Environment-wide association study to comprehensively test and validate associations between nutrition and lifestyle factors and testosterone deficiency: NHANES 1988-1994 and 1999-2004

PURPOSE

Testosterone (T) plays an important role in men's health and its deficiency is linked with poorer health. However, the role of nutritional and lifestyle factors in T regulation and production remains unclear. The objectives are to comprehensively test the cross-sectional associations of nutritional and lifestyle factors with T deficiency and to validate the associations in the NHANES survey.

METHODS

We performed weighted multivariable logistic regression analysis to examine the association of 173 nutritional and lifestyle factors with T deficiency (total testosterone ≤ 3.5 ng/mL) in NHANES III as the discovery set (mean age 41). We controlled for multiple comparisons with a false discovery rate (FDR) < 5% and replicated in NHANES 1999-2004 (mean age 44).

RESULTS

We identified seven nutritional factors as being inversely associated with T deficiency in NHANES 1999-2004, namely dietary intake of vitamin A, protein, saturated fatty acids, monounsaturated fatty acids, total fats, saturated fatty acid 16:0, and phosphorus. In a multivariable model, only vitamin A intake remained significantly associated with T deficiency (OR 0.97, 95% CI 0.94-0.99). Principal component analysis suggested that the two principal components, (1) dietary fats, protein, and phosphorous and (2) total vitamin A, may be associated with T deficiency.

CONCLUSION

Our systematic evaluation provided new insight into the modifiable factors that could play a role in the regulation of T production. This study has the potential to contribute to the current body of literature which seeks to formulate a clinical definition of T deficiency after taking into account nutritional and lifestyle factors.

Robot assisted radical prostatectomy: the new standard?

Over the past decade, the robotic assisted radical prostatectomy (RARP) has grown increasingly popular and quickly equated itself as the most commonly used modality to treat locally-confined prostate cancer. Despite increased utilization, there is limited comparative research demonstrating superiority for RARP over the conventional radical retropubic prostatectomy (RRP). Furthermore, though perioperative and short-term oncologic outcomes are equivalent if not superior for the robotic approach, the optimal utilization of robotic technology remains to be determined with cost serving as a primary driver. In this review, we performed a literature search to identify comparative effectiveness research as it pertains to RARP versus RRP. We performed a PubMed literature search for a review of articles published between 2000 and 2014 using the following keywords to identify pertinent research: "robot or robotic prostatectomy", "open or retropubic prostatectomy", "cost", "resource utilization". Long-term data comparing RARP and RRP remains limited, though short-term positive surgical margins, biochemical recurrence-free survival, and need for adjuvant therapy appear at least equivocal, if not in favor of RARP versus RRP. Functional outcomes including return of continence and potency favor RARP while cost still favors RRP. Nonetheless, the generalization of results remains difficult with surgeon volume playing a large role in improving efficiency and quality. For the foreseeable future, an increasing number of prostatectomies will continue to be performed robotically. Though RARP appears to offer improved functional outcomes with good short-term oncologic outcomes, there is a need for longer-term studies to assess the true value of RARP. Outcomes aside, rigorous, prospective randomized-controlled trials must also be performed on the cost-effectiveness of RARP to determine its overall utility in an era of health care delivery reform.

Allelic variation of the β-, γ- and δ-kafirin genes in diverse Sorghum genotypes

The β-, γ- and δ-kafirin genes were sequenced from 35 Sorghum genotypes to investigate the allelic diversity of seed storage proteins. A range of grain sorghums, including inbred parents from internationally diverse breeding programs and landraces, and three wild Sorghum relatives were selected to encompass an extensive array of improved and unimproved germplasm in the Eusorghum. A single locus exists for each of the expressed kafirin-encoding genes, unlike the multigenic α-kafirins. Significant diversity was found for each locus, with the cysteine-rich β-kafirin having four alleles, including the first natural null mutant reported for this prolamin subfamily. This allele contains a frame shift insertion at +206 resulting in a premature stop codon. SDS-PAGE revealed that lines with this allele do not produce β-kafirin. An analysis of flour viscosity reveals that these β-kafirin null lines have a difference in grain quality, with significantly lower viscosity observed over the entire Rapid ViscoAnalyser time course. There was less diversity at the protein level within the cysteine-rich γ-kafirin, with only two alleles in the cultivated sorghums. There were only two alleles for the δ-kafirin locus among the S. bicolor germplasm, with one allele encoding ten extra amino acids, of which five were methionine residues, with an additional methionine resulting from a nucleotide substitution. This longer allele encodes a protein with 19.1% methionine. The Asian species, S. propinquum, had distinct alleles for all three kafirin genes. We found no evidence for selection on the three kafirin genes during sorghum domestication even though the δ-kafirin locus displayed comparatively low genetic variation. This study has identified genetic diversity in all single copy seed storage protein genes, including a null mutant for β-kafirin in Sorghum.

Exploring the mechanical basis for acceleration: pelvic limb locomotor function during accelerations in racing greyhounds (Canis familiaris)

Animals in their natural environments are confronted with a regular need to perform rapid accelerations (for example when escaping from predators or chasing prey). Such acceleration requires net positive mechanical work to be performed on the centre of mass by skeletal muscle. Here we determined how pelvic limb joints contribute to the mechanical work and power that are required for acceleration in galloping quadrupeds. In addition, we considered what, if any, biomechanical strategies exist to enable effective acceleration to be achieved. Simultaneous kinematic and kinetic data were collected for racing greyhounds undergoing a range of low to high accelerations. From these data, joint moments and joint powers were calculated for individual hindlimb joints. In addition, the mean effective mechanical advantage (EMA) of the limb and the ;gear ratio' of each joint throughout stance were calculated. Greatest increases in joint work and power with acceleration appeared at the hip and hock joints, particularly in the lead limb. Largest increases in absolute positive joint work occurred at the hip, consistent with the hypothesis that quadrupeds power locomotion by torque about the hip. In addition, hindlimb EMA decreased substantially with increased acceleration - a potential strategy to increase stance time and thus ground impulses for a given peak force. This mechanism may also increase the mechanical advantage for applying the horizontal forces necessary for acceleration.

Functional anatomy and muscle moment arms of the thoracic limb of an elite sprinting athlete: the racing greyhound (Canis familiaris)

We provide quantitative muscle-tendon architecture and geometry data for the racing greyhound thoracic limb. Muscle mass, belly length, fascicle lengths, pennation angles and moment arms were measured, as were tendon masses and lengths. Maximum isometric force and maximum power were estimated for muscles, and maximum stress and strain were estimated for tendons. Results are compared with other fast quadrupedal runners, and to previously published data in mixed-breed dogs. The implications of the functional adaptations of the greyhound thoracic limb for sprinting performance are discussed. The thoracic limb was found to benefit from a similar proportion of locomotor muscle mass to the pelvic limb, suggesting that it may be used to some extent in propulsion, or alternatively that stabilisation is very important in this animal. Extrinsic muscles, especially latissimus dorsi and pectoralis profundus, were predicted to be powerful and important for generating net positive work during accelerations. Proximal biarticular muscles show specialisation toward preventing collapse of the shoulder and elbow joints to enable strut-like limb function, or some form of dynamic control. Distal muscles did not appear specialised for elastic energy storage, a functional difference to pelvic limb muscles, and the equivalents in horse thoracic limbs. The greyhound thoracic limb appears to possess substantial differences from both that of more 'sub-maximal specialist' quadrupeds, and from the greyhound pelvic limb.

Functional anatomy and muscle moment arms of the pelvic limb of an elite sprinting athlete: the racing greyhound (Canis familiaris)

We provide quantitative anatomical data on the muscle-tendon architecture and geometry of the pelvic limb of an elite sprint athlete, the racing greyhound. Specifically, muscle masses, muscle lengths, fascicle lengths, pennation angles and muscle moment arms were measured. Maximum isometric force and power of muscles, the maximum muscle torque at joints and tendon stress and strain were estimated. We compare data with that published for a generalized breed of canid, and other cursorial mammals such as the horse and hare. The pelvic limb of the racing greyhound had a relatively large volume of hip extensor muscle, which is likely to be required for power production. Per unit body mass, some pelvic limb muscles were relatively larger than those in less specialized canines, and many hip extensor muscles had longer fascicle lengths. It was estimated that substantial extensor moments could be created about the tarsus and hip of the greyhound allowing high power output and potential for rapid acceleration. The racing greyhound hence possesses substantial specializations for enhanced sprint performance.

Functional specialisation of the thoracic limb of the hare (Lepus europeus)

We provide quantitative anatomical data on the muscle-tendon architecture of the hare thoracic limb (specifically muscle mass, fascicle length, pennation angle, tendon mass and length). In addition, moment arms of major thoracic limb muscles were measured. Maximum isometric force and power of muscles, the moment of force about a joint, and tendon stress and strain were estimated. Data are compared with those from other cursorial mammals. The thoracic limb of the hare consists predominantly of extrinsic musculature with long parallel fascicles, specialised for generating force over a large range. A large shoulder flexor/elbow extensor muscle mass is present, in particular Triceps brachii. The pennate nature of the long head of this muscle suggests it has an important role in stabilising the elbow joint during stance, whilst moment arm curves suggest that it may also play a role in initiating shoulder flexion. In addition, Supraspinatus and Infraspinatus are capable of generating high forces, potentially to stabilise the shoulder joint during the stance phase of locomotion. Supraspinatus may in addition play an important role in forelimb protraction. The Subscapularis muscle was capable of generating surprisingly high forces, suggesting that the hare must be able to withstand/produce high forces during activities that need medio-lateral stability, such as turning. Distally, tendons were relatively short, showing little potential for elastic energy storage when compared with both their pelvic limb counterparts and their equivalents in the horse thoracic limb. Thus, a 'stiffer' thoracic limb may be beneficial in terms of behaving like a strut, simply supporting and deflecting the body during high-speed running. This more distal/less proximal distribution of limb mass is also likely to be important in retaining the manipulative/adaptive/non-locomotor capabilities of the limb.

Functional specialisation of the pelvic limb of the hare (Lepus europeus)

We provide quantitative anatomical data on the muscle-tendon architecture of the hare pelvic limb (specifically muscle mass, fascicle length, pennation angle, tendon mass and length). In addition, moment arms of major pelvic limb muscles were measured. Maximum isometric force and power of muscles, the moment of force about a joint, and tendon stress and strain were estimated. Data are compared with published data for other cursorial mammals such as the horse and dog, and a non-specialised Lagamorph, the rabbit. The pelvic limb of the hare was found to contain substantial amounts of hip extensor and adductor/abductor muscle volume, which is likely to be required for power production and stability during rapid turning. A proximal to distal reduction in muscle volume and fascicle length was also observed, as is the case in other cursorial quadrupeds, along with a reduction in distal limb mass via the replacement of muscle volume by long distal limb tendons, capable of storing large amounts of elastic energy. The majority of hare pelvic limb muscle moment arms varied with joint position, giving the hare the capacity to vary muscle function with limb posture and presumably different locomotor activities.

Effects of supplemental dietary phytase and pharmacological concentrations of zinc on growth performance and tissue zinc concentrations of weanling pigs1,2

Three experiments were conducted to determine the effects of phytase, excess Zn, or their combination in diets for nursery pigs. In all experiments, treatments were replicated with five to seven pens of six to seven pigs per pen, dietary Ca and available P (aP) levels were decreased by 0.1% when phytase was added to the diets, excess Zn was added as ZnO, a basal level of 127 mg/kg of Zn (Zn sulfate) was present in all diets, and the experimental periods were 19 to 21 d. In Exp. 1, pigs (5.7 kg and 18 d of age) were fed two levels of phytase (0 or 500 phytase units/kg) and three levels of excess Zn (0, 1,000, or 2,000 ppm) in a 2 x 3 factorial arrangement. Added Zn linearly increased ADG and ADFI during Phase 1 (P = 0.01 to 0.06), Phase 2 (P = 0.02 to 0.09), and overall (P = 0.01 to 0.02). Gain:feed was linearly increased by Zn during Phase 1 (P = 0.01) but not at other times. Dietary phytase decreased ADG in pigs fed 1,000 or 2,000 ppm Zn during Phase 2 (Zn linear x phytase interaction; P = 0.10), did not affect (P = 0.27 to 0.62) ADFI during any period, and decreased G:F during Phase 2 (P = 0.01) and for the overall (P = 0.07) period. Plasma Zn was increased by supplemental Zn (Zn quadratic, P = 0.01) but not affected (P = 0.70) by phytase addition. In Exp. 2, pigs (5.2 kg and 18 d of age) were fed two levels of phytase (0 or 500 phytase units/kg) and two levels of Zn (0 or 2,000 ppm) in a 2 x 2 factorial arrangement. Supplemental Zn increased ADG and G:F during Phase 2 (P = 0.02 to 0.09) and overall (P = 0.07 to 0.08), but it had no effect (P = 0.11 to 0.89) on ADG during Phase 1 or ADFI during any period. Phytase supplementation increased ADG (P = 0.06) and G:F (P = 0.01) during Phase 2. Gain:feed was greatest for pigs fed 2,000 ppm Zn and phytase (Zn x phytase interaction; P = 0.01). Bone (d 20) and plasma Zn (d 7 and 20) were increased (P = 0.01) by added Zn but not affected (P = 0.51 to 0.90) by phytase. In Exp. 3, pigs (5.7 kg and 19 d of age) were fed a basal diet or the basal diet with Ca and aP levels decreased by 0.10% and these two diets with or without 500 phytase units/kg. Supplemental phytase had no effect (P = 0.21 to 0.81) on growth performance. Reduction of dietary Ca and aP decreased (P = 0.02 to 0.08) ADG, ADFI, and G:F for the overall data. These results indicate that excess dietary supplemental Zn increases ADG and plasma and bone Zn concentrations. Dietary phytase did not affect plasma or bone Zn concentrations.

Effect of phytase addition and dietary calcium and phosphorus levels on plasma metabolites and ileal and total-tract nutrient digestibility in pigs

Two experiments were conducted to determine the effect of phytase on plasma metabolites and AA and energy digestibility in swine. In Exp. 1, eight barrows (surgery BW = 52 kg) were fitted with steered ileocecal cannulas. The experiment was a Latin rectangle and the treatments were 1) corn-soybean meal diet adequate in Ca and P (0.5% Ca, 0.19% available P [aP]), 2) corn-soybean meal diet with reduced Ca and P (0.4% Ca, 0.09% aP), 3) Diet 1 with 500 phytase units/kg, or 4) Diet 2 with 500 phytase units/kg. Pigs were fed twice daily to a total daily energy intake of 2.6 x maintenance (106 kcal of ME/kg of BW(0.75)). For each ileal digesta sample, digesta samples were collected for two 24-h periods and combined for each pig. The combination of supplementing with phytase and decreasing the concentration of dietary Ca and P increased average ileal AA (P < 0.02), starch (P < 0.02), GE (P < 0.04), and DM (P < 0.03) digestibilities. In Exp. 2, a feeding challenge was conducted with barrows (eight per treatment; average BW of 53 kg). The treatments consisted of a corn-soybean meal diet or corn-soybean meal diet + 500 phytase units per kilogram of diet. In the diet with no phytase, Ca and aP were at 0.50% and 0.19%, respectively, and, in the diet with phytase, Ca and aP were each decreased by 0.12%. A catheter was surgically inserted into the anterior vena cava of each pig 6 d before the start of the feeding challenge. The barrows were penned individually, and the diets were fed for 3 d before the challenge. The pigs were held without feed for 16 h, and blood samples were obtained at -60, -30, and 0 min before the pigs were fed (2% of BW). Blood samples were then collected at 10, 20, 30, 40, 50, 60, 75, 90, 105, 120, 150, 180, 210, 240, 270, and 300 min after feeding. Glucose area under the response curve and plasma glucose, insulin, urea N, and total alpha-amino N concentrations were increased (P < 0.05) in pigs fed the diet with reduced Ca and P and the phytase addition. Area under the response curve for insulin, urea N, and total alpha-amino N; insulin:glucose; and plasma NEFA concentration, clearance, and half-life were not affected by diet. In conclusion, the combination of Ca and P reduction and phytase addition increased nutrient and energy digestibility in diets for pigs and increased plasma concentrations of glucose, insulin, urea N, and alpha-amino N.

A Cyanobacterial Circadian Timing Mechanism

Cyanobacteria such as Synechococcus elongatus PCC 7942 exhibit 24-h rhythms of gene expression that are controlled by an endogenous circadian clock that is mechanistically distinct from those described for diverse eukaryotes. Genetic and biochemical experiments over the past decade have identified key components of the circadian oscillator, input pathways that synchronize the clock with the daily environment, and output pathways that relay temporal information to downstream genes. The mechanism of the cyanobacterial circadian clock that is emerging is based principally on the assembly and disassembly of a large complex at whose heart are the proteins KaiA, KaiB, and KaiC. Signal transduction pathways that feed into and out of the clock employ protein domains that are similar to those in two-component regulatory systems of bacteria.

Attenuation and activation characteristics of steel and tungsten and the suitability of these materials for use in a fast neutron multileaf collimator

A computer controlled multileaf collimator (MLC) is being designed to replace the multirod collimator (MRC) at present used to shape the d(48.5) + Be neutron beam from the Harper Hospital superconducting cyclotron. The computer controlled MLC will improve efficiency and allow for the future development of intensity modulated radiation therapy with neutrons. The existing MRC uses tungsten rods, while the new MLC will use steel as the leaf material. In the current study the attenuation and activation characteristics of steel are compared with those of tungsten to ensure that (a) the attenuation achieved in the MLC is at least equivalent to that of the existing MRC, and (b) that the activation of the steel will not result in a significant change in the activation levels within the treatment room. The latter point is important since personnel exposure (particularly to the radiation therapy technologists) from induced radioactivity must be minimized. Measurement of the neutron beam attenuation in a broad beam geometry showed that a 30 cm thick steel leaf yielded 2.5% transmission. This compared favorably with the 4% transmission obtained with the existing MRC. Irradiation of steel and tungsten samples at different depths in a 30 cm steel block indicated that the activation of steel should be no worse than that of tungsten.

Conformational regulation of the fibronectin binding and alpha 3beta 1 integrin-mediated adhesive activities of thrombospondin-1

The recognition of extracellular matrix components can be regulated by conformational changes that alter the activity of cell surface integrins. We now demonstrate that conformational regulation of the matrix glycoprotein thrombospondin-1 (TSP1) can also modulate its binding to an integrin receptor. F18 1G8 is a conformation-sensitive TSP1 antibody that binds weakly to soluble TSP1 in the presence of divalent cations. However, binding of the antibody to melanoma cells was strongly stimulated by adding exogenous TSP1 in the presence of calcium, suggesting that TSP1 undergoes a conformational change following its binding to the cell surface. This conformation was not induced by known cell surface TSP1 receptors, whereas binding of F18 was stimulated when TSP1 bound to fibronectin but not to heparin or fibrinogen. Conversely, binding of F18 to TSP1 enhanced TSP1 binding to fibronectin. Exogenous fibronectin also stimulated TSP1-dependent binding of F18 to melanoma cells. Binding of the fibronectin-TSP1 complex to melanoma cells was mediated by alpha4beta1 and alpha5beta1 integrins. Furthermore, binding to F18 or fibronectin strongly enhanced the adhesive activity of immobilized TSP1 for some cell types. This enhancement of adhesion was mediated by alpha3beta1 integrin and required that the alpha3beta1 integrin be in an active state. Fibronectin also enhanced TSP1 binding to purified alpha3beta1 integrin. Therefore, both fibronectin and the F18 antibody induce conformational changes in TSP1 that enhance the ability of TSP1 to be recognized by alpha3beta1 integrin. The conformational and functional regulation of TSP1 activity by fibronectin represents a novel mechanism for extracellular signal transduction.

CikA, a bacteriophytochrome that resets the cyanobacterial circadian clock

The circadian oscillator of the cyanobacterium Synechococcus elongatus, like those in eukaryotes, is entrained by environmental cues. Inactivation of the gene cikA (circadian input kinase) shortens the circadian period of gene expression rhythms in S. elongatus by approximately 2 hours, changes the phasing of a subset of rhythms, and nearly abolishes resetting of phase by a pulse of darkness. The CikA protein sequence reveals that it is a divergent bacteriophytochrome with characteristic histidine protein kinase motifs and a cryptic response regulator motif. CikA is likely a key component of a pathway that provides environmental input to the circadian oscillator in S. elongatus.

Use of advance information in patients with schizophrenia

To document possible motor disturbance in schizophrenia, we examined the ability to use advance information (or cues) to plan movements in a sequential button pressing task in 12 Clozapine medicated patients. Programming of movements under various cues revealed that patients with schizophrenia, relative to controls, initiated movements slower to the right than left, providing possible evidence for right hemineglect (left hemisphere dysfunction). Additionally, patients with schizophrenia had difficulty in the initiation of movements in the absence of a cue, suggesting internal cue generation difficulty for movement related to some form of fronto-striatal disturbance. Motor abnormalities were predominantly observed at the level of movement initiation, but not execution, contrary to basal ganglia disorders such as Parkinson's and Huntington's disease.

A kaiC-interacting sensory histidine kinase, SasA, necessary to sustain robust circadian oscillation in cyanobacteria

Both regulated expression of the clock genes kaiA, kaiB, and kaiC and interactions among the Kai proteins are proposed to be important for circadian function in the cyanobacterium Synechococcus sp. strain PCC 7942. We have identified the histidine kinase SasA as a KaiC-interacting protein. SasA contains a KaiB-like sensory domain, which appears sufficient for interaction with KaiC. Disruption of the sasA gene lowered kaiBC expression and dramatically reduced amplitude of the kai expression rhythms while shortening the period. Accordingly, sasA disruption attenuated circadian expression patterns of all tested genes, some of which became arrhythmic. Continuous sasA overexpression eliminated circadian rhythms, whereas temporal overexpression changed the phase of kaiBC expression rhythm. Thus, SasA is a close associate of the cyanobacterial clock that is necessary to sustain robust circadian rhythms.

Functional similarities among two-component sensors and methyl-accepting chemotaxis proteins suggest a role for linker region amphipathic helices in transmembrane signal transduction

Signal-responsive components of transmembrane signal-transducing regulatory systems include methyl-accepting chemotaxis proteins and membrane-bound, two-component histidine kinases. Prokaryotes use these regulatory networks to channel environmental cues into adaptive responses. A typical network is highly discriminating, using a specific phosphoryl relay that connects particular signals to appropriate responses. Current understanding of transmembrane signal transduction includes periplasmic signal binding with the subsequent conformational changes being transduced, via transmembrane helix movements, into the sensory protein's cytoplasmic domain. These induced conformational changes bias the protein's regulatory function. Although the mutational analyses reviewed here identify a role for the linker region in transmembrane signal transduction, no specific mechanism of linker function has yet been described. We propose a speculative, mechanistic model for linker function based on interactions between two putative amphipathic helices. The model attempts to explain both mutant phenotypes and hybrid sensor data, while accounting for recognized features of amphipathic helices.

Glycocalicin levels in the plasma of HIV+ patients: an indicator of platelet turnover

Glycocalicin (GC) is the carbohydrate-rich portion of platelet membrane glycoprotein Ib(alpha) that can be cleaved from circulating platelets by proteases. The plasma GC level is an indicator of platelet turnover. Using an ELISA for GC, we assayed the plasma of 20 normal children (age 6 to 13 years), 50 HIV+ children (ages 4 to 18 years), 32 normal adults (ages 21 to 53 years), and 50 HIV+ adults (ages 24 to 66 years). The results were adjusted for individual platelet counts to give GC indexes (GCI). The normal children and the normal adults had significantly different GCI distributions (P = .002). In both normal and HIV+ individuals the GCI decreased with increasing platelet count (-.73 < r < -.34). Twenty-eight percent of the HIV+ children and 28% of the HIV+ adults had elevated GCI values. The majority of these elevated values occurred in patients with platelet counts >100,000/microL. Neither the GCI nor the platelet count was correlated with viral load. The platelet count, however, was weakly correlated with the CD4 count in both children (r = .31) and adults (r = .30) infected with HIV. Also, the CD4 count was weakly and inversely correlated with GCI in HIV+ adults (r = -.34) and in children (r = -.24). We conclude that increased GCI and, by implication, increased platelet turnover is a relatively common feature of advanced HIV disease. Furthermore, GCI may be elevated in HIV+ patients even with a platelet count >100,000/microL, suggesting increased platelet turnover before thrombocytopenia develops.

Managed health care and resident education

OBJECTIVE

We wished to determine the impact of managed health care on resident education in obstetrics and gynecology.

STUDY DESIGN

A multiquestion survey was mailed to program directors of the 267 obstetrics-gynecology resident training programs in the United States. The questions ascertained departmental philosophy regarding the role of obstetrician-gynecologists as primary care versus specialist physicians, the extent of involvement with managed health care companies, educational curriculum content, the effect of managed care on patient volume, faculty time available for resident teaching, and the effect of managed care on resident education.

RESULTS

Completed surveys were received from 210 (79%) program directors. One hundred twenty-six (63%) program directors responded that obstetrician-gynecologists should be primary care physicians for women, and 120 (60%) believed that the role of subspecialists will be reduced in the near future. In 1996, 177 (94%) programs had managed care contracts; many (57%) had >20 contracts. All programs participate with other specialties to teach primary care to their residents. One hundred twelve (59%) programs have had a decrease in patient volume, prompting 90 (45%) programs to increase their number of teaching sites. Of concern, 54 (26%) program directors noted that managed care companies discourage but do not restrict resident participation in the care and treatment of managed care patients, and 41 (20%) programs had some restrictions placed on such resident involvement. Budgetary constraints have decreased resources to 97 (47%) programs and threaten the time available for faculty teaching.

CONCLUSIONS

Managed health care is having an effect on many resident teaching programs. Program directors are integrating managed care concepts into the educational curriculum and are negotiating with managed care organizations to involve residents in the care and treatment of managed care patients.

Acute hyperglycemia attenuates endothelium-dependent vasodilation in humans in vivo

BACKGROUND

Endothelial function is impaired in patients with diabetes mellitus. However, the factors contributing to this defect are currently unknown. Hyperglycemia attenuates endothelium-dependent relaxation in normal rabbit arteries in vitro and rat arterioles in vivo. Accordingly, this study examined the effect of acute hyperglycemia on endothelium-dependent vasodilation in nondiabetic humans in vivo.

METHODS AND RESULTS

Endothelium-dependent vasodilation was assessed through brachial artery infusion of methacholine chloride both before and during 6 hours of local hyperglycemia (300 mg/dL) achieved by intra-arterial infusion of 50% dextrose. Forearm blood flow was determined by plethysmography. In a group of 10 subjects, there was a trend toward attenuated methacholine-mediated vasodilation during hyperglycemia compared with euglycemia (P=.07 by ANOVA; maximal response, 13.3+/-2.8 versus 14.7+/-1.5 mL x min(-1) x 100 mL(-1), respectively). In these subjects, the systemic serum insulin levels increased significantly during the dextrose infusion (P<.001). To eliminate the confounding vasoactive effects of insulin, the protocol was repeated during systemic infusion of octreotide (30 ng x kg(-1) x min(-1)) to inhibit pancreatic secretion of insulin. In these subjects (n=10), hyperglycemia significantly attenuated the forearm blood flow response to methacholine (P<.01 by ANOVA; maximal response, 16.9+/-2.5 before versus 12.7+/-1.8 mL x min(-1) x 100 mL(-1) during hyperglycemia). Methacholine-mediated vasodilation was not attenuated by an equimolar infusion of mannitol (P>.40), nor did hyperglycemia reduce endothelium-independent vasodilation to verapamil (P>.50).

CONCLUSIONS

Acute hyperglycemia impairs endothelium-dependent vasodilation in healthy humans in vivo. This finding suggests that elevated glucose may contribute to the endothelial dysfunction observed in patients with diabetes mellitus.

Discrimination between structurally related ligands nitrate and nitrite controls autokinase activity of the NarX transmembrane signal transducer of Escherichia coli K-12

Anaerobic respiratory gene expression in Escherichia coli is differentially controlled by nitrate and nitrite through dual interacting two-component regulatory systems. The NarX sensor is one of two membrane-spanning sensor kinases that control the phosphorylation state of two DNA-binding response regulators. We have studied NarX autophosphorylation in crude membrane preparations from cells that overexpress NarX protein. The low basal autophosphorylation rate was stimulated about sixfold and threefold by nitrate and nitrite respectively. This demonstrates that nitrate and nitrite differentially activate NarX autokinase activity. We also isolated single-residue substitutions in NarX that affect its ability to respond to or discriminate between nitrate and nitrite. Most of these substitutions affect residues within the conserved P-box sequence in the periplasmic domain. We characterized several of the mutants in vivo, by monitoring ligand-regulated gene expression, and in vitro, by monitoring ligand-responsive autophosphorylation. At least one change, K491 (Lys at position 49 changed to Ile), resulted in a protein with greatly impaired ability to discriminate between nitrate and nitrite. Other changes (H45E and R59K) resulted in proteins that responded normally to nitrate but were unable to respond to nitrite. These results implicate the P-box region in discrimination between subtly different small molecules.

Nitrate- and nitrite-sensing protein NarX of Escherichia coli K-12: mutational analysis of the amino-terminal tail and first transmembrane segment

Nitrate and nitrite control of anaerobic respiratory gene expression is mediated by dual two-component regulatory systems. The sensors NarX and NarQ each communicate nitrate and nitrite availability to the response regulators NarL and NarP. In the presence of nitrate, the NarX protein acts as a positive regulator ("kinase") of both NarL and NarP activity. In the presence of nitrite, the NarX protein acts primarily as a negative regulator ("phosphatase") of NarL activity but remains a positive regulator of NarP activity. In other topologically similar sensory proteins, such as the methyl-accepting chemotaxis proteins, the transmembrane regions are important for signal transduction. We therefore used localized mutagenesis of the amino-terminal coding region to isolate mutations in narX that confer an altered signaling phenotype. Five of the mutations studied alter residues in the amino-terminal cytoplasmic tail, and five alter residues in the first transmembrane segment. Based on patterns of target operon expression in various regulatory mutant strain backgrounds, most of the mutant NarX proteins appear to have alterations in negative control function. One mutant, with a change of residue Leu-11 to Pro in the cytoplasmic tail, exhibits strikingly altered patterns of NarL- and NarP-dependent gene expression. We conclude that the amino terminus of the NarX protein is important for the differential response to nitrate and nitrite.

Glycoprotein Ib alpha peptides inhibit thrombin and SFLLRN-induced platelet aggregation

The platelet glycoprotein Ib(alpha) (GPIb(alpha)) receptor contains a high-affinity binding site for thrombin that, when occupied, augments platelet activation and aggregation in part via the 7-transmembrane domain receptor (7-TMDR). We have constructed a series of peptides derived from GPIb(alpha) that encompass the amino acid sequence F216-T240. We have studied the effect(s) of these peptides on platelet aggregation induced by thrombin or by the 7-TMDR peptide SFLLRN. Twenty-four peptides were synthesized from the peptide sequence F216-T240. Several of the peptides derived from the sequence W219-V227 of GPIb(alpha) inhibited platelet aggregation, which was primarily dependent on the presence of the amino acid sequence A224-N226 (AEN). These data suggest that a region within the GPIb(alpha) chain modulates the platelet aggregation induced by alpha-thrombin. These GPIb(alpha) peptides did not interfere with platelet aggregation induced by other agonists--for example, collagen, ristocetin, calcium ionophore, or botrocetin--which indicates that these GPIb(alpha) peptide-platelet interaction(s) are specific. Our studies provide another potential mechanism for modulating platelet activation and aggregation via synthetic and natural peptides.

Activation of ATP-sensitive potassium channels contributes to reactive hyperemia in humans

Activation of ATP-sensitive potassium (KATP) channels present on vascular smooth muscle cells causes membrane hyperpolarization and vasodilation. The purpose of this study was to determine whether KATP channels contribute to reactive hyperemia in humans. Accordingly, we studied the effect of tolbutamide, a KATP channel inhibitor, on reactive hyperemic forearm blood flow. Forearm blood flow was measured by venous occlusion plethysmography. Forearm ischemia was produced by inflating a sphygmomanometric cuff on the arm to suprasystolic pressures for 5 min. After cuff release, forearm blood flow was measured during the reactive hyperemic phase for 5 min. Tolbutamide (1 mM blood concentration, n = 6) did not affect basal (2.4 +/- 0.2 to 2.2 +/- 0.1 ml.100 ml-1.min-1) or peak reactive hyperemic forearm blood flow (21.9 +/- 3.8 to 22.6 +/- 2.9 ml.100 ml-1.min-1, each P = NS), but it significantly attenuated total hyperemic volume (12.6 +/- 1.7 vs. 9.2 +/- 1.8 ml/100 ml, P < 0.02). Vehicle (n = 6) did not affect basal flow, peak reactive hyperemic flow, or total hyperemia. To determine whether adenosine or endothelium-derived nitric oxide contribute to reactive hyperemia via KATP channels, adenosine (1.5-500 micro grams/min, n = 6) and acetylcholine (30 micrograms/min, n = 6) were infused before and during tolbutamide coinfusion. Tolbutamide did not significantly alter the forearm blood flow response to either adenosine or acetylcholine. In conclusion, KATP channels contribute to vasodilation during reactive hyperemia in humans.

Role of surgery in the management of primary lymphoma of the gastrointestinal tract

The role of surgery in the management of primary gastrointestinal lymphoma remains controversial. We retrospectively reviewed the management and outcome of 107 patients with the diagnosis of gastrointestinal lymphoma treated at the UCLA Medical Center during the period 1956-1990. Sixty-four patients underwent surgical exploration at the UCLA Medical Center; 35 of these underwent resection for cure. Sixteen of these 35 patients received no postoperative adjuvant therapy. Twenty-nine patients underwent palliative or "noncurative" resection. There were five postoperative deaths (mortality rate 8%). The overall morbidity rate was 48% There were 3 perforations in a total of 53 patients receiving multiagent chemotherapy. Five-year actuarial survival was as follows: 59% for curative resection alone, 51% for curative resection plus adjuvant therapy, and 28% for "noncurative" resection (P<0.05). Multivariate analysis revealed that stage of disease (P<0.01) and resection for cure (P<0.05) were independent predictors of survival. These results suggest that patients undergoing resection for cure have improved survival. The apparent low risk of perforation during chemotherapy, along with the considerable risk of morbidity and mortality associated with operation, suggests that a policy of debulking large tumors prior to chemotherapy is unwarranted.

Role of surgery in the management of primary lymphoma of the gastrointestinal tract

The role of surgery in the management of primary gastrointestinal lymphoma remains controversial. We retrospectively reviewed the management and outcome of 107 patients with the diagnosis of gastrointestinal lymphoma treated at the UCLA Medical Center during the period 1956-1990. Sixty-four patients underwent surgical exploration at the UCLA Medical Center; 35 of these underwent resection for cure. Sixteen of these 35 patients received no postoperative adjuvant therapy. Twenty-nine patients underwent palliative or "noncurative" resection. There were five postoperative deaths (mortality rate 8%). The overall morbidity rate was 48% There were 3 perforations in a total of 53 patients receiving multiagent chemotherapy. Five-year actuarial survival was as follows: 59% for curative resection alone, 51% for curative resection plus adjuvant therapy, and 28% for "noncurative" resection (P<0.05). Multivariate analysis revealed that stage of disease (P<0.01) and resection for cure (P<0.05) were independent predictors of survival. These results suggest that patients undergoing resection for cure have improved survival. The apparent low risk of perforation during chemotherapy, along with the considerable risk of morbidity and mortality associated with operation, suggests that a policy of debulking large tumors prior to chemotherapy is unwarranted.

Impaired nitric oxide-mediated vasodilation in patients with non-insulin-dependent diabetes mellitus

OBJECTIVES

This study sought to determine whether nitric oxide-mediated vasodilation is abnormal in patients with non-insulin-dependent diabetes mellitus.

BACKGROUND

Multiple investigations, both in experimental models and in patients with insulin-dependent diabetes mellitus, demonstrate impaired endothelium-dependent vasodilation. Decreased availability of endothelium-derived nitric oxide may contribute to the high prevalence of vascular disease in diabetes.

METHODS

Vascular reactivity was measured in the forearm resistance vessels of 21 patients with non-insulin-dependent diabetes mellitus and 23 matched healthy control subjects. No patient had hypertension or hypercholesterolemia. Each subject was pretreated with aspirin to inhibit endogenous production of vasoactive prostanoids. Methacholine chloride (0.3 to 10 microg/min) was administered through a brachial artery cannula to assess vasodilation to endothelium-derived nitric oxide. Sodium nitroprusside (0.3 to 10 microg/min) was infused to evaluate vasodilation to an exogenous nitric oxide donor. Verapamil (10 to 300 microg/min) was administered to distinguish impaired nitric-oxide-mediated vasodilation from general dysfunction of vascular smooth muscle. Forearm blood flow was determined by venous occlusion plethysmography, and dose-response curves were generated for each agent. To assess the role of vasoconstrictor prostanoids, a subset of eight diabetic subjects were reexamined in the absence of aspirin treatment.

RESULTS

Basal forearm blood flow in diabetic and nondiabetic subjects was comparable. The forearm blood flow responses to both methacholine chloride and nitroprusside were significantly attenuated in diabetic compared with nondiabetic subjects (p < 0.005 by analysis of variance for both agents). In contrast, the response to verapamil was not significantly different between the groups (p > 0.50). The forearm blood flow responses to these agents were not significantly affected by cyclooxygenase inhibition.

CONCLUSIONS

Nitric oxide-mediated vasodilation is impaired in non-insulin-dependent diabetes mellitus. Vasoconstrictor prostanoids do not contribute significantly to vascular dysfunction. The attenuated response to exogenous as well as endogenous nitric oxide donors suggests that the abnormality is due to increased inactivation of nitric oxide or to decreased reactivity of the vascular smooth muscle to nitric oxide.

Platelet adhesion at high shear rates: the roles of von Willebrand factor/GPIb and the beta 1 integrin alpha 2 beta 1

We have previously described a monomeric rvWf fragment, Leu504-Lys728 that contains one disulfide bond linking Cys509-Cys695. This fragment, VCL, has previously been shown to inhibit vWf-ristocetin, asialo-vWf, and botrocetin-induced vWf binding and aggregation of platelets. VCL inhibited 50% of vWf binding to heparin, but it did not inhibit vWf binding to type I collagen. At a high shear force (2600-1 sec), VCL inhibited platelet adhesion to the subendothelial surface of human umbilical arteries. The maximum inhibition of platelet adhesion was 83 +/- 4% at a VCL concentration of 7.6 mumol/L. Various monoclonal anti-Very Late Activation antigens (VLA) antibodies were added to the VCL and tested for their ability to enhance the inhibition of platelet adhesion at high shear forces. Of all of the VLA antibodies tested, only the anti-VLA-2 antibody (176D7) inhibited platelet aggregation in the absence of VCL and enhanced the inhibition of platelet adhesion in the presence of VCL. The VLA-2 antibody and VCL together inhibited 96 +/- 4% of platelet adhesion at high shear forces.

Endothelial release of nitric oxide contributes to the vasodilator effect of adenosine in humans

BACKGROUND

The endogenous nucleoside adenosine plays an important role in the regulation of vascular tone, especially during ischemia. Experimental data derived from animal models suggest that nitric oxide (NO) contributes to the vasodilator effect of adenosine. The primary purpose of this investigation was to determine whether the endothelial release of NO contributes to adenosine-induced vasodilation in humans.

METHODS AND RESULTS

Venous occlusion plethysmography was used to assess the forearm blood flow (FBF) responses to graded intra-arterial infusions of adenosine (1.5 to 500 micrograms/min). Dose-response curves were constructed before and during intra-arterial infusion of the NO synthase inhibitor NG-monomethyl-L-arginine (L-NMMA) (2 mg/min, n = 6) or vehicle (n = 6). Before infusion of L-NMMA, adenosine caused a dose-dependent increase in FBF from 2.3 to 15.9 mL.min-1.dL-1. During concurrent infusion of L-NMMA, adenosine increased FBF from 1.7 to 10.0 mL.min-1.dL-1, and this change from baseline was significantly reduced compared with that before L-NMMA (P < .05). L-NMMA also attenuated the FBF response to adenosine when the basal constrictor effect of L-NMMA was prevented by coinfusion of the NO donor sodium nitroprusside (n = 6, P < .01). In contrast, L-NMMA did not affect the FBF response to intra-arterial infusion of the endothelium-independent vasodilator verapamil (from 2.0 to 13.9 mL.min-1.dL-1 before L-NMMA and from 1.3 to 13.6 mL.min-1.dL-1 during L-NMMA; n = 6, P = NS). The second objective of this study was to determine whether the adenosine-induced release of NO is mediated by activation of endothelial potassium channels, putatively coupled to adenosine receptors. Thus, the FBF response to adenosine was measured before and during infusion of the ATP-dependent potassium channel blocker tolbutamide (1 mg/min, n = 6), or the potassium channel blocker quinidine (0.5 mg/min, n = 6). The adenosine-mediated increments in FBF were not attenuated by either potassium channel blocker.

CONCLUSIONS

Adenosine-induced vasodilation in humans is mediated, at least in part, by endothelial release of NO. The transducing mechanism of this phenomenon is not known, but it does not appear to involve the activation of either ATP-dependent or quinidine-sensitive potassium channels.

Ectomesenchymal chondromyxoid tumor of the anterior tongue. Nineteen cases of a new clinicopathologic entity

We present 19 cases of a previously undescribed myxoid tumor of the anterior tongue. These lesions occurred in nine women and 10 men aged 9 to 78 years (median, 32 years). Most tumors were seen as slow growing, painless nodules in the anterior dorsal tongue. The duration of growth ranged from a few months to 10 years. All tumors were treated by surgical excision, and two recurred. Microscopically, they exhibited a lobular proliferation of ovoid and fusiform cells, which often had multilobated nuclei and occasional foci of atypia, in a chondromyxoid background. Some tumors entrapped muscle or nerve fibers and had a tendency for blunt infiltration of adjacent tissue. The cells were diffusely and intensely immunoreactive for glial fibrillary acidic protein (GFAP) and cytokeratin but were decorated less frequently with antibodies for smooth muscle actin and S-100 protein. Reactivity for epithelial membrane antigen and desmin was not found. We believe these tumors fail to meet established clinicopathologic criteria for any existing myxoid neoplasms of the tongue, including nerve sheath myxoma, myoepithelioma, benign mixed tumor, ossifying fibromyxoid tumor of soft parts, extraskeletal myxoid chondrosarcoma, and glial and chondroid choristomas or heterotopias. Although the histogenesis of this neoplasm is unclear, we suspect that a cell of undifferentiated ectomesenchyme is the progenitor and suggest the descriptive term ectomesenchymal chondromyxoid tumor (ECT) of the anterior tongue be adopted.

Characterization of the glycosylation of a human IgM produced by a human-mouse hybridoma

We analysed the oligosaccharides of a human IgM produced by a human-human-mouse hybridoma at each of its five conserved heavy chain glycosylation sites. Consistent with previous reports, this IgM possesses sialylated oligosaccharides at Asn171, Asn332 and Asn395, and high-mannose-type oligosaccharides at Asn402. In contrast to previous reports for human IgMs, we find that Asn563 is not occupied by oligosaccharide on perhaps 25% of IgM heavy chains, while occupied Asn563 sites contain both high-mannose-type and sialylated oligosaccharides. These latter results are consistent with the glycosylation at Asn563 previously reported for the mouse MOPC 104E IgM. We demonstrate that both the human hybridoma IgM and the mouse MOPC 104E IgM are mixtures of pentamers and hexamers, raising the possibility that the unique findings concerning the glycosylation at Asn563 in this study and the previous study of the MOPC 104E IgM could be related, at least in part, to the different packing requirements of the hexameric geometry and the accessibility of oligosaccharides in the hexameric geometry for processing to complex type. In addition, we used high-pH anion-exchange (HPAE) chromatography, neutral anion-exchange chromatography, fluorophore-assisted carbohydrate electrophoresis and Western blots to compare the oligosaccharide compositions of the human hybridoma IgM, pooled human serum IgM and two mouse monoclonal IgMs (MOPC 104E and TEPC 183). Of note is the presence of N-glycolylneuraminic acid (NeuGc) and N-acetylneuraminic acid (NeuAc) at a 2:1 ratio in the oligosaccharides of the human hybridoma IgM. The presence of both NeuGc and NeuAc complicates the interpretation of HPAE chromatographs.

Salmonella typhi chorioamnionitis in a human immunodeficiency virus-infected pregnant woman. A case report

Opportunistic prenatal infection is a recognized problem in human immunodeficiency virus (HIV)-infected women from inner city communities. We report a case of intrapartum Salmonella typhi infection and discuss the possible route of infection. An HIV-infected pregnant woman was admitted for fever and ruptured membranes. Maternal blood, cervical and uterine cultures, and placental surface and intramembranous space cultures grew S typhi. The patient responded to antibiotic therapy, with no relapse. The infant did not show signs or symptoms of Salmonella sepsis. Salmonella infection should be treated aggressively in HIV-infected pregnancies with chorioamnionitis and postpartum endometritis.

Purification and characterization of human platelet von Willebrand factor

Platelet von Willebrand factor (vWf) was purified from human platelet concentrates. The multimeric structure of the purified platelet vWf was similar to that observed in the initial platelet lysate, and, like the platelet lysate, the purified platelet vWf contained higher molecular weight multimers than plasma vWf. The apparent molecular weight of the reduced platelet vWf subunit was similar to the plasma vWf subunit. The N-terminal amino acid of the purified platelet and plasma vWf was blocked. In concentration dependent binding to botrocetin- or ristocetin-stimulated platelets, 125I-plasma vWf bound with a higher affinity than platelet. The ristocetin cofactor activity per mg of purified plasma vWf was 5-fold greater than the platelet vWf activity. Platelet and plasma vWf bound to collagen with similar affinities; however, platelet vWf bound to thrombin-stimulated platelets and to heparin with a higher affinity than plasma vWf. The differences in the binding affinity(s) of plasma and platelet vWf to platelet GPIb and GPIIb/IIIa and extracellular matrix proteins may reflect different roles for plasma and platelet vWf in the initial stages of haemostasis and thrombosis.

Normal fetal outcome in a pregnancy with central nervous system toxoplasmosis and human immunodeficiency virus infection. A case report

A pregnant woman was diagnosed with central nervous system toxoplasmosis and human immunodeficiency virus infection. Diagnosis was made by evaluating computed tomography scan results and toxoplasma antibody titers. The patient was treated with pyrimethamine and sulfadiazine, with an excellent fetal outcome. She responded well to this regimen but developed a delayed exanthematous hypersensitivity reaction. Treatment with a substitute regimen resulted in a recurrence of symptoms, leaving undesirable neurologic deficits.

Epithelioid hemangioendothelioma with osteoclastlike giant cells

This article describes histopathologic and immunohistologic features of an epithelioid hemangioendothelioma that presented in the neck of a 40-year-old man. This tumor was unusual because of the presence of osteoclastlike giant cells scattered throughout the entire lesion. The tumor cells reacted positively for factor VIII-related antigen, and the osteoclastlike giant cells were reactive for KP1 antibody, a macrophage-associated antigen. We are aware of only one other previously reported example of soft-tissue epithelioid hemangioendothelioma with an abundance of osteoclast-like giant cells.