HIV-associated neurocognitive disorder: rate of referral for neurorehabilitation and psychiatric co-morbidity

Despite advances in antiretroviral therapy, HIV-infected patients continue to present with HIV-associated neurocognitive disorder (HAND) which may be associated with significant psychiatric co-morbidity. We audited our patients with HAND referred for psychiatric assessment against the National Service Framework guidelines that they should receive neurorehabilitation. We found that despite these patients posing a risk to themselves and others due to poor insight and medication adherence, high rates of psychiatric co-morbidity and severely challenging behaviour, few were referred for neurorehabilitation. We recommend that clear referral pathways for psychiatric intervention and neurorehabilitation are established in HIV treatment centres.

Waist-to-height ratio is a better screening tool than waist circumference and BMI for adult cardiometabolic risk factors: systematic review and meta-analysis

Our aim was to differentiate the screening potential of waist-to-height ratio (WHtR) and waist circumference (WC) for adult cardiometabolic risk in people of different nationalities and to compare both with body mass index (BMI). We undertook a systematic review and meta-analysis of studies that used receiver operating characteristics (ROC) curves for assessing the discriminatory power of anthropometric indices in distinguishing adults with hypertension, type-2 diabetes, dyslipidaemia, metabolic syndrome and general cardiovascular outcomes (CVD). Thirty one papers met the inclusion criteria. Using data on all outcomes, averaged within study group, WHtR had significantly greater discriminatory power compared with BMI. Compared with BMI, WC improved discrimination of adverse outcomes by 3% (P < 0.05) and WHtR improved discrimination by 4-5% over BMI (P < 0.01). Most importantly, statistical analysis of the within-study difference in AUC showed WHtR to be significantly better than WC for diabetes, hypertension, CVD and all outcomes (P < 0.005) in men and women. For the first time, robust statistical evidence from studies involving more than 300 000 adults in several ethnic groups, shows the superiority of WHtR over WC and BMI for detecting cardiometabolic risk factors in both sexes. Waist-to-height ratio should therefore be considered as a screening tool.

Audit of receptionists' records of symptoms and concurrence with clinician consultation: data collected for the Department of Health

Audit of reliability of data collected by genitourinary (GU) medicine reception staff in north Cumbria for Department of Health mandatory returns suggests that receptionist-logged presence or absence of symptoms does not concur well with subsequent symptom disclosure to clinicians during consultations, even after the use of patient-completed symptom-specific questionnaires. Triage or fast-tracking based upon symptoms in order to select those at risk of sexually transmitted infection (STI) is likely to fail for a significant proportion of patients. Department of Health symptoms data need to be interpreted with caution.

HIV-related posttraumatic stress disorder: investigating the traumatic events

This study examined the relationship between the experience of various HIV-related events (receiving the diagnosis, receiving treatment, experiencing physical symptoms, self-disclosing HIV positive status, and witnessing HIV-related death) and posttraumatic stress symptoms in a sample of 100 gay men living with HIV. Self-report data revealed that 65% met criteria for having experienced a traumatic event in accordance with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) posttraumatic stress disorder (PTSD) criterion A. The experience of shame, humiliation, or guilt during an event was measured but not found to be a significant indicator of having been traumatized. A total of 33% qualified for a PTSD diagnosis. Stepwise multiple regression analysis showed that receiving medical treatment, experiencing physical symptoms, and witnessing HIV-related death were most associated with HIV-related PTSD symptoms. Given that multiple HIV-related events are potentially traumatic, the screening, assessment and treatment for HIV-related PTSD may need to be considered by HIV services.

Measurement of 25-hydroxyvitamin D in the clinical laboratory: current procedures, performance characteristics and limitations

In this review we describe procedures, performance characteristics and limitations of methods available for the measurement of 25-hydroxyvitamin (25OHD) since the year 2000. The two main types of methods are competitive immunoassay and those based on chromatographic separation followed by non-immunological direct detection (HPLC, LC-MS/MS). Lack of a reference standard for 25OHD has, until recently, been a major issue resulting in poor between-method comparability. Fortunately this should soon improve due to the recent introduction of a standard reference material in human serum (SRM 972) from the National Institute of Standards and Technology (NIST). For immunoassay, specificity can be an issue especially in relation to the proportion of 25OHD2 that is quantified whereas HPLC and LC-MS/MS methods are able to measure the two major vitamin D metabolites 25OHD2 and 25OHD3 independently. HPLC and LC-MS/MS require more expensive equipment and expert staff but this can be offset against lower reagent costs. Increasingly procedures are being developed to semi-automate or automate HPLC and LC-MS/MS but run times remain considerably longer than for immunoassays especially if performed on automated platforms. For most HPLC and LC-MS/MS methods extraction and procedural losses are corrected for by the inclusion of an internal standard which, in part, may account for higher results compared to immunoassay. In general precision of immunoassay, HPLC and LC-MS/MS are comparable and all have the required sensitivity to identify severe vitamin D deficiency. Looking to the future it is hoped that the imminent introduction of a standard reference method (or methods) for 25OHD will further accelerate improvements in between method comparability.

Trends in energy and sugar intakes and body mass index between 1983 and 1997 among children in Great Britain

BACKGROUND

It has been suggested that rising obesity among children is partly attributable to sugary foods and soft drinks driving an increase in energy intake (EI). Yet historical data on sugar intake are sparse. The present study calculated total sugar intake de novo among 3296 children aged 10-11 and 14-15 years in 1983 and compared EI, macronutrients and sugar sources with data from 459 children of same age in the 1997 National Diet and Nutrition Survey.

METHODS

Secondary analysis of 7-day weighed diet records and anthropometric data from two British surveys. Compositional data on sugars applied to individual food codes to calculate sugar intake and sources for 1983. Trends examined before/after adjustment for low/high energy reporting (LHER) defined as EI : basal metabolic rate <1.16 or >2.65.

RESULTS

Mean EI (kJ day(-1)) was 7% lower in 1997 than in 1983, mainly as a result of lower fat intake. After excluding LHER, mean EI was 3% lower in 1997. Mean body mass index (BMI) increased by 0.7-1 kg m(-2) (2-3 kg). Total sugar intake averaged 115 g day(-1) in 1983 and 113 g day(-1) in 1997 (122 versus 127 g day(-1) excluding LHER, P = 0.08). Excluding LHER, fat energy was lower in 1997 (35.4% versus 37.8%) and sugars slightly higher (23.6% versus 22.3%). Sugar sources showed a marked shift away from table sugar with smaller falls in milk, biscuits and cakes, counterbalanced by an significant increase in sugar from soft drinks and, to a lesser extent, fruit juice and breakfast cereals.

CONCLUSIONS

Although the study design precludes drawing causal inferences regarding nutrient intake and obesity, a higher prevalence of under-reporting and lower levels of physical activity in 1997 could explain the paradox of lower reported EI and rising BMI.

Dynamics of cognitive change in impaired HIV-positive patients initiating antiretroviral therapy

OBJECTIVE

To rigorously evaluate the time course of cognitive change in a cohort of individuals with HIV-associated neurocognitive disorders (HAND) initiating combination antiretroviral therapy (CART), and to investigate which demographic, laboratory, and treatment factors are associated with neuropsychological (NP) outcome (or "any NP improvement").

METHODS

Study participants included 37 HIV+ individuals with mild to moderate NP impairment who initiated CART and underwent NP testing at 12, 24, 36, and 48 weeks thereafter. NP change was assessed using a regression-based change score that was normed on a separate NP-stable group thereby controlling for regression toward the mean and practice effect. Mixed-effect regression models adjusting for loss to follow-up were used to evaluate the time course of cognitive change and its association with baseline and time-varying predictors.

RESULTS

In persons with HAND initiating CART, cognitive improvement happens soon after initiation (13% at week 12), but more often 24, 36, and up to 48 weeks after initiation (up to 41%), with fewer than 5% demonstrating significant worsening. In multivariate analyses, unique predictors of NP improvement included more severe baseline NP impairment and higher CART CNS penetration index. Greater viral load decrease was associated with NP improvement only in univariate analyses.

CONCLUSION

Clinically meaningful neuropsychological improvement seemed to peak around 24-36 weeks after combination antiretroviral therapy initiation and was prolonged over the 1-year study period. This study also provides new evidence that benefit may be maximized by choosing antiretroviral medications that reach therapeutic concentrations in the CNS.

Survey of public perceptions of prion disease risks in Canada: what does the public care about?

A national public survey on public perceptions of prion disease risk in Canada was conducted from October to December 2007. The survey aimed at documenting the public's perceptions of prion diseases, within the broader context of food safety, in establishing parameters of risk acceptability. It also documented the public's perceptions of prion diseases in delineating social values and ethics that can guide Canada's future policies on prion disease risk management. In addition, the survey served to establish baseline data against which to monitor the evolution of the public's views on and understanding of this important risk issue. In total, 1517 Canadians were randomly selected to be representative of the adult population by region, age, and gender, as per the 2001 Census. This study presents descriptive findings from the survey regarding perceived risk, perceived control, uncertainty, sources of information, trust and knowledge, and beliefs pertaining to bovine spongiform encephalopathy (BSE). The survey data reveal that Canadians do not perceive mad cow disease as a salient risk but consider it more of an economic, political, social, and foreign trade issue than a public health one. Canadians are somewhat prepared to pay a premium to have a safer food supply, but not to the same extent that they desire extra measures pertaining to BSE risk management. In the context of increasing accountability in risk management decisions about food safety and population health issues, it is important to understand the way Canadians perceive such matters and identify their information needs and the factors that influence the acceptability of risks and of risk management policies.

Hepatitis C is associated with type 2 diabetes mellitus in HIV-infected persons without traditional risk factors

OBJECTIVES

Hepatitis C virus (HCV) monoinfection has been linked to type 2 diabetes mellitus (DM). We evaluated the effect of HCV on risk of DM in relation to traditional risk factors such as age, body mass index (BMI) and family history of DM in an HIV-infected population.

METHODS

This was a retrospective, cross-sectional study of 1529 HIV-infected out-patients. An adjusted multivariate logistic regression was performed to assess the effect of HCV seropositivity on DM stratified by low and high propensity for DM based on age, BMI and family history.

RESULTS

Race, age, BMI, family history and HCV were associated with DM. Use of protease inhibitors (PIs) was not associated with DM, but HIV/HCV-coinfected patients were less likely to be on PIs than those with HIV infection alone. In a multivariate analysis controlled for race, the association between HCV and DM was stronger in lean, young patients without a family history of DM; the low-risk group. No association between HCV and type 2 DM was seen in patients who were older or overweight or had a family history of DM; the high-risk group. PI use did not affect the association between HCV and DM.

CONCLUSIONS

Hepatitis C is an independent risk factor for type 2 diabetes in young, lean, HIV-infected patients. HIV-infected patients with HCV infection, regardless of whether they are on PIs, should be carefully screened for DM even if traditional risk factors for DM are not present.

Platelet-derived growth factor receptors and ligands are up-regulated in paediatric fibromatoses

AIMS

Platelet-derived growth factors (PDGF) and their receptors (PDGFR) play an essential role in pathways involved in the regulation of cell proliferation, growth and function. Overexpression of PDGF/R is reported in a wide range of solid tumours. The aim was to determine levels of PDGF/R expression in paediatric fibromatoses and myofibromatosis.

METHODS AND RESULTS

Quantitative real-time polymerase chain reaction was used to examine the expression level of alpha and beta isoforms of PDGF/R in 17 fibromatoses, four myofibromatoses and three dermatofibrosarcoma protuberans (DFSP) in children. Fifteen of 17 (88%) fibromatoses and all myofibromatoses and DFSPs demonstrated increased expression of PDGFalpha and beta compared with a panel of normal tissues. In terms of the cognate receptors, 13/17 (76%) fibromatoses demonstrated increased expression for PDGFRalpha and Rbeta, whereas 3/4 myofibromatoses demonstrated increased expression of PDGFRalpha and all four had increased PDGFRbeta expression. All DFSPs were associated with increased expression of both PDGFRalpha and PDGFRbeta compared with normal control tissues.

CONCLUSIONS

Increased expression of PDGF/Ralphabeta may play an important role in the mechanism of growth of these paediatric fibromatous lesions and warrants further investigation, since novel therapeutic interventions could potentially be developed in the light of the expression patterns.

Investigation of the effect of a countywide protected learning time scheme on prescribing rates of ramipril: interrupted time series study

BACKGROUND

Protected learning time (PLT) schemes have been set up in primary care across the UK. There is little published evidence of their effectiveness.

OBJECTIVE

To investigate the effect of a PLT intervention for general practice to increase prescribing of ramipril for prevention of cardiovascular outcomes.

DESIGN

Quasi-experimental, interrupted time series.

SETTING

Lincolnshire, UK.

METHODS

Prescribing data were analysed one year before and after the education for change in rate of increase of prescribing of ramipril, whether change in prescribing was related to postulated explanatory variables and to determine intervention costs.

MAIN OUTCOME

The primary outcome was the rate of change of ramipril (10 mg) prescription items 12 months after compared with before the educational intervention. Secondary outcomes included cost.

RESULTS

Ramipril prescribing at therapeutic dosage increased significantly (odds ratio 1.50, 95% CI 1.07-1.93) following education by 52,345 items (31,132 items at 10 mg) at a cost of pound 292k to pound 460k depending on formulation. This occurred despite a background of secular change. Most practices were represented by GPs, nurses or both during the education. Single-handed GPs were less likely to attend. Practices showed considerable variation in response to the educational intervention. The only predictor of whether practices increased in prescribing rate after the education was whether a practice nurse had undertaken specific diabetes training. Total list size, dispensing, training or single-handed status and GP attendance did not predict a change in prescribing.

CONCLUSION

PLT schemes can contribute to beneficial changes in prescribing across a large geographical area.

Prolonged function of macrophage, von Willebrand factor-deficient porcine pulmonary xenografts

Porcine von Willebrand factor (vWF) activates human and primate platelets. Having determined the importance of pulmonary intravascular macrophages (PIMs) in pulmonary xenotransplantation, we evaluated whether, in the absence of PIMs, vWF might play a role in pulmonary xenograft dysfunction. Utilizing a left single-lung transplant model, baboons depleted of anti-alphaGal antibodies received lungs from either vWF-deficient (n = 2); MCP-expressing (n = 5); MCP PIM-depleted (n = 5); or vWF-deficient PIM-depleted swine (n = 3). Two out of three of the PIM-depleted, pvWF deficient grafts survived longer than any previously reported pulmonary xenografts, including PIM-depleted xenografts expressing human complement regulatory proteins. Depletion of PIM's from vWF-deficient lungs, like depletion of PIM's from hMCP lungs, resulted in abrogation of the coagulopathy associated with pulmonary xenotransplantation. Thus, in terms of pulmonary graft survival, control of adverse reactions involving pvWF appears to be equally or even more important than is complement regulation using hMCP expression. However, based on the rapid failure of PIM-sufficient, pvWF-deficient pulmonary xenografts, pVWF-deficient pulmonary xenografts appear to be particularly sensitive to macrophage-mediated damage. These data provide initial evidence that vWF plays a role in the 'delayed' (24 h) dysfunction observed in pulmonary xenotransplantation using PIM depleted hMCP organs.

Risk of malignancy associated with chronic lymphocytic leukemia: A population based Canadian study

20020

Background: Patients with Chronic Lymphocytic Leukemia (CLL) may have an increased risk of other malignancies. Available literature reports on malignancies that develop after the diagnosis of CLL, but does not discuss malignancies that precede the diagnosis of CLL. Methods: All patients diagnosed with CLL between 01/1998 and 12/2003 were extracted from the provincial cancer registry and a centralized flow cytometry database. All other malignancies were obtained from the cancer registry. Dates of diagnoses were compared. A malignancy within 30 days before or after the diagnosis of CLL was considered synchronous with that diagnosis. Results were compared with the age-adjusted incidence of cancer in the province, excluding CLL. Results: Of the 713 cases of CLL, 333 invasive cancers and 38 in situ neoplasia were identified before, synchronous to, or after the diagnosis of CLL. Synchronous malignancies occurred in 4% of cases. The Standardized Incidence Ratio (SIR) for other malignancy subsequent to CLL was 1.40 (95% confidence interval [CI] 1.09–1.80) derived from 65 tumors for males, and 1.29 (95% CI 0.90–1.80) from 35 tumors for females. Mean time to diagnosis of subsequent cancer was 2.0 years (standard deviation[SD] 1.5). The SIR for other malignancy in the 5 years preceding the diagnosis of CLL was 1.36 (95% CI 0.93–1.94) from 31 tumors for males and 0.77 (95% CI 0.54–1.08) from 35 tumors for females. Mean time from diagnosis of preceding malignancy to CLL was 9.4 years (SD 8.7). Conclusions: In this population based study, patients with CLL are at increased risk of other invasive and in situ cancers. This risk is apparent after but not before the diagnosis of CLL, particularly in males. The mechanism of this increased risk may be acquired with the presence of CLL through an underlying but undetermined mechanism, as opposed to an inherent or more longstanding predisposition to malignancy.

No significant financial relationships to disclose.

Expression of ETV6-NTRK in classical, cellular and mixed subtypes of congenital mesoblastic nephroma

AIM

Congenital mesoblastic nephroma (CMN) is the commonest renal tumour of infancy, with classical, cellular and mixed histological subtypes described. A specific ETV6-NTRK3 fusion-gene product is reported in association with the cellular variant. The aim was to investigate the relationship between the presence of this product and morphological phenotype using paraffin-embedded archival material.

METHODS AND RESULTS

Cases of CMN from a single centre during a 15-year period (1989-1994) were identified, anonymized and blindly classified using morphological criteria. RNA was extracted from frozen and paraffin sections for both conventional reverse transcriptase-polymerase chain reaction (RT-PCR) and quantitative real-time RT-PCR. Fifteen samples were analysed; two were non-informative and three expressed ETV6-NTRK3 using both techniques, two showing similar expression, whilst one showed expression two orders of magnitude lower, from a cellular tumour. All fusion positive cases were previously classified as cellular subtype. Six patients had mixed-subtype tumours in which the cellular components, morphologically indistinguishable from cellular tumours, were fusion negative, as were all classical cases.

CONCLUSIONS

Real-time PCR Taqman assays, using both fixed and frozen tissue, provide highly reproducible detection and quantification of fusion transcript expression. Differences in expression levels may explain previous conflicting data on fusion gene detection in these tumours.

On judgment and judgmentalism: how counselling can make people better

Counsellors, like other members of the caring professions, are required to practise within an ethical framework, at least in so far as they seek professional accreditation. As such, the counsellor is called upon to exercise her moral agency. In most professional contexts this requirement is, in itself, unproblematic. It has been suggested, however, that counselling practice does present a problem in this respect, in so far as the counsellor is expected to take a non-judgemental stance and an attitude of "unconditional positive regard" toward the client. If, as might appear to be the case, this stance and attitude are at odds with the making of moral judgments, the possibility of an adequate ethics of counselling is called into question. This paper explores the nature and extent of the problem suggesting that, understood in a Kantian context, non-judgmentalism can be seen to be at odds with neither the moral agency of the counsellor nor that of the client. Instead, it is argued, the relationship between the non-judgmental counsellor and her client is a fundamentally moral relationship, based on respect for the client's unconditional worth as a moral agent.

The importance of metabolic rate and the folly of body surface area calculations

Mathematical formulae to calculate body surface area from measurements of height, weight and other parameters date from the late 19th century. Drug doses, fluid therapy, caloric requirements and physiological parameters such as cardiac output, glomerular filtration rate and a variety of respiratory function parameters are all frequently expressed in terms of a body surface area. Body surface area is often used in preference to body mass (weight). However, the original rationale for using body surface area as an estimate for metabolic rate has never been tested and the algorithms used to approximate body surface area have little evidence to support their use in this role. Recent developments in technology using indirect calorimetry allow easy measurement of metabolic rate in the clinical setting. Such measurements should be used for standardisation when weight alone is considered inadequate.

Dietary sugars and micronutrient dilution in normal adults aged 65 years and over

OBJECTIVE

To examine the relationship between non-milk extrinsic sugars (NMES) concentration and micronutrient intakes and status in free-living older people.

DESIGN

The National Diet and Nutrition Survey of people aged 65 years and over; a cross-sectional study in Britain in 1994/5.

SUBJECTS AND METHODS

Eight hundred and six men and women living in private households who were not on medication for nutritional disorders. Subjects were classified into four groups (Q1 to Q4), using cut-off points corresponding to quartiles of energy from NMES. Relationships were examined between dietary NMES concentration and intakes of calcium, iron, riboflavin, folate, vitamin C and vitamin D. Status indices were also assessed in each group.

RESULTS

Overall, a small proportion of men and women had intakes below the Lower Reference Nutrient Intake (LRNI) for calcium, iron, folate, riboflavin or vitamin C, while vitamin D intakes were universally low. Intakes of micronutrients tended to be highest at moderate levels of NMES in the diet (Q2 and Q3, equivalent to 8-15% of energy from NMES). Micronutrient status was low for riboflavin in 38% of the sample, while 15% had low vitamin C status and more than 10% were anaemic. There was little evidence that poorer nutrient status was associated with higher levels of dietary NMES. Although some indices of folate status were lower in Q4, this is most likely to reflect confounding by smoking. Energy intake accounted for 20-40% of the variance in micronutrient intakes, compared with less than 5% for NMES concentration.

CONCLUSIONS

A diet moderately high in NMES (up to around 15% of energy) is unlikely to have a detrimental impact on micronutrient intake or status in this age group. Energy intake is the major determinant of micronutrient adequacy.

Comparison of test characteristics of urine dipstick and urinalysis at various test cutoff points

STUDY OBJECTIVE

We compare the test characteristics of urine dipstick and urinalysis at various test cutoff points in women presenting to emergency departments and an intermediate care center with symptoms of urinary tract infection.

METHODS

This was a prospective, observational study of adult women presenting to 1 of 2 community hospital EDs or an intermediate care center with dysuria, urgency, or urinary frequency on history, or suprapubic or costovertebral angle tenderness on examination. Patients who had taken antibiotics in the past 72 hours, had indwelling Foley catheters, symptomatic vaginal discharge, diabetes mellitus, immunodeficiency disorders, or were unable to provide a reliable history were excluded. The patient's clean-catch or catheterized urine specimen was tested immediately by a nurse using a Multistix 9 SG reagent strip. A second aliquot was sent within 1 hour of collection to the hospital laboratory, where a semiautomated microscopic urinalysis and a urine culture were performed. A positive urine culture was defined as more than 100,000 colonies of 1 or 2 uropathogenic bacteria per mL of urine at 48 hours. Dipstick and urinalysis data were compared with urine culture results. Sensitivity, specificity, and predictive values were calculated at various definitions of a positive test, or "test cutoff points," for combinations of leukocyte esterase, nitrite, and blood on dipstick and for RBCs and WBCs on urinalyses. The probability of an erroneous decision to withhold treatment on the basis of a negative test result was defined as "undertreatment," or 1 minus the negative predictive value. "Overtreatment" was defined as 1 minus the positive predictive value.

RESULTS

Three hundred forty-three patients were enrolled in this study. Twelve patients were withdrawn because of missing laboratory results. Forty-six percent (152/331) of patients had positive urine cultures. If urine dipstick results are defined as positive when leukocyte esterase or nitrite is positive or blood is more than trace, the overtreatment rate is 47% (156/331) and the undertreatment rate is 13% (43/331). If urinalysis results are defined as positive when WBCs are more than 3 per high-power field or RBCs are more than 5 per high-power field, the overtreatment rate is 44% (146/331) and the undertreatment rate is 11% (36/331). Matched pairs of test characteristics were identified when the analysis was repeated using more than 10,000 colonies per mL as a positive culture.

CONCLUSION

In this patient population, similar overtreatment and undertreatment rates were identified for various test cutoff points for urine dipstick tests and urinalysis. Although a urine dipstick may be equivalent to a urinalysis for the diagnosis of urinary tract infection, the limitations in the diagnostic accuracy of both tests should be incorporated into medical decisionmaking.

Rapid irreversible G protein alpha subunit misfolding due to intramolecular kinetic bottleneck that precedes Mg2+ "lock" after GTP/GDP exchange

Stoichiometric exchange of GTP for GDP on heterotrimeric G protein alpha (Galpha) subunits is essential to most hormone and neurotransmitter initiated signal transduction. Galphas are stably activated in a Mg2+ complex with GTPgammaS, a nonhydrolyzable GTP analogue that is reported to bind Galpha, with very high affinity. Yet, it is common to find that substantial amounts (30-90%) of purified G proteins cannot be activated. Inactivatable G protein has heretofore been thought to have become "denatured" during formation of the obligatory nucleotide-free or empty (MT) Galpha-state that is intermediary to GDP/GTP exchange at a single binding site. We find Galpha native secondary and tertiary structure to persist during formation of the irreversibly inactivatable state of transducin. MT Galpha is therefore irreversibly misfolded rather than denatured. Inactivation by misfolding is found to compete kinetically with protective but weak preequilibrium nucleotide binding at micromolar ambient GTPgammaS concentrations. Because of the weak preequilibrium, quantitative protection against Galpha aggregation is only achieved at free nucleotide concentrations 10-100 times higher than those commonly employed in G protein radio-nucleotide binding studies. Initial GTP protection is also poor because of the extreme slowness of an intramolecular Galpha refolding step (isomerization) necessary for GTP sequestration after its weak preequilibrium binding. Of the two slowly interconverting Galpha x GTP isomers described here, only the second can bind Mg2+, "locking" GTP in place with a large net rise in GTP binding affinity. A companion Galpha x GDP isomerization reaction is identified as the cause of the very slow spontaneous GDP dissociation that characterizes G protein nucleotide exchange and low spontaneous background activity in the absence of GPCR activation. Galpha x GDP and Galpha x GTP isomerization reactions are proposed as the dual target for GPCR catalysis of nucleotide exchange.

Discovery and SAR of org 24598-a selective glycine uptake inhibitor

The discovery of Org 24598, one of the first potent and selective inhibitors of the glycine transporter is discussed. In vitro structure-activity relationships (SARs) data for interaction of a ligand with this system is discussed.

No association of an interleukin 4 gene promoter polymorphism with Graves' disease in the United Kingdom

Graves' disease (GD) is an autoimmune thyroid disease of unknown etiology, although predisposition to the development of this disease is thought to be caused by both genetic and environmental factors. Recently, an association between a promoter polymorphism of the interleukin 4 gene and GD has been reported. A C-T base change at position -590 showed modest protection against the development of GD in a United Kingdom data set of 135 patients with GD and 101 controls. This polymorphism was, therefore, investigated in a much larger case-control cohort of 384 patients with GD and 288 control subjects using PCR, followed by restriction fragment length polymorphism analysis. No protective effect of the T allele of this polymorphism was observed in our data set, and indeed no significant difference in either allelic or genotypic distribution was seen between the patient and control groups. Moreover, calculation of probabilities indicate that the original study lacked sufficient power to support the conclusions drawn. Our data support the hypothesis that the C-T promoter polymorphism of the interleukin 4 gene does not confer protection against the development of GD in Caucasians in the United Kingdom.

Episodic Evolution of Growth Hormone in Primates and Emergence of the Species Specificity of Human Growth Hormone Receptor

Growth hormone (GH) evolution is very conservative among mammals, except for primates and ruminant artiodactyls. In fact, most known mammalian GH sequences differ from the inferred ancestral mammalian sequence by only a few amino acids. In contrast, the human GH sequence differs from the inferred ancestral sequence by 59 amino acids. However, it is not known when this rapid evolution of GH occurred during primate evolution or whether it was due to positive selection. Also, human growth hormone receptor (GHR) displays species specificity; i.e., it can interact only with human (or rhesus monkey) GH, not with nonprimate GHS: The species specificity of human GHR is largely due to the Leu-->Arg change at position 43, and it has been hypothesized that this change must have been preceded by the His-->Asp change at position 171 of GH. Is this hypothesis true? And when did these changes occur? To address the above issues, we sequenced GH and GHR genes in prosimians and simians. Our data supported the above hypothesis and revealed that the species specificity of human GHR actually emerged in the common ancestor of Old World primates, but the transitional phase still persists in New World monkeys. Our data showed that the rapid evolution of primate GH occurred during a relatively short period (in the common ancestor of higher primates) and that the rate of change was especially high at functionally important sites, suggesting positive selection. However, the nonsynonymous rate/synonymous rate ratio at these sites was <1, so relaxation of purifying selection might have played a role in the rapid evolution of the GH gene in simians, possibly as a result of multiple gene duplications. Similar to GH, GHR displayed an accelerated rate of evolution in primates. Our data revealed proportionally more amino acid replacements at the functionally important sites in both GH and GHR in simians but, surprisingly, showed few coincidental replacements of amino acids forming the same intermolecular contacts between the two proteins.

Nutritional status in elderly female hip fracture patients: comparison with an age-matched home living group attending day centres

Fractured neck of femur occurs mostly in the older female population and is generally caused by falls. Malnutrition has been postulated as a factor that increases the tendency to suffer falls. Nutritional status of older female hospital patients admitted for emergency surgery for fractured neck of femur recruited (n 75), was compared with an age-matched independent-living group of females attending one of three local day centres (n 50). Dietary assessment was undertaken using three consecutive 24 h dietary recalls and, in the hip fracture group, completed menu cards were used as memory prompts. Data concerning key lifestyle characteristics were obtained using a face-to-face administered questionnaire. Blood samples were taken to determine levels of plasma albumin, transferrin, C-reactive protein (CRP), cholesterol, vitamin C, Se, Zn and total antioxidant status. Haemolysate samples were analysed for Se-dependent glutathione peroxidase activity. There were no significant differences in age between the two groups, but the hip fracture patients had lower mean values for body weight (59.6 v. 67.5 kg; mindex (weight/demispan) (83.1 v. 94.4 kg/m; calculated BMI (24.1 v. 27.5 kg/m2 mid-upper arm circumference; 27.1 v. 31.3 cm, and triceps skinfold thickness; 17.0 v. 18.9 mm, than the home-living group. The hip fracture patients had lower intakes of energy (4.3 v. 5.4 MJ, fat carbohydrate protein thiamine vitamin B6 calcium K Mg P Fe Se and NSP Mean intakes of both groups were below the estimated average requirement for energy and below the reference nutrient intakes for folate, Ca, vitamin D, Mg, K, Se and Zn. In a high percentage of the hip fracture group the dietary intake of particular nutrients fell below the lower reference nutrient intake for Se (73 %), Mg (54 %) and Fe (19 %). As expected, the fracture patients had reduced plasma albumin and increased CRP values. They had higher plasma vitamin C levels and lower cholesterol levels than the day centre attendees. There were no significant differences in plasma levels of Se, Zn, transferrin or haemolysate glutathione peroxidase activity between the two groups. However, there was evidence of under-nutrition in both groups as key anthropometric values were low, plasma nutrient and metabolite levels were below the standard reference ranges and many individuals had low dietary intakes for specified nutrients.

A randomized controlled trial of the effects of multi-sensory stimulation (MSS) for people with dementia

OBJECTIVES

To investigate short-term effects of Multi-Sensory Stimulation (MSS) on behaviour, mood and cognition of older adults with dementia, the generalization of effects to day hospital and home environments and the endurance of any effects over time.

DESIGN

A randomized controlled trial comparing MSS with a credible control of one-to-one activities.

METHODS

Fifty patients with diagnoses of moderate to severe dementia were randomized to either MSS or Activity groups. Patients participated in eight 30-minute sessions over a 4-week period. Ratings of behaviour and mood were taken before, during and after sessions to investigate immediate effects. Pre, mid, post-trial, and follow-up assessments were taken to investigate any generalization of effects on cognition, behaviour at the day hospital and behaviour and mood at home and endurance of effects once sessions had ceased.

RESULTS

Immediately after MSS and Activity sessions patients talked more spontaneously, related better to others, did more from their own initiative, were less bored/inactive, and were more happy, active or alert. Both groups were more attentive to their environment than before, with a significantly greater improvement from the MSS group. At the day hospital, patients in the Activity group improved on their 'speech skills' (amount of speech; initiation of speech), whereas the MSS group remained unchanged during the trial. The MSS group showed a significant improvement in mood and behaviour at home compared to the Activity group whose behaviour deteriorated. No longer-term benefits were shown; indeed, behaviour declined sharply during the month follow-up period.

CONCLUSIONS

Both MSS and Activity sessions appear to be effective and appropriate therapies for people with dementia.

Reovirus-induced apoptosis is mediated by TRAIL

Members of the tumor necrosis factor (TNF) receptor superfamily and their activating ligands transmit apoptotic signals in a variety of systems. We now show that the binding of TNF-related, apoptosis-inducing ligand (TRAIL) to its cellular receptors DR5 (TRAILR2) and DR4 (TRAILR1) mediates reovirus-induced apoptosis. Anti-TRAIL antibody and soluble TRAIL receptors block reovirus-induced apoptosis by preventing TRAIL-receptor binding. In addition, reovirus induces both TRAIL release and an increase in the expression of DR5 and DR4 in infected cells. Reovirus-induced apoptosis is also blocked following inhibition of the death receptor-associated, apoptosis-inducing molecules FADD (for FAS-associated death domain) and caspase 8. We propose that reovirus infection promotes apoptosis via the expression of DR5 and the release of TRAIL from infected cells. Virus-induced regulation of the TRAIL apoptotic pathway defines a novel mechanism for virus-induced apoptosis.

Dental caries in pre-school children: associations with social class, toothbrushing habit and consumption of sugars and sugar-containing foods. Further analysis of data from the National Diet and Nutrition Survey of children aged 1.5-4.5 years

This project examined the relative significance of dietary sugars, toothbrushing frequency and social class as predictors of caries experience (caries vs. no caries) among 1,450 British pre-school children who took part in the National Diet and Nutrition Survey. This cross-sectional survey was based on a representative sample of children aged 1.5-4.5 years studied in 1992/3. Children were classified into four groups according to social class and toothbrushing habit. Diet/caries associations were examined for biscuits and cakes, sugar confectionery, chocolate confectionery and soft drinks, and the percentage of energy from non-milk extrinsic sugars, using data on amount and frequency of consumption from 4-day weighed dietary records. In stepwise logistic regressions, the strength of the association between social class and caries experience was twice that between toothbrushing and caries, and nearly three times that between sugar confectionery and caries (other dietary variables were not significant). The association of caries with sugar confectionery (both in amount and frequency) was only present among children whose teeth were brushed less than twice a day. Toothbrushing frequency appeared to have a stronger impact on caries prevention in non-manual compared with manual children. Household expenditure on confectionery was associated with caries only among children from the manual group. The findings suggest the hypothesis that regular brushing (twice a day) with a fluoride toothpaste may have greater impact on caries in young children than restricting sugary foods.

Delayed recurrence of hepatocellular carcinoma after liver transplantation: detection of origin by chromosomal analysis

We report on a 41-year-old man undergoing liver transplantation for chronic hepatitis C who presented 26 months later with hepatocellular carcinoma. No evidence of hepatocellular carcinoma could be found in the native liver, although features of small cell dysplasia were prominent. Although he had recurrent hepatitis C, the transplanted liver was not cirrhotic. Chromosomal analysis was used to resolve whether this was a de novo tumor or a recurrence of an unsuspected tumor present at the time of transplantation. This male patient had received a liver from a female donor, and in situ hybridization for the Y chromosome showed reactivity in the tumor but not in surrounding nontumorous liver. Thus, this is an example of the use of chromosomal analysis to resolve the origin of a tumor occurring in the transplant setting.

Antisense-mediated inhibition of the bcl-2 gene induces apoptosis in human malignant glioma

BACKGROUND

The bcl-2 protooncogene represses a number of cellular apoptotic pathways and is known to be expressed in increasing amounts in glial tumors of higher malignancy. We tested whether antisense oligonucleotides to the bcl-2 gene would affect glioma cell viability.

METHODS

Antisense oligonucleotides directed to the first six codons of the human bcl-2 gene, and nonsense oligonucleotides as a control, were transfected into malignant glioma cells. Two human Bcl-2 positive glioblastoma cell lines from our tumor bank (Jon52 and Roc) were both transfected in vitro with bcl-2 antisense (AS) and nonsense (NS) oligonucleotides at 1 microm and 5 microm concentrations for 5 and 24 hr. Cell viability was assessed at 2, 4, 5, and 7 days by using an MTT mitogenic assay and by cell counting via direct visualization using a hemocytometer.

RESULTS

There was up to a log-fold decrease in cell growth of the bcl-2 AS treated cells compared to the NS transfected cells for both Roc (p = 0.007 and p = 0.004) and Jon52 (p = 0.02 and p = 0.004) at 5 and 24 hr of transfection. There was as much as 50% cytotoxicity in both glioblastoma cell lines at 1 microm and 5 microm concentrations after 24 hr transfection with AS bcl-2 oligonucleotides (all p < 0.01). Western blot analysis demonstrated a decrease in the expression of the Bcl-2 protein in one cell line, whereas there was a statistically significant increase in the apoptotic index of both cell lines (p < 0.05 by chi square analysis).

CONCLUSIONS

Our results suggest that transfection of human glioma cells with antisense bcl-2 results in an increase in apoptotic death. This provides evidence that Bcl-2 plays a role in tumor progression of glioma by acting as an oncogene, and suggests that inhibition of the bcl-2 gene could have a therapeutic effect.

Pain and hyperalgesia in osteoarthritis of the hands

OBJECTIVE

Tissue damage and pain can lead to a change in the stimulus/response characteristics of the nociceptive system. Hyperalgesia has been described in experimental pain states and some clinical conditions, but has not been investigated in osteoarthritis (OA). We sought to establish the presence of hyperalgesia at the thumb in subjects with OA of the hand and to explore any relationship between sensitivity to extrinsic stimuli and the experience of clinical pain.

METHODS

Subjects with OA of the hand were divided into groups according to their pain profile. The sample also included pain-free OA cases and pain-free controls. Intensity ratings were obtained for each of 3 types of pain: continuous pain, incident pain, and movement pain. Thermal and mechanical detection and pain thresholds were measured over the forearm and the carpometacarpal joint of the thumb.

RESULTS

Lower thermal and mechanical pain thresholds were evident over the thumb relative to forearm in the groups with persistent pain. Subjects complaining only of incident pain, pain-free OA cases, and pain-free controls did not exhibit regional differences in sensitivity to thermal and mechanical stimuli. Increased ratings of continuous pain were associated with lower thermal and mechanical pain thresholds. Variance in movement pain ratings was predicted by mechanical forearm pain thresholds.

CONCLUSION

OA in the hands is associated with cutaneous and deep hyperalgesia to thermal and mechanical stimuli. Increased levels of continuous pain are associated with more pronounced hyperalgesia. The associations of movement pain suggest the contribution of central mechanisms in the stimulus/response changes accompanying movement pain.