Relaxation: mapping an uncharted world

Nine hundred and forty practitioners of massage, abbreviated progressive muscle relaxation (PMR), yoga stretching, breathing, imagery meditation, and various combination treatments described their technique experiences on an 82-item wordlist. Factor analysis yielded 10 interpretable relaxation categories: Joyful Affects and Appraisals (Joyful), Distant, Calm, Aware, Prayerful, Accepted, Untroubled, Limp, Silent, and Mystery The relaxation response and cognitive/somatic specificity models predict Calm and Limp, which account for only 5.5% of the variance of relaxation experience. Unlike much of previous relaxation research, we found important technique differences. PMR and massage are associated with Distant and Limp; yoga stretching, breathing, and meditation with Aware; meditation with Prayerful and all techniques except PMR with Joyful. Results are consistent with cognitive-behavioral relaxation theory and have implications for relaxation theory, treatment, training, assessment, and research. We close with a revised model of relaxation that posits three global dimensions; tension-relief, passive disengagement, and passive engagement.

An outcomes study of cochlear implants in deaf patients. Audiologic, economic, and quality-of-life changes

OBJECTIVES

To investigate and quantitate the changes in economic, emotional, and health-related quality of life after cochlear implantation.

SUBJECTS

Nine patients between the ages of 18 and 60 years who qualified for surgery.

METHODS

Patients underwent assessment using four socioeconomic indicator scales administered preoperatively, and at 6 months, 1 year, 2 years, 30 months, and 3 years postoperatively. All patients continued to use their cochlear implants during the 3-year follow-up period.

RESULTS

Uniform and systematic improvement in quality of life and psychologic well-being, and a steady increase in mean personal income for the group that underwent implantation, supporting the contention that cochlear implantation is a beneficial surgical procedure for profoundly deaf patients.

Validity of the Quality of Well-Being Scale for persons with human immunodeficiency virus infection. HNRC Group. HIV Neurobehavioral Research Center

To evaluate the validity of the Quality of Well-Being Scale (QWB) for studies of patients with human immunodeficiency virus (HIV) disease, 514 men were studied who were divided among four categories: Centers for Disease Control and Prevention (CDC) Group A (N = 272), CDC-B (N = 81), CDC-C (N = 47), and uninfected male controls (N = 114). The QWB and a variety of medical, neuropsychological, and biochemical measures were administered to all participants. When QWB scores were broken down by HIV group, the CDC-C group was significantly lower (.614) than the CDC-B (.679), CDC-A (.754), or control group (.801). The difference between Groups CDC-C and CDC-A was about .14 units of well-being, which suggests that individuals lose 1/7 equivalents of 1 well year of life for each year they are in Group CDC-C in comparison to the asymptomatic group (Group CDC-A). In comparison to the controls, this would equal a 1-year of life loss for each seven infected individuals. The QWB was shown to be significantly associated with CD4+ lymphocytes (p < .001), clinician ratings of neuropsychological impairment (p < .04), neurologists ratings of dysfunction (p < .001), and all subscales of the Profile of Mood States. Baseline QWB scores were significant prospective predictors of death over a median follow-up time of 30 months. Multivariate models demonstrated high covariation between predictors of QWB. It was concluded that the QWB is a significant correlate of biological, neuropsychological, neurological, psychiatric, and mortality outcomes for male HIV-infected patients.

Morphology and primary crystal structure of a silk-like protein polymer synthesized by genetically engineered Escherichia coli bacteria

The morphology and primary crystal structure of SLPF, a protein polymer produced by genetically engineered Escherichia coli bacteria, were characterized. SLPF is a segmented copolymer consisting of amino acid sequence blocks modeled on the crystalline segments of silk fibroin and the cell attachment domain of human fibronectin. Wide angle x-ray scattering (WAXS), transmission electron microscopy (TEM), selected area electron diffraction (SAED), and molecular simulations were used to analyze the primary crystal structure of SLPF. TEM experiments conducted on SLPF droplets cast from formic acid on amorphous carbon film demonstrated that these protein films have a microstructure formed of woven sheaves. The sheaves are composed of well-defined whisker crystallites. The width of the whiskers, 11.8 +/- 2.2 nm, may be correlated to the length of the silk-like segment in SLPF as predicted by molecular simulations. WAXS data, TEM images, SAED, patterns, molecular simulations, and theoretical diffraction patterns all were consistent with the crankshaft model proposed for Silk I by Lotz and Keith.

Effects of offering advance directives on quality adjusted life expectancy and psychological well-being among ill adults

Two hundred and four patients from various clinical services at the San Diego Veterans' Administration Medical Center and the University of California, San Diego Medical Center were randomly assigned to either experimental (offered the opportunity to execute an Advance Directive regarding the level of care they wanted to receive if incapacitated) or control (no Advance Directive offered) conditions. Patients were given a baseline interview and re-interviewed at specific intervals (3 months, 6 months, 1 year and 2 years after baseline, and every 6 months thereafter). Outcome measures included the Qualitty of Well-being Scale, a measure of health status, and the General Well-being Index, a measure of psychological well-being. All differences between the health status and psychological well-being of experimental and control groups 3.5 years after the randomization were non-significant. Methodological implications of including mortality as part of the outcomes are discussed.

Functional limitation after major trauma: a more sensitive assessment using the Quality of Well-being scale--the trauma recovery pilot project

Little is known about the degree of disability and quality of life of patients after major trauma. We conducted a prospective study to examine the incidence and predictors of functional limitation (FL). Between January 1, 1990 and March 30, 1990, 61 eligible trauma patients were enrolled in the study (admission GCS score > or = 12, LOS > 24 hours). Functional limitation after trauma was measured at discharge and 3 months after discharge using the Quality of Well-being (QWB) scale, a more sensitive index to the well end of the functioning continuum (range, 0 = death to 1.000 = optimum functioning). Functional limitation was also measured using a standard ADL scale (range, 17 = full function to 41 = maximum dysfunction). Risk factors measured were injury severity, body region, depression (CES-D) scale, and social support. Follow-up was achieved in 42 patients (70%). The mean age was 30 years, 74% were male, 52% white, 41% hispanic, and 3% other. The mean ISS was 15, with 69% blunt injuries and a mean LOS of 12 days. The QWB scores improved between discharge and follow-up; discharge mean = 0.457 (+/- 0.048), follow-up mean = 0.613 (+/- 0.118), but the mean QWB score at follow-up still reflected a significant degree of functional limitation. The mean percentage of change in QWB scores was 34.5% (+/- 25.5%) with a range of -6.34% to 103.8%. The discharge mean FDS was 29 (+/- 6.2) while the follow-up FDS mean was 17 (+/- 3.8), reflecting that most patients at follow-up reported near-perfect ADL functioning.(ABSTRACT TRUNCATED AT 250 WORDS)

Binding of vascular heparan sulfate proteoglycan to Alzheimer's amyloid precursor protein is mediated in part by the N-terminal region of A4 peptide

The exact mechanisms of deposition and accumulation of amyloid in senile plaques and in blood vessels in Alzheimer's disease remain unknown. Heparan sulfate proteoglycans may play an important role in amyloid deposition in Alzheimer's disease. Previous investigations have demonstrated high affinity binding between heparan sulfate proteoglycans and the amyloid precursor, as well as with the A4 peptide. In the current studies, a specific vascular heparan sulfate proteoglycan found in senile plaques bound with high affinity to two amyloid protein precursors (APP695 and APP770). Vascular heparan sulfate proteoglycan also bound the Alzheimer's amyloid A4 peptide, and not other amyloid protein precursor regions studied, with high affinity. Both heparan sulfate glycosaminoglycan chains and chemically deglycosylated vascular heparan sulfate proteoglycan protein core bound to A4. High affinity interactions between vascular heparan sulfate proteoglycan and the A4 peptide may play a role in the process of amyloidogenesis in Alzheimer's disease, by localizing the site of deposition of A4, protecting A4 from further proteolysis, or by promoting aggregation and fibril formation.

An alternative secretase cleavage produces soluble Alzheimer amyloid precursor protein containing a potentially amyloidogenic sequence

Cell culture studies have shown that the Alzheimer amyloid precursor protein (APP) is secreted after full-length APP is cleaved by a putative secretase at the Lys16-Leu17 bond (secretase cleavage I) of the amyloid peptide sequence. Because this cleavage event is incompatible with amyloid production, it has been assumed that secreted APP cannot serve as a precursor of the amyloid depositions observed in Alzheimer's disease. Here we show that in neuronally differentiated PC12 cells and human kidney 293 cell cultures a portion of the secreted extracytoplasmic APP reacted specifically with both a monoclonal antibody recognizing amyloid protein residues Leu17-Val24 and a polyclonal antiserum directed against amyloid protein residues Ala21-Lys28. Furthermore, this APP failed to react with antisera recognizing the cytoplasmic domain of the full-length protein. These data indicate the presence of an alternative APP secretase cleavage site (secretase cleavage II), C-terminal to the predominant secretase cleavage I. Depending on the exact location of cleavage site II, potentially amyloidogenic secreted APP species may be produced.

The genesis of the senile plaque. Further evidence in support of its neuronal origin

Senile plaques are among the most conspicuous neuropathologic changes found in the brains of elderly individuals and patients with Alzheimer's disease (AD). The origin of the amyloid beta protein (A beta P) that accumulates in senile plaques continues to be highly controversial. Recently, using quantitative immunohistochemistry and computerized image analysis, we obtained evidence that at least a subset of early ("diffuse") senile plaques originate from neurons. In the current investigation, we employed monoclonal antibodies to A beta P and the same computerized methodology to examine in further detail the quantitative patterns of A beta P deposition in diffuse plaques in a population of intellectually intact elderly individuals. The presence of neurocentric concentration gradients of A beta P accumulation was confirmed in this study. Most significantly, this was the most predominant pattern of early amyloid deposition in the population studied. The highest concentration of A beta P was centered around neuronal cell bodies or their processes, and occasionally along neuronal plasma membranes. Computerized images showed patterns that can be interpreted as a pathogenetic sequence ranging from initial neurogenic concentration gradients centered around one single neuron to larger deposits (diffuse plaques) composed of several "anastomosing" gradients involving several adjacent neurons. It is proposed that the described very early deposits constitute the initial stage in the development of the senile plaque. Although this study does not fully prove that the accumulated A beta P is synthesized in the neuron or neuronal process it surrounds, the images herein presented suggest that neurons are the initial nidus of plaque formation.

Effects of offering advance directives on medical treatments and costs

OBJECTIVE

To examine the effects of advance directives on medical treatments and on patient satisfaction and well-being and to determine whether the enhancement of patient autonomy through advance directives provides a more ethically feasible approach to cost control than does the imposition of limits through rationing.

DESIGN

Randomized, controlled trial.

SETTING

University and Veterans Affairs medical center.

PATIENTS

Two hundred and four patients with life-threatening illnesses, 100 of whom died after enrollment in the study.

INTERVENTION

Patients randomly assigned to the experimental group were offered the California Durable Power of Attorney (a typical proxy-instruction directive), and patients assigned to the control group were not offered the advance directive. Hospital admissions were monitored to assure that a summary of the document was present in the active medical record at each hospitalization.

MEASUREMENTS

Cognitive function, patient satisfaction, psychological well-being, health locus of control, sense of coherence, health-related quality of life, receipt of medical treatments, and medical treatment charges.

RESULTS

No significant differences were found between advance-directive and control groups regarding psychosocial variables, health outcome variables, and medical treatments or charges. Patients offered an advance directive had an average hospital stay of 40.8 days (95% CI, 32.2 to 49.4 days), compared with an average of 33.1 days (95% CI, 26.0 to 40.2 days) for controls. Patients offered an advance directive were charged an average of $19,502 (95% CI, $13,030 to $25,974) for medical treatments in the last month of life compared with $19,700 (95% CI, $13,704 to $25,696) for controls.

CONCLUSIONS

Despite claims that public demand for longer life accounts for rising medical costs, most surveys suggest that patients are calling for less, not more, of the expensive, high-technology treatment often used in terminal phases of illness. Executing the California Durable Power of Attorney for Health Care and having a summary copy placed in the patient's medical record had no significant positive or negative effect on a patient's well-being, health status, medical treatments, or medical treatment charges.

Relationship of general advance directive instructions to specific life-sustaining treatment preferences in patients with serious illness

OBJECTIVE

To determine whether brief general instructions in a typical proxy-instruction advance directive (California Durable Power of Attorney for Health Care [DPAHC]) provide interpretable information about patient requests to limit life-saving treatments, and to determine whether patient treatment preferences are stable over time.

DESIGN

Prospective structured interviews.

SETTING

University of California, San Diego Medical Center and Veterans Affairs Medical Center, La Jolla.

PATIENTS

One hundred four patients (from a randomly chosen sample of 185) with a 5-year life expectancy of no better than 50% as judged by their physicians.

MAIN OUTCOME MEASURES

Patients completed the California DPAHC, a proxy-instruction advance directive, at entry and at 1 year. The patients also completed a questionnaire at entry, after 6 months, and after 1 year, indicating their preferences on a five-point Likert-format comparative rating scale for cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition, and hospitalization for pneumonia.

RESULTS

Sixty-eight percent of the subjects executed the DPAHC. Most patients wished treatments to be limited or withheld under certain conditions of reduced quality of life. Although general instructions noted on the DPAHC and preferences regarding specific procedures were stable over the course of a year, the advance directive's general instructions were often inconsistent with, and poor predictors of, specific procedure preferences.

CONCLUSIONS

The brief general instruction component of the California DPAHC is not helpful in communicating patient wishes regarding specific life-saving procedures.

Evidence for intracellular cleavage of the Alzheimer's amyloid precursor in PC12 cells

The Alzheimer's amyloid precursor (APP) is cleaved by an unidentified enzyme (APP secretase) to produce soluble APP. Fractionation of PC12 cell homogenates in a detergent-free buffer showed the presence of the Kunitz protease inhibitor (KPI)-containing soluble APP (nexin II) in the particulate fraction. Digitonin or sodium carbonate treatment of this fraction solubilized nexin II suggesting that it is contained in the lumen of vesicles. Nexin II production was not affected by lysosomotropic agents, suggesting that APP secretase is not a lysosomal enzyme. Labelling of cell surface proteins by iodination failed to detect full-length APP on the surface of PC12 cells, suggesting that most of this protein is located intracellularly. Furthermore, pulse-chase experiments showed that nexin II is detected in cell extracts before it appears in the culture medium. Cellular nexin II was detected at zero time of chase after only 5 min of pulse labelling with 35S-sulfate, indicated that APP secretase cleavage takes place immediately after APP is sulfated. Temperature block, pulse-chase, and 35S-sulfate-labelling experiments suggested that APP is cleaved by APP secretase intracellularly in the trans-Golgi network (TGN) or in a post-Golgi compartment.

Quality of life and policy analysis in arthritis

Problems in the American health care system have stimulated interest in cost-effectiveness methodologies. However, there is little consensus on how to define a common unit of health outcome. Many measures used in policy studies consider only mortality and do not fully capture the significant impact of disease-related dysfunction. The impact of conditions, such as osteoarthritis, that have little impact on mortality rates but substantial impact on functioning and well-being may be underestimated in these analyses. In this article, we propose a measurement and policy model that is based on a theoretical conceptualization of health outcome. The model considers the impact of disease and its treatment in terms of both morbidity and mortality. The value of the model for clinical trials, population assessments, and policy analysis is reviewed. A public policy application of the model in Oregon is briefly described.

Chondroitin sulfate proteoglycan form of the Alzheimer's beta-amyloid precursor

The Alzheimer's amyloid beta protein is derived from a family of membrane glycoproteins termed amyloid precursor proteins (APP). Here we show that APP exists as the core protein of a chondroitin sulfate (CS) proteoglycan, ranging in apparent molecular size from 140 to 250 kDa, secreted by glial cell line C6. After partial purification on ion-exchange and gel chromatography, the secreted APP proteoglycan was recognized on Western blots by several antibodies specific to different regions of APP. Chondroitinase AC or ABC treatment of our samples completely eliminated the high molecular weight proteoglycan with a concomitant increase in the APP protein. This digested product reacted with an anti-stub antibody which recognizes 4-sulfated disaccharide. Sequencing of the N terminus of the core protein of this CS proteoglycan yielded 18 residues identical to the N terminus sequence of the mature APP. Quantitative analysis showed that, in this cell line, about 90% of the secreted nexin II form of APP occurs in the proteoglycan form, suggesting that the CS chains have a role in the biological function of this protein. The close proximity of two consensus CS attachment sites to both the N terminus of the amyloid beta protein and the secretase cleavage site, suggests that the CS chains may affect the proteolysis of APP and production of the amyloid beta protein.

Insulin influences astroglial morphology and glial fibrillary acidic protein (GFAP) expression in organotypic cultures

Variations in the levels and timing of exposure to insulin-related peptides influence the phenotypic appearance of astroglia present in organotypic cultures of the E17 mouse cerebellum as well as the expression of glial fibrillary acidic protein (GFAP) mRNA and its encoded protein. The morphology of GFAP-immunoreactive cells was influenced by the levels of insulin added in an age-specific manner. Fetal radial glia were selectively and significantly (P less than 0.001) increased by high (10 micrograms/ml) insulin levels, comprising the majority of the GFAP-positive cells seen. In contrast, there was an almost complete reversal of this pattern elicited by low (10 pg/ml) insulin levels, where GFAP-positive cells appeared undifferentiated and epithelioid (P less than 0.001). In newborn cultures, on the other hand, the morphological responses to both high and low levels of insulin were considerably attenuated and involved radial glia primarily, whose numbers were significantly increased by the high insulin levels. Exposure to high levels of insulin was accompanied by an increase in GFAP mRNA expression, as determined by non-isotopic (biotin) in situ hybridization histochemistry, and intense GFAP immunoreactivity, while low insulin levels elicited minimal expression of both message and protein product. In view of the critical interdependence of developing neurons and radial glia with respect to neuronal migration and the differentiation of neurons and astroglia, the responses observed suggest developmentally regulated mechanisms by which insulin-related peptides themselves may influence directly and indirectly both neuronal and astroglial differentiation.

Exact cleavage site of Alzheimer amyloid precursor in neuronal PC-12 cells

We have identified the secretory cleavage site in the Alzheimer amyloid precursor (APP) in a non-transfected neuronal cell line, using cyanogen bromide digests of APP purified from medium conditioned by PC-12 cells which were differentiated to a neuronal phenotype. The results obtained are most consistent with proteolysis of the Lys16-Leu17 bond in the beta amyloid peptide, followed by partial removal of Lys16 by a basic carboxypeptidase.

A research-oriented medical cost accounting system

Prospective research into factors affecting health care costs for individual patients requires a hybrid information management system with some features usually associated with a medical billing package and other features common to research databases. Furthermore, data collection for such a project must often be done in the field where a portable computer is most convenient. A software program is described which has been developed to address these disparate needs. It allows classification by study protocol assignment and provides multiple summary formats for the assessment of costs. For example, charges can be stratified by specialty, by category of service (pharmacy, room, surgery, respiratory therapy, etc.), by magnitude of expense ('big' vs 'little' ticket items) and so forth. The system design described may prove useful to other investigators studying variation in health care costs.

A possible mechanism of action of the neurotoxic agent iminodipropionitrile (IDPN): a selective aggregation of the medium and heavy neurofilament polypeptides (NF-M and NF-H)

Juvenile male rats treated acutely with the neurotoxic agent, iminodipropionitrile showed no changes in the levels of total neurofilament subunit mRNA or protein for up to 28 days. However, the drug promoted aggregation of the neurofilaments, both spontaneously upon isolation and in an in vitro reassembly assay. This observation correlated with a basic pI shift of the heavy neurofilament subunit, due to a yet to be identified modification. Because of the crucial involvement of this neurofilament subunit in axonal integrity, it is likely that iminodipropionitrile produces a major portion of its neurotoxicity through this mechanism.

Expression of the Alzheimer amyloid precursor in brain tissue and effects of NGF and EGF on its metabolism

Alzheimer's disease (AD) is the major cause of serious dementia and memory loss in several million elderly Americans. The most prominent lesions in the brains of these patients are the depositions of two types of abnormal filaments: the predominantly intraneuronal neurofibrillary tangles (NFT), which consist of paired helical filaments (PHF), and the extracellular amyloid fibers. These changes are characteristic of AD, and a final diagnosis of this disease is based on the presence of large numbers of these abnormal filamentous structures in the patient's brain. The amyloid fibers consist of a peptide subunit termed beta-protein or A4 peptide, which derives from a larger precursor protein. In this study we review the structural characteristics, regulation of expression, and metabolism of the Alzheimer amyloid precursor in brain tissue and cell cultures.

Gender differences in health-related quality of life

In 1986 the life expectancy at birth was 71.3 years for males and 78.3 years for females--providing a 7-year advantage for women. Although women live longer, it has been reported that they paradoxically experience more physical and psychological illnesses. In this article, we estimate the expected well-years or quality-adjusted life years for men and women in the general population. The data were obtained in a random sample of 1,034 residents of San Diego. The well-life expectancy uses standard life expectancies with adjustments for quality of life. The well-life expectancy for men was 59.8 years; for women, it was 62.7 years. Thus, the quality adjustment had significantly more impact on women (15.6 years) than on men (11.5 years). Age-specific estimates of health-related quality of life suggested a male advantage before age 45 and a female advantage after age 45. The benefits of well-years of life as a public health statistic are discussed.

Differential brain expression of the Alzheimer's amyloid precursor protein

The expression of the Alzheimer amyloid protein precursor (AAPP) was examined in human, monkey, dog and rat brains. Two proteins, one identified as AAPP695 and the other as AAPP751, were immunoprecipitated from the in vitro translation of human, dog and rat brain polysomes. The AAPP751 to AAPP695 ratio was highest in human, intermediate in dog and lowest in rat brain polysomes. Human cerebral cortex contained higher levels of the AAPP751 mRNA than either dog or rat cortex. AAPP695 was detected in both cerebral cortex and cerebellum of all species examined. In contrast, AAPP751 was detected predominantly in the cortex of human, monkey and to a lesser extent dog brains while it was not detected in rat brain. These findings indicate that the amyloid precursors are differentially expressed in different mammalian brains and suggest that AAPP751 is mainly expressed in the brain regions involved in plaque formation.

Nerve and epidermal growth factors induce the release of the Alzheimer amyloid precursor from PC 12 cell cultures

Antisera against specific sites of the Alzheimer beta Amyloid protein precursor (beta APP) were used to study the effects of nerve and epidermal growth factors on the expression and processing of this protein in PC12 cell cultures. Two major beta APP proteins (140 and 105 kDa) both containing the Kunitz-protease inhibitor insert (KPI), were detected in cell extracts of naive PC12 cells. Treatment of these cultures with nerve growth factor (NGF) induced the release of two beta APP species 125 and 120 kDa, both of which contained the KPI domain and lacked the carboxy-terminal portion of the precursor. The released beta APP contained O-linked sugars. Only one of the released beta APP proteins bound to the lectin Concanavalin A indicating that they differ in their glycosylation. Epidermal growth factor (EGF) also induced the release of beta APP proteins into the culture medium with similar electrophoretic mobilities as those released by NGF.

Alzheimer's disease-associated reduction of polysomal mRNA translation

Polysomes from the frontal cortices of individuals who had histopathologically confirmed Alzheimer's disease were compared with polysomes from individuals who exhibited no neuropathological conditions. The cytosolic polysome yield from Alzheimer's disease frontal cortex was reduced 40% compared with that obtained from control frontal cortex. The translational activity per unit polysome of the Alzheimer's disease polysomes was only 50% of control in a reticulocyte lysate in vitro translation assay in which human polysomes do not undergo reinitiation. These differences exhibited brain region specificity in that polysomes isolated from Alzheimer's disease cerebellum were not different from control cerebellar polysomes. Thus, the disruptions are not due to a secondary and general response of the entire brain to the disease. These reductions were reflected by similar decreases in the translation of the mRNA for high molecular weight neurofilament polypeptide. Thus, the inhibition of polysomal mRNA translation is a mechanism by which gene expression is impaired in pathologically involved brain regions of individuals afflicted by Alzheimer's disease.

The Quality of Well-being Scale. Applications in AIDS, cystic fibrosis, and arthritis

The Quality of Well-being (QWB) Scale combines preference-weighted measures of symptoms and functioning to provide a numerical point in-time expression of well-being that ranges from zero (0) for death to 1.0 for asymptomatic optimum functioning. The QWB includes three scales of function: mobility, physical activity, and social activity. Each step of these scales is associated with preference weights. Preference adjustments for symptoms are also included. This paper describes how this general system was used to evaluate outcomes in three different clinical conditions: acquired immune deficiency syndrome (AIDS), cystic fibrosis, and arthritis. In one study, the QWB was administered to 31 patients participating in evaluation of azidothymidine (AZT) treatment for AIDS. The QWB system demonstrated substantial benefits of AZT treatment in comparison to placebo. In a second study, the QWB and a series of pulmonary function measures were administered to 44 patients with cystic fibrosis. The QWB was demonstrated to be significantly correlated with measures of pulmonary function, including FEV1 and maximal midexpiratory flow rate (MMEFR). In addition, there were significant associations between the QWB and measures of exercise tolerance. In the third study, the QWB and an arthritis-specific measure were administered to 83 arthritis patients before and after their treatment. The QWB was at least as capable of detecting clinical change in this population as was the disease-specific measure. For all three conditions, the QWB considered side effects and benefits of treatment in a common unit. Clinical trial data are cited to suggest that the QWB is a valuable outcome measure in arthritis treatment evaluation. We conclude that the QWB has substantial validity as a general health outcome measure and that the system can be used with different populations.

Using composite health status measures to assess the nation's health

Research in progress at the National Center for Health Statistics for evaluating the usefulness of composite measures of health status for assessing the nation's health is described. Three measures suitable for use in the general population, the Health Insurance Experiment-Functional Limitations (HIE-FL), the Health Utility Index (HUI), and the Quality of Well-being (QWB) scale, have been mapped to data collected in the 1980 National Health Interview Survey (NHIS). Analysis using current algorithms for making composite function status measures according to the QWB methods suggests that traditional single indicators of health tend to overestimate the level of health by about 10%. When symptoms and problems are added to the composite function score, the overestimate as measured by the single indicator is at least 50%. The authors are continuing to validate these algorithms, to develop similar ones for the HIE-FL and HUI, and to extend the analysis to data collected in 1977, 1979, and 1984. Current results indicate that to realize fully the benefits of composite measures, well-established, valid, and reliable measures of health-related quality of life should be included as part of the regular NHIS data collection procedures.

Efficacy of soft splints in reducing severe knee-flexion contractures

This study evaluated the effectiveness of soft splints made from polyurethane foam in reducing severe knee-flexion contractures of patients with cerebral palsy. The splints were applied nightly over a period of 10 months. Knee-flexion contractures were reduced by an average of 24 degrees in all patients. Younger patients generally presented with less severe initial contractures and had the greatest percentage of improvement. When used on a single limb when bilateral contractures were present, sympathetic reduction of the contracture occurred to varying degrees in the unsplinted limb. It is recommended that the splints be replaced regularly to maximize their effectiveness. The benefit-to-cost ratio is extremely high and their low cost makes soft splints feasible for use in developing countries and by low-income families.

A general health policy model: update and applications

This article describes the development of a General Health Policy Model that can be used for program evaluation, population monitoring, clinical research, and policy analysis. An important component of the model, the Quality of Well-being scale (QWB) combines preference-weighted measures of symptoms and functioning to provide a numerical point-in-time expression of well-being, ranging from 0 for death to 1.0 for asymptomatic optimum functioning. The level of wellness at particular points in time is governed by the prognosis (transition rates or probabilities) generated by the underlying disease or injury under different treatment (control) variables. Well-years result from integrating the level of wellness, or health-related quality of life, over the life expectancy. Several issues relevant to the application of the model are discussed. It is suggested that a quality of life measure need not have separate components for social and mental health. Social health has been difficult to define; social support may be a poor criterion for resource allocation; and some evidence suggests that aspects of mental health are captured by the general measure. Although it has been suggested that measures of child health should differ from those used for adults, we argue that a separate conceptualization of child health creates new problems for policy analysis. After offering several applications of the model for the evaluation of prevention programs, we conclude that many of the advantages of general measures have been overlooked and should be given serious consideration in future studies.

Internal Consistency Analysis: a method for studying the accuracy of function assessment for health outcome and quality of life evaluation

Social, mental and physical function are major components of health outcomes and health related life quality, but the accuracy of function measurement is difficult to study rigorously. Internal Consistency Analysis (ICA) uses multiple sources of evidence from a survey interview to study the accuracy of a classification. It was developed to study function classifications for a general health outcome measure, the Quality of Well-being (QWB) scale. ICA is described and evidence of its utility in improving the classifications needed for the QWB is presented.

The interaction of calmodulin with human erythrocyte spectrin. Inhibition of protein 4.1-stimulated actin binding

The functional significance of calmodulin binding to human erythrocyte spectrin has been investigated under native conditions. Both native calmodulin and calmodulin derivatized with the photoactivable cross-linker methyl 4-azidobenzimidate (azidocalmodulin) have been used. When azidocalmodulin is photolyzed in the presence of erythrocyte ghosts, ghost extracts, or purified protein, it cross-links predominately to the beta subunit of erythrocyte spectrin. This cross-linking is calcium-dependent, requires photolysis, and is inhibited by 100 microM trifluoperazine or unlabeled calmodulin. Calmodulin labeled spectrin exhibits a specific and non-calcium-dependent inhibition of its ability to bind actin, even in the presence of protein 4.1. Its ability to self-associate or to bind spectrin-depleted membrane vesicles is unperturbed. Native calmodulin also inhibits protein 4.1-stimulated spectrin-actin binding, but unlike that of covalently bound calmodulin, inhibition by the uncross-linked calmodulin requires calcium. The degree of inhibition of spectrin-actin-4.1 binding induced by native calmodulin is significant since 109 microM calmodulin inhibits over 63% of the spectrin-actin binding induced by 4.5 microM protein 4.1. These results demonstrate a specific effect of calmodulin on erythroid spectrin function and suggest that calmodulin may influence the binding of protein 4.1 and actin to spectrin within the cytoskeleton.

Classifying function for health outcome and quality-of-life evaluation. Self- versus interviewer modes

Validity assessment and the underreporting of dysfunction have been major problems in health-related quality-of-life measurement, including collecting data for analysis by the General Health Policy Model, using the Quality of Well-being scale (QWB). This analysis compares the results of self- versus interviewer modes of measurement and short, direct-answer questions versus probing algorithms in the QWB. The comparisons are made in terms of 1) correlations; 2) aggregate frequencies; 3) individual subject classifications; and 4) the actual state, established using evidence from multiple sources. Despite extremely high correlations between QWB scores from the two modes (greater than 0.98), the lowest interviewer mode sensitivity (0.86) and predictive value dysfunctional (0.91) were substantially superior to the highest self-classification characteristics (0.66 and 0.73). In the populations studied, specificities and predictive values functional were equivalent (greater than 0.94) for the two modes. The probe pattern of the interviewer mode was also less susceptible to false reports of dysfunction. These results are consistent with the underreporting of dysfunction noted by several major investigations of health status measurement. The authors conclude that interviewer-administered instruments using question algorithms are necessary if health-related quality of life is to be measured with sufficient reliability and validity to evaluate major clinical trials and follow-up studies.

Mechanisms of cytoskeletal regulation: functional and antigenic diversity in human erythrocyte and brain beta spectrin

A study of human erythrocyte and brain spectrin with particular emphasis on the beta subunits revealed a structural homology but functional dissimilarity between these two molecules. Six monoclonal antibodies raised to human erythrocyte beta spectrin identify three of the four proteolytically defined domains of erythrocyte beta spectrin. Five of these monoclonal antibodies cross-react with human brain spectrin. None of a previously identified set of alpha erythrocyte spectrin monoclonal antibodies [Yurchenco et al: J Biol Chem 257:9102, 1982] reacted with brain spectrin. A domain map generated by limited tryptic digestion shows that brain spectrin is composed of proteolytically resistant domains analogous to erythrocyte spectrin, but the brain protein is more basic. The binding of brain spectrin to erythrocyte ankyrin, both in solution and on erythrocyte IOVs, yielded an association constant approximately 100 time weaker than for erythrocyte spectrin. The binding of azido-calmodulin under native conditions was specific for the erythrocyte beta subunit but was not calcium dependent. In contrast, azido-calmodulin bound only to the alpha subunit of brain spectrin in a calcium-dependent manner. The similarity of structure but modified functional characteristics of the brain and erythrocyte beta spectrins suggest that these proteins serve different cellular roles.

Parasite screening and treatment among Indochinese refugees. Cost-benefit/utility and the General Health Policy Model

The General Health Policy Model and the Quality of Well-being scale are used to describe a "cost-benefit/utility" evaluation of a screening and treatment program for intestinal parasites among indochinese refugees in the United States. Cost-benefit/utility analysis subsumes conventional cost-effectiveness by explicitly adding social utility factors to the dollar dimension. Using actual data on parasite prevalence and program costs from one screening project and estimated figures for other factors, this article demonstrates calculation of the cost-benefit/utility outcome measure, dollars per well-year. Dollars per well-year for parasite screening are calculated for a number of examples. Further analysis and final conclusions on the worth of parasite screening and treatment programs await more reliable data for some terms of the developed model.

A poison education program for primary school

A program with which to teach children in grades 1 and 2 to identify poisons and hazard symbols, to learn where poisons should be stored and to recognize a poisoning and contact a poison control center in the event of a poisoning was developed. Each objective was taught in one 30-minute lesson by the children's school teachers. Evaluation of the approximately 400 children who received the program by pre- and post-tests demonstrated that they learned to identify poisons, to recognize hazard symbols and the telephone number of the local poison control center. The children were also asked to identify their source of knowledge about poisons and cited parents, television and school as their most important sources.

Comparison of Degradative Ability, Enzymatic Activity, and Palatability of Aquatic Hyphomycetes Grown on Leaf Litter

Stream fungi have the capacity to degrade leaf litter and, through their activities, to transform it into a more palatable food source for invertebrate detritivores. The objectives of the present study were to characterize various aspects of fungal modification of the leaf substrate and to examine the effects these changes have on leaf palatability to detritivores. Fungal species were grown on aspen leaves for two incubation times. Leaves were analyzed to determine the weight loss, the degree of softening of the leaf matrix, and the concentrations of ATP and nitrogen associated with leaves. The activities of a protease and 10 polysaccharide-degrading enzymes produced by each fungus were also determined. Most fungi caused similar changes in physicochemical characteristics of the leaves. All fungi exhibited the capability to depolymerize pectin, xylan, and cellulose. Differences among fungi were found in their capabilities to produce protease and certain glycosidases. Leaf palatability was assessed by offering leaves of all treatments to larvae of two caddisfly shredders ( Trichoptera ). Feeding preferences exhibited by the shredders were similar and indicated that they perceived distinct differences among fungi. Two fungal species were highly consumed, some moderately and others only slightly. No relationships were found between any of the fungal characteristics measured and detritivore feeding preferences. Apparently, interspecific differences among fungi other than parameters associated with biomass or degradation of structural polysaccharides influence fungal palatability to caddisfly detritivores.

"Counterintuitive" preferences in health-related quality-of-life measurement

The published preferences for scale steps in a health-related quality-of-life scale have been noted to be contrary to some prior assumptions about their rank ordering. The differences noted are actually statistically nonsignificant, and the observed ordering has a clear intuitive explanation. Several alternative explanations, including vagueness in the case descriptions, inaccuracy in the scaling method, the presence of interactions in the subjects' cognitive integration rules and chance inversions in the presence of the flat response surface characteristic of linear models, are all shown to be impossible or unlikely contributors to the empirical results. The implications of the "negative preferences" for other measurement approaches are discussed, as well as the role of separate attribute coefficients in health policy analyses.

Chlorflurenol-methyl in soil: degradation, leaching, and effects on microbiological processes

Tests were conducted with the synthetic growth regulator chlorflurenol-methyl to investigate its rate of degradation in soil, leaching behavior, and possible side-effects on the soil microflora and on soil physiological processes. With two sandy soils (Ct = 1.0 and 2.58%) which were treated with 11.35 mg kg-1 chlorflurenol-methyl (congruent to 2.8 kg a.i. ha-1), over 90% of the compound disappeared within 4 to 8 days. The degradation products were 2-chloro-9-hydroxyfluorene-9-carboxylic acid and 2-chlorofluorenone, which undergo further decomposition. In leaching tests with three sandy soils (Ct = 0.69, 1.0 and 2.58%), chlorflurenol-methyl was not washed from the soil; however, with one soil (0.69% C), very small residues were observed in the effluent identified as 2-chlorofluorenone. In side-effects experiments with a parabrown (Ct = 1.26%) and a chernozem soil (Ct = 2.3%), which were treated with 1 and 10 mg kg-1 chlorflurenolmethyl, no persistent inhibition of anaerobic or aerobic nitrogen fixation (C2H2-reduction) was detected. Ammonification, nitrification, and mineralization of soluble starch were also not influenced. The mineralization of cellulose in compost soil (Ct = 13.59%) was temporarily delayed; however, this delay was later compensated for by a higher mineralization rate. The colonization density of fungi on soil particles and the numbers of bacteria, actinomycetes, and fungi were not negatively influenced. Chlorflurenol-methyl does not significantly influence these microbiological processes and populations in the soil.

Influence of selected pesticides on the microbial degradation of 14C-triallate and 14C-diallate in soil

Degradation in soil of [allyl-2-14C]triallate and [carbonyl-14C]diallate herbicides, as affected by other selected pesticides, was studied in an incubation system that allowed recovery of 95 to 100% of added 14C. The amount and sequence of pesticide additions simulated field use in the protection of wheat (triallate) and sugar beets (diallate). Neither the rate nor the pattern of triallate degradation in soil was influenced by the following sequence of formulated pesticides: dinoseb acetate, (bentazon + dichlorprop + 2,4,5-T), 2,4-D, (chlorcholinchloride + cholinchloride), tridemorph, and thiophanate. Similarly, diallate degradation was unaffected by pyrazon, dimethoate, and thiophanate. The effect of azinphosmethyl was unclear. In contrast, chlorpyrifos reduced diallate degradation by approximately 14% relative to the occurring in the insecticide's absence. This effect was caused by chlorpyrifos and not its formulation components. Chlorpyrifos was also found to partially inhibit degradation of triallate in soil. Inhibition of neither herbicide was considered to be of ecological significance. Triallate, diallate, and thiophanate were applied at 1 microgram/g; all others were at 2 microgram/g.