a minority of tumours. Preliminary evidence was obtained in a tumour with low enzyme activity and a high P450arom transcript level for the presence of an endogenous aromatase inhibitor. This study highlights the necessity to characterize factors involved in the regulation of aromatase activity in such tumours.

Recurrent tarsal tunnel syndrome and the radial forearm free flap

Tarsal tunnel syndrome results from posterior tibial nerve entrapment beneath the flexor retinaculum and the deep fascia. The syndrome consists of pain, paresthesias, and vasomotor changes. Surgical correction via release of the flexor retinaculum is the treatment of choice. There is however, a 10% to 20% failure rate, with little in the literature addressing treatment options in this subset of individuals. Two patients with recurrent tarsal tunnel syndrome were treated with re-release of the retinaculum, followed by nerve coverage with a radial forearm free flap. At 15 and 27 months, both patients were pain-free, ambulatory, and able to return to work.

Brief cognitive screening in a field survey of the oldest old

A nationally representative survey of living conditions among persons aged 77 to 98 years included a short instrument for cognitive impairment consisting of items from the Mini-Mental State Examination (MMSE). Because of the wide range of social, health, and economic domains included in the survey, it was necessary that the instrument could be administered in a short time by interviewers without experience in neuropsychological testing. Because of the age of the subjects, the instrument must be relatively independent of sensory or motor disabilities, and be acceptable to both interviewers and older adults. There were very few problems with the use of the instrument and very little missing data. A cut-off point for cognitive impairment was ascertained for the items included in this instrument using other data sets where diagnostic confirmation was available. Being able to identify subjects who are probably cognitively impaired is helpful in a multipurpose survey study of the oldest old, both in documenting the cognitive status of the sample and in evaluating the quality of other information being collected in the study.

Predictors of physical function among the oldest old: a comparison of three outcome variables in a 24-year follow-up

This study has measured physical function in a nationally representative sample of persons aged 77 to 98 (N = 508) in 1992. Three measures of function are used: activities of daily living (ADL), an index of mobility, and performance tests. These are used as outcomes and analyzed in relation to variables gathered in a survey in 1968. Variables from 1968 include education, mobility, smoking, and an index of circulation problems. All four variables predict some limitations in physical function in old age. However, there are different patterns of predictors found for the three outcome measures. All three outcomes are associated with age, education, and previous circulation problems. ADL limitations are also associated with poor previous mobility and smoking; mobility limitations are also associated with sex and smoking; performance limitations are also associated with sex.