Depression symptom outcomes and re-engagement among VA patients who discontinue care while symptomatic

OBJECTIVE

Evaluate outcomes of Veterans who discontinued treatment with at least moderate ongoing depressive symptoms.

METHOD

Veterans with elevated depression symptoms from 29 Department of Veterans Affairs facilities completed baseline surveys and follow-up assessments for one year. Analyses examined rates and predictors of treatment discontinuation, treatment re-engagement, and subsequent symptoms among patients who remained out of care.

RESULTS

A total of 242 (17.8%; n = 1359) participants discontinued treatment while symptomatic, with Black participants, participants with less severe depression, and participants receiving only psychotherapy (versus combined psychotherapy and antidepressant medications) discontinuing at higher rates. Among all participants who discontinued treatment (n = 445), 45.8% re-engaged within the following six months with participants receiving combined treatment re-engaging at higher rates. Of participants who discontinued while symptomatic within the first 6 months of the study and did not return to care (n = 112), 68.8% remained symptomatic at 12 months. Lower baseline treatment expectancy and greater depression symptom severity were associated with remaining symptomatic while untreated.

CONCLUSIONS

Black race, lower symptom severity, and treatment modality may help identify patients at higher risk for discontinuing care while symptomatic, whereas patients with lower treatment expectations may be at greater risk for remaining out of care despite continuing symptoms.

Rezidivvarizen: Progression der Varikosis

Ziel: Welche klinische Bedeutung hat das echte Magnakrossenrezidiv (MKR) im Kontext mit der natürlichen Progression der Varizenkrankheit in einem Kollektiv von Voroperierten (KVO)? Methode: Bei 221 Patienten mit erneuter Varizenbildung bei Zustand nach früher erfolgten Krossektomien mit oder ohne Stripping epifaszialer Varizen werden die MKR und die von ihnen ausgehenden Rezidivvarizen auf ihre klinische und hämodynamische Relevanz hin untersucht und den im Rahmen der Progression der Varikosis neu aufgetretenen Magnakrosseninsuffizienzen (nMKI) gegenübergestellt. Ergebnisse: Neben 112 nMKI bestehen 118 MKR, 46 von ihnen stehen in Verbindung mit einem noch in situ gelegenen Magnastamm (oder kalibermäßig vergleichbarem Gefäß). In 50% lässt sich in diesen Fällen photoplethysmographisch ein pathologischer T0-Wert <19 s nachweisen. 54 MKR, in Verbindung stehend mit unsystematischen Seitenastvarizen oder einer Vena saphena magna accessoria zeigen nur in 24% T0-Werte <19 s (p = 0,014). 39% der MKR erfordern eine erneute operative Revision. Dies entspricht 20% der duplexsonographisch nachgewiesenen MKR und nMKI im KVO. Schlussfolgerung: Die klinische Relevanz der MKR bleibt bescheiden im direkten Vergleich mit der Progression der Varizenkrankheit.

Long-distance dispersal suppresses introgression of local alleles during range expansions

During range expansions, even low levels of interbreeding can lead to massive introgression of local alleles into an invader's genome. Nonetheless, this pattern is not always observed in human populations. For instance, European Americans in North America are barely introgressed by Amerindian genes in spite of known contact and admixture. With coalescent spatially explicit simulations, we examined the impact of long-distance dispersal (LDD) events on introgression of local alleles into the invading population using a set of different demographic scenarios applicable to a diverse range of natural populations and species. More specifically, we consider two distinct LDD models: one where LDD events originate in the range core and targets only the expansion front and a second one where LDD events can occur from any area to any other. We find that LDD generally prevents introgression, but that LDD events specifically targeting the expansion front are most efficient in suppressing introgression. This is likely due to the fact that LDD allows for the presence of a larger number of invader alleles at the wave front, where effective population size is thus increased and local introgressed alleles are rapidly outnumbered. We postulate that the documented settlement of pioneers directly on the wave front in North America has contributed to low levels of Amerindian admixture observed in European Americans and that this phenomenon may well explain the lack of introgression after a range expansion in natural populations without the need to evoke other mechanisms such as natural selection.

New Results from the Search for Low-Mass Weakly Interacting Massive Particles with the CDMS Low Ionization Threshold Experiment

The CDMS low ionization threshold experiment (CDMSlite) uses cryogenic germanium detectors operated at a relatively high bias voltage to amplify the phonon signal in the search for weakly interacting massive particles (WIMPs). Results are presented from the second CDMSlite run with an exposure of 70 kg day, which reached an energy threshold for electron recoils as low as 56 eV. A fiducialization cut reduces backgrounds below those previously reported by CDMSlite. New parameter space for the WIMP-nucleon spin-independent cross section is excluded for WIMP masses between 1.6 and 5.5  GeV/c^{2}.

First direct limits on lightly ionizing particles with electric charge less than e/6

While the standard model of particle physics does not include free particles with fractional charge, experimental searches have not ruled out their existence. We report results from the Cryogenic Dark Matter Search (CDMS II) experiment that give the first direct-detection limits for cosmogenically produced relativistic particles with electric charge lower than e/6. A search for tracks in the six stacked detectors of each of two of the CDMS II towers finds no candidates, thereby excluding new parameter space for particles with electric charges between e/6 and e/200.

Search for low-mass weakly interacting massive particles with SuperCDMS

We report a first search for weakly interacting massive particles (WIMPs) using the background rejection capabilities of SuperCDMS. An exposure of 577 kg days was analyzed for WIMPs with mass <30  GeV/c(2), with the signal region blinded. Eleven events were observed after unblinding. We set an upper limit on the spin-independent WIMP-nucleon cross section of 1.2×10(-42)  cm(2) at 8  GeV/c(2). This result is in tension with WIMP interpretations of recent experiments and probes new parameter space for WIMP-nucleon scattering for WIMP masses <6  GeV/c(2).

Search for low-mass weakly interacting massive particles using voltage-assisted calorimetric ionization detection in the SuperCDMS experiment

SuperCDMS is an experiment designed to directly detect weakly interacting massive particles (WIMPs), a favored candidate for dark matter ubiquitous in the Universe. In this Letter, we present WIMP-search results using a calorimetric technique we call CDMSlite, which relies on voltage-assisted Luke-Neganov amplification of the ionization energy deposited by particle interactions. The data were collected with a single 0.6 kg germanium detector running for ten live days at the Soudan Underground Laboratory. A low energy threshold of 170  eVee (electron equivalent) was obtained, which allows us to constrain new WIMP-nucleon spin-independent parameter space for WIMP masses below 6  GeV/c2.

Silicon detector dark matter results from the final exposure of CDMS II

We report results of a search for weakly interacting massive particles (WIMPS) with the silicon detectors of the CDMS II experiment. This blind analysis of 140.2 kg day of data taken between July 2007 and September 2008 revealed three WIMP-candidate events with a surface-event background estimate of 0.41(-0.08)(+0.20)(stat)(-0.24)(+0.28)(syst). Other known backgrounds from neutrons and 206Pb are limited to <0.13 and <0.08 events at the 90% confidence level, respectively. The exposure of this analysis is equivalent to 23.4 kg day for a recoil energy range of 7-100 keV for a WIMP of mass 10  GeV/c2. The probability that the known backgrounds would produce three or more events in the signal region is 5.4%. A profile likelihood ratio test of the three events that includes the measured recoil energies gives a 0.19% probability for the known-background-only hypothesis when tested against the alternative WIMP+background hypothesis. The highest likelihood occurs for a WIMP mass of 8.6  GeV/c2 and WIMP-nucleon cross section of 1.9×10(-41)  cm2.

Intermediary quantitative traits--an alternative in the identification of disease genes in asthma?

Intermediary quantitative traits are a possible alternative for the identification of disease genes. This may be particularly relevant when diagnostic criteria are not very well defined as described for asthma. We analyzed serum samples from 944 individuals of 218 asthma families for 17 cytokines (eotaxin, GM-CSF, IFNγ, IL1B, IL1RA, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12(p40), IL-13, IL-17, IL-23, IL-33, TSLP and TNF-α) and determined the heritability. Linked chromosomal regions were identified by a genome-wide analysis using 334 autosomal microsatellite marker and association tested by further 550 SNP marker at genes implicated earlier with immune response. Heritability varied with TNF-α and IL-8 levels having the highest and TSLP having the lowest heritability. Linkage was significantly increased only for IL-12(p40) at D17S949. There were multiple significant single-nucleotide polymorphisms (SNP) associations (P<0.05) as found in the transmission disequilibrium test, whereas only a few replicated in parents or children only. These include SNPs in IL1RN that were associated with IL-33 and TSLP levels, and a SNP in NR3C2 that was associated with eotaxin, IL-13 and IFN-γ levels. Circulating level of serum cytokines exhibits genetic associations with asthma traits that are otherwise not detected using clinical diagnosis or when the clinical details are ambiguous.

Irradiation-induced morphea: x-rays as triggers of autoimmunity

We report on 3 females with breast cancer who developed morphea at the site of post-surgery radiotherapy. One was suffering from other autoimmune skin diseases before the diagnosis and treatment of breast cancer. Postirradiation morphea is a potential complication after radiotherapy, particularly radiotherapy for cancer. This troublesome skin disease can occur months to years after treatment, and is associated with remarkable morbidity and pain, and also cosmetic aspects. Therefore, it is crucial to be aware of this condition, and to try to identify patients who might be at an increased risk of developing morphea.

[Chronic venous insufficiency in postthrombotic syndrome and varicose veins]

Venous disorders have a high prevalence and require approximately 1% of health budgets of industrialized countries. The postthrombotic syndrome (PTS) is defined by subjective symptoms and morphologic trophical skin changes following deep venous thrombosis. Prevention of venous thromboembolism in risk situations, easy availability of diagnostic tools (D-dimers, colour-coded duplex sonography) and early detection of deep venous thrombosis, as well as immediate therapeutic anticoagulation along with leg compression during the acute phase and over a two year period of time significantly reduce the incidence of PTS. Chronic venous insufficiency (CVI) includes trophical skin and soft tissue pathologies of the lower leg due to venous hypertension in the distal venous system of the lower extremity. Roughly, two main causes can be distinguished. (A) Deep venous insufficiency (A1 in postthrombotic syndrome; A2 in primary deep venous insufficiency) and (B) superficial venous reflux, usually varicose veins. Compression therapy, surgical ablation of superficial venous reflux, and tangential ablation with split skin graft (shave treatment) of refractory venous ulcers are the mainstays in the treatment of CVI.

Detecting loci under selection in a hierarchically structured population

Patterns of genetic diversity between populations are often used to detect loci under selection in genome scans. Indeed, loci involved in local adaptations should show high F(ST) values, whereas loci under balancing selection should rather show low F(ST) values. Most tests of selection based on F(ST) use a null distribution generated under a simple island model of population differentiation. Although this model has been shown to be robust, many species have a more complex genetic structure, with some populations sharing a recent ancestry or due to the presence of barriers to gene flow between different parts of a species range. In this paper, we propose the use of a hierarchical island model, in which demes exchange more migrants within groups than between groups, to generate the joint distribution of genetic diversity within and between populations. We show that tests not accounting for a hierarchical structure, when it exists, do generate a large excess of false positive loci, whereas the hierarchical island model is robust to uncertainties about the exact number of groups and demes per group in the system. Our approach also explicitly takes into account the mutational process, and does not just rely on allele frequencies, which is important for short tandem repeat (STR) data. An application to human and stickleback STR data sets reveals a much lower number of significant loci than previously obtained under a non-hierarchical model. The elimination of false positive loci from genome scans should allow us to better determine on which specific class of genes selection is operating.

A rare cause for discomfort of the legs

This paper presents two women who visited the phlebology surgery in the opinion that varices would be responsible for their symptoms. Patient 1 complained of nocturnal pain that radiated from the posterior surface of the left thigh to the anterior and lateral surfaces of the knee and lateral aspect of the calf. This pain occurred whenever she changed position. Patient 2 felt numbness in her right foot and an annoying burning sensation in her right heel. She was known to have lumbar discopathy and stenosis of the spinal canal which however, according to neurological diagnosis, could not explain the symptoms. On clinical examination neither had visible nor palpable varices, nor any recognisable dermal signs of venous hypertension. However, it was conspicuous that the left foot of patient 1 barely reached the floor when she was sitting down. In patient 2 the circumference of the right calf was increased by 2 cm.

In both cases a coarse, circumscribed thickening was palpable deep in the posterior surface of the thigh (patient 1) and the proximal calf (patient 2). This was responsible for the asymmetrical posture in sitting of patient 1. Doppler/duplex sonography did not reveal any pathological findings in either patient. Thanks to MRI scans the cause in both cases was found to be a subfascial tumour that was displacing the musculature, thus compressing nervous structures; once in the thigh (patient 1: 600 g), once in the calf (patient 2: 200 g). In both women the symptoms disappeared after surgical extirpation of the clinically and histologically verified lipomas.

An epistemology of patient safety research: a framework for study design and interpretation. Part 3. End points and measurement

This article builds on the previous two articles in this series, which focused on an evaluation framework and study designs for patient safety research. The current article focuses on what to measure as evidence of safety and how these measurements can be undertaken. It considers four different end points, highlighting their methodological advantages and disadvantages: patient outcomes, fidelity, intervening variables and clinical error. The choice of end point depends on the nature of the intervention being evaluated and the patient safety problem it has been designed to address. This paper also discusses the different methods of measuring error, reviewing best practice and paying particular attention to case note review. Two key issues with any method of data collection are ensuring construct validity and reliability. Since no end point or method of data collection is infallible, the present authors advocate the use of multiple end points and methods where feasible.

An epistemology of patient safety research: a framework for study design and interpretation. Part 1. Conceptualising and developing interventions

This is the first of a four-part series of articles examining the epistemology of patient safety research. Parts 2 and 3 will describe different study designs and methods of measuring outcomes in the evaluation of patient safety interventions, before Part 4 suggests that "one size does not fit all". Part 1 sets the scene by defining patient safety research as a challenging form of service delivery and organisational research that has to deal (although not exclusively) with some very rare events. It then considers two inter-related ideas: a causal chain that can be used to identify where in an organisation's structure and/or processes an intervention may impact; and the need for preimplementation evaluation of proposed interventions. Finally, the paper outlines the authors' pragmatist ontological stance to patient safety research, which sets the philosophical basis for the remaining three articles.

An epistemology of patient safety research: a framework for study design and interpretation. Part 2. Study design

This is the second in a four-part series of articles detailing the epistemology of patient safety research. This article concentrates on issues of study design. It first considers the range of designs that may be used in the evaluation of patient safety interventions, highlighting the circumstances in which each is appropriate. The paper then provides details about an innovative study design, the stepped wedge, which may be particularly appropriate in the context of patient safety interventions, since these are expected to do more good than harm. The unit of allocation in patient safety research is also considered, since many interventions need to be delivered at cluster or service level. The paper also discusses the need to ensure the masking of patients, caregivers, observers and analysts wherever possible to minimise information biases and the Hawthorne effect. The difficulties associated with masking in patient safety research are described and suggestions given on how these can be ameliorated. The paper finally considers the role of study design in increasing confidence in the generalisability of study results over time and place. The extent to which findings can be generalised over time and place should be considered as part of an evaluation, for example by undertaking qualitative or quantitative measures of fidelity, attitudes or subgroup effects.

Dose-controlled exposure of A549 epithelial cells at the air-liquid interface to airborne ultrafine carbonaceous particles

The geometry of commercially available perfusion chambers designed for harbouring three membrane-based cell cultures was modified for reliable and dose-controlled air-liquid interface (ALI) exposures. Confluent A549 epithelial cells grown on membranes were integrated in the chamber system and supplied with medium from the chamber bottom. Cell viability was not impaired by the conditions of ALI exposure without particles. Expression of the inflammatory cytokines interleukin 6 and interleukin 8 by A549 cells during ALI exposure to filtered air for 6h and subsequent stimulation with tumor necrosis factor was not altered compared to submersed controls, indicating that the cells maintained their functional integrity. Ultrafine carbonaceous model particles with a count median mobility diameter of about 95+/-5 nm were produced by spark discharge at a stable concentration of about 2 x 10(6) cm(-3) and continuously monitored for accurate determination of the exposure dose. Delivery to the ALI exposure system yielded a homogeneous particle deposition over the membranes with a deposition efficiency of 2%. Mid dose exposure of A549 cells to this aerosol for 6h yielded a total particle deposition of (2.6+/-0.4) x 10(8) cm(-2) corresponding to (87+/-23) ng cm(-2). The 2.7-fold (p < or = 0.05) increased transcription of heme oxygenase-1 indicated a sensitive antioxidant and stress response, while cell viability did not reveal a toxic mechanism.

Patient and surgeon correlates of shared decision making for surgical breast cancer treatment

6031

Background: The choice of surgical breast cancer treatment represents an opportunity for shared decision making (SDM), since both mastectomy and breast conserving surgery are viable options. Yet women vary in their desire for involvement in this decision. Correlates of SDM and/or the level of involvement in breast cancer surgical treatment decision-making are not known. Methods: Breast cancer patients of Detroit and Los Angeles SEER registries were mailed a questionnaire shortly after diagnosis in 2002 (N = 1,800, RR: 77%). Their responses were merged with a surgeon survey (N = 456, RR: 80%) for a dataset of 1,547 patients of 318 surgeons. Surgical treatment decision making was categorized into: 1) surgeon-based; 2) shared; or 3) patient-based. The concordance between a woman’s self-reported actual and desired decisional involvement was categorized as having more, less, or the right amount of involvement. Decision making and concordance were each analyzed as three-level dependent variables using multinomial logistic regression controlling for clustering within surgeons. Independent variables included patient clinical, treatment and demographic factors, surgeon demographic and practice-related factors, and a measure of surgeon-patient communication. Results: 37% of women reported the surgery decision was shared, 25% that it was surgeon-based, and 38% that it was patient-based. Two-thirds experienced the right amount of involvement, while 13% had less and 19% had more. Compared to women who reported a shared decision, those with surgeon-based decision were significantly (p < 0.05) more likely to have male surgeons, and those reporting a patient-based decision were more likely to have received mastectomy vs. breast conserving surgery. Women who were less involved in the surgery decision than they wanted were younger and had less education, while those with more involvement (vs. the right amount) more often had male surgeons. Patient-surgeon communication was associated with decisional involvement. Conclusions: Correlates of SDM and decisional involvement relating to surgical breast cancer treatment differ. Determining patients’ desired role in decision making may as important as achieving a shared decision for evaluating perceived quality of care.

No significant financial relationships to disclose.

Mitochondrial DNA mutations, oxidative stress, and apoptosis in mammalian aging

Mutations in mitochondrial DNA (mtDNA) accumulate in tissues of mammalian species and have been hypothesized to contribute to aging. We show that mice expressing a proofreading-deficient version of the mitochondrial DNA polymerase g (POLG) accumulate mtDNA mutations and display features of accelerated aging. Accumulation of mtDNA mutations was not associated with increased markers of oxidative stress or a defect in cellular proliferation, but was correlated with the induction of apoptotic markers, particularly in tissues characterized by rapid cellular turnover. The levels of apoptotic markers were also found to increase during aging in normal mice. Thus, accumulation of mtDNA mutations that promote apoptosis may be a central mechanism driving mammalian aging.

Die Perforansvenen bei der Entwicklung der epifaszialen Varikosis

AIM

Does it make sense to dissect any incompetent perforator which is found with the color duplex sonography during the preoperative mapping of varicose veins?

PATIENTS AND METHODS

221 patients with recurrent varicose veins were examined by color duplex sonography for new transfascial insufficiencies.

RESULTS

Among 371 transfascial insufficiencies there were 61 (16.4%) incompetent perforators. 31 isolated perforators (25 (9.4%) of 266 legs isolated perforators of the thigh,6 (2.3%) isolated perforators of the calf) were exclusively responsible for the recurrence of varicose veins. 13 incompetent perforators of the calf were associated with additional transfascial insufficiencies,as well as superficial and in 3 cases even deep varicose veins, resulting at an advanced clinical stage (CEAP-classification C3-CS).

CONCLUSION

The dissection of the thigh perforators and the rare isolated perforators of the calf may help to protect from possible and early recurrence.

[Malignant skin tumours in a private dermatology practice. A quality control study]

BACKGROUND AND OBJECTIVE

The campaign for early detection of malignant melanoma and the increase in people with photodamaged skin have a remarkable influence on the daily dermatological routine. Could these factors lead to the introduction of quality control in a private dermatology practice?

PATIENTS AND METHODS

Over a period of one year the diagnoses of all patients were registered. The clinical diagnosis of any skin tumour undergoing surgical removal was compared with the final histopathological diagnosis.

RESULTS

56% of 3004 diagnoses involved females; 44%, males. In 40.5%, the possibility of a pigmented or non-pigmented skin tumour was raised. 49% of the 291 tumours removed were malignant (107 basal cell carcinoma, 20 squamous cell carcinoma, 16 melanoma) while 11.7% were malignant precursor lesions. 48% of 44 melanocytic naevi with clinical atypia showed histopathological dysplasia but none were a malignant melanoma. No cancers were detected among 59 clinically benign tumors. In 71.8% of cases, the clinical diagnosis agreed with the result of the histopathological examination.

CONCLUSIONS

This study shows, in concordance with literature, that a dermatologist can provide high quality treatment and prophylaxis of malignant skin tumours. With an optimal cost-performance ratio, he or she is the most competent partner for patients and health insurance companies.

Palmar digital vein thromboses: their different expressions

There have only been a few reports about thrombotic events in the volar digital veins. The observation of 2 such cases gives reason to discuss this rare symptomatology. Thrombosis of the digital veins can be categorised into three subtypes: the first shows clinical similarity to thrombotic events in veins or varicose veins of the limbs and may be related to a hypercoagulable state; the second group develops in a pre-existing normal vein or an acquired venous cavernoma and does not show clinical or histological signs of inflammation; the third category resembles Mondor's disease and may be named Mondor's phlebitis of the finger; histopathological examination has yet to be done. In any case of thrombosis of the volar digital veins, an inherited or acquired hypercoagulable state must be ruled out.

The effectiveness of budesonide therapy for Crohn's disease

AIM

To assess the effectiveness and safety of budesonide in comparison to corticosteroids, 5-aminosalicylic acid (5-ASA), or placebo for inducing remission of active Crohn's disease and for maintaining remission.

STUDY SELECTION CRITERIA

Randomized controlled trials comparing budesonide to corticosteroids, 5-ASA products or placebo were included. Trials had to report on the effectiveness of treatment (defined as decreasing or maintaining Crohn's Disease Activity Index, CDAI, scores < or = 150) or adverse events.

DATA ANALYSIS

After assessing the validity of study design and independent, duplicate data extraction from selected trials, summary relative risks (RR) were calculated for each outcome. A test of heterogeneity was also calculated for each outcome using a random effects model.

RESULTS

Budesonide was more likely to induce remission than placebo (RR=1.82, 95% CI: 1.15-2.88) or 5-ASA (RR=1.73, 95% CI: 1.26-2.39), although only one trial compared budesonide to 5-ASA products. Although budesonide induced remission less frequently than conventional corticosteroids (RR=0.87, 95% CI: 0.76-0.995), there was no significant difference between conventional corticosteroids and budesonide for inducing remission among patients with a low disease activity (initial CDAI=200-300). Budesonide was significantly less likely to cause corticosteroid-associated adverse events than conventional corticosteroids (RR=0.65, 95% CI: 0.53-0.80). No significant difference in total adverse events or corticosteroid-associated adverse events was demonstrated between budesonide and 5-ASA or placebo.

CONCLUSION

Budesonide is significantly more effective than placebo or 5-ASA for inducing remission of active Crohn's disease. Although budesonide is 13% less effective for the induction of remission in active Crohn's disease than conventional corticosteroids, it is less likely to cause corticosteroid-related adverse effects. Budesonide is ineffective in maintaining remission.

[Myerson nevus as a primary patch of Gibert pityriasis rosea. A case report]

There are only few articles in literature which discuss the association between Meyerson's naevi and Pityriasis rosea. And when so, the discussion is done in a controversial way. Here an 18 year old man is presented who visits the outpatient clinic. He has a ten day history of a solitary Meyerson's naevus on his back. Over the next three weeks this naevus will develop to the typical herold patch followed by the classical exantheme of Pityriasis rosea.

CONCLUSION

Halo dermatitis associated with Pityriasis rosea don't represent Meyerson's naevi. But they reflect the rare "nevocentric" property of a not so rare dermatose.

Hypoxia affects expression of circadian genes PER1 and CLOCK in mouse brain

The key elements of circadian clockwork and oxygen homeostasis are the PAS protein family members PER and CLOCK and hypoxia-inducible factor 1alpha (HIF-1alpha). The PAS domain serves as an interface for protein-protein interactions. We asked whether a cross-talk exists between the PAS components of hypoxic and circadian pathways. We found several isoforms of PER1 protein that exhibit tissue-specific size differences. In the mouse brain, a predominantly nuclear 48 kDa isoform that followed a daily rhythm was observed. The 48 kDa form was found in the nuclear fractions derived from mouse liver, Swiss3T3 fibroblasts, and N2A neuroblastoma cells. In mouse kidney and human 293 kidney cells, a 55 kDa PER1 form was detected. CLOCK was observed as a predicted 100 kDa protein in rat-1 cells and in all analyzed mouse tissues including brain, liver, kidney, and spleen. In contrast to PER1, CLOCK protein expression was not rhythmic. Exposure to hypoxia led to increased PER1 and CLOCK protein levels in mice. Based on coimmunoprecipitation experiments that showed protein-protein interaction between PER1 and the alpha subunit of HIF-1, we suggest that these hypoxic effects may be modulated by HIF-1alpha.-Chilov, D., Hofer, T., Bauer, C., Wenger, R. H., Gassmann, M. Hypoxia affects expression of circadian genes PER1 and CLOCK in mouse brain.

Dissecting hypoxia-dependent and hypoxia-independent steps in the HIF-1alpha activation cascade: implications for HIF-1alpha gene therapy

The heterodimeric hypoxia-inducible factor (HIF)-1 is a master transcriptional regulator of oxygen homeostasis and a possible target for gene therapy of ischemic disease. Although the role of oxygen concentration in HIF-1a protein stabilization is well established, it is less clear whether and how oxygen-regulated mechanisms contribute to HIF-1a protein modifications, nuclear translocation, heterodimerization with the b-subunit, recruitment of cofactors, and gene trans-activation. Because the HIF-1a protein is proteolytically degraded under normoxic conditions, we established two HeLa Tet-Off cell lines (HT42 and HT43), which inducibly overexpress high levels of HIF-1a under normoxic conditions, allowing to distinguish hypoxia-dependent from hypoxia-independent activation mechanisms. Using these cells, we found that normoxically induced HIF-1a is localized to the nucleus, binds DNA, and trans-activates reporter and endogenous target genes. The levels of p53 expression remained unaffected. The MAP kinase inhibitor PD98059 attenuated HIF-1a protein modifications and trans-activation ability but not protein stabilization and DNA-binding activity. Because overexpressed HIF-1a is fully localized to the nucleus but displays only partial DNA-binding and trans-activation activity, mitogen-activated protein kinase-dependent phosphorylation might be required for full HIF-1 activation. HIF-1a protein was also overexpressed in vivo, following the transplantation of HT42 cells into nude mice, demonstrating the feasibility of HIF-1a gene transfer.

Mammalian PASKIN, a PAS-serine/threonine kinase related to bacterial oxygen sensors

The PAS domain is a versatile protein fold found in many archaeal, bacterial, and plant proteins capable of sensing environmental changes in light intensity, oxygen concentration, and redox potentials. The oxygen sensor FixL from Rhizobium species contains a heme-bearing PAS domain and a histidine kinase domain that couples sensing to signaling. We identified a novel mammalian PAS protein (PASKIN) containing a domain architecture resembling FixL. PASKIN is encoded by an evolutionarily conserved single-copy gene which is ubiquitously expressed. The human PASKIN and mouse Paskin genes show a conserved intron-exon structure and share their promoter regions with another ubiquitously expressed gene that encodes a regulator of protein phosphatase-1. The 144-kDa PASKIN protein contains a PAS region homologous to the FixL PAS domain and a serine/threonine kinase domain which might be involved in signaling. Thus, PASKIN is likely to function as a mammalian PAS sensor protein.

[Acne inversa: a dapsone-sensitive dermatosis]

Acne inversa is a chronic disease with a major impact on the quality of life. Therapeutic options were long restricted to local disinfectants and systemic antibiotics, as well as repeated incision and drainage which produce only short term benefits. Retinoids, antiandrogens and radiation therapy are only partially successful. The best approach appears to be surgical removal of the entire apocrine sweat gland apparatus. Dapsone is used in dermatology to treat inflammatory dermatoses such as dermatitis herpetiformis and pyoderma gangrenosum, and was formerly the treatment of choice for acne conglobata. We report its successful use in acne inversa. Five female patients aged 23-40 years with acne inversa for a mean of 9.6 years were included. All patients showed an almost complete resolution of their symptoms within 2-4 weeks. All patients rated the treatment results with dapsone as good or very good. The treatment was well tolerated and no important side effects occurred. Because of its lack of teratogenicity, dapsone may be the most favorable treatment option in young women with acne inversa.

Immunologic characterization of normal human pleural macrophages

Human pleural macrophages (PLM) have been studied in effusions, but little is known about normal human PLM. We therefore analyzed resting human PLM recovered by lavage before lobe resection from patients with a central bronchial tumor, not involving the pleura, and from patients with pulmonary chondroma, intrapulmonary hemorrhage, and pneumothorax. Analysis of surface antigens, phagocytosis capacity, and cytokine production was done in comparison to the regular CD14(++) blood monocytes and the recently described blood monocyte subset CD14(+)CD16(+) monocytes. When defining fluorescence intensity for the various markers on CD14(++) monocytes as 100%, the PLM gave the following pattern: CD14, 45%; CD32, 200%; CD64, 72%; CD11b, 128%; CD33, 74%; CD54, 299%; and HLA-DR, 1,906%. When CD16 on the CD14(+)CD16(+) monocytes was set as 100%, the level of CD16 expression on PLM was 7.7%. Taken together, when compared to blood monocytes, PLM appear to represent a cell-type intermediate of regular CD14(++) monocytes and the CD14(+)CD16(+) subset. In functional studies, we demonstrate that PLM can perform efficient Fc-receptor-mediated phagocytosis of antibody-coated sheep red blood cells. Compared with blood monocytes, the capacity of PLM to produce tumor necrosis factor is similar, but a striking finding in PLM was the constitutive interleukin-10 messenger RNA expression that could not be substantially increased by lipopolysaccharide stimulation. This first characterization of normal, noneffusion human PLM can form the basis for a better interpretation of findings in malignant and inflammatory exudates.

Magnetic phagosome motion in J774A.1 macrophages: influence of cytoskeletal drugs

The role of the different cytoskeletal structures like microfilaments (MF), microtubuli (MT), and intermediate filaments (IF) in phagosome motion is unclear. These cytoskeletal units play an important role in macrophage function (migration, phagocytosis, phagosome transport). We investigated ferromagnetic phagosome motions by cell magnetometry. J774A.1 macrophages were incubated with 1.3-microm spherical magnetite particles for 24 h, after which more than 90% of the particles had been phagocytized. Phagosome motions can be caused either by the cell itself (relaxation) or by applying magnetic twisting forces, yielding cell stiffness and viscoelastic properties of the cytoskeleton. Apparent viscosity of the cytoplasm was non-Newtonian and showed a shear-rate-dependent power law behavior. Elastically stored energy does not force the magnetic phagosomes back to their initial orientation: 57% of the twisting shear was not recoverable. Cytoskeletal drugs, like Cytochalasin D (CyD, 2 - 4 microM), Colchicine (CoL, 10 microM), or Acrylamide (AcL, 40 mM) were added in order to disturb the different cytoskeletal structures. AcL disintegrates IF, but affected neither stochastic (relaxation) nor directed phagosome motions. CyD disrupts MF, resulting in a retarded stochastic phagosome motion (relative decay 0.53 +/- 0.01 after 5 min versus 0.34 +/- 0.01 in control), whereas phagosome twisting shows only a small response with a 9% increase of stiffness and a small reduction of recoverable strain. CoL depolymerizes the MT, inducing a moderately accelerated relaxation (relative decay 0.28 +/- 0.01 after 5 min) and a 10% increase of cell stiffness, where the pure viscous shear is increased and the viscoelastic recoil is inhibited by 40%. Combining the two drugs conserves both effects. After disintegrating either MF or MT, phagosome motion and cytoskeletal stiffness reflect the behavior of either MT or MF, respectively. The results verify that the dominant phagosome transport mechanism is MF-associated. MT depolymerization by CoL induces an activation of the F-actin synthesis, which may induce an accelerated relaxation and an increase of stiffness. Cell mechanical properties are not modulated by MF depolymerization, whereas MT depolymerization causes a loss of viscous resistance and a loss of cell elasticity. The mean energy for stochastic phagosome transport is 5*10(-18) Joules and corresponds to a force of 7 pN on a single 1.3-microm phagosome.

Chirality and circular dichroism of oriented molecules and anisotropic phases

The results of the "Chirality measurement" circular dichroism along different viewing directions within molecules and phases-the anisotropy of circular dichroism can give suitable information in order to check helicity rules or to analyze the suprastructural chirality of films of organic materials, respectively. These results of the ACD spectroscopy (the CD of anisotropic phases and oriented molecules) show that in an oriented state different information about "chirality" will be gained from different viewing directions. ACD measurements of alpha,beta-unsaturated ketosteroids, TADDOLes and binaphthol derivatives were analyzed. The chiral induction of cholesteric phases, the helical twisting power, is introduced as another chirality measurement which may possibly be a new relative method for the determination of the absolute configuration. Copyright 2000 Wiley-Liss, Inc.

32P-postlabeling high-performance liquid chromatography (32P-HPLC) adapted for analysis of 8-hydroxy-2'-deoxyguanosine

8-Hydroxy-2'-deoxyguanosine (8-OH-dG) is a promutagenic lesion in DNA caused by reactive oxygen species. It normally exists at a level of 0.1-1 per 10(5) 2'-deoxyguanosines (dG). To analyze the lesion in easily obtainable biological samples, a very sensitive analytical method is required. The method should also handle the problem with potential oxidation of dG to 8-OH-dG during workup and analysis. 32P-postlabeling high-performance liquid chromatography (32P-HPLC) is an analytical method previously used to analyze lipophilic DNA adducts at levels as low as 1 per 10(9) normal nucleotides when analyzing microgram amounts of DNA. This method was adapted for analysis of 8-OH-dG. The aim was to develop an analytical method that provided a high sensitivity and good reproducibility, prevented oxidation of dG present in samples to 8-OH-dG, was capable of analyzing DNA from very small samples and still offered high sample throughput and ease of use. In analysis of calf thymus DNA, the method had a detection limit of 0.1 8-OH-dG per 10(5) dG when 1 microgram of DNA was used. The standard deviation of repeated analyses of the same sample was +/-10% and the result corresponded well with the established analytical method using HPLC with electrochemical detection. 32P-HPLC is sensitive enough to enable analysis of low levels of 8-OH-dG in biological samples such as small volumes of blood, needle biopsies and tissue swabs. It also substantially reduces oxidation of dG to 8-OH-dG during sample workup and analysis.

Characterization of the Escherichia coli CcmH protein reveals new insights into the redox pathway required for cytochrome c maturation

The CcmH protein of Escherichia coli is encoded by the last gene of the ccm gene cluster required for cytochrome c maturation. A mutant in which the entire ccmH gene was deleted failed to synthesize both indigenous and foreign c-type cytochromes. However, deletion of the C-terminal hydrophilic domain homologous to CycH of other gram-negative bacteria affected neither the biogenesis of indigenous c-type cytochromes nor that of the Bradyrhizobium japonicum cytochrome c550. This confirmed that only the N-terminal domain containing a conserved CXXC motif is required in E. coli. PhoA fusion analysis showed that this domain is periplasmic. Site-directed mutagenesis of the cysteines of the CXXC motif revealed that both cysteines are required for cytochrome c maturation during aerobic growth, whereas only the second cysteine is required for cytochrome c maturation during anaerobic growth. The deficiency of the point mutants was complemented when 2-mercapto-ethanesulfonic acid was added to growing cells; other thiol compounds did not stimulate cytochrome c formation in these strains. We propose a model for the reaction sequence in which CcmH keeps the heme binding site of apocytochrome c in a reduced form for subsequent heme ligation.

Interpreting risk-adjusted length of stay patterns for VA hospitals

OBJECTIVES

The Veterans Health System must become more competitive with the private sector in terms of efficiency of care. Studies have shown significantly longer lengths-of-stay (LOS) in facilities operated by the Department of Veterans Affairs (VA) compared with private sector facilities. Most comparisons, however, have not controlled well for casemix differences or have involved small numbers of patients. The aims of this study were: (1) controlling for casemix, to accurately measure the degree by which average length of stay in Veterans Affairs facilities exceeds that of private sector hospitals and (2) to demonstrate a methodology with which individual VA facilities can identify clinical and demographic subgroups of patients associated with the higher length-of-stay averages.

METHODS

Subjects of the study were Veterans Health System patients hospitalized during 1991-1993 and veteran respondents to the 1991 National Hospital Discharge Survey. Hospitals' mean length of stay adjusted for patients' diagnosis related groups, severity, demographics, and travel distances were measured.

RESULTS

Veterans Affairs medical centers' average risk-adjusted length of stay was 36% higher (8.9 days compared with 6.5 days) than that of the private sector. For individual hospitals, relative length-of-stay efficiency typically varied by condition. Among 14 hospitals in the VA's midwest region, none were high risk-adjusted length-of-stay outliers in all conditions studied, and four were high outliers for some conditions and low outliers for others.

CONCLUSIONS

Controlling for differences in patient demographic and clinical factors, Veterans Affairs medical centers consumed significantly more days of care than private sector hospitals. Veterans Affairs medical centers will be able to improve efficiency by identifying specific subgroups of patients whose clinical treatment should be examined.

Methodological considerations and factors affecting 8-hydroxy-2-deoxyguanosine analysis

Oxidative stress is related to a number of diseases due to the formation of reactive oxygen species (ROS). There are also several substances found in the occupational environment or as life style related situations that generates ROS. A stable biomarker for oxidative stress on DNA is 8-hydroxy-2'-deoxyguanosine (8-OH-dG). A potential problem in the work-up and analysis of 8-OH-dG is oxidation of dG with false high levels as a result of analysis. This paper summarizes and discusses some of the critical moments in terms of auto-oxidation. The removal of transition metals, low temperatures, absence of isotopes (or 2'-deoxyguanosine) and incubation times are all important factors. Removal of oxygen is complicated while the problem is reduced if a nitroxide (TEMPO) is added during work-up. Certain reducing agents and enzymes could be critical if added during work-up. The application of the 32p-HPLC method to analyze 8-OH-dG is discussed. The 32P-HPLC method is suitable for 8-OH-dG analysis and avoids several factors that oxidizes dG by removal of dG before addition of isotopes. Factors of crucial importance (columns, eluents, gradients and detection of 32p) for the analysis of 8-OH-dG are commented upon and certain recommendations are made to make it possible to apply the 32P-HPLC methodology for this type of analysis.

Reduction of oxidation during the preparation of DNA and analysis of 8-hydroxy-2'-deoxyguanosine

The promutagenic base 8-hydroxy-2'-deoxyguanosine (8-OH-dG) in DNA is known to be formed from oxygen radical attack on 2'-deoxyguanosine (dG) as a result of oxidative stress. Formation of 8-OH-dG from dG during workup is strongly dependent on temperature and transition metals and is mediated by oxygen radicals. The 8-OH-dG formation at temperatures between 0 and 140 degrees C for 1.5 h in an "ultrapure" solution followed a third-order equation. Fe2+ in the nM range mediated the formation of 8-OH-dG from dG without addition of H2O2. Fe3+, Cu+, and Cu2+ were shown to have weaker oxidative effects in comparison to Fe2+. The pH (5.0-9.0) had a very limited effect on 8-OH-dG formation. Acid phosphatase, which contains iron at its active site, caused the formation of 8-OH-dG, whereas alkaline phosphatase did not. Phenol was not found to be oxidative. Fe2+-catalyzed formation of 8-OH-dG was completely blocked by the nitroxide 2,2,6,6-tetramethylpiperidine-N-oxyl (TEMPO), whereas DMSO, mannitol, and DMPO had a significantly weaker protecting effect. Catalase cleaved the dG molecule and was not suitable for use. A simple, fast, and inexpensive method for 8-OH-dG workup and analysis was developed, and the background level seen in liver from 13-week-old male Sprague-Dawley rat was 0.23 +/- 0.020 8-OH-dG/10(5) dG, which is up to 200 times lower than reported values from some other methods and up to 26 times lower when compared to other reports using HPLC-EC methods. In summary, the TEMPO method reduces oxidation of dG to 8-OH-dG during workup by (1) using chemicals low in transition metals, (2) using a cold workup procedure, (3) limiting the incubation time, and (4) using the nitroxide TEMPO in all steps.

[Responsibilities of psycho-oncology]

Psychooncology is the application of the biopsychosocial concept with cancer patients. Advising the patient and his circle of relatives and friends in crises, discussing topics important to the patient and negotiating in difficult situations makes it possible for the patient and his relatives and friends to take active part in coping with the illness. This also serves to relieve nurses and physicians in their care of the patient.

[32P]ATP mediates formation of 8-hydroxy-2'-deoxyguanosine from 2'-deoxyguanosine, a possible problem in the 32P-postlabeling assay

8-Hydroxy-2'-deoxyguanosine (8-OH-dG) is a biomarker for oxidative stress on DNA, a common lesion in mammalian cells. A correlation between increased levels of 8-OH-dG and diseases like diabetes, infections and cystic fibrosis has been found in humans. 8-OH-dG levels have been shown to be decreased by antioxidants, an indication of the importance of dietary habits. 8-OH-dG is used as a biomarker for oxidative stress in vivo as well as in vitro and is suggested to be a mutagenic DNA lesion. Different methods are used for the analyses of 8-OH-dG, i.e. GC-MS, HPLC-EC and 32P-postlabeling. The most commonly used method is HPLC-EC. In the analysis of 8-OH-dG, the work-up procedure for DNA, as well as the preparation for analysis, are of critical importance as there is a risk for auto-oxidation of deoxyguanosine (dG), which would result in false high background levels and low sensitivity in analysis. 32P-Postlabeling has recently been applied to the analysis of 8-OH-dG and has shown to be a very sensitive method for the detection of DNA adducts. It is shown here that after extrapolation to normal 32P-postlabeling conditions, [32P]ATP generated 8-OH-dG to levels of 25 8-OH-dG/10(5) dG. [32P]ATP mediated the formation of 8-OH-dG from dG in a dose-dependent manner at all dose levels (0.13-12 microCi). The reaction occurred immediately and increased with time in a linear dose-response fashion. At high doses (6.0 and 12 microCi) the dose-response declined after 24 h, which indicates a possible decomposition or rearrangement of 8-OH-dG. A repeated experiment with 5 microCi [32P]ATP during 2 h resulted in a linear formation of 8-OH-dG and a level of 19 8-OH-dG/10(5) dG. The results indicated that awareness of the auto-oxidation generated by 32P[ATP] in the postlabeling assay is of utmost importance and that dG must be separated before 32P-postlabeling of 8-OH-dG.

How not to miss a somatic needle in the haystack of chronic pain

Interviews with 18 male patients with predominantly psychogenic pain (DSM-III and DSM-III-R) and with 18 male patients with pain of mainly physical origin, consecutively admitted to a medical department, were rated by blinded and independent raters with respect to "symptom description," "manner of speech," "personality characteristics," "interviewer reactions," "interpersonal relationships," and "relationships at work." Patients with predominantly organic pain significantly more often described a clear localization of the pain symptom, used more sensory words for the description of pain quality; more often described discrete changes of pain intensity and periodicity; more often showed pain-intensifying factors dependent on movement and pain-decreasing factors; more often believed pain to be a symptom versus as a disease itself, and tended to have fewer difficulties in their interpersonal relationships than those with predominantly psychogenic pain (p < 0.05 for all factors, two-tailed Fisher's Exact test).