Testing a Prostate Cancer Educational Intervention in High-Burden Neighborhoods

To better capitalize on our enhanced understanding of prostate cancer (PCa) risk factors, it is important to better understand how knowledge and attitudes contribute to ethnic disparities in PCa outcomes. The goal of this study was to test the impact of a targeted PCa educational intervention vs. a healthy lifestyle educational control intervention on levels of knowledge, concern, and intention to screen for PCa.We recruited 239 men from neighborhoods with the highest PCa burden in Philadelphia. We assigned 118 men from two of the neighborhoods to the control group 121 men from 2 other neighborhoods to the intervention group. Repeated outcome assessment measures were obtained by administering the survey at baseline, post-session, 1 month post-session, and 4 months post-session.We conducted descriptive statistics to characterize the study sample and linear mixed effect regression models to analyze the intervention's effect on the outcomes. At baseline, we observed no differences in the outcomes between the PCa-targeted intervention and healthy lifestyle control groups.We found that knowledge of PCa and intention to screen increased significantly over time for both the control and intervention groups (p ≤ 0.01 at the 4-month follow-up). In contrast, change in the level of PCa concern was only significant for the intervention group immediately post-session and at 1-month follow-up (p = 0.04 and p = 0.01, respectively).This study showed that gathering at-risk men for discussions about PCa or other health concerns may increase their PCa knowledge and intention to talk to a doctor about PCa screening.

Metabolic responses to change in disease activity during tumor necrosis factor inhibition in patients with rheumatoid arthritis

Assessment of disease activity in patients with rheumatoid arthritis (RA) is of importance in the evaluation of treatment. The most important measure of disease activity is the Disease Activity Score counted in 28 joints (DAS28). In this study, we evaluated whether metabolic profiling could complement current measures of disease activity. Fifty-six patients, in two separate studies, were followed for two years after commencing anti-TNF therapy. DAS28 was assessed, and metabolic profiles were recorded at defined time points. Correlations between metabolic profile and DAS28 scores were analyzed using multivariate statistics. The metabolic responses to lowering DAS28 scores varied in different patients but could predict DAS28 scores at the individual and subgroup level models. The erythrocyte sedimentation rate (ESR) component in DAS28 was most correlated to the metabolite data, pointing to inflammation as the primary effect driving metabolic profile changes. Patients with RA had differing metabolic response to changes in DAS28 following anti-TNF therapy. This suggests that discovery of new metabolic biomarkers for disease activity will derive from studies at the individual and subgroup level. Increased inflammation, measured as ESR, was the main common effect seen in metabolic profiles from periods associated with high DAS28.

Altered metabolic signature in pre-diabetic NOD mice

Altered metabolism proceeding seroconversion in children progressing to Type 1 diabetes has previously been demonstrated. We tested the hypothesis that non-obese diabetic (NOD) mice show a similarly altered metabolic profile compared to C57BL/6 mice. Blood samples from NOD and C57BL/6 female mice was collected at 0, 1, 2, 3, 4, 5, 6, 7, 9, 11, 13 and 15 weeks and the metabolite content was analyzed using GC-MS. Based on the data of 89 identified metabolites OPLS-DA analysis was employed to determine the most discriminative metabolites. In silico analysis of potential involved metabolic enzymes was performed using the dbSNP data base. Already at 0 weeks NOD mice displayed a unique metabolic signature compared to C57BL/6. A shift in the metabolism was observed for both strains the first weeks of life, a pattern that stabilized after 5 weeks of age. Multivariate analysis revealed the most discriminative metabolites, which included inosine and glutamic acid. In silico analysis of the genes in the involved metabolic pathways revealed several SNPs in either regulatory or coding regions, some in previously defined insulin dependent diabetes (Idd) regions. Our result shows that NOD mice display an altered metabolic profile that is partly resembling the previously observation made in children progressing to Type 1 diabetes. The level of glutamic acid was one of the most discriminative metabolites in addition to several metabolites in the TCA cycle and nucleic acid components. The in silico analysis indicated that the genes responsible for this reside within previously defined Idd regions.

Time spent in the lymphedema state: Area under the curve

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Background: The experience of lymphedema (LE) is variable as related to the pattern of LE emergence, with characteristics related to time since diagnosis, duration of the LE episode, frequency of limb volume change (LVC) events, and overall time spent in the state defined as LE. Recognition of these characteristics, examination of trajectories, and application of the ability to quantify LE state through calculation of Area Under the Curve provide an opportunity to explore new ways to quantify LE occurrence to better examine the impact of LE on survivorship outcomes. Further, through these findings researchers and clinicians will better understand the potential variations in lymphedema experience, including patterns of emergence, duration of each episode, frequency of events, and time spent in the lymphedema state.

Methods: Participants were enrolled following BC diagnosis and followed every 6 months through 60 months. The criterion of 10% LVC (LePCT) by perometry was chosen to demonstrate use of trajectories and utility of calculating Area Under the Curve (AUC). We examined times when a participant met the criterion as a means of following the trajectory of LE and quantified the proportion of (calendar) time that a participant appeared to have LE by looking at the AUC determined by the individual’s graph. As study time differed, rather than look at AUC alone, we looked at the percent of time that a participant met the LE criterion by dividing AUC by total study time.

Results: Over the 60-month time-stamps of data collection points, we examined trajectories or patterns of events where participants met the LE criterion of interest. An individual may have a single LVC “spike” or may have multiple “spikes.” These cases may be acute, transient, or chronic. Further, individuals may experience the LVC early or late in the survivorship trajectory. These variations contribute to varying AUC and percent of the (calendar) time that a participant meets the LE criterion.

Conclusions: These approaches provide an opportunity to further examine the association of LVC with psychosocial and functional outcomes of interest in cancer survivorship. They also provide preliminary data for exploring phenotypic differences in presentation and progression of post-breast cancer lymphedema.

Chemometrics in metabolomics--a review in human disease diagnosis

Metabolomics is a post genomic research field concerned with developing methods for analysis of low molecular weight compounds in biological systems, such as cells, organs or organisms. Analyzing metabolic differences between unperturbed and perturbed systems, such as healthy volunteers and patients with a disease, can lead to insights into the underlying pathology. In metabolomics analysis, large amounts of data are routinely produced in order to characterize samples. The use of multivariate data analysis techniques and chemometrics is a commonly used strategy for obtaining reliable results. Metabolomics have been applied in different fields such as disease diagnosis, toxicology, plant science and pharmaceutical and environmental research. In this review we take a closer look at the chemometric methods used and the available results within the field of disease diagnosis. We will first present some current strategies for performing metabolomics studies, especially regarding disease diagnosis. The main focus will be on data analysis strategies and validation of multivariate models, since there are many pitfalls in this regard. Further, we highlight the most interesting metabolomics publications and discuss these in detail; additional studies are mentioned as a reference for the interested reader. A general trend is an increased focus on biological interpretation rather than merely the ability to classify samples. In the conclusions, the general trends and some recommendations for improving metabolomics data analysis are provided.

Predicting mortality in nursing home residents with lower respiratory tract infection: The Missouri LRI Study

CONTEXT

Lower respiratory tract infection (LRI) is a leading cause of mortality and hospitalization in nursing home residents. Treatment decisions may be aided by a clinical prediction rule that identifies residents at low and high risk of mortality.

OBJECTIVE

To identify patient characteristics predictive of 30-day mortality in nursing home residents with an LRI.

DESIGN, SETTING, AND PATIENTS

Prospective cohort study of 1406 episodes of LRI in 1044 residents of 36 nursing homes in central Missouri and the St Louis, Mo, area between August 15, 1995, and September 30, 1998.

MAIN OUTCOME MEASURE

Thirty-day all-cause mortality.

RESULTS

Thirty-day mortality was 14.7% (n = 207). In a logistic analysis, using generalized estimating equations to adjust for clustering, we developed an 8-variable model to predict 30-day mortality, including serum urea nitrogen, white blood cell count, body mass index, pulse rate, activities of daily living status, absolute lymphocyte count of less than 800/microL (0.8 x 10(9)/L), male sex, and deterioration in mood over 90 days. In validation testing, the model exhibited reasonable discrimination (c =.76) and calibration (nonsignificant Hosmer-Lemeshow goodness-of-fit statistic, P =.54). A point score based on this model's variables fit to the entire data set closely matched observed mortality. Fifty-two percent of residents had low (score of 0-4) or relatively low (score of 5-6) predicted 30-day mortality, with 2.2% and 6.2% actual mortality, respectively.

CONCLUSIONS

Our model distinguishes nursing home residents at relatively low risk for mortality due to LRI. If independently validated, our findings could help physicians identify nursing home residents in need of different therapeutic approaches for LRI.

A convenient route to higher sugars by two-carbon chain elongation using Wittig/dihydroxylation reactions

The combination of a Wittig olefination and a dihydroxylation reaction constitutes a facile synthetic protocol for the transformation of unprotected carbohydrates into higher sugars. The Wittig reaction is carried out with tert-butyl or diphenylmethyl ester stabilized phosphoranes to give (E)-configured alpha,beta-unsaturated esters as the only products in most cases. These are dihydroxylated in a diastereoselective fashion using OsO(4)/NMO. The stereochemical outcome in the dihydroxylation follows Kishi's empirical rule and gives high diastereoselectivity (5:1-8:1) when starting from sugars with the 2,3-threo configuration. When starting from sugars with the 2,3-erythro configuration, the diastereoselectivity in the dihydroxylation is low (2:1-2.5:1). As a result, the Wittig/dihydroxylation protocol is most effective for producing higher sugars with the galacto configuration at the reducing end. The two steps can either be carried out individually or, more efficiently, as a one-pot procedure.

Efficient synthesis of enantiopure conduritols by ring-closing metathesis

Two short synthetic approaches to enantiopure conduritols are described starting from the chiral pool. In both cases, the cyclohexene ring is assembled via ring-closing olefin metathesis. The terminal diene precursers for the metathesis reaction are prepared either from octitols or from tartaric acids. The former route involves a new method for selective bromination of the primary positions in long-chain carbohydrate polyols. Subsequent reductive elimination with zinc then generates the diene. The latter route uses a highly diastereoselective addition of divinylzinc to tartaric dialdehydes for preparation of the dienes.

An evaluation of satisfaction with telemedicine among health-care professionals

A survey was conducted among non-doctor health-care professionals in six rural counties in Missouri. The purpose of the survey was to establish baseline data to evaluate the effect of changes in the health-care sector, especially technology changes, on the job satisfaction, career satisfaction, relationships and communication activities of health professionals. The survey included three rural counties in which integrated telecommunication and interactive video telemedicine services were being installed, but before significant activities had begun, and three comparator counties without substantial integrated telecommunications infrastructure and telemedicine services. During a one-month study period, 1108 questionnaires were distributed. The total response rate was 50.1% (n = 555). Of the respondents, 30.3% indicated that technology in health-care was having a large effect on their work, although only 18.2% indicated that telemedicine and telecommunications were having a large effect. No systematic differences were found among the health professionals in the two communities at the time telemedicine equipment was being installed.

Prevalence, incidence, management, and predictors of venous ulcers in the long-term-care population using the MDS

OBJECTIVE

To describe the prevalence, incidence, management, and predictors of venous ulcers in residents of certified long-term-care facilities using the Minimum Data Set.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

32,221 residents admitted to long-term-care facilities in Missouri between January 1, 1996, and October 30, 1998.

MAIN OUTCOME MEASURES

Version 2.0 of the Minimum Data Set was utilized. Assessment items included selected measures from background information, disease diagnoses, physical functioning and structural problems, health conditions, oral/nutritional status, and skin condition.

MAIN RESULTS

Venous ulcer prevalence on admission was 2.5%. The incidence of venous ulcer development for long-term-care residents admitted without an ulcer at 90, 180, 270, and 365 days after admission was 1.0%, 1.3%, 1.8%, and 2.2%, respectively. The most frequent skin treatments for residents with a venous ulcer were ulcer care, dressings, and ointments. Factors associated with venous ulcer development within a year of admission were diabetes mellitus, peripheral vascular disease, and edema.

CONCLUSION

Venous ulcer prevalence and incidence are greater in the long-term-care population than in the community at-large. Residents with a venous ulcer are likely to have comorbid conditions such as diabetes mellitus, peripheral vascular disease, congestive heart failure, edema, wound infection, and pain. Based on these data, risk factors such as history of leg ulcers, recent edema, diabetes mellitus, congestive heart failure, or peripheral vascular disease should prompt clinicians to carefully plan care that will manage a resident's risk for venous ulcer development.

Usefulness of a pediatric colonoscope for colonoscopy in adults

BACKGROUND

There are few published data on how different types of colonoscopes affect success in reaching the cecum and patient comfort. We examined the feasibility of using a pediatric colonoscope for routine colonoscopy in adults and investigated whether there were subgroups of patients in whom use of this instrument was preferable.

METHODS

One-hundred fifty adults undergoing outpatient colonoscopy were randomized to colonoscopy with a standard colonoscope (Olympus CF-100L) or with a pediatric colonoscope (Olympus PCF-100). All procedures were performed by a faculty endoscopist and timed by an independent observer. After examinations, the endoscopist graded procedure difficulty and patients were given a questionnaire that assessed their experience.

RESULTS

The adult (n = 77) and pediatric (n = 73) colonoscope groups were comparable in all outcomes measured, including success in reaching the cecum (91% vs. 93%, p = 0.61), mean time to reach the cecum (11.4 vs. 9.7 min, p = 0.07), mean total procedure time (21.8 vs. 21.9 min, p = 0.95), mean meperidine dose (55 vs. 52 mg, p = 0.17); median midazolam dose (2.0 mg in both groups, p = 0.10), the endoscopists' perception of procedure difficulty, and patient comfort scales. Of the 7 patients in whom colonoscopy with the adult colonoscope was unsuccessful, the cecum was reached in 4 by switching to a pediatric colonoscope (all women, 3 of whom had prior hysterectomy). In the 5 patients in whom colonoscopy with the pediatric colonoscope was unsuccessful, the cecum was reached in 1 by switching to an adult colonoscope. Including the cases in which the cecum was reached by switching to the alternative colonoscope, the overall frequency of cecal intubation was 143 of 150 (95%). Subgroup analysis disclosed no difference between the 2 groups in outcomes when gender, presence of diverticulosis, and patient size were considered. Colonoscopy with the pediatric colonoscope was more successful than with the adult instrument in reaching the cecum in women with prior hysterectomy (11 of 12 [92%] vs. 15 of 21 [71%]); however, the numbers in each group were relatively small and the difference was not significant (p = 0.22).

CONCLUSIONS

The pediatric colonoscope is suitable for routine colonoscopy in adults. It is also useful in patients in whom colonoscopy with the adult colonoscope is unsuccessful in reaching the cecum (particularly in women). Additional study is needed to see if the pediatric colonoscope is actually superior to the adult colonoscopy for routine colonoscopy in women with prior hysterectomy.

An instrument to measure symptom experience. Symptom occurrence and symptom distress

This article describes the development of an instrument that measures symptom experience (symptom occurrence and symptom distress). The Adapted Symptom Distress Scale-2 (ASDS-2), adapted from the McCorkle and Young Distress Scale, is a 31-item, 5-point, self-report paper-and-pencil instrument that measures patients' perception of the occurrence and distress of 14 symptoms: nausea, vomiting, pain, eating, sleep, fatigue, bowel elimination, breathing, coughing, concentration, lacrimation, changes in body temperature, appearance, and restlessness. Use of the instrument yields a total score for symptom experience, scores for symptom occurrence, scores for symptom distress, and subscale scores for six symptom categories: gastrointestinal, fatigue/restlessness, concentration, pain/discomfort, respiratory, and appearance. Reliability and validity were determined with well adults (n = 97), medical-surgical patients (n = 82), and oncology patients (n = 175). Findings revealed a Cronbach's alpha of 0.91 for symptom experience, 0.90 for symptom occurrence, and 0.76 for symptom distress. Cronbach's alpha for the subscales ranged from 0.38 for appearance symptoms to 0.83 for gastrointestinal symptoms. Inclusion of symptoms reported by patients with cancer strengthened content validity. A contrasted groups approach was used to demonstrate construct validity.

Use of GHb (HbA1c) in screening for undiagnosed diabetes in the U.S. population

OBJECTIVE

To evaluate the use of GHb as a screening test for undiagnosed diabetes (fasting plasma glucose > or =7.0 mmol/l) in a representative sample of the U.S. population.

RESEARCH DESIGN AND METHODS

The Third National Health and Nutrition Examination Survey included national samples of non-Hispanic whites, non-Hispanic blacks, and Mexican Americans aged > or =20 years. Of these subjects, 7,832 participated in a morning examination session, of which 1,273 were excluded because of a previous diagnosis of diabetes, missing data, or fasting time of <8 h before examination. Venous blood was obtained to measure fasting plasma glucose and GHb in the remaining 6,559 subjects. Receiver operating characteristic curve analysis was used to examine the sensitivity and specificity of GHb for detecting diabetes at increasing GHb cutoff levels.

RESULTS

GHb demonstrated high sensitivity (83.4%) and specificity (84.4%) for detecting undiagnosed diabetes at a GHb cutoff of 1 SD above the normal mean. Moderate sensitivity (63.2%) and very high specificity (97.4%) were evident at a GHb cutoff of 2 SD above the normal mean. Sensitivity at this level ranged from 58.6% in the non-Hispanic white population to 83.6% in the Mexican-American population; specificity ranged from 93.0% in the nonHispanic black population to 98.3% in the non-Hispanic white population.

CONCLUSIONS

GHb is a highly specific and convenient alternative to fasting plasma glucose for diabetes screening. A GHb value of 2 SD above the normal mean could identify a high proportion of individuals with undiagnosed diabetes who are at risk for developing diabetes complications.

Physician satisfaction with Medicaid managed care: the Missouri experience

BACKGROUND

Medicaid managed care is important to health reform at the state level. However, little is known about physician satisfaction with these programs. We sought to measure this satisfaction in Missouri and determine its predictors.

METHODS

We surveyed a random sample of primary care physicians participating in Medicaid managed care (n = 670) or traditional Medicaid (n = 670). Primary outcomes measured were physicians' satisfaction Medicaid managed care, traditional Medicaid and commercial managed care. Satisfaction was measured on a 5-point Likert-type scale.

RESULTS

The response rate was 52%. Physicians participating in Medicaid managed care were less likely to be satisfied or very satisfied with Medicaid managed care (28.6%) than with commercial managed care (40%) or their previous experience with traditional Medicaid (39.7%). Among physicians participating in traditional Medicaid, 29.8% were satisfied or very satisfied with traditional Medicaid. Physicians participating in Medicaid managed care were less satisfied with clinical autonomy under that system in comparison with their previous experience with traditional Medicaid (relative difference = 10.8%, P =.001). In multiple linear regression analyses, clinical autonomy (R2 = 0.40) was a strong predictor of overall satisfaction with Medicaid managed care.

CONCLUSIONS

Enhancing physicians' clinical autonomy may result in improved satisfaction with Medicaid managed care. State Medicaid agencies should include physician satisfaction as a measure of Medicaid managed care plans' quality.

Increased arterial stiffness in children with a parental history of hypertension

The vascular dynamics of children with a parental history of hypertension has not been defined. The purpose of the current study was to determine whether or not these children have different arterial stiffness compared to the offspring of normotensive parents. One hundred healthy, nonobese subjects (ages 10-21 years) were divided into two groups of 50. Group A included the offspring of hypertensive patients and group B the offspring of normotensive parents. The variables studied were body surface area, blood pressure, and systolic and diastolic diameters of the aortic and carotid arteries as well as maximum velocity flow of these vessels. Carotid and aortic stiffness were calculated. Children and adolescents with a parental history of hypertension had higher carotid stiffness and smaller carotid diameters. These differences continued to be significant when correcting for body surface area. A higher blood pressure and a greater body surface area were also found.

The effect of a rapid sequence induction protocol on intubation success rate in an air medical program

The purpose of this study was to examine the percentage of successful intubations before and after implementation of a rapid sequence induction (RSI) protocol in patients treated by our flight nurses and paramedics. The records of 100 intubation attempts before the RSI protocol was implemented and 98 after implementation were reviewed. Success rate of intubation was 79% in the preRSI patient group and 84.7% in the postRSI group. No significant difference existed in the number of patients successfully intubated preRSI compared with postRSI. The statistically significant patient characteristics associated with unsuccessful intubation were facial trauma, combativeness, vomiting, and nasal bleeding.

Laser wire for crossing chronic total occlusions: "learning phase" results from the U.S. TOTAL trial. Total Occlusion Trial With Angioplasty by Using a Laser Wire

The Prima laser guidewire system (Spectranectics Corp., Colorado Springs, CO) consists of an 0.018" hypotube containing a bundle of 45-microm optical fibers coupled to a pulsed excimer laser operating at a tip fluence of 60 ml/mm2 and a repetition rate ranging from 25-40 Hz. This laser guidewire was specifically designed to cross total occlusions refractory to passage with conventional wires. The Prima wire was evaluated in a feasibility study at 15 U.S. centers. Following failure to cross a total occlusion with approved guidewires, the Prima wire was utilized in 179 patients. Average age of subjects was 61 yr. Lesion locations included left anterior descending (36%), right (45%), and circumflex (19%) coronary arteries. Mean angiographic age of total occlusions was 70 wk (range, 2-1,020 wk, median, 14 wk). The use of the Prima wire either solely or in combination with conventional guidewires resulted in successful crossing in 61% of these previously impenetrable occlusions. Failure of the device was commonly related to length of the occlusion and tortuosity along the occluded pathway. Major complications included myocardial infarction in 7 patients (3.9%), tamponade in 3 (1.7%), and death in 2 (1.1%). This "learning phase" pilot study confirmed the feasibility of a laser guidewire in chronic total occlusions that are resistant to passage of conventional guidewires. An extended registry at these investigative sites is planned.

Effects of ischemic tolerance on mRNA levels of IP3R1, beta-actin, and neuron-specific enolase in hippocampal CA1 area of the gerbil brain

Global cerebral ischemia induced to Mongolian gerbils by ligation of common carotid arteries (CCAs) is known to result in injury to the hippocampal CA1 region. In this study, we examined whether neuronal injury can be depicted by measuring levels of mRNA encoding inositol 1,4,5-trisphosphate receptor type 1 (IP3R1), neuron specific enolase (NSE) and beta-actin and whether these measurements can be use to assess ischemic tolerance. Gerbils were subjected either to cerebral ischemia induced by ligation of both CCAs for 5 min, or to an ischemic tolerance paradigm in which a 2 min ischemic preconditioning was performed 24 hr prior to the 5 min ischemia. At 48 hr after the 5 min ischemic insult, significant decreases in mRNA levels for IP3R1 (26%), NSE (38%) and beta-actin (50%) could be observed in the hippocampal CA1 region. Although levels of mRNA in the preconditioning group were decreased as compared to the sham control, the levels were significantly higher than those in the ischemic group. These results indicate the feasibility of using mRNA measurement as a parameter to assess cerebral ischemic damage. In addition, based on the differences in the decline in mRNA levels between the ischemia group and the preconditioned ischemia group, it can be concluded that this ischemic tolerance paradigm could offer partial protection (around 45%) against the injury due to the 5 min cerebral ischemic insult.

Long-term follow-up of kidney donors: a longitudinal study

BACKGROUND

Kidney donors are not adversely affected by compensatory hyperfiltration of the remaining kidney in the early years after nephrectomy, but longterm longitudinal studies are lacking.

METHODS

The renal function and blood pressure of 75 donors was evaluated in 1984, 1.4-20.7 years after surgery. Forty-seven of the original cohort (23 male, age 38-80 years) underwent repeat study a decade later (12-31 years post-nephrectomy), using identical laboratory techniques.

RESULTS

Glomerular filtration rates (GFR) as measured by 51Cr EDTA clearance was relatively unchanged a decade later with 41 of 47 subjects (87%) having EDTA clearance within the normal laboratory reference range at review. The change in GFR in the remaining six subjects was statistically not significant. No correlation between GFR and time after nephrectomy was detected. Albumin excretion rate (AER), on timed overnight urine collections, was increased (> 20 micrograms/min) in 16 subjects (34%), although 14 of these individuals were also hypertensive. The prevalence of hypertension was significantly increased compared with age/sex matched data from epidemiological studies of the general population (both in the UK and the US), especially in those over the age of 55 years.

CONCLUSION

This study demonstrates that the function of the solitary kidney is not adversely affected by prolonged compensatory hyperfiltration, although there appears to be an increased prevalence of microalbuminuria and hypertension. Regular follow-up of kidney donors is recommended in order to manage their complications effectively and to detect hypertension and or renal impairment early in those who may develop it.

Deoxyiminoalditols from aldonolactones--V. Preparation of the four stereoisomers of 1,5-dideoxy-1,5-iminopentitols. Evaluation of these iminopentitols and three 1,5-dideoxy-1,5-iminoheptitols as glycosidase inhibitors

The four stereoisomeric 1,5-dideoxy-1,5-iminopentitols with D-arabino-(D-lyxo-) (3), ribo- (9), L-lyxo (L-arabino-) (13) and xylo-(18) configurations were synthesized. The corresponding aldonolactones (1, 7 and 11) or aldonic acid ester (15b) having a leaving group at C-5 gave by reaction with aqueous ammonia, the 5-amino-5-deoxy-1,5-lactams, 2, 8, 12 and 17, respectively. Reduction of the lactam function using sodium borohydride/acetic or trifluoroacetic acid, or borane dimethyl sulfide complex yielded the iminopentitols. The compounds 3, 9, 13 and 18, together with the three 1,5-dideoxy-1,5-iminoheptitols 19,20 and 21 were tested for inhibition of the glycosidase activities present in an extract from human liver. Compound 18 was a potent and 19 a moderately good inhibitor of beta-glucosidase. Compound 3 together with 19, 20 and 21, all having D-arabino-configuration at the hydroxy-substituted carbon atoms, were good inhibitors of alpha-L-fucosidase.

The effects of taxol, methylprednisolone, and 4-aminopyridine in compressive spinal cord injury: a qualitative experimental study

BACKGROUND

Taxol is a diterpene alkaloid that stimulates tubulin production in cells. It may be effective in preserving the cytoskeleton of spinal cord axons after injury.

METHODS

Thirty-nine rats were submitted to spinal cord compression. The animals were divided into three groups that received taxol (18.75 mg/m2), methylprednisolone (30 mg/kg), or 4-aminopyridine (1 mg/kg). Taxol was administered as one dose immediately after injury and two additional doses on days 14 and 21. Methylprednisolone was given as a single injection immediately postinjury. Four-aminopyridine was administered on days 25, 26, and 27. A group of nine injured animals served as a control without any treatment. Evoked potentials were recorded before, during, and 4 weeks postinjury. Behavioral tests were measured to evaluate recovery of motor function.

RESULTS

The taxol and methylprednisolone-treated animals demonstrated a significant improvement in comparison with the control group. No functional improvement was found at 1 mg/kg treatment of 4-aminopyridine in rats.

CONCLUSIONS

We conclude that taxol and methylprednisolone given shortly after the compression injury improve functional outcome after an incomplete spinal cord injury.

Effect of desflurane anesthesia on transcortical motor evoked potentials

The effect of the volatile anesthetic desflurane on motor evoked potentials was examined in male rats. Animals underwent cortical stimulation using small platinum ball stimulating electrodes secured on the motor cortex. To record evoked compound muscle action potentials (CMAPs), single-shock electrical stimulation was delivered to the forelimb representation of the motor cortex. Muscle responses were readily obtained in the contralateral extensor muscles. The effect of desflurane was examined at various concentrations ranging from 0.7 to 11.4%. With increasing concentrations of desflurane, there was a progressive decrease in the CMAP amplitude and systemic blood pressure over the baseline values. This decrease became statistically significant (p = 0.0078) at 5.7% [1 maximum alveolar concentration (MAC)] concentration of desflurane. Although there was a decrease in heart rate, the results were not statistically significant (p = 0.03). No significant difference in the onset latency or the duration of the CMAP was noted at different concentrations of the anesthetic. We conclude that desflurane anesthesia significantly alters the amplitude of the muscle response evoked by motor cortex stimulation in experimental animals.

Gender, social networks and survival time: a 20-year study of the rural elderly

The study design is a 20-year panel of 1700 rural elderly individuals who were interviewed in 1966, 1974 and in 1986-1987. The dependent variable was survival time. Proportional hazards and time dependent covariates were used to analyze the data. Gender differences in survival were explored. Participation in formal social networks predicted survival time. The findings support Durkheim's theory of social integration and call into question genetic differences as the explanation for the differential survival time of men and women.

The effect of droperidol on objective markers of patient cooperation and vital signs during esophagogastroduodenoscopy: a randomized, double-blind, placebo-controlled, prospective investigation

We investigated the effect of droperidol on objective markers of cooperation and vital signs in 140 patients undergoing elective diagnostic esophagogastroduodenoscopy. Procedure duration and the total doses of midazolam and meperidine required during the procedure were evaluated as objective markers of patient cooperation. The droperidol group comprised 66 patients and the placebo group 74 patients. Patient and procedure characteristics were similar for both groups. Droperidol produced a 10% reduction in procedure duration. Linear multiple regression modeling revealed droperidol to be a significant predictor of procedure duration (p = .036). Droperidol significantly reduced midazolam and meperidine requirements (p < .01). Nonetheless, four patients in the droperidol group received naloxone to reverse prolonged, excessive drowsiness. Droperidol produced a significant reduction in procedure-associated increase in pulse rate but did not exacerbate procedure-associated reduction in mean arterial pressure. Droperidol favorably influences markers of patient cooperation during elective, diagnostic esophagogastroduodenoscopy. However, the clinical significance of these changes is unclear.

Evaluation of the calcium channel antagonist nimodipine after experimental spinal cord injury

The cortical somatosensory evoked potentials (CSEPs) were recorded to determine if the administration of nimodipine improves axonal function after spinal cord injury. Animals receiving a 52 g compression injury (a moderately severe injury) for 5 minutes were randomly allocated to one of five treatment groups. Each group was given an infusion of one of the following nimodipine regiments over 2 hours, commencing 1 hour before compression: placebo (n = 20), 0.5 micrograms/kg (n = 10), 0.25 micrograms/kg (n = 20), 0.125 micrograms/kg (n = 10), and 0.25 micrograms/kg + Hetstarch (n = 10). In the control group, 65% of animals lost the CSEPs immediately after the injury with almost all (95%) of these regaining the CSEPs within 15 minutes after decompression of the spinal cord. In the treated groups, the rate of the CSEP loss was highest in the 0.5 micrograms/kg group. This group also had the lowest CSEP recovery. The proportion of the CSEP loss was essentially the same for the other nimodipine-treated groups, although it seemed that there was an increasing number of nonresponses with increasing the nimodipine dose. Our data indicate lack of any beneficial effects of nimodipine on axonal function as measured by evoked activities in experimental spinal cord injury.

Modified nucleosides in human serum

Methylated purines and pyrimidines derived from the degradation of transfer ribonucleic acid have been shown to be excreted in abnormal amounts in the urine of patients with cancer. Recent technology developed by Gehrke and Kuo has allowed the separation and quantification of modified nucleosides in serum using reversed-phase high-performance liquid chromatography with diode-array measurement. Serum levels of ten modified nucleosides were measured in 37 normal healthy adults to establish normal values and to correlate activity with age and sex. In addition, serum levels of patients with several malignancies were measured to determine activity in these diseases. Levels of modified nucleosides in normal individuals were consistently reproducible and showed no significant variation among males versus females or with age. Patients with malignant diseases showed consistent elevations and these were highest in patients with more advanced disease. The evidence of no significant differences in the mean levels of modified nucleosides in serum with age or sex in normal adults and elevations in patients with malignancies demonstrate the potential value of modified nucleosides as cancer biomarkers.

Osmotic blood-brain barrier disruption and chemotherapy in the treatment of high grade malignant glioma: patient series and literature review

In the past, chemotherapeutic treatment of patients with high grade malignant gliomas following surgery and radiation has not added significantly to the 12-14 month median survival rate. Over four years, 37 patients with high grade malignant gliomas underwent 246 treatment procedures with a combination of methotrexate, cyclophosphamide, and procarbazine given in association with hyperosmolar mannitol-induced transient breakdown of the blood-brain barrier. These patients have demonstrated a median survivorship of 22 months after considering age, Karnofsky Performance Score, and necrosis by the Cox Proportional Hazards model. The study group had a mean age of 43 years, and mean Karnofsky Performance Score of 67%. Sixty-five percent of the procedures had well-documented barrier disruption. Sixteen percent remained in complete remission while 24 patients (65%) had partial or temporary remission. Progression-free intervals after blood-brain barrier disruption/chemotherapy ranged from 1-47 (mean 15) months. Neurotoxicity has been minimal with one peri-procedural mortality and five patients suffering an increase in neurologic deficit after a procedure. The results of this study are consistent with and further extend the reported literature on this method of brain tumor therapy as described in other centers. Chemotherapy in conjunction with osmotic disruption of the blood-brain barrier may provide the pharmacokinetic advantage sufficient to significantly improve survival in patients with high grade malignant glioma.

Impact of unstable angina on operative mortality with coronary revascularization at varying time intervals after myocardial infarction

We have performed a retrospective study of patients undergoing coronary artery bypass grafting for postinfarction angina in an effort to determine the influence of recency of myocardial infarction and unstable angina on operative mortality. Time from myocardial infarction to bypass was arbitrarily divided into five intervals. Nine hundred ninety-three patients having isolated coronary bypass for postinfarction angina were analyzed, and a significant trend of increased operative mortality with recency of myocardial infarction was found (p less than 0.001). When patients were operated on during the time interval zero to 24 hours after infarction, the operative mortality rate was 18.6%. In the interval from 1 day to 1 week after infarction, the operative mortality rate was 7.4%; 1 week to 3 weeks, 5.9%; and 3 weeks to 3 months, 2.7%. In patients operated on more than 3 months after infarction, the operative mortality rate was 3.9%. The operative mortality rate in 360 patients with postinfarction stable angina was 0.83% compared with 7.3% in 633 patients with postinfarction unstable angina (p less than 0.001). Of 18 risk factors tested, 12 were found by univariate analysis to be independent predictors of operative mortality, including recency of myocardial infarction and unstable angina. Stepwise logistic regression analysis of independent predictive variables revealed that unstable angina, previous surgical revascularization, preoperative hypotension, nonelective surgery, preoperative cardiac arrest, and female sex were the strongest predictors of mortality; recency of myocardial infarction was not a factor. When acute surgical reperfusion is not the primary treatment strategy for patients with myocardial infarction, operative mortality with coronary bypass is increased with the recency of myocardial infarction. The reason for this increase in operative mortality is a patient selection process in which those with persistent or intermittent myocardial ischemia, as reflected in the clinical syndrome of unstable angina, are selected for operation. Unstable angina is a major determinant of operative mortality after myocardial infarction. In patients with stable angina, operative mortality is not increased by the recency of myocardial infarction.

Suppression of Motor Evoked Potentials by Inhalation Anesthetics

The purpose of this study was to record evoked action potentials from forearm muscles in response to single-shock supramaximal electrical stimulation of motor cortex in room air and under different concentrations (0.5-1.5%) of isoflurane, enflurane, and halothane anesthesia in rats. Anesthesia was induced with a mixture of fentanyl and droperiodol, which was then followed by 10-min inhalation of each gas anesthetic under controlled ventilation. Increasing concentrations of isoflurane (n = 12) caused a progressive increase in onset latency and a decrease in peak-to-peak amplitude and duration. Similar increases in latency and decreases in amplitude and duration occurred under enflurane (n = 10) and halothane (n = 10) anesthesia. The three anesthetics caused a significant latency increase over baseline (room air) values for concentrations from 0.5 to 1.5% (p < 0.01). The amplitude and duration of muscle responses under all three volatile anesthetics at 0.5-1.5% concentrations were significantly lower than baseline (p < 0.01). Isoflurane, enflurane, and halothane anesthesia significantly altered the muscle response evoked by motor cortex stimulation in experimental animals.

Elevated hemidiaphragm after cardiac operations: incidence, prognosis, and relationship to the use of topical ice slush

We have reviewed chest roentgenograms of 745 patients before hospital dismissal after cardiac operations and serially to determine the incidence and prognosis of elevated hemidiaphragm and any relationship to the use of topical ice slush (TIS) in myocardial preservation. All patients had similar myocardial preservation techniques including moderate systemic hypothermia and 4 degrees C saline solution poured over the heart at aortic clamping. During a 12-month period, TIS was added to the saline bath. Two (2.4%) of 84 patients before TIS and 5 (2.5%) of 201 consecutive patients operated on since discontinuing TIS had elevated hemidiaphragm on the predismissal roentgenogram. Of 460 patients in whom TIS was employed, 109 (23.7%) had elevated hemidiaphragm (p less than 0.001). When TIS was employed, elevated hemidiaphragm developed in 72 (26%) of 280 patients without internal mammary artery takedown versus 13 of 33 patients (39.4%) with takedown of the internal mammary artery (p = 0.047). Ninety-nine patients with elevated hemidiaphragm were available for follow-up at 1 month, at which time 79 (79.8%) continued to have elevated diaphragm. At 1 year, 14 (21.9%) of 64 patients had persistent diaphragm elevation. We conclude that TIS predisposes to elevated diaphragm and that the incidence is increased when the internal mammary artery is harvested.

[Maxillo-mandibular sagittal relations in the lateral facial examination]

For the purpose of developing a clinical method of facial examination that could permit a determination of the skeletal position of the upper jaw and the mandible, a sample of 70 teleradiographies of individuals among 8 and 18 years of both sexes was analyzed. The anteroposterior relationship of the maxila to the cranium was analyzed through perpendiculars from skin points Nasion, Glabela and Subnasal to the Frankfurt horizontal plane and it was found that Glabela was 2 mm behind Subnasal. The anteroposterior position of the mandible related to the maxila was studied on a perpendicular to Tragion-Subnasal plane descended from point Subnasal and it was found that the labiomental fold was coincident with this perpendicular. A new clinical method using a square rule leaned on the cheek using these reference points is recommended.

Bone marrow involvement in small cell lung cancer. Clinical significance and correlation with routine laboratory variables

Of 129 patients with small cell lung cancer (SCLC) who underwent bone marrow examination for staging, 39 (30%) had bone marrow involvement. Only three of 129 patients (2.3%) had bone marrow involvement as the only site of metastatic disease. When patients with bone marrow metastasis were compared with patients whose bone marrow was normal, there were significant differences in serum levels of lactate dehydrogenase (LDH), glutamic oxalacetic transaminase (SGOT), glutamic pyruvic transaminase (SGPT), alkaline phosphatase (AP), albumin, and sodium (Na). We found no clinically significant difference in survival between patients with extensive disease with or without bone marrow involvement. Serum Na, albumin, SGOT, and uric acid were important prognostic determinants of survival. Based on the results of this study, we do not recommend routine bone marrow examinations in the staging of SCLC.

Myelodysplastic syndrome: prospective evaluation of fifty-one patients using the Dutcher scoring system

Fifty-one patients with primary myelodysplastic syndrome were prospectively evaluated using a scoring system based on the presentation blood and bone marrow findings. Twenty-four patients (47%) evolved to acute nonlymphocytic leukemia. Stepwise regression model showed that the scoring system was the only significant variable for predicting transformation to acute leukemia (p = 0.0007, sensitivity 70.8%, specificity 77.8%). Seventy-six percent of patients with a score of 14 or greater developed acute leukemia compared to 19% with a score of 13 or less. Median survival of the entire group was 10 months. The most important prognostic factor for predicting survival was the scoring system (p = 0.0001). Survival correlated inversely with the score. This scoring system may be useful in the management of patients with myelodysplasia.

Gastric bezoars. A technique of endoscopic removal

Gastric bezoar formation is an uncommon sequela of gastroduodenal surgery or unusual eating habits. Because they generally produce severe symptoms, their removal is always necessary. Previously, this required surgical extirpation or slow enzymatic dissolution. We present here an endoscopic procedure for bezoar removal utilized successfully in five patients with vegetable-mucus bezoars. This technique employs a jet spray of water under direct vision to mechanically disrupt the bezoar, which may then be removed using a large gastric lavage tube. This procedure is simple, safe, and rapid and is therefore recommended as an alternative to surgical removal or enzymatic dissolution of gastric bezoars.