Inconclusive decisions and error rates in forensic science

In recent years, there has been discussion and controversy relating to the treatment of inconclusive decisions in forensic feature comparison disciplines when considering the reliability of examination methods and results. In this article, we offer a brief review of the various viewpoints and suggestions that have been recently put forth, followed by a solution that we believe addresses the treatment of inconclusive decisions. We consider the issues in the context of method conformance and method performance as two distinct concepts, both of which are necessary for the determination of reliability. Method conformance relates to an assessment of whether the outcome of a method is the result of the analyst's adherence to the procedures that define the method. Method performance reflects the capacity of a method to discriminate between different propositions of interest (e.g., mated and non-mated comparisons). We then discuss implications of these issues for the forensic science community.

Development of video tutorials to help parents manage children with acute illnesses using a modified Delphi method

AIM

Children often fall sick, which causes concern among parents. Online health information can be confusing and difficult to understand. We aimed to produce simple, informative video tutorials on the symptoms ill children present.

METHODS

We used a modified Delphi method to produce video tutorials on the symptoms fever, vomiting & diarrhea, abdominal pain, breathing difficulties, sore throat, red eyes, earache, and rash. We identified the most common symptoms in acutely ill children. During the first consensus round, experts rated statements on out-of-hospital management from existing health information. Video tutorials were produced from statements rated to be included. Second consensus involved video showings and editing. Two videos were evaluated in focus groups by parents.

RESULTS

During the first round, experts rated median 79 (40-154) statements for each symptom. Panels consisted of median seven (6-11) experts, primarily. Panels reached consensus on inclusion, neutral, or exclusion in 83% of statements. Second round led to adjustments to the videos and final approval by experts. Most parents evaluated the videos as "informative, easy to understand, and calming".

CONCLUSION

We produced video tutorials on the common symptoms ill children present using a modified Delphi method. Feedback from parents in focus groups was positive.

P10.12.A CDK12/CDK13 inhibition disrupts a transcriptional program critical for glioblastoma survival

Background

Glioblastoma multiforme (GBM) is the most prevalent and aggressive malignant tumor of the central nervous system. With a median survival of only one year, GBM patients have a particularly poor prognosis, highlighting a clear need for novel therapeutic strategies to target this disease. Transcriptional cyclin-dependent kinases (CDK), which phosphorylate key residues of RNA polymerase II (RNAPII) C-terminal domain (CTD), play a major role in sustaining aberrant transcriptional programs that are key to development and maintenance of cancer cells.

Material and Methods

We used pharmacological inhibition and genetic ablation to study effects of CDK12/CDK13 depletion on the proliferatory and migratory capacity of GBM cells and mouse xenografts. SLAM-seq, CUT&RUN and cell cycle assays were used to study the mechanistic effects of CDK12/CDK13 depletion in GBM cells.

Results

CDK12/CDK13 depletion markedly reduced the proliferatory and migratory capacity of GBM cells, as well as in vivo growth. CDK12/CDK13 inhibition potentiated existing chemotherapeutic treatments. Mechanistically, inhibition of CDK12/CDK13 leads to a genome-wide abrogation of RNAPII CTD phosphorylation, which in turn disrupts transcription and cell cycle progression in GBM cells.

Conclusion

These results provide proof-of-concept for the potential of CDK12 and CDK13 as therapeutic targets for GBM.

Dental professionals' perspectives working with Aboriginal children in Western Australia: a qualitative study

BACKGROUND

The disproportionate burden of oral disease in Aboriginal children and the issues in accessing mainstream dental services are well documented. Yet little is known about dental professionals' perspectives in providing oral care for Aboriginal children. This paper presents findings from a study exploring such perspectives.

METHODS

Semi-structured interviews were carried out in Western Australia following purposive sampling of non-Aboriginal dentists, dental clinic assistants (dental nurses) and oral health therapists/dental hygienists. Interviews were recorded, transcribed and analysed guided by grounded theory for key themes related to the topic.

RESULTS

Findings included a service delivery model sometimes unresponsive to Aboriginal families' needs; dental professionals' limited education and training to work with confidence and cultural sensitivity with Aboriginal patients and socioeconomic influences on Aboriginal children's poor oral health considered outside dental professionals' remit of care.

DISCUSSION

Findings suggest oral health policies and practices and dental professionals' education and training need reviewing for how well such policies support dental professionals in an Aboriginal context. This includes engaging with Aboriginal stakeholders, working effectively with Aboriginal families, and developing shared understandings about what is needed to increase access to care and improve oral health outcomes for Aboriginal children.

Chronic maternal inflammation or high-fat-feeding programs offspring obesity in a sex-dependent manner

BACKGROUND/OBJECTIVES

The current world-wide obesity epidemic partially results from a vicious circle whereby maternal obesity during pregnancy predisposes the offspring for accelerated weight gain and development of metabolic syndrome. Here we investigate whether low-grade inflammation, characteristic of the obese state, provides a causal role for this disastrous fetal programming in mice.

METHODS

We exposed pregnant and lactating C57BL/6JBom female mice to either high-fat diet (HFD), or continuous infusion of lipopolysaccharide (LPS), a potent trigger of innate immunity, and studied offspring phenotypes.

RESULTS

Both maternal LPS or HFD treatments rendered the offspring hyperphagic and inept of coping with a HFD challenge during adulthood, increasing their adiposity and weight gain. The metabolic effects were more pronounced in female offspring, while exposed male offspring mounted a larger inflammatory response to HFD at adulthood.

CONCLUSIONS

This supports our hypothesis and highlights the programming potential of inflammation in obese pregnancies.

Registered Replication Report

According to the facial feedback hypothesis, people’s affective responses can be influenced by their own facial expression (e.g., smiling, pouting), even when their expression did not result from their emotional experiences. For example, Strack, Martin, and Stepper (1988) instructed participants to rate the funniness of cartoons using a pen that they held in their mouth. In line with the facial feedback hypothesis, when participants held the pen with their teeth (inducing a “smile”), they rated the cartoons as funnier than when they held the pen with their lips (inducing a “pout”). This seminal study of the facial feedback hypothesis has not been replicated directly. This Registered Replication Report describes the results of 17 independent direct replications of Study 1 from Strack et al. (1988), all of which followed the same vetted protocol. A meta-analysis of these studies examined the difference in funniness ratings between the “smile” and “pout” conditions. The original Strack et al. (1988) study reported a rating difference of 0.82 units on a 10-point Likert scale. Our meta-analysis revealed a rating difference of 0.03 units with a 95% confidence interval ranging from −0.11 to 0.16.

Background intensity correction for terabyte-sized time-lapse images

Several computational challenges associated with large-scale background image correction of terabyte-sized fluorescent images are discussed and analysed in this paper. Dark current, flat-field and background correction models are applied over a mosaic of hundreds of spatially overlapping fields of view (FOVs) taken over the course of several days, during which the background diminishes as cell colonies grow. The motivation of our work comes from the need to quantify the dynamics of OCT-4 gene expression via a fluorescent reporter in human stem cell colonies. Our approach to background correction is formulated as an optimization problem over two image partitioning schemes and four analytical correction models. The optimization objective function is evaluated in terms of (1) the minimum root mean square (RMS) error remaining after image correction, (2) the maximum signal-to-noise ratio (SNR) reached after downsampling and (3) the minimum execution time. Based on the analyses with measured dark current noise and flat-field images, the most optimal GFP background correction is obtained by using a data partition based on forming a set of submosaic images with a polynomial surface background model. The resulting image after correction is characterized by an RMS of about 8, and an SNR value of a 4 × 4 downsampling above 5 by Rose criterion. The new technique generates an image with half RMS value and double SNR value when compared to an approach that assumes constant background throughout the mosaic. We show that the background noise in terabyte-sized fluorescent image mosaics can be corrected computationally with the optimized triplet (data partition, model, SNR driven downsampling) such that the total RMS value from background noise does not exceed the magnitude of the measured dark current noise. In this case, the dark current noise serves as a benchmark for the lowest noise level that an imaging system can achieve. In comparison to previous work, the past fluorescent image background correction methods have been designed for single FOV and have not been applied to terabyte-sized images with large mosaic FOVs, low SNR and diminishing access to background information over time as cell colonies span entirely multiple FOVs. The code is available as open-source from the following link https://isg.nist.gov/.

Reduced cannabinoid receptor 1 protein in subcutaneous adipose tissue of obese

BACKGROUND

Cannabinoid 1 receptors are identified in various tissues involved in the internal metabolism including adipose tissue and the endocannabinoid system is claimed to be overactive in the obese state. To study the potential involvement of cannabinoid receptor 1 in the endocannabinoid system over-activity in adipose tissue in the obese state, we investigated the cannabinoid receptor 1 levels in adipose tissue from different fat depots in lean and obese humans.

MATERIALS AND METHODS

The adipose tissue samples were analysed by Western blot and by RT-PCR.

RESULTS

Both the gene expression and the protein of cannabinoid receptor 1 were lower in subcutaneous abdominal adipose tissue from obese subjects as compared with lean subjects (P < 0.01 and P = 0.058). Moreover, in lean subjects, the level of cannabinoid receptor 1 was significantly higher in subcutaneous adipose tissue compared with visceral adipose tissue (P < 0.05) for both gene expression and protein. The level of cannabinoid receptor 1 was similar between the two depots in obese subjects. The expression of cannabinoid receptor 1 was higher in subcutaneous gluteal adipose tissue as compared with subcutaneous abdominal adipose tissue (P < 0.05).

CONCLUSION

We found in lean subjects, a robust lower level of cannabinoid receptor 1 in visceral adipose tissue compared with subcutaneous adipose tissue (both RNA and protein levels), but similar levels of cannabinoid receptor 1 between the two depots in obese subjects. Our present findings do not indicate that cannabinoid receptor 1 is directly involved in the endocannabinoid system over-activity in adipose tissue in obesity.

A novel insulin sensitizer (S15511) enhances insulin-stimulated glucose uptake in rat skeletal muscles

Type 2 diabetes is preceded by the presence of skeletal muscle insulin resistance, and drugs that increase insulin sensitivity in skeletal muscle prevent the disease. S15511 is an original compound with demonstrated effects on insulin sensitivity in animal models of insulin resistance. However, the mechanisms behind the insulin-sensitizing effect of S15511 are unknown. The aim of our study was to explore whether S15511 improves insulin sensitivity in skeletal muscles. Insulin sensitivity was assessed in skeletal muscles from S15511-treated rats by measuring intracellular insulin-signaling activity and insulin-stimulated glucose transport in isolated muscles. In addition, GLUT4 expression and glycogen levels were assessed after treatment. S15511 treatment was associated with an increase in insulin-stimulated glucose transport in type IIb fibers, while type I fibers were unaffected. The enhanced glucose transport was mirrored by a fiber type-specific increase in GLUT4 expression, while no improvement in insulin-signaling activity was observed. S15511 is a novel insulin sensitizer that is capable of improving glucose homeostasis in nondiabetic rats. The compound enhances skeletal muscle insulin sensitivity and specifically targets type IIb muscle fibers by increasing GLUT4 expression. Together these data show S15511 to be a potentially promising new drug in the treatment and prevention of type 2 diabetes.

Cellular expansion and gene expression in the developing grape (Vitis vinifera L.)

Expression profiles of genes involved in cell wall metabolism and water transport were compared with changes in grape (Vitis vinifera L.) berry growth, basic chemical composition, and the shape, size, and wall thickness of cells within tissues of the berry pericarp. Expression of cell wall-modifying and aquaporin genes in berry pericarp tissues generally followed a bimodal expression profile with high levels of expression coinciding with the two periods of rapid berry growth, stages I and III, and low levels of expression corresponding to the slow-growth period, stage II. Cellular expansion was observed throughout all tissues during stage I, and only mesocarp cellular expansion was observed during stage III. Expansion of only exocarp cells was evident during transition between stages II and III. Cell wall-modifying and aquaporin gene expression profiles followed similar trends in exocarp and mesocarp tissues throughout berry development, with the exception of the up-regulation of pectin methylesterase, pectate lyase, two aquaporin genes (AQ1 and AQ2), and two expansin genes (EXP3 and EXPL) during stage II, which was delayed in the exocarp tissue compared with mesocarp tissue. Exocarp endo-(1-->3)-beta-glucanase and expansin-like gene expression was concurrent with increases in epidermal and hypodermal cell wall thickness. These results indicate a potential role of the grape berry skin in modulating grape berry growth.

Amyloid plaques arise from zinc-enriched cortical layers in APP/PS1 transgenic mice and are paradoxically enlarged with dietary zinc deficiency

The ZnT3 zinc transporter is uniquely expressed in cortical glutamatergic synapses where it organizes zinc release into the synaptic cleft and mediates beta-amyloid deposition in transgenic mice. We studied the association of zinc in plaques in relation to cytoarchitectural zinc localization in the APP/PS1 transgenic mouse model of Alzheimer's disease. The effects of low dietary zinc for 3 months upon brain pathology were also studied. We determined that synaptic zinc distribution within cortical layers is paralleled by amyloid burden, which is heaviest for both in layers 2-3 and 5. ZnT3 immunoreactivity is prominent in dystrophic neurites within amyloid plaques. Low dietary zinc caused a significant 25% increase in total plaque volume in Alzheimer's mice using stereological measures. The level of oxidized proteins in brain tissue did not changed in animals on a zinc-deficient diet compared with controls. No obvious changes were observed in the autometallographic pattern of zinc-enriched terminals in the neocortex or in the expression levels of zinc transporters, zinc importers or metallothioneins. A small decrease in plasma zinc induced by the low-zinc diet was consistent with the subclinical zinc deficiency that is common in older human populations. While the mechanism remains uncertain, our findings indicate that subclinical zinc deficiency may be a risk factor for Alzheimer's pathology.

Dose-response effects of free fatty acids on glucose and lipid metabolism during somatostatin blockade of growth hormone and insulin in humans

CONTEXT

GH and other stress hormones stimulate lipolysis, which may result in free fatty acid (FFA)-mediated insulin resistance. However, there are also indications that FFAs in the very low physiological range have the same effect.

OBJECTIVE

The objective of the study was to address systematically the dose-response relations between FFAs and insulin sensitivity.

DESIGN

We therefore examined eight healthy men for 8 h (6 h basal and 2 h glucose clamp) on four occasions.

INTERVENTION

Intralipid was infused at varying rates (0, 3, 6, 12 microl.kg(-1).min(-1)); lipolysis was blocked by acipimox; and endogenous GH, insulin, and glucagon secretion was blocked by somatostatin and subsequently replaced at fixed rates.

RESULTS

This resulted in four different FFA levels between 50 and 2000 micromol/liter, with comparable levels of insulin and counterregulatory hormones. Both in the basal state and during insulin stimulation, we saw progressively decreased glucose disposal, nonoxidative glucose disposal, and forearm muscle glucose uptake at FFA levels above 500 micromol/liter. Apart from forearm glucose uptake, the very same parameters were decreased at low FFA levels (approximately 50 micromol/liter). FFA rate of disposal was linearly related to the level of FFAs, whereas lipid oxidation reached a maximum at FFA levels approximately 1000 micromol/liter.

CONCLUSION

In the presence of comparable levels of all major metabolic hormones, insulin sensitivity peaks at physiological levels of FFAs with a gradual decrease at elevated as well as suppressed FFA concentrations. These data constitute comprehensive dose-response curves for FFAs in the full physiological range from close to zero to above 2000 micromol/liter.

‘Endotoxin tolerance’: TNF-α hyper-reactivity and tubular cytoresistance in a renal cholesterol loading state

The term 'endotoxin tolerance' defines a state in which prior endotoxin (lipopolysaccharide (LPS)) exposure induces resistance to subsequent LPS attack. However, its characteristics within kidney have not been well defined. Hence, this study tested the impact of LPS 'preconditioning' (LPS-PC; 18 or 72 h earlier) on: (i) selected renal inflammatory mediators (tumor necrosis factor (TNF)-alpha, interleukin-10 (IL-10), monocyte chemotactic protein-1 (MCP-1), inducible nitric oxide synthase (iNOS), Toll-like receptor 4 (TLR4); protein or mRNA); (ii) cholesterol homeostasis (a stress reactant); and (iii) isolated proximal tubule (PT) vulnerability to hypoxia or membrane cholesterol (cholesterol oxidase/esterase) attack. Two hours post LPS injection, LPS-PC mice manifested reduced plasma TNF-alpha levels, consistent with systemic LPS tolerance. However, in kidney, paradoxical TNF-alpha hyper-reactivity (protein/mRNA) to LPS existed, despite normal TLR4 protein levels. PT TNF-alpha levels paralleled renal cortical results, implying that PTs were involved. LPS-PC also induced: (i) renal cortical iNOS, IL-10 (but not MCP-1) mRNA hyper-reactivity; (ii), PT cholesterol loading, and (iii) cytoresistance to hypoxia and plasma membrane cholesterol attack. A link between cholesterol homeostasis and cell LPS responsiveness was suggested by observations that cholesterol reductions in HK-2 cells (methylcyclodextrin), or reductions in HK-2 membrane fluidity (A2C), blunted LPS-mediated TNF-alpha/MCP-1 mRNA increases. In sum: (i) systemic LPS tolerance can be associated with renal hyper-responsiveness of selected components within the LPS signaling cascade (e.g., TNF-alpha, iNOS, IL-10); (ii) PT cytoresistance against hypoxic/membrane injury coexists; and (iii) LPS-induced renal/PT cholesterol accumulation may mechanistically contribute to each of these results.

Predicting prognosis in patients with advanced cancer

BACKGROUND

Patients with advanced cancer and their carers frequently wish to know how long they can expect to live. Improved prognostication would enable patients and their carers to be better prepared for their impending death, and would allow clinicians to make better informed decisions about place of care. However, clinician estimates of survival are inaccurate and systematically overoptimistic. Recently, attempts have been made to improve upon clinician estimates of survival by devising prognostic scales incorporating clinical information with biochemical and haematological results.

DESIGN

A descriptive and critical review of palliative prognostic scales, on the basis of the recommendations of the European Association of Palliative Care prognosis working group (2005) supplemented by an Ovid Medline search 1966-March 2006 using the key words 'prognosis', 'neoplasms', 'palliative care' and 'terminal care'.

RESULTS

This paper reviews the advantages and limitations of the palliative prognostic score, the palliative prognostic index, the Chuang prognostic scale, the terminal cancer prognostic score and the poor prognostic indicator.

CONCLUSIONS

All the currently available prognostic scales have limitations, but nonetheless offer an improvement on unadjusted clinician estimates of survival. Further research is required to systematically develop a prognostic scale on the basis of all the known prognostic variables in patients with advanced cancer.

Acute nephrotoxic and obstructive injury primes the kidney to endotoxin-driven cytokine/chemokine production

Gram-negative sepsis is a frequent complication in patients with acute renal failure. This study tested whether acute tubular injury, for example, induced by cisplatin (CP) or urinary tract obstruction, enhances renal cytokine responses to endotoxin (lipopolysaccharide (LPS)), potentially contributing to tissue damage. CD-1 mice were subjected to CP or vehicle injection. After 24 or 72 h, LPS or its vehicle was given. At 2 h post LPS or vehicle administration, plasma/renal cortical tumor necrosis factor (TNF)-alpha, monocyte chemoattractant protein-1 (MCP-1), and interleukin-10, and their corresponding renal cortical mRNAs were assessed (representing pro-anti-inflammatory cytokines, and a chemokine, respectively). Comparable studies were conducted in mice 24 h post unilateral ureteral obstruction (UUO). Cultured human proximal tubular (HK-2) cell TNF-alpha responses to CP+/-LPS were also assessed. CP alone caused either minimal or no increases in cytokine levels. However, CP dramatically augmented cytokine responses to LPS (up to 5-10 x vs LPS alone). The cytokine increases were paralleled by changes in their mRNAs. UUO also sensitized to LPS. CP alone did not alter HK-2 cell TNF-alpha/mRNA. However, CP 'primed' the cells to LPS (approximately 50-100% greater TNF-alpha/mRNA increases vs LPS alone). CP+LPS also caused synergistic cell death (lactate dehydrogenase release). We conclude that (1) diverse forms of tubular injury can sensitize the kidney to LPS, increasing cytokine production; (2) proximal tubules are involved; (3) LPS 'priming' has broad-based consequences, impacting diverse pro- and anti-inflammatory pathways; and (4) increased transcriptional events may be at least partially involved.

Lamivudine is not effective in primary Sjögren's syndrome

BACKGROUND

Retroviral infection has been implicated in the pathogenesis of primary Sjögren's syndrome.

OBJECTIVE

To examine the efficacy of the reverse transcriptase inhibitor lamivudine in patients with this syndrome.

METHODS

16 patients with primary Sjögren's syndrome were randomised to receive either lamivudine 150 mg twice daily or placebo for three months. Measures of lacrimal and salivary function, including minor salivary gland biopsies, were obtained before and after treatment.

RESULTS

Treatment with lamivudine did not result in significant improvement in the primary outcome measure of unstimulated whole salivary flow or other secondary measures, including minor salivary gland biopsy focus scores.

CONCLUSION

Lamivudine is not effective in patients with primary Sjögren's syndrome, suggesting either that a retroviral aetiology is not present or that it may be important only in early disease.

Skeletal muscle glucose uptake, glycogen synthase activity and GLUT 4 content during hypoglycaemia in type 1 diabetic subjects

In healthy subjects, hypoglycaemia induces a profound 80% reduction in skeletal muscle glucose uptake and a similar suppression of glycogen synthase activity. The aim of this study was to examine the efficacy of this counterregulatory mechanism in type 1 diabetic subjects, who are especially prone to hypoglycaemic incidents. Nine type 1 diabetic male subjects were examined twice; during 120 min of hyperinsulinaemic (1.5 mU x kg(-1) x min(-1)) euglycaemia followed by (i) 240 min of graded hypoglycaemia (glucose nadir 2.8 mM) or (ii) 240 min of euglycaemia. At 345-360 min a muscle biopsy was taken and indirect calorimetry was performed at 210-240 and 320-340 min. The sensitivity of glycogen synthase to glucose-6-P was reduced by hypoglycaemia, as shown by an increase in A0.5 for glucose-6-P (at 0.07 mmol/L) from 0.21+/-0.02 to 0.28+/-0.03 mM (p=0.06). Likewise, the fractional velocity for glycogen synthase was reduced by 25%; i.e. from 20.8+/-2.0 to 15.5+/-1.4% (p<0.05). Total glucose disposal was decreased during hypoglycaemia (5.3+/-0.6 vs. 8.3+/-0.7 mg x kg(-1) x min(-1) (euglycaemia), n = 9; p<0.05), primarily due to a reduction of non-oxidative glucose disposal (2.7+/-0.3 vs. 5.1+/-0.6 mg x kg(-1) x min(-1) (euglycaemia), n=7; p<0.05). Forearm arteriovenous glucose differences were decreased by 50% in the hypoglycaemic situation (0.7+/-0.1 vs. 1.4+/-0.3 mmol/L (320-340 min)), and counterregulatory hormonal responses seemed less conspicuous than described in healthy subjects. We conclude that hypoglycaemia induces decrements of forearm glucose uptake and glycogen synthase activity in type 1 diabetic subjects. The study indicates a decreased magnitude of these responses, but this remains to be confirmed.

Rosiglitazone treatment of patients with extreme insulin resistance and diabetes mellitus due to insulin receptor mutations has no effects on glucose and lipid metabolism

BACKGROUND

Rosiglitazone, a thiazolidinedione (TZD), increases insulin sensitivity by reducing levels of plasma NEFA, triglycerides (TG), glucose and serum insulin. Rosiglitazone treatment decreases insulin resistance in type 2 diabetic patients, but no data exist concerning rosiglitazone treatment of patients with syndromes of extreme insulin resistance.

OBJECTIVES

To evaluate whether hyperglycaemia in two lean patients with primary severe insulin resistance due to insulin receptor (IR) mutations and diabetes mellitus could be reduced by supplement of rosiglitazone for 180 days and secondary, to evaluate the effects on plasma NEFA, TG, Apo B, PAI-1 and serum insulin.

SUBJECTS

Both patients (brothers) have known mutations in the IR gene localized to the tyrosine kinase domain and a deletion of exon 17 in part of their IR mRNA. Prior to the study the HbA1c values were higher than 10% in both patients for more than 12 months during treatment with insulin and metformin.

RESULTS

After 180 days of rosiglitazone supplement (8 mg day(-1)), no changes were observed in fasting plasma glucose and HbA1c. Incremental plasma glucose areas under the curves during a 75-g oral glucose tolerance test (OGTT) were unchanged. Likewise, no improvements were seen in either first or second phase insulin secretion during a 0.3 g kg(-1) intravenous glucose tolerance test (IVGTT). Fasting plasma VLDL and HDL cholesterol, TG and Apo B levels were unchanged, whereas a small increase was seen in total and LDL cholesterol levels. Fasting plasma NEFA increased by 51% in KC after 90 days of treatment, and after 180 days plasma NEFA was still 26% higher, when compared with pretreatment levels. In BC an initial 16% decrease was seen in plasma NEFA after 90 days of treatment. Plasma NEFA was increased 14% after 180 days of treatment, when compared with pretreatment levels, but 35% when compared with day 90. Plasma PAI-1 decreased in both patients after 45 and 90 days of treatment but the decrease was only maintained in KC (47%).

CONCLUSIONS

Rosiglitazone treatment, in combination with insulin and metformin, of patients with severe primary insulin resistance due to IR mutations and diabetes mellitus, had no impact on the measured estimates of glucose and lipid metabolism. These findings may suggest that the effect of rosiglitazone on glucose and lipid metabolism are dependent on the presence of intact IR protein.

Autoregulated glomerular filtration rate during candesartan treatment in hypertensive type 2 diabetic patients

BACKGROUND

Impaired autoregulation of the glomerular filtration rate (GFR) implies disturbances in the downstream transmission of the systemic blood pressure into the glomerulus, leading to capillary hypertension or hypotension dependent of the level of blood pressure. The impact on renal autoregulation of different antihypertensive drugs in animals has been elucidated, whereas information in humans is lacking.

METHODS

A randomized, double-blind crossover study with candesartan cilexetil 16 mg o.d. and placebo was performed in 17 hypertensive type 2 diabetic patients without nephropathy. Each treatment arm lasted four weeks. On the last day, GFR (single shot [51Cr] EDTA plasma clearance technique for 4 hours) was measured twice between 8 a.m. and 5 p.m., first without clonidine and then after an intravenous injection of clonidine 75 microg. Blood pressure (Takeda TM2420, A&D, Tokyo, Japan) was measured every ten minutes, and the urinary albumin excretion rate (UAER) was measured by ELISA during each GFR determination.

RESULTS

Candesartan induced a mean (SE) reduction in mean arterial blood pressure (MABP) of 6 (2) mm Hg (P < 0.02) and had a tendency to reduce UAER (P = 0.07), while GFR remained unchanged (95 vs. 93 mL/min/1.73 m2). Clonidine reduced MABP with 17 (2) versus 16 (1) mm Hg during placebo versus candesartan 16 mg o.d., respectively (NS). GFR diminished in average from 95 (3) to 92 (4) mL/min/1.73 m2 with placebo (NS), and from 93 (3) to 89 (4) mL/min/1.73 m2 during treatment with candesartan (NS). The mean difference (95% CI) in the changes in GFR between the examination with placebo and with candesartan was 0.1 (-5.5 to 5.8) mL/min/1.73 m2 (NS).

CONCLUSION

Candesartan reduces blood pressure without adversely altering the preserved ability to autoregulate GFR in hypertensive type 2 diabetic patients without nephropathy.

In Vivo and in Vitro Evidence for Extracellular Caspase Activity Released from Apoptotic Cells

While caspases play an established role as intracellular executors of apoptosis, little is known about extracellular activities of this ubiquitously expressed family of proteases. We demonstrate here that recombinant caspase-3 retained enzymatic activity in various extracellular fluids. Experiments with cell lines, primary cells, and mice with fulminant CD95-triggered hepatitis showed that significant amounts of DEVD-aminofluoromethylcoumarine-cleaving activity, indicative of active effector caspases, were released into the medium/plasma during apoptosis. Furthermore, caspase activities were detected in liquor samples from human head trauma patients. These findings warrant closer investigation of DEVDase activity as a diagnostic marker, and of potential extracellular substrates for caspases.

Insulin and contraction directly stimulate UCP2 and UCP3 mRNA expression in rat skeletal muscle in vitro

To study the regulation of the mitochondrial uncoupling protein 2 and 3 (UCP2 and UCP3), we studied the effect of insulin and muscle contraction on UCP mRNA expression in rat skeletal muscle in vitro. Insulin dose-dependently increased skeletal muscle UCP2 and UCP3 mRNA expression in m. extensor digitorum longus (EDL) with maximal stimulation obtained at around 0.6-6 nM. The concentration of insulin giving half-maximal stimulation was 60 pM for the UCP2 and 48 pM for the UCP3 mRNA expression. The effect of insulin was maximal after 2 h and the effect was sustained during the whole study period (6 h). The insulin-induced increase in UCP mRNA was independent of the glucose uptake (as UCP mRNA was stimulated even in incubations without glucose). In addition, electrically induced contractions (in vitro) increased UCP2 and UCP3 mRNA expression 60-120 min after a single bout of contraction (for 10 min). Both the increment of UCP2 and UCP3 mRNA were sustained throughout the study period (4 h) (153 +/- 62 and 216 +/- 71% above basal, P < 0.05 respectively). Finally, 5-aminoimidazole-4-carboxamid-ribosid (AICAR), an activator of the AMP-activated protein kinase (AMPK), that is activated during exercise, was able to mimic the increase in UCP2 and UCP3 mRNA expression. In conclusion, UCP2 and UCP3 mRNA expression in skeletal muscle are stimulated rapidly by insulin and contraction in vitro, thus the stimulation is direct and not caused by changes in other hormones or metabolites. Even a brief bout of contraction induces an increase in UCP2 and UCP3 expression, an effect that could be mimicked by activation of the AMP-activated protein kinase by AICAR.

The impact of glycaemic control on autoregulation of glomerular filtration rate in patients with non-insulin dependent diabetes

The ability of the kidney to maintain constancy of glomerular filtration rate (GFR) over a wide range of renal perfusion pressures is termed autoregulation. Defective autoregulation of GFR has been demonstrated in patients with diabetic and non-diabetic nephropathy and in streptozotocin diabetic rats during hyperglycaemia. Information on the potential impact of acute changes in glycaemic control on autoregulation of GFR in diabetic patients is lacking. Therefore the aim of our study was to evaluate the effect of acute lowering of blood pressure (BP) on GFR during normoglycaemia and hyperglycaemia. We investigated 14 (12m/2f) normoalbuminuric patients with non-insulin dependent diabetes (NIDDM). The patients were examined in random order on two separate days with blood glucose (BG)<10 mmol/L or with BG>15 mmol/L. GFR (single shot [51Cr] EDTA plasma clearance technique) was measured twice each day; first without clonidine (baseline) followed by intravenous injection of clonidine 100-150 microg. We measured BG (One Touch 2), and BP (Takeda TM2420) several times during each GFR measurement. Clonidine reduced mean arterial blood pressure with 20 (1.4) vs. 16 (1.2) mmHg (mean (SE)) with BG<10mmol/L and with BG>15 mmol/L, respectively (p=0.053). GFR diminished in average from 92 (3.1) to 86 (3.7) ml/min/1.73m2 with BG<10 mmol/L (p<0.05), and from 102 (4.1) to 98 (4.2) ml/min/1.73 m2 with BG> 15 mmol/L, NS. Mean difference between changes in GFR (95% confidence interval) between the examination with BG<10 mmol/L and with BG>15 mmol/L were 2.3 (-1.3 to 5.9) ml/min/1.73 m2 (NS). The mean BG during normoglycaemia was 6.9 (0.3) vs.16.9 (0.4) during hyperglycaemia.

CONCLUSION

Our study suggests that acute changes in glycaemic control have no detectable effect on autoregulation of GFR in NIDDM patients. Hyperglycaemia enhances GFR.

Chronic treatment with 5-aminoimidazole-4-carboxamide-1-beta-D-ribofuranoside increases insulin-stimulated glucose uptake and GLUT4 translocation in rat skeletal muscles in a fiber type-specific manner

Recent studies have demonstrated that chronic administration of AICAR (5-aminoimidazole-4-carboxamide- 1-beta-D-ribofuranoside), an activator of the AMP-activated protein kinase, increases hexokinase activity and the contents of total GLUT4 and glycogen in rat skeletal muscles. To explore whether AICAR also affects insulin-stimulated glucose transport and GLUT4 cell surface content, Wistar rats were subcutaneously injected with AICAR for 5 days in succession (1 mg/g body wt). Maximally insulin-stimulated (60 nmol/l) glucose uptake was markedly increased in epitrochlearis (EPI) muscle (average 63%, P < 0.001, n = 18-19) and in extensor digitorum longus muscle (average 26%, P < 0.001, n = 26-30). In contrast, administration of AICAR did not maximally influence insulin-stimulated glucose transport in soleus muscle. Studies of EPI muscle with the 4,4'-O-[2-[2-[2-[2-[2-[6-(biotinylamino)hexanoyl]amino]ethoxy]ethoxy] ethoxy]-4-(1-azi-2,2,2,-trifluoroethyl)benzoyl]amino-1,3-propanediyl]bis-D-mannose photolabeling technique showed a concomitant increase (average 68%, P < 0.02) in cell surface GLUT4 content after insulin exposure in AICAR-injected rats when compared with controls. In conclusion, 5 days of AICAR administration induces a pronounced fiber type-specific increase in insulin-stimulated glucose uptake and GLUT4 cell surface content in rat skeletal muscle with the greatest effect observed on white fast-twitch glycolytic muscles (EPI). These results are comparable with the effects of chronic exercise training, and it brings the AMP-activated protein kinase into focus as a new interesting target for future pharmacological intervention in insulin-resistant conditions.

Muscle glycogen content affects insulin-stimulated glucose transport and protein kinase B activity

We investigated the possible regulatory role of glycogen in insulin-stimulated glucose transport and insulin signaling in skeletal muscle. Rats were preconditioned to obtain low (LG), normal, or high (HG) muscle glycogen content, and perfused isolated hindlimbs were exposed to 0, 100, or 10,000 microU/ml insulin. In the fast-twitch white gastrocnemius, insulin-stimulated glucose transport was significantly higher in LG compared with HG. This difference was less pronounced in the mixed-fiber red gastrocnemius and was absent in the slow-twitch soleus. In the white gastrocnemius, insulin activation of insulin receptor tyrosine kinase and phosphoinositide 3-kinase was unaffected by glycogen levels, whereas protein kinase B activity was significantly higher in LG compared with HG. In additional incubation experiments on fast-twitch epitrochlearis muscles, insulin-stimulated cell surface GLUT-4 content was significantly higher in LG compared with HG. The data indicate that, in fast-twitch muscle, the effect of insulin on glucose transport and cell surface GLUT-4 content is modulated by glycogen content, which does not involve initial but possibly more downstream signaling events.

[Quality assurance in palliative medicine. Survey of the structure and processing quality in palliative care units in North Rhine-Westphalia in Germany]

BACKGROUND AND METHODS

The aim of this study was to get detailed information about the current situation and the quality of the palliative care units in North Rhine-Westphalia (NRW). The aim of palliative medicine is the achievement of the best possible quality of life for patients and their families. Unrelieved pain and other symptoms or major social problems are the reason for the admission of a patient to a palliative care unit. Questionnaires were distributed to the 13 palliative care units in NRW.

RESULTS

Most palliative care units in NRW focus on the achievement of pain relief and symptom control, trying to achieve the best possible quality of life. However, the quality of palliative care shows some significant deficits (in the availability of nursing staff, cooperation with general practitioners, standardised documentation and education). A multi-professional team is available in only four units. A total of 90 beds were available in NRW. In 1998 and 1999 palliative care units cared for 2308 patients, most of them (97.5%) suffering from cancer.

CONCLUSION

There is a need for further education, not only for physicians but also for nursing staff and physicians already working in palliative care units. Furthermore, we need specialists in palliative medicine for the care for patients with particularly severe problems, and to initiate educational programmes and research in palliative medicine. In order to achieve an improvement of palliative care in Germany, we need to convince not only physicians and nursing staff of the advantages of palliative care, but also health care officials, the government and the public. Palliative care is not for free. However, palliative care does not necessarily lead to increasing costs in health care. Better pain management and symptom control may help to save the overall costs of medical treatment.

Use of a novel impermeable biotinylated photolabeling reagent to assess insulin- and hypoxia-stimulated cell surface GLUT4 content in skeletal muscle from type 2 diabetic patients

Cell surface GLUT4 levels in skeletal muscle from nine type 2 diabetic subjects and nine healthy control subjects have been assessed by a new technique that involves the use of a biotinylated photo-affinity label. A profound impairment in GLUT4 translocation to the skeletal muscle cell surface in response to insulin was observed in type 2 diabetic patients. Levels of insulin-stimulated cell surface GLUT4 above basal in type 2 diabetic patients were only approximately 10% of those observed in healthy subjects. The magnitude of the defect in GLUT4 translocation in type 2 diabetic patients was greater than that observed for glucose transport activity, which was approximately 50% of that in healthy subjects. Reduced GLUT4 translocation is therefore a major contributor to the impaired glucose transport activity in skeletal muscle from type 2 diabetic subjects. When a marked impairment in GLUT4 translocation occurs, the contribution of other transporters to transport activity becomes apparent. In response to hypoxia, marked reductions in skeletal muscle cell surface GLUT4 levels were also observed in type 2 diabetic patients. Therefore, a defect in a common late stage in signal transduction and/or a direct impairment in the GLUT4 translocation process accounts for reduced glucose transport in type 2 diabetic patients.

Contraction-stimulated muscle glucose transport and GLUT-4 surface content are dependent on glycogen content

The influence of muscle glycogen content on basal and contraction-induced glucose transport and cell surface GLUT-4 content was studied in rat skeletal muscle. Wistar rats were preconditioned by a combination of swimming exercise and diet, resulting in 40% lower (LG) or threefold higher (HG) muscle glycogen content compared with nonexercised controls (NG). At rest and during contractions, 2-deoxy-D-glucose uptake in perfused fast-twitch muscle, but not slow-twitch muscle, was significantly lower in HG compared with LG. Cell surface GLUT-4 content in the fast-twitch plantaris was 994 +/- 180, 1,173 +/- 311, and 2,155 +/- 243 dpm/g in the basal condition and increased (P < 0.05) to 2,285 +/- 239, 3,230 +/- 464, and 4,847 +/- 654 dpm/g during contractions with HG, NG, and LG, respectively, the increase being significantly smaller in HG compared with LG. The contraction-induced increments in glucose transport and in cell surface GLUT-4 content were negatively correlated with the initial glycogen content (P <0.01). In conclusion, glucose transport and cell surface GLUT-4 content in resting and contracting fast-twitch muscle are dependent on the muscle glycogen content.

Aspects of secretion and actions of amylin: interplay between amylin and other hormones

Amylin is a second beta-cell hormone, co-localized and co-secreted with insulin in response to nutrient stimuli. Amylin is released in a pulsatile pattern similar to insulin. It is mostly expressed in pancreatic islet cells but smaller amounts are present elsewhere, e.g. in the central nervous system. Apparently amylin (and amylin analogues) has actions capable of modifying glucose homeostasis. It suppresses arginine-stimulated and postprandial glucagon secretion, inhibits insulin secretion and slows gastric emptying. Furthermore, amylin seems to be a satiety agent. In vitro and in vivo studies in animals have demonstrated that amylin may induce insulin resistance. However, it exerts no effect on insulin sensitivity in humans. The literature on the possible actions of amylin/amylin analogues on secretion of growth hormone (GH) is limited. Hypothetically, amylin treatment could be of relevance to improve glycemic control in diabetes mellitus. Muticenter trials with an amylin analogue are ongoing and results are being awaited with interest.

Evidence against protein kinase B as a mediator of contraction-induced glucose transport and GLUT4 translocation in rat skeletal muscle

Both insulin and muscle contraction stimulate glucose transport activity. However, contraction stimulation does not involve the insulin signalling intermediate phosphatidylinositol 3-kinase (PI 3-kinase). Protein kinase B (PKB) has recently been identified as a direct downstream target of PI 3-kinase in the insulin signalling pathway. We have examined here whether the two stimuli share PKB as a convergent step in separate signalling pathways. Insulin stimulates both glucose transport, GLUT4 cell-surface content and PKB activity (by 4-6-fold above basal) in a wortmannin-sensitive manner in in vitro incubated rat soleus muscles. By contrast, muscle contraction, which stimulates glucose transport and the cell surface content of GLUT4 by 3-fold above basal levels, had no effect on PKB activity. These data demonstrate that PKB is not a mediator of contraction-induced glucose transport and GLUT4 translocation.

Effect of insulin on GLUT4 cell surface content and turnover rate in human skeletal muscle as measured by the exofacial bis-mannose photolabeling technique

Insulin-stimulated glucose transport across the skeletal muscle cell membrane is a major regulatory step in postprandial glucose disposal. To estimate the total molar concentration of GLUT4 as well as the turnover rate of GLUT4 in human vastus lateralis muscles at the cell surface in the basal state and after insulin exposure, we have applied the sensitive exofacial bis-mannose photolabeling technique on in vitro incubated human skeletal muscle strips from healthy subjects. In addition, we have measured 3-O-methylglucose transport in other muscle strips prepared from the same surgically removed human skeletal muscle biopsies to compare glucose transport with cell surface level of GLUT4. Maximal in vitro insulin stimulation (2,400 pmol/l) resulted in a twofold increase compared with basal in both surface GLUT4 content (0.38 +/- 0.05 vs. 0.19 +/- 0.03 pmol/g wet muscle wt, P < 0.005) and 3-O-methylglucose transport (1.24 +/- 0.13 vs. 0.63 +/- 0.08 pmol x ml(-1) x h(-1), P < 0.005). The insulin-induced increment in 3-O-methylglucose transport was strongly correlated with the insulin-induced increase in cell surface GLUT4 content (r2 = 0.91; P < 0.005). The calculated turnover rate of human skeletal muscle GLUT4 amounted to approximately 8 x 10(4) min(-1) at 35 degrees C and was unaffected by insulin. In conclusion, maximal in vitro insulin stimulation of vastus lateralis muscle strips from healthy subjects resulted in a twofold rise in glucose transport as well as in cell surface content, whereas the turnover rate of GLUT4 was unaffected by insulin under the chosen experimental conditions.

Safe biotechnology. 8. Transport of infectious and biological materials. Working Party "Safety in Biotechnology" of the European Federation of Biotechnology

The transport of infectious and biological material is regulated by a number of international organizations. This mini-review has been compiled to increase awareness within the scientific community of problems caused by differences in terminology (such as infectious materials/substances, biological products, diagnostic specimens, genetically modified microorganisms) and certain technical aspects of the main international guidelines, and to assist policy makers in the creation of harmonized guidelines. A list of relevant Internet resources has been compiled.

Increased circulating leptin concentrations in insulin-resistant first-degree relatives of patients with non-insulin-dependent diabetes mellitus: relationship to body composition and insulin sensitivity but not to family history of non-insulin-dependent diabetes mellitus

OBJECTIVE

To explore a possible association between serum concentration of leptin, insulin sensitivity and non-insulin-dependent diabetes mellitus (NIDDM).

DESIGN

Forty first-degree relatives of NIDDM patients and 35 control subjects matched for age, gender and body mass index underwent a hyperinsulinaemic (insulin infusion rate 0.6 mU/kg per min) euglycaemic clamp combined with indirect calorimetry. Serum leptin was measured in fasting blood samples obtained before the clamp.

RESULTS

All subjects had a normal oral glucose tolerance test. Insulin-stimulated glucose uptake (M) was decreased in the relatives compared with the control subjects (4.58 +/- 0.27 versus 6.06 +/- 0.25 mg/kg per min, P < 0.001). Conversely, serum leptin was increased in the relatives (9.6 x/divided by 1.1 versus 6.1 x/divided by 1.2 ng/ml (geometric mean x/divided by antilog S.E.M.), P < 0.05). A positive correlation was observed between circulating levels of leptin and percentage body fat (P < 0.001) and inverse correlations were found between leptin, M (P < 0.01), maximal aerobic capacity (VO2 max) (P < 0.01), and energy expenditure (P < or = 0.01) in both groups. In multiple linear regression analysis, percentage body fat, gender and M significantly determined the level of leptin (r2 = 0.71, P < 0.001) whereas family history of NIDDM and VO2 max did not.

CONCLUSION

Serum leptin is increased in insulin-resistant offspring of NIDDM patients. The association between leptin, anthropometric measures and insulin sensitivity is, however, comparable with that of a control group. The increased concentrations of serum leptin in the relatives appear to be associated with the insulin resistance, but not with a family history of NIDDM.