The perception of sleep as a function of the level of daytime sleepiness among patients with obstructive sleep apnea

Subjective estimates of sleep onset among patients with a variety of sleep disorders have been shown to be inaccurate. This inability in perceiving sleep onset is potentially dangerous for this population, in particular, for individuals who are required to drive long distances or operate heavy machinery as part of their daily activities. This study evaluated the perception of sleep among 237 consecutive patients diagnosed with obstructive sleep apnea. Patients completed an overnight sleep-laboratory evaluation followed by an objective evaluation of sleep propensity. The latter was done using the Multiple Sleep Latency Test (MSLT). Patients with an accurate perception of having slept on the MSLT were found to have shorter sleep latencies when compared with those with an inaccurate perception of their sleep. The results of this study suggest that the rapidity with which sleep is manifested is an important contributor to the accurate perception of sleep.

The novel analog 1,24(S)-dihydroxyvitamin D2 is as equipotent as 1,25-dihydroxyvitamin D3 in growth regulation of cancer cell lines

The physiologically active metabolite of the vitamin D seco-steroid hormone, 1,25-dihydroxyvitamin D3 (1,25(OH)2D3), is a major regulator of mineral homeostasis. Recent evidence also suggests its role in regulating proliferation and differentiation of cells, including cancer cells. Therapeutic application of 1,25(OH)2D3 to hyperproliferative disease, such as cancer, is thwarted by its hypercalcemic activity. To overcome this problem, analogs of 1,25(OH)2D3 have been produced which retain growth regulating properties and exhibit decreased hypercalcemic activity. In the present study, the efficacy of the vitamin D2 analog, 1,24(S)-dihydroxyvitamin D2 (1,24(S)-(OH)2D2) in the inhibition of cancer cell proliferation and in inducing differentiation of cancer cells was compared to that of 1,25(OH)2D3. By the [3H]-thymidine incorporation procedure, 1,24(S)-(OH)2D2 is as equipotent as 1,25(OH)2D3 in inhibiting the proliferation of five different cell lines, ROS 17/2.8, the rat osteosarcoma cell line, MCF-7, the human breast cancer cell line, HD-11, the chick bone marrow v myc transformed cell line, HT-29, the human colon cancer cell line and HL-60, the human leukemia cell line. The inhibitory action was dose and time-dependent. The NBT reduction method indicated that 1,24(S)-(OH)2D2 induces the differentiation of the human leukemia cell (HL-60) to the same extent as 1,25(OH)2D3. Notwithstanding the vast similarity between 1,24(S)-(OH)2D2 and 1,25(OH)2D3 with regard to the above activities, they differ in their effects on calcium regulation. In conclusion, the present results encourage the use of 1,24(S)-(OH)2D2 for the treatment of cancer disease in vivo.

Alerting effects of methylphenidate under basal and sleep-deprived conditions

Six men and 3 women on each of 4 days received 10 mg of methylphenidate or placebo (2 times a day) at 0800 and 1200 after 8 hr or 0 hr of sleep. Sleep latency was measured by the Multiple Sleep Latency Test (MSLT) at 0930, 1130, 1330, 1530, and 1730. Participants also completed divided-attention and auditory vigilance tasks at 1000 and 1400 and the Profile of Mood States (POMS) and the Addiction Research Center Inventory (ARCI) after the 0930 and 1330 latency tests. The drug increased mean latency on the MSLT in both sleep conditions. Performance only showed drug effects after prior sleep deprivation. On the POMS, the drug increased Vigor and reduced Fatigue and Depression scale scores, primarily after sleep deprivation. The drug increased the ARCI Amphetamine and Morphine-Benzedrine scores only in the basal state. The ARCI Pentobarbital score was increased by sleep deprivation and decreased by the drug.

A hidden complication of out-patient arteriography

Rapid progression of arterial disease may occur between out-patient diagnostic arteriography and therapeutic angioplasty. We have studied the incidence of this complication in our institution. Sixty-seven consecutive out-patient arteriograms were assessed. Thirty-four patients were re-admitted for angioplasty within a median interval of 4 weeks (range 5 days-3 months). We compared immediate pre-angioplasty arteriograms with the out-patient images. Twenty-five pairs of films showed disease progression. Three patients showed new disease, one remote from the site of the arterial lesion and two in the opposite limb. Six patients showed marked progression of the original disease. The policy of delayed treatment after out-patient arteriography may require reconsideration in the light of our complication rate of 18%.

The effects of predetermined payment rates for Medicare home healthcare

OBJECTIVE

To assess the effects of an alternative method of paying home health agencies for services to Medicare beneficiaries, based on a demonstration program.

DATA SOURCES/STUDY SETTING

Primary and secondary data collected on participating home health agencies in five states and their patients during the three-year demonstration period. Primary data included patient surveys at discharge and six months later, and two rounds of interviews with executive staff of the agencies. Secondary data included agencies' Medicare cost reports, quality assurance reviews, Medicare claims data, demonstration claims data, demonstration patient intake forms, and plan of treatment forms.

STUDY DESIGN

The 47 agencies volunteering to participate in the demonstration were each randomly assigned to the treatment or control group. Treatment group agencies were paid a predetermined rate based on their inflation-adjusted cost per visit during the year preceding the demonstration; control group agencies were paid under Medicare's conventional cost reimbursement method. Demonstration impacts were estimated by comparing outcomes for the two groups of agencies and their respective patients, using regression models to control for any remaining differences.

PRINCIPAL FINDINGS

Agencies paid under prospective rate setting were slightly better at holding per-visit cost increases below inflation than were control group agencies. The change in payment method had no effect on agencies' volume of Medicare visits or quality of care, nor on patients' use of Medicare services or other formal or informal care services.

CONCLUSION

Changing from cost-based reimbursement to predetermined payment rates for Medicare home healthcare visits would not lead to large savings for the Medicare program, but would not increase costs to Medicare or adversely affect patients or their caregivers.

The sleep/wake habits of patients diagnosed as having obstructive sleep apnea

STUDY OBJECTIVE

To determine the sleep/wake habits of patients diagnosed as having obstructive sleep apnea (ie, respiratory event index [REI] > or = 5).

DESIGN

Case series with prospective data collection to determine the relationship among sleepiness, REI, and sleep/wake habits. Patients were grouped according to their multiple sleep latency test (MSLT) results (< or = 5 and > 5) and REI (mild REI < or = 20; moderate REI > 20 but < or = 60; and severe REI > 60).

SETTING

An American Sleep Disorders Association-accredited sleep laboratory.

PATIENTS

Three hundred ninety (325 male, 65 female) consecutive patients seen between June 1993 and January 1995 for evaluation of sleep apnea. This included a sleep, medical, and psychiatric evaluation followed by a physical examination. Sleep histories and sleep/wake habits were recorded by a physician trained in sleep medicine. Polysomnographic evaluation consisted of a nocturnal clinical polysomnogram (CPSG) and an MSLT on the following day. Of 390 patients, 268 completed polysomnographic evaluation (CPSG and MSLT).

MEASUREMENTS AND RESULTS

Sleepy (MSLT < or = 5) patients with mild (REI < or = 20) and moderate apnea (REI > 20 < or = 60) reported spending significantly less time in bed than sleepy patients with severe apnea (REI > 60). Those with severe apnea (REI > 60) reported napping significantly more and experienced a more severe disruption of their routine daily activities because of sleepiness when compared with mild and moderate OSA patients.

CONCLUSIONS

These data suggest that sleep habits have an important modulatory effect on the level of sleepiness and this effect is lost as the severity of sleep-disordered breathing increases.

Gene sequence, localization, and evolutionary conservation of DAZLA, a candidate male sterility gene

We have isolated the human homologue of the mouse germ cell-specific transcript Tpx2, which we had previously mapped to mouse chromosome 17. Sequence analysis shows that the human gene is part of the DAZ (Deleted in Azoospermia) family, represents the human homologue of the mouse Dazla and Drosophila boule genes, and is termed DAZLA. Like Dazla and boule, DAZLA is single copy and maps to 3p25. This defines a new region of synteny between mouse chromosome 17 and human chromosome 3. Unlike DAZ, which has multiple DAZ repeats, DAZLA encodes a putative RNA-binding protein with a single RNA-binding motif and a single DAZ repeat. DAZLA is more closely related to Dazla in the mouse than to the Y-linked homologue DAZ (88% identity overall with mouse Dazla compared to 76% identity with the human DAZ protein sequence). Southern blot analysis showed that DAZLA is autosomal in all mammals tested and that DAZ has been recently translocated to the Y chromosome, sometime after the divergence of Old World and New World primates. To investigate the evolutionary relatedness of DAZLA and DAZ further, their partial genomic structures were obtained and compared. This revealed that the genomic organization of both genes in the 5' region is highly conserved. DAZLA is a new member of the DAZ family of genes, which is associated with spermatogenesis and male sterility. Familial cases of male infertility in humans show an autosomal recessive mode of inheritance. It is possible that some of these families may carry mutations in the DAZLA gene.

The alerting effects of short and long naps in narcoleptic, sleep deprived, and alert individuals

Eleven narcoleptic patients and 22 age- and gender-matched normal controls participated in a study to determine the alerting effects of differing nap lengths. All narcoleptic patients had been previously diagnosed [mean sleep latency on the multiple sleep latency test (MSLT) < or = 5 minutes with two or more sleep-onset rapid eye movement periods (SOREMPs)]. Healthy, normal subjects with a mean sleep latency on the screening MSLT > or = 8 minutes were randomly assigned to one of two groups (i.e. sleep-deprived and alert). All subjects completed two experimental night and days with at least 5 days between sessions. On the evening prior to each experimental day, narcoleptic and alert subjects spent 8 hours in bed and sleep-deprived subjects spent 0 hours in bed. The following day, all subjects underwent one of two napping conditions, 15 or 120 minutes in bed. Both naps were terminated at noon. Every subject underwent both conditions and the order of conditions was counterbalanced. From 1215 to 1355 hours all subjects underwent a modified MSLT. At 1500 hours, the subjects had a 1-hour nap. The results showed that the 120-minute nap condition was more beneficial than the 15-minute nap. Narcoleptic and sleep deprived subjects were shown to have comparable levels of sleepiness on the modified MSLT. However, a differential response pattern on their latency to sleep was noted on the 1-hour nap. Sleep-deprived subjects were shown to be differentially more alert following a 120-minute nap opportunity. In contrast, for narcoleptic patients the beneficial effects of the nap were lost when tested 3 hours later. These results show that narcoleptic patients benefit from a longer nap but that these benefits are short-lived.

The frequency of multiple sleep onset REM periods among subjects with no excessive daytime sleepiness

The multiple sleep latency test (MSLT) is a valuable tool in the assessment of excessive daytime sleepiness (EDS). Additionally, multiple sleep onset rapid eye movement periods (SOREMPs) are a frequent occurrence in patients with narcolepsy. To date, however, few studies have evaluated the frequency of SOREMPs in a population of healthy control subjects. Subjects participating in a variety of sleep studies were screened with a nocturnal clinical polysomnogram, followed by the MSLT. Subjects were required to be drug free and have no sleep-related symptoms or medical or psychiatric conditions. Of the 139 subjects who were screened, 24 (17%) had two or more SOREMPs. These individuals were more likely to be male, younger, and sleepier than those with one or zero SOREMPs. The etiology of two or more SOREMPs in healthy controls was not apparent from the clinical or polysomnographic evaluation. Although it is possible that these findings are early signs of narcolepsy, subjects reported being free of any sleep-related complaints. Further investigations into the determinants of multiple SOREMPs and their reliability among asymptomatic populations are warranted.

Non-invasive assessment of arterial stenoses in angioplasty surveillance: a comparison with angiography

OBJECTIVES

Comparison of non-invasive arterial measurements with angiography and their use for angioplasty surveillance.

DESIGN

Prospective assessments of arterial stenoses in patients undergoing angioplasty in a 9 month surveillance period.

MATERIALS

Fifty consecutive patients undergoing angioplasty.

METHODS

(i) One hundred and thirty-one sets of clinical assessments, ankle brachial Doppler pressure indices and colour Duplex velocities and diameters were compared to time-matched angiographic diameter stenosis. (ii) Fifty patients undergoing femoropopliteal angioplasty (32 stenoses and 18 occlusions) were studied with ankle branchial Doppler pressure indices and colour Duplex and angiography during a 9 month surveillance period.

RESULTS

(i) Symptoms, pulses, resting ABPI, and exercise ABPI showed no useful correlation with angiography. Duplex velocity ratio and Duplex diameters showed correlation and agreement with angiography respectively. (ii) On surveillance, restenosis was universal but not always clinically significant. Angioplasty caused a rapid improvement in ABPI and imaging studies which worsened at later times. ABPI did not predict clinical failure however, Duplex and angiography predicted all clinical failures.

CONCLUSIONS

Restenosis should be assessed with imaging of the angioplasty site during angioplasty surveillance.

The significance of increased 111indium platelet accumulation at post-angioplasty sites

We assessed prospectively the significance of 111indium labelled platelet accumulation following angioplasty procedures in 12 patients (9 femoral angioplasties (2 laser, 1 atherectomy) and 3 iliac stents). Autologous 111indium labelled platelets were re-injected immediately after angioplasty. Radioactivity was measured over treated and reference sites, by single probe and gamma camera, and expressed as a radioactivity ratio (RR). All patients had duplex ultrasound assessment and occlusions were confirmed by arteriography. RR was always raised after angioplasty. Three patients who had acute occlusions showed markedly raised average RRs (significant at 99% ANOVA). RR was not raised after laser assisted angioplasty, however, our numbers were small. 111Indium platelet radioactivity did not predict subsequent occlusion after angioplasty but effectively detected existing acute post-angioplasty occlusions.

Nocturnal sleep latencies among alert, alert-deprived and sleepy subjects

Twenty-seven healthy, asymptomatic subjects participated in a study to determine repeated nocturnal sleep latencies as a function of level of daytime sleepiness. Subjects were screened polysomnographically and were determined to be free of any sleep pathology. Nine subjects had a screening multiple sleep latency test (MSLT) of < or = 5 min and 18 had a MSLT of > or = 10 min. Subjects were assigned to 3 groups, sleepy (MSLT < or = 5 min), alert, and alert sleep-deprived groups (MSLT > or = 10 min). Repeated nocturnal latencies to sleep were determined at 2300, 0110, 0310 and 0510 h on 2 nights with at least 5 days between nights. The results showed a main effect of group on the repeated nocturnal sleep latencies. Post-hoc tests demonstrated longer repeated nocturnal latencies among alert subjects compared to the sleepy and alert sleep-deprived subjects. The latter two groups had comparable sleep latencies. A significant main effect of time of night was also shown. The 0510 h latency was significantly shorter than the latencies at 2300 and 0110 h. The 0310 h latency was significantly shorter than the 0110 h latency and comparable to the 2300 and 0510 h latency. Significant correlations were found between daytime MSLT, repeated nocturnal sleep latencies, and nocturnal sleep time. These results show systematic differences in repeated nocturnal sleep latencies among sleep and alert subjects and extend the already described characteristics of these subjects by comparing them to a group of alert sleep-deprived subjects.

Auditory awakening thresholds in sleepy and alert individuals

Twenty-seven healthy men and women with regular sleep-wake habits (and no habitual napping) participated in a study to determine the relation between auditory awakening thresholds (AAT) and multiple sleep latency test (MSLT) scores. Subjects were free of any sleep complaints and were screened polysomnographically. Nine subjects had a screening MSLT of < or = 5 minutes (sleepy group), and 18 subjects had an MSLT of > or = 10 minutes. Subjects were assigned to three groups: a sleepy group, alert group and an alert sleep-deprived group. Subjects underwent 2 nights of AAT testing with at least 5 days in between each study night. AATs were determined at 0100, 0300, 0500 and 0730 hours. There were a total of 209 available AAT determinations, with a comparable number of trials across the groups. Because 68% of AAT determinations were done out of stage 2 non-rapid eye movement (NREM) sleep, the thrust of the analysis was based on the results of this stage of sleep. The AATs were averaged across the two experimental nights. Trials 1 and 2 (first half of the night) and 3 and 4 (second half of the night) were averaged for each subject. There was no main effect of group on AATs. However, there was a significant main effect of time and a significant group by time interaction. The former indicated an overall decline in AATs across the night. More importantly, the three groups had comparable AAT levels during the first half of the night:. Sleepy and alert-deprived subjects, however, failed to show a decline in AATs, whereas the alert group showed a significant decline in the second half of the night. This differential rate of decline in AATs is suggested to be related to the differences in sleep homeostasis among alert and sleepy individuals.

The status and scope of health communication

We examine the field of health communication with a multimethodological analysis, presenting a brief historical synopsis of the academic literature as well as the results of a survey administered to academicians who identified communication and health to be major fields of interest. After this descriptive backdrop of health communication, we offer a prescription for an ideal health communicator--that is, one with an interdisciplinary background--to use ethical, persuasive means to craft, deliver, and evaluate campaigns that promote good health and disease prevention; to plan, influence, and implement health policy; and to employ ethical decision making that will enhance the quality of life for individuals and communities throughout the globe.

Inhibition of intimal hyperplasia in balloon injured arteries with adjunctive phthalocyanine sensitised photodynamic therapy

OBJECTIVES

We investigated the effects of Photodynamic therapy (PDT) using Aluminium disulphonated phthalocyanine (AlS2Pc) on experimental intimal hyperplasia (FCIH).

MATERIALS AND METHODS

(a) Pharmacokinetics: Normal rats were injected with Als2Pc and carotid artery fluorescence was measured. (b) Normal artery PDT: Sensitised rats underwent carotid artery laser irradiation (50J/cm2, 675nm) and were assessed after 3 and 14 days and 1-6 months. (c) PDT: Rats underwent standard carotid artery balloon injury immediately prior to PDT and arteries were assessed at 2 to 26 weeks, together with laser, AlS2Pc, and untreated controls.

CHIEF OUTCOME MEASURES

(a) Fluorescence intensity in different arterial layers. (b) Medial smooth muscle cell counts per high power field (light microscopic). (c) Percentage amount of FCIH (area of intimal hyperplasia) as a ratio of the IEL (area enclosed by the internal elastic lamina).

RESULTS

(a) AlS2Pc fluorescence intensity increased with increasing dosage, with maximal fluorescence in the arterial media at 30 min. (b) PDT produced medial cell depletion at 3 days and persisted over 6 months without loss of vessel integrity. (c) PDT completely inhibited FCIH at 2 and 4 weeks. This was partial at 6 to 26 weeks (51% of untreated level). PDT inhibition of FCIH was significantly greater than in any of the control groups. p < 0.0001. Mann-Whitney Test.

CONCLUSION

Adjunctive AlS2Pc sensitised photodynamic therapy inhibits experimental intimal hyperplasia, by causing medial smooth muscle cell depletion. This offers a new approach to the management of angioplasty restenosis in patients.

A systematic approach to health surveillance in the workplace

This paper reviews the range of health surveillance activities which can be utilized in the workplace by occupational health professionals for assessing fitness for work and contributing to the prevention of occupational illness and promotion of good health. The systematic approach described categorizes health surveillance procedures into occupational or non-occupational, risk-based or unfocused, and as primary, secondary or tertiary preventive measures. All categories of health surveillance are currently being practised to some extent, but the type of surveillance may not match the needs of the workplace in some situation. In order to aid health professionals in deciding which procedures should be implemented, recommendations based on an assessment of health risks are made. The key proposal is to establish a minimum level of periodic health surveillance for all workers based on a targeted lifestyle health risk assessment and a structured health questionnaire. Additional procedures can then be added sequentially as appropriate to manage any health risks in the workplace. The role of the unfocused periodic general medical examination is discussed in the context of the systematic approach and allows occupational professionals to critically appraise its usefulness.

Aortic root replacement and extraanatomic bypass for interrupted aortic arch in an adult

We describe an unusual case of interrupted aortic arch, aneurysmal ascending aorta, and aortic regurgitation in a 24-year-old man. He presented with general malaise, weakness of his legs, and hypertension. A single-stage operation was performed in which the aortic root was replaced with concomitant extraanatomic bypass of the interrupted segment of the aortic arch. He made a full recovery and has returned to work.

Physiological modelling of oxygen consumption in birds during flight

This study combines data on changes in cardiovascular variables with body mass (Mb) and with exercise intensity to model the oxygen supply available to birds during flight. Its main purpose is to provide a framework for identifying the factors involved in limiting aerobic power input to birds during flight and to suggest which cardiovascular variables are the most likely to have been influenced by natural selection when considering both allometric and adaptive variation. It is argued that natural selection has acted on heart rate (fh) and cardiac stroke volume (Vs), so that the difference in the arteriovenous oxygen content (CaO2-Cv¯O2) in birds, both at rest and during flight, is independent of Mb. Therefore, the Mb exponent for oxygen consumption (V(dot)O2) during flight can be estimated from measurements of heart rate and stroke volume. Stroke volume is likely to be directly proportional to heart mass (Mh) and, using empirical data, values for the Mb coefficients and exponents of various cardiovascular variables are estimated. It is concluded that, as found for mammals, fh is the main adaptive variable when considering allometric variation, although Mh also shows a slight scaling effect. Relative Mh is likely to be the most important when considering adaptive specialisations. The Fick equation may be represented as: (V(dot)O2)Mbz = (fh)Mbw x (Vs)Mbx x (CaO2 - Cv¯O2)Mby , where w, x, y, z are the body mass exponents for each variable and the terms in parentheses represent the Mb coefficients. Utilising this formula and data from the literature, the scaling of minimum V(dot)O2 during flight for bird species with a 'high aerobic capacity' (excluding hummingbirds) is calculated to be: 166Mb0.77&plusmn;0.09 = 574Mb-0.19&plusmn;0.02 x 3.48Mb0.96&plusmn;0.02 x 0.083Mb0.00&plusmn;0.05 , and for hummingbirds (considered separately owing to their unique wing kinematics) it is: 314Mb0.90&plusmn;0.22 = 617Mb-0.10&plusmn;0.06 x 6.13Mb1.00&plusmn;0.11 x 0.083Mb0.00&plusmn;0.05 . These results are largely dependent on the cardiovascular values obtained from pigeons flying near to the minimum power speed of 10 m s-1, but would appear to provide realistic values. Both the measured and the estimated V(dot)O2 for hummingbirds appear to scale with a larger Mb exponent than that for all other birds, and it is suggested that this is as a result of the larger Mb exponent for flight muscle mass as the larger species of hummingbirds try to maintain hovering performance. It is proposed that estimated V(dot)O2 for birds during flight, which is based on Mh in combination with estimates of fh and CaO2-Cv¯O2, gives an indirect measure of relative aerobic power input and, when corrected for the estimated scaling influences of the mechano-chemical conversion efficiency and lift generation with respect to Mb, may be a useful indicator of the relative capacity of the muscle to sustain power output and lift production during flight.

Cystic fibrosis mutations among African Americans in the southeastern United States

Since the cloning of the cystic fibrosis (CF) gene and the identification of delta F508, the most common CF mutation, screening the general population for CF has been vigorously debated. Adding to the controversy is the question of whether screening should be offered to African Americans, whose incidence of CF (1/17,000) is much lower than that of whites (1/2500). We tested for five common mutations (delta F508, G551D, G542X, R553X, and N1303K) in order to determine the frequency of common mutations in African Americans with CF from the southeastern United States. delta F508 was found on 50% of CF chromosomes; 46% of CF mutations were undetermined mutations. Our data indicate that at the current detection rate, the sensitivity of CF screening in African Americans would be appreciably lower than that of whites, and thus their inclusion in screening programs probably would not be warranted.

Autonomic dysreflexia--don't let it be a surprise

This article discusses autonomic dysreflexia, which can occur in patients with spinal cord injury. This potentially life-threatening complication can be managed through an understanding of the disorder and its primary causes. The primary cause of this problem is usually a noxious stimuli that precipitates an abnormal response from the autonomic nervous system. Prevention is the primary nursing treatment and includes implementation of a bladder and bowel management program early in the treatment of the patient with spinal cord injury.

Photodynamic therapy of normal and balloon-injured rat carotid arteries using 5-amino-levulinic acid

BACKGROUND

Although the management of atherosclerotic disease by the use of balloon angioplasty is widespread, the treatment is limited by restenosis in 30% to 50% of cases. Fibrocellular intimal hyperplasia, the main cause of restenosis, arises from proliferation and migration of medial smooth muscle cells (SMC) into the intimal layer. Factors leading to intimal hyperplasia are incompletely understood, and drugs have universally failed to influence clinical restenosis. Photodynamic therapy (PDT), the light activation of photosensitizing drugs to generate cytotoxic mediators, may have potential as prophylaxis for intimal hyperplasia. 5-Amino-levulinic acid-induced protoporphyrin IX (ALA-PPIX), a naturally occurring porphyrin precursor, and its product, -PPIX, offers a novel method of sensitization for PDT. We have investigated the pharmacokinetics of ALA in arteries and the effects of ALA-PPIX-sensitized PDT on normal and balloon-injured arteries.

METHODS AND RESULTS

ALA (20 to 200 mg/kg) was injected into healthy rats, and PPIX fluorescence was measured in the carotid arteries. In a second group of rats, the exposed carotid artery was laser illuminated (50 J/cm2, 630 nm) 30 to 90 minutes after sensitization. Three and 14 days after PDT, histological sections from treated arteries were analyzed by light microscopy. Subsequently, two new groups of rats underwent PDT (ALA, 100 mg/kg; laser, 50 J/cm2, 630 nm [at 60 to 90 minutes]). The left carotid arteries underwent balloon angioplasty by intraluminal passage of a Fogarty FG2 catheter immediately before irradiation. These rats were killed at 14 and 28 days together with laser-only, ALA-only, and untreated control rats. The arteries were perfusion-fixed in vivo. ALA-PPIX induced arterial media fluorescence in a dose-dependent manner. In the normal arteries, PDT produced a dose-dependent cellular depletion in the treated arterial segment at 3 days, and this was complete with 100 and 200 mg/kg of ALA. At 14 days, the media remained acellular, although the endothelial lining had regenerated. In the balloon-injured arteries, PDT produced complete inhibition of intimal hyperplasia at both 14 and 28 days (0%). This was significantly greater than that produced by any of the control rats (34% to 69% and 37% to 66% at the two times, respectively). Significance was at 99% using ANOVA and Fisher's PLSD test. No hemorrhage, thrombosis, or aneurysm formation was seen.

CONCLUSIONS

ALA-PPIX-sensitized PDT applied at the time of angioplasty effectively inhibits experimental intimal hyperplasia development in rats. This may offer a new approach to the management of angioplasty restenosis in patients.

Impact of special care unit for patients with advanced Alzheimer's disease on patients' discomfort and costs

OBJECTIVE

To compare outcomes in patients with the clinical diagnosis of probable dementia of the Alzheimer type (DAT) cared for in a Dementia Special Care Unit (DSCU) with those in traditional long-term care (TLTC).

DESIGN

Two-year prospective cohort study.

SETTING

Two Veterans Administration Hospitals. The DSCU concentrated on assuring patients' comfort instead of promoting maximal survival; in some patients this excluded transfer to acute medical settings, the use of antibiotics, and tube feeding.

MEASUREMENTS

Data were collected regarding disease severity, patient discomfort, use of medical resources, and mortality rate.

RESULTS

Patients at both settings were similar on baseline measures, and most were severely demented. The monthly levels of observed discomfort were lower in DSCU than in TLTC patients. The costs of medications, radiology, and laboratory procedures were lower in DSCU than in TLTC patients. DSCU patients were also transferred less frequently to an acute medical setting. The average 3-month cost for a DSCU patient was $1477 less than the cost of care for a TLTC patient. However, DSCU patients with lower severity of DAT had a higher mortality rate then TLTC patients.

CONCLUSIONS

These results suggest that management of patients with advanced DAT on a DSCU using a palliative care philosophy may result in less patient discomfort and lower costs than management on a TLTC.

Cystic fibrosis mutations in white and black Americans: an approach to identification of unknown mutations with implications for cystic fibrosis screening

OBJECTIVE

We sought to define the frequency of common cystic fibrosis mutations in white and black American probands from our geographic region.

STUDY DESIGN

Mutation analysis was performed for delta F508, G551D, G542X, R553X, S549N, an d N1303K. For probands with undetermined mutations single-stranded conformational polymorphism analysis was performed.

RESULTS

Among 40 white subjects with cystic fibrosis 26 (65%) were homozygous for delta F508, 10 (25%) were heterozygous for delta F508 and another unknown mutation, and two were homozygous for unknown mutations. Among 10 black probands one was homozygous for delta F508, seven (70%) were heterozygous for delta F508 and another unknown mutation, and one was homozygous for unknown mutations. Single-stranded conformational polymorphism analysis for selected exons was performed for 11 probands with unknown mutations. One mutation was detected in a white proband. Sequencing of this exon showed the mutation to be Q493X.

CONCLUSIONS

Thirty percent of white subjects and 80% of black subjects carried unknown mutations. In one family single-stranded conformational polymorphism was informative in identifying an undetermined cystic fibrosis mutation.

Recent growth of Medicare home health

Medicare spending for home health services has grown at an unprecedented rate since regulations were revised in 1989. To address the implications of this striking growth, it is necessary to examine the causes. This paper finds that the most important source of growth has been in the number of home health visits received per beneficiary, not in the number of beneficiaries that have been added in response to redefined eligibility criteria. Policymakers should clarify the objectives of the Medicare home health benefit, in light of increased attention to long-term care financing and expanded services for older Americans.

Farm accidents in children

OBJECTIVE

To examine the problem of accidental injury to children on farms.

DESIGN

Prospective county based study of children presenting to accident and emergency departments over 12 months with injuries sustained in a farm setting and nationwide review of fatal childhood farm accidents over the four years April 1986 to March 1990.

SETTING

Accident and emergency departments in Aberystwyth, Carmarthen, Haverfordwest, and Llanelli and fatal accidents in England, Scotland, and Wales notified to the Health and Safety Executive register.

SUBJECTS

Children aged under 16.

MAIN OUTCOME MEASURE

Death or injury after farm related accidents.

RESULTS

65 accidents were recorded, including 18 fractures. Nine accidents necessitated admission to hospital for a mean of two (range one to four) days. 13 incidents were related to tractors and other machinery; 24 were due to falls. None of these incidents were reported under the statutory notification scheme. 33 deaths were notified, eight related to tractors and allied machinery and 10 related to falling objects.

CONCLUSIONS

Although safety is improving, the farm remains a dangerous environment for children. Enforcement of existing safety legislation with significant penalties and targeting of safety education will help reduce accident rates further.

Apolipoprotein A-I metabolism in subjects with a PstI restriction fragment length polymorphism of the apoA-I gene and familial hypoalphalipoproteinemia

Familial hypoalphalipoproteinemia (hypoalpha), characterized by a decreased high density lipoprotein level, is associated with an increased incidence of premature cardiovascular disease. Restriction fragment length polymorphism analysis of genomic DNA has detected a polymorphism for the PstI restriction endonuclease near the apoA-I gene, with either a 2.2 or a 3.3 kb fragment. The latter has been previously found to occur with significantly higher frequency in probands of families with familial hypoalpha. ApoA-I was isolated from three unrelated subjects with familial hypoalpha and the 3.3 kb PstI polymorphism of the apoA-I gene, and from normal control subjects. The apoA-I from the hypoalpha subjects was structurally normal as determined by amino acid analysis and by two-dimensional gel electrophoresis. When normal apoA-I and hypoalpha apoA-I were simultaneously injected into either normal controls or hypoalpha subjects, both forms of apoA-I were catabolized at the same rate in the same subject, indicating that the hypoalpha apoA-I is also metabolically normal. Analysis of the kinetics of metabolism of apoA-I in the hypoalpha subjects, compared to the normal controls, revealed that the reduced plasma levels of apoA-I were due to an increased apoA-I fractional catabolic rate, and that the synthetic rate was normal. Based on these results, we conclude that the apoA-I gene in these hypoalpha subjects is normal, and the PstI polymorphism near the apoA-I gene, which is associated with familial hypoalpha, is likely to be a marker for a mutant gene closely linked to, but not in, the apoA-I gene.

Mast cell tumors in three ferrets

Pruritic open skin lesions (5 mm diameter) on the thorax, neck, or head of 3 ferrets were diagnosed as mast cell tumors. Diagnosis of the tumors was based on histologic examination of biopsy specimens. Histologic diagnosis was necessary because the lesions had been treated as mycotic or bacterial ulcers and did not respond to conventional treatment. Excised mast cell tumors did not recur, and malignant behavior of the tumors was not observed.

Whole blood staining in suspension for nonspecific esterase and alkaline phosphatase analyzed with a Technicon H-1

We adapted previously published methods for nonspecific esterase and alkaline phosphatase staining of white blood cells in suspension for use on a Technicon H-1 hematology analyzer. The objective was to develop a semiautomated method using whole blood that could be employed on a large scale for hematology laboratory applications, including toxicology studies, measurement of neutrophil left shift, and cytochemical classification of myeloid leukemias. The nonspecific esterase method uses the pararosaniline stain, generating the unstable substrate from two stable precursors. Whole blood is added to the substrate plus dye mix. Next, acid lysis and fixation steps destroy red cells and stabilize the monocyte staining. The alkaline phosphatase stain employs a stable naphthyl phosphate substrate and fast blue B coupling dye. The red cells are lysed with a pH 10.3 propanediol buffer, and the white blood cells are then stabilized with formalin fixation. For both methods the staining is performed off-line, and the sample is then diluted with propanediol to match the refractive index of the sheath on the H-1 analyzer, before aspiration into the direct cytometry port. A cytogram of scattered versus absorbed light is obtained. The number of cells staining and the intensity of the stain can be quantified from the cytogram.

Central hemodynamic assessment of normal term pregnancy

Ten carefully screened primiparous patients between 36 and 38 weeks' gestation underwent pulmonary artery catheterization, arterial line placement, and central hemodynamic assessment in the left lateral recumbent position. Studies were repeated in the same patients between 11 and 13 weeks post partum. Compared with the nonpregnant state, there was a significant fall in systemic vascular resistance, pulmonary vascular resistance, colloid oncotic pressure, and colloid oncotic pressure-pulmonary capillary wedge pressure gradient by the late phase of the third trimester (p less than 0.05). Pregnancy was associated with a significant rise in cardiac output and pulse in all patients (p less than 0.05). There was no significant change in pulmonary capillary wedge pressure, central venous pressure, left ventricular stroke work index, or mean arterial pressure. Normally the late phase of the third trimester is not associated with hyperdynamic left ventricular function as assessed by the left ventricular stroke work index/pulmonary capillary wedge pressure ratio.

Working with the elderly

Having recently completed my training and qualified as an RGN I would like to explain why I have left the health service.

Localization of murine X and autosomal sequences homologous to the human Y located testis-determining region

Recently a candidate gene for the primary testis-determining factor (TDF) encoding a zinc finger protein (ZFY) has been cloned from the human Y chromosome. A highly homologous X-linked copy has also been identified. Using this human sequence it is possible to identify two Y loci, an X and an autosomal locus in the mouse (Zfy-1, Zfy-2, Zfx and Zfa, respectively). Suprisingly ZFY is more homologous to the mouse X and autosomal sequences than it is to either of the Y-linked loci. Both Zfy-1 and Zfy-2 are present in the Sxr region of the Y but Zfy-2 is absent in the Sxr deletion variant Sxrb (or Sxr") suggesting it is not necessary for male determination. Extensive backcross analyses map Zfa to mouse chromosome 10 and Zfx to a 5-cM interval between anonymous X probe MDXS120 and the tabby locus (Ta). We also show that the mouse androgen receptor locus (m-AR) believed to underlie the testicular feminization mutation (Tfm) shows complete linkage to Zfx. Comparative mapping indicates that in man these genes lie in separate conserved DNA segments.

Towards an understanding of position effect variegation

Most variegating position effects are a consequence of placing a euchromatic gene adjacent to alpha-heterochromatin. In such rearrangements, the affected locus is inactivated in some cells, but not others, thereby giving rise to a mosaic tissue of mutant and wild-type cells. A detailed examination of the molecular structure of three variegating white mottled mutations of Drosophila melanogaster, all of which are inversions of the X chromosome, reveals that their euchromatic breakpoints are clustered and located approximately 25 kb downstream of the white promoter and that the heterochromatic sequences to which the white locus is adjoined are transposons. An analysis of three revertants of the wm4 mutation, created by relocating white to another euchromatic site, demonstrates that they also carry some heterochromatically derived sequences with them upon restoration of the wild-type phenotype. This suggests that variegation is not controlled from a heterochromatic sequence immediately adjacent to the variegating gene but rather from some site more internal to the heterochromatic domain itself. As a consequence of this observation we have proposed a boundary model for understanding how heterochromatic domains may be formed. It has been recognized for many years that the phenotype of variegating position effects may be altered by the presence of trans-acting dominant mutations that act to either enhance or suppress variegation. Using P-element mutagenesis, we have induced and examined 12 dominant enhancers of variegation that represent four loci on the second and third chromosomes. Most of these mutations are cytologically visible duplications or deficiencies. They exert their dominant effects through changes in the copy number of wild-type genes and can be divided into two reciprocally acting classes. Class I modifiers are genes that act as enhancers of variegation when duplicated and as suppressors when mutated or deficient. Conversely, class II modifiers are genes that enhance when mutated or deleted and suppress when duplicated. The available data indicate that, in Drosophila, there are 20-30 loci capable of dominantly modifying variegation. Of these, most appear to be of the class I type whereas only two class II modifiers have been identified so far.(ABSTRACT TRUNCATED AT 400 WORDS)

In vivo metabolism of proapolipoprotein A-I in Tangier disease

Tangier disease is a rare familial disorder characterized by extremely low levels of apolipoprotein A-I (apoA-I) and high density lipoproteins (HDL). In normal subjects, proapoA-I is secreted into plasma and converted to mature apoA-I by the cleavage of the amino-terminal six amino acids with the major isoprotein in plasma being mature apoA-I. In contrast, in Tangier disease there is a marked relative increase of proapoA-I as compared with mature apoA-I. ProapoA-I and mature apoA-I were isolated from normal and Tangier disease subjects, radio-labeled, and autologous apoA-I isoproteins injected into normal and Tangier subjects. The in vivo catabolism and conversion of proapoA-I and mature apoA-I in normal and Tangier disease subjects were quantitated. A comparison of the rate of catabolism of apoA-I isoproteins from plasma revealed a significantly faster rate of catabolism of both isoproteins of apoA-I in Tangier subjects when compared with normal subjects. The fractional conversion rate of proapoA-I to mature apoA-I was 3.9 d-1 in normal subjects and 3.6 d-1 in Tangier subjects. The results indicate that (a) apoA-I enters plasma as the pro isoprotein in both normal and Tangier subjects, (b) Tangier disease subjects have a normal fractional rate of conversion of proapoA-I to mature apoA-I, (c) proapoA-I is catabolized at the same rate as mature apoA-I in Tangier subjects, and (d) Tangier subjects catabolize both pro and mature apoA-I at a much greater rate than do normal subjects. Therefore, the relative increase in proapoA-I in Tangier disease is due to a marked decrease in mature apoA-I resulting from rapid catabolism of both pro- and mature apoA-I and not to defective conversion of proapoA-I to mature apoA-I.

Anaphylactoid and anti-ovulatory activities of LHRH antagonists in rats

Studies were conducted with LHRH antagonists examining the relationship of structure to anaphylactoid-like activity and the relationship of anaphylactoid-like activity to anti-ovulatory activity in rats. Substitution of basic amino acids appeared to enhance the anaphylactoid-like activity of these peptides but other complex structural characteristics may also be involved. Anaphylactoid and anti-ovulatory activities were clearly independent and potent LHRH antagonists with minimal anaphylactoid-like activity were identified.

Human preproapolipoprotein C-II. Analysis of major plasma isoforms

Apolipoprotein C-II plays a major role in lipid metabolism as a cofactor for lipoprotein lipase, the enzyme involved in the hydrolysis of triglyceride-rich lipoproteins. Apo-C-II is initially synthesized as a 101 amino acid protein that undergoes subsequent cotranslational cleavage of a signal peptide. Post-translational processing of apo-C-II has not been previously described. In this manuscript we identify four major plasma isoforms of apo-C-II by two-dimensional gel electrophoresis and immunoblot analysis that result from post-translational modification of apo-C-II. Neuraminidase studies have shown that two of these isoforms are early secreted sialic acid containing glycoproteins. Amino acid compositional and amino-terminal analysis have established that the major plasma isoform of apo-C-II is proapo-C-II. Proapo-C-II undergoes proteolytic cleavage of its amino-terminal hexapeptide to generate the mature form of apo-C-II. Thus, apo-C-II appears to be secreted as a carbohydrate containing proprotein that then undergoes deglycosylation and proteolytic cleavage to generate mature apo-C-II, a minor isoform in plasma. An improved understanding of the structural relationship of the various plasma isoforms of apo-C-II will help to elucidate the mechanisms involved in normal, as well as defective, processing of apo-C-II.