The Industrial Resurgence of Southern California? Advanced Ground Transportation Equipment Manufacturing and Local Economic Development

Southern California is in a deeply rooted process of economic restructuring. Much of the region's manufacturing base is made up of two groups of industries: A declining aerospace–defense sector, and a low-wage, low-skill sweatshop sector. What are the prospects for creating a growing manufacturing base focused on high-wage, high-skill industries? In this paper we examine the opportunities presented by the Los Angeles County Metropolitan Transportation Authority's $183 billion thirty-year capital improvement plan as the potential catalyst of a set of technological and manufacturing synergies that would reorient the regional economy towards a new advanced ground transportation equipment industry. We investigate the dynamics of agglomerated complexes of industry in general, and the institutional and infrastructural arrangements that create and sustain competitive advantage within regional economic systems. Next, we evaluate the potential for the successful development of a technologically dynamic advanced ground transportation equipment industry in Southern California. This central part of the analysis focuses on (a) the existing industrial assets of the region, (b) specific forms of institution building that need to be carried out in the interests of local economic development and high-quality job creation, and (c) the importance of building a cooperative, high-trust manufacturing system. We then offer suggestions for specific types of policy intervention that might foster new forms of local economic growth. We argue that a coordinated response by both the public and the private sectors could conceivably set the region on a successful new economic development trajectory.

Abstract 1019: Investigation of cabozantinib, a MET and VEGFR2 inhibitor, on tumor metabolism and efficacy in a colorectal cancer patient-derived tumor explant model

Background:

Anti-angiogenic therapy is commonly used for the treatment of metastatic colorectal cancer (mCRC). Although patients derive some clinical benefit, treatment resistance inevitably occurs. Upregulation of MET in response to anti-VEGF therapy may play an essential role in treatment resistance. Based on this premise, we investigated cabozantinib, an inhibitor of kinases including MET and VEGFR2, in mCRC patient-derived tumor explant (PDTX) models. Based on initial observations of anti-tumor activity, we hypothesized that cabozantinib may alter tumor metabolism concurrent with its antitumor effects, and compared its efficacy with regorafenib in our models.

Material and Methods:

Ten CRC PDTX models were treated with cabozantinib (30 mg/kg daily) or regorafenib (10 mg/kg daily) and treatment responses were determined after 28 days. The tumor growth inhibition index (TGII) was calculated to compare treatment effects on tumor growth between cabozantinib and regorafenib. RNA Seq was used to assess gene expression and pathways modulated by cabozantinib treatment. Proteins involved in metabolism and autophagy were evaluated by immunoblotting at day 3, 7 and 28. The effects of cabozantinib on tumor glucose metabolism were investigated by 18FDG-PET at baseline, 7 and 28 days following treatment. Lastly, combination effects of cabozantinib and an ULK1 inhibitor, an autophagy inhibitor, were evaluated on the HCT116 cell line by a clonogenic assay.

Results:

Cabozantinib (average TGII: 3.202) demonstrated antitumor effects among all 10 CRC explants that compared favorably to regorafenib (average TGII: 48.48). In addition, cabozantinib significantly reduced glucose uptake measured by 18FDG-PET at days 7 and 28. A comprehensive pathway analysis using RNA Seq post-cabozantinib treatment revealed a significant reduction in pyruvate metabolism and the TCA cycle in the most sensitive tumors. Protein analyses showed downregulation of hexokinase 1 and pyruvate dehydrogenase and a marked increase in many components of oxidative phosphorylation and autophagy (LC3 and Beclin) at day 7 and 28 following cabozantinib treatment. The combination of an ULK1 inhibitor and cabozantinib enhanced the activity of cabozantinib in the HCT116 CRC cell line.

Conclusions:

Cabozantinib showed significant antitumor activity compared to regorafenib in our CRC PDTX models. Alterations in glucose metabolism and autophagy were identified in cabozantinib sensitive tumors, suggesting that a shift in cellular metabolism facilitates the survival of tumor cells following treatment. The combination effect of cabozantinib and an ULK1 inhibitor supports the hypothesis that induction of autophagy may be a mechanism of cabozantinib resistance. These findings support further evaluation of cabozantinib in patients with mCRC.

Acknowledgements: Exelixis for providing cabozantinib.

Citation Format: Aaron J. Scott, Rachel Yahn, Stacey Bagby, Kendra Huber, Natalie Serkova, Wells Messersmith, John Arcaroli. Investigation of cabozantinib, a MET and VEGFR2 inhibitor, on tumor metabolism and efficacy in a colorectal cancer patient-derived tumor explant model. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1019.

Completion of hand-written surgical consent forms is frequently suboptimal and could be improved by using electronically generated, procedure-specific forms

INTRODUCTION

Completion of hand-written consent forms for surgical procedures may suffer from missing or inaccurate information, poor legibility and high variability. We audited the completion of hand-written consent forms and trialled a web-based application to generate modifiable, procedure-specific consent forms.

METHODS

The investigation comprised two phases at separate UK hospitals. In phase one, the completion of individual responses in hand-written consent forms for a variety of procedures were prospectively audited. Responses were categorised into three domains (patient details, procedure details and patient sign-off) that were considered "failed" if a contained element was not correct and legible. Phase two was confined to a breast surgical unit where hand-written consent forms were assessed as for phase one and interrogated for missing complications by two independent experts. An electronic consent platform was introduced and electronically-produced consent forms assessed.

RESULTS

In phase one, 99 hand-written consent forms were assessed and the domain failure rates were: patient details 10%; procedure details 30%; and patient sign-off 27%. Laparoscopic cholecystectomy was the most common procedure (7/99) but there was significant variability in the documentation of complications: 12 in total, a median of 6 and a range of 2-9. In phase two, 44% (27/61) of hand-written forms were missing essential complications. There were no domain failures amongst 29 electronically-produced consent forms and no variability in the documentation of potential complications.

CONCLUSION

Completion of hand-written consent forms suffers from wide variation and is frequently suboptimal. Electronically-produced, procedure-specific consent forms can improve the quality and consistency of consent documentation.

Apatinib: a promising oral antiangiogenic agent in the treatment of multiple solid tumors

Aberrant proangiogenic pathways have long been implicated in tumorigenesis and metastasis. Antiangiogenic therapies have shown efficacy in the treatment of a variety of solid tumors including lung, breast, colon, glioblastomas, and other solid tumor types. Apatinib, a small-molecule inhibitor of vascular endothelial growth factor receptor-2 (VEGFR-2), is an orally bioavailable agent currently being studied in multiple tumor types. Apatinib has shown a survival benefit in gastric cancer in a phase III trial and non-small cell lung cancer in a phase II trial. With a favorable side effect profile and improved outcomes, apatinib has demonstrated a substantial potential to augment therapeutic options in a variety of tumor types.

A phase II/III randomized study to compare the efficacy and safety of rigosertib plus gemcitabine versus gemcitabine alone in patients with previously untreated metastatic pancreatic cancer

BACKGROUND

Rigosertib (ON 01910.Na), a first-in-class Ras mimetic and small-molecule inhibitor of multiple signaling pathways including polo-like kinase 1 (PLK1) and phosphoinositide 3-kinase (PI3K), has shown efficacy in preclinical pancreatic cancer models. In this study, rigosertib was assessed in combination with gemcitabine in patients with treatment-naïve metastatic pancreatic adenocarcinoma.

MATERIALS AND METHODS

Patients with metastatic pancreatic adenocarcinoma were randomized in a 2:1 fashion to gemcitabine 1000 mg/m(2) weekly for 3 weeks of a 4-week cycle plus rigosertib 1800 mg/m(2) via 2-h continuous IV infusions given twice weekly for 3 weeks of a 4-week cycle (RIG + GEM) versus gemcitabine 1000 mg/m(2) weekly for 3 weeks in a 4-week cycle (GEM).

RESULTS

A total of 160 patients were enrolled globally and randomly assigned to RIG + GEM (106 patients) or GEM (54). The most common grade 3 or higher adverse events were neutropenia (8% in the RIG + GEM group versus 6% in the GEM group), hyponatremia (17% versus 4%), and anemia (8% versus 4%). The median overall survival was 6.1 months for RIG + GEM versus 6.4 months for GEM [hazard ratio (HR), 1.24; 95% confidence interval (CI) 0.85-1.81]. The median progression-free survival was 3.4 months for both groups (HR = 0.96; 95% CI 0.68-1.36). The partial response rate was 19% versus 13% for RIG + GEM versus GEM, respectively. Of 64 tumor samples sent for molecular analysis, 47 were adequate for multiplex genetic testing and 41 were positive for mutations. The majority of cases had KRAS gene mutations (40 cases). Other mutations detected included TP53 (13 cases) and PIK3CA (1 case). No correlation between mutational status and efficacy was detected.

CONCLUSIONS

The combination of RIG + GEM failed to demonstrate an improvement in survival or response compared with GEM in patients with metastatic pancreatic adenocarcinoma. Rigosertib showed a similar safety profile to that seen in previous trials using the IV formulation.

Risk stratification by the Appendicitis Inflammatory Response score to guide decision-making in patients with suspected appendicitis

BACKGROUND

Current management of suspected appendicitis is hampered by the overadmission of patients with non-specific abdominal pain and a significant negative exploration rate. The potential benefits of risk stratification by the Appendicitis Inflammatory Response (AIR) score to guide clinical decision-making were assessed.

METHODS

During this 50-week prospective observational study at one institution, the AIR score was calculated for all patients admitted with suspected appendicitis. Appendicitis was diagnosed by histological examination, and patients were classified as having non-appendicitis pain if histological findings were negative or surgery was not performed. The diagnostic performance of the AIR score and the potential for risk stratification to reduce admissions, optimize imaging and prevent unnecessary explorations were quantified.

RESULTS

A total of 464 patients were included, of whom 210 (63·3 per cent) with non-appendicitis pain were correctly classified as low risk. However, 13 low-risk patients had appendicitis. Low-risk patients accounted for 48·1 per cent of admissions (223 of 464), 57 per cent of negative explorations (48 of 84) and 50·7 per cent of imaging requests (149 of 294). An AIR score of 5 or more (intermediate and high risk) had high sensitivity for all severities of appendicitis (90 per cent) and also for advanced appendicitis (98 per cent). An AIR score of 9 or more (high risk) was very specific (97 per cent) for appendicitis, and the majority of patients with appendicitis in the high-risk group (21 of 30, 70 per cent) had perforation or gangrene. Ultrasound imaging could not exclude appendicitis in low-risk patients (negative likelihood ratio (LR) 1·0) but could rule-in the diagnosis in intermediate-risk patients (positive LR 10·2). CT could exclude appendicitis in low-risk patients (negative LR 0·0) and rule-in appendicitis in the intermediate group (positive LR 10·9).

CONCLUSION

Risk stratification of patients with suspected appendicitis by the AIR score could guide decision-making to reduce admissions, optimize utility of diagnostic imaging and prevent negative explorations.

Dielectric response of pentagonal defects in multilayer graphene nano-cones

The dielectric response of pentagonal defects in multilayer graphene nano-cones has been studied by electron energy loss spectroscopy and ab initio simulations. At the cone apex, a strong modification of the dielectric response is observed below the energy of the π plasmon resonance. This is attributed to π → π* interband transitions induced by topology-specific resonant π bonding states as well as π*-σ* hybridization. It is concluded that pentagonal defects strongly affect the local electronic structure in such a way that multi-walled graphene nano-cones should show great promise as field emitters.

Extended interplanar linking in graphite formed from vacancy aggregates

The mechanical and electrical properties of graphite and related materials such as multilayer graphene depend strongly on the presence of defects in the lattice structure, particularly those which create links between adjacent planes. We present findings which suggest the existence of a new type of defect in the graphite or graphene structure which connects adjacent planes through continuous hexagonal sp2 bonding alone and can form through the aggregation of individual vacancy defects. The energetics and kinetics of the formation of this type of defect are investigated with atomistic density functional theory calculations. The resultant structures are then employed to simulate high resolution transmission electron microscopy images, which are compared to recent experimental images of electron irradiation damaged graphite.

A moving target: challenges in treating BRAF-mutant colorectal cancer

SUMMARY Biomarker-oriented clinical studies have shown mounting evidence for improved efficacy with targeted therapy. Unfortunately, single-agent BRAF inhibition has shown limited efficacy in patients with metastatic BRAF-mutant colorectal cancer. Multiple mechanisms for potential BRAF inhibitor resistance demonstrate the complex biology behind tumorigenesis in colorectal cancer and highlight the obstacles of acquired and intrinsic drug resistance in treating this disease. Biomarker-related strategies with potential predictive value for specific molecular anomalies offer the possibility for improved targeted agents and rational combinations. Synthetic lethality gene array has become a major focus in current research for developing such agents. Combination therapy based on molecular profiles may further enhance individualized patient care.

Weight gain and lipid-glucose profiles among patients taking antipsychotic medications: comparisons for prescriptions administered using algorithms versus usual care

The purpose of this study was to determine if treatment strategy had a significant effect on the occurrence of physiological changes consistent with metabolic syndrome and/or type 2 diabetes in patients using atypical antipsychotic medications. The four variables assessed were: weight gain, fasting blood sugar, triglycerides and cholesterol. The two strategies compared were (1) evidence-based practice, derived from the Texas Medication Algorithm Project, and (2) practitioner preference. A retrospective chart review was performed on patients diagnosed with a chronic psychiatric disorder being treated with atypical antipsychotics. The dates of the reviewed records were from 1 January 2008 to 31 December 2008. The sample of patients totaled 113. Statistical analysis included logistic regression for each of the four variables assessed. The use of evidence-based practice guidelines was found to have strong positive effects on two of the four variables assessed. Further studies need to be conducted to include medications being taken to lower lipids and blood sugar. Overall, the use of evidence-based practice guidelines has a positive effect on weight, triglycerides and cholesterol. It is important that patients be closely monitored and changes made in a timely manner to minimize adverse effects of atypical antipsychotics.

Social determinants of health among African Americans in a rural community in the Deep South: an ecological exploration

INTRODUCTION

African Americans living in rural USA experience multiple health disparities as a result of both race and rural geography. An increasing literature suggests that social determinants of health, the social contexts in which people live their lives, are key contributors to these health disparities. Ecological theory provides a valuable conceptual framework for exploring social determinants of health in communities, but few US rural health community-based studies have utilized this approach, or engaged ecological theory to explore rural contexts. This exploratory study blended a community-based, qualitative approach with ecological theory with the objective of identifying potential social determinants of health among African Americans in a rural community in the Deep South, from the perspectives of participants.

METHODS

In-depth interviews were conducted with rural, Deep South African Americans participants who were purposefully sampled to incorporate a range of perspectives. Interview guides structured around five ecological levels (individual, relational, environmental, structural, and superstructural) were used to frame interviews. Iterative content analysis of interview transcripts and field notes identified potential social determinants of health. An 'editing' approach to content analysis was used. Data and analysis quality was tested by triangulation at the level of the researcher, and by member checking with community members.

RESULTS

Potential determinants of health were identified at all five levels of the ecological framework. At the individual level, lack of engagement with personal health and health promotion was a recurring theme. Participation in preventive health activities and education was minimal, even when offered in community settings. At the relational level, lack of social capital emerged as another potential social determinant of health, with estrangement between the younger and elder generations as one source, and fractiousness among churches (key institutions in the community) representing another. At the environmental level, the community built environment was an area of concern as it lacked opportunities for physical activity and access to healthy foods. The local job environment was identified as a potential social determinant of health, given the strong ties between income and health. At the structural level, participants complained of cronyism and nepotism favoring Whites in access to jobs, including those where local policies and funding allocations were made (eg funding for the local health department). In education, school system tracking policies were perceived to discourage African Americans from university education. At the superstructural level, high rates of poverty and racism emerged as potential social determinants. Poverty directly limited many African Americans' access to quality health care, and subtle racism was perceived in some delivery of care. Persistent stress from poverty and racism was reported, which creates health risks through physiologic pathways.

CONCLUSION

This study identified potential social determinants of health, at multiple ecological levels, among African Americans in a rural community in the Deep South. The social determinants identified had the ability to impact a variety of health behaviors and health outcomes. The results demonstrate the value of this approach to conducting rural, community-based research. This descriptive and exploratory study highlights the need for quantitative exploration of these issues, as well as the development of context-appropriate, community-based health interventions that address multiple ecological levels.

Design effects associated with dietary nutrient intakes from a clustered design of 1 to 14-year-old children

OBJECTIVE

To calculate intra-cluster and intra-household design effects and intra-class correlation coefficients for dietary nutrients obtained from a 24 h record-assisted recall.

DESIGN

Children were recruited using clustered probability sampling. Randomly selected starting-point addresses were obtained with probability proportional to mesh block size.

SETTING

Children aged 1-14 years in New Zealand.

SUBJECTS

There were 125 children in 50 clusters, giving an average of 2.498 children per cluster. In 15 homes, there were two children for the calculation of intra-household statistics.

RESULTS

Intra-cluster design effects ranged from 1.0 for cholesterol, beta-carotene, vitamin A, vitamin D, vitamin E, selenium, fructose and both carbohydrate and protein expressed as their contribution to total energy intakes to 1.552 for saturated fat, with a median design effect of 1.148. Their corresponding intra-cluster correlations ranged from 0 to 0.37, respectively. Intra-household design effects ranged from 1.0 for height to 1.839 for vitamin B(6), corresponding to intra-household correlations of 0 and 0.839. The median intra-household design effect was 1.550. Using a sampling design of two to three households per cluster for estimating dietary nutrient intakes would need, on average, a 15% increase in sample size compared with simple random sampling with a maximum increase of 55% to cover all nutrients.

CONCLUSIONS

These data enable sample sizes for dietary nutrients to be estimated for both cluster and non-cluster sampling for children aged 1-14 years. The larger design effects found within households suggest that little extra information may be obtained by sampling more than one child per household.

Family-specific approaches to the analysis of case-control family data

Case-control studies augmented by the values of responses and covariates from family members allow investigators to study the association between the response and genetics and environment by relating differences in the response directly to within-family differences in covariates. However, existing approaches for case-control family data parameterize covariate effects in terms of the marginal probability of response, the same effects that one estimates from standard case-control studies. This article focuses on the estimation of family-specific covariate effects and develops efficient methods to fit family-specific models such as binary mixed-effects models. We also extend the approach to cover any setting where one has a fully specified model for the vector of responses in a family. We illustrate our approach using data from a case-control family study of brain cancer and consider the use of weighted and conditional likelihood methods as alternatives.

Electron energy-loss near-edge structure -- a tool for the investigation of electronic structure on the nanometre scale

Electron energy-loss near-edge structure (ELNES) is a technique that can be used to measure the electronic structure (i.e. bonding) in materials with subnanometre spatial resolution. This review covers the theoretical principles behind the technique, the experimental procedures necessary to acquire good ELNES spectra, including potential artefacts, and gives examples relevant to materials science.

Respiratory sinus arrhythmia in persons with organic solvent exposure: comparisons with anxiety patients and controls

Persons exposed to organic solvents have psychiatric symptomatology and cognitive impairments. The results of several studies have suggested that some psychiatric symptoms in these patients reflect similar reactions observed in patients with anxiety disorders. Respiratory sinus arrhythmia provides an indication of impaired autonomic functioning. Whereas decreased respiratory sinus arrhythmia has been reported in anxiety patients, investigators have also noted that higher respiratory rates in these patients obscure differentiation of respiratory sinus arrhythmia from normal values. In this study, the authors recorded multiple parameters of respiratory sinus arrhythmia under a paced-breathing condition in 28 patients with solvent exposure, in 18 patients with anxiety disorder, and in 31 controls. The authors observed a high 1-y retest reliability for a subset of the subjects. Significantly reduced respiratory sinus arrhythmia was observed in both anxiety and solvent-exposed patients, compared with controls. Maximum mean heart rates/cycle did not differ among groups, but minimum heart rates were significantly lower for controls than for the two patient groups. The findings suggested that reduced respiratory sinus arrhythmia among patients is not related to higher maximum rates but, rather, to a decrease in vagally mediated alteration associated with respiratory changes observed in both patient groups.

Shift work and health

Night work and rotating shift work disrupt the circadian timing system. This disruption may produce significant deleterious symptoms in some workers. Certain medical conditions may be aggravated by shift-work scheduling, and shift workers are at increased risk of experiencing cardiovascular, gastrointestinal, and reproductive dysfunction. Vulnerable individuals may develop clinical depression when working shifts. Primary care practitioners may intervene by providing medical surveillance and educational programs for shift-working patients and their families.

Monitoring internalization of Histoplasma capsulatum by mammalian cell lines using a fluorometric microplate assay

We have developed a fluorometric microtiter plate assay to quantify the internalization of Histoplasma capsulatum yeasts by macrophages. The assay utilizes the fluorescent dye Calcofluor White to label the yeast cell wall and the vital dye trypan blue, which does not enter viable macrophages, to quench fluorescence of extracellular labeled yeasts. Murine RAW 264.7 cells showed more efficient internalization of strain G217B yeasts than human U937 cells. Both cell lines exhibited a dependence upon actin, and, to a lesser degree, microtubules, in G217B uptake.

A simple method for analysing overdispersion in clustered Poisson data

A simple method is proposed for analysing grouped count data exhibiting overdispersion relative to a Poisson model. The method is similar to the approach suggested for the analysis of clustered binary data in Rao and Scott (1992). It requires no specific model for the overdispersion and it can be implemented easily using standard programs designed to handle independent Poisson counts, after a small amount of preprocessing.

The impact of influenza and influenza-like illness on productivity and healthcare resource utilization in a working population

Four hundred and eleven subjects who either reported to Occupational Health at onset of influenza or influenza-like illness (I/ILI) symptoms or on return to work completed questionnaires on entry to the study and after 28 days. On average they were incapacitated or confined to bed for 2.4 days, missing 2.8 days from work per episode of illness. On return to work, they reported reduced effectiveness and inability to resume normal activity until a mean 3.5 days after the onset of symptoms. Each participant reported a mean of 6.5 I/ILI symptoms. There was a positive correlation between the number of symptoms and bed days (r = 0.24) and missed work days (r = 0.18). There was a positive correlation between the number of healthcare contact and the number of reported symptoms (r = 0.23). A relatively high level of contact with general practitioners and pharmacists was observed and there was substantial use of both prescription and over-the-counter medication. In conclusion, the impact of I/ILI on productivity in a working population and the resultant cost to employers and employees may be considerable.

Aqueous solubilization of transmembrane peptide sequences with retention of membrane insertion and function

We recently reported that the peptide C-K4-M2GlyR mimics the action of chloride channels when incorporated into the apical membrane of cultured renal epithelial monolayers. C-K4-M2GlyR is one of a series of peptides that were prepared by the addition of lysine residues to the N- or C-terminus of the M2 transmembrane sequence of the brain glycine receptor. This study addresses how such modifications affect physical properties such as aqueous solubility, aggregation, and secondary structure, as well as the ability of the modified peptides to form channels in epithelial monolayers. A graded improvement in solubility with a concomitant decrease in aggregation in aqueous media was observed for the M2GlyR transmembrane sequences. Increases in short-circuit current (I(SC)) of epithelial monolayers were observed after treatment with some but not all of the peptides. The bioactivity was higher for the more soluble, less aggregated M2GlyR peptides. As described in our previous communication, sensitivity of channel activity to diphenylamine-2-carboxylate, a chloride channel blocker, and bumetanide, an inhibitor of the Na/K/2Cl cotransporter, was used to assess changes in chloride selectivity for the different assembled channel-forming peptides. The unmodified M2GlyR sequence and the modified peptides with less positive charge are more sensitive to these agents than are the more highly charged forms. This study shows that relatively insoluble transmembrane sequences can be modified such that they are easier to purify and deliver in the absence of organic solvents with retention of membrane association, insertion, and assembly.

Re-using data from case-control studies

Despite its ability to maximize statistical power while keeping data collection costs to a minimum, case-control sampling provides a non-representative sample of the population. When fitting a logistic regression model to data obtained in such a study, using the variable stratifying the population as the response, it is well known that the estimate of the constant term will be biased, but those of the coefficients of the covariates will not. However, subsequent to the case-control study, it is often desired to conduct a secondary analysis, using a variable that was previously a covariate in the main study as the response. If this new response is associated with the original variable used to stratify the population into cases and controls, a conventional logistic regression analysis will usually result in biased estimates of all the regression coefficients, not just the constant. This situation has recently been studied by Nagelkerke et al. who describe some situations where no bias occurs. In this paper we discuss how to calculate maximum likelihood estimates of all the regression coefficients, in the situation where the sampling rates for cases and controls are known. An example using data from the New Zealand Cot Death Study is presented.

Suppression of an inhibitory jaw reflex by the anticipation of pain in man

Electromyographic recordings (EMGs) were made from the active masseter muscle, of the inhibitory reflex evoked by application of electrical stimuli to the skin of the upper lip in 15 human subjects. In control sequences, the reflex had a mean latency and duration (+/- S.E.M.) of 45.4 +/- 1.3 msec and 47.9 +/- 2.8 msec, respectively. Significant decreases in the reflex as well as increases in heart rate and anxiety levels assessed by a visual analogue scale, occurred when the subjects were stressed by the anticipation of receiving painful electrical stimuli above the ankle (P < 0.00005; Student's t-tests). During such sequences, the magnitude of the reflex measured by integration of the EMG, was reduced by 47.7 +/- 5.6%. This effect involved a reduction in both the duration and depth of the inhibitory wave. It occurred regardless of whether the painful stimuli were applied during or after the recording of the reflex and of whether the baseline activity in the muscle was inadvertently raised or lowered during the stressful sequences. It is concluded that stress induced by the anticipation of pain, can markedly reduce an inhibitory jaw reflex in man by exerting an influence on the reflex pathway prior to the motoneurones.

A comparison of methods for correlated ordinal measures with ophthalmic applications

For many clinical trials and epidemiologic investigations in the field of ophthalmology, paired ordinal data are often collected through the detailed grading of retinal photographs. One method for analysis of these data is the extension of the generalized estimating equation (GEE) methodology to multinomial data with cumulative link functions. Prior to the development of this advanced technique, however, ophthalmologists developed a method of combining the ordinal responses of both eyes of a patient into a single person-level response on a new ordinal scale. A relationship between the regression coefficients of these two methods is derived as a function of the correlation between eyes. We investigate the applicability of this result and the relationship of the standard errors in simulation experiments and in an example from the Wisconsin Epidemiologic Study of Diabetic Retinopathy.

Tests for trend in developmental toxicity experiments with correlated binary data

In this article, the operating characteristics of recently proposed tests for trend in correlated binary data arising in laboratory studies of developmental toxicity are examined using both computer-generated and experimental data. Specifically, we consider adjusted Cochran-Armitge tests based on the Rao-Scott transformation which are of the same general form as that for uncorrelated data. In addition, generalized score tests based on generalized estimating equations allowing for extrabinomial variation in the data are discussed. Specific forms of these statistics demonstrating favorable type I and type II error rates are identified and recommended for use in practice. The application of these tests is illustrated using data from studies of developmental toxicity that have been reported in the literature.

Microalbuminuria in a middle-aged workforce. Effect of hyperglycemia and ethnicity

OBJECTIVE

To determine the prevalence of microalbuminuria in a mixed, ethnic population and to find the extent that ethnic variation in microalbuminuria can be explained by abnormal glucose metabolism, obesity, hypertension, hypertriglyceridemia, and life-style factors.

RESEARCH DESIGN AND METHODS

Urinary albumin concentrations were measured in 5467 middle-aged Maori, Pacific Islander, and European workers who participated in a health-screening survey of 46 New Zealand companies. Participants provided a first-voided, morning urine sample; had a 75-g oral glucose tolerance test; had weight, height, and blood pressure measured; and completed a self-administered questionnaire about past medical history and sociodemographic status.

RESULTS

A significantly higher prevalence of microalbuminuria was found in individuals with new cases of diabetes mellitus (24.1%), in cases of diabetes mellitus previously diagnosed (20.6%), and in those with impaired glucose tolerance (16.1%) compared with nondiabetic individuals (4.0%). Moreover, in the general population, a piecewise linear relationship was detected between albuminuria and plasma glucose with significant changes of slope corresponding with 2 h plasma glucose concentrations (95% confidence interval) of 6.7 (6.4-7.0) and 9.2 (8.6-9.8) mM, respectively. After adjusting for sex, obesity, hypertension, hypertriglyceridemia, cigarette smoking, and heavy alcohol consumption in a multivariate model, glycemia was the most significant determinant of urinary albumin concentrations in all three ethnic groups. However, blood glucose concentrations did not completely explain the higher relative risk (95% confidence interval) of microalbuminuria in Maori (5.97; 4.48-7.78) and Pacific Islander (5.33; 4.13-6.87) workers compared with European workers.

CONCLUSIONS

Of the variables investigated, hyperglycemia was the most important factor explaining the high prevalence of microalbuminuria in Maori and Pacific Islander workers compared with the European workers. However, only 14.9% of the variation in urinary albumin concentrations was found in our multivariate model, and we have speculated on the contribution of other factors such as diet and coexisting renal diseases.

Dietary nutrient intakes and slight albuminuria in people at least 40 years old

We studied the relation between diet and slight albuminuria in 5416 people, ages 40 years and over, who participated in a health screening survey of a local workforce. Degree of albuminuria showed log-linear univariate relations with dietary protein, cholesterol, and sodium intakes, and negative log-linear univariate relations with dietary fiber and polyunsaturated to saturated fat (P/S) ratio. After adjusting for age, gender, and ethnicity, the relative risk (95% confidence interval) for slight albuminuria was significantly increased in people reporting dietary cholesterol consumption &gt; 226 mg/day compared with people reporting consumption &lt; or = 226 mg/day [1.32 (1.02, 1.70)], and significantly reduced in people reporting dietary fiber consumption &gt; 26 g/day compared with people reporting consumption &lt; or = 26 g/day [0.74 (0.58, 0.95)]. There was no significant effect of dietary protein, P/S ratio, or salt intake. We conclude that risk of slight albuminuria is increased by consumption of dietary cholesterol and reduced by consumption of dietary fiber.

Dietary nutrient intakes and slight albuminuria in people at least 40 years old

We studied the relation between diet and slight albuminuria in 5416 people, ages 40 years and over, who participated in a health screening survey of a local workforce. Degree of albuminuria showed log-linear univariate relations with dietary protein, cholesterol, and sodium intakes, and negative log-linear univariate relations with dietary fiber and polyunsaturated to saturated fat (P/S) ratio. After adjusting for age, gender, and ethnicity, the relative risk (95% confidence interval) for slight albuminuria was significantly increased in people reporting dietary cholesterol consumption > 226 mg/day compared with people reporting consumption < or = 226 mg/day [1.32 (1.02, 1.70)], and significantly reduced in people reporting dietary fiber consumption > 26 g/day compared with people reporting consumption < or = 26 g/day [0.74 (0.58, 0.95)]. There was no significant effect of dietary protein, P/S ratio, or salt intake. We conclude that risk of slight albuminuria is increased by consumption of dietary cholesterol and reduced by consumption of dietary fiber.

Albuminuria in people at least 40 years old: effect of alcohol consumption, regular exercise, and cigarette smoking

We investigated the relation between albuminuria and life-style factors in 5670 people, ages 40 years and over, who participated in a health screening survey of a local workforce. The degree of albuminuria showed piecewise log-linear relationships with alcohol consumption and cigarette smoking, with changes in slope (and 95% confidence interval) corresponding with 5 (2, 8) g of alcohol/day and 10 (6, 14) cigarettes/day. After adjusting for age, gender, ethnicity, and other life-style variables, relative risks (95% confidence interval) of slight albuminuria for people consuming > 32 g of alcohol/day compared with nondrinkers, and for cigarette smokers compared with nonsmokers, were 1.74 (1.02, 2.98) and 1.37 (1.01, 1.88), respectively. However, there was no significant effect of exercise. We conclude that slight albuminuria is significantly associated with cigarette smoking and heavy alcohol consumption, consistent with its role as an index of risk of cardiovascular disease.

Relationships amongst some bacterial and yeast lactate and mandelate dehydrogenases

Five yeast strains were isolated by enrichment culture on the basis of their ability to grow on mandelate and two of these strains were identified as Rhodotorula glutinis. In addition, a range of yeasts from culture collections was screened for growth on mandelate. The results suggest that mandelate utilization is a widespread but not universal characteristic within the genus Rhodotorula. Several of the yeasts contained an inducible NAD-dependent D(-)-mandelate dehydrogenase and an inducible dye-linked (presumably flavoprotein) L(+)-mandelate dehydrogenase. All the D(-)-mandelate dehydrogenases from the yeasts showed immunological cross-reactivity with each other (as judged by both immunoinhibition and immunoblotting), as did all the yeast L(+)-mandelate dehydrogenases that were tested. Determination of N-terminal amino acid sequences of several bacterial and yeast lactate and mandelate dehydrogenases, together with the evidence from the immunological studies, confirmed and extended previous proposals that there are several major groups of such dehydrogenases: FMN-dependent, membrane-bound L(+)-lactate and L(+)-mandelate dehydrogenases (M(r) = approx. 44,000) in bacteria, mitochondrial flavocytochrome b2 L(+)-lactate and L(+)-mandelate dehydrogenases (M(r) = approx. 59,000) in yeasts, FAD-dependent, membrane-bound D(-)-lactate and D(-)-mandelate dehydrogenases in bacteria, and soluble NAD-dependent D(-)-mandelate dehydrogenases in both bacteria and yeasts.

A simple method for the analysis of clustered binary data

A simple method for comparing independent groups of clustered binary data with group-specific covariates is proposed. It is based on the concepts of design effect and effective sample size widely used in sample surveys, and assumes no specific models for the intracluster correlations. It can be implemented using any standard computer program for the analysis of independent binary data after a small amount of preprocessing. The method is applied to a variety of problems involving clustered binary data: testing homogeneity of proportions, estimating dose-response models and testing for trend in proportions, and performing the Mantel-Haenszel chi-squared test for independence in a series of 2 x 2 tables and estimating the common odds ratio and its variance. Illustrative applications of the method are also presented.

Health proposals and NZMA

NZMA welcomes the opportunity for public debate over the degree to which the community should fund health care for all. It views the attempts to improve the integration of the health service with interest and hopes to enter a vigorous debate with government to ensure that the detailed proposals yet to be formulated will achieve the purpose we both desire. But the association is disappointed to see policies promoted that are often so reliant upon anecdote and a naive theory of economics. It is disappointing to see health policy altered so radically with so little analysis of facts. Waiting lists, as an example, are analysed with no statement of what proportion of hospital admissions are represented by waiting list patients. Part charges have been introduced in areas where there is no experimental justification for supposing that they will usefully alter patient behaviour. A more sophisticated approach is required. Some change must be sought in the so-called nonnegotiable part of the proposals.

Breast cancer diagnosis by screening mammography: early results of the Central Sydney Area Health Service Breast X-ray Programme

The Central Sydney Area Health Service (CSAHS) Breast X-ray Programme is a pilot mammography screening project for breast cancer detection funded by the NSW Government. Screening by two-view mammography is carried out in a mobile van and is offered free to women aged over 45 years living in the CSAHS region, the inner western suburbs of Sydney. In the first 18 months of operation from March 1988, 7193 women were screened: 99 women underwent excision biopsy and 53 cancers were diagnosed. This is an overall detection rate of seven cancers per thousand women screened. Sixty per cent of the cancers were impalpable to the examining surgeon; 19% of all cancers were shown to have axillary node metastasis at the time of diagnosis. These results compare well with those of the major European screening studies.

Acute rhabdomyolysis associated with atypical Guillain-Barré syndrome

We report a patient with atypical Guillain-Barré syndrome associated with acute rhabdomyolysis. Rhabdomyolysis may be the cause of elevation of creatine kinase sometimes seen in patients with Guillain-Barré syndrome.

Bile duct emptying in response to fat: a validation study

Fatty meal sonography has been suggested to assess patients with biliary pain after cholecystectomy, but the effects of gallbladder removal on biliary dynamics has not been studied prospectively. Before elective cholecystectomy, 25 patients had their common hepatic ducts' diameter measured by ultrasonography before and after a fat stimulus. In 23, tests were repeated 1 month, 1 year, and 5 years after surgery. In preoperative studies, 5 patients showed dilatation after fat and 2 of these had stones in the common bile duct. However, another 4 patients with stones or sludge in the duct did not show dilatation, so that the response to fat was a poor indicator of patients requiring common bile duct exploration. No patient had major symptoms after surgery. At 1 month and 12 months, the response to fat was variable with more than half of those tested showing no decrease in duct size. A more consistent pattern emerged at 5 years, when 14 of 18 patients tested showed a decrease in common hepatic duct after fat; 3 were unchanged and 1 increased by 1 mm. The response to fat was less consistent and more difficult to measure in the common bile duct, even 5 years after operation. It was concluded that not all patients with indications for exploration of the common bile duct on operative cholangiography show a dilatation response to fat on preoperative testing. Also, fatty meal sonography should be used with caution because the response to fat in asymptomatic patients soon after operation is unpredictable, with occasional patients showing dilation without apparent obstruction. Measurement of common hepatic duct is preferred to common bile duct and increases in diameter of 1 mm are probably not significant.

Pre-operative ultrasound measurement of bile duct diameter: basis for selective cholangiography

In this prospective study, prior to cholecystectomy, the diameter of the common hepatic duct was measured; duct size was then compared with probability of finding stones at operation. Of 115 patients entering the study, 36 had stones removed from the common duct at the time of cholecystectomy but only three (8%) were demonstrated by ultrasonography. No stones were found in ducts less than or equal to 3 mm in size (31% patients). Only two of 26 patients with ducts measuring 4 mm had stones. As duct size increased, so did the probability of stones and all patients with ducts greater than or equal to 9 mm in diameter had stones. It is concluded that pre-operative ultrasound provides a reliable basis for a policy of selective cholangiography.