Rituximab for the treatment of relapsed or refractory stage III or IV follicular non-Hodgkin’s lymphoma

This paper presents a summary of the evidence review group report into the clinical effectiveness and cost-effectiveness of rituximab for the treatment of relapsed or refractory stage III or IV follicular non-Hodgkin’s lymphoma (NHL), in accordance with the licensed indication, based upon the evidence submission from Roche Products Ltd to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The submitted clinical evidence included two randomised controlled trials [European Organisation for Research and Treatment of Cancer (EORTC) and German Low Grade Lymphoma Study Group – Fludarabine, Cyclophosphamide and Mitoxantrone and (GLSG-FCM)] comparing the clinical effects of chemotherapy with or without rituximab in the induction of remission at first or second relapse and the clinical benefits of rituximab maintenance therapy versus the NHS’s current clinical practice of observation for follicular lymphoma (FL) patients. Both trials showed that in patients with relapsed FL the addition of rituximab to chemotherapy induction treatment increased overall response rates. Furthermore, rituximab maintenance therapy increased the median length of remission when compared with observation only. Safety data from the two trials showed that while the majority of patients reported some adverse events, the number of patients withdrawing from treatment in the EORTC trial was low, with rates not being reported for the GLSG-FCM trial. The most commonly reported adverse events were blood/bone marrow toxicity, skin rashes and allergies. The ERG reran the manufacturer’s economic model after altering several of the assumptions and parameter values in order to recalculate the cost–utility ratios, quality-adjusted life-years (QALYs) and estimates of benefits. The manufacturer reported that maintenance therapy with rituximab was cost-effective compared with observation against commonly applied thresholds, with an incremental cost-effectiveness ratio of £7721 per QALY gained. The greatest clinical effectiveness is achieved by R-CHOP followed by rituximab maintenance (R-CHOP > R) and this treatment strategy had the greatest probability of being cost-effective for a QALY of approximately £18,000 or greater. The guidance issued by NICE as a result of the STA states that in people with relapsed stage III or IV follicular NHL, rituximab is now an option in combination with chemotherapy to induce remission or alone as maintenance therapy during remission. Rituximab monotherapy is also an option for people with relapsed or refractory disease when all alternative treatment options have been exhausted.

Rituximab for the first-line treatment of stage III/IV follicular non-Hodgkin's lymphoma

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of rituximab for the first-line treatment of stage III/IV follicular non-Hodgkin's lymphoma (FNHL) based upon the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The manufacturer's scope restricts the intervention to rituximab in combination with CVP (cyclophosphamide, vincristine and prednisolone) (R-CVP); the only comparator used was CVP alone. The evidence from the one included randomised controlled trial (RCT) suggests that the addition of rituximab to a CVP chemotherapy regimen has a positive effect on the outcomes of time to treatment failure, disease progression, overall tumour response, duration of response and time to new lymphoma treatment in patients with stage III/IV FNHL compared with CVP alone. Adverse events were comparable between the two arms. This study was confirmed as the only relevant RCT. The economic analyses provided by the manufacturer were modelled using a three-state Markov model with with the health states being defined as progression-free survival (PFS), progressed (in which patients have relapsed) and death (which is an absorbing state). The model generated results for a cohort of patients with an initial age of 53 and makes no distinction between men and women. The model is basic in design, with several serious design flaws and key parameter values that are probably incompatible. Attempting to rectify the identified errors and limitations of the model did not increase the incremental cost-effectiveness ratio (ICER) above 30,000 pounds. Although the cost-effectiveness results obtained appear to be compelling in support of R-CVP compared with CVP for the trial population the results may not be so convincing for a more representative population. The results of the ERG analysis on the impact of age suggest that ICERs increase steadily with age, as the proportion of PFS that can be converted to overall survival (OS) is diminished by rising mortality rates in the general population. For the most extreme scenario (no OS gain) the ICER appears to remain below 30,000 pounds per QALY gained. On balance the evidence indicates that R-CVP is more cost-effective than CVP. The guidance issued by NICE in July 2006 as a result of the STA states that rituximab within its licensed indication (in combination with cyclophosphamide, vincristine and prednisolone) is recommended as an option for the treatment of symptomatic stage III/IV follicular non-Hodgkin's lymphoma in previously untreated patients.

Erlotinib for the treatment of relapsed non-small cell lung cancer

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of erlotinib for the treatment of relapsed non-small cell lung cancer (NSCLC), according to its licensed indication, based upon the evidence submission from Roche Products to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The submitted clinical evidence includes one randomised controlled trial (RCT) (BR21) investigating the effect of erlotinib versus placebo, which demonstrates that erlotinib significantly increases median overall survival, progression-free survival and response rate compared with placebo. The majority of patients in the trial experienced non-haematological drug-related adverse effects. Currently there are no trials that directly compare erlotinib with any other second-line chemotherapy agent. For the purposes of indirect comparison, the manufacturer’s submission provides a narrative discussion of data from 11 RCTs investigating the use of docetaxel. From these data the manufacturer concludes that erlotinib has similar clinical efficacy levels to docetaxel but results in fewer serious haematological adverse events; however, it is difficult to compare the results of BR21 with those of the docetaxel trials or with current UK clinical practice because, for example, the BR21 patient population is younger than that expected to present in UK clinical practice and almost half of the BR21 participants received erlotinib as third-line chemotherapy, with third-line chemotherapy being rare in the UK. The manufacturer’s submission included a three-state model comparing erlotinib with docetaxel, reporting an incremental cost-effectiveness ratio (ICER) of –£1764 per quality-adjusted life-year (QALY) gained for erlotinib compared with docetaxel. Rerunning the manufacturer’s economic model with varied parameters and assumptions increases the ICER to in excess of £52,000 per QALY gained. There is still a large amount of unquantifiable uncertainty in the model and it is unlikely that erlotinib could be considered to be cost-effective compared with docetaxel at a willingness to pay of £30,000 and there may even be the potential for docetaxel to dominate erlotinib. Because of the limitations of the indirect analysis undertaken by the manufacturer and the subsequent economic modelling exercise there is a need for a head-to-head trial comparing erlotinib with docetaxel. The guidance issued by NICE in February 2007 as a result of the STA states that erlotinib is not recommended for the treatment of locally advanced or metastatic NSCLC.

Rituximab for the first-line treatment of stage III/IV follicular non-Hodgkin’s lymphoma

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of rituximab for the first-line treatment of stage III/IV follicular non-Hodgkin’s lymphoma (FNHL) based upon the manufacturer’s submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The manufacturer’s scope restricts the intervention to rituximab in combination with CVP (cyclophosphamide, vincristine and prednisolone) (R-CVP); the only comparator used was CVP alone. The evidence from the one included randomised controlled trial (RCT) suggests that the addition of rituximab to a CVP chemotherapy regimen has a positive effect on the outcomes of time to treatment failure, disease progression, overall tumour response, duration of response and time to new lymphoma treatment in patients with stage III/IV FNHL compared with CVP alone. Adverse events were comparable between the two arms. This study was confirmed as the only relevant RCT. The economic analyses provided by the manufacturer were modelled using a three-state Markov model with with the health states being defined as progression-free survival (PFS), progressed (in which patients have relapsed) and death (which is an absorbing state). The model generated results for a cohort of patients with an initial age of 53 and makes no distinction between men and women. The model is basic in design, with several serious design flaws and key parameter values that are probably incompatible. Attempting to rectify the identified errors and limitations of the model did not increase the incremental cost-effectiveness ratio (ICER) above £30,000. Although the cost-effectiveness results obtained appear to be compelling in support of R-CVP compared with CVP for the trial population the results may not be so convincing for a more representative population. The results of the ERG analysis on the impact of age suggest that ICERs increase steadily with age, as the proportion of PFS that can be converted to overall survival (OS) is diminished by rising mortality rates in the general population. For the most extreme scenario (no OS gain) the ICER appears to remain below £30,000 per QALY gained. On balance the evidence indicates that R-CVP is more cost-effective than CVP. The guidance issued by NICE in July 2006 as a result of the STA states that rituximab within its licensed indication (in combination with cyclophosphamide, vincristine and prednisolone) is recommended as an option for the treatment of symptomatic stage III/IV follicular non-Hodgkin’s lymphoma in previously untreated patients.

13 EFFECTS OF PLASMA PROGESTERONE CONCENTRATIONS ON LH RELEASE AND OVULATION IN BEEF CATTLE GIVEN GnRH

Two experiments were conducted to determine the effects of plasma progesterone (P4) concentrations on LH release and ovulation in beef heifers and lactating beef cows given gonadotropin-releasing hormone (GnRH). Previously autoclaved, once-used CIDR inserts (Colazo et al. 2004 Anim. Reprod. Sci. 81, 25-34) were used for experimental purposes to induce differential plasma progesterone concentrations. In Experiment 1, postpubertal heifers received 25 mg of dinoprost i.m. (prostaglandin F (PGF); Lutalyse; Pfizer Animal Health, Montreal, Quebec, Canada). On Day 4 (estrus = Day 0), heifers were randomly assigned (10/group) to receive no treatment (control) or 1 or 2 autoclaved once-used CIDR (Pfizer Animal Health) inserts (1CIDR and 2CIDR, respectively). On Day 5, heifers in the 1CIDR group were given PGF twice 12 h apart. On Day 6, all heifers received 100 �g of GnRH i.m. (Cystorelin; Merial Canada, Inc., Victoriaville, Quebec, Canada). Once daily on Days 4 to 9, a blood sample was collected and ultrasonography was performed. On Day 6, heifers in the control (3.0 � 0.4 ng/mL; mean � SD) and 1CIDR groups (3.0 � 0.3 ng/mL) had lower (P < 0.01) plasma progesterone concentrations than those in the 2CIDR group (5.7 � 0.4 ng/mL). However, the diameter of the dominant follicle was larger (P < 0.001) in heifers in the control and 1CIDR groups than in the 2CIDR group (12.1 � 1.0, 11.5 � 0.7, and 10.1 � 0.7 mm, respectively). More (P < 0.01) heifers ovulated in response to GnRH in the control and 1CIDR groups than in the 2CIDR group (10/10, 9/10, and 3/10, respectively). In Experiment 2, ultrasound-guided follicular ablation (FA) was performed (to synchronize ovarian follicular wave emergence) 4 to 6 days after estrus in 20 postpubertal heifers and 20 mature lactating cows. Cattle were randomly and equally assigned to receive an autoclaved, once-used CIDR, either with no further treatment (High-P4) or with two PGF treatments 12 h apart (Low-P4) given after FA. All cattle received 100 �g of GnRH either 6 days after FA or the day after the dominant follicle reached 9 mm in diameter. Ultrasonography was performed daily (from 4 days after FA to ovulation or to 3 days after GnRH treatment). In three cows and three heifers per group, blood samples were collected every 30 min for 12 h after GnRH. The dominant follicle at GnRH treatment was larger in cows than heifers (11.0 � 1.1 vs. 10.3 � 0.9 mm, respectively; P = 0.05) and tended to be smaller in the High-P4 group vs. the Low-P4 group (10.3 � 1.0 vs. 11.0 � 1.0 mm; P = 0.06). Ovulatory response was not different (P = 0.9) between heifers (77.7%) and cows (78.9%), but combined for heifers and cows, was lower in High-P4 vs. Low-P4 cattle (61.1 vs. 94.7; P < 0.01). The GnRH-induced LH surge did not differ (P = 0.23) between cows and heifers, but it was lower and of shorter duration (P < 0.001) in the High-P4 group than in the Low-P4 group. In summary, higher plasma P4 concentrations resulted in decreased LH release and the proportion of cattle ovulating in response to GnRH treatment. There was no significant difference between heifers and cows in LH release or ovulatory response.

11 EFFECTS OF CIDR-BASED PRESYNCHRONIZATION AND eCG ON FERTILITY FOR A GnRH-BASED TIMED-AI PROTOCOL IN BEEF CATTLE

The objectives were to determine the effects of presynchronization and eCG on fertility for a GnRH-based timed-AI (TAI) protocol in beef cattle. Previously autoclaved once-used CIDR inserts (Colazo et al. 2004 Anim. Reprod. Sci. 81, 25-34) were used for experimental purposes so that all cattle had equivalent exogenous progesterone after Day 7 in Experiment 1, and to induce GnRH-responsive follicles in Experiment 2. In Experiment 1, 12-15 month old beef heifers (n = 447) were used (three locations, A, B, and C). On Day 0, half received a new CIDR insert (Pfizer Animal Health, Montreal, Quebec, Canada) and 500 �g of cloprostenol i.m. (PGF: Estrumate; Schering-Plough Animal Health, Pointe-Claire, Quebec, Canada). On Day 7, the remainder received an autoclaved once-used CIDR and all received 100 �g of GnRH i.m. (Cystorelin; Merial Canada, Inc., Victoriaville, Quebec, Canada). On Day 14, CIDR inserts were removed, PGF was given to all heifers, and heifers were given either 300 IU eCG i.m. (Pregnacol; Bioniche Animal Health, Belleville, Ontario, Canada) or no treatment (2 � 2 factorial design). On Day 16 (54-56 h after CIDR removal and PGF administration), heifers were given 100 �g of GnRH i.m., concurrent with TAI. Transrectal ultrasonography was done on Day 0 to assess ovarian structures, and on approximately Day 50 (range, 44-69) to confirm pregnancy. Overall, 72.7% of heifers were puberal on Day 0 (150/150, 5/37, and 170/260 for locations A, B, and C, respectively; P < 0.001). Pregnancy rate was affected (P < 0.001) by location (27.3, 62.2, and 51.1% for the three locations, respectively) but was not affected (P = 0.3) by puberal status at locations B and C. Pregnancy rate was not affected (P = 0.5) by presynchronization, but tended (P = 0.1) to be reduced by eCG treatment (40.4 vs. 47.7%, respectively). In Experiment 2, lactating crossbred beef cows (n = 411), 2-12 years of age were randomly allocated to receive either a previously used, autoclaved CIDR for 7 days and 25 mg of dinoprost i.m. (PGF: Lutalyse; Pfizer Animal Health) or no treatment (control; Day 0). At CIDR removal (Day 7), all cows received 100 �g of GnRH. On Day 14, all cows received PGF and were allocated to receive either 400 IU of eCG i.m. or no treatment (2 � 2 factorial design). On Day 16 (54-56 h after PGF), cows were given 100 �g of GnRH concurrent with TAI. Transrectal ultrasonographic examinations were done on approximately 65 cows in each group on Days 0, 7, and 14 to assess ovarian structures and on all cows on Day 42 to confirm pregnancy. Overall, 88.8% of cows had a corpus luteum (CL) on Day 0. Presynchronization increased both the proportion of cows that ovulated to GnRH treatment on Day 7 (76.7 vs. 55.0%; P < 0.001) and pregnancy rate (58.2 vs. 45.4%; P = 0.03) for cows that had received a CIDR vs. control cows. However, eCG treatment did not affect pregnancy rate (P = 0.3) in either group. In summary, presynchronization with a used CIDR and PGF prior to a Cosynch protocol increased ovulation rate to the first GnRH treatment and pregnancy rate in cows but not in heifers. In a GnRH-based TAI protocol, treatment with eCG had no significant effect on fertility in cows, but tended to decrease fertility in heifers.

Frisby Davis distance stereoacuity values in visually normal children

AIMS

To establish the range of normal distance stereoacuity in young children using the Frisby Davis distance stereo test (FD2).

METHODS

Children passing preschool vision screening assessments underwent measurement of distance stereoacuity with the FD2 using a standard testing protocol.

RESULTS

59 visually normal children aged between 36 months and 68 months were recruited to this study. All 59 were able to understand the test requirements and were examined with the FD2 stereo test. Four (6.8%) had no measurable stereoacuity; 13 (24%) had stereoacuity measurable only at a 3 metre testing distance (mean 92.3 seconds of arc; SD 52.6). These children were significantly younger than the remaining 42 (76%) who demonstrated a stereoacuity response at a 6 metre testing distance (mean 29.6 seconds of arc; SD 13.1, p=0.008).

CONCLUSION

The FD2 stereo test enables the measurement of distance stereoacuity in young children. There appears to be a maturational effect with distance stereoacuity improving between 36 months and 68 months. The data on age related normal values will provide a baseline from which to compare outcomes in clinical populations.

A link between prompt optical and prompt γ-ray emission in γ-ray bursts

The prompt optical emission that arrives with the gamma-rays from a cosmic gamma-ray burst (GRB) is a signature of the engine powering the burst, the properties of the ultra-relativistic ejecta of the explosion, and the ejecta's interactions with the surroundings. Until now, only GRB 990123 had been detected at optical wavelengths during the burst phase. Its prompt optical emission was variable and uncorrelated with the prompt gamma-ray emission, suggesting that the optical emission was generated by a reverse shock arising from the ejecta's collision with surrounding material. Here we report prompt optical emission from GRB 041219a. It is variable and correlated with the prompt gamma-rays, indicating a common origin for the optical light and the gamma-rays. Within the context of the standard fireball model of GRBs, we attribute this new optical component to internal shocks driven into the burst ejecta by variations of the inner engine. The correlated optical emission is a direct probe of the jet isolated from the medium. The timing of the uncorrelated optical emission is strongly dependent on the nature of the medium.

Transgenic overexpression of neuromedin U promotes leanness and hypophagia in mice

Recent work has shown that neuromedin U (NmU), a peptide initially identified as a smooth muscle contractor, may play a role in regulating food intake and energy homeostasis. To further evaluate this putative function, we measured food intake, body weight, energy expenditure and glucose homeostasis in transgenic mice that ubiquitously overexpress murine proNmU. NmU transgenic mice were lighter and had less somatic and liver fat, were hypophagic, and had improved insulin sensitivity as judged by an intraperitoneal insulin tolerance test. Transgenic mice had higher levels of hypothalamic NPY, POMC and MCH mRNA. There was no difference in O2 consumption between genotypes; however, NmU transgenic mice displayed a modest increase in respiratory quotient during food deprivation and refeeding. There were no behavioral disturbances in the NmU transgenic mice that could account for the results (e.g. changes in locomotor activity). When placed on a high-fat diet, transgenic mice remained lighter than wild-type mice and ate less, but gained weight at a rate similar to wild-type mice. Despite the increased weight gain with high-fat feeding, glucose tolerance was significantly improved in the transgenic mice. These findings support the hypothesized role of NmU as an endogenous anorexigenic peptide.

Use of computerized health claims data to monitor compliance with antibiotic prophylaxis in sickle cell disease

OBJECTIVE

To demonstrate how computerized claims data can be used to identify children with sickle cell disease probably having low compliance with antibiotic prophylaxis of pneumococcal disease.

METHODS

The study included under-5-year-old children with sickle cell disease who were on antibiotic prophylaxis and covered by Medicaid in Michigan (N=158), Missouri (N=64), and New York (N=297). Medicaid pharmacy claims from 10-month periods were used to estimate the total days' supply of antibiotics dispensed for each child. Low compliance was defined as a ratio less than 0.33 for the child's estimated total days' supply of antibiotics divided by days in the child's study period. Two slightly different methods of estimating antibiotic supplies were used to generate a low and high estimate of the percentage of children having low compliance.

RESULTS

Low and high estimates of the percentage of children having low compliance were 20% and 25% in Michigan, 19% and 31% in Missouri, and 16% and 24% in New York. With each method of estimating antibiotic supplies, low compliance was not associated with age in any state.

CONCLUSIONS

Computerized claims data can be used, potentially by Medicaid programs and managed care organizations, to identify children with sickle cell disease who probably have low compliance with antibiotic prophylaxis.

Developmental neurotoxicity of ketamine: morphometric confirmation, exposure parameters, and multiple fluorescent labeling of apoptotic neurons

Ketamine is a widely used pediatric anesthetic recently reported (C. Ikonomidou et al., 1999, Science 283, 70-74) to enhance neuronal death in neonatal rats. To confirm and extend these results, we treated four groups of PND 7 rats with seven sc doses, one every 90 min, of either saline, 10 mg/kg ketamine, 20 mg/kg ketamine, or a single dose of 20 mg/kg ketamine. The repeated doses of 20 mg/kg ketamine increased the number of silver-positive (degenerating) neurons in the dorsolateral thalamus to a degree comparable to previous results (Ikonomidou et al., 1999, Science 283, 70-74), i.e., 28-fold vs. 31-fold respectively. However, blood levels of ketamine immediately after the repeated 20 mg/kg doses were about 14 micrograms/ml, about seven-fold greater than anesthetic blood levels in humans (J. M. Malinovsky et al., 1996, Br. J. Anaesth. 77, 203-207; R. A. Mueller and R. Hunt, 1998, Pharmacol. Biochem. Behav. 60, 15-22). Levels of ketamine in blood following exposure to the multiple 10 mg/kg doses of ketamine or to a single 20 mg/kg dose ranged around 2-5 micrograms/ml; although these blood levels are close to an anesthetic level in humans, they failed to produce neurodegeneration. To investigate the mode of ketamine-induced neuronal death, coronal sections were stained with both Fluoro-Jade B (a green fluorescent stain selective for neurodegeneration) and DAPI (a blue DNA stain), as well as for caspase-3 (using an antisera labeled red with rhodamine). These histochemical results confirmed the developmental neurotoxicity of ketamine, demonstrated that Fluoro-Jade B (FJ-B), like silver methods, successfully stained degenerating neurons in neonatal rats, and indicated that ketamine acts by increasing the rate of neuronal apoptosis.

Positive tensilon test and intracranial tumor: a case report

PURPOSE

To report a case of intracranial tumor in a patient with positive tensilon test.

METHODS

Interventional case report. A 19-year-old male presented with left 6th nerve palsy and had a tensilon test, which was highly positive and was diagnosed as having myasthenia gravis.

RESULTS

The neurologist scanned the patient, which showed an intracranial tumor in the floor of the temporal fossa on the left side. The patient had surgery and a schwannoma was removed. The VIth nerve palsy did not improve up to two years after surgery.

CONCLUSIONS

A patient with a positive tensilon test can also have an associated intracranial tumor.

Infant-mother interaction as a predictor of child's chronic health problems

BACKGROUND

Psychological stress is associated with physical illnesses like asthma or infections. For an infant, situations perceived as stressful are highly dependent on the relationship with the caregiver. Constantly poor mother-infant interaction increases the child's vulnerability to stressful conditions and experiences. The aim of the study was to investigate the impact of the quality of early mother-infant interaction on the subsequent physical health of the child. Poor mother-infant interaction was hypothesized to be associated with chronic or recurrent health problems in the child.

PARTICIPANTS

Fifty-seven mother-infant dyads from families at risk of psychosocial problems and 63 from non-risk families, altogether 120 dyads, participated in the study. Families were drawn from normal population, from well-baby clinics in the city of Tampere, Finland. Infants were full-term and healthy, families with severe risks like psychotic illnesses of the parents or a history of child protection concerns were excluded from the study.

METHODS

After the initial interview with the mother, the mother-infant interaction was videotaped when the infants were 8-11 weeks of age and the interaction was assessed using the Global Rating Scale for Mother-Infant Interaction (Murray et al. 1996a). After the 2-year follow-up mothers were interviewed again and the health problems of the child were elicited.

RESULTS

Poor dyadic mother-infant interaction and infant's poor interactive behaviour assessed at two months were separately associated with the physical health of the child during the two-year follow-up. After adjusting for other factors in the logistic regression analysis infant's poor interactive behaviour remained as a significant predictor of chronic or recurrent health problems in the child. Infant's health problems at the time of the initial interview and day care centre attendance were also significant predictors.

CONCLUSIONS

The results suggest that interactional issues between a mother and her infant are related to the child's subsequent physical health. Children with recurrent or chronic health problems may have relationship difficulties with which they need help. Also, early avoidant behaviour of the infant should be regarded as an indicator of the infant's distress with possibly adverse outcomes in the child's physical health, among other consequences.

Can tonic accommodation predict surgical performance?

BACKGROUND

Pilots undergo many visual tests for both selection and assessment, and we know that there are many similarities between pilots and surgeons. Hence, it would not be unreasonable to bring similar visual tests into surgery. Tonic accommodation (TA) is a stable parameter that is adopted by the eye in the absence of any stimulation. Over recent years, surgery has undergone change from traditional open surgery to minimally invasive procedures, bringing many advantages. However, not every surgeon has the ability to perform under conditions where the operative field is represented on a flat monitor.

METHOD

We determined the TA values in medical students and then correlated this with their performance on a virtual reality surgical simulator.

RESULTS

We found that TA values predicted the number of errors made with the dominant hand, accounting for 27% of the variance.

CONCLUSION

The data suggest that TA may play a role in the individual differences that are noted when surgeons perform laparoscopic surgery. Further studies are needed to evaluate the exact role of TA in surgical performance.

Characterization of a novel and specific inhibitor for the pro-apoptotic protease Omi/HtrA2

Omi/HtrA2 is a mammalian serine protease with high homology to bacterial HtrA chaperones. Omi/HtrA2 is localized in mitochondria and is released to the cytoplasm in response to apoptotic stimuli. Omi/HtrA2 induces cell death in a caspase-dependent manner by interacting with the inhibitor of apoptosis protein as well as in a caspase-independent manner that relies on its protease activity. We describe the identification and characterization of a novel compound as a specific inhibitor of the proteolytic activity of Omi/HtrA2. This compound (ucf-101) was isolated in a high throughput screening of a combinatorial library using bacterially made Omi-(134-458) protease and fluorescein-casein as a generic substrate. ucf-101 showed specific activity against Omi/HtrA2 and very little activity against various other serine proteases. This compound has a natural fluorescence that was used to monitor its ability to enter mammalian cells. ucf-101, when tested in caspase-9 (-/-) null fibroblasts, was found to inhibit Omi/HtrA2-induced cell death.

Activation of central melanocortin receptors by MT-II increases cavernosal pressure in rabbits by the neuronal release of NO

1. Melanotan-II had been reported to cause penile erections in men with erectile dysfunction. In the present study, we investigated the mechanisms by which systemic administration of MT-II increases intracavernosal pressure in anaesthetized rabbits. 2. MT-II (10 microM) had no effect on electrical field stimulation-evoked relaxations of rabbit corpus cavernosal strips in vitro. 3. Intravenous injection of MT-II (66 and 133 microg kg(-1) elicited dose-related increases in cavernosal pressure. SHU 9119 (3 microg kg(-1), i.v.), a non-selective antagonist of MC(3) and MC(4) receptors did not significantly affect either cavernosal pressure or systemic blood pressure but abolished the MT-II-induced increases in cavernosal pressure. SHU 9119 also inhibited the depressor response produced by MT-II. 4. Intracavernosal injection 100 microl of the cocktail containing phentolamine mesylate (1 mg ml(-1)), papaverine (20 mg ml(-1)) and PGE1 (20 microg ml(-1)) increased the cavernosal pressure by about 4 fold. 5. The role of NO-cyclic GMP dependent pathway to MT-II-induced increases in cavernosal pressure was investigated by bilateral transection of the pudendal nerves and by inhibition of NO synthase with L-NAME (20 mg kg(-1), i.v. over 30 min). Ablation of the pudendal nerves or pretreatment with L-NAME abolished the MT-II-induced increases in intracavernosal pressure in anaesthetized rabbits. 6. The data suggest that activation of central melanocortin receptors by MT-II increases cavernosal pressure by the neuronal release of NO.

Impact of Transcendental Meditation on cardiovascular function at rest and during acute stress in adolescents with high normal blood pressure

OBJECTIVE

This study examined the impact of the Transcendental Meditation (TM) program on cardiovascular (CV) reactivity in adolescents with high normal BP.

METHOD

Thirty-five adolescents [34 African Americans (AAs), 1 Caucasian American (CA); ages 15-18 years] with resting systolic blood pressure (SBP) between the 85th and 95th percentile for their age and gender on three consecutive occasions, were randomly assigned to either TM (n=17) or health education control (CTL, n=18) groups. The TM group engaged in 15-min meditation twice each day for 2 months including sessions during school lunch break. Primary CV outcome measures were changes in blood pressure (BP), heart rate (HR), and cardiac output (CO) at rest and in response to two laboratory stressors, a simulated car driving stressor and an interpersonal social stressor interview.

RESULTS

The TM group exhibited greater decreases in resting SBP (P<.03) from pre- to postintervention, compared to the CTL group. The TM group exhibited greater decreases from pre- to postintervention in SBP, HR, and CO reactivity (P's<.03) to the simulated car driving stressor, and in SBP reactivity (P<.03) to the social stressor interview.

CONCLUSION

The TM program appears to have a beneficial impact upon CV functioning at rest and during acute laboratory stress in adolescents at-risk for hypertension.

Randomised controlled trial of an interactive multimedia decision aid on benign prostatic hypertrophy in primary care

OBJECTIVE

To determine whether a decision aid on benign prostatic hypertrophy influences decision making, health outcomes, and resource use.

DESIGN

Randomised controlled trial.

SETTING

33 general practices in the United Kingdom.

PARTICIPANTS

112 men with benign prostatic hypertrophy.

INTERVENTION

Patients' decision aid consisting of an interactive multimedia programme with booklet and printed summary.

OUTCOME MEASURES

Patients' and general practitioners' perceptions of who made the decision, decisional conflict scores, treatment choice and prostatectomy rate, American Urological Association symptom scale, costs, anxiety, utility, and general health status.

RESULTS

Both patients and general practitioners found the decision aid acceptable. A higher proportion of patients (32% v 4%; mean difference 28%, 95% confidence interval 14% to 41%) and their general practitioners (46% v 25%; 21%, 3% to 40%) perceived that treatment decisions had been made mainly or only by patients in the intervention group compared with the control group. Patients in the intervention group had significantly lower decisional conflict scores than those in the control group at three months (2.3 v 2.6; -0.3, -0.5 to -0.1, P<0.01) and this was maintained at nine months. No differences were found between the groups for anxiety, general health status, prostatic symptoms, utility, or costs (excluding costs associated with the video disc equipment).

CONCLUSIONS

The decision aid reduced decisional conflict in men with benign prostatic hypertrophy, and the patients played a more active part in decision making. Such programmes could be delivered cheaply by the internet, and there are good arguments for coordinated investment in them, particularly for conditions in which patient utilities are important.

Randomised controlled trial of an interactive multimedia decision aid on hormone replacement therapy in primary care

OBJECTIVE

To determine whether a decision aid on hormone replacement therapy influences decision making and health outcomes.

DESIGN

Randomised controlled trial.

SETTING

26 general practices in the United Kingdom.

PARTICIPANTS

205 women considering hormone replacement therapy.

INTERVENTION

Patients' decision aid consisting of an interactive multimedia programme with booklet and printed summary.

OUTCOME MEASURES

Patients' and general practitioners' perceptions of who made the decision, decisional conflict, treatment choice, menopausal symptoms, costs, anxiety, and general health status.

RESULTS

Both patients and general practitioners found the decision aid acceptable. At three months, mean scores for decisional conflict were significantly lower in the intervention group than in the control group (2.5 v 2.8; mean difference -0.3, 95% confidence interval -0.5 to -0.2); this difference was maintained during follow up. A higher proportion of general practitioners perceived that treatment decisions had been made "mainly or only" by the patient in the intervention group than in the control group (55% v 31%; 24%, 8% to 40%). At three months a lower proportion of women in the intervention group than in the control group were undecided about treatment (14% v 26%; -12%, -23% to -0.4%), and a higher proportion had decided against hormone replacement therapy (46% v 32%; 14%, 1% to 28%); these differences were no longer apparent by nine months. No differences were found between the groups for anxiety, use of health service resources, general health status, or utility. The higher costs of the intervention were largely due to the video disc technology used.

CONCLUSIONS

An interactive multimedia decision aid in the NHS would be popular with patients, reduce decisional conflict, and let patients play a more active part in decision making without increasing anxiety. The use of web based technology would reduce the cost of the intervention.

[Vaginismus--a psychiatric perspective, "secrets" and other psychodynamic causes]

Vaginismus is a disorder involving both psychiatry and gynecology. Psychiatric help is sought in only a small proportion of cases, although it is probable that the psychological etiology of the disorder is more frequent than generally recognized. This article deals with the causes and psychological circumstances of the disorder. Five cases are presented. In the first three cases, primary vaginismus caused unconsummated marriage in young women of religious or traditional background. In these cases a "secret" was revealed relating to a previous sexually related experience. This provides the basis for therapy. The other cases describe secondary vaginismus which appeared in older women who developed the symptom after a number of years of marriage. This article discusses the different psychotherapeutic approaches for the two types of cases. In the former cases, therapy may be brief and the prognosis is favorable. In the second case type, there is often more significant personality or marital pathology requiring prolonged and extensive psychotherapy. The authors stress the need for physicians to be mindful of cases of vaginismus requiring psychiatric intervention rather than gynecological treatment.

An HIV-1 transgenic rat that develops HIV-related pathology and immunologic dysfunction

We report, to our knowledge, the first HIV type 1 (HIV-1) transgenic (Tg) rat. Expression of the transgene, consisting of an HIV-1 provirus with a functional deletion of gag and pol, is regulated by the viral long terminal repeat. Spliced and unspliced viral transcripts were expressed in lymph nodes, thymus, liver, kidney, and spleen, suggesting that Tat and Rev are functional. Viral proteins were identified in spleen tissue sections by immunohistochemistry and gp120 was present in splenic macrophages, T and B cells, and in serum. Clinical signs included wasting, mild to severe skin lesions, opaque cataracts, neurological signs, and respiratory difficulty. Histopathology included a selective loss of splenocytes within the periarterial lymphoid sheath, increased apoptosis of endothelial cells and splenocytes, follicular hyperplasia of the spleen, lymphocyte depletion of mesenteric lymph nodes, interstitial pneumonia, psoriatic skin lesions, and neurological, cardiac, and renal pathologies. Immunologically, delayed-type hypersensitivity response to keyhole limpet hemocyanin was diminished. By contrast, Ab titers and proliferative response to recall antigen (keyhole limpet hemocyanin) were normal. The HIV-1 Tg rat thus has many similarities to humans infected with HIV-1 in expression of viral genes, immune-response alterations, and pathologies resulting from infection. The HIV-1 Tg rat may provide a valuable model for some of the pathogenic manifestations of chronic HIV-1 diseases and could be useful in testing therapeutic regimens targeted to stages of viral replication subsequent to proviral integration.

Effects of position and speed on joint torques and knee shear after ACL injury

PURPOSE

The purpose of this study was to assess the effect of joint position and movement speed on hip (HT) and knee (KT) extensor torque, HT/KT ratio (HKR), and anterior tibial shear (S) in presurgical-ACL deficient (PRE; N = 15), post-ACL reconstructed (POST; N = 15), and uninjured controls (CON; N = 15).

METHODS

Measurements were recorded on a semirecumbent variable resistance, closed-chain dynamometer. Tests were conducted at 1 and 1.5 Hz and maximum speed at 33% and 50% 1RM. HT, KT, and S were recorded during the extension phase of the cycle (85 degrees -25 degrees of knee flexion).

RESULTS

KT was greatest when the knee was more flexed, whereas HT dominated when it was more extended. This suggests that the hamstrings, as a component of the hip extensors, may generate considerable propulsive force during knee extension, which may help counter anterior tibial shear. S increased whereas KT decreased, suggesting that the quadriceps continue to generate shear force despite the decreasing mechanical advantage producing KT. Increasing knee extension speed significantly decreased S in the POST and CON groups. The correlations between KT and S changed from significantly negative to significantly positive as the knee extended from 85 degrees to 25 degrees in the POST and CON groups. This may be related to the orientation of the patellar tendon, relative to the tibial longitudinal axis that shifts from a posterior to anterior direction, as the knee extends.

CONCLUSIONS

Joint position and movement speeds affect the magnitude of hip and knee torques and anterior tibial shear. Reducing the magnitude of S during heavy loads may be a normal phenomenon, and POST surgical subjects may retain or regain this function by 1 yr after surgery.

Discrimination between individual humans by domestic fowl (Gallus gallus domesticus)

1. We demonstrate that Barred-Rock and Isa-Brown hens can discriminate between the presence of 2 different humans and use this information as a cue for whether or not to make an operant response. 2. This demonstration in domestic fowl, the first of its kind in any avian subject, is consistent with a growing body of evidence that many species, including agricultural animals, are surprisingly adept at differentiating between humans. 3. Such a discriminative ability carries considerable implications for issues related to husbandry, production and welfare.

Cardiovascular (CV) responsivity and recovery to acute stress and future CV functioning in youth with family histories of CV disease: a 4-year longitudinal study

Blood pressure (BP) and heart rate (HR) data obtained during supine rest, in response to and recovery from four laboratory stressors in a baseline year were used to predict supine resting BP and HR values obtained during each of four consecutive annual follow-up evaluations. Subjects were 385 normotensive youth [95 African American (AA) males, 106 AA females, 92 European American (EA) males, 92 EA females] (mean age 12.7+/-2.6 at baseline year) with a positive family history of cardiovascular disease (CVD). During the baseline evaluation subjects were presented with four laboratory stressors (namely, postural change, video game challenge, social competence interview, and parent--child conflict discussion). The BP and HR values taken during each of the laboratory stressors and during the post stressor recovery periods were converted to z-scores which were averaged to yield aggregate measures for systolic and diastolic BP and HR responsivity and recovery. The data obtained during the baseline evaluation were subsequently used to predict the follow-up values of supine resting BP and HR. The prediction models were fairly consistent across each of the 4 follow-up years. Responsivity or recovery accounted for up to 6% of the total variance after accounting for baseline values. Within the prediction models responsivity or recovery accounted for 4--56% of the variance. The predictive value of the derived models did not decline from one annual evaluation to the next over the length of the study. CV recovery may supplement resting and responsivity in the prediction of future development of CVD

The wandering psychiatric emergency room--design, location and transformations

We describe the changes in location and philosophy of a psychiatric emergency room over a period of 20 years. Four phases are described in which location, size, modes of access as well as internal and external boundaries reflect philosophies of treatment and the evolving identity of a psychiatric emergency room. The four phases include an early embryonic stage, a second stage involving rapid development of services, a third stage involving regression and consolidation and a fourth stage representing a fully developed independent service. The authors stress both external and rational considerations, such as mental health policies and budget, as well as unconscious irrational processes, which reflect the dynamic forces within the organization.

Determination of twin zygosity: a comparison of DNA with various questionnaire indices

This study examined cross-validation and test-retest reliability of questions and questionnaire indices commonly used for twin zygosity classification. Mothers of 58 monozygotic (MZ) and 52 dizygotic (DZ) same sex twin pairs were interviewed by telephone to answer questions regarding the similarity of their twins (mean age = 14.6 +/- 2.8 years). A logistic regression equation correctly classified 91% of both MZ and DZ twin pairs in our sample using 7 of the 12 zygosity questions. The internal consistency for the total questionnaire (Cronbach's alpha) was 0.88. The median two month temporal stability estimate for the individual questions was r = .56 and r = .79 for the test total. For the cross-validation, zygosity classification indices taken from 9 previous studies were applied to our sample and compared to classification according to DNA microsatellite analyses (agreement range = 44 to 100%). The accuracy of the classification indices was significantly lower than the original studies for 62% of the comparisons. If zygosity determination with DNA markers or blood group typing for all subjects is not feasible, rather than using classification indices based on other studies, an optimal classification scheme can be achieved by using a zygosity questionnaire of which the reliability and validity of the questions is established in a random subsample of the same twin cohort.

Schizophrenia patients demonstrate a dissociation on declarative and non-declarative memory tests

Declarative memory refers to the recall and recognition of factual information. In contrast, non-declarative memory entails a facilitation of memory based on prior exposure and is typically assessed with priming and perceptual-motor sequencing tasks. In this study, schizophrenia patients were compared to normal comparison subjects on two computerized memory tasks: the Word-stem Priming Test (n=30) and the Pattern Sequence Learning Test (n=20). Word-stem Priming includes recall, recognition (declarative) and priming (non-declarative) components of memory. The schizophrenia patients demonstrated an impaired performance on recall of words with relative improvement during the recognition portion of the test. Furthermore, they performed normally on the priming portion of the test. Thus, on tests of declarative memory, the patients had retrieval deficits with intact performance on the non-declarative memory component. The Pattern Sequence Learning Test utilizes a serial reaction time paradigm to assess non-declarative memory. The schizophrenia patients' serial reaction time was significantly slower than that of comparison subjects. However, the patients' rate of acquisition was not different from the normal comparison group. The data suggest that patients with schizophrenia process more slowly than normal, but have an intact non-declarative memory. The schizophrenia patients' dissociation on declarative vs. non-declarative memory tests is discussed in terms of possible underlying structural impairment.

The effects of life events on cardiovascular reactivity to behavioral stressors as a function of socioeconomic status, ethnicity, and sex

OBJECTIVE

The purposes of this study were 1) to examine the effects of stressful life events on cardiovascular reactivity to acute laboratory stressors in youth and 2) to determine whether these effects varied as a function of socioeconomic status, ethnicity, and/or sex.

METHODS

Four hundred eighty-three youths (mean age = 16.7 years; 249 Caucasian Americans [126 males, 123 females] and 234 African Americans [109 males, 125 females]) completed the Adolescent Resources Challenge Scale (ARCS), a measure of stressful life events, and underwent two laboratory stressors (a car-driving simulation and the Social Competence Interview) during which blood pressure, heart rate, cardiac output, and total peripheral resistance were assessed.

RESULTS

Youths who reported high levels of stressful life events showed smaller increases in blood pressure (both systolic and diastolic) and heart rate to the car-driving simulation but larger increases in cardiac output in response to the Social Competence Interview than did youths who reported low levels of stressful life events. The effect of stressful life events on cardiovascular reactivity was not moderated by sex, ethnicity, or socioeconomic status. Higher family socioeconomic status was associated with greater blood pressure, heart rate, and cardiac output increases in response to the Social Competence Interview.

CONCLUSIONS

The attenuating effects of stressful life events on cardiovascular reactivity in response to car-driving simulation in youths are consistent with an inoculation effect, whereas the potentiating impact of stressful life events on reactivity observed during the social stressor interview is compatible with a possible cost of coping effect.

Can rabbits tell humans apart?: Discrimination of individual humans and its implications for animal research

To predict when food reward was available, 12 New Zealand White rabbits were trained to discriminate between two humans. All subjects had significantly higher response rates and greater behavioral arousal in the presence of the positive stimulus person. The ability to discriminate between individual humans sets the stage for unanticipated Pavlovian conditioning, which may have considerable implications for animal research in behavioral and biomedical settings.

Human hip and knee torque accommodations to anterior cruciate ligament dysfunction

It has been postulated that the adaptations of lower extremity function exhibited by anterior cruciate ligament (ACL) deficient and post-ACL surgical patients represent early accommodations to the loss of ACL function after injury so that excessive anterior displacement of the tibia is prevented. Prior studies have suggested that compensation patterns in ACL deficient and post-ACL surgical subjects may affect joint moments of the knee as well as the hip. However, the variance in knee and hip forces between ACL deficient, post-surgical ACL and uninjured groups has not been clearly elucidated. The purpose of this study was to assess hip:knee extensor torque ratios relative to anterior tibia shear in pre-surgical-ACL deficient, post-surgical and uninjured subjects. Measurements of hip and knee joint moments and anterior tibia shear were recorded from 45 injured and uninjured subjects (21 men, 24 women) during lower extremity, variable resistance exercise. Anterior tibia shear was computed by decomposing joint moments and reaction forces according to a model derived from cadaver knee dissections and radiography, in combination, to estimate the tibio-femoral compressive and shear forces generated by the patellar tendon at various angles throughout the knee joint range. Three groups of subjects were studied: recently injured ACL deficient pre-surgical subjects who were scheduled for immediate surgery (PRE; n = 15); postsurgical subjects who had undergone ACL reconstructive surgery at least 1 year prior to testing (POST; n = 15); and uninjured controls (CON; n = 15). All PRE and POST subjects had a normal contralateral limb. Tests were conducted under six conditions: 1 and 1.5 Hz cadence and maximal speed at 33% and 50% one repetition maximum resistance. The results revealed that the hip:knee ratios were significantly greater for the post-ACL surgical group than the PRE and CON groups (P<0.01; P<0.03). There were significant negative correlations between the hip extensor:knee extensor torque ratios and maximal anterior tibia shear across all groups. The hip:knee extensor torque ratio increased with decreased anterior tibia shear in all groups with significant correlations ranging from -0.55 to -0.88 (P<0.01) for the injured limbs of PRE and POST groups, and -0.64 to -0.78; (P<0.01) for the CON group. The highest overall correlations were found for the post-surgical subjects. The results revealed that anterior tibia shear declined significantly with speed (P<0.01) in all groups. However, the converse was true for the hip:knee extensor torque ratio across speeds. The ratio increased significantly with speed (P<0.001) for all groups at the 33% and 50% resistances. The results suggest (1) that post-ACL surgical subjects appear to accommodate to ACL substitution by using hip extensors to a significantly greater extent than the uninjured controls in closed-chain lower extremity exercise; (2) that the hip:knee extensor torque ratio is significantly related to the magnitude of anterior tibia shear; and (3) that the anterior tibia shear is significantly reduced as speed increases in closed-chain lower extremity exercise.